Every finding on record at Life Care Center of Richland

Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards of practice regarding a peripherally inserted central catheter [(PICC) a long flexible tube that goes into a vein in the upper arm to a large vein in your chest, used to put medications into the bloodstream} dressing for 1 of 5 residents reviewed for nursing care and services. This failed practice placed residents at risk for infection, prolonged illness, and a failed/unusable PICC line.Findings included. Review of a policy titled, Infusion Therapy - Intravenous (IV Fluids), revised 05/05/2026, showed the facility assured that each resident received care and services consistent with professional standards of practice in order to provide care consistent with the resident's input, goals and preferences, as outlined in their care plan, and monitoring for complications and assuring the provision of appropriate infection control practices. Resident 1Record review of the medical record showed Resident 1 was admitted to the facility with diagnoses including osteomyelitis (an infection of the bone and bone marrow), absence of the left foot, and peripheral vascular disease (a blood circulation problem that slows or blocks blood flow in the vessels out the heart and brain). The 08/06/2026 comprehensive assessment showed Resident 1 required partial/moderate assistance of one staff member for activities of daily living (activities related to personal care). The assessment also showed Resident 1 had a severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). During a concurrent observation and interview on 08/18/2026 at 11:50 AM, Resident 1 was seated on the edge of their bed in their room. There was a PICC line with a transparent dressing covering the insertion site on their left upper arm. The dressing was rolled at all four edges and there was dark, reddish brown, old blood covering the insertion site, extending 3 centimeters (a unit of measurement) along the PICC line. There was a Bio Patch (a pale yellow, small, disc shaped dressing that absorbs fluid and releases an antiseptic medication to prevent the growth of bacteria for seven days) over the insertion site that was brown and misshapen. The dressing was dated 07/30. Resident 1 stated they received medications through the PICC line. They stated the nurses had not changed their dressing since they had been admitted . Record review of a hospital nursing care plan dated 08/01/2026, showed Resident 1 had their PICC line placed on 07/30/2026. The care plan showed the next dressing change was due on 08/06/2026. Record review of Resident 1's August 2026 Medication Administration Record (MAR) showed a provider's order dated 08/04/2026. The order showed Resident 1 was to have a PICC line dressing change weekly, every Tuesday. The MAR showed Staff F, Registered Nurse, completed a dressing change on 08/11/2026, despite the current dressing showing the 07/30/2026 date. A concurrent observation and interview on 08/18/2026 at 12:48 PM with Staff B, Director of Nursing, showed Resident 1 sitting on the edge of their bed. Resident 1 removed their jacket and showed their PICC line site to Staff B. Staff B observed the compromised PICC line dressing and stated the dressing had not been changed for 19 days. During an interview on 08/19/2026 at 9:07 AM, Staff F stated they provided care for Resident 1 on 08/11/2026. They stated they assessed Resident 1's PICC line to make sure the dressing was current and observed the area for signs of infection, including redness or bleeding. Staff F stated they did not remember changing the dressing or seeing a date on the dressing. Staff F stated they did not remember marking the dressing change as completed on the MAR on 08/11/2026. During an interview on 08/19/2026 at 11:21 AM, Staff G, Admissions Nurse, stated they were responsible for entering the new admission orders. They stated when a resident was admitted with a PICC line, they would enter the dressing change order to be completed seven days after the last dressing change. Staff G stated they tried to review a new admission's hospital notes but did not review Resident 1's and was not aware of the hospital care plan showing the next dressing change was due on 08/06/2026. Staff G stated they could have entered Resident 1's dressing change order incorrectly and had probably entered it to be changed a week from Resident 1's admit date of 08/04/2026. During a follow up interview on 08/19/2026 at 11:43 AM, Staff B stated the process for care of a PICC line included completing dressing changes every seven days. They stated they were frustrated that Staff F had documented the dressing change and had not completed it. Staff B stated the process for PICC line care was not followed. Reference: WAC 388-97-1620(2)(b)(ii)(6)(b)(i)(ii) This is a repeat deficiency from the Statement of Deficiencies dated 01/15/2026.

Based on interview and record review, the facility failed to provide a written notice of bed-hold (holding or reserving a resident's bed while the resident is absent from the facility) at the time of transfer to the hospital for 3 of 3 residents (Resident 1, 2, and 3) reviewed for hospitalization. This failure placed the residents at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility.Findings included. Review of a policy titled, Bed-Hold Policy, revised 08/05/2025, showed the bed-hold policy should be given upon admission, upon transfer of a resident to the hospital (if in an emergency within 24 hours). The facility will provide written information to the resident or their representative of the nursing facility policy on bed-hold periods and the residents return to the facility, to ensure that residents are made aware of the bed-hold and reserve bed payment policy before, and upon transfer to a hospital. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including healing of a broken leg, anxiety (a group of mental health conditions that cause excessive, ongoing fear and worry that are hard to control and interfere with daily life), and vision loss in both eyes. The 07/23/2026 comprehensive assessment showed Resident 1 was dependent on one to two staff members for activities of daily living [(ADLs) activities related to personal care]. The assessment also showed Resident 1 had a moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Review of nursing progress notes (PN) dated 07/28/2026 at 9:32 AM, showed Resident 1 was transferred to the hospital for evaluation for a change in condition. Record review of the medical record showed there was no documentation that a written notice of bed-hold was provided to the resident and/or their representative at the time of transfer as required. Resident 2Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including metabolic encephalopathy (a change in how your brain works due to an underlying condition), kidney disease, and generalized muscle weakness. The 06/17/2026 comprehensive assessment showed Resident 2 required partial assistance/was dependent on one to two staff members for ADLs. The assessment also showed Resident 2 had a severely impaired cognition. Record review of a facility transfer form dated 07/26/2026, showed Resident 2 had an unplanned transfer to the hospital for uncontrollable pain. Record review of the medical record showed there was no documentation that the required notice of bed-hold was provided to the resident and/or their representative at the time of transfer. During an interview on 07/30/2026 at 12:14 PM, Resident 2's Representative stated they were present at the facility when Resident 2 was transferred to the hospital on [DATE]. They stated that they did not receive a notice of bed-hold at that time. Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including respiratory failure, diabetes (a condition where blood sugar levels are too high), and heart failure. The 07/14/2026 comprehensive assessment showed Resident 3 was dependent on one to two staff members for ADLs. The 07/20/2026 cognitive assessment showed Resident 3 had an intact cognition. Record review of a facility transfer form dated 07/14/2026, showed Resident 3 had an unplanned transfer to the hospital for evaluation related to fever, altered mental status, and pain. Record review of the medical record showed there was no documentation that the required notice of bed-hold was provided to the resident and/or their representative at the time of transfer. During an interview on 07/30/2026 at 1:36 PM, Resident 3's representative stated they did not receive a notice of bed-hold when Resident 3 went to the hospital on [DATE]. During an interview on 07/30/2026 at 2:59 PM, Staff A, Director of Nursing, stated the nurses were responsible for ensuring the notice of bed-hold was provided to the resident and/or their representative upon transfer, or within 24 hours if an emergent transfer. They stated they were unable to locate the notice of bed-hold for Resident 1, Resident 2, or Resident 3. Staff A stated the process for providing notice of bed-hold was not followed. This is a recurring deficiency previously cited in the Statement of Deficiencies dated 07/23/2025. Reference: WAC 388-97-0120(4)

Based on interviews and record review the facility failed to provide notification to the residents' representative of a significant change in condition for 1 of 3 residents (Resident 1) reviewed for notification of changes. This failure placed the residents at risk of not having their representative involved in health care decision making for timely care and services.Findings included. Review of a policy titled, Changes in Resident's Condition or Status, reviewed 08/29/2025, showed the facility would notify the resident, their primary care provider, and their resident representative of changes in the resident's condition or status. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including healing of a broken leg, anxiety (a group of mental health conditions that cause excessive, ongoing fear and worry that are hard to control and interfere with daily life), and vision loss in both eyes. The 07/23/2026 comprehensive assessment showed Resident 1 was dependent on one to two staff members for activities of daily living (activities related to personal care). The assessment also showed Resident 1 had a moderately impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Record review of a nursing progress note (PN) dated 07/28/2026 at 9:32 AM, showed Resident 1 was sent to the hospital for evaluation. A follow up PN at 11:24 AM showed a nursing assistant had reported to Staff B, Registered Nurse, that Resident 1 was not responding to verbal stimuli (the use of words or sounds to trigger a response). Resident 1 was transferred to the hospital for further evaluation. The provider and Staff A, Director of Nursing, were notified. The PN showed Resident own responsible party. There was no documentation that Resident 1's Representative (emergency contact) was notified. During an interview on 07/30/2026 at 10:24 AM, Resident 1's Representative (RR) stated they were the emergency contact for Resident 1. They stated they were not notified of Resident 1's episode of unresponsiveness and subsequent transfer to the hospital. They stated they had received a voicemail (a digital voice message left by a caller) from the hospital at 1:30 PM on 07/28/2026, but no details were left. The RR stated they received a second call from the hospital at 8:00 PM that night and were informed at that time that Resident 1 had been hospitalized . During an interview on 07/30/2026 at 1:28 PM, Staff B stated Resident 1 was sent to the hospital because they were not responding to verbal stimuli. They stated the process for transfers included completing the paperwork transfer packet that included their medication administration record, POLST [(Physicians Orders for Life Sustaining Treatment) a binding medical order for a resident's end-of-life care wishes), and the notice of bed hold (an agreement that save a specific room or bed for a resident when they are temporarily away from a care facility). They stated they notify Staff A, the residents' provider, and the residents' Power of Attorney (a legal document that gives someone else the authority to act on your behalf). Staff B stated the resident was their own responsible party and they did not call their emergency contact to inform them of the residents' change in condition and transfer to the hospital. During an interview on 07/30/2026 at 2:59 PM, Staff A stated Staff B should have notified Resident 1's Representative. They stated Staff B did not follow the process for notification of change or transfers. This is a recurring deficiency previously cited in the Statement of Deficiencies dated 05/06/2026. Reference: WAC 388-97-0320(1)(b)(d)

Based on interview and record review, the facility failed to ensure timely notification of changes in a resident's condition for 1 of 5 residents (Resident 1) reviewed for falls. Specifically, a nursing assistant failed to promptly report a resident's fall, resulting in delayed assessment, monitoring, intervention, and required notifications. This failure placed the residents at risk for undetected or worsening injuries, delayed medical intervention, and serious complications.Findings included. Review of a policy titled, Change in Status, Identifying and Communicating, Long Term Care, revised 09/15/2026, showed every health care team member is responsible for communicating a resident's change in status from baseline. However, the nursing assistant is typically the first to notice a change in a resident's status because the nursing assistant usually spends more time with the resident than other health care team members.a nursing assistant who notices such status changes should immediately report them to a nurse.vague, subjective communication may lead to misdiagnosis and delayed treatment. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including chronic kidney disease (long term, irreversible loss of kidney function), lower back pain, and an irregular heartbeat. The 04/21/2026 comprehensive assessment showed Resident 1 was independent with activities of daily living (activities related to personal care). The assessment also showed the resident had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Review of a facility investigation dated 05/06/2026, prepared by Staff C, Registered Nurse, showed Resident 1 had an unwitnessed fall as they had self-transferred from their bed to their wheelchair and slipped on the floor on 05/01/2026 at 12:00. The investigation showed the resident stated they slipped and fell, were ok and had gotten up by themselves. Resident 1 complained of hip pain rated at 10/10 on the pain scale (a tool used by healthcare providers to quantify a patient's subjective pain intensity with zero indicating no pain and 10 indicating the worst imaginable pain). They had mild confusion. The provider was notified and an order was obtained for an x-ray. Record review of a witness statement dated 05/01/2026, written by Staff D, Nursing Assistant, showed Resident 1 was getting into their wheelchair and slipped down. They documented the resident got up by themselves. Review of a nursing progress note dated 05/01/2026 at 3:01 PM, Staff C documented that the resident was self-transferring and slipped to the floor, despite their investigation initiated at 12:00 PM that same day. Record review of an emergency medical service provider report dated 05/01/2026, showed they were notified of a need for transport to the emergency room at 3:35 PM. The report showed the facility staff reported they were assisting the resident from the wheelchair to the bed when they fell to the ground and had a change in mental status. Facility staff stated there was no trauma during the fall. Record review of hospital records dated 05/01/2026 at 5:58 PM, showed Resident 1 was admitted to the hospital with diagnoses of a right femur fracture (a serious break or crack in the right thighbone, typically resulting from high-impact trauma like car crashes or falls) and acute metabolic encephalopathy (a change in how your brain works due to an underlying condition) possible from pain and fall. During an interview on 05/06/2026 at 10:16 AM, Resident 1's Representative (RR) stated they had arrived at the facility on 05/01/2026 between 11:30 AM and 12:00 PM. They stated Resident 1 had told them they had fallen earlier that morning. The RR had helped Resident 1 to the restroom because they were unable to bear weight on their right leg, which was unusual for the resident. They stated they were ready to leave the facility and needed help getting Resident 1 back into bed. The RR stated they approached Staff E, Licensed Practical Nurse/Unit Care Coordinator, and told them Resident 1 stated they fell that morning. Staff E stated they were not aware of a fall and asked Staff D (who was caring for Resident 1 that day) if Resident 1 fell that morning. The RR stated Staff D told Staff E that the resident had fallen, got back up, and told Staff D not to tell anyone they fell. During an interview on 05/06/2026 at 10:49 AM, Staff D stated they had seen Resident 1 on the floor last week. They stated they were in Resident 1's room making their bed. Staff D stated they had turned around and saw that Resident 1 had slipped and got themselves back up. They stated Resident 1 was good and had gotten back into their wheelchair. Staff D stated the incident occurred around 1:40 PM. Staff D stated they had many things going on that day and forgot to report the incident to the nurse. They stated, I should have reported it. During an interview on 05/06/2026 at 12:27 PM, Staff E stated the RR approached them around 2:30 PM on 05/01/2026 and asked if Resident 1 fell. They stated they were not aware of a fall and would check into it. Staff E stated they asked Staff C if they were aware of the fall and were told no. They stated both Staff E and Staff C approached Staff D and questioned them about Resident 1 falling. Staff D told them the resident fell around lunchtime and had gotten themselves up. Staff D stated they helped Resident 1 back into their wheelchair. Staff D also stated that Resident 1 told them not to tell a nurse that they fell. Staff E stated Staff D knew Resident 1 had fallen and had not reported it to any licensed nurse. They stated Resident 1 went without assessments from the time of the fall at approximately 11:30 AM to 12:00 PM until three hours later when they were notified of the fall. Staff E stated Staff D should have immediately called for assistance when Resident 1 fell so assessment could have been completed and treatment could have been initiated. During an interview on 05/06/2026 at 3:36 PM, Staff B, Director of Nursing, stated when a resident had a fall, the process would be to call for assistance over the radio. A licensed nurse would immediately complete an assessment to determine if they were safe to help them up, notify the provider, and send them to the emergency department if necessary. They stated the staff did not entirely follow the process and improvements should be made. During an interview on 05/06/2026 at 3:49 PM, Staff A, Administrator, stated the process should have been for Staff D to report the fall to the nurses. They stated the process was not followed. Reference: WAC 388-97-0320(1)(a)

Based on interview and record review, the facility failed to ensure nursing assistants were verified on the state Nurse Aide Registry prior to start of employment for 1 of 3 staff (Staff D) reviewed for staff qualification and background review. This failure placed the residents at risk for poor care, injury, and negative outcomes.Findings included. Review of a policy titled, Abuse - Screening of Employees and Residents, reviewed 04/01/2026, showed the facility may not employ individuals that had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment, or have had a finding entered into the State nurse aide registry concerning abuse, neglect, exploitation, mistreatment of residents, or misappropriation of property, or have a disciplinary action in effect against their professional license by a state licensure body. Record review of a personnel file for Staff D, Nursing Assistant (NA), showed they were hired on 03/26/2026. There was no documentation that they were on the Omnibus Budget Reconciliation Act registry [(OBRA) a state-operated database that tracks the credentials, training, and competency evaluations of certified nursing assistants to ensure they meet federal requirements] as required. During an interview on 05/06/2026 at 2:46 PM, Staff H, Staffing Coordinator, stated there was no record of Staff D on the state registry. They stated there had been some switching of positions at the facility and it got missed. During an interview on 05/06/2026 at 3:36 PM, Staff B, Director of Nursing, stated OBRA registry verification was completed prior to moving forward in the hiring process. They stated the verification should have been completed prior to starting orientation and were unsure of how the failure occurred. Staff B stated there should be a process in place to verify the nursing assistance OBRA status before starting work. Reference: WAC 388-97-1660(3)(c)

Based on interview and record review, the facility failed to complete a baseline care plan [(BCP) an initial, temporary plan of care, developed within 48 hours of admission to ensure immediate safety and continuity of care] that included the essential needs, physician orders, social services, and Preadmission Screening and Resident Review [(PASARR) - a federal requirement to help ensure that individuals were not inappropriately placed in nursing homes] recommendations for 3 of 3 residents (Resident 1, 2, and 3) reviewed for baseline care plan. This failure placed the residents at risk for immediate health and safety concerns.Findings included. Review of a policy titled, Baseline Care Plan, reviewed 08/29/2025, showed the facility must develop and implement a BCP for each resident that included instructions needed to provide effective, person-centered care that met professional standards of quality care. The BCP must be developed within 48 hours of admission and include the minimum healthcare information necessary to properly care for a resident, including initial goals based on admission orders, physician and dietary orders, therapy services, social services, and PASARR recommendations. Resident 1Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (a serious condition where body tissues don't get enough oxygen), hypoparathyroidism (a condition where the parathyroid glands do not make enough parathyroid hormone, resulting in too little calcium in the blood), anxiety, and insomnia (a sleep disorder that causes difficulty falling and staying asleep). The 01/05/2026 comprehensive assessment showed Resident 1 required set-up to partial assistance of one staff member for activities of daily living (ADLs) and supervision/touch assistance of one staff member for transfers. The assessment also showed the resident had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Record review of Resident 1's BCP dated 01/02/2026, provided by Staff B, Director of Nursing, showed no focus area, goals, or interventions related to Resident 1's use of quetiapine (an antipsychotic medication that works by altering brain chemicals to stabilize mood and thought processes), their use of acetazolamide (a medication used to decrease swelling caused by heart disease) for edema (swelling), Synthroid (a brand name medication used to treat low thyroid conditions), use of temazepam (a medication used short term to treat insomnia), use of hydroxyzine (a medication used to treat anxiety) or use of continuous oxygen. There were no focus areas, goals, or interventions related to Resident 1's preferences regarding medical treatments in emergent situations. The focus area for PASARR showed no information regarding Resident 1's Level II PASARR recommendations (a detailed assessments for individuals that have a potentially serious mental illness that determines if they need specialized services). Record review of Resident 1's Skilled Nursing Facility Transfer Orders, dated 01/02/2026, showed a medication order for levothyroxine 100 microgram (a unit of measure) tablet, take one tablet by mouth every morning (before breakfast) MUST BE BRAND NAME SYNTHROID. Resident 2Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses including care following hip replacement surgery, long term use of anticoagulants (a medication used to slow down the blood clotting process), anxiety, and depression. The 01/05/2026 comprehensive assessment showed Resident 2 required substantial assistance of one staff member for showers, lower body dressing, and transfers. The assessment also showed Resident 2 had a moderately impaired cognition. Record review of Resident 2's BCP dated 01/02/2026, provided by Staff B, showed no focus area, goals, or interventions related to Resident 2's anxiety disorder, PASARR or PASARR Level II recommendations. There were no focus areas, goals, or interventions related to Resident 2's preferences regarding medical treatments in emergent situations. Resident 3Review of the medical record showed Resident 3 was admitted to the facility on [DATE] with diagnoses including broken hip, post-traumatic stress disorder [PTSD) a mental health condition that develops after experiencing or witnessing a traumatic event], and anxiety. The 12/29/2025 comprehensive assessment showed Resident 3 required substantial/maximal assistance of one to two staff members for ADLs. The assessment also showed Resident 3 had an intact cognition. Record review of Resident 3's BCP dated 12/29/2025, provided by Staff B, showed no focus area, goals, or interventions related to Resident 3's PTSD diagnoses, or PASARR Level II recommendations. During an interview on 01/15/2026 at 11:27 AM, Staff C, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), stated the process for completing a BCP included opening the BCP User-Defined Assessment [UDA) a template tool in the electronic medical record] and completing the assessment. They stated it was important to complete the BCP to have established goals and interventions for the staff to follow and care for the resident. Staff C stated the residents code status (preferences for medical treatment in emergent situations) did not automatically populate on the BCP UDA, and they had to manually enter it. They stated the BCP should be completed the first day a resident was admitted . Staff C stated the need for Resident 1 to have a brand name medication should have been on the BCP. During an interview on 01/15/2026 at 11:21 AM, Staff D, Social Services Director, stated they were responsible for completing the PASARR and social services area of the BCP. They stated it should include PASARR information, the residents' cognitive status, and discharge planning. Staff D stated PASARR information included the information related to the Level II PASARR, the date it had been sent out for review and any recommendations if it was received. Staff D stated for Resident 1, the Level II PASARR had been sent out by the hospital staff and that date should have been on the BCP. Staff D stated a Level II evaluation was required for Resident's 1, 2, and 3 and that information should have been on the BCP. During an interview on 01/15/2026 at 12:18 PM, Staff B stated the process for completing a BCP included filling out the BCP UDA when the resident arrives to the facility. They stated the purpose of the BCP was to establish the care and services a resident needed when they were admitted to the facility and communicate those needs to the staff. Staff B stated the resident's code status should have been on the BCP. During an interview on 01/15/2026 at 1:18 PM, Staff A, Administrator, stated the facility needed to follow the regulatory requirement to have a complete BCP for all new admits within a short amount of time after admission that included at least the basics for necessary care and services.Reference: WAC 388-97-1020(3)

Based on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed when nursing staff failed to accurately transcribe and follow physician orders for 1 of 3 residents (Resident 1) reviewed for medication administration. This failure placed the residents at risk for a delay in receiving medications, medication errors, and adverse outcomes. Findings included. Review of the Lippincott Manual of Nursing Practice, 11th edition, copyright 2019, Chapter 2, showed professional nursing had standards of practice that set minimum levels of acceptable performance for which practitioners were accountable. Departure of standards of care included failure to implement a provider's order properly or in a timely fashion, failure to make prompt, accurate entries in a medical record, and failure to adhere to facility policy or procedural guidelines. Review of a policy titled, Medication Reconciliation Across the Continuum of Care, revised 09/09/2025, showed upon admission or readmission to the facility, the licensed nurse would reconcile the resident's medications. The home medication list would be completed in the electronic medical record with input from the resident/representative, even if the resident was admitted from a hospital or other setting. The home medication list, the physician admitting order, and the hospital admitting form received by the licensed nurse would be reconciled, phone the provider as needed for clarification, obtain the provider orders, and update the electronic medical record. The licensed nurse would complete a medication reconciliation from in the electronic medical record. Resident 1Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (a serious condition where body tissues don't get enough oxygen), hypoparathyroidism (a condition where the parathyroid glands do not make enough parathyroid hormone, resulting in too little calcium in the blood), anxiety, and insomnia (a sleep disorder that causes difficulty falling and staying asleep). The 01/05/2026 comprehensive assessment showed Resident 1 required set-up to partial assistance of one staff member for activities of daily living (ADLs) and supervision/touch assistance of one staff member for transfers. The assessment also showed the resident had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Record review of the Skilled Nursing Facility Transfer Orders dated 01/02/2026, showed a provider order for levothyroxine (a synthetic thyroid hormone used to replace missing thyroid hormone in the body) 100 mcg (microgram - a unit of measure) tablet, take one tablet by mouth every morning (before breakfast) MUST BE BRAND NAME SYNTHROID. A second provider order showed oxycodone-acetaminophen (a powerful narcotic prescription pain medication that is used to treat moderate to severe pain) 10-325 mg (milligram - a unit of measure), take one table by mouth every four hours as needed (pain). A concurrent observation and interview on 01/08/2026 at 10:57 AM, showed Resident 1 lying in bed on their left side with their bedside table next to them. The drawers to the bedside were open; the top drawer held a clear bag that contained a prescription bottle and an inhaler (a small, handheld medical device that delivers medication directly into the lungs). There were three additional unopened boxes of prescription inhalers in the drawer. The prescription bottle was labeled Synthroid (a brand name synthetic thyroid hormone) 100 mcg. Resident 1 stated they kept their own home Synthroid medication in their drawer because the generic (levothyroxine) did not work for them. They stated they had informed the nursing staff multiple times that they needed the brand name, but they did not listen. Resident 1 stated when the staff brought the levothyroxine in to administer it, they would either throw it on the floor or in the trash can, and they would administer their own Synthroid. Resident 1 stated the nursing staff would leave the medication in the room and did not watch them take their medications. Resident 1 stated the first day and throughout their first night at the facility, they had requested their oxycodone for pain. They stated they were told the facility did not have the medication and it would be a lengthy process to get it. Resident 1 stated they did not receive any oxycodone until the next day. During an interview on 01/08/2026 at 3:20 PM, Staff E, Licensed Practical Nurse (LPN), stated Resident 1 had requested their pain medication the morning of 01/03/2026. They stated the facility did not have the oxycodone available to administer. Staff E stated the pharmacy had not sent the medication and they needed to wait for the provider to send a prescription to the pharmacy. Staff E stated they were not able to obtain the medication from the pyxis (a locked, automated medication dispensing system that requires an authorization code to open) because they did not have an authorization code. Staff E stated they did not call the on-call provider (available 24 hours a day, seven days a week) because they were already contacted. During an interview on 01/15/2026 at 9:22 AM, Staff F, Registered Nurse, stated on 01/02/2026, they had received report from the licensed nurse that worked that evening that Resident 1's medications were not available. They stated Resident 1 had an order for oxycodone, and it was available in the pyxis, but they could not get an authorization code from pharmacy to open the pyxis. They stated unless the resident was admitted with a hard copy of the prescription or the pharmacy spoke to the provider directly, they would not be able to get the medication. Staff F stated, when in that situation, the process would have been to call the provider and have them contact the pharmacy in order to provide the medication. Staff F stated they did not call the on-call provider because calls had already been made to the on-call provider. Staff F stated Resident 1's order for thyroid medication showed levothyroxine and that was what was in the medication card. They stated Resident 1 had told them they took Synthroid. Staff F stated they saw Resident 1's bottle of Synthroid in their drawer and told the resident they could not take it from them and to have a loved one take it home for them. Staff F stated they informed Resident 1 they would need to speak to their provider about changing the order from levothyroxine to Synthroid. During an interview on 01/15/2026 at 11:39 AM, Staff C, LPN/Unit Care Coordinator, stated they usually reviewed the list of home medications with the resident and made necessary changes on the day of admission. They stated they verbally reviewed home medications with Resident 1 on 01/02/2026 and they had no concerns and there were no changes needed. They stated Resident 1 did not mention the levothyroxine order. Staff C stated when there was a specific medication, such as the use of the brand name medication, they would receive an alert from the pharmacy. They stated they did not recall receiving any alerts for Resident 1. Staff C stated the process for transcribing provider orders included one licensed nurse entering the orders into the electronic medical record, and a second licensed reviewing them for accuracy. Staff C stated they entered the initial orders and had not seen the additional note on the levothyroxine order that stated to use brand name Synthroid only. Staff C stated the process for obtaining the oxycodone for Resident 1 would have included calling the on-call provider if the medication was not available, obtain a verbal order, and obtain an authorization code from the pharmacy to pull the medication from the pyxis. Staff C stated they were unsure why the process had not been followed. During an interview on 01/15/2026 at 12:35 PM, Staff B, Director of Nursing Services, stated the process for obtaining the oxycodone would have been for the licensed nurse to contact the provider on-call to eScribe (a system that allows a provide to electronically transmit prescription requests to the pharmacy) a prescription to the pharmacy, which would allow the licensed nurse to obtain an authorization code for the pyxis to administer the medication. Staff B stated the licensed nurses should have followed that process. They stated medications were only kept at the bedside once an assessment was completed, a physician order was obtained, and the care plan was updated. They stated once it was determined a resident was able to self-administer medications, they would be provided with a lock box with a key to ensure the medications were properly stored. Staff B stated the process and importance of reviewing home medications with the resident was to ensure accuracy. During an interview on 01/15/2026 at 1:18 PM, Staff A, Administrator, stated the facility needed to follow the regulatory requirements for medication reconciliation and administration. Reference: WAC 388-97-1620(1)(2)(i)(ii)(6)(i)(ii)

Based on interview and record review, the facility failed to ensure physician ordered physical therapy (PT) was received in a timely manner for 2 of 3 residents (Residents 1 and 2) reviewed for specialized rehabilitation services. This failure placed the residents at risk for decline in function and/or not achieving the highest practicable level of physical, mental, and functional well-being. Findings included . Review of a policy titled, Specialized Rehabilitative Services, revised 09/04/2025, showed the facility would ensure that each resident received specialized rehabilitative services to assist them to attain, maintain, or restore their highest level of physical, mental, functional and psychosocial well-being. Resident 1Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including respiratory failure with hypoxia (a serious condition where body tissues don't get enough oxygen), metabolic encephalopathy (a change in how your brain works due to an underlying condition), and anxiety. The 01/05/2026 comprehensive assessment showed Resident 1 required set-up to partial assistance of one staff member for activities of daily living (ADLs) and supervision/touch assistance of one staff member for transfers. The assessment also showed the resident had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Record review of the Skilled Nursing Facility Transfer Orders dated 01/02/2026, showed an order for physical therapy (PT) and occupational therapy evaluation and treat. Record review of the medical record showed Resident 1 received their initial PT and OT evaluations and treatment plan on 01/06/2026, five days after their admission to the facility. During an interview on 01/08/2026 at 10:57 AM, Resident 1 stated they were not getting much therapy and would be better off at home doing their own therapy. Resident 2Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses including care following hip replacement surgery, long term use of anticoagulants (a medication used to slow down the blood clotting process), anxiety, and depression. The 01/05/2026 comprehensive assessment showed Resident 2 required substantial assistance of one staff member for showers, lower body dressing, and transfers. The assessment also showed Resident 2 had a moderately impaired cognition. Record review of the medical record showed Resident 2 received their initial PT evaluation and treatment plan on 01/05/2026, four days after their admission to the facility, and their initial OT evaluation and treatment plan on 01/06/2026. Resident 2 discharged home on [DATE] after receiving one 37-minute PT treatment on 01/06/2026, and one 30-minute OT treatment on 01/07/2026. During an interview on 01/08/2026 at 11:56 AM, Resident 2 stated they were admitted to the facility after having their hip replaced. They stated they received their first physical therapy session on Monday (01/05/2026) and that had put them back a few days. Resident 2 stated they wished they had physical therapy starting on Friday (day of admission). They stated the facility staff told them Staff E, Director of Rehabilitation, was not there on Friday and they could not have therapy that day. During an interview on 01/15/2026 at 10:49 AM, Staff E stated the facility was short PT staff. They stated their full-time PT staff work Monday through Thursday and if a resident were admitted on a Friday, they would have to wait until Monday for their therapy evaluations. Staff E stated the professional standard for therapy evaluations was to complete them within 3 days of admission. During an interview on 01/15/2026 at 1:06 PM, Staff A, Administrator, stated their expectation was to complete therapy evaluations in a timely manner, within the capacity of the facility to provide them. Staff A stated their understanding was to have therapy evaluations completed within the first three days of admission. They stated they were aggressively trying to obtain additional therapy staff to ensure the residents were receiving their therapy evaluations within the regulatory requirement. Reference WAC: 388-97-1280(1)(a)(b)(2)

Based on interview and record review, the facility failed to report an incident involving a missing resident to the administrator, local law enforcement, and the State Agency (SA) for 1 of 2 residents (Resident 1) reviewed for missing residents. This failure disallowed the administrator to conduct a thorough investigation, local law enforcement to assist in the search for Resident 1, and lack of oversight from the SA.Findings included. A review of the Nursing Home Guidelines or The Purple Book, dated October 2015, showed that facilities were required to report a missing resident to Law Enforcement and the State Agency Hotline. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including aftercare for hip replacement surgery, bipolar disorder (a lifelong mental health condition causing extreme mood swings, from manic highs [euphoria, high energy, impulsivity] to depressive lows [sadness, fatigue, hopelessness], significantly affecting energy, mood, and daily functioning), and anxiety. The 11/01/2025 comprehensive assessment showed Resident 1 required partial/moderate assistance of one staff member for transfers, bed mobility, lower extremity dressing, and toileting hygiene. The assessment also showed Resident 1 had a moderately impaired cognition. Review of a nursing progress note (PN) dated 11/03/2025 at 5:09 PM, showed Resident 1 left the facility at 9:30 AM with a friend to pay their rent and would return in a couple hours. The PN showed Resident 1 had not yet returned to the facility. There was no documentation that the Administrator or law enforcement had been notified. Review of a NP note dated 11/04/2025 at 3:00 AM, showed Resident 1 had still not returned to the facility. There was no documentation that the Administrator or law enforcement had been notified. During an interview on 12/03/2025 at 2:20 PM, Staff B, Director of Nursing, stated at the time, they had not considered Resident 1 as missing. During an interview on 12/03/2025 at 3:06 PM, Staff A, Administrator, stated they were unaware that Resident 1 was missing. They stated the facility would have followed the process for reporting and investigation if they had known. Refer to F689 for further information. Reference: WAC 388-97-1620(7)(b)

Based on interview and record review, the facility failed to develop and implement an effective discharge plan that included education for care and maintenance of an indwelling urinary catheter ([IUC] a flexible tube inserted into the bladder to drain the urine) and ensuring home health services were provided for 1 of 3 residents (Resident 3) reviewed for discharge planning. This failure placed the resident at risk of serious injury, rehospitalization, and lack of necessary care and services after discharge.Findings included. Review of the policy titled, Discharge Planning Process, reviewed 08/29/2025, showed the process included caregiver support and referrals to local contact agencies. The process focused on the residents' discharge goals and preparation for the residents to effectively transition them to post-discharge care. Document any referrals to local agencies/appropriate entities based on the residents' choices. Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood), heart failure, and urinary retention (inability to fully empty the bladder). The 10/21/2025 comprehensive assessment showed Resident 3 required moderate/maximum assistance of one staff member for activities of daily living. The assessment showed Resident 3 had an IUC and a moderately impaired cognition. Record review of physician discharge orders dated 10/20/2025, showed Resident 3 required PT (physical therapy) and OT (occupational therapy) eval(uation) and treat for physical debility. Skilled nursing for medication management and post discharge assessment. Record review of a Discharge summary dated [DATE], showed Resident 3 was discharging to home with an IUC in place and would be set up with home health services. There was no documentation that Resident 3 or the Resident Representative (RR) had received education regarding necessary care and maintenance of the IUC. During an interview on 12/02/2025 at 3:42 PM, the RR stated they were the caregiver for Resident 3 after they discharged from the facility on 10/21/2025. They stated they were not provided with any education on the care of the IUC and were not familiar with how to maintain it. They stated they did not receive home health services and Resident 3 had to return to the hospital due to a decline in their health. During an interview on 12/03/2025 at 1:30 PM, Staff G, Licensed Practical Nurse/Unit Care Coordinator, stated the process for discharging a resident included providing education for individualized specialty needs such as diabetic care. Staff G stated they did not recall providing any education/training to Resident 3 or the RR regarding care of the IUC. During an interview on 12/03/2025 at 11:59 AM, Collateral Contact (CC), Home Health Representative, stated they were unable to locate a referral for Resident 3. They stated their process for documentation of referrals included keeping the originals on file. They stated if they did not accept the referral, there would be documentation/notes in their system reflecting that. The CC stated they had nothing on file for Resident 3. During an interview on 12/03/2025 at 2:30 PM, Staff H, Social Services Director, stated they were responsible for sending the referral for home health services. The process included sending the referral by fax or email and receiving confirmation of receipt. Staff H stated they had no documentation that the referral had been completed. During an interview on 12/03/2025 at 2:03 PM, Staff B, Director of Nursing, stated anytime there was a resident discharging with equipment needs, diabetes, oxygen use, etcetera, education should be completed on discharge with return demonstration by the resident and/or their representative. Staff should have reviewed IUC care and emptying of the bag with Resident 3 and their RR. Staff B stated they were unable to locate any documentation that the education/training had been completed. During an interview on 12/03/2025 at 3:06 PM, Staff A, Administrator, stated Social Services was responsible for completing the home health referrals upon discharge. Staff A stated they needed to look into why the referral was not completed. Reference: WAC 388-97-0120(3)(a)

Based on interview and record review, the facility failed to provide adequate supervision and notification to administrative staff and local law enforcement for 1 of 3 residents (Resident 1) reviewed for elopement. This failed practice placed the residents at risk for serious injury and/or exposure to the elements.Findings included. Review of a policy titled, Missing Residents/Actual Elopement Event, reviewed 04/03/2024, showed elopement occurred when a resident left the facility without authorization (an order for discharge or leave of absence) and/or necessary supervision. A resident with decision making capability's, who chose to leave the facility intentionally would not be considered an elopement unless the facility is unaware of the resident's departure and/or whereabouts. If staff were unable to account for the whereabouts of a resident during the course of the day, the sign out log should be reviewed to determine if the resident/representative had signed out of the facility. The Executive Director or representative and department heads would be notified that the resident cannot be located. A search of the facility and facility grounds would be conducted, and law enforcement would be notified. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including aftercare for hip replacement surgery, bipolar disorder (a lifelong mental health condition causing extreme mood swings, from manic highs [euphoria, high energy, impulsivity] to depressive lows [sadness, fatigue, hopelessness], significantly affecting energy, mood, and daily functioning), and anxiety. The 11/01/2025 comprehensive assessment showed Resident 1 required partial/moderate assistance of one staff member for transfers, bed mobility, lower extremity dressing, and toileting hygiene. The assessment also showed Resident 1 had a moderately impaired cognition. Review of the facility's Resident Sign In/Out Log showed Resident 1 had signed out of the facility on 11/03/2025 at 9:00 AM to pay rent. There was no documented time in, showing when Resident 1 returned to the facility. Review of Staff D's, Registered Nurse, nursing progress (NP) note dated 11/03/2025 at 5:09 PM, showed Resident 1 stated they would be going home and would not be coming back. The PN showed after receiving education, Resident 1 agreed to wait for a provider and therapy to clear them for discharge. Resident 1 stated a friend was going to pick them up, they were going to go pay their rent and would be back in a couple hours. Resident 1 left at 9:30 AM and had not returned to the facility. Review of Staff E's, Licensed Practical Nurse (LPN), NP note dated 11/04/2025 at 3:00 AM, showed Resident 1 was out of facility. Review of a NP note dated 11/04/2025 at 8:10 AM, showed Staff C, LPN/Unit Care Coordinator, received a call at the nurse's station from Resident 1, who stated they were at home. Resident 1 reported they had signed out of the facility the previous day to visit home with a friend but currently had no transportation back to the facility. Resident 1 further stated they were unable to ambulate or transfer from the bed to the wheelchair independently. Staff C contacted 911 to arrange transportation to the emergency room for further evaluation due to a decline in Resident 1's activities of daily living functioning. During an interview on 12/03/2025 at 11:03 AM, Staff D stated on 11/03/2025, Resident 1 told them they were going to the bank to pay their rent. Staff D stated Resident 1 had not returned by 5:30 PM. They stated they did not try to call Resident 1 to see where they were. Staff D stated they told the night shift nurse that Resident 1had not returned from their outing. During an interview on 12/03/2025 at 12:46 PM, Staff E stated Resident 1 had left the facility prior to the start of their shift. They stated they were waiting for Resident 1 to return. Staff E stated they did not try to call Resident 1. They stated they did not know if anyone knew where Resident 1 was. During an interview on 12/03/2025 at 1:17 PM, Staff C stated they had received a call from Resident 1. They stated Resident 1 was at their apartment and unable to move from the bed to their wheelchair. Staff C stated they had called 911 to enter Resident 1's apartment and transport them to the emergency room for an evaluation because they were unable to transfer themselves and that was a change in condition from the previous day. Staff C stated the process for residents leaving the facility included making sure the resident was alert and orientated, checking with therapy to ensure they were safe with transport, and signing out of the facility with an expected return time. If the resident did not return at their expected time, the facility would follow up with a phone call to see where they were. They stated if they were unable to reach the resident, the facility would initiate their missing person's protocol and contact the resident's emergency contact. Staff C stated Resident 1 was not safe at home alone. During an interview on 12/03/2025 at 1:56 PM, Staff B, Director of Nursing, stated the process for a resident that had left the facility and not returned would include calling them by the end of the business day to locate them. They stated they assumed Resident 1 had left against medical advice. Staff B stated they would have expected the nursing staff to call Resident 1 as they were clearly not safe at home by themselves. Staff B stated if they had called Resident 1 and did not get an answer, the facility should have called law enforcement to do a wellness check to ensure the resident was safe. During an interview on 12/03/2025 at 3:06 PM, Staff A, Administrator, stated if a resident did not return from an outing in a reasonable time, the process would be to reach out to the resident. If staff were unable to reach the resident, the missing person's policy would be initiated, and the staff would notify them (the Administrator). Staff A stated they were not notified that Resident 1 had not returned to the facility until the following day. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure residents who had an indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag) received care and services to prevent urinary tract infections (UTI, a condition were bacteria enter through the urinary meatus [a passage or opening leading to the interior of the body] and infect the kidneys or bladder) for 1 of 2 residents (Resident 2), reviewed for urinary catheter care. This failure placed the residents at risk of developing serious medical complications, secondary to an infection in the bladder.Findings included. Review of a Centers for Disease Control and Prevention document titled, Indwelling Urinary Catheter Culture Stewardship: Overview, dated 03/14/2024, showed if the IUC had been in place for longer than 14 days, the IUC should be replaced prior to specimen collection. Further review showed never collect a urine culture from the collection bag. Review of a policy titled, Indwelling Urinary Catheter (Foley [a type of IUC]) Management, reviewed 09/04/2025, showed IUC and drainage bags should be changed based on clinical indications such as infection, obstruction, or when the closed system was compromised. Resident 2Review of the medical record showed Resident 2 was admitted to the facility on [DATE], with diagnoses including chronic kidney disease (moderate to severe kidney damage), neuromuscular dysfunction of the bladder (caused when an injury or disease interrupts the electrical signals between the nervous system and bladder function), and retention of urine. The 11/18/2025 comprehensive assessment showed Resident 2 required maximum assistance of one staff member for toileting/personal hygiene and bed mobility and was dependent on one to two staff members for transferring. The assessment also showed Resident 2 had no memory issues and was able to make independent decisions regarding their daily life. Record review of a nursing progress note (PN) dated 09/02/2025, showed Resident 2 had an IUC in place upon admission. Record review of a nursing PN dated 09/16/2025, showed Resident 2 was not feeling well, with episodes of confusion. The resident's provider was notified on 09/16/2025, and a new order was received to obtain a urine specimen, with culture and sensitivity (a medical test that identifies germs and effective treatments). The record showed the specimen was collected on 09/16/2025 and the resident was started on antibiotics on 09/19/2025. Record review of a nursing PN dated 09/25/2025, showed Resident 2 had continued altered mental status and a recent UTI. The resident had completed antibiotic therapy for their previous UTI on 09/24/2025 but was still symptomatic. Orders were received for a urinalysis with culture and sensitivity. The record showed the specimen was collected and the resident was started on antibiotics. Record review of the September 2025 Medication Administration Record (MAR) showed an order to change the IUC for infection, obstruction, or when the closed system was compromised. A second order showed change catheter bag as needed for infection, obstruction, or when the closed system is compromised. There was no documentation that the IUC or catheter bag was changed. Record review of a nursing PN dated 10/21/2025, showed Resident 2 was symptomatic for a UTI and a verbal order was received from the provider to collect urine for urinalysis and culture if indicated. The urine was collected, and antibiotics were initiated for Resident 2. Record review of the October 2025 MAR showed no documentation that the IUC or catheter bag had been changed. During an interview on 12/03/2025 at 1:45 PM, Staff F, Registered Nurse/Unit Care Coordinator, stated the frequency for changing IUCs included changing them as needed and with signs/symptoms of a UTI. Staff F stated there was no documentation in the medical record that the IUC was changed at the time of the UTIs. During an interview on 12/03/2025 at 2:09 PM, Staff B, Director of Nursing, stated the process for changing IUCs included changing them when the resident was started on an antibiotic. They stated the facility had a standing order for changing the IUC for obstruction and/or infection. Staff B stated the process was not followed. Reference: WAC 388-97-1060(3)(c)

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent elopement (a resident leaving the facility unsupervised and undetected) for 1 of 2 residents (Resident 1) reviewed for avoidable accidents. This failure placed the residents at risk for exposure to extreme weather temperatures, serious injury, and/or death. Findings included . Review of a policy titled, Incident and Reportable Event Management, revised 08/15/2023, showed an avoidable accident was an accident that occurred when the facility failed to implement interventions, including adequate supervision consistent with the resident's needs, goals, care plan, and current professional standards of practice to eliminate and/or reduce the risk of an accident. <Resident 1>Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including broken pelvic bones, Alzheimer's disease (a progressive brain disorder that gradually impairs memory, thinking, and the ability to carry out simple tasks), and difficulty walking with a history of falls. The 06/04/2025 comprehensive assessment showed Resident 1 required partial/moderate assistance of one staff member for transfers and walking and used a walker and/or wheelchair for mobility. The assessment also showed Resident 1 had a severely impaired cognition. An observation on 08/11/2025 at 2:30 PM showed Resident 1's room, the day of the elopement, was located across from the nurse's station, next to the exit door. The exit led to the parking lot of the facility with access to the neighboring parking lots and main road. Record review of a nursing evaluation titled, Elopement Risk Evaluation, dated 06/03/2025, showed Resident 1 had been identified as an elopement risk due to their cognitive impairment, ability to walk independently, and wandering behaviors. Record review of Resident 1's care plan dated 06/03/2025, revised on 07/14/2025, showed a focus area identifying Resident 1's risk for elopement and interventions that included adding their information to the elopement binder (a book located at the nurses stations that contained a photo and identifying information for resident's identified at risk for elopement), monitoring and documenting wandering behaviors, participation in activities to divert exit seeking behaviors, hourly safety checks, and providing structured activities such as toileting, walking inside/outside, and reorientation strategies that included signage, pictures, and memory boxes. Record review of a facility investigation dated 08/07/2025, showed on 08/02/2025 at 3:05 PM, Resident 1 was returned to the facility by Staff C, Activities Assistant. Resident 1 had been found walking on the sidewalk in the opposite direction of the facility, 0.8 miles away. The investigation showed a newly employed licensed nurse had opened the door for Resident 1 when they approached the door and stated, I'm just going out for my walk. Resident 1 had been let out of the facility at 2:15 PM and returned at 3:05 PM. The investigation showed the new employee was not aware that Resident 1 was an elopement risk. During an interview on 08/11/2025 at 2:15 PM, Staff D, Licensed Practical Nurse, stated they were new to the facility and had been working there for about two weeks. Staff D stated on their first day working with residents, Resident 1 had approached them at the exit door near the resident's room. They stated Resident 1 wanted to go outside for a walk. Staff D stated they put the code in to disarm the alarm and opened the door for Resident 1. They stated Resident 1 had no identification such as a wrist band that indicated they were a resident. Staff D stated they were unfamiliar with the residents since it was their first day working with them. Staff D stated they received elopement training during their orientation on the two days prior to Resident 1's elopement. Staff D stated, this was all on me, I let Resident 1 out, I didn't know my residents. During an interview on 08/12/2025 at 1:03 PM, Staff E, Registered Nurse, stated they were training Staff D the day Resident 1 eloped. They stated when Resident 1 was returned to the facility by a staff member and observed them being sweaty. Staff E stated Resident 1 had been identified as exit seeking and staff were aware of those behaviors. Staff E stated Staff D was a new employee and had stated they did not know Resident 1 was a resident and had let them out the door. Staff E was unaware that Resident 1 had left the facility until they had been returned by Staff C. During an interview on 08/11/2025 at 2:27 PM, Staff C stated they were driving home after leaving work at 3:00 PM on 08/02/2025 and saw Resident 1 walking on the sidewalk. They stated Resident 1 was hot, breathing heavy, and sweating. Staff C stated they opened their car door and Resident 1 got in and asked, are we going to Seattle? Staff C returned Resident 1 to the facility, took them to their room, and provided cool water. They stated they informed Staff E, Registered Nurse, who was unaware that Resident 1 had left the facility. During an interview on 08/12/2025 at 1:17 PM, Staff B, Director of Nursing, stated Resident 1 had been assessed and identified as an elopement risk on admission. There were care plan interventions in place to prevent elopement. They stated Staff D, who was a new employee, had seen Resident 1 at the exit door, checked on them, and was told they wanted to go for a walk. Staff D opened the door for Resident 1. Staff B stated the protocol would have been for Staff D to assess the situation, not enter the key code to disarm the door alarm, check the elopement binder and with their trainer before allowing any resident to exit the facility. During an interview on 08/12/2025 at 1:42 PM, Staff A, Administrator, stated all employees needed to be aware of who the elopement risks were, including the new hires. They stated they expected the new hires to shadow their trainer and were unsure why Staff D was not with their trainer at the time of the elopement. Staff A stated the prevention of elopements included improving staff education and awareness. Reference: WAC 388-97-1060(3)(g) This is a repeat deficiency from the Statement of Deficiencies dated 12/05/2024 and 03/12/2025.

Based on observation, interview, and record review the facility failed to 1) recognize a change in condition for 3 of 6 residents (Residents 39, 9 and 35) reviewed for quality of care, and 2) ensure residents received treatment and care in accordance with professional standards of practice and physician orders for 2 of 5 residents (Resident 8 and 71) reviewed for unnecessary medications. This failure placed residents at risk for a delay in treatment, unmet care needs, and negative health outcomes. Resident 39 experienced harm when the facility failed to recognize the immediacy of a change of condition and did not notify the physician with a resident who exhibited signs and symptoms of change in orientation, oxygen level, blood pressure and pulse which resulted in hospitalization. Resident 9 experienced harm when their nephrostomy tube (a flexible tube inserted through the skin into the kidney to drain urine externally when normal drainage is blocked) became obstructed, resulting in hospitalization intervention. Findings included . Review of a policy titled Changes in Resident's Condition or Status, dated 09/05/2024, showed the facility would notify the resident's Primary Care Provider and the resident or Resident's Representative (RR), the resident would be thoroughly assessed, and the facility would monitor the resident for changes. The policy showed the Licensed Nurses (LNs) would communicate with other team members for continuity of care and were to document their assessments and monitoring.<Resident 39> Review of the medical record showed Resident 39 initially admitted to the facility on [DATE] then readmitted to the facility from the hospital on [DATE] with diagnoses including a Urinary Tract Infection (UTI) with Septic Shock (life threatening infection which arises when the body responds to infection causes injury to the body), respiratory issues with use of continuous oxygen, and heart disease. Resident 39 previously sustained a fracture of the upper back and sternum (breastbone or flat T-shaped bone in the middle of the chest), and wore a hard plastic neck collar for stability. The 06/30/2025 comprehensive assessment showed the resident was alert and oriented and able to make their needs known and required substantial assistance with toileting and hygiene and was dependent on staff with dressing. During an interview on 07/15/2025 at 10:15 AM, Resident 39 was seated on their recliner in their room. The resident had a house coat on with a large plastic neck collar around their neck. The resident stated they had an episode of confusion and severe pain at the facility on 07/03/2025 when they had not been feeling well for a few days and ended up in the hospital with an infection and stayed in the hospital for 12 days. Resident 39 stated they were admitted back to the facility for physical therapy before they could discharge home. Review of the 07/02/2025 nurses progress notes showed that the physician had ordered laboratory testing for Resident 39 which showed an elevation in the resident’s white blood cell count (which is used to measure the amount of these cells in the blood which may determine infection) and other laboratory results. Additionally, the physician ordered a chest x-ray and increased Resident 39’s pain medication. Review of the 07/03/2025 progress notes showed the following changes were charted for Resident 39 which showed at 8:58 AM the resident who was on continuous oxygen, had an oxygen level of 79% (normal is 90% to 100%), at 9:53 AM the resident had an increase of severe pain, at 12:38 PM the resident’s pulse was 117 (normal is 60-100 beats per minute). Review of the 07/03/2025 at 2:55 PM nurses progress notes showed Resident 39 was sent to the emergency room (ER) due to abnormal vital signs (blood pressure and pulse), increased lethargy (lack of energy), and oxygen level drop despite increases of oxygen administered. Resident 39's blood pressure was 62/48 (120/80 normal range). The resident was clammy and speech was slurred/difficult to understand. The paramedics (emergency medical service) were called, while the resident was on the phone with Resident Representative (RR) at that time. RR asked Staff H and then the paramedics to take Resident 39 to the ER as the resident was not themselves for the last three days. There was no change of condition assessment completed by the licensed nurse. During an interview on 07/16/2025 at 11:20 AM, Resident 39 stated they had not experienced that type of infection before and had no recollection about being asked to go to the hospital or any memory about that day. Resident 39 stated they did not recall speaking with their RR at that time. The resident stated they woke up in the hospital in the Intensive Care Unit (ICU) and were there for two weeks. Review of the hospital 07/03/2025 emergency room intake encounter notes stated the resident was not able to answer questions and resident’s representative stated the resident had not been eating and had changes over the last two to three days at the facility. The resident was admitted to ICU for management. Review of the 07/13/2025 hospital discharge summary showed the resident was admitted to the hospital on [DATE] through 07/13/2025 and readmitted to the facility on [DATE]. Admitting diagnoses to the hospital were Septic shock due to bacterial urinary tract infection, heart failure, lung issues and diabetes (chronic condition where the body cannot regulate blood sugar levels). The summary showed that resident was admitted to ICU with significant low blood pressure that required medication with intravenous (IV) fluids. Additionally, the resident received four different antibiotics IV for their bladder infection. During an interview on 07/17/2025 at 10:30 AM, Staff H, Registered Nurse, (RN) stated Resident 39 started having issues around 9:00 AM on 07/03/2025 where they had so much pain that it would not respond to the pain medication given to them. Staff H stated that Resident 39’s oxygen level dropped to 79%. Staff H stated turned the oxygen up and the oxygen level was okay then dropped down again. Staff H stated the resident did not want to go to the hospital. Staff H stated the resident was in and out of falling asleep and Staff H did not want to disturb the resident. Staff H stated this change of condition continued and the resident who was a full code did not want to go to the hospital. Staff H stated Resident 39 called their RR and decided to go to the hospital around 2:45 PM. Staff H stated they felt they could not make the resident go to the hospital even though they had significant changes. Resident 39 was on the phone with their RR and the RR asked Staff H that Resident 39 be sent to the hospital due to the resident’s decrease in orientation and increased pain. Staff H called the paramedics around 2:55 PM and documented they notified the nurse practitioner. During an interview on 07/17/2025 at 1:08 PM, Resident 39’s RR stated they had concerns with the resident on 07/01/2025 when people visited the resident, they noticed a change in the resident’s memory and felt they were confused. Resident 39 complained of not feeling well. On Tuesday 07/01/2025 the resident had a change in condition the resident was pale and looked bad.” On Wednesday 07/02/2025 the resident was not coherent, and the nurse did not think anything was wrong. Resident 39 did not know what time of day it was and was confused. While the RR was talking to Resident 39 on the phone and Staff M, Medical Director (MD), who was in the resident’s room ordered a chest X-ray and blood work on 07/02/2025 and increased the residents pain medication. The RR stated they had spoken to on 07/02/2025 that afternoon to Staff F, RN, who was informed of Resident 39’s change in their ability to think clearly and not being themself when expressing our concerns. Staff F stated they attributed Resident 39’s complaints to participation in physical therapy and medication. During an interview on 07/17/2025 at 1:55 PM, Staff M stated if they had known about those changes in vital signs on 07/03/2025 and Resident 39’s change in condition they would immediately have had the resident transferred to the hospital. During an interview on 07/18/2025 at 11:44 AM, Staff N, Advanced Registered Nurse Practitioner (ARNP) stated they did not receive a call from the facility concerning Resident 39’s change of condition or decreased on oxygen level. If that information was communicated to them, they would immediately have admitted the resident to the hospital. During an interview on 07/21/2025 at10:18 AM, Staff I, RN, stated after the morning meeting on 07/03/2025 at 10:00 AM they saw that Resident 39 had a 79% oxygen level on their computer. Staff I went to Resident 39’s room with a pulse oximeter to check the resident’s oxygen level. Staff H stated to Staff I that they increased the resident’s oxygen from 1 liters (unit of measure) to 4 liters and the oxygen level improved to 90% at that time. Staff I asked Staff H to notify the physician about the change made by increased oxygen from 1 liter to 4 liters of oxygen to Resident 39. <Resident 9> Review of Resident 9’s medical record showed they were admitted to the facility on [DATE] with diagnoses to include epilepsy (a brain disease where nerves cells do not signal properly, which causes seizures), neuromuscular dysfunction of the bladder (condition where the bladder cannot properly store or release urine due to nerve damage) and pyelonephritis (a bacterial infection causing inflammation of the kidneys). Review of the resident’s comprehensive assessment dated [DATE] showed Resident 9’s cognition was intact and able to make their needs known. Resident 9 required assistance from two staff members for mobility and activities of daily living. During an observation and concurrent interview on 07/15/2025 at 3:07 PM, Resident 9 stated they had a nephrostomy tube (a flexible tube inserted through the skin into the kidney to drain urine externally when normal drainage is blocked) to help with their kidneys. The nephrostomy drainage bag had a yellow-colored liquid within the bag. Review of Resident 9’s physician orders showed the resident had a nephrostomy tube that required monitoring for signs infection and the monitoring of the resident’s output into the bag twice a day. During an observation and a concurrent interview on 07/18/2025 at 9:27 AM, Resident 9 was lying in bed, the nephrostomy tube laid to their left side empty on the bed. The resident stated their bag was emptied during the night shift and was unsure how often the staff emptied the bag and that the tube hurt when it was moved too much. During an observation and concurrent interview on 07/22/2025 at 10:05 AM, Resident 9 was fully dressed, with a blanket on their lap, sitting in their wheelchair at the front desk stated they were going for a scheduled appointment and would be back that afternoon. During an observation and concurrent interview on 07/22/2025 at 3:26 PM, Resident 9 was lying in their bed speaking to paramedics in their room. The resident’s representative (RR) also in the room, stated “I'm making this happen. The RR stated the resident had texted them the night before, about their pain. The RR stated the pain was in their abdomen and were also complaining of some burning with their urine. The RR stated the last time Resident 9 went through that type of pain and burning, was a few months ago and the resident had to stay in the hospital intensive care for three days, as they had sepsis (a serious condition in which the body responds improperly to an infection) which cause them to have grand-mal seizures (a type of seizure that causes a sudden loss of consciousness, stiffening of the body, and jerking movements). Review of the nursing treatment administration record (TAR) dated July 2025 showed the licensed nurses were to document nephrostomy tube output twice a day. On 07/13/2025 there had been no output documented for the evening shift. Further review of the documentation showed on 07/18/2025 with zero output documented for the day shift. On 07/19/2025 zero output was documented for the evening shift. On 07/20/2025 through 07/22/2025, zero output had been documented for both shifts. During an interview on 07/23/2025 at 8:40 AM, Staff O, Licensed Practical Nurse (LPN), stated Resident 9 had been admitted to the local hospital with sepsis. Staff O stated they had received that in a report from the prior shift nurse but had not followed up with the hospital. During an interview on 07/23/2025 at 9:02 AM, Staff C, LPN, stated Resident 9 had refused to go to their appointment. Staff C stated the resident became nauseated and vomited, so they gave the resident an antinausea medication and went back to their med cart. Staff C stated the next thing they saw were Paramedics, RR, and the Resident Care Manager (RCM) in Resident 9’s room, and the resident being sent out to the local hospital to be evaluated. During an interview on 07/23/2025 at 9:10 AM, Staff E, LPN/RCM, stated Resident 9 had pain to the abdomen that radiated to their back, and that they had talked with their primary physician who told Resident 9 to get to the hospital. Staff E then stated the RR was also in the room and verified the information from the resident. Staff E stated Resident 9 had been admitted to the local hospital but unsure why they had been admitted , and they would need to call for an update. Staff E stated they did not document the conversation they had with the resident or RR. In an interview on 07/23/2025 at 10:42 AM, Resident 9’s RR stated that the resident was admitted to the local hospital on [DATE], due to their nephrostomy tube being blocked, a UTI and abnormal labs. The RR stated the resident had requested pain medication but, the nurse stated could only administer a small dose due to the blood pressure being low, The RR stated, “I kept watching the blood pressure waiting for it to drop, I was scared”. The RR stated, it was the third time that the resident had to be seen by the local hospital. The RR stated on 07/20/2025 the resident had contacted them about significant pain; staff did not seem to listen to Resident 9’s concerns. Review of the local hospital admission note dated 07/22/2025, showed Resident 9 was admitted to the hospital with the diagnoses of a complicated urinary tract infection and sepsis. In an interview on 07/23/2025 at 11:21AM, Staff O, LPN, stated the nurses documented in the TAR for Resident 9’s nephrostomy drain output. Staff O stated if the drain did not put anything out, they would call the doctor. Staff O stated the prior shift report would let them know how much output the resident had from the nephrostomy drain. Staff O stated they had not informed the physician for the resident’s zero output. In an interview on 07/23/2025 at 11:32 AM, Staff E, LPN/RCM, stated the expectation of the nurses on the floor was for the nurse to call the doctor for any signs of infection and when there was zero output from Resident 9’s nephrostomy drainage bag. Staff E stated that the nurses did not follow the orders to monitor the output and did not contact the doctor about the lack of output. During an interview on 07/23/2025 at 1:17 PM, Staff B, DNS stated the expectation was for nursing to document and follow doctor orders. Staff B stated they had reviewed the documentation of Resident 9’s nephrostomy tube output and acknowledged that the doctor had not been notified of the zero output from the resident’s nephrostomy. <Resident 35> Review of the resident’s medical records showed they were admitted to the facility with diagnoses to include a stroke (blood flow to the brain is blocked or a blood vessel bursts) with right side deficits and brain aneurysms (a bulge in a blood vessel). The 06/20/2025 comprehensive assessment showed Resident 35 was cognitively intact and their vision was not impaired. During an interview and concurrent observation on 07/15/2025 at 4:18 PM, Resident 35 stated they had trouble seeing, their vision was blurry, and they experienced dizziness. Resident 35 stated they informed the staff and asked to speak to the provider. Resident 35 stated the provider, a Contracted Nurse Practitioner (CNP), had seen them on 07/14/2025 and the resident informed the CNP of their vision issues. Resident 35 stated they informed the CNP that they had a history of having three brain aneurysms, and these were some of the symptoms they had experienced and requested imaging to ensure that was not the issue. Resident 35 stated they were told by the CNP that they did not feel that was the issue and would have to discuss with the facility whether imaging was appropriate or not and asked them if they “really wanted to put your body through that…are you even going to be here next year.” Resident 35 stated they had not heard anymore about it. Resident 35 was observed squinting at the television, with the left eye smaller than the right (this was normal per the resident), and complained of head pain over the left eye and some dizziness. During an interview on 07/16/2025 at 12:08 PM, Resident 35 was lying in bed and stated they felt like their vision was “better today but not much.” Resident 35 stated they had not talked to the nurse regarding their vision changes, only the CNP and had not heard anything about the imaging being ordered. During an interview on 07/18/2025 at 3:42 PM, Resident 35 stated they had not heard anything regarding the imaging. Resident 35 stated they felt like their vision symptoms were coming and going and had “nauseous waves going over me [feelings of being sick to your stomach that come and go].” Resident 35 stated when they would lay flat, they would feel pressure in their head but if they elevated the head of their bed, the pressure seemed to relieve. Resident 35 stated they informed Staff F, RCM, about the pressure when lying flat and vision changes. Resident 35 stated Staff F informed them they had received an order from the CNP for a Computed Tomography (CT, a type of imaging that can visualize details inside the body) scan and they would get that scheduled. Review of the July 2025 Physician orders showed an order on 07/14/2025 for Resident 35 to be scheduled for a CT scan. The order showed a reason for the CT scan was for “visual changes and dizziness.” The order showed it was discontinued on 07/17/2025. Review of Resident 35’s progress notes showed no documentation from the CNP for the 07/14/2025 visit, no LN documentation as to who ordered the CT scan or why it was ordered, and no documentation that showed Resident 35’s current vision changes, dizziness, nausea, or increased pressure to their head had been monitored or assessed. The review also showed no notification to the provider regarding the increased pressure to Resident 35’s head when lying flat. During an interview on 07/22/2025 at 3:28 PM, Staff E, RCM, stated they knew about Resident 35’s concerns with their vision changes and dizziness and knew the CNP had ordered a CT scan for the resident. Staff E stated they were unaware Resident 35 had experienced feeling pressure to their head while lying flat and had not seen any nursing documentation regarding those concerns. Staff E stated Resident 35 should have been put on alert charting so they could monitor the symptoms they were having but they did not do that. Staff E stated they did not see the CNP’s progress note from their visit on 07/14/2025 in Resident 35’s medical record and would call to request them. Staff E stated they “assumed” the order was discontinued because “maybe it had been scheduled.” Review of the CNP’s progress note provided by Staff E, dated for 07/21/2025 at 4:16 PM, showed Resident 35 reported they had “vague vision/dizziness” complaints and had experienced “waves” of lightheadedness and dizziness that would last seconds before resolving. The note showed the television appeared “more blurry” and was concerned their symptoms were related to their history of brain aneurysms. The note further showed the CNP educated and reassured Resident 35 that their symptoms were “unlikely related” to the aneurysms because of the intermittent dizziness. The note showed a CT scan had been ordered and the RCM had been notified. The note was signed and dated 07/22/2025 at 4:16 PM. During an interview on 07/23/2025 at 12:48 PM, Staff F stated they had received an order from the CNP through an electronic mail (email) on 07/14/2025. Staff F stated they had processed the order on 07/14/2025 and faxed the order over but the order was not completed correctly so needed to amend the order and resend it. Staff F stated they had been “busy” and had not done that yet “I will probably get to that today.” Staff F further stated when they received the email they should have placed Resident 35 on alert charting to monitor for any worsening of their symptoms, and they did not do that. Staff F stated they did speak to the resident regarding their symptoms but were unaware they had pressure in their head when lying flat. Staff F stated the order they received was not an emergent order. Review of a note that was emailed on 07/14/2025 at 4:33 PM, sent to Staff F by the CNP, showed they had seen Resident 35 and would be ordering a CT scan. The note showed Resident 35 had complained of on and off dizziness and “brain zaps [brief electric shock-like sensations in the head],” and worsening vision symptoms that were related to their brain aneurysms. The note showed since symptoms were improving the CNP assured Resident 35 that it was unlikely related to the brain aneurysms, and even if it was, they would most likely not be a candidate for surgery, “so what’s the point of doing imaging,” but Resident 35 insisted. During an interview on 07/23/2025 at 1:54 PM, Staff B, DNS, stated when a resident experienced a change in their health condition, the LNs should assess the resident, notify the provider, notify the family, update the care plan as needed, and put the resident on alert charting. Staff B stated the alert charting would have remained in place until the resolve of symptoms or as ordered. Staff B stated Staff E and Staff F should have placed the resident on alert charting when they became knowledgeable Resident 35 had vision changes, dizziness, or increased pressure to their head. <Resident 8> Review of the resident’s medical records showed they were admitted to the facility with diagnoses to include lumbar spondylopathy (wear and tear to the lower back region) and nerve pain. The 07/01/2025 comprehensive assessment showed the resident’s cognition was intact and they received routine and as needed pain medication. Review of the 05/19/2025 through 05/31/2025 Medication Administration Records (MAR), showed an order dated 05/19/2025 for Oxycodone (a brand of medication used for pain) five milligrams (mg, a unit of measure), give one tablet every four hours as needed (PRN) for a pain level of six or seven (a pain scale of 0-10 with zero meaning no pain at all and 10 meaning the most excruciating pain ever felt). The record showed an order dated 05/19/2025 for Oxycodone five mg, give two tablets for a pain level of eight, nine, or ten. Both orders showed pain location and non-pharmacological (does not involve medication) interventions were to be documented in a progress note. The order for one tablet was administered three times with one administration given outside of the parameters ordered (pain level of ten). The order for two tablets was administered 12 times with one administration given outside of the parameters ordered (pain level of seven). Review of the June 2025 MARs showed the same Oxycodone orders (05/19/2025) as the May 2025 MAR did. The records showed the order for one tablet of Oxycodone was administered seven times, with five of those administrations given outside of the ordered parameters (greater than a pain level of seven). The record showed the order for the two tablets of Oxycodone was administered 38 times, with 22 of those administrations given outside of the ordered parameters (for pain levels of five to seven). Review of the 07/01/2025 through 07/21/2025 MAR showed the same Oxycodone orders (05/19/2025) as the May 2025 MAR. The record showed the order for one tablet was administered three times with one of those administrations given outside of the ordered parameters (pain level of eight). The record showed the order for two tablets was administered 23 times and 15 of those administrations were given outside of the ordered parameters (pain levels of four to seven). Review of the nursing progress notes from 05/19/2025 through 07/21/2025 showed no non-pharmacological interventions had been documented prior to administering the PRN Oxycodone and two notes on 05/25/2025 and 05/26/2025 that showed the location of Resident 8’s pain. During an interview on 07/23/2025 at 10:03 AM, Staff K, LPN, stated their process for administering PRN medication was to assess the resident’s pain level and location, attempt to see if a non-pharmacological intervention would help, and then administer the pain medication if that was not effective. Staff K stated they then would document in a progress note. During an interview on 07/23/2025 at 10:14 AM, Staff O, LPN, stated they would ask the resident what their pain level was and give them their pain medication. Staff O stated the residents “know what they want and just tell me what to give them.” Staff O stated they would document where their pain location was in the progress notes. During an interview on 07/23/2025 at 1:54 PM, Staff B stated they would expect the LNs to follow physician orders as they were written. Staff B stated if the pain medications were not effective, they would expect the LNs to notify the provider for additional directions or to lower or increase the pain levels ordered or change the medication. Staff B stated the LNs should have documented their location assessment and the non-pharmacological interventions they attempted prior to administering the PRN pain medication. <Resident 71> Review of the resident medical record showed they were admitted to the facility on [DATE] with diagnosis including heart complications, dementia (a progressive disease that destroys the memory and other important mental functions) pancreatic (an organ inside the body that aid in digestion and introducing hormones need for the body’s daily function) cancer and placed on comfort measures (provider orders to assist with a resident’s suffering during their end of life). The 07/09/2025 comprehensive assessment showed the resident had cognitive impairments but was awake/alert to themselves, was talking with staff and understood where they were at. Review of Resident 71’s provider orders showed Lorazepam (a specific antianxiety medication belonging to a group of drugs that affect brain activities associated with mental processes, emotions and behavior. The common side effects include drowsiness, confusion, loss of balance and memory problems) could be administered every two hours as needed for anxiety and terminal agitation (a set of behaviors characterized by sudden agitation, anxiety, anger or confusion). Review of Resident 71’s care plan dated 07/02/2025 showed the resident was at risk for rehospitalization that timely communication to the provider was needed regarding any change in the resident’s condition. Additionally, Resident 71 was at risk for falls, and the goal was for the resident to not have an injury that would require them to be hospitalized . Review of a progress note on 07/09/2025 showed that on 07/08/2025 at 8:30 PM Resident 71 was found after a fall on the floor of their room with blood where the resident’s head was resting. Staff L, LPN, noted Resident 71 was weak, unable to sit up on their own and their range of motion was “ .limited due to weakness.” Staff L documented that neurological checks (a comprehensive evaluation of a person’s nervous system, to assess brain/nerve function to help diagnose potential neurological disorders that may require emergency treatment and would be needed following a head injury, increased confusion or change in behavior) were started and that the facility’s provider was notified. No documentation showed that the Resident 71’s representative was notified after the fall. Review of the facility’s investigation into Resident 71’s 07/08/2025 unwitnessed fall, showed the resident was bleeding from a head injury after being found on the floor of their room. The neurological checks showed no evaluation was conducted until 07/09/2025 at 8:00 AM (11 and a half hours after Resident 71’s fall) and Lorazepam was administered due to Resident 71 becoming “ .very restless and was trying to get out of bed .” The investigation showed the cognitive assessment of the resident on 07/09/2025 was “ .nonverbal and very hard to arouse (to wake up) .” Additionally, Resident 71’s resident representative was notified of the unwitnessed fall on 07/11/2025 (three days after the residents fall). Review of Resident 71’s MAR for July 2025, showed Lorazepam was administered on 07/08/2025 at 9:40 PM and 07/09/2025 at 12:00 AM, 5:00 AM, 7:20 AM, 3:33 PM and 8:30 PM. Observation on 07/16/2025 at 10:08 AM showed Resident 71 in their bed, unable to wake or open eyes. During an interview on 07/18/2025 at 12:40 PM, Staff F, RCM, stated the process for a resident having an unwitnessed fall and hitting their head would be to start neurological checks to assess for complications that may require emergency treatment and to notify the provider and Resident 71’s representative. Staff F stated that neurological checks were to be started right after a resident had been found and performed every 15 minutes (min) for one hour, then every 30 min for two hours, then every hour for four hours, and then every four hours for the next 24 hours. Staff F stated that Resident 71 was unable to make care decisions due to their cognitive ability and the resident’s representative would need to be notified after Resident 71s fall. Staff F stated they would be unable to assess changes in the Resident 71’s mentation nor accurately evaluate neurological checks since the resident was being administered their Lorazepam medication. Staff F stated that neurological checks should have been completed per the facility process, and they were not per Resident 71’s neurological assessment documentation and the provider/resident representative would have needed to be involved in a discussion on continued care interventions with the residents unwitnessed fall, head injury, and Lorazepam administration. During an interview on 07/18/2025 at 3:21 PM, Staff L, LPN, stated they had notified the on-call provider about Resident 71’s fall, but did not communicate that it was an unwitnessed fall, that the resident had hit their head, or clarify orders with completion of neurological checks versus Lorazepam medication administration. Staff L stated they did not notify Resident 71’s representative of the fal

Based on observation, interview and record review, the facility failed to ensure that residents requiring assistance with showers, oral care, and nail care, were provided timely assistance according to their needs and preference for 6 of 10 sampled residents (Residents 11, 35, 13, 82, 9, and 26) reviewed for activities of daily living (ADLs). This failed practice placed residents at risk of infection, decreased dignity, and a decreased quality of life. Findings Included . <Resident 11> Review of the resident’s medical records showed they were admitted to the facility with diagnoses to include Alzheimer disease (a brain disorder that slowly destroys a person’s memory and thinking skills). The 06/26/2025 comprehensive assessment showed Resident 11’s cognition was severely impaired and was dependent upon staff for bathing and personal hygiene. During an interview on 07/16/2025 at 9:13 AM, the Resident Representative (RR) of Resident 11 stated they would arrive to the facility between 6:30 AM and 7:00 AM daily and remain there all day until 3:00 PM to 4:30 PM. The RR stated they did not see Resident 11 provided with oral care and wondered if “they left it up to me to do.” Resident 11 had white substance buildup in between their teeth, and the RR was going to provide them with oral care. The RR stated they would prefer Resident 11 to shower every other day, but oral care provided twice a week was fine, if it was completed. During an observation and concurrent interview on 07/18/2025 at 11:50 AM, the RR of Resident 11 wandered the hall looking for staff. The RR stated they had been with the resident since close to 6:45 AM and Resident 11 had not been checked or changed and smelled of bowel movement and urine (five hours after RR arrived). The RR walked to the Nurse’s station and informed them Resident 11 needed to be changed. During an interview on 07/18/2025 at 12:19 PM, Staff T, Nursing Assistant (NA), stated there were a lot of showers scheduled, and it had been “stressful” and needed to take a break from them. Staff T stated there were many mechanical lift (machines used to transfer residents unable to stand or have limited mobility and required minimum of two staff) transfers that took up most of their time. Staff T stated they would no longer be the shower aide after the month of July 2025. Staff T said residents had showers scheduled for Sundays but there were no shower aides that worked on Sundays. Staff T stated they would try to review the shower list and if a resident had a shower the previous week on Saturday, they would try to fit one of the Sunday scheduled residents in their place but then would leave that resident short a shower for the week, “but I still can’t get to everyone like that.” During an interview on 07/21/2025 at 11:11 AM, the RR of Resident 11 stated they arrived at the facility at 7:00 AM and Resident 11 had not been checked or changed since their arrival. The RR stated Resident 11 had not been provided with oral care before or after breakfast. The RR stated Resident 11 did not receive a shower during the weekend and did not receive showers regularly. The RR stated at one time, Resident 11’s hair had been so oily and dirty looking they paid $28 dollars to take them to the beauty shop to have it done. During an interview on 07/21/2025 at 12:36 PM, Staff AA, NA, stated they provided care to residents at the beginning of their shift (6:00AM), would complete ADL care, and then by the time they completed that, it would be time for breakfast. Staff AA stated after breakfast they would make another round to ensure residents were dry. Staff AA stated they checked again before residents went to the dining room for lunch. Staff AA stated they checked residents for wetness every 30 minutes, but Resident 11 was not a “heavy wetter [not having wet briefs as often as others]” so they did not get checked that often. Staff AA stated Resident 11’s RR would “accuse” them of not providing the resident care so they would bring another NA in when providing care. Staff AA stated they checked the documentation, and at 9:22 AM they checked the resident, and they were dry. Staff AA stated they did not have another NA with them when they “just checked on the resident,” only when they changed the resident. Resident 11’s hair was not groomed and appeared oily and lay flat on their face. During an observation of care for Resident 11 on 07/21/2025 at 1:23 PM, Staff AA and Staff BB, NA, assisted Resident 11 to the bathroom and removed their soiled brief. The brief and purple liner inside the brief appeared saturated with yellow and brown (indicating old urine) urine. When Resident 11 was wiped clean on their bottom and perineal-area (the region located between the anus and the genitals), the wipes had brown on them and Resident 11 did not have a bowel movement. Review of Resident 11’s bathing task for 06/21/2025 through 07/21/2025 showed Resident 11 received three showers in 30 days (out of 10 showers scheduled), 06/26/2025, 07/10/2025, and 07/18/2025. The bathing task showed Resident 11 was to receive showers on Thursdays and Sundays. During an interview on 07/21/2025 at 1:23 PM, Staff EE, NA, stated Resident 11’s showers were on Thursday and Sunday. Staff EE stated Resident 11 did not receive their shower on Sunday 07/20/2025 because there was no shower staff scheduled for Sundays. Staff EE stated there had not been shower staff scheduled on Sundays for “quite some time.” An observation on 07/22/2025 at 10:42 AM, showed Resident 11 sitting in their wheelchair, their hair was uncombed, and appeared oily. Review of Resident 11’s Care Plan (CP), showed a CP dated 12/20/2024 for toileting before and after meals and at bedtime and required the assistance of one staff. The CP showed no person-centered bathing/showering care plan or preferences. Review of the shower schedule provided by Staff EE, showed Resident 11 had Wednesday and Sundays as their scheduled shower days. The shower schedule also showed there were 20 showers scheduled on Sundays when there were no shower aides. During an interview on 01/23/2025 at 1:54 PM, Staff B, Director of Nursing Services (DNS), stated the showers that were scheduled for Sundays were to be split amongst the staff on the floor. Staff B stated they recently hired a new shower aide and had another NA on the floor to help out with showers and did not know why residents were not getting their showers. Staff B stated if residents wanted showers more often, “we would try to accommodate them as best as we can.” <Resident 35> Review of the resident’s medical records showed they admitted with diagnoses to include a stroke (blood flow to the brain is blocked or a blood vessel bursts) with deficits to their right side. Review of the 06/20/2025 comprehensive assessment showed Resident 11 was cognitively intact and required staff assistance with bathing and oral care. An observation and concurrent interview on 07/15/2025 at 4:33PM, showed Resident 35 lying in bed in their night clothes. Resident 35’s hair was uncombed, their teeth were yellow and had a white substance built up in between their teeth. An observation on 07/21/2025 at 3:42 PM showed Resident 35 in bed, with their RR at their bedside visiting. Resident 35 had white and yellow build up substance in between their teeth. Resident 35 stated they did not ask the NAs for help, and they did not offer help, “they are so busy.” During an observation and concurrent interview on 07/22/2025 at 2:35 PM, Resident 35 was lying in bed, with their robe on. Resident 35 stated they had not had their teeth brushed or oral care provided in “quite some time.” Resident 35 stated “only my [RR]” would brush their teeth. Resident 35’s teeth continued with white and yellow substance build up in between the teeth. Review of Resident 35’s CP showed on 10/25/2022 Resident 35 had missing teeth and needed assistance with their dental care. An intervention for the CP goal was to “assist [Resident 35] with oral care” with no schedule or when or how often oral care should have been provided. <Resident 13> Review of Resident 13 medical records showed the resident was admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (a chronic autoimmune [a condition where the body attacks itself] disease of the nervous system), dysfunction of the bladder (difficulty passing urine), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). The comprehensive assessment dated [DATE] showed Resident 13’s cognition was intact and required assistance from two staff members for dressing of their lower body transfers, and showering. During an interview and concurrent observation on 07/15/2025 at 10:42 AM Resident 13 stated it was mid-morning, and they had not been changed or cleaned up for the day. Resident 13 was lying in bed, their hair greasy, uncombed, dressed in a T-shirt and adult brief. The resident stated they had their T-shirt on from the day before. In an interview on 07/16/2025 at 8:48 AM, Resident 13 stated they arrived at the facility 13 days prior. Resident 13 stated they had only one shower since they arrived and that their hair felt greasy and looked it. The resident stated, “I'm not used to that”. Review of the undated facility shower schedule showed Resident 13’s shower days were on Tuesday and Fridays. Review of the Nursing task report dated July 2025, showed bathing/showering documentation on July 4th and July 11th, “that the activity did not occur”. There were no other documented bathing/showering for Resident 13 (12 days without bathing/showering). <Resident 82> Review of the medical records showed Resident 82 had been admitted to the facility on [DATE] with diagnoses to include diabetes (a disease in which the body does not control sugar in the blood), heart failure, and presence of an artificial left hip joint. The comprehensive assessment dated [DATE] showed the resident’s cognition was moderately impaired and required substantial assistance of one staff member for transfers, dressing and showering. In an observation on 07/15/2025 at 2:06 PM, Resident 82 was lying in bed resting their hands on their chest and their fingernails long (extended over the finger), with a dark substance underneath the fingernails on both hands. During an interview and concurrent observation on07/18/2025 at 10:34 AM, Resident 82 was lying in bed, covered with a blanket with their hands grasping the blanket. Resident 82 stated their nails were long, and that they did not like to have their nails that long. Resident 82 stated “these are women nails”, “too long”. Resident 82 stated, but they did not have a nail clipper to take care of them. In an observation on 07/18/2025 at 4:33 PM Resident 82 was sleeping, both of their hands outside of blankets and their fingernail extended over their fingers on both hands with dark substance underneath the fingernails on both hands. Review of the resident’s medical record showed the resident was to receive diabetic nail care weekly. Review of the 06/09/2025 physician orders for Resident 82, showed the resident was to receive diabetic nail care weekly every dayshift, every Monday. Review of Resident 82’s July 2025 medication administration record showed nursing documentation on 07/14/2025 that the resident had received diabetic nail care. <Resident 9> Review of the medical records showed Resident 9 had been admitted to the facility on [DATE] with diagnoses to include muscle weakness, quadriplegia (a condition where there’s a partial or complete loss of function in arms, legs and torso), and epilepsy (a neurological condition characterized by recurrent, unprovoked seizures). The comprehensive assessment dated [DATE], showed the resident required assistance of two staff members for transfers, dressing, and showering. During an observation and concurrent interview on 07/15/2025 at 3:07 PM, showed Resident 9 lying in bed reading, the resident’s hair greasy, they were wearing a left wrist splint wrapped with an ace bandage. The resident stated it had been a while since their last shower, that sometimes staff will get pulled off their duties if they are short staffed. Resident 9 stated they were scheduled to have showers on Thursdays and Sundays. Review of the June 2025 Nursing task report showed there were no bathing/showering documented for Resident 9. The Nursing task report for July 2025, there was no documentation of bathing/showering from July 10th through July 16th, (six days without bathing/showering). During an interview on 07/23/2025 at 1:17PM, Staff B, DNS, stated the expectation was for nursing staff to document all cares and follow orders. Staff B stated they were a new team and could see they had some education to do for sure. <Resident 26> Review of the medical record showed the resident was admitted to the facility 05/29/2025 with diagnoses including an infectious germ which caused inflammation of the colon (large intestine) and diarrhea, end stage renal disease with dialysis (treatment that filters waste and fluid from your blood when your kidneys are failing) and diabetes (condition where your blood sugar levels are too high because your body either does not produce enough hormone insulin or can not use insulin properly). Review of the 06/02/2025 comprehensive assessment showed the resident was alert and oriented and dependent on staff for bathing, toileting, transfers and personal care. The 05/29/2025 bath schedule showed Resident 26 had been on Sundays and Wednesdays. Resident 26 discharged to the hospital on [DATE]. During an interview on 07/10/2025 at 2:45 PM, Resident 26's RR stated the resident did not receive their baths and had been unclean. The RR stated Resident 26 had experienced diarrhea and was nauseated and vomiting while there and was sent to the hospital. Review of Resident 26's documented baths showed they received baths on 06/01/2025 and 06/04/2025 only. There were no other documented baths for Resident 26 (16 days without a bath). During an interview on 07/18/2025 at 1:05 PM, Staff T, NA stated they were part of the bath team and that Resident 26 was scheduled for baths on Wednesdays and Sundays. Staff T stated they stopped giving baths on Sundays since the second week in June 2025. During an interview on 07/21/2025 at 11:45 AM Staff E, Registered Nurse, stated we do not do baths on Sundays and have not for a while. Reference: WAC 388-97-1060(2)(c)

Based on observation, interview, and record review, the facility failed to ensure adequate staffing levels in order to provide care and services needed for 8 of 10 residents (Residents 11, 35, 13, 82, 9, 26, 8, and 18) reviewed for activities of daily living (ADLs), restorative therapy, and specialized therapy services (therapy that improves performing daily tasks, mobility and function). This failed practice placed residents at risk for an undignified existence and unmet care and service's needs. Findings included.<ADLs><Resident 11>Review of the resident's medical records showed they were admitted to the facility with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills). During an interview and concurrent observation on 07/16/2025 at 9:13 AM, showed Resident 11 had a build up of a white substance between their teeth and the Resident Representative (RR) stated they wanted the resident to receive showers more than twice a week. The RR stated they felt the staff left it up to them to provide the resident their daily oral care. During an interview and concurrent observation on 07/18/2025 at 11:50 AM, the RR was observed wandering the halls looking for assistance before they took Resident 11 to the dining room for lunch. The RR stated the resident smelled of bowel movement and had not been checked or changed since the RR arrived at 6:45 AM (more than five hours later). During an interview on 07/21/2025 at 11:11 AM, the RR stated they arrived to the facility at 7:00 AM and Resident 11 had not been checked or changed (more than four hours later), no oral care had been provided before or after breakfast, and Resident 11 did not receive their shower over the weekend. <Resident 35>Review of the resident's medical records showed they were admitted to the facility with diagnoses to include a stroke (blood flow to the brain is blocked or a blood vessel bursts) with weakness to their right side. An observation on 07/15/2025 at 4:33 PM and 07/22/2025 at 2:35 PM, showed Resident 35's hair was uncombed, and their teeth were yellow with a buildup of a white substance in between their teeth. During an interview on 07/15/2025 at 10:45 AM, Resident 35 stated the facility needed to hire more help. Resident 35 stated they each had 15-20 rooms each and they would have to wait up to an hour to get up and ready and would have to sit in their wet urine and bed. During an interview and concurrent observation on 07/21/2025 at 3:42 PM, showed Resident 35's had not been provided oral care and stated they did not ask the Nursing Assistants (NAs) for help, nor did the NAs offer help they are so busy. <Resident 13>Review of the resident's medical records showed they were admitted to the facility with diagnoses to include multiple sclerosis (a chronic autoimmune [a condition where the body attacks itself] disease of the nervous system). During an interview and concurrent observation on 07/15/2025 at 10:42 AM, Resident 13 stated they had not been provided with ADL care. Resident 13 had greasy, uncombed hair. During an interview on 07/16/2025 at 8:48 AM, Resident 13 stated they had been at the facility for 13 days and had only received one shower I am not used to that. <Resident 82>Review of Resident 82's medical records showed they admitted to the facility with diagnoses to include diabetes (a disease in which the body does not control sugar in the blood). During an observation on 07/15/2025 at 2:06 PM, showed Resident 82's fingernails were long and had a dark substance underneath the nails. During an interview and concurrent observation on 07/18/2025 at 10:34 AM, Resident 82 stated they had women nails, and they were too long, and they did not like having nails that long. Resident 82's nails extended over their fingers on both hands. <Resident 9>Review of Resident 9's medical records showed they admitted to the facility with diagnoses to include muscle weakness. During an interview and concurrent observation on 07/15/2025 at 3:07 PM, showed Resident 9 had greasy hair and stated they had not had a shower in a while. Resident 9 stated staff get pulled from their duties when they are short of staff. Review of Resident 9's shower task records showed in June 2025 they received no showers, and from 07/10/2025 through 07/16/2025 showed Resident had not received a shower. <Resident 26>Review of Resident 26's medical records showed they admitted to the facility with diagnoses to include end stage kidney failure with dialysis (treatment that filters waste and fluid from your blood when your kidneys are failing). During an interview on 07/10/2025 at 2:45 PM, the RR stated Resident 26 had not received their baths and they were unclean. Review of Resident 26's shower tasks from 06/01/2025 through discharge date of 06/25/2025 showed Resident 26 received a bath/shower on 06/01/2025 and 06/04/2025 (16 days without a bath/shower). During an interview on 07/17/2025 at 2:23 PM, Staff HH, Nursing Assistant (NA), stated they had just started working at this facility. Staff HH stated they worked at the sister facility in Kennewick and were asked to come to this facility and help out until the end of the month. Staff HH stated there were two other NAs from the sister facility helping out as well. During an interview on 07/18/2025 at 12:19 PM, showed Staff T, NA, stated there were a lot of resident showers and they had been stressful. Staff T stated there were a lot of residents that required two persons to transfer so they took up a lot of their time. Staff T stated they did not have shower staff scheduled for Sundays. Staff T stated they requested to be moved out of the showers and moved to the floor because they needed a break. During an interview on 07/21/2025 at 11:45 AM, showed Staff EE stated they did not do baths on Sundays and had not for a while. Review of the shower schedule provided by Staff EE, NA, showed there were 20 showers scheduled for Sundays when there was no shower staff scheduled. <Restorative Therapy><Resident 8>Review of Resident 8's medical records showed they admitted to the facility with diagnoses to include muscle weakness and nerve pain. During an interview on 07/15/2025 at 11:40 AM, Resident 8 stated they were supposed to receive exercise therapy six times a week but had not received them consistently. During an interview on 07/21/2025 at 11:18 AM, Resident 8 stated Staff Y, Restorative Nursing Assistant (RNA), was too busy covering the floor and did not receive their exercise program. <Resident 35>During an interview on 07/15/2025 at 10:45 AM, Resident 35 stated they were to receive Restorative therapy but had not been consistent. Resident 35's roommate intervened and stated Staff Y gets pulled to work the floor a lot and Resident 35 agreed. Resident 35 stated they would wear a brace (none observed) to their right hand but had not had that done. Resident 35's right hand appeared turned inward at the wrist in a fixed position. During review of Resident 35's Restorative program tasks from 06/22/2025 through 07/22/2025 showed the resident received their active range of motion (AROM, exercises provided without assistance/help) program on 15 days out of 25 days and an out of bed activity was completed five days out of nine days. Nine of the tasks completed were documented by Staff Y during hours they did not work (11:44 PM). During an interview on 07/22/2025 at 10:59 AM, Staff Y stated they worked Tuesday through Saturdays and there were no other staff scheduled to pick up the 6th day of the Restorative programs. Staff Y stated the facility hired someone to assist them but needed to move them to the floor because they were short of staff. Staff Y stated they would have to be re-assigned to cover shifts on the floor at the least three times a week. During an interview on 07/23/2025 at 2:02 PM, Staff B, Director of Nursing Services, stated they hired an NA to help Staff Y, Staff T, and Staff EE with showers and the Restorative programs and did not know why the tasks were not being completed. Staff B stated if Staff Y was pulled to work the floor, then the Restorative programs would not be completed because Staff Y was not replaced with anyone else. <Specialized Therapy Services><Resident 13>During a Resident Council meeting on 07/17/2025 at 10:27 AM, Resident 13 stated they had been at the facility since the beginning of July 2025 and had not had therapy evaluations completed because they were behind on assessments. <Resident 18>Review of Resident 18's medical records showed they admitted to the facility with diagnoses to include peripheral neuropathy (when the nerves that are located outside of the brain and spinal cord (peripheral nerves) are damaged). During an interview on 07/16/2025 at 12:24 PM, Resident 18 stated they had been at the facility since April and had not received their evaluations for PT/OT as they were ordered on admission [DATE]. Resident 18 stated they requested to have equipment that would assist them to be more independent and needed to have those evaluations in order to get the equipment. Review of physician orders from 04/09/2025 through 06/02/2025 showed an order on 04/09/2025 for PT and OT services, and then again on 06/02/2025 an order for PT and OT services. Review of provider visit notes showed on 04/14/2025 Resident 18 was developing a contracture. A note on 04/21/2025 showed Resident 18 requested therapy evaluations, and a note on 06/02/2025 showed Resident 18 requested therapy so they could work on transferring. During an interview on 07/22/2025 at 10:10 AM, Staff V, Director of Rehab (DOR) stated they had issues with obtaining therapy staff (therapists) coverage because one was out of the country and the other one was out with an injury. Staff V stated they informed Resident 18 I'll try to squeeze you in. During an interview on 07/23/2025 at 2:02 PM, Staff B, Director of Nursing Services, stated they were aware of the therapist staff shortage but expected the evaluations to be completed as ordered. <Additional Resident Concerns>During an interview on 07/15/2025 at 11:40 AM, Resident 8 stated staff shortage is my frustration. Resident 8 stated they had to wait for an hour before receiving help at times and would be left lying in their urine it's disturbing. During a Resident Council meeting on 07/17/2025 at 10:01 AM, Resident 16 stated lack of staffing was a big issue. Resident 16 stated the NAs would have up to 25 residents to care for and that was too many for one person. Resident 16 stated these same concerns at the last meeting and the NAs were provided with some education. Resident 16 stated the call lights had improved, but not much. During a Resident Council meeting on 07/17/2025 at 11:09 AM, Resident 19 stated they were not receiving their showers consistently and seven other residents that were present during this meeting agreed. Resident 19 stated they were concerned because Staff T were too overwhelmed with showers and would no longer be doing the showers anymore at the end of the month. Reference WAC: 388-97-1080 (1)

Based on observation, interview, and record review, the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and discard medications when medications were not in use and when medications have expired on 2 of 2 medication carts (Team 1 and 2 medication carts) and 1 of 2 medication rooms (Team 2), reviewed for medication storage. This failure placed the residents at risk for receiving compromised or ineffective medication. Findings included. Review of the facility's policy titled, Storage and Expiration Dating of Medications and Biologicals dated 12/01/2007, showed the facility should ensure medications and biologicals: (1) have an expired date on the label, (2) have been retained longer than recommended by manufacturer or supplier guidelines, and (3) have been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy or supplier. <Team 1> An observation of the Team 1 medication cart on 07/22/2025 at 11:00 AM, with Staff D Licensed Practical Nurse (LPN), showed as follows: one Rezvoglar insulin (a brand of medication used to control sugar in the blood) Kwik pen, had no label to identify who the medication was for, no dosage, or an open date to ensure efficacy (effectiveness) of the medication. one Tresiba insulin Flex touch pen had no label identifiers, no dosage, or an open date. one Novolin insulin Flex pen had no label identifiers, no dosage, no open date. one Lyumjev insulin Kwik pen had no label identifiers, no dosage, but had an open date 5/20/25. (38 days past manufacturer recommended for medication storage at room temperature) one vial of Humulin R had no label identifiers, no dosage for administration, and1 had an opened date of 6/4/25 (17 days past manufacturer recommended medication storage at room temperature) one bottle Potassium tablets 99 milligrams (mg) that expired on 05/2025. (60 days past expiration date) Further review of the medication cart showed a locked narcotic (a drug or substance that affects mood or behavior, relieves pain, induces drowsiness, and insensibility) drawer, within the narcotic drawer were medications of residents that had been discharged from facility and residents whose medications orders had changed: one opened bottle of liquid morphine sulfate had 12 milliliters (ml) in bottle, one unopened bottle of liquid morphine, and one unopened bottle of lorazepam. Staff D stated Resident 71 had passed away. one card of oxycodone 5 mg tablets that had 8 tablets. Staff D stated Resident 97 had been discharged from the facility. one card of oxycodone 5 mg tablets that had 27 tablets. Staff D stated Resident 83 was in the facility, but the resident's order had changed. one card of oxycodone 10 mg tablets that had 16 tabs left in the card. Staff D stated Resident 45 was in the facility, but the resident's order had changed. During an interview on 07/22/2025 at 11:10 AM, Staff D stated they were unsure who the insulin pens belonged to, and they were aware of medications within their cart that needed to be destroyed or sent back to the pharmacy. Staff D stated they usually destroyed the medications with a Registered Nurse or the Director of Nursing Services. <Team 2> An observation of the Team 2 medication cart on 07/22/2025 11:29 AM, with Staff C, LPN, showed as follows: one Lantus insulin Kwik pen for Resident 86 showed the pen had no open date to ensure efficacy of the medication. one Lantus insulin Kwik pen for Resident 20 showed the pen had no open date to ensure efficacy of the medication. one Lantus insulin Kwik pen for Resident 74 showed the pen had no open date to ensure efficacy of the medication. one Lantus insulin Kwik pen for Resident 3 showed the pen had no open date to ensure efficacy of the medication. one Lispro insulin Kwik pen for Resident 20 showed the pen had no open date to ensure efficacy of the medication. one Lispro insulin Kwik pen for Resident 87 had no open date to ensure efficacy of the medication. During an interview on 07/22/2025 at 11:41 AM Staff C, LPN stated they believed the insulin pens were kept at room temperature for 30 days per pharmacy recommendations but would need to verify the information. <Team 2 Medication Room> A concurrent observation and interview on 07/22/2025 at 10:13 AM, with Staff E, Resident Care Manager, they stated the Team 2 medication room had been cleaned up by pharmacy recently. The Team 2 med room had one bottle of Potassium that expired 05/2025 (60 days ago). Staff E stated the night shift nurses were responsible for cleaning the medication room, rotating (rotate to be used before expiration) the medications and returning medications to the pharmacy if a resident had been discharged or orders had changed. Staff E acknowledged expired medications in the medication carts and in the medication room. Staff E stated they needed to educate the nurses in the storage of medications. WAC Reference: 388-97-1300(2)

Based on observation, interview and record review the facility failed to inform the Resident Representative (RR) of changes in the resident's pain medication regimen for 1 of 2 residents (Resident 57) reviewed for an order change for pain medication. This failure disallowed the RR to make an informed decision concerning the resident's care needs.Findings Included .<Resident 57> Review of the medical record showed the resident was admitted on [DATE] with diagnoses of a right hip fracture, muscle weakness, seizures and dementia (cognitive impairment). The 07/01/2025 nursing assessment/ care plan showed Resident 57 was totally dependent on staff for all activities of daily living to include bed mobility and transfers to a wheelchair. Resident 57's pain medication orders included a narcotic pain reliever which was discontinued on 07/10/2025. Tylenol (a non-narcotic pain reliever) was started on 07/10/2025 as needed. A 07/12/2025 order was initiated for Robaxin (a muscle relaxant) initiated three times a day on a routine basis. During an observation on 07/15/2025 at 3:02 PM, Resident 57 was up in their wheelchair with metal leg extenders connected to the resident's wheelchair where both legs rested on and extended legs forward. Resident 57 was alert but non-verbal and did not respond verbally or non-verbally when spoken to. The RR stated that they were concerned about not being notified of the new order on 07/12/2025 Robaxin order for Resident 57. The RR stated they were at the facility most of the day with Resident 57 and was not notified of the change in their Robaxin medication and felt that the Robaxin had made the resident drowsier where they could not participate in their physical therapy. During an interview on 07/15/2025 at 3:30 PM, Staff K, Licensed Practical Nurse (LPN), stated that Staff N, Advanced Registered Nurse Practitioner (ARNP) wrote the order, and it was on the Medication Administrative Record as ordered. During an interview on 07/17/2025 at 11:46 AM, Staff N stated that they wrote the order for the Robaxin and did not inform Resident 57's RR about the change. Reference: WAC 388-97-0300(3)(a)

Based on observation, interview, and record review, the facility failed to ensure clinical appropriateness for safe self-administration of medication, leaving medications at bedside for 1 of 2 residents (Resident 82), reviewed for medication administration. This failure placed the residents at risk for medication errors and adverse medication interactions. Findings included .Review of the facility's policy titled, Administration of Medications, dated 09/16/2024, showed, the facility would ensure medications were administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms.<Resident 82> Review of the resident's medical record showed Resident 82 was admitted to the facility on [DATE] with diagnoses to include heart failure, diabetes (a disease in which the body does not control glucose [a type of sugar] in the blood), and dysphagia (difficulty swallowing). Review of Resident 82's comprehensive assessment dated [DATE], showed the resident's cognition was moderately impaired and required setup assistance with eating. During an observation on 07/15/2025 at 10:27 AM, Resident 82 was lying asleep, and next to the resident was a bedside table with a pitcher of water, a tube of Vaseline, and a medication cup. The medication cup contained three medications: one elongated white pill and two beige and green capsules. In an observation and concurrent interview on 07/15/2025 at 2:06 PM, Resident 82 was awake lying in bed, the bedside table had a medication cup with three medications: one elongated white pill and two beige and green capsules. The resident stated they were not aware if the medications were theirs or when they were brought into their room. During an observation on 07/16/2025 at 8:45 AM, Resident 82 was lying in bed sleeping, the resident's bedside table with a water pitcher, butter package and a medication cup with three medications. The medication cup contained three medications: one elongated white pill and two beige and green capsules. During an interview on 07/17/2025 at 12:53 PM, Staff S, Registered Nurse, stated their process for completing a medication pass depended on the resident and how they preferred to take their meds. Staff S stated they looked at the medications because physician orders get changed so quickly and then mark off the medication in computer. Staff S stated for Resident 82, they gave their medications with apple sauce. Staff S stated they could not verify the medications observed at Resident 82's bedside. Staff S stated, it would have not been me because I give their medications with apple sauce. Staff S stated they were not sure how long the medications were on the bedside table, and they did not see the medications when they were in Resident 82's room during their night shift. Staff S stated they did not usually look around the room when delivering medications but, maybe they should start doing a scan of the room with their medication pass. During an observation and concurrent interview on 07/16/2025 at 10:17 AM, Staff B Director of Nursing Services, stated the expectation was for the nurse to follow the rights during medication administration, such as the right med, the right resident, the right route etc., give medication and hand wash when done.Leaving the medications at the bedside was not the expectation. Reference: WAC 388-97-1060 (3)(k)

Based on interview and record review, the facility failed to ensure quarterly financial statements for resident trust accounts were provided in accordance with generally accepted standards of accounting practice for 1 of 3 residents (Resident 6), reviewed for trust accounts. Failure to provide resident /resident representative's quarterly financial statements for the months of January, March, November and October 2024, placed the resident at risk for loss of personal funds. Findings included . <Resident 6> Review of the resident's medical record showed Resident 6 was admitted on [DATE] with diagnoses to include bipolar disorder (a brain disorder that causes changes in a person's mood, energy, or ability to function), dementia [the loss of thinking, remembering, and reasoning- to the extent that in interferes with Activities of Daily Living (ADLs)] and muscle weakness. The comprehensive assessment dated [DATE] showed the resident's cognition was severely impaired and required the assistance of two staff members with all care. In an interview on 07/16/2025 at 2:14 PM, Resident 6's Resident Representative (RR) stated the resident has a trust account with the facility. The RR stated the account did not hold much but had not received financial statements from the facility to verify if Resident 6 still had money in their account. The RR stated the facility had gone through a change in the financial department, but that they had not received a quarterly statement for the first quarter of the year 2024. In an interview on 07/22/2025 at 1:04 PM, Staff J, Business Office Manager, stated the resident had not received financial statements for the months of January, March, October and November of 2024. Staff J stated they had started as the BOM in October 2024 they realized residents had not received their financial statements, so they started a new process of sending out monthly statements. Reference: WAC 388-97-0340 (3)(a)(b)(c)

Based on interview and record review, the facility failed to consistently assess, perform dressing changes as ordered, and implement wound provider recommendations timely for application of a wound treatment device for 1 of 3 residents (Resident 2), reviewed for pressure injuries (PIs - injury to the skin and underlying tissue due to prolonged pressure). The facility failed to timely monitor, assess, implement wound provider recommendations, and perform dressing changes as ordered. This failed practice resulted in harm to Resident 2, when they experienced worsening/deterioration of the PI to the sacrum (the triangular bone at the base of the spine that connects the lower back to the pelvis). Findings included . Review of the National PI Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined PI stages as follows: Stage 1 PI had intact skin with a localized area of non-blanchable erythema (redness). Stage 2 PI was a partial thickness skin loss with exposed dermis (the top inner layers of skin). Stage 3 PI was a full thickness loss of skin, in which adipose (fat) tissue was visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) might be visible, granulation tissue and epibole (rolled or curled under edges) might include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which might be shallow or deep and impaired wound closure). Stage 4 PI was a full-thickness skin and tissue loss with exposed or directly palpable fascia (connective tissue), muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar might be visible. If slough or eschar hides the extent of tissue loss that was an unstageable PI. <Resident 2> Review of the medical record showed Resident 2 was admitted to the facility on [DATE] with diagnoses which included PIs, cellulitis of right lower leg (infection that could cause pain, swelling, redness and tenderness), heart problems and Parkinsons (chronic, progressive and degenerative brain condition that affected the central nervous system). Review of the resident's comprehensive assessment, dated 08/15/2024, showed severely impaired cognitive function and was dependent on staff for activities of daily living. Review of the resident's plan of care, dated 08/27/2024, showed they had an unstageable PI to the right and left buttocks due to immobility. Interventions included weekly treatment documentation to include measurements of skin breakdown's width, length, depth, type of tissue and exudate (fluid that leaked out of blood vessels into nearby tissues). Review of Resident 2's Wound Observation Tool, dated 08/15/2024 (day of admission), showed an unstageable PI to the sacrum which measured 5.0 by 8.0 centimeters (cm), eschar to areas, moisture-associated skin damage (MASD - inflammation caused by prolonged exposure to moisture such as urine, stool, wound drainage), and epithelial tissue (type of body tissue that covered the inside and outside of the body, including the skin) present with necrosis (death of body tissue). Review of Resident 2's Wound Observation Tool, dated 08/24/2024, showed an unstageable PI to the sacrum that had worsened with measurements of 4.5 by 6.0 with 0.7 cm of depth. There was a moderate amount of serosanguinous drainage (thin, watery fluid that leaked from the wound) present with necrotic tissue. The consulting wound provider (Nurse Practitioner - NP) performed debridement to the wound (procedure that removed unhealthy or dead tissue from a wound to help it heal). New treatments orders were obtained. Review of a wound assessment of Resident 2, dated 08/24/2024, by the consulting wound provider (NP), showed a Stage IV PI measuring 4.5 by 6.0 by 0.7 cm. The wound bed was covered in slough and eschar with minimal granulation tissue (new connective tissue that formed during the healing process) in the wound bed. Wound edges were rolled and there was a large amount of serous exudate (the drainage that seeps out of wounds). There was no redness or thickening/hardness of the skin surrounding the wound. Review of Resident 2's Wound Observation Tool, dated 08/30/2024, showed an unstageable PI to the sacrum that had not changed since the previous assessment dated [DATE]. Review of a wound assessment of Resident 2, dated 08/30/2024, by the consulting wound provider, Nurse Practitioner (NP), showed a Stage 4 PI to the sacrum measuring 4.5 by 6.0 by 0.7 cm. There was a large amount of foul smelling purulent drainage (pus that indicated an infection). There was no redness or thickening/hardness of the skin surrounding the wound. The area was debrided by the NP. A wound culture was recommended due to the increased drainage. The assessment stated the necrotic tissue was likely the source of the drainage rather than an infection. The NP recommended a wound vac (treatment that used suction to help wound healing) to be placed after the wound culture results were received and treated if needed. Review of physician's orders showed a wound vac was ordered for Resident 2 on 09/04/2024 with dressing change to be performed three times weekly and as needed. Review of the facility delivery receipt showed the wound vac for Resident 2 was delivered on 09/05/2024. Review of Resident 2's Progress Notes, dated 09/09/2024 at 5:54 PM, showed the wound vac was applied to the sacral area (five days after it was ordered). Resident 2's plan of care, dated 08/24/2024, showed treatment assessments were to be performed weekly. Review of assessments, for the time period between 08/30/2024 through 09/18/2024 showed there was no documentation of an assessment of the sacrum by nursing or providers until 09/18/2024 (19 days later). Review of the 09/18/2024 assessment, performed by the consulting wound physician, showed the Stage 4 PI to the sacrum had worsened as shown by measurements of 4.9 by 3.5 by 2.5 cm (extended depth). The wound bed was covered with brown/gray, necrotic smelling and slough. The wound edges were rolled. The fascia was exposed across the base and the wound physician was able to probe to the bone, although it was not visualized. The physician recommended immediate evaluation and treatment at the hospital. Review of hospital records, dated 09/18/2024, showed imaging would be performed on Resident 2 to evaluate for an underlying abscess (painful, pus-filled lump that developed in the body and usually caused by an infection) and possible osteomyelitis (serious bone infection). Intravenous (via the vein) antibiotic therapy was initiated and a surgical consult was obtained. Review of Resident 2's Treatment Administration Record (TAR) for August 2024, showed daily wound care to the sacrum was not documented on 08/27/2024, 08/28/2024, and 08/29/2024. Review of Resident 2's TAR for September 2024, showed daily wound care to the sacrum was not documented on 09/03/2024 and 09/12/2024. During an interview on 09/26/2024 at 3:42 PM, Staff K, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), stated they remembered measuring Resident 2's wound when the wound vac was applied on 09/09/2024. The measurements were written on a paper towel and Staff K did not recall where that was located as it was never documented in the resident's medical record. Staff K stated the wound vac was ordered but it was not placed on the wound for an entire week. Resident 2's family was very upset due to the wound vac sitting in the resident's room that long. The resident's sacrum had 100% necrotic tissue, thus it had to be surgically debrided at the hospital. During an interview on 09/27/2024 at 9:00 AM, the consulting wound provider (NP), stated they had planned to see Resident 2 following their visit on 08/30/2024, however Staff I, Administrator, told them they could no longer see residents in the facility as they did not have all the credentialing information on them that they needed. Resident 2 had granulation tissue and eschar to the sacral wound so they were a candidate for the wound vac. On their visit on 08/30/2024 the resident did not need any surgical debridement. The wound was bad, but they did not need to go to the hospital at that time. During an interview on 09/30/2024 at 9:00 AM, the consulting physician, stated they assumed the NP was covering for them while they were on vacation. On 09/18/2024 observation of Resident 2's sacral wound showed it stunk, and it was soft and boggy (sign of a deep tissue injury which was damage to the soft tissue caused by pressure). In probing the sacral wound with a Q-tip it went right to the bottom (indicative of increased wound depth). The consulting wound provider stated it was unacceptable for the PI to get to that point as the smell alone was so bad. They stated that Staff J, Director of Nursing, was present during the observation and stated they had no idea. There was necrosis all over the wound and that was why the resident needed to be hospitalized . During an interview on 09/30/2024 at 10:29 AM, Resident 2's representative, stated instead of the resident's wound to the bottom getting better it got worse. Dressing changes were not done as ordered. The wound vac should have been applied to the wound on 09/05/2024, but it was not done until 09/09/2024. It took a long time for the consulting wound physician to see the resident. When the wound physician did see the resident they stated there was nothing they could do at the facility thus the resident was sent to the hospital so fast. During an interview on 10/11/2024 at 2:30 PM, Staff K, stated they had taken over performing wound assessments on all residents when the consulting wound physician made their weekly visits at 6:00 AM. The second week of September 2024, they informed Staff J that one nurse could not do all the wound assessments and it was not working. Additional help was obtained for one week from administrative nursing staff, but it still was not working. Reference (WAC) 388-97-1060(3)(b) This is a repeat deficiency from the Statement of Deficiencies dated 07/17/2024.

Based on interviews and record review, the facility failed to identify and take timely action when a change of condition after a fall occurred for 1 of 3 residents (Resident 1) reviewed for changes in condition. Resident 1 experienced harm due to right hip pain and a delay in medical treatment for a fractured right hip. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included heart problems. Review of the resident's comprehensive assessment, dated 09/10/2024, showed they had moderately impaired cognition. Review of the resident's plan of care, dated 09/04/2024, showed they required two staff to turn and reposition in bed, toileting and transfers; and one staff to assist with dressing and personal hygiene. Review of a facility investigation form, dated 09/11/2024 at 9:30 PM, showed Resident 1 was found by staff lying on the floor. Resident 1 stated they were trying to go to the bathroom and lost their balance upon standing. The resident was transferred by three staff using a mechanical lift from the floor to their bed. No injuries were observed and the resident denied pain. Review of a facility investigation form, dated 09/13/2024 at 9:45 PM, documented by Staff A, Registered Nurse (RN), three days later on 09/16/2024 at 6:02 PM, showed Staff A heard Resident 1 yelling out. Staff A found the resident with both feet on the floor trying to walk. The resident's back was leaning on the bed so Staff A assisted them to sit on the floor. Staff B, Nursing Assistant (NA), assisted Staff A to lift the resident back to bed. There were no identified injuries, range of motion was within normal limits and the resident denied pain. Resident 1 stated they were trying to walk. Review of a written statement by Staff B showed that sometime after dinner on 09/13/2024 Staff A came to find them to report Resident 1 was on the floor and had slid out of bed. Staff A requested assistance to place the resident back in bed. An hour later, Staff B wrote that Staff A told them not to tell anyone as the other nurses and aides would give Staff A a hard time if they knew Resident 1 was on the floor. Staff A stated they did not want to call the family or document the fall and to keep it a secret. Staff B stated they were not comfortable in not reporting the fall so they informed Staff C, RN. Review of a written statement by Staff D, NA, showed the incident occurred after dinner on 09/13/2024. Staff D passed by Resident 1's room and observed Staff A and B in the room. Staff B told Resident 1 that they could not be transferring on their own and needed to use the call light. Staff A asked Resident 1 if anything hurt and they needed to stay in bed. Staff D stated Staff B informed them on 09/13/2024 that the resident fell . Review of Resident 1's Progress Notes (PNs), dated 09/13/2024 at 3:06 PM, showed swelling and pain were observed to the left hip area (documented following the resident's fall on 09/11/2024 at 9:30 PM). The physician was notified and orders received for an x-ray of the resident's left hip. The order was placed with the portable x-ray company, who stated they would be at the facility on 09/14/2024 to take the x-ray. Review of Resident 1's PNs, dated 09/13/2024 at 10:00 PM, but not documented by Staff A until 09/16/2024 at 6:02 PM (approximately three days following the fall), showed Resident 1 sustained no injuries following the fall on 09/13/2024. Staff A documented Resident 1 already had an order for an x-ray to be obtained due to swelling from a previous fall on 09/11/2024. Review of PNs, dated 09/13/2024 at 11:15 PM, documented by Staff C, RN, showed ongoing follow up for fall showed no signs or symptoms of a latent injury. Resident 1 continued with impulsive behaviors and was a significant fall risk. There were no further assessments documented by Staff C of the resident. Review of PNs, dated 09/14/2024 at 7:00 AM, documented by Staff E, Licensed Practical Nurse, showed they received report from Staff C that Resident 1 did not sleep at all that night. The resident was alert and oriented to self only. Swelling was observed to the right and left thighs with skin tight and hard to the right thigh. The resident complained of pain to their right thigh at times and stated they were unable to move their right leg as it was too painful. The physician was notified and orders received to transport the resident to the emergency room for possible blood clots. Review of the resident's Medication Administration Record for September 2024, showed Tylenol was administered by Staff A at bedtime on 09/13/2024. There was no further pain medication administered to the resident, and no documentation of the resident refusing Tylenol. Review of hospital records, dated 09/14/2024, showed Resident 1 had a fractured right hip and surgery was planned for 09/15/2024. The resident was readmitted to the facility on [DATE]. During an interview on 09/26/2024 at 3:20 PM, Staff E, stated when they received shift report from Staff C the morning of 09/14/2024, they reported Resident 1 did not sleep well, but there was no report of the resident having a fall the evening of 09/13/2024. Staff E stated they did not find out the resident had fallen the evening of 09/13/2024 until 5:00 PM on 09/14/2024. Staff E stated they wondered why the resident was complaining of their right leg hurting. Staff E stated their assessment of the resident the morning of 09/14/2024 was that they could not turn as they were in so much pain. The resident yelled out they had not slept all night. It was very different from the day before as Staff E had assisted the resident off the toilet without difficulty. During an interview on 09/26/2024 at 12:50 PM, Staff F, Physical Therapist/Director of Rehab, stated during the day on 09/13/2024 Resident 1 had physical and occupational therapy. In addition to a group exercise program they walked 75 feet with one person assist and a walker. During an interview on 09/26/2024 at 3:40 PM, Staff C, stated they were aware of Resident 1's left hip problem on 09/11/2024 but did not know they had fallen the evening of 09/13/2024 (despite being informed of the fall by Staff B on 09/13/2024). Staff C stated they took over the care of Resident 1 at 10:00 PM on 09/13/2024 from Staff A and continued until 6:00 AM on 09/14/2024. The resident was restless and moving around in bed. Staff C stated they offered the resident Tylenol but they refused it. They did not find out Resident 1 fell on [DATE] until the next day. During an interview on 09/26/2024 at 4:05 PM, Staff B, stated that Staff A asked them for assistance in getting Resident 1 off the floor. In observing the resident they could definitely tell [Resident 1] was in pain and [Staff A] wasn't doing anything, heavy to get into bed, [Staff A] only grabbed [Resident 1's] feet. The resident's face was really red and they were grimacing in pain. An hour later, Staff B stated that Staff A told them not to tell anyone Resident 1 had fallen as they did not want to do the paperwork. Staff A stated they had witnessed the fall so they did not need to fill out paperwork. Staff B then reported to Staff C regarding Resident 1's fall and that Staff A did not want to tell anyone about it. Staff C responded the resident was already on the fall list so there wasn't much they could do. Staff B stated they wrote their statement regarding the resident's fall on 09/13/2024, three days later on 09/16/2024. During an interview on 09/30/2024 at 9:48 AM, Staff G, NA, stated they received shift report at 10:00 PM from Staff B that Resident 1 fell earlier that evening on 09/13/2024. Not too long after that, the resident told Staff G they were aware they had a fall and complained of pain in their right leg. The resident was not able to move their right leg. Staff G stated usually they could turn the resident without assistance but they had to get help that night due to the resident's pain and inability to move their right leg. Staff G obtained assistance from Staff H, NA, to change the resident as they were incontinent. After changing the resident Staff G reported to Staff C at approximately 11:30 PM on 09/13/2024 that the resident was in a lot of pain. Staff C stated they would give the resident something for pain. The resident was not sleeping much and stated they were in pain. Staff G turned the resident with assistance every two hours. Staff G stated they informed the day shift NA on 09/14/2024 that the resident fell the previous evening and was getting an x-ray that morning. During an interview on 09/30/2024 at 12:19 PM, Staff H, stated they and Staff G tried to change Resident 1's brief and noticed they were in a lot of pain in their right hip. Staff H stated they had informed Staff C the resident was having pain in their right hip. The resident was restless but different that night as they were not trying to get out of bed due to not being able to move their right leg. During an interview on 09/30/2024 at 12:26 PM, Staff D, stated they were walking by Resident 1's room after dinner and could hear Staff A and B in the room. Staff B was telling the resident to stay in bed and Staff A was asking the resident if anything hurt. The resident was in bed at the time of the observation. Later, Staff B came to the nursing station and stated the resident fell again. Either on on 09/14/2024 or 09/15/2024 Staff D stated they were asked to write a statement as nothing had been reported regarding the resident's fall. Staff D stated they did not report it to the night shift NAs as they thought it would be reported in shift report by the Licensed Nurses. Staff E did not know the resident fell until later in the day. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 07/17/2024, 04/16/2024, 01/09/2024, and 09/13/2023.

Based on interviews and record review the facility failed to consistently monitor and develop planned interventions for edema (swelling caused by too much fluid in the tissues), monitor weight gain and effectiveness of diuretic therapy (medications that help reduce fluid buildup in the body) for 1 of 3 residents (Resident 1) reviewed for changes in condition. Resident 1 experienced harm due to a decline in their mobility and delay in receiving medical treatment. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] from the hospital with diagnoses which included congestive heart failure (CHF - a weakened heart that causes fluid buildup in feet, arms and lungs), heart and lung disease. Review of the 11/20/2023 comprehensive assessment showed Resident 1 had moderate impairment in their cognition; required supervision or touching assistance with upper body dressing, personal hygiene, walking 10 feet, chair/bed to chair transfers and sit to stand position; partial/moderate assistance with lower body dressing and toilet transfers. Review of Resident 1's hospital records, dated 11/17/2023, showed Lasix 20 milligrams (mgs) - (a diuretic medication used to treat edema and swelling) was ordered to be given daily as needed for edema or shortness of breath. The resident's weight at the hospital on 11/17/2023 was 193.5 pounds. Review of Resident 1's complete weight history between 11/18/2023 to 12/19/2023 showed the following increase of 34.6 pounds: 11/18/2023 - 192.8 pounds 11/20/2023 - 197.8 pounds 11/21/2023 - 200.6 pounds 12/05/2023 - 220.2 pounds 12/19/2023 - 227.4 pounds Review of the 11/21/2023 assessment by the Registered Dietician showed Resident 1's weight was trending upward and might be fluid, had pitting edema (type of swelling often in the legs that causes enough fluid retention to leave an indentation when pressing on the affected area) The pitting edema scale of 1+ showed trace of edema; 2+ showed mild edema; 3+ showed moderate edema and 4+ showed severe edema. The resident's ideal body weight range was 160-196 pounds. Review of Resident 1's December Medication Administration Record (MAR) showed the resident received the as needed Lasix 20 mgs on 12/02/2023, 12/03/2023, 12/07/2023 and 12/11/2023. On 12/11/2023 the physician ordered the Lasix 20 mgs to be given daily for seven days through 12/18/2023 which was done. There was no documentation Lasix was administered to Resident 1 on 12/19/2023, even though the resident continued to experience edema. Review of Resident 1's plan of care, dated 11/20/2023, showed a problem addressing Resident 1 being at risk for weight fluctuation due to multiple diagnoses which included CHF. There were no planned interventions for edema. Review of the following Progress Notes between 12/10/2023 to 12/19/2023 showed Resident 1's change in condition and lack of a thorough assessment/monitoring for edema and a delay in obtaining medical treatment: 12/10/2023 at 11:10 PM - no assessment for edema 12/13/2023 at 11:37 AM - no SOB, no assessment for edema despite new physician's orders to administer Lasix daily for seven days 12/15/2023 at 2:41 PM - only vital signs documented, no other assessments 12/16/2023 at 5:20 PM - no SOB, no assessment for edema 12/17/2023 at 3:09 PM - no SOB, no assessment for edema 12/19/2023 at 3:31 PM - resident tested positive for COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death), labored breathing, physician and family notified 12/19/2023 at 7:49 PM - resident continued to display increased labored respirations and lethargy (a state of weariness that involves diminished energy, mental capacity and motivation), resident continued to remove the oxygen and began to reach out in the air for things not there, slow to respond and increased sleepiness, did not eat any meals that day, urinated on the floor which was not their normal behavior; physician did see the resident late in the afternoon, resident's family member voiced concern over the resident's condition and increased edema with weeping to the lower legs, 3+ pitting edema to their knees, physician gave orders to transport the resident to the emergency room (ER). Review of the 12/19/2023 and 12/26/2023 hospital records showed Resident 1 was admitted to the hospital with increased SOB and increased lower leg edema of 3+. The hospital assessment showed they had diagnoses which included chronic respiratory failure secondary to chronic CHF, lung disease and COVID-19. Resident 1 received Lasix 80 mgs intravenously (IV-administered through a vein) in the ER and 40 mgs of Lasix IV twice daily in the hospital, daily weights, and fluid and salt restrictions. Resident 1 was hospitalized for seven days. Review of Resident 1's PT sessions between 12/12/2023 to 12/19/2023 showed the following: 12/11/2023 - resident with noticeable decreased level of alertness and required long rest breaks due to SOB and over fatigue, required increased level of assistance for functional mobility, increased noticeable edema, fatigue and difficulty staying alert unless provided with constant verbal stimulation 12/12/2023 - resident with increased fatigue, swelling in both legs and abdomen and decreased alertness - all reported to nursing 12/14/2023 - therapist communicated with nursing due to resident's most recent decline in overall alertness and functional mobility and level of assistance required for all functional performance, resident with increased edema and swelling 12/15/2023 - noticeable increased edema and overall increased respirations, increased fatigue and needed extra time for mobility and tasks, safety concerns with mobility training 12/17/2023 - recent decline in medical status including increased edema in lower legs and reduced alertness, nursing aware of the change in condition, resident had been sleeping in their chair at night which was likely contributing to their increased edema 12/18/2023 - most recent decline with overall health due to fragile medical condition and history of heart concerns with increased fluid retention, nursing will address resident's family concerns along with therapy regarding the amount of swelling in both legs and abdomen 12/19/2023 - resident required two staff to assist in turning in bed, noted increased swelling and overall increased respirations with complaints of SOB, therapist notified nursing staff immediately to assess resident's medical condition due to noted increased swelling to lower legs and abdomen In an interview on 01/09/2024 at 9:30 AM with Staff G, PT Assistant, they stated Resident 1 had been walking well when admitted . They began having a functional decline due to the swelling in their lower legs. Staff G stated on 12/19/2023 they were not appropriate for therapy due to the weeping of their lower legs so therapy was not performed. On 12/18/2023 Staff G requested a care conference with Resident 1's family due to their decline in function. They had fluid overload and were doing minimal range of motion to get the fluid moving. Their stomach was also distended (swollen due to pressure inside). Resident 1 needed a recliner chair and refused to use leg rests as they self propelled and they placed additional pressure on their stomach. In an interview on 01/09/2024 at 2:51 PM with Staff H, Registered Nurse, they had notified the physician the morning of 12/19/2023 as Resident 1 was gasping for air while lying down. The physician increased the dosage of Lasix from 20 mgs to 40 mgs at that time. Staff H was unable to accurately recall if any Lasix had been administered to Resident 1 that day as there was no documentation on the MAR of the medication being given on 12/19/2023. Staff H stated staff should have been doing daily weights on residents with CHF and checking their legs for edema. Staff I, LPN, stated on 01/08/2024 at 11:45 AM, Resident 1's family member had come to them on 12/19/2023 asking them to observe the resident's legs. Upon observation of the resident's legs Staff I replied the resident's Lasix needed to be increased thus they instructed Staff H to notify the physician. The family member also wanted the resident's legs elevated so a recliner was found and placed in the resident's room. Staff E, Director of Nursing, stated on 01/08/2024 at 8:40 AM, the physician did not see Resident 1 until late evening on 12/19/2023. The physician also did not recall ever seeing the electronic fax sent to them by Staff F on 12/17/2023 regarding Resident 1's leg edema and family concerns. Staff E also stated there was no facility policy on monitoring of edema but per corporate staff they were to use best practice which was checking for pitting edema every shift or doing daily weights. Collateral Contact 1 (Resident 1's representative) stated on 01/05/2024 at 12:11 PM, that all the resident did all day was sit in their wheelchair with their legs down until they got the recliner. Their edema had not been a consistent problem since their admission to the facility, but had worsened when they visited on 12/15/2023. Collateral Contact 2 (family member of Resident 1) stated on 01/05/2024 at 11:45 AM, that staff was aware of their edema on 12/14/2023 but nothing was being done. On 12/18/2023 Resident 1's legs had ballooned, and the excuse staff gave was that they were waiting for the physician to give orders for medications. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 09/13/2023 and 04/24/2023.

Based on observation, interview, and record review, the facility failed to provide a safe transfer utilizing the sit-to-stand lift (a mechanical lift used to assist residents that have difficulty standing up on their own) for 2 of 2 residents (Residents 1 and 2), reviewed for resident's that used a sit-to-stand transfer device. Resident 1 experienced a left arm fracture when they slipped out of the mechanical lift device during the transfer from their bed to the wheelchair when the waist support strap was not tightly secured. This failure placed other residents at risk for injury, falls, and a diminished quality of life. Findings included . The facility policy titled Transfer using a Sit to Stand Mechanical Lift, last reviewed on 09/15/2023, showed the facility will ensure two staff members are present during the transfer of residents that required a mechanical lift. The policy also showed when staff utilized the support slings, they must be snug, and comfortable or the resident could slide out of the sling. Additionally, staff were to ensure the resident's knees were secured against the knee pads and their feet were positioned on the foot plate. Review of the [NAME] II Sit-to-Stand (the mechanical lift utilized in the transfers involving Residents 1 and 2) lift instructions for use, showed the calf support straps may be used for residents that needed to have their weakened legs secured or as a reminder not to step off the footrest. <Resident 1> Review of the Resident 1's medical record showed they were admitted to the facility on [DATE] with diagnoses which included stroke with left sided weakness and arthritis. The 07/19/2023 comprehensive assessment showed Resident 1 had severe cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions that affect everyday life) and required extensive assistance of two staff to assist with transfers. Review of the post fall nursing documentation, dated 09/21/2023 at 3:53 PM, showed Resident 1 was lowered to the floor when staff attempted to transfer them from the bed to the wheelchair. At 3:54 PM documentation showed the fall happened at 8:15 AM on 09/21/2023 and the physician was notified at 12:00 PM, when the resident complained of left arm pain and refused to move it. On 09/21/2023 at 5:54 PM, the resident had an x-ray of their left shoulder, elbow and wrist which showed an acute left humeral neck fracture (a broken bone in the upper part of the arm near the shoulder). The resident was then transferred to the local emergency room (ER) for an evaluation. Review of hospital records, dated 09/21/2023, showed Resident 1 was discharged from the ER with their left arm in a sling and they were to follow up with an orthopedic physician (specializes in conditions involving the musculoskeletal system). During an interview on 09/27/2023 at 9:11 AM, Resident 1 stated they had injured their left arm during a transfer when staff had gotten them out of bed using a sit-to-stand lift device, which caused them to fall to the floor. Resident 1 stated their left arm began to hurt immediately. During an interview on 09/28/2023 at 2:08 PM, Staff D, Nursing Assistant (NA), stated they were assisting Resident 1 with Staff E, NA, from their bed to the wheelchair using a sit-to-stand lift. During the transfer Staff D stated Resident 1 would not keep their right foot on the foot plate. Staff D stated they placed the support strap around the resident's waist when the resident was sitting on the bed. When they stood the resident up the support strap became loose and they were unable to tighten or adjust it during the transfer. Staff D stated when the resident raised their arms above their head they became dead weight during the transfer and slipped out of the mechanical lift. Staff D and Staff E assisted the resident to the floor. Staff D and Staff E stated there were no calf support straps on any of the sit-to-stand lift devices in the facility, and they had not been trained on how to use them. Staff D stated the sit-to-stand lift device was required to be performed with two staff members. During an interview on 09/27/2023 at 3:43 PM, Staff A, Licensed Practical Nurse/Resident Care Manager, stated the sit-to-stand was not used correctly, and calf support straps should have been used. <Resident 2> Review of Resident 2's medical record showed they were admitted to the facility on [DATE] with diagnoses which included stroke with paralysis on the right side of their body and history of falls. The 08/23/2023 comprehensive assessment showed the resident had severly impaired cognition and required limited assistance with two staff with transfers. Review of the Resident 2's plan of care, dated 08/18/2023, showed they required a sit-to-stand lift by two staff to transfer between surfaces and they were at risk for falls. An observation on 09/27/2023 at 4:09 PM showed Resident 2 was being transferred from their bed to the wheelchair by one staff member. The resident had their left hand resting on the sit-to-stand sling support bar and their right arm was hanging down. The upper body support strap was around their upper chest which raised the resident's shoulders upwards, suspending them by the upper body chest support. The calf support straps were not utilized during the transfer despite the resident's paralysis/weakness to their right side. During an interview on 09/27/2023 at 4:14 PM, Staff F, NA, stated they had multiple trainings on the usage of the sit-to-stand lift. Staff F stated they had never used the calf support straps, and had not seen them in the facility. Staff F stated Resident 2 had no strength on their right side. Reference WAC: 388-97-1060(3)(g) This is a repeat deficiency from the Statement of Deficiencies dated 06/14/2023 and 12/06/2022.

Based on observation, interview and record review, the facility failed to respond timely to a visibly swollen and painful ankle for one of three residents (Resident 1) reviewed for quality of care. This deficient practice of delay in treatment and services, and lack of pain control caused actual harm to Resident 1, when the facility took over 48 hours to identify that their change in condition required a transfer to a higher level of care facility for evaluation and treatment, and during that time failed to adequately assess and treat pain. Findings included . Review of the facility policy titled Changes in Resident's Condition or Status, updated on 08/18/2022, stated .any change from baseline in a resident's status must be identified and addressed ., and .notable changes include decline in functional status, new or increasing confusion, (new) onset of pain, falls, deteriorating mobility . Further review of the policy showed the procedure to include .identify a suspected change .complete a physical assessment focusing on identified change .communicate the change to the appropriate practitioner, notify the resident's family .document the procedure . Resident 1. Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses of generalized muscle weakness, history of falling, and alcoholic cirrhosis of the liver (a condition in which the liver is scarred and permanently damaged from drinking excessive alcohol). Review of the comprehensive assessment completed on 03/31/2023 showed the resident had moderately impaired cognition, required extensive assistance of one person for transfers, bed mobility, dressing, toileting, personal hygiene and used a wheelchair for mobility. During an interview on 04/21/2023 at 11:00 AM, Staff L, Nursing Assistant (NA), stated they were able to get the resident out of bed to the bathroom the morning of 04/10/2023 but they were not able to put weight on the left leg due to pain. Staff L explained they observed the left ankle to be swollen and notified Staff P, Registered Nurse (RN), and Staff N, Physical Therapist (PT) of the change on 04/10/2023 at 10:00 AM. Staff L stated the resident was always confused. During an interview on 04/24/2023 at 11:34 AM, Staff N confirmed they were notified by Staff L the morning of 04/10/2023 that the resident complained of left ankle pain. Staff N explained they assessed the left ankle to be red, swollen, and tender to touch. Due to the significant changes in the resident's ankle Staff N stated therapy was held on that day and confirmed the presentation of the left ankle was new compared to their last therapy session on 04/05/2023. Staff N stated that Staff L had informed them they had already notified the nurse in charge, Staff P of the changes in the resident's ankle. The following day (04/11/2023) Staff N stated they went to Staff O, Agency Licensed Practical Nurse (LPN), (Licensed Nurse in charge of the resident's care that day), to check on the status of the resident's left ankle. Despite significant changes in the resident's ankle on 04/10/2023 Staff O was unaware of those changes and did not have an update. Staff N further explained they requested Staff Q, Medical Director (MD), to evaluate the resident's left ankle as they were in the facility that day (04/11/2023). Despite Staff L stating they had notified Staff P on 04/10/2023 of the changes to the resident's left ankle, Staff P stated on 04/21/2023 at 12:54 PM they were unable to recall the notification. They stated they did not observe or assess the resident's feet or ankles on that day (04/10/2023). Review of Staff Q's Progress Note (PN), dated 04/11/2023 at 9:00 AM, showed the resident had a painful left ankle and complained they could not walk, which had developed in the last few days and had not occurred before. The MD assessment showed the left ankle was firm with swelling, thus questionable dislocation or lesion. The stated plan was to obtain an x-ray Stat (immediately). During an interview on 04/24/2023 at 10:37 AM, Staff Q stated they were notified of a concern with the resident's left ankle by Staff N on the morning of 04/11/2023. Staff Q explained their evaluation of the left ankle showed redness and a bony prominence to the lateral (outer) side of the (left) ankle indicating the bones were not aligned. Staff Q explained they gave a verbal order to the nursing staff for an x-ray of the left ankle to be done right away. Review of the above physician's orders in the Electronic Health Record (EHR) showed Staff O placed an order for x-ray two views of left ankle for tenderness/swollen ankle on 04/11/2023 at 9:26 AM to a mobile x-ray company. When staff processed/transcribed the physician's verbal order, it showed no indication it needed to be completed urgently as originally requested by the physician. During an interview on 04/24/2023 at 9:40 AM, Staff O, Agency Licensed Practical Nurse, stated they could not recall details from the xray order they verbally received for Resident 1. During an interview on 04/24/2023 at 12:01 PM, Staff R, Collateral Contact, confirmed the mobile x-ray company electronically received an order for a left ankle x-ray for the resident on 04/11/2023 at 11:42 AM. Staff R explained the order was placed as routine which allowed the x-ray technician to determine the x-ray's priority based on their current workload. Staff R further explained the technician was dispatched at 11:48 AM, arrived at the facility at 6:46 PM, and completed the x-ray at 7:00 PM (9.5 hours after Staff Q gave verbal orders for the x-ray to be done right away). Staff R confirmed the mobile x-ray company made the maximum number of attempts to fax the completed x-ray report to the facility but was not successful. Staff S, NA, (caregiver for the resident on the evening shifts of 04/10/2023 and 04/11/2023) stated on 04/21/2023 at 2:30 PM that they were aware the resident's foot was sore but did not notice that the resident was in pain. The resident was restless in bed and frequently throwing their blankets on the floor. The resident was different in that they were not trying to get up on their own like they usually did. Review of the PN, dated 04/12/2023 at 7:15 AM, showed the resident had an unwitnessed fall at 4:10 AM on 04/12/2023 and was found lying on their back between the bed and window of their room. Staff M, LPN, assessed the resident's range of motion to all limbs and noted .diminished flexibility with swollen ankle . to the left lower extremity, and the results from the x-ray performed earlier were still pending. Despite noted changes in the resident's left ankle (pain, redness, swelling and difficulty walking) the morning of 04/10/2023 an interview with Staff M on 04/24/2023 at 3:16 PM, showed no information was given to them during shift report on 04/10/2023 at 6:00 PM regarding the resident's left ankle. On 04/11/2023 they were informed by the previous shift that an x-ray had been ordered by the physician, which was performed by a mobile x-ray company between 7:00 to 8:00 PM on 04/11/2023. Following the x-ray the technician left a CD (compact disc) with the images of the x-ray at the nursing station. When Staff M observed the resident's ankle during medication administration on 04/11/2023 it was twisted outward and not straight. Tylenol was administered for resident complaints of pain in their neck and lower back following their fall the morning of 04/12/2023. Staff M stated they did not attempt to locate the x-ray results when there was a delay in receiving the results, or notify the physician that a CD was made available following the x-ray. Review of the resident's Medication Administration Record showed Tylenol was administered on 04/12/2023 at 5:08 AM and the medication was ineffective. During an interview on 04/24/2023 at 1:10 PM, Staff H, RN/Minimum Data Set Coordinator, stated the facility never received a faxed copy of the resident's x-ray report. Staff H explained they were looking up x-ray reports for another resident and observed the resident's x-ray report was available. They printed the report from the mobile x-ray company's EHR system on 04/12/2023 at 9:50 AM (over 24 hours after the x-ray was first ordered and over 14 hours after the x-ray was completed) and documented the results of an .unstable ankle fracture . in a PN. Review of the PN dated 04/12/2023 at 11:16 AM, showed the MD was notified of the x-ray results and gave orders to send the resident to the emergency department for evaluation and treatment (one and a half hours after receiving the x-ray report and 26 hours after the x-ray was completed). Review of the ambulance report, dated 04/12/2023 showed the emergency call for transport to the hospital was received on 04/12/2023 at 11:50 AM and the resident arrived at the hospital at 12:28 PM. Review of the hospital records, dated 04/12/2023, showed the resident arrived at the hospital with main complaints of left ankle closed displaced fracture (broken bones with a gap between the pieces) and increased confusion. Further review showed the resident was admitted to the hospital for a surgical fusion (connecting bones together using hardware such as pins and screws) procedure of the left ankle. The resident had swelling and pain to the left ankle and increased confusion secondary to their liver disease. During an interview on 04/21/2023 at 12:00 PM, Staff K, Director of Nursing Services (DNS), stated the resident's ankle should have been assessed on 04/10/2023 when the change was initially identified by staff. Staff K stated they understood STAT meant be done right away and the time it took to complete the x-ray and receive the report seemed slow. Further interview with Staff Q on 04/24/2023 at 10:37 AM, showed that Staff Q stated the amount of time it took from ordering the x-ray to being notified of the x-ray results (25 hours and 50 minutes) was not acceptable. Staff Q explained pain could have been the cause of the resident's confusion. Staff T, Emergency Medical Technician (EMT), stated during a telephone interview on 04/19/2023 at 11:02 AM, that the resident's foot was very swollen, damaged, with a possible dislocation upon arrival to the facility on [DATE]. Staff T stated, they did not attempt to stablize it, ice it or elevate the foot, nothing was being done. The resident had an altered level of consciousness and was not registering pain. Staff U, EMT, stated during a telephone interview on 04/18/2023 at 6:57 PM, that the resident complained of pain when a splint was applied to the left ankle prior to transport to the hospital on 04/12/2023. They stated staff had only given one dose of Tylenol to the resident despite the left ankle being an obvious fracture. Despite the observations of pain, and/or swelling and tenderness to the resident's left ankle between the morning of 04/10/2023 to 04/12/2023 at 12:00 PM, review of their medical record during that time showed there were no nursing assessments regarding the change of condition (with the exception of the resident's fall on 04/12/2023). Despite the resident's complaints of ankle pain and changes in behavior, the only pain medication administered to the resident during that time was Tylenol (given for mild pain) which was administered for complaints of neck and back pain following the fall on 04/12/2023. Staff did not reach out to the physician when pain measures were ineffective. There were no other pain medications ordered by the physician for the resident. In addition, despite Resident 1's known fracture on 04/12/2023 at 9:50 AM, staff failed to provide non-pharmacological interventions to decrease swelling and pain regarding a fracture such as ice, elevation, and splinting. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the statement of deficiencies dated 02/25/2022.

Based on observation, interview, and record review, the facility failed to verify and ensure Licensed Nurses (LNs) had the appropriate competencies, skill sets and proficiencies to provide nursing and related services for each resident in the areas of identification and response to significant change in condition, assessment with appropriate interventions, lab review and reporting, reporting of change of condition to responsible parties and the physician and to assure resident safety. The lack of ongoing clinical assessments and timely identification of changes in condition to meet the resident's needs, resulted in a delay in timely intervention, medical care, and hospitalization s. These failures resulted in a significant decline in condition and hospitalization for three of three residents (24, 30, 40), delay in interventions and services for two of two residents (29, 26) and increased the likelihood of serious injury, serious harm, serious impairment, or death. On 02/17/2022 the facility was notified of an Immediate Jeopardy at CFR 483.35(a)(3) F726 related to the facility's failure to ensure that licensed nurses were trained, competent and qualified. The facility removed the immediacy on 02/18/2022 with a validation date of 02/22/2022 at 4:08 PM by implementing a removal plan with interventions to ensure all LNs received competency training which included but was not limited to: change of condition, intervention and assessment; critical labs, follow-up labs and physician notification; utilization and implementation of Situation, Background, Assessment, Recommendation (SBAR - an assessment tool which facilitates prompt and effective communication) and when to notify the physician. Findings included . Review of the facility's policy Nursing Competency Assessment revised 11/08/2021, showed an assessment of clinical competency of nursing personnel would be done prior to employment, during the orientation period and at regular intervals throughout employment in order to provide a measurement of nursing competency .assure ongoing education to improve and maintain competency skills; and .provide written documentation concerning the capabilities of nursing personnel to provide quality patient care. Review of the facility's policy titled, Change in Status, Identifying and Communicating, dated August 2021, showed the facility utilized, Stop and Watch Early Warning Tool (process for notification of change in condition), Situation Background Assessment Reporting (SBAR) tool, and included an addendum of Lippincott's 2021 procedures Change in Resident's Condition .Residents should be assessed for changes from normal status .whenever the resident's status changes .The resident's current status should also be checked against baseline status .and notable changes include a decline in functional status, new or increasing confusion, incontinence, weight gain or loss in excess of 5% of body weight .at minimum, the assessment should include reviewing the medical record, asking how the resident feels and what symptoms the resident has, obtaining vital signs, observing the resident's overall condition, including function and cognition and exploring complaints .recognizing changes, assessing the resident, and intervening early on allows the resident to receive appropriate care, decreasing the need for transfer to an acute care facility or emergency department .The nurse must communicate a resident's change in status, including assessment findings, to the practitioner. Review of five medical records revealed that the facility nurses did not comprehensively assess Residents (24, 30, 40, 29, 26) and did not implement timely interventions when the residents experienced a change in condition. The facility failed to identify and assess change in the residents' conditions and failed to report assessment findings to the physician timely. See F684 for additional information regarding Residents 24, 30, 40, 29 and 26. 1) Resident 24. Review of the medical record showed no documentation regarding LN assessments and/or a comprehensive record review had been completed in reference to the lab orders. There was also no documentation to show a notification to the physician about the 02/14/2022 ordered labs not being obtained. Resident 24 had critical electrolyte levels of sodium and chloride on 02/11/2022, resulting in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional sodium and chloride level labs were ordered for 02/14/2022 to monitor the effectiveness of the subcutaneous hydration. From 02/11/2022 through 02/13/2022, the resident received a hydration solution of sodium and chloride (which the resident already had lab-confirmed critical values established on 02/11/2022) instead of the ordered Dextrose solution; as a result, Resident 24 was sent to the hospital for an evaluation. The facility failed to ensure professional standards of practice were implemented when they ordered an administration of fluids via hypodermoclysis (subcutaneous hydration (sq) indicated for mild to moderate dehydration). Review of the facility's contracted pharmacy policy titled Hypodermoclysis dated 06/01/2021, showed that hypodermoclysis was not intended for Patients with severe electrolyte imbalances. 2) Resident 30. Review of medical record showed the resident, at baseline status, was able to communicate needs and preferences, was able to feed self when positioned upright in bed and enjoyed participating in activities. On 01/15/2022 the resident acquired a respiratory infection and experienced gradual declines in ability to feed themself, communicate needs and preferences and was slower to respond to questions and occasionally would not answer questions. On 02/06/2022 the facility received labs which showed Resident 30 had several lab values out of normal range and a Blood Urea Nitrogen (a blood test that measures the amount of nitrogen in your blood that comes from waste, this test is done to see how well the kidneys are functioning) lab value showed a critical level - indication of 109 (normal range 8-27). When kidneys are not working well, the urea nitrogen will stay in the blood. Other causes of high or critical levels include dehydration and heart failure. The record showed no SBAR, no interventions or new orders from the physician regarding the critical lab and no monitoring for other signs/symptons related to kidney function (such as urine output). Review of a progress noted showed on 02/12/2022 at 9:20 PM the resident was non verbal. Blank stare. Unable to follow directions. Holding medications crushed in apple sauce in mouth. Coughing with swallow. Unable to use straw successfully. Holding food and medications in mouth. Coughing with swallowing. Review of a progress note showed on 02/13/2022 at 2:50 PM no response verablly (sic) when cued to swallow. Was not able to drink / eat, and could not respond verbally the doctor was notified and Resident 30 was emergently sent to the hospital. 3) Resident 40. Review of medical record showed LNs did not notify physician or conduct a thorough assessment and report to the physician when the resident experienced debilitating pain and decline in level of function. The facility did not note or follow-up when a 02/05/2022 lab report showed Resident 40's labs were high in several areas which included high in C-Reactive Protein (CRP- measures protein in the blood) at 109 (normal range 0-10). High levels of CRP may be a sign of serious infection or other disorder. Review of a 02/02/2021 progress note showed the resident experienced a 9 out of 10 (0 being no pain and 10 being greatest pain) pain. The record showed the narcotic pain medication was changed from as needed to routinely scheduled. The progress notes showed no on-going assessment or that alert charting had been initiated to monitor the effectiveness of the change in pain medication. 4) Resident 29. Review of the resident's medical record showed the resident admitted on [DATE] with a small pimple like lesion on the left upper lip. Review of a physician's note dated 01/27/2020 showed the resident's lesion was crusty and raised. The physician instructed the staff to monitor the lesion and consider follow up with a dermatologist (a physician that specializes in diseases of the skin). During an interview on 02/22/2022 at 10:44 AM, Staff J, RCM stated that the lesion had noted growth in March 2021. Staff J was unable to recall if the physician had been notified or if the resident's lesion had been assessed related to the changes. Staff J did not have documentation to show that staff had been monitoring the lesion as directed by the physician over two years ago. Review of a physician's note date 08/25/2021 showed another referral from the physician for the resident to see a dermatologist. Review of the dermatologist note dated 10/19/2021 showed the resident's upper lip lesion was too advanced for treatment. 5) Resident 26. A review of medical record showed that blood in the resident's brief was first noted on 10/24/2021, per a progress note written that day. Subsequent progress notes in October, November, December 2021, and January 2022 showed some reference to the resident bleeding (either blood in urine, vaginal bleeding or blood noted in the resident's brief) and that the physician was informed or was aware. A further review of the resident's record back to 10/24/2021 did not show any referral or appointments made to any specialists, to determine the underlying cause of the bleeding. A progress note, dated 01/31/2022, showed that the resident was sent by ambulance to the local hospital emergency room . While hospitalized , the resident was diagnosed with new [CONDITION(S)]. They were discharged back to the facility on [DATE] with a urinary catheter (tube inserted into the bladder to drain urine) and a left nephrostomy tube (a tube that goes directly into the kidney to drain urine). Record review of a physician order, dated 02/09/2022, showed to Cleanse around nephrostomy tube site with normal saline and cover tube site dressing (gauze), then cover with bordered foam dressing. Check every shift and change when soiled. On 02/22/2022 at 1:48 PM, observed Staff N, Licensed Practical Nurse (LPN) perform nephrostomy site care with Staff J, RCM. There was a blue foam securement device, covered in brownish drainage, sticking to the tubing. It was crumpled, moist, sticky and not attached to the skin. In a concurrent interview, Staff J referred to the securement device as the original surgical dressing. Staff N stated that it's the same one that she came here with (from the hospital, 13 days ago). Staff J stated that usually the nephrostomy tubes only have a split gauze around it, not that part. After Staff N cleansed the area, they laid the same soiled securement device over the insertion site and covered it with a new adhesive foam dressing. Neither Staff J nor Staff N recognized that it was a securement device (not a surgical dressing) that should not have been in direct contact with the insertion site, possibly allowing for infection to get directly into the left kidney. In a review of the EMR from 02/09/2022 until 02/21/2022, there was no documentation of attempts to reach out to a physician about what to do about the original surgical dressing at the nephrostomy site, although the TAR showed site care was done. During a concurrent interview and record review on 02/15/2022 at 2:24 PM, Staff M, Accounts Payable/Payroll, stated they were responsible to maintain employee files with competency and training records. Staff M stated the facility did not have anyone appointed to the nursing Staff Development Position, wherein oversight and training was provided to assure LN and Nursing Assistant (NA) competencies were completed and documented. Review of the facility's personnel files of 11 of 11 LNs, showed no current record of clinical competencies since 2019. During an interview on 02/17/2022 at 2:46 PM, Staff A, Administrator requested more information regarding what information was needed regarding LN staff competencies. This surveyor informed Staff A to provide LN records showing competencies in nursing related functions. During interviews which were conducted on 02/17/2022 between 3:30 PM and 3:47 PM, six of six LNs stated they had not received competency based training or skills check-off conducted by the facility. As of 02/17/2022 at 4:00 PM, no additional LN training/competency assessment records were provided by the facility. During an interview on 02/18/2022 at 12:48 PM with Staff L, Medical Director (MD), they stated the identification and notification to (Staff L) regarding change of condition was very simple because They (LNs) see these people (residents) more than I do. Staff communicate via text or phone call. If it's a critical lab - I would get them right away. Staff L stated they did not review the resident's electronic medical record (EMR) and that was because - the reason the nursing staff were there (at facility) was to identify needs and let me (Staff L) know. That's what they are here for. See Cross Reference: F-684 Reference: WAC 388-97-1680(2)(a)(b)(i)(ii)

Based on observation, interview and record review, the facility failed to; 1) identify changes in condition for three out of five residents (24, 30, 40) reviewed for quality of care, that experienced a significant decline in overall health conditions which resulted in hospitalization , 2) identify/act on a significant change in condition which resulted in the advancement of a cancerous lesion beyond curative treatment for one of five residents (29) reviewed for quality of care, and 3) facilitate a referral of a resident with three months of hematuria (blood in the urine) to a specialist (which resulted in delayed treatment for Hematuria) and provide care that met professional standards for the same resident with a new Nephrostomy (a tube that goes directly into the kidney to drain urine) tube for one of five (26) residents reviewed for quality of care. This lack of ongoing clinical assessments and timely identification of changes in condition to meet the resident's needs resulted in a delay in timely intervention, medical care, and hospitalization s which resulted in an Immediate Jeopardy (IJ). On 02/17/2022 the facility was notified of an IJ at CFR 483.25 F684 related to the facility's failure to identify a change in condition for five of five residents. The facility removed the immediacy on 02/18/2022 with a validation date of 02/22/2022 at 4:08 PM by implementing a removal plan with interventions to ensure all Licensed Nurses (LN's) received competency training, which included but was not limited to: change of condition, intervention and assessment, critical labs/follow-up labs and physician notification, utilization and implementation of SBAR (assessment tool which facilitates prompt and effective communication) and when to notify the physician. Findings included . Review of the facility's policy titled Changes in Resident's Condition or Status, dated 02/02/2021, showed the facility would notify .his/her primary care provider .of changes in the resident's condition or status. Resident 24. Review of the resident's medical record showed that the resident admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) The record further showed Resident 24's cognition was moderately impaired. During a concurrent observation and interview, on 02/09/2022 at 9:43 AM, the resident had been lying in bed sleeping, hair disheveled and in a hospital gown. The Resident's Representative (RR) was at the bedside visiting. The Surveyor attempted to communicate with the resident, but the resident did not respond, only stared blankly. The RR stated the resident had been working with therapies, and doing well, but noticed a decline in the past week. The RR stated the resident was able to get up and walk a few steps with maximum 2-person assistance and sit on the edge of the bed, but the resident was no longer doing that. The dementia seems like it has been progressively getting worse quick. The RR further stated that the resident had been refusing to eat and drink. Review of the Occupational Therapy notes from 02/03/2022 to 02/07/2022, showed Staff LL, Occupational Therapist (OT), documented the resident had improvements in functional ability with 1-2 step tasks, standing, and positioning in the wheelchair (w/c). The OT notes from 02/07/2022 to 02/16/2022, showed the resident had restlessness, lethargy during sessions, and was uninterested in therapy. Review of the Physical Therapy notes from 02/02/2022 to 02/04/2022, showed Staff DD, Physical Therapist (PT), documented the resident had made progress with sitting to standing tasks during the session. The PT notes from 02/04/2022 to 02/16/2022 showed the resident had lethargy, fatigue, weakness, drowsiness, unable to sleep, verbal aggression, couldn't stand, and had constant moving of the arms and legs. These changes were reported to nursing staff eight times, from 02/07/2022 through 02/11/2022, and from 02/14/2022 through 02/16/2022. The PT completed a Stop and Watch (a tool used to communicate changes in condition to nursing staff) on 02/15/2022, and informed Staff HH, Licensed Practical Nurse (LPN). Review of the Stop and Watch completed by Staff DD, PT, dated 02/15/2022, showed the resident's changes in condition were mentioned in the PT notes and was received by Staff HH. Review of Resident 24's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 24's nursing progress notes showed the following: (1) dated 02/07/2022- resident combative with staff, resistive to care, nutrition, and medication refusals. The note showed no notification to Primary Care Provider (PCP) or assessment of change in condition (CIC) that had been reported by the PT. (2) dated 02/08/2022- no documentation of resident's CIC reported by the PT. (3) dated 02/10/2022- no documentation of CIC reported by the PT, and no notification to PCP regarding medication refusal. (4) dated 02/11/2022 and 02/12/2022- no notification to PCP for medication refusals. During an observation, on 02/09/2022 at 12:25 PM, the resident had been observed up in the wheelchair, in a reclined position, hair disheveled, and their arms pulled out of the shirt sleeves, tucked in under the shirt. Resident 24's RR attempted to offer the resident a drink of their health shake, but the resident yelled out No! The resident had been thrashing around in the chair and attempted to remove their shirt while the RR attempted to talk them out of removing their shirt. During a concurrent observation and interview, on 02/10/2022 at 10:47 AM, Resident 24 appeared squirmy, they couldn't sit still, their arms and legs moving without purpose, their hospital gown pulled off and up over their head, their upper body was exposed, and they did not communicate when being talked to. The Surveyor said good morning to the resident, and the resident blankly stared with no reply. The resident's RR was in the room visiting. The RR stated the resident complained of pain all over, all the time, even when the resident was barely touched. The RR then stated the resident received pain medications to assist with the pain but didn't seem to help any. Lastly, the RR stated, I guess the doctor ordered some blood and urine to see why she has been so sluggish, supposed to be today. Review of Resident 24's progress note, dated 02/09/2022 at 1:59 PM, showed Staff HH documented that the provider had been in to assess the resident for decreased level of consciousness (LOC) and gave new orders for labs, a urinalysis (an analysis that includes various tests to examine the urine contents for any abnormalities that indicate a disease condition or infection), and to discontinue the use of the resident's twice a day antipsychotic (a medication primarily used to manage delusions, hallucinations, paranoia or disordered thoughts) medication, to once daily. Review of Resident 24's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the same record showed the labs and urinalysis were obtained on 02/10/2022 at 2:50 PM. Review of Resident 24's nursing progress notes, dated 02/11/2022 at 2:02 PM, showed the lab results were received and showed critical electrolyte levels of sodium at 162 (normal values are 134-144) and chloride at 122 (normal values are 96-106). The note further showed the provider ordered intravenous (IV) hydration. Review of Resident 24's medical record, showed on 02/11/2022, a preliminary urine culture was received and showed indications of a urinary tract infection, multiple bacteria and elevated white blood cell count (indicates infection). No antibiotics were prescribed for the infection. Staff HH, documented on the bottom of the lab requisite sent to (Staff L, Medical Director), with the date of 02/11/2022 and Staff HH initials. Although a final urine culture was obtained, the facility did not receive it and did not contact the lab for follow-up. Review of the facility's contracted pharmacy policy titled Hypodermoclysis, (a subcutaneous [sq, under the skin] administration of fluid used for short term fluid deficits), dated 06/01/2021, showed that hypodermoclysis was not intended for Patients with severe electrolyte imbalances, the order was to include the type of solution, rate of infusion, and length of therapy. Additionally, the policy showed the sites of infusion were to be rotated .after 1.5-2 liters (1500-2000 milliliters) has infused .at least every 24-48 hours. Review of the resident's physician orders, dated 02/11/2022 at 3:00 PM, showed Staff HH obtained a telephone order for Dextrose Solution 5%, use 50 milliliters (ml)/per hour, the nurse wrote intravenously (IV, in the vein) every shift for Hydration, Infuse with hypodermoclysis in abdomen. The order showed no stop date, or directions of when and how often to alternate the site of infusion. If given as ordered, the amount of fluid received every 24 hours would be 1200ml's. In addition to the dextrose order, there was an order dated 02/11/2022 at 5:00 PM, to obtain labs on 02/14/2022 to monitor abnormal labs. During an observation on 02/11/2022 at 2:25 PM, Resident 24 had dextrose solution running by hypodermoclysis into the abdomen, secured with transparent dressings on both sides of the abdomen. The bag or the tubing had not been initialed or dated. The dial was set to 50 ml/per hour. An unidentified nursing assistant (NA) had been struggling to keep the resident from pulling the hypodermoclysis out, the resident was trying to pull off the transparent dressings and the NA was trying to pull the resident's gown down, but before the NA could get the gown down, the resident was pulling it back up. As the Surveyor exited the room to look for a nurse to assist the NA, Staff B, Director of Nursing Services, was walking by and assisted. During an observation, on 02/11/2022 at 3:35 PM, the Surveyor exited a room across from the nurse's station and the same unknown NA had reported to Staff HH that Resident 24 had pulled out the hypodermoclysis. Review of the nursing progress notes showed the following: (1) dated 02/11/2022- no documentation for the hypodermoclysis being pulled out, or notification to the PCP for new orders. (2) dated 02/12/2022- Staff KK, LPN, documented the resident pulled out the hypodermoclysis at 1pm, PCP ordered to put the hypodermoclysis back in. The LPN further documents will talk to the RN to see if it would be better to put it in peripherally (in a vein), or do another one sq? (3) dated 02/13/2022- hypodermoclysis restarted at 6:00 PM on 02/12/2022. (4) dated 02/14/2022- resident pulled out hypodermoclysis, awaiting orders. (5) dated 02/14/2022- the resident pulled out the sq hydration twice, and the sq hydration was discontinued, .got report from night shift that they (Resident 24) pulled their sq hydration out again. During an observation, on 2/14/2022 at 2:51 PM, Resident 24 had an IV pole in their room with 0.9% Sodium Chloride IV solution hanging from the pole, the pharmacy label on the IV solution showed a date of 02/11/2022, Resident 24's name, and the order read 50ml/hr continuously sq (subcutaneous) by hypodermoclysis tubing. Review of Resident 24's physician orders, dated 02/12/2022 at 2:34 PM, showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Change site every 3 days. During an interview on 02/14/2022 at 3:09 PM, Staff KK, LPN, stated Resident 24 had pulled out the hypodermoclysis twice and they had received new orders to discontinue the sq hydration. The LPN stated they thought the current order was for normal saline at 50 ml/hr but would have to look it up to be sure. The LPN checked the order and confirmed the order continued to be Dextrose 5%. The LPN further stated that they worked on Saturday, 02/12/2022, and the hypodermoclysis had been pulled out and the PCP wanted the IV to be restarted. During that time the LPN informed the doctor that the resident was diabetic and received dextrose (sugar) solution orders, so the doctor changed the order to normal saline. The LPN then stated that instead of discontinuing the 02/11/2022 order of dextrose, I think I made a mistake and updated the dextrose order instead of changing the order to the normal saline. The LPN confirmed the pharmacy originally sent normal saline on 02/11/2022, so I just used the stock they brought. The LPN further stated they believed the other nursing staff through the weekend used the normal saline because it was right here in the nurse's station (pointing to a shelf behind them) and we had taken it from there. There were no bags of fluid left on the shelf. The LPN confirmed the order for the normal saline solution came from Staff L, MD, Resident 24's primary care provider. According to the facility investigation documentation and the MAR, the pharmacy delivered normal saline instead of dextrose 5% and Staff KK, Staff MM, LPN, and Staff SS, Registered Nurse, administered normal saline instead of the dextrose 5% that was ordered. Review of the facility's incident report for the medication error, dated 02/14/2022, showed Staff B, DNS, documented MD was notified and follow up labs to be obtained to review electrolyte levels. Review of Resident 24's medical record showed no labs were obtained on 02/14/2022. Review of the resident's nursing progress notes, dated 02/16/2022 at 11:14 AM, showed Staff HH and another unnamed nurse, obtained labs that were to be obtained immediately, and sent them to the lab for evaluation. Additionally, at 2:02 PM, Staff HH documented the resident had critical electrolytes of sodium at 169 and critical chloride at 130. Both increased from the previous critical lab results on 02/11/2022. Staff HH received orders from the resident's PCP to send the resident to the emergency room for evaluation. Review of Resident 24's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 02/18/2022 at 12:48 PM, Staff L, Medical Director, stated the order they gave was for dextrose to have been administered to Resident 24 on 02/11/2022 for three days, and denied ever changing the order to normal saline. The MD further stated that the expectation of the nursing staff would have been to follow the lab orders that were given to Staff HH on 02/11/ . The MD further stated they were not aware the 02/14/2022 labs were not obtained. Additionally, the MD clarified they ordered the fluids to be administered by hypodermoclysis, obviously that's not the best way to do it, but I am not going to send someone to the hospital to lay on a gurney, just for fluids . we had to start somewhere, then follow the labs. The labs will tell you which way to go. Resident 30. Review of the medical record showed the resident admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a comprehensive assessment, dated 11/12/2021, showed the resident required extensive two-person assistance for bed mobility and transfers, did not reject care, was able to communicate their needs and was cognitively intact. Review of the resident's POLST (physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record showed from 01/08/2022 through 02/13/2022 the resident had one weight recorded on 01/08/2022 of 267 pounds. Review of a 02/06/2022 lab Patient Report showed Resident 30 had several lab values out of normal range and a Blood Urea Nitrogen (BUN - a blood test that measures the amount of nitrogen in your blood that comes from waste, this test is done to see how well the kidneys are functioning) lab value showed a critical level - indication of 109 (normal range 8-27). When kidneys are not working well, the urea nitrogen will stay in the blood. Other causes of high or critical levels include dehydration and heart failure. There was no documentation of urinary output. Review of the resident's medical record did not show the labs were reviewed. The record showed no interventions were initiated in response to the 02/06/2022 lab report. During an observation on 02/10/2022 at 1:03 PM, the resident was observed in bed, with their eyes closed, head tilted back, and mouth open. A noon meal tray, on the resident's over-bed table was untouched. The resident's lips were dry and cracked and the upper and lower teeth had plaque build-up and were a brownish color on both inside and outside of the teeth. The resident's fingernails were long and soiled beneath the nail with a brown substance. When awakened, Resident 30 made eye contact and did not respond when asked questions. Later, that same day, at 1:40 PM, Staff Y, NA, was observed to enter the resident's room and shut the door. Within approximately three to four minutes, Staff Y exited the room with the meal tray which showed a small portion (approximately 1/3 of the portion) of one bowl pureed food missing, while all other food was untouched. During an interview on 02/10/2022 at 4:53 PM Staff J, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated that Resident 30 previously responded to questions and would feed themselves when positioned. However, after the resident had a respiratory virus in January 2022, in the past weeks they were on a decline had not been speaking and was no longer able to feed themselves. During an interview on 02/14/2022 at 2:21 PM, Staff Y, NA, stated that they regularly cared for Resident 30 who was previously very talkative and cheerful. Staff Y stated that in the past couple of weeks, the resident no longer was responding or speaking as previous. We would try to feed her, and she would start gagging. I was able to feed her some, but too much came up she would throw up. Further, the resident within the last two weeks no longer allowed staff to brush their teeth [it irritated her]. I always let the nurse know that she was not eating or that she was throwing up. When providing care to the resident, Staff Y stated that areas of irritation and redness were seen under the breasts, under the folds of the back and the armpits and those areas appeared to be worsening - they were reddened and inflamed. Staff Y stated that the LNs were treating the areas with [MEDICATION(S)] (antifungal medication), as this task was considered a treatment and only the LNs could apply the ointment. Review of the January and February 2022 Treatment Administration Record (TAR) showed an order dated 02/19/2021 to apply [MEDICATION(S)] to affected areas topically (to the surface of affected areas) every 12 hours as needed for recurrent yeast rash to under breasts and under arms. The record showed no treatments were applied in January 2022 and from 02/01/2022 to 02/13/2022. During an interview on 02/14/2022 at 1:46 PM, Staff CC, NA, Medication Administration Technician stated that they regularly provided medications to the resident and in the past couple of weeks, she noticed a change. Staff CC stated that the resident was no longer taking pills as well and was having difficulty swallowing, would pocket the pills or it (pill) would just roll right out of their mouth. Review of the resident's medical record showed the physician was not consulted regarding the resident's significant changes in condition until 02/13/2022 at 2:50 PM, at which time orders were received to transport the resident to the emergency room as the resident was no longer responding to staff and was unable to eat or drink. Review of hospital records, dated 02/22/2022, showed the resident's primary problems/diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's weight was documented as 239 pounds (weight loss of 18 pounds in five weeks). Additionally, the record showed the skin of the buttocks and legs was indurated (a thickening of the skin that can result from inflammation) and raw with wounds present under the armpits, buttock and between the thighs. During an interview on 02/23/2022 at 9:41 AM, Staff B, DNS, stated that they were unsure of the results of the 02/06/2022 labs and/or if the physician had been notified. The orders for topical treatment for the yeast areas may have been deleted by accident. Resident 40. Review of the medical record showed the resident admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility's Weights and Heights policy, dated 07/17/2021 showed newly admitted residents were to be weighed weekly for four weeks. The EMR showed the resident was weighed once during the first week, no other weights were listed. Review of a 01/25/2022 comprehensive assessment showed the resident required assistance with transfers, bed mobility and was independent with meals. The assessment showed the resident was cognitively intact. Review of progress notes between 01/19/2022 through 02/14/2022 showed the resident had increased pain to bilateral heels due to pressure injuries, decline in appetite and intake of food. During concurrent observations on: *02/09/2022 from 10:30 AM to 3:30 PM the resident was observed seated in a wheelchair with their feet on wheelchair pedals. No repositioning observed. *02/10/2022 from 8:30 AM to 12:30 PM feet on wheelchair pedals. No repositioning observed. *02/10/2022 from 1:00 PM to 3:24 PM the resident was observed seated in the wheelchair, feet on wheelchair pedals. No repositioning observed. During an interview on 02/10/2022 at 2:49 PM Staff I, RCM confirmed the resident was up in the wheelchair most often and stated the resident's pressure injuries on the heels were not healing and caused the resident pain. Staff I stated that the resident's nutritional intake was not very good. Review of the resident's most current care plan, last revised on 01/07/2022 showed to elevate legs when sitting or sleeping . encourage resident to change position frequently, not sitting in one position for long periods of time. Review of the facility's contracted wound specialist reports showed: *1/28/2022 [Resident 40] .rapid decline in health . * 02/04/2022 recently started c/o (complaints of) resting wound pain in (bilateral) heels . decreased appetite and poor intake . with exam findings which showed resting wound pain are concerning for ischemic (inadequate blood supply) tissue and recommend urgent vascular referral * 02/11/2022 .Recommend more aggressive pain control measures for helping manage ischemic wound pain . Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . No additional pain control measures were added to help manage the pain per the wound specialist's recommendation. Review of the resident's vitals record showed on: *02/12/2022 at 1:59 PM, blood pressure was 185/75 (normal 120/80) and the pulse was 80 (normal 60-100) and was documented as irregular-new onset *02/13/2022 at 10:04 AM, blood pressure was 203/52 The record did not show LN staff nor the physician were notified of the elevated blood pressure readings or pulse rate, which were outside of the resident's baseline. Review of the physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The medical record did not show physician awareness regarding the changes to the wound, request for urgent vascular referral or additional measures to manage the resident's increased pain nor issues with declined intake and appetite. The 02/04/2022 physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's medical record showed a 02/05/2022 lab report for Resident 40, which indicated the resident's labs were high in several areas which included high in C-Reactive Protein (CRP- measures protein in the blood) at 109 (normal range 0-10). High levels of CRP may be a sign of serious infection or other disorder. Review of the record showed no order for the lab draw, nor additional interventions or measures from the physician in response to those values outside of normal. On 02/23/2022 (eight days after the resident discharged ) it was noted on the lab report that the resident had chronic kidney disease and [CONDITION(S)]. During an interview on 02/15/2022 at 8:43 AM, Staff AA, RN, stated that she regularly provided care to resident 40 and that The resident would not use her call light or ask for anything . the pain was ungodly. The facility decided to schedule the pain control medication instead of PRN (as needed), because (Resident 40) would never ask for it. Further, Staff AA stated that in the last three weeks the left heel had worsened and was boggy. Review of Resident 40's Admission Pain Assessment, dated 12/29/2021, showed the resident indicated an acceptable pain was at a pain level of 5 and that sitting for long periods of time made the pain worse. Review of the January and February 2022 Treatment Administration Record (TARs) showed beginning January 19th the resident more frequently asked for pain medication and ultimately (on 02/02/2022) the pain medication was changed from as needed to routinely scheduled when the resident experienced pain at 9 out of 10 (0 being no pain and 10 being worst pain experienced). Review of the record showed the resident was seen for a vascular study on 02/15/2022 which showed that the resident was unable to bend their knees or hip, both LE (lower extremities) are frozen. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a nurse progress note on 02/15/2022 showed the resident did not return to the facility following the vascular study/consultation and discharged from the facility against medical advice (AMA) and admitted to the hospital on the same day. Review of an emergency room visit, dated 02/15/2022 showed Resident 40 was frail appearing and dry and presented with acute kidney injury, dehydration and infection. The resident required extensive assistance for all activities of daily living, multiple people to transfer them from wheelchair to bed and then to logroll the patient. The resident admitted to the hospital with failure to thrive, urinary tract infection, and pneumonia diagnoses. Resident 29. Record review showed the resident admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 02/14/2022 at 1:42 PM. Resident 29 was sitting in their room drinking from a cup at their bedside table. A dark, blackish, cracked, raised, lesion was observed on the resident's left upper lip ending at the bottom of the left nares. In an interview on 02/14/2022 at 2:05 PM, Staff U, NA, stated they worked with the resident and was familiar with their care. Staff U stated the resident's lip lesion had been there for a long time as a small pimple however, had started to grow really big. Staff U further stated they had noted a change in the resident's mood since the lesion had gotten big I know it hurts. In an interview on 02/22/2022 at 10:44 AM, Staff J, RCM, stated the resident had the skin lesion when admitted to the facility on [DATE]. Staff J stated staff had first noticed changes to the resident's lesion in March 2021 because a measurement had been taken as it was growing really fast. Staff J stated they did not have a process for measuring the lesion to monitor for additional changes. Staff J was unable to recall if the physician had been notified, whether an assessment was completed, or if the resident's representative had been informed in March 2021 when the lesion had started to grow and change. Staff J was unable to find supportive documentation to verify that any follow up had been completed. Record review of a 03/07/2021 skin assessment form (referred to by Staff J) as the initial measurement when the resident's lesion was first noted to change, showed the measurement of the resident's left lip lesion was 1 by 0.3 centimeters. Review of a wound measurement dated 12/03/2021, showed the resident's lip lesion had significantly worsened and had grown to 1.8 centimeters by 2 centimeters by 0.5 centimeters in depth and was spreading to the left upper nares. Record review of physician's note dated 01/27/2020 showed the physician had noted the resident's left lip lesion to be crusted and raised. The note instructed staff to monitor the lesion and consider a referral to a dermatologist (physician that specializes in skin conditions). Further record review of physician's notes showed on 08/25/2021 the physician made another referral to the dermatologist (approximately 18 months after the first dermatology reference). The resident did not see the dermatologist until 10/19/2021 (almost 20 months after the first reference that the resident needed to see a dermatologist). Review of the dermatologist note dated 10/19/2022 showed the resident had advanced basal cell [CONDITION(S)] (skin cancer) which was too advanced for treatment. Resident 26. A review of the medical record showed that Resident 26 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was readmitted to the facility on [DATE], following a hospitalization for severe abdominal pain and hematuria. The hospital discharge summary, dated 02/09/2022, showed the resident was admitted to the hospital on 01/31/2022. The admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the document, the onset of symptoms was weeks ago. While hospitalized , the resident was diagnosed with new bladder cancer. They were discharged back to the facility with a urinary catheter (tube inserted into the bladder to drain urine) and a left Nephrostomy tube. A progress note, dated 10/24/2021, showed bleeding noted in the resident's brief that was mixed with urine. The note further showed that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Subsequent progress notes on 10/27/2021, 11/02/2021, 11/16/2021, 12/22/2021, 01/14/2022 and 01/15/2022, showed some reference to resident bleeding (either hematuria, vaginal bleeding or blood noted in the resident's brief). Progress notes dated 11/16/2021, 12/22/2021, 01/14/2022 and 01/15/2022 showed that the MD was notified or was aware of the bleeding. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A progress note, dated 01/31/2022, showed that the resident complained of seve [TRUNCATED]

Based on observation, interview and record review, the facility failed to ensure three of five sampled residents (36, 7, 8) were free from abuse after the facility became aware of staff to resident abuse allegations. Additionally, the facility failed to immediately implement interventions towards protection of residents (36, 7) from further abuse when identified staff (E, F) reported to work with unsupervised access to resident, 13 hours after the allegation were reported to the facility. Resident 36 was observed with an emotionally distraught and fearful reaction once Staff E entered their room. These failures placed residents at risk for further physical/psychosocial harm and placed all the residents at risk for abuse. The failure of the facility to ensure residents were free and protected from abuse resulted in an Immediate Jeopardy (IJ) on 02/10/2022. On 02/10/2022 at 4:30 PM, the facility was notified of an IJ at CFR 483.12 (a)(1) F600 related to the facility's failure to immediately protect residents from identified staff in allegations of abuse that were assigned to provide unsupervised direct care to Residents 36 and 7. The facility removed the immediacy on 02/11/2022 with a validation date of 02/16/2022 at 1:14 PM by re-educating staff (prior to working their next scheduled shift) regarding abuse policies and procedures, to ensure an effective system was in place to keep residents free from abuse. Findings included . Record review of the facility policy titled, Protection of Residents: Reducing the Threat of Abuse & Neglect, dated 01/21/2019, showed that residents have the right to live at ease in a safe environment without the fear of retaliation when allegations are reported. The policy further showed, Following identification of alleged abuse, the resident(s) .are protected during the course of the investigation to prevent recurrence. Staff will respond immediately to protect the alleged victim(s)/others and integrity of the investigation. Additionally, .if the accused individual is an employee, the alleged perpetrator will be removed from resident care areas immediately and placed on suspension pending results of the investigation . Resident 36. The resident admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive assessment, dated 01/25/2022, showed Resident 36's short/long term memory were ok and the resident could recall the current season, location of their own room, staff names and faces and that they were in a nursing home. During an interview on 02/09/2022 at 2:53 PM, Resident 36 reported that about two weeks ago (around 01/26/2022), Staff E (an identified staff member whose nick/shortened name was used by the resident), just grabbed (them) by the pants and threw (them) into the bed .(Staff E) wanted me to see (Staff E) muscles .(Staff E) scared me. The resident also stated that they Cussed out (used bad words) Staff E, to which they replied with aww just be quiet. The resident further stated they had informed another staff member, told the girls (later identified as Staff F), of the incident when it took place and that they felt safe right now because they had not seen Staff E since the incident. During an interview on 02/09/2022 at 3:36 PM, Staff B, Director of Nursing Services (DNS), and Staff C, Regional Director of Clinical Services (RDCS), stated that there had been no reports of an allegation of abuse that involved Resident 36. Staff B and Staff C were then informed of all details of Resident 36's allegation of abuse against Staff E. Staff B, DNS, confirmed/identified Staff E, NA. During a concurrent observation and interview in Resident 36's room on 02/10/2022 at 10:54 AM, Staff E and Staff F, NA , were observed going into Residents 36's room unsupervised. Upon surveyor entrance, Resident 36 appeared unsettled/agitated then pointed to Staff E and stated, That's him (Staff E) .I do not feel safe with him .I do not feel safe with (Staff E) doing my shower. Surveyor intervened and directed Staff F to inform Resident 36's nurse of the events that had just taken place. Observations showed an emotionally terrified/scared look on Resident 36's face as they pointed at Staff E, during their communication to the Surveyor and Staff F. During an observation of Staff J, Resident Care Manager's (RCM), interview of Resident 36 that took place in the resident's room on 02/10/2022 at 10:57 AM, the resident stated the same incident/allegation of abuse (included Staff E) that was reported (on 02/09/2022 at 3:36 PM to Staff B, DNS) to Staff J, RCM. Additionally, Resident 36 stated, I did not like how he treated me .I do not feel safe with him .(Staff E) treated me roughly, and that Staff F, was one of the girls that they had informed when the incident/allegation of abuse had happened two weeks ago. Observations showed an emotionally distraught (deeply upset and agitated) Resident 36 when they recalled/described the incident/allegation of abuse. During an interview in the 200 hallway on 02/10/2022 at 11:17 AM, Staff B stated that they had ruled out, Staff E as the identified staff in Resident 36's allegation of abuse and it did not even cross my mind that it was (Staff E). (Staff B, was noted to have ruled out Staff E with minimal/inadequate information that did not include an interview of Staff E prior to them reporting to work, did not have Resident 36 rule out Staff E with an observation prior to Staff E providing cares, did not remove or supervise Staff E from providing Resident 36's care and did not stop Staff E from working with the resident prior to the incident on 02/10/2022 at 10:54 AM). Record review of the completed investigation for Resident 36's allegation of abuse, received from the facility on 02/15/2022 at 9:10 AM, showed Resident 36 was interviewed by Staff B, on 02/09/2022 (no time documented). Resident 36 stated to Staff B that it happened three weeks ago (which would be around 01/19/2022), confirmed his name is [Staff E] actually, and that they informed some of the facility staff (at the time of the incident). Resident 36 further stated, The next day I was extra taken care of so I thought he had been reported. Record review of the facility's task (a report that shows what care was provided, the time the care was provided, and who provided the care) report for January 2022, showed Staff E, was working with Resident 36 on 01/17/2022 and provided bedside care to the resident. Resident 7. Resident admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the comprehensive assessment, dated 12/17/2021, showed the resident was cognitively intact. During an interview on 02/09/2022 at 2:23 PM, Resident 7, room [ROOM NUMBER], reported that there was a nursing assistant (NA) that worked with them at times, and when they did, their handling during transfers and toileting was insensitive and jerks me around, and I will yell out in pain, and they don't stop. They just continue on with their job as if my pain doesn't even bother them. Resident 7 then named Staff F and then spelled out Staff F's name because they were unsure if they were pronouncing the name correctly. During an interview on 02/09/2022 at 4:55 PM, Staff B and Staff C were informed that Resident 7 had made an allegation of abuse regarding Staff F. The Surveyor informed Staff B and Staff C of the details of the allegation, and Staff B denied any reports had been previously made regarding Resident 7 and Staff F. During an observation on 02/10/2022 at 11:29 AM, the Surveyor identified Staff F exiting Resident 7's room. The same day at 1:37 PM, Staff F was observed exiting Resident 7's room again. During an interview on 02/10/2022 at 11:33 AM, Staff W, NA, stated they were assigned to Resident rooms 227 through 305 and Staff F was assigned to Resident rooms 305 through 315. Staff W further stated that Staff F had been working with those residents but was on a lunch break. Staff F was assigned to room [ROOM NUMBER], which was Resident 7's room. During an interview, on 02/10/2022 at 2:13 PM, Staff B, stated the investigation had not been completed, however, the Surveyor had observed Staff F continuing to work with unsupervised access to residents, including Resident 7, who made the allegation of abuse. Staff B stated they had interviewed Resident 7 on 02/09/2022 after the Surveyor reported the allegation of abuse. Staff B further reported that Resident 7 stated Staff F did not abuse them. Staff B further stated they still needed to provide education to Staff F (who was waiting outside Staff B's office during this interview) and had moved the allegation of abuse to a grievance. Record review of Resident 7's statement, dated 02/02/2022, showed the resident still had concerns about the pain that Staff F caused them during care. Review of the facility's grievance log, dated 02/09/2022, showed Resident 7 was entered into the log, and the resident's allegation of abuse was changed to a grievance by Staff B. Review of facility's task report, dated 02/09/2022 and 02/10/2022, showed that Staff F (who had not been educated yet) provided unsupervised care to residents, including transferring and toileting assistance to Resident 7, which had been identified as the tasks that caused them pain completed by Staff F. Review of the completed grievance documents, dated 02/11/2022, received at 1:05 PM, showed Staff B at 5:45 PM, concluded that the grievance was Determined to be a customer service issue, no allegation of abuse. No suspension needed. Staff will be educated upon return . Further review of the grievance showed, on 02/10/2022, Staff F had been provided education after working with residents and their shift was completed. Review of the facility's time 02/10/2022 clock sheets, showed Staff F clocked in at 5:51 AM and clocked out at 2:59 PM. Resident 8. The resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 8's medical record, showed they resided in the 100 hallway from 12/27/2021 through 01/13/2022 (2-16 days post surgical recovery) for their replacement of both knees. Review of the comprehensive assessment, dated 01/02/2022, showed the resident was cognitively intact. During a concurrent observation and interview on 02/11/2022 at 12:08 PM, Resident 8 stated shortly after they admitted to the facility, and while in the 100 hallway, they had reported an allegation of abuse to the facility regarding Staff II. The resident stated Staff II had not treated the resident very nicely and wouldn't help me when I asked. The resident stated during that time, they had been over medicated with pain medication and a little weaker than normal, and during assistance with toileting, Staff II refused to use a gait belt (a device put on a patient who has mobility issues, by a caregiver prior to that caregiver moving the patient) during a transfer from the bathroom to the bed. The resident then re-enacted the scenario for the Surveyor. The resident stood with the front wheel walker (FWW) in front of the toilet in the bathroom, slumped over the front of it, with their abdomen/chest leaning on the front bar of the walker, took a few shuffled steps towards the door of the restroom, asked Staff II to please get the gait belt, or my wheelchair, I feel like I am going to fall, and you aren't going to be able to catch me! The resident stated they asked this multiple times. The resident then stated Staff II told them in a condescending, snarly tone, Oh no, you're not going to fall, this isn't happening on my shift, and then demanded the resident to stand up straight, so you can get to your bed, while their FWW was being pulled by Staff II. The resident stated that they felt weak, their legs felt wobbly and shaky, they stayed leaning over the front of their walker, and shuffled their way back to the bed. The resident further stated they were fearful their legs were going to give out on them, and injure their knees they just had surgery on. Resident 8 confirmed that Staff II never applied the gait belt. Resident 8 then stated they reported this issue to the nurses and the therapist, Staff LL, Occupational Therapist (OT). The resident explained they did not know who Staff II was at first, and couldn't recall what nurse she reported it to, but could describe Staff II because she wore a bracelet that dangled around her wrist all the time. The resident also stated the lady with all the tattoos came and talked to them about the issue, and assured the resident there was no need to worry because they terminated Staff II. Then a week or two later, Staff II came to their room to assist packing up and moving their belongings, and the resident was shocked to see them because they were told Staff II had been fired. During an interview on 02/11/2022 at 12:52 PM, Staff LL stated Resident 8 informed them of their complaint on a Monday morning, regarding Staff II over the past weekend that refused to use a gait belt or a wheelchair when they asked them to. Staff LL could not recall the exact date, or identify Staff II, but did state this incident occurred when the resident resided in the 100 hallway. Staff LL further stated, they did not report to administration because Resident 8 told them they had reported the incident to nursing staff over the weekend and they were aware that Staff D, Infection Preventionist (IP), had knowledge of the incident. They did give the resident a grievance card and informed Resident 8 to fill the card out and give to the Administration if there were any more issues. During an interview on 02/11/2022, at 1:07 PM, Staff D stated they could not recall how they came to have knowledge of this incident, but could easily recall the incident. Staff D then identified the complaint was about Staff II and it happened over the weekend. Staff D further stated that the resident complained that Staff II took away their walker or wheelchair and refused to use the gait belt when asked to. Staff D also stated Staff II told the resident no, it's only a short distance, and that the resident told them they were scared and felt like they were going to fall. Staff D denied an investigation was completed. In addition, Staff D stated that Staff II had multiple complaints, and I have had to have multiple conversations with them. Most of the complaints came from staff and were complaints about Staff II being lazy, residents were being left wet, wet linen and garbage was being left in the rooms. I have done lots of education with [Staff II]. Staff D denied having any documented education for Staff II, I wouldn't even know where to document that, even if I did. They further stated, when Staff II came in to talk about the complaint, their initial comment was I know (Staff D's name), when you want to talk to me that I am in trouble. Staff D stated the initial plans were to terminate Staff II, but the agency they worked for contacted someone higher up, and they ended up not terminating. Staff D additionally stated, they got called to the facility on their day off due Staff II questioning other staff about who complained about them. Review of the facility's Incident Reporting Log from December 2021, January 2022, and February 1st through February16th, 2022, showed Resident 8's allegation of abuse had not been logged. Review of the facility's 12/20/2021 to 02/02/2022 Grievance logs received on 02/09/2022, showed Resident 8's allegation of abuse had not been listed. However, February 2022's log, updated as of 02/16/2022 showed Resident 8's allegation of abuse had been entered as a grievance on 02/11/2022 and not identified as an allegation of abuse. Review of the facility's 02/22/2022 grievance documents, showed Staff C documented the findings as No staff identified. Zero other incident-appears isolated. Staff have had transfer training/Kardex (A system that gives a brief overview of each patient's care) training ongoing, even though Staff D had identified Staff II involved in the allegation of abuse. During an interview on 02/16/2022 at 9:57 AM, Staff B, DNS, stated they followed state and federal guidelines of abuse. When asked their process if an allegation of abuse against a staff member was made, Staff B stated that they would suspend any named staff member to protect the resident and begin/conduct a thorough investigation. Cross Reference to: F-607, F-609, F-610 Reference WAC: 388-97-0640 (1)

Based on interview and record review the facility failed to effectively ensure, Staff L, Medical Director (MD) fulfilled their responsibilities with regulatory requirements related to the MD's coordination of adequate and appropriate medical care for facility residents which resulted in harm for five of five residents (24, 30, 40, 29, 26). The failure to ensure MD oversite of nursing staff and coordination of care caused; 1) residents to experience Substandard Quality of Care at an Immediate Jeopardy (IJ) level regarding Freedom from Abuse/Neglect and Quality of Care, 2) further risk of residents receiving unnecessary [CONDITION(S)] medications prescribed without the necessary indication for use/rational documented, along with a risk of adverse complications due to a delay in the timely review of pharmacy recommendations by the MD, 3) an IJ related to Competent Nursing Staff, by the MD's failure to ensure Licensed Nurses (LNs) had the appropriate competencies, skill sets and proficiencies to provide nursing and related services and, 4) a violation of residents' rights related to the inability of the resident to choose whether they want to formulate an Advance Directive (AD). Findings included . Review of the MEDICAL DIRECTOR AGREEMENT, signed by the facility's Executive Director and the contracted entity (MD) on 10/05/2016, showed the MD shall assist with implementing resident care policies and coordinate medical care in the facility to ensure that adequate and appropriate medical services are provided to the residents. Furthermore, both parties agreed that the time the MD shall spend rendering services to the facility shall not exceed 15 hours per month ., and shall perform such services in accordance with all the requirements of the facility's policies and federal/state rules/regulations. Review of facility's policy titled, Medical Director, revised 08/20/2021, showed the MD is responsible in ensuring .the appropriateness and quality of medical care and medically related care ., along with oversite on formation of AD/end-of-life care decisions of residents which include choices regarding medical care options, advising residents and families about formulating advance directives. Furthermore, the policy stated that the MD was to assist in the development of educational programs for facility staff and if the MD was also the attending physician (which Staff L MD was) then the operational leadership (Executive Director, Regional Vice President, and Division Vice President), were to ensure that the MD practice shows no concerns. Review of the facility's policy titled, Physician Services Guidelines, revised 09/21/2021, showed, At the time of each visit, the physician (which is the Medical director) must review the patient's total program of care, medications, treatments, and the care plan .review, sign, and date all orders .all orders are signed within 14 days unless . 1) Coordination of adequate and appropriate medical care for facility residents Refer to CFR 483.12(a)(1), F600, freedom from Abuse, Neglect and Exploitation: The MD along with the facility failed to protect the residents from abuse and neglect which resulted in a risk of immediate jeopardy for residents. Refer to CFR 483.25, F684 Qualify of Care: During an interview on 02/18/2022 at 12:48 AM, when ask MD their process for reviewing facility resident charts during physician visits, Staff L, MD, stated, I haven't done any chart review [NAME] .I leave it to these people (nursing home staff). Resident 24. During the same interview on 02/18/2022 at 12:48 PM, Staff L, MD, stated that they were unaware that labs for 02/14/2022 were not obtained (even though Staff L was aware of Resident 24 change in condition/critical lab values/critical electrolyte imbalance). MD stated that they would expect the nursing staff to follow- up on labs and that standing orders (written protocols that authorized designated member of a health care team to complete certain tasks without having to first obtain a physician order) are to repeat labs in seven days (which Staff L, MD, had not signed off on until 02/18/2022 during the interview with the Surveyor). The MD further stated that they ordered an administration of fluids via hypodermoclysis (indicated for mild to moderate dehydration and per facility policy, not intended for severe electrolyte imbalances), obviously that's not the best way to do it, but I am not going to send someone to the hospital to lay on a gurney (a bed), just for fluids . Neither facility nor MD were able to present physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, the MD failed to ensure nursing staff competency and identifying change in condition and applying interventions. Resident 30. Review of a 02/06/2022 lab Patient Report showed Resident 30 had several lab values out of normal range and a Blood Urea Nitrogen (BUN - a blood test that measures the amount of nitrogen in your blood that comes from waste, this test is done to see how well the kidneys are functioning) lab value showed a critical level - indication of 109 (normal range 8-27). When kidneys are not working well, the urea nitrogen will stay in the blood. Other causes of high or critical levels include dehydration and heart failure. There was no documentation of urinary output. Review of the resident's medical record did not show the labs were reviewed. The record showed no interventions were initiated in response to the 02/06/2022 lab report. During an interview on 02/10/2022 at 4:53 PM Staff J, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated that Resident 30 previously responded to questions and would feed themselves when positioned. However, after the resident had a respiratory virus in January 2022, in the past weeks they were on a decline had not been speaking and was no longer able to feed themselves. Review of the resident's medical record showed the physician was not aware of the resident's significant changes in condition until 02/13/2022 at 2:50 PM, at which time orders were received to transport the resident to the emergency room as the resident was no longer responding to staff and was unable to eat or drink. During an interview on 02/18/2022 at 12:48 AM, Staff L, stated since the nursing staff see these people more than I do, that if there was a critical lab, I would get them right away. 2) Coordination of adequate and appropriate medical care for facility residents (medications) Refer to CFR 483.45(c)(3)(e)(1)(2), F758 Free from Unnecessary [CONDITION(S)] Medications/PRN use: The MD along with the facility failed to ensure that [CONDITION(S)]/psychoactive (any drug that affects brain activities associated with mental processes and behavior) medications had the necessary documented rationale for treatment and Individualized Target Behaviors (ITB) were developed, monitored, and implementation for Resident 24. Resident 24. During an interview on 02/18/2022 at 12:48 AM, Staff L, MD, was asked about the process regarding Resident 24 psychotropics medication (which had been continued after admitted on 01/11/2022 despite a lack of interventions for identification/monitoring/justification for Resident 24's [CONDITION(S)] medication or a lack of a serious mental illness documented on resident preadmission screening and resident review tool) and gradual dose reduction (possible weaning down/off medication). Staff L stated, I don't like to just take away a person's psych medication, just because the government tells me I have to, and that they would review the behavior monitoring documentation to determine if Resident 24 [CONDITION(S)] medication need to be changed (Staff L was unaware that the behavior monitoring documentation was never started on Resident 24). Refer to CFR 483.45(c)(1)(4)(5), F756 Drug Regimen Review, Report Irregular, Act On: The MD along with the facility failed to ensure the timely process regarding pharmacy recommendation review and follow through of recommendation were implemented for residents. Record review of pharmacy consultation summary report of recommendations for September 2021, October 2021, November 2021 and December of 2021 showed multiple delays (beyond 14 days) in signing/acknowledgment that recommendations were reviewed by a physician. Resident 36. Review of medical records showed resident admitted on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview on 02/24/2022 at 10:08 AM, (when asked about the assessment/implementation process towards Resident 36's antidepressant medication; from the time the behaviors were assessed, to the time the pharmacy recommendations were made, to the time Staff L, MD, confirms/signs recommendations, to when the medication was administered to the resident), Staff B, DNS, stated, it wasn't a good process. Staff B stated that the facility should get medication changes (that are noted in the facility's psychoactive meetings) to a resident as soon as possible. Furthermore, that Staff B stated identified concerns towards Staff L, MD, on the timeliness of their review of pharmacy recommendations, which included that Staff L is sometimes unable to sign them (monthly pharmacy recommendations), did not have enough time, to sign off on the recommendation and had to complete them during their next visit to the facility. Staff B stated, we need to button up the process, some are a month later (Staff B referring to how long some medication recommendation changes have taken to get to residents). 3) Assist in the development of educational programs for facility LN staff Refer to CFR 483.35, F726 Competent Nursing Staff: The MD along with the facility failed to ensure development of educational programs for facility's Licensed Nurses (LNs) that had the appropriate competencies, skill sets and proficiencies to provide nursing and related services for residents' which resulted in a significant decline in condition, delay in interventions which placed all residents at risk of serious injury, serious harm, serious impairment, or death. Resident 24. Review of the medical record showed no documentation regarding LN assessments and/or a comprehensive record review had been completed in reference to the lab orders. There was also no documentation to show a notification to the physician about the 02/14/2022 ordered labs not being obtained. Resident 24 had critical electrolyte levels of sodium and chloride on 02/11/2022, resulting in an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Additional sodium and chloride level labs were ordered for 02/14/2022 to monitor the effectiveness of the subcutaneous hydration. From 02/11/2022 through 02/13/2022, the resident received a hydration solution of sodium and chloride (which the resident already had lab-confirmed critical values established on 02/11/2022) instead of the ordered Dextrose solution; as a result, Resident 24 was sent to the hospital for an evaluation. The facility failed to ensure professional standards of practice were implemented when they ordered an administration of fluids via hypodermoclysis (subcutaneous hydration (sq) indicated for mild to moderate dehydration). Review of the facility's contracted pharmacy policy titled Hypodermoclysis dated 06/01/2021, showed that hypodermoclysis was not intended for Patients with severe electrolyte imbalances. Resident 30. Review of medical record showed the resident, at baseline status, was able to communicate needs and preferences, was able to feed self when positioned upright in bed and enjoyed participating in activities. On 01/15/2022 the resident acquired a respiratory infection and experienced gradual declines in ability to feed themself, communicate needs and preferences and was slower to respond to questions and occasionally would not answer questions. On 02/06/2022 the facility received labs which showed Resident 30 had several lab values out of normal range and a Blood Urea Nitrogen (a blood test that measures the amount of nitrogen in your blood that comes from waste, this test is done to see how well the kidneys are functioning) lab value showed a critical level - indication of 109 (normal range 8-27). When kidneys are not working well, the urea nitrogen will stay in the blood. Other causes of high or critical levels include dehydration and heart failure. The record showed no SBAR, no interventions or new orders from the physician regarding the critical lab and no monitoring for other signs/symptoms related to kidney function (such as urine output). Review of a progress noted showed on 02/12/2022 at 9:20 PM the resident was non verbal. Blank stare. Unable to follow directions. Holding medications crushed in apple sauce in mouth. Coughing with swallow. Unable to use straw successfully. Holding food and medications in mouth. Coughing with swallowing. Review of a progress note showed on 02/13/2022 at 2:50 PM no response verablly (sic) when cued to swallow. Was not able to drink / eat, and could not respond verbally the doctor was notified and Resident 30 was emergently sent to the hospital. Resident 40. Review of medical record showed LNs did not notify physician or conduct a thorough assessment and report to the physician when the resident experienced debilitating pain and decline in level of function. The facility did not note or follow-up when a 02/05/2022 lab report showed Resident 40's labs were high in several areas which included high in C-Reactive Protein (CRP- measures protein in the blood) at 109 (normal range 0-10). High levels of CRP may be a sign of serious infection or other disorder. Review of a 02/02/2021 progress note showed the resident experienced a 9 out of 10 (0 being no pain and 10 being greatest pain) pain. The record showed the narcotic pain medication was changed from as needed to routinely scheduled. The progress notes showed no on-going assessment or that alert charting had been initiated to monitor the effectiveness of the change in pain medication. Resident 29. Review of the resident's medical record showed the resident was admitted in September 2017 with a small pimple like lesion on the left upper lip. Review of a physician's note dated 01/27/2020 showed the resident's lesion was crusty and raised. The physician instructed the staff to monitor the lesion and consider follow up with a dermatologist (a physician that specializes in diseases of the skin). During an interview on 02/22/2022 at 10:44 AM, Staff J, RCM stated that the lesion had noted growth in March 2021. Staff J was unable to recall if the physician had been notified or if the resident's lesion had been assessed related to the changes. Staff J did not have documentation to show that staff had been monitoring the lesion as directed by the physician over two years ago. Review of a physician's note date 08/25/2021 showed another referral from the physician for the resident to see a dermatologist. Review of the dermatologist note dated 10/19/2021 showed the resident's upper lip lesion was too advanced for treatment. Resident 26. A review of medical record showed that blood in the resident's brief was first noted on 10/24/2021, per a progress note written that day. Subsequent progress notes in October, November, December 2021, and January 2022 showed some reference to the resident bleeding (either blood in urine, vaginal bleeding or blood noted in the resident's brief) and that the physician was informed or was aware. A further review of the resident's record back to 10/24/2021 did not show any referral or appointments made to any specialists, to determine the underlying cause of the bleeding. A progress note, dated 01/31/2022, showed that the resident was sent by ambulance to the local hospital emergency room . While hospitalized , the resident was diagnosed with new [CONDITION(S)]. They were discharged back to the facility on [DATE] with a urinary catheter (tube inserted into the bladder to drain urine) and a left nephrostomy tube (a tube that goes directly into the kidney to drain urine). Record review of a physician order, dated 02/09/2022, showed to Cleanse around nephrostomy tube site with normal saline and cover tube site dressing (gauze), then cover with bordered foam dressing. Check every shift and change when soiled. On 02/22/2022 at 1:48 PM, observed Staff N, Licensed Practical Nurse (LPN) perform nephrostomy site care with Staff J, RCM. There was a blue foam securement device, covered in brownish drainage, sticking to the tubing. It was crumpled, moist, sticky and not attached to the skin. In a concurrent interview, Staff J referred to the securement device as the original surgical dressing. Staff N stated that it's the same one that she came here with (from the hospital, 13 days ago). Staff J stated that usually the nephrostomy tubes only have a split gauze around it, not that part. After Staff N cleansed the area, they laid the same soiled securement device over the insertion site and covered it with a new adhesive foam dressing. Neither Staff J nor Staff N recognized that it was a securement device (not a surgical dressing) that should not have been in direct contact with the insertion site, possibly allowing for infection to get directly into the left kidney. In a review of the EMR from 02/09/2022 until 02/21/2022, there was no documentation of attempts to reach out to a physician about what to do about the original surgical dressing at the nephrostomy site, although the TAR showed site care was done. 4) MD oversite on supporting and promoting residents' rights on formation of AD's Refer to CFR 483.10(g)(12)(i)-(v), F-578 Request/Refuse/Discontinue Treatment; Formulate AD: The MD along with the facility failed to ensure resident's right to make an informed decision regarding formulation of an AD and placed residents at risk for losing the right to have their preferences and choices honored regarding emergent/end-of-life care for eight out of 11 residents. During an interview on 02/24/2022 at 2:13 PM, Staff A, Administrator (responsible for oversite/training for Social Service Director (SSD) on AD's) stated that they were aware that the SSD had not been providing the opportunity for residents to make a decisions/choice towards formulating AD's. Staff A also stated that the important information is on the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . (Staff L, MD, did not have oversite on formation of AD/end-of-life care decisions along with residents' choices and preferences due to facility not implementing a process to obtain/ask residents about their wishes on formulating an AD). During an interview on 02/24/2022 at 11:11 AM, when asked who was in charge and/or who supervised the MD, Staff OO, Northwest Division Vice President, stated, I'm not sure . (no other information was provided to Surveyor by Staff OO). During an interview on 02/24/2022 at 1:10 PM, Staff G, Regional Vice President, stated that they were one of the Operational Leadership facility staff members that were responsible in identifying concerns with Staff L, MD. When asked if Staff G had identified any concerns with MD, Staff G stated, yes they have identified some concerns with the MD, but I will not discuss that with you. (No additional information was provided on this subject). Cross Reference: F-600, F-684, F-578, F-758 Reference: WAC 388-97-1700 (1)-(2)

Based on observation, interview and record review the facility failed to assess, monitor, treat, or implement interventions necessary to prevent the development of pressure ulcers for one of seven residents (24) reviewed for pressure ulcers. This failure caused harm to Resident 24 when the resident developed a facility acquired, avoidable, unstageable (Per The National Pressure Injury Advisory Panel) as 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.) pressure injury on their right ankle. Findings included . Review of the facility's policy titled Skin Integrity & Pressure Ulcer/Injury Prevention and Management, dated 08/25/2021, showed the facility must ensure the resident received care to prevent pressure ulcers, unless the resident's clinical condition showed they were unavoidable. The policy further showed the resident should have received treatment, and services to promote healing, prevent infection, and prevent new ulcers from developing. Resident 24. Review of the resident's medical record showed the resident admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .) Record review of the comprehensive assessment, dated 01/16/2022, showed the resident's cognition was moderately impaired. The record further showed Resident 24 was at risk of developing pressure ulcers, incontinent of bowel and bladder, required total assistance of two persons for bed mobility, toileting, and transfers, and was admitted with Moisture Associated Skin Damage (MASD, caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate, [MEDICATION(S)], saliva, and their contents). Record review of the facility's Skin Admission Assessment, dated 01/11/2022, showed Staff J, Resident Care Manager (RCM), documented a yeast infection to Resident 24's breasts and groin area, and scattered bruises, no MASD had been documented. The record further showed the resident was at risk for pressure ulcers. During an observation, on 02/09/2022 at 9:44 AM, Resident 24 was observed lying in bed, slightly turned toward the window. There were no off-loading devices observed at this time. During a concurrent observation and interview, on 02/09/2022 at 12:25 PM, the resident was observed sitting in a tilt-in-space (allows the patient to tilt backwards; the seat itself tilts backwards while the lower frame and the wheels remain in place) wheelchair (w/c), in a reclined position. The Resident's Representative (RR) stated the resident could not position themself on their own and required staff assistance. Record review of the resident's weekly skin assessments showed: (1) dated 01/27/2022- showed Staff JJ, Registered Nurse (RN), no documentation of skin issues to the right, outer ankle. (2) dated 02/05/2022- showed Staff AA, RN, documented right outer ankle, small blistery type abrasion-no drainage, warmth or redness. Staff AA further documented this was not a new finding, and there were no measurements. (3) dated 02/10/2022- showed Staff HH, Licensed Practical Nurse (LPN), documented the resident had a red blanchable area to their right lateral ankle. The LPN further documented this was not a new finding, and there were no measurements. (4) dated 02/13/2022- showed Staff KK, LPN, documented a new finding of right under arm redness and yeast smelling rash and showed no documentation regarding the right outer ankle. During an observation, on 02/10/2022 at 10:37 AM, Resident 24's RR was observed asking Staff HH what the facility was doing about the wound on Resident 24's ankle because the dressing was coming off. Staff HH stated they had no idea there was anything on Resident 24's ankle and would assess it. During a concurrent observation and interview, on 02/10/2022 at 10:58 AM, the resident was observed lying in bed, on their right side, with a loose (partially off the ankle), white gauze dressing in place around the right ankle. The RR stated there was a wound on the resident's right ankle with a dressing that was falling off. The RR clarified that a main nurse assessed the wound and applied the dressing. The RR further stated, the therapists found it a little over a week ago during therapy and the nurse and the therapist told me It's a 'pressure' or 'bed sore' is what they called it. The RR identified Staff DD, and Staff LL as the therapists, and Staff I as the nurse. There were no pressure relieving boots observed on Resident 24's feet. During an observation, on 02/11/2022 at 9:24 AM, the resident was observed lying in bed, disheveled, their gown was off, and the resident was naked. The Surveyor observed a dark red/purplish, soft, wrinkly looking area, on the outer right ankle, that was encircled beyond the shape of the ankle bone. There were no pressure relieving boots observed on the resident or in the resident's room. The bed mattress was too long for the bed and was hanging over the end of the footboard of the bed. During an observation, on 02/11/2022 at 12:33 PM, the resident was observed sitting up in a tilt-in-space w/c, in a reclined position, on their back, with their right leg turned to the right, resting on the bar of the footrest on the w/c. The resident's feet were not elevated, and there were no pressure relieving boots observed on the resident or in the resident's room. During an observation, on 02/11/2022 at 2:25 PM, the resident was observed sitting up in a tilt-in-space w/c, in the same position as they were at 12:33 PM on the same day. During an observation, on 02/14/2022 at 1:55 PM, the resident was sitting up in a tilt-in-space w/c, in a reclined position. The resident's feet were resting on a pillow that was wrapped with a wrinkled blanket, and a raveled-up bath towel under the left side of the resident's thigh area. Resident 24 continued to favor leaning to their right side, with the right outer ankle face down against the wrinkled blanket/pillow. The long bed mattress was pushed down to fit the bed, causing the mattress to roll under at the foot of the bed. During an observation, on 02/15/2022 at 8:18 AM, the resident was lying in bed, on their right side, covered with a sheet, no clothes/gown on, and there were no pressure relieving boots observed on the resident's feet. The long bed mattress continued to be rolled under at the end of the bed, which caused the mattress to have increased elevation, applying pressure where the resident's feet were resting. During an observation, on 02/15/2022 at 9:16 AM, the resident continued to be lying in bed and on their right side. In the same position observed at 8:18 AM. During an observation, on 02/15/2022 at 12:30 PM, Resident 24 was sitting in a tilt-in-space w/c, in a reclined position, leaning toward their right side, with their right mid leg/knee resting against the bar of the armrest of the w/c, and their right ankle resting against the leg rest pedal. During an observation, on 02/15/2022 at 2:34 PM, the resident was observed to be in the same position as they were at 12:30 PM, on the same day. Upon entrance of the resident's room the Surveyor noted a strong foul odor. The resident was observed to have a sling underneath her while in the w/c. During an observation, on 02/15/2022 at 3:46 PM, the resident was observed being transferred by Staff T and Staff UU with Staff J, from their w/c to the bed, by a mechanical lift (allows patients to be transferred between a bed and a chair or other similar resting places, by the use of electrical or hydraulic power). While Staff T was removing the sling (an accessory that attached to the mechanical lift, applied under the resident while transferring), the resident's bare skin was sticking to the sling, as if there was moisture present. The sling had been left underneath the resident when transferred to the w/c earlier. There was no barrier observed between the resident's bare/exposed skin and the sling. Resident 24 had a reddened peri-area and had a bowel movement. Record review of the facility's Wound Observation Tool, dated 02/16/2022 at 7:10 AM, showed Staff I, documented a facility acquired, right outer ankle wound, and they documented this was the first observation of the wound. The wound measured 6.5 centimeters in length and 6.5 centimeters in width. Staff I identified the area had blanchable redness and bruising. Staff I further documented a treatment was to be completed twice daily, and pressure reducing boots applied to the resident's feet while in bed. The tool further showed the RR indicated the resident hit their foot on the w/c. During an interview, on 02/16/2022 at 9:56 AM, Staff F, NA, stated they recently reported skin issues for Resident 24 to Staff KK. They stated they had redness in the upper chest/neck area on the right side. Staff F further stated they were aware the resident had a sore to the right ankle and would make sure there was a dressing and if not, they would report it to the nurse. During an interview, on 02/18/2022 at 12:16 PM, Staff DD, PT, stated they observed the pressure injury on the resident's ankle and immediately reported it to the RR, who was present at the time they found it, and to Staff I, who assessed it and applied a dressing. The PT stated they obtained pressure relieving boots, and a cushion for the resident's heels to be off-loaded and gave them to the NA's. Review of the resident's PT notes, dated 02/02/2022, validated the above statement by Staff DD. Additionally, review of the medical record showed no documentation of intervention entered on the Kardex (care directives for nursing assistants; A system that gives a brief overview of each patient's care) to apply pressure relieving boots to the resident's feet while in bed. During an interview, on 02/22/2022 at 10:27 AM, Staff HH, LPN, stated when they completed skin assessments, they reviewed to see what other people had documented on prior assessments, and since the ankle had previously been documented I didn't completely fill it out, and assumed what needed to be done, had already been done. The LPN then stated the process if they find a new skin issue is to report it to the doctor, complete a new skin issue report, and obtain a new treatment or monitoring order. Lastly, the LPN stated they weren't aware Resident 24 was supposed to have been wearing pressure relieving boots or off-loading their feet. The LPN stated that equipment would have orders and the orders would be found on the resident's treatment record. I do not know if that equipment would be found on the Kardex. During an interview, on 02/22/2022 at 11:18 AM, Staff U, NA, stated Resident 24's sore to their right ankle was noticed a few weeks prior and it was reported to Staff HH. Staff U further stated that if the resident had any changes for equipment, it would be communicated to them during shift report, or they could find it on the resident's Kardex. Staff U confirmed the resident had pressure relieving boots that were to be on while in bed. During an interview, on 02/22/2022 at 3:47 PM, Staff I, RCM, stated they noticed the resident's right ankle injury on the day they were obtaining a urine culture from the resident, the injury was described as a bruise that had blanchable redness around it. Staff I stated the RR said the resident hit their ankle on their w/c. Staff I applied a dressing and pressure relieving boots. The Surveyor informed Staff I that the urine culture was obtained on 02/10/2022 (per record review), and Staff DD reported the right ankle injury to them (Staff I) on 02/02/2022. Staff I then confirmed, yes, that was the day they (Staff I) noticed it, and the same day it was reported to the doctor. During an interview, on 02/23/2022 at 9:46 AM, Staff HH, LPN, stated therapy communicated equipment needs to the floor nurses or the RCMs. Additionally, the floor nurses would let the RCMs know if they felt the resident would benefit from a piece of equipment, such as a bigger, wider, or longer bed. The LPN stated all changes in equipment go through the RCMs in case there needed to be an assessment done. During an interview, on 02/23/2022 at 10:02 AM, Staff F, NA, stated the nurses would communicate changes of equipment to the NA's during shift report, and the NAs would report if something was or wasn't working right to the nurses during the same time. Staff F further stated they could find equipment changes in the resident's Kardex. They explained that NAs should be checking the Kardex every day at the start of their shift. Staff F then demonstrated to the Surveyor how to find the Kardex in the resident's medical record. Record review of Resident 24's Kardex, dated 02/16/2022, showed there were no directives for applying pressure relieving boots, a cushion for off-loading the feet, or turning or repositioning interventions documented on the Kardex. Record review of the resident's care plan, dated 01/16/2022, showed no interventions for positioning, pressure ulcer injury, pressure reducing boots, or a pressure relief cushion. Record review of the facility's Incident Reporting Log, from 02/01/2022 through 02/16/2022, showed Resident 24's skin issue had not been logged. Record review the resident's Treatment Administration Record (TAR), dated 02/01/2022 through 02/16/2022, showed no monitoring or treatment orders for Resident 24's right outer ankle, or for the reddened, odorous rash on the right under arm. Resident 24 discharged to the hospital on 02/16/2022 and returned to facility on 02/23/2022. Review of Resident 24's hospital admission records, dated 02/16/2022, showed the resident had an unstageable pressure injury to their right lateral ankle. During an interview, on 02/24/2022 at 11:41 AM, the Resident's Representative stated they do not recall the resident hitting their ankle on the wheelchair. During an interview, on 02/23/2022 at 3:36 PM, Staff B, Director of Nursing (DNS), stated the process they would expect the Licensed Nurses (LN's) to follow when there was a new skin issue, would be to complete a risk management report, notify the doctor, the resident/RR, and the DNS, and obtain an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Reference WAC: 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to provide ongoing comprehensive pain assessments with interventions for one of three residents (40) who experienced severe, progressive pain for nearly four weeks. Additionally, the facility failed to time the administration of pain medications as ordered for effective pain control, especially during wound care for one of three residents (34). These failures to assess the pain comprehensively, recognize and address the severity of the pain, and failure to consult with the physician when the pain medicine was not controlling the pain resulted in actual harm to Residents 40 and 34 who experienced severe pain and distress. Findings included . Resident 40. Review of the medical record showed the resident admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 01/25/2022 comprehensive assessment showed the resident required assistance with transfers, bed mobility and was independent with meals. The assessment showed the resident was cognitively intact. During an observation on 02/09/2022 at 12:28 PM, Staff DD, Physical Therapist, was removing the resident's socks to view the feet. Staff DD stated they were fitting the resident for pressure relieving shoes to allow the resident to participate in therapy. While Staff DD attempted to remove the sock on the left foot, the resident winced and moaned and repeated oh, oh, oh. Staff DD acknowledged the pain the resident was experiencing and told Resident 40, I know that is very painful. On 02/10/2022 at 2:15 PM, the resident stated they were experiencing a great deal of pain to the feet and their bottom. Resident 40 said if they did not move, the pain was not as severe. They stated they wanted to get better and be able to participate in therapy so they would be able to discharge to their home. During an interview on 02/10/2022 at 2:49 PM Staff I, Registered Nurse (RN)/Resident Care Manager (RCM) confirmed that the resident had been up in the wheelchair and stated the resident's pressure injuries on the heels were not healing and caused the resident severe pain when in bed. I think the pain on the foot hurts more when (Resident 40) is in bed, circulation factor is better in the chair . it's not putting direct pressure on the heels. During an interview on 02/10/2022 at 3:06 PM, Staff AA, RN stated that she regularly provided care to the resident and stated that it did not hurt Resident 40's feet as much if they were up in the wheelchair. Staff AA stated when the resident was laying down it puts more pressure on their heels. Review of the xx/xx/xxxx facility's contracted wound specialist reports showed that more aggressive pain control was recommended. During an interview on 02/15/2022 at 8:39 AM, Staff Z, Nursing Assistant (NA), stated the resident was on a decline and experienced severe pain when they moved. Resident 40 would refuse to transfer from the chair to the bed, due to the pain. Staff II described how they used a gait belt to transfer and that the resident would not bear weight on the heels of the feet. During an interview on 02/15/2022 at 8:43 AM, Staff AA stated that she regularly provided care to Resident 40 and the pain the resident experienced was ungodly. Further Staff AA stated that the wounds to the heels had gotten worse in the last three weeks. Review of the Resident 40's Admission Pain Assessment, dated 12/29/2021 showed the resident indicated an acceptable pain was at a pain level of 5 and that sitting for long periods of time made the pain worse. Review of the resident's January and February 2022 Treatment Administration Record (TARs) showed the area to indicate the resident's acceptable level of pain was blank. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . After the 19th the resident consistently (two to three times daily) requested pain medication. On the 27th, the resident rated pain at 8 out of 10 (0 being no pain, 10 being worst pain experienced) pain and on the 28th, 29th, and 31st the resident rated pain at 7 out of 10 pain. Review of the resident's record showed no notification to physician, no follow-up to determine effectiveness of PRN (as needed) pain management and no non-pharmacological interventions. Review of a 02/02/2022 nurse progress note showed the facility reached out to the Resident's Representative (RR) to update on the change in pain medications. Resident was in 9/10 pain in AM, crying out, not wanting to eat, refusing therapy. The pain medication (narcotic) was changed from PRN to routine, scheduled three times per day. Review of the medical record did not show thorough pain assessments conducted from 02/02/2022 to 02/15/2022 to determine the effectiveness of the medications and did not show any more aggressive pain control measures in place per the recommendation of the wound specialist. During an interview on 02/16/2022 at 6:15 PM, Resident 40's Representative stated they arrived and accompanied the resident to the scheduled 02/15/2021 at 1:30 PM consultation appointment at the vascular clinic. The RR stated that when the practitioner unwrapped Resident 40's feet, the pain was rated at 10 out of 10 and the practitioner only unwrapped part of one foot as the resident was in so much pain, the practitioner stopped. Resident 40 had been in a set position for so long, (Resident 40's) legs were locked. During an interview on 02/23/2022 at 11:17 AM, Staff I, RCM acknowledged Resident 40's progressively increased pain and stated that there should have been ongoing pain assessments and interventions. Staff I did not know why the physician was not notified when the wound specialist indicated more aggressive pain control measures and was unsure of why there had been a delay in initiating the urgent vascular referral. Resident 34. Review of the medical record showed the resident admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . They had severe cognitive impairment and required staff assistance with all Activities of Daily Living (ADL's). Per the Nursing 2022 Drug Handbook by Wolters Kluwer, page 1005, [MEDICATION(S)] (a narcotic pain medicine), administered by mouth, begins working in 30 minutes after administration and reaches peak effectiveness for pain relief in one to two hours after administration. A wound observation note, dated 02/09/2022, showed that the resident was at the end of their life and the family wanted them to be kept comfortable. A review of Resident 34's Electronic Medical Record (EMR) showed that since 2020, the resident had orders for Tylenol daily at bedtime and as needed for generalized pain, and [MEDICATION(S)] (a narcotic pain medicine) as needed for pain due to diabetes. An order, dated 02/09/2022, showed [MEDICATION(S)] liquid by mouth every 4 hours as needed for pain. On 02/10/2022 at 9:18 AM, Resident 34 was observed squirming in the wheelchair and stated that their butt was sore. During an intervew on 02/10/2022 at 9:22 AM, Staff O, Activities Assistant, said that they were aware of the resident's pain, and had just informed the nurse that the resident wanted pain medicine. During an interview on 02/11/2022 at 1:03 PM, Staff J, Resident Care Manager, stated that the resident had recently declined, and the family had decided to focus on just keeping the resident comfortable. A review of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No routine pain assessments were listed at that time. In addition, the document for 02/10/2022, showed that no [MEDICATION(S)] was given that day, no Tylenol was given after the resident requested pain medication, and [MEDICATION(S)] was given at 3:47 PM (over 6 hours later). A 02/18/2022 note showed orders to apply [MEDICATION(S)] (a gel medication applied directly in the wound, to temporarily numb the area) 15 minutes prior to the wound care, and to administer pain medicine by mouth 45 min-1 hour prior to wound care (to give the medicine time to work). A review of the February 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the MAR, on 02/22/2022 at 10:56 AM, Resident 34 was given a dose of [MEDICATION(S)]. On 02/22/2022 at 2:19 PM, Staff N, Licensed Practical Nurse (LPN) and Staff J, Resident Care Manager (RCM) were observed loosening the dressing over resident's sacrum to show the wound to the surveyor. Staff J stated that they needed to change the dressing. Staff J cleansed the wound to get off some of the drainage before putting the [MEDICATION(S)] on at 2:32 PM. The resident winced, moaned, and said ouch whenever the wound was touched. This was 3 hours and 23 minutes after the dose of [MEDICATION(S)]. Staff J said that they would let the [MEDICATION(S)] sit there for 15 minutes and would get the surveyor to observe the rest of the wound care. Per the MAR, on 02/22/2022 at 3:12 PM, the resident was given another dose of [MEDICATION(S)]. On 02/22/2022 at 3:37, Staff J stated that the wait was longer as new wound care orders just arrived (orders from 02/18/2022 from a contracted wound specialist). When asked what time the resident had pain medicine, Staff J stated she wasn't sure exactly, but that Staff N had given the medication. As Staff J performed the wound care, Resident 34 moaned and grimaced throughout. Staff J continued the wound care. When finished, Staff J asked the resident if they were OK? The resident replied, I'm a little bit OK. When comparing the timing of the observations during wound care, to the administration times of medication listed on the MAR, the following was noted: The [MEDICATION(S)] was ordered to apply 15minutes prior to wound care. Some of the wound cleansing was done prior to the [MEDICATION(S)] administration, so that the wound wasn't numb. The rest of the wound care was done 65 minutes after the [MEDICATION(S)] was applied, and likely was no longer effective. The [MEDICATION(S)] was ordered 45-60 minutes before wound care, and instead was given 25 min prior to the wound care, so possibly hadn't started to take effect yet and was not at peak effectiveness. Reference: WAC 388-97-1060 (1)

Based on observation, interviews and record review the facility failed to assess the effectiveness of the treatment plan and obtain medical evaluation in a timely manner, perform accurate wound assessments, and/or ensure preventative measures were in place for two of two residents (1,2) reviewed for non-pressure related skin issues. This failed practice resulted in actual harm to Resident 1, who after several months of receiving the same treatment to the left third toe and no medical assessment, was evaluated by a Physician's Assistant (PA), who specialized in wound care, and after debridement (removal of dead tissue from a wound to improve or facilitate the healing process) of the toe observed bone, thus ordered additional testing. The resident was transferred to the emergency room (ER) where she was diagnosed with [CONDITION(S)] (bone infection) in the left third toe and was scheduled for an amputation. Findings included . Resident 1. Review of the resident's medical record showed she was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Wound Observation Tool, dated 11/17/2020 by Staff D, Registered Nurse, showed the wound to the left third toe developed on 10/30/2020. The wound had 100% necrotic (dead) tissue, measured 0.6 by 0.8 centimeters (cms), and was being treated with [MEDICATION(S)] solution (used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/07/2021 the measurements to the left third toe increased to 1.0 by 0.5 cms, and by 05/25/2021 the area measured 1.3 by 0.8 cms. There was no weekly assessment of the left third toe on 05/11/2021, 05/18/2021, 03/09/2021, and on 02/02/2021. Despite staff assessing only one wound to the left third toe, review of the wound assessment of the left toe by the PA, Wound Care Consultant, dated 05/28/2021, showed there were two identified non-pressure chronic ulcers to the left third toe -left proximal (near the center) and left anterior (front of the toe) distal (furthest from the center). Documentation by the PA showed the left anterior distal ulcer was mechanically debrided which revealed dry bone and was worrisome for [CONDITION(S)]. The treatment was changed to irrigate the wound daily and as needed with normal saline (solution used in the cleaning of the ulcer) and cover with a protective dressing. Review of Progress Notes (PNs), dated 05/28/2021, showed the Wound Care Consultant had debrided the dead tissue from the left third toe which revealed possible bone being observed. The physician was notified with orders to obtain xrays to rule out [CONDITION(S)], with possible cultures and antibiotics being ordered pending the xray results. Review of the assessment by the Wound Care Consultant, dated 06/11/2021, showed the resident's left toe ulcer had worsened with tissue ischemia (decrease in blood flow). The consultant orderd an urgent consult with a surgeon to evaluate and treat to avoid amputation of the toe. Review of PNs, dated 06/11/2021, showed the physician was notified of the changes in the resident's left third toe and ordered for the resident to be transferred to the ER for a possible amputation. Review of ER records, dated 06/11/2021, showed the resident had probable [CONDITION(S)] and was started on intravenous antibiotics. Review of PNs, dated 06/28/2021, showed the resident was readmitted to the facility following hospitalization for possible amputation. Surgery was not performed as the resident was not a good surgical candidate. Despite the Wound Observation Tool on 11/17/2020 showing the left third toe wound developed on 10/30/2020, review of the PNs that day showed the resident had developed a pressure ulcer to the inner side of her right foot, and no documentation of the left foot. Review of physician assessments dated 11/11/2020, 01/15/2021, 01/22/2021, 04/07/2021 showed no assessment of the non-pressure ulcer on the resident's left third toe. During a telephone interview on 08/18/2021 at 10:58 AM, the Wound Care Consultant stated she had just started in the facility as a wound consultant on 05/28/2021. On that day she performed mechanical debridement to the resident's left anterior distal toe with normal saline and a gauze dressing with some pressure to remove the dead tissue. She stated the tissue peeled right off, which allowed her to visualize the area, at which time she observed bone which you treat as infected unless proven otherwise. Staff D stated during a telephone interview on 08/18/2021 at 9:45 AM, that the resident's left third toe was a chronic problem for which the only treatment, prior to the wound consultant, had been [MEDICATION(S)]. She verified inaccuracies of assessments of the ulcer, which included the date the ulcer to the left third toe started, missed assessments, and two assessments of the right foot and none on the left on 03/09/2021 and 05/11/2021, which made it very confusing in the evaluation of the ulcer. Resident 2. Review of the resident's medical record showed she was readmitted to the facility from the hospital on 04/24/2021 following an amputation of the right leg. Other diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Wound Observation Tool assessments between February to August 2021 showed Prevalon boots (pressure relieving) were worn by the resident when in bed. An assessment by the Wound Care Consultant on 05/28/2021 showed orders to offload (minimize or remove weight placed on the foot to help prevent and heal ulcers especially those caused by poor circulation) the resident's left foot. On 08/17/2021 at 5:04 PM the resident was observed lying in bed. Her Prevalon boot was not on and her left foot was directly on the mattress and not offloaded as ordered. The resident stated she did not have to wear the boot, and did not know where it was. Staff D stated during a telephone interview on 08/18/2021 at 4:48 PM, that the resident did not want to wear the Prevalon boots, and she had a right not to wear them. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 07/29/2021 and 01/08/2021.

Based on observations, interviews, and record review the facilty failed to provide the necessary care and services to prevent an avoidable accident for 1 of 1 resident (1) reviewed for substantial injury. This failed practice resulted in harm to the resident as Staff A, Housekeeper, failed to closely observe the hallway area as she was pushing the laundry cart thus hitting the resident from behind causing a deep laceration to the back of the resident's lower right leg. Findings included . Resident 1. Review of the resident's medical record showed she was admitted with diagnoses of respiratory, kidney, and heart problems. In addition, the resident had a blood circulation diagnosis. Review of the comprehensive nursing assessment, dated 11/18/20, showed the resident required supervision of one staff for turning/repositioning in bed, transfers, dressing, toilet use, walking in room and corridor, and personal hygiene. Comprehensive assessments dated 11/18/20 and 05/21/2021 showed the resident was cognitively intact. The resident stated during an interview on 06/09/2021 at 12:50 PM, that she was about to go home when she was hit from behind by a laundry cart, which caused bleeding to the back of her right leg. Resident 1 stated she was pushing her wheelchair when she stopped to readjust the blanket on the back of the wheelchair. It was at that time that she was hit by the cart. The resident stated she could see bone and tendon. Resident 1 was taken to the emergency room (ER) for treatment. The person who hit the resident could not see around or over the laundry cart. Resident 1 stated the back of her leg was still sore. Staff A stated during a telephone interview on 06/09/2021 at 2:43 PM, that the resident had stepped out of room 222 in front of the laundry cart. Staff A stated she did not see the resident come out of the room. The laundry cart was being pushed along the wall on the left side of the hallway. Staff A stated, The cart is kind of hard to see around .I hit her from behind. Staff A stated she tried to do the personal laundry when staff and residents were at lunch or breakfast, and not in the hallway. On 06/09/2021 at 3:05 PM the resident performed a reenactment of the laundry cart incident. Resident 1 was observed pushing her wheelchair along the left side of the hall just before the entrance to room 222 when she stopped to adjust her blanket on the back of the wheelchair. Resident 1stated it was at that time when she was hit on the back of her leg by the cart. Resident 1 pointed to the middle of the back of her right lower leg, just above the ankle, where dark discoloration of the skin with indentation was observed. The resident stated she had not entered room 222. On 06/09/2021 at 3:37 PM Staff B, Administrator, took measurements of the laundry cart which was 36 inches wide and slightly less than six feet tall. A long metal piece connecting the wheels was at the bottom of cart, which Staff B stated probably caused the injury to the resident's right leg. Despite the resident's injury there was no alteration of the cart to prevent further injuries. Staff B stated that upon his observation of the resident's leg he believed the resident was in the hallway at the time of the incident and was hit by the cart directly on the back of her leg. He stated, I think she [Staff A] is distracted .We have to be aware of our surroundings. Review of the facility investigation form, dated 12/07/2020 at 8:30 AM, showed the resident was standing in the doorway of room 222 when she was hit by the laundry cart, being pushed by Staff A. Staff A was unable to see the resident as she was standing in the doorway. The injury to the leg was relatively deep, thus the resident was sent to the ER. The resident stated she was standing in the hallway. Review of the resident's ER record, dated 12/07/2020, showed there was a 12 centimeter (cm) laceration to the back of the right lower leg approximately 10 cms above the right ankle. The laceration went through the subcutaneous tissue (deepest layer of skin) exposing the fascia (thin layer of tissue that surrounds and holds every blood vessle, bone, nerve, and muscle in place). Blood vessels were exposed but were not lacerated. The area required nine sutures. Observation of a picture in the ER record showed the resident's laceration was directly midline to the lower area of the back leg. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interviews, and record review, the facility failed to timely evaluate/monitor the condition of one of three residents (#1) newly admitted to the facility from the hospital. Failure to evaluate/monitor the resident's condition disallowed staff from determing if changes were occurring necessitating medical treatment. This resulted in actual harm to Resident #1, who had been recently hospitalized for [REDACTED]. Findings included . Resident #1. Review of the resident's medical record showed the [AGE] year old resident was admitted from the hospital on [DATE] at 12:00 PM with multiple [DIAGNOSES REDACTED]. Review of the hospital Discharge Summary, dated 01/30/2020, showed the resident spent ten days in the hospital with initial time in the ICU due to [MEDICAL CONDITION] from [MEDICAL CONDITION] (lack of oxygen) and required intubation (insertion of a tube into the trachea to assist with breathing). The summary showed the resident had recurrent pleural effusions (excess fluid builds around the lungs). Review of admission physician's orders [REDACTED]. Review of a nursing admission assessment, dated 01/30/2020 at approximately 1:12 PM, showed the resident's oxygen saturation level was 88% on oxygen (normal is 95-100% - measures the oxygen saturation level of the resident's blood using a pulse oximeter placed on the finger). There was noted swelling to the left arm and right leg. The resident had wheezing (high pitched [MEDICATION NAME] noise made during respirations - may be indicative of a mild airway obstruction due to narrowing of the airways of the lungs) to the right and left upper lobes of the lung, and diminished lung sounds to the right and left lower lobes. The resident required extensive assistance with turning in bed, transferred utilizing a mechanical lift, and had an open pressure ulcer to the tailbone. Review of Progress Notes (PNs), dated 01/30/2020 at 6:09 PM, showed the resident's lungs had expiratory wheezes. The resident was on five liters of oxygen via nasal cannula. He stated he would have shortness of breath and respiratory distress at times, and would utilize a face mask rather than a nasal cannula at night. The resident's color was pale and he was without cough, congestion, or nasal drainage. The next documented evaluation/monitoring of the resident was at 7:30 PM on 01/30/2020 by Staff B, Licensed Practical Nurse, where PNs showed the resident was without shortness of breath, cough, or difficulty breathing. His oxygen saturation level was between 96% to 98%. Documentation at that time also showed the resident's blood glucose reading was 313, (normal range is less than 140 two hours following a meal), and the resident stated he did not take routine insulin. There was no further evaluation/monitoring of the resident until 01/31/2020 at 7:22 AM (approximately 12 hours later) where PNs showed the resident was found in bed without pulse or heart rate. The resident was very warm, clammy with a small amount of vomit on his chest. The resident had oxygen being administered via a nasal cannula (despite his statement above showing he wore a face mask at night). Cardiopulmonary resuscitation was immediately started by staff. Emergency medical services was activated and responded, however the resident remained without a pulse or respirations. Despite the resident's recent 10 day hospitalization ; and history of heart, kidney, and lung diseases treated with medications; review of his medical record showed no vital signs were ever obtained in the facility. During an interview with Staff B on 02/06/2020 at 12:20 PM, she stated that she was the resident's assigned nurse between 6:00 PM on 01/30/2020 to 6:00 AM on 01/31/2020. She stated she did not perform a physical assessment of the resident such as listening to heart and lung sounds, obtaining vital signs, and observation of the resident's skin. Staff A, Registered Nurse, stated during an interview on 02/06/2020 at 11:00 AM that she had received shift report at 6:00 AM on 01/31/2020 from Staff B, however there was no mention of the resident. She stated between 6:00 AM to 7:22 AM on 01/31/2020 she had been up and down the halls and could hear the resident snoring from the hallway. She stated she was obtaining vital signs on residents receiving blood pressure medications when she entered the resident's room and found him without a pulse or respirations. She stated the resident was a big guy and the paramedics had a difficult time with his airway. One of the paramedics had stated, appeared his lungs were full of fluids. A telephone interview on 02/11/2020 at 11:00 AM with a paramedic who had responded when emergency services was notified, stated that when they intubated (a tube placed into the lungs for breathing) the resident they obtained large amounts of fluid from the lungs with suctioning. Reference (WAC) 388-97-1060(1). This is a repeat deficiency from Statement of Deficiencies dated 12/13/2019.

Based on interviews and record review the facility failed to timely evaluate/monitor and take appropriate measures for one of three residents (#1) reviewed for changes in condition. This failed practice resulted in actual harm to Resident #1 due to her complaints of significant pain and/or delay in obtaining medical treatment in response to her change of condition. Findings included: Resident #1. Review of the resident's medical record showed she was admitted to the facility on [DATE] from the hospital following two abdominal surgeries. Review of the admission nursing assessment, dated 11/18/19, showed the resident was alert and oriented to person, place, time, and situation; able to make herself understood and understood others. Review of Progress Notes (PNs), dated 11/18/19, showed the resident required a mechanical lift for transfers, and extensive assistance with two staff for toileting and turning in bed. The resident had an indwelling [MEDICAL CONDITION] catheter due to issues with skin, however review of hospital records, dated 11/26/19, showed the catheter was inserted due to urinary obstructive symptoms and inability to urinate. On 11/20/19 PNs at 2:30 PM showed the urinary catheter was removed by Staff A, Registered Nurse (RN). Documentation at the time of removal showed the urine was clear and yellow. The next documented entry in the PNs was on 11/21/19 at 12:58 AM by Staff B, RN, which showed at 10:30 PM on 11/20/19 the resident had not urinated. A bladder scan at that time showed 307 cubic centimeters (cc's) of urine in her bladder (30 cc = 1 fluid ounce). Staff B informed the resident she would have to try and urinate in the coming hours, and was educated on drinking more water. The resident stated at that time she did not have the urge to urinate. There was no further documented assessment of the resident until 11/21/19 at 10:34 AM. The assessment by Staff C, Licensed Practical Nurse (LPN), showed the resident had not voided as of 8:00 AM on 11/21/19 (17.5 hours later) and was feeling uncomfortable. The resident's abdomen was distended and she was unable to eat breakfast. The physician was notified and orders received to insert a [MEDICAL CONDITION] catheter and retrain the bladder by clamping the catheter every three hours and unclamping it for 15 minutes. At 10:34 AM 520 cc's of dark yellow, nearly orange urine was in the urinary drainage bag. The resident stated during an interview on 12/13/19 at 9:15 AM that she was terribly uncomfortable with not being able to urinate after her urinary catheter had been removed (11/20/19). She stated, Uncomfortable was the understatement of the century, very uncomfortable. Two nurses had come into her room with their coats on as they had just arrived to work on the dayshift, They took care of it right away. She stated that prior to that staff had not paid any attention, I kept calling them and telling them. Staff B stated during a telephone interview on 12/13/19 at 1:00 PM that if the resident would have had any complaints of pain she would have acted on it. She stated she had not performed any further assessment of the resident's bladder since earlier in her shift when a bladder scan was done (10:30 PM on 11/20/19). Interviews conducted on 12/13/19 at 10:50 AM with Staff C and Staff D, both LPNs, showed they both arrived to work at approximately 8:00 AM on 11/21/19. They had their coats on and were walking down the hall and heard the resident crying from her room. Staff D stated, She was hurting so bad .the resident had stated she had to pee so bad and didn't have a catheter in. Staff C stated following the insertion of the [MEDICAL CONDITION] catheter 300 cc's of urine was obtained within 20 to 30 seconds. The catheter was clamped at 400 cc's. At approximately 10:30 AM there was 520 cc's of urine which was drained from the collection bag. By 5:00 PM that evening an additional 800 to 1000 cc's of urine was observed in the collection bag. Further review of PNs dated 11/26/19 at 2:50 PM, documented by Staff A, showed she had received report from the night nurse that the resident had been vomiting since 5:00 AM. The physician evaluated her and gave orders to transport the resident to the emergency room (ER). Review of hospital records, dated 11/26/19, showed the resident informed hospital staff that she developed stomach pain, chest pain, continued nausea with eventual emesis at approximately 11:00 PM on 11/25/19. She also had a fever and diaphoresis (sweating). She informed ER staff her symptoms continued through the night. Staff at the facility had reported the resident had coffee-ground emesis (vomiting which resembles coffee grounds - usually result of bleeding into the stomach) that morning. The resident was admitted to the hospital with [REDACTED]. Review of the resident's vital signs showed on 11/26/19 at 12:47 AM the resident was afebrile (free from fever) at 97.1 degrees orally with a pulse rate of 73 beats per minute, and at 9:31 AM she was febrile (having a fever) at 101.6 degrees orally with a pulse rate of 111 beats per minute. Review of the resident's Medication Administration Record [REDACTED]. The resident stated on 12/13/19 at 9:15 AM that she was never so sick in my life. She stated she got sick during the early morning hours of 11/26/19, it was still dark outside. She stated it took longer than it should have to get me transferred to the hospital. Staff D stated on 12/13/19 at 11:00 AM that when staff went to do wound rounds on the resident with the physician on 11/26/19 at approximately 7:30 AM the resident had a coffee ground emesis in front of the physician. The physician evaluated her and ordered for her to be sent to the ER. Staff E, RN, stated during interviews conducted on 12/13/19 at 12:23 and 2:20 PM that the resident became nauseated and vomited at approximately 5:00 AM on 11/26/19 when she was doing the morning medication pass. Staff [NAME] stated she checked to see if the resident had anything ordered for nausea but she did not. She confirmed the resident did have abdominal pain but it was better after she vomited. Staff [NAME] stated the resident had an appointment scheduled with her surgeon that day. When Staff [NAME] was questioned as to the Tylenol given at 12:05 AM on 11/26/19 she stated, may have been for her stomach, but really did not help her pain. Staff F, Nursing Assistant, stated that between 4:00 to 5:00 AM on 11/26/19 she heard the resident vomiting. She stated she changed her gown and bedding at that time. Between then and 5:30 AM the resident had three to four emesis of dark brown liquid. Staff [NAME] stated the resident had informed her she had an upset stomach earlier during the night and it felt like heartburn. She stated the resident was worried about her condition due to her recent abdominal surgeries as maybe something was going on internally. Despite the significant changes in the resident's condition and ineffective results of the Tylenol during the early morning hours of 11/26/19 review of PNs showed no assessment or monitoring (including lack of vital signs at the time of her vomiting episodes) of the resident's condition until the physician evaluated her with orders to transfer her to the ER. Reference (WAC) 388-97-1060(1) This is a repeat citation from the Statement of Deficiencies dated 03/01/19.

Based on interviews and record review the facility failed to notify the physician relative to symptoms of vomiting and possible bleeding in the stomach for one of one resident (#1) who recently had two abdominal surgeries and was reviewed for change in condition. This failed practice resulted in actual harm to Resident #1 due to resultant pain and nausea with delay in obtaining medical treatment. Findings included . Resident #1. Review of the resident's medical record showed she was admitted to the facility on [DATE] from the hospital following two recent abdominal surgeries. Review of the admission nursing assessment, dated 11/18/19, showed the resident was alert and oriented to person, place, time, and situation; able to make herself understood and understood others. The resident stated during an interview on 12/13/19 at 9:15 AM that she had recently been transferred to the emergency room (ER) for pancreatitis (inflammation of the pancreas) and gall bladder issues. She stated, never been so sick in my life, I know I was really sick. She stated it took longer than it should have to transfer her to the hospital. She stated the physician came in and told her she needed to go to the hospital. The resident's collateral contact stated during an interview on 12/13/19 at 10:09 AM that the resident had told her she had been sick all night (early morning hours of 11/26/19). She stated the resident had asked staff to call the physician but they wouldn't as they did not want to bother him, and told her they would get in trouble the only time she got help is when she stated she would call 911. The collateral contact stated the resident was vomiting and was really sick, shouldn't have been left sick all night. An interview with the resident's physician on 12/13/19 at 12:20 PM showed that when he entered her room the morning of 11/26/19 she was having symptoms of abdominal discomfort and vomiting. He stated he became aware at that time that the resident had an episode of vomiting during the night. He stated he was concerned that staff had not notified him of the changes in the resident's condition especially since she had been recently admitted to the facility following abdominal surgery. He stated,to let it go that long that's not the way we should be doing things. Staff D, Licensed Practical Nurse, stated on 12/13/19 at 11:00 AM, that the resident's physician had asked why he was not notified as the resident had been vomiting since 5:00 AM. The physician did not know anything about the resident's change in condition until he walked into her room to do wound rounds on 11/26/2019 (at approximately 7:30 AM on 11/26/19). Staff E, Registered Nurse (nurse in charge at the time of the resident's change in condition), stated during a telephone interviews on 12/13/19 at 12:23 PM and 2:20 PM that it was her first interaction with the resident as she normally worked the other side of the building. When Staff [NAME] was questioned as to why the resident had received Tylenol at 12:05 AM on 11/26/19, she replied, may have been for her stomach. She stated the resident had informed her later that the Tylenol had not really worked for her pain. Review of hospital records, dated 11/26/19, showed the resident informed hospital staff that she developed stomach pain, chest pain, continued nausea with eventual emesis at approximately 11:00 PM on 11/25/19. She also had a fever and diaphoresis (sweating). She informed ER staff her symptoms continued through the night. Staff at the facility had reported the resident had coffee-ground emesis (vomiting which resembles coffee grounds - usually result of bleeding into the stomach) that morning. The resident was admitted to the hospital with [REDACTED]. Refer to F684 for additional information. Reference (WAC) 388-97-0320(1)(b)

Based on interview and record review, the facility failed to provide care and treatment, in accordance with professional standards of practice. Deficient practice was identified for one of three residents (#1) reviewed for changes of condition. Resident #1 received a skin injury on his right knee during a therapy treatment (and on other occasions) and the facility failed to conduct appropriate assessments and follow-up treatment to promote healing. In addition, Resident #1 experienced a change of condition and the facility failed to recognize the seriousness of his progressive physical decline, recontact the physician, and facilitate timely transfer to the hospital. Resident #1 experienced harm as his condition continued to decline prior to a family member arriving at the facility and requesting staff transfer the resident to the hospital. Findings included: Resident #1. Review of the medical record showed the resident was admitted to the facility on [DATE] following a right total knee replacement. The resident also had muscle weakness, diabetes, [MEDICAL CONDITION], and dementia without behavioral disturbance. Resident #1's face sheet, containing pertinent information about the resident, listed contact telephone numbers for family members. According to the 11/19/18 ADL (Activities of Daily Living) Self-Care Deficit plan of care, the resident had a right total knee replacement surgery and was admitted with a surgical incision with some swelling but the incision was healing well. The resident also had neuromuscular disease (a condition affecting the nerves and muscles). Per the plan of care, the resident required extensive assistance from two persons for his activities of daily living. However, Resident #1 was able to eat independently after his meal was set up. He had difficulty with weight bearing on the left leg as well. The resident needed to be able to transfer with assistance from one person prior to returning home with family. Skilled therapies were to be provided, such as physical therapy, occupational therapy, and speech therapy when ordered. Additionally, the 11/19/18 plan of care for impaired cognition showed the resident had a [DIAGNOSES REDACTED]. They were also to provide cues, prompting, and demonstration if the resident was unable to complete a task independently. The resident was noted to be very cooperative and usually in a good mood. Per the 11/19/18 plan of care for skin, the resident had pressure ulcer(s) present. Staff were to complete weekly skin checks. All staff were to notify nurse immediately of any new areas of skin breakdown, redness, blisters, bruises, discoloration noted during bathing or daily care(.) Additionally, there was a directive to notify the resident/responsible party of any new areas of skin breakdown. The Licensed Nurses (LNs) were to observe effectiveness of/response to treatment(s) as ordered . Additionally, the LNs were to report changes in skin status (i.e. s/s (signs and symptoms) infection, non healing, new areas) to physician. Wound care was to be provided as ordered by the physician. According to an 11/27/18 nursing entry, the resident was having skilled therapy treatments. The incision on the resident's right knee was healing well and showed no signs of infection. The knee dressing was discontinued. A 12/21/18 nursing entry showed the resident had an onset of difficulty speaking and weakness in his right hand. Staff contacted the physician and there was an order to send the resident to the hospital for an evaluation. On 12/26/18 the nursing entry noted the resident had readmitted to the facility with a new [DIAGNOSES REDACTED]. The resident was receiving speech therapy services. The 12/30/18 nursing entry showed the resident's knee incision was healing well and had no sign of infection. According to documentation from the orthopedic physician, the resident had follow-up visit on 12/31/18. The resident's right knee incision was healed but there was a central area of scabbing due to being bumped on an exercise bike. Review of the 07/16/18 Wound Management Protocol, showed: 4. Treatment is obtained immediately following identification of a wound. Additionally, after assessment, 14. The wound care progress note is (sic) should be documented in (the electronic medical record) weekly. The progress note needs to include: a. Current wound treatment and patient response(,) b. Physician and family notifications(,) c. Nutritional interventions(,) d. Pain before, during and after treatment and any pain management needed(,) e. Therapy involvement in wound care(,) f. Preventative measures that are in place(,) (and) g. Any other information not included in the wound care module. A nursing entry on 01/17/19, noted as for 01/16/19, showed the resident's right knee with old scabbed area that was moist with a small amount of bleeding, area cleaned and new bandaid applied, no s/sx (sign or symptom) of infection. Review of the Weekly Skin Integrity Data Collection form for weekly skin monitoring entries, between 11/19/18 through 01/19/19, did not show documentation of a scabbed area or injury site on the resident's right knee. The 01/2019 Treatment Record did not show monitoring of the right knee scabbed area. A 01/23/19, late Medicare charting entry for 01/22/19, noted the resident's right knee had no signs of infection and had limited range of motion. The resident was wearing a brace on the right knee and splints to both lower legs and feet. Similar findings were noted on 1/24/19, for 01/23/19, in the nursing entry. Right knee incision is healing well with no s/sx of infection. No 01/24/19 nursing entry was located in the medical record. According to a 01/25/19 nursing entry at 8:30 PM, Staff A, Registered Nurse (RN), noted the resident was self-propelling in his wheelchair. Two staff transferred the resident with a mechanical lift. No vital signs were recorded but the charting reflected the resident's respirations were unlabored. There was no night shift entry for 01/25/19 going into 01/26/19 or documentation of vital signs recorded in the medical record that shift. Per the 01/26/19 day shift nursing entry by Staff B, RN, the resident had a temperature reading of 100.3 degree Fahrenheit (F) and was having trouble speaking. The resident's right knee was warm to touch, red, and swollen. The resident complained of pain. No other assessments were noted. The physician was notified and he ordered stat (to be done as soon as possible) lab tests and an x-ray of the resident's right knee. The physician also ordered Tylenol 500 milligrams every six hours as needed for fever for possible [MEDICAL CONDITION] (infection in the tissue). The resident and Family Member #1 were aware of new orders. Will continue to monitor. According to the (MONTH) 2019 Medication Administration Record [REDACTED]. No other pain medication was documented as administered on 01/26/19, other than Tylenol. On 01/26/19 at 2:04 PM, Staff B documented the resident's temperature continues to increase. Family requested to have him sent to (specific hospital) ER The physician was also notified. The resident left via ambulance. No other vital signs, including the resident's actual temperature readings, were documented following the administration of the Tylenol earlier. No further assessments were noted in the nursing entry. A Nursing Home To Hospital Transfer form, dated 01/26/19, showed the resident's temperature was 103.4 F at 1:55 PM. The resident's pulse was 106 and his respiratory rate was 17. His most recent pain level was reported as 10, on a scale of 1 to 10, with 10 being the highest possible. The reason for the transfer was noted as (increased) confusion, temp (temperature)(.) Review of the laboratory slip, collected on 01/26/19 in the morning, to be run as soon as possible, showed the results were not forwarded to the facility until the morning of 01/28/19, two days after they were drawn. According to the 01/26/19 hospital records, the resident presented to the emergency department (ED) following an onset of symptoms the previous night and with an ongoing course of confusion and fevers since that time. While in the ED, the staff had difficulty placing an intravenous line and ultimately a central line was placed in the resident's neck. The resident's fever continued to rise to 105 degrees F and his respirations were also elevated. The resident's final ED [DIAGNOSES REDACTED]. The resident was sent to the intensive care unit thereafter. A 01/27/19 physician's evaluation in the hospital showed [MEDICAL CONDITION] with metabolic [MEDICAL CONDITION] (mental status changes caused by the infection) was due to an undetermined organism but the source of the infection appeared to be a right lower extremity [MEDICAL CONDITION] which had come on very acutely with high fevers. Additionally, there was a pyogenic (involving pus) arthritis of the right knee joint with history of a right total knee replacement .There is [MEDICAL CONDITION] overlying the joint, including around a small focal superficial ulcer overlying the patella (knee cap). This may have been the initial route of entry for the [MEDICAL CONDITION]. This does place the joint itself at risk. Further review of the hospital records showed orthopedic procedures were performed thereafter, including a right total knee revision. On 02/22/19 at approximately 11:50 AM, a telephone interview was conducted with Staff C, Nursing Assistant (NA). Staff C stated she had been Resident #1's assigned caregiver on the day shift of 01/26/19. The resident had a fever at the beginning of the shift. Staff C took the resident's temperature, wrote it on a sticky note, and gave it to the nurse. The resident continued to have a fever throughout the shift. He was talking more but was confused. The resident was able to feed himself his breakfast but by lunch time he was much more confused and was no longer able to feed himself. Staff had to feed him his lunch and he only ate about 50% despite staff helping him. By that time, the resident was only able to mumble a few words. Staff typically were able to understand his normal sounding speech. Family Member #2 came in to visit the resident around 1:00 PM when lunch was almost finished. A telephone interview was conducted with Staff B (the 01/26/19 day shift nurse) on 02/22/19 at approximately 12:45 PM. Staff B stated she had received report from the off-going night shift nurse (Staff A) that the resident had a fever of 101 degrees F during the night and Staff A had given the resident Tylenol at 5:30 AM or 6:00 AM. Staff B recalled on 01/26/19 she was called by a therapy staff member (Staff D, Occupational Therapy Assistant, COTA) because the resident was slower than usual during his therapy session. It was the first day Staff B had cared for the resident so she called the nursing manager on-duty, Staff E, Licensed Practical Nurse (LPN) to also check him. The resident was having difficulty speaking. The resident's right knee was red and hot to the touch in the area of the surgical incision. Staff B called the resident's physician and he ordered stat lab tests and Tylenol every six hours. Staff B also notified Family Member #1 of the resident's fevers since the night shift. Per Staff B, she re-checked the resident's temperature often (but not documented). Family Member #2 came in to see the resident and he wanted the resident to be sent to the hospital. Prior to leaving the facility, the resident's temperature was greater than 103 degrees F and he was having increased effort to breathe. Staff F, NA, was interviewed via telephone on 02/22/19 at approximately 2:05 PM. Staff F stated on 01/26/19 during the day shift he had assisted with getting the resident up for the day. Resident #1 was alert initially but later the resident started to not respond appropriately. His speech was slurry and he had a blank look on his face. The nurse was notified of the change in the resident's condition. The family member came and wanted him sent to the hospital. On 02/22/19 at approximately 2:30 PM, Staff D, COTA, was interviewed about the resident's condition on 01/26/19 during the morning therapy session. Staff D had worked with the resident frequently. On 01/26/19 the resident would get half way through a task and stop. He appeared to be in and out of reality. Something was not right with him. He had never seen the resident in that condition before. He had to shorten the therapy session; there was no way he was able to finish the complete session. Staff D took the resident to a nurse to check him. On 02/22/19 at approximately 2:40 PM a telephone interview was conducted with Staff A, the Registered Nurse, who cared for the resident during a portion of the evening and during the night shifts of 01/25/19 going into 01/26/19. Staff A recalled the resident was in good spirits during the evening shift when assisted into bed. She did not recall redness on the resident's right knee. Additionally, Staff A was unable to recall if vital signs were taken that night or any other details related to the resident's condition or care that night. Also interviewed by telephone on 02/22/19 at approximately 9:00 PM, Staff G, NA, stated she had cared for Resident #1 on 01/25/19 during the evening shift. Staff G could not recall if vital signs were taken that evening but she recalled the resident had a scabbed area in the middle of his right knee that had opened repeatedly over time. Staff H, the Director of Nursing Services (DNS), was interviewed via telephone on 02/25/19 at approximately 11:35 AM. The DNS was asked about a policy or expectation related to rechecking residents' temperatures following the administration of Tylenol for elevated temperature readings. Staff H stated they did not have a written facility policy but she would expect staff to recheck the resident's temperature unless they were sleeping. On 02/25/19 at approximately 11:58 AM, a telephone interview was conducted with Staff I, Physical Therapist (PT). Staff I described the resident's therapy activities following his right knee placement and some of the resident's challenges with [DIAGNOSES REDACTED] and knee extension. Staff I also recalled an incident during a PT session when Resident #1 hit his right knee on the exercise bicycle resulting in a skin injury with some minor bleeding. The PT could not recall when the incident occurred. He did not chart it in the therapy note but reported the incident to a unit nurse. The unit nurse checked the area and placed a bandaid. The equipment was adjusted. The resident was also known to hit his knee on the wheelchair on other occasions. Staff J, NA, was interviewed via telephone on 02/25/19 at approximately 2:30 PM. Staff J recalled she had taken care of the resident during the night shift beginning on 01/25/19 and ending on 01/26/19. During the first rounds of her shift she checked on the resident and found him very groggy and his face was very flushed. Staff J checked the resident's temperature and she recalled it was 101 degrees F. She wrote the resident's temperature on a sticky note and gave it to the nurse. Staff J was in the resident's room when the nurse came in and gave the resident medication. The nurse told Staff J the medication was Tylenol and that Staff J needed to recheck the resident's temperature later. Staff J was also directed to place a thin sheet on him so he wouldn't overheat. About an hour later, Staff J rechecked the resident's temperature and she recalled his temperature was down but only a little (but there was no documentation of the temperature recheck). On 02/25/19 at approximately 3:00 PM, a telephone interview was conducted with Family Member #2. Family Member #2 stated he had spoken with Family Member #1 by telephone and she had requested he check on the resident's condition as the facility had reported the resident had a fever. Family Member #2 stated he arrived at one something and the resident was in the dining room. Resident #1 did not recognize his family member. He couldn't talk and sounded like a stroke victim, lethargic. The resident also had hand tremors and was breathing heavily like he had been running laps. Family Member #2 approached one of the nurses on-duty and requested the resident be sent to the hospital. The nurse stated they were getting some labs and if they sent the resident to the hospital they would just likely send him back to the facility. Family Member #2 insisted the resident be sent to the hospital so he could be checked by a physician. When staff rechecked the resident's temperature prior to the hospital transfer he recalled it was 103.9 degrees F. Family Member #1 was interviewed on 02/25/19 at approximately 3:45 PM and she stated Staff I had reported to her that the resident had bumped his right knee on the exercise bike during therapy and it had caused a skin injury. However, no one from the nursing department had reported the wound issue to her. She could not recall exactly when the skin injury had occurred but she recalled that during the 12/31/18 physician's appointment, the physician had noticed it and stated it could become a problem. On some occasions Family Member #1 saw a bandaid on the area. On the morning of 01/26/19, the facility had called her and reported the resident had a low grade fever and confusion. The facility did not plan to transfer the resident to the hospital so she spoke with a family member and asked him to go and check on the resident. Family Member #1 was out of town at the time. She returned later that night and found the resident in the hospital intensive care unit. Per Family Member #1, a physician visited the resident in the ICU the following day (on 01/27/19) and stated the right knee infection could have entered through the knee wound or from the [MEDICAL CONDITION]. While in the hospital, the resident's right knee was full of pus and it had to be drained. Later, the resident had the knee hardware replaced. He was currently receiving a long course of IV (intravenous) antibiotics.Staff K, Licensed Practical Nurse (LPN)/Resident Care Manager, was interviewed on 03/01/19 at approximately 11:30 AM and stated the primary care physician had standing orders for Extra Strength Tylenol 500 milligrams one orally every four hours as needed for pain or fever but the Tylenol order needed to be written when implemented. No Tylenol order or nursing entries/assessments were found that corresponded with the night shift of 01/25/19 going into 01/26/19 night shift. On 01/26/19 the day shift nursing entry did not include a temperature recheck value after the 100.3 degree and Tylenol administration. (Tylenol had a one hour onset of action per the Medscape drug reference). Staff K stated the resident's temperature should be rechecked following administration of the Tylenol. The hospital transfer sheet showed the resident's temperature was 103.4 degrees F (at 1:55 PM) despite receiving Tylenol a little over three hours earlier. When Staff K was asked why the stat lab value report was dated two days later, Staff K called the laboratory and they reported it was not ordered stat, but as a routine order on 01/26/19. Staff K stated she was involved in weekly wound rounds and wound care. She had not been notified about any skin injury on the resident's right knee. Reference (WAC) 388-97-1060(1)

Based on interviews and record review staff failed to perform cardio-pulmonary resuscitation (CPR) in a timely manner to 1 of 1 resident (#1), due to Staff B's (Registered Nurse), decision too much time had elapsed to warrant basic life support measures be initiated. In addition, the facility failed to ensure Staff A was current with CPR certification. Failure to respond in a timely manner with CPR resulted in a significant delay of life support measures to Resident #1, which constituted a Past Non-Compliance Immediate Jeopardy. The facility was notified on [DATE]. Findings included: Resident #1. Review of the medical record revealed the resident was admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of the POLST (physician's orders [REDACTED]. Review of Progress Notes, dated [DATE], noted the resident was cognitively intact, was in the facility for therapy and strengthening, continent of bowel and bladder, and required two staff to assist with transfers using a sit to stand lift system. Review of the resident's weight noted she was 328 pounds on [DATE]. Review of a facility investigation report, dated [DATE], noted a timeline was documented by Staff A relative to the sequence of events that occurred the morning of [DATE] involving the resident which was as follows: 7:00 - Staff C, Nursing Assistant (NA), answered the resident's call light. The resident requested to be repositioned in bed. 7:05 - Staff B checked the resident's blood sugar. The resident was awake, made eye contact, and was in no distress. 7:,[DATE]:15 - Staff B prepared medications for other residents in addition to the resident. 7:15 - Staff D, Nursing Assistant, calls out for Staff B to quickly come to the resident's room. Staff B grabbed her stethoscope, examined resident, and found no pulse, unresponsive to sternal rub, and was foaming at the mouth. Staff B instructed Staff D to turn the resident to the side. 7:16 - Staff B called Staff A, Administrator, on the telephone to explain the situation involving the resident. 7:,[DATE]:19 - Staff E, Director of Nursing, arrived at the facility and starts assisting. Staff B called the resident's spouse and left a message, then notified the resident's father. Staff B then left a message for the coroner. 7:20 - Staff B called the resident's primary care physician and received physician's orders [REDACTED]. Staff E gets the crash cart and three NAs assist Staff E with CPR. At the same time Staff B placed a call to 911. 7:23 - Staff B returns to the resident's room to assist with CPR. Per interview with Staff B on [DATE] at 12:55 PM she referenced the sequence of events as noted in the above timeline. Staff B stated she was in shock as 10 minutes prior resident was alive. She acknowledged she had not checked the resident's POLST form to determine the resident's wishes. She stated she had called the resident's family as the resident had expired. An interview with Staff E on [DATE] at 11:50 AM revealed when she arrived at the facility on [DATE] at approximately 7:15 AM Staff B handed her a personal cell phone in which she had been talking with Staff A. Staff E questioned Staff A as to what was going on, to which Staff A replied the resident had expired. Staff B then stated the resident had passed away as she was in the process of calling the physician. Staff E asked Staff B as she (Staff E) was grabbing the resident's medical record to determine the resident's code status. Upon review of the resident's POLST form Staff E immediately noted the resident was a full code, thus she instructed Staff B to get off the phone and call 911. Staff E immediately went and retrieved the crash cart and took it to the resident's room. Staff E enlisted the help of four NAs to place the resident on the floor. She stated due to the resident's weight and the crash cart having a half back board CPR would have been ineffective. Staff E started compressions on the resident while Staff D utilized an Ambu bag (a bag-valve-mask used for artificial respirations) to perform the breathing. Cardiopulmonary resuscitation was continued by staff until the paramedics arrived and took over. The paramedics continued CPR until approximately 7:45 AM, however the resident could not be revived. Staff E stated Staff B had not checked the resident's POLST form to determine the resident's wishes. Staff B had called the resident's family to inform them the resident had passed. The resident's father had arrived at the facility at the time the paramedics were performing CPR on the resident. The resident's physician was interviewed by telephone on [DATE] at 12:30 PM, and stated Staff B had called to inform him the resident had expired. Staff B had referenced a certain amount of time had gone by. The physican had stated to Staff B he did not care how much time had gone by as the resident was a full code and Staff B needed to be doing CPR. The physician stated, this individual didn't do what she should have which compromised everything. Per telephone interview on [DATE] at 9:41 AM with Staff D revealed on [DATE] at approximately 6:55 AM Staff B had gone into the resident's room to administer medication when she could be heard trying to wake up the resident. Her voice tone got louder and louder, thus Staff D proceeded to the resident's room at which time Staff B yelled out for her. Staff D observed Staff B rubbing the resident's chest in an attempt to wake up the resident. The resident was foaming at the mouth. Staff B utilized her stethocsope to listen to the resident's heart, and Staff D checked for a pulse. The resident was pale and her fingertips were blue. Staff B then stated the resident was gone and requested Staff D to turn her on her side. Staff B looked like she was in shock, and she did not elicit any help from the two other LNs in the facility at the time. Staff B then requested Staff F, Nursing Assistant, to assist Staff D with cleaning up the body. Staff D stated she was aware of the location of the POLST form in the resident's medical record, however she was following the directions given by Staff B. Review of CPR certification records for all LNs working in the facility revealed the only expired certification card was Staff B, which had expired in (MONTH) (YEAR). Prior to the onsite visit on [DATE], the facility provided documentation which revealed Staff B was immediately suspended pending an investigation of the incident, all nursing staff had been educated in responding to an unresponsive resident or a resident without a pulse and the code status of each resident and where it is found, a full audit of CPR certifications for all staff to ensure they were current with certifications. Multiple interviews with LN staff on [DATE] revealed staff were knowledgable of the protocols for responding to an unresponsive resident.

Based on interviews and record reviews, the facility failed to perform thorough assessments and closely monitor the condition of 1 of 3 residents (#1) reviewed with enteral feeding tube. The facility failed to recognize significant changes in the condition of Resident #1, subsequently, emergent medical treatment was not obtained in a timely manner. This failed practice resulted in actual harm to Resident #1 due to the severity of his condition upon arrival to the emergency room . Findings included: Resident #1. Review of a hospital Discharge Summary, dated 08/02/17, showed the resident was admitted to the facility from the hospital on [DATE] (following a 14 day hospitalization ), with [DIAGNOSES REDACTED]. The Discharge Summary noted the chest x-ray, obtained on 07/27/17, relative to the pneumonia, had improved from the x-ray taken on 07/19/17. The chest x-ray taken two days later on 07/29/17 noted no cardiopulmonary process. Review of physician orders [REDACTED]. Oxygen therapy was ordered at three liters per nasal cannula. In addition, the resident's head of bed was to be elevated to 30 degrees for 30-60 minutes following feedings every shift. An initial nursing assessment form, dated 08/02/17, showed the resident was alert and oriented with short term memory loss, and able to communicate his needs. His blood pressure reading was 129/72 with a respiratory rate of 18 breaths per minute. Rhonchi lung sounds (coarse, rattling, respiratory sounds usually caused by secretions in the [MEDICATION NAME] airways), were audible in his lower lung fields. Oxygen therapy was at three liters per minute, and his pulse oximeter reading was at 97%. A pulse oximeter is a medcal device that indirectly measures levels of [MEDICAL CONDITION] (low oxygen). It senses levels of oxygen saturation in arterial blood, with a normal reading being between 95-100%. Review of a Speech Therapy (ST) evaluation, dated 08/03/17, showed the evaluation was requested due to increased problems with the resident's swallowing. The evaluation stated the resident had been eating by mouth with supplemental enteral feedings until his recent hosptalization for pneumonia in July. Recommendations following a swallowing study on 07/21/17 noted the resident was to receive nothing by mouth due to aspiration with all food consistencies. At that time the resident and family decided to use the feeding tube for all of his nutrition and hydration, and continue recreational feedings of puree food items as the resident desired, using swallowing precautions and strategies. The ST assessed the resident with moderate to severe dysphagia. An interview on 11/21/17 at 11:20 AM with Staff A, above ST, noted the resident was at high risk for aspiration. He could receive one pureed food item at lunch, per his request, otherwise was to receive nothing by mouth. Review of a Physical Therapy assessment, dated 08/03/17, revealed the resident ambulated 60 feet with a front wheeled walker and minimal assistance; transferred with minimal assistance; and stand by assistance with bed mobility. His vital signs at the time of the assessment revealed a blood pressure of 104/71 and pulse oximeter of 98% on two liters of oxygen therapy. Review of a physician's assessment, dated 08/04/17, noted the resident had inspiratory and expiratory wheezes with rhonchi, thus physician orders [REDACTED]. Review of Progress Notes, dated 08/06/17, and documented by Staff B, Registered Nurse, at 12:46 PM, revealed the resident was in bed sleeping and hard to wake up. Staff attempted to wake the resident up asking if he was okay. Res (resident) was in and out of consciousness, he opens his eyes to his shoulders being shaken and then drifts off to slleep again. The feeding tube was flushed with water followed by medication administration via feeding tube. Resident by this time is back in deep sleep again. Pulse oximeter reading was low at 82% with oxygen therapy. Unable to obtain a BP (blood pressure) reading. The resident's family member arrived at that time and she tried to wake the resident up, however he would not wake up. The family member wanted the resident sent to the hospital via 911. The family member stated that usually the resident would have called her on the phone, as that was his usual behavior, but that morning she did not receive a call from him. The resident was transported by ambulance at 10:40 AM to the emergency room (ER). Review of hospital records, dated 08/06/17, revealed the resident was in respiratory distress, completely obtunded, with [DIAGNOSES REDACTED]. Review of Emergency Services report, dated 08/06/17, revealed emergency responders were dispatched at 10:20 AM and arrived at the facility seven minutes later on 08/06/17. The resident's blood pressure was 114/56, and his respirations were labored at 24 breaths per minute. His pulse oximeter was significantly low at 78%. Upon review of the resident's Medication Administration Record [REDACTED]. [MEDICATION NAME], a medication used in the treatment of [REDACTED]. In addtion to the four medications, the resident also received a bolus feeding of 500 ml. formula with water flushes. Staff B stated during an interview on 11/21/17 at 12:56 PM, the first time she saw the resident was at approximately 8:00 AM on 08/06/17, at which time she gave his tube feeding. The resident was sleeping, thus she attempted to awaken him by tapping his shoulder. She stated the resident acknowledged her by opening his eyes, slightly grunted, and then immediately returned to sleep. Staff B administered his medications at approximately 9:00 AM via the feeding tube. Staff B stated the resident's head of bed was elevated at approximately 35 degrees. The resident again opened his eyes upon touch, and immediately returned to sleep. Staff B then questioned Nursing Assistant staff if she/he had attempted to wake the resident up and the NA responded stating yes s/he had attempted, however he went back to sleep. The resident's pulse oximeter reading was low at 82% at that time. Staff B returned to the medication cart to check the resident's [DIAGNOSES REDACTED]. As Staff B was checking the resident's Medication Administration Record [REDACTED]. Emergency services was then notified (approximately 2.5 hours following the intial resident observation by Staff B). Telephone interviews on 11/20/17 at 12:12 PM, and 11/21/17 at 5:51 PM, with the resident's family members, revealed a family member entered the facility at approximately 10:00 AM on 08/06/17. A Licensed Nurse (LN) was just walking out of the resident's room and stated she had just finished the resident's feeding. Despite the resident's change in level of consciousness, as noted per above interview with Staff B, there was no discussion at that time with the family member. Upon entering the resident's room it was noted to be dark, and the resident was lying flat in bed with no staff in the room. The family member immediately attempted to awaken the resident by yelling and performing a sternal rub, with no response from the resident. The family member then ran out of the room and told Staff B to call 911. Despite the significant history of recent aspiration pneumonia with dysphagia, and chronic lung and [MEDICAL CONDITION], there was no evidence vital signs, or pulse oximeters were taken by nursing staff since the initial admission assessment on 08/02/17. In addition, review of Progress Notes between 08/02-06/17, revealed only three documented entries by licensed nursing staff of lung assessments being performed. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 08/30/17.

Based on observation, interview and record review, the facility failed to identify, assess and treat pressure ulcers and prevent new ulcers from developing for one of two residents (#91) reviewed with pressure ulcers. This failed practice resulted in harm to Resident #91, who acquired multiple pressure ulcers while in the facility. Findings included: The facility's 02/25/15 Assessment of Wound policy showed it was the responsibility of the licensed nurse to complete a wound assessment and document findings. Assessments and documentation are to be identified upon admission, re-admission, weekly, and as-needed. The National Pressure Ulcer Advisory Panel redefined the definition of pressure ulcers during the (NPUAP) 2016 Staging Consensus Conference that was held April 2016. Stage 2 Pressure Ulcer: Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Unstageable Pressure Ulcer: Obscured 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. Stable eschar (i.e. dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Resident #91. The 07/16/17 comprehensive assessment showed the resident was alert and made decisions about her care. The resident was at high risk for skin breakdown and had an unstageable pressure ulcer to the left heel, and a Stage 2 pressure ulcer to the resident's coccyx (tailbone). The assessment identified risk for the resident's skin breakdown and the need for extensive assistance to turn the resident in bed and the resident's total dependence on staff for transfer to and from the wheelchair. Additionally, the resident had a bladder catheter that leaked urine continually so the resident wore incontinent briefs. A review of the resident's record showed the resident experienced a change of condition and was transported to the hospital and admitted on [DATE]. A review of the 08/13/17 hospital assessment/encounter data form showed the resident was admitted from the facility with three pressure ulcers. One was located on the right upper buttock at the cleft which was Unstageable with eschar, another Unstageable pressure ulcer to the left heel, and a third Stage 2 pressure ulcer to the lower part of the right buttocks. A review of the resident's record did not show the facility had assessed or began treatment to the right lower buttuck pressure sore prior to being transported to the hospital. According to the medical record, dated 08/18/17, the resident was readmitted to the facility with [DIAGNOSES REDACTED]. The 08/18/17 hospital discharge record of the resident's skin condition showed the three pressure ulcers to include the left heel unstageable pressure ulcer, a pressure ulcer to the right upper buttock, and a Stage 2 pressure ulcer to the right lower buttock. On 08/24/17 at 10:30 AM, Staff H, Registered Nurse (RN), Resident Care Manager (RCM), was observed performing resident wound care and dressing changes to the left heel and the right upper inner buttock. The resident's skin to the buttocks was very moist and macerated (made soft by moisture of urine to the skin). The left heel and the right upper inner aspect of the buttock area were not visible due to the wound bed being covered with eschar (scab-like brown dead tissue). According to Staff H, the resident had specialty boots that were to be worn in bed at all times. The speciality boots were not on the resident's feet and were located in the resident's chair. Staff H stated the resident had restless legs and the boots were used to prevent pressure of the resident's feet on the bed. On 08/24/17 at 12:40 PM, a skin/pressure ulcer assessment and treatment had yet to be developed for the pressure ulcer to the right lower buttuck region. According to Staff B, Director of Nursing (DNS), there was no assessment of the newly developed pressure ulcer. The DNS stated she thought the pressure ulcer was started by shearing of the resident's skin on the bed. The DNS stated she failed to investigate the incident or determine why the pressure ulcer developed in the first place. On 08/28/17 at approximately 11:30 AM, Staff R, Nursing Assistant (NA), provided hygienic care and changed the resident's incontinent brief. The dressing to the right upper buttuck pressure ulcer was soaked with urine. Resident #91 stated that the dressing had not been changed for four days. The 08/18/17 physician order [REDACTED]. On 08/28/17 at approximately 12:30 PM, while Staff R provided care, the resident's skin was observed to be red at the coccyx (tail bone). There were two Stage 2 pressure ulcers on the lower right side of the resident's buttocks, thus an additional pressure sore had developed next to the Stage 2 pressure ulcer on the right lower buttuck (a 4th pressure sore). Staff B, DNS, was asked to assess the pressure ulcers and stated that they were not identified or assessed on admission, or since admission. Reference (WAC) 388-97-1060(3)(b)

Based on interview and record review, the facility failed to provide adequate supervision to ensure the plan of care was followed, for 1 of 3 residents (#1), reviewed for incidents with injuries. Resident #1 sustained actual harm due to a head injury, which resulted from an improper mechanical lift transfer. Findings included: Resident #1: review of the resident's medical record revealed [REDACTED]. In addition, he had a history of [REDACTED]. Review of the plan of care, dated 05/31/17, noted the resident was at risk for falls, and required two staff members for transfers and toileting. Review of a therapy assessment, dated 06/01/17, noted the resident required two staff for transfers, utilizing the sit to stand mechanical lift device (allows for resident transfers between bed and chair, using electrical or hydraulic power). In addition, the assessment indicated the resident had no sitting or standing balance, and was unsafe when sitting down. Review of a facility investigation report revealed on 06/08/17 at 1:25 p.m., the resident was transferred from the wheelchair to his bed by Staff A, Nursing Assistant. A sit to stand mechanical device was used. With the resident seated on the bed, Staff A released the last strap on the mechanical device, which caused the resident to fall backwards, hitting his head against the wall. The resident sustained [REDACTED]. The resident's family member was in the room during the time of the incident. Review of Progress Notes, dated 06/08/17 at 1:30 p.m., documented a couple of minutes after the incident, the resident's family member asked Staff A to have Staff B (Licensed Nurse) return to the resident's room. At that time the resident's eyes were rolled back and pupils were large, and he was more confused. The resident's blood pressure was low at 99/73. Review of the resident's blood pressures following admission, noted an average reading of 130/66. The resident was transferred to the hospital by emergency personnel. Review of hospital records, dated 06/08/17, noted the resident was diagnosed with [REDACTED]. An interview on 06/21/17 at 4:20 p.m. with Staff C, Rehab Manager, revealed the resident had a strong retrograde movement (moving backwards against the usual direction), which caused him to fall backwards, when the straps were released from the mechanical device. Per interview on 06/21/17 at 4:00 p.m. with the resident's family member, the resident was 218 pounds, and six feet four inches tall. Due to the resident's large size she asked Staff A, don't you want to get some help? when she observed her preparing to transfer the resident, from wheelchair to the bed, using the sit to stand mechanical device. Staff A stated, you can help me, to which the family member informed her she was not going to assist with the transfer, as she did not know how to operate the machine, and had back problems. Staff A then stated she could perform the transfer by herself, as she had just learned how to use the equipment(review of therapy notes revealed Staff A had assisted a therapist eariler that day with the transfer of the resident, using the mechanical lift). Once Staff A released the bottom straps of the mechanical device, the resident, who was seated at the edge of the bed, immediately fell backwards slamming his head against the wall. The family member stated the resident was not able to sit up by himself. Staff A was interviewed at approximately 11:00 a.m. on 06/21/17. She stated she did not review the resident's care plan prior to the transfer, which directed 2-person assistance. Staff Asaid she thought she would be able to transfer the resident safely, since she had been with a therapist earlier on the day of the incident, and had assisted with transferring Resident #1. Reference (WAC)388-97-1060(3)(g)

Based on observation, record review, and interviews, the facility failed to accurately identify, perform timely assessments and prescribed treatments, implement interventions to prevent worsening, and/or assess to determine the cause of the pressure ulcers in 3 of 4 residents (#'s 1,2,3) reviewed with pressure ulcers. This failed practice resulted in harm to Resident #1, who was admitted with a pressure ulcer on the toe which staff failed to identify on admission, and developed an additional pressure ulcer on the buttocks. In addition, Resident #2 sustained actual harm due to the lack of assessing the cause of the pressure ulcers to his right foot, and implement interventions to promote healing. Findings include: Resident #1: admitted to the facility on [DATE] from the hospital with [DIAGNOSES REDACTED]. Review of the comprehensive nursing assessment, dated 05/19/17, revealed the resident was cognitively intact, required extensive assistance with bed mobility, transfers, and toileting, and was unable to ambulate. The resident utilized a mechanical lift system for transfers. Review of notes taken by Staff C (LN) on 05/13/17, via telephone report from hospital staff just prior to the resident's admission, revealed her left toe was open to air. Review of the Inter-Facility Transfer Form, sent with the resident upon discharge from the hospital on [DATE], noted the left foot was circled and stated left toe. Review of hospital records, dated 05/13/17, noted a pressure ulcer to the resident's fifth toe on the left foot that was purple in color. Despite knowledge of existing skin problems of the left foot review of the admission head to toe skin assessment, completed by Staff C on 05/13/17, revealed no skin problems to the resident's feet. There were identified Stage II pressure ulcers (partial thicknes loss of the skin presenting as a shallow open ulcer with a red or pink wound bed) to the back of the right and left thighs, and lower back. Review of documentation by the Occupational Therapist (OT) on 05/14/17 noted the resident had reported difficulty with bed mobility and requested side rails be provided. The OT wrote a note to the nursing department on their 24 hour report book regarding the resident's request. The following day, 05/15/17, the resident again reported wanting side rails, thus the OT discussed the request with Staff D (LN). Additional requests by the resident were made on 05/24 and 05/26/17, which at that time the resident also requested an air mattress. Staff E (OT) stated during an interview on 05/30/17 at 11:45 A.M., she had recommended right away to nursing to obtain side rails to assist the resident in turning. In addition, the resident wanted an air mattress. Despite her known pressure ulcers, and need for assistance with turning, there was a delay of approximately two weeks in obtaining both items for the resident. On 05/31/17 at 9:30 a.m. observations were made of Staff D (Licensed Nurse LN) and Staff F (interim Director of Nursing) performing treatments to the resident's pressure ulcers (back of left and right thighs, lower back, and fifth toe of the left foot). A new Stage II pressure ulcer, located on the left lower buttock and measured 2.5 by 2.5 centimeters (cms)., was identifed at that time by Staff D and F, however it had been visualized by the state investigator during a skin observation made the day before on 05/30/17 at 11:30 a.m. The resident was observed with an air mattress and side rails on her bed. Staff D stated the air mattress and side rails were obtained for the resident the previous week. Staff D also reported that prior to that time the resident was on a regular pressure relieving mattress, and staff was not floating her heels (despite the existance of a pressure ulcer on the fifth toe of the left foot). Despite the above hospital documentation on 05/13/17 regarding an existing pressure ulcer to the fifth toe on the left foot assessed as purple in color, review of Progress Notes, dated 05/22/17 (nine days later), noted the right fifth toe had a bruise and a blister had formed, which was unstageable, thus indicating further deterioration of the ulcer. A physician's orders [REDACTED]. There was no evidence of an assessment of the area at that time, such as measurements, color, necrotic tissue. Per a phone interview with Staff F on 06/02/17 at 2:20 p.m., documentation was noted to be inaccurate on 05/22/17, as the area was on the left foot, not the right as documented. There was no further documentation of the area until 5/30/17 (eight days later), at which time it was noted to be 2.7 by 2.2 cms with eschar present. Review of the Treatment Administration Record (TAR), revealed a physician prescribed treatment order to the resident's fifth toe on the right foot (inaccurate as noted above) to be done daily. There was no evidence a treatment was performed by staff on 05/26/17, & 5/27/17. Despite the resident's multiple pressure ulcers, a review of the Care Directive (utilized by nursing assistant staff in the care of the resident) revealed no evidence of a turning/repositioning program. Timely assessments of the resident's pressure ulcers were not completed as evidenced by review of the Pressure Ulcer Status Records which noted the open areas to the lower back, and both thighs were not assessed between 05/13/17 & 5/30/17 (17 days). On 05/31/17 at 1:10 p.m. the resident stated it took staff about two weeks to obtain side rails and an air mattress for her. At the beginning of her stay staff was not turning her every two hours, which was why she requested side rails. She stated due to her lower body paralysis she did not have any feeling in her legs/feet. Resident #2: admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's plan of care, dated 05/11/17, revealed he had impaired cognition, required one person assist with transfers and toileting, and had pressure ulcers (location not specified). Nursing interventions included float heels, minimize pressure over bony prominences, treatments as ordered, and heel pads. Review of the resident's Pressure Ulcer Status Record revealed on 05/11/17 he had a Stage I (intact skin with redness) to the right heel measuring 0.5 by 0.5 cms. There was no further assessment of the area until 05/30/17 (19 days later). At that time the assessment noted no changes in the size of the wound. However, upon observation at 1:05 p.m. on 05/31/17 it was noted to be a Stage II, which was verified with Staff F at 3:00 p.m. that same day. In addition, review of the wound physician's evaluation of the resident's right heel on 05/26/17 noted the area was a Stage II. The resident had two additional pressure ulcers to his right foot, the medial metatarsal, and top of the ankle, which were identified on 05/11/17. Both areas had improved in size, however upon observation on 05/31/17 at 1:05 p.m., the medial metatarsal ulcer was very reddened upon removal of the resident's heavy, (non-therapeutic) leather shoes. Despite pressure ulcers to the resident's right foot there was no assessment to determine the possible cause of the ulcers. Heel pads were noted on the resident's bed, however upon return to the resident's room at 2:50 p.m. on 05/31/17 he was lying in bed with his shoes on both feet, which placed unnecessary pressure on the bony prominences of the feet. The resident's spouse stated the shoes were not diabetic shoes, and the resident had the reddened area to the medial metatarsal for several months. Review of the TAR for May 2017 revealed no evidence of documentation prescribed treatmentes had been performed on the pressure ulcers to the right foot between May 11-30, 2017 for 21 of the 40 shifts. An interview with the resident on 05/31/17 at 11:30 a.m. revealed he had just started being seen by the wound physician on 05/26/17. He stated staff had not been doing treatments to his right foot twice daily, and were not keepiing his feet off the mattress. Resident #3: review of the resident's medical record revealed [REDACTED]. Review of the initial nursing assessment, dated 05/04/17, noted she required a mechanical lift for transfers, and had a Stage I pressure ulcer to the coccyx area measuring 3 by 3 cms., which was nonblanchable (skin did not lose redness with pressure). There was no further assessment of the area until 05/30/17 (26 days later), at which time the size remained the same at 3 by 3 cms, however the area was noted to be blanchable. Review of the resident's TAR revealed a physician's orders [REDACTED]. Between May 4-30, 2017 there were no evidence of documentation they had been done for 16 of the 27 days. Interviews conduced on 05/30/17 at 4:15 p.m., and 05/31/17 at 11:05 a.m. with two LNs (requested anonymity), revealed there had been numerous recent changes with job assignments, thus staff had difficulty knowing what the expectations were, which included the area of treatments. Reference (WAC) 388-97-1060(3)(b)

Based on interview and record review, the facility failed to perform thorough and ongoing assessments for one of one resident (#1), in a sample of five, who sustained a head injury from a fall. This failure resulted in a delay of treatment and a worsening of the resident's injuries. Findings include: Resident #1. admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the comprehensive assessment dated [DATE] the resident required the assistance of 2 staff for transfers. Review of investigative reports dated 03/06/15 at approximately 8:30 p.m., Staff Member A, a Registered Nurse (RN), received a phone call from the resident's legal representative stating that the resident did not answer the phone in her room. While the resident's representative stayed on the phone, the RN went to the resident's room and found the resident on the floor. Staff Member A informed the representative that the resident had a "fall" and a possible "head injury." Staff Member A, said that the floor nurse would contact the physician and he would probably send the resident to the ER. The representative authorized transport to the hospital if the resident's injuries appeared serious. During an interview on 03/25/15 at approximately 11:30 a.m., Staff Member B, also a RN, who had worked the evening shift at the time of the incident said that she was told by Staff Member A that the resident's representative did not want the resident to go to the ER. Staff Member B assessed the resident as having had a "superficial skin tear" above her left eye brow and placed a dressing on it and felt the resident was okay. Staff Member B and Staff Member A assisted the resident to the wheel chair and back to bed. At approximately 12:15 a.m. on 03/07/15, Staff Member B faxed a note to the physician's office concerning the resident's fall. Staff Member B did not call the physician. During an interview on 03/25/15 at 11:45 a.m., Staff Member B recalled that on 03/06/15 at approximately 10:00 p.m., Staff Member C, a Licensed Practical Nurse (LPN), was given report for her shift by Staff Member B and had told Staff Member C that the resident had a fall with a head injury and she was doing okay. According to nursing progress notes there was no documentation about the resident's neurological assessment or any other documentation of the resident's condition for that night shift. An interview on 03/25/15 at approximately 12:30 p.m. with Staff Member E, a RN, who worked the day shift for 03/07/15 revealed that there was a brief report about Resident #1's fall but no specific details were given. According to Staff Member E, she came to work and received the report from Staff Member C that the resident had a fall and had some shoulder and lower back pain but that the resident was "fine." The families of the resident came to visit the morning of 3/7/15 and were extremely concerned and wanted x-rays. Staff Member E said that she "was unaware" of the severity of the resident's injury. According to Staff Member E she removed the bandage from the resident's left eye brow and saw how "severely deep the laceration was over the left eye" and the bruising of the resident's face and left hand. The resident had complained of severe and unbearable head pain. The family then wanted the resident to go to the hospital to be assessed. The ambulance was called on 03/07/15 at approximately 11:30 a.m. Staff Member E said she would have called for emergency transport anyway to get the resident to the hospital. On 03/25/15 at approximately 1:00 p.m., Staff Member D, the Director of Nursing (DNS), stated that Staff Member B did not notify her of the suspected fall until 03/07/15. The DNS's expectation was that, first a full assessment would have been done for a substantial injury like that and the staff would call 911 to transport the resident to the hospital. A review of the hospital report, dated 3/7/15, revealed the resident was found to have shoulder and back pain from fractures, a [MEDICAL CONDITION] requiring staples, facial fractures, and a subdural hematoma (bleeding in the brain).

Based on observation, interviews, and record review the facility failed to identify the cause and implement measures within their control to ensure 1 of 3 sampled residents (#11) admitted with a stage II pressure ulcer (partial thickness skin loss) on her coccyx did not develop additional pressure ulcers in the facility. This failed practice resulted in harm to Resident #11 as she acquired a stage II pressure ulcer in the facility. Findings include: Resident #11. admitted on [DATE] with [DIAGNOSES REDACTED]. A comprehensive assessment dated [DATE] documented the resident required staff assistance with bed mobility, transfers and personal hygiene. The assessment also noted the resident was incontinent of bowel and bladder. Review of a pressure ulcer record dated 01/11/15 revealed a stage II pressure ulcer which measured 1 centimeter (cm, approximately 4/10th of an inch) by 1 cm on the coccyx area. The resident's blood work dated 10/14/14 included a low [MEDICATION NAME] (an indicator of protein and nutritional status). The [MEDICATION NAME] was 3.0 (reference range is 3.3-4.8). On 02/21/15 at approximately 4:50 p.m., Staff Member I, a licensed nurse (LN), stated, We have not been able to keep the stage II pressure ulcer healed, it healed in September then reopened in October. Her skin was known to be fragile. We identified a new stage II pressure ulcer on 01/11/15 and it is above the pressure ulcer she was admitted with. She added a pressure relieving mattress was provided to the resident after the second pressure ulcer was identified. She concluded by stating she was not sure how the resident developed the second pressure ulcer. On 01/22/15 at approximately 5:00 p.m., Staff Member I, a LN, stated the pressure ulcer she acquired in the facility was probably avoidable. She does not like to be on her side so she usually ends up lying on her back. She does not like how her stomach feels when she lies on her side. She added the resident was known to be in her wheelchair about 40% of the time during the day. She added she had not referred the resident to the registered dietitian or to the physical or occupational therapist to re-assess the resident's nutrition status and/or the wheelchair cushion or wheelchair fit related to positioning. Review of the nursing assessment on admit revealed the resident had been admitted with a stage II pressure ulcer on her coccyx. The resident's September 2014 treatment sheet revealed the stage II pressure ulcer on the resident's coccyx had been resolved and treatments were stopped. The October treatment revealed the coccyx pressure ulcer treatment had been restarted on 10/14/14. On 01/23/15 at approximately 9:20 a.m., Staff Member G, a nursing assistant (NA), stated resident #11 was not able to turn herself. Her preference was to lie on her left side or her back. She added the resident likes being up in her wheelchair, She is not able to shift her weight and tends to lean to the right, with her left leg extended. She does the same thing (leaning her body to the right) on the shower chair. On 01/23/15 at approximately 9:20 a.m., the resident was observed sitting in her wheelchair, slouched back and leaned to the right with her left leg extended. On 01/23/15 at approximately 9:38 a.m., Staff Member O, a NA, stated the resident was placed in her wheelchair and taken to dining room for all of her meals. She stayed in her wheelchair about 1 1/2 hours after her meals. On 01/23/15 at approximately 9:46 a.m., Staff Member P, a NA, stated I got her up today at 7:40 in the morning and took her to the dining room for breakfast. She has been in her wheelchair since. She added the resident did not have the ability to shift her weight. On 01/23/15 at approximately 10:02 a.m., Staff Member Q, an occupational therapist, stated she was not aware of the resident's acquired pressure ulcer. If I had known I would have re-assessed her chair and provided a pressure relieving cushion. When she came in she had a new chair and the pressure reduction contour cushion and it appeared fine for her at the time. On 01/26/15 at approximately 11:40 a.m., Staff Member R, the registered dietitian, stated she was not aware the resident had a new pressure ulcer. She is on some protein but had I known she had a new pressure ulcer, I would have requested they put her on a fortified protein. On 01/28/15 at approximately 9:45 a.m., Staff Member S, a physical therapist, stated Resident #11 is not able to off load when she is sitting in her wheelchair. The facility was aware of the resident's stage II pressure ulcer on her coccyx upon admit to the facility, but failed to implement measures to prevent further skin breakdown, including assessment of the resident's positioning, re-evaluation of the type of cushion in her wheelchair and re-evaluation of her nutrition needs. This resulted in Resident #11 developing an avoidable pressure ulcer in addition to the pressure ulcer she was admitted with.

Based on record review and interviews the facility failed to comprehensively assess, recognize and competently address causes of the resident's decline in physical and mental condition for 1 of 3 sampled residents (#6) reviewed for changes in condition. This deficient practice resulted in actual harm to Resident #6, who was transferred to the emergency room (ER) and diagnosed with [REDACTED]. Findings include: Resident #6: admitted to the facility on [DATE] from the hospital following acute [MEDICAL CONDITION] after heart surgery. Other [DIAGNOSES REDACTED]. The resident was admitted with a [MEDICAL CONDITION] catheter. Review of the initial nursing assessment dated [DATE] noted the resident was alert and oriented, required staff assistance with ambulation, and was on continuous oxygen per nasal cannula at two liters per minute. Review of Progress Notes revealed the resident's [MEDICAL CONDITION] catheter was discontinued per physician's orders [REDACTED]. output. Without that information staff was unable to accurately determine the hydration status of the resident. Staff documented the following: [DATE] - resident voided twice on the dayshift [DATE] - resident voided once on the dayshift and three times on the evening shift [DATE] - resident voided once on the dayshift [DATE] - no documentation of any voidings [DATE] - resident voided once on the dayshift [DATE] - no documentation of any voidings [DATE] - no documentation of any voidings Review of the resident's weights noted his/her weight increased from 152 pounds on admission ([DATE]) to 170 pounds on [DATE], for a weight gain of 18 pounds over 28 days. Review of documentation by the therapy department revealed on [DATE] the foot of the resident's bed was raised for "managing fluids accumulated in LE's (lower extremities)." On [DATE] the therapist documented the resident's lower extremities were "extremely swollen" and was unable to bend his/her knees to place his/her feet on the standard leg rests, thus he/she was provided with elevating leg rests. Despite the increase in the resident's weights and above noted assessments by therapy staff there was no assessment or recognition by nursing of the resident's [MEDICAL CONDITION] and need for monitoring. Review of Physical Therapy (PT) notes revealed on [DATE] the resident was able to ambulate 27 feet with his/her walker and minimal staff assistance. On [DATE] documentation by PT noted a "significant decline" as he/she only tolerated standing for one minute due his/her complaint of shortness of breath and fatigue. The PT dicussed the resident's decline, unstable heart rate, and drop in oxygen saturation levels with nursing. On [DATE] review of the physician's assessment revealed abnormal lab results (decline in kidney function tests) were reviewed with the resident. The physician documented the abnormal labs were consistent with dehydration or [MEDICAL CONDITION] (accumulation of fluid in the resident's lungs). The physician had recommended the resident be transferred to the ER at that time, but the resident declined. The resident was to be encouraged to increase his/her oral intake. On [DATE] documentation by Staff C (PT Assistant) noted the resident reported feeling "very sleepy." His/her oxygen saturations were low at ,[DATE]% on three liters of oxygen. The PT Assistant then increased the oxygen to four liters which increased the saturation level to 98%. The resident was unable to sit up unsupported and remained very sleepy. The oxygen level had decreased to ,[DATE]% after lying the resident down in bed and his/her heart rate fluctuated between ,[DATE] beats per minute. Nursing staff was informed by the PT Assistant of the resident's lethargic condition and unstable vitals. An interview on [DATE] at 3:00 p.m. with Staff C revealed the above therapy session on [DATE] began at approximately 10:00 a.m. Despite the resident's significant change of condition (as noted by the physician and therapy staff) and need for close monitoring there was no evidence of a nursing assessment on [DATE]. The next nursing assessment was documented at 10:49 p.m. on [DATE] stating the resident was transferred to the emergency room (ER) due to lethargy. His/her oxygen saturation levels had decreased to 86% on three liters of oxygen. A nebulizer breathing treatment had been given with very slight increase to 87%. The resident was having difficulty in breathing and his/her abdomen was distended. The physician saw the resident at that time and ordered the transfer to the ER, which was done at 5:15 p.m. Review of hospital ER records revealed the resident was diagnosed with [REDACTED]. A [MEDICAL CONDITION] catheter was inserted after two unsuccessful attempts, and over one liter of urine was obtained following the catheter insertion. The resident expired at the hospital on [DATE]. Despite the resident's recent history of kidney failure and [MEDICAL CONDITION], significant weight increase and noted [MEDICAL CONDITION], removal of the [MEDICAL CONDITION] catheter on [DATE], above noted abnormal lab results, and noted decline by therapy staff; nursing staff failed to recognize the need to monitor the resident's clinical condition closely, and alert the physician to changes in his condition in a timely manner.

Based on observation, interview and record review the facility failed to ensure each resident was treated with dignity and respect. Two of 2 residents (#5, 22) who required assistance were ignored and/or not provided assistance in the dining room causing one resident to spill food on herself and one resident to be pushed to eat in a short time frame. One resident (#46) seated in a public area was spoken to disrepectfully by a department head. One of 1 resident (#133) who did not receive timely assistance with toileting needs. And, 1 of 1 known confused resident (#88) was not treated with respect, leading the resident to feel ill-treated and unsuccessful in her social interactions. This caused the residents to have a diminished quality of life. Findings include: Resident #5. admitted on [DATE] with [DIAGNOSES REDACTED]. At 12:45 p.m. on 10/21/13, the resident was observed in the main dining room reaching out with her hands seeking the food on her divided tilted plate. Several times throughout the meal she touched the plate in front of her searching for the food. She used her hands/fingers to pull the spaghetti and meat ball from her plate. Her hands, chin, lower face, and protector were red-orange from the spaghetti sauce. As she removed the spaghetti from her plate she spilled a portion of the noodles onto her lap. Throughout the meal, Staff Member B, nursing assistant (NA) sat at the same table across from the resident yet she made no attempt to assist the resident. The NA offered no verbal cues during the meal. Mid-way through the meal Staff Member C, NA also seated herself at the resident's table and made no attempt to assist the resident. At 1:00 p.m. the resident stated "I am done" and Staff Member C responded with "don't you want your milk?" and the resident responded with "where is it?" Staff Member C then handed the resident the glass of milk which she drank quickly. On 10/28/13 at approximately 11:00 a.m. Staff Member B stated she had worked in the facility for three years as an NA. "I know the type of assistance a resident needs in the dining room by asking the nurses and I read the "Care Directive Manual." The manual lets us know the type of assistance the resident's need and it is always at the nurse's station." She added "Resident #5 needs set up and I tell her where exactly the food is on her plate. She always uses a divided tilted plate so I let her know where her food is on the plate and I let her know what type of food is on her plate since she is blind. The resident likes to use a spoon instead of a spork (combination spoon and fork utensil)." On 10/28/13 at approximately at 11:15 a.m., Staff Member C stated she had worked at the facility for approximately 3 months. Staff Member C also stated she used the "Care Directive Manual to guide her in providing the required level of assistance a resident needs." With Resident #5, she needs set up in the dining room and you have to tell her where the food is on the spin divided plate and we have to put a utensil in her hand because she is blind. She uses regular utensils. She prefers the regular spoon over the spork. Sometimes she puts her fingers inside the plate and tries to eat with her hands but we are supposed to redirect her but are are not always able to." Although both the NA's were fully aware of Resident #5's type of assistance during meals, neither of them offered the resident verbal cues or utensils. They allowed her to eat her meal with her hands in front of all residents and visitors in the main dining room. This behavior led to the resident's chin, lower face, and hands to be smeared with spaghetti sauce and noodles on her lap. This lack of respect and dignity led to diminished quality of life. Resident #22. Her most current comprehensive assessment dated [DATE] documented her as totally dependent at meals. On 10/21/13 at approximately 1:15 p.m. the resident was observed in the main dining room being fed by Staff Member A. Not once during the meal service did the Staff Member A speak to the resident. Staff Member A was observed to be feeding the resident in a quick manner. Once while Staff Member A was putting a spoon full of food into the resident's mouth the resident raised her right arm and Staff Member A paused the feeding for approximately one minute than proceeded to rapidly feed the resident. The resident was removed from the dining room at approximately 1:25 p.m., after approximately 10 minutes of assistance for the meal. On 10/29/13 at approximately 9:15 a.m. Staff Member A stated "I know the type of assistance our residents need by reading the Care Directives and also from the other NA's. Since we work with the residents we learn their likes and dislikes." She added she was aware Resident #22 was totally dependent on staff assistance for her meals, "We need to feed her.... I was feeding her too fast." She also acknowledged she had not spoken to the resident during the meal service. Resident #133. admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The 10/01/13 nursing assessment revealed the resident was alert and needed assistance with dressing, toileting, bed mobility, and transfer. The resident was continent of bladder and bowel as long as staff responded timely to his requests to use the toilet. On 10/28/13 at 1:45 p.m. the resident's representative reported Staff Member DD, NA (nursing assistant), had not been responsive to a request to help the resident to the bathroom. The resident concurred by shaking his head "yes" in agreement with the representative's statement. The representative reported the delays by Staff Member DD in assisting the resident to the toilet resulted in incontinent episodes of bowel and bladder. She also had overheard Staff Member DD make negative remarks about the resident to other staff members in the facility. On 10/28/13 at 2:11 p.m. Staff Member DD was asked to help the resident to the bathroom. Staff Member DD told the representative "I have two other residents in front of you. You will have to wait." The representative stated "he has to wait for someone to respond to his call light to use the bathroom and doesn't understand why staff does not assist him." The facility failure to respond to the resident's request to toilet in a timely manner resulted in incontinent episodes for the resident. Resident #88. Per her most recent comprehensive assessment dated [DATE], she was cognitively impaired. On 10/30/13 at 12:40 p.m., Resident #88's food tray was observed spilled onto the floor and the resident's lap right after it was served to her in her room. Staff Member C, Nursing Assistant (NA) was heard to say in a direct and accusatory tone "I tried to give you the tray." The resident responded by saying "I know you knew this would happen." Staff Member C said, "No, I didn't." Resident #88 stated "I'm so tired of being in a place with so many lies," and then, "They are so good to me here. I don't know what I'd do without them." The resident then stated to Staff Member C, "I told you to put my chair so it wouldn't rock." Staff Member C responded in an argumentative tone "I put it against the wall." A short while later the resident stated "I'm sorry I'm so mean. I've been made into what I am today. You treat me like a dog." Another aide offered to help her change her clothes and told her they would get her another food tray. Resident #88 said "Lock the door." The facility failed to treat Resident #88 with respect and dignity by allowing the interaction between the resident and staff member on 10/30/13 to escalate in tone and end with the resident stating she felt ill-treated and unsuccessful in her social interactions. Resident #46. admitted [DATE] with multiple [DIAGNOSES REDACTED]. Per her most recent comprehensive assessment dated [DATE] she was severely cognitively impaired, but could recognize staff names and faces. She had adequate hearing. On 10/22/13 at 2:30 p.m., Resident #46 was observed sitting in her wheel chair across from the Team Two nurse's station. An odor was noted about the resident. Staff Member E, Social Services Director walked near the resident, called her by her first name, and then said "Are you poopy?" in a voice loud enough to be overheard by other staff and residents. A licensed nurse overheard the remark and stated she would get someone to take care of the resident. Failure to address Resident #46 with respect and dignity diminished the quality of her life.

Based on observation, interview and record review the facility failed to A) recognize situations of potential abuse, neglect and mistreatment for 1 of 3 sampled residents (#88), causing psychosocial harm to Resident #54. This failure allowed continued abuse and mistreatment. And also failed B) to ensure that residents knew how to access the State "hotline" number; three of 6 sampled residents (#35, 53 and 32) did not know how to access the "hotline" in an event they needed to report mistreatment, neglect, abuse and misappropriation of their property per CFR 483.13(b)(c). Findings include: A) Recognizing Situations of Abuse. Resident #88. admitted [DATE] with multiple [DIAGNOSES REDACTED]. Per her most recent comprehensive assessment dated [DATE], she was cognitively impaired, particularly in regard to date and time. The assessment documented the resident displayed verbal behaviors directed toward others that occurred on a daily basis. These verbal behaviors were noted to have increased in frequency from previous assessments. On 10/29/13 through 11/01/13 many staff were interviewed concerning Resident #88's behavior risks and interventions that were in place in the care plan. Even though the staff at times removed Resident #88 from the hallway to her room, staff failed to recognize verbal altercations as abuse and did not report them to the nurse or supervisor. On 11/01/13 at 1:45 p.m. Staff Member U, NA (nursing assistant) stated that on 10/27/13 between the hours of 6:30 a.m. and 1:30 p.m. Resident #88 was in hallway talking to Resident #54. Resident #88 stated that Staff Member U was "Satan's devil and a (expletive)." Resident #54 was crying and very upset related to the statements Resident #88 was making. Staff Member U redirected Resident #88 by wheeling her further down the hallway. Staff Member U further stated that after moving the resident down the hallway, the resident wheeled herself into the activities room where other residents were sitting. She became negative and loud, and was telling others what to do. According to Staff Member U, the other residents in the activities room asked Resident #88 to leave. The NA then knelt down by the resident's wheel chair to talk to her and the resident slapped the NA. Another NA removed the resident from the activities room and redirected her to the resident's room. Staff Member U stated neither incident was reported to facility administration or to the state hotline number. Despite facility knowledge of Resident #88's aggressive behaviors affecting Resident #54 and other residents, the facility failed to recognize the behaviors exhibited by Resident #88 were abusive to other residents. This caused psycho-social harm to Resident #54. B) Access to state "hotline" number information. Resident #35. On 10/24/13 at approximately 11:35 a.m. he stated "I do not recall if they (referring to the facility staff) gave me the "hotline" number, or if they told me what to report or who to tell if I have a problem in this place." He added "I do not see well so whatever is given to me to read, the letters have to be at least two inches and I would not mind having the number." Resident #53. On 10/24/13 at approximately 12:35 p.m. she stated she had been in the facility since 2011. "I cannot get out of bed so I stay in my room all the time." The resident was bed bound. She stated she knew there was a complaint process and knew there was a hotline number. "I have a phone in my room but I do not know the "hotline" phone number. I guess if I have a concern I will have to ask the nurses." Although the facility had posted the "hotline" number throughout the facility, due to the resident being bed bound she did not have access to the posted "hotline" number. Resident #32. On 10/22/13 at approximately 9:00 p.m. during the interview he stated another resident in the facility had threatened to murder him. He added he was not aware of the State "hotline" number. On 10/25/13 at approximately 11:00 a.m. review of the Facility Admission packet provided to all newly admitted residents and families revealed there were no phone numbers provided for the Washington State Complaint Resolution Unit (hotline) or for the State Ombudsman. On 10/24/13 at approximately 2:45 p.m. during an interview with Staff Member E, Social Services Director stated "my process is to revisit the newly admitted residents within 72 hours of resident's admit." She added "I try to get back to the new residents to make sure they have the Washington State hotline phone number but I admit that I do not always go back and readdress the specific hotline number."

Based on observation, interview and record review the facility failed to provide the necessary supervision to prevent accidents including A) 1 of 1 sampled resident #88 with known history of resident to resident altercations, as evidenced by resident #54 experiencing emotional distress. B) prevention of falls for 1 of 4 sampled residents (#11), and C) failure to safely store potentially dangerous chemicals and sharp equipment in 2 of 3 hallways observed (100 and 300 hallways). Findings include: A) Resident #88. admitted on [DATE] with multiple [DIAGNOSES REDACTED]. It also noted the resident intruded on privacy of other residents and significantly disrupted care or living environment. Review of the plan of care revealed Resident #88 was able to wheel herself once assisted to the wheel chair. Further, resident had a history of [REDACTED]." A history of running her wheel chair into other residents was also documented. The approaches for the resident's behaviors were to "remind her not to swear at staff or peers, makes constant accusations of staff and peers, i.e. don't touch me. Monitor in group settings-not tolerant of others." Review of the facility investigative documentation noted the resident had been involved in resident to resident altercations without provocation. On 10/23/13 at 12:23 p.m. Staff Member I, the Director of Nursing, stated she was aware of a previous resident to resident verbal altercation with Resident #88 on 07/31/13. Resident #88 was observed on 10/24/13 at approximately 2:00 p.m. in the resident's room verbally stating, "This is like a jail here. They treat you like (expletive)." Resident was observed to be very restless, wheeling back and forth and making negative statements which were heard by other residents who passed by the resident's room. On 10/29/13 at approximately 1:30 p.m. Staff Member C, Nursing Assistant (NA), monitored the resident as the resident was yelling in the hallway. There were three other residents in the hallway located by the resident and the NA did not remove Resident #88 from the area. On 10/30/13 Staff Member W, NA, stated that Resident #88 was verbally aggressive with another resident on 10/27/13 and Resident #88 was "removed from the hallway." On 10/30/13 at approximately 4:00 p.m. Staff Member T, a Registered Nurse, said that the resident was "confrontational and does direct it to others.... when I saw it, we brought her to her room." On 10/30/13 Resident #88's family member stated the resident had delusional thinking and will report she sees things. The resident refused medication. On 11/01/13 at 1:45 p.m. Staff Member U, NA stated that on 10/27/13 between the hours of 6:30 a.m. and 1:30 p.m. Resident #88 was in the hallway talking to Resident #54. Resident #88 stated that Staff Member U was "Satan's devil and a (expletive)." Resident #54 was crying and very upset related to the statements the Resident #88 was making. Staff Member U redirected the resident. Staff Member U further stated that on 10/27/13 the resident wheeled herself into the activities room where other residents were sitting. She became negative and loud, and was telling others what to do. According to Staff Member U, the other residents in the activities room asked Resident #88 to leave. The NA then knelt down by the resident's wheel chair to talk to her and the resident slapped the NA. Another NA removed the resident from the activities room and redirected her to the resident's room. By not providing enhanced supervision to a resident identified as having a history of resident to resident altercations and behaviors affecting others the facility failed to prevent Resident #54 from experiencing emotional distress. B) Resident #11. admitted [DATE] with [DIAGNOSES REDACTED]. The resident's comprehensive assessment dated [DATE] identified her as requiring extensive assistance with toilet use. Record review on 10/28/13 revealed an incident report dated 09/27/13. The report documented Resident #11 was found on the bathroom floor at 7:15 a.m. The resident's wheelchair was to the left of the resident and staff noted the brakes on the wheelchair were not locked. The report concluded the resident had fallen while attempting to self-transfer, but had sustained no apparent injuries. Though the resident was assessed to require extensive assistance when using the toilet, the Fall Scene Investigation Report documented she was "...alone and unattended" at the time of the fall. On 10/28/13 at approximately 4:15 p.m. Resident #11 stated she fell when she tried to self-transfer from the toilet to her wheelchair. "The brakes on my wheelchair were not locked, and they (referring to Nursing Assistants) took me to the toilet but forgot to lock the brakes." On 10/29/13 at approximately 9:15 a.m., Staff Member A, Nursing Assistant (NA), stated they were to assist her. "She is 2 person assist for toileting and we know we have to set the brakes on her wheelchair even though she likes to be independent and tries to self- transfer." On 10/29/13 at approximately 10:00 a.m., Staff Member D, NA, stated, "We know that with her we need to take her to the bathroom using the wheelchair and we are always to put the brakes on the wheelchair at all times because she does try to get in the chair by herself. I stand outside her bathroom just in case she tries to self-transfer." Even though the staff were aware of Resident #11's fall history and frequent attempts to self transfer, they failed to protect the resident by not consistently setting her wheel chair brakes when assisting her to the toilet. This placed the resident at risk of further falls and potential injury. C) On 10/21/13 at approximately 12:55 p.m., a housekeeping cart was observed in the 100 hallway. The housekeeper was in a room cleaning and the cart was unattended. The cart had a platform with a mop bucket sitting on the platform, about 18 inches off of the floor. In the dry mop bucket was an open and partly full spray bottle of Clorox Clean Up. The storage area of the cart was unlocked and the door to that area was ajar. Behind the partly opened door was a box cutter, a spray bottle of Windex glass cleaner and a spray bottle of Clorox Clean Up. On 10/21/13 at approximately 5:50 p.m. a housekeeping cart was observed in the 300 hallway. A housekeeping staff person was not visualized and the cart was unattended. The door to the storage compartment was unlocked and partly open. In the storage compartment there was a bottle of VirexTB (a commercial disinfectant that is clear and colorless and with a caustically high alkalinity) and a spray bottle of glass cleaner. There were three residents in the general vicinity of the cart, two self-propelling in wheel chairs and one walking with a walker. On 10/30/13 at 10:00 a.m. Staff Member S, Housekeeping, stated the housekeeping staff had been told to keep the door to the housekeeping cart closed and locked at all times so a resident could not get into the cleaning chemicals stored on the cart. On 10/31/13 at 8:20 a.m., Staff Member G, the Plant Manager, stated he was the housekeeping supervisor. He stated he taught the staff that chemicals on the housekeeping cart need to be locked behind the cabinet door of the cart at all times. After the staff uses the cleaning products, they are to immediately return them to the locked cabinet on the cart and not leave them on the top of the cart.