Every finding on record at Life Care Center of South Hill

Based on observation, interview and record review the facility failed to develop care plans for 1 of 19 sampled residents (Resident 126) when reviewed for comprehensive care plans. Failure to care plan Resident 126's bowel functions and half a side rail equipment placed the Residents at risk of avoidable injuries, loss of functions and diminished quality of life. Findings included. Resident 126 was admitted to the facility on [DATE] with diagnoses to include malnutrition, diabetes (high blood sugar), anemia (low red blood cells) and depression. Review of the admission minimum data set (MDS) an assessment tool, dated 10/25/2025, showed Resident 126 was able to communicate needs. During an observation and interview on 11/18/2025 at 9:50 AM, Resident 126 stated they had a fall trying to go to the bathroom, and they use the half side rails in bed for mobility. Resident 126 was sitting next to their bed and was pointing towards the rails on the bed. Resident 126 stated they had diarrhea (multiple loose stools) all previous day and night. Review of Resident 126 care plan dated 10/24/2025 showed no instructions about bed rails or bowel functions. During an interview on 11/20/2025 at 1:58 PM, Staff D, Resident Care Manager, stated Resident 126's care plan did not address half side rails and bowel functions, and should have. During an interview on 11/21/2025 at 10:26 AM, Staff B, Director of Nursing Services, Stated Resident 126's care planning did not meet expectations. Reference WAC 399-97-1020(1),(2)(a)(b)

Based on interview and record review, the facility failed to initiate, investigate, and resolve a grievance for 1 of 2 sampled residents (Resident 142) when reviewed for grievances. This failure placed the residents at risk for lack of comfort and a diminished quality of life.Findings included .Review of the electronic health record (EHR) showed Resident 142 admitted to the facility on [DATE] with diagnoses that included congestive heart failure (condition that happens when your heart is unable to pump blood well enough to give your body a normal supply) and chronic kidney disease (condition where the kidneys are damaged and unable to filter blood). Resident 142 was able to make needs known. During an interview on 11/17/2025 at 3:05 PM, Resident 142 stated they did not have enough room in their bed to turnover comfortably. Resident 142 stated they had requested a larger bed upon admission however they did not get a response.Review of the EHR showed a progress noted dated 10/31/2025, the progress note stated Resident 142 had requested a bariatric bed and side rails. Further review showed no bed assessment or documentation related to the bed or side rail request.Review of the grievance log for October 2025 showed no grievances related to Resident 142.During an interview on 11/20/2025 at 2:09 PM, Staff N, Resident Care Manager/Licensed Practical Nurse, stated a grievance should have been initiated on behalf of Resident 142.During an interview on 11/21/2025 at 10:30 AM Staff B, Director of Nursing Services (DNS) stated the expectation was that staff would initiate a grievance for concerns expressed by residents.Reference WAC 388-97-0460

Based on observation, interview, and record review, the facility failed to implement safety interventions to ensure safety from potential further abuse for 1 of 3 sampled residents (Resident 143) when reviewed for abuse. This failure placed the resident at risk for physical harm, mental anguish, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 143 admitted to the facility on [DATE] with diagnoses that included dementia (a group of thinking and social symptoms that interfere with daily functioning), anxiety (feeling of worried thoughts) and depression (feeling of sadness and/or loss of interest). Resident 143 was able to make needs known. During an interview on 11/18/2025 at 9:42 AM, Resident 143 stated they would like to share a room with their spouse who was also a resident in the facility (Resident 306). Resident 143 stated their Power of Attorney (POA) had also spoken to the facility about the concern; however, Resident 143 did not know the outcome. Observations on 11/18/2025 at 12:48 PM showed Resident 143 and Resident 306 in Resident 143's room eating lunch. Observation on 11/18/2025 at 1:30 PM showed Resident 143 and Resident 306 in the room prior to the door being closed. During an interview on 11/18/2025 at 1:39 PM, Staff F, Certified Nursing Assistant, stated they were unaware of any abuse allegations between Resident 143 and Resident 306. Review of the care plan, dated 11/13/2025, showed no focus, goal, or interventions related to allegations of abuse. Review of the November 2025 incident and grievance logs showed no documentation of an investigation related to the allegation of abuse. Observation on 11/19/2025 at 10:38 AM showed Resident 143 in their room with Resident 306 watching television. During an interview on 11/19/2025 at 10:43 AM, Staff O, Social Services Director, stated the social services department was informed by the admissions coordinator that Resident 143 made an allegation of physical abuse against Resident 306 prior to admission to the facility and it was reported to Adult Protective Services (APS). Staff O stated they did not have any details about the case and did not know the status of the case. Staff O stated if the residents were together in one room it should have been supervised to protect Resident 143. During an interview on 11/19/2025 at 2:15 PM, Staff P, Social Services Assistant, stated Resident 143's POA requested Resident 143 and 306 room together upon admission. Staff P informed the POA that due to the allegation of abuse the residents could not room together. Staff P stated they did not care plan safety interventions related to the allegation because they did not have confirmation the allegation was true. Staff P stated they followed up earlier that day with APS to obtain the status of the investigation. During an interview on 11/25/2025 at 4:15 PM, Collateral Contact Q stated the APS case related to Resident 143 was currently open and abuse had not been ruled out as additional interviews needed to be conducted. During a group interview on 11/20/2025 at 9:46 AM, Staff A, Administrator, Staff R, Regional Director, and Staff S, Assistant Administrator, stated the facility took precautions by not allowing Residents 143 and 306 to room together. Staff S stated they made nursing staff aware of the allegation yesterday (11/19/2025). Staff S stated the facility should have care planned, interviewed, and had a safety plan for Resident 143 to not be alone with Resident 306. Reference WAC 388-97-0640(1)

Based on observation and interview, the facility failed to ensure proper storage of medications in 1 of 6 halls (700 hall) when reviewed for medication storage. This failure placed residents at risk for medication errors, ineffective treatment, and diminished quality of life. Findings included .Observation on 11/17/2025 at 11:12 AM showed room [ROOM NUMBER] with a medicine cup on the bedside table with three pills. Resident 92 stated one of the pills was an antibiotic but did not know what the others were. During an interview on 11/17/2025 at 11:31 AM, Staff H, Registered Nurse, stated they would leave medications with the resident when they were refusing. During an interview on 11/17/2025 at 11:16 AM, Staff D, Resident Care Manager, stated the medications should not been left at bedside. During an interview on 11/21/2025 at 8:04 AM, Staff J, Licensed Practical Nurse, stated the process for medication administration was when a resident refused, the nurse was to dispose of the medication and reapproach later. During an interview on 11/21/2025 at 11:29 AM, Staff B, Director of Nursing Services, stated the medications left at bedside were not acceptable practice. Reference WAC 399-97-1300(2)

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 sampled residents (Resident 121) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs and potential negative outcomes. Findings included . Review of the electronic health record (EHR) showed Resident 121 admitted to the facility on [DATE] with diagnoses that included congestive heart failure (condition that happens when your heart is unable to pump blood well enough to give your body a normal supply) and a fractured vertebra (broken bone in the spine). Resident 121 was able to make needs known. Review of Resident 121's care plan, dated 11/13/2025, showed no intervention for oxygen therapy. Observation on 11/17/2025 at 10:40 AM showed Resident 121 received O2 set to 6 liters (L) per minute via a nasal canula (device to deliver O2 through a tube into the nose). Review of a provider's order, dated 11/13/2025, showed oxygen at 2 L per minute via nasal cannula as needed. An additional provider's order, dated 11/13/2025, showed oxygen saturation (amount of O2 in the blood) rates every shift and may titrate (increase O2) to keep above ninety percent. During an interview and observation on 10/21/2025 at 9:07 AM, Staff H, Registered Nurse (RN), observed Resident 121's O2 and stated it was set at 6 L, but should have been at 3 L per minute per the provider's order. Staff H stated nursing staff adjust Resident 121's O2 after taking their oxygen saturation. During an interview on 11/20/2025 at 2:01 PM, Staff N, Resident Care Manager/Licensed Practical Nurse, stated the oxygen should have been care planned and the provider contacted for parameters of the order. During an interview on 11/21/2025 at 10:26 AM, Staff B, Director of Nursing Services, stated the oxygen orders should have been care planned and the providers order clarified. Reference WAC 388-97-1060(3)(i)(vi)

Based on observation, interview, and record review, the facility failed to monitor and implement residents' fluid restrictions for 1 of 2 sampled residents (Resident 132) when reviewed for nutrition. This failure placed residents at risk of fluid overload, discomfort, and a diminished quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 132 admitted to the facility on [DATE] with diagnoses to include end stage renal disease (the kidneys can no longer filter waste and excess fluid from the blood), muscle weakness, and diabetes (too much sugar in the blood). Resident 132 was able to make needs known. During an interview and observation on 11/17/2025 at 12:48 PM, Resident 132 stated they had a fluid restriction, was not sure how much, and facility staff did not monitor their fluid intake. Observation showed Resident 132 had a measured cup with 500 millimeters (ml) of fluid and an empty coffee mug on their overbed table. Review of provider's orders showed an order, dated 11/04/2025, for a fluid restriction of 2000 ml a day with dietary proving 360 ml at breakfast, 360 ml at lunch, and 360 ml at dinner and nursing providing 460 ml during the day and 460 ml at night. During an interview on 11/20/2025 at 2:11 PM, Staff E, Certified Nursing Assistant (CNA), stated they knew if a resident was on a fluid restriction by getting advice from nurses and they did not know Resident 132 was on a fluid restriction. During an interview on 11/20/2025 at 2:14 PM, Staff F, CNA, stated they knew a resident was on a fluid restriction by asking a nurse or looking at the care directive and knew how much fluid a resident with a fluid restriction could consume by asking a nurse or looking at the red tag on the resident's door. Staff F stated they were unaware Resident 132 was on a fluid restriction. During an interview on 11/20/2025 at 2:18 PM, Staff G, Resident Care Manager/Licensed Practical Nurse (RCM/LPN), stated nurses monitor fluid restrictions and there were no signs/indicators to indicate a resident was on a fluid restriction. Staff G stated CNA should access a resident's care plan to determine if a resident was on a fluid restriction. Staff G stated residents on fluid restrictions should not have extra liquids available in the room and they were unaware Resident 132 kept sparkling water in their room. Observation on 11/20/2025 at 2:22 PM showed Resident 132 in their room with a metered cup with 500 ml of water and four plastic bottles of sparkling water on a shelf. During an interview on 11/21/2025 at 10:55 PM, Staff B, Director of Nursing Services, stated fluid restrictions were included in the care plan and there should be a sign indicating to staff residents were on a fluid restriction. Staff B stated staff should access a resident's care plan to know which residents had a fluid restriction. Staff B stated fluids at bedside should be limited. Staff B stated CNA being unaware of Resident 132's fluid restriction and sparkling water near bedside did not meet expectations. Reference WAC 388-97-1060(3)(i)

Based on interview and record review, the facility failed to provide ordered bowel medications for constipation per provider's orders for 2 of 5 sampled residents (Residents 136 and 124) when reviewed for quality of care. This failure placed the residents at risk for decreased comfort and a diminished quality of life. Findings included.Resident 136Review of the electronic health record (EHR) showed Resident 136 admitted to the facility on [DATE] with a diagnosis of recent spinal surgery. The resident was able to make needs known. Review of the bowel management documentation showed Resident 136 did not have a bowel movement (BM) from 11/07/2025 through 11/12/2025. Review of the medication administration record (MAR) for November 2025 showed no as needed bowel medications were offered to Resident 136. Resident 124Review of the EHR showed Resident 124 admitted to the facility on [DATE] with a diagnosis of dementia. The resident was unable to make needs known. Review of the bowel management documentation showed Resident 124 did not have a BM from 10/30/2025 through 11/03/2025. Review of October and November 2025 MAR showed Resident 124 did not receive an as needed bowel medication until 11/03/2025 (day 5). During an interview on 11/20/2025 at 10:03 AM, Staff C, Licensed Practical Nurse (LPN), stated if a resident went three days without a BM they were notified on the computer, and staff should give ordered bowel medications to those residents on the morning of day four with no BM. During an interview on 11/20/2025 at 10:19 AM, Staff D, Registered Nurse/Resident Care Manager (RN/RCM), stated the facility had a bowel protocol and after three days residents should receive bowel medication and then follow up to make sure it works. Staff D stated if a resident refused, it should be documented. During an interview on 11/20/2025 at 10:22 AM, Staff B, Director of Nursing Services, stated it was their expectation staff follow the bowel protocol and that Residents 124 and 136 should have received bowel medications after three consecutive days with no BM. Reference WAC 388-97-1060(1)-(3).

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed received care and treatment in accordance with professional standards of practice regarding placement of an indwelling urinary catheter (a flexible tube inserted into the bladder to drain urine). This failure placed residents at risk of unmet care needs, pain, and medical complications Findings included . The facility policy for Indwelling Urinary Catheter (Foley) Management, revised 06/27/2023 and reviewed 09/04/2025, documented the facility would ensure that, for residents admitted with a urinary catheter, staff would adhere to professional standards of practice protocols and infection prevention and control procedures for insertion, ongoing care and catheter removal. The policy referenced [NAME] on Procedural Guidance on Routine care for indwelling urinary catheter (Foley) care and management. According to Lippincott Nursing Procedures (8th ed.) (2019). Wolters Kluwer, after insertion of a urinary catheter, documentation should record the date and time of insertion, the size and type of catheter used, and the amount of sterile water used to inflate the balloon, and the characteristics of the urine obtained. Documentation should also include any complications, the date and time the practitioner was notified, the prescribed interventions, the patient's response to those interventions, and to record patient teaching and the patient's comprehension of the teaching. Resident 1 was admitted to the facility on [DATE] for skilled nursing and rehabilitation services after presenting to the hospital and being diagnosed with generalized weakness, adult failure to thrive, complicated urinary tract infection (UTI), hematuria (blood in the urine), and high blood sugars. Resident 1 also had a history of bladder cancer and admitted to the facility with a chronic (long-term use) indwelling urinary catheter, and was also on anticoagulant ( blood-thinner) medication to treat a deep vein thrombosis, a blood clot in a deep vein that can cause swelling, pain and redness. Resident 1 was alert and oriented and able to participate in care and make his needs known. Review of nursing progress notes dated 12/23/2024 documented Resident 1 had bright red blood in their urinary catheter and collection bag, and new orders were received to hold the resident's anticoagulant ( blood thinner) medication for four days. Review of nursing progress notes showed the color of Resident 1's urine had lightened to pink, and then cleared by 12/26/2024 and the anticoagulant medication was restarted. Between 12/28/2024 and 01/02/2025, Nursing documented [on 12/28/2024, 12/31/2024, 01/01/2025, and 01/02/2025] that Resident 1's urinary catheter was in place and draining clear yellow or amber urine, with no complaints of pain or other problems. On 01/01/2025 at 6:06 PM, an order was entered to change the resident's Foley (urinary) catheter. On 01/03/2025 at 12:06 PM, Nursing documented Resident 1's indwelling urinary catheter was changed, and that hematuria (blood in the urine) was noted after the catheter was changed. Nursing documented the provider was notified and new orders were received to hold the resident's anticoagulant medication and to irrigate (flush) the catheter up to three times a day as needed. A Communication with Physician, dated 01/04/2025 at 5:44 PM, documented Resident 1 had bleeding from their penis that had started during the catheter change on 01/03/2025. Nursing documented the catheter was removed and the bleeding continued, and another new catheter was inserted. Nursing documented that on 01/04/2025 Resident 1 reported continued bleeding from the penis and had a large amount of blood in their brief when they went to the restroom. A provider note, dated 01/06/2025, documented that nursing staff reported concern that the resident had some blood in their Foley catheter, and the catheter was replaced which slowed down the bleeding. The provider noted the resident's anticoagulant medication was briefly held and the resident continued to have bleeding around the urethral meatus (where the catheter entered the resident's body). The provider documented Resident 1 had hematuria most likely secondary to trauma from Foley catheter insertion being inserted incorrectly. The provider documented Resident 1's Foley catheter was replaced and the hematuria had resolved. Resident 1 continued to have bleeding from the urethral meatus, and new orders for continued monitoring and labs to be collected were given. On 01/08/2025, review of Resident 1's record showed the resident began experiencing low back pain and fever, and increased lethargy. On 01/09/2025, the provider noted Resident1 had left-sided flank pain and fever likely due to a UTI, and new orders written that included labs to be drawn, antibiotics and IV fluids to be started, and medication for pain management. On 01/09/2025, Nursing documented, via Communication with Physician, that Resident 1's oxygen saturation level was at 87% (normal 92% - 100%), and they were put on oxygen via nasal cannula (plastic tubing that delivers oxygen via the nasal passages), and the provider was notified. On 01/10/2025, the provider examined Resident 1 and noted they were diaphoretic (sweaty) and in notable pain. The provider determined the resident had a UTI and likely pyelonephritis (kidney infection). The provider documented they discussed treatment options with the resident, their spouse and another family member, and that the resident's kidney function was worsening, the UTI had likely turned into pyelonephritis, and the potential for the infection to worsen and the resident could become septic (develop an overwhelming infection). The resident and their family did not want the resident to go to the hospital and decided to continue treating the resident at the facility. On 01/11/2025, the provider noted that Resident 1 had pain in the right upper side of their abdomen and had difficulty breathing, and ordered labs, a chest x-ray and abdominal x-ray. On 01/11/2025 at 4:10 AM, Nursing documented Resident 1 had blood around the catheter site and a large blood clot in their brief. Nursing documented the catheter was flushed without resistance. On 01/11/2025 at 9:30 PM, Nursing documented Resident 1 had a large blood clot around the penis area, and blood was actively oozing around the catheter. Nursing noted that after cleaning the site, blood continued to flow around the catheter. The provider was notified, and Resident 1 agreed to go to the hospital and was sent out for additional evaluation. Review of the record showed the provider spoke with the resident and family member about the potential for sepsis and other concerns. Review of the record showed the resident was transported to the hospital for evaluation and treatment of the continuing low back pain and fevers and bleeding after the foley catheter insertion. Review of hospital documentation, dated 01/12/2025, documented Resident 1 had urethral bleeding and a tear/laceration at the urethral meatus, and noted the resident had undergone exchange of their Foley catheter three days before coming to the hospital, when trauma occurred. The hospital provider noted a second attempt at catheterization was successful. The resident was found to have acute blood loss anemia and required transfusion, and consultation and follow-up by urology. On 09/30/2025 at 12:59 PM, Staff C, a Licensed Practical Nurse (LPN), recalled Resident 1's Foley catheter had been changed during their stay at the facility. Staff C reviewed Resident 1's record and noted that the resident had some problems going on with bleeding and blood clots at the tip of the penis. Staff C said the resident had initially refused to go to the Emergency Department but was later sent out to the hospital. On 09/30/2025 at 1:59 PM, when asked, Staff B, a Registered Nurse and the facility Director of Nursing, agreed documentation of placement of a urinary catheter that included how the resident tolerated the procedure, how much urine was returned, etc. would be recommended. Reference WAC 388-97-1060(1) .

Based on interview and record review, the facility failed to provide an ordered medication, significant to the health of the resident, for 1 of 6 sampled residents (Resident 27) reviewed for medication administration. Resident 27 experienced harm when they developed stroke like symptoms and was emergently transferred to the hospital for a change in condition. The facility has corrected the above deficiency prior to the standard survey and constituted as past non-compliance (the facility was not in compliance at the time the incident occurred; however there was sufficient evidence the facility corrected the non-compliance after it was identified) and is no longer outstanding. Findings included . Review of Lippincott Manual of Nursing Practice, Eighth Ed., 2006, showed an anticoagulant (blood thinning) medication can be used to disrupt the blood's natural clotting function, when there is a risk of blood clots forming. Such a risk is present with a diagnosis of atrial fibrillation (A-fib, an abnormal heart rhythm). Review of a facility policy titled, Medication Reconciliation across the Continuum of Care, reviewed 09/05/2024, showed .hospital transfer form (if coming from the hospital) are received by the licensed nurse who reconciles the medication list, phones the physician if necessary for clarification, obtains physician orders, and then updates the electronic health record. Review of the electronic health record (EHR) showed Resident 27 admitted to the facility on [DATE] and discharged on [DATE]. Resident 27 admitted with diagnoses of atrial fibrillation, encounter for orthopedic aftercare following surgical amputation (post-surgery care of removed limb), and peripheral vascular disease (a circulatory condition that occurs when blood vessels outside of the brain and heart narrow, spasm, or become blocked). Review of hospital discharge orders showed Resident 27 was to continue taking an anticoagulant (blood thinning) medication. Review of the provider's orders from 10/10/2024 through 10/21/2024 showed Resident 27 did not receive an order for an anticoagulant. Review of a progress note, dated 10/21/2024, showed Resident 27 experienced face drooping, left-sided weakness, and left eye dilation (increase in size) and was transported to the hospital. Review showed the hospital emergency department called the facility several times requesting information about an anticoagulant including that the resident was supposed to be receiving one. It was discovered Resident 27 had not received the hospital ordered anticoagulant medication while at the facility. Review of the investigative report regarding Resident 27's lack of anticoagulant medication, dated 10/25/2024, showed the facility failed to transcribe the anticoagulant medication into the resident's EHR and Resident 27 had not received the anticoagulant medication while at the facility. Review showed this was considered a medication error. During an interview on 10/30/2024 at 12:16 PM, Staff A, Administrator, stated Resident 27 had not received the anticoagulant medication as it was not transcribed into the resident's EHR. During an interview on 10/30/2024 at 12:16 PM, Staff S, Regional Nurse, stated Resident 27's emergent transfer to the hospital could potentially have been caused by the lack of anticoagulant medication. During an interview on 10/31/2024 at 9:53 AM, Staff B, Director of Nursing Services, stated Resident 27's lack of anticoagulant medication was a significant medication error and a contributing factor in their transfer to the hospital. During an interview on 10/31/2024 at 9:55 AM, Staff A, Administrator, stated Resident 27's lack of anticoagulant medication was a significant medication error and a contributing factor in their transfer to the hospital. During an interview on 10/31/2024 at 1:25 PM, Staff A, Administrator, stated after the incident was reported to them they immediately began working on and developed an internal plan of correction which included audits of all newly admitted residents in the prior 14 days for hospital order transcription, in-servicing of staff on transcribing hospital orders, ongoing audits of all newly admitted resident's for hospital order transcription, and referral to the Quality Assurance and Performance Improvement program for ongoing monitoring. Staff A stated they had achieved compliance as of 10/25/2024. Review of documentation and review of current facility resident EHR showed facility had achieved compliance as of 10/25/2024. Past noncompliance - no plan of correction required. Reference WAC 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 1 of 2 sampled residents (Resident 26) reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included . Review of the facility policy titled Antibiotic Stewardship, revised 05/16/2024, showed the facility would implement antibiotic time-out at 72 hours after antibiotic initiation or first dose in the facility. Each resident should be reassessed for consideration of antibiotic need by reviewing lab results, response to therapy and resident condition. It further showed the facility would design and use a system to identify residents with multidrug resistant organisms (MDRO, infections resistant to multiple antibiotics) by reviewing microbiology culture results. Resident 26 Review of the electronic health record (EHR) showed Resident 26 admitted to the facility on [DATE] with diagnoses of sepsis (a serious condition in which the body responds improperly to an infection), obstructive uropathy (difficulty urinating), and a urinary tract infection (UTI). There was no diagnosis of pneumonia included in the resident's diagnosis list. Review of Resident 26's provider's orders showed an order for cefdinir (a broad-spectrum antibiotic) twice a day for five days for a UTI with a start date of 10/10/2024 which was completed on 10/15/2024. Review of an outside provider's note dated 10/10/2024, provided to the facility by Resident 26's family member on 10/24/2024, showed the resident had a culture result positive for pseudomonas (a MDRO) and should have been changed to ciprofloxacin (an antibiotic) as pseudomonas was resistive to the cefdinir. During an interview on 10/29/2024 at 11:37 AM, Staff M, Infection Preventionist, stated they did not review the lab/culture results for all UTIs and they trusted the provider's judgment on whether the resident was on the appropriate antibiotic treatment. Staff M stated they believed it was a typical UTI. During an interview on 10/31/2024 at 11:13 AM, Staff B, Director of Nursing Services, stated it was their expectation that the infection preventionist review infections and associated laboratory culture results for antibiotic stewardship. No Associated WAC

Based on observation, interview, and record review the facility failed to implement an infection control program that included the application of enhanced barrier precautions (EBP) for 2 of 3 sampled residents (Residents 5 and 226) when reviewed for EBP. Also, the facility failed to track all infectious organisms for 2 of 3 months (August and September 2024) when reviewed for infection control. These failures placed residents at risk of communicable diseases, avoidable side effects, and a diminished quality of life. Findings included . <EBP> Review of the facility policy titled Enhanced Barrier Precautions, dated 06/03/2024, showed the facility should use EBP for residents who had chronic wounds, such as pressure wounds, or indwelling devices, such as urinary catheters. It further showed that EBP included posting a sign outside the resident's door instructing staff on the use of a gown and gloves for all high contact resident care activities. Resident 5 Review of Resident 5's electronic health record (EHR) showed Resident 5 readmitted to the facility on [DATE] with a pressure injury to their bottom. Further review showed the resident's pressure injury resolved on 07/12/2024 but continued to have a chronic wound to their left ankle which was still present on 10/28/2024. Observation on 10/29/2024 showed Resident 5 did not have an EBP sign on the door. During an interview on 10/29/2024 at 11:23 AM, Staff L, Certified Nursing Assistant, stated Resident 5 had not been requiring EBP. During an interview on 10/31/2024 at 9:57 AM, Staff M, Infection Preventionist (IP), stated it was their expectation that residents who had significant chronic wounds, such as Resident 5, would have EBP in place. Resident 226 Review of the EHR showed Resident 226 admitted to the facility on [DATE] with a diagnosis of obstructive and reflux uropathy (difficulty urinating) and required an indwelling urinary catheter (a tube inserted into the bladder to drain urine). Observation and interview on 10/28/2024 at 12:03 PM showed Resident 226 in their room. There was no EBP sign on the door and Resident 226 stated they had admitted to the facility with an indwelling urinary catheter. Resident 226 stated staff did not wear gowns when providing direct care. During an interview on 10/29/2024 at 4:54 PM, Staff M, IP, stated Resident 226 had a indwelling urinary catheter and should have had EBP sign and a PPE isolation cart with appropriate supplies by the doorway, and it should have been care planed. During an interview on 10/30/2024 at 11:20 AM, Staff A, Administrator, stated it was their expectation that residents with chronic wounds and indwelling urinary catheters be placed on EBP and Resident 5 and Resident 226 should have had EBP in place. <Tracking> Review of the facility policy titled Infection prevention and Control Program, revised 01/25/2023, showed the program includes early detection, management of a potentially infectious, symptomatic resident that requires laboratory testing and/or the implementation of appropriate TBP/PPE (the plan may include tracking this information in an infectious disease log). August 2024 Review of the infection control log, map and monthly summary for August 2024 included no identified organisms and listed no multidrug resistant organism (MDRO, infections resistant to multiple antibiotics) for tracking. September 2024 Review of the infection control log, map and monthly summary for September 2024 showed no identified organisms and listed no MDRO for tracking. Review of Resident 177's EHR showed the resident was identified to have disseminated shingles (a viral infection that is highly contagious) on 09/11/2024 and was sent to the emergency room for evaluation. The September 2024 infection control log did not include this infection. Review of Resident 278's EHR showed the resident admitted on [DATE] with diagnosis of urinary tract infect (UTI) and was receiving cephalexin (an antibiotic) every eight hours for UTI. The September 2024 infection control log did not include this infection. During an interview on 10/30/2024 at 10:36 AM, Staff M, IP, stated it was their practice to track all infections on the infection control log, update the map daily, and complete a summary every month which included a section for tracking MDROs. During an interview on 10/29/2024 at 11:47 AM, Staff B, Director of Nursing Services, stated it was their expectation that the IP review lab results for new admissions and current residents who are receiving antibiotics for the infectious organisms, if applicable, and include each on the infection control logs for tracking. Reference WAC 388-97 -1320 (2)(a)(c)

Based on interview and record review, the facility failed to timely initiate monitoring of adverse side effects and target behaviors for 3 of 6 sampled residents (Residents 24, 276 and 226) when reviewed for unnecessary psychotropic (affecting the mind) medications. These failures placed the residents at risk for unidentified mental health needs and a decreased quality of life. Findings included . Resident 24 Review of the electronic health record (EHR) showed Resident 24 admitted to the facility on [DATE] with a diagnosis of depression. Review of the EHR showed a provider order dated 09/23/2024 for nortriptyline (an antidepressant medication) at bedtime for depression. Review of Resident 24's medication administration record (MAR) from 09/23/2024 through 10/28/2024, showed Resident 24 was provided nortriptyline per provider orders; however, the order to monitor targeted behaviors related to the use of an antidepressant was not initiated until 10/28/2024. Resident 276 Review of the EHR showed Resident 276 admitted to the facility on [DATE] with a diagnosis of depression. Review showed provider orders for the following psychotropic medications: amitriptyline (an antidepressant) daily for depression, start date 10/20/2024, trazadone (an antidepressant) daily at bedtime for depression, start date 10/21/2024, and sertraline (an antidepressant) daily for depression, start date 10/20/2024. Review of Resident 276's MAR from 10/20/2024 through 10/28/2024 showed Resident 276 was provided the above antidepressants per provider orders; however, the order to monitor targeted behaviors related to the use of an antidepressant was not initiated until 10/28/2024. During an interview on 09/29/2024, Staff O, Licensed Practical Nurse (LPN), stated they did not know why there was no behavior monitoring in place until 10/28/2024 but there should have been. During an interview on 10/30/2024 at 2:25 PM, Staff B, Director of Nursing Services (DNS), stated resident's on a psychotropic medications, such as an antidepressant, should have targeted behavior monitoring in place on the day they start the medication. 38344 Resident 226 Resident 226 admitted to the facility on [DATE] with a diagnosis of depression and was able to make needs known. Review of Resident 226's EHR showed a provider order dated 10/16/2024 for duloxetine (an antidepressant medication) one time a day for depression. It showed an order dated 10/17/2024 to monitor for target behaviors related to a diagnosis of depression, listed several behaviors, and listed interventions to utilize/offer. It showed an order dated 10/24/2024 to monitor for side effects for use of duloxetine every shift. Review of Resident 226's October 2024 MAR from 10/16/2024 through 10/28/2024 showed Resident 226 was provided duloxetine per provider orders; however, the order to monitor for side effects for use of duloxetine was not initiated until 10/24/2024 (eight days after being provided the medication). An order dated 10/17/2024 to monitor for target behaviors with listed interventions showed documentation of nurses' initials for day and night shift; however, there was no documentation for evening shift, or to show if behaviors were or were not exhibited, or if interventions were offered. During an interview on 10/29/2024 at 1:51 PM, Staff G, Registered Nurse/Unit Care Coordinator (RN/UCC), stated Resident 226's order to monitor side effects related to use of antidepressant medication was started eight days after being provided the medication and should have been initiated upon admission. Staff G stated Resident 226's order to monitor target behaviors was entered into the system inaccurately and should have included supplemental documentation to show if the resident had behaviors and what interventions were provided if needed. During an interview on 10/30/2024 at 2:25 PM, Staff B, Director of Nursing Services, stated Resident 226's monitoring for adverse side effects for antidepressant medication use was initiated too late. Staff B stated Resident 226's October 2024 MAR did not show a space to document a code to show if Resident 226 had behaviors or if interventions were provided. The documentation should have been in the MAR but there was an error when they put the order in for codes for behaviors and interventions and this did not meet expectations. Reference WAC 388-97-1060 (3)(k)(i)

Based on interview and record review, the facility failed to implement non-pharmacological interventions (NPI, methods to reduce pain without medication) prior to providing pain medications for 5 of 5 sampled residents (Residents 6, 24, 32, 41 and 226) reviewed for unnecessary medications. This failure placed the residents at risk of receiving unnecessary pain medications and a decreased quality of life. Findings included . Resident 6 Review of the electronic health record (EHR) showed Resident 6 admitted to the facility on [DATE] with a diagnosis of fracture of the left forearm. Review of the EHR showed the resident had a provider order for oxycodone tablet (a narcotic pain medication) every four hours as needed for severe pain which was provided daily from 10/01/2024 through 10/28/2024. Included was a separate provider order to attempt NPI prior to administering the narcotic pain medication. Review of the medication administration record (MAR) from 10/01/2024 through 10/28/2024 showed all day shift administrations marked as NA for NPI and 12 night shift administrations marked as NA. Resident 24 Review of the EHR showed Resident 24 admitted to the facility on [DATE] with a diagnosis of left lower leg amputation. Review of the EHR showed the resident had a provider order for oxycodone every four hours as needed for severe pain with a start date of 09/24/2024. Included was a separate provider order to attempt NPI prior to administering the narcotic pain medication. Review of the MAR from 10/01/2024 through 10/28/2024 showed the resident received oxycodone daily and 15 of the day shift administrations and 19 night shift administrations were marked as NA. During an interview on 10/29/2024 at 1:02 PM, Staff O, Licensed Practical Nurse, stated the nursing staff should have documented NPI that was attempted prior to narcotic pain medications each shift and they should not mark NA (not applicable). 40817 Resident 32 Review of the EHR showed Resident 32 admitted to the facility on [DATE] with a diagnosis of respiratory failure (lung failure). Review of Resident 32's provider's orders showed an order for acetaminophen (an over-the-counter pain medication), dated 10/03/2024, as needed for pain and an order for staff to provide NPI prior to use. Review of Resident 32's October 2024 MAR showed the resident was provided acetaminophen without NPI on 10/05/2024. 34567 Resident 41 Review of the EHR showed Resident 41 admitted to the facility on [DATE] with a diagnosis of osteomyelitis (infection of the bone) of the right ankle and foot. The resident had a provider's order for oxycodone tablet every 12 hours as needed for pain levels 6 to 10. Included was a separate provider order to attempt NPI prior to administering the narcotic pain medication. Review of the MAR for October 2024 showed the LNs had not documented any NPI for 18 oxycodone administrations for Resident 41. Review of a focus care plan, dated 10/04/2024, showed Resident 41 expressed pain/discomfort related to muscle weakness and wound. The interventions included for the licensed nurse (LN) to evaluate the effectiveness of pain interventions and administered the pain medications as ordered. During an interview on 10/29/2024 at 2:31 PM, Staff C, Licensed Practical Nurse/Unit Care Coordinator (LPN/UCC), stated the NPI documentation was wrong in the MAR for Resident 41 and the LNs were to provide NPI whenever they administered narcotics and document in the residents' EHR. 38344 Resident 226 Resident 226 admitted to the facility on [DATE] with diagnoses that included arthritis (swelling and tenderness of joints) and spinal stenosis (narrowing of the spinal canal in the lower part of the back that could result in pain, numbness, or weakness). Resident 226 was able to make needs known. Review of Resident 226's October 2024 MAR from 10/16/2024 through 10/28/2024 showed orders dated 10/16/2024 to include acetaminophen every four hours as needed for pain. The MAR showed this was provided to Resident 226 without NPI on 10/17/2024 and 10/28/2024. The MAR showed hydrocodone-acetaminophen (use to treat severe pain) every eight hours as needed for pain that was provided 20 times without NPI documented. THe MAR showed an order for staff to provide NPI prior to as needed pain medication use per shift; however, it showed no specific time NPI provided. During an interview on 10/29/2024 at 2:08 PM, Staff G, Registered Nurse/UCC, stated Resident 226's order to attempt to provide NPI prior to giving as needed pain medication was per shift and did not pertain to the specific dose or time an as needed pain medication was provided, and this did not meet expectations. Staff G stated Resident 226's as needed pain medication orders needed to have supplemental documentation added to the orders to include NPI and interventions. During an interview on 10/30/2024 at 2:52 PM, Staff B, Director of Nursing Services, stated the expectation was NPI should be offered and provided prior to administering as needed pain medication and it should be documented in the MAR. Reference WAC 388-97 -1060 (3)(k)(i)

Based on observation, interview, and record review, the facility failed to accurately monitor resident fluid intake and/or ensure dietary and supplement orders were obtained/transcribed according to standard of practice for 2 of 2 sampled residents (Residents 40 and 42) reviewed for nutrition. This failure placed residents at risk of fluid overload, swelling, discomfort, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 40 admitted to the facility on [DATE] with diagnoses of chronic heart failure (CHF), ankylosing spondylitis (a type of arthritis that affects the spine and other parts of the body), and pneumonia (a lung infection). Review of provider's orders showed Resident 40 had an order for a 2000 milliliters (ml) fluid restriction related to CHF. Review of the order showed for nursing to provide 480 ml fluid during day, evening, and night and for dietary to provide 200 ml day and 180 ml evening and night. Review of Resident 40's October 2024 medication administration record (MAR) showed fluid tracking for nursing day and evening shifts and did not have documentation of dietary provided liquids. Review showed no area to total Resident 40's fluid intake. During an interview on 10/30/2024 at 9:54 AM, Staff R, Licensed Practical Nurse/Resident Care Manager, stated Resident 40 was on a fluid restriction and it was tracked through the MAR and nursing was responsible for monitoring total fluid intake. Staff R stated Resident 40's MAR had only two spaces in the MAR to record fluid intake, dietary fluids were not being tracked, and nursing was not totaling or monitoring total fluid intake. Staff R stated Resident 40's monitoring of fluid restriction did not meet expectation. During an interview on 10/30/2024 at 1:16 PM, Staff B, Director of Nursing Services, stated Resident 40 did not have fluid monitoring for the evening shift, dietary fluids were not being monitored, and nursing was not totaling or monitoring total fluid intake. Staff B stated Resident 40's monitoring of fluid restriction did not meet expectation. 38344 Resident 42 Review of Resident 42's EHR showed the resident readmitted to the facility on [DATE] with diagnoses to include anemia (lack of healthy red blood cells to carry oxygen throughout the body), diabetes (a condition resulting in high blood sugar levels), hyperkalemia (a condition where there is too much potassium, a mineral/electrolyte that helps muscles and nerves function, in the blood), and chronic (persistent/long lasting) kidney disease. The resident was able to make needs known. During an interview and observation on 10/28/2024 at 1:02 PM, Resident 42 stated they were on fluid restrictions and pointed to a dietary meal tray slip dated 10/28/2024 that showed Resident 42 was on a fluid restriction of 1200 ml thin liquids. During an interview on 10/30/2024 at 11:28 AM, Resident 42 stated they thought that they were to have 1.5 liters of fluids in 24 hours; however, staff did not keep track of their intake and never asked them how much fluid they had consumed. Review of the dietary provider order dated 09/21/2024 showed Resident 42 was prescribed a diet that included a fluid restriction of 1200 ml (this order did not specify fluids that would be provided by the kitchen for meals or how much fluids would be provided by nursing in between meals). Review of Resident 42's provider order dated 09/22/2024 showed, ProSource Sugar Free two time a day for wound care. (This order did not show the route or the amount of ml to be provided). Review of the provider order dated 10/25/2024 showed Resident 42 was prescribed fluid restrictions of 1500 ml per day (300 ml more than the dietary provider order). Dietary to provide; breakfast = 360 ml, lunch = 240 ml, dinner = 360 ml, and from Nursing: day shift = 180 ml, evening shift = 180 ml, night shift = 120 ml, and every shift document amount consumed. (This order did not show the rationale or related diagnosis for the fluid restriction). Review of Resident 24's 05/21/2024 initiated care plan showed no care plan or interventions documented for fluid restrictions. During an interview on 10/31/2024 at 11:24 AM, Staff K, Certified Assistant Nursing (CNA), stated Resident 42 was on fluid restrictions. Staff K stated they did not document how much fluid the residents on fluid restrictions drank but informed the nurse [licensed nurse] verbally or on a sticky note how much they drank for meals and throughout their shift. During an interview on 10/31/2024 at 12:30 PM, Staff J, Registered Nurse (RN), stated CNA documented how much fluids were consumed during meals in the computer system and would inform nursing [licensed nurses] what fluids were provided in between meals during their shift. Staff J stated that fluids provided in between meals were all documented in the MAR. Staff J stated Resident 42's order for ProSource Sugar Free did not show the route or amount to be provided, the October 2024 MAR did not have a spot to document amount consumed, and the order needed to be clarified with the provider. Staff J stated the dietary order dated 09/21/2024 showed Resident 42 was on a 1200 ml fluid restriction which conflicted with the provider order dated 10/25/2024 that showed a fluid restriction of 1500 ml and both orders needed to be clarified with the provider. Staff K stated all fluids should be totaled for a 24-hour period and documented in the MAR to ensure provider orders were followed; however, that did not happen for Resident 42. Staff J stated that Resident 42's care plan did not include fluid restrictions and should have been included in the care plan when fluid restriction orders were obtained. Staff J stated Resident 42's fluid restrictions monitoring, and documentation did not meet expectations. Reference WAC 388-97-1060 (3)(h)(i)

Based on interview and record review, the facility failed to consistently monitor and document bowel movements and implement the bowel program as needed for 3 of 4 sampled residents (Residents 177, 176 and 40) reviewed for care and services. These failures placed the residents at risk for worsening condition, discomfort, and a decreased quality of life. Findings included . Review of a policy document titled, Bowel Protocol, dated 09/16/2024, showed the facility should provide effective interventions for signs and symptoms of constipation that were consistent with current standards of practice. The nursing staff was to record, in the electronic health record (EHR), each time a resident had a bowel movement (BM). In addition, the facility, in coordination with the resident's provider, would implement standing orders to address a lack of a BM. Resident 177 Review of Resident 177's entry minimum data set (MDS), an assessment tool, dated 09/22/2024, showed the resident readmitted on [DATE] with diagnoses to include heart and kidney disease, diabetes, depression and anxiety. The MDS showed Resident 177 was able to make needs known and required assistance with personal care needs. During an interview on 10/28/2024 at 10:21 AM, Resident 177 stated constipation had been an issue for them since admission to the facility. Review of Resident 177s EHR showed several provider orders dated 09/22/2024 for the licensed nurse (LN) to administer, as necessary, medication used in the treatment of constipation to include: Bisacodyl 5 milligrams (mgs) delayed release (orally) as necessary daily, Bisacodyl 10 mg suppository to be administered (rectally) as needed for constipation if the oral Bisacodyl was ineffective. The provider ordered the LN to administer fleets mineral oil enema (rectally) if the Bisacodyl suppository was ineffective. Review of Resident 177's EHR task section showed 9 days (10/15/2024 to 10/23/2024) had elapsed without the LNs administering any provider orders for the treatment of constipation. Resident 176 Review of Resident 176's MDS, dated [DATE], showed the resident admitted on [DATE] with diagnoses to include heart disease and depression. The MDS showed Resident 176 was able to make needs known and required staff assistance with personal care needs. Review of Resident 176's focus care plan, dated 09/26/2024, showed the resident used antidepressant medication related to depression. The goal showed the resident would be free from discomfort or adverse reactions related to antidepressant therapy. Interventions included for the LN to observed for and report as necessary for adverse reactions to antidepressant therapy to include constipation and fecal (stool) impaction. Review of Resident 176's EHR showed several provider orders, dated 09/26/2024, for the LN to administer, as necessary, medication used in the treatment of constipation to include: Bisacodyl 5 mgs delayed release (orally) as necessary daily, Bisacodyl 10 mg suppository to be administered (rectally) as needed for constipation if the oral Bisacodyl was ineffective. The provider ordered the LN to administer fleets mineral oil enema (rectally) if the Bisacodyl suppository was ineffective. Review of Resident 176's EHR task section showed multiple days (greater than 72 hours) from 10/10/2024 to 10/12/2024 and 10/14/2024 to 10/16/2024 had elapsed without the LNs administering any provider orders for the treatment of constipation. Resident 40 Review of Resident 40's EHR showed the resident admitted on [DATE] with diagnoses to include kidney disease, stroke with hemiplegia (paralysis or loss of function to a part of or all the body) and depression. The MDS showed Resident 40 was able to make needs known and required assistance with personal care needs. During an interview on 10/28/2024 at 12:05 PM, Resident 40 stated they had constipation for several days and the staff have not provided them any medication. Review of Resident 40's EHR showed several provider orders dated 10/18/2024 for the LN to administered (as necessary) medication used in the treatment of constipation to include: Bisacodyl 5 mgs delayed release (orally) as necessary daily, Bisacodyl 10 mg suppository to be administered (rectally) as needed for constipation if the oral Bisacodyl was ineffective. The provider ordered the LN to administer fleets mineral oil enema (rectally) if the Bisacodyl suppository was ineffective. Review of Resident 40's EHR task section showed greater than 72 hours had elapsed from (10/22/2024 to 10/24/2024) without LNs administering any provider orders for the treatment of constipation. Review of 40's focus care plan, dated 10/25/2024, showed the resident used antidepressant medication related to depression. The goal showed the resident would be free from discomfort or adverse reactions related to antidepressant therapy. Interventions included for the LN to observed for and report as necessary for adverse reactions to antidepressant therapy to include constipation, and fecal impaction. During an interview on 10/29/2024 at 1:58 PM, Staff C, Licensed Practical Nurse/Unit Care Coordinator, stated the LN should have administered the ordered (as necessary) constipation medication if there was greater than 72 hours since the resident had a BM. During an interview on 10/30/2024 at 11:14 AM, Staff B, Director of Nursing Services, stated it was their expectation LNs were to administer the providers orders as necessary for the resident's constipation. Reference WAC 388-97-1060(1)(2)(3)(b)(c)

Based on observation, interview, and record review, the facility failed to include all required services in the plan of care for 3 of 20 sampled residents (Residents 40, 42, and 226) when reviewed for comprehensive care plan. This failure placed residents at risk of not receiving required services, staff being unaware of how to assist residents, and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 40 admitted to the facility on [DATE] with diagnoses of ankylosing spondylitis (a type of arthritis that affects the spine and other parts of the body) and pneumonia (a lung infection). Review of provider's orders showed Resident 40 had an order for a fluid restriction. Review of Resident 40's care plan, initiated 09/26/2024, showed no information related to a fluid restriction. During an interview on 10/30/2024 at 9:54 AM, Staff R, Licensed Practical Nurse/Resident Care Manager, stated residents on a fluid restriction should have a care focus area for it in the care plan. Staff R stated there was no information related to Resident 40's fluid restriction in their care plan and this did not meet expectation. During an interview on 10/30/2024 at 1:16 AM, Staff B, Director of Nursing Services, stated information about a fluid restriction should be in the plan of care. Staff B stated Resident 40's care plan had no information about a fluid restriction, and this did not meet expectation. 38344 Resident 42 Review of Resident 42's EHR showed the resident readmitted to the facility on [DATE] with diagnoses to include anemia (lack of healthy red blood cells to carry oxygen throughout the body), diabetes (a condition resulting in high blood sugar levels), hyperkalemia (a condition where there is too much potassium, a mineral/electrolyte that helps muscles and nerves function, in the blood), and chronic (persistent/long lasting) kidney disease. The resident was able to make needs known. During an interview and observation on 10/28/2024 at 1:02 PM, Resident 42 stated they were on fluid restriction and pointed to a dietary meal tray slip dated 10/28/2024 that showed Resident 42 was on a fluid restriction. Review of the provider order dated 09/21/2024 showed that Resident 42 was prescribed a diet that included a fluid restriction. Review of Resident 42's current care plan on 10/30/2024 at 8:23 AM showed no care plan or interventions documented for fluid restrictions. During an interview on 10/31/2024 at 12:30 PM, Staff J, Registered Nurse (RN), stated Resident 42 was on fluid restrictions and it should have been care planned when Resident 42 had orders obtained for fluid restrictions. Resident 226 Review of Resident 226's EHR showed the resident admitted on [DATE] with diagnoses to include arthritis (inflammation of the joints), paroxysmal atrial fibrillation (an irregular heart rate that commonly causes poor blood flow), and chronic obstructive pulmonary disease (COPD, lung disease that causes restricted airflow and breathing problems). Resident 226 was able to make needs known. During an interview on 10/28/2024 at 12:06 PM, Resident 226 stated they had a wound on their bottom and their wounds were being looked at and treated routinely. Review of Resident 226's EHR showed a provider order dated 10/17/2024 to treat a deep tissue injury (DTI) to the right heel and an order dated 10/25/2024 for a treatment to the right buttock wound. It showed a care plan dated 10/16/2024 for at risk for break in skin integrity; however, there was no care plan for actual skin integrity impairment. During an interview on 10/31/2024 at 9:26 AM, Staff G, Registered Nurse/Unti Care Coordinator (RN/UCC), stated Resident 226 had a pressure ulcer/skin injury to the right buttock and a DTI to the heel. Staff G stated they did not see a care plan for actual skin integrity issues and there should have been. Reference WAC 388-97-1020(1), (2)(a)(b)

Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 2 sampled residents (Residents 226) reviewed for respiratory care. Failure to transcribe/obtain and follow physician orders for oxygen (O2) therapy, care plan, ensure O2 tubing was regularly changed and maintained, placed the resident at risk for unmet needs and potential negative outcomes. Findings included . Resident 226 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, lung disease that causes restricted airflow and breathing problems), and chronic (long lasting/ongoing) respiratory failure with hypoxia (low levels of O2 in the blood). Resident 226 was able to make needs known. Observation on 10/28/2024 at 9:40 AM showed Resident 226 laid in bed receiving O2 set to two liters (L) per minute via nasal canula (devise to deliver O2 through a tube into the nose) and the tubing was not dated. Observation and interview on 10/29/2024 at 10:48 AM showed Resident 226 received O2 set to two L per minute via nasal canula. Resident 226 stated they had received O2 continuously at two liters through the nose via the tube since they had admitted to the facility. Review of Resident 226's hospital discharge orders dated 10/16/2024 showed, Continue taking these medications, and the list included Oxygen 2 liter daily. Review of the admission collection tool, dated 10/16/2024, Devices and Treatments (care profile) showed Resident 226 had O2 at 2 L/minute by nasal canula/mask and was a Chronic (treatment). Review of Resident 226's electronic health record (EHR) showed no orders for O2 therapy or to change and maintain oxygen tubing; however, documented respiratory symptoms screening tools dated 10/17/2024, 10/18/2024, 10/19/2024, 10/21/2024, 10/22/2024, 10/24/2024, 10/25/2024, 10/26/2024, 10/27/2024, and 10/28/2024 showed the resident received O2 via nasal canula. Review of Resident 226's 05/21/2024 initiated care plan showed no care plan or interventions documented for O2 therapy. During an interview on 10/29/2024 at 5:16 PM, Staff G, Registered Nurse/Unit Care Coordinator, stated Resident 226 was observed receiving O2 at two L per minute via nasal canula and the tubing and humidifier were not dated and should have been. Staff G stated Resident 226 had no orders for O2 therapy and O2 therapy had not been cared planned and should have been. During an interview on 10/30/2024 at 3:02 PM, Staff B, Director of Nursing Services, stated Resident 226's orders for O2 therapy should have been initiated and care planned upon admission. Staff B stated this did not meet expectations. Reference WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview, and record review, the facility failed to ensure enteral nutrition (the delivery of nutrients through a feeding tube directly into the stomach or small intestine) was administered in accordance with provider's orders and professional standards of practice for 1 of 2 sampled residents (Resident 72) reviewed for enteral nutrition. The facility failed to have a system in place which ensured the amount of enteral formula (liquid food products) a resident received was reconciled with the amount they were ordered to receive. This failure placed the residents at risk for inadequate nutrition, dehydration, and other adverse outcomes. Findings included . Review of Resident 72's admission minimum data set (MDS), an assessment tool, dated 10/15/2024, showed the resident admitted on [DATE] with diagnoses to include stroke, kidney disease, aphasia (a language disorder that affects a person's ability to understand and express language), and muscle weakness. Resident 72's electronic health record (EHR) showed the resident had dysphagia (swallowing difficulty), required an enteral feeding tube for nutrition, and was dependent on facility staff for all activities of daily living. Review of a focused care plan, revised on 10/22/2024, showed Resident 72 required (enteral) tube feeding related to dysphagia. The goal for Resident 72 was to remain free of side effects or complications related to the tube (enteral) feed (TF). Interventions included the registered dietician (RD) to evaluate quarterly and when necessary and make recommendations for changes to the resident's tube feed as needed. An additional care plan focus showed the resident was at risk for weight fluctuations related to current health status with tube feed and risk for malnutrition. Review of a provider order, dated 10/14/2024, showed an order for the licensed nurse (LN) to infuse enteral feeding every shift, Nepro at 50 milliliters (ml) for 24 hours via pump for a total of 1200 ml. The LN's were instructed to flush with 250 ml of purified water every four hours. Review of Resident 72's medication administration record (MAR), dated October 2024, showed the LNs had been documenting (initialed) the resident's tube feed every shift as being infused along with the water flushes; however, no totals were being recorded or documented within the resident's EHR. Observation and interview on 10/30/2024 at 9:55 AM showed Staff E, Licensed Practical Nurse (LPN), provided care and treatment to Resident 72's sacral pressure wound (lower back and buttocks) area. The resident was initially positioned flat on their back and then turned onto their right side for the LN to provide the needed wound care. The resident's tube feed was off temporarily during the wound care (approximately 10-15 minutes). Staff E stated the TF was turned off during the wound care because the resident was positioned onto their back and was required to prevent aspiration (breathing in liquid) of the TF. Interview at 10:59 AM, Staff E was asked where the TF total was being documented in the EHR. Staff E stated they did not see where they were to document in the resident's MAR, but it should have been totaled every shift and documented. Review of Resident 72's EHR showed a decline in their weights for the past several weeks as follows: 10/14/2024 - 165 pounds (lbs.), 10/25/2024 - 160 lbs. and 10/31/2024 - 158.2 lbs. During an interview on 10/30/2024 at 11:01 AM, Staff C, LPN/Unit Care Coordinator (UCC), stated it was their expectation Resident 72's enteral tube feed was to be totaled up every shift and documented in the MAR by the LNs to ensure the resident received their enteral tube feeds as ordered. Review of a document titled, Nutrition: Assessment /Nutritional Data Collection, dated 10/20/2024, for Resident 72 showed a registered dietitian (RD) had recommended a change to the resident's initial TF order to increase the TF to 60 ml per hour for 20 hours to equal 1200 ml total to infuse and to turn on the TF at 2:00 PM and off at 10:00 AM. During an interview on 10/30/2024 at 12:22 PM, Staff F, RD, stated they did not want Resident 72 to be on continuous TF for 24 hours, so they recommended to the UCC on 10/20/2024 to change the resident's TF order as indicated during their last evaluation on 10/20/2024. The TF recommendation was sent via email to the facility staff to change. Staff F stated the LN were to document the TF total every shift to ensure that the resident received their required nutritional intake. During an interview on 10/30/2024 at 12:55 PM, Staff B, Director of Nursing Services, stated it was their expectation that the RD's recommendation was to occur within 72 hours and that the LNs were to total up the resident's TF every shift. Reference WAC 388-97-1060 (3)(f)

Based on observation, interview, and record review, the facility failed to ensure the minimum data set assessment (MDS), an assessment tool, accurately reflected resident status for 1 of 20 sampled residents (Resident 226) reviewed for accuracy of assessments. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the electronic health record (EHR) showed Resident 226 admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD, lung disease that causes restricted airflow and breathing problems) and chronic (long lasting) respiratory failure with hypoxia (low levels of oxygen [O2] in the blood). Resident 226 was able to make needs known. Review of the admission MDS, dated [DATE], showed Resident 226 was not receiving O2 while a resident. Observation on 10/28/2024 at 9:40 AM showed Resident 226 laid in bed receiving O2 set to two liters per minute via nasal cannula (devise to deliver O2 through a tube into the nose). Observation and interview on 10/29/2024 at 10:48 AM showed Resident 226 receiving O2 set to two liters per minute via nasal cannula. Resident 226 stated that they had received O2 continuously at two liters through the nose via the tube since they had admitted to the facility. Review of Resident 226's EHR showed documented respiratory symptoms screening tools dated 10/17/2024, 10/18/2024, 10/19/2024, 10/21/2024, 10/22/2024, 10/24/2024, 10/25/2024, 10/26/2024, 10/27/2024, and 10/28/2024 which showed the resident received O2 via nasal cannula. During an interview on 10/29/2024 at 5:16 PM, Staff H, Licensed Practical Nurse/MDS Nurse, stated Resident 226's admission MDS, dated [DATE], was coded in error for oxygen therapy and needed to be modified. During an interview on 10/30/2024 at 3:02 PM, Staff B, Director of Nursing Services, stated Resident 226's MDS dated [DATE] was coded inaccurately and should have been coded yes for O2 therapy while a resident and needed to be modified. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to provide information on formulating an advanced directive for 1 of 3 sampled residents (Resident 36) when reviewed for advanced directives. This failure placed residents at risk of not having an established decision maker, lacking input into care, and a diminished quality of life. Findings included . Review of the electronic health record showed Resident 36 admitted to the facility on [DATE]. Review of progress notes showed the social services department called Resident 36's representative on 09/19/2024 to schedule a care conference, which was held on 09/23/2024 (20 days after admitting to the facility). Review of the Social Service Assessment, dated 09/04/2024, showed the advanced directive area left blank. Review of the care plan, dated 09/03/2024, showed no information regarding Resident 36's advanced directive status. During an interview on 10/29/2024 at 1:46 PM, Staff P, Social Service Director, stated Resident 36 was provided information regarding formulating an advanced directive on 09/19/2024 (13 days after admitting to the facility) and this did not meet their expectation. During an interview on 10/29/2024 at 3:43 PM, Staff A, Administrator, stated residents should be asked about their advanced directive status within 48 hours of admission to the facility and provided information on formulating an advanced directive if they did not have one. Staff A stated Resident 36's delay in addressing an advanced directive did not meet expectation. Reference WAC 388-97-0280 (3)(c)(i-ii), -0300 (1)(b), (3)(a-c)