Every finding on record at Madison Post Acute

Based on interview, and record review the facility failed to protect residents right to be free from sexual abuse for 1 of 2 sampled residents (Resident 1) reviewed for resident-to-resident allegation of sexual abuse. This failure placed Resident 1 at risk for potential sexual, physical or mental abuse, feeling safe, experiencing fear, and a decreased quality of life. Findings included.Review of the facility policy Abuse, Neglect and Exploitation undated, documented the definition of sexual abuse is non-consensual sexual contact of any type with a resident.VI. Protection of Resident-The facility will make efforts to ensure all residents are protected from physical and psychosocial harm as well as additional harm during and after the investigation.VII. Reporting/ResponseReporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes.Review of the Nursing Home Guidelines the purple book, dated October 2015, Appendix A, Definition Diagram-Abuse, Sexual abuse means any form of nonconsensual contact.Appendix D, Reporting Guidelines for Nursing Homes-Resident to Resident sexual abuse/assault;DSHS HotlineDSHS Log Within 5 daysPolice or 9-1-1. <RESIDENT TO RESIDENT SEXUAL ABUSE>RESIDENT 1Resident 1 admitted to the facility on [DATE] with diagnoses to include Alzheimer's, Dementia, and hemiplegia to right side (total or partial paralysis of one side of the body). Review of an admission Minimum Data Set (MDS - an assessment tool) assessment, dated 06/05/2026, documented the resident had severe cognitive impairment. Resident 1 required staff assistance for activities of daily living including wheelchair mobility and eating.Review of the facilities Reporting Log dated August 2026 did not show documentation of the incident for Resident 1.Review of Resident 1's electronic medical record (EMR) did not show documentation of the facility offering to send the resident to the hospital for further evaluation.In an interview on 08/20/2026 at 2:05 PM, Staff B, Licensed Practical Nurse (LPN), stated they were told that Resident 2 had been observed with their hand in Resident 1's pants. Staff B stated they contacted Resident 1's Power of Attorney (POA) about the incident and did not contact Law Enforcement. In an interview on 08/20/2026 at 2:14 PM, Staff C, Nursing Assistant Certified, stated they observed Resident 1 and Resident 2 in the dining room and Resident 2 had their hand in Resident 1's pants, Resident 2's hand was not visible. RESIDENT 2Resident 2 admitted to the facility on [DATE] with diagnoses including mild cognitive impairment, cognitive communication deficit, and depression. Review of a quarterly MDS, dated [DATE], documented the resident had moderate cognitive impairment. Resident 2 was independent with wheelchair mobility.Review of the facilities Reporting Log dated August 2026 did not show documentation of the incident for Resident 2.In an interview on 08/20/2026 at 12:13 PM, Resident 2 stated no when asked if they had an incident with another resident and stated no when asked if they had concerns with any residents in the facility. RESIDENT TO RESIDENT INCIDENT INVESTIGATIONReview of a facility incident investigation dated 08/09/2026 documented a sexual interaction was observed between Resident 1 and Resident 2. Resident 1 and Resident 2 were sitting side by side in the dining room watching TV and Resident 2 was observed with their hand in Resident 1's pants. Residents 1 and 2 were separated.The investigation documented acknowledgement that the incident occurred, Resident 1 cannot consent to any sexual conduct, and due to both parties being cognitively challenged the facility cannot rule out abuse, however, there is no evidence to suggest that there was intent to harm or that there was any premeditated plan for inappropriate touching. Documentation showed per staff witness Resident 1 did not appear aware or in any distress or in any way opposed to any touching by Resident 2. The investigation did not document Resident 1 being offered to go to the hospital for further evaluation and did not document law enforcement notification.In an interview and record review on 08/20/2026 at 2:32 PM, Staff A, Registered Nurse, Director of Nursing, stated neither Resident 1 nor Resident 2 were able to consent to sexual interaction related to cognitive impairment. Staff A was asked about Resident 2's cognition and stated the resident had cognitive impairment with short term memory and has been having a cognitive decline. Staff A was asked if the facility offered to send Resident 1 to the hospital for further evaluation and if there was documentation. Staff A stated Resident 1's POA was contacted and declined to send the resident to the hospital but did not see documentation. Staff A stated law enforcement was not contacted because neither resident was cognitively intact or aware and because they were not cognitively aware they were worried about the residents wellbeing and wanted to prevent further trauma. Staff A reviewed the August 2026 reporting log and acknowledged that the incident was not documented. Reference WAC 388-97-0640(1)

Based on interview, observation and record review the facility failed to periodically inform the residents of their rights after the resident was admitted to the facility. This failure had the potential to diminish the residents' quality of life.Findings included .According to the facility policy titled Resident Rights, dated 2025, documented, the resident has the right to be informed of his or her rights and of rules and regulations governing resident conduct and responsibilities during his or her stay in the facility.In the Resident Council interview on 06/22/2026 at 12:45 PM the residents in attendance (11, 14, 15, 58 and 63) were asked if the staff talked about and reviewed the rights of the residents. Resident 58 stated staff had not talked to them about resident's rights. Resident 63 stated they remembered reading resident rights in their admission packet but that was four years ago. The rest of the residents stated no.Review of Resident Council minutes from April to May 2026 did not show documented evidence that residents' rights were reviewed.In an observation on 06/23/2026 at 8:30 AM, there were no postings about resident's rights in the facility.In an interview on 06/24/2026 at 10:45 AM, Staff M, Activities Director, stated that they had been the Activities Director for a year. Staff M stated they had never discussed resident's rights in their resident council meetings in the last year. When asked why there were no postings of residents' rights in the facility, Staff M later stated they used to be posted in the dining room but was taken off when they did some construction work.In an interview on 06/26/2026 at 11:47 AM, Staff A, Administrator stated that they provide resident rights on admission and were supposed go over them during resident council meetings. Staff A added that they used to have residents' rights posted in the dining room but was taken down during construction and staff did not put it back. No WAC reference.

Based on observation, interview and record review, the facility failed to ensure dining rooms included enough space for residents to dine, and for residents to enter and exit a dining room without having to move other residents in 1 of 1 dining rooms. This failure created risk for the inability of staff to respond quickly in an emergency situation, and risk for decreased quality of life for residents unable to dine with their peers. Findings included .In an observation on 06/22/2026 at 8:18 AM, the facility was observed to have one room designated for dining. The room included one refrigerator and one section of upper and lower cabinets. There was one table in the back left corner facing a wall with one resident sitting facing the wall. There were three other square tables in the room. A total of seven residents were in the room for breakfast. All seven residents were in wheelchairs. One resident wheelchair blocked the doorway, and there was no space to walk between the two center tables without moving residents. There was visible table space at tables for 10 residents. The posted facility census on 06/22/2026 was 53 residents. In an observation and interview in the facility dining room on 06/25/2026 at 11:37 AM, residents were beginning to arrive for lunch and Resident 61 stated the dining room got really crowded especially with wheelchairs. Resident 61 stated sometimes there were 10 residents in there and they would run out of room, so if you weren't there early then you just had to eat in your room. Resident 70 was observed to self-propel into the room and over to the corner table that faced the wall. Resident 70 stated they were not crazy about facing the wall but liked to sit alone. Resident 70 stated the problem was that when they were done eating, they had to wait to leave because they couldn't get out past the other resident's wheelchairs blocking the way and stated they wanted there to be a pathway that stayed open. In an observation and interview on 06/25/2026 at 11:48 AM, Staff L, Maintenance Director, was observed measuring rooms, and stated the dining room measured 24 feet by 14 feet. Staff L stated there were usually about eight residents in the dining room. Staff L stated if all 50 (or so) residents wanted to eat in there, that would be an issue. In an interview on 06/25/2026 at 1:54 PM, Staff A, Administrator, stated the prior larger dining room had been converted to the therapy gym and was aware of the small size of the current resident dining room. Staff A stated there was not enough space in the current dining room for more than about 10 residents and stated the facility needed to make a plan for more dining space. Reference WAC 388-97-2760(1)

Based on interview and record review, the facility failed to obtain a psychotropic medication consent for 4 of 6 residents (Residents 3, 16, 72, and 77) reviewed for psychotropic medications (medication that affects the mind, altering mood, thoughts, perceptions, or behavior). This failure placed residents at risk of receiving medications without being informed of the possible risks, or side effects, and a decreased quality of life.Findings included .According to the facility policy titled, Use of Psychotropic Medication(s), dated 2025, the facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care and the resident had the right to accept or decline treatment. RESIDENT 72> Resident 72 was admitted to the facility on [DATE] with diagnosis to include depression. Review of Resident 72's provider's order documented Mirtazapine (an antidepressant) for depression, dated 06/14/2026. Review Resident 72's Medication Administration Record (MAR) for June 2026 documented Mirtazapine was given daily since 06/14/2026. Review of Resident 72's progress note did not document any discussion with resident about starting Mirtazapine. Review of psychotropic medication consents in Resident 72's electronic chart did not show a consent for the Mirtazapine. In an interview on 06/26/2026 at 10:06 AM, Staff I, Resident Care Manager (RCM), stated prior to administering psychotropic medications the licensed nurse was required to obtain consent from the resident or the resident's representative. Staff I could not provide the consent for Resident 72's Mirtazapine medication. Staff I stated they had a new provider for behavioral health and they had placed an order for the Mirtazapine and failed to notify the nursing staff of the new order. <RESIDENT 3> Resident 3 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder (mental health condition characterized by significant mood swings) and depression. Review of Resident 3's provider orders documented lamotrigine (mood stabilizing medication) was ordered for bipolar disorder twice daily on 05/12/2026. Review of Resident 3's MAR dated May 2026 and June 2026, documented they received lamotrigine twice daily. Review of Resident 3's Electronic Medical Record (EMR) showed no consent had been completed for the use of lamotrigine. <RESIDENT 16> Resident 16 was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, anxiety disorder, and bipolar disorder. Review of Resident 16's provider's orders documented olanzapine (antipsychotic medication used to manage psychosis, which includes hallucinations, delusions, paranoia, and disordered thinking) was ordered for depression and bipolar disorder twice daily on 04/02/2026. Review of Resident 16's MAR's dated April 2026, May 2026 and June 2026 documented they received olanzapine twice daily. Review of Resident 16's EMR showed no consent had been completed for the use of olanzapine. <RESIDENT 77> Resident 77 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder, and panic disorder. Review of Resident 77's provider's orders documented lamotrigine was ordered for bipolar disorder twice daily on 05/18/2026. Review of Resident 77's MAR's dated May 2026 and June 2026 documented they received lamotrigine twice daily. Review of Resident 77's EMR showed no consent had been completed for the use of lamotrigine. In an interview on 06/26/2026 at 8:43 AM, Staff G, Licensed Practical Nurse, stated they did not obtain psychotropic medication consents, and the facility Resident Care Managers obtained consents for psychotropic medications. In a joint interview on 06/26/2026 at 9:54 AM, Staff H, RCM and Staff I, stated they were responsible for reviewing risks and benefits of the psychotropic medications with the resident or the resident's responsible party and have a consent signed before the medication was given. Staff H and Staff I confirmed Residents 3, 16, and 72 did not have psychotropic medication consents completed. In an interview on 06/26/2026 at 11:00 AM, Staff B, Director of Nursing Services, stated their expectation was a psychotropic medication consent was completed before psychotropic medications were administered. Refer to WAC 388-97-0260

Based on interview and record review, the facility failed to ensure resident MDS (Minimum Data Set, a required assessment tool) assessments were transmitted as required and within the required timeframes for 3 of 5 residents (Residents 4, 14 and 50) reviewed. This failure had the potential to affect facility CMI (Case Mix Index) and facility payments. Findings included . According to the Resident Assessment Instrument (RAI) Manual, Chapter 2, MDS Discharge Assessments must be electronically transmitted within 14 days of the event that triggered the form. Quarterly MDS Assessments must be electronically transmitted within 14 calendar days of the completion date. <Resident 4> Review of Resident 4's MDS assessment records documented their Discharge MDS dated [DATE] was created and assessment data was collected. The MDS remained in completed status and had not been transmitted within 14 days. <Resident 14> Review of Resident 14's MDS assessment records documented a Quarterly MDS assessment had been created and showed a status of accepted dated 05/13/2026 in the facility system, however the MDS reference date was not until 05/15/2026. The assessment was not included in the validation report of transmitted assessments for the time period. <Resident 50> Review of Resident 50's MDS assessment records documented their Discharge MDS dated [DATE] was created and assessment data was collected. The MDS remained in completed status and had not been transmitted within 14 days. In an interview on 06/23/2026 at 12:35 PM, Staff J, Registered Nurse, MDS Nurse, stated they completed the MDS assessments but were not doing the transmissions. Staff J stated all discharges were supposed to be transmitted. Staff J reviewed Resident 14's quarterly MDS data and stated that the dates made no sense. Staff J confirmed Resident 4 and 50's Discharge Assessments and Resident 14's quarterly MDS had not been transmitted within 14 days as required. In an interview on 06/23/2026 at 12:58 PM, Staff B, Director of Nursing (DNS) stated they used a 3rd party software system for transmission, and they had not been able to view the information and transmissions. Staff B stated the system should not have marked an assessment as accepted if it was not in a transmission batch and the validation reports should have been reviewed to ensure all assessments had been transmitted and accepted. Reference WAC 388-97-1000 (5)(e)(ii,iii)

Based on observation, interview and record review, the facility failed to ensure Minimum Date Set (MDS-an assessment tool) were accurate for 3 of 15 residents (Residents 34, 56 and 72) reviewed for resident assessment. The failure to accurately complete MDS assessments resulted in lack of triggering and completion of Care Area Assessments (CAA -triggered by MDS responses which indicates additional assessments for specific care areas), lack of comprehensive care plan development, inaccurate facility payment, and diminished quality of life. Findings included . <RESIDENT 72> Resident 72 was admitted to the facility on [DATE] with diagnosis to include rheumatoid arthritis (chronic autoimmune disease where the immune system mistakenly attacks the lining of the joints), depression and metabolic encephalopathy (a problem in the brain that is caused by a chemical imbalance in the blood). <VISION> Review of Resident 72's admission MDS assessment dated [DATE] under section B for vision, documented that the resident's vision was adequate with no glasses. In an interview on 06/24/2026 at 2:38 PM, Resident 72 stated they could not see things up close and they used eyeglasses to help them read. Review of Resident 72's care plan documented that resident had impaired visual function due to advanced age. The care plan intervention initiated on 05/07/2026 documented the resident wore glasses and requested assist with glasses. <PAIN> Review of Resident 72's MDS section J for pain documented that non-medication interventions were provided. Review of Resident 72's June 2026 Medication Administration Record (MAR) and progress notes (print date) 06/23/2026, reviewed there was no documentation that non-medication interventions were provided for the resident prior to giving pain medication. Review of Resident 72's care plan did not show any documentation of non-medication interventions for pain. Review of Resident 72's CAA for pain and the characteristics of the pain, frequency and intensity of pain, non-verbal indicators of pain were all blank. There was no resident/representative input regarding pain. <ANTIPSYCHOTIC MEDICATION> Review of Resident 72's MDS section N documented that the resident received antipsychotic (medication that alters brain chemistry to reduce symptoms such as hallucinations, delusions or disordered thinking) medication but under section N it was marked that resident did not receive any antipsychotic medications. Review of Resident 72's CAA for psychotropic (medication that alters brain function, affecting a person's mood, thoughts, feelings or behaviors) drug use, revealed there was no documentation on any specific behaviors the resident exhibited or any specific adverse side effects. There was no input from the resident or their representative regarding psychotropic drug use. Review of Resident 72's care plan had no documentation regarding psychotropic drug use. In an interview on 06/25/2026 at 2:06 PM, Staff J, Registered Nurse, MDS Nurse stated their process for gathering information for the MDS was interviewing the resident and reviewing notes in the resident's chart. Staff J stated the Resident Care Managers (RCM) were the ones that did initial pain assessment and they reviewed the notes the RCM documented to code for the pain section of the MDS. When asked their process in filling out the CAA, Staff J stated that they were supposed to answer the questions on the CAA's that got triggered but had not been answering them prior to this month. Staff J looked at Resident 72's MDS, under vision, it documented that resident's vision was adequate, but care plan showed Resident 72 had impaired vision. Staff J was unable to answer why the care plan and MDS contradicted. Staff J was not able to provide evidence the resident had adequate vision. For non-medication intervention, Staff J stated they were unable to find evidence that staff provided non-medication intervention to the resident. Regarding psychotropic medication, Staff J stated they made a mistake in answering the question and they should have marked yes since the resident received antipsychotic medications. Staff J was unable to explain why the CAA's for pain and psychotropic sections were not answered for Resident 72. Staff J stated it's mostly the RCMs that updated the care plan. Staff J was unable to explain why psychotropic drug use was not in Resident 72's care plan. Staff J stated they would be updating the MDS for Resident 72. <RESIDENT 56> Resident 56 admitted [DATE]. Review of the Nursing admission assessment dated [DATE] documented the resident had missing and broken teeth. A baseline care plan was initiated related to oral/dental problems. In an observation and interview on 06/23/2026 at 9:24 AM, Resident 56 stated their teeth were terrible. Resident 56 opened their mouth and pointed to their lower jaw with visible tooth fragments and missing teeth. Resident 56 said their teeth had been in bad shape for a long time and said they had been seen by someone here at the facility who told them they needed them all pulled. Resident 56 stated they had to avoid certain foods and if they bit down wrong they sometimes got a sharp shooting pain. Resident 56 had not been told about any further follow up. Review of the admission MDS dated [DATE] documented no for abnormal mouth tissue, obvious or likely cavity or broken natural teeth, inflamed or bleeding gum tissue. As a result of the negative MDS responses, no CAA for Dental was triggered or completed, and the comprehensive care plan was not revised. In an interview on 06/25/2026 at 11:25 AM, Staff J stated they were doing their own physical assessments of residents, observed their mouth and interviewed the residents when doing the MDS and stated they must have missed Resident 56's mouth issues, and should complete correction. Staff J stated they did review the other nursing assessments but completed their own assessments as well. Staff J stated they did the Care Area Assessments that triggered but the Resident Care Managers did the care plans. <RESIDENT 34> Resident 34 was readmitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD-a progressive lung disease which blocks airflow and makes breathing difficult). Review of the admission MDS assessment dated [DATE], coded Resident 34 as having COPD with shortness of breath or trouble breathing when lying flat. This assessment coding placed the resident into a special high nursing category, which resulted in a higher reimbursement rate. Review of Resident 34's Electronic Health Record (EHR), showed no clinical documentation supporting the coding the resident experienced shortness of breath or trouble breathing when lying flat during the assessment coding window. In an interview on 06/24/2026 at 12:15 PM, Staff J stated there should be supporting clinical documentation to code the resident as having shortness of breath or trouble breathing when lying flat. Staff B confirmed they could not find any such documentation to validate the assessment coding. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- assessment/a federal requirement for Medicaid-certified nursing facilities to ensure individuals, especially those with mental illness, seeking admission are appropriately placed and receive necessary services) level I were referred for a PASRR level II and followed up on for 6 of 7 residents (Residents 2, 3, 30, 56, 72, and 77) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life. Findings included .<RESIDENT 56> Resident 56 admitted on [DATE] with diagnoses which included substance abuse, mood and anxiety disorders. Review of Resident 56's level I PASSR dated [DATE], identified mood disorder, anxiety disorder and substance abuse disorder and identified a level II evaluation was required. A Notice of Determination was noted in the record dated [DATE], which identified that Resident 56 had been in the skilled nursing facility for greater than 30 days and required level II evaluation. Review of Resident 56's medical record revealed no level II evaluation had been completed since their admission. In an interview on [DATE] at 10:25 AM, Staff C, Social Services Director, stated Resident 56 required a level II PASSR evaluation and stated they received the Notice of Determination but nothing else at this time. Staff C confirmed no level II had been completed for Resident 56 and had no evidence of communication or attempts to follow up with the PASSR coordinator regarding Resident 56. <RESIDENT 72> Resident 72 was admitted to the facility on [DATE] with diagnosis to include depression and metabolic encephalopathy (a problem in the brain that is caused by a chemical imbalance in the blood). Review of Resident 72's PASRR documented the resident met the criteria of 30-day exemption. However, the date of the PASRR was [DATE] which expired prior to the resident's admission to the facility. Review of Resident 72's electronic chart did not have any other PASRR on file. In an interview on [DATE] at 11:42 AM, Staff S, admission Marketing Director, stated that they reviewed the PASRR prior to accepting the resident to their facility. They reviewed the accuracy of the PASRR. If they had a 30-day exemption Staff S notified the Social Worker to follow up. If they were not exempted, then they needed the notice of determination prior to accepting residents to their facility. Staff S reviewed Resident 72's PASRR and stated they missed the date. <RESIDENT 30> Resident 30 readmitted to the facility on [DATE] with diagnoses to include bipolar disorder (a mental health condition that caused extreme shifts in mood, energy, activity levels, and concentration). Review of Resident 30's updated Level I PASRR, dated [DATE], showed Resident 30 had indicators of a Serious Mental Illness and a level II evaluation was required. Review of Resident 30's Electronic Health Record (EHR) showed no Level II PASRR was completed prior to the resident being admitted in the facility. In an interview on [DATE] at 2:50 PM, Staff C confirmed Resident 30 required a Level II PASRR but there was not one in their EHR. In an interview on [DATE] at 11:13 AM, Staff A, Administrator, stated the expectation was to obtain Level II required PASRR prior to admission. <RESIDENT 2> Resident 2 was admitted to the facility on [DATE] with diagnoses to include major depressive disorder, and generalized anxiety disorder. Review of Resident 2's PASRR level I, dated [DATE], documented the PASRR level II was not indicated due to 30 days hospital exemption and a PASRR level II must be completed if a scheduled discharge in 30 days did not occur. Review of Resident 2's progress note dated [DATE] at 8:55 AM, Staff C documented they faxed the PASRR level I to the PASRR level II evaluator. <RESIDENT 3> Resident 3 was admitted to the facility on [DATE] with diagnoses to include bipolar and depression. Review of Resident 3's PASRR level I, dated [DATE], documented a PASRR level II evaluation referral was required. Review of Resident 3's EHR showed the PASRR level I was faxed to the PASRR level II evaluator on [DATE]. Review of Resident 3's progress notes dated [DATE] through [DATE] showed no documentation related to PASRR level II follow up. <RESIDENT 77> Resident 77 was admitted to the facility on [DATE] with diagnoses to include bipolar disorder, and panic disorder. Review of Resident 77's PASRR level I, dated [DATE], documented the PASRR level II was not indicated due to hospital exemption and a PASRR level II must be completed if a scheduled discharge in 30 days does not occur. Review of Resident 77's progress note dated [DATE] at 9:03 AM, Staff C documented they faxed the PASRR level I to the PASRR level II evaluator. In an interview on [DATE] at 10:27 AM, Staff C stated they did not have a system in place to track residents who need PASRR follow up for PASRR level II evaluations or to track when residents were approaching 30 days in the facility if previously exempted. Staff C stated they had not followed up with the PASRR level II evaluator for Residents 2, 3, and 77 within 30 days if previously exempted or every 30 days if awaiting a PASRR level II evaluation. In an interview on [DATE] at 11:00 AM, Staff B, Director of Nursing Services, stated their expectation was PASRRs were followed up on. Reference WAC 388-97-1915 (1)(2)

Based on observation, interview and record review, the facility failed to ensure development and implementation of comprehensive care plans for 7 of 14 residents (Residents 2, 11, 30, 34, 53, 72 and 77) reviewed for comprehensive care plans. These failures placed residents at risk for unmet care needs, inadequate pain interventions, unnecessary medications, skin issues, accidents, and decreased quality of life. Findings included .According to the facility policy titled Comprehensive Care Plans, dated 2025, documented the comprehensive care plan would describe at a minimum, the following: the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. <ELOPEMENT RISK> <RESIDENT 11> Resident 11 was admitted to the facility on [DATE] with diagnosis to include dementia. Review of the elopement binder at the front desk on 06/23/2026, showed Resident 11 as one of the residents who were at high risk to elope. Review of Resident 11's elopement risk assessment dated [DATE] showed a score of 17 which meant a high risk for elopement. Review of Resident 11's care plan did not document the resident's risk for elopement. In an interview on 06/24/2026 at 2:42 PM, Staff W, Nursing Assistant Certified (NAC) stated that they looked at the resident's care plan and Kardex (quick summary of resident's medical history and daily care plan) if they wanted to know how to care for a resident. In an interview on 06/24/2026 at 2:46 PM, Staff X, Licensed Practical Nurse (LPN) stated that a resident was at risk for elopement if they tried to get out of the facility. They added that there was an elopement binder in the nurse's station that lists residents who were at high risk for elopement. Staff X stated that Resident 11 was on the list because they kept saying they wanted to go home. In a joint interview on 06/26/2026 at 10:10 AM, Staff I, Resident Care Manager (RCM) and Staff H, RCM, Staff I stated they assessed residents on admission to determine if the resident was at risk for elopement. Then they put the resident's name and other information in the elopement binder. Then updated the care plan and include elopement risk. Staff I stated that Resident 11 scored high on admission that's why they added them in the elopement binder, but had not had an actual elopement. They did not know why elopement risk was not in the resident's care plan. <PSYCHOTROPIC MEDICATIONS> <RESIDENT 72> Resident 72 was admitted to the facility on [DATE] with diagnosis to include depression and metabolic encephalopathy (a problem in the brain that is caused by a chemical imbalance in the blood). According to the admission MDS dated [DATE], the resident had a moderate cognitive impairment and received antipsychotic (medication that alters brain chemistry to reduce symptoms such as hallucinations, delusions or disordered thinking) and antidepressant medications. Review of Resident 72's physician's order dated 05/07/2026 documented an antipsychotic medication and antidepressant medication were ordered. Review of Resident 72's MAR for May and June of 2026 documented the resident received antipsychotic and antidepressant medications daily. Review of Resident 72's care plan did not show any documentation about resident's antipsychotic and antidepressant medications. There was no documentation of behaviors or monitoring for any adverse side effects. In a joint interview on 06/26/2026 at 10:06 AM, Staff H and Staff I, Staff H stated they included psychotropic (any medication that altered the brain function, affecting a person's mood, thoughts, feelings or behaviors) medications in the care plan for residents receiving psychotropic medications. They included resident's behaviors and listed possible side effects of psychotropic medication. They tried to make the behaviors resident specific. Staff H was unsure why Resident 72 did not have psychotropic medications in their care plan. In an interview on 06/26/2026 at 11:35 AM, Staff B, Director of Nursing Services, stated their expectation when it came to developing a comprehensive care plan was to have it completed before day 21, it had to be accurate and all the information about the resident had to be in the care plan to include elopement risk, non-pharmacological interventions for pain and psychotropic medications. Staff B added that they tried to review care plans during their interdisciplinary Meetings, but it had not been working effectively lately. <PAIN MANAGEMENT> <RESIDENT 72> Resident 72 was admitted to the facility on [DATE] with diagnosis to include rheumatoid arthritis (chronic autoimmune disease where the immune system mistakenly attacks the lining of the joints). According to the admission Minimum Data Set (MDS – an assessment tool) assessment, dated 05/12/2026, resident received scheduled and as needed pain medications and had frequent pain. Review of Resident 72's physician's order dated 05/07/2026, documented a narcotic pain medicine every 6 hours as needed for pain. Review of Resident 72's Medication Administration Record (MAR) for May and June 2026 documented the resident received the pain medication on average two to three times daily. Review of Resident 72's May and June 2026 MAR and Treatment Administration Record (TAR) did not show any non-pharmacological interventions for pain. Review of Resident 72's care plan with a print date of 06/23/2026 showed no documentation of non-pharmacological interventions for pain. <RESIDENT 2> Resident 2 was admitted to the facility on [DATE] with diagnoses to include polyneuropathy, low back pain, and partial amputation of right foot. Review of Resident 2's admission MDS dated [DATE] documented they had moderate pain, chronic low back pain, and neuropathy (nerve pain). Review of Resident 2's pain care plan documented pain related to amputation of 4th and 5th toes of the right foot. The care plan did not address Resident 2's chronic back pain, or neuropathy. Resident 2's care plan was incomplete and did not have specific goals or interventions to address their comprehensive pain management based on their comprehensive assessment. The care plan did not include non-pharmacological interventions for pain management. Review of Resident 2's pain assessment dated [DATE] documented they had frequent moderate pain daily. The pain assessment was not thorough and complete and did not document non-pharmacological interventions for pain management. Review of Resident 2's MAR and TAR dated April 2026, May 2026 and June 2026 did not include non-pharmacological interventions for pain management. <RESIDENT 77> Resident 77 was admitted to the facility on [DATE], readmitted on [DATE] with diagnoses to include osteoarthritis. Review of Resident 77's pain care plan documented unspecified pain, the pain characteristics, or the location the resident experienced pain. The care plan did not include non-pharmacological interventions for pain management. Review of Resident 77's pain assessment, dated 04/10/2026, documented they reported frequent pain, interventions were documented as distraction and repositioning. The pain assessment documented interventions of distraction and repositioning and did not document the effectiveness of those interventions. Review of Resident 77's pain assessment, dated 05/18/2026, documented they reported frequent pain. The pain assessment did not have documentation related to non-pharmacological interventions. Review of Resident 77's MAR and TAR, dated June 2026, did not include non-pharmacological interventions for pain management. In an interview on 06/26/2026 at 8:46 AM, Staff G, LPN, stated there were non-pharmacological interventions for pain for any resident who received pain medication. Staff G stated they documented the non-pharmacological interventions on the MAR or TAR. Staff G confirmed Resident 2 , 72 and 77 did not have non-pharmacological interventions on their MAR's or TAR's. In an interview on 06/26/2026 at 9:54 AM, Staff I stated all residents who received pain medications should have non-pharmacological interventions to document before administration of pain medications. Staff I stated the non-pharmacological interventions were the same for all residents. Staff I confirmed Resident 2, 72 and 77 did not have non-pharmacological interventions in their care plan or on their MAR's or TAR's. In an interview on 06/26/2026 at 11:00 AM, Staff B stated their expectation was non-pharmacological interventions would be appropriately documented and attempted before using medications. <RESTORATIVE> <RESIDENT 30> Resident 30 was readmitted to the facility on [DATE]. Review of the facility Restorative Program Binder showed Resident 30 had nursing restorative programs for bilateral upper and lower extremities. Review of Resident 30's Medical Record on 06/23/2026, there was no documentation regarding restorative programs. Review of Resident 30's current care plan, revealed no corresponding focus area, goals or interventions about restorative programs. <RESIDENT 53> Resident 53 was readmitted to the facility on [DATE]. Review of the facility Restorative Program Binder showed Resident 53 had nursing restorative programs for bilateral upper and lower extremities. Review of Resident 53's medical record on 06/23/2026, showed there was no documentation regarding restorative programs. Review of Resident 53's current care plan, revealed no corresponding focus area, goals or interventions about restorative programs. In an interview on 06/23/2026 at 1:54 PM, Staff Y, Director of Rehab, stated Resident 30 and 53 had recommended restorative programs upon discharge from active therapies. In an interview on 06/23/2026 At 2:21PM, Staff Z, NAC, stated they were actively performing Resident 30 and 53's restorative programs but were documenting on papers logs. In an interview on 06/24/2026 at 2:18 PM, Staff B, stated the care plan was supposed to be updated to include the resident's restorative programs. <SKIN CONDITION> <RESIDENT 53> Resident 53 was readmitted to the facility on [DATE]. According to the quarterly MDS assessment, dated 06/05/2026, the resident had an unhealed pressure ulcer. Review of Resident 53's June 2026 MAR, documented the resident had an active pressure ulcer and was receiving wound treatment. Review of Resident 53's current care plan on 06/23/2026, revealed no focus area, goals, or interventions regarding pressure ulcer care. <RESIDENT 34> Resident 34 was readmitted to the facility on [DATE]. In an observation on 06/22/2026 at 9:15 AM, Resident 34 was observed wearing an offloading heel boot on the left heel. Review of Resident 34's June 2026 MAR, documented the resident had a left heel pressure ulcer with treatment. Review of a wound consultation progress note dated 06/17/2026, documented a clinical recommendation to offload the left heel using a sage or moon boot. Review of Resident 34's current care plan on 06/23/2026, revealed no interventions regarding heel offloading or application of a specialized boot. In an interview on 06/24/2026 at 1:47 PM, Staff H and Staff I, stated for resident 34, the care plan should include the offloading boot intervention but confirmed it had not been updated. Staff H and Staff I stated Resident 53 had a pressure ulcer and the care plan should have included pressure ulcer interventions. Reference WAC 388-97-1020(1)

Based on interview and record review, the facility failed to ensure there was eight consecutive hours of Registered Nurse (RN) coverage each day. Failure to have adequate RN coverage placed residents at risk for inadequate assessment of medical conditions which could cause their health to decline. Review of the 30-day staffing pattern form, dated 05/23/2026 - 06/22/2206, documented six of the 31 days did not have eight consecutive hours of RN coverage.During an interview on 06/25/2026 10:06 AM, Staff B, Director of Nursing services, stated they were aware that they did not meet the requirement for RN coverage as they did not have enough RNs on staff. Refer to WAC 388-97-1080 (8)

Based on observation and interview, the facility failed to ensure dietary staff were following USDA Food Code requirements for hair restraints in 1 of 1 facility kitchens. Failure of staff with facial hair to wear beard restraints created the potential for physical and biological contamination of facility food. Findings included .In an observation through the kitchen door on 06/22/2026 at 8:00 AM, one cook and two other kitchen staff were observed in the food area plating breakfast items. Both the cook and one of the two dietary staff were observed with beards and neither were wearing beard coverings. In an observation and interview on 06/24/2026 at 11:52 AM, Staff K, Dietary Manager, and Staff O, Dietary Aid were observed with facial hair and without beard coverings in the food service areas. Staff O stated they believed they were not required to wear beard restraints because their facial hair was not over an inch long. Staff O further stated they did not have a supply of beard restraints due to the belief they were not required. Staff O stated they would have to order beard coverings. In an interview on 06/25/2026 at 1:49 PM, Staff A, Administrator stated any kitchen staff with facial hair needed to wear a beard cover and stated they had provided reminders recently about this. Staff A was not aware that beard restraints had not been ordered or available in the kitchen due to misinformation about their requirement. This is a repeat deficiency from SOD dated 07/21/2025. Reference WAC 388-97-1100 (3)

Based on observation, interview and record review, the facility failed to ensure that Enhanced Barrier Precautions (EBP -infection control intervention designed to reduce transmission of multidrug-resistant organisms requiring staff to wear gowns and gloves during high-contact resident care activities) were observed for 2 of 3 residents (Resident 6 and 76) sampled for medication administration and 1 of 1 resident (Resident 47) observed during a Hoyer lift (an assistive medical device used to safely transfer residents between a bed to wheelchair) transfer. These failures placed residents at risk of infection and diminished quality of life. Findings included .According to facility policy titled: Enhanced Barrier Precautions, dated 2025, documented EBP will be used during care of feeding tubes and central lines, and high contact care activities such as transferring. <MEDICATION ADMINISTRATION><RESIDENT 6>Resident 6 was admitted to the facility on [DATE]. Resident 6 has a feeding tube. In an observation on 06/22/2026 at 8:51 AM, prior to entering Resident 6's room, there was an EBP sign posted at the door. In an observation and interview on 06/22/2026 at 8:51 AM, Staff P, Licensed Practical Nurse administered medication to Resident 6 via feeding tube (medical device inserted directly through the abdomen into the stomach). Staff P did not wear a gown. Staff P stated the EBP sign that was posted at the door was for Resident 6 because of their feeding tube. Staff P stated they should have worn a gown when they were giving medications to the resident. <RESIDENT 76>Resident 76 was admitted to the facility on [DATE]. Resident 76 has a central line. In an observation on 06/24/2026 at 4:06 PM, prior to entering the Resident 76's room, there was an EBP sign posted at the door. In an observation and interview on 06/24/2026 at 4:06 PM, Staff N, Registered Nurse, flushed and connected the intravenous (IV) medication for Resident 76 without wearing a gown. Staff N stated the EBP sign that was posted at the door was for Resident 76. Staff N added they should have worn a gown prior to administering Resident 76's IV medication. <HOYER LIFT>Resident 47 was admitted to the facility on [DATE]. Resident has a feeding tube.In an observation on 06/22/2026 at 11:13 AM, prior to entering Resident 47's room, there was an EBP sign posted at the door. In an observation and interview on 06/22/2026 at 11:13 AM, Staff Q, Nursing Assistant Certified (NAC) and Staff R, NAC, transferred Resident 47 from their bed to their wheelchair using the Hoyer lift. Neither staff were wearing gowns. Asked both staff what the EBP sign that was posted on resident's door and Staff Q stated it meant they were to wear a gown when changing briefs or cleaning the resident. Staff Q then added that they should have worn a gown when they transferred the resident to their wheelchair.In an interview on 06/25/2026 at 10:05 AM, Staff D, Infection Control Nurse, reported they do rounds, on the spot checks and audits and if they notice a staff member not following precautions signs, they will provide an education for that staff right away. Staff D was unable to explain why the staff did not follow the precaution signs.In an interview on 06/26/2026 at 11:40 AM, Staff B, Director of Nursing Services, stated staff were able to verbalize that they were to wear gowns and gloves when providing high-contact care to residents on EBP but unable to explain why the staff did not follow the precaution signs. Refer to WAC 388-97-1320(1)(a)

Based on interview and record review, the facility failed to timely complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS-an assessment tool) for 1 of 2 residents (Resident 53), reviewed for SCSA. This failure placed the residents at risk for delayed care planning, unmet care needs, and diminished quality of life. Findings included .Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed that an SCSA is a comprehensive assessment that must be completed when the Interdisciplinary Team determines a resident meets the significant change guidelines for a major decline or improvement in status that impacts more than one area of health status, and the condition is not expected to return to baseline within two weeks.Resident 53 was admitted to the facility on [DATE].Review of a quarterly MDS dated [DATE], coded Resident 53 with no pressure ulcer, no skin treatment, rejecting care one to three days, and required dependent assistance for toilet transfers.Review of a dietary progress note dated 04/15/2026, documented Resident 53 had an 8.1% weight loss over 180 days.Review of a progress note dated 04/23/2026 at 9:38 PM, documented Resident 53 had dysphagia (difficulty of swallowing) and ate less than 50% of meals.Review of a dietary progress note dated 05/06/2026, documented Resident 53 had an 11.2% weight loss over 180 days.Review of a skin observation dated 05/22/2026 at 11:44 AM, showed Resident 53 had developed two pressure ulcers.Review of an initial wound consultant progress note, dated 05/27/2026 at 07:07 AM, documented per discussion with nursing staff and Director of Nursing, the resident had significant decline in function, weight loss, increased weakness, a decline in getting out of bed, and refusal of position changes over the past several months.Review of a quarterly MDS dated [DATE], coded Resident 53 with stage three pressure ulcers with pressure ulcer care, holding food in mouth/cheeks or residual food in mouth after meals, and toilet transfers were coded as not applicable.Review of Resident 53's Electronic Health Record (EHR), showed there was no completed comprehensive SCSA after Resident 53 sustained a decline in status that impacted multiple areas of their health status.In an interview on 06/24/2026 at 1:47 PM, Staff B, Director of Nursing, stated Resident 53 developed facility-acquired pressure ulcers after declining ADLs (Activities of Daily Living), exhibiting poor nutritional intake, experiencing weight loss, and refusing to transfer. Staff B stated Resident 53's condition was not expected to return to baseline within two weeks. Staff B confirmed and stated they expected an SCSA would have been completed following this multi-system decline. Reference WAC 388-97-1000 (3)(b)

Based on observation, interview and record review, the facility failed to ensure professional standards were met for 1 of 1 resident (Resident 76) sampled for intravenous (IV-into the vein) medication administration. The failure to have a physician's order for the IV flush (injecting a sterile solution to clear medications, prevent blood clots and verify the line is working) placed resident at risk for complications included blockage of line and adverse outcomes. Findings included . According to the facility policy titled Intravenous Therapy, dated 2025, the policy documented to utilize a 10 milliliter (ml) syringe of normal saline to inject and confirm patency of vascular access device per protocol. Resident 76 was admitted to the facility on [DATE] with diagnoses to include pyogenic arthritis (serious, painful bacterial infection of joint space). In an observation on 06/24/2026 at 4:06 PM, Staff N, Registered Nurse flushed Resident 76's central line (long flexible tube inserted into a large vein from the chest with the tip near the heart, use to give IV antibiotics) with 5 ml of normal saline then started an IV antibiotics infusion for the resident. Record review of Resident 76's physician's orders with a print date of 06/24/2026 did not show an IV flush order. In an interview on 06/24/2026 at 4:40 PM, Staff N, stated they must have an order for IV flushes, and they were supposed to flush before and after the IV antibiotics were infused. Staff N could not find the order for the IV flush for Resident 76. Staff N stated that the night before, an IV nurse needed to be paged to the facility to clear Resident 76's central line for blockage. In an interview on 06/26/2026 at 7:18 AM, Staff B, Director of Nursing Services stated it's an expectation to have an order for IV flushes and they were unsure as to why Resident 76 did not have an order. Reference WAC 388-97-1620(2)(b)(ii)

Based on observation, interview, and record review, the facility failed to ensure residents received proper assistive devices to maintain their hearing abilities for 1 of 2 residents (Resident 30) reviewed for hearing services. This failure placed the resident at risk for declined communication and decreased quality of life. Findings included .Review of the facility policy titled, Hearing and Vision Services, copyright date 2026, documented employees would assist the resident with the use of any devices or adaptive equipment needed to maintain hearing. Resident 30 was readmitted to the facility on [DATE]. In an interview and observation on 06/22/2026 at 8:34 AM, Resident 30 stated they could not hear when asked questions and they needed their hearing aids. It was observed the resident was not wearing hearing aids. In an observation on 06/22/2026 at 1:34 PM, Resident 30 was observed not wearing hearing aids. In an interview and observation on 06/23/2026 at 8:56 AM, Resident 30 stated they needed their hearing aids. It was observed that the resident was not wearing hearing aids. In an interview on 06/23/2026 at 1:28 PM, Staff Q, Nursing Assistant Certified (NAC), stated Resident 30 had hearing impairment and did not have hearing aids. Staff Q stated they simply increased their speaking volume and spoke closely into the resident's left ear since their left side had better hearing. In an interview and observation on 06/23/2026 at 1:41 PM, Staff T, NAC, stated they had not seen Resident 30 wore hearing aids. Staff U, Licensed Practice Nurse (LPN), joined the conversation and stated they had just placed the hearing aids on the resident. Together with Staff T present, Resident 30 stated the hearing aids did not work and they still could not hear.In an observation on 06/24/2026 at 8:55 AM, Resident 30 was observed not wearing hearing aids. In an interview and observation on 06/24/2026 at 8:58 AM, Staff V, LPN, stated Resident 30's hearing aids did not work because they could not be charged, and noted that one aid was missing. Staff V stated the hearing aids stopped working recently and the missing aid was reported yesterday. It was observed that the hearing aids case was kept in the medication cart; there was no charger with the case, and only one hearing aid was in.Review of Resident 30's care plan, initiated 11/25/2023, documented the resident wore bilateral hearing aids. Review of Resident 30's June 2026 Medication Administration Record (MAR) documented an order to provide bilateral hearing aids in the morning and remove them at night, effective since 08/25/2025. The MAR further documented a code 9 indicating Other/See Progress Notes on the night of 06/06/2026 and the morning of 06/22/2026. Review of Resident 30's progress notes on 06/06/2026 and 06/22/2026, revealed no documentation corresponding to the code 9.In an interview on 06/24/2026 at 1:36 PM, Staff V stated they documented a code 9 on 06/22/2026 because the hearing aids were not working .In an interview on 06/25/2026 at 9:46 AM, Staff I, LPN/Resident Care Manager, stated they documented a code 9 on 06/06/2026 because Resident 30 had not been wearing the hearing aids since that morning.In an interview on 06/26/2026 at 12:31 PM, Staff B, Director of Nursing, stated they expected the nurse to apply the hearing aids for the resident and replace the missing the hearing aid. Reference WAC 388-97-1060(3)(a)

Based on interview and record review, the facility failed to ensure dialysis communication documents were filled out after the resident had their dialysis appointments and returned to the facility for 1 of 1 resident (Resident 77) reviewed for dialysis. This failure placed Resident 77 at risk of inadequate or lack of assessment and documentation upon arrival back at the facility, undetected dialysis complications, and a decreased quality of life.Findings included .Review of the facility provided policy ''Hemodialysis,'' with an implementation date of 06/10/2026 documented the facility would assure that each resident received care and services for the provision of hemodialysis consistent with professional standards of practice. The ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatments The nurse would monitor and document the status of the resident's access site upon return from the dialysis treatment Resident 77 was admitted to the facility on [DATE] with diagnoses to include end stage renal disease and severe chronic kidney disease. Review of Resident 77's care plan documented they required dialysis three days per week on Mondays, Wednesdays and Fridays at the dialysis clinic. Review of Resident 77's pre and post dialysis assessments dated 06/10/2026, 06/12/2026, 06/17/2026, 06/19/2026, 06/24/2026, and 06/26/2026 did not have post dialysis assessment documentation. In an interview on 06/26/2026 at 8:46 AM, Staff G, Licensed Practical Nurse, stated they did not have an assessment or form to complete after the resident returned from the dialysis clinic. In an interview on 06/26/2026 at 9:54 AM, Staff I, Resident Care Manager, stated the nurse should document on the post dialysis assessment form when they returned from a dialysis treatment and confirmed the documentation was not completed. In an interview on 06/26/2026 at 11:00 AM, Staff B, Director of Nursing Services, stated they had issues with dialysis documentation and were in the process of finding a solution, possibly a different form to complete. Staff B stated their expectation was the post dialysis assessment and documentation would be completed. Reference WAC: 388-97-1900(1)(6)(a-c)

Based on observation, interview and record review, the facility failed to ensure routine and emergency dental services were provided for 1 of 1 resident (Resident 56) reviewed for dental services. This failure had the potential to result in infection, pain and decreased quality of life. Findings included . Resident 56 admitted [DATE]. Review of the Nursing admission assessment dated [DATE] documented the resident had missing and broken teeth. A baseline care plan was initiated related to oral/dental problems. In an observation and interview on 06/23/2026 at 9:24 AM, Resident 56 stated their teeth were terrible. Resident 56 opened their mouth and pointed to their lower jaw with visible tooth fragments and missing teeth. Resident 56 said their teeth had been in bad shape for a long time and said they had been seen by someone here at the facility who told them they needed them all pulled. Resident 56 stated they had a prior dentist and was able to state the name and place of their community dental office. Resident 56 stated they had to avoid certain foods and if they bit down wrong they sometimes got a sharp shooting pain. Resident 56 had not been told about any further follow up and voiced anxiety about the whole process. Review of a dental hygienist visit note dated 05/14/2026 included instructions to refer to a dentist for lower root tip extractions and full upper denture. Further review of the record found no evidence of any follow up related to the dental hygienist visit and recommendations. In a joint interview on 06/23/2026 at 2:49 PM, Staff H, Resident Care Manager, stated Resident 56 did have broken teeth and it was recommended that they pull them. Staff I, Resident Care Manager, stated Resident 56's family member also wanted them to be seen by a dentist. Staff J added that there were no dental appointments scheduled, stating that Resident 56 had been unsure about wanting their teeth pulled and may refuse the appointment due to anxiety. Staff J stated they had not spoken to Resident 56 about their teeth lately and had not been been aware Resident 56 was having complaints about their diet or that they had tooth pain. Staff J had not reached out to the prior dental office for information stating they did not know about them. Reference WAC 388-97-1060(3)(vii)

Based on observation, interview and record review, the facility failed to ensure 7 resident rooms (Rooms 107,108, 110, 302, 305, 306, and 307) measured at least 80 square feet per resident in multiple resident rooms and at least 100 square feet in single resident rooms. Failure to ensure residents reside in rooms which met the regulatory requirements for square footage, placed them at risk for living in a physical environment too small to meet their needs. Findings included .Square footage (sq ft):room [ROOM NUMBER] 142 sq ft,room [ROOM NUMBER] 143 sq ft,room [ROOM NUMBER] 143 sq ft,room [ROOM NUMBER] 154 sq ft,room [ROOM NUMBER] 154 sq ft,room [ROOM NUMBER] 154 sq ft,room [ROOM NUMBER] 153 sq ft.Review of the facilities census showed that rooms 107, 108, 110, 302, 305, 306 and 307 all had two beds in each room. In observations made on 06/22/2026, 06/23/2026, 06/24/2026, 06/25/2026 and 06/26/2026 the rooms 107, 108, 110, 302, 305, 306 and 307 had two beds for each room. In an interview on 06/26/2026 at 11:30 AM, Staff A, Administrator stated they had requested an exemption for rooms 107, 108, 110, 302, 305, 306 and 307 with the state, and had not been granted exemption as of current. Reference WAC 388-97-2440(1)

Based on interview and record review, the facility failed to ensure 3 of 5 residents reviewed for pre-admission screening and resident review (PASRR) received the required screening for mental health needs prior to admission for (Resident 1) and screenings were updated as required for (Residents 2 and 3). This failure placed the residents at risk of not receiving timely and necessary services to meet their mental health needs.Findings included.Review of a facility policy titled, Pre-admission Screening and Resident Review revised date 09/2025, documented any resident with a positive Level 1 screen must have a Level 2 evaluation conducted prior to admission.<RESIDENT 1>Resident 1 admitted to the facility on [DATE] with diagnosis of anxiety.Review of the PASSR level 1 screen, dated 09/26/2025, documented Resident 1 required a Level 2 evaluation for treatment of anxiety and depression.Review of a social services note, dated 09/29/2025, showed the state PASSR coordinator was contacted as resident required a level 2 evaluation.Review of Resident 1's electronic health record (EHR) showed no evidence of a level 2 PASSR being completed.During an interview on 11/24/2025 at 12:43 PM, Staff C, Social Services, reported they were not aware that a positive PASSR Level 1 screen required a level 2 evaluation prior to admission.During an interview on 11/24/2025 at 1:13 PM, Staff B, Director of Nursing Services, stated if a PASSR level 2 evaluation was required based on the Level 1 screen, the admission staff were to ensure it was done prior to admitting. <RESIDENT 2>Resident 2 was admitted to the facility on [DATE].Review of the PASSR Level 1 screen for Resident 2 showed they would be admitted to a different skilled nursing facility and was dated 06/29/2025. The form showed Resident 2 had indicators of Serious Mental Illness. The form documented that Resident 2 did not require a Level 2 evaluation as they were expected to remain at the facility less than 30 days. The form documented if the scheduled discharge did not occur, a Level 2 evaluation must be done.Review of a social service note dated 08/27/2025 at 12:27 PM, documented resident had a 30-day exemption level 1 PASSR, and it would need to be updated if they stayed longer than 30 days.Review of Resident 2's EHR showed no evidence that a more recent PASSR Level 1 screen had been completed nor was there evidence that a PASSR level 2 evaluation was done. <RESIDENT 3>Resident 3 was admitted to the facility on [DATE] and was readmitted on [DATE].Review of the PASSR Level 1 screen for Resident 3 was dated 09/23/2025, which was just prior to their initial admission to the facility. The form showed Resident 3 had indicators of Serious Mental Illness. The form documented that Resident 3 did not require a Level 2 evaluation as they were expected to remain at the facility less than 30 days. The form documented if the scheduled discharge did not occur, a Level 2 evaluation must be done.Review of Resident 3's EHR showed no evidence that a more recent PASSR Level 1 screen had been completed nor was there evidence that a PASSR level 2 evaluation was done.During an interview on 11/24/2025 at 12:43 PM, Staff C stated if a resident admits to the facility and the PASSR level 1 screen documented a 30-day exemption, the facility would have to submit a PASSR Level 2 evaluation request to the state PASSR coordinator when the residents stay reached 30 days. Staff C reported they had not sent a PASSR level 2 evaluation request to the state PASSR coordinator for Resident 2 or Resident 3. Reference WAC 388-97-1915 (1)(2) (a-c)

Based on interview and record review, the facility failed to ensure the person designated to serve as the Director of Food and Nutrition Services (Staff S) had the required qualifications. This failure placed all residents at risk of receiving dietary services from staff without the required competencies and skills to carry out food and nutrition services.Findings included .In an interview on 07/16/2025 at 9:47 AM, Staff S, Dietary Manager (DM), stated they were not a certified DM. Staff S stated they were enrolled in the educational program to obtain their certification. Staff S stated the facility was using the certification of Staff T, Assistant DM, in place of their certification.In a review of the staff roster, undated, documented Staff S was the culinary director.\In a review of the facility assessment dated [DATE], documented Staff S as the certified dietary manager.In an interview on 07/21/2025 at 11:04 AM, Staff A, Administrator, stated Staff T was the dietary manager last year and thought the facility could use their certification until Staff S was certified.Refer to WAC 388-97-1160 (2)(3)(a)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one of one facility kitchens, and one of one snack/nourishment refrigerators. The failure to ensure cleanliness of the kitchen, label opened food/beverage items, wash hands, and ensure dishwashing temperature were maintained at the proper temperature. These failures placed all residents at risk for their food to be contaminated, development of food borne illnesses, and consuming spoiled food.Findings included.<CLEANLINESS>On 07/17/2025 at 11:04 AM observed the dishwashing area to have a large hole (approximately 6 -8 inches) in the wall underneath the dishwashing basin. Observed a rusty gallon can (content unknown and not able to be determined), below pipes, underneath the dishwasher appeared to hold up one of the copper pipes. Observed a leak from underneath the handwashing station, which included a pool of discolored liquid directly underneath the sink drainpipe. Observed food debris and remnants and cracker wrappers on the floor in and around the dishwashing area.In an interview on 07/17/2025 at 11:04 AM Staff U, Dietary Aide, stated they had informed every one of the pool of liquid accumulated beneath the handwashing sink. Staff U stated they tried y to do a deep clean in the morning when they arrive and night shift was expected to complete a deep cleaning at night.In an interview on 07/15/2025 Staff V, Maintenance Director, stated there had been a report of cockroaches in the kitchen from kitchen staff. Staff V stated they contacted a pest control company, and the facility was currently on a weekly maintenance plan for pest control.<DISHWASHING STATION>In an observation on 07/15/2025 at 10:00 AM, the dishwashing temperature log showed missing entries for 07/11-07/12/2025. The temperature logged for 07/15/2025 was 127 degrees.In an interview on 07/15/2025 at 10:00 AM Staff S, Culinary Director, stated they had just seen the dishwasher log was missing a few entries.In a follow up visit to the kitchen on 07/17/2025 at 11:04 AM, observed the dishwasher temperature log showed the temperatures recorded for 07/16/2025 for AM at 118 degrees Fahrenheit and for the PM 116 degrees.In an interview on 07/17/2025 at 11:04 AM Staff U, who was operating the dishwasher, stated the dishwasher was a low temperature-chemical dishwasher, and the temperature was to get up to 130 degrees. Staff U stated they run the dishwasher empty a few times to get it up to temperature before running a load of dishes.In an interview on 07/17/2025 at 11:29 AM Staff S stated they were not aware of the temperatures logged on 07/16/2025. Staff S stated the employee working that day was new and English was their second language. Staff U stated they had educated their staff on running the dishwasher a few times empty, to get it to temperature.<FREEZER>In an observation on 07/15/2025 at 9:44 AM, observed a large amount of ice buildup in and around the door of the freezer.In an interview on 07/15/2025 at 9:44 AM, Staff S stated the facility had just completed maintenance on the freezer two to three weeks ago, and the door seals had not been installed and the maintenance director was coordinating the replacement of the seals.In an interview on 07/15/2025 at 10:20 AM Staff V, stated the door seals were not replaced when the freezer unit was replaced and were due to be delivered soon. Staff U stated they were aware the freezer door was icing up.<HAND WASHING>In an observation on 07/17/2025 at 12:09 PM, Staff S prepared a chopped sandwich for a resident's lunch tray. Staff S removed their soiled gloves and placed a new pair of gloves on their hands without completing hand hygiene. Staff S repeated this observation two more times within minutes of each other.<NOURISHMMENT REFRIGERATOR>On 07/16/2025 at 8:29 AM, observed the dining room nourishment refrigerator to contain opened and undated coconut water and vanilla boost shake.<DRY STORAGE>During the initial tour on 07/15/2025 at 9:44 AM the dry storage was observed to contain opened/unlabeled items including three different types of dry cereal and two bags of pasta.In an interview on 07/18/2025 at 1:48 PM, Staff A, Administrator, stated the facility was on the scheduled to replace the dishwasher and complete a deep cleanof the kitchen. Staff A stated they were aware of the need for a deep clean of the dishwashing area but were waiting for the replacement of the dishwasher.Refer to WAC 388-97-1100(3)

Based on interview and record review, the facility failed to ensure 1 of 2 sampled residents (Resident 11) was free from physical and mental abuse from staff. The facility failed ensure resident protection, and implement interventions to prevent mental and physical abuse when Staff AA, Nursing Assistant Certified (NAC), was allowed to continue to care for vulnerable residents. Resident 11 experienced harm when the facility did not intervene, safeguard, or protect the resident after they alleged on [NAME] than one occasion unwanted physical touching, laughing at the resident's requests, and emotional distress from Staff AA. These failures placed all residents at risk for abuse. Findings included . According to the [NAME] State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, mental abuse was defined as verbal or nonverbal action that humiliates, harasses, coerces, intimidates, or isolates a vulnerable adult. Mental abuse may include ridiculing. Physical abuse included striking, slapping, pinching, choking, kicking, shoving or prodding. Resident 11 admitted on [DATE] with diagnoses to include stroke with left side hemiparesis (weakness) and hemiplegia (partial or nearly complete paralysis), and depression. Review of a nursing progress note, dated 08/07/2023 at 4:07 PM, showed Resident 11 was on alert for a grievance. There were no details of the grievance. Review of the quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 09/13/2023, showed Resident 11 was cognitively intact with no behaviors or rejection of care. The MDS assessment showed the resident had both upper and lower extremity range of motion limitation on one side and required extensive assistance for toileting. Review of the care plan, revised on 09/20/2023, showed Resident 11 required one-person extensive assist for a stand pivot transfer to their wheelchair (w/c) or to the toilet with a gait belt placed prior to the transfer. In an interview on 10/09/2023 at 10:23 AM, Resident 11 was asked about abuse and if they had experienced any instances where staff made them feel afraid, humiliated, degraded, or handled them roughly. Resident 11 said they had an issue with Staff AA, Nursing Assistant Certified (NAC). Resident 11 said Staff AA put them on the toilet and they didn't like it. Resident 11 told Staff AA they did not like it and Staff AA would laugh at them. The resident said the facility was so short of staff they had kept Staff AA working. Resident 11 said Everyone knows about it. [Staff AA] uses [their] hip to move me because I don't move my leg fast enough. I have had a stroke. [Staff AA] makes fun of me and laughs when I tell them my concerns about them. I do not feel safe with them, and the prior Administrator knew that. But now they have [Staff AA] taking care of me again. I do not want them to care for me, they make fun of me. Resident 11 said [Staff D, Licensed Practical Nurse (LPN)/Nurse Manager] knows I do not want [Staff AA] to touch me, I told them personally and [Staff AA] still cares for me. At 10:54 AM, the resident was asked if they were treated with dignity and respect. Resident 11 stated Staff AA does not treat me with respect. I do not feel safe with them. The resident stated staff were aware of this, but Staff AA was reassigned to care for them again. In an interview on 10/09/2023 at 11:00 AM, Staff B, interim Director of Nursing (DNS), was informed about Resident 11's abuse interview. Staff B stated they would interview the resident and report the allegation to the hotline. Review of the current facility staffing scheduled showed Staff AA was scheduled to work with Resident 11 on 10/09/2023, 10/10/2023, and 10/12/2023. Review of Staff AA's employee file showed the staff member was hired on 05/03/2023 and did not have any professional reference checks. In an interview on 10/10/2023 at 9:58 AM, Staff B stated they had talked with Resident 11 yesterday had filled out a grievance. Staff B was asked if this allegation had been escalated to an abuse investigation and they responded, No, I talked with [Staff D] and they thought it was a grievance. [Staff D] is my right-hand man and knows this place inside and out. They are an LPN. Staff B said they would discipline Staff AA. Staff B commented they were unaware if Staff AA had any prior disciplinary action. In an interview on 10/10/2023 at 3:11 PM, Resident 11 said no one had come and talked to them about their complaint about (Staff AA besides the surveyor. Resident 11 said this place is going to hell in a handbasket. The resident stated they had not yet met the DNS. In an interview on 10/11/2023 at 9:28 AM, Resident 11 was in their room and stated Staff B had just talked to them about Staff AA this morning. The resident said they told Staff B they did not feel safe and that Staff AA hits them. When asked if Staff AA hits you, Resident 11 replied, Yes, with their hip, they hit me. In an interview on 10/11/2023 at 10:22 AM, Staff A, Administrator, stated they were just informed about Resident 11's concern that involved Staff AA this morning. Staff A said Staff B told them the resident was perseverating on a past incident from August 2023. Staff A said they called Staff O, former Administrator, and was told this interaction was from an August incident. Staff A said from what they heard this occurred in August 2023, and Staff AA will not be working here any longer as of (looked at their watch) 11 [AM] today. Staff A said this was an abuse allegation. Staff A was informed the abuse allegation was reported to Staff B on 10/09/2023, two days prior, and there was a delay in protecting Resident 11 from further mental and/or physical abuse. Staff A was informed there had been no record of the allegation in the resident's clinical record, the past five months of incident reports, or the grievance logs. Staff A was asked to provide any investigations involving Staff AA from August 2023. No investigations were provided involving Resident 11 and Staff AA. In an interview on 10/11/2023 at 11:13 AM, Staff A said they met with Resident 11 who reiterated the incident involving Staff AA and stated it also occurred sometime in September 2023. Staff A said the resident told him Staff AA would use their hip to physically move their leg and then when the resident told Staff AA not to do that, they would laugh at them. Staff A said from what they understood Staff P, former DNS, had told the resident that Staff AA would no longer care for them. Staff A said Staff B and Staff D thought this allegation was a grievance and would counsel them on abuse. Staff A was shown a disciplinary action for Staff AA on 07/24/2023 who did not answer Resident 25's call light for 115 minutes. Staff A commented there was no signature from a witness and Staff AA refused to sign. Staff A said that incident involving Resident 11 was an allegation of abuse. Staff A was shown a grievance the following day (07/25/2023), involving the same resident (Resident 25) and Staff AA was assigned to them, who had concerns that their call light was going on for 35 minutes. Staff A commented this one did not have signatures either. Review of the staffing sheets showed Staff AA worked with Resident 11 from 10/09/2023 to 10/11/2023. In an interview on 10/11/2023 at 12:15 PM, Staff A said they had terminated Staff AA and they informed Staff B to call the hotline and report the 10/09/2023 allegation. Staff A said Staff B asked them if they really needed to report this today. Staff A said they told them Yes, it should have been done on Monday, now we are getting an abuse and neglect tag and for lack of reporting. Staff A said they would be educating Staff B and Staff D later today. In an interview on 10/13/2023 at 3:00 PM, Staff E, LPN/Staff Development Coordinator, stated one abuse allegation that happened was when someone said staff was too rough with them Staff E said they had escalated that to a full abuse investigation and did interviews on one hall. Staff E said if the allegation involved a specific NAC, then they tried to conduct the interviews in the one area the NAC worked, and if the staff worked all over the facility, they would conduct interviews all over. Staff E said they had heard Staff AA's name come up a lot. Staff E said they had done an investigation involving Staff AA when Staff P, former DNS, was there. Staff E said the investigation was that another resident (Resident 5) reported Staff AA dumped water all over them and didn't clean them up. Staff E said when they interviewed staff and residents about Staff AA, more complaints did come up. Staff E said staff and residents said Staff AA would not answer their call lights in a timely manner and did not finish residents' care. There had been even more complaints come up from multiple people (residents and staff) who complained about Staff AA. Staff E said Resident 11 did not want Staff AA near them, and Staff D told Staff E to do their best to assign Staff AA not on Resident 11's hall. Staff E said Staff D was very well aware about Resident 11's desire not to have Staff AA near them. Staff E said Staff P fired Staff AA, but Staff O brought Staff AA back to work and told Staff P they didn't follow the disciplinary process with human resources approval. Staff E said they knew they had personally counseled Staff AA several times, so they were not sure where those disciplinary actions were. Staff E commented they had agreed with Staff P, that Staff AA should have been let go. Staff E said Staff AA's competency skills were also not up to par either. Staff E said Staff AA would not follow through with all resident requests. Review of an incident report, dated 08/11/2023 at 11:00 AM, showed a resident (Resident 5) reported to Staff P staff was rough while giving care to them and rough when they changed them. The resident reported the aide, later identified to be Staff AA had spilled water on their bed, covered the spill with a blanket, and did not change the sheets. A statement written by Staff W, NAC, was included in the investigation, that the resident reported to them that Staff AA threw the table at them, and water went all over their clothes. The resident asked Staff W not to send Staff AA to their room and the resident did not want to see Staff AA again. The investigation revealed, Staff AA would be released from their position permanently. Staff P noted there had been several instances where residents complained of Staff AA's care of them. Refer to WAC 388-97-0640(1)

Based on interview, and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse and/or neglect for four of four residents (21, 28, 254, and 255) reviewed for abuse and neglect. These failures resulted in one resident's grievance of rough handling, one resident's grievance of verbal abuse, and two residents that had injuries of an unknown origin to not be identified, protected, investigated, or reported as potential allegations of abuse and/or neglect by the facility. These failures left all residents at risk for abuse and/or neglect and psychosocial harm. An Immediate Jeopardy (IJ) was called on 08/15/2022 at 5:15 PM related to Code of Federal Regulation (CFR) 483.12(b)(1)(2) F-607, Develop/Implement Abuse and/or Neglect Policies and Procedures. The date of the IJ immediacy removal plan for F-607 was 08/16/2022 at 6:00 PM. The facility educated all staff on abuse and/or neglect, and mandated reporter role. The abuse and/or neglect policy was updated to reflect current stated and federal guidelines. The IJ was verified during unannounced onsite visit to the facility. Findings included . Review of the CFR 483.12, abuse is defined as a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology .The facility must provide a safe resident environment and protect residents from abuse. Review of the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated 10/2015 defined abuse was a willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish .In general, you must presume that abuse has occurred whenever there has been some type of impermissible, in justifiable, harmful, offensive, or unwanted contact with a resident. Review of the facility policy titled, Abuse/Neglect Incident Reporting Policy and Procedure effective 04/01/2019, failed to instruct staff on the required procedure for investigation of allegations of abuse and/or neglect of residents, how the staff identify abuse and/or neglect, the protection of residents during investigations, the reporting of allegations and investigative findings and taking corrective actions. Review of the facility policy titled; Resident Grievance Procedure effective 05/22/2019 showed a grievance is any dispute or question concerning a resident's care or treatment within the facility . complaints of a nature that fall under reporting requirements will be reported to the appropriate agency. The facility policy did not delineate how a grievance was different than an allegation of abuse. RESIDENT 28 Resident 28 admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility grievance log titled, 2021/2022 showed an entry on 07/14/2022 with no time, for Resident 28. The log showed that the resident had reported long call light wait times, and staff were rough with them. There were no findings, no action, and no notification documented on the log. Review of the Resident Grievance Form dated 07/13/2022 at 11:00 PM - 12:00 AM for Resident 28 showed the resident had expressed when they were getting ready for bed the staff got frustrated during the transfer process and threw the resident into bed. The resident also stated that it was taking a long time to answer their call light. The grievance form was initiated by Staff D, Social Services (SS). The action taken stated staff were spoken too, and a refresh on proper transfers was completed and well as a talk regarding the call light times and was signed by Staff D on 07/15/2022, 2 days after the initial allegation of rough handling. The follow up indicated staff were reminded to go slow when they transferred the resident and explain the procedure it was signed by the Director of Nursing Services (DNS) and dated 07/16/2022, three days after the resident reported rough handling. The grievance form did not indicate how the resident was protected, the investigation was not complete and thorough, and the facility failed to report the allegation to the required agencies. RESIDENT 255 Resident 255 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Quarterly MDS dated [DATE] showed the resident had intact cognition. Review of the facility grievance log titled, 2021/2022 showed an entry on 03/15/2022 at 1:30 PM for Resident 255. The log showed that the resident had reported they felt bullied by their roommate. The action taken per the log was the resident was placed on alert. The family and DNS were not notified. Review of the Resident Grievance Form dated 03/15/2022 for Resident 255 showed the resident had expressed feeling mistreated by their roommate, they felt their roommate would not allow them to talk, the roommate had responded in a nasty manner and does not feel their area was treated with respect was initiated by Social Services. The action taken was the administrator and Staff D spoke with roommate and the resident would be moved to a more appropriate room. This occurred twenty-four hours after the resident had alleged verbal mistreatment by their roommate. There was no outcome documented on the form. The grievance form did not indicate how the resident was protected, the investigation was not complete and thorough, and the facility failed to report the allegation to the required agencies. RESIDENT 254 Resident 254 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility incident log dated 05/05/2022 at 10:00 AM, showed Resident 254 had two bruises to their upper arm. The action taken documented on the incident log was to update the care plan, and other, which did not indicate location of documentation. Review of the incident report dated 05/05/2022 at 10:00 AM, by Staff H, RN stated the nurse found two discolorations to Resident 254's left upper arm. One bruise measured 6 centimeters (cm) by 4.5 cm and was dark purple in color. The second bruise measured 4.5 cm by 3 cm and was also dark purple. The resident was unable to describe what occurred as they were only alert to themselves with poor cognition. The summary dated 05/06/2022 by the DNS indicated the resident was combative with cares and likely injured themselves. The incident report did not indicate how the resident was protected. The investigation was not complete and thorough, and the facility failed to report the incident/injury of unknown source to the required agencies. RESIDENT 21 Resident 21 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility incident log dated 07/09/2022 at 11:15 AM, showed Resident 21 had a bruise to their shin. The action taken documented on the incident log was to update the care plan, first aid and other, which did not indicate the location of documentation. Review of the incident report dated 07/09/2022 at 11:15 AM, by Staff A, RN stated a therapist had alerted them to a bruise on the resident's right shin. The report indicated that the bruise was blue and purple in color with small 0.5 cm scab on the top. The resident was unable to tell the nurse how it occurred. The nurse stated that the resident transferred using a mechanical lift sometimes, and with therapy would use a transfer pole. The nurse stated due to vulnerable area the injury likely occurred during transfer handling. The summary of the incident dated 07/11/2022 completed by the DNS indicated the bruise was potentially from the resident self-inflicted injury by bumping into a table and to refer to the attached statements. The incident report did not indicate how the resident was protected. There were no statements or any investigation. The facility failed to report the allegation to the required agencies. In an interview on 08/12/2022 at 11:58 AM, Staff D, Social Services, stated they were responsible for the grievance log and completed the grievance forms. Staff D stated that the staff would leave sticky notes on their desk for them to follow up with. Staff D stated they work Monday through Friday, so notes that are left over the weekend would get followed up with on Monday. In an interview on 08/15/2022 at 3:06 PM, the DNS stated that all grievances are initiated by the Social Worker then they are brought to stand-up (daily meeting with all department managers). They then as a group decide what department needs to address the grievance. The DNS confirmed that the entry for Resident 28 on 07/14/2022 was an allegation of abuse that should have been investigated and reported. The DNS confirmed that the social worker failed to identify an allegation of abuse, and during the stand-up meeting the managers failed to identify an allegation of abuse. In an interview on 08/15/2022 at 3:55 PM, Staff BB, RN stated they were an agency staff member that was contracted to work at the facility. Staff BB stated they have had no training on abuse and neglect while working at this facility. In an interview on 08/15/2022 at 3:56 PM, Staff Z, Nursing Assistant Certified (NAC) stated if a resident reported rough handling by a staff member, they would complete a paper report for the nurse. Staff Z was unable to identify themselves as a mandated reporter and were unable to identify an allegation of abuse. They were unaware they needed to protect, investigate, and report allegations of abuse to the required agencies. In an interview on 08/15/2022 at 3:57 PM, Staff U, Housekeeping had worked for the facility for three years. They stated if a resident reported rough handling by a staff member, they would let the DNS or Administrator know. Staff U was unable to identify themselves as a mandated reporter, were unable to identify an allegation of abuse, and were unaware they needed to protect, investigate, and report allegations of abuse to the required agencies. In an interview on 08/15/2022 at 4:02 PM, Staff C, Nurse Manager (NM), stated if a resident reported rough handling by a staff member, the social worker would investigate the allegation and report the findings to the DNS. Staff C stated that sometimes it may be a legitimate complaint or a misunderstanding that's a tough one, it could be either. Staff C was unable to determine the difference between a resident grievance and a reportable allegation of abuse. In an interview on 08/15/2022 at 4:03 PM, Staff CC, Laundry Assistant has worked at the facility for [AGE] years. They stated if a resident reported rough handling by a staff member, they would let the nurse know. Staff CC was unable to identify themselves as a mandated reporter, were unable to identify an allegation of abuse, and were unaware they needed to protect, investigate, and report allegations of abuse to the required agencies. In an interview on 08/15/2022 at 4:04 PM Staff D Social Worker stated if a resident reported rough handling by a staff member, they would talk to staff and just see. Staff D stated they would complete a grievance or document in a care conference note. Staff D was unable to identify themselves as a mandated reporter, were unable to identify an allegation of abuse, and were unaware they needed to protect, investigate, and report allegations of abuse to the required agencies. In an interview on 08/15/2022 at 4:06 PM, Staff DD, NAC was unable to identify themselves as a mandated reporter, and stated they had 24 hours to report an allegation of abuse. In an interview on 08/16/2022 at 1:06 PM, DNS stated the expectation for their staff when they find a bruise of an unknown origin would be for them to complete an incident report and interview the staff working that day. The DNS confirmed the investigation should be complete and thorough. In reference to the investigation for Resident 21, the DNS confirmed they did not complete a thorough investigation and confirmed without a complete investigation, abuse and neglect could not be ruled out as the cause of the bruise. In reference to the investigation for Resident 254, the DNS stated, the resident was going downhill, and the medications were not enough to keep her quite. The DNS confirmed they did not complete a thorough investigation of the bruises to the resident's arm, and abuse and neglect could not be ruled out as the cause of the bruise. In an interview on 08/16/2022 at 2:03 PM, the Administrator confirmed the grievance for Resident 255 was identified as a potential allegation of abuse, and was not thoroughly investigated, nor reported to the required agencies. The facility failed ensure their abuse and neglect policies and procedures instructed staff on how to prevent, identify, investigate, protect, and report allegations of potential abuse and/or neglect. This failure allowed allegations of rough handling, verbal mistreatment, and bruises of an unknown source to go uninvestigated for abuse and/or neglect and placed all residents in immediate jeopardy, and at risk for harm. Reference: (WAC) 388-97-0640 (2)(b),(5)(a),(6)(a)(b)(c)

Based on observation, interview, and record review the facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for three of three halls. The facility failed to ensure the staff appropriately cleaned and disinfected glucometers (point of care device used to assess the level of sugar in blood) per the device and manufacturer's instructions. The facility failed to ensure oversight and implementation of their Infection Prevention and Control Program and management of the Coronavirus Disease 2019 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death). The facility failed to ensure appropriate hand hygiene practices were followed during wound care and peri-care (cleaning the private areas of a patient), failed to ensure staff used personal protective equipment (PPE) in accordance with national standards, failed to ensure Transmission Based Precautions (TBP) were implemented with suspected residents of COVID-19, the facility failed to ensure their infection prevention and control procedures were up to date with national standards, and failed to develop a water management program to reduce the growth and spread of Legionella (a bacteria found in water that can cause a serious type of pneumonia). These failures placed all residents, visitors, and staff at risk for potential exposure to COVID-19, other infections and increased the likelihood of serious harm or death, which constituted an Immediate Jeopardy (IJ). An IJ was called on 08/10/2022 at 11:47 AM related to CFR 483.80(a)(1) F-880, to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. A review of the facility IJ removal plan on 08/10/2022 at 3:34 PM stated that the facility would educate the licensed staff on standard precautions during routine testing of blood glucose, education on proper cleaning/disinfectant of the glucometers and audit for completion. The Director of Nursing Services (DNS) would audit and review to ensure proper infection control technique was performed. The removal plan stated all aspects would be completed by 08/12/2022. Findings included . <GLUCOMETER> A review of the facility policy titled, Obtaining a Fingerstick Glucose Level dated October 2011, stated clean and disinfect reusable equipment between uses according to the manufactures instructions and current infection control standard of practice. In a combined observation and interview on 08/10/2022 at 9:50 AM Staff I, Registered Nurse (RN) exited room [ROOM NUMBER] where Resident 9 resides, with a glucometer placed on a white foam tray. At 9:55 AM Staff I returned to medication cart with glucometer and placed the glucometer in a case marked for Resident 17. Staff I stated that each resident had their own glucometers, however they were unable to locate Resident 9's glucometer that morning so they borrowed Resident 17's. Staff I stated they are to wipe the glucometer with an alcohol wipe and wait 30 seconds. Staff I stated they had forgot to do that when they returned Resident 17's glucometer to the medication cart. In a combined observation and interview o 08/10/2022 at 10:40 AM Staff A, RN stated they use the grey top Sani-Wipes AF3 as that was what they were instructed to use to disinfect the glucometers. In a combined observation and interview on 08/10/2022 at 10:42 AM Staff I, RN was observed to return to the medication cart with a glucometer placed on a white foam tray. Staff I stated the glucometer was for Resident 45 and that they had just checked their blood sugar. Staff I was observed to remove a disinfectant wipe from a container labeled Sani-cloth AF3. Staff I wrapped the cloth around the glucometer, allowed it to sit for 2 minutes then unwrapped and placed the glucometer in the case. In an interview on 08/10/2022 at 12:01 PM with the Administrator, the glucometer manufacturer instructions showed Super Sani-Cloth Wipes were the required disinfectant, the facility was currently using Sani-Wipe AF3 which was not acceptable as an approved source for their glucometers. The Administrator was unaware there was a difference between the wipes. <TRANSMISSION BASED PRECAUTIONS> Review of the facility policy titled, Infection Control Policy revised 06/20/2022 stated that infection can easily spread from person to person .during resident care, health care worker carrying out their duties, or interaction with others in a skilled nursing facility. The policy did not include any information regarding COVID-19. Review of Centers of Disease Control and Prevention (CDC) Interim Infection Prevention and Control stated to prevent COVID-19 spread in Nursing homes updated 02/02/2022, stated residents with suspected or confirmed COVID-19 infection should use full PPE (gowns, gloves, eye protection, and a NIOSH-approved N95 or equivalent or higher-level respirator) and it was stated that the door to the room remain closed to reduce transmission. In an observation on 08/08/2022 at 1:10 PM, room [ROOM NUMBER] had a transmission-based precaution sign that read modified standard precautions, the guidance stated everyone must clean their hands when they entered and left the room, they are to cover their mouth and nose with arm or tissue when they cough or sneeze, they are to wear a glove and face protection for any risk of body fluid contact. Staff are instructed to wear appropriate mask and eye cover, gown, and gloves if contact with body fluids likely. There was a resident lying in the bed visible from the doorway, the door was open. In an observation on 08/10/2022 at 12:22 PM, room [ROOM NUMBER] had a transmission-based precaution sign that read modified standard precautions, the guidance stated everyone must clean their hands when they entered and left the room, they are to cover their mouth and nose with arm or tissue when they cough or sneeze, they are to wear a glove and face protection for any risk of body fluid contact. Staff were instructed to wear appropriate mask and eye cover, gown, and gloves if contact with body fluids likely. A resident was observed lying in the bed visible from the doorway, the door was open. In an observation on 08/10/2022 at 12:25 PM, room [ROOM NUMBER] had a transmission-based precaution sign that read modified standard precautions, the guidance stated everyone must clean their hands when they entered and left the room, they were to cover their mouth and nose with arm or tissue when they cough or sneeze, they are to wear a glove and face protection for any risk of body fluid contact. Staff were instructed to wear appropriate mask and eye cover, gown, and gloves if contact with body fluids likely. Resident 251 was lying in the bed visible from the doorway, the door was open, the therapist that walked by stated Resident 251 was a new admit. In an observation on 08/10/2022 at 12:26 PM, room [ROOM NUMBER] had a transmission-based precaution sign that read modified standard precautions, were to cover their mouth and nose with arm or tissue when they cough or sneeze, they are to wear a glove and face protection for any risk of body fluid contact. Staff were instructed to wear appropriate mask and eye cover, gown, and gloves if contact with body fluids likely. Resident 252 was lying in the bed visible from the doorway, the door was open. The medical record for Resident 252 indicated they were a new admit. In an interview on 08/10/2022 at 12:32 PM, the DNS confirmed that all new admits were placed on a seven-day quarantine for suspected COVID-19 transmission. In an observation on 08/11/2022 at 9:59 AM, room [ROOM NUMBER] had a transmission-based precaution sign that read modified standard precautions, the guidance stated everyone must clean their hands when they entered and left the room, they were to cover their mouth and nose with arm or tissue when they cough or sneeze, they were to wear a glove and face protection for any risk of body fluid contact. Staff were instructed to wear appropriate mask and eye cover, gown, and gloves if contact with body fluids likely. Resident 252 was sitting on the edge of the bed, and the door was open. In an observation on 08/12/2022 at 11:02 AM, room [ROOM NUMBER] had a transmission-based precaution sign that read modified standard precautions, the guidance stated everyone must clean their hands when they entered and left the room, they were to cover their mouth and nose with arm or tissue when they cough or sneeze, they are to wear a glove and face protection for any risk of body fluid contact. Staff were instructed to wear appropriate mask and eye cover, gown, and gloves if contact with body fluids likely. Resident 252 was lying in the bed with a therapist at bedside with the door was open. In an interview on 08/12/2022 at 11:12 AM, Staff M, Nursing Assistant Certified (NAC) stated all the new admits were placed on isolation for seven days for suspected COVID-19. In an observation on 08/12/2022 at 11:15 AM, room [ROOM NUMBER] had a transmission-based precaution sign that read modified standard precautions, the guidance stated everyone must clean their hands when they entered and left the room, they were to cover their mouth and nose with arm or tissue when they cough or sneeze, they were to wear a glove and face protection for any risk of body fluid contact. Staff was instructed to wear appropriate mask and eye cover, gown, and gloves if contact with body fluids likely. Resident 251 was lying in the bed visible from the doorway as the door was open. In an observation on 08/15/2022 at 8:57 AM, room [ROOM NUMBER] had a transmission-based precaution sign that read modified standard precautions, the guidance stated everyone must clean their hands when they entered and left the room, they were to cover their mouth and nose with arm or tissue when they cough or sneeze, they were to wear a glove and face protection for any risk of body fluid contact. Staff were instructed to wear appropriate mask and eye cover, gown, and gloves if contact with body fluids likely. Resident 252 was visible with the door was open. In an observation on 08/15/2022 at 8:58 AM, room [ROOM NUMBER] had a transmission-based precaution sign that read modified standard precautions, the guidance stated everyone must clean their hands when they entered and left the room, they were to cover their mouth and nose with arm or tissue when they cough or sneeze, they were to wear a glove and face protection for any risk of body fluid contact. Staff were instructed to wear appropriate mask and eye cover, gown, and gloves if contact with body fluids likely. Resident 251 was visible with the door was open. In an observation on 08/15/2022 at 8:59 AM, room [ROOM NUMBER] had personal protection equipment bin outside of room, there was no guidance to instruct staff upon entering the room, a resident was visible in the room and the door was open. In an observation on 08/15/2022 at 1:22 PM, Resident 251 was observed to be walking with a walker in the hallway on the other side of the nursing home with a therapist. The resident was not wearing a face mask, and the therapist was only wearing a surgical mask and glasses. The resident was currently on COVID-19 isolation precautions for suspected possible exposure of COVID-19 as a new admit. In an observation on 08/17/2022 at 8:52 AM, Rooms 401, 307, 304, 303 all had a transmission-based precaution sign that read modified standard precautions, the guidance stated everyone must clean their hands when they entered and left the room, they are to cover their mouth and nose with arm or tissue when they cough or sneeze, they were to wear a glove and face protection for any risk of body fluid contact. Staff were instructed to wear appropriate mask and eye cover, gown, and gloves if contact with body fluids likely. The residents in the rooms were visible from hallway as the door was open. rooms [ROOM NUMBERS] had PPE bin outside of room, there was no guidance to instruct staff upon entering the room, a resident was visible in the room with the door open. In an interview on 08/17/2022 at 8:55 AM Staff A, RN was asked why there was PPE bins outside of the rooms [ROOM NUMBERS]. Staff A stated, I guess they are on isolation for new admits suspected of COVID-19. <PERSONAL PROTECTIVE EQUIPEMENT> Review of the facility policy titled, Infection Control Policy revised 06/20/2022 did not address policies and procedures to direct staff on proper use of PPE with COVID-19 suspected residents. Review of Centers of Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic updated 02/02/2022, showed counties with high level of community transmission were required to wear eye protection (i.e., goggles that fit securely to the face or a face shield that covers the front and sides of the face) should be worn during all patient care encounters. The Level of Community Transmission Rate on 06/27/2022, showed Island County (the county where the facility was located) had a high level of community transmission. A National Institute of Occupational Safety and Health (NIOSH) approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH-approved N95 or equivalent or higher-level respirator) during the care of a patient with or suspected COVID-19. Review of the Center for Disease and Control (CDC) policy titled, Strategies for Optimizing the Supply of Eye Protection, updated September 13, 2021, ensured appropriate cleaning and disinfection after each use if reusable face shields or goggles are used. In an observation on 08/09/2022 at 9:41 AM, Staff U, Housekeeping Assistant was observed entering resident rooms to clean while residents were present within six feet or less while wearing safety glasses that did not fit securely to their face or cover all sides. In an observation on 08/09/2022 at 2:01 PM, Staff V, Activity Assistant was wearing only a surgical mask while conducting an activity with Resident 12 and Resident 8. The staff member was not wearing any eye protection. In an interview on 08/09/2022 at 2:08 PM, Staff V stated they forgot they needed to wear eye protection. In an observation and interview on 08/10/2022 at 3:06 PM, Staff E, Activities Director was observed to push a wheelchair with a resident into their room, not wearing eye protection. Staff E state they forgot they needed to wear eye protection. In a continuous observation on 08/11/2022 at 9:58 AM Staff W, Physical Therapist Assistant (PTA) was observed to enter room [ROOM NUMBER] with Resident 251 present, on isolation for suspected COVID-19. Staff W was wearing an N95, gown, eye protection and gloves. The staff was observed to work with Resident 303 with in a six feet proximity. At 10:10 AM Staff W did not remove their N95, and did not disinfect their eye protection, they went down the hall and into another room. In an observation and interview on 08/15/2022 at 8:57 AM, Staff H, RN was observed exiting room [ROOM NUMBER] wearing two surgical masks, one over the other. room [ROOM NUMBER] had isolation bin outside of room with N95, surgical mask, gown, and gloves. Staff H confirmed that the Resident in 318 was on COVID-19 quarantine for new admission. Staff H stated they could not wear a N95 due to a medical condition, and they have a medical note from their provider. Staff H stated that they had spoken with the DNS about their inability to wear a N95 and that they did not feel they should be working with residents that are on isolation for suspected COVID-19. Staff H stated they were told by the DNS it would be ok. In an interview on 08/15/2022 at 9:08 AM, DNS confirmed that Staff H, RN was not able to complete the fit test for a N95 respirator due to their medical condition. The DNS confirmed the resident in room [ROOM NUMBER] was on TBP isolation for suspected COVID-19. The DNS confirmed the expectation was that all staff that enter the room should be fit tested and wear the appropriate N95 respirator. The DNS stated they rotate the licensed staff on the medication carts and the other two nurses working had already worked the isolation side and that was why Staff H was placed on that hall. The DNS confirmed that Staff H was not able to wear the appropriate PPE for the resident in room [ROOM NUMBER]. At that time, the DNS said they would remove Staff H from the isolation hall. <HAND HYGIENE> A review of the facility policy titled, Hand Hygiene Policy, dated October 2017 defined hand decontamination as to clean hands with alcohol-based antiseptic .before care of resident, after care of resident, before and after using gloves, and when changing gloves during any procedure. In an observation and interview on 08/09/2022 at 2:42 PM, Staff I, RN entered the room to perform wound care for Resident 27. Staff I set up the supplies on the residents over the bed table and adjusted the residents' pillows to support their leg for wound care. Staff I then removed their gloves, did not perform hand hygiene with alcohol-based antiseptic and applied a new pair of gloves to hands. Staff I removed the old dressing from the resident's leg then removed their gloves and did not perform hand hygiene with alcohol-based antiseptic, then applied a new pair of gloves to hands. Staff I then cleaned the wound then removed their gloves and did not perform hand hygiene with alcohol-based antiseptic and applied a new pair of gloves to hands. Staff I then applied the new treatment to wound, removed their gloves, did not perform hand hygiene with alcohol-based antiseptic and applied a new pair of gloves to hands. Staff I applied the dressing to the leg wound, removed their gloves, did not perform hand hygiene. Staff I stated they usually bring a bottle of alcohol-based antiseptic but had forgot this time. In an observation and interview on 08/11/2022 at 2:55 PM, Staff Z, NAC was observed performing peri-care (cleaning of the private area of a resident) with Resident 27. Staff Z removed the residents soiled incontinent brief, cleaned the residents back side, and then placed clean brief under the resident. Staff Z then cleaned the front private area of the resident and fastened the brief. Staff Z never removed their gloves between dirty and clean areas, Staff Z never performed hand hygiene. Staff Z exited the room with soiled gloves on, opened the door handle to the room and exited the room with gloves on and proceeded down hallway with soiled gloves on hands while holding garbage bag. Staff Z stated they keep their gloves on until they drop off the trash. Staff Z touched door handled to soiled utility room door and entered. Staff Z exited the soiled utility room with no gloves on and was observed to be rubbing hands together. <INFECTION CONTROL POLICIES AND PROCEDURES> A review of the facility policy titled, Infection Control Policy revised 06/20/2022 lacked Infection Prevention and Control Procedures (IPCP) that were current and based on national standards (e.g., for undiagnosed respiratory illness and COVID-19). The policy did not address how the staff are to identify communicable diseases, healthcare associated infections, or potential outbreaks. The policy and procedures had not been reviewed for over two years. A review of the CDC guidance titled, Symptoms of COVID-19 updated 08/11/2022, showed that people with COVID-19 have had a wide range of symptoms reported - ranging from mild symptoms to severe illness. Symptoms may appear 2-14 days after exposure to the virus. Anyone can have mild to severe symptoms: Fever or chills, Cough, Shortness of breath or difficulty breathing, Fatigue, Muscle or body aches, Headache, New loss of taste or smell, Sore throat, Congestion or runny nose, Nausea or vomiting, and Diarrhea. In an observation on 08/10/2022 at 8:33 AM, Resident 36 was observed to be coughing and shivering in bed. The resident shared a room with three other residents. In an interview on 08/10/2022 at 8:42 AM, Staff I, RN stated they were aware Resident 36 was coughing. Staff I stated they would assess the resident's oxygen level, and temperature. Staff I stated the resident has had a cough for some time and had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff I acknowledged that Resident 36's respiratory symptoms were consistent with symptoms of COVID-19. The resident was not placed on isolation precautions for signs and symptoms of COVID-19. In an observation and interview on 08/10/2022 at 9:03 AM, Staff C, Nurse Manager (NM) stated they should test Resident 36 for COVID-19 as that would be their protocol. Staff C stated they would not place the resident on isolation until they received a positive test result. Staff C entered resident room and performed a nasal swab test on the resident while wearing a surgical mask, eye protection and gloves. Staff C did not remove their gloves, exited the room, and proceeded to nurse station while they carried the potential COVID-19 sample. Staff C was observed to touch multiple services with gloved hands and did not disinfect those surfaces. Staff C was observed to not follow national standards in infection prevention and control procedure while obtaining the COVID-19 test, nor did the resident get placed on isolation precautions for their symptoms as the current facility policies were not current with the national standards or address COVID-19 virus. <WATER MANAGEMENT PROGRAM> In a review of CDC document titled, Developing a Water Management Program to Reduce Legionella Growth and Spread in Buildings updated 06/24/2021stated Legionnaires' disease is a serious type of pneumonia caused by bacteria, called Legionella, that live in water. Legionella can make people sick when they inhale contaminated water from building water systems . Legionella can grow in many parts of building water systems that are continually wet, examples include: water faucets, showerheads and hoses, eyewash stations, ice machines, decorative fountains. A review of the facility policy titled, Legionnaires Disease Policy, Water Management Program dated 11/2017 stated that the facility Water Management Team consists of the Infection Preventionist, Maintenance Director, Medical Director, Facility Administrator, Contractual Microbiologist, and [NAME] Utilities. Under the title Areas of Risk was the directions for what to list as an area of risk, the policy indicated the facility had one shower/soiled utility. In a physical review of the facility environment there were two shower/tub rooms, utility rooms, an eye wash station, ice machine, several sinks, and a fish tank. In an interview on 08/16/2022 at 11:38 AM Staff Q, Maintenance Director stated they cleaned the ice bins, placed antibacterial tabs in the drains and changed the filters on the water fountain. Staff Q confirmed they were unaware of facility Legionnaire Water Management Program and what was required. Staff Q stated they had never tested water lines or areas of risk for waterborne pathogens such as Legionella. In an interview on 08/16/2022 at 11:41 AM, the Administrator confirmed they were not testing for Legionella, or any other waterborne pathogens. In an interview on 08/17/2022 at 10:09 AM, DNS stated education to staff for COVID-19 and other infection prevention control procedures was completed at the all-staff meetings monthly, and recently they had begun on-line education. The DNS stated they have not completed audits to monitor for compliance or competency checks to ensure staff understood the education they had received. The DNS confirmed that the new residents that were admitted to the facility were placed on quarantine isolation for suspected COVID-19, and that the expectation was all staff were to follow the TBP guidance on the wall outside of the rooms. The DNS confirmed that the TBP guidance they were using currently did not direct staff to wear an N95 respirator, which was required for suspected or positive COVID-19 residents. The DNS stated they were not using the accurate TBP guidance, as the TBP guidance for COVID-19 specified the resident's door were required to be closed and here at their facility they do not close any resident doors. The DNS confirmed they had not completed risk assessments on the new admissions for fall prevention and confirmed they had not included this in the plan of care that the door needed to be open for fall prevention. The DNS confirmed the expectation for hand hygiene for the staff was they needed to use an alcohol-based antiseptic between every glove change, and they needed to also change their gloves when going from an area of dirty to clean such as wound care, and peri-care. The facility failed to ensure the staff disinfected a point of care device for blood sugar monitoring in accordance with manufactures instructions and current infection control standard of practice. The facility failed to ensure the staff wore appropriate PPE within close contact with suspected COVID-19 residents, there was failure by staff to perform proper hand hygiene, and to follow national standards for TBP for residents with suspected COVID-19. These breaches in infection prevention and control procedures placed all residents in immediate jeopardy, and placed all residents, visitors, and staff at risk for potential exposure to COVID-19, other infections and increased the likelihood of serious harm or death. WAC Reference 388-97-1320 (1)(a)(c)(2)(a)(b)(5)(c)(e)

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent pressure ulcer development for 4 of 5 residents (41,13,17 and 36) reviewed for facility acquired pressure ulcers. This failure caused harm to Resident 41, who developed a preventable unstageable (eschar/dead tissue) left heel ulcer and an un-blanchable reddened left great toe ulcer, causing the resident pain and impacting the resident's rehabilitation and discharge potential. The facility additionally failed to prevent the development of new stage 2 pressure injury for Resident 36 and failed to implement effective preventitive skin measures for residents 13 and 17. These failures placed residents at risk for adverse outcomes and decreased quality of life. Findings included . PRESSURE ULCER DEFINITION AND STAGES The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, defined Pressure Ulcer (PU) Definition and Stages as: -A PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (a combination of downward pressure and friction). -Stage 1 Pressure Injury (also known as a PU): Non-blanchable [CONDITION(S)] of intact skin Intact skin with a localized area of non-blanchable [CONDITION(S)] (redness), which may appear differently in darkly pigmented skin. Presence of blanchable [CONDITION(S)] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. -Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis 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. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar (dead tissue) are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [CONDITION(S)] (IAD), intertriginous [CONDITION(S)] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, [CONDITION(S)], abrasions). -Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, intact without [CONDITION(S)] or fluctuance) on the heel or ischemic limb should not be softened or removed. RESIDENT 41 Resident 41 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review on 08/15/2022 of the resident's nursing admission assessment dated [DATE] showed the assessment to be in progress with none of the skin assessment fields completed. Review on 08/15/2022 of the resident's baseline care plan dated 07/15/2022 showed the nursing sections had not been initiated or filled out. Review of the Braden Scale (an assessment tool that measures risk for pressure injury) dated 07/15/2022, scored the resident as 13 which was moderate risk for PU development. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident had no skin issues present on admission and was identified as at risk. The resident's Care Area Assessment stated, Braden 13, no PI (pressure injury), see admission skin note. Review of the nursing admit note dated 07/15/2022 showed arm bruising and an old incision. No other skin issues noted. There were no preventative interventions implemented. Review of a progress note dated 8/2/2022, showed the resident reported pain to their left heel. The nurse noted a dry scab measuring 1.5 cm (centimeter) x 1.5cm with blanchable redness around it. Another scab was noted on top of their left great toe measuring 0.5 cm x 0.5 cm with persistent redness. Therapy suggested that a tight blanket might have caused the redness. The plan to offload (redistribute weight) the heels and use a foot cradle on bed (a device used to keep the blankets off the resident's toes). Review of the resident's Treatment Administration Record (TAR) showed the following interventions dated 08/02/2022 and 08/03/2022 were added: Apply skin prep to both of the resident's heels twice daily; Float (to keep the resident's heels off of the bed and decrease pressure) the resident's heels when in bed. Monitor the left heel, left great toe scab, and redness every shift. Use a foot cradle when in bed and check for its placement every shift. Record review on 08/11/2022 showed no further skin assessments were found in the record since the progress note on 08/02/2022. In an observation on 08/08/2022 at 9:00 am, the resident's left heel was lying on the mattress with no boot. There was no foot cradle on the bed. In an interview and observation on 08/08/2022 at 2:48 PM, Resident 41 stated their pain was mostly concentrated on their left foot, on the outside and inside edge of the heel. The left foot was in a large foam boot with the toes visible revealing a persistent reddened area on the top of the left great toe. The resident stated they were not supposed to have blankets touching their foot, but they did. There remained no foot cradle present on the bed. In an observation on 08/09/22 at 2:45 PM and 08/10/2022 at 9:20 AM, the resident was observed in bed positioned on his back, blankets over the resident's toes touching the tops of the toes. In an interview on 08/10/2022 at 1:13 PM, Staff A, Registered Nurse (RN), stated they had been looking for a foot cradle for days stating they needed to provide it but had been unable to find one for the resident's bed. Staff A stated the resident had a red toe and left heel but stated they were looking better. In an observation on 08/11/2022 at 1:45 PM, Staff A removed Resident 41's left heel boot and lifted the resident's foot up to allow observation of the heel area. There was a noted quarter sized thick dark area on the outer aspect of the resident's left heel consistent with an unstageable pressure ulcer due to eschar. There was a second area the size of a quarter on the inner aspect of the left heel which was soft and reddened with thick calloused tissue covering the center. Staff A touched the heels on both the inner and outer aspects and the resident was noted to have a furrowed brow while the heel and foot were being moved and touched. In a follow-up interview on 08/11/2022 at 2:11 PM, Staff A was asked regarding the process for preventative skin care and wound care for pressure ulcers. Staff A stated there would be assessments in the progress notes and pressure ulcers would be followed by the wound team weekly. When asked to find such notes for Resident 41, Staff A was unable to find any notes in the system, stating that they should be there but that the facility system for skin and wounds was not working. Staff A was evasive when asked to verbally describe the wounds that had just been observed and would only state they needed to make themselves a note to chart an assessment later. In an interview on 08/11/2022 at 2:15 PM, Staff P, Advanced Registered Nurse Practitioner (ARNP), was asked regarding whether they had observed Resident 41's pressure ulcers to which Staff P stated, I was not aware that (they) had any skin issues. I will have to look into that. In an interview on 08/15/2022 at 12:57 PM, Staff C, Licensed Practical Nurse (LPN)/Care Manager, stated they conducted the admission assessments and baseline care plans. Staff C was asked regarding Resident 41's assessments being blank when they had admitted nearly a month ago, and Staff C stated, I must not have gotten to then yet, I have been gone. Staff C stated if a resident developed a pressure ulcer in house, they would have an assessment, be placed on weekly wound rounds, there would be an incident report done, the ARNP would be notified, and they would be on alert charting. When asked regarding Resident 41, Staff C stated they were not aware that the resident had any skin issues so none of those things had occurred because the floor nurses did not tell them. Staff C stated they knew there was at least one foot cradle in the facility so was not sure why it would not have been put on Resident 41's bed. Staff C stated they had no knowledge of progress notes or interventions put in place on 08/02/2022 and 08/03/2022 and could not articulate any type of process for coordination of care with the floor staff adding, I wish they would have told me his heel was like that. RESIDENT 13 Resident 13 was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 13 was assessed to have intact cognition. Resident 13 had a prior PU on her buttock which had resolved at the beginning of the year. Review of nursing order, dated 07/09/2020, showed staff should encourage and monitor for pressure relief especially to their bottom and repositioning throughout day and evening and as awakens on night shift, every shift for skin risk management. Review of physician order, dated 07/30/2020, showed Resident 13 was to have a skin assessment every Thursday on day shift. Staff were to document all skin issues including current and/or new concerns. Review of a Skin/Wound Note, dated 07/08/2022, showed 'No noted skin issues at this time currently resolved issue to buttocks/coccyx area. Routine protective preventive skin care in place including house barrier, pressure reduction with turn reposition.' Review of the care plan showed no PU prevention or interventions to the resident's bottom or coccyx area. In an observation and interview on 08/08/2022 at 9:43 AM, Resident 13 said they had a sore on their bottom, It really hurts. They don't do much. Resident 13 was sitting tilted to the left in their chair. Resident 13 said it hurt so they did not sit on it. Resident 13 said they got the PU at the facility. In an observation and interview on 08/08/2022 at 2:38 PM, Resident 13 was sitting in their chair amd stated they did not like to sit on the wound because it hurt. Resident 13 said there was no cushion, just the chair. On 08/09/2022 at 10:17 AM, Resident 13 was observed sitting in their chair, tilted to the left. At 1:45 PM, Resident 13 continued to sit in her chair in the same position as previously observed. On 08/10/2022 at 8:18 AM, Resident 13 was observed sitting in their chair, slightly tilted to the left. In an interview on 08/10/2022 at 12:30 PM, Staff M, Certified Nursing Assistant (CNA), said Resident 13's bottom had redness but was not open. Staff M said Resident 13 had an open sore, but it had healed. Staff M said when Resident 13 was in their chair, they would have the resident stand up to relieve the pressure. Staff M said, no they did not reposition Resident 13 when they sat in the chair. Resident 13 was in the same position as previously observed in their chair, over four hours prior. In an interview on 08/10/2022 at 2:35 PM, Resident 13 stated they did not get stood up when in the chair. Resident 13 stated they had not been out of the chair today since being placed in her chair this morning. Resident 13 said they did not get reminders to turn. Resident 13 said their bottom still hurt. Resident 13 was sitting in the same position. On 08/10/2022 at 2:37 PM, Staff K, CNA, personal care observations: two staff assisted the resident to transfer from the chair to the bed. No cushion or pillow had been used in the chair. When the adult brief was removed, there was a nickel size area of drainage that corresponded to an open area on Resident 13's coccyx. The skin around the open area was dark red. Staff J, LPN, said the area looked fragile with two open spots. Staff K said they knew it was healing because Resident 13 did not complain that it hurt. On 08/11/2022 at 10:50 AM, Resident 13 was observed up in their chair. At 2:27 PM, Resident 13 was in the same position as the last observation over three and a half hours later. At 3:13 PM, Staff N, CNA, said Resident 13 was usually in their chair when they [evening shift] got there and they put her to bed after dinner. Staff N said they did not reposition Resident 13 when in their chair, she's already comfortable. Staff N said they had not been trained on skin prevention in the year they had worked at the facility. Review of the electronic health record from 08/10/2022 to 08/18/2022, showed no new interventions or documentation of the pressure wound. RESIDENT 17 Resident 17 was admitted [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS assessment, dated 06/18/2022, showed Resident 17 needed extensive assistance of staff for activities like toileting and mobility. Resident 17 was assessed to be moderately cognitively impaired. Resident 17 was assessed to be at moderate risk for skin breakdown. Review of the facility's contracted wound company noted, dated 06/16/2022, showed the stage four PU had healed and Resident 17 was discharged from their service. Review of a progress note, dated 07/09/2022, showed Resident 17's PU had healed with pink, clear skin. Review of a Physician order, dated 07/18/2022, showed the PU had resolved. In an interview on 08/11/2022 at 12:18 PM, Staff H, RN, was completing a skin check. Staff H stated they brought in a dressing, just in case. It's for protection. Staff H described Resident 17's coccyx as having a 2.5 cm x 3 cm red and blanchable area. Staff H said the top layer skin was gone in this area. Staff H said there was a raised whiteish tiny skin tag appearing piece of skin in the center of the red area. In an interview on 08/11/2022 at 2:17 PM, Staff P, ARNP, said the last time she saw Resident 17's pressure wound, it was pink and closed. Staff P said the wound did not have the open, missing skin. Staff P was not sure if Resident 17 was still on wound rounds. In an interview on 08/11/2022 at 2:23 PM, Staff H said they would do an incident report for the coccyx wound on Resident 17. Staff H went to tell the Director of Nursing Service who said to turn, reposition and put cream on Resident 17. In an interview on 08/11/2022 at 3:13 PM, Staff N said Resident 17 had a wound. Staff N said they made sure the resident was clean and dry. That's it. Staff N did not provide additional skin interventions. When asked how they knew what to do for each resident, Staff N said they would get the information from the previous aide during report, or the nurses would tell them. Staff N said they reviewed the Kardex (a care guide for the NACs) every 2-3 days before they would chart. RESIDENT 36 Resident 36 was admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 36 was assessed to be severely cognitively impaired. Review of a physician order, dated 08/31/2020, showed Resident 36 needed prompting and assist to turn/reposition at least every 2 hours or more often as needed. Review of a physician order, dated 09/01/2020, showed staff should complete weekly skin assessments on Tuesdays and document in the progress notes. Review of the previous Tuesday's progress notes, dated 08/02/2022 and 08/09/2022, showed no skin assessments. Review of electronic health record showed no skin assessments were completed under the assessments section. On 08/10/2022 at 8:24 AM, Resident 36 was observed sleeping on their back in bed, slightly tilted to the left. In an interview on 08/10/2022 at 12:57 PM, Staff I, RN, said nurses complete the skin assessments and document in the progress notes. Staff I reviewed the progress notes and was unable to locate an assessment. Yeah, I don't see one. In an observation on 08/10/2022 at 12:42 PM, Staff T, CNA, provided personal cares: On Resident 36's buttock was an approximately three centimeters by half a centimeter dark loose skin, covered with white cream. When the cream was wiped off, the top skin layer was open. Staff T said yes it appeared open. Staff T said this was new to them, they did not know Resident 36 had an open area and called the nurse to come assess. Staff T said they tried to reposition Resident 36 on their side twice a day, after breakfast and after lunch. Staff T said they received report from the nurse, they tell us (care aides) who needed cream or skin interventions. At 2:04 PM, Staff I measured the area as 0.4 x 0.5 centimeters. Staff I, RN, described the pressure wound as open, blanchable around edges, warm to touch, and slight redness. This observer did not see the skin blanch medial to the open area. Staff C came in to observe the wound and said it looked like blanchable excoriation, not like a stage 2, just dry skin. When asked if the top skin layer was missing, Staff C said yes. Staff C said they could not stage the wound, only the RN could stage it. Staff I did not respond when asked about staging of the wound. Staff T positioned Resident 36 in the same position as previously observed. Resident 36 was on a regular facility bed and had one flat pillow used for turning which was not adequate to offload pressure. On 08/10/2022 at 4:31 PM, Resident 36 was in the same position as previously observed after personal care. Review of new physician orders, dated 08/10/2022, showed additional skin interventions were put in place, after observation of the pressure wound, which included to turn resident every two hours and as needed to prevent skin breakdown. Additional order stated to apply barrier cream every shift to coccyx area for stage two excoriation. Review of progress note, dated 08/10/2022, showed Resident 36 had a stage 2 excoriation on her coccyx. On 08/11/2022 at 11:17 AM, Resident 36 was observed in bed, on her back, slightly tilted to the left. At 2:26 PM, over three hours later, Resident 36 remained in the same position. On 08/15/2022 at 8:32 AM, Resident 36 was observed up in her wheelchair for breakfast. At 1:33 PM, five hours later, Resident 36 continued in her wheelchair. Their position had not changed. At 2:33 PM, Resident 36 remained in the same position as previously noted. At 4:05 PM, Resident 36 remained in her wheelchair in the same position as noted for a total of seven and a half hours. In an interview on 08/10/2022 at 1:03 PM, Staff C said, after discovery of a new skin wound, they expected the staff to document, complete an incident report, place the resident on alert charting and make interventions. Staff C said the nurses on the floor did the weekly skin assessments. If the floor nurse found a new pressure wound, they should put in interventions. The CNAs used the Kardex to find the interventions. Staff C said they went around and observed, the floor nurses signed off they monitored the wounds. Staff C said the Director of Nursing Services (DNS) was responsible for risk management. Refer to F 692- Nutrition/Hydration Status Reference (WAC) 388-97-1060 (1)(2)(3)(b)

Based on observation, interview and record review, the facility failed to ensure a resident with a history of trauma was provided appropriate treatment and services for one of two residents (4) reviewed for mental health treatments. The failure to monitor and evaluate the resident's status and underlying causes for changes in mood/behavior, offer resources and services to help cope with their depression, and create an individualized treatment plan; resulted in psychosocial harm, unmet emotional needs, and a diminished quality of life. Findings included . RESIDENT 4 Resident 4 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident had intact cognition. The resident was able to walk with limited one person assist with their four-wheel walker. The resident's patient's health questionnaire - 9 (PHQ-9) an indicator of depression showed the resident scored a 10 which indicated the resident had an impairment of moderate depression and to determine if treatment was necessary. The care area assessment (CAA) triggered for mood, with medication and monitoring of target behaviors and adverse effects of medications. A review of the Quarterly MDS dated [DATE] showed the resident had intact cognition. The resident was able to walk with limited one person assist with their four-wheel walker. The resident's PHQ-9 score was 15 which indicated that the resident had increased depression, categorized as moderately severe depression which warrants active treatment with psychotherapy, medications, or a combination. A review of the resident's care plan with a focus date 02/28/2021 for use of an anti-depressant medication, showed the care plan was not individualized to reflect the resident's emotional and psychosocial needs. The care plan did not reflect any revisions to the plan of care due to an increase in the resident's depression and no changes to the dose of medication was made. In an observation and interview on 08/08/2022 at 9:30 AM, the resident was observed in bed, wearing their pajamas. They stated they felt down in the dumps and did not really feel like interacting. In an interview on 08/08/2022 at 9:41 AM, Resident 4 stated they have had depression for a long time. The resident was tearful and stated they missed their children; it had been a long time since they saw them. The resident explained tearfully they had three children, and that they lived nearby, but they did not visit or call and that was very hard for them. The resident stated they do not have anyone at the facility to talk to about their feelings of sadness. The resident stated they used to see a therapist every week prior to their admission, and it was very helpful. The resident expressed tearfully that their relationship with their children had been strained for a long time, the resident stated, things happened a long time ago, but I am different now. Resident 4 stated it would be beneficial to them if they could speak to a therapist again on a regular basis. In an observation and interview on 08/09/2022 at 8:31 AM, Resident 4 was awake and dressed, they stated they were going to a dentist appointment and were excited to get out of the facility for a few hours. In an observation and interview on 08/09/2022 at 1:24 PM, resident was lying in bed with a sad expression on their face. They stated that their transportation did not arrive, and they did not get to go to their appointment. The resident was asked whether they were able to go for a walk instead and the resident stated no. In an observation and interview on 08/10/2022 at 12:12 PM, Resident 4 had a smile on their face and stated they were able to walk the hallway to get weighed. The resident stated anytime they get to go out of their room it makes them feel a bit better. In an observation on 08/11/2022 at 8:29 AM, 10:12 AM, and 11:42 AM, the resident was lying in bed in their pajamas. In an interview on 08/11/2022 at 11:44 AM, Staff T, Nursing Assistant Certified (NAC) stated the resident used to attend activities but had not for a few months. Staff T stated, they just lie in bed. Staff T stated that the nursing staff were aware of the residents decline in participation. In an interview on 08/11/2022 at 1:34 PM, Staff E, Activity Director stated they were hired in April of 2022 and Resident 4 used to attend activities and participate in resident council but over the last couple of months they have not been attending. Staff E stated the resident's mood had declined in the last few months. In an interview on 08/11/2022 at 1:52 PM, Staff D, Social Worker stated that if the resident had a rough day, they would just check in on them. Staff D said there was no mental health services offered at the facility at that time. In an interview on 08/12/2022 at 8:31 AM, the resident stated they were feeling depressed and became tearful when talking about their feelings. The resident stated no one had been in to see them or talk to them about how they felt. In an interview on 08/12/2022 at 12:05 PM, Staff D confirmed they were hired on 12/08/2021. Staff D stated they were responsible for the PHQ-9 assessment on the MDS. Staff D stated when a resident had an increase in depression, they would notify the nurse manager or the DNS, and maybe give the resident some one-on-one time. Staff D stated they do not have any mental health services at this time, as they stopped coming into the facility during Coronavirus 2019 (COVID-19). Staff D stated they had not approached the resident about a therapist and relied on the nursing staff to let them know when the residents were not on in a good mood. Staff D confirmed they had not tried to obtain appropriate mental health services including outside resources for Resident 4. In an observation and interview on 08/12/2022 at 12:40 PM, the resident was lying in bed with clothes on. The resident stated that yesterday was a rough day and they had been trying to shake this poor mood so they decided to put clothes on in hopes that would make them feel better. Resident confirmed with surveyor they had not had any thoughts of self-harm and thanked this surveyor for caring. In an observation and interview on 08/15/2022 at 8:28 AM, Resident 4 was in their pajamas stated they were doing ok. In an interview on 08/15/2022 at 10:34 AM, Staff H, Registered Nurse (RN), stated the resident used to attend activities but had recently stopped attending. In an interview on 08/15/2022 at 10:40 AM, Staff L, NAC stated the resident used to come out of the room more and go to activities but had not for some time. In an observation and interview on 08/17/2022 at 9:02 AM, the resident was observed in their pajamas. They stated their mood was ok and shrugged their shoulders. The resident said they were used to dealing with their depression and mood for a long time. The resident stated no one at the facility had been in to talk to them about any mental health services. In an interview on 08/17/2022 at 11:01 AM the DNS stated they do not have any mental health services that will come into the facility since pandemic of COVID-19. The DNS stated that the nurse manager or the social worker will talk to residents if they are feeling down. The DNS confirmed they were not aware that Resident 4 had an increase in their depression. The DNS acknowledged that Resident 4 had been tearful, but they were not aware that Resident 4 had stopped attending activities. The DNS confirmed they were not meeting the needs of Resident 4's mental health needs. The facility failed to ensure the mental health of a resident with past trauma needs were met and failed to provide any mental health services after staff recognized they had an increased depressed state, and had withdrawn from social activities. The resident experienced harm, a negative psychosocial outcome of their mental health that was expressed by an increased depressed state with outcomes of sad facial expressions; crying and tearfulness; withdrawal from activities of interest; and reduced social interactions. REFERENCE: WAC 388-97-0960(1)

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to prevent and/or to heal pressure ulcers for four of eight residents (#14, #22, #26, #1) reviewed for skin care. This failed practice caused harm to Resident #14 when staff: 1) stopped assessing, monitoring and documenting a known pressure ulcer, 2) failed to supervise nurse and nursing assistant care, assessments and documentation 3) failed to initiate an investigation why a resident reportedly without a pressure ulcer developed a new pressure ulcer, 4) failed to give the resident her weekly shower and to perform the weekly comprehensive skin assessments, 5) failed to follow a physician's order regarding type of dressing, and 6) failed to document communication with a physician regarding a new pressure ulcer; all contributed to Resident #14 harm, either by not healing a known pressure ulcer and/or preventing the resident from developing a new pressure ulcer. Findings included . Review of the facility policy titled Pressure Ulcers, revised date [DATE], revealed: - The facility would ensure that all residents at risk for pressure ulcers were identified and given care to prevent the development of pressure ulcers; - The facility would ensure that a resident with pressure ulcers received necessary treatment and serves (sic) (services) to promote healing, prevent infection and prevent new sores from developing; - The floor nurse would instruct and supervise Nursing Assistants Certified (NAC) to ensure that care and interventions were implemented to prevent skin breakdown; - The floor nurse would provide wound care as prescribed by the physician, and document in the resident's chart and treatment administration record that wound care was administered as prescribed; - The nurse manager would track the healing progress of pressure ulcers, and alter the plan of care and treatment when needed by filling out the weekly pressure ulcer status report for each resident with skin breakdown that includes type of wound, location, shape, measurements, stage, color, redness, warmth, swelling, granulation, surrounding tissue, ulcer edges, exudate, bleeding, odor, treatments, dressing changes, presence of infection or other complications, and pain; and - The nurse manager would evaluate pressure ulcer treatment weekly for effectiveness and informing the resident's physician of pressure ulcer status. Review of the facility policy titled Shower, Weight and Skin Checks, dated [DATE], revealed: - While showering a resident the nursing assistants were to fill out a Comprehensive NAC Shower Review skin monitoring sheet, and give a copy to the nurse manager, the nurse manager would then do a complete skin check; - Any new skin issues were to have an Incident Report and skin sheets filled out for them; and - Weekly skin assessments would be done on bath/shower days once a week unless otherwise warranted. Review of the facility policy titled Skin Program, dated [DATE], revealed: - The MDS (Minimum Data Set assessment) would serve as an additional assessment tool to aid in identifying resident with skin at risk; - NACs would assess skin conditions throughout each shift as they're caring for the resident and notify LN (Licensed Nurse) of problems observed; - Change resident's position at least every two hours while in bed, wheelchair, chair, etc ., frail resident may need to be positioned more frequently; and - Signs of irritation and pressure need to be reported to the LN immediately. Review of the facility's Center for Medicare and Medicaid Services Resident Census and Conditions of Residents report, dated [DATE], revealed the facility reported they had no residents with pressure ulcers. Review of the facility's Resident Matrix, dated [DATE], revealed Resident #14 had a Stage 2 pressure ulcer (a stage 2 pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising). RESIDENT #14 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the annual MDS assessment dated [DATE], showed the resident had moderate cognitive impairment, had an unhealed Stage 2 pressure ulcer that was not present on admit, required extensive staff assistance of one-two staff with bed mobility, locomotion, dressing, eating, and personal hygiene, had total dependence on staff for transfers and toilet use, and was always incontinent of urine and bowels, and had not exhibited any rejections of care. Review of the skin book revealed Wound Assessment Flow Sheets, with weekly wound documentation from [DATE] - [DATE], showed the resident had a coccyx wound Stage 2 pressure ulcer details. The [DATE] documentation was the last assessment found and it indicated the resident still had a Stage 2 pressure ulcer on her coccyx that was 2.7 centimeters (cm) by 2.0 cm by UD (unable to determine depth). The assessment stated the resident's wound was improving. There was no documentation the wound had ever resolved. Review of the Braden Scale for Predicting Pressure Sore Risk, dated [DATE], revealed the resident was assessed as moderate pressure sore risk. In observations on [DATE] the resident was observed in bed, positioned on her back at 8:33 AM, 9:03 AM, 10:59 AM, 11:28 AM, 12:57 PM, and 1:09 PM. On [DATE], she was observed in bed on her back at 8:58 AM, 10:05 AM, and 11:00 AM. Review of the resident's (MONTH) 2019 Treatment Administration Records (TAR), revealed a treatment the resident was to be turned side to side or bridged every two hours related to a coccyx wound. In an interview on [DATE] at 3:15 PM, Staff A, Licensed Practical Nurse (LPN)/Nurse Manager, stated the resident had no open areas on her skin. In an observation on [DATE] at 11:09 AM, the resident's sacrum skin condition was observed. There was a white gauze dressing (not duoderm as ordered) that had blood soaked through it. After removal of the blood soaked dressing, there was an open area on the coccyx area that was approximately 3 x 3 x 0.2 centimeters (cm), the open area appeared angry red. The staff placed some skin prep and then put on a duoderm dressing. Review of the (MONTH) 2019 Medication Administration Records/Treatment Administration Records (MARs/TARs) revealed: -an order to change the duoderm dressing (preferably a thick one) to sacrococcygeal area every three days for WOUND, dated [DATE], -an order, dated [DATE], to please check dressing every shift to ensure placement and change as needed if dislodged, all shifts on [DATE], [DATE] and [DATE] had on documented for all three shifts each day, -an order, dated [DATE], to turn resident side to side or bridge every two hours related to a coccyx wound, there were no refusals to turn documented in (MONTH) 2019 at all. In an interview on [DATE] at 11:20 AM, the resident stated staff turned her once a day, or maybe two times a day. She denied that she had ever refused turning side to side. She said her buttocks can hurt her a little bit. She didn't know how often she was supposed to be turned to relieve pressure, but said if it's more than once a day you had better tell them (staff) because I can't turn by myself. In an interview on [DATE] at 1:34 PM, Staff A stated she too had noticed there was a gauze dressing, and not the duoderm dressing that was ordered. She stated she assumed the duoderm dressing may have fell off and the nurse that replaced it put on a gauze dressing instead of a duoderm as an emergency wound cover. Review of the [DATE], [DATE] and [DATE] progress notes revealed no documentation why gauze dressing was used to cover the resident's wound, but there was documentation the resident refused to get out of bed for meals. After the coccyx pressure ulcer was observed on [DATE] there was no documentation of wound assessment details done on [DATE]. The skin book flowsheets were copied on [DATE] at 12:52 PM, there was still no wound documentation in the skin book or progress notes. In an interview on [DATE] at 12:52 PM, Staff A was asked about the lack of documentation regarding the new open area, she stated she had not yet documented the new open area, she said she was being pulled in 20 different directions so she hadn't yet been able to document it. She said she was very upset the resident had a new open area. She said she had notified the resident's nurse practitioner but had not documented it. On [DATE] at 8:23 AM, the skin book and progress notes were reviewed, there was still no documentation of the new open area. On [DATE] at 8:12 AM, the skin book and progress notes were reviewed and there was still no documentation of the new open area. The Director of Nursing Services (DNS) was interviewed and she thought there should have been some documentation by then. She was unable to provide any information about the lack of documentation since the open area was discovered three days prior. She stated the floor nurses, not the nurse manager were responsible for daily wound monitoring and documentation, and the nurse manager was responsible for overseeing the floor nurses' work. The DNS was informed the weekly Wound Assessment Flow Sheets had not been done since [DATE] and at that time the resident still had an open wound. The DNS was unable to provide any information about the lack of wound assessments and documentation after [DATE]. The DNS was unable to provide documentation the resident's previous coccyx Stage 2 pressure ulcer had ever healed. The DNS was informed of the observations the resident wasn't being turned every two hours as was documented, she stated she knew the resident was turned some because they had to have done some care. She stated the floor nurses should be making sure the routine care was done, not the nurse manager. The DNS stated she agreed there was a lack of documentation, and she was aware and she was going to be fixing it, and it was something they needed to take a look at. On [DATE] at 8:35 AM, Staff F, Medical Records, was asked for copies of all skin records for the resident, she was unable to provide any Wound Assessment Flow Sheets dated after [DATE], she stated she had looked in the overflow records and in the previous electronic health record. In an interview on [DATE] at 9:35 AM, Staff F provided some Skin Monitoring: Comprehensive CNA (certified nursing assistant) Shower Review forms, however the dates skipped all the way from [DATE] to [DATE]. Staff F was asked if there were more forms available, she stated that was it. The dates on the forms provided were: [DATE] - it had no information at all listed about the resident's skin, and the charge nurse assessment was blank, [DATE] - it stated No new skin issues, and the charge nurse assessment was blank, [DATE]- it stated No new issues, and the charge nurse assessment was blank, [DATE] - it stated No new issues, and dressing applied over coccyx area on diagram, and the charge nurse assessment was blank, [DATE] - it stated No new issues, and the charge nurse assessment was blank, [DATE] - it stated No new issues, the form was not signed by a charge nurse, and the charge nurse assessment was blank, [DATE] - it stated No new issues, and dressing intact with a circle drawn in over the resident's buttocks area, the charge nurse assessment was blank, [DATE] - it stated No new issues, and the charge nurse assessment was blank, [DATE]- it stated No new issues, and the charge nurse assessment was blank, [DATE] - it stated No new issues, and the charge nurse assessment was blank. Review of the quarterly MDS assessment, dated [DATE], revealed the facility had assessed the resident as having no unhealed pressure ulcers (this directly contradicts the Wound Assessment Flow Sheets assessments dated [DATE] (sic) and [DATE] that both indicated she had a Stage 2 coccyx pressure ulcer). In an interview on [DATE] at 11:14 AM, the DNS stated the [DATE] MDS pressure ulcer documentation was miscoded. In an interview on [DATE] at 2:23 PM, the DNS was asked if the facility had yet initiated an incident report (per the Shower, Weight and Skin Checks policy) regarding the new skin open area (observed on [DATE]), she looked in her computer and said No. On [DATE] at 8:00 AM, the resident's skin records were reviewed and there still was no documentation of the details of the open wound observed on [DATE]. On [DATE] at 8:30 AM, the resident's skin book records were reviewed with the DNS, there was still no documentation of the details of the coccyx wound observed on [DATE]. The DNS stated she would talk to the floor nurse about the lack of documentation as it was their (floor nurses') responsibility. The DNS also stated they had a new wound care team/doctor starting the following week, and that the facility lost their previous wound care provider in (MONTH) (YEAR). Review of progress notes dated [DATE] at 9:13 AM, revealed Staff G, LPN, had made a late entry in the progress notes detailing his wound observation from [DATE] (there still was no details of the wound status from [DATE]), that read Duoderm Dressing changed to coccyx/sacrum - wound bed is 100% beefy red, granulated, measures 4cm x 2.5cm x superficial depth. Absent of s/sx (signs/symptoms) of infection. On [DATE], a review of the resident's Record of Showers and Weights, copy date [DATE], revealed she had last been bathed on [DATE]. In summary: The facility's skin management program has failed Resident #14, a summary of the failures included: MDS assessment miscoded as having no unhealed pressure ulcers, a lack of pressure ulcer assessment/documentation, nursing assistants not routinely performing their comprehensive skin assessments on shower days and were really only documenting No new issues and nothing about current skin issues, staff not consistently turning resident every two hours to relieve pressure, not initiating an incident investigation for a new pressure injury, not timely documenting assessment of a new pressure injury, not using the appropriate dressing that was ordered, and overall there was a lack of skilled nursing supervision over the skin care management program for Resident #14. Refer to: F641, Accuracy of Assessments RESIDENT #22 Resident 22 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment dated [DATE], showed the resident's cognitive skills for daily decision making was severely impaired, and the resident required the assist of two staff members for bed mobility, transfer and toileting. During an observation on [DATE] at 9:29 AM, the resident was lying in bed and she was wearing a hospital gown. In another observation on [DATE] at 8:34 AM, [DATE] at 10:38 AM, [DATE] at 11:50 AM, the resident was in bed sleeping and in the same position (head turned to the right side) since 8:34 AM that day. On [DATE] at 3:10 PM, the resident was observed lying in bed sleeping. During a joint observation and interview on [DATE] at 7:48 AM, the resident was lying in bed, Staff K, NAC was changing the resident's brief and the surveyor noted redness on the left buttock. Staff K called the nurse to check the resident's skin. Staff G, LPN and Staff S, RN came in the room and observed the wound. Staff G, described it as a stage 1, non-blanchable redness on the left ischial (buttock) area, measuring 2.5 cm x 0.5 cm. Staff G stated it was the first time he had seen it. During an interview and record review on [DATE] at 3:24 PM, Staff A, LPN/Nurse Manager, stated that any skin issues such as pressure or non-pressure related wounds should have a skin impairment flowsheet documented and monitored in the Skin Book. A Joint record review of the Skin Book with Staff A showed the stage 1 pressure ulcer on the left ischial area was not documented in the Skin Book. Staff A, stated she was hoping the nurse wrote it up, and stated that whoever found the skin problem should initiate it in the Skin Book. During an interview on [DATE] at 11:17 AM, the DNS was informed about the resident's skin issues and stated she concurred with the surveyors report and stated that they identified that skin was an issue for Resident #22. RESIDENT #26 Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Significant Change MDS assessment, dated [DATE], showed the resident's cognitive skills for daily decision making was severely impaired, and the resident required the assist of two staff members for bed mobility, transfer and toileting. Review of the Skin Book showed no monitoring and no documentation for the stage 2 pressure ulcer on the left gluteal (buttock). During an observation on [DATE] at 8:56 AM, the resident had a dressing on the gluteal fold (left buttock) dated [DATE]. At 9:06 AM, Staff G, LPN cleaned the wound and described the gluteal fold wound open area measuring 2.0 cm x 1.5 cm, 100% red tissue covering the wound and it was a stage 2 (partial thickness loss of dermis presenting as shallow open ulcer, red or pink wound bed) pressure ulcer. Staff B, NAC, assisted Staff G with turning the resident, and Staff S, RN was assisting Staff G with the wound care. In an interview on [DATE] at 3:24 PM, Staff A, LPN/Nurse Manager, stated that any skin issues such as pressure and non-pressure related wounds should have a skin impairment flowsheet documented in the Skin Book. A Joint record review of the Skin Book with Staff A showed there was no skin assessment and monitoring for the stage 2 on the left gluteal fold. Staff A stated that she can't help it if nurses don't document in the Skin Book. RESIDENT #1 Resident #1 was admitted [DATE] and had multiple [DIAGNOSES REDACTED]. He had an indwelling catheter (tubing inserted into the bladder to drain urine) from the time of admission. According to the most recent quarterly MDS assessment, dated [DATE] he had severe cognitive impairment, no behaviors, no rejection of cares and required extensive assistance from one to two staff members for all activities of daily living. The assessment indicated no pressure ulcers and identified him at high risk for pressure ulcers. Review of the skin impairment flow sheets dating from [DATE] - [DATE], revealed the last entry, for issues on the buttocks, was [DATE] describing excoriation (raw, irritated skin) that had been noted weekly, starting on [DATE], as resolved. Review of the TARs for the month of July, 2019 revealed weekly skin assessments on (MONTH) 4, 11, 18 and 25 had been completed. There was no accompanying documentation on skin flow sheets or in the clinical record progress notes related to the skin assessments. (Per facility policy when there was no further documentation on the dates of the assessments, there were no new skin issues observed.) The care plan included the problem, The resident has potential and actual impairment to skin integrity related to a biliary drain site, chronic indwelling foley catheter with history of penile erosion-redness to peri-area/buttocks, incontinent of bowel. One of the interventions listed was to turn every two hours in bed, float heels off bed. The care plan also included a problem related to his altered respiratory status. An intervention was to keep the head of the bed elevated to 30 degrees or more to comfort, does not tolerate lying flat. During all observations beginning on [DATE] at 11:23 AM the resident was in his bed with the head of the bed elevated 30 - 45 degrees. Observations through 1:05 PM on [DATE] the resident was turned slightly to the right side. At 3:10 PM he was on his back. On [DATE] during observations at 07:50 AM, 8:46 AM, 9:56 AM and 11:36 AM the resident was flat on his back with the head of the bed elevated approximately 45 degrees. On [DATE] during observations at 7:55 AM, 9:03 AM, 9:22 AM, 9:34 AM, 10:15 AM and 11:53 AM the resident was flat on his back with the head of bed elevated 30 - 45 degrees. At the time of the first observation at 7:55 AM Staff H, NAR was in the resident's room making the roommate's bed. Requested to Staff H, who was assigned to care for the residents, to watch all care she provided for the 2 residents residing in the room for the day. At 11:53 AM Staff H was in the hallway near Resident #1's room. When asked if any care encounters for the two residents had been missed, she responded no and said she would be doing care in about 15 minutes. On [DATE] at 12:15 PM resident care was provided and observed. Staff H, NAR and Staff B, NAC were observed. When the resident was turned to the side the buttocks area was reddened with three small darker areas that were potentially opened and/or excoriated, one on each buttock and one on the sacral area. When care was completed the resident was left positioned on his back with the head of the bed elevated 30 - 45 degrees. The Staff providing care reported the resident's potential issues to the nurse. Resident #1 expired a short while after the care observation on [DATE]. Reference: (WAC) [DATE] (3)(b)

Based on interview and record review, the facility failed to ensure 2 of 4 sample residents (1,4) were free of significant medication errors. Failure to administer the correct physician-ordered dose of insulin resulted in actual harm to Resident 1 who was subsequently hospitalized for [REDACTED]. Findings include: RESIDENT 1 Resident 1 had [DIAGNOSES REDACTED]. Review of Resident 1's June 2014 Medication (Administration) Record (MAR) revealed a 5/5/14 physician order [REDACTED]. Novulin R (Regular short-acting insulin) 100 Units(U)/ML(milliliters) 6 Units SQ (Subcutaneously) before each meal. A nursing progress note dated 6/19/14 at 1900 revealed the resident's 1630 (4:30 p.m.) BS reading was 178. The note then indicated, "Order in MAR indicated [REDACTED]. Misread dose for 100 units. Gave resident 100 units, subcutaneous. Within 10 minutes, realized med error and immediately spoke with Dr.__, MD advise to immediately call 911 ...Resident conscious, answering questions ...next blood sugar 169, administered 2 tubes of instant glucose ...and drank 180 mls of orange juice..." The resident was sent to the emergency room at 4:50 pm. A physician progress notes [REDACTED]. The note also indicated the resident was taken to the emergency department, started on a [MEDICATION NAME] (sugar) intravenous infusion/drip, and admitted for glucose management. The resident was in the hospital from 6/19/14-6/26/14. The hospital discharge summary listed the principal problem as diabetes, profound [DIAGNOSES REDACTED]. During an interview on 7/18/14 at 12:20 p.m., the Director of Nursing said the nurse who administered the 100 units of insulin was a newer nurse who realized almost immediately that she had administered the wrong dose, sought out MD advice, and quickly implemented the orders to counteract potential effects of the insulin medication error. RESIDENT 4 Resident 4 had [DIAGNOSES REDACTED]. Review of Resident 4's July 2014 MAR indicated [REDACTED] [MEDICATION NAME] Insulin Sliding Scale (SS) before meals SQ: (For a) BS (Blood Sugar reading of) <150 = (give) 0 Units (of insulin) 151 - 200 = (give) 2 Units 201 - 250 = (give) 4 Units 251 - 300 = (give) 6 Units 301 - 350 = (give) 8 Units 351 - 400 = (give) 10 Units >400 = (give) 12 Units. According to the July 2014 MAR, [MEDICATION NAME]was administered as follows: July 5, 2014 at Dinner, 4 U were given for a BS of 252. Per the order, 6 U should have been administered. July 15, 2014 at Lunch, 2 U were given for a BS of 212. Per the order, 4 U should have been administered. July 16, 2014 at Dinner, 2 U were given for a BS of 201. Per the order, 4 U should have been administered. Review of Resident 4's July 2014 MAR indicated [REDACTED] [MEDICATION NAME] Insulin Sliding Scale at HS (bedtime): BS <200 = 0 Units (of insulin) 201 - 250 = (give) 2 Units 251 - 300 = (give) 4 Units 301 - 350 = (give) 6 Units 351 - 400 = (give) 8 Units >400 = (give) 10 Units. According to the July 2014 MAR, [MEDICATION NAME]was administered as follows: July 15, 2014 at HS, 6 U were given for a BS of 266. Per the order, 4 U should have been administered. Resident 4's July 2014 MAR indicated [REDACTED].

Based on observation, interview and record review the facility failed to ensure staff provided transfer assistance as care planned for 1 of 4 residents (Resident 1) reviewed. This failed practice resulted in harm for the resident, who fell to the floor and sustained a dislocated hip. Findings include: Resident 1 was admitted to the facility on [DATE], for rehabilitation services after hip surgery. Interviews with the resident and staff revealed the resident was ambulating with a walker and required a 2 person assist for transfers at the time of admission to the facility. On 9/2/10, interview with facility staff revealed the resident had been assisted to the floor during a transfer on 8/15/2010, one day after admission. This resulted in a dislocation of her hip. The resident was sent back to the hospital. Hospital notes indicated the emergency room was not able to reduce the hip so the resident was prepped for surgery. The surgeon was able, under anesthesia, to reduce the hip. The resident returned to the facility but was now on non weight bearing status. Interview with the head nurse revealed a new staff person was working and when she couldn't find anyone to help her, she transferred the resident by herself. She did not check the care plan or check with a nurse to find out what the resident's transfer requirements were. On 9/2/10, the resident was observed sitting in her chair in her room. She had a pillow placed between her legs. She said she was no longer able to ambulate because she had been dropped and dislocated her hip. She was tearful and frustrated stating, "I didn't do anything wrong, it wasn't my fault". Her spouse was in the room and stated, "They didn't do what they were supposed to do and now she has to stay here longer".