Every finding on record at Martha and Mary Health Service

Based on interview and record review, the facility failed to assess, monitor and document a controlled fall timely for 1 of 3 (Resident 1) residents reviewed for quality of care. This failure placed residents at risk of delayed medical intervention and pain.Findings included.Resident 1 was admitted on [DATE] with diagnoses of heart disease and arthritis. The annual Minimum Data Set Assessment, dated 02/25/2026, showed Resident 1 had moderate cognitive impairment.Resident 1's fall risk care plan, dated 02/24/2025, showed Resident 1 was at high risk of falls and had limited physical mobility.On 05/07/2026 at 1:01 PM, Collateral Contact 1 (CC1), said they had visited Resident 1 on Monday, 04/27/2026. CC1 said during the visit Resident 1 complained that their wrist hurt and they had sore foot. CC1 said Resident 1's roommate said Resident 1 had fallen. CC1 said the staff had not contacted them and they had to bring it to the attention of the nurse. CC1 said they were very concerned they were not contacted about the fall and the delay in care. CC1 said Resident 1 did not have xrays taken until Tuesday evening 04/28/2026 and was sent to the hospital late Tuesday night. Review of the facility incident report, dated 04/27/2026, showed Resident 1 was found to have significant bruises and swelling on their right ankle and wrist on Tuesday morning 04/28/2026, during an assessment before their shower. The report showed Resident 1 stated they had fallen the other night in the bathroom. The report showed a witness statement by Staff A, Certified Nursing Assistant (CNA), that indicated they were transferring Resident 1 from the toilet to the wheelchair on Monday 04/27/2026 at 4:45 AM, Resident 1 suddenly lost energy and had to be caught and helped the rest of the way to the wheelchair. The statement showed Resident 1 said they could not complete the transfer and started to sit as they were going to the floor. The statement showed Staff A caught Resident 1 and hoisted them the rest of the way to the wheelchair. The statement showed Staff A told the nurse on the unit about the event since it was unusual for Resident 1. The incident report showed Staff B, Registered Nurse (RN) was contacted on 04/29/2026 for a statement and Staff B said Staff A had reported the event to them, but they did not further assess the resident afterwards and/or place Resident 1 on alert charting. The incident report showed the root cause was Resident 1 had sustained an acute right distal metaphyseal (wrist) fracture and a fractured right ankle from an event that occurred on NOC (night) shift on 04/26/2026.On 05/13/2026 at 1:40 PM, Staff C, Unit Manager, said on Tuesday 04/28/2026, the shower aide notified Staff C that Resident 1 was unable to transfer to the wheelchair, and their right ankle was very swollen and black and blue in color. Staff C said they went and assessed Resident 1 and Resident 1's roommate told Staff C that Resident 1 had fallen. Staff C said they were unaware that an incident occurred and started an investigation. Staff C said it revealed on Monday 04/27/2026, Staff D, Licensed Practical Nurse (LPN) had placed an order request in the medical provider's binder that indicated Resident 1 had a swollen and painful wrist and a bruise on their shin. Staff C said no further assessment and/or documentation was completed from the time of the incident on 04/27/2026 at 4:45 AM until Staff C initiated an investigation and clinical intervention on 04/28/2026 in afternoon. Staff C said Staff D left the order request in the medical provider's binder but did not call and/or contact the provider. Staff C said the medical provider was not aware of the injury until Tuesday 04/28/2026 when they came to the facility and reviewed the documents in the binder. Staff C said Staff B, RN, told them they were aware of the incident but did not assess Resident 1, put them on alert and did not complete an incident report because Staff B thought it wasn't a fall if the resident did not hit the ground. Staff C said Staff B should have assessed Resident 1 when Staff A, CNA, notified Staff B that Resident 1 had an incident in the bathroom while transferring and was not acting like themselves. Staff C said if a Resident had a controlled fall an incident report should be initiated. Staff C said that when Staff D found Resident 1 with a swollen and painful wrist and a bruise, they should have placed Resident 1 on alert charting and contacted the medical provider.Resident 1's order request, dated 04/27/2026, showed Resident 1 had stated they had pain in the right wrist, wrist appeared swollen and they did not want their blood pressure taken on that side and bruising on the left shin was noted.On 05/13/2026 at 2:18 PM, Staff D, LPN, said they were assigned to resident 1 on day shift 04/27/2026. Staff D said Resident 1 had swelling on their right wrist and bruise on the shin. Staff D said they could not remember if CC1 had made them aware of the swelling and pain. Staff D said they completed an order request and placed it in the medical provider's binder. Staff D said they did not contact the medical provider. Staff D said they thought they had placed Resident 1 on alert and notified the oncoming nurse.On 05/13/2026 at 2:23 PM, Staff E, RN, said they were the evening shift nurse on 04/27/2026 and had taken over the care of Resident 1 from the day shift nurse Staff D on 04/27/2026. Staff E said they had no knowledge of any incident and/or injuries with Resident 1. Staff E said if they would have been aware they would have monitored the wrist and leg for further swelling, pain and/or discoloration. Staff E said Resident 1 was not on alert charting.Review of Resident 1's electronic medical record on 05/13/2026 showed no alert charting and/or monitoring of Resident 1's right wrist and/or bruising to their leg on day, evening and/or night shift on 04/27/2026.On 05/13/2026 at 3:47 PM, staff F, Director of Nursing, said they thought Resident 1 was placed on monitoring for their right wrist on 04/27/2026.WAC Reference 388-97-1060(1)-(3).

Based on interview and record review, the facility failed to report an allegation of abuse to the state agency timely for 1 of 3 residents (Resident 1) reviewed for abuse. This failure placed residents at risk of abuse, fear and delayed investigation.Findings included.Review of the facility's policy titled, Abuse and Neglect Protocol, revised July 2024, showed that the following definitions of abuse are sexual abuse is defined as but is not limited to, sexual coercion or sexual assault, and an incident or suspected incident of resident abuse be reported immediately, but not later than two hours after allegation is made if the events involve abuse.Resident 1 was admitted on [DATE] with diagnoses of dementia. The Quarterly Minimum Data Set Assessment, an assessment tool, dated 12/23/2025, showed Resident 1 had severe cognitive impairment and was dependent on staff for toileting hygiene.Resident 1's progress notes dated 03/07/2026, showed Resident 1 verbalized to an aide that a person inserted a finger into their vagina at around 2:00 PM.On 04/06/2026 at 3:19 PM, Staff B, Certified Nursing Assistant, said they were providing care to Resident 1 on 03/07/2026. Staff B said Resident 1 told them they had woken up the previous night with two fingers in their bottom. Staff B said they immediately reported it to their licensed nurse. Staff B said they did not report to the state agency because they were agency staff and were not familiar with the resident and situation.Resident 1's incident report dated 03/23/2026, showed during a chart review the LN [licensed nurse] noticed an entry made on 03/07/2026 that showed the resident reported to staff that they were allegedly touched inappropriately by another person. The report showed the facility reported the allegation to the state agency on 03/23/2026 - 16 days after the allegation was made. On 04/06/2026 at 4:06 PM, Staff A, Director of Nursing, said any allegation of abuse should be reported to the state agency within two hours. Staff A said Resident 1's allegation was an abuse allegation. Staff A said they were not aware of the allegation until they were conducting a chart review on 03/23/2026 and read the progress note. Staff A said the staff should have reported to the state abuse hotline when they became aware of the allegation and then to management.Reference WAC 388-97-0640(5)(a)

Based on interview, and record review, the facility failed to ensure fluid intake was accurately monitored, documented, and assessed for 2 of 2 residents (Residents 16 & 4) reviewed with a fluid restriction. The failure to accurately record fluid intake and to calculate the 24-hour fluid intake total, precluded staff from determining if residents was adherent with or were exceeding the fluid restriction. This placed residents at risk for fluid volume overload, fluid and electrolyte imbalances, unidentified education needs and other medical complications. Findings included .Review of the facility's Fluid Restriction policy, revised 01/2025, showed a fluid restriction order would include the total amount of the fluid restriction per day, and identify how the fluid would be distributed between dietary department and nursing. If a resident was non-adherent or refused the fluid restriction, staff would identify and document why, educate the resident on the risks and benefits of non-adherence and notify the physician.Resident 16Resident 16 was admitted to the facility on [DATE]. Record review showed the resident had a 07/18/2025 order for a 1500 milliliter (ml) fluid restriction. The order showed that day shift was allotted 800 ml; evening shift 500 ml; and night shift 200 ml. The order did not allot any fluids to the dietary department as directed in the facility's fluid restriction policy.An activity of daily living care plan, revised 08/01/2025, listed Resident 16's 1500 ml fluid restriction as an intervention. The comprehensive care plan did not include the reason for the fluid restriction (hyponatremia, low sodium) or identify what the goals of the fluid restriction were. Review of the electronic health record (EHR) showed Resident 16's fluid intake with meals was recorded under Nutrition-Fluids in point of care (POC), and the fluids provided by nursing were documented on the Medication Administration Record (MAR.) Review of the February 2025 MAR showed nurses recorded the amount of fluid they provided each shift. The MAR did not include any instruction to staff to reconcile the fluids recorded on the MAR with the fluid intake at meals recorded in POC. Nor was there a space provided for nurses to record the resident's total 24-hour fluid intake.When the fluid intake recorded on the MARs was reconciled with the fluid intake recorded with meals, for the seven-day period of 02/04/2026 -02/10/2026, it showed the following:02/04/2026 total fluid intake = 2240 ml; exceeded restriction.02/05/2026 total fluid intake = 2330 ml; exceeded restriction.02/06/2026 total fluid intake = 2060 ml; exceeded restriction.02/07/2026 total fluid intake = 2080 ml; exceeded restriction.02/08/2026 total fluid intake = 2080 ml; exceeded restriction.02/09/2026 total fluid intake = 2950 ml; exceeded restriction.02/10/2026 total fluid intake = 2440 ml; exceeded restriction.Additionally, during the seven-day period Resident 16's fluid intake for 5 of the 21 meals was left blank. Review of the EHR showed there was no documentation present to show Resident 16's 24-hour fluid intake totals had been calculated or that staff had identified the resident routinely exceeded the restriction. Resident 4Resident 4 was admitted to the facility on [DATE]. Record review showed the resident had a 07/31/2025 order for a 1500 ml fluid restriction. The order showed that day shift was allotted 800 ml; evening shift 500 ml; and night shift 200 ml. The order did not allot any fluids to the dietary department as directed in the facility's fluid restriction policy.A nutrition care plan, revised 02/09/2026, listed Resident 4's 1500 ml fluid restriction as an intervention. The comprehensive care plan did not include the reason for the fluid restriction (hyponatremia, low sodium) or identify what the goals of the fluid restriction were. Review of the EHR showed Resident 4's fluid intake with meals was recorded under Nutrition-Fluids in POC, and the fluids provided by nursing were documented on the MAR. Review of the February 2025 MAR showed nurses initialed off on Resident 4's fluid restriction but did not record the amount of fluid they provided the resident on their shift. The failure of facility nurses to record the amount of fluid they provided Resident 4 precluded staff from being able to calculate the resident's 24-hour fluid intake totalDuring an interview on 02/13/2026 at 12:11 PM, Staff B, Director of Nursing Services, said Resident 16's and Resident 4's fluid restriction orders should have identified how much of the 1500 ml per day was allotted to dietary and how much to nursing, nursing should have recorded the amount of fluid they provided, and the person or shift responsible for reconciling the resident's fluid intake and calculating the 24-hour fluid intake total, should have been identified and a place to document the total provided. Reference WAC 388-97-1060 (3)(i)

Based on interview and record review, the facility failed to initiate the bowel protocol and accurately document bowel protocol interventions for 4 of 6 sampled residents (Resident 12, 8, 58 & 63) reviewed for bowel care. The failure to initiate and document bowel care, placed residents at risk for pain/discomfort, unmet care needs and other potentially negative health outcomes.Findings included . Review of facility policy titled, Bowel Management, dated January 2024, documented, If no BM [bowel movement] for 3 days or more, offer Bowel meds of resident choice listed below, along with non- pharmacological Interventions . MiraLAX 17gm [grams] in 4 – 8oz [ounce] of fluid, applesauce or pudding, PO [by mouth] QD [everyday] / PRN [as needed] no BM x 2 days. May be repeated two consecutive days Bisacodyl 5mg PO, 1 tablet PO Q 24 hours, PRN no BM x 2 days, if client does not prefer MiraLAX. May be repeated two consecutive days. Bisacodyl, 10mg PR, every 24 hrs., PRN for constipation. Fleets Enema (Mineral Oil) once daily PRN for failure of PO meds, and suppository, or per client request for constipation. Document Provider notification and orders in PCC notes. Resident 58 Resident 58 admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 11/14/2025, showed the resident was cognitively intact, and was not constipated during the assessment period. On 02/10/2025 at 11:57 AM, Resident 58 reported they had been struggling with constipation for a while. Record review showed Resident 58 had the following 11/28/2025 bowel care orders: a) Miralax every 24 hours as needed, administer if no bowel movement (BM) for two days.b) Bisacodyl 5 mg every 24 hours, as needed, if no BM times two days. May be repeated for two consecutive days.c) Bisacodyl Suppository insert rectally every 24-hours as needed for constipation.d) Fleet Oil Enema insert rectally every 24-hours as needed, if no results from suppository. Review of Resident 58s December 2025 bowel record showed they went the following periods without a BM:12/15/2025 - 12/19/2025 (5 days no BM)12/25/2025 - 12/29/2025 (5 days no BM) Review of the December 2025 Medication Administration Record (MAR) showed facility nurses failed to administer as needed bowel medications as ordered and in accordance with the facility bowel protocol. On 02/13/2026 at 12:50 AM, Staff B, Director of Nursing Services (DNS), acknowledged on the two above referenced occasions facility nurses failed to administer as needed bowel medication as ordered and as directed by the facility's bowel protocol. Resident 63 Resident 63 admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact, and was not constipated during the assessment period. Review of Resident 63's February 2026 bowel record showed they went the following periods without a BM or with only a small BM:-02/07/2026 - 02/11/2026 (5 days with one small BM) On 02/13/2026 at 12:50 AM, when asked if facility nurses administered Resident 63 as needed bowel medication on the above referenced occasion in accordance with the physician's orders and the facility bowel protocol Staff B, DNS, stated, No. Resident 8Resident 8 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 8 had short and long term memory problems and needed substantial to dependent assistance with activities of daily living (ADLs). A review of Resident 8's January 2026 MAR showed Resident 8 had orders for: - Bisacodyl tablet to be given orally every 24 hours as needed for constipation if no BM (Bowel Movement) after 2 days. May be repeated two consecutive days. Non-Pharmacological Interventions (evidence-based, non-invasive, and drug-free treatments designed to prevent, manage, or treat health conditions) done prior to administering this medication: 1. Offered prune juice. 2. Encouraged to drink more fluids. 3. Increase fiber intake. 4. Exercise. Dated 12/05/2023. - Bisacodyl suppository given rectally every 24 hours as needed for constipation, if Bisacodyl tablet and Miralax were ineffective. Non-Pharmacological Interventions done prior to administering this medication: 1. Offered prune juice. 2. Encouraged to drink more fluids. 3. Increase fiber intake. 4. Exercise. Dated 02/12/2025. - Fleet Oil Enema given rectally every 24 hours as needed for constipation. 1 time for failure of oral bowel medications and suppository, or per if the patient requests for constipation. Dated 12/05/2023. - MiraLax Powder given orally every 24 hours as needed for no BM after 2 days. Non-Pharmacological Interventions done prior to administering Miralax: 1. Offered prune juice. 2. Encouraged to drink more fluids. 3. Increase fiber intake. 4. Exercise. Dated 12/05/2023. A review of Resident 8's bowel movement record documented the resident did not have a bowel movement on 01/16/2026, 01/17/2026, 01/18/2026 and 01/19/2026, a span of 4 days. A review of Resident 8's January 2026 MAR documented no bowel medications ordered were given in January. On 02/12/2026 at 10:39 AM, Staff H, Licensed Practical Nurse (LPN)/Unit Manager (UM), said Resident 8 should have been administered bowel medications on January 18th. On 02/13/2026 at 12:55 PM, Staff B, DNS, said his expectation was for the bowel protocol to have been started, for staff to document if a resident refused and to notify the provider. Resident 12Resident 12 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 12 was rarely/never understood or able to understand others. Review of the January 2026 and February 2026 Bowel Elimination record documented Resident 12 had no BM's from 01/12/2026-01/14/2026 (3 days) (with a small BM on 01/15/2026), 01/16/2026-01/19/2026 (4 days), and 01/29/2026-02/02/2026 (5 days). Review of the January 2026 and February 2026 Documentation Survey Report Bowel Elimination record documented Resident 12 had no BM's from 01/10/2026-01/14/2026 (with a medium BM on 01/15/2026), 01/16/2026-01/19/2026 (4 days), and 01/29/2026-02/02/2026 (5 days). A nursing progress note dated 01/14/2026 at 7:00 PM, documented Bisacodyl was administered. with a follow up progress note, dated 01/15/2026 at 4:17 PM, that documented the Bisacodyl was ineffective. Bisacodyl was administered again on 01/15/2026 at 7:02 PM. A progress note, dated 01/16/2026 at 5:40 AM, documented the Bisacodyl was ineffective. No further progress notes were found related to the current no BM episode. No progress notes were found showing the bowel protocol had been initiated for the 01/16/2026-01/19/2026 (4 days) no BM episode. No progress notes were found showing the bowel protocol had been initiated for the 01/29/2026-02/02/2026 (5 days) no BM episode. On 02/12/2026 at 9:40 AM, Staff C, Unit Manager/Licensed Practical Nurse (LPN), said the bowel protocol included 6 shifts with no BM, after that the day shift would complete non-pharmacological interventions, like prune juice or exercise, then evening shift with administer Miralax or Bisacodyl, resident preference. Staff would repeat this the following day. When shown the inconsistent documentation (Bowel Elimination record with small BM, Survey Report with medium BM and progress notes documenting no BM), Staff C said the documentation needed to be consistent, because they would not be able to tell if the resident had a BM or not. Staff C was shown the 01/16/2026 and 01/29/2026 no BM episodes and said the bowel protocol should have been initiated, and the documentation should have reflected that. On 02/12/2026 at 10:13 AM, Staff B, DNS, was shown the inconsistent documentation for the 01/10/2026 BM episodes. Staff B said the documentation should have been consistent but stated the resident may have used the bathroom without staff knowledge. When shown the 01/16/2026 and 01/29/2026 no BM episodes, Staff B said the bowel protocol should have been initiated and documented. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to provide documentation of records and evidence of real time analysis of their infection control program for 2 of 6 months (December 2025 and January 2026) reviewed for monthly line listings, monthly maps and/or monthly summaries for the facility's surveillance program. These failures could prevent the facility from identifying trends and implementing interventions that would prevent residents from acquiring facility related infections.Findings included.The facility's policy titled Infection Surveillance. dated 11/2025, documented Monthly time periods will be used for capturing and reporting data. Line charts will be used to show data comparisons over time and will be monitored for trends. On 02/12/2026 at 1:15 PM, Staff I, Infection Preventionists (IP)/Registered Nurse (RN), when asked if she had a line listing for December 2025, said no. Staff I said, she had been behind in December and decided to keep up with January and February because they were currently happening.On 02/13/2026 at 8:45 AM, Staff I, IP/RN, said she had been working on the line listing for December 2025 and she would be able to provide it within an hour. When asked if she had performed the antibiotic stewardship in real time in December, Staff I said there had been quite a few infections in the month of December that had not met criteria for antibiotics and she was working on it currently. Staff I said she had not had time to complete the line listing in December because she had been doing two jobs at that time.On 02/13/2026 at 9:25 AM, Staff I, IP/RN, said she was currently working on the December 2025 line listing. Staff I said she did not have monthly summaries for December 2025 and January 2026 and did not have a surveillance map for December 2025. Staff I said the purpose of the monthly summaries and surveillance maps was to document patterns of infections to see if there were concerns about transmission from resident to resident. Staff I said, I could not see what I was doing in December and what was going on as far as trends but the other months, yes I had a map, and I could see the trends. On 02/13/2026 at 12:55 PM, Staff B, Director of Nursing Services (DNS) said, the infection control program should contain monthly documentation that included a line listing, surveillance map, and a monthly summary. Staff B said the documentation was important for reporting, tracking, following where a source of infection was started, how long residents were to be on isolation, and when staff could come back to work. Staff B said going forward the line listing and map should be kept up to date.On 02/13/2026 at 11:44 AM, Staff I, IP/RN, provided a surveillance map and line listing for December 2025. On 02/13/2026 at 1:09 PM, Staff B, DNS, said the monthly summaries should be kept up to date and his expectation was for it all to be completed in real time.On 02/15/2026 at 1:35 PM, Staff A, Administrator, provided monthly summaries for November 2025, December 2025, and January 2026.Reference WAC 388-97-1320 (1)(a),1320 (2)(a)

Based on observation, record review and interview, the facility failed to maintain a medication error rate of less than 5%, by having an error rate of 8%, with 2 of 25 medication administration errors for observed opportunities. This failure placed residents at risk of medication complications, misuse of medications, and a diminished quality of life. Findings included.MEDICATION NOT GIVEN AS ORDEREDOn 02/11/2026 at 9:37 AM, Staff E, Registered Nurse, said that Resident 13 had just finished their breakfast and she would be giving ferrous sulfate, a medication ordered to be taken with breakfast.On 02/11/2026 at 9:51 AM, Resident 13 was observed to be given the ferrous sulfate, along with pantoprazole.Review of the order for Pantoprazole, dated 11/18/2025, included to take the medication with an empty stomach approximately 30 minutes to 1 hour before meal. On 02/12/2026 at 11:13 AM, Staff E, said the pantoprazole should have been give on an empty stomach, not after breakfast. On 02/12/2026 at 11:35 AM, Staff B, Director of Nursing Services (DNS), when asked about Staff E giving ferrous sulfate and pantoprazole when Resident 13 had just had breakfast, said it did not meet their expectations. MEDICATION LEFT AT BEDSIDEOn 02/11/2026 at 8:56 AM, Staff F, Licensed Practical Nurse, was observed giving medications to Resident 36. Staff F gave Resident 36 a plastic cup with approximately 8 ounces of liquid with medication polyethylene glycol (bowel medication) dissolved in the liquid. Staff F told Resident 36 to keep the medication and sip on it, then left the room leaving the medication with the resident.On 02/11/2026 at 9:01 AM, Staff F was asked if it was acceptable to leave medication with the resident, Staff F said she probably should have stayed with Resident 36, but they would not have drank the medication right away. On 02/12/2026 at 10:39 AM, Staff B, DNS, regarding the observation of polyethylene glycol being left with Resident 36 to finish, said a resident should have a self-assessment prior to having medication left at bedside. Staff B said they believed Resident 36 had a self-administration of medication assessment done.Review of the electronic health record showed there was a self-administration of medication document for Resident 36, dated 02/11/2026 at 10:01 AM, over an hour after the observation of the medication being left at Resident 36's bedside.Reference WAC 388-97-1060(3)(k)(ii)

Based on record review and interview, the facility failed to ensure medications were administered within ordered parameters for 1 of 5 residents (Resident 3) reviewed for unnecessary medications. This failure placed residents at risk of receiving medications outside of ordered parameters and a decreased quality of life.Findings included.Resident 3 was admitted to the facility on [DATE]. According to the Quarterly Minimum Data Set (an assessment), dated 12/23/2025, Resident 3's skills for daily decision making were moderately impaired.Resident 3 had an order, dated 02/17/2025, for Hydrocodone-Acetaminophen (pain medication) to be given every four hours as needed for moderate to severe pain with a pain score of 6-10 (the numbers were based on a numeric rating scale for pain assessment, where 0 represent no pain and 10 represents the worst pain imaginable)Review of Resident 3's Medication Administration Record (MAR) from 01/01/2026 through 01/31/2026, documented the Hydrocodone-Acetaminophen had been administered 38 times outside of the ordered parameters, with numeric pain scores documented under level 6. Review of Resident 3's MAR from 02/01/2026 through 02/10/2026, documented the Hydrocodone- Acetaminophen had been administered four times outside of the ordered parameters, with numeric pain scores documented under level 6.On 02/12/2026 at 3:16 PM, Staff C, Unit Manager/Licensed Practical Nurse, reviewed the January and February 2026 MARs and acknowledged the pain medication had been given outside of ordered parameters and said it should not have been given outside of parameters.On 02/13/2026 at 8:47 AM, Staff B, Director of Nursing Services, regarding Resident 3's pain medication given outside of parameters in January and February 2026, said this did not meet his expectations. Staff B said staff should try nonpharmacological interventions (non-medication interventions) first, then other pain medications if available next, and if pain was not relieved then staff should check with the provider to see if they were able to give the medication outside of parameters. Reference WAC 388-97-1060(3)(k)(i)

Based on observation, record review and interview, the facility failed to ensure bathing services were provided as scheduled, or reoffered if refused, for 1 of 1 resident (Resident 14) reviewed for Activities of Daily Living (ADL) care. This failure placed residents at risk for poor hygiene, skin breakdown, reduced dignity and a diminished quality of life. Findings included.Review of the facility's Promoting Resident Self Determination policy, revised 11/2025, documented Each resident has the right to choose aspects of their daily routine (including sleeping, eating, bathing and waking times), consistent with their interests, assessments, and plans of care. In the event a resident refuses care or treatment, the refusal is to be documented and the care/treatment reoffered.Resident 14 was admitted to the facility on [DATE] with diagnosis of dementia. The Annual Minimum Data Set, (an assessment tool), dated 12/29/2025, documented Resident 14 was moderately cognitively impaired and had no rejections of care. On 02/10/2026 at 9:44 AM, Resident 14 was observed to have shiny oily looking hair, which was slicked down to their head. Resident 14's hair looked unkempt and messy, and observation showed a brown substance under their fingernails. When asked when their last shower was, Resident 14 was unsure. On 02/11/2026 at 8:25 AM, Resident 14 was observed to have hair plastered to their head, appearing to have oil in it, it appeared unkempt and the hair was going in different directions. When asked if they were offered showers regularly, Resident 14 said they did not remember.Review of Resident 14's care plan, reviewed on 02/10/2026, documented Resident 14 had an ADL self-care performance deficit related to increased weakness and decreased mobility secondary to dementia. The care plan documented for Bathing/Showering that Resident 14 required 1-2-person assistance with showers with a goal of once weekly or as needed. On 02/11/2026 at 1:06 PM, Staff D, Certified Nursing Assistant/Lead Shower Aide, said that Resident 14's shower day was Fridays. Staff D said Resident 14 sometimes refused showers. On 02/11/2026 at 1:12 PM, Staff C, Unit Manager/Licensed Practical Nurse, looked in the electronic health record at the last 30 days of showers for Resident 14, and reported Resident 14 last had a shower on 01/23/2026, 19 days previous. When asked for records of refusals and reapproaches since 01/23/2026, Staff C said she would check with the shower aide and find the information.On 02/11/2026 at 1:41 PM, Staff C said Resident 14 should have had two showers since their last one on 01/23/2026, but she could not find any documentation of refusals or reapproaches since that time. Staff C said there should have been documentation of refusals and reapproaches, it was not unusual for Resident 14 to refuse showers, but Resident 14 should have been showered since that time.On 02/13/2026 at 8:44 AM, Staff B, Director of Nursing Services, was informed of the observations of Resident 14's hair being oily and unkempt. Staff B was informed Staff C had provided documentation and confirmed Resident 14 had not been showered since 01/23/2026 and was unable to provide documentation of refusals or reapproaches since that time. When asked if this met his expectations, Staff B said staff should attempt showers and reapproach if a resident was refusing and there should have been documentation of this. Reference WAC 388-97-1060(2)(c)

Based on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 3 of 24 residents (Residents 4, 16 & 38) whose care plans were reviewed. These failures placed residents at risk for unidentified and/or unmet care needs and diminished quality of life.Findings included .Resident 4Resident 4 was admitted to the facility on [DATE]. Record review showed an order, dated 07/31/2025, for a 1500 milliliter (ml) per day fluid restriction secondary to hyponatremia (low sodium). A nutrition CP, revised 02/09/2026, documented the resident was on a 1500 ml per day fluid restriction. The care plan did not identify the goal of the fluid restriction, identify how the fluid would be allotted between the dietary department and nursing; instruct staff what action, if any, should be taken if the resident was non-adherent with the restriction (e.g., patient education, risk versus benefits, Physician notification etc.), or indicate whether the resident should have a water pitcher at bedside. On 02/13/2026 at 12:17 PM, Staff B, Director of Nursing Services, said a fluid restriction CP should have been developed that identified the goals of the fluid restriction and that included direction to staff related to what to assess and monitor, whether a water pitcher should be at bedside, and what action , if any, should be taken if the resident was non-adherent with the restriction. Resident 16, COVID-19 Care PlanResident 16 was admitted to the facility on [DATE]. Record review showed a 02/01/2026 nurses note that documented Resident 16 had a COVID rapid test performed which was positive for COVID-19. The resident was placed on isolation with aerosol precautions. Review of the COVID-19 CP, initiated 01/31/2026, directed staff to follow contact/droplet precautions when providing care, monitor the resident for psychosocial symptoms/risks related to being on isolation, educate family members on transmission-based precautions, provide alternate methods of communication and to provide or modify activities of choice within guidelines and limitations of isolation precautions. The CP did not include direction to staff to assess/monitor the residents for respiratory signs and symptoms and/or complications. On 02/13/2026 at 12:17 PM, Staff B, DNS, said Resident 16's COVID CP should have included direction to assess/monitor their respiratory status and to notify the provider of any changes or complications. Fluid RestrictionReview of Resident 16's electronic health record showed they had an order, dated 07/18/2025, for a 1500 ml per day fluid restriction secondary to hyponatremia. An activity of daily living self-care deficit CP, revised 08/01/2025, had an intervention of Fluid restriction: 0600-1400 [day shift] = 800mL, 1400-2200 [evening shift] = 500mL, 2000-0600 [Night shift] = 200mL. The CP did not identify what the 24-hour fluid restriction was (e.g. 1500 ml/day); identify how the fluid would be allotted between the dietary department and nursing; direct staff what action, if any, staff should take if the resident was non-adherent with the restriction; identify what the goal of the fluid restriction was (e.g. fluid volume overload, hyponatremia etc.); indicate whether the resident should have a water pitcher at bedside. During an interview on 02/13/2026 at 12:17 PM, Staff B, DNS, said a fluid restriction CP should have been developed that identified the goals of the fluid restriction and that included direction to staff related to what to assess and monitor, whether a water pitcher should be at bedside, and what action , if any, should be taken if the resident was non-adherent with the restriction. Resident 38, PASRRResident 38 was admitted to the facility on [DATE]. Review of a level I Preadmission Screening and Resident Review (PASRR) showed the resident had diagnoses of mood disorder; anxiety disorder, delusional disorder (a type of serious mental illness (psychotic disorder) characterized by the presence of one or more, often non-bizarre, false beliefs (delusions) lasting at least one month, while the person otherwise functions relatively normally) and personality disorder (a type of mental health condition characterized by long-term, inflexible, and unhealthy patterns of thinking, functioning, and behaving). Review of the Level II PASRR treatment plan, dated 02/25/2020, showed facility staff were directed to speak with the Resident 38's family members to determine what the resident's delusions presented as in the past and to clarify that delusions were present in the absence of metabolic encephalopathy and infection. Review of the comprehensive CP, initiated 07/11/2019, showed the resident's diagnoses of delusional disorder and personality disorder were not identified as problems/Focus, no goals of treatment or interventions were developed or implemented. The only mention of delusions was on a behavior monitor CP, initiated 07/11/2019, that directed staff to monitor for delusions or hallucinations. Nor did the comprehensive CP identify what Resident 38's delusions were. During an interview on 02/13/2026 at 1:05 PM, when asked if Resident 38's diagnoses of delusional disorder and personality disorder were addressed in the comprehensive CP Staff N, Social Service Director/ Case Manager, stated, No. Fluid RestrictionReview of the comprehensive CP, initiated 01/16/2020, showed under Special Instructions it was documented that Resident 38 was on a 1700 ml per day fluid restriction. Review of Resident 38's electronic health record showed the resident had an order, dated 09/22/2023, for a 1700 ml per day fluid restriction but it was discontinued on 10/23/2023. During an interview on 02/13/2026 at 1:05 PM, Staff N, Social Services Director/ Case Manager, said the CP needed to be updated.Reference WAC 388-97-1020(2)(c)(d)

Based on observation and interview, the facility failed to provide a clean, comfortable and homelike environment on 1 of 2 shower rooms ([NAME] Unit). The failure to ensure the floor was clean and in good repair and the vinyl wall panels were free of damage (cracks, missing pieces etc) placed resident at risk for a diminished quality of life and resulted in a less than homelike environment. Findings included . On 02/10/2026 at 10:16 AM, Resident 38 wanted to discuss the The state of the shower room. They stated, there are cracks in the floor that are filled with caulking, the walls are damaged, tiles are cracked and/or missing. It needs to be fixed. It is a mess. I suggested they stop using the shower room because it needs work badly. On 02/10/2026 2:19 PM, observation of the shower room outside the double doors to the [NAME] Unit revealed the following:The shower room flooring consisted of a seamless resinous (epoxy) surface. The flooring demonstrated extensive discoloration, surface wear, and areas of patching. The finish appeared degraded with heavy uneven discoloration throughout the room, particularly around the floor drain and high-traffic areas. A crack in the flooring greater than six feet long was filled with white one-inch-wide caulking. The fiberglass reinforced plastic (FRP) wall panel was damaged in multiple areas. One area at the lower right corner of the shower room was observed to be cracked and partially detached, exposing the underlying substrate material, which was not smooth, intact or cleanable. On 02/13/2026 at 12:58 PM, Staff B, Director of Nursing Services, observed the shower room and confirmed the degraded and heavily discolored flooring and damaged FRP panels. Staff B said the facility had plans to redo the shower room but had not gotten to it yet. Reference WAC 388-97-0880

Based on interview and record review, the facility failed to promote and facilitate resident choice related to frequency and type of bathing and access to fluids of choice for 3 of 3 residents (Residents 4, 38 & 6) reviewed for choices. The failure to promote and facilitate resident self-determination by offering and honoring residents' choices related to bathing type and frequency and access to beverages of choice, placed residents at risk for poor hygiene, dehydration, feelings of powerlessness, and diminished quality of life.Findings included .Review of the facility's Promoting Resident Self Determination policy, revised 11/2024, showed it was the facility's practice to protect and promote resident rights by promoting and facilitating resident self-determination through support of resident choice. The facility would ensure that each resident had the opportunity to exercise autonomy regarding those things that were important in their life such as preferences. Each resident had the right to choose aspects of their daily routine (including sleeping, eating, bathing and waking times), consistent with their interests, assessments, and plans of care. In the event a resident refused care or treatment, the refusal would be documented and the care/treatment reoffered. Resident 4Resident 4 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 12/15/2025, showed the resident was cognitively intact, bathing/showering was not attempted, and choices related to bathing were Very Important. On 02/09/2026 at 3:12 PM, when asked if they could choose their frequency of bathing Resident 4 stated, No, I would prefer two showers a week, but you only get one. Resident 4 went on to explain each room had an assigned shower day and whatever day was assigned was when you would be showered. A self-care deficit care plan, revised 02/09/2026, showed Resident 4 required one-to-two-person assistance with bathing. Staff were directed to provide bathing with a goal of once a week, if they were unable to perform a shower, staff were to offer a bed bath. Another intervention on the same care plan directed staff to provide Bi-Weekly shower/bath/bed bath, shampoo and nail care. On 09/12/2026 at 10:23 AM, Resident 4 said being bathed bi-weekly or even once a week did not represent their goal for bathing which they indicated would be at least two times a week. Review of Resident 4's bathing record for the 30-day period of 01/14/2026 - 02/09/2026 showed the following.01/16/2026- Bed bath given01/23/2026- Bed bath given01/30/2026- refused02/06/2026- Bed bath given Review of the electronic medical record showed no documentation related to why the resident refused bathing on 01/30/2026 or documentation that staff offered the resident bathing the next day. Resident 38Resident 38 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact, dependent on staff for bathing, and choices related to bathing were Very Important. On 02/10/2026 at 10:16 AM, when asked if they could choose their frequency of bathing Resident 38 stated, No, when I came in, I would get two [showers] a week, but now I only get one and that is just terrible. Resident 38 said staff would tell you what your assigned shower day was, they did not ask for resident input. An activity of daily living (ADLs) care plan, revised 01/05/2026, documented Resident 38 required one person assistance with bathing, with a goal of providing bathing once weekly or as needed. If unable to perform a shower staff were directed to offer a bed bath. The care plan did not specify what unable to perform a shower meant (e.g. resident refusal or staff convenience). Further review showed Resident 38 was previously care planned to receive one to two showers a week, but the care plan was revised to one shower a week on 12/04/2023. On 09/12/2026 at 10:23 AM, when asked if they were included in establishing a goal of being bathed once a week as documented on their care plan, Resident 38 stated, No, that's not enough. Review of Resident 38's bathing record for the 30-day period of 01/14/2026 - 02/09/2026 showed the following.01/14/2026- Bed bath given01/21/2026- Bed bath given01/28/2026- Bed bath given02/04/2026- Bed bath given On 02/11/2026 at 11:44 AM, the facility was requested to provide information on who identified/obtained resident preferences, when and where they were documented. The facility provided their Promoting Resident Self Determination policy but it did not include who, how or when resident care preferences were identified or where they were documented. During an interview on 01/13/2026 at 12:40 PM, when asked how it was determined that Resident 4's and 38's goal for provision of bathing/showers was once a week when both resident's indicated that was not their goal Staff B, Director of Nursing Services, explained that the default was once a week, but the facility would provide bathing more frequently if requested. When asked if the facility staff asked the residents if one shower a week was an acceptable before care planning it as the goal Staff B indicated they would check into what the process was. No further information was provided. Resident 6 Resident 6 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 6 was cognitively intact and needed staff set up or clean up assistance for eating and activities of daily living (ADLs) except Resident 6 was dependent on staff for bathing. On 02/09/2026 at 11:23 AM, no water or fluids were observed at Resident 6's bedside and they said, I don't have water and I would like to get it. Resident 6 was asked, have you asked for water? And they said, No I just go without. On 02/10/2026 at 10:23 AM, no water or fluids were observed at Resident 6's bedside. Resident 6 was asked, do you have water? And they said, no. On 02/11/2026 at 8:12 AM, Resident 6 said they did not have water, and they were waiting on their breakfast tray. On 02/11/2026 at 8:26 AM, Resident 6 was sitting up in bed, eating their breakfast. A carton of milk and a cup of water were observed on Resident 6's tray. On 02/11/2026 at 11:26 AM, No water or fluids were observed at Resident 6's bedside, Resident 6 was asked if they wanted water and Resident 6 said yes. On 02/11/2026 at 11:27 AM, Staff K, Licensed Practical Nurse (LPN) went into Resident 6's room and said he did not see water at Resident 6's bedside. Resident 6 said they would like water with ice and Staff K said he would bring Resident 6 some water with ice. Staff K said he brings Resident 6 a cup of water to take with their medications, but Resident 6 will ask him to pour it out after they have taken their medications. Staff K said Resident 6 was not on a fluid striction and Resident 6 could have water at bedside, including a pitcher of water. On 02/11/2026 at 12:26 PM Staff H, Licensed Practical Nurse/Unit Manager said it was the responsibility of the hospitality aides to be offering water to residents, but there was not a hospitality aide today. Staff H said we should be offering water to residents if they were not on a fluid restriction or if we were not monitoring their fluids. The Certified Nursing Assistants should have been offering water throughout the day when there was not a hospitality aide. On 02/11/2026 at 1:20 PM, Staff B, Director of Nursing Services, said it was the hospitality aide's responsibility to offer water to the residents and water would be offered by the staff. Reference WAC 388-97-0900(1)-(4)

Based on interview and record review, the facility failed to follow physician orders for a surgical wound for 1 of 3 (Resident 1) residents reviewed for quality of care. This failure placed residents at risk for clinical complications, infections and discomfort. Findings included . Resident 1 was admitted to the facility on [DATE]. Resident 1's Hospital's Skilled Nursing Facility Transfer Orders, dated 02/15/2025, showed the resident had a C2-T10 PSF, T4 Corpectomy (surgical procedure on the spine) on 02/06/2025. The orders showed discharge instructions to the SNF [skilled nursing facility] to remove the staples in the incisionthree weeks postop (post-surgery) unless there were any concerns about the incision and then call the surgeon. Review of Resident 1's electronic medical record on 05/13/2025, showed no documentation the staples were removed from the resident's incision and/or the surgeon was contacted. Resident 1's discharge orders, dated 03/03/2025, showed the resident had a follow up appointment with the surgeon on 03/20/2025. The orders showed no documentation the resident had staples in their incision and/or instructions for removal. Resident 1's progress notes, dated 03/04/2025, showed the resident was discharged to their prior living facility with medications and orders. On 05/13/2025 at 04:02 PM, Staff A, Registered Nurse Case Manager, said Resident 1 was discharged to their assisted living facility with their current orders and referrals for home health. Staff A said there was no documentation sent regarding the staples in the resident's incision and/or documentation the facility staff had removed them. On 05/13/2025 at 4:43 PM, Staff B, Director of Nursing, said the facility staff missed Resident 1's order for staple removal from the surgical incision and failed to relay the information to the assisted living facility. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to provide assistance with toileting and bed mobility for 1 of 3 residents (Resident 1) reviewed for quality of care. This failure placed residents at risk for skin breakdown, poor hygiene and pain. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses of cancer and pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure). Resident 1's admission screening and history evaluation, dated 04/03/2025, showed the resident was cognitively intact, needed assistance from staff with bed mobility, totally dependent for toileting and had acute and chronic pain. Resident 1's care plan, dated 04/03/2025, showed the resident was a 1 PA [person assist] with bed mobility and a 1-2 PA with maximum assist using bed pan for bowel movements. The care plan showed the resident had impairments to the skin integrity in the perineal area (sensitive skin between the anus and the genitals), lower extremities, coccyx (tailbone) and heels. Review of the facility's incident report, dated 04/09/2025, showed Resident 1 was placed on the bedpan at approximately 9:15 PM on 04/08/2025 by the evening shift staff. The report showed the evening staff failed to report to the night shift staff the resident was using the bedpan. The report showed the night shift staff had provided the resident with medication and assessment. The report showed the night shift staff were unaware the resident was lying on the bedpan and there was no evidence the staff had repositioned the resident during their shift. The report showed on 04/09/2025, at approximately 7:15 AM, Staff A, Licensed Practical Nurse (LPN), and the wound care team rolled the resident onto their side to assess the resident's wounds and discovered the bedpan. The report showed the resident remembered asking to be placed on the bedpan the night before but said they must have fallen asleep with the bedpan under them and never asked for it to be removed. The report showed the resident sustained a possible deep tissue injury (a type of pressure injury where the soft tissue is damaged by prolonged pressure) measuring approximately 1.0 centimeters (cm) x 2.0 cm on their left gluteal fold (crease between the buttocks and the upper thigh). On 04/14/2025 at 2:32 PM, Staff A, LPN, said Resident 1 had pressure ulcers on their coccyx and heels that were present on admission. Staff A said residents with pressure ulcers and/or at risk for pressure ulcers should be repositioned at least every two hours. Staff A said if a resident refused to be repositioned, they would expect the licensed nurse to provide education to the resident of the risks of not changing positions. Staff A said Resident 1 required assistance from staff to turn on their side due to pain and weakness. On 04/14/2025 at 3:09 PM, Staff B, Director of Nursing, said they expected the nursing staff to turn and reposition Resident 1 every two hours during their shift. Staff B said the night shift aides were unaware the bedpan was under Resident 1, and they assumed the staff had not turned the resident due to their pain. Staff B said the resident was lying on the bedpan from approximately 9:15 PM on 04/08/2025 until 04/09/2025 at 7:15 AM. Reference WAC 388-97-1060 (2)(c)

Based on observation, interview, and record review the facility failed to ensure residents on enhanced barrier precautions (EBP, infection control precaution of wearing gown and gloves during high contact activities during resident care) had precaution signage implemented correctly for 5 out of 14 residents (Residents 19, 576, 59, 24, and 155) reviewed for EBP, that infection control precautions were followed for 2 of 3 residents (Residents 54 and 91) sampled for observation of infection control practices, the antibiotic surveillance was accurate and complete, the Legionella Water Management Program identified and monitored internal areas of risk, and to store and clean continuous positive airway pressure machines (CPAP, device that uses mild air pressure to keep breathing airways open while you sleep) for 1 of 3 residents (Resident 51) reviewed for CPAP. This failure placed residents at risk for spread of infection, health complications, unidentified care needs, and a diminished quality of life. Findings included . Review of the facility policy titled Enhanced Barrier Precautions, reviewed 10/2024, defines enhanced barrier precautions as, the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO [multidrug-resistant organisms] as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). The policy showed clear signage will be posted by the door outside of the room and the wall above the resident bed indicating EBP precautions. The policy also showed a True Blue magnet would be used as signage outside of resident rooms on the door frame. Review of the facility policy titled, Influenza, Prevention and Seasonal Control, dated 09/2024, showed under Standard Precautions hand hygiene should be performed by staff frequently, including before and after resident contact, after any contact with potentially infectious material, and before/after removal of PPE such as gloves. < EBP Isolation Precaution Signage> 1) Review of Resident 19's Electronic Health Record (EHR) showed they admitted to the facility on [DATE], were on dialysis and had a wound. Review of the document titled [NAME] Isolation Precautions, provided on 12/13/2024, listed Resident 19 as being on EBP. Observation on 12/10/2024 at 9:34 AM, showed there was no EBP signage for Resident 19's room. 2) Review of Resident 576's EHR showed they admitted to the facility on [DATE] and had a urinary catheter. Observation on 12/13/2024 at 12:47 PM, showed Resident 576 did not have EBP signage posted on the door or in their room. 3) Review of Resident 159's EHR showed they admitted to the facility on [DATE]. Review of the document titled Bay Isolation Precautions, provided on 12/13/2024, listed Resident 159 as being on EBP for a slow healing wound. Observation on 12/13/2024 at 12:41 PM, showed Resident 159 had no EBP signage outside of their room. 4) Review of Resident 24's EHR showed that they admitted to the facility on [DATE]. Review of the document titled Bay Isolation Precautions, provided on 12/13/2024, did not have Resident 24 listed as being on an isolation precaution such as EBP. During an interview on 12/12/2024 at 8:58 AM, Staff L, Unit Manager (UM)/Licensed Practical Nurse (LPN), said residents with wounds or urinary catheters would need to be on EBP. Staff L said that Resident 24 was no longer on EBP. During an observation and interview on 12/12/2024 at 9:07 AM, Resident 24 was observed to have a True Blue EBP sticker on their side of the room on their wall. Staff L, UM/LPN looked at wall, removed the sign from the wall, and said that the signage was put up for the wrong resident, as Resident 24's roommate, Resident 155, was missing signage. Staff L said Resident 24 no longer needed to be on EBP as they no longer had a wound, but it was possible the signage was left up in error. 5) Review of Resident 155's EHR showed that they admitted to the facility on [DATE] and had a urinary catheter. During an observation and interview on 12/12/2024 at 9:07 AM, Resident 155 was observed to be missing signage for EBP. Staff L, UM/LPN said Resident 155 needed to be on EBP for a urinary catheter. During an interview on 12/13/2024 at 1:08 PM, Staff F, Infection Preventionist/LPN, said it did not meet expectations that Resident 19 did not have EBP signage, Resident 576 should have been placed on EBP, and it did not meet expectations that Resident 159 only had EBP signage inside the room and nonvisible from outside the room. During an interview on 12/16/2024 at 3:07 PM, Staff B, Director of Nursing Services (DNS), said it did not meet expectations that Resident 19 and Resident 576 did not have EBP signage, and there should have been an EBP sticker (sign) outside of Resident 159's room to let staff know there was a precaution. Staff B said it did not meet expectations Resident 24 was on EBP when it was no longer needed or that Resident 155 was not on EBP for a catheter. <Observations of Infection Control Practices> 6) Review of the EHR showed Resident 54 was admitted to the facility on [DATE] and was on EBP for having a suprapubic catheter (small tube that drains urine from bladder by an incision through the abdomen). An observation on 12/12/2024 at 10:17 AM, showed Staff I, LPN, did not wear a gown during catheter care. Further observation showed Staff I only used hand sanitizer/washed hands when entering and exiting the room and missed multiple opportunities for hand hygiene. Staff I hand sanitized, entered room, touched blinds, put on gloves, then provided suprapubic catheter care (involving removal of a soiled gauze), took gloves off, opened blinds, and then washed hands. During an interview on 12/12/2024 at 11:15 AM, Staff I, LPN, said for EBP rooms, staff should wear a gown and that they should have worn a gown when caring for Resident 54. Staff I said hand hygiene should be performed after catheter care, going in or out of the room, and if staff touched anything that was 'soiled.' During an interview on 12/13/2024 at 1:19 PM, Staff F, Infection Preventionist/LPN, said it did not meet expectations that staff did not wear a gown in Resident 54's room for suprapubic catheter care and there were multiple opportunities for hand hygiene including after touching blinds or other items in the room. During an interview on 12/16/2024 at 2:58 PM, Staff B, DNS, said it did not meet expectations that staff did not wear a gown during patient care for Resident 54. 7) Review of the EHR showed Resident 91 was admitted to the facility on [DATE] and was not on a special isolation precaution. Observation on 12/12/2024 at 10:13 AM, showed Staff K and Staff J, Certified Nursing Assistants (CNA), provided care to Resident 91 using a Hoyer (assistive equipment for moving a resident). Staff K was observed to wear gloves, then touched multiple surfaces in the residents' room including Resident 91, the resident's wheelchair and the Hoyer lift. The Hoyer was moved out of the room to a storage area. Staff K was observed to not clean the Hoyer and proceeded to go down the hall. During an interview at 12/12/2024 at 10:20 AM, Staff J, CNA, said since the pandemic was no longer a factor, that the Hoyer could be cleaned any time and as needed. Staff J said it was not cleaned before and after use anymore, unless the resident was on an isolation. During an interview on 12/12/2024 at 10:26 AM, Staff K, CNA, said they do not wipe the Hoyer down after every use, only if the resident is on precautions or if it is soiled. During an interview on 12/13/2024 at 1:19 PM, Staff F, Infection Preventionist/LPN, said CNAs should clean the Hoyer between use, the observation and interviews did not meet expectations, and staff would need more education. When asked about the residents that should be on EBP and have no signage, Staff F said that was why staff should clean after each resident. During an interview on 12/16/2024 at 2:59 PM, Staff B, DNS, in response to the observation and interviews regarding the Hoyer, said standard precautions should be followed and staff needed more training on this. <Infection Surveillance> Review of a document provided on 12/10/2024 for October, November, and December 2024 antibiotic line listing (a document that facilities use to monitor residents for infection, to list symptoms of the infection, to show what organism was present in any cultures, what treatment the resident was on, if they met criteria for antibiotics, etc.), showed: 1. Multiple residents had no dates listed for when symptoms started 2. Multiple residents only had one or two symptoms listed 3. Multiple residents being treated for urinary tract infection did not have cultures listed 4. Multiple residents were missing outside records for cultures During an interview on 12/12/2024 at 3:03 PM, Staff F, Infection Preventionist/LPN, said the antibiotic line listing should be fully filled out, that not all signs and symptoms were listed on the sheet, and they had missed the onset date for symptoms. Regarding labs, Staff F said the facility had switched labs, they were unable to scan any of the labs into the records, and they were not receiving an end of the month microbiology report from pharmacy, with the last report being given in September 2024. During an interview on 12/16/2024 at 1:06 PM, Staff F, Infection Preventionist/LPN, when asked about Resident 156 having a negative urine sample, said the resident had an additional urine test done by the urologist that was positive for yeast, and the urologist had wanted the resident to stay on the antibiotic and added an additional medication to treat the yeast. Staff F said they did not document the result from the urologist. During an interview on 12/16/2024 at 1:06 PM, Staff F, Infection Preventionist/LPN, when asked about Resident 79 and why the line listing did not include any information on the blood cultures ran at the hospital, due to sepsis (infection of the blood) and urinary tract infection being listed, Staff F said they were unaware the hospital ran blood cultures and did not have a copy of the results. At 1:54 PM, Staff F followed up on what symptoms Resident 79 had (only low blood pressure/hypotension was listed) and said that Resident 79 had pelvic discomfort, hematuria (blood in urine), hypotension, and elevated troponin (test used to measure heart damage). During an interview on 12/16/2024 at 2:44 PM, Staff F, Infection Preventionist/LPN, when asked about Resident 66 and how facial swelling met antibiotic criteria, said Resident 66 had facial swelling, redness, and pain. Resident 66 had a CT/computed tomography scan (a machine that takes a series of X-rays and a computer for images of bones and soft tissue) that showed the resident had parotitis (inflammation of the major salivary gland). Staff F said they did not put this information on the line listing and there should have been more information on the form. During an interview on 12/16/2024 at 2:44 PM, Staff F, Infection Preventionist/LPN, when asked about Resident 82 having the same symptoms listed in both October and December 2024 but not listed as meeting criteria for antibiotics in December, said there were more symptoms that were left off of the antibiotic line list for October, and in December there were less symptoms and those symptoms were now baseline. When asked about Resident 82 being on antibiotics despite the resident not meeting criteria to be on one, Staff F said they did not have documentation of any conversation with the provider. Review of the surveillance documents of residents currently on transmission-based precautions titled Bay Isolation Precautions and [NAME] Isolation Precautions, provided on 12/13/2024, showed the list: 1. Was missing a resident with EBP signage outside their room 2. Had residents on the list, with no EBP signage outside their room 3. Had incorrect room numbers for multiple residents During an interview on 12/13/2024 at 1:08 PM, Staff F, Infection Preventionist/LPN, said this form was updated the previous day on 12/12/2024 due to a new admission requiring isolation precaution. When asked about that admission not having signage up on 12/13/2024 for EBP, Staff F said the staff that admitted the resident should have placed the resident on EBP or notified nursing, and they would follow up with admissions. When asked about the room numbers not being updated, Staff F said they could be updating the room numbers. During an interview on 12/16/2024 at 3:07 PM, Staff B, DNS, said the antibiotic line listing should have been more detailed and should have included all of the resident symptoms, and that they will give the infection preventionist more tools to track laboratory values. <Legionella Water Management Program> Review of the facility's document titled, [NAME] & [NAME] Health Services Legionella Water Management Program, revised 08/2024, defined Legionellosis as a condition caused by the bacterium Legionella that can reside in facility water distribution systems. The document had sections for: Areas of Risk, Control Measures and Monitoring Plan and Review Process Review of Areas of Risk showed the facility had not identified any possible internal areas of risk. The document then included ice machines and eye wash stations and explained why there were not considered areas of risk. Review of Control Measures and Monitoring Plan showed the facility was to regularly test hot water temperatures to ensure they were within acceptable limits. No ranges were listed in this section of what temperatures they were monitoring for. During an interview on 12/16/2024 at 1:56 PM, Staff F, Infection Preventionist/LPN, said temperature logs were done daily, that Legionella grew best from 77 to 113 degrees Fahrenheit (F), and then showed documentation of temperature logs. When asked what happens when the temperature was within 77 to 113 degrees F, as was noted frequently on the temperature log shown, Staff F said they continued to monitor for changes, prevented stagnation, and checked on the hot water heater/boiler. When asked if these temperature logs had identified potential areas for Legionella to grow, Staff F said no because water flows through it. Staff F said to prevent Legionella, nothing should stay in the pipes. During an interview on 12/16/2024 at 2:07 PM, Staff R, Project Manager, when asked about the provided documentation of temperature logs provided above, being mostly within the range of temperature Legionella grows best in, said the facility had never identified that area as high risk to test, and that hot water heater/boilers were left at 112 to 113 degrees F to prevent burning residents. When asked about what was done in rooms not being used, Staff R said the empty rooms were cleaned but the faucets did not need to be flushed. When asked if the area from the valve to the faucet had stagnant water in that section of the pipe, Staff R said yes that section had stagnant water, and they should develop a log to track and record flushing the sinks not being used. Review of Review Process showed the Legionella Water Management Program was approved annually by the Quality Assurance and Performance Improvement (QAPI) Team. Documentation was requested on 12/16/2024 at 11:18 AM from Staff F that the program was reviewed by QAPI, and none was provided. The facility's Legionella Water Management Program included a document titled, Developing a Water Management Program to Reduce Legionella Growth & Spead in Buildings, dated 06/24/2021, a toolkit from the Centers for Disease Control and Prevention (CDC). The toolkit had information for facilities on where Legionella could grow or spread which included: Hot and cold-water storage tanks Water heaters Water filters Faucets Shower heads and hoses Pipes, valves, and fittings Eyewash stations Ice machines CPAP machines During an interview on 12/16/2024 at 1:56 PM, Staff F, Infection Preventionist/LPN, when asked about the CDC list for where Legionella could grow, said the CPAPs would be an area of concern and this would need to be addressed in the policy. When asked how the facility was monitoring the program if there were no identified areas of concern, Staff F said that was a valid concern and they would need to address that in QAPI. During an interview on 12/16/2024 at 3:31 PM, Staff A, Administrator, said their expectation for recognizing risk for Legionella was the facility should explore more avenues than they had been. Staff A said they had not gotten any Legionella test kits because they had not identified any areas of risk. 50392 <Failure to clean CPAP humidifier reservoir> Review of the facility policy titled CPAP/BIPAP SUPPORT dated 2024, documented general guidelines for cleaning: 1. Humidifier (if used): a. use clean, distilled water only in the humidifier chamber. b. clean humidifier weekly and air dry. c. To disinfect, place vinegar-water solution (1:3) in clean humidifier. Soak for 30 minutes and rinse thoroughly. Resident 51 admitted to the facility 07/31/2024. Review of the Significant Change Minimum Data Set Assessment showed Resident 51 had a diagnosis of obstructive sleep apnea (intermittent airflow blockage during sleep) and was severely cognitively impaired. On 12/10/2024 at 9:48 AM, Resident 51 had a CPAP machine on their bedside table with a humidifier reservoir visible. Review of physician's orders showed Resident 51 used a CPAP machine. No orders were located regarding cleaning of humidifier reservoir. On 12/13/2024 at 2:24 PM, Staff P, LPN, said Resident 51 had a humidifier with a reservoir tank for water placement. On 12/16/2024 at 10:39 AM, Staff Q, Registered Nurse, said the CPAP reservoirs for the humidifier should be cleaned periodically, there should be physician's orders to clean the reservoir, and it should be on the Treatment Administration Record (TAR) to make sure it was getting done. Staff Q could not locate physician's orders or anything on the TAR for the cleaning of the humidifier reservoir for Resident 51. On 12/16/2024 at 12:08 PM, Staff L, Unit Manager said for Resident 51 said they could not locate orders or directions on the TAR for cleaning the CPAP reservoir, there should be orders, and it should be on the TAR. <Failure to store CPAP to prevent contamination/infection> On 12/09/2024 at 4:13 PM and 12/10/2024 at 8:42 AM, observed CPAP machine and mask on Resident 51's bedside table, mask was not in plastic bag and was resting on the tabletop. On 12/11/2024 at 12:33 PM, observed CPAP machine and mask on Resident 51's bedside table, mask was not in plastic bag and was resting on top of a radio that was on tabletop. On 12/12/2024 at 12:23 PM, Staff F, Infection Preventionist/LPN, said her expectation was for CPAP masks be wiped down daily and stored in a plastic bag at bedside after cleaning. Staff F said it did not meet expectations that Resident 51's mask was stored uncovered on the tabletop. On 12/12/2024 at 12:40 PM, Staff B, DNS, said CPAP masks should be stored in a sealed bag or container to prevent infection. Reference WAC 388-97-1320 (1)(a)(c),(2)(a)(b)

AMENDED 01/02/2024 Based on interview and record review, the facility failed to ensure 7 of 7 sampled residents (Residents 11, 73, 78, 27, 62, 22, and 82) reviewed for unnecessary medications were free from unnecessary psychotropic (affect mind, emotions and/or behaviors) medications. Facility staff failed to fully complete the Abnormal Involuntary Movement Scale (AIMS, an assessment used to determine the severity of abnormal movements in a patient's body) for residents using antipsychotic (a class of drugs used to treat mental health conditions characterized by psychosis) medication. The facility also failed to identify, monitor, and document observed target behaviors and non-pharmacological interventions. These failures placed residents at an increased risk for experiencing medication-related adverse side effects, unmet needs, and a diminished quality of life. Findings included . Review of the facility policy titled, Psychotropic Drugs Utilization, dated 12/2024, documented, A. Movement disorder evaluation will be completed (AIMS, DISCUS [Dyskinesia Identification System: Condensed User Scale (DISCUS), assessment tool], etc). This record will remain in the resident's chart. D. Targeted unacceptable behavior will be defined. Acceptable levels of this activity will be indicated in the care plan. (see Target Behavior Reference Guide) E. Specified behaviors to be modified will be defined if applicable. IV. The specific behavior or manifestation of the disordered thought process and the medication side effects to be monitored will be identified for each resident in their Care Plan. V. Data collection will be done on the medication administration record. VII. Documentation of observed adverse reactions will be on the medication administration record and will be summarized monthly. VIII. Staff will continue to document significant behaviors or unusual behaviors or levels of behavior in the progress notes, as they are observed on a daily and shift-to-shift basis . XI. Each psychotropic medication will be monitored separately and documented independently. 1) Review of the Electronic Health Record (EHR) showed Resident 11 was admitted on [DATE]. Resident 11 had diagnoses of depression (decreased pleasure or interest) and post-traumatic stress disorder (PTSD, traumatic event that triggers thoughts/distress/anxiety). The Significant Change Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 11 was able to make needs known, was cognitively intact, and had documented delusions. Review of Resident 11's orders showed they were receiving two psychotropic medications: 1. Duloxetine (an antidepressant) once a day for major depressive disorder 2. Abilify (an antipsychotic) once a day for PTSD and depression <AIMS Assessment Form> Review of Resident 11's care plan showed they were supposed to have AIMS assessments done every six months and as needed, initiated 02/17/2023, due to being on psychotropic medications. Resident 11's AIMS forms completed on 03/27/2024, 05/01/2024, and 11/01/2024 were reviewed, and all were missing the top section on the form (the part that asks the resident to perform certain tasks). During an interview on 12/11/2024 at 8:29 AM, Resident 11, after reviewing some of the questions from the top of the AIMS form that was blank, said the facility has not asked them to do them. Question seven was reviewed, Ask resident to tap thumb, with each finger, as rapidly as possible for 10-15 seconds: separately with right hand, then with left hand, and Resident 11 said they had not been asked to do that. During an interview on 12/11/2024 at 11:32 AM, Staff E, Unit Manager (UM)/Licensed Practical Nurse (LPN), said Resident 11's last AIMS form was not filled out completely as Resident 11 could complete some of tasks in the section left blank. Staff E said their expectation was to redo the AIMS assessment with all the tasks Resident 11 was capable of completing, with every box filled out with what Resident 11 could and could not complete. During an interview on 12/11/2024 at 2:16 PM, Staff B, Director of Nursing Services (DNS), said the whole form for the AIMS should be attempted. For Resident 11, Staff B said it did not meet expectations that the last AIMS form had the top section blank, and their expectation was that staff would have attempted and documented an attempt to fill out the top of the form, with a reason documented if a question was not performed. <Psychotropic Medication Behavior Monitoring> Review of Resident 11's EHR showed documentation that Certified Nursing Assistant's (CNAs) were documenting that behaviors occurred, with behaviors noted in the past 30 days on: 11/18/2024 at 5:59 AM 11/19/2024 at 8:39 PM 11/25/2024 at 9:59 PM Review of Resident 11's EHR, showed no further documentation of follow up to those behaviors being noted. No progress notes were found on those dates. No descriptions of the behaviors were found. During an interview on 12/11/2024 at 11:32 AM, Staff E, UM/LPN, when asked what the process was for behavior monitoring, said the CNA should chart and mark if a behavior happens, but cannot be descriptive. Staff E said some nurses charted on behavior monitoring also, which allowed them to write a progress note. Staff E said that behaviors needed to be monitored to investigate them, in order to know what correct interventions were needed, to determine if social services needed to be involved, if there needed to be a care conference, and if the resident needed to be put on an alert. When asked what behaviors Resident 11 had on 11/18/2024, 11/19/2024, 11/25/2024, Staff E said they were unable to find a progress note for those dates, and their expectation was for nurses to write a progress note if Resident 11 was having behaviors. During an interview on 12/11/2024 at 2:16 PM, Staff B, DNS, said when a behavior was witnessed, the CNAs were to tell the nurses, then the nurses were to provide interventions. Regarding Resident 11's behaviors, Staff B said their expectation was for Resident 11 to have been placed on alert and have monitored behaviors. <Psychotropic Medications Without Non-pharmacological Interventions> Review of Resident 11's EHR showed no documentation of non-pharmacological interventions being implemented, despite Resident 11 receiving psychotropic medication and having documented behaviors. During an interview on 12/11/2024 at 2:16 PM, Staff B, DNS, said for psychotropic medications, CNAs were able to provide non-pharmacological interventions if there were behaviors noted. Staff B said nurses had the opportunity to chart on non-pharmacological interventions when they administered psychotropic medications, and that nurses should chart in the progress notes. During an interview on 12/12/2024 at 11:23 AM, Staff E, UM/LPN, said they were unable to find any documentation that Resident 11 had non-pharmacological interventions done for psychotropic medications. 37044 2) Resident 73 admitted to the facility on [DATE]. Review of the Annual MDS showed the resident had severe cognitive impairment, diagnoses of dementia with agitation, and anxiety and depressive disorders. Resident 73 required treatment with antidepressant, antianxiety, and antipsychotic medications during the assessment period. A psychotropic drug use care plan (CP), revised 10/25/2024, showed the resident received clonazepam (an antianxiety medication) and Seroquel (an antipsychotic medication) for anxiety. Staff were directed to monitor behaviors and document them on the behavior flowsheet. The CP did not indicate what behaviors the resident's anxiety manifested; no specific target behaviors (TBs) were identified that each medication was initiated to treat. A Behavior Monitor CP, revised 10/25/2024, identified the TBs for each psychotropic medications as follows: a) clonazepam- anxiousness as evidenced by calling out. b) Seroquel- agitation related to dementia with inability to self-soothe. c) mirtazapine- diminished appetite or lack of interest in food. d) Nuedexta (not a psychotropic medication)- involuntary crying/laughter, related to Major Depression Disorder. On 12/12/2024 at 12:38 PM, Staff L, UM, said the CP inaccurately identified the diagnosis for the use of Seroquel as anxiety, rather than dementia with severe agitation. Staff L, also said that the specific TB(s) a medication was initiated to treat should be included in the CP. A 09/30/2024, Pharmacist's Recommendation to Prescriber note, showed a recommendation to perform a gradual dose reduction (GDR) of the residents Seroquel to 25 milligrams (mg) three times daily. The recommendation was approved by the physician on 10/02/2024 and implemented. A 11/16/2024, Order Request, documented Resident 73 was calling out multiple times throughout the evening shift. A copy of 09/30/2024 GDR recommendation was attached. The provider responded on 11/18/2024 with an order to return the resident's Seroquel order to 25mg twice daily and 50 mg at bedtime. Review of the EHR showed Resident 73 had not demonstrated any increase in behaviors to include agitation, which had been identified as the target behavior for the use of Seroquel, since the 10/02/2024 GDR was initiated. The 11/16/2024 nurses note and order request was the first time a nurse had documented increased calling out, or any other behavior issues. No documentation was present to support the determination of a failed GDR. Additionally, calling out was the identified TB for the use of clonazepam, not Seroquel. On 12/12/2024 at 1:14 PM, Staff L, UM, confirmed calling out was the identified TB for the use of clonazepam not Seroquel. When asked if there was any documentation to support Resident 73 had demonstrated increased agitation since the Seroquel GDR was performed Staff L stated, not that I see. No further information or documentation was provided to support the determination that the resident had a failed GDR of their Seroquel. 42960 3) Resident 78 was admitted to the facility on [DATE] with diagnoses including depression and anxiety. The Quarterly MDS, dated [DATE], showed the resident required setup to partial assistance with activities of daily living (ADLs) and was cognitively intact. A review of the EHR showed an order for Lexapro (a drug used to treat depression and certain anxiety disorders) 5 milligrams (mg) to be given in the morning for depression and an order for buspirone (an antianxiety medication) 5 mg to be given in the morning for anxiety. A review of the EHR showed Behavior Tracking #2 Did monitored behavior, tearfulness, statements of sadness, related to Depression DX r/t use of Lexapro occur during shift? If so, then notify LN.and yes was documented on 11/26/2024 and 12/5/2024. A review of the progress notes revealed no corresponding notes from the nurse. A review of the EHR showed Behavior Tracking #3 Did monitored behavior, break through anxiety AEB panic attacks, related to anxiety dx r/t use of Buspar occur during shift? If so, then notify LN. and yes was documented on 11/21/2024 and 12/3/2024. A review of the progress notes revealed no corresponding notes from the nurse. On 12/11/2024 at 12:57 PM, Staff E, UM/LPN said we don't have behavior monitors and her expectation was that monitors be ordered so that if there were increased depression or anxiety symptoms, an adjustment could be made. On 12/11/2024 at 1:36 PM, Staff B, DNS said the CNAs documented behavior monitoring in Point of Care (POC) and if there were behaviors, the CNAs would report them to the nurse. The nursing staff would charted by exception when Resident 78 has those behaviors. When the DNS was asked if the nursing staff were documenting the behaviors the CNAs were charting for Lexapro and Buspirone, he said I don't see any documentation in the progress notes for Resident 78 . 46793 4) Resident 27 was admitted to the facility on [DATE], with diagnoses including cognitive communication deficit (communication difficulty caused by cognitive impairment), major depressive disorder, anxiety disorder and unspecified dementia (decline in mental abilities that affect daily life), with other behavioral disturbances. The Quarterly MDS, dated [DATE], documented Resident 27 was severely cognitively delayed with limited communication abilities. Resident 27's orders showed they were receiving four psychotropic medications: 1. venlafaxine (an antidepressant) once a day for depression. 2. buspirone (an antianxiety) two times a day for anxiety. 3. lorazepam (an antianxiety) three times a day and PRN for anxiety. 4. mirtazapine (an antianxiety) one time a day for appetite stimulant. Review of Resident 27's EHR showed no documentation or implementation of target behavior monitoring for any of the psychotropic medications. 5) Resident 62 was admitted to the facility on [DATE], with diagnoses to include Alzheimer's Disease (a brain disorder that gradually destroys memory and thinking skills, and eventually the ability to perform everyday tasks), major depressive disorder, anxiety disorder, unspecified psychosis (a mental health condition characterized by a loss of contact with reality), and unspecified dementia, severe with agitation. The Quarterly MDS, dated [DATE], documented Resident 62 was severely cognitively delayed, with limited communication abilities. Resident 62's orders showed they were receiving three psychotropic medications: 1. Lexapro (an antidepressant) once a day for depression/anxiety. 2. Seroquel (an antipsychotic) two times a day for agitation. 3. buspirone (an antianxiety) twice a day for anxiety. Review of Resident 62's EHR showed no documentation or implementation of target behavior monitoring for any of the psychotropic medications. On 12/12/2024 at 10:48 AM, Staff B, DNS, said target behaviors and monitoring should have been implemented and documented in the EHR. 50488 6) Resident 82 admitted to the facility on [DATE] and was diagnosed with major depressive disorder on 05/30/2024 and anxiety disorder on 12/02/2024. The Quarterly MDS, dated [DATE], showed Resident 82 was cognitively intact and was able to make needs known. A review of the EHR showed a PRN order for lorazepam (a psychotropic medication that produces a calming effect on the brain and nerves) 0.5mg. Give 0.25mgs every six hours as needed for anxiety until 11/11/2025.The medication start date was 11/11/2024. Directions to staff were: Document behaviors exhibited and non-pharmacological interventions used before giving PRN Ativan: 1. Yelling 2. Inability to self-soothe 3. Temper outburst 4. Inconsolable crying 5 refusing care. Interventions were: 1. Redirection 2. Food/beverage 3. Reassurance 4. Offered activities/exercise 5. Offer warm blanket 6. Manage pain. A review of the December MAR showed Resident 82 had received the PRN dose on the 3rd, the 6th, and the 10th. There was no documentation of behaviors exhibited or of non-pharmacological interventions. On 12/11/2024 at 4:08 PM, Staff C, Assistant Director of Nursing Services (ADNS), said lorazepam should not be ordered as a PRN for longer than two weeks as there was not sufficient documentation by the ordering provider. Behaviors exhibited should have been documented. Non-pharmacological interventions should have been implemented and documented before lorazepam was given. 7) Resident 22 admitted to the facility on [DATE]. The Quarterly MDS dated [DATE], showed Resident 22 was moderately cognitively impaired, was dependent on staff for most ADLs, and had diagoses of depression and dementia. A review of the MAR showed Resident 22 recieved two psychotropic medications: buproprion HCI ER (an anti-depressant) oral tablet extended release 100 mg every morning for major depressive disorder. Start date of 12/07/2023. duloxetine HCI (an anti-depressant) oral capsule delayed release 60 mg daily for depression/pain. Start date of 01/30/2024. A review of the CNA November task list showed Resident 22 exibited behaviors on 11/13/2024, 11/14/2024, 11/15/2024, 11/17/2024 and on 11/19/2024. The CNAs charted non-med interventions did not alter behaviors. The charting did not specify what those interventions were. There was no documentation completed by the nurse. On 12/11/24 at 04:08 PM, Staff C, ADNS, said the expectation was that the nurses monitored for side effects and the aides monitored for behaviors. They made a check mark and then were expected to tell the nurse. The nurse was expected to assess, chart, and put the resident on alert. Staff C noted these behaviors were not addressed and that there was a breakdown in the system. Non-pharmacologic interventions and behavior monitoring should have been on the Treatment Administration Record to be signed off by the nurse, for both psychoactives and narcotics. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review the facility failed to comprehensively assess residents for the use of bed rails/mobility bars for 4 of 5 residents (Residents 11, 51, 40,and 91) reviewed for physical restraints. This failure placed residents at risk for potential injury, potential restraint, unmet care needs, and a diminished quality of life. Findings included . Review of the facility policy, titled Proper Use of Side Rails, revised 09/2024, documented side rails will not be offered to residents on admission. A full assessment will be completed and informed consent obtained prior to authorizing the use of side rails. 1) Review of the Electronic Health Record (EHR) showed Resident 11 was admitted on [DATE]. Resident 11 had diagnoses of depression (decreased pleasure or interest), anxiety (increased stress), and post-traumatic stress disorder (traumatic event that triggers thoughts/distress/anxiety). The Significant Change Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 11 was able to make needs known and was cognitively intact, but had documented delusions. The MDS showed that Resident 11 was dependent (helper does all the effort) for positioning for: 1. rolling left to right 2. sit to lying 3. lying to sitting on side of bed 4. sit to stand 5. chair to bed transfer Review of Resident 11's document, titled Assessment and Consent for Safety Enabling Device-V2, dated 04/04/2024, showed that Resident 11 had bilateral side rails 1/2 size for bed mobility. The form had a section that said Explain Why it is not a restraint and filled in is the answer enhanced bed mobility. Review of the document showed that it was missing: 1. Any attempt to use an alternative 2. Assessment of the resident for risk of entrapment prior to installation Review of Resident 11's orders showed the side rails, ordered 04/04/2024, were for enhanced mobility and were not to be used for patients with confusion or altered mental status unless recommended by therapy. Review of the EHR showed Resident 11 had a fall on 07/23/2024. A progress note from later that day described Resident 11 as having hallucinations, and telling staff they wanted to get into bed despite already being in bed. During an observation and interview on 12/12/2024 at 8:25 AM, Resident 11 had upper bilateral bed rails/mobility bars in an up position. Resident 11 said they were never instructed on how to lower them, did not use the mobility bars to independently position in bed, and only used the mobility bars when being repositioned by staff. During an interview on 12/13/2024 at 9:15 AM, Staff E, Unit Manager (UM)/LPN, said normally Physical Therapy/Occupation Therapy (PT/OT) was responsible for an evaluation within the first 24 hours of admission, to assess whether mobility bars were appropriate for the resident. Staff E said consent was required because they could be considered a restraint, and then the resident would need an order and care plan. When asked when mobility bars were contraindicated, Staff E said for residents that no longer need them, such as from a change of condition. In this situation, then a reevaluation would be needed to determine if they were appropriate or if it was unsafe. Documentation was requested to show if Resident 11 had any assessment completed, related to mobility bar safety, continued necessity and re-assessments after the 07/23/2024 fall. During a follow up interview on 12/13/2024 at 1:53 PM, Staff E, UM/LPN, said the requested documentation did not exist. Staff E said their expectation was for better assessments for mobility bars in resident rooms, and that the lack of documentation did not meet expectations. During an interview on 12/16/2024 at 3:25 PM, Staff B, Director of Nursing Services (DNS), when provided the list of documentation requested for Resident 11 that did not exist, said it did not meet expectations. When asked about Resident 11's fall in July, said it did not meet expectations that it was not reevaluated. 50392 2) Resident 91 readmitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed Resident 91 had diagnoses including slurred speech and aphasia (a language disorder that affects a person's ability to communicate), and was rarely/never understood. Review of Resident 91's document titled, Assessment and Consent for Safety Enabling Device, showed no area indicating an evaluation/assessment was done. The form did not identify what less restrictive options were attempted, did not evaluate for safety or entrapment concerns or propose ways to reduce risks to the resident. Observation on 12/09/2024 at 9:08 AM, showed Resident 91 had two bed rails/mobility bars by the head of the bed, positioned up. On 12/11/2024 at 12:08 PM, Staff L, UM, said Resident 91 had bed rails and they used them. On 12/12/2024 at 6:52 AM, Staff J, Certified Nursing Assistant (CNA), said Resident 91 could not independently release the bed rails/mobility bars. 3) Resident 40 readmitted to the facility on [DATE]. Review of the Significant Change MDS, dated [DATE], showed Resident 40 had diagnoses that included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) affecting their left non dominant side, dizziness, and repeated falls and was cognitively intact. Review of Resident 40's document titled, Assessment and Consent for Safety Enabling Device, showed no area indicating an evaluation/assessment was done. The form did not identify what less restrictive options were attempted, did not evaluate for safety or entrapment concerns or propose ways to reduce risks to the resident. Observation and interview on 12/12/2024 at 7:41 AM, showed Resident 40 had two bed rails/mobility bars by the head of the bed, positioned up. Resident 40 said she could not release the bed rails by herself. 4) Resident 51 admitted to the facility 07/31/2023. Review of the Significant Change MDS dated [DATE] showed Resident 51 had diagnoses that included hemiplegia and hemiparesis affecting their right dominant side and was severely cognitively impaired. Review of Resident 51's document titled, Assessment and Consent for Safety Enabling Device, showed no area indicating an evaluation/assessment was done. The form did not identify what less restrictive options were attempted, did not evaluate for safety or entrapment concerns or propose ways to reduce risks to the resident. Observation on 12/12/2024 at 8:22 AM, showed Resident 51 had two bed rails/mobility bars by the head of the bed, positioned up. On 12/12/2024 at 6:56 AM, Staff J, CNA, said Resident 51 could not independently release the side rails to the downward position. On 12/11/2024 at 2:19 PM, Staff L, UM/LPN, said only the form titled Assessment and Consent for Safety Enabling Device was being done and there was no additional document of a safety assessment done prior to placement of bed rails/mobility bars. On 12/13/2024 at 10:53 AM, Staff B, DNS, said there should be an evaluation/assessment done prior to placement of side rails/mobility bars, and a periodic reevaluation to see if they are still beneficial, safe, and appropriate for the resident. When asked for documentation for Resident's 51, 40, and 91 that an evaluation or assessment had been done for bed rails/mobility bars, Staff B said they would follow up on that. Additional documentation was provided on 12/13/2024 at 1:11 PM, by Staff B, DNS, for Resident 51 and 91. Review of the documentation showed no assessments for side rails/mobility bars. No additional documentation was received for Resident 40. During a follow up interview on 12/13/2024 at 2:03 PM, when specifically asked for bedrail assessments, Staff B, DNS, was unable to provide any documentation that bedrail assessments had been completed. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure resident care plans (CPs) were reviewed, revised, and accurately reflected residents' care needs for 6 of 25 sampled residents (Residents 73, 99, 81, 8, 11 and 91) whose care plans were reviewed. These failures placed residents at risk for unmet care needs and diminished quality of life. Findings included . 1) Resident 73 admitted to the facility on [DATE]. Review of the Annual Minimum Data Set (MDS, an assessment tool) showed the resident had severe cognitive impairment, diagnoses of dementia with agitation, and anxiety and depressive disorders. Resident 73 required treatment with antidepressant, antianxiety, and antipsychotic medications during the assessment period. A psychotropic drug use CP, revised 10/25/2024, showed the resident received clonazepam (an anxiolytic medication) and Seroquel (an antipsychotic medication) for anxiety. Staff were directed to monitor behaviors and document them on the behavior flowsheet. The CP did not indicate what behaviors the resident's anxiety manifested, no target behaviors (TBs) were identified that each medication was initiated to treat. On 12/12/2024 at 12:38 PM, Staff L, Unit Manager (UM), said the CP inaccurately identified the diagnosis for the use of Seroquel as anxiety, rather than dementia with severe agitation. Staff L, also said that the specific TB(s) a medication was initiated to treat should be included in the CP. Resident 73 started on mirtazapine (an antidepressant medication) daily on 04/03/2024. The indication for use was depression with a decreased appetite. Loss of interest in food was the identified TB. Review of the psychotropic drug use CP, revised 10/25/2024, showed Resident 73's mirtazapine use was not identified or addressed on the CP. On 12/12/2024 at 12:43 PM, Staff L, UM, said, Resident 73's mirtazapine should have been included on the psychotropic drug CP, but was missed. An order for Nuedexta (a central nervous system agent), dated 03/12/2023, showed it was initiated to treat pseudobulbar affect (PBA, a neurological disorder that causes uncontrollable bouts of emotion such as laughing and crying). Review of the Behavior Monitors CP, revised 10/25/2024, showed the resident was started on Nuedexta for involuntary crying/laughter related to Major Depressive Disorder (MDD), rather than PBA as stated in the order. On 12/16/2024 at 10:47 AM, Staff L, UM, said the CP was inaccurate and needed to be updated/revised to reflect a diagnosis of PBA. 2) Resident 99 admitted to the facility on [DATE]. Review of a Behavior Monitors CP, revised 10/29/2024, showed direction to staff to monitor the number of times the target behavior (SPECIFY) related to (SPECIFY Dx), (SPECIFY medication) occurred during the shift. On 12/16/2024 at 10:27 AM, Staff L, UM, said Resident 99's behavior CP was incomplete and needed to be updated to include what psychotropic medication was in use, the supporting diagnosis and the resident specific target behaviors. 50488 3) Resident 81 was admitted to the facility on [DATE] with diagnosis of Guillain-Barre Syndrome (a condition in which the immune system attacks the nerves) and malnutrition (lack of sufficient nutrients in the body). The Quarterly MDS, dated [DATE], showed Resident 81 was moderately cognitively impaired and did not receive nutrition via a feeding tube. On 12/10/2024 at 2:24 PM, review of Resident 81's care plan, revised 09/23/2024, showed a PEG (Percutaneous Gastrostomy) tube (used when someone is unable to eat or drink enough food or liquids to meet their nutritional needs) had been placed on 01/31/2024 and was pending discontinuation. On 12/10/2024 at 2:30 PM, a note from a medical provider, dated 09/27/2024, said the PEG tube was removed on 09/27/2024. On 12/11/2024 at 4:05 PM, Staff C, Assistant Director of Nursing Services, said care plans should be updated quarterly and/or with significant changes, by either the Unit Manager or the MDS nurse. The expectation was that care plans were updated as changes took place. 50945 4) Resident 11 was admitted on [DATE]. Resident 11 had diagnoses of depression (decreased pleasure or interest) and anxiety (increased stress). Review of the Significant Change MDS, dated [DATE], showed that Resident 11 was no longer on hospice (end of life care with limited interventions). Review of Resident 11's care plans, showed that a care plan for psychotropic drug (medication that affects the mental state) use still mentioned that Resident 11 was on comfort care (hospice), and was last revised 10/06/2024, before Resident 11 was discharged from hospice. The same care plan had an intervention, last revised 10/06/2024, for lorazepam (anti-anxiety medication) as needed every two hours for anxiety and/or restlessness. Review of the Electronic Health Record (EHR) showed Resident 11's lorazepam dose was discontinued on 11/7/2024. During an interview on 12/11/2024 at 11:32 AM, Staff E, UM/ Licensed Practical Nurse (LPN), said Resident 11's care plan was not updated since it still mentioned hospice and their care plan should have been revised when they were discharged from hospice. Staff E reported Resident 11 was not receiving lorazepam, that it had been discontinued. During an interview on 12/11/2024 at 2:16 PM, Staff B, Director of Nursing Services (DNS), said their expectation for revising care plans was for any significant change, change of condition, or any new orders or recommendations from the provider. Regarding Resident 11's care plan mentioning hospice, Staff B said their expectation was that it would have been completed timely and been up to date. 5) Resident 91 was admitted on [DATE]. On 12/11/2024 at 10:20 AM, an observation of Resident 91's door from the hallway showed no signage was posted that indicated the resident required any transmission based precautions. Review of Resident 91's care plan showed an intervention, initiated 12/30/2023, for enhanced barrier precautions (EBP, infection control precaution of wearing gown and gloves during high contact activities during resident care). During an interview on 12/13/2024 at 1:08 PM, Staff F, Infection Preventionist/LPN, said Resident 91 was not on EBP, did not need to be on EBP currently, the care plan needed to be updated, and this did not meet expectations. During an interview on 12/16/2024 at 2:59 PM, Staff B, DNS, said the care plan for Resident 91 should have been updated. 6) Resident 8 was admitted on [DATE]. Review of Resident 8's care plans showed on 07/31/2024, a care plan for aerosol contact isolation had been initiated. Resident 8 was no longer on this precaution on 12/09/2024. During an interview on 12/13/2024 at 1:08 PM, Staff F, Infection Preventionist/LPN said Resident 8's care plan needed to be updated, and their care plan did not meet expectations. During an interview on 12/16/2024 at 3:07 PM, Staff B, DNS, said this did not meet expectations. Reference WAC 388-97-1020(2)(c)(d)

Based on interview and record review, the facility failed to use nonpharmacological interventions (NPI, nonmedicated methods of achieving an outcome) prior to the use of as needed (PRN) pain medications for 4 of 8 sampled residents (Residents 11, 24, 78 and 355) when reviewed for unnecessary medications and pain. This failure placed residents at risk of avoidable side effects, taking unneeded medications, and a diminished quality of life. Findings included . 1) Resident 78 was admitted to the facility on [DATE] with diagnoses including dementia and chronic pain. The Quarterly Minimum Data Set (MDS), an assessment tool, dated 10/17/2024, showed the resident required partial to setup assistance with activities of daily living (ADLs) and was cognitively intact. A review of Resident 78's Electronic Health Record (EHR) showed an order for oxycodone 5 milligram (mg, a unit of measurement for weight in the metric system) every 4 hours as needed for chronic pain and an order for acetaminophen 325 mg tablet, to give two tablets for mild pain/fever every six hours. A review of Resident 78's Pain Tool, dated 12/10/2024, listed Repositioning Warm blanket/towel Distraction on Phone/Tv Coloring pages as What non-pharmacological interventions reduce pain/discomfort. A review of the Medication Administration Record (MAR) for November 2024 showed Resident 78's PRN oxycodone was given 29 times and the acetaminophen was given 21 times and no NPIs were documented as provided in Resident 78's progress notes. A review of the MAR for December 2024 showed Resident 78's PRN oxycodone was given ten times and the acetaminophen was given five times and no NPIs were documented as provided in Resident 78's progress notes. On 12/11/2024 at 1:36 PM Staff B, Director of Nursing Services (DNS), said he did not see NPIs being documented for Resdient 78 in a progress note and his expectation was that the nursing staff document NPIs more when a resident complains of pain. 50488 2) Resident 355 admitted to the facility on [DATE] with a diagnosis of age-related osteoporosis (a condition where the bones become weak and brittle) with current pathological fracture (bone fracture caused by weakness of the bone structure). The Medicare 5-Day MDS showed Resident 355 was moderately cognitively impaired and was able make needs known. Review of the MAR showed an order for Tramadol (a narcotic used to treat moderate to severe pain). The order was for 100 mg every six hours as needed for pain. Resident 355 received 12 doses from December 1st through December 9th. Resident 355's care plan, dated 11/21/2024, said to monitor/document the side effects of the pain medication. There was no documentation on the side effects of the pain medication or of NPIs. On 12/10/2024 at 3:21PM, Staff D, Assistant Director of Nursing Services, said the expectation was that pain medications would have side effect monitoring and non-pharmocological interventions on the Treatment Administration Record (TAR). 50945 3) Review of the EHR showed Resident 11 was admitted on [DATE]. The Significant Change MDS, dated [DATE], showed Resident 11 was able to make needs known and was cognitively intact. Review of Resident 11's orders showed that they were being given acetaminophen three times a day for pain and had an order for morphine (narcotic pain medication) as needed for every two hours. Review of the MAR on 12/10/2024, for November 2024 and 12/01/2024 to 12/09/2024, showed Resident 11 received morphine 12 times total in November and only once thus far in December. Pain scores were not found with scheduled acetaminophen administration. Review of the EHR showed no documentation of NPIs used for November and December 2024. Review of the previous five weekly pain assessments showed pain score out of 10 where 1 is mild pain and 10 is worst pain possible: 12/05/2024 no pain location listed, current pain 1, worst pain 1 11/28/2024 no pain location listed, current pain 1, worst pain 1 11/21/2024 no pain location listed, current pain 1, worst pain 1 11/14/2024 no pain location listed, current pain 1, worst pain 1 11/07/2024 no pain location for medications (does mention Orajel for tooth ache); No pain scores provided During an interview on 12/11/2024 at 8:29 AM, Resident 11 said they would be interested in switching to a longer acting medication for pain, had not had any discussion with the facility on changing the morphine order, and was not asked for a pain score every time acetaminophen was given. During an interview on 12/11/2024 at 3:48 PM, Resident 11 said once a week someone came and asked if they were having pain or not, but they did not remember being asked to give a specific number. Resident 11 said they did not know if they needed scheduled acetaminophen three times a day. During an interview on 12/11/2024 at 11:32 AM, Staff E, UM/LPN, said pain management was reviewed when there was a change of status such as discharging from hospice. When asked for documentation that Resident 11's narcotic pain medication, morphine, was reevaluated after Resident 11 was discharged from hospice, Staff E was unable to provide documentation. Staff E said their expectation was that staff would follow up with the provider on the necessity for pain management, or that a discussion was had on if there was an alternative option. Staff E said there was not a discussion on longer acting pain medication for Resident 11. Staff E reviewed the MAR and reported Resident 11 only received morphine three times thus far in December. Staff E said their expectation for pain management was that staff would use a pain scale, have documented the location of the pain, followed up on if the pain medication was effective, and documented a progress note of the NPIs implemented. During this interview, Staff E confirmed that there was no documentation in the EHR under progress notes of NPIs for pain, for Resident 11. Staff E said there were no pain scores connected to the scheduled acetaminophen dose, that the order needed to be updated to include scores, and that staff would not know if the acetaminophen was effective without the scores. During an interview on 12/11/2024 at 2:16 PM, Staff B, DNS, said their expectation when a resident was discharged from hospice was that medications would have been reviewed for appropriateness and staff should have referred to provider to re-evaluate medications. Staff B said Resident 11 used morphine only 12 times in November 2024, and that number did not reflect that they had persistent chronic pain. When asked if Resident 11 needed every two-hour PRN narcotic pain medication, Staff B said no because Resident 11 was not receiving medication every day. When asked about Resident 11 not having NPIs documented, Staff B said nurses had the opportunity to document in progress notes or the administration record. During this interview, Staff B said for scheduled pain medication, staff always gave the medication even when there was no pain. Staff B said Resident 11 was being monitored weekly with pain assessments for the continued need for acetaminophen. Staff B said the weekly assessments let staff know if the acetaminophen was needed. Staff B stated the resident reported the acetaminophen relieved pain during the last assessment, so the medication was still needed. When asked their expectation if a general resident that received scheduled acetaminophen was having pain scores obtained with each administration and the resident reported no pain each time for a week, Staff B said they would expect staff to review if the medication was needed. 50392 4) Resident 24 was admitted to the facility 04/09/2024. Review of the Quarterly MDS, dated [DATE], showed Resident 24 had a diagnosis of chronic pain and was moderately cognitively impaired. Review of the MARs, dated November 2024 and December 2024, showed Resident 24 had an order for oxycodone every every hours PRN, with no NPIs documented. On 12/16/2024 at 12:16 PM, Staff L, UM said NPIs should be part of the pain medication orders and documented on the MAR. When asked to provide documentation that NPIs had been attempted for Resident 24, Staff L said there was no documentation this had been done. Reference WAC 388-97-1060 (3)(k)(i)

Based on observations, interview, and record review the facility failed to obtain an assessment, orders, consent, and develop a care plan for the use of potential restraints for 1 of 4 residents (Resident 91) reviewed for physical restraints. This failure placed residents at risk for potential injury, potential restraint, unmet care needs, and a diminished quality of life. Findings included . Resident 91 readmitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set, an assessment tool, dated 09/19/2024, showed Resident 91 was dependent with mobility abilities, was rarely/never understood, and was moderately impaired for daily decision making. On 12/10/2024 at 2:49 PM, Resident 91 was observed in bed with body pillows (longer than standard pillows) on both sides of their bed positioned under the fitted sheet. Review of Resident 91's Electronic Health Record showed no assessment, consent, orders, or care plan documentation for the body pillows. On 12/11/2024 at 8:45 AM, Resident 91 was observed eating breakfast in bed with body pillows on both sides of the bed positioned under the fitted sheet. On 12/12/2024 at 6:23 AM, Resident 91 was observed to have one standard pillow on the left side of their bed, positioned under the fitted sheet. On 12/12/2024 at 6:52 AM, Staff J, Certified Nursing Assistant, when asked why body/standard pillows had been placed for Resident 91, Staff J said staff put pillows there because Resident 91 moved back and forth, could turn themselves, and sometimes their feet would slide off the bed. Staff J said they knew the pillow should not be under the fitted sheet and they were placed there to keep Resident 91 from falling out of bed. On 12/12/2024 at 12:12 PM, Staff L, Unit Manager, said they were conducting an audit for the use of body pillows due to there not being orders, care plan, or consent and those things should have been done, especially if the resident could not remove the pillows themselves. When asked about an assessment for bed pillows, Staff L said she would have to follow up with the Director of Nursing (DNS), and she believed a policy discussion was on the horizon. On 12/13/2024 at 2:03 PM, Staff B, Director of Nursing Services, said for the use of body/bed pillows his expectation was that an assessment, consent, orders, and a care plan would be done, and these had not been done. Reference WAC 388-97-0620(1)

Based on interview and record review, the facility failed to ensure residents and/or their representatives were provided accurate information regarding the risks and benefits associated with proposed drug therapies for 2 of 5 sampled residents (Residents 11 & 73) reviewed for unnecessary medications. The failure to accurately identify medication/drug class and associated adverse side effects (ASEs) detracted from residents' ability to make informed decisions about proposed drug therapies, and placed them at risk for making treatment decisions based on inaccurate information. Findings included . Review of the facility's Psychotropic Drug Utilization policy, dated 12/2024, showed a psychotropic drug was defined as any drug that affects brain activities associated with mental process and behavior. In the event a psychoactive medication was ordered, licensed staff would obtain informed consent for the use of the medication prior to initiating therapy. 1) Review of the Electronic Health Record (EHR) showed Resident 11 was admitted on [DATE]. Resident 11 had diagnoses of depression (decreased pleasure or interest) and post-traumatic stress disorder (PTSD, traumatic event that triggers thoughts/distress/anxiety). Review of the EHR showed Resident 11 was receiving Abilify (anti-psychotic medication, decreases symptoms of disconnect with reality) for depression and post traumatic stress disorder (PTSD). The Significant Change Minimum Data Set Assessment (MDS), dated [DATE], showed Resident 11 was able to make needs known and was cognitively intact. Review of Resident 11's consent form for Abilify on 04/04/2024 listed Abilify as an antidepressant. During an interview on 12/11/2024 at 11:32 AM, Staff E, Unit Manager/Licensed Practical Nurse, said the purpose of reviewing risk and benefits during consent for psychotropic medications was so residents would know what the side effects were, what the medication did, and how the medication could help them. For informed consent, Staff E said the residents needed to know the class the drug was and what medication they were to receiving. Staff E said that antipsychotic medication consent should go over antipsychotic risks and benefits, and for Resident 11, the Abilify consent was incorrectly done under antidepressant but should have been redone to be an antipsychotic medication. During an interview on 12/11/2024 at 2:16 PM, Staff B, Director of Nursing Services, said the resident or their power of attorney needs to be informed about the risk and benefits of psychotropic medications, for informed consent. When asked if the risks and benefits were the same for an antidepressant and an antipsychotic, Staff B said they were not exactly the same. Staff B said Resident 11 should have had their Abilify consent done as an antipsychotic, and it was an error that it was completed as an antidepressant. 37044 2) Resident 73 admitted to the facility on [DATE]. The Annual MDS, dated [DATE], showed the resident was cognitively impaired, had diagnoses of anxiety, depression and agitation, and received antianxiety, antidepressant and antipsychotic medication during the assessment period. On 10/11/2024 a new order was obtained for Nuedexta (a central nervous system agent) daily for pseudobulbar affect (PBA, causes episodes of uncontrollable laughing, crying, or anger that were unrelated to mood). An Authorization for Psychoactive Medication consent form, dated 12/11/2023, showed staff presented Nuedexta to the resident as an antipsychotic medication and a mood stabilizer. The indications for use were documented as calling out, yelling, and dementia with behaviors (agitation). On 12/12/2024 at 12:38 PM, when asked if Nuedexta was accurately identified as an antipsychotic medication and mood stabilizer Staff L, Unit Manager, stated, No. When asked if calling out, yelling, and dementia with agitation were appropriate indications for use of Nuedexta, Staff L said no and acknowledged Resident 73 was provided inaccurate drug information for Nuedex, to include the drug class, indications for use and potential adverse side effects. Reference WAC 388-97-0300(3)(a), -0260, -1020(4)(a-b)

Based on observation, interview and record review, the facility failed to ensure one of seven sampled residents (Resident #269) was free from physical and emotional abuse. The failure to protect Resident #269 from physical and psychological abuse, caused harm to Resident #269 as she experienced symptoms of psychological harm and diminished quality of life, when a visitor forcefully and repeatedly pulled Resident #269's hair, put food into her mouth, and pushed on her forehead. Findings included . Record review of Admission Minimum Data Set (MDS), a required assessment tool, dated 08/07/17, showed Resident #269 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had impaired communication, was rarely understood, unclear speech, and sometimes understood others. Resident #269 was dependent on two staff for bed mobility, transfers, dressing, toileting and bathing, and one person assistance with hygiene and eating. In an interview on 08/22/17 at 3:07 PM with Resident #73, when asked if she had seen any resident being abused, Resident #73 stated she saw her roommate's spouse being mean to the resident. He would talk to her throught his teeth and make her cry. She overheard staff talk about the bruises on Resident #269's body when the nurses' assessed her on admission. There was one day, about four days after she was admitted , lunch was served in the room and staff was not present. The spouse assisted her with the meal. The bites were large, served another bite when she wasn't done chewing the last bite, and had food everywhere. Resident #73 was told by the spouse that Resident #269 was faking her condition. Resident #73 stated she believed Resident #269 was abused by the spouse. The spouse was not allowed to visit anymore, and was glad because she had started coming out of her shell since he had not returned. In an interview on 08/23/17 at 12:40 PM, Staff K, Resident Care Manager (RCM), stated Resident #269 did not initially speak when she was first admitted . It was unclear how much the resident recalled, however appeared to be aware of more than she verbalized. Since the husband was no longer able to visit, due to a restraining order, Resident #269 had started coming out of her shell, started talking, which the facility was not aware she could, and did more things for herself. Record review of incident report dated 07/28/17, showed Resident #269 had multiple bruises to the chest, abdominal area, bilateral legs, ankles and feet, of various colors, shapes and sizes. Family and previous caregiver stated the resident did not have a fall in weeks, was not diabetic and not on a blood thinner. Root cause and follow up to the investigation showed Social Services, state hotline and Adult Protective Services (APS) were notified. Supervised visits were to occur when the husband visited, to include a log book to keep track of his visits. A sign was posted outside the door for all visitors to see the nurse before entering the room to alert staff when visitors were present. Record review of incident report dated 08/11/17, an incident between Resident #269 and the spouse occurred in the dining room during dinner. An unidentified nursing assistant (NA) witnessed Resident #269's spouse grab the resident's hair forcefully, which resulted in the resident's head pulled backwards. At that time, the spouse stated, I told you that if you are going to cough to cover your mouth. The spouse grabbed Resident #269's arm and poked her with his finger. Resident #269 affect appeared scared and appeared as if she wanted to cry. The family member was removed from the dining room and escorted out of the facility. APS was notified and instructed the facility not to leave the resident unattended previous suspicious actions. Record review of the document titled, Temporary Order for Protection and Notice of Hearing, dated 08/16/17, the facility and APS completed a temporary Vulnerable Adult Protection Order, to restrict the spouse from access to Resident #269. In an interview on 08/23/17 at 11:41 AM, when asked how she was feeling that day, Resident #269 looked around the television (TV) room and returned to look at this surveyor. When asked if she was getting ready for lunch, the resident again looked at this surveyor. When asked if it was okay to return after lunch to say hello, Resident #269 nodded her head yes, in response. Observation on 08/24/17, Resident #269 ate lunch with occasional assistance from staff. The resident responded positively to staff that assisted her, did not speak, demonstrated good eye contact with those that interacted with her, other residents at the table, and appeared relaxed. Record review of Interdisciplinary (IDT) notes dated 08/01/17 at 10:55 AM, showed Staff U, Licensed Practical Nurse (LPN), stated All visits will be supervised. Extensive bruising was found on Resident #269's legs and chest during the admission skin assessment on Friday, 07/28/17 and was reported to APS. The APS representative stated it was not the first report of abuse that had been made on the resident, and that there had been previous reports made while the resident was living at home. Law enforcement was contacted and also reported previous reports of abuse made, as evidenced by unexplainable and sometimes extensive bruising. Staff were currently providing safety for this resident by monitoring the resident's husband while he visited with the resident as he was a possible suspect. Investigation was ongoing. Record review of IDT notes dated 08/13/17, 08/14/17, and 08/15/17, showed Resident #269 was on alert for emotional well-being related to events that occurred in the dining room on 08/10/17 and 08/11/17. No signs and symptoms of distress noted and the resident appeared at baseline. Review of IDT progress notes showed no documented incident for an event that occurred on 08/10/17. On 08/11/17 at 9:43 PM, Staff T, LPN, stated the resident was placed on alert and did not exhibit signs or symptoms of anxiety or fear following a family visit. Review of Interdisciplinary Progress notes dated 08/15/17 at 10:56 showed the spouse came to visit during dinner time and the resident did not appear in distress. In interview on 08/29/17 at 1:00 PM, Staff R, Certified Nurse Aide (NAC), stated she was aware of an incident occurred in the dining room on swing shift around 08/19/17, where the spouse pulled Resident #269's hair forcefully, to get her to turn and look at him and answer him when he asked her a question. The spouse also shoved the spoon in the resident's mouth and pushed on her on the forehead, as the aide gestured pushing my forehead with her fingers repeatedly. I was with the resident the whole time. Staff R, NAC, stated the facility had a binder that any staff were to able document observations of the family visits and interactions. The aides mostly documented in the binder. Staff R stated there was a restraining order between Resident #269 and her spouse due to the spouse's behavior. Staff R stated there was more than one occurrence of this type of interaction between Resident #269 and the spouse, in the dining room during a meal and other residents and staff present. Record review of the Visitation Monitor Log dated 08/06/17 at 12:30 PM to 12:49 PM, showed (Resident #269) was in dining room at table. Husband came over and tried to kiss her. She backed away then looked at the nurse and I. She looked terrified. Record review of the Visitation Monitor Log dated 08/08/17 between 5:00 PM and 6:00 PM, showed (Resident #269) was in the dining room with the husband and the resident's husband was feeding the resident. Looks scared and was looking at the nurse the whole time. Saw resident's husband pushing glasses (the resident's) on her face when not answering husband's questions, as well as pushing with his finger on resident's face when asked. The Visitation Monitor Log entry, undated, pm shift 5:00 PM to 5:10 PM (entry followed 08/09/17 AM shift), showed (Resident #269's) husband was feeding her at dinner, and anytime the resident looked away while he was trying to talk to her, he pulled her hair and said, 'Look at me, I'm trying to help you.' He pulled her hair multiple times and was forceful when he did it. The resident's face looked scared and sad, even though I tried to smile at her. An entry dated 08/10/17 that occurred at approximately 5:12 PM to 5:40 PM, showed a licensed nurse (LN) was approached by an aide in tears needing to be relived from helping this resident eat because the husband was pulling the resident's hair continuously. The unnamed LN cued the spouse multiple times to be gentler with Resident #269. The spouse continued to poke at the resident's arm, push her glasses up to her face and pull the resident's chin toward him to get her to respond. The resident did not smile and continued to look at the LN as the interactions occurred. Record review of an entry dated 08/11/17 at roughly 5:45 PM, showed Staff S, NAC, witnessed Resident #269's spouse grab a handful of her hair and pull it along with her head backwards and say, I told you if you were going to cough, to cover your mouth. He let go and Reisdnet #269 looked scared and as if she was going to cry. The spouse was aggressive all night during dinner, as evidenced by his tone of voice, poking her and grabbing her left arm. Staff S, NAC, reported the incidents to the nurse and Staff K. The spouse then took the resident into the TV room and told staff he was leaving for the night at about 6:00 PM. Record review of the Visitor Log, Resident #269's spouse continued to visit. On 08/15/17, the spouse came in the facility at dinner time and stayed the entire meal. The husband would shove a spoonful of food to the resident's mouth and keep pushing her glasses in a rough manner. Resident looked scared and was shaking. The aide then held Resident #269's hand to calm her down. In response, the resident smiled. The spouse was cued to gently replace her glasses on her face. In interview on 08/29/17 at 1:41 PM, Staff X, Social Services (SS), Staff Y, SS and Staff Z, Minimum Data Set Coordinator (MDS) stated Resident #269 was admitted from home, with extensive bruising without a reasonable explanation or cause. Abuse was suspected, so APS, Law Enforcement and the state hotline were contacted. APS and the police stated there were previous reports of abuse, thus it was reasonable to believe a family member or caregiver was the perpetrator. A log of all visitors was initiated, and visitors were to be monitored. When asked what the monitoring looked like, Staff X, SS and Staff Y, SS stated supervision while in the facility. When asked who provided the supervision, Staff X, Staff Y, and Staff Z stated all staff did, whomever was available, but it was mostly the nursing assistants. Staff Z, MDS, stated staff would peek in, watch the interaction, and document the observations. When asked to clarify the amount of supervision, Staff X, Staff Y and Staff Z stated Resident #269 did not have one to one (1:1) supervision while visitors were present. It was possible the resident was alone at times with a visitor, without supervision, without knowledge of possible abuse during those times. When asked if Resident #269's roommate was interviewed about interactions between the resident and family, Staff X, SS and Staff Y, SS stated the roommate was interviewed after the incident on 08/11/17. Staff X and Staff Y were not aware of previous negative interactions or incidents between Resident #269 and the spouse prior to the incident in the dining room on 08/11/17. Staff X and Staff Y were not aware of any incidents of the spouse possibly verbally or physically abusing the resident in her room. Staff X, Staff Y, and Staff Z all stated they would expect any staff member to report any incidents of possible abuse or neglect, as they were mandatory reporters. In interview on 08/30/17 at 2:44 PM, Staff K, Resident Care Manager (RCM), stated the log was started on 08/01/17 to monitor the family visits, mostly the visits of the husband. Anyone did the monitoring that was able and continued to be updated. Staff were to watch the spouse, stay 1:1, then moved to public places as things escalated. Staff K, RCM, stated he was not certain how often the log was reviewed, or a way to ensure staff were monitoring the visits at all times, but expected staff to say something and report to the RCM if something occurred. Approximately two to three incidents occurred, which started on 08/10/17. The incident on 08/10/17 was not reported until the next day, 08/11/17, after the second incident. The spouse visited Resident #269 until the restraining order was in place. Staff K, RCM, continued to say he discussed the incidents with the spouse, who down-played and made light of the situations. Staff K was uncertain why the incident on 08/10/17 and previous incidents were not documented in the progress notes or on an incident report. In interview on 08/30/17 at 4:45 PM, Staff B, Director of Nursing Services (DNS), stated she was aware of the bruises found on Resident #269 upon admission, which was reported. Staff B, DNS, stated she was not aware of anything suspicious until the incident in the dining room on 08/11/17. Staff B, DNS, was aware of the log, and said the RCM was in charge of making sure it was complete, but uncertain if he was being checked to see what was written. Staff B, DNS, was not aware of the spouse's similar patterns of behavior over several additional days, to include witnessed and recorded incidents on 08/06/17, 08/08/17, 08/09/17, 08/10/17 and 08/15/17. Despite multiple cues and redirection from various licensed staff to assist the spouse to correct his behavior, the attempts were unsuccessful. Staff B, DNS was not aware of Resident #73's reports that she witnessed additional negative interactions while staff were not present. The facility failed to immediately protect Resident #269 from abuse and prevent reoccurrence, when a reasonable suspicion of abuse occurred. This resulted in the resident repeatedly exposed to abuse, experience psychological harm, and potentially affect the safety of all other residents. Reference (WAC) 388-97-0640(1)(3)(c)

Based on observation, interview, and record review, the facility failed to ensure residents in a common area dining room were free from willful intimidation, verbal and mental abuse from a visitor for 1 of 3 dining rooms reviewed. Facility's failure to recognize demonstrated inappropriate behaviors by the visitor allowed verbal abuse and a threat of harm to residents/staff in the facility, resulting in psychological harm to Residents #33 &185 who stated feelings of fearfulness, crying, loss of sleep and distress, and placed other residents at risk. Findings include: Resident #33 Resident #33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his Minimum Data Set (MDS) an assessment tool, dated 4/25/14, he was cognitively intact with no memory impairment. According to the facility documentation, on 6/2/14, a visitor (Resident # 216's family member) well known to staff, was in the dining room occupied by facility residents during the evening meal. The visitor came behind Resident #33, grabbed a condiment bottle labeled with Resident #216's name (placed on the wrong table in error by staff) off the table while residents were seated. As the visitor grabbed the condiment bottle, he yelled profane, degrading remarks at Resident #33 and other residents present. The visitor stated the residents were stupid and could not read since the bottle had been labeled with Resident #216's name. The visitor's mannerisms and actions were documented by staff witnesses to the event as "very wild, angry, agitated, badgering, and intimidating." The visitor was documented as using "very loud, profane, bigoted and racially offensive terms" in the dining room in front of the residents who occupied it. The visitor upon being asked to leave the building, threatened by stating, "I will take you down for all of that." Staff D documented an Interdisciplinary Note on 6/3/14, that Resident #33 stated to staff regarding the incident with the visitor he "felt I was in danger and threatened." Staff D documented Resident #33 when describing the incident was "upset with some emotional shake to his voice, " and had become teary eyed. Staff D documented the visitor was asked not to come back, and staff would ensure Resident #33's safety. On 6/4/14, Staff H documented in the Interdisciplinary Notes "Resident states he was unable to sleep that night as he was shaken up by the encounter." Resident #33 was documented as stating he felt safe at the facility "as long as that mad man is not around." Staff H documented Resident #33 was told "things have been put in place to keep all residents and staff safe." Staff H documented the resident "was happy with this." On 6/7/14 at 2:12 pm, Resident #33 was observed in his room sitting in his electric wheelchair with oxygen on. He was reaching for an item and had difficulty due to some physical limitations. Resident #33 stated he recalled the incident very clearly, stating it wasn't the first time the visitor had come over to his and the other residents' dining room table, and had taken "stuff like our hot sauce and then uses what he wants." Resident #33 stated the visitor would sometimes return the items, and sometimes would not. As Resident #33 elaborated, he was observed getting upset, shaking his fist in the air, and having a harder time breathing. Resident #33 stated, "Have you seen him? He is...dirty and uncouth. I don't want to use it (the items) after he had his paws on it." Resident #33 stated he was not afraid to remain in the facility "as long as he doesn't walk in here I'm fine- but now a days, you hear about people going crazy and mad and then shooting up people. He was crazy that day when I told him not to take our stuff." Resident #33 continued that he has a garden plot outside that he enjoys going to weather permitting." I can't even go out there without being worried and constantly to look over my shoulder to see if he is there." Resident #185 Resident #185 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his MDS dated [DATE], she was cognitively intact with no memory impairment. On 6/2/14, Resident #185 was present at the table on the date of the incident and was a witness to the visitor's behavior and actions. After the incident, later that evening, Staff I documented in the Interdisciplinary Notes, Resident #185 witnessed the incident with the visitor and described him as "very angry," and "he was talking very bad, he scared me." Resident #185 identified that other residents in the dining room witnessed the incident, not only those residents sitting at the table. Resident #185 stated to Staff J she thought the visitor was going to physically strike someone and believed it was Resident #33. Staff H documented on 6/4/14, a late entry for the day previous in the Interdisciplinary Notes, she was "pretty scared" after what happened. Staff H documented further Resident #185 stated she talked to her tablemates and they reassured her the facility doors are locked at night, which made her feel better. Resident #185 told Staff H she was "glad he (the visitor) didn't hurt anyone, as he was really mad, " and that she felt safe in the facility "as long as (the) visitor is not present." Resident #185 stated she was glad the facility doors were locked at night and precautions were in place for resident safety. On 6/7/14, at approximately 5 pm, Resident #185 was in the dining room waiting for her meal to be served. She recalled the incident with the visitor. "It rattled me for sure, but they (facility staff) said the gates are locked so as long as they are, I'm ok here. But I'm sure don't want to see him again." On 6/8/14, Staff E documented in the Interdisciplinary Notes, Resident #185 had verbalized she was anxious and afraid but was unable to verbalize what her feelings were regarding specifically. The front door was observed unlocked at various times from 6/4/14- 6/8/14 ranging from 6:45 a.m. to 11:00 p.m. On 6/7/14 at approximately 7:15 a.m., two police men were in the facility. An officer stated the facility called that the visitor was present in the building again and they were there to remove him if he would not leave. On 6/7/14 at approximately 8:00 a.m., Staff B stated the visitor was well known to the facility, visited nearly every day since his family member had been admitted to the facility, and had had problems with boundary issues previously involving other residents that staff brought to his attention as inappropriate or infringing on other resident rights. Staff B described the incident that took place 5 days prior regarding what was done to prevent further incidents involving him (the visitor) and residents. Staff B stated the visitor was told not to return, and staff were directed to call the police if he did and there were problems. Staff B stated the visitor was believed to not have a permanent residence or phone, and the police suggested a restraining order against the visitor but didn't know how to contact him although he did visit frequently. Staff B stated the usual routine for the visitor and Resident #216 was to go out into the community together on weekends and return to the facility. Staff B stated the visitor came into the building the morning of 6/7/14, walked through the facility halls, onto the unit where his family member resided and had left with her to go on an outing. Staff B stated the visitor was expected to return Resident #216 to the building later in the day, and he was going to be asked to return at the beginning of the week to discuss the incident that occurred 6/2/14. Staff B stated he and Staff A were planning on speaking with the visitor in a "couple of days" about his inappropriate behaviors. At approximately 1:15 p.m., Resident #146 was observed in his room. Resident #146 stated he was present at the table and witnessed the incident involving the visitor, stating "The guy was irate and yelling."Resident #146 stated he wasn't afraid of the visitor because he felt he could physically defend himself but stated he could understand how residents could be afraid. Staff E stated she observed the visitor walk down the facility hallway in the early morning, past common areas occupied by residents and went to his family member's room, Staff E stated Staff C had called the police. Staff C stated that morning, she saw the visitor walk down the hall and into his family member's room. Staff C called Staff D on what she should do about the visitor being in the building, and was instructed to contact the police. Staff C stated she did not approach the visitor because she was frightened of him, after other staff members told her how "crazy he went" regarding the incident involving a condiment bottle. Staff C did not want to anger him and jeopardize her own safety or other residents. Staff F stated the visitor was well known to her and other visitors because of the frequency of his visits. Staff F stated prior to the visitor's most recent inappropriate behavior on 6/2/14, she observed Resident #52 in a common area she frequently sits in as part of her daily routine, be removed physically from the area by the visitor, so he and Resident #216 could visit in the room. Staff F stated Resident #52 did not talk, but seemed upset by the visitor's actions. On 6/7/14, Staff A stated the visitor was well known to the facility and verified he visited nearly daily. Staff A stated she didn't believe anything more could be done besides what was in place, citing Resident #216's rights to see her visitor. Staff A gave information about what the plan was to protect residents ranging from not allowing the visitor in common areas, contacting the police if the visitor was in building, to contacting the police only if the visitor caused any problems. Staff A stated there had not been anything documented to communicate a plan, and there was nothing in resident care plans to address the documented effects of the incident on the residents. Staff A stated she felt several of the facility residents were prejudiced toward the visitor because of his looks, and the visitor's diminished mental capacity. At approximately 3:15 pm, Staff A and B were told of Staff and resident statements concerning their safety with the visitor's bahaviors. Staff A stated the visitor was being judged by residents and staff, exaggerating their safety concerns based off "this only one instance of really bad judgment (by the visitor)." Staff A stated the building was secure with the front doors being locked from 9 pm at night until 7:00 a.m. Staff A stated there are some facility doors that are open 24 hours a day. Staff A stated housekeeping staff were responsible for locking the doors, but that was not documented anywhere, nor was there documentation to verify it was being done. Staff A and B stated the facility planned to continue with the plan of having staff contact the police if the visitor came to the building and to communicate with the visitor and his mother (Resident #216) regarding restrictions to his visits. At 6:31 pm, the visitor was observed in the building. He was observed getting something to drink in a common area, waited outside the front door, then appeared to leave. Staff K verified the visitor was the same visitor from the previous incident but did not call the police because she was asked to relay a message to him to have him return at a later time to the facility for a meeting. Refer to F225 .

Based on observation, interview and record review it was determined that the facility failed to provide comprehensive necessary care and services related to pressure ulcers for 2 of 3 Sampled Residents (#s 171 & 249) of the 45 residents who were included in the Stage 2 review. Failure to conduct ongoing pressure ulcer assessments and to follow physician prescribed pressure ulcer treatments for Resident #249 placed this resident at potential risk for a delay in pressure ulcer healing. Failure to fully investigate circumstances regarding ulcer development; develop a comprehensive care plan for prevention and to promote healing; timely inform the physician of the condition of the ulcer or implement all dietary recommendations resulted in harm for Resident #171. Findings include: RESIDENT #171 Resident #171's Minimum Data Set Assessments (MDS, a required assessment tool), identified the resident admitted to the facility three times. Resident admissions included time periods 2/19/13 through 4/16/13; 4/20/13 through 5/9/13 and current readmission on 5/16/13. Twice, Resident #171 left the facility for hospitalization s due to medical complications. An admission MDS dated [DATE] identified the resident had [DIAGNOSES REDACTED]. The MDS dated [DATE] and MDS assessment dated [DATE] both identified Resident #171 had cognitive impairment, disorganized thinking and could not participate in a complete mental status interview. ADMISSION #1 (2/19/13 - 4/16/13) An admission MDS dated [DATE] identified the resident did not have a pressure ulcer at the time of admission (2/19/13) and required extensive assistance from two staff for bed mobility, transfers and toileting and used a wheelchair. The MDS also identified the resident frequently had urine incontinence. A "Nursing Assessment" dated 2/19/13, identified on admission, Resident #171 had a red, blanchable painful area drawn on a picture of a human form across the upper buttocks. An assessment dated [DATE] identified the resident had risk factors for developing a pressure ulcer that included slightly limited sensory perception; occasionally moist; chairfast and limited mobility to make frequent changes to body position. A blanchable red area of skin turns white when pressed with a fingertip and then immediately returns to red when pressure is removed. Tissue exhibiting blanchable redness usually resumes normal color within a short period of time and often causes no long-term effects. However, the longer it takes for tissue to recover from finger pressure it could indicate a higher risk for developing pressure ulcers. A "Skin Impairment" form documented on 3/6/13, 16 days after admission, staff discovered Resident #171 had a 1.5 cm by 1.5 cm pink skin wound in the area of the left buttock. The next day, on 3/7/13, staff documented the wound as Stage II. A Stage II ulcer is loss of the skin surface which presents as a shallow open ulcer with red-pink wound bed. The form did not identify how staff classified the wound to identify if it was a pressure ulcer or if it had another type of wound origin. On 5/23/13 at 9:31 a.m. Staff G reported there should be a progress note that described the wound in more detail. When asked if the facility conducted investigations on ulcers that developed in the facility, Staff G reported "there would be a progress note." Staff G reported the Resident #171's skin wound was a pressure ulcer. The "Skin Impairment" form identified the ulcer resolved on 3/25/13. On 5/29/13 at 7:17 a.m., when asked to describe the investigation process the facility used when pressure ulcers developed in-house, Staff B reported it was discussed informally and not written down. No evidence was found in progress notes or in the record staff fully analyzed factors that may have contributed to development of Resident #171's pressure ulcer such as impact on the resident's skin tolerance while seated, type of wheelchair cushion and mattress used, frequency of current position changes to determine if increased frequency of re-positioning was needed for this resident, resident compliance with care or impact of moisture on the skin. On 3/28/13 (three days after the Skin Impairment form, dated 3/25/13, identified the ulcer as resolved), staff documented in the Skin Impairment form the resident developed another "red area" that measured 6.0 cm x 9.0 cm and 0.5 cm x 0.5 cm. The resident's record did not contain evidence staff identified the type or location of the red areas discovered, or assessed underlying conditions that may have led to its development. Resident #171's medical record did not contain evidence staff continued to monitor the second red areas. Resident #171's Care Plan did not identify interventions staff implemented to prevent development of the first Stage II pressure ulcer and to promote healing or measures taken to prevent re-development of a second red area/s after they documented the first Stage II pressure ulcer healed. The record did not contain evidence staff implemented dietary recommendations made on 4/8/13 for an Every Bite Counts (EBC) diet and Resource Supplement three times a day to fortify the resident's diet with additional calories and protein to promote healing. On 4/16/13 the resident discharged to the hospital. ADMISSION #2 (4/20/13 - 5/9/13) An interdisciplinary note dated 4/20/13 documented Resident #171 was readmitted to the facility on [DATE] following surgery for [REDACTED]. The Admission MDS dated [DATE] identified the resident required total dependence from two staff for bed mobility, transfer, had a urinary catheter, frequent incontinence of bowels and used a wheelchair. The assessment identified the resident had risk factors for developing a pressure ulcer and did not have an ulcer at the time of the assessment. A "Nursing Assessment" conducted the day of admission, 4/20/13 identified the resident had "red areas blanchable" noted and a picture of a human form that circled an area across the upper buttocks. A dietary assessment conducted five days later on 4/25/13 noted to request clarification of previous additions to the Resident's diet (made on 4/8/13 during the first admission) to add additional calories, protein and fluids to ensure they were "added back in." Eight days following admission on 4/28/13, staff documented on a "Skin Impairment" form Resident #171 developed a 5.0 cm by 2.0 cm black bruise and 2.0 cm by 2.0 cm slough area identified as unstagable. Slough is tissue in a wound bed that is in the process from separating from the body. On 5/5/13 the form identified the wound increased in size and had a total size that measured 5.5 cm by 4.5 cm and an area of eschar that measured 3.0 cm by 1.0 cm. Eschar is a dark colored (black or brown) area of necrotic tissue. An MDS dated [DATE] classified the wound as an unstagable suspected deep tissue injury (SDTI). The record did not contain an analysis when or how the resident may have developed an SDTI or why the facility determined the wound was a SDTI. The record did not identify prevention measures in place to attempt to minimize risks to prevent or promote healing of the unstageable wound that developed on 4/28/13, eight days after admission. On 5/23/13 at 10:28 a.m., when asked if staff completed a comprehensive assessment regarding the development of the ulcer, Staff H reviewed the resident's record and did not locate one. The facility plan of care did not identify Resident #171 had an SDTI and did not include specific interventions that were in place for ulcer prevention and to promote healing. A Resident Care Directive and a nursing note documented ten days after discovery of the unstagable ulcer, on 4/30/13, staff implemented an air mattress and updated the care plan to turn the resident every two hours side to side or bridge to keep pressure off the lower back. On 5/29/13 at 8:13 a.m. Staff E reported staff had turned Resident #171 every two hours according to the standard of care and was up in a Geri chair for meals. Staff E also reported when the resident did not eat staff offered protein shakes or other additional calories and should document protein shakes offered at meals on the medication record. The resident's care plan and "Resident Care Directive" did not identify for staff when, how often or for how long to get the resident up in a Geri chair. No evidence was found in the record that identified how much Resident #171 ate or when staff offered Resident #171 protein shakes and how much the resident consumed. On 5/2/13 a dietary reassessment recommended dietary changes needed for wound healing. The reassessment note documented to continue with fortified dietary changes and add multi-vitamins and Vitamin C to aide with healing. No evidence was found staff implemented dietary interventions originally recommended on 4/8/13 for the EBC diet and Resource Supplement and did not follow through to ensure they were added back in when re-admitted on [DATE]. No evidence was found staff implemented dietary recommendations for multi-vitamins and Vitamin C recommended on 5/2/13. On 5/27/13 at 7:27 a.m. Staff B reported the nurse who admitted the resident (on 4/20/13) should review the chart from the previous admission to see if any orders from the prior admission needed to be added to current orders. On 5/9/13 Resident #171 returned to the hospital due to [MEDICAL CONDITION]. THIRD ADMISSION (5/16/13 TO PRESENT) Resident #171 readmitted to the facility on [DATE]. A "Skin Impairment" form identified the resident readmitted with a pressure ulcer on the left upper buttock. Notes indicated the ulcer had a black center, white edges and the surrounding area was red and blanched. The form did not identify the stage of the ulcer. The column to identify the stage documented "pending" or "unable to assess". On 5/23/13 beginning 8:57 a.m. Staff H changed the resident's dressing with Staff G present. While turned on the right side Staff H removed the dressing to the wound. Staff H reported the wound measured approximately 4.5 cm by 2.5 cm. The wound bed contained slough and black eschar in the center of the wound. On 5/29/13 at 1:30 p.m. during a second observation of dressing change, Staff H palpated the area surrounding the wound bed and reported the area beneath the ulcer felt hard, like bone. A significant change MDS Care Area Assessment (CAA) titled "Pressure Ulcer" dated 5/23/13 documented the facility identified Resident #171 admitted with an SDTI to the left buttock/coccyx area. The CAA identified interventions implemented included a wheelchair cushion, turning and positioning to avoid time on coccyx, pressure relief mattress and dietary consult and received cueing and assistance for poor food intake and supplemental shakes when intake was poor at meals. Resident #171's record did not contain evidence staff monitored food intake, identified when they offered health shake supplementation and resident response. On 5/23/13, Staff J reassessed the resident's dietary need. A dietary note documented the resident lost a total of 11.7 lbs. or 8.3% of body weight between 2/25/13 and 5/17/13. This timeframe included Resident #171's three admissions and two hospitalization s. The note stated to re-fax requests to the physician to implement previously made recommendations for multivitamins and minerals, Vitamin C, Resource Shakes and to add a trial of an additional protein supplement. The dietary note identified the resident ate poorly at meals and would benefit from the most caloric and protein dense foods and calculated needs to promote wound healing and to help regain lost weight. The May 3013 Medication Record (MAR) identified staff did not initiate administration of the Resource Shake (originally recommended on 4/8/13 during the first admission) until 5/24/13 during the third admission. The May 2013 MAR indicated [REDACTED]. On 5/23/13 at 11:50 a.m. when asked how important the EBC diet and Resource Shake was for Resident #171's wound healing, Staff J reported they were "very important" for healing. Staff J reported the Resource Shake provided additional protein. SUMMARY During the first admission the facility failed to conduct a thorough assessment/investigation that identified the type of wound Resident #171 developed or circumstances that may have led to the development of a Stage II pressure ulcer. The facility also failed to develop a comprehensive careplan and implement all prevention measures to prevent a blanchable reddened area from developing into a pressure ulcer and did not maintain consistent monitoring of two red areas identified on 3/28/13 that re-developed after the facility documented the ulcer healed. The facility failed to timely follow up with dietary recommendations made when the facility identified weight loss occurred. When Resident #171 re-admitted to the facility on [DATE] and 5/16/13, staff did not develop a comprehensive plan of care to prevent re-occurrence of a pressure ulcer although Resident #171 was determined high risk for it to reoccur. Staff also did not provide evidence they timely informed the physician of worsening of the condition of the ulcer when staff identified it unstagable on 5/5/13. At the time of subsequent re-admissions the facility also failed to review previous dietary recommendations and timely initiate follow up for implementation for nutritional support to promote healing of an ulcer. The record did not contain evidence staff consistently monitored Resident #171's food intake and health shake supplementation provided when meals were not consumed. Nutritional interventions to promote wound healing were not timely implemented in the facility during all three admissions and did not get implemented until nine days after Resident #171 admitted the third time. Failure to not provide all necessary care and services and interventions Resident #171 needed to attempt to prevent the development and re-occurrence of an ulcer or to promote healing of an unstagable pressure ulcer constituted harm for this resident. Refer to F 157 for failure to fully inform the physician Refer to F 280 for failure to develop a comprehensive plan of care Refer to F 281 for failure to follow through with dietary recommendations Refer to F 325 for failure to timely implement dietary recommendations RESIDENT #249 Former Resident #249 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Resident #249's Admission Minimum Data Set (MDS), dated [DATE], noted the resident developed a Stage 2 pressure ulcer after admission to the facility. This MDS identified the resident as being at high risk for pressure ulcer development and a care plan was developed. On 5/24/13 at 11:06 a.m. Staff C, who completed the Resident #249's Admission MDS dated [DATE], reported the resident's Stage 2 coccyx pressure ulcer was developed after admission to the facility on [DATE]. Review of a form titled: "Skin Impairment", used by the facility to document weekly assessments of Resident #249's pressure ulcer, noted the first entry on the form was dated 2/26/13 identifying a Stage II pressure ulcer with length/width 0.4 centimeters (cm) x 0.4 cm; no depth; no drainage; pink wound color; no odor; no tunneling. A small circle was drawn on the upper inner right buttock area of a body outline contained on the form indicating the site of the wound. The second and last entry on this form was dated 3/29/13 which indicated the resident's wound was "Discontinued-Resolved". A physician's orders [REDACTED]. QOD (every other day) and as needed (prn). Review of the resident's March 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Further review of former Resident #249's record noted no ongoing assessments of the resident's Stage 2 coccyx pressure ulcer after it was first discovered on 2/26/13 and no assessments of the effectiveness of the prescribed Allevyn treatment since Allevyn had not been applied every other day and as needed during the month of March 2013. The only other documentation of the resident's Stage 2 pressure ulcer was on 3/29/13 where a note "Discontinued-Resolved" was written onto the resident's "Skin Impairment" record. On 5/24/13 at during a meeting starting at 1:30 p.m. with the survey team, Staff D and Staff E were briefed that former Resident #249 was identified on 2/26/13 as having a Stage 2 coccyx pressure ulcer with no other documentation in the record until 3/29/13 when Staff D documented the resident pressure was healed. Staff D reported she/he would check the resident's record. On 5/28/13 at 11:13 a.m. Staff D did not provide additional documentation of ongoing assessments of former Resident #249's Stage 2 coccyx pressure ulcer. At this interview, the surveyor reviewed the resident's March 2013 treatment record which showed the prescribed treatment of [REDACTED]. Staff D agreed the orders for Allevyn were ordered by the physician to be done QOD and prn. On 5/30/13 at approximately 2:15 p.m. during the exit conference Staff A and Staff B did not provide further evidence regarding the care of Resident #249's Stage 2 coccyx pressure ulcer. The facility initially identified Resident #249's Stage 2 coccyx pressure ulcer on 2/26/13 and obtained a prescribed treatment on the same day. After the initial assessment of the resident's Stage 2 pressure ulcer on 2/26/13, the facility failed to conduct ongoing assessments of the resident's Stage 2 coccyx pressure ulcer to determine if the resident's Stage 2 pressure ulcer had worsened. In addition, the facility failed to provide prescribed physician pressure ulcer treatments (Allevyn) as ordered during the month of March 2013 and failed to assess whether or not Allevyn treatments promoted prompt healing of the resident's Stage 2 pressure ulcer. The only other documentation of the resident's Stage 2 coccyx pressure ulcer was on 3/29/13 where the facility documented the resident's pressure ulcer was resolved. These failures placed Resident #249 at potential risk for a delay in pressure ulcer healing. Refer to F281 Resident #249 for failure to follow professional standards of conduct related to pressure ulcer care and treatment.

Based on interview and record review the Facility failed to ensure residents remained fee of significant medication errors for 1 of 10 Sample Residents (#292) reviewed for medication administration. This failure placed Resident #292 at risk for jeopardized health and safety related to a medicatin error. Findings Include: Resident #292 admitted to the facility for therapy and pain control on 9/19/11 after undergoing back surgery. Resident #292 has a history of multiple drug allergies and a history of anaphylactic reactions to medications as indicated in her medical record. During an interview on 10/4/11 at 12:36 p.m. Resident #292 reported she has had increased back pain since being taken to the emergency room in the ambulance two days ago. Resident #292 also reported she had been given medications that were intended for the resident in the next room and because of her allergies she had to go to the emergency room . The bumpy ride in the ambulance to the hospital felt like it had jarred her back and she has had increased back pain since the incident. During the same interview Resident #292 further reported that Staff G always brings her evening medications in a cup with another cup of water and puts them on her bedside table, and she takes them. Resident #292 stated that on Sunday (10/2/11) Staff G came into her room as his usual routine and put the medications on her table. Resident #292 then reported "I am just so used to it I didn't even think about that I had already taken my meds for the night, and I just took them." Resident further reported her face became red and itchy. The itching then started to move down to her chest and that is when they decided to send her to the emergency room . Review of Resident #292's medical record revealed a note from facility faxed to her physician dated 10/3/11 which reported resident was "sent to the emergency room last night because of a medication error". Record review revealed a progress note dated 10/2/11 at 10:15 p.m. which reported Resident #292 received medications that were meant to go to another resident. The medications received by Resident #292 in error were: -[MEDICATION NAME] 10mg (used to treat pain or withdrawal) -Advil 400mg (to treat pain or fever) -[MEDICATION NAME] 20mg by mouth (muscle relaxer) -[MEDICATION NAME] xl 10mg by (to treat urinary bladder spasms) -[MEDICATION NAME] 10mg (to treat nausea) -[MEDICATION NAME] 80mg (to lower cholesterol) -[MEDICATION NAME] 800mg (muscle relaxer) The same progress note further indicated 911 had been called at 10:30 p.m. Review of emergency room records indicated Resident #292 had been diagnosed as having an allergic reaction to medication. emergency room records also indicated Resident #292 had been treated with medications to stop the reaction and alleviate the symptoms. Medications given to Resident #292 were: -[MEDICATION NAME] 125mg (steroid used to treat allergic responses with known effects of suppressing the immune system). -[MEDICATION NAME] 20mg (used to decrease stomach acid) -[MEDICATION NAME] 50mg (used to block allergic reactions) The emergency room physician also requested the resident to continue to receive [MEDICATION NAME] 20mg (steroid) two times daily for 5 days. A significant medication error placed Resident #292 at risk for developing an allergic reaction that could have led to life threatening symptoms. Because Resident #292 had a reaction to the medications given in error she endured increased back pain related to an emergent transfer to the emergency room . Resident #292 was also placed at an increased risk of post-surgical infection related to having been given steroids that are known to decrease the body's immune system. .