Every finding on record at Mira Vista Care Center

Based on interview and record review, the facility failed to ensure that resident-identifiable information was not shared with the public for 1 of 1 sampled resident (Resident 3) reviewed for safeguarding a resident's Portable Orders for Life-Sustaining Treatment (POLST - a form designated a resident's code status and other treatment options). The facility failed to ensure Resident 3's POLST was not given to another resident's (Resident 1) family member when Resident 1 was discharged from the facility. This failure placed residents at risk for their privacy to be violated and their personal medical information being shared with an unauthorized person. Findings included.Resident 3 was discharged from the facility on 03/27/2026.Resident 1 was discharged from the facility on 03/27/2026. Review of an email communication from Collateral Contact 1 (CC1 - Resident 1's family member), dated 05/2/2026 at 4:16 PM, showed Resident 3's POLST had been sent home with Resident 1's discharge information. CC1 was concerned and wanted to ensure Resident 3's original POLST was returned to the facility. In an interview on 05/15/2026 at 12:13 PM, Staff B, Licensed Practical Nurse/Resident Care Manager, stated when a resident was discharged from the facility, their original POLST was included in their discharge paperwork. When asked what Health Insurance Portability and Accountability Act (HIPAA) meant, Staff C stated it was to protect a residents' healthcare information. Staff C was asked if sending a residents POLST home that was not theirs was a HIPPA violation, Staff C replied it was. In an interview on 05/15/2026 at 4:52 PM, Staff A, Registered Nurse/Director of Nursing Services, stated the facility placed the resident's original POLST with a resident's discharge paperwork upon discharging from the facility. Staff B stated Resident 3's POLST should not have been sent home with Resident 1. This is a repeat citation from 03/11/2026 and 06/06/2025.Reference WAC 388-97-1720 (1)(a)(b)

Based on observation, interview, and record review the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 3 of 3 halls (Residents 15,16, 18, 20, 27, 33, 43, 44, 47, 54, 64, 63, 67, 68, 70, 71, 5, 95, 94, 86) reviewed for influenza outbreak, 4 of 4 rooms reviewed for TBP (Rooms 212, 316, 213 and 115) and failed to implement their respiratory protection plan (RPP - a safety plan ensuring staff are properly trained, medically cleared, and fit-tested to wear an N95 mask) for 85 of 109 employed staff. The facility failed to ensure the staff used appropriate hand hygiene practices, staff were wearing personal protective equipment (PPE) in accordance with national standards (room [ROOM NUMBER]) and clean and disinfect universal resident medical equipment (room [ROOM NUMBER]). These failures placed all residents and staff at risk for potential infections. Findings included . Review of facility policy titled, Infection Prevention and Control Program, revised date 04/2025, documented that facility personnel will wash their hands after each direct resident contact and that the facility will use effective methods for safe storage, transport and disposal of garbage and infectious waste. Review of the facility policy titled, IPCP Standard and Transmission-Based Precautions, revised date 03/2024, documented that residents on Contact Precautions (precautions used for residents with known or suspected infections that can be transmitted through direct or indirect contact) should include a plan for discontinuation, and private rooms are preferred but if not available may be roomed with residents that have the same pathogen (germs that cause infection and disease). Contact Precautions require a gown and gloves for all interactions with the resident or resident's environment and the resident should be restricted to their room. Review of the facility policy titled, IPCP Standard and Transmission-Based Precautions, revised date 03/2024, documented that resident's on Droplet Precautions (precautions used for residents with known or suspected to be infected with pathogens transmitted by respiratory droplets) should be in a single room if possible. Mask and eye protection if indicated upon entry to the room is required. The policy also stated that a trash can must be positioned inside of the resident's room and near the exit for discarding PPE after removal, prior to exit of the room and that patient-care equipment (such as vitals equipment) would be preferred dedicated or disposable but if common use of equipment for multiple patients is unavoidable, to clean and disinfect the equipment before use on another patient. Review of the facility policy titled, IPCP Standard and Transmission-Based Precautions, revised date 03/2024, documented that resident's on Enhanced Barrier Precautions need to have expended PPE of gown and gloves during high-contact care activities. High-contact care activities can include wound care and urinary catheter (a tube inserted into the bladder to drain urine) care. Review of the untitled policy for the RPP, dated [DATE], documented that every employee who must wear a respirator will be provided with a medical evaluation before they are allowed to use an N95 mask, that fit testing will be repeated in accordance with State and Federal guidance, and that the records will be kept in the employees personnel file. <INFLUENZA OUTBREAK> In an observation on [DATE] at 9:06 AM, there was a sign posted on the facility's entrance door notifying all individuals who entered the facility was experiencing an increase in respiratory infections and visitor were encouraged to wear masks. The receptionist was handing out Aura 1870+ N95 respirators and requested the survey team to place one on. Note: each individual should be fit tested for a N95 respirator to ensure respirator was specifically fitted for that person. On [DATE], multiple observations from 9:06 AM to 4:00 PM, were made throughout the facility of staff wearing the same type of N95 respirator. In an interview on [DATE] at 10:48 AM, Staff D, Registered Nurse (RN)/Infection Preventionist (IP)/Assist Director of Nursing (ADON), was asked regarding the N95 respirators' being handed out to individuals who entered the building and if they have been specifically tested to the N95 respirator being handed out by the receptionist. Staff D stated N95 respirators should not have been handed out. Staff D stated the local health department directed the facility to wear N95 respirators during the influenza outbreak. Staff D stated the local health department directed the facility staff to wear surgical masks in the hallways but should continue to wear the N95 respirators when entering a resident's room identified as being on droplet precautions. In a record review, on [DATE], at 12:46 PM, Staff G, Acting Administrator, documented the facility's N95 respirator fit test program was incomplete and outdated. <RESPIRATORY PROTECTION PROGRAM> In a record review, on [DATE], at 12:46 PM, Staff G, Acting Administrator, provided N95 fit testing documentation for staff. N95 fit testing forms documented 50 staff had expired N95 fit testing and 35 staff had not been tested at all. The documentation the facility provided did not include the staff's medical evaluations. In an interview on [DATE], at 10:48 AM, Staff D stated that staff were fit tested on hire and annually. In an interview on [DATE], at 1:44 PM, Staff A, Interim Administrator, and Staff G stated that no medical evaluations were documented for staff who were to wear N95 masks. <CONTACT ENTERIC PRECAUTIONS> <room [ROOM NUMBER]> In an observation on [DATE], at 10:59 AM, room [ROOM NUMBER] was observed to have a Contact Enteric Precautions sign posted outside the door signifying the resident had Clostridium Difficile (C. Diff - a highly contagious bacteria that causes severe diarrhea and intestinal inflammation). Contact Enteric Precaution sign notified staff they must wear gown and gloves upon entry to the room and must wash hands upon exit. The sign also signified that the resident should be isolated until their room unless medically necessary. In a record review on [DATE], at 11:00 AM, the electronic medical record confirmed that room [ROOM NUMBER] had a diagnoses of C. Diff. In a continuous observation on [DATE], at 11:01 AM, Staff BB, Physical Therapy Assistant (PTA), was walking the resident from room [ROOM NUMBER] down the hallway without the required PPE. Staff BB continued to walk down the hallway and then sat down in the reception area with the resident. In an interview on [DATE] at 11:04 AM, Staff D, Registered Nurse (RN)/Infection Preventionist (IP)/Assist Director of Nursing (ADON), was notified of the situation and immediately informed Staff BB they could not take residents out of their room who were on Contact Enteric Precautions and they were required to wear gown and gloves at all times. In a continuous interview with Staff BB stated they did not understand or know about the Contact Enteric Precautions. <room [ROOM NUMBER]/RESIDENT 32> Resident 32 was admitted to the facility on [DATE] and had a diagnoses of C. Diff active on [DATE]. Resident 32 was in room [ROOM NUMBER]-2. In an observation on [DATE] at 9:20 AM, room [ROOM NUMBER] was observed to have a Contact Enteric Precautions sign posted outside the door signifying the resident had C. Diff. It was observed that two residents resided in the room. In an interview on [DATE] at 9:21 AM, Staff M, RN, stated the resident in bed two did have an active diagnosis of C. Diff, but the resident in bed one did not have a diagnosis of C. Diff. Staff M stated bed two was off their antibiotics prescribed for the C. Diff, and were not having the associated symptoms, such as, watery diarrhea. Staff M stated they do not know why room [ROOM NUMBER] was not off of Contact Enteric Precautions. In an interview on [DATE], at 9:21 AM, Staff D stated that the resident in bed two had not been taken off Contact Enteric Precautions due to the resident cancelling their appointment for [DATE] on [DATE] that would have potentially cleared them of C. Diff. Staff D stated they were still waiting for next steps from the provider to be able to discontinue the Contact Enteric Precautions. Staff D stated bed one, resident without C. Diff, was in there because bed two used a brief and bed pan. Staff D could not recall if bed one was offered a room move. <HAND HYGIENE> In an observation of meal tray delivery on [DATE] at 12:13 PM, Staff A, Interim Administrator, was observed to take a resident meal tray out of the cart, delivered to a resident in room [ROOM NUMBER], assisted the resident with set up of their meal. The resident requested condiments for their meal, Staff A was observed to leave the resident room without performing hand hygiene, go to the meal cart, open it, pull out a box of condiments, touched items in the box, took out the condiments the resident requested, close the meal cart, and deliver condiments into the resident room without performing hand hygiene. <TRANSMISSION BASED PRECAUTIONS (TBP)> In an observation and interview on [DATE] at 1:09 PM, Staff C, Registered Nurse (RN), was observed in a TBP room with PPE signage on the room door that indicated an N95 respirator and eye protection were required to enter. Staff C was observed wearing a surgical mask and no eye protection while in the room. Staff C obtained vital signs on the resident and left the room when completed. When asked about the signage on the door, Staff C stated they did not follow the PPE signage on the door and should have worn an N95 respirator and eye protection to enter the room. <RESIDENT 32/room [ROOM NUMBER]> Resident 32 was admitted to the facility on [DATE] with diagnoses to include high blood pressure, heart failure, and weakness. In a review of Resident 32's Kardex (resident specific guide for staff on how to care for the resident), dated [DATE], documented conflicting information related to infection control/precautions. Under the safety section of the Kardex, Resident 32 was documented to require contact precautions and under infection control documented they were on enhanced barrier precautions. In a review of Resident 32's progress note, dated [DATE], documented the resident was having foul smelling bowel movements, tested positive for Clostridioides difficile (C-diff-a bacteria causing severe often healthcare associated diarrhea and colitis), and placed on contact precautions. On [DATE] at 12:20 PM Staff F, Nursing Assistant Certified (NAC), was observed to leave Resident 32's room with a lunch tray wearing a gown, placed the meal tray on the top of the dining meal cart, then removed their gown in the hallway next to the meal cart. On [DATE] at 11:30 AM, a contact precaution sign was observed on the door to room [ROOM NUMBER], belonging to Resident 32 and Resident 81. Observed two white trashcans with lids lined with red plastic bags, one labeled for trash and the other one for gowns. The trashcans were located in the middle of the room. Both trashcans' lids were observed to be covered with a fabric sling (flexible strap used with mechanical lift systems to move residents from one place to another) which hung to the floor. <RESIDENT 12/room [ROOM NUMBER]> Resident 12 admitted to the facility on [DATE] with diagnoses to include a pressure ulcer to their sacral region and complete paraplegia. On [DATE] at 1:40 PM, observed the door to Resident 12's room, 213, with a sign indicating droplet precautions, use of PPE of eye protection and mask. After an interview with Resident 12, this surveyor was unable to locate a trash can in the room or immediately outside the room to dispose of used PPE. In an interview on [DATE] at 1:40 PM Staff F stated they disposed of used PPE in trashcans in the resident rooms. On [DATE] at 2:12 PM observed Staff E, NAC, enter room [ROOM NUMBER], responding to their call light, wearing a mask and no eye protection. Observed a sign on the door indicating droplet precautions, underneath the droplet precautions sign was an enhanced barrier precaution sign indicating Resident 12 required PPE of a gown, gloves and mask. Observed Staff E assisting Resident 12 in their bed and adjusting linens. Observed Staff E exit room [ROOM NUMBER] with no gown, gloves or eye protection. In an interview on [DATE] at 2:12 PM Staff E stated they were assisting Resident 12 and they should have been wearing gloves and a gown. <room [ROOM NUMBER]> In an observation and interview on [DATE] at 1:58 PM observed Staff F, NAC in room [ROOM NUMBER] with a sign on the door for enhanced barrier precautions, wearing no gown or gloves. When Staff F exited room [ROOM NUMBER], asked what care they were providing and what precautions were in place, Staff F stated they were emptying catheters for each of the residents in the room. Staff F stated they had not realized the PPE required in the room. <MEAL DELIVERY> In an observation on [DATE] at 12:45 PM, Staff I, NAC delivered a meal tray to room [ROOM NUMBER] with a posted droplet precaution room. Staff I was wearing a N 95 mask and goggles but no gown or gloves. In an observation on [DATE] at 12:47 PM, Staff I, NAC entered room [ROOM NUMBER] and 115 with posted droplet precaution sign with a N 95 on and face mask but no gown or gloves. No hand hygiene was performed prior to entry to the rooms or after. In an observation on [DATE] at 2:03PM, Staff J, NAC, was putting on PPE prior to entering a room on droplet precautions and an EBP sign (single occupant room [ROOM NUMBER]) on the door. Staff J was observed to put on a mask, face shield, gloves, and did not put on a gown. Staff J entered room [ROOM NUMBER] with the Vital Sign (VS) cart, which had a blood pressure cuff, thermometer, and pulse oximeter. Staff J exited room [ROOM NUMBER] at 2:04 PM, with no face shield or gloves, sanitized hands and took the VS cart down the 300-hall next to the treatment medication cart. In an interview on [DATE] at 2:19 PM, Staff J was observed sanitizing the VS cart. Staff J was asked regarding exiting room [ROOM NUMBER] with the VS cart and not sanitizing the VS cart. Staff J stated they would be sanitizing the care in between residents. Reference WAC 388-97-1320(1)(a)(c)(2)(b)(4)(5)(c)

Based on interview and record review, the facility failed to ensure the level one Pre-admission Screening and Resident Review (PASRR- assessment/a federal requirement for Medicaid-certified nursing facilities to ensure individuals, especially those with mental illness, seeking admission are appropriately placed and receive necessary services) were accurate, referred after expiration of an exemption, and updated for 4 of 5 residents (Residents 2, 5, 11 and 20) reviewed for PASRR. This failure placed residents at risk of unmet mental health services and a diminished quality of life. Findings included .In a review of the facility policy titled, PASRR screening for Mental Disorder/ Intellectual Disability (F644) revised 03/10/2026 documented the facility procedures included Social Services Director/ Social Services Assistant must ensure the facility coordinated with appropriate, state-designated authority, all individuals would be screened for possible serious mental disorders or intellectual disabilities and related conditions, and a referral for a level two evaluation upon identification that an individual may have a serious mental illness/developmental disability. Expiration of an exemption was not part of the policy. <RESIDENT 2> Resident 2 admitted to the facility on [DATE] with diagnoses to include high blood pressure and right hip fracture. Review of Resident 2's PASRR dated 12/01/2025 documented they had no serious mental illness or intellectual disability (SMI/ID), the physician certified they required fewer than 30 days of nursing level of care and a were exempted from a Level II evaluation. In an interview on 03/09/2026 at 1:15 PM Staff R, Social Services Director (SSD), stated Resident 2 admitted on [DATE], discharged to the hospital 01/14/2026 and readmitted on [DATE]. Staff R stated the only PASRR in Resident 2's electronic health record was the initial Level I with a 30-day exemption. Staff R stated they had not seen the exemption and must have missed it. Staff R stated they reviewed provider orders and if a resident was not on any psychotropic medications, then would assume the PASSR Level I was negative. Staff R stated they keep track of exemptions on their computer and send them to the evaluator on the 25th day. <RESIDENT 11> Resident 11 admitted to the facility on [DATE] with diagnoses to include right hip fracture, history of stroke, and unspecified dementia. Review of Level I PASRR evaluation dated 10/04/2025 documented Resident 11 did not have symptoms of serious mental illness, nor depressive or anxiety disorder. Review of Resident 11's psychiatric evaluation dated 10/23/2025 documented they had been struggling with agitation and anxiety to include verbal aggression and presented as such during the evaluation which could be related to depression. Review of Resident 11's Significant Minimum Data Set (MDS-an assessment tool) dated 12/26/2026 documented they took psychotropic medications routinely. The Care Area Assessment (CAA-care planning tool) documented Resident 11 was diagnosed with dementia and had agitation and aggression at times and use of an anti-anxiety medication was helpful. In a review of Resident 11's clinical record showed no other PASRR's were completed. In an interview on 03/11/2026 at 9:07 AM Staff R, SSD, stated they could not locate an updated Level I PASRR for Resident 11. Staff R stated if a resident had a change in condition the resident would be discussed by the interdisciplinary team for psychotropics and an updated Level I PASRR would be completed. Staff R stated Resident 11 required an updated Level I PASRR. <RESIDENT 5> Resident 5 was admitted to the facility on [DATE] with diagnoses to include major depressive disorder with psychotic symptoms. Review of Resident 5's electronic medical record (EMR) documented the PASRR Level I was completed on 01/28/2026 and they required a referral for a PASRR Level II. The document showed Resident 5 was exempted from the PASRR Level II referral since they would require less than 30 days of care at the facility. The PASRR Level I documented a PASRR Level II must be completed if the anticipated discharge within 30 days does not occur. Review of Resident 5's EMR showed no documentation related to PASRR Level II follow up. In an interview on 03/09/2026 at 11:12 AM, Staff D, SSD, stated they kept a list of exempted residents and followed up with a PASRR Level II referral on 25th day after admission. Staff D confirmed they did not complete any documentation in Resident 5's EMR related to the PASRR Level II referral and stated they failed to get any documentation completed. <RESIDENT 20> Resident 20 admitted to the facility on [DATE] with diagnoses to include unspecified dementia (a disease that is a decline in mental abilities severe enough to interfere with daily life), insomnia, and anxiety. Review of Level l PASRR, dated 08/12/2025, documented Resident 20 had a 30-day hospital exemption but would require a Level ll PASRR if the scheduled discharge did not occur. Review of Level ll PASRR, dated 12/20/2025, documented an invalidation of the PASRR Level ll due to the resident being discharged from the facility, however Resident 20 had not been discharged . In a review of Resident 20's progress notes, dated 12/20/2025, at 5:42 PM, Staff R, SSD, documented that an incorrect PASRR invalidation was received from the evaluator. Staff R documented they emailed the PASRR evaluator about the error and was awaiting reply. No further documentation regarding the PASRR was located in Residents 20's EMR. In an interview on 03/09/2026, at 1:20 PM, Staff R, stated they had emailed the PASRR evaluator the incorrect PASRR from December 2025 and had not received a new one. Staff R reviewed their email correspondences and found an email from 12/27/2025 with a PASRR invalidation for Resident 20. Staff R stated they missed the email and their process did not include documenting correspondence with the PASRR evaluator. Reference: (WAC) 388-97-1975 (1)(5)(9)

Based on interview and record review, the facility failed to ensure medical records were complete and accurate for 7 of 7 residents (Residents 20, 32, 53, 92, 2, and 93) reviewed for certified nursing assistant (CNA) documentation, and 2 of 3 residents (Residents 92 and 53) reviewed for resident weekly skin checks. This failure included missing documentation for activities of daily living (ADLs - routine self-care such as dressing, bathing, eating, toilet, etc.), behaviors/interventions, meal consumption, voiding, and the completion of timely skin check observations which placed residents at risk for incomplete and inaccurate medical records and unmet care needs. Findings included . Review of the facility policy titled, Charting and Documentation, revised April 2008, documented all services provided to the resident shall be documented in the resident's medical record. <NURSING ASSISTANT CERTIFIED DOCUMENTATION> <RESIDENT 20> Resident 20 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, unspecified muscle weakness, unspecified dysphagia (difficulty swallowing), and cognitive communication deficit. Review of Resident 20's care plan, dated 12/01/2025, documented they had an ADL self-care performance deficit related to dementia and weakness. Resident 20 required assistance of one person for toileting, transferring, bed mobility, bathing, personal hygiene, dressing, and eating. Review of Resident 20's Minimum Data Set (MDS - an assessment tool) assessment, dated 02/04/2026, documented substantial/maximum assistance was required for oral hygiene, toileting hygiene, showering, dressing, personal hygiene, and transferring. Review of Resident 20's Documentation Survey Report v2 (DSR-v2 - a report that showed the Nursing Assistant Certified documentation to specific tasks performed with a resident) report, dated 03/01/2026 to 03/08/2026, showed no documentation for the following areas: -Behavior Monitoring and Interventions on the evening shift on 03/01/2026, 03/02/2026, 03/04/2026, and 03/06/2026. -Bladder Continence on the evening shift on 03/02/2026, 03/04/2026, and 03/06/2026. -Bowel Movement on the evening shift on 03/01/2026, 03/02/2026, 03/04/2026, and 03/06/2026 and on night shift on 03/06/2026. -Toileting Hygiene on the evening shift on 03/02/2026, 03/04/2026, and 03/06/2026. -Turned and repositioned on the evening shift on 03/01/2026, 03/02/2026, 03/04/2026, and 03/06/2026. Review of Resident 20's February 2026 DSR -2 report, showed missing documentation was identified for the following: -Behavior Monitoring and Interventions on the evening shift on 02/19/2026, 02/20/2026, 02/25/2026, and 02/28/2026. -Bladder Continence on the evening shift on 02/19/2026, 02/20/2026, 02/25/2026, and 02/28/2026. -Bowel Movement on evening shift the on 02/07/2026, 02/19/2026, 02/20/2026, 02/25/2026, and 02/28/2026. -Toileting Hygiene on the evening shift on 02/19/2026, 02/20/2026, 02/25/2026, and 02/28/2026. -Turned and repositioned on the evening shift on 02/19/2026, 02/20/2026, 02/25/2026, and 02/28/2026. Review of Resident 20's January 2026 DSR v-2 report, showed missing documentation was identified on: -Behavior Monitoring and Interventions on the evening shift on 01/14/2026, 01/21/2026, and 01/31/2026 and on the night shift on 01/22/2026 and 01/31/2026. -Bladder Continence on the evening shift on 01/14/2026, 01/21/2026, and 01/31/2026 and the night shift pm 01/22/2026 and 01/31/2026. -Bowel Movement on the evening shift on 01/14/2026, 01/21/2026, and 01/31/2026 and night shift on 01/22/2026 and 01/31/2026. -Oral Hygiene on the evening shift on 01/22/2026 and 01/31/2026. -Personal Hygiene on the evening shift on 01/22/2026 and 01/31/2026. -Toileting Hygiene on the evening shift on 01/14/2026, 01/21/2026, and 01/31/2026 and on the night shift on 01/22/2026 and 01/31/2026. -Turned and repositioned on the evening shift on 01/14/2026, 01/21/2026, and 01/31/2026 and on the night shift on 01/22/2026 and 01/31/2026. <RESIDENT 32> Resident 32 was admitted to the facility on [DATE] with diagnoses to include muscle weakness, after surgical care, and heart failure. Review of Resident 32's care plan, dated 02/26/2026, documented that they had an ADL self-care performance deficit related to generalized weakness, impaired balance, decreased activity tolerance, and decreased motivation. Resident 32 required substantial to dependent assistance toileting, two-person assistance for transferring, one person assistance for bed mobility, bathing, and dressing. Review of Resident 32's Documentation Survey Report v2 (DSR-v2 - a report that showed the Nursing Assistant Certified documentation to specific tasks performed with a resident) report, dated 03/01/2026 to 03/08/2026, showed no documentation for the following care: -Behavior Monitoring and Interventions on day shift on 03/02/2026 and evening shift on 03/03/2026, 03/07/2026 and night shift on 03/06/2026. -Bladder Continence on day shift on 03/02/2026, evening shift on 03/03/2026 and 03/07/2026, and on night shift on 03/06/2026. -Bowel Movement on day shift on 03/02/2026, on evening shift on 03/03/2026 and 03/07/2026, and on night shift on 03/06/2026. -Oral Hygiene on day shift on 03/02/2026, and on evening shift on 03/06/2026. -Personal Hygiene on day shift on 03/02/2026 and on evening shift in 03/06/2026. -Toileting Hygiene on day shift on 03/02/2026, on evening shift on 03/03/2026 and 03/07/2026, and on night shift on 03/06/2026. -Turned and repositioned on day shift on 03/02/2026. -Evening shift: 03/03/2026 and 03/07/2026 and on night shift on 03/06/2026. In a review of Resident 32's February 2026 DSR-v2 report, showed no documentation was identified for the following: -Behavior Monitoring and Interventions on day shift on 02/16/2026 and on evening shift on 02/12/2026, 02/16/2026, 02/17/2026, and 02/22/2026. -Bowel Movement on day shift on 02/16/2026 and on evening shift on 02/12/2026, 02/16/2026, 02/17/2026, and 02/22/2026. In an interview on 03/11/2026 at 9:36 AM, Staff D, Registered Nurse (RN)/Infection Preventionist (IP)/Assist Director of Nursing (ADON), stated there was a designated staff member that reviewed the NAC documentation daily, report it to the team, and the team was responsible to inform the NAC's to review and complete their daily documentation. <RESIDENT 53> Review of Resident 53's January 2026 Documentation Survey Report v2 (DSR-v2 - a report that showed the Nursing Assistant Certified documentation to specific tasks performed with a resident) report, showed missing documentation on all shift under the intervention/task sections of activities of daily living (ADL's – dressing, transfers, upper body and lower body dressing, oral hygiene, personal hygiene, toileting, bathing, bed mobility, bowel and bladder continence, walking, and eating), of behavioral symptoms, and bowel monitoring. There was missing documentation for three days on the AM shift (on 01/01/2026, 01/28/2028, and 01/29/2026), two days on the PM shift (on 01/17/2026 and 01/26/2026), and four days on the night shift (on 01/01/2026, 01/17/2026, 01/21/2026 and 01/31/2026) Review of Resident 53's 03/01/2026 through 03/07/2026 DSR-v2 report, showed missing documentation in the intervention/task sections of ADL's, behavioral symptoms, and bowel monitoring once on the PM shift (on 03/06/2026), and five days on the night shift (from 03/03/2026 to 03/07/2026). <RESIDENT 92> Review of Resident 92's 12/01/2025 through 02/04/2026 DSR-v2 report, showed missing documentation in the intervention/task sections of ADL's, behavioral symptoms, and bowel monitoring six days on the AM shift (on 12/20/2025, 12/31/2025, 01/01/2026, 01/28/2026, 01/29/2026,and 02/01/2026), six days on the PM shift (on 12/05/2025, 12/09/2025, 12/25/2025, 12/28/2025, 01/17/2026, and 01/26/2026), and 14 days on the night shift (on 12/05/2025, 12/10/2025, 12/24/2025- 12/28/2025, 12/31/2025, 01/01/2026, 01/14/2026, 01/21/2026, 01/27/2026, 01/31/2026, and 02/01/2026). <RESIDENT 2> Resident 2 was discharged to the hospital on [DATE] and re-admitted on [DATE]. Review of Resident 2's 01/22/2026 through 01/31/2026 DSR-v2 report, showed missing documentation in the intervention/task sections of ADL's, behavioral symptoms, and bowel monitoring twice on AM shift (on 01/29/2026 and 03/02/2026), once on the PM shift (01/26/2026 and) and eight times on the night shift (on 01/27/2026 and 01/31/2026, 02/01/2026, 02/06/2026, 02/08/2026, 02/18/2026, 02/22/2026, and 03/03/2026). <RESIDENT 93> Resident 93 was admitted to the facility on [DATE] and discharge to the hospital the morning of 03/05/2026. Review of Resident 93's 02/23/2026 through 03/04/2026 DSR-v2 report, showed missing documentation in the intervention/task sections of ADL's, behavioral symptoms, and bowel monitoring on the PM shift of 02/28/2026 and twice on the day shift (on 03/01/2026 and 03/02/2026). In an interview on 03/11/2026 at 9:36 AM, Staff D, Registered Nurse (RN)/Infection Preventionist (IP)/Assist Director of Nursing (ADON), stated there was a designated staff member that reviewed the NAC documentation daily, report it to the team, and the team was responsible to inform the NAC's to review and complete their daily documentation. In an interview on 03/11/2026 at 3:12 PM, Staff CC, stated the expectation was to completed their charting by the end of their shift. Staff CC stated they tried to chart throughout their shift regarding the residents' meals and toileting needs. <NURSING SKIN ASSESSMENTS> <RESIDENT 92> Review of Resident 92's December 2025 Treatment Administration Record (TAR), with an order date of 12/02/2025, directed the Licensed Nurse (LN) to perform a skin check every seven days and complete the skin eval UDA (User-Defined Assessment) PRN (as needed weekly) on the day shift every Monday. Review of Resident 92's LN (Licensed Nurse)- Skin Evaluation – PRN (as needed)/ Weekly, showed no documentation on the TAR the skin evaluation was completed on 12/08/2025 and 12/15/2025. Review of Resident 92's January 2026 TAR, documented a skin check was completed on 01/10/2026. Review of Resident 92's LN- Skin Evaluation – PRN, dated 01/10/2026, showed the skin assessment was not completed/locked until 01/13/2026, three days after it was documented completed. Review of Resident 92's LN- Skin Evaluation – PRN, dated 01/31/2026, showed the skin assessment was not completed/locked until 02/03/2026, three days after it was documented completed. <RESIDENT 53> Review of Resident 53's January TAR, directed the LN to perform a skin check every seven days and complete the skin eval UDA PRN form every Friday. The LN documented a skin assessment was completed on 01/23/2026 and 01/30/2026. Review of Resident 53's LN- Skin Evaluation – PRN, dated 01/23/2026, showed the skin assessment was not completed/locked until 01/26/2026, three days after it was documented completed. Review of Resident 53's LN- Skin Evaluation – PRN, dated 01/30/2026, showed the skin assessment was not completed/locked until 02/09/2026, 10 days after it was documented completed. Review of Resident 53's February 2026 TAR, directed the LN to perform a skin check every seven days and complete the skin eval UDA PRN weekly form every Friday. The LN documented a skin assessment was completed on 02/22/2026. Review of Resident 53's LN - Skin Evaluation – PRN / Weekly, dated 02/20/2026, showed the skin assessment was not completed/locked until 03/05/2026, 13 days after it was documented completed. On 03/10/2026 at 1:40 PM, a interview was conducted with Staff B, Registered Nurse (RN)/Director of Nursing Services, and Staff AA, Clinical Resource RN. Staff B stated the expectation was when the LN filled out a UDA it should be completed at the same time. Staff B and Staff AA were made aware this was not done for Resident 92 and 53. Reference WAC 388-97-1720 (1)(a)(i)(ii)(iii)

Based on interview and record review, the facility failed to provide required liability notices for 3 of 3 residents (Residents 28, 101, and 102) reviewed for liability notices who remained in the facility after skilled services ended and 1 of 3 residents (Resident 28) reviewed for issuance of Notification of Medicare Non-Coverage (NOMNC) at least two calendar days prior to their Medicare services ending. These failures placed residents at risk for not being fully informed of the cost of, and/or fully understanding their Medicare benefits.Findings included.Review of Resident 28's notification review documented their Medicare Part A service episode started on 11/28/2025 and ended 12/24/2025. The facility documented they were unable to locate the NOMNC or the liability notice provided to Resident 28 or their representative. Resident 28's medical record documented they remained in the facility after their Medicare A service episode ended.Review of Resident 101's notification review documented their Medicare Part A service episode started 01/22/2026 and ended 02/11/2026 and the liability notice was unable to be located.Review of Resident 102's notification review documented their Medicare Part A service episode started 11/28/2025 and ended 01/18/2026 and the liability notice was unable to be located.In an interview on 03/11/2026 at 9:05 AM Staff R, Social Services Director, stated there was a change in the business office managers, who had been directing when to provide a liability notice to residents, and since that change the liability notices had not been completed. Staff R stated they were unable to locate the NOMNC for Resident 28, no other information was provided.Reference WAC 388-97-0140

Based on interview and record review, the facility failed to initiate grievances for 2 of 4 residents (Residents 32 and 39) reviewed for grievances. The facility's failure to initiate, log, investigate verbalized concerns, and inform the residents of their findings and the actions taken, precluded the facility from identifying grievance trends and placed the residents at risk of feeling frustrated, unimportant, and with a decreased self-worth and quality of life.Findings included . Review of the facility policy titled, Grievances, revised date 02/01/2017, documented the facility grievance process is to make prompt efforts to resolve grievances the resident may have. The policy's procedures documented the grievance official is to respond to the individual expressing the concern withing three working days of the initial concern. The grievance log was to be maintained by the grievance official. <RESIDENT 32>In an interview on 03/04/2026 at 11:45 AM, Resident 32 stated their current mattress was uncomfortable and felt like they were laying on metal bars. Resident 32 stated they had complained a few months ago of their mattress being uncomfortable and felt that it had a hole in the middle and it was replaced with the current one. Resident 32 stated they had complained and nothing had been done. Resident 32 stated the mattress was not fitted properly for the bed frame and the metal securement device (preventing movement of the mattress on the bed frame) were not able to be used because the mattress was too big for the bed frame. In a joint interview on 03/10/2026 at 3:00 PM Staff S and T, Maintenance, stated they had initially replaced the mattress on 01/13/2026 and had not filled out a grievance related to the replacement. No other details about why the mattress was replaced was provided. In review of a maintenance request dated 01/13/2026 at 12:39 PM documented nursing requested Resident 32's mattress to be replaced and was inputted by Staff S and completed by Staff T. No other information was provided in the maintenance request. In an interview on 03/10/2026 at 3:08 PM Staff U, Resident Care Manager/Licensed Practical Nurse, stated they were unaware of any concerns related to Resident 32's mattress. Staff U stated the process for grievances included when a grievance was reported by a cart nurse, they would meet with the resident, gather details, fill out a grievance and provide it to social services. In an interview on 03/10/2026 at 3:15 PM Staff V, Nursing Assistant Certified (NAC), stated the grievance process included providing residents with a grievance form, located outside the office of the administrator, and assist the resident in filling it out if needed. <RESIDENT 39>In an interview on 03/04/2026, at 11:09 AM, Resident 39 stated they had two blouses that went missing. Resident 39 stated they had reported the missing blouses and were told to order two more blouses to replace the missing ones, and the facility would reimburse them. Resident 39 stated they still had not been reimbursed and one of the new blouses had already gone missing. In an interview on 03/06/2026, at 9:27 AM, Resident 39 stated they reported the missing blouses to their nurse and social services. Review of the grievance logs from October 2025 through February 2026 and March 1st through 6th 2026, contained no documentation with regard to Resident 39's missing blouses. In an interview on 03/09/2026, at 9:28 AM, Staff R, Social Services Director, stated they were aware of Resident 39's missing blouses. Staff R stated they put the missing blouses on a grievance form and handed it off to the previous administrator for reimbursement in January 2026. Staff R stated they needed invoices to reimburse Resident 39 and they didn't have them. Staff R was unaware of the follow-up with Resident 39 as they had handed it off to the prior administrator. In an interview on 03/09/2026, at 9:58 AM, Staff G, Acting Administrator, stated that they would take care of Resident 39's missing blouses. Staff G stated that Resident 39's grievance was done during transition of the Administrator and that it was missed. Reference WAC 388-97-0460

Based on observation, interview, and record review, the facility failed to ensure 2 of 5 residents (Residents 11 and 48) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) as required. The facility failed to ensure appropriate indication for psychotropic medications. This deficient practice placed residents at risk of experiencing unnecessary side effects such as sedation, decline in physical functioning, and placed residents at risk of experiencing an undignified life. Findings included . As referenced in the Food and Drugs/Drug (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause, there was little chance that they would be effective, and they commonly cause complications such as movement disorders, falls with injury, stroke, and increased risk of death. The FDA Boxed Warning, which accompanied, second-generation anti-psychotics stated, Elderly patients with dementia-related psychosis treated with atypical anti-psychotic drugs are at an increased risk of death. Review of the facility policy titled, Chemical Restraints and Psychotropic Medication Management, revised April 2025 documented it was the policy of the facility to ensure that residents were free from chemical restraints imposed for the purpose of discipline or convenience or that are not required to treat a specific condition as diagnoses or documented in the clinical record. <RESIDENT 11>Resident 11 admitted to the facility on [DATE] with diagnoses to include right hip fracture, history of stroke, and unspecified dementia (a disease that causes loss of memory, language, problem-solving and other thinking abilities). Review of Level 1 Pre-admission Screening and Resident Review (PASRR- a mental health screening tool) evaluation dated 10/04/2025 showed Resident 11 did not have symptoms of serious mental illness, nor depressive or anxiety disorder. Review of Resident 11's psychiatric evaluation dated 10/23/2025 documented resident and their representative discussed use of an antidepressant for signs and symptoms of depression. Per the evaluation Resident 11 had been struggling with agitation and anxiety to include verbal aggression and presented as such during the evaluation. Review of Resident 11's Behavioral Health Progress Note dated 12/08/2026 documented no hallucinations reported or observed during assessment, however the narrative documented the resident as almost paranoid. The note documented Resident 11's thoughts were potentially delusional due to dementia, and their thought process was severely impaired related to dementia. The recommendations were to monitor for increased signs of emotional or behavioral disturbance such as increased confusion, psychosis (hallucination-perceptual experiences in the absence of real external sensory stimuli) or delusions (misconceptions or beliefs that are firmly held, contrary to reality) or delusions), changes in sleep or appetite or refusals of care. Review of Resident 11's order summary documented behaviors being monitored for the use of antipsychotics included agitation, anger, hitting, and yelling every shift starting 11/28/2025. Review of Resident 11's progress notes from 12/08/2025-03/05/2026 showed no monitor or documentation of signs of psychosis as outlined in the behavioral health recommendations. Review of Resident 11's Medication Administration Record (MAR) for December 2025 showed a physician's order for Seroquel (an antipsychotic medication) 12.5 milligrams (mg) at bedtime for dementia with agitation dated 11/28/2025. In an interview on 03/11/2026 at 9:31 AM Staff U, Resident Care Manager/Licensed Practical Nurse, stated they did not know if Resident 11 had a diagnosis of psychosis and would need to confirm with the psychiatric provider. Staff U stated Resident 11 did have a diagnosis of dementia with behaviors. Staff U stated Resident 11 had not been prescribed an antidepressant during their stay at the facility. Staff U stated there was not a discussion of use of an antidepressant for Resident 11 in their clinical interdisciplinary meetings and did not always review the behavioral health notes, often relying on the provider to discuss orders/recommendations after their visit with residents. When asked how interventions were developed when a resident was started on a psychoactive medication, Staff U, stated they use batch orders to choose from. <RESIDENT 48>Resident 48 admitted [DATE] with diagnoses to include dementia with behavioral disturbance and depression. Review of the PASRR dated 04/14/2025 showed Resident 48 had mood and anxiety disorder. Psychosis was not marked as a condition. Review of level II PASRR invalidation on 04/15/2025 showed Resident 48 did not have symptoms of serious mental illness, nor depressive or anxiety disorder. Review of Resident 48's quarterly Minimum Data Set assessment, dated 01/08/2026, showed the resident did not experience signs of psychosis such as hallucinations. The resident was taking an antipsychotic medication, and a gradual dose reduction had not been attempted. Review of physician's orders showed Resident 48 began receiving Seroquel, an antipsychotic daily for dementia with agitation, an inappropriate indication since admission. Review of the psychotropic care plan showed Seroquel was used related to agitation and dementia. Review of Resident 48's behavior monitoring directed staff to monitor for episodes of psychotic behavior as evidenced by yelling, aggressive language, name calling, and demanding tasks every shift beginning 12/16/2025. Psychotic behavior is defined as a severe mental state characterized by loss of contact with reality, where the person experiences hallucinations-sensing things not present and delusions-false fixed beliefs, or disorganized thinking. Behavior monitors showed there were no behaviors documented December 2025, two shifts with behaviors in January 2026, one behavior in February and no behaviors in March as of 2026. Review of progress notes beginning 04/15/2025 to 03/10/2026 showed no documentation Resident 48 exhibited psychosis. Review of psychoactive medication evaluations on 04/15/2025, 07/15/2025 10/15/2025, and 01/15/2026 showed Resident 48 had no paranoia, delusions or hallucinations observed in the look back period. Review of Resident 48's sleep monitors showed the resident sleeps 12-17.5 hours a day. In observations on 03/09/2026 at 9:11 AM and 11:40 AM Resident 48 was observed in bed asleep. In observations on 03/10/2026 at 9:14 AM, 10:25 AM, 11:13 AM Resident 48 was observed in bed asleep. In an interview on 03/10/2026 2:02 PM Staff G, Nursing Assistant Certified stated Resident 48 did not see or hear things not there and their thinking was clear. In an interview on 03/11/2026 at 9:25 AM, Staff D, Registered Nurse/Assistant Director of Nursing stated the monitoring should be modified to monitor delusions and hallucinations. Reference WAC 388-97-0620 (1)(a)

Based on record review and interview, the facility failed to provide written bed hold notice to the resident and their representative at the time of transfer to the hospital for 2 of 3 residents (Residents 53 and 92), and failed to ensure a resident hospital transfer documentation was completed as required to include the basis for hospital transfer and what specific resident needs were unable to be met by the facility for 1 of 3 residents (Resident 53) reviewed for hospitalization. These failures placed residents and their representative at risk for not having an opportunity to make informed decisions about their transfer/discharge rights, placed residents at risk with their right to hold their bed while in the hospital, and a diminished quality of life. Findings included. <RESIDENT 53> Resident 53 was transferred to the emergency room (ER) on 03/08/2026 related to an acute change in their medical condition and was unresponsive. On 03/10/2026 Resident 53's Electronic Medical Record (EMR) was reviewed for a Nursing Home Transfer or Discharge Notice and a Bed Hold Notification given to the resident and their responsible representative. There was no documentation or copies of the notifications documented in Resident 53's EMR. In an interview on 03/10/2026 at 11:11 AM, Staff Z, Social Service, stated if a resident's transferred or discharged was planned, then a Nursing Home Transfer or Discharge Notice was filled out and given to the resident and/or their representative, a copy placed in the resident's EMR, and a copy was sent to the office of the State Long-Term Care Ombudsman (an advocate for residents of nursing homes who protected and promoted resident rights under federal and state law and regulations). If the transfer or discharge was emergent, the transfer/discharge notice was filled out by the license nurse who was working, given to the resident and the resident's representative, and scanned to the Ombudsman. Staff Z stated a bed hold notification was also filled out and given to the resident or their representative upon transfer. Staff Z stated both notices were sent to medical records to be uploaded into the residents' EMR. Staff Z could not locate Resident 53's bed hold policy or a transfer/discharge notice and stated they could be with medical records waiting to be scanned into the resident's EMR. In an interview on 03/10/2026 at 11:34 AM, Staff Y, Medical Records Supervisor, located Resident 53's transfer/discharge and bed hold notices that were waiting to be scanned into the resident's EMR. Staff Y gave a copy of the resident's transfer/discharge and bed hold notice to the surveyor. Review of Resident 53's Nursing Home Transfer or Discharge Notice, dated 03/08/2026, documented this notice was given to the resident. Review of the transfer/discharge notice documented: -Under the section the reason for discharge or transfer a box was checked indicating the transfer or discharge was necessary for the resident's welfare and their needs could not be met at the facility. There was a section left blank where the facility was to provide a brief explanation to support this action and to attach additional documentation if necessary. -A box was checked indicating a written notice of the facility's bed-hold policy was provided to the resident and the resident's representative. -There was a line drawn through the box titled, Resident Representative Printed Name and Date. Review of Resident 53's Bed Hold Notification, dated 03/08/2026, documented the resident was unresponsive at the time of transfer to the ER. There was documentation the resident's representative was called four times and was not available. There was no further documentation in Resident 53's medical record that the resident's representative was notified in writing of the transfer/discharge or offered a bed hold. On 03/10/2026 at 3:10 PM, an interview with Resident 53 was attempted while admitted to the local hospital. Resident 53 could not answer any questions asked. <RESIDETN 92> Resident 92 was sent to an outside wound care appointment, and the wound care center transferred the resident to the ER for a wound infection. Review of Resident 92's EMR showed no documentation the resident was offered a bed hold. In an interview on 03/10/2026 at 11:18 AM, Staff Z was asked about Resident 92's bed hold. Staff Z looked in the resident's EMR and could not find one. In an interview on 03/10/2026 at 11:24 AM, Staff Y was asked if there was a bed hold document waiting to be scanned into Resident 92's EMR. Staff Y looked in what documents were waiting to be scanned into residents' EMR, then looked at Resident 92's EMR. Staff Y stated they could not find a bed hold for Resident 92. In an interview on 03/10/2026 at 3:10 PM, Resident 92 was interviewed at a local hospital. Resident 92 was asked if they had been offered a bed hold from the facility. Resident 92 shook their head and said no. Reference WAC 388-91-0120(4)

Based on observation, interview, and record review the facility failed to provide assistance with activities of daily living (ADL's) to include personal hygiene and bathing for 1 of 2 dependent residents (Resident 10), reviewed for ADLs. Facility failure to provide the residents, who were dependent on staff for assistance with grooming, placed the resident and others at risk of embarrassment, poor hygiene, unmet care needs and a diminished quality of life.Findings included . Review of the facility's policy, Activities of Daily Living, revised 07/2015 documented nursing assistants would provide assistance with ADL's based on the residents individualized plan of care. <RESIDENT 10> Resident 10 admitted on [DATE] with diagnoses to include diabetes (high blood sugar resulting from inadequate insulin production or usage), muscle weakness and cognitive communication deficit. Review of the admission Minimum Data Set (MDS) assessment on 01/09/2026 showed Resident 10 could not perform grooming and were dependent on staff for ADL's. The resident did not reject care. Review of the ADL care plan initiated on 01/06/2026 showed Resident 10 needed total assistance from one staff for ADL needs including grooming. In an observation on 03/05/2026 at 1:29 PM, Resident 10 was lying in bed. Their hair was greasy and they had multiple white chin hairs approximately 1/8 inch long, each fingernail was jagged and filled with brown matter. In observations on 03/06/2026 at 9:09 AM, 11:15 AM, 1:08 PM the resident was lying in bed watching TV. The resident continued to have greasy hair, long facial hair and jagged fingernails with brown matter under them. In observations on 03/09/2026 at 9:10 AM, 11:09 AM, 1:27 PM, 2:32 PM and 3:40 PM, the resident was lying in bed and continued to have greasy hair, long facial hair and jagged fingernails with brown matter under them. In an interview on 03/10/2026 at 1:59 PM, Staff M, Registered Nurse (RN) and Staff N, RN stated nurses were responsible for nail care for residents who were diabetics. They stated the diabetic nail care should be in an order and on the Treatment Administration Record (TAR) which would prompt nurses to complete it. Review of Resident 10's January, February and March 2026 TAR did not include an order to do diabetic nail care. In observations on 03/10/2026 at 9:18 AM, 10:20 AM, 12:09 PM and 1:51 PM, Resident 10 was lying in bed watching TV. The resident continued to have long facial hair and jagged fingernails with brown matter under them. In an interview on 03/10/2026 at 2:01 PM, Staff H, Nurses Aide Certified stated Resident 10 required total care/assistance for ADLs. Staff H stated nurses were to complete diabetic nail care and shaving was to be done with showers. Staff H stated Resident 10 did not refuse care. In observation on 03/11/2026 at 7:25 AM, the resident was lying in bed watching television with long facial hair and jagged fingernails with brown matter under them. In an interview on 03/11/2026 at 9:25 AM, Staff D, RN/Assistant Director of Nursing was asked about Resident 10's lack of grooming. Staff D stated the nurses completed diabetic nail care, and they should be on the TAR, so the nurses would know they need to perform the task. In an observation on 03/11/2026 at 12:37 PM, Resident 10 was resting in bed and stated their nails got trimmed. They waved their fingers and smiled. Their fingernails were clean and trimmed. Resident 10's facial hair remained and the resident said they would agree to be shaved. Reference WAC 388-97-1060(2)(c)

Based on interview, and record review, the facility failed to assess, thoroughly monitor, and take timely action in accordance with professional standards of practice for 1 of 3 residents (Resident 92) reviewed for non-pressure wounds, and 1 of 1 hospice residents (Resident 11) reviewed for hospice services. Failure to ensure Resident 92's left thigh wound was assessed and measured to ensure the wound was healing and no further medical interventions were required, the failure to implement a change in Resident 11's blood pressure medications placed residents at risk for potential complications in wound healing going undetected, and risk for continued low blood pressures, and a decreased or diminished quality of life. Findings included . <NON-PRESSURE SKIN> Resident 92 was admitted to the facility on [DATE] with diagnosis to include paraplegia (the impairment of motor or sensory function in the lower body). Review of Resident 93's Initial Admissions assessment, dated 10/25/2026, showed no documentation that the resident had a left thigh wound. Review of Resident 92's physician order, dated 10/30/2025 and discontinued 12/02/2025, directed the License Nurse to clean and apply foam dressing every three days to the resident's left thigh wound. Review of Resident 92's progress note, dated 10/31/2025, documented there was a wound to the resident's left thigh and a treatment order was implemented. There was no description of the wound documented. Review of Resident 92's progress note, dated 11/01/2025, documented the resident had a skin injury with a dressing in place on their left thigh. Review of Resident 92's progress notes, dated 11/04/2025, 11/05/2025, 11/07/2025, 11/07/2025, and 11/14/2025, documented the resident had a pre-existing injury to the left thigh. There was a dressing in place. Review of Resident 92's LN- Skin Evaluation – PRN, dated 11/01/2025, 11/10/2025, 11/1/2025, 11/22/2025, 11/24/2025 showed no documentation of the resident's left thigh wound. Review of Resident 92's Electronic Medical Record showed no description, size, or assessment of the resident's left thigh wound. There was no documentation located regarding when the left thigh wound healed. On 03/10/2026 at 1:40 PM, a interview was conducted with Staff B, Registered Nurse (RN)/Director of Nursing Services, and Staff AA, Clinical Resource RN. Both staff were asked regarding the lack of Resident 92's left-high wound documentation. Staff B was shown Resident 92's October 2025 and November 2025 Treatment Medication Administration Record documented what treatment was being done to their left thigh wound. Staff B stated they would investigate the lack of documentation to the resident's left thigh wound. <RESIDENT 11> Resident 11 admitted to the facility on [DATE] with diagnoses to include right hip fracture, history of stroke, and unspecified dementia. Resident 11 admitted to hospice services on 12/19/2025. Review of Resident 11 hospice comprehensive admission assessment dated [DATE] with a faxed timestamp of 12/19/2025 documented they had documented low blood pressures in the prior week an order to reduce Lisinopril (medication to treat high blood pressure) and Amlodipine (medication to treat high blood pressure). Review of Resident 11's hospice routine visit note by the registered nurse, dated 12/23/2025, documented the medication list was refaxed as the facility had not implemented the changes for ordered decrease in Lisinopril and Amlodipine. In a review of Resident 11's December 2025 Medication Administration Record showed their Lisinopril and Amlodipine were decreased on 12/23/2025. In an interview on 03/11/2026 at 9:21 AM Staff U, Resident Care Manager/Licensed Practical Nurse stated when hospice completed a visit the facility received a fax with any new orders, the orders would be reviewed by the provider and then implemented. Staff U stated the floor nurses reviewed them and placed them in their box for further review. When asked about the delay in processing Resident 11's hospice orders received on 12/19/2025, Staff U stated they were not sure why there was a delay. Staff U stated there were no progress notes documenting that the orders were received on 12/19/2025. Refer to WAC 388-97-1060(1)(3)(c)

Based on interview and record review, the facility failed to ensure 1 of 2 residents (Resident 10) received the necessary care and services to prevent significant and severe weight loss within the first 60 days of admission. This failed practice caused potential harm for Resident 10 in the form of severe weight loss and placed the resident and others at risk for adverse health, safety and diminished quality of life.Findings included . According to the State Operations Manual (SOM), with an implementation date of 11/22/2017, the Centers for Medicare and Medicaid Services defined the parameters for significance of unplanned and undesired weight loss for severe weight loss as greater than 5% in one month. Review of the facility's policy titled, Nutrition Status Management, revised on April 2025 showed any resident weight that varies from the previous reporting by more than 5 percent (%) in 30 days, 7.5% in 90 days and 10% in 180 days will be evaluated by the Interdisciplinary Team (IDT) to determine the cause of weight loss/gain and intervention required. The policy documented the nurse will notify physician, family and/or resident of weight loss/gain with interventions. Further, any resident meeting the criteria for weight loss and any resident at risk would be weighed weekly with the weight entered into the electronic medical record and reviewed by the Registered Dietician (RD)/designee. If there was a significant change in the resident's condition related to weight or nutrition, the RD would make recommendations to offer additional nutrition to those residents including all high-risk residents. Options included, but were not limited to, fortified cereal, large portions, between meal snacks, and commercial nutritional supplements. Weights would be reviewed by the RD/designee. Resident 10 admitted on [DATE] with diabetes, cognitive communication deficit, difficulty swallowing and vitamin D deficiency. Review of the care plan, dated 01/06/2026, documented Resident 10 had a potential nutritional problem/risk for nutrition related to decreased intake, weakness, difficulty swallowing, lack of teeth, advanced age, diabetes, memory deficit and vitamin D deficiency. The goal was for Resident 10 to maintain adequate nutritional status as evidenced by maintaining weight with no signs of malnutrition through 04/22/2026. The interventions were diet as ordered, honor resident rights to make personal dietary choices and provide dietary education, meals in the dining room if resident is in agreement, monitor and report to doctor for any signs of decreased appetite, unexpected weight loss, offer snacks and fluids between meals and the RD to evaluate and make changes as needed. The interventions listed were not individualized and there were no revisions to the care plan after 01/16/2026. Review of the Minimum Data Set (MDS-an assessment tool) dated 01/09/2026, defined a clinically significant weight loss episode for nursing home residents as a loss equal to or greater than 5% within a 30-day period or 10% within a 180-day period. The assessment documented weight loss did not occur or was unknown. The resident required partial/moderate assistance for eating, had no teeth and had coughing or choking during meals and complaints of difficulty or pain while swallowing. Review of the Nursing nutrition/hydration Dietary Evaluation dated 01/09/2026 showed Resident 10 was lethargic, was able to feed themselves with verbal cues, had missing teeth, poor food intake of less than 25% of most meals and refused snacks and supplements. The total score of the evaluation was 18. The evaluation stated if the total score was 10 or greater, a prevention protocol should be initiated immediately and documented in the care plan. Review of the Care Area Assessment (CAA-tool used to create the care plan) dated 01/09/2026 showed Resident 10 was currently on mechanical soft diet, thin liquid. Intake had been variable and poor. They were on a house oral nutritional supplement related to risk for malnutrition. The CAA documented the goal was for weight stability, improved intake and no signs of malnutrition. The CAA showed the weight was trending down with a trigger for weight loss of 7.5% for one week. Review of the resident's admission weight on 01/07/2026 was 157 pounds. The corresponding weights were: 01/08/2026 155.0 pounds 01/09/2026 152.0 pounds 01/13/2026, 145.3 pounds 01/16/2026 141.5 pounds 02/13/2026 137.7 pounds 03/03/2026 138.8 pounds Review of the physician orders on admission directed staff to obtain weekly weights. Review of the medical record showed they were not obtained weekly for close monitoring. Review of a Weight Change Note dated 01/20/2026 at 5:36 PM showed Resident 10 was discussed during the nutrition meeting. The note documented a weight loss of 9.9% or 15.5 pounds in two weeks. The note did not include any new interventions or provider notification. Review of the nutrition IDT note on 01/21/2026 documented a weight loss of 6.9 %. Meal intake was noted at 42.5%. The resident reported not enjoying food provided by the facility. The note documented that they would maybe have activities help with menu selection. Review of a Provider note dated 01/27/2026 documented poor oral intake, consistently refusing meals with minimal intake of supplements and noted a 7.5% decrease in weight since admission. Labs were reviewed and indicated a malnutrition risk. Review of the nutrition IDT note on 01/28/2026 documented a weight change of 6.9 % for one week, noting a clinically significant weight loss. Meal intake was at 44%. Resident 10 stated they did not care for the food, and they may have activities go over the menu with them weekly to help find things they liked. Review of a Weight Change Note dated 02/24/2026 at 8:36 AM documented Resident 10's weight loss of 12.3% or 19.3 pounds since admit was reviewed with the RD. The note did not include any new interventions or provider notification. Review of the 30-day lookback of Resident 10's meal monitors on 03/10/2026 showed the resident ate 0-25% of their meals at one lunch and 15 dinners. Resident 10 ate 26-50% for 10 breakfasts, 15 lunches & 8 dinners. They refused snacks for 10 days. Review of a Weight Change Note dated 03/06/2026 at 1:33 PM showed Resident 10 currently received house supplements twice daily and they would review with RD next week if the resident continued to trigger for weight loss. A weight warning showed the resident had a loss of 11.6% of body weight or 18.2 pounds. The note did not include any new interventions or provider notification. In an interview and observation on 03/11/2026 at 12:37 PM, Resident 10 was in bed with their lunch tray in front of them containing cottage cheese, kiwi fruit, orange slices and strawberries. There were only bites of the cottage cheese consumed. Resident 10 was asked about their weight loss, and they said they did not know they had lost weight, but it could be because they did not eat much. Resident 10 pointed to their plate and stated they could only eat the cottage cheese because they had no teeth and that fruit was too hard for them to eat. In an interview on 03/11/2026 10:59 AM Staff D, Registered Nurse/Assistant Director of Nursing was asked about Resident 10's significant weight loss of 11.6 %/18.2 pounds in two months. Staff D stated Resident 10 did not care for the food and activities were going to go through the menu weekly with them. Staff D stated the resident did not like supplements and they had offered them to go to the dining room. Staff D stated they would look to see if their diet was fortified and add sauces and gravies to meals. Staff D stated Resident 10 was seen by the RD and they would call them tomorrow. Staff D stated they would need to see if the provider had been recently notified of the continued weight loss. Review of Resident 10's dietary slip from the kitchen on 03/11/2026 showed the resident was on a mechanical soft diet, with menu notes for whole milk and water. In a phone interview on 03/11/2026 at 2:08 PM, Collateral Contact 1 (CC1), RD, stated they were going to discuss Resident 10 with the IDT tomorrow. CC 1 stated the resident was 157 pounds then 155 pounds, then 152 pounds then 145 pounds, then 141 pounds, to 137 pounds. CC 1 stated Resident 10's last weight on 03/03/2026 was 138.8 pounds but could have been a result of no recent bowel movement. They stated the resident was not taking their supplement often and they needed to give them something more enticing so they would accept it. CC 1 stated Resident 10 had been eating 45.37 % of their meals, and with this intake Resident 10 would have weight loss. CC 1 said maybe the facility could try a different supplement or another alternative to get them more calories. CC 1 said they saw the Resident 10 yesterday and recognized the weight loss and had yet to document their visit note. CC 1 said the resident needed to be prompted to go to the dining room. CC 1 said their expectation would be weekly weights with this amount of weight loss. CC 1 commented that the resident had been there for 2 months and 2 days and they needed to get ahead of the weight loss. In an interview on 03/11/2026 3:18 PM Staff L, Nurse's Aide Certified stated Resident 10 did not eat a whole lot and ate small amounts of their dinners. Staff L said Resident 10 would sometimes ask for snacks and accept a cookie. Reference WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to ensure annual Certified Nursing Assistant (CNA) performance reviews were completed timely for 2 of 4 employees (Staff J and O) reviewed who had been employed longer than one year. This failed practice had the potential to negatively affect the competency of the CNAs and the quality of care provided to residents. Findings included .Staff J, CNA was hired on 02/08/2024. Review of Staff J's employee file showed the employee evaluation was completed late on 09/15/2025. Staff O, CNA was hired on 04/11/2025. Review of Staff O's employee file showed the employee evaluation was completed late on 09/12/2025. In an interview on 03/11/2026 at 9:25 AM, Staff D, Assistant Director of Nursing, confirmed there were two of four performance evaluations that were late. Staff D said there was a process and a plan to ensure performance evaluations were completed timely. Reference WAC 388-97-1680 (2) (a-c)

Based on observation, interview and record review, the facility failed to ensure nurse staffing information postings were current, accurate, and included the census/number of residents in the facility. These failures placed residents and visitors at risk for not being fully informed of current nurse staffing levels and resident census information. Findings included . In an observation on 03/04/2026 at 8:21 AM, the daily nurse staffing posting did not contain the census. At 4:01 PM, there were no totals at end of the shift. In an observation on 03/09/2026 at 8:50 AM, the daily nurse staffing posting did not contain the census. The daily nurse staffing postings from the weekend showed no census or hours worked on Sunday 03/08/2026. In an interview on 03/09/2026 at 10:20 AM, Staff P, Nurse's Aide Certified and interim scheduling stated they were responsible for updating the daily staffing posting. Staff P stated they updated the hours worked after shifts and would add the census if they knew it. Staff P stated they were unaware the postings needed to be revised as changes occured. Staff P stated there was no one to update the postings after hours or on weekends. They stated they updated the sheets from the weekends on Mondays. No associated WAC reference.

Based on observation and interview the facility failed to ensure 1 of 4 medication carts and 1 of 2 treatment carts on 2 of 3 halls had unsecured medications. These failures placed residents at risk for unauthorized access to medications and biologicals, and potential drug misuse. Findings included . Review of the facility policy titled, Storage of Medications dated April 2007 showed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes.) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available. <MEDICATION CART> In an observation on 03/11/2026 from 9:44 AM to 9:51 AM the 200-hall medication cart was observed to be unlocked and unattended. Resident 2 was in a wheelchair across from the cart. Staff B, Director of Nursing (DNS) walked up at 9:51 AM and commented they could see the medication cart was unlocked. Staff B then stayed at the medication cart. In an interview on 03/11/2026 at 11:01 AM, Staff Q, Licensed Practical Nurse/Supervisor said the expectation was for medication carts to be locked when a nurse walked away. <TREATMENT CART> In an observation on 03/05/2026, at 8:43 AM, the 300-hall treatment cart was observed to be unlocked and unattended. The treatment cart contained Betadine Solution (antiseptic), Santyl ointment (prescribed medication to remove dead tissue from wounds), Hydrocortisone cream (used to treat irritation and itching on the skin), Nystatin/triamcinolone (topical medication to treat skin infections) and more. Staff C, Registered Nurse, returned to the treatment cart from a resident's room and acknowledged the unlocked cart and then locked the treatment cart. Reference WAC 388-97-1300(2)

Based on observation, interview, and record review the facility failed to obtain and provide routine dental services for 1 of 2 sampled residents (Resident 39) reviewed for dental services. This failure placed residents at risk for continued dental problems, difficulty chewing, associated health complications, and a diminished quality of life. Findings included Resident 39 was admitted on [DATE] with diagnoses to include dysphagia (difficulty swallowing). In an interview on 03/04/2026, at 11:06 AM, Resident 39 stated their teeth were falling apart and needed to see a dentist. Resident 39 stated they had a hard time eating at times. In an observation during the interview Resident 39 had no upper teeth and their lower teeth were discolored and partially broken. In an interview on 03/06/2026, at 9:18 AM, Resident 39 stated they had not been offered to see a dentist while at the facility and would accept a referral. Review of Resident 39's admission MDS, dated [DATE], documented Resident 39 had no upper teeth and had many missing lower teeth with obvious and likely cavities/broken teeth. Review of Resident 39's Quarterly Minimum Data Set (MDS - an assessment), dated 02/05/2026, documented Resident 39 had a mechanically altered diet and no tooth, mouth or facial pain or discomfort/difficulty with chewing. Review of Resident 39's care plan, dated 01/02/2026, documented they had oral/dental problems related to no upper teeth and poor dentition on their lower teeth with many missing and obvious/likely cavities/broken teeth related to history of poor oral hygiene. In an interview on 03/09/2026, at 9:33 AM, Staff R, Social Services Director (SSD), stated they did not see Resident 39 on the facility dental hygienist list or any other dental care documentation. Staff R stated they discussed dental needs during care conferences, however had not been documenting it. In an interview on 03/11/2026 at 10:09 AM, Staff W, Licensed Practical Nurse/MDS Nurse, stated when they complete a MDS assessment for a resident they assessed for their dental health/dentition, interviewed them and offered them a dental referral. When asked where the documentation was located for dental referrals that were offered, Staff W stated it was not documented. In an interview on 03/11/2026, at 3:30 PM, Staff B, Director of Nursing, stated they would find documentation to support dental services; however, in an electronic communication received on 03/12/2026 they wrote there was no additional documentation located for dental services for Resident 39. Reference WAC 388-97-1060 (3)(j)(vii)

Based on interview and record review the facility failed to ensure the responsible party was immediately notified and failed to update the physician timely when there was a change in condition for 1 of 3 residents (Resident 1) reviewed for hospitalization. This failure placed the resident at risk of receiving less than optimum care.Findings included.Review of a facility policy titled, Change in Condition, revised date 04/2025, documented:There will be certain circumstances where immediate attention will be warrantedThe nurse will use clinical judgment and contact physician based on urgency of the situationThe resident representative will be notified of the change of condition.Resident 1 admitted to the facility on [DATE]. Review of the face sheet showed two emergency contacts.During an email interview on 02/04/2026 at 7:50 PM, Collateral Contact 1 (CC1), Resident 1's emergency contact, reported they had received a call from Resident 1's spouse reporting the resident had had a stroke (blood flow to brain impaired causing brain damage). CC1 reported Resident 1's spouse came to visit and discovered the resident with weakness and they could not speak. CC1 reported they did not have any notification from the facility regarding a change of condition for Resident 1 despite being one of Resident 1's emergency contacts.Review of a progress note, dated 01/04/2026 at 5:54 AM, documented there was a change of condition for Resident 1 that was identified at 5:30 AM. The note documented that the on-call doctor was notified and gave instructions to monitor the resident and if condition did not clear or condition worsened in the next 30 minutes to call back. There was no documentation that the responsible party was notified of a change of condition.Review of a progress note, dated 01/04/2026 at 10:11 AM, documented Resident 1 had an acute (new) neurological change (condition effecting nerves, nervous system, and brain). The progress note was written by Staff C, Registered Nurse. The note reflected Resident 1 had facial droop, slurred speech, left arm flaccidity (weakness) and visual problems. The note reflected that Resident 1's spouse arrived at 8:00 AM and they were notified of the change of condition. The note documented that the doctor was notified that the family was declining transfer to hospital. The note did not document that the doctor had been notified if no change within 30 minutes as instructed earlier. There was no documentation either responsible party had been immediately notified. The progress note documented CC1 arrived at 9:00 AM and agreed to transfer to hospital.Review of a local hospital emergency room note, dated 01/04/2026 at 9:40 AM, showed Resident 1 had an acute stroke.During an interview on 02/27/2026 at 10:30 AM, Staff D, Certified Nursing Assistant, stated they had observed Resident 1 at 6:00 AM. Staff D reported they noted Resident 1 had a change in condition and was leaning to the side and could not focus their gaze. Staff D reported they went and got Staff C to check on resident. Staff D stated Staff C checked on Resident 1 at 6:10 AM.During a phone interview on 02/27/2026 at 11:37 AM, Staff C reported if a resident was found with new onset arm weakness and visual problems, that would be a critical situation, and they would notify the doctor and family. Staff C reported when they checked on Resident 1 on 01/04/2026, resident already had acute neurological changes that had occurred on the night shift. Staff C could not remember why she had not called the family. Staff C reported they did contact the doctor.During an interview on 02/27/2026 at 1:01 PM, Staff A, Assistant Director of Nursing, stated acute neurological changes was an acute episode and would be a priority and the doctor and family should be notified at the same time. Staff A reviewed Staff C's progress note of 01/04/2026 and reported it was difficult to determine a timeline as there were no times when events or notifications occurred. Staff A stated they did not see documentation that the family had been immediately notified of Resident 1's change of condition and did not see documentation that the doctor was notified within 30 minutes per their earlier instructions.Refer to WAC 388-97-0320 (1)(b-d)

<RESIDENT 261> Resident 261 admitted to the facility on [DATE] with diagnoses which included recent norovirus (a contagious gastrointestinal virus spread by contact) infection and Clostridium Difficile infection (a contagious gastrointestinal toxin spread by contact). Both Norovirus and Clostridium difficile organisms required enteric precautions of soap and water hand hygiene; alcohol hand sanitizer does not kill those organisms. According to regulation based on Centers for Disease Control and Prevention standards, contact precautions require the staff to put on personal protective equipment (PPE) before entering the room, which included gowning and gloving, to perform hand hygiene that is appropriate to the organism, and require the facility to post signage to communicate the required level of precautions for staff and visitors. In an observation on 06/02/2025 at 2:11 PM, Resident 261's room was observed which showed a contact precautions sign on the door. The contact precautions sign showed instructions for staff to perform hand hygiene prior to entering and exiting the room. The signage did not provide organism specific enteric precautions to wash hands with soap and water prior to exiting the room. In an interview on 06/02/2025 at 2:30 PM, Staff E stated that Resident 261 was still being treated for Clostridium Difficile and should be on contact enteric precautions which would include hand hygiene with soap and water, which should be posted for staff and visitors. In an interview and observation on 06/04/2025 at 1:44 PM, Collateral Contact (CC1), contract staff, was observed to enter Resident 261's room without stopping to don PPE. CC1 was observed to walk to the bedside and begin speaking with Resident 261. Staff A, Administrator and Staff E went to the doorway of the room and told CC1 they needed to don PPE. CC1 stated they had not noticed the sign on the door. In an interview on 06/06/2025 at 9:00 AM, Staff E stated they had found that further education of the staff was needed related to ensuring the proper signage was posted and followed, and records were clear regarding infection precautions. Reference WAC 388-97-1320 (1)(a)(c),(2)(b) <Transmission based precautions> During an observation/interview on 06/02/2025 at 12:15 PM, Staff H entered a resident's room that had an 'enteric precautions' sign on the door without wearing PPE. When Staff H exited the room, they stated that it was unnecessary to wear PPE in the room because the precautions were for a wound. <Enhanced Barrier Precautions (EBP)> <RESIDENT 214> Resident 214 was a new admission to the facility. The resident was admitted to the facility with a diagnosis of a newly placed PEG tube (feeding tube inserted through the abdomen to the stomach), to allow the resident to receive nutrition directly to the stomach. Review of Resident 214's Order Summary Report with a print date of 05/06/2025, documented provider orders for EBP: Personal Protective Equipment (PPE) for high contact care activities due to the resident's PEG tube ordered on 06/01/2025. During multiple observations on 05/02/2025, 05/03/2025, and 05/04/2025, it was noted that Resident 214 did not have an EBP sign displayed on their door. During an observation on 06/03/2025 at 12:44 PM, Staff D, LPN, entered Resident 214's room and administered medication via the PEG tube. Staff D did not don appropriate PPE while providing care to the resident. During an interview on 05/062025, at 8:22 AM, Staff C stated that residents who were admitted with a PEG tube were to be placed on EBP upon arrival at the facility. During an interview on 06/06/2025 at 8:27 AM, Staff E stated that Resident 214 should have been on EBP upon arrival at the facility. Based on observation, interview and record review, the facility failed to ensure that staff were compliant with Infection Prevention and Control Guidelines (IPCP) and standards of practice of using Personal Protective Equipment ([PPE] - specialized clothing including gowns and gloves worn to protect from infection or illness) for 3 of 5 residents (Residents 11, 214, and 261). These failures placed all residents and staff at an increased risk for the potential transmission of infections. Findings included . Review of a facility policy titled, Transmission-Based Precaution, revised in October 2022, documented for contact precaution, wearing a gown and gloves for all interactions what involved contact with the patient's environment and donning PPE upon room entry was required. <RESIDENT 11> Resident 11 readmitted to the facility on [DATE] with diagnoses to include extended spectrum beta lactamase (ESBL) resistance (an enzyme produced by bacteria that confers resistance to many common antibiotics). In an observation and record review on 06/02/2025 at 11:16 AM, a contact enteric precautions signage was posted on Resident 11's room door. The signage documented Gown and glove when entering the room. In an interview on 06/02/2025 at 2:28 PM, Staff E, Licensed Practical Nurse (LPN)/Infection Preventionist, stated Resident 11 required contact precaution which was recommended by the health department. In an observation and interview on 06/03/2025 at 12:15 PM, observed Staff F, Nursing Assistant Certified (NAC) enter the room with a lunch tray without applying a gown and gloves Staff F touched the bedside table, set up the lunch on the bedside table, and moved the bedside table with lunch closer to Resident 11. Staff F stated they did not need to wear a gown or gloves because they did not provide care. Reviewed the signage on the door with Staff F about Gown and glove when entering the room; Staff F stated gown and gloves were only required for providing care. In an observation and interview on 06/03/2025 at 12:44 PM, observed Staff G, NAC enter Resident 11's room, without donning a gown and gloves, . Staff G touched the bedside table and collected the lunch tray from Resident 11's bedside table. Staff G stated they did not need to wear a gown and gloves which were only required for providing care like changing briefs. In an interview on 06/04/2025 at 1:30 PM, Staff H, NAC, stated gowns and gloves were only needed for doing care for residents with contact enteric precautions. In a joint interview on 06/06/2025 at 2:05PM with Staff C, LPN/Resident Care Manager (RCM), and Staff B, Registered Nurse/Director of Nursing, Staff B stated staff should follow the instructions on the signage posted on the doors.

Based on interview and record review the facility failed to ensure 2 of 6 residents (Residents 50, and 214) reviewed for unnecessary medications received medication specific monitoring. This failure placed residents at risk for unrecognized effects and/or side effects of high-risk medications. Findings included . <RESIDENT 50> Resident 50 admitted [DATE] with diagnoses which included depression and anxiety. Review of Resident 50's medical record on 06/05/2025 documented the resident admitted to the hospital after experiencing a side effect of their antidepressants which caused Syndrome of Inappropriate Antidiuretic Hormone (SIADH), (an issue with their body's production of antidiuretic hormone causing their body to retain more fluid) which caused their sodium levels to be too low. In an interview on 06/02/2025 at 1:00 PM, Resident 50 stated they had depression and a history of trauma. Resident 50 stated they were abruptly taken off the antidepressants they had been taking for 30 years. Resident 50 stated the medications had affected their sodium levels, and they had gotten really confused, dizzy, were falling and were told they had to stop those medications. Resident 50 stated they were now having more depression, and stated they had no motivation to do anything at all and just didn't care about anything. Resident 50 said they talked to someone about it and they had an order to start a new antidepressant medication tonight. Resident 50 stated they were worried about starting the new medication and how it would affect them. Review of the resident's mood and behavior monitoring since admission on [DATE] showed the resident had not been on any kind of depression symptom monitor. The resident's admission Minimum Data Set Assessment (a required assessment tool) dated 05/01/2025 showed the resident initially denied depression symptoms during interview and also during an admission visit with the facility behavioral health provider. A follow up behavioral health provider note dated 05/28/2025, documented the resident acknowledged they had not been truthful about their mood during the initial visit with them. The provider conducted a standardized depression screening tool (PHQ-9) which showed a score of 10, which indicated mild to moderate depression recommending follow up. Review of Resident 50's record showed there had been no implementation of target behaviors or depressive symptom monitoring following this provider visit. Review of Resident 50's physician's orders showed an order for Trazodone (an antidepressant) to start the evening of 06/02/2025. Review of Resident 50's record on 06/05/2025 showed the resident's new antidepressant medication had been administered as ordered on 06/02/2025, 06/03/2025 and 06/04/2025. There were no target behaviors, side effect monitoring, depressive symptom monitoring or update to the care plan put in place related to the new medication. In an interview on 06/05/2025 at 10:34 AM, Staff B, Director of Nursing Services (DNS), stated it was not indicated to have a depression monitoring in place for Resident 50 on admission despite their history and admitting diagnosis, because Resident 50 had denied depression symptoms and had not presented as being depressed. Staff B stated that typically the facility reviewed new orders for medications as a team to ensure that all the components were in place which would include target behaviors, symptom monitoring, side effect monitoring and updates to the care plan and stated this had been missed for Resident 50. <RESIDENT 214> Resident 214 was a new admission to the facility. Resident 214's diagnoses included depression. Record review of Resident 214's 'Provider's Orders' on 06/06/2025, documented that Resident 214 was prescribed two different types of antidepressant medication. Orders did not contain behavior monitors, medication side effect monitors or non-pharmacological interventions. Record review of Resident 214's 'Medication Monitors' on 06/06/2025, documented that Resident 214 was prescribed antidepressant medication. Orders did not contain behavior monitors; medication side effects monitors or non-pharmacological interventions. During an interview on 06/05/2025 at 1:00 PM, Staff D, Licensed Practical Nurse (LPN), stated that Resident 214 did not have behavior monitors, medication side effect monitors or non-pharmacological intervention for antidepressant medications. During a joint interview on 06/05/2025 at 1:15 PM, Staff B, and Staff C, Resident Care Manager (RCM)/LPN, stated that Resident 214 did not have behavior monitors, medication side effects monitors or non-pharmacological interventions in place. Reference WAC 388-97-0620

<RESIDENT 31> Resident 31 was admitted to the facility on [DATE] with diagnoses to include CHF and HTN. Review of Resident 31's MAR for June 2025 showed the following order: - Carvedilol tablet 6.25 mg, give one tablet by mouth two times daily for HTN. Hold for HR <55 or SBP <100. There was no documentation indicating that BP or HR had been monitored prior to administering eight of eleven doses per physician orders. Review of Resident 31's clinical record vital signs with a print date of 06/06/2025, showed no documented BP or HR for the eight of the eleven doses of the Carvedilol given in June 2025. The documentation for the vital signs included: - On 06/01/2025, BP and HR were documented once. - On 06/04/2025, BP and HR were documented once. - On 06/05/2025, BP and HR were documented once. In an interview on 06/06/2025 at 8:30 AM, Staff D, LPN stated that for medications that have BP and HR parameters, they check the BP and HR first to ensure they are within the parameters and document the BP and HR results on the MAR or in the resident's chart under the vital signs tab. If the vital signs being taken are within the parameters, then they give the medications. In an interview on 06/06/2025 at 8:42 AM Staff M, LPN stated that the Nursing Assistant Certified (NAC) takes the BP and HR and if they were outside the parameters they would re-check them prior to giving the medications with parameters. Staff M stated that document the BP and HR in the MAR or in the resident's chart under the vital signs tab. In an interview on 06/06/2025 at 8:50 AM, Staff B stated that Licensed Nurses (LNs) were expected to document the vital signs in the residents' chart whether it's on the MAR or under the vital signs tab. Staff B stated their expectations for LNs is that the nurse reviews the vital signs obtained by [NAME] NAC and if they are outside the parameters the LN would recheck that resident's vital signs prior to administering the medications. Staff B stated they don't audit for medications given outside the parameters, and it does not print in their medication error report. If they find an error, then they would provide education to staff. Staff B was not aware of missing vitals in Resident 31's clinical record for Carvedilol medication parameters but stated they would review it. <RESIDENT 40> Resident 40 was admitted to the facility on [DATE] with diagnoses to include HTN and CHF. Review of Resident 40's physician orders showed the following: - Carvedilol 6.25 mg, give 1.5 tablet by mouth two times a day. Hold if SBP <110 or HR <60 bpm. Order date was 05/17/2025. - Carvedilol 12.5 mg, give half a tablet by mouth two times a day. Hold if SBP <110 or if diastolic BP (DBP - bottom number in the blood pressure reading, the pressure in your arteries when your heart is at rest between beats) or HR <60 bpm. Order date was 04/11/2025 and was discontinued on 05/17/2025. Review of Resident 40's June 2025 MAR with a print date of 06/03/2025 and electronic chart under the vital signs tab with a print date of 06/05/2025 showed no documentation of resident's HR for five of the nine doses for the Carvedilol given. Review of Resident 40's May 2025 MAR, with a print date of 06/03/2025 showed Carvedilol was given outside the parameters three times. Review of Resident 40's April 2025 MAR with a print date of 06/03/2025 showed Carvedilol was given outside the parameters once. Review of Resident 40's physician orders showed the following order: - Hydralazine Hydrocholoride (HCl) 10 mg, give 1 tablet by mouth two times a day. Only administer if SBP is greater than 150. Order date 05/17/2025. Review of Resident 40's May 2025 MAR with a print date of 06/03/2025 showed that Hydralazine medication was given outside the parameters four times. In an interview on 06/06/2025 at 8:30 AM, Staff D stated that for medications that have BP and HR parameters, they check the BP and HR first, to ensure they are within the parameters and they document the BP and HR in the MAR or in the resident's chart under the vital signs tab. If it's within the parameters, then they give the medications. In an interview on 06/06/2025 at 8:42 AM Staff M, LPN stated that the NAC takes the BP and HR and if they were outside the parameters they would re-check them prior to giving the medications. Staff M stated that they document the BP and HR in the MAR or in the resident's chart under the vital signs tab. Staff M reviewed Resident 40's June 2025 MAR and stated there was no BP and HR documentation for the Carvedilol. In an interview on 06/06/2025 at 8:50 AM, Staff B stated that Licensed Nurses (LNs) were expected to document the vital signs in the residents' chart whether it's on the MAR or under the vital signs tab. Staff B stated their expectations for LNs is that the nurse reviews the vital signs obtained by [NAME] NAC and if they are outside the parameters the LN would recheck that resident's vital signs prior to administering the medications. Staff B stated they don't audit for medications given outside the parameters, and it does not print in their medication error report. If they find an error, then they would provide education to staff. Staff B was not aware that Resident 40 received medications when their vital signs were outside the ordered parameters in April and May 2025 or that there was missing documentation of the residents BP and HR in the clinical record but stated they would review it. Reference WAC 388-97-1620(2)(ii) Based on observation, interviews, and record reviews, the facility failed to follow professional standards of practice for 3 of 5 residents (Residents 54, 40, and 31) reviewed for unnecessary medications. Failure to follow physician orders when administering medications, and administering medications outside established parameters or without documented parameters placed residents at risk of medication errors and acute medical problems. Findings included . <RESIDENT 54> Resident 54 was a short-term resident of the facility with diagnoses that included congestive heart failure (CHF- a condition where the heart does not pump blood as well as it should), and hypertension (HTN- high blood pressure). According to the admission Minimum Data Set (MDS-an assessment tool) assessment dated [DATE] showed the resident had mild cognitive impairment. Review of Resident 54's Physician order summary report as of 05/14/2025 showed the following orders: - Midodrine (a blood pressure (BP) medication) 2.5 milligrams (mg) by mouth two times daily for heart failure, hold for Systolic Blood Pressure (SBP), top blood pressure number, greater than (>) 110. Order discontinued on 05/14/2025. - Midodrine 5 mg by mouth three times daily for heart failure, hold for SBP > 140. Order started on 05/22/2025. - Metoprolol (a BP medication) 200 mg by mouth one time daily for HTN, hold for SBP less than (<) 110 or a Heart Rate (HR) < 60. Order was initiated on 05/15/2025 with dose increased to 400 mg daily on 05/16/2025. Review of Resident 54's May and June 2025 Medication Administration Record (MAR) documented the following: - On 05/17/2025 AM dose, SBP=96, and metoprolol was administered outside physician-ordered parameters. - On 05/18/2025 AM dose, SBP =100 and the medication was administered. - On 05/25/2025 AM dose, SBP=102 and the medication was administered. - On 05/31/2025 AM dose, SBP=104 and the medication was administered. - On 06/01/2025 AM dose, SBP=105 and the medication was administered. Review of Resident 54 May 2025 Medication Administration Record (MAR) documented the following: - On 05/15/2025, PM dose, SBP=115, and midodrine was administered outside physician-ordered parameters. - On 05/16/2025 AM dose, SBP=129 and the medication was administered. - On 05/16/2025 PM dose, SBP =138, and the medication was administered. - On 05/17/2025 PM dose, SBP =119, and the medication was administered. - On 05/20/2025 AM dose, SBP =113, and the medication was administered. - On 05/20/2025 PM dose, SBP =145, and the medication was administered. During a joint interview on 06/05/2025 at 1:15 PM, Staff B, the Director of Nursing Services (DNS), and Staff C Resident Care Manager (RCM)/Licensed Practical Nurse (LPN) stated that a check mark by medication in the MAR indicated that the medication had been administered. Staff B and Staff C stated that on 05/17/2025 the metoprolol had been administered outside of the established parameters, but they were unable to navigate the MAR to view any of the other dates. Staff B and Staff C reviewed Resident 54's May 2025 Mar's and stated that the Midodrine medication had been administered outside of the parameters on 05/17/2025, but they were unable to access the computer system to check the other dates.

Based on observation and interviews, the facility failed to prepare food under safe and sanitary conditions in the facility kitchen. The failure to ensure hand hygiene when changing gloves and staff not wearing beard nets placed residents at risk for food contamination and foodborne illnesses. Findings included . According to the facility policy titled Dress policy dated 03/02/2015, kitchen staff, hair and beards must be effectively restrained upon entering the kitchen. Hair restraints include beard nets. In an observation on 06/03/2025 at 11:45 AM during tray line (a system used to assemble and distribute meal trays), Staff N, Dietary Supervisor and Staff O, Dietary Aid had beards and were not wearing beard nets. In an interview on 06/03/2025 at 11:45 AM, Staff N stated that as long as the beard was trimmed and short then staff did not need to wear a beard net. Both Staff N and Staff O had facial hair. In an observation on 06/03/2025 at 12:09 PM, Staff N put gloves on without washing their hands prior to preparing a salad plate with two slices of tomatoes and handed the plate to the cook, then Staff N took the gloves off and did not wash their hands. In an observation on 06/03/2025 at 12:25 PM, Staff N wearing gloves grabbed a container from the fridge and gave it to the cook. Staff N was then observed removing their gloves and did not wash their hands. Staff N put on new gloves without washing their hands and grabbed a turkey wrap from the fridge and gave it to the cook. Staff N removed their gloves and did not wash their hands. In an interview on 06/05/2025 at 8:49 AM Staff N stated that they wear gloves whenever they do food preparation, when they touch food or utensils and drinks. Staff N stated that the process prior to applying new gloves was for staff to wash their hands. Staff N stated when staff leave what they were doing to do something else, like when touching raw meat then they move to touching vegetables they should be changing their gloves. When asked about my observation regarding them not washing their hands before and after putting on gloves, they stated they were not touching anything before they put on new gloves. Staff N stated that if staff beard's are trimmed short, they don't have to wear beard nets. Reference WAC 388-97-1100(3)

Based on interview and record review, the facility failed to provide the necessary supervision for 1 of 3 residents (Resident 1) reviewed for wandering and elopement. The failure to provide necessary supervision caused harm to Resident 1 when found cold, wet, and confused after exiting the facility unsupervised, falling from their wheelchair (w/c) and subsequently located by a community member lying on the side of the road. Based on the reasonable person concept, Resident 1 was harmed and distressed not knowing where they were, how long they would lay there, or what might happen to them. This facility failed practice placed other residents at risk for elopement and injury. Findings included . Review of the facility's, Elopement/Unsafe Wandering policy, revised 01/2022, residents are assisted in attaining or maintaining their highest practicable level of function through providing the resident adequate supervision and diversional programs to prevent unsafe wandering while maintaining the least restrictive environment. The facility would provide the safest environment through an appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Resident 1 admitted to the facility on [DATE] with diagnoses to include dementia with behavioral disturbance, anxiety disorder, delusional disorder (a type of psychotic disorder), and alcohol and nicotine dependence in remission. Review of Resident 1's quarterly Minimum Data Set (MDS) assessment, dated 02/08/2023, showed the resident had wandering behaviors which occurred one to three days of the observation period. The wandering significantly intruded on privacy or activity of others and was worse compared to their prior MDS assessment. Resident 1 required supervision with physical assist of one staff for dressing, toileting, and hygiene, and required supervision and set-up help for locomotion. Review of Resident 1's orders revealed they had a Wander Guard (a system where the resident wore a bracelet and sensors mounted on doors sent alarms when the resident attempted to open the door) bracelet on their wheelchair (w/c), placed on 12/13/2022. Review of Resident 1's progress note, dated 02/04/2023, documented the resident tried to get out the door and stated they wanted to go home. Review of a progress note, dated 02/05/2023, documented Resident 1 was very agitated all night shift, packed their belongings, and went outside twice. Review of a progress note, dated 02/10/2023, documented Resident 1 got outside three times through three different doors during the night shift. Review of Resident 1's Medication Administration Record and Treatment Administration Records for March 2023, showed nursing staff monitored the resident for episodes of anxiety, as evidenced by agitation when redirected, perseveration about going home with their mother, or finding their dogs. Documentation showed the resident had symptoms ten times on the night shift (10:00 PM to 6:00 AM) on 03/14/2023-03/15/2023 when they eloped. Review of documentation for other night shifts in March 2023, showed the resident had symptoms between one and five times on four other nights, and no symptoms the remaining 26 nights. Review of Resident 1's most recent elopement/wandering evaluation, dated 03/15/2023, the date of elopement, showed the resident was mobile in their w/c, had intermittent confusion, made statements of desire to leave, and wandering placed them at significant risk of getting to a dangerous place. The assessment showed the resident's wandering was aimless, and their wandering was described as worse from the prior elopement/wandering assessment, completed on 07/09/2022. Review of the Montreal Cognitive assessment (MOCA), a rapid screening instrument for cognitive dysfunction, dated 03/17/2023, documented Resident 1 scored 10 out of 30 points. Scores of 10-17 may indicate moderate cognitive impairment. Scores of less than 10 show severe cognitive impairment. Review of the facility investigation, dated 03/15/2023, revealed a community member (CM-1) found Resident 1 somewhere between the facility and a nearby assisted living facility (ALF), and brought the resident to the ALF because they did not know where they lived. The nursing home facility staff brought Resident 1 back to the facility via their w/c. The ALF staff informed the facility staff that Resident 1 had arrived at the ALF at 4:10 AM, and they had immediately provided the resident with warm blankets. The facility's Director of Nursing Services (DNS) reported to the nursing home facility staff to immediately check all exit doors for function of the Wander Guard system and found the wander guard component, located at the exit door by the kitchen area, was not functioning properly. Staff statements were attached to the facility investigation documents. Review of an undated statement signed by Staff A, Registered Nurse (RN), documented Staff A reported Resident 1 had wandered since 1:00 AM the night of the elopement and they had last seen Resident 1 at 3:55 AM. Staff A reported they were informed at 4:30 AM Resident 1 had been found outside the facility and had been brought to a nearby ALF. Review of a statement, dated 03/15/2023, showed Staff E, Licensed Practical Nurse (LPN), documented they went to the ALF and brought Resident 1 back at 4:45 AM. Staff E documented Resident 1 was wearing shoes and a jacket. Review of a statement, dated 03/15/2023, showed Staff D, Nursing Assistant (NA), documented they last saw Resident 1 when the resident received medication from the nurse, and then they received a call at 4:30 AM, from a friend who worked at the nearby ALF, that Resident 1 was there. Review of a statement, dated 03/15/2023, showed Staff B, NA, documented Resident 1 was wandering from 1:00 AM on 03/15/2023, and they had last seen the resident at 3:30 AM. Staff B stated they started their rounds at 3:45 AM. Review of a statement, dated 03/15/2023, showed Staff C, NA, documented they observed Resident 1 wandering up and down the hall numerous times during the night shift, and the last time they saw the resident was at 3:00 AM when they started their rounds. Review of Resident 1's hospital records, dated 03/15/2023 - 03/16/2023, showed Resident 1 was evaluated in the Emergency Department (ED) and was diagnosed with a urinary tract infection. In an interview on 04/04/2023 at 12:45 PM, showed Staff F, NA, stated they had observed Resident 1 attempt to exit the facility at times. In an interview on 04/04/2023 at 1:09 PM, Resident 1 stated they did not know why they had left the building that night and did not know where they were going. Resident 1 was unable to provide any details other than stating staff came and got them from wherever they were. In an interview on 04/04/2023 at 1:32 PM, Staff G, NA, stated Resident 1 had exited through the 100-hall door the previous day about 10:30 or 11:00 AM and another NA had brought them back inside. Staff G stated prior to the elopement, Resident 1 would attempt to exit the building and staff would stop them. In a telephone interview on 04/06/2023 at 10:10 AM, Staff B stated they were Resident 1's assigned NA on the night of their elopement. Staff B stated Resident 1 had not wandered much at night in the past; however, recently had been wandering about two nights a week of which they were aware. Staff B stated on the night of Resident 1's elopement, staff had tried to keep an eye on the resident because they were wandering so much. Staff B stated they had last seen Resident 1 between 3:30 AM and 3:45 AM and started doing last resident care rounds close to 4:00 AM. Staff B stated one of the other staff received a call from a nearby ALF that Resident 1 was there, and Staff E brought Resident 1 back to the facility. Staff B stated Resident 1 complained of being cold when they had assisted Staff A to assess the resident for injury. Staff B stated Resident 1 had been wearing a dress, jacket, and slippers that night. In an interview on 04/06/2023 at 1:00 PM, the DNS stated Staff E had picked up Resident 1 from the ALF the night of the elopement, and stated Staff E was currently out of the country. The DNS stated Resident 1 was seen in the ED the day of the elopement and tested positive for a urinary tract infection. In an interview on 04/06/2023 at 3:40 PM, Staff H, LPN, stated this was the first they had heard that Resident 1 had eloped. Staff H stated Resident 1 had gotten out the door in the past, but staff had gone out and brought her back in the facility. In a telephone interview on 04/07/2023 at 10:36 AM, a CM-1 stated when driving home from work on 03/15/2023 at approximately 4:00 AM, they saw a w/c on the side of the road the facility was located on. CM-1 stated they did not know the precise location of the nursing home facility as they were not familiar with it, but according to landmarks discussed with CM-1, it appeared it was a short distance north of the facility. CM-1 stated the weather was cold, was raining quite hard, and visibility had been poor. CM-1 stated they slowed down and saw a person laying in the gutter still partially on the road, obscured by the w/c. CM-1 stated they stopped and discovered a frail elderly female laying on the ground. CM-1 stated Resident 1 stated they had been there a long time and said they were from Louisiana. CM-1 stated Resident 1 was unable to tell them exactly where they had come from, so they put the resident in the w/c and put their (CM-1's) coat over the resident as they were wet from the rain and wearing a thin dress or nightgown and a thin jacket. CM stated they brought the resident to a nearby ALF because they did not know where Resident 1 lived. CM-1 stated ALF staff immediately got warm blankets for the resident. CM-1 stated staff at the ALF stated Resident 1 was not one of their residents, and called the nursing home and found that was where Resident 1 was from. CM-1 stated a staff member from the facility arrived on foot to pick up the resident. In a telephone interview on 04/07/2023 at 1:00 PM, Staff D stated they were working the night Resident 1 eloped. Staff D stated on night shift of the day of elopement, the resident had been wandering the hallways looking for their puppy and their mother and was moving around very quickly in their w/c. Staff D stated staff were taking turns watching the resident, and stated when the resident was wandering like that, nothing staff did seemed to distract the resident from wandering. Staff D stated the time the resident was able to exit the building was a terribly busy time of the night shift as staff was starting their last rounds for resident cares. Staff D stated the last time they personally saw the resident was about 3:30 AM. Staff D stated they received a call that night from an acquaintance who worked at the nearby ALF asking if they had a missing resident because they had a female there, they thought belonged at the facility. Staff D stated they were shocked when the ALF staff showed them Resident 1 on a video call. In a telephone interview on 04/07/2023 at 2:30 PM, Staff A stated they were the assigned nurse for Resident 1 on the night of their elopement. Staff A stated Resident 1 was an exit-seeker and would go to all the exit doors to attempt to get out. Staff A stated Resident 1 had tried to exit several times that night. Staff A stated they worked three nights a week, and Resident 1 had been wandering and exit seeking two of the past three nights. Staff A stated they had last observed Resident 1 at approximately 3:50 AM when they started their resident rounds. Staff A stated interventions were often ineffective with Resident 1 when they were on the go, and they could rarely distract the resident. Staff A stated when (Resident 1) was looking for her dogs and her mom, nothing gets through to her. Staff A stated staff had not realized Resident 1 had left the building until Staff D received a call from staff at the ALF. Staff A stated Resident 1 complained of being cold when they returned so they got them warmed up. Staff A expressed surprise that Resident 1 had scored as cognitively intact on their last MDS assessment, and stated the resident was confused and often thought they were in Louisiana and did not know what town or state they lived in. In a telephone interview on 04/08/2023 at 9:45 AM, Staff C stated they had been working on the night of Resident 1's elopement. Staff C stated Resident 1 had been wandering from hall to hall the night of the elopement and stated the resident had been very quick propelling their w/c. Staff C stated usually when Resident 1 had a real focus on leaving the building like they did that night, another NA watched the resident when the assigned NA did their rounds. In a telephone interview on 04/10/2023 at 10:53 AM, a staff member from the nearby ALF stated they were present when CM-1 brought Resident 1 to the ALF sometime after 4:00 AM on 03/15/2023. ALF staff stated CM-1 brought Resident 1 to the ALF and stated they had found the resident laying on the side of the road in the pouring rain, after falling out of their w/c. The ALF staff stated when Resident 1 arrived at the ALF, complained of being cold and stated they were very wet from the rain, so they wrapped up Resident 1 in three blankets. The ALF staff stated the resident was wearing a thin, lightweight jacket when they arrived. In an interview with Staff I, Social Services, staff referred to Resident 1 as an escape artist. Staff I stated even with their office door being so heavy and the door latch broken, Resident 1 could open it independently. Staff I stated the facility staff loved Resident 1 and hated to have the resident discharge to another facility; however, they were always exit-seeking, and needed to be in a locked facility. Staff I stated Resident 1's cognition ranges from 100% to total confusion. Reference: (WAC) 388-97-1060(1)(3)(g)

Based on interview and record review the facility failed implement a safe discharge plan that included ensuring home health was set up for wound care treatments one of one residents (1) reviewed for discharge planning. In addition, failed to ensure clear concise instructions for care and follow up were given to the resident and their representative. This failure caused harm to Resident #1 when their pressure ulcer worsened due to lack of treatment required for pressure ulcers. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses including caude equina syndrome (dysfunction of lower spinal nerves), and conus medullaris syndrome (spinal injury that cause numbness). Review of the Admissions Minimum Date Set (MDS) Assessment completed on 07/27/2022 showed the resident had intact cognition, no refusals of care or treatment. Resident 1 required extensive two person assist for bed mobility for turning side to side, transfers between surfaces and extensive one person assist for toilet use, personal hygiene care and dressing themselves. Review of the care plan with a focus dated 07/21/2022 stated the resident wished to return to their home with care givers. Interventions dated 07/28/2022, showed home health services will be needed for discharge, evaluate motivation to return to community, schedule follow up appointment with primary care physician, and encourage to discuss feelings. Review of a wound assessment by the Physician's Assistant (PA) on 10/26/2022 (day before discharge) showed the PA debrided their Stage III (full thickness skin loss) pressure injury to the right buttock that measured 8.2 centimeters (cm) in length by 2.7 cm in width by 0.2 cm in depth. The PA's recommendation for care was to use wound cleanser to the wound bed, skin prep to outside of the wound, medi-honey (type of wound ointment) inside the wound and cover with a border dressing every Monday, Wednesday, and Fridays or as needed for accidental removal, saturation or soiled. Review of the discharge summary given to the resident and their representative dated 10/27/2022 (day of discharge), showed the resident had been referred to a home health agency for nursing, physical therapy, occupational therapy, and bathing assistance. There was no contact information provided for the referred home health agency. The discharge summary did not include the updated wound orders from 10/26/2022. The document showed the box was checked that indicated the facility reviewed all discharge instructions with the resident and the resident's representative. Review of the resident progress note dated 10/27/2022 showed the resident discharged home and that the resident's skin was intact, which was incorrect. Review of the facility document titled, Face to Face Encounter for Home Health, dated 10/27/2022 signed by the physician showed the following services that were requested by the facility to the home health agency was a bath aide, physical therapy, and occupational therapy. There was no referral for nursing or wound care requested. In an interview and record review on 12/28/2022 at 1:55 PM with Collateral Contact (CC) 2, home health agency clinical coordinator, they stated a note report dated 11/01/2022 through 11/16/2022 showed the home health agency did not receive referral orders for wound care from the facility. The home health agency was alerted to a wound on the buttocks when the physical therapist arrived at the resident's home on 11/01/2022, 5 days after discharge. The home health agency conducted a nurse assessment at the resident's home on 11/04/2022, 9 days after the discharge. The nurse documented that the wound was found to be uncovered and was unstageable. The documentation stated that the resident was unable to follow wound orders due to the location of the wound and the resident required a skilled assessment and wound dressings by a nurse. The documentation showed on 11/13/2022 the home health agency had requested a wound physician referral related to the wound had not improved. In an interview on 12/19/2022 at 3:12 PM, CC 1 stated they assisted the resident home from the facility on 10/27/2022. CC1 stated they did not receive any wound care education or supplies for the resident from the facility when they assisted the resident home the day of their discharge. CC1 stated the home health agency was unaware the resident required wound care, and had only received referral for a bath aide, physical therapy, and occupational therapy. CC1 stated the home health agency obtained orders to have a nurse referral, and the resident was assessed on 11/04/2022 for their wound. CC1 stated that the home health agency nurse informed them that the wound needed a wound specialist, and that they would make a referral and continue to provide wound care. CC1 stated on 11/18/2022 they took the resident to the emergency room at the hospital related to wound on the buttocks. Review of the hospital admission note dated 11/18/2022 the resident was admitted to the hospital related to septic shock (blood infection) related to Stage to the buttocks, osteomyelitis (bone infection) of the coccyx (butt bone) related to Stage IV pressure injury. Review of hospital wound consultation note dated 11/21/2022 showed the resident presented with a Stage 4 pressure injury that measured 4.5 cm in length by 3.8 cm width by 2.5 cm with 6 cm undermining (significant erosion underneath the outwardly visible wound margins which results in more extensive damage beneath the skin surface) at 7 o'clock and 1.8 cm undermining from 10 o'clock to 2 o'clock. In an interview on 01/12/2023 at 9:35 AM, Staff G, Social Services stated the face to face was completed by the RCM, then once completed with all the orders and referrals given to the physician to be signed on day of discharge. Staff G stated the resident should had been referred to home health agency for nursing, bath aide, and therapy. Staff G acknowledged that the facility document titled, Face to Face Encounter for Home Health, dated 10/27/2022 signed by the physician did not request nursing services. In an interview and record review on 01/12/2023 at 10:25 AM, Staff C, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) stated the discharge progress note on 10/27/2022 that read the resident's skin was intact was invalid, as they were the one that had documented the note. Staff C stated the resident's skin was not intact, and that they had a wound on their buttocks. Staff C stated they were the responsible staff member that provided the discharge summary to the resident and their representative on 10/27/2022, however they did not review the instructions of care, wound treatments, or medications with them. Staff C stated that they had been busy at the time the resident had discharged from the facility and had assumed someone else had provided them with that information. In an interview on 01/12/2023 at 11:08 AM, Staff F, RN/Staff Development stated the expectation for a discharged resident was the discharging nurse would review all medication and treatment orders with the resident and their representative. Staff F stated they had only initiated the discharge assessment in the electronic medical record on 10/26/2022, they had not been involved in the resident's discharge. In an interview on 01/12/2023 at 11:19 AM, Director of Nursing Services (DNS) stated they assisted as needed and completed some of the sections of the discharge summary assessment for the resident in the electronic medical record. The DNS stated that Staff C had been responsible to review the medication and treatment orders with the resident and their representative and was unaware they had not. The DNS was unaware that the face-to-face referral sent to the home health agency did not include nursing/wound care. The DNS did not offer any other information regarding the discharge of Resident 1. Reference WAC 388-97-0080.

Based on interview, and record review the facility failed to identify risk factors, initiate preventative measures, and monitor the assessment of the treatment ordered for the development of a facility-acquired pressure ulcer for one of two residents (1) reviewed for pressure ulcers. This failure caused harm to Resident 1, who developed a Stage III (full thickness skin loss) to their buttocks that was not present upon admission. This failed practice placed other potential residents at risk for the development of a pressure ulcer. Findings included . PRESSURE ULCER DEFINITION AND STAGES The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, defined Pressure Ulcer (PU) Definition and Stages as: -A PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear (a combination of downward pressure and friction). -Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Review of the facility policy titled, Skin Monitoring and Management, revised 06/2016 stated that the facility would identify risk factors which would relate to the possibility of skin break down and/or development of a pressure ulcer .such as impaired feeling to extremities, incontinence (lack of bowel/bladder control) .nursing will implement appropriate and consistent approaches to prevent a pressure ulcer by monitoring and modifying interventions based on any change in condition .if an assessment shows a change in condition related to a pressure ulcer the nurse is document in the medical record. Resident 1 admitted to the facility on [DATE] with diagnoses including caude equina syndrome (disfunction of lower spinal nerves), conus medullaris syndrome (spinal injury that causes numbness), congestive heart failure, difficulty walking, weakness, major depression disorder. Review of the residents Admission Skin assessment dated [DATE] showed that the resident had no skin impairments to their buttocks. Review of the Braden Assessment (a tool used to determine the risk for pressure injury) dated 07/21/2022 failed to document that the resident had a sensory impairment to their legs, failed to document that the resident was incontinent of bowel, and failed to document that the resident required extensive assist for transfers. Review of the Admissions Minimum Date Set (MDS) Assessment completed on 07/27/2022 showed the resident had intact cognition, no refusal of care or treatment. Resident 1 required extensive two person assist for bed mobility for turning side to side, transfers between surfaces and extensive one person assist for toilet use, personal hygiene care and dressing themselves. Review of the Skin section of the MDS dated [DATE] showed the resident did not have any pressure injuries. A focused Care Area Assessment (CAA) triggered for the resident that they were at risk for a pressure injury. Interventions to be addressed on the care plan did not address the resident's decreased mobility, decreased sensory perception, weakness, or incontinence. Review of the resident's care plan showed a focus dated 07/21/2022 that the resident was at risk for a pressure injury related to, the space was blank. The interventions that were dated 07/21/2022 did not identify preventative measures that were specific to the resident and their diagnosis and functional abilities. Review of the Weekly Skin Evaluation assessment dated [DATE] showed no documentation of a skin impairment, and the comment read no new skin issues at this time. Review of the physician orders dated 10/06/2022 showed an order for zinc oxide (topical ointment) to buttocks and sacrum every shift related to moisture associated skin damage (MASD). Review of the resident's progress notes dated 10/06/2022 through 10/12/2022 showed no ongoing assessment of the treatment, and preventative measures related to the skin damage on the resident's buttocks and sacrum area. There was no notification to the physician. Review of the Weekly Skin Evaluation assessment dated [DATE] by the licensed nurse showed the resident had two open areas to their buttocks. Wound 1 was documented as MASD to the right buttock fold that measured 3 centimeters (cm) in length by 2.5 cm in width and the depth was unable to be determined. Wound 2 was documented as MASD to the middle buttock fold that measured 5 cm in length by 1 cm in width and the depth was unable to be determined. The documentation stated the resident had MASD that had now opened with minimal blood to resident's linens. The document stated the facility would obtain a referral for a contract wound provider to assess the wounds, they would request an air mattress, and the resident had been encouraged to reposition however the resident had refused. Review of the resident's progress notes dated 10/13/2022 through 10/19/2022 showed no ongoing assessment of the treatment, and preventative measures related to the skin damage on the resident's buttocks and sacrum area. Review of the contracted wound assessment by the physician assistant (PA) dated 10/19/2022 showed the resident had a Stage III pressure injury to the right buttock that measured 9.5 cm in length by 5 cm in width and 0.1cm in depth. The PA recommendation for care was wound cleanser to the wound bed, skin prep to outside of the wound, medi-honey (type of wound ointment) inside the wound and cover with a border dressing every other day or as needed for accidental removal, saturation or soiled. The documentation recommended to have the resident reposition and offload the wound. Review of the Interdisciplinary Team Skin Review dated 10/19/2022 showed the resident had a pressure ulcer/injury to coccyx and right buttock. Treatment orders were per the contracted wound assessment recommendations. The document was signed by the Director of Nursing Services (DNS), Staff C Licensed Practical Nurse (LPN)/ Resident Care Manager (RCM), Staff D Registered Nurse (RN)/RCM, and the registered dietician. Review of the Weekly Skin Evaluation assessment dated [DATE] showed that the resident had two open areas to their buttocks. Wound 1 was documented as MASD to the right buttock fold that measured 5 centimeters (cm) in length by 2.5 cm in width and the depth was unable to be determined. Wound 2 was documented as MASD to the middle buttock fold that measured 3 cm in length by 3 cm in width and the depth was unable to be determined. The document stated the resident had MASD to right and middle buttocks, the nurse documented the treatment that was applied was zinc oxide to the wound bed. Review of the physician orders showed the wound treatment orders given on 10/19/2022 for; wound cleanser to wound bed, skin prep to outside of wound, medi-honey (type of wound ointment) inside wound and cover with border dressing every other day or as needed for accidental removal, saturation or soiled were not started till 10/22/2022, three days after they were ordered. Review of the resident progress notes dated 10/20/2022 through 10/26/2022 showed no ongoing assessment of the treatment, and preventative measures related to the skin damage on the resident's buttocks and sacrum area. Review of the contracted wound assessment by the PA on 10/26/2022 showed the resident had a Stage III pressure injury to the right buttock that measured 8.1 cm in length by 2.6 cm in width by 0.1 cm in depth. The PA performed a debridement (removal of damaged tissue) procedure at the resident's bedside and the measurements of the wound after the procedure were then 8.2 cm in length by 2.7 cm in width by 0.2 cm in depth. The wound care orders were updated to be completed on Monday, Wednesday, and Fridays. Review of the resident progress note dated 10/27/2022 showed the resident discharged home and that the resident's skin was intact. Review of the discharge summary dated 10/27/2022 showed the resident had a wound that required daily wound dressing changes. Review of the MDS discharge assessment dated [DATE] showed the resident had never had a pressure injury. In an interview on 01/10/2023 at 10:11 AM Staff A, Nursing Assistant Certified (NAC) stated they worked with Resident 1 during their admission at the facility. Staff A stated they recalled the resident did not have any skin impairments before they took two weeks off, when they returned to work the resident had a dressing on their buttocks. In an interview on 01/10/2023 at 11:18 AM, Staff B, LPN stated that they recalled the resident had complained their bottom was sore. Staff B stated they looked at the area and they thought it was MASD, they stated they cleaned the area and applied zinc ointment. Staff B stated they were going to get orders for a wound treatment, however found the active zinc oxide physician order so did not do anything else. Staff B stated the resident tended to sit in one place often. Staff B stated if a resident had any form of skin breakdown, they were educated to place the resident on alert to be monitored every shift. Staff B could not recall if they placed the resident on alert, Staff B acknowledged there was no documentation in the progress notes that showed ongoing assessment of the treatment, and preventative measures related to the skin damage on the resident's buttocks and sacrum area. In an interview on 01/12/2023 at 9:01 AM, Staff E, LPN/MDS stated they did not code the pressure injury on the MDS due to conflicting documentation. Staff E stated the wound documentation showed the resident had a Stage III pressure injury, but the weekly skin notes stated the wound was MASD. Staff E stated that they were informed by Staff C that the wound was MASD so that was how they coded the MDS. In an interview on 01/12/2023 at 10:25 AM, Staff C, LPN/RCM stated they transitioned to the RCM role from floor cart nurse in October/2022. Staff C stated they were told the resident had MASD on their buttocks and was unaware of the contracted wound assessments that was completed on 10/19/2022 and 10/26/2022 had staged the wound as a Stage III pressure injury. Staff C acknowledged they did not participate or review the IDT Skin review dated 10/19/2022 even though they were listed as part of the team. Staff C stated they never assessed the residents' buttocks and did not review any skin review documentation for the resident. Staff C acknowledged they should have reviewed the documentation. In an interview on 01/12/2023 at 10:51 AM, Staff D, RN/RCM stated they rounded with the wound PA for the residents' wound assessments completed on 10/19/2022 and 10/26/2022. Staff D was unaware as to why the wound was not updated in the orders. Staff D was unaware why the care plan was not updated to reflect the wound was a Stage III pressure injury. Staff D confirmed the contracted wound assessment documentation was available to all nursing staff. In an interview on 01/12/2023 at 11:08 AM, Staff F, RN/Staff Development confirmed they opened the discharge assessment on 10/27/2022, and stated it was completed by the DNS. Staff F confirmed they were the RCM for the resident, however in October had transitioned to Staff Development and Staff C was responsible for Resident 1's skin evaluations and review. Staff F confirmed they never reviewed the contracted wound assessments and were aware the resident had an open area to the buttocks. Staff C confirmed they did the admission skin assessment and confirmed the resident did not have any skin impairment to their buttocks on admission. In an interview on 01/12/2023 at 11:19 AM, DNS confirmed they never assessed Resident 1's wound, and stated that Staff D would have been the nurse that would round with the contracted wound PA. The DNS confirmed that the contracted wound PA had staged the wound as a Stage III pressure injury, and they documented the wound was pressure on the IDT Skin review dated 10/19/2022. The DNS stated they had not reviewed the contracted wound assessment dated [DATE] and was unaware the wound had been debrided. The DNS confirmed that MASD was not a wound that would require debridement, and that a pressure injury would. The DNS stated the expectation for all new skin impairments were that the nursing staff would complete a change in condition assessment, notify the physician, start a treatment plan, and place the resident on monitoring for effectiveness of the treatments and interventions set in place to prevent further skin breakdown. The DNS confirmed that monitoring would be in the resident's progress notes. The DNS acknowledged that these were not completed. No further information provided. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review the facility failed to ensure a treatment was stopped when one of one resident (#[AGE]) was observed during a wound treatment who called out multiple times to stop the treatment during what appeared to be an attempted removal of wound tissue. This failed practice resulted in harm in the form of pain, mental anguish and abuse for Resident #[AGE]. Findings included . Review of the facility's policy titled, Abuse Prevention Program, revised on December 2016, showed that the facility residents had the right to be free from abuse . That included but not limited to. physical abuse not required to treat the resident's symptoms. As part of the resident abuse prevention, the administration will protect their residents from abuse by anyone including but not necessarily limited to facility staff. consultants. or any other individual. Conduct employee background checks. According to the State Operations Manual (SOM), with an implementation date of 11/22/17 the definition of abuse and willful are as follows: · Abuse, is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. · Willful, is defined as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident #[AGE] was admitted to the facility on [DATE]. According to the Admission Minimum Data Set assessment dated [DATE], the resident was able to express her wants and needs and able to understand others. In an observation on 01/14/20 at 9:44 AM, wound care rounds were being conducted by Staff N, Physician Assistant, Wound Care Specialist, Staff D, Registered Nurse (RN)/ Resident Care Manger (RCM) and Staff C, RN/RCM were observing, measuring and documenting Resident #[AGE]'s wounds. During an observation at 9:49 AM, Staff N was measuring the resident's left heel and indicated that he pulled off a scab from the resident's left heel wound at which time the resident yelled out to stop. At 9:50 AM, Staff N measured the resident's wound to her right sacral at which time, Staff N was observed to attempt to pull off a portion of nonviable tissue located on the superior portion of the wound and the resident began to cry out, STOP, STOP, STOP it is my body. At this time the Surveyor intervened and stated that the staff had to comply with the resident's directions to stop. In an interview at 01/14/20 at 10:09 AM, the Administrator and Director of Nursing Services (DNS) were informed of Resident #[AGE]'s calling out multiple times for Staff N to stop during the wound treatment and Staff N did not stop nor did Staff C or Staff D intervene to stop Staff N. In an interview on 01/14/20 at 10:25 AM, the resident stated that she felt terrible to be attacked this morning, I want to kill them, I do not understand why all this attention is now to my wounds and took too long and I usually do not call out unless it is painful. It is the professional guys who do the most hurting. In an interview on 01/14/20 at 10:49 AM, the DNS stated that she had started an incident report and had in-serviced Staff C, Staff D and Staff N and had them sign to premedicate prior to dressing changes and if a resident stated stop they were to stop. In an interview on 01/14/20 at 1:25 PM, Staff D, RN/RCM, stated that they were going over standard of care of listening to residents, pain assessment and to pre-medicate, or if in the middle of care, stop and reassess for pain interventions. Staff D was asked if the resident wound care by Staff N was usually similar to the treatment observed earlier that morning. Staff D, stated not typically, that they talk to the resident and they (the residents) tolerate the procedure. Staff D, stated that if Staff N did wound debridement he would use [MEDICATION NAME], some residents would be pre-medicated, and it was a case by case basis. Staff D was asked what he considered pulling a scab off of a wound. Staff D, stated that he would consider it flipping off a dry scab. Staff D, stated that Staff N would do things superficial, if a wound had an area that was lifting he would lift it but usually he would pre-medicate the area or the resident. Staff D, was asked why he did not intervene when the resident was crying out repeatedly to stop. Staff D, stated that was a good question. Staff D, further stated that when a resident stated to stop you should stop, and stated that he did not feel it was excessive at the time of the treatment. In a co-interview on 01/14/20 at 1:43 PM, with Staff C, RN/RCM, and the DNS, Staff C, stated that they had received in-service training earlier in the day regarding pain medication prior to wound care and how well the resident tolerated the treatment, if the resident expresses pain or indicated to stop that they were to make sure the treatment was stopped and make sure the resident was safe and re-approach at a later time. Staff C was asked if it was usual to pull a scab off a heel wound. Staff C, stated that it depended on the scab, if the edges were lifted they would check to see if it was anchored and Staff N would remove the scab. Staff C, stated that Staff N would use the edge of the measurement slips to lift a scab. Staff C was asked if a resident stated to stop when you would stop a treatment. Staff C, stated when indicated, could be when the resident grimaced, it depended on the resident, it was very rare that happened, but sometimes with wound care you can't avoid an element of discomfort. Staff C, stated that she would interject and suggest that they re-approach but from where she was she could not see that Staff N was pulling off a scab. Staff C, stated that if it had gone on any longer that she would have interjected to have Staff N stop and she was comfortable doing that with an upper level practitioner. In an interview on 01/14/20 at 12:04 PM, Staff BB, RN, stated that she had received in-service training today and would stop if a resident stated to stop during care or a treatment, it was something that she had practiced. Staff BB stated that she would politely tell a doctor to stop if it was a doctor doing a treatment. Staff BB, stated that they would have to respect the resident and to stop, it might not be comfortable depending on the doctor. In an interview on 01/14/20 at 12:16 PM, Staff S, Licensed Practical Nurse, stated that she had received an in-service on pain and wound care earlier in the day. Staff S, stated that if people are going to have wound care they were to offer pain management and check afterward to see if effective. Staff S, stated, therapy staff when doing wound care, the staff were really good at telling her when they are going to treat a resident. Staff S, stated that was all that she could remember about the in-service, I read it really quickly. Staff S was asked if a resident stated to stop during a treatment what she would do. Staff S, stated she would definitely stop and would notify the doctor the resident said to stop. In an interview on 01/14/20 at 1:19 PM, L, RN, stated that she had two in-services today, one was to check doors to make sure they were locked and had another one . Cannot recall but can check. Staff L was asked if a resident stated to stop during a treatment what she would do. Staff L, stated that she would stop, offer pain medication and notify the doctor. Staff L was ask if a doctor was doing the treatment, Staff L, stated that she would ask them to stop and would report to the DNS. Review of the in-service sign in sheet dated 01/14/20 showed the subject was pain with wound care. The content showed anytime you were going to perform a dressing change or wound care, review the care plan to determine if a pain medication maybe needed prior to a dressing change or wound care. Return to the resident after medication was taken to determine the effect and make sure they were comfortable. If at any time the resident complained of pain or asked for the procedure to be stopped make sure the resident was safe, leave and reapproach at a later time and implement as the resident could tolerate. If the resident still complained of discomfort notify the physician for implementation of further treatment plan. Review of the facility's State Reporting log on 01/22/20 at 12:27 PM, showed no evidence Resident #[AGE]'s incident of the reported allegation of abuse was logged. Review of Staff N's, background check showed the facility did not provide or have the Federal and/or State required background check. Reference: (WAC) 3[AGE]-[AGE]-0640 (1)

Based on observation, interview and record review the facility failed to prevent avoidable pressure ulcers for one of one resident (#[AGE]) reviewed for pressure ulcers (also known as a pressure injury). The facility failed to implement a focused care plan which identified the resident's risk of pressure ulcers, failed to implement preventative interventions which caused harm to Resident #[AGE] who developed an unstageable coccyx and left heel pressure ulcer (PU), causing pain/discomfort and a diminished quality of life. Findings included . Review of the facility's policy titled, Prevention of Pressure Ulcers/Injuries, revised July 2017, showed that the resident was assessed on admission, within eight hours, for existing pressure ulcer/injury risk factors, conducted a comprehensive skin assessment upon admission and inspected the skin on a daily basis when performing or assisting with personal care. The facility would select an appropriate supportive surface and pressure redistribution based on the resident's overall risk factors. The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (also known as a Pressure Ulcer) definition and stages include the following: · A Pressure Ulcer (PU) was a localized damage to the skin and/or underlying soft tissue usually over a bony prominence (refer to parts of the body where the bones were over layed by skin), related to a medical condition or other device. The injury could present as intact skin or an open ulcer and may be painful. The injury occurred as a result of intense and/or prolonged pressure or pressure in combination with shear (a strain in the structure of a substance produced by pressure, when its layers were laterally shifted in relationship to each other). The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. · A Stage II PU was a partial-thickness skin loss with exposed dermis (skin). The wound bed was viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. · A Stage III PU was a full-thickness skin loss, in which adipose (fat) was visible in the ulcer and granulation tissue and epibole (rolled wound edges) were often present. Slough (non-viable yellow, tan, gray, green or brown tissue) and/or eschar (dead or devitalized tissue that was hard or soft in texture) may be visible. · Unstageable PU was described as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer could not be confirmed because it was obscured by slough or eschar. If slough or eschar was removed, a Stage III or Stage IV PU would be revealed. Stable eschar on the heel should not be softened or removed. Resident #[AGE] was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set assessment dated [DATE], showed the resident was at risk of developing a PU, had pressure reducing devices on the resident's chair and bed, was on a turning and repositioning program and had no identified PUs. Review of the Braden Scale for Predicting Pressure Ulcer/Injury Risk (an assessment tool) dated [DATE], showed the resident was assessed to be at risk for pressure ulcers/injuries. Review of the Clinical Admission Evaluation form dated [DATE], showed the detailed documentation of the resident's skin was completed on the Skin Only Evaluation assessment form. Review of the PU Care Area Assessment from the Admission assessment reference date [DATE], showed the care plan consideration would minimize the risk of PU development and would be addressed in the care plan. Review of the Skin Only Evaluation form dated 01/05/20, showed an unstageable PU to the top of the resident's coccyx that measured 1.5 centimeters (cm) by 0.5 cm. The clinical suggestions were to advise the resident to frequently shift her weight and raise her buttocks while sitting in a chair, evaluate the resident for pain/discomfort and perform dressing changes and treatments as ordered. Additionally, excoriation (which was new) to the resident's buttocks measured 1.5 cm by 0.5 cm. Review of the Skin Only Evaluation form dated 01/07/20 showed the following: · An unstageable left heel PU which measured 1.5 cm by 1.5 cm by 0.2 cm; · A Stage II partial thickness skin loss to the right sacral which measured 1.5 cm by 1.0 cm by 0.2 cm that was noted to be painful; and · A Stage II partial thickness skin loss to the left buttock which measured at 0.5 cm by 1.0 cm by 0.1 cm which was noted to be painful (there was no assessment in the medical record of the resident's unstageable coccyx PU which was identified on the 01/05/20 assessment). The clinical suggestions were noted to advise resident to frequently shift weight, raise buttocks while sitting in chair, evaluate for pain/discomfort, perform dressing changes/treatments as ordered, turn, ambulate, move resident at least every two hours, and evaluate for signs of infection. In an interview on [DATE] at 9:47 AM, Resident #[AGE], stated that she had a sore on her bottom and it was sore. Review of the mood and behavior care plan dated [DATE], showed the resident did not want her legs wrapped, had a PU to her heel (did not specify which heel), refused to wear a heel lift boot (did not specify which heel to apply the boot to), and to only use cream to the resident's coccyx. The goal was for the resident to comply with wound healing interventions. On 0[DATE] a ROHO (a type of pressure relieving device) cushion and an air pressure relieving mattress was initiated. Additionally, there was no PU care plan in place. In an interview on 0[DATE] at 12:38 PM, the resident stated she was getting the royal treatment, got these things on my feet to prevent ulcers, and wished she could have her legs elevated. Review of a physician progress notes [REDACTED]. The physician documented, Per staff, has Stage 3 sacral ulcer and right heel ulcer. In an observation and interview on 01/14/20 at 9:44 AM, Staff D, Registered Nurse (RN)/Resident Care Manager (RCM), Staff C RN/RCM and Staff N, Physician Assistant/Wound Care Specialist, were in to assess the resident's wounds. The resident's wound were measured by Staff N and Staff C was inputting the measurements. The left heel wound was unable to be visualized due to the positioning of the bed and with Staff N and Staff C on either side of the resident's left heel. Staff N stated that the left heel measured 0.3 cm by 0.8 cm and verbalized was removing a scab as the resident called out to stop. The right sacral wound measured 0.5 cm by 0.9 cm by 0.2 cm, the wound bed was observed to have a yellow cream colored wound base and had what appeared to be attached gray/tan nonviable tissue across the superior portion of the wound. Staff N appeared to attempt to pick this tissue off of the wound as the resident called out to stop. The left buttock was observed to have resolved and no measurement was obtained. Review of the Skin Only Evaluation progress note dated 01/14/20, showed: - A left heel Stage III PU that measured 0.3 cm by 0.8 cm by 0.2 cm. There was granulation (part of the healing process in which lumpy, pink tissue containing new connective tissue and capillaries forms around the edges of a wound) noted to the wound bed; and - A right sacral full thickness skin loss Stage III PU that measured 0.5 cm by 0.9 cm by 0.2 cm (which deteriorated from Stage II to a Stage III) with noted granulation to the wound bed (there was no assessment in the medical record of the resident's unstageable coccyx PU which was identified on the 01/05/20 assessment or the Stage II left buttock PU identified on 01/07/20). In an interview on 01/14/20 at 1:25 PM, Staff D, confirmed the documentation in the resident's medical record that the resident did not have any PUs upon admission to the facility. In an observation and interview on 01/16/20 at 9:39 AM, the resident stated that she had owies, on her behind and that they were not healing liked she wanted them to. There was no pressure reducing overlay mattress observed on the resident's bed. In an observation and interview on 01/17/20 at 1:03 PM, Staff D was asked what interventions were put into place to prevent the resident's PUs. Staff D stated that the resident was on a low air loss mattress. Staff D walked into the resident's room and confirmed the resident did not have a pressure relieving mattress on her bed even though the care plan stated it was initiated on 0[DATE]. In an observation on 01/17/20 at 1:37 PM, a contracted healthcare provider was placing a pressure relieving air loss mattress onto Resident #[AGE]'s bed frame. In a follow up interview on 01/17/20 at 1:39 PM, Staff D, stated that there was no documentation the resident had a pressure relieving mattress placed on her bed and the PUs were first noted on 01/05/20. In an interview on 01/21/20 at 10:55 AM, Staff N, stated that he used the NPUAP pressure injury staging guidelines. Staff N stated that a Stage II was a partial thickness affecting the epidermis (the upper or outer layer of the two main layers of cells that make up the skin) or dermis (the vascular, thick layer of the skin lying below the epidermis), a partial thickness wound which had no necrotic (death of cells through injury) or granulated tissue. Staff N stated that a Stage III pressure injury was a full thickness wound that may have granulation tissue but did not include muscle, tendon or bone. This is a repeat deficiency from SOD dated 02/04/19. Reference: (WAC) 3[AGE]-[AGE]-10[AGE](3)(b)

Based on interview and record review, the facility failed to ensure one of five residents (#53) received the necessary care and services to prevent a significant and severe weight loss within the first 30 days from admission. This failed practice caused harm for Resident #53 in the form of severe weight loss and placed the resident at risk for adverse health, safety and diminished quality of life. Findings included . The Minimum Data Set (MDS) assessment dated [DATE], defined a clinically significant weight loss episode for nursing home residents as a loss equal to or greater than 5% within a 30-day period or 10% within a 1[AGE]-day period. According to the State Operations Manual (SOM), with an implementation date of 11/22/17, the Centers for Medicare and Medicaid Services defined the parameters for significance of unplanned and undesired weight loss for severe weight loss as greater than 5% in one month. Review of the facility's policy titled, Weight Assessment and Intervention, revised on September 2008 showed the threshold for significant unplanned and undesired weight loss would be based on 5% (percent) in one month 7.5% in three months and 10% in six months. The individualized care plan should address the identified causes of weight loss, goals and benchmarks for improvement and time frames and parameters for monitoring and reassessment. The interventions included for undesirable weight loss should be based on careful consideration of the resident's choice and preferences, nutrition and hydration needs, medications that may interfere with appetite. The dietitian would review the weight record, negative trends would be evaluated by the treatment team whether or not the criteria for significant weight change had been met. Resident #53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission weight on 12/0719 at 5:00 PM, was 1[AGE].5 Lbs (pounds) in the wheelchair and at 9:34 PM, the resident weighed 1[AGE] Lbs in the wheelchair. The resident was then weighed on 12/08/19 at 1:30 PM, standing with a weight of 1[AGE].1 Lbs. Further review of the resident's weight from the Weights showed over a four week period: On 12/09/19 at 1:13 PM, the resident weighed 1[AGE].9 Lbs while sitting in his wheelchair. By 01/13/20 at 1:25 PM, the resident weighed 163.3 Lbs while sitting in the wheelchair, a 19.8 lb weight loss. Review of the Medication Administration Record [REDACTED]. Review of the Dietary Evaluation dated 12/12/19 showed the resident's identified pertinent [DIAGNOSES REDACTED]. The resident's intake was noted to be greater than 76% for most meals with no noted chewing or swallowing difficulty. The resident was noted to dine independently in his room. The recommendations were noted that the resident was at nutritional risk related to altered skin integrity and dementia with a goal the resident would have no significant weight changes. Monitor intake, weight, labs with a follow up to see the resident during meal time. Otherwise no recommendations were made at that time but to monitor per plan of care and the Registered Dietician (RD) to follow up routinely and as needed. Review of the Admission MDS assessment dated [DATE] showed the resident had a weight loss of 5% or more in the last month and was not on a physician prescribed weight loss regime. Review of the Care Area Assessment (CAA) dated 12/13/19 showed the resident had lost 10 Lbs since admission and that the resident had stated he was just not hungry. The resident was referred to the RD for evaluation. The resident was able to eat independently with set up and was on a regular diet with thin fluids. The resident was noted to have functional problems that affected his ability to eat which included functional limitation in range of motion and inability to perform activities of daily living without significant physical assistance. Cognitive and mental status behaviors that could interfere with the resident's eating were noted as poor memory and dementia. Other diseases and conditions that could have affected the resident's appetite were noted as cardiovascular disease, depression, pain, [MEDICAL CONDITION] and weight loss. The CAA care plan considerations were the nutritional status of the resident would be addressed in the care plan and the overall objective was for improvement. The goal was for the resident to not have a significant weight loss. Review of the MAR for January 2020, from 01/01/20 through 01/13/20 showed the resident received bedtime snacks for two of the 13 nights due to refusals. In an interview on 0[DATE] at 2:48 PM, Resident #53 stated that he did not find food appealing like he used to shortly after he arrived at the facility and had a noted weight loss. Review of the RD progress note dated 0[DATE], showed the resident had refused 11 of 30 meals in the 30 day look back per the meal monitor, with noted severe weight loss in the past month. At nutrition risk, related to altered skin integrity, dementia, weight loss and variable oral intake with a goal for weight stability. The RD noted that changing the resident's dining location from the resident's room to the main dining room for more assistance was discussed with the resident and the RCM(Resident Care Manager). The RD recommendations were for a fortified diet, fruit smoothies with breakfast and a Magic Cup (Fortified Nutrition Snack) with lunch and dinner meals. Review of the care plan printed on 0[DATE] showed the resident did not have a plan of care for nutrition risk. The only interventions associated with the resident's nutrition were noted in the focus problem of Activity of Daily Living self-care performance deficit dated 12/08/19 which showed the resident was on a regular diet with thin fluids and was able to eat independently with set up. The resident preferred apple juice, orange juice and Gatorade for fluid preference and preferred to eat in his room. In an interview on 01/16/20 at 10:20 AM, Staff D Registered Nurse/RCM, stated that the RD came in to see new admissions, quarterly and if a resident had a weight gain/loss or had a referral. Staff D stated that the RD recommendations were given to the RCM to give to physician for orders and then updated on the care plan and the family was notified. Staff D stated that the care plan was available and should be updated with the CAA. Staff D further stated that the RD recommendations should get updated to the kitchen and administered with the residents' meal trays, added to the diet order, updated onto the care plan. Staff D confirmed the information from the medical record including the weight loss, the CAA and the lack of nutritional at risk care plan. Review of Resident #53's dietary slip from the kitchen on 01/16/20 showed the resident was on a regular diet, dines in his room, and with menu notes for assorted fruit juice, milk and water and breakfast was for toast and fruit only. In an interview on 01/16/20 at 10:31 AM, Staff O, RD, stated that the nurse was supposed to process the RD recommendations. Staff O, stated that she placed her recommendations in a file in the nurses station. Staff O, stated she saw the resident on 0[DATE] and sent a second notice out because her recommendation was not in the file. She stated that she verbally informed the case manager and the Director of Rehab had also sent a note of concern about the resident's weight loss. In an interview on 01/24/20 the Director of Nursing Services (DNS), confirmed the resident's weight loss. The DNS, stated that the resident had a splint removal that could have affected the resident's weight loss but was uncertain how much the splint weighed. The DNS, stated that on 0[DATE] supplements had been ordered. This is a repeat deficiency from SOD dated 02/04/19. Reference: (WAC) 3[AGE]-[AGE]-10[AGE] (3)(h)

Based on observation, interview and record review the facility failed to provide timely and adequate dental services for two of three residents (#26, #29) reviewed for dental services. This failure caused harm to Resident #29 at who experienced pain and infection related to necrotic carious teeth and an oral cyst. Resident #26 experienced difficulty eating and experienced mouth pain related to a broken jagged tooth, and placed all other resident at risk of not having dental pain. Findings included . A review of the facility's policy titled Dental Services, dated (MONTH) (YEAR) showed that routine and emergency dental services would be provided to residents through personal dentists, community dentists or other health organizations that provide dental services. The policy further stated that residents would be assisted with appointments and transportation arrangements. RESIDENT #29 Resident #29 admitted [DATE] with [DIAGNOSES REDACTED]. A review of the quarterly MDS dated [DATE] showed that the resident required extensive assistance for personal hygiene, exhibited rejections of care and did not correctly identify known dental issues. A review of the care plan dated 12/14/17 showed the resident was identified as having a deficit in his ability to perform oral hygiene and required dental extractions. There had been no further updates to the care plan for dental. The resident was identified as having hallucinations and delusions such as believing his tube feeding had worms or that there were bugs in his medications. In an observation and interview on 01/29/19 at 10:58 AM, the resident was observed to be missing many teeth with several noted to be broken, dark, discolored and caked with thick gray and yellow buildup. The resident's breath was noted to be strongly unpleasant and he stated that he was told not to brush his teeth, they say I can't brush them. He stated his mouth had bees in it. On 02/01/19 at 2:28 PM, when asked if he had pain in his mouth, he again stated bees. In an interview on 01/29/19 at 3:22 PM, Staff D, Licensed Practical Nurse, stated that Resident 29 often refused medications or tube feedings believing that they were poisoned or had bugs, bees or worms in them, If he doesn't like something. In an interview on 02/01/19 at 2:25 PM, Staff G, Nursing Assistant (NA), stated the resident often refused assistance with oral care. She stated there is a place for NA's to chart refusals in the computer. Staff G stated when he allowed her to assist him he did not act like he was having pain, and she stated she used a swab to clean his mouth rather than a toothbrush. Record review showed that on 01/02/18 the resident was seen for dental consultation and was noted to have a cyst, two necrotic teeth and needed removal of a total of four teeth. No further treatment had been received. Record Review showed that on 04/02/18 an Advanced Nurse Practitioner note identified a tender left cheek and beginning on 04/03/18 the resident was treated with antibiotics for an infection in the mouth. In an interview on 02/01/19 at 2:42 PM, Staff M, Registered Nurse, Resident Care Manager (RCM) stated that the resident had been set up for follow up appointments but first there was a problem with insurance. She then stated he had been set up for appointments, one on 10/01/18 and another on 10/04/18 but he missed both of them due to transportation issues. She stated at that time there were calls to attempt to reschedule at the same provider but the policy of the dental office was that if you miss two appointments they will not see you any longer. Staff M had no response for why these initial attempts had not taken place until (MONTH) when the initial consult was in January. When asked what had been done since then, she said I do not think we have done anything as far as that is concerned. In an interview on 02/01/19 at 3:10 PM, the DNS was made aware of the concern regarding lack of dental follow-up for Resident #29 and the DNS had no further information. There was no further documentation on the part of the facility regarding attempts to schedule with an alternate provider for the resident to have the necessary dental care and services recommended over a year prior. RESIDENT #26 Resident #26 admitted on [DATE]. According to the Admission Minimum Data Set (MDS) assessment dated [DATE]. The resident was alert and oriented and admitted with no dental issues. A review of the care plan dated 07/17/18 stated: has own teeth, missing several. The care plan had no further updates regarding dental status. In an interview on 01/29/19 at 2:05 PM, the resident stated she was worried that she could not afford to go to dentist, she stated she had a tooth that pokes and that the doctor had told her she needed to go to the dentist over a month ago. She stated she had not heard from anyone about an appointment. She stated the doctor told her she could try and put some wax over the tooth to keep it from poking into her mouth until she could get an appointment but she stated nobody ever brought her any wax. She stated she thought the tooth had broken a couple weeks before she had seen the doctor. In a follow up interview and observation on 02/01/19 at 10:56 AM, the resident opened her mouth to allow an observation and to point out the sharp jagged tooth on the lower left. The resident was missing many teeth and had a clearly broken, sharp jagged tooth and the surrounding tissue appeared swollen. The resident's left inner cheek was reddened as was the side of her tongue. She stated the tooth itself did not hurt, but it hurts so bad when it poked into the side of her mouth and her tongue. She stated I have to be really careful when I eat. Record review showed a physician's orders [REDACTED]. Remove prior to eating. Schedule dental exam for evaluation of sharp tooth. Further review showed no evidence of any attempts to schedule a dental appointment. The order for dental wax was included in the resident's Medication Administration Record [REDACTED]. In an interview on 02/01/19 at 10:54 AM, Staff D, Licensed Practical Nurse (LPN), stated he often cared for Resident #26 and was unaware of any dental issues or of any order for dental wax. Staff D stated the Resident Care Manager (RCM) would make dental appointments for residents if they needed one. In an interview on 02/01/19 at 11:04 AM, Staff M, Registered Nurse, RCM stated I don't know anything about an appointment for Resident #26, I have not made one, I never knew about any issue. In an interview on 02/01/19 at 1:41 PM, the Director of Nursing Services stated that the expectation was that residents were seen as soon as possible and verbalized frustration related to coordination with transportation to local providers. She denied prior knowledge of an issue with Resident #26 but acknowledged that no appointment had been scheduled, even though she signed off on the physician's orders [REDACTED].>Reference (WAC) 388-97-1060 ( 2)(c), (3)(j)(vii)

Based on observation, record review and interview the facility failed to ensure hazardous chemicals, medications and sharps (bladed razors and finger stick devices) were secured when not in use in resident rooms on 3 of 3 hallways and 2 of 2 shower rooms. These failures placed cognitive impaired residents' access to medications, chemicals and sharps. The failure to safely secure potential hazardous items caused an unsafe environment and placed cognitively impaired residents at risk for potential harm from ingestion of inappropriate substances and potential harm from unsecured razors and sharps. An Immediate Jeopardy was called on 03/27/18. The jeopardy was removed on 03/28/18 by removing hazardous items, securing medications and educated staff to assure vulnerable residents did not have access to hazards. Findings included . Record review of the facility's policy titled, Hazardous Areas, Devices and Equipment, revised on (MONTH) (YEAR), showed all hazardous areas, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible including: - A hazard was defined as anything in the environment that had the potential to cause injury or illness, - Sharp objects that were accessible to vulnerable resident, - Access to toxic chemicals, - Any element of the resident environment that had the potential to cause injury and that was accessible to a vulnerable resident was considered hazardous. An observation and interview on 03/27/18 at 10:05 AM, showed room [ROOM NUMBER] had three bottles of TUMS (an antacid medication which contained a warning label) in view on the bedside table, and a bottle of Thera Tears (lubricating eye drops). Resident 1 stated she does not take the TUMS but uses the eye drops on occasion. Resident 1 stated there had been a confused woman who comes into her room. In an observation at 10:10 AM, showed room [ROOM NUMBER] had a bottle of saline nasal spray and a bottle of xylitol xlear nasal spray (which contained a warning label) in view on the resident's bedside table. In an observation at 10:15 AM, showed Shower room [ROOM NUMBER] door was open with no staff in the immediate vicinity. The counter in the shower room had a tub of Sani Cloth Plus (a germicidal wipe), an antifungal powder, and an oversized container of bath/shampoo along with multiple bottles of lotion (all of which contained a warning label) easily accessible. In an interview and observation at 10:25 AM, showed room [ROOM NUMBER] bed 2 had a bottle of Gold Bond Ultimate lotion (which contained a warning label) in view on Resident 2's nightstand. Resident 2 stated confused residents came into her room. In an observation of room [ROOM NUMBER] Bed 1 there were three inhalers, Qvar, beclomethasone inhaler (a steroid medication), [MEDICATION NAME] inhaler (a medicated inhaler), [MEDICATION NAME] Diskus inhaler (a medicated inhaler) and [MEDICATION NAME] nasal spray (a corticosteroids inhaler) along with a medicine cup filled half full of mixed pills were in view on Resident 3's bedside table. Resident 3 was observed lying in bed, turned away from the bedside table with her eyes closed. All medications were easily accessible and Resident 3 did not note when the medications were removed to give to the facility's administrator. At 10:26 AM, the facility's Administrator was informed of the medication left unattended on Resident 3's bedside table. In an observation at 10:28 AM, room [ROOM NUMBER] had a bottle of Derma Daily lotion (which contained a warning label) in view and accessible on the bedside table. In an observation at 10:29 AM, room [ROOM NUMBER] had a bottle of Derma Daily and a bottle of McKesson mouthwash in view and accessible on the sink counter, both items contained warning labels. An interview and observation at 10:36 AM, Resident 4 stated confused residents come into the room. A bottle of Garnier Style cream, containing a warning label, was in view and easily accessible in the resident's room. In an observation at 10:39 AM, room [ROOM NUMBER] had a box of safety lancets (sharp pointed lancing device used to check blood sugars) were in view on the window seal and a bladed razor on the sink counter top. Both items were easily accessible. In an observation at 10:42 AM, room [ROOM NUMBER] had a 1.5-liter bottle of blue mouthwash, a bottle of antiseptic mouthwash, a bottle of Med Spa, antiperspirant, Armor Hammer deodorant, dental cleansing tablets all items with warning labels and easily accessible on the sink counter top. At 10:44 AM, multiple staff members were observed going in and out of resident rooms. The Director of Nursing Services (DNS) was invited to accompany the surveyor for the remaining resident room observations. An observation and interview at 10:45 AM, room [ROOM NUMBER] had a bottle of baby powder, Gold Bond lotion, Life Scent Air Wick spray, 1.5-liter bottle of mouthwash, bottle of baby powder, perineal cleanser and dental cleansing tablets, all with warning labels, in view in the resident's room. The DNS stated the items should not be out and easily accessible. The DNS stated we just do not have the room to store the resident's personal items. In an observation at 10:50 AM, room [ROOM NUMBER] had a bottle of mouthwash and dental cleansing tablets (both with warning labels) in view on the sink countertop. In an observation at 10:55 AM, room [ROOM NUMBER] had a bottle of Derma Daily lotion, which had a warning label, in view on the nightstand. An interview and observation at 11:00 AM, the beauty shop was open and had a bottle of shaving cream and mouthwash, both with warning labels in view on the counter. The DNS confirmed the items should not have been left out. In an observation at 11:10 AM, room [ROOM NUMBER] had a bottle of baby powder in view in the resident's room. In an observation at 11:12 AM, room [ROOM NUMBER] had two bottles of shaving cream, mouthwash, and a bladed razor in view on the nightstand. In an observation at 11:14 AM, room [ROOM NUMBER] had a bottle of hand sanitizer, shower bath powder and lotion in view on the resident's bedside table. An interview and observation at 11:15 AM, room [ROOM NUMBER] had a bottle of shaving cream and mouthwash in view on the sink countertop. The DNS stated the bladed razors should not be left out. In an observation on or about 11:18 AM, room [ROOM NUMBER] had a bottle of Vaseline lotion in view on the nightstand. In an interview with the DNS at 11:20 AM, while passing Shower room [ROOM NUMBER], which was now closed, the DNS stated the shower rooms should not be left open when not attended. In an observation at 11:22 AM, room [ROOM NUMBER] had a bottle of Gel Tears, two bottles of lotion, a bottle of [MEDICATION NAME] and a bottle of mouthwash in view on the sink countertop. In an observation on or about 11:25 AM, Shower room [ROOM NUMBER] door was propped open with no staff in attendance. There was a multitude of bottles of shaving cream, lotion, shampoo, body wash, all with warning labels in view in the shower room. The DNS confirmed again, the shower doors should not be left open when unattended. In an observation at 11:28 AM, room [ROOM NUMBER] had a bottle of no rinse foam cleanser, three bottles of Phytoplex cream, a bottle of baby powder, and a bottle of full body cleanser; all items were easily accessible and had warning labels. In an interview and observation on or about 11:35, room [ROOM NUMBER] had a bottle of [MEDICATION NAME] (a disinfectant agent) with a warning label, sitting out on the sink countertop and easily accessible. Resident 5 stated confused residents do come into his room at times. In an observation at 11:35 AM, room [ROOM NUMBER] had a bottle of mouthwash and a bottle of lotion in view on the sink countertop. In an observation at 11:40 AM, room [ROOM NUMBER] had a bottle of aloe [MEDICATION NAME], refreshing gel, cocoa butter and a bag of Halls cough drops in view on the resident's bedside table. In an interview and observation on or about 11:45 AM, Rooms 308, 310 and 312 also had easily accessible items, which had warning labels. The DNS reconfirmed the items with warning labels should not have been out easily accessible for vulnerable residents. On 03/27/18 the facility's Resident Alarm Tracking System was reviewed. The facility had identified Residents' 6, 7, 8, 9 and 10 with a high risk of wandering and used an alarm device. Review of Residents' 6, 7, 9 and 10 Minimum Data Set (MDS) assessments, identified the residents' had severe cognitive impairment. Resident 8 MDS assessment, indicated the resident had moderate cognitive impairment. Further review of residents with cognitive impairment and the potential to wander showed the facility had identified two additional vulnerable residents (11, 12). Review of Resident 11's quarterly MDS assessment dated [DATE], showed the resident was severely cognitively impaired and was supervised with location with the use of a wheelchair. The MDS assessment also showed the resident wandered daily. Review of Resident's 12 admission MDS assessment dated [DATE], showed the resident was severely cognitively impaired and used a wheelchair with locomotion with limited assistance. The resident had a Wandering Risk assessment dated [DATE], which identified the resident to have a high risk for wandering. In a follow up interview on 03/27/18 on or about 12:20 PM, the DNS stated, Any items with warning labels should not be kept out on the resident's bedside table or sink countertop along with bladed razors, they should not be left out. Items should be placed in a bin and put away. There is just not enough room or drawers to place items and the shower rooms should be locked. In an interview at 12:25 PM, Staff D, Nursing Assistant (NA), stated We try to remove items immediately, anything that would trip the patients, wires, walkers, stuff like frayed lights, chemicals, anything, lotions, meds (medications). Staff D was asked about resident access to bladed razors, Staff D stated They should be put up also. In an interview at 12:24 PM, Staff E, NA, stated We have a lot of confused residents here. We have a pink basin and we should place items up higher to keep out of the residents reach. Items like mouthwash, peri-wash, creams; they all should be put away. The razors should be put up also. It is very dangerous when residents are confused and they do not know what they are doing. In an interview on 12:38 PM Staff A, Registered Nurse (RN), stated If a resident leaves personal items at their sink, I ask who it belongs to and then place in a bag in their nightstand drawer. Staff A was asked about the residents having bladed razors out in their rooms. Staff A stated Oh no, they go into the sharps container. They (the staff) know not to leave those out . The NAC's (nursing assistant certified) are the ones who use the razors. In an interview at 12:50 PM, Staff B, NA, stated We put them (the resident's personal items) away in the bathroom or the resident's bedside table and the razors should not be out. In an interview at 1:00 PM, Staff C, RN, was asked about items with warning labels left out in the resident's room on the sink, bedside tables or nightstands. Staff C stated We take care of them and remove the hazards, along with any medications which have not been cleared for the resident to manage, or any over the counter medications the resident's family might have brought in. The razors are only kept in the shower room. The facility identified a number of cognitively impaired residents at risk to wander throughout the facility. The facility failed to provide an environment free from potential hazards. This failure placed cognitively impaired resident at risk of potential harm. Reference: (WAC) 387-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent pressure ulcers for 2 of 3 residents (1 and 3) reviewed for pressure ulcers (PU). The facility failed to define, follow and implement interventions consistent with the residents' clinical needs and identified goals. The facility failed to evaluate Resident 1 and 3's clinical condition and pressure ulcer risk factors. This failure caused harm to Resident 1 when the resident developed an unstageable PU to the sacrum and Resident 3 developed a stage III left sacrum PU. Findings included: Review of the facility's Skin Integrity/Pressure Ulcer Management policy, dated 8/2017, showed the Licensed Nurse (LN) assessed the residents skin upon admission. The LN removed any dressings to complete the comprehensive assessment of wounds unless otherwise specified in the physician orders. The LN completed a weekly Skin/Wound progress note. The progress note included the location and description of the PU, condition of the skin around the PU, progress towards healing, risk factors to prevent healing, interventions to prevent healing and education to the resident or family. Per the Resident Assessment Instrument (RAI) Manual defined the stage of a PU as followed: - Stage II pressure ulcer was a partial thickness loss of the dermis presenting as a shallow open ulcer with a re-pink wound bed, without slough. -A stage III pressure injury (ulcer) was described a full thickness loss of the skin. - An unstageable pressure injury (ulcer) was full thickness skin and tissue loss was obscured by slough or eschar (dead tissue). -A Deep Tissue Injury (DTI) was described as intact of non-intact skin with localized area of persistent non-blanchable deep red, marron, or purple discoloration. RESIDENT 1 Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimal Data Set (MDS) assessment, dated 01/04/18, the resident required extensive assistance of two people for bed mobility and toileting, was dependent on two people for transfers, and did not walk. The resident had 6 stage II PUs and was identified as being at risk for PU breakdown. Review of the skin integrity care plan showed staff were to directed to reposition the resident every 2 hours, follow the resident's wounds weekly on wound rounds, limit time out of bed to less than two hours, off load pressure every 30 to 60 minutes by leaning from side to side to relieve pressure, air mattress in bed and was to have a pressure reducing cushion in the wheelchair (w/c). Review of an admission progress note, dated 12/28/17 at 4:44 PM, the LN documented the wounds would be assessed the next day since the dressings had been changed that day in the hospital. Review of a skin/wound note, dated 12/29/17, showed the resident had the following PUs: - Left upper buttock stage II PU, measured 0.5 centimeters (cm) by 0.5 cm by 0.1 cm. - Left lower buttock stage II PU, measured 1 cm by 1.5 cm by 0.1 cm. - Right buttock stage II PU, measured 2 cm by 1 cm by 0.1 cm. - Right posterior calf stage II PU, measured 9 cm by 9 cm by 0.1 cm. - Right lower calf stage II PU, measured 2.5 x 0.5 cm. - Left posterior left calf stage II PU, measured 4.5 cm x 4.5 cm x0.1 The LN documented, the cause of the calf wounds was related to the resident spending long periods of time in bed and she preferred to lay on her back. In a progress note, 5 days later, dated 01/03/18, Staff C, Registered Nurse, documented Resident 1's lower extremity wounds were measured. Staff C did not measure/assess the resident's buttocks wound because she was sitting in her wheelchair (w/c). In a progress note, dated 01/04/18, the Director of Nursing Services (DNS) documented, Resident 1's buttock wounds were not able to be assessed because the resident was out of bed all afternoon and working with therapy. The DNS documented the Nursing Assistant reports wounds look better . Review of a skin/wound note dated 01/10/18, showed the resident's right lower leg PUs had closed. There was two PUs on the left posterior calf that measured: 2.2 cm by 1.1 cm and the other one was, 1.1 cm by 0.9 cm. The resident's PUs on the buttocks were not assessed. Review of a late entry progress note dated 01/12/18 (created on 01/15/18), showed the resident's wounds were not assessed related to the resident's dressing had just been changed and the resident did not want the dressings removed. Review of a skin/wound note, dated 01/15/18, showed the following PUs: - a left buttock stage II PU that measured 0.5 cm by 0.5 cm by 0.1 cm. - a right buttock PU that measured 9 cm by 4 cm by 0.2 cm. The LN did not stage the right buttock PU, but documented the PU had worsened from the prior the assessment, 18 days prior, because the resident preferred to lay on her back for comfort and had occasional bowel incontinence. The LN referred the resident to a wound healing agency, which came on-site to the facility. The LN did not measure/assess the PU on the left calf. On 01/17/18, the contracted wound care team assessed the resident and had: -an unstageable PU on the left medial lower extremity which measured 9 cm by 1 cm by 0.2 cm. -an unstageable 9 cm by 5 cm PU on the buttocks. On 01/24/18, the contracted wound care team assessed the resident and had: -The left medial lower leg had a stage III PU that measured 1.6 cm by 9 cm by 0.1 cm. -The sacral (previously documented as a right buttock PU) was unstageable and measured 7.3 cm by 5 cm. The resident was sent to the hospital on [DATE] and was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a MRI in the hospital which did not indicate infection to the sacral PU, but cultures were still pending. The resident was admitted with a wound vac (a negative pressure wound therapy system that promoted healing) to the sacral PU. On 02/08/18, the wound vac was discontinued. In an observation and interview on 02/14/18 at 11:10 AM, the resident was sitting in her w/c. The resident stated she was recently hospitalized because the physician thought the wound on her buttocks was infected. The resident stated there was a small hole down to the bone, .but it was not infected . The resident declined to have her PU's observed by this assessor. At 11:18 AM, Staff A, agency nurse, assigned to the resident's hall stated she was not familiar with Resident 1. At 11:20 AM, Staff B, RN, stated she was not familiar with Resident 1. At 12:31 PM, the DNS stated PU's were assessed weekly. The information was documented in the resident's electronic medical record. The DNS was not aware Resident 1's PU's were not thoroughly assessed or measured weekly. At 1:11 PM, Staff C was responsible to assess the resident's wounds weekly. Staff C was not able to find any additional documentation supporting why Resident 1's PU's deteriorated or evidence they were assessed weekly. Review of the nursing progress notes from admission to 02/13/18 showed the resident occasionally would refuse to lay on her side. There was no supporting documentation how the facility intervened, educated or other interventions promoting PU healing. RESIDENT 3 Resident 3 admitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment, dated 12/05/17, the resident required extensive assistance of two for bed mobility, transfers and toileting. Resident 3 had cognitive impairment, was at risk for skin breakdown and did not refuse care. A Braden assessment (a tool used to identify risk of developing skin breakdown), dated 12/04/17, showed the resident had a score of 17, which was low risk for skin breakdown. On 01/29/18, a PU was found on the resident's sacrum. There was no measurements or thorough assessment documented in the medical record. In a progress note, dated 01/31/18, showed a 1 cm by 0.5 cm stage III PU on the resident's sacrum. The depth of the PU was not measurable due to slough being present. On 02/03/18, the skin care plan was updated to reflect the resident had a stage III PU on the coccyx. The resident was repositioned every two hours, limit time out of bed, and the resident preferred to lay on the left side. In a progress noted, dated 02/03/18, the DNS documented the resident had a stage III PU on the coccyx. The resident did not have a history of skin breakdown, but did prefer to lay on his left side when in bed which placed him at risk. In a skin/wound progress noted, dated 02/07/18, the LN documented the resident's PU was located .to the left of the sacrum and not coccyx region. Wound is covered is slough; debrided some As of 02/14/18, there were no current PU measurements found in the medical record. In an interview on 02/14/18 at 12:31 PM, the DNS stated the resident was at low risk for developing a PU. The DNS stated the resident had gone out of the facility the day prior to the PU being found with his sister for several hours. The resident preferred to lay on his left side and did perform his own peri-care needs. The DNS stated the facility was alerted to the PU because the resident stated his bottom hurt. The DNS was not able to find any additional PU measurements or what interventions the facility had in place to prevent the PU from developing. In an interview and observation at 1:25 PM, Resident 3 was sitting in his w/c. The resident was not able to state how he obtained the PU on his coccyx. Reference: WAC 388-97-1060 (3)(b)

Based on interview and record review the facility failed to provide necessary care and services to maintain the highest level of well-being for 3 of 4 residents (222, 229 and 232). The facility failed to arrange for post-operative surgical follow up for Resident 229, failed to identify and treat constipation for Resident 232, and failed to thoroughly and timely assess the etiology of Resident 222's discomfort. These failures resulted in harm for Resident 229 as evidenced by infection to the resident's surgical site, decline in functional status and pain. Additionally, the failure of the facility to identify and timely treat Resident 222 and 232 resulted in unnecessary discomfort. Findings include: RESIDENT 229 Resident 229 was a newly admitted resident with [DIAGNOSES REDACTED]. In an interview on 09/29/17 at 2:18 PM, the resident's family member stated the facility refused to arrange or provide transportation for the resident's post-operative surgical follow up appointment. The resident now has a surgical wound infection and the facility stated they do not typically provide transportation for follow up appointments to Seattle. In an interview on 10/06/17 at 8:48 AM, the resident's family member stated, On admit we informed the facility the surgeon wanted a follow up appointment in 2 weeks. The facility stated they would not transport but would look into it. My Mom still has not had a surgical follow up and she got an infection to her surgical site. Review of the hospital Discharge Summary dated 09/14/17, with a fax time stamp of 09/28/17 revealed, at the time of discharge, the surgical incision was clean with scant drainage and with no evidence of infection. The Discharge Summary also revealed, CLINICAL FOLLOW-UP, INCLUDING APPOINTMENTS: . at 10/02/2017 at 10:20 AM. Review of a Progress Note of a Medicare/Skilled Meeting dated 09/19/17 documented by the Director of Nursing Services (DNS) revealed, Recommendations: (1) NCM (Nurse Case Manger) f/u (follow up) on oncology appointments and orthopedic. Remains skilled with concurrent insurance review. Review of a Progress Note dated 09/19/17 revealed, CNM (Case Nurse Manager) spoke with [MEDICAL CONDITION] Care Alliance and confirmed appointment with ortho oncologist .for post op visit .on [DATE]nd at 10:20 AM . Review of a Progress Note dated 09/22/17 revealed, CNM in with patient and family and reviewed upcoming appointments with oncology and ortho/oncologist appts are in Seattle and IDT (interdisciplinary team) will meet to work out transportation issues. Patient states that she has constant pain that can get to 10/10 that interrupts sleep and ADL's (activities of daily living). Patient states . knee up thigh-sharp spasms when it hits, it is over the top . Review of a Progress Note of a Medicare/Skilled Meeting dated 09/26/17 documented by the DNS revealed, Recommendations: (1) NCM (Nurse Case Manager) to f/u on transportation for oncology appointments on 9/28 in Seattle and orthopedic date/time as well (likely will need to be rescheduled). Remains skilled with concurrent insurance review. Review of a Progress Note of a Medicare/Skilled Meeting dated 09/27/17 revealed, Discussion Notes: Therapy: patient is severely limited due to pain. Last Friday she was walking in parallel bars. Patient modA (moderate assistance) with mobility . Discussion Notes (2): nursing: pain is main barrier. DNS and ARNP (Advanced Registered Nurse Practitioner) had visited with patient. Patient showing signs of infection in hip will need to start ABO (antibiotic). Will reschedule ortho and oncology f/u. Review of a Progress Note dated 09/27/17 revealed, Seattle appointments have been cancelled . Review of an ARNP note dated 09/27/17 revealed, Assessment: Postoperative wound [MEDICAL CONDITION] . the depth or extent of wound cannot be visualized in the facility and that there is a risk of deeper infection and/or to any hardware, particularly given severe pain in leg . Review of the resident's Medication Administration Record [REDACTED]. In a continuous observation on 10/06/17 beginning at 9:16 AM until 9:55 AM, the dressing to the resident's surgical site was saturated with blood as well as the resident's bed linens. At 9:34 AM, the physician observed the resident's blood saturated dressing, at 9:35 AM, the physician stated, Oh my goodness it is just oozing and oozing. Staff G, Registered Nurse (RN) stated, The blister must have busted. At 9:53 AM, Staff G, RN, removed the blood saturated dressing and stated, The blister has not popped. The resident's surgical incision was observed to have what appeared to be a moderate sized purple/red raised area to the top of the incision approximately the size of a dime. The lower portion of the incision had constant blood draining down the side of the resident's leg. At 9:55 AM, the physician requested the DNS to visualize the resident's wound. The physician asked the DNS if steri-strips were still indicated for the resident's wound. In an interview at 10:27 AM, the physician stated the DNS had reported the wound had been draining and had a blister. The plan was to contact the orthopedic surgeon who did the work, the ARNP had previously thought the resident had [MEDICAL CONDITION] to the wound and started an antibiotic. The physician was unaware that a post operative visit had not yet occurred and stated one was needed but transportation would be difficult. In an interview on 10/06/17 at 10:57 AM, Staff E, Medical Records Assistant stated, I arranged transportation for residents up until May 2017 and had arranged transports for the past 2 ½ years. (Staff K, Receptionist) had been doing the job since; I trained her. Staff E was asked specifically about how transportation was arranged and paid for Skilled Nursing residents. Staff E stated if the appointment was local, we use SKAT Dial-A-Ride, which is a wheelchair public bus system for health care. Then we use Cabulance, which is a wheelchair van or stretcher, ambulance companies will take residents in certain cases like [MEDICAL CONDITION] and Medicare will cover in some cases. The bus is free; it is the first choice for appointments in the county, if outside the county and wheelchair transport is needed the resident usually is responsible for the cost. We are generally not responsible for the cost of out of town appointments. I know we have covered the cost of transport but it is the patients' responsibility because Medicare does not cover wheelchair or stretcher transport to appointments. Staff E stated, if it was a hardship situation for the patients, I would just go to the DNS or the Administrator and they would decide. In an interview on 10/06/17 at 2:17 PM, Staff C, Admissions Assistant stated, the business office completed the offsite medical appointment transport and chaperone plan. Some families want to take the resident via private vehicle, if not we arrange for transport. If local, we try via Cabulance or Dial-A-Ride. We try to get pricing from the transport, I believe the DNS would see if it were a covered transport, then the DNS would make the decision whether to cover the transport. On 10/07/17 at 8:45 AM, the DNS stated, I do not remember having the financial conversation regarding the resident's follow up surgical appointment. The DNS was asked if the facility attempted to arrange for a local follow up surgical appointment. The DNS stated the only thing I see is the CNM note on 09/19/17. In a clarifying interview on 10/09/17 at 4:31 PM, the resident's family member confirmed the facility informed the family during a care conference held on 09/27/17 the facility would not arrange or pay for the follow up surgical orthopedic appointment, which had been scheduled in Seattle. The facility failed to facilitate post-operative surgical orthopedic consultation follow-up for the resident with surgical wound complications. Resident 229 subsequently suffered pain, an infection to the surgical incision and had a declined in ADL function. RESIDENT 232 Resident 232 was a recent admission with [DIAGNOSES REDACTED]. In an interview on 10/03/17 at 9:05 AM, the resident stated, Not good, have an impacted bowel, when asked how the resident was feeling. At 3:09 PM, the resident stated, Still feel bad but they gave me MOM (Milk of Magnesia). On 10/04/17 at 5:39 AM, Staff N, Nursing Assistant stated the resident was asking for MOM. Staff O, Registered Nurse stated, he has been asking for MOM every 2 hours, but this is the first time he had asked me. They gave him a suppository on evening shift. Staff O continued to state the resident had not had a bowel movement since 09/27/17. Usually after a resident has not had a BM after three days MOM is given, then the next shift would give a suppository if no BM, and then if by the next shift the resident did not have a BM, an enema would be given. Usually each night we make out a list of residents who have not had bowel movements. In an interview on 10/05/17 at 8:41 AM, the resident stated, I feel terrible, I still have not had a BM. I had an enema last night but I had no results. Review of the resident's Bladder/Bowel Admit/Readmit Screener dated 09/26/17 revealed the resident was assessed to have Impaction/Constipation. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have constipation. Review of the resident's care plan revealed the resident was not care planned for constipation as identified on the resident's Bladder/Bowel Admit/Readmit Screen or the MDS. Review of the resident's admission orders [REDACTED]. If no result by the following morning, the Director of Nursing Services (DNS) was to be notified. Review of the resident's Bowel Movement and Bowel Continence record revealed the resident had no BM documented from 09/27/17 until 10/05/17. Review of the Progress notes revealed no indication the resident's orders were followed after the third day without a BM. Additionally on the sixth day when the resident was given the first dose of MOM, six days after the resident's last BM, there was no indication the DNS had been notified. Review of an ARNP Progress Note dated 10/03/17 revealed the ARNP had been asked to see the resident related to pain to the resident's right shoulder. During the visit the resident complained to the ARNP of constipation stating the last bowel movement had been 5 days ago, prior to his fracture. Resident 232 was admitted with identified problems with constipation, was on pain management medications without a routine or an as needed bowel medication administered until the resident had gone 6 days without a bowel movement. The facility failed to follow the admission physician ordered bowel regimen, failed to notify the DNS and failed to notify the physician of the resident's constipation. This resulted in unnecessary discomfort for Resident 232. RESIDENT 222 Resident 222 was a newly admitted resident with [DIAGNOSES REDACTED]. In an interview on 10/01/17 at 11:57 AM, the resident reported feeling nauseated. In an interview on 10/02/17 at 12:59 PM, the resident was asked if he had any discomfort with no relief. The resident stated, Yes, nauseated with no relief. In an interview on 10/03/17 at 1:47 PM, the resident stated, Still nauseated, always nauseated. In an interview on 10/04/17 at 9:59 AM the resident stated, Doing terrible, still nauseated. In a follow up interview at 11:09 AM, the resident stated, Feel awful, I'm nauseated all the time, I have told the nurses but they have not done anything. At 1:32 PM, the resident stated, I'm not feeling very good, still nauseated. In an interview at 1:07 PM, the Director of Nursing Services stated the nursing staff should conduct nonverbal and verbal assessments of pain or discomfort to identify environmental issues, check to see if a medication could be given based on the assessment, if not seek out the nurse case manager or the physician. At 2:32 PM, the resident was yelling out, Staff L, Physical Therapist responded and stated, the resident was calling out a few minutes ago and complained of nausea. In an interview on 10/05/17 at 8:48 AM, Staff G, Registered Nurse (RN) stated the resident was doing better. The ARNP was informed of the resident's nausea yesterday and the ARNP ordered medications for nausea and vomiting. The resident is doing better. As a nurse when you go into a resident's room if they are in discomfort, you have to follow up. review of the resident's medical record revealed [REDACTED]. The resident had nursing services 10/01/17 through 10/04/17 with no indication, the resident had been thoroughly assessed for discomfort until the evening on 10/04/17. The resident suffered nausea for three and a half days with no interventions to resolve the resident's discomfort. Reference: (WAC) 388-97-1060 (1) (a) (ii) (3) (b)

Based on interview and record review, the facility failed to ensure ongoing assessment and monitoring was provided to provide healing and prevention of development of pressure ulcers for 1 of 3 residents (2) reviewed. The facility failed to consistently assess Resident 2's skin, provide intervention or alter treatment with known risk factors for skin breakdown. This failed practice caused harm to Resident 2 who developed multiple pressure ulcers (PU) involving the left lateral foot, right buttock and left buttock. Findings include: Per the Resident Assessment Instrument (RAI) Manual defined the stage of a pressure ulcer (PU) as followed: - Stage II PU was a partial thickness loss of the dermis presenting as a shallow open ulcer with a re-pink wound bed, without slough. - Stage III PU had full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle was not exposed. Slough may be present but does not obscure the depth of tissue loss. The wound may include undermining or tunneling. -Unstageable pu that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present such that the anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed, should be classified as unstageable. -A Deep Tissue Injury (DTI) was described as intact of non-intact skin with localized area of persistent non-blanchable deep red, marron, or purple discoloration. Review of the facility's Skin Integrity/Wound Care policy included the following: 1. Document to the wound weekly in the medical record (this included the size, location, condition of wound and surrounding skin). 2. The physician will be notified when a wound does change in approximately 14 days. 3. The care plan was updated to reflect new interventions and goals. Resident 2 was a long term care resident with [DIAGNOSES REDACTED]. According to the Minimum Data Set assessment dated [DATE], Resident 2 had no cognitive impairment, demonstrated no refusals of care, was incontinent of bowel, required extensive assist of two people for bed mobility and toileting. Review of the care plan included the following: turn the resident every 2 hours, float heels when in bed, report resident's refusals to be turned to the primary care nurse and follow weekly on wound rounds for progress/decline. Review of a physician order [REDACTED]. This order was discontinued on 12/02/16. Review of the 08/09/16 through 12/02/16 Treatment Administration Record (TAR) revealed this treatment was never done. Review of the October of 2016 through 06/20/17 TAR directed staff to perform a skin check every week. The LN was to document a + for intact skin and a - skin not intact and to initiate a plan. The LN documented a - every week, but did not provide corresponding documentation assessing the resident's skin in the medical record. Additionally, the TAR directed the skin team to follow skin issues per policy and procedures. Review of a progress note dated 10/03/16, Staff D, LN, documented the resident had two superficial excoriations on both buttocks. There was a 2 centimeter (cm) x 2 cm x less than 0.01 cm open area on the left buttock and a 1 cm x 0.5 cm x less than 0.01 cm open area on the right buttock. The wounds were not measured until 10/11/16 (8 days after initial documentation). Review of wound care notes dated 10/19/16 and 11/02/16, revealed Staff D did not measure or assess the bilateral buttock excoriations. Staff D documented the excoriations were moisture related. Even though the care plan and progress notes did not reflect moisture related skin issues. Review of a dermatologist appointment dated 11/04/16, stated the resident had a stage I pu on the buttocks. Other complicating factors included chronic cutaneous candidiasis and impetigo (infection of the skin) of the buttocks. The Physician Assistant (PAC) recommended to apply [MEDICATION NAME] 0.1% cream mixed with [MEDICATION NAME] cream twice daily for two weeks then only on Monday, Wednesday and Friday and then on all remainder days apply [MEDICATION NAME] cream to the affected area twice daily until the next appointment. Review of the November 2016 TAR revealed the nurse continued the twice daily treatment beyond the recommend 2 weeks and did not implement the [MEDICATION NAME] cream twice daily as directed. Review of the dermatologist appointment dated 12/01/16, stated the stage I pressure ulcer on the (left) buttock(s)(which seems to have worsened in the last few weeks . The PAC again prescribed the same treatment (as ordered on [DATE]). The physician documented the resident's primary care physician was contacted discussing the progression of the left buttock ulcer. Review of the wound care notes revealed the wounds were not assessed until 12/02/16, a month and a half later after the first initial assessment. The left buttock wound had deteriorated and measured 2 cm x 1cm x 0.3 cm. There was no documentation regarding the right buttock wound. The resident developed a stage III pu to the left lateral foot that measured 3 cm x 3 cm x 0.2 cm. The LN had documented the left lateral foot stage III pu was found about a week ago. The LN documented the resident's mattress had been changed out about a month ago which led to the skin breakdown. Review of the December 2016 TAR revealed a new treatment beginning 12/02/16 to the resident's left buttock stage III pu. On 12/07/16, the left lateral stage III pu measure 4 cm x 4.2 cm x 0.2 cm with 0.2 cm with undermining at 9 o'clock and the left buttock measured 2 cm x 1 cm x 0.2 cm. Review of the MDS dated [DATE] revealed the resident then had two stage III pu's. Review of the wound care notes dated 12/16/16, 12/22/16 and 01/06/17, showed the LN documented to the left lateral foot pu, but did not document to the resident's buttocks. On 01/13/17, over a month later, the LN documented the resident had a 1.7 cm x 2.5 cm x 0.1 cm stage III pu to the left lateral foot, a callous on the right heel and the left buttock measured 10 cm x 10 cm. The left buttock had deteriorated, and there was no change in the resident's treatment regimen. On 01/27/17, two weeks later, the LN measured the left lateral foot, but did not measure or assess the resident's buttocks. On 02/20/17, over three weeks later, the LN documented the left lateral foot was healed. The LN documented buttocks wounds unchanged from previous in depth assessment last month. Right and left buttocks wounds raw appearance but superficial . Review of the dermatologist appointment dated 03/08/17, stated the .stage 2 pressure ulcer on the (left) buttock(s) (which seems to have worsened since the last appointment) . The PAC ordered the same treatment as prior appointments and to start [MEDICATION NAME], if not contraindicated, for 3 days. Review of a wound car note dated 03/13/17, over three weeks later, the LN documented the resident's bilateral buttocks measured 5 cm x 5 cm x 0.1 cm and a 2 cm x 2 cm x 0.1 cm right lateral heel stage II pu. On 04/21/17, a month later, the LN stated the resident's buttocks were raw as previously noted, but the left side was worse than the right. There were no measurements documented regarding the resident's buttocks or right lateral heel. The resident was discharged to the hospital on [DATE]. The discharge MDS assessment dated [DATE] revealed the resident had two stage II pu's. The resident readmitted to the facility on [DATE] after debridement of her bilateral sacral ulcers. Review of the nursing home admission assessment, the nurse did not assess the resident's wounds. The nurse documented to refer to the wound care note from the hospital. Review of the MDS assessment dated [DATE], revealed the resident had a stage I pu, five stage III pu and 1 unstageable pu. On 05/05/17, there was documentation in the medical record regarding the resident's skin. This was a week after the resident admitted to the facility. The resident had the following: - A 2.6 cm x 6 cm x 0.2 cm stage III pu to the left upper buttock - A 7.5 cm x 4.8 cm x 1 cm stage III pu to the left lower buttock - A 5.2 cm x 6 cm x 0.1 cm stage III pu to the right upper buttock - A 2 cm x 4 cm x 0.1 cm stage III pu to the left lower buttock - A 1 cm x 0.3 cm stage II pu on the left heel - A scab to the left ankle Review of the Wound Care Center (WCC) visit dated 05/10/17 revealed the resident had the following wounds: - A 16.0 cm x 7.2 cm x 1.1 cm wound to the left superior buttock. There was eschar present. - A 7.0 cm x 7.0 cm x 2.1 cm wound to the left inferior buttock. There was eschar present. - A 5.2 cm x 5.2 cm x flush wound to the right superior buttock. The wound bed was red. - A 2.5 cm x 4.5 cm x 0.9 cm wound to the right inferior buttock. The wound bed was red. - A 0.3 cm x 0.2 cm x 0.1 cm wound to the left lateral ankle. The WCC recommended not debride the wounds at this time, initiate a fluidized (specialty) bed and specific treatments to each wound. Review of the MDS assessment dated [DATE], revealed the resident had three stage III pu's and 2 unstageable pu's. Review of a wound care note dated 05/18/17, the LN documented: - A 15.5 cm x 9 cm x 0.3 cm pu on the left buttock. There was eschar present which measured 10 cm x 4 cm. - A 10.5 cm x 5 cm x 0.3 cm stage III pu to the left lower buttock - A 4 cm x 5 cm x 0.1 stage III pu to the right upper buttock - A 2 cm x 4 cm x 0.1 cm stage III pu to the right lower buttock - Left heel had resolved - A 0.3 cm x 0.3 cm scab to the left lateral ankle. On 05/22/17, the facility's physical therapist mechanically debrided the resident's left buttock. There was no documentation in the record regarding the measurement of the wound. Review of a wound care noted dated 05/25/17, the LN measured the left buttock wounds. The LN documented the wounds have deteriorated. The LN did not document measurements of the right buttock wounds. The LN documented the resident agreed to the use of a Clinitron bed (the wound care center had recommended this bed on the 05/10/17 appointment, and there was no documentation in the medical record reflecting why this was not implemented immediately). Review of a wound care note dated 06/02/17, the LN documented the following: - A 16.3 cm x 11 cm x 2.5 cm unstageable pu to the left buttock, the wound had deteriorated. - A 8.2 cm x 9.5 cm x 0.4 cm stage III pu to the back of the left thigh - A 4 cm x 4 cm x less then 0.1 cm stage III pu to the right upper buttock - A 2 cm x 4 cm x less than 0.1 cm wound to the right lower buttock - Left lateral ankle had healed - Left lateral foot was fragile with a 0.2 x 0.2 x less than 0.1 cm wound. On 06/07/17, the resident was seen at the WCC. The physician stated the left buttock decubitus ulceration required further operative debridement. The buttock ulcers had the following measurements: - A 25.5 cm x 11 cm x 6.0 cm ulcer on the left buttock. There was evidence of necrotic wound edges with black eschar and yellow necrotic soft tissue in the center of the wound. - A 18 cm x 13 cm x 0.5 cm ulcer on the right buttock. The resident re-admitted to the facility on [DATE] after debridement of the left buttock pressure ulcer. Review of the nursing home admission assessment, the nurse did not assess the resident's wounds. Review of the hospital documentation dated 06/16/17, the following measurements were noted: - A 20 cm x 15 cm x 2.5 cm pressure ulcer to the left buttock. There was bone palpable at the coccyx and some slough in the wound bed. - A 20 cm x 10 cm x 0.2 cm pressure ulcer to the right buttock. - 4th left toe remains dark but is not draining. On 06/20/17, five days after admission, Resident 2's pressure ulcer still had not been assessed by the facility. Review of the nursing progress notes from 10/01/16 to 06/19/17, there was very limited documentation the resident refused to be repositioned, refused care, or had any behavioral concerns. In an interview on 06/20/17 at 8:45 AM, Resident 2 was observed lying in bed. The resident stated she had a history of [REDACTED]. The resident stated she went to see a dermatologist and it was recommended a treatment done twice daily, but was only being done once. The resident stated now they are following the order from the hospital. The resident declined to have her wounds observed. In an interview at 2:00 PM, the Director of Nursing Services (DNS) was not able to provide any additional information regarding why Resident 2's wounds had not been assessed and documented weekly. The DNS stated the resident had multiple factors that impacted her risk for skin breakdown. In an interview on 06/23/17 at 9:00 AM, the DNS stated the Clinitron bed was not implemented until 05/29/17. The DNS was not able to state why this had not been implemented after the WCC recommended it. The DNS stated the bed she was on was sufficient to meet her pressure relief needs. Reference: (WAC) 988-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to promote care in a manner that maintained or enhanced the dignity of the resident and failed to respect the resident's private space for 1 of 3 residents (32). This failure resulted in the resident expressing feelings of a diminished quality of life. Findings include: Resident 32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was on hospice for a terminal condition. In an interview with the resident on 7/9/14 at 9:51 a.m., the resident was observed to be lying in her bed, she was wearing lipstick and her hair was styled. Two pairs of high heeled shoes were observed above her dresser, the resident stated she might never walk again but she would want to wear the heels "too look cute, even if I'm lying in bed wearing them." She continued to state that fashion and self-care had always been the most important focus to her. The resident became upset and started crying while she stated, the facility had taken away her perfumes. "I was born with mascara in one hand and perfume in the other." The resident continued to state, "My husband visits me every day after he gets off of work; I used to put a little perfume on right before he got here so he could smell me when he gave me a hug. They came and took my perfumes away, it's taken my pride away." The resident further stated, "I don't feel pretty anymore, perfume is very important to me, I like to smell good." Observation of the room, revealed the resident had 2 scented lotions, no perfumes were observed. A hospice note dated 6/24/14 documented, ... "She was very weepy this week as the facility requested she not use her spray perfume ..." The resident continued to state, "They also don't let me open my window more than two inches because it gets too cold for my roommate. What about my comfort? I need fresh air and I'm always warm, I don't think that's right." MSW (Social Worker) Note dated 6/23/14, documented, "Pt. reports difficult coping stating she doesn't open the window unless it's in the 80's and yesterday, a staff member came in and told her to shut it completely." Progress note dated 7/1/14 documented, Pt. was tearful with the recent disappointments. Observation of the residents window revealed a red tape marking the two inch limit to where the window could be opened to. "It can't go past the red line, I feel like a child. "The resident stated staff came into her room to check the window was not opened more than two inches and would close it without asking her permission. "If it's past the red line, they get upset and close it all the way." In an interview with the Director of Nursing Services (DNS) on 7/10/14 at 11:15 a.m. she stated, the residents perfumes were taken away because a few of the staff members had severe asthma attacks when they went in the room to provide care and it was also smelling up the hallways. She further stated, the window sill was marked to open no more than two inches because the resident was making the room too cold for her roommates. "I know that it is important to the resident because she can't go outside and it is the only form of fresh air she can get but her roommates are always cold or it affects the air conditioning." When asked if other resident's windows were marked and if staff walked into other resident's rooms to close their window, she stated no, only Resident 32's. Random resident room observations revealed several windows to be opened all the way. No other window sills were marked with red tape. In an interview with Staff B, the Director of Clinical Services on 7/10/14 at 1:00 p.m., Staff B stated there was a history of the resident wanting her window open and "running roommates out" by making the room too cold. When asked about the residents perfumes, Staff B stated, the resident was over using her perfumes. She further stated due to the residents behaviors, the facility interdisciplinary team with the advice of the hospice MSW (Social Worker) decided to implement the window and perfume restrictions. The perfume and window restriction implemented by the facility, did not assist the resident to maintain and enhance her self-esteem and self-worth and was not respectful of the resident ' s private space.