Every finding on record at Mirabella

Based on observation, interview, and record review, the facility failed to ensure a foam pressure offloading dressing was consistently applied and changed per physician order to prevent pressure injury/pressure ulcer (PI/PU - localized damage to the skin and/or underlying soft tissue usually over a bony prominence as a result of intense and/or prolonged pressure), and to consistently complete weekly skin assessments for 1 of 3 residents (Resident 1), reviewed for PI/PU. Resident 1 experienced harm when they developed an unstageable pressure ulcer (injury occurs when the extent of tissue damage is obscured when slough [dead tissue forms over a wound] or eschar [a thick, dry, leathery layer of dead tissue that forms over a deep wound] on their left heel that required debridement by a wound care specialist. This failure placed residents at risk for skin injury, adverse outcomes, infection, and a diminished quality of life.Findings included. Review of the facility policy titled, Pressure Injury and Prevention, revised in June 2025, showed that a Braden Scale (a tool used to assess a patient's [resident's] risk of developing a pressure injury) would be completed upon admission, weekly for four weeks, and quarterly thereafter. It showed that actions taken to continue ongoing evaluation of skin include weekly total body examination, documentation, and that nurses must obtain physician orders for the removal of devices and/or methods to check skin. Further review showed, During showers/bathing and ongoing care, certified nursing assistants will observe the resident's skin and report to the licensed nurse (LN) any signs of skin abnormalities.Review of Resident 1's comprehensive care plan initiated on 12/07/2020 showed a self-care performance deficit related to immobility and directed staff to perform weekly and as needed skin inspection to observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse.Review of electronic medical records showed Resident 1 was readmitted to the facility on [DATE] with a diagnosis to include paraplegia (paralysis from the waist down).Review of Braden Scale completed on 01/15/2026 showed a score of15, indicating mild risk for developing pressure ulcers.Review of Resident 1's annual Minimum Data Set (MDS - an assessment tool) dated 01/05/2026, showed Resident 1 had intact cognition and required assistance with bed mobility. The MDS further showed Resident 1 had no pressure ulcer on their left heel.Review of Resident 1's nursing progress notes dated 03/09/2026 showed that they had abrasion on their right toe and excoriation on their coccyx (tailbone), and no pressure ulcer on their left heel.Review of the facility's investigation summary report titled, Pressure ulcer:. house-acquired, dated 04/05/2026 showed that on 04/05/2026, Staff E, Certified Nurse Assistant, noticed a dried fluid leaking through Resident 1's left sock and notified Staff D, Registered Nurse. The investigative report showed Staff D observed that the dressing on the resident's left heel was dated 03/08/2026, and that when the dressing was removed, an unstageable pressure ulcer was discovered on Resident 1's left heel. Staff B, Director of Nursing, interviewed Staff F, Licensed Practical Nurse, and Staff F stated that on 03/30/2026, I did peel it off and peeked only and reapplied the same dressing . I did not see the date though. I should have checked and changed the dressing. Review of the March 2026 Treatment Administration Records showed, Foam dressing to Left heel for protection one time a day every Mon [Monday] for skin integrity maintenance were initiated/signed on 03/09/2026, on 03/16/2026, on 03/23/2026, and on 03/30/2026. However, per the investigative report dated 04/05/2026, the last foam dressing changes was dated 03/08/2026.Review of Resident 1 nursing progress notes dated 04/05/2026, showed Resident 1 had developed an unstageable pressure ulcer on their left heel.In an interview on 04/20/2026 at 1:47 PM, Resident 1 stated that the dressing on their left heel was applied by Staff D on 03/08/2026 and it stayed there for a month. Resident 1 further stated that they were paraplegic and could not feel anything from the waist down. In an interview on 04/28/2026 at 11:50 AM, Staff C, Resident Care Manager, stated that for high-risk residents, comprehensive skin assessments were completed once a week as per physician order and that staff were expected to apply new dressing with current date and initials.A joint observation and interview on 04/28/2026 at 12:15 PM with Staff D, showed Resident 1 had an oval-shaped pressure injury on their left heel with yellow slough in the center and with dark discoloration along the wound edges. Staff D stated that the wound had been debrided by wound care specialist on 04/10/2026, and the wound remained unstageable, measuring 2.4-centimeter (cm) x 1.80 cm x 0.20 cm.In a joint record review and interview on 04/28/2026 at 12:37 PM with Staff B revealed that the 04/05/2026 investigative report showed that Staff F had peeked at the wound and reapplied the old dressing. When asked if the dressing had been changed weekly from 03/08/2026 through 04/05/2026, Staff B stated, No. Staff B stated that it was their expectation that staff would follow physician orders and perform wound dressing as prescribed.Reference: (WAC) 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 4 residents (Resident 1), reviewed for medication administration. The failure to administer and/or document medication administration in accordance with professional standards of practice placed the resident at risk of negative outcomes and a diminished quality of life.Findings included .Review of the facility's policy titled, Medication and Treatment Administration, dated January 2024, showed that medications would be administered as prescribed. The policy further showed that the Seven Rights of medication administration would be observed for right resident, right drug, right dose, right time, right route, right manufacturer/pharmacy recommendations, and right documentation.Resident 1 readmitted to the facility on [DATE] with diagnoses that included hiatal hernia (the upper part of the stomach [a muscular organ that digests food] bulges up into the chest through an opening in the diaphragm [muscle barrier that separates the abdominal cavity from the chest cavity]), gastroesophageal reflux disease with esophagitis (stomach acid flows back into the esophagus [tube that carries food from the throat down to the stomach] causing irritation and discomfort).Review of the admission Minimum Data Set (an assessment tool) dated 06/09/2025 showed Resident 1's cognition was intact.Review of the August 2025 and September 2025 Medication Administration Record (MAR), showed Resident 1 had the following medication orders:- Aluminum-Magnesium Simethicone (Mylanta - antacid medication that treats heart burn, upset stomach, and gas) Oral Suspension. Give 20 milliliters (ml - a unit of measurement) by mouth with meals at 8:00 AM, 12:00 PM, 6:00 PM; and at bedtime at 8:00 PM for gastrointestinal issues (conditions that affect the digestive system including the stomach and intestines). Give 30 ml of Lido [lidocaine-local anesthetic used to numb painful areas in the mouth and throat) oral solution]/Antacid 1:2 oral suspension.- Lidocaine Mouth/Throat Solution 2 %. Give 10 ml by mouth with meals at 8:00 AM, 12:00 PM, 6:00 PM; and at bedtime at 8:00 PM for gastrointestinal issues. Give 30 ml of Lido/Antacid 1:2 oral suspension. Review of the August 2025 MAR showed Resident 1 was not given their Mylanta on the following dates and times:- 08/01/2025 at 8:00 PM- 08/02/2025 at 8:00 AM and 12:00 PM- 08/06/2025 at 6:00 PM and 8:00 PM- 08/07/2025 at 8:00 AM, 12:00 PM, 6:00 PM, and 8:00 PM- 08/08/2025 at 12:00 PM, 6:00 PM and 8:00 PM- 08/12/2025 at 12:00 PM, 6:00 PM and 8:00 PM- 08/13/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/14/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/15/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/30/2025 at 8:00 PM- 08/31/2025 at 12:00 PM, 6:00 PM, and 8:00 PMFurther review of August 2025 MAR showed Resident 1 was not given their Lidocaine oral solution on the following dates and times:- 08/01/2025 at 8:00 PM- 08/02/2025 at 8:00 AM and 12:00 PM- 08/06/2025 at 6:00 PM and 8:00 PM- 08/07/2025 at 8:00 AM, 12:00 PM, 6:00 PM, and 8:00 PM- 08/08/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/12/2025 at 12:00 PM, 6:00 PM and 8:00 PM- 08/13/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/14/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/15/2025 at 8:00 AM, 12:00 PM, 6:00 PM and 8:00 PM- 08/30/2025 at 8:00 PM- 08/31/2025 at 8:00 AM, 12:00 PM, 6:00 PM, and 8:00 PMReview of the September 2025 MAR showed Resident 1 was not given their Mylanta on the following dates and times:- 09/01/2025 at 8:00 AM and 12:00 PM- 09/02/2025 at 8:00 AM and 12:00 PFurther review of September 2025 MAR showed Resident 1 was not given their lidocaine oral solution on the following dates and times:- 09/01/2025 at 8:00 AM and 12:00 PM- 09/02/2025 at 8:00 AM and 12:00 PM- 09/07/2025 at 8:00 AM and 12:00 PM- 09/15/2025 at 8:00 AM and 12:00 PMReview of the progress note from 07/21/2025 to 09/15/2025 did not show documentation that the doctor was notified of the Mylanta and lidocaine medication not being available and/or not given to Resident 1.On 09/15/2025 at 12:55 PM, Resident 1 stated they had discomfort and bloating (swollen with fluid or gas) when they did not get their Mylanta-lidocaine. Resident 1 further stated that when they had bloating, it was hard to breathe, eat, sit-up, and walk. Observation on 09/15/2025 at 1:05 PM showed Staff C providing Resident 1 their medications. Staff C gave Resident 1 a white liquid in a medication cup stating, this is your aluminum magnesium simethicone. In an interview and joint record review on 09/15/2025 at 1:48 PM, Staff C, Licensed Practical Nurse, stated they followed the MAR when administering medications to the residents. A joint record review of September 2025 MAR showed Resident 1 had orders for Mylanta 20 ml by mouth before meals. Give 30ml of Lido/Antacid 1:2 oral suspension and for Lidocaine oral solution 10 ml before meals. Give 30ml of Lido/Antacid 1:2 oral suspension. Staff C stated they gave Resident 1 their aluminum magnesium simethicone (Mylanta) medication. Staff C stated they did not find lidocaine viscous and did not give it to Resident 1. Staff C stated they gave 20 ml of lido/antacid 1:2 oral suspension at 8:00 AM and 12:00 PM on 09/07/2025 and today [09/15/2025] to Resident 1. A joint observation of the medication refrigerator showed there were three bottles of 1200 ml of Resident 1's lido/antacid. The instructions on the bottle indicated, Give 30 ml of Lido/Antacid 1:2 oral suspension. Staff C stated they did not find Resident 1's Mylanta and lidocaine oral solution on 09/02/2025 and did not give Resident 1 their 8:00 AM and 12:00 PM doses. Staff C stated they did not know there was another refrigerator in the medication room and that on 09/07/2025 they found Resident 1's aluminum magnesium simethicone [Mylanta]. Staff C further stated they did not notify the doctor Resident 1's Mylanta and lidocaine oral solution was not available because they were not pertinent medications.In an interview on 09/15/2025 at 4:15 PM, Staff D, Pharmacist, stated that Aluminum-Magnesium Simethicone Oral Suspension 200- 200-20 MG/5ML. Give 20 ml and Lidocaine Mouth/Throat Solution 2% Give 10 ml were a compound (mixed medication). Staff D further stated that if the lido/antacid bottle indicated to give 30 ml, nurses should administer 30ml and sign the MAR for the medication separately as the facility software did not allow for the medications to be written as one order.In a follow-up interview on 09/18/2025 at 10:40 AM, Staff D stated nurses should give 30 ml of lido/antacid to Resident 1 before meals and at 8:00 PM.In an interview and joint record review on 09/18/2025 at 2:04 PM, Staff B, Resident Care Manager, stated they expected nurses to follow resident's MAR to provide medications. Saff B stated that when medications were not available, they expected the nurses to contact the pharmacy to reorder the medication, notify the family, notify the doctor that medication was not given, and document it in the resident's progress notes. A joint record review of August 2025 and September 2025 MARs showed Resident 1 was not given their Mylanta/lidocaine oral solution on 08/01/2025, 08/02/2025, 08/06/2025, 08/07/2025, 08/08/2025, 08/12/2025, 08/13/2025, 08/14/2025, 08/15/2025, 08/30/2025, 08/31/2025, 09/01/2025, 09/02/2025, 09/15/2025, 09/07/2025, and 09/15/2025. Staff B stated that the nurses should have notified the doctor about Resident 1's medication not being available. Staff B further stated that Staff C should have given 30 ml of lido/antacid to Resident 1 on 09/07/2025 and 09/15/2025.On 09/18/2025 at 3:11 PM, Staff A, Director of Nursing Services, stated nurses should have notified the doctor about Resident 1's lidocaine/antacid medications not being available and/or given. Staff A further stated that Staff C should have administered 30 ml of lido/antacid to Resident 1 on 09/07/2025 and 09/15/2025.Reference: (WAC) 388-97-1300 (1)(b)(ii)(3)(a).

Based on observation, interview, and record review, the facility failed to ensure food items were handled appropriately in accordance with professional standards of food safety for 1 of 1 Freezer (Kitchenette Freezer), 2 of 2 seasoning shelves (Kitchenette Seasoning Shelf & Spices in Process Shelf on the 9th floor) and 1 of 1 dry storage room (Dry Storage Room on the 9th Floor), reviewed for food services. The failure to date and discard expired food items placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, General Food Storage Standards, dated November 2024, showed that food storage should incorporate specific standards and criteria to maintain a clean and safe environment for healthful delivery to the residents. The policy further showed, All potentially hazardous foods must be labeled with a date sticker as soon as the package is opened or the item is prepared. KITCHENETTE FREEZER A joint observation and interview on 06/24/2025 at 6:39 AM with Staff G, Dietary Aide, showed a small to go cup vanilla ice-cream that was prepared on 04/28/25 [04/28/2025] with Must use by Thu [Thursday] 05/01/25 [05/01/2025]. Further observation showed nine small to go cup vanilla ice cream with no prepared and use by dates. Staff G stated that the expired vanilla ice cream should have been discarded. Staff G further stated that those vanilla ice cream with no prepared and use by dates should have been labeled with prepared and use by dates. KITCHENETTE SEASONING SHELF A joint observation and interview on 06/24/2025 at 6:49 AM with Staff G, showed that A1 steak sauce (Brand name) that was prepared on 06/06/25 [06/06/2025] with Must use by Fri [Friday] 06/20/25 [06/20/2025]. Staff G stated, no one uses this sauce, and I don't [I do not] know why it is here. Staff G further stated that the sauce should have been discarded. SPICES IN PROCESS SHELF A joint observation and interview on 06/27/2025 at 8:21 AM with Staff M, Health Center Lead Cook, showed the following: - One opened spice container of Cr Chimichurri Blend [Brand name] that was prepared on Thu 04/04/24 [04/04/2024] with Must use by Fri 04/04/25 [04/04/2025] and manufacture's expiration date of 05/25/2025. -One opened spice container of RH Ras El Hanout Blend [Brand name] with no prepared date, use by date and without a visible manufacturer's use-by date. -One opened spice container of Al Alderwood smoked salt [Brand name] without an open date and with a Must use by 06/26/25 [06/26/2025]. When asked what their process for food items with no open and use by dates, Staff M stated that it was the chef's responsibility to monitor open and use by dates for the spices. DRY STORAGE ROOM A joint observation and interview on 06/27/2025 at 8:41 AM with Staff N, Dietary Manager, showed one opened container of Be African Bird's Eye [type of hot pepper] with no opened and use by date. Staff N stated it should have been labeled when it was first opened. In an interview on 06/27/2025 at 1:37 PM, Staff N stated that the food items that were expired should have been discarded. Staff N further stated that opened food items without an open and use-by date should have been labeled. In an interview on 06/27/2025 at 3:09 PM, Staff A, Administrator, stated that they expected kitchen staff to check the food items regularly, to date when first opened, and discard when expired/passed the use by date. Staff A further stated that food items that were undated/passed the use by date should have been dated and/or discarded. Reference: (WAC) 388-97-1100 (3) .

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-precaution to protect residents from Multidrug-Resistant Organism [a germ that is resistant to medications that treat infections]) practices were followed for 1 of 5 residents (Resident 137), and failed to disinfect/sanitize medical equipment between resident use for 2 of 3 staff (Staff E & Saff F), reviewed for infection control. These failures placed the residents, staff, and visitors at an increased risk of infection and related complications. Findings included . Review of the facility's policy titled, Enhanced Barrier Precautions, revised on 02/20/2025, showed, EBP refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities. It further showed that high-contact care activities included dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting. Review of the facility's policy titled, Cleaning & [and] Disinfecting Resident Care Items and Equipment, dated February 2025, showed, Resident-care equipment, including reusable items and durable medical equipment [DME-reusable medical equipment and supplies intended for long term use], will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations for disinfection and the OSHA Blood borne Pathogens Standard (a regulation designed to protect workers from health hazards caused by exposure to blood and other potentially infectious materials). The policy further showed that DME must be cleaned and disinfected before re-use by another resident. EBP PRECAUTION Observation on 06/26/2025 at 2:15 PM, showed Resident 137 had an EBP signage on their door for urinary catheter (flexible tube that collects urine from the bladder [organ that stores urine] and drains to a bag and that their call light was on. Staff I, Certified Nursing Assistant (CNA), entered Resident 137's room without wearing gown or gloves. Staff I was inside the bathroom with Resident 137. When Staff I was done, they came out of the bathroom holding a trash bag, exited the room and performed hand hygiene. In an interview on 06/26/2025 at 2:25 PM, Staff I stated that they wiped and pulled up Resident 137's pants while assisting them in the bathroom. When asked if they wore gown and gloves, Staff I stated, I had gloves on, but I didn't [did not] have a gown and that they should have. Staff I further stated that when residents were on EBP, they had to wear gown and gloves when providing care. In an interview on 06/27/2025 at 8:52 AM, Staff B, Director of Nursing, stated that residents on EBP would have a signage posted on their door and that staff were aware of the EBP precaution and what Personal Protective Equipment (PPE - a safety gear [gown and gloves] used to reduce exposure to substances, germs and objects) they should wear when providing direct contact care like transferring, Activities of Daily Living care, toileting assistance and toileting hygiene. Staff B further stated that they expected Staff I to look at the EBP signage posted outside Resident 137's room prior to going into their room and to wear the appropriate PPE when they assisted them. DISINFECTING DME STAFF E Observation on 06/25/2025 at 1:24 PM, showed Staff E, CNA, took the sit-to-stand lift (a medical device designed to assist individuals with limited mobility in transitioning from a seated position to a standing position) from the hallway and brought it to room [ROOM NUMBER] that had an Aerosol (suspension of fine solid particles or liquid droplets) Generating Procedure (AGP-medical procedure that can produce tiny airborne particles called aerosols which may carry infectious pathogens and pose a risk of transmission to healthcare workers) signage outside the room. Staff E left Resident 23's room with the sit-to-stand lift and placed it in the hallway without cleaning or disinfecting it. In an interview on 06/25/2025 at 2:02 PM, Staff E stated that they assisted Resident 23 in repositioning them to sit upright in their wheelchair using sit-to-stand lift. When asked if they cleaned/disinfected the sit-to-stand lift before and/or after they used it, Staff E stated, No, I forgot to clean it. Staff E further stated, We are supposed to clean it before and after each use. STAFF F Observation on 06/25/2025 at 1:32 PM, showed Staff F, CNA, took the sit-to-stand lift that was used in room [ROOM NUMBER] from the hallway and assisted Resident 11 in room [ROOM NUMBER]. Staff F left Resident 11's room with the sit-to-stand lift and placed it in the hallway without cleaning or disinfecting it. In an interview on 06/25/2025 at 1:57 PM, Staff F stated that they assisted Resident 11 to transfer using the sit-to-stand lift. Staff F stated that they did not clean/disinfect the sit-to-stand lift before and/or after use. Staff F stated, I forgot to clean it before and after use, but I will go back and take care of it. In an interview on 06/26/2025 at 8:34 AM, Staff D, Resident Care Manager, stated that it was their expectation staff followed their standard protocol and cleaned shared medical equipment between use. Staff D further stated that Staff E and Staff F should have cleaned/disinfected the sit-to-stand lift before and after use. In an interview on 06/26/2025 at 1:18 PM, Staff B stated that it was their expectation for DME to be cleaned and disinfected before and after use. Staff B further stated that Staff E and Staff F should have cleaned and disinfected the sit-to-stand lift before and after they used it. Reference: (WAC) 388-97-1320 (1)(a) (5)(c) .

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed and posted with actual hours worked after the start of each shift for 4 of 4 days (06/24/2025, 06/25/2025, 06/26/2025 & 06/27/2025), reviewed for sufficient and competent staffing. This failure placed the residents and their representatives at risk of not being fully informed of current staffing levels, potentially affecting their understanding of staff availability and care delivery. Findings Included . Review of the facility's policy titled, Postings - Required for SNF [Skilled Nursing Facility], dated March 2025, showed, It is the policy of the Company to post information according to state specific and federal guidelines for Skilled nursing. The policy further showed that the facility would post the total number and actual hours worked of direct care staff per shift. Multiple observations of the posted daily nurse staffing form showed the planned actual hours, and did not show the actual hours worked on the following dates and times: - On 06/24/2025 at 1:15 PM - On 06/25/2025 at 10:40 AM - On 06/26/2025 at 11:55 AM - On 06/27/2025 at 11:02 AM A joint record review and interview on 06/27/2025 at 2:22 PM with Staff B, Director of Nursing, showed that the nurse staff posting did not show actual hours worked. Staff B stated, At the moment, our current nursing staff posting form includes the number of staff scheduled for each shift and their scheduled hours. It did not reflect the actual hours worked. Staff B further stated that it was their expectation that the nurse staff posting form included the actual hours worked for each shift. In an interview on 06/27/2025 at 3:09 PM, Staff A, Administrator, stated that the nurse staff posting form should have included the actual hours worked per shift. No associated WAC .

Based on observation, interview, and record review, the facility failed to ensure bed controls were in a safe operating condition for 1 of 4 residents (Resident 6), reviewed for environment. This failure placed the resident at risk for injury and a decreased quality of life. Findings included . Review of the facility's policy titled, Preventative Maintenance, dated in March 2024, showed, they practice preventive maintenance in order to minimize down time of equipment and machinery and maximize resident comfort. Preventive maintenance ensures that all equipment is operating at optimal efficiency. Staff is trained to monitor for early detection of malfunction to prevent further breakdown. Review of a face sheet printed on 06/27/2025 showed Resident 6 admitted to the facility on [DATE]. In an interview and observation on 06/24/2025 at 8:14 AM, Resident 6 stated that they were worried about their bed control. Observation showed that Resident 6's bed remote control wiring was exposed at the base of the bed control. Resident 6 stated that they did know how long it had been that way. Observations on 06/25/2025 at 1:29 PM and 06/27/2025 at 10:36 AM, showed Resident 6's bed remote control wiring was exposed at the base of the bed control. In an interview and joint observation on 06/26/2025 at 9:58 AM, Staff I, Certified Nursing Assistant (CNA), stated that if there was something wrong with the resident beds, they would complete a maintenance work order request, and would notify the Resident Care Manager or housekeeping staff. A joint observation showed Resident 6's bed remote control had exposed wiring at the base of the bed control. Staff I stated, We've [we have] all noticed it and that it still works. Staff I further stated that they did not notify maintenance and that they did not know if anyone had. In an interview and joint observation on 06/27/2025 at 10:50 AM, Staff J, Facility Services Director, stated that they conducted monthly preventative maintenance inspections of the bed and if the nurse requested for one. Staff J stated that staff could submit a maintenance work order request through maintenance connection [software] and that staff could call them directly for any urgent needs. A joint observation of Resident 6's bed remote control showed exposed wiring at the base of the bed control. Staff J stated, It's [it is] safe but it needs to be replaced and that if it was not replaced, it could damage the functionality of the bed, and that Resident 6 would not be able to get the bed to go up or down. Staff J further stated that staff should have placed a maintenance work order request for anything they see like this. Staff J further stated that if staff noticed something like this, we need to know. It needs to be replaced. In an interview on 06/27/2025 at 11:17 AM, Staff K, Registered Nurse, stated that if the resident's equipment was not working properly or was broken, they would contact maintenance and complete a maintenance work order request. Staff K stated that a maintenance work order request was not completed for Resident 6's bed remote control and that the CNAs should have completed one and let the nurse know. A joint record review and interview on 06/27/2025 at 11:42 AM with Staff J, showed the Maintenance Connection log had no work order for Resident 6's bed remote control. Staff J stated that staff should have completed a maintenance work order request for Resident 6's bed remote control. In an interview on 06/27/2025 at 1:51 PM, Staff B, Director of Nursing, stated that they expected facility equipment to be fixed right away and that whoever noticed it should have requested for a maintenance work order. In an interview on 06/27/2025 at 2:41 PM, Staff A, Administrator, stated that they expected the facility equipment to be maintained safely, and if not, it would be communicated to the maintenance facility staff and fixed promptly. Staff A further stated that they expected staff to have completed a work order request when they observed the exposed wiring on Resident 6's bed remote control. Reference: (WAC) 388-97- 2100(1) .

Based on observation, interview, and record review, the facility failed to ensure medications were properly labeled with open date in accordance with current accepted professional standards for 1 of 2 medication carts (Health Center 2 [HC 2]), reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised or ineffective medications, unsafe medication administration, and potential adverse side effects. Findings included . Review of the facility's policy titled, Medication Storage and Accounting, dated February 2025, stated that all medications must be labeled in compliance with regulations. Labels must include the resident's name, prescribing physician, drug name/strength/quantity, date filled, prescription number, issuing pharmacy, instructions, and expiration date. During a joint observation and interview on 06/26/2025 at 8:29 AM with Staff K, Registered Nurse, showed the HC 2 medication cart had following medications: - One opened box with four Lidocaine (medication to treat pain) patches labeled for Resident 13 with no open or expiration date. - One opened tube of Voltaren (medication to treat joint pain) gel labeled for Resident 25 with no open date. In an interview on 06/26/2025 at 9:11 AM, Staff K stated that the above medications were not properly labeled and that all opened medications should include the resident's name, open date, and expiration date. In an interview on 06/27/2025 at 10:56 AM, Staff B, Director of Nursing, stated that it was their expectation that opened medication should have an open date, resident's name and expiration date. Reference: (WAC) 388-97-1300 (2) .

Based on interview and record review, the facility failed to ensure Medication Regimen Review (MRR- a comprehensive assessment of resident's medications, performed by a pharmacist [a qualified professional to provide expert advice on medication management, safety, and regulatory compliance] to identify and address potential problems) was completed for 1 of 5 residents (Resident 1), reviewed for unnecessary medications. This failure placed the resident at risk of receiving unnecessary medications and a diminished quality of life. Findings included . Review of the facility's policy titled, Drug Regimen Review, Report & [and] Act on Irregularity, dated February 2024 showed, The Consultant Pharmacist will review the drug regimen, including medical records of each resident, at least once a month and will report any irregularities to the Attending Physician, Director of Nursing and Medical Director. Review of Resident 1's May 2025 MRR dated 05/21/2025 showed a pharmacist recommendation to discontinue melatonin (a medication/supplement to help with sleep) due to potential side effects. It further showed that the recommendation to discontinue melatonin was not implemented. Review of Resident's 1 physician order printed on 06/27/2025 showed an order for melatonin with a start date of 06/13/2023. Review of Resident 1's June 2025 Medication Administration Record showed that they received melatonin from 06/01/2025 through 06/26/2025. In an interview on 06/27/2025 at 9:32 AM, Staff C, Minimum Data Set (an assessment tool) Coordinator, stated that the pharmacist emailed the MRRs monthly to the Director of Nursing (DON), Resident Care Managers and were reviewed by medical providers for approval or denial. During a joint record review and interview on 06/27/2025 at 10:43 AM with Staff B, DON, showed that the MRR recommendation dated 05/21/2025 was not reviewed by the provider for approval or denial. Staff B stated that the facility did not follow up with the pharmacy and that Resident 1 continued to receive melatonin after the recommendation to discontinue it. Reference: (WAC) 388-98-1300 (4)(c) .

Based on observation, interview, and record review, the facility failed to ensure assessment and care plan were in place for side rail use, and/or inform the resident and/or their representative the risks and benefits prior to side rail use/installation for 1 of 4 residents (Resident 9), reviewed for side rails. This failure placed a resident at risk for entrapment, injury, and a diminished quality of life. Findings included . Review of the facility policy titled: Side Rail Assessment, revised in April 2024 showed that individual side rail assessments will be performed on a regular basis and the side rail evaluation would include data collection analysis and determination of potential alternatives to side rail usage. The policy showed that when the side rails are deemed necessary and appropriate, the facility will provide education to the residents or residents' representatives pertaining to the risk and benefits of side rail use. The policy further showed that it is the policy of the facility to review the risk and benefits with the resident and/or representative, obtain informed consent, obtain physician order, and care plan for use of side rail. Review of the quarterly Minimum Data Set (MDS- an assessment tool) dated 05/01/2025 showed that Resident 9 admitted to the facility on [DATE]. The MDS further showed that Resident 9 had highly impaired vision. Review of the care plan revised on 11/04/2024 showed that Resident 9 required two-person substantial/maximum assistance (helper does more than half the effort) for bed mobility and that they were totally dependent on one staff for transfers. Further review of the care plan showed that Resident 9 was a fall risk d/t [due to] impaired mobility, weakness, impaired vision, cognitive deficits [memory loss], poor safety awareness and judgement, non-compliant behavior, medications and history of multiple falls. Review of the Fall Risk Evaluation dated 04/17/2025 showed that Resident 9 was a high risk for fall. Observations on 06/24/2025 at 1:26 PM and on 06/25/2025 at 2:57 PM, showed that Resident 9 had upper half side rails on each side of the bed in the raised position. During a joint observation and interview on 06/26/2025 at 7:49 AM with Staff O, Registered Nurse, showed Resident 9 was lying in bed with the upper half side rails on each side of the bed in the raised position. Staff O stated that Resident 9 used the side rails for bed mobility. A joint record review and interview on 06/26/2025 at 8:34 AM with Staff D, Resident Care Manager, showed that Resident 9 did not have an assessment, physician's order, care plan, and/or the resident and their representative were notified of the side rails use. Staff D stated that Resident 9 did not have an assessment, order, consent, or care plan for side rails. Staff D stated that physician's order for side rails should have been placed, along with an assessment, consent, and care plan. In an interview on 06/26/2025 at 1:18 PM, Staff B, Director of Nursing, stated that their expectation was that an assessment, physician's order, consent, and care plan for side rails use should have been completed before Resident 9 started using it. Reference: (WAC) 388-97-1060 (3)(g) .

Based on observation, interview, and record review, the facility failed to ensure proper labeling and storage of respiratory equipment were followed for 1 of 3 residents (Resident 237), reviewed for respiratory care. This failure placed the resident at risk for respiratory infections, related complications, and diminished quality of life. Findings included . Review of the facility's policy titled, Oxygen/Respiratory therapy & [and] safety, dated January 2025 showed, Oxygen/respiratory equipment tubing/cannula [a flexible tubing that delivers oxygen]/mask and plastic container bag will be changed at least weekly and anytime as needed. Oxygen/respiratory equipment tubing/cannula/mask and bag will be dated and initiated each time it is changed. When oxygen/respiratory equipment is not in use, place the tubing/cannula/mask into the bag to keep clean and prevent contamination. Review of a face sheet printed on 06/27/2025 showed Resident 237 was admitted to the facility on [DATE] with diagnosis that included acute bronchitis (a short- term disease that affects the airways of the lungs and can cause chest discomfort and Shortness of Breath [SOB]). Review of Resident 237's physician orders printed on 06/25/2025 showed an order to administer an Ipratropium-Albuterol inhalation (medication used to treat breathing problems) every four hours as needed for SOB or wheezing (breathing with a whistling or rattling sound in the chest). Review of Resident 237's June 2025 medication administration record showed that they received Ipratropium-Albuterol inhalation treatment on 06/07/2025 and 06/12/2025 for SOB. Multiple observation on 06 /24/2025 at 7:25 AM, on 06/25/2025 at 1:27 PM, and on 06/26/2025 at 8:11 AM, showed the nebulizer (a machine that converts liquid medicine into a mist that can be inhaled) connected to a mask was laying on top of Resident 237's nightstand. The nebulizer tubing was not dated/labelled, and the mask was not properly stored. During a joint observation and interview on 06/26/2025 at 9:19 AM with staff Q, Registered Nurse, showed the nebulizer tubing and mask was laying on top of Resident 237's nightstand and was not dated/labelled or properly stored. Staff Q stated that the nebulizer tubing and mask should have been dated/labelled and stored in a bag even when not in use. In an interview on 06/27/2025 at 10:47 AM, Staff B, Director of Nursing, stated it was their expectation that a nebulizer tubing and mask should have been dated/labelled, and properly stored when not in use. Reference: WAC 388-97-1060(3)(j)(vi) .

Based on interview and record review, the facility failed to facilitate quarterly care conferences or care plan meetings for 1 of 13 residents (Resident 6), reviewed for care planning. This failure placed the residents at risk for unidentified and unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Planning, revised in November 2025, showed, Care planning and implementation of care will involve the resident and/or resident's legal representative, resident's attending physician and interdisciplinary team including licensed nurse, certified nursing assistant and food service staff. Review of a face sheet printed on 06/27/2025 showed that Resident 6 admitted to the facility on [DATE]. In an interview on 06/24/2025 at 3:09 PM, Resident 6 stated that they had not attended a care conference or care plan meeting. Review of Resident 6's Electronic Health Records (EHR) did not show documentation that they had a care conference and/or care plan meeting that they were involved in since September 2022. In an interview and joint record review on 06/26/2025 at 10:31 AM, Staff C, Minimum Data Set (an assessment tool) Coordinator, stated that care conferences were completed on admission, quarterly and as needed. Staff C stated that during the care conference meetings they talked about care planning and involved the residents/representatives. Staff C stated that the residents attended the meetings and that if they were severely dependent, they would have the meeting with their representative. A joint record review of Resident 6's EHR showed no documentation that they had a care conference or care plan meeting since September 2022. Staff C stated, It doesn't [does not] look like she had one recently and that Resident 6 should have had one unless their representative did not want to have one and that we still should have contacted them. In an interview on 06/26/2025 at 3:45 PM, Staff B, Director of Nursing, stated that they expected care conferences to be completed on admission, quarterly and as requested. Staff B stated that residents were involved in care planning during care conferences and that residents needed to know about the changes made in their care plan. Staff B reviewed Resident 6's EHR and stated that they were not able to see any care conference progress notes. Staff B further stated that Resident 6 should have had one and was overdue for a care conference. In an interview on 06/26/2025 at 1:13 PM, Staff A, Administrator, stated that care conferences were completed on admission and quarterly. Staff A stated that residents attended care conferences and that they talked about the residents' medications, therapy goals, diet and overall change in condition with the interdisciplinary team. Staff A stated that residents should always be involved unless the resident stated to leave me out of it. Staff A further stated that they were not able to find documentation that Resident 6 had a care conference and that they should have had one. Reference: (WAC) 388-97-1020 (2)(e)(f) .

Based on interview and record review, the facility failed to ensure Level II Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions are not inappropriately placed in nursing homes for long-term care) referral was made for 1 of 5 residents (Resident 23), reviewed for PASARR screening. This failure placed the resident at risk of not receiving the care and services appropriate for their needs. Findings included . Review of the facility's policy titled, PASRR - Preadmission Screening and Resident Review, dated January 2025, showed that it was the policy of the facility to abide by the federal requirement for PASARR to ensure that individuals are not inappropriately placed in nursing facilities for long term care. The policy further showed, A resident who has or is suspected to have MI or ID/ developmental disability or related conditions may not be admitted to a Medicaid [public health insurance program]-certified nursing facility unless approved through Level II PASRR determination. Review of a quarterly Minimum Data Set (MDS-an assessment tool) dated 05/08/2025 showed Resident 23 admitted to the facility on [DATE]. Review of Resident 23's Level I PASARR dated 10/25/2024 showed that a diagnosis of mood disorders (a mental health condition that affects a person's emotional state, causing persistent feelings of sadness, irritability, or extreme mood swings) was marked. Further review of the Level I PASARR showed that the question in Section IA (SMI Indicators) regarding whether Resident 23 had exhibited indicators of any mental disorders within the past two years was marked, Yes. In an interview and joint record review on 06/26/2025 at 8:55 AM, Staff C, MDS Coordinator, stated that Resident 23 was admitted to the facility with mood disorders and their Level I PASARR was marked for SMI. A joint record review of Resident 23's PASARR showed that mood disorder diagnosis was marked in Section IA. A joint record review of Resident 23's electronic health record showed no documentation that a Level II PASARR referral was completed. Staff C stated that they did not think Resident 23 needed a Level II PASARR because all the questions in Section IA (1, 2 and 3) were not marked, Yes. In an interview on 06/26/2025 at 1:18 PM, Staff B, Director of Nursing, stated that they expected residents' PASARR to be completed timely, accurately, and if they were not, they expected to be corrected timely. Staff B stated that they expected residents with SMI indicators to have a [NAME] II PASARR to be completed. Staff B further stated that Resident 23 should have had Level II PASARR completed. In an interview on 06/27/2025 at 3:09 PM, Staff A, Administrator, stated that when a residents' Level I PASARR screening indicated SMI, they should be referred for a Level II PASARR evaluation. Staff A further stated that Resident 23's Level II PASARR referral should have been made and there should have been documentation for it. Reference: (WAC) 388-97-1975 (1)(2) .

Based on interview and record review, the facility failed to accurately assess 1 of 3 residents (Resident 36), reviewed for closed records. The failure to ensure resident assessments were completed accurately on the Minimum Data Set (MDS-an assessment tool) regarding discharge status placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated in October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). Review of the discharge MDS dated [DATE] showed Resident 36 discharged from the facility on 05/19/2025. Further review of the MDS showed Section A (Identification Information) was marked that they were discharged to the hospital. Review of the nursing progress note dated 05/19/2025 showed that Resident 36 was discharged to the community. In an interview and joint record review on 06/26/2025 at 8:55 AM, Staff C, MDS Coordinator, stated that they followed the RAI manual when they completed Section A of the MDS. A joint record review of the discharge MDS showed that Resident 36 was discharged to the hospital. Staff C stated that Resident 36 was discharged to the community, and that the MDS coding was inaccurate. Staff C further stated that Resident 36's discharge status should have been coded accurately. In an interview on 06/26/2025 at 1:18 PM, Staff B, Director of Nursing, stated that they expected the MDS to be completed accurately. Reference: (WAC) 388-97-1000(1)(b) .

Based on observation, interview, and record review, the facility failed to ensure timely reporting of an injury of unknown source to the State Agency for 1 of 1 resident (Resident 15), reviewed for abuse/neglect reporting. This failure placed the resident at risk for potential unidentified and ongoing abuse and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse and incident reporting, dated in May 2024, showed, The facility will ensure that all alleged violations involving abuse neglect exploitation or mistreatment including injury of unknown origin and misappropriation of resident property are reporting [reported] appropriately and timely in accordance with the federal and state requirements. Review of a face sheet printed on 06/27/2025, showed Resident 15 was readmitted to the facility on [DATE] with diagnosis that included dementia (memory loss). Review of a quarterly Minimum Data Set (an assessment tool) dated 05/01/2025, showed Resident 15 had severe cognitive impairment and was totally dependent on staff for bed mobility, including turning left and right. Review of the investigation report dated 06/27/2025 showed Resident 15 was found on the floor by Staff P, Security Officer, during routine patrol. It further showed Resident 15's head was facing downward, partially on a floor mat, with visible blood on the carpet near their face. Resident 15 who was alert and oriented to self but unable to provide a detailed account of the incident due to dementia . Review of Resident 15's post-fall evaluation note dated 05/23/2025 showed that the fall was unwitnessed, occurred at bedside, and was of unknown cause. Further review showed the fall resulted in a nosebleed and required an emergency room visit for treatment. Review of Resident 15's nursing progress note dated 05/23/2025 showed that they were diagnosed with a nose bone fracture due to a fall. Review of the May 2025 incident log showed Resident 15's fall occurred on 05/22/2025 and was logged on 05/23/2025. Further review of the incident log showed that Resident 15's fall was not reported to the State Agency. During an observation and interview on 06/24/2025 at 7:53 AM, Resident 15 was lying in bed with visible bruising (light purple discoloration) on both cheekbones. When Resident 15 was asked about the fall incident they had, Resident 15 was not able to communicate or provide any information regarding the fall. In an interview on 06/26/2025 at 11:04 AM, Staff D, Resident Care Manager, stated the facility followed their abuse and neglect policy and that unwitnessed injuries of unknown origin resulting in major injury should be reported to the State Agency. A joint record review and interview on 06/27/2025 at 11:16 AM with Staff B, Director of Nursing, showed that the incident was logged on 05/23/2025 and was not reported to the State Agency. Staff B stated that they did not report it to the State Agency because they believed it was an accident due to Resident 15 rolling out of bed and falling. When asked whether unwitnessed falls resulting in major injury should be reported per the facility policy, Staff B stated major injury of unknown origin should be reported to the State Agency. Staff B further stated that Resident 15 could not explain the cause of the fall. In an interview on 06/27/2025 at 12:03 PM, Staff A, Administrator, stated the facility policy required a thorough investigation and timely reporting of suspected abuse, neglect, or major injury of unknown origin. Reference: WAC 388-97-0640(5)(a) .

RESIDENT 20 Review of a face sheet printed on 06/27/2025 showed that Resident 20 was admitted to the facility on [DATE]. Review of Resident 20's EHR on 06/26/2025 showed there was no copy of an Advance Directive or documentation that the resident was asked for or offered assistance in completing one. In an interview on 06/26/2025 at 3:32 PM, Resident 20 stated that they had a copy of their Advance Directive at home, and that the facility staff did not request a copy. A joint record review and interview on 06/26/2025 at 3:48 PM with Staff C, showed that there was no documentation in the EHR that an Advance Directive was requested, offered, or obtained. Staff C stated that it should have been requested during admission. In an interview and joint record review on 06/27/2025 at 10:49 AM, Staff B, Director of Nursing, stated that staff should have asked Resident 20 and/or their representative for an Advance Directive during admission. If one exists, a copy should be in their EHR. If a resident did not have it, Social Services should have offered assistance in creating one and documented in the EHR. A joint record review of Resident 20's EHR showed no copy or documentation of an Advance Directive. Staff B stated Resident 20 should have had a copy of their Advance Directive in their EHR. Reference: (WAC) 388-97-0280 (1)(3)(a) Based on interview and record review, the facility failed to obtain and/or offer assistance in formulating an Advance Directive (a written document describing a resident's wishes for care if they became incapacitated such as a living will or Power of Attorney [POA] for health care) for 2 of 5 residents (Residents 21 & 20), reviewed for Advance Directives. This failure placed the residents and/or their representatives at risk of losing their right to have their preferences honored to receive care according to their choice. Findings included . Review of the facility's policy titled, Advance Directives, revised in May 2025 showed, It is the policy of the Company to inform and educate residents and/or responsible party of their right to make health care decisions on admission and periodically .The Social Services Director or designee will then ask the resident or the resident's legal representative whether the resident has completed an Advance Directive or POLST [Portable Orders for Life Sustaining Treatment-a physician order form that describes the patients care directions], and if not, whether the resident wishes to formulate an Advance Directive. If a resident has completed an updated Advance Directive or POLST, the Social Services Director or designee will document this in the Advance Directive section of the medical record and include a copy of the Advance Directive as well. It further showed, If the resident or legal representative has executed one or more advance directive(s), these documents are obtained, incorporated and consistently maintained in the same section of the resident's health information record readily retrievable by any facility staff, and the facility will communicate the resident's wishes to the resident's direct care staff and physician. RESIDENT 21 Review of a face sheet printed on 06/27/2025 showed Resident 21 admitted to the facility on [DATE] and that they had a POA. In an interview on 06/25/2025 at 1:16 PM, Resident 21 stated that they had a POA and that it would be in their file. Review of Resident 21's Electronic Health Record (EHR) did not show documentation for a POA. In an interview on 06/26/2025 at 1:43 PM, Staff C, Minimum Data Set (an assessment tool) Coordinator, stated that Social Services would ask for Advance Directive paperwork on admission and if they obtained those records, they would be uploaded into their EHR under the miscellaneous tab. If the resident did not have one, they would offer to assist in formulating one and if the residents declined or did not have an Advance Directive, it should be documented. A joint record review of the face sheet showed that Resident 6 had a POA. A joint record review of the miscellaneous tab in the EHR showed no POA paperwork. Staff C stated that they did not see one. Staff C further stated that Resident 21 should have had a copy of their Advance Directives in their EHR if they had one. In an interview on 06/26/2025 at 4:02 PM, Staff A, Administrator, stated that Advance Directives were to be collected upon admission and by the initial care conference. Staff A stated that until they have that document, they could not honor just by word of mouth and that based on cognition, if the resident was alert and able to make decisions, POA did not come into effect. Staff A further stated that they expected if residents had an Advance Directive, they would expect a copy to be in the resident's EHR.

Based on interview and record review, the facility failed to ensure the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents) was updated to include and consider specific staffing needs for each resident unit/each shift and plans to maximize direct care staff recruitment and retention. This failure placed the residents at risk for unmet care needs. Findings included . Review of the facility's policy titled, Facility assessment, dated in October 2023, showed that the facility must address the factors as identified in the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities to enable the facility to thoroughly assess their resident population and resources that are needed to provide the care the residents need. A review of the Facility Assessment, dated January 2025 did not show documentation of specific staffing needs for each resident unit in the facility and staffing needs for each shift. It further showed that they did not have documentation on how the facility would develop and maintain a plan to maximize recruitment and retention of direct care staff. In an interview and joint record review on 06/27/2025 at 2:47 PM, Staff A, Administrator, stated that they reviewed the Facility Assessment annually and as needed, and that they expected it to be completed accurately. A joint record review of the Facility Assessment dated in January 2025 showed that it did not include specific staffing needs for each resident unit in the facility and staffing needs for each shift. It further showed that they did not have documentation on how the facility would develop and maintain a plan to maximize recruitment and retention of direct care staff. Staff A stated that it was not included in the facility assessment and that they expected the facility assessment to have been completed accurately. No associated WAC .

Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent avoidable accidents during mechanical lift transfers for 1 of 2 residents (Residents 1), reviewed for falls. Resident 1 experienced harm from an avoidable fall when left unsupervised on edge of their wheelchair after staff attempted applying a mechanical lift sling under the resident, subsequently falling out of their wheelchair and sustained a broken tibia (shin bone fracture) requiring a transfer to the emergency room (ER). This failure placed all residents at risk for avoidable falls, physical injuries, functional decline, and diminished quality of life. Findings included . Review of the facility's policy titled, Transfer/Lift Techniques, last revised in October 2023, showed, It is the policy of the Company [facility] to establish a policy to minimize, to the best of our ability, the potential for injury to residents and employees during transfers/lifting by appropriate assessment of assistance needed. Steps will be taken by the facility to minimize the manual lifting of residents that require more than one person assist by using a mechanical lifting device, if determined necessary .The Licensed Nurse will assess the resident's need for assistance with transfer/lift and will determine the appropriate type of assistance or mechanical lifting device to be used. This information will be placed on the resident's care plan and touch screen profile. Resident 1 admitted to the facility on [DATE] with diagnosis that included paraplegia (the loss of muscle function in the lower half of the body, including both legs). Review of Resident 1's annual Minimum Data Set (an assessment tool) dated 01/23/2025 showed Resident 1 was cognitively intact. The assessment further showed Resident 1 had functional limitations on their both upper and lower extremities and was dependent on staff with transfers. Review of the care plan and Kardex (summary of care plan) printed on 04/28/2025 showed Resident 1 was dependent on staff with transfers and uses a Hoyer [mechanical lift transfer device]. Further review of the care plan did not show the number of staff needed for the mechanical lift transfer assistance for Resident 1. Review of the nursing progress note dated 04/19/2025, showed that on 04/18/2025 at 9:30 PM, Resident 1 had an unwitnessed fall during mechanical lift transfer and was sent to ER. Review of the ER visit summary dated 04/19/2025 showed that Resident 1 was diagnosed with fall and fracture of the tibial tuberosity (bony bump on the upper part of the shin). Review of the online incident report dated 04/19/2025 showed, CNA [Certified Nursing Assistant] had placed Hoyer sling under resident . CNA left the room to get assistance from another CNA to transfer the resident. When they returned to the room [the] resident was on the floor. Review of a statement from Staff F, CNA, dated 04/18/2025, showed that when Resident 1 requested help with transfer, Staff F put the mechanical lift sling underneath the resident's bottom. The statement showed Resident 1's bottom was on the edge of their chair, and Staff F offered to pull the resident back on the chair, but Resident 1 declined due to their shoulder arthritis (a disease that causes swelling, stiffness, and pain in a person's joints). The statement further showed that Staff F stepped out of the resident's room and when they returned to the room, they found the resident on the floor. Review of the undated facility investigation document titled, Interview with [Resident 1] showed that Staff F would not be able to work at the facility due to not following the correct protocol. During an observation and interview on 04/28/2025 at 11:17 AM, Resident 1 was in bed with their right shin wrapped with elastic bandage. When asked about the fall incident on 04/18/2025, Resident 1 stated they were in their powerchair, when staff F was trying to get the mechanical lift sling under them to transfer them. Resident 1 stated that Staff F kept pulling them out of the seat cushion of their power chair to apply the sling underneath them. Resident 1 stated, I was probably halfway off the cushion, and [Staff F] decided that [Staff F] needed some help because [Staff F] was having trouble getting the sling between my legs and left my room to get some help. Resident 1 stated Staff F was probably gone about ten minutes and, in that time, they just kept slipping out of their power chair and ended up on the floor. Resident 1 stated their right leg landed on the mechanical lift base. Resident 1 stated, I actually hollered at the top of my lungs after I was on the floor. Resident 1 further stated that they went to ER and learned that they had the right tibia fracture from the fall. In an interview and joint record review on 05/12/2025 at 10:38 AM, Staff E, CNA, stated that they would know the level of assistance a resident need from the resident's care plan and Kardex. Staff E stated two staff needed to transfer Resident 1 with a mechanical lift. A joint record review of Resident 1's Kardex did not show the number of staff needed for transfer assistance. Staff E further stated that the Kardex did not show Resident 1 required two-person assistance with a mechanical lift and it should have shown that. In an interview and joint record review on 05/12/2025 at 10:46 AM, Staff C, Resident Care Manager, stated that if a resident required mechanical lift transfer, the number of staff needed for assistance would be addressed under the resident's care plan. A joint record review of the care plan printed on 04/28/2025 did not show Resident 1 required two-person assistance with a mechanical lift transfer. Staff C stated that they did not see in the resident's care plan that the resident needed two-person assistance with mechanical lift transfers, and it should have been reflected in the care plan. Staff C further stated mechanical lift transfers should be completed with two-person assistance including sling application and Resident 1 should have had two staff assist during the transfer. In an interview on 05/12/2025 at 1:50 PM, Staff B, Director of Nursing, stated that mechanical lift transfer always required assistance from two staff and that the care plan should have had reflected two-persons assistance with the transfer. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nurse aide for 2 of 3 staff (Staff F and Staff G), reviewed for nursing aide registry. This failure placed the residents at risk for potential abuse, neglect and unmet care needs. Findings included . Review of the facility's policy titled, Abuse and Incident Reporting - SNF [Skilled Nursing Facility] [NAME], last revised in June 2024, showed, Before new employees are permitted to work with residents, references provided by the prospective employee will be verified as well as board registrations and certifications. The facility will not employ or otherwise engage individuals who have been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This applies to all employees .The facility will not employ or otherwise engage an individual who: 1. Has a finding entered into the State Nurse Aide Registry concerning abuse, neglect, exploitation, mistreatment of residents or misappropriation of property. STAFF F Review of the facility's April 2025 staffing schedule showed Staff F, Certified Nursing Assistant (CNA), was a contract staff and worked at the facility on 04/08/2025, 04/10/2025, 04/18/2025, 04/20/2025, and 04/21/2025. A review of Staff F's employee file did not include documentation from the nurse aide registry. STAFF G Review of the facility's April 2025 staffing schedule showed Staff G, CNA, was a contract staff and worked at the facility on 04/02/2025, 04/07/2025, 04/08/2025, 04/09/2025, 04/10/2025, 04/15/2025, 04/16/2025, 04/17/2025, 04/21/2025, 04/22/2025, 04/24/2025, and 04/25/2025. A review of Staff G's employee file did not include documentation from the nurse aide registry. A review of e-mail communication on 05/14/2025 at 12:58 PM, Staff A, Director of Health Services, stated that they did not have the registry verification for Staff F and Staff G. In an interview on 05/14/2025 at 1:41 PM, Staff A stated that they assumed the contract agency would obtain registry verification for the contracted staff as part of their compliance package. Staff A further stated that the facility should have received the contract staff registry verification prior to working at the facility. Reference: (WAC) 388-97-1660(3)(c)

Based on interview and record review, the facility failed to conduct a thorough investigation for 1 of 2 residents (Resident 1), reviewed for abuse and/or neglect investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse and/or neglect, and a diminished quality of life. Findings included . Review of the Nursing Home Guidelines, The Purple Book, Sixth Edition, dated October 2015, showed, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse, neglect, abandonment personal and/or financial exploitation or misappropriation of resident property occurred, and how to prevent further occurrences . All incidents require thorough investigation and reporting, as necessary, according to state and federal regulations. All such investigations attempt to determine if such injury or allegation of injury results from abuse or neglect. Review of the facility's policy titled, Abuse and Incident Reporting - SNF [Skilled Nursing Facility] [NAME], last revised in June 2024, showed, A prompt and thorough investigation is the process used to determine what happened. The Nurse supervisor or designee at the scene will immediately begin the investigation upon notification of an incident and/or alleged abuse. As the investigation continues root cause(s) will, if at all possible, be identified. The information gained will be entered into the resident's electronic health record (EHR) .Initiate further investigation, gathering witness statements and scanning them into the record. After the initial investigation, the full completion will be done by DNS [Director of Nursing Services] or designee and will include a summary of the findings, root cause analysis and a plan of correction as needed. Review of the nursing progress note dated 04/19/2025, showed that on 04/18/2025 at 9:30 PM, Resident 1 had an unwitnessed fall during mechanical lift transfer and was sent to the emergency room (ER). Review of the ER visit summary dated 04/19/2025 showed that Resident 1 was diagnosed with a tibial tuberosity (bony bump on the upper part of the shin) fracture (broken) after a fall. Review of the online incident report dated 04/19/2025 showed, CNA [Certified Nursing Assistant] had placed Hoyer sling under [the] resident . CNA left the room to get assistance from another CNA to transfer the resident. When they returned to the room [the] resident was on the floor. Review of the undated facility investigation document titled, Interview with [Resident 1] showed that Staff F, CNA, would not be able to work at the facility due to not following [the] correct protocol. Further review of the investigation did not show the summary of the findings, root cause analysis or to rule out or establish the likelihood that abuse, or neglect had occurred or may have contributed to the incident. In an interview and joint record review on 05/12/2025 at 1:50 PM, Staff B, Director of Nursing, stated that the goal of an investigation was to be able to determine if the incident was avoidable or unavoidable, rule out abuse/neglect, and to identify what interventions needed. A joint record review of the undated facility investigation for Resident 1 showed no summary of the findings, root cause analysis or the likelihood that abuse/neglect had occurred or may have contributed to the incident. Staff B stated that they did not think an investigation summary was completed or abuse/neglect was ruled out for Resident 1's fall investigation. In an interview on 05/14/2025 at 1:41 PM, Staff A, Director of Health Services, stated that their expectation was that when completing a possible abuse/neglect investigation, the facility would follow their abuse/neglect investigation policy and regulations. Staff A further stated they expected Resident 1's incident to be thoroughly investigated, and abuse/neglect ruled out. Reference: (WAC) 388-97-0640 (6)(a)(b)

Based on interview and record review, the facility failed to implement abuse and neglect policies and procedures to protect residents from misappropriation of property during the investigation of allegation for 1 of 3 residents (Resident 1), reviewed for abuse investigation. This failure placed the resident at risk for unidentified misappropriation/exploitation and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse and Incident Reporting, approved in June 2024, showed that a prompt and thorough investigation is the process used to determine what happened and the nurse supervisor or designee would immediately begin the investigation upon notification of an incident and/or alleged abuse. The policy further showed if a staff member is identified as allegedly/possibly involved in suspected abuse, they must be removed from all residents care pending further investigation in order to do all to protect the resident/other residents from further abuse. Review of the quarterly Minimum Data Set (an assessment tool) dated 02/20/2025 showed Resident 1's was cognitively intact. Review of the facility's undated incident investigation report showed that on 02/14/2025 Resident 1 reported that their [NAME] ceramic carriage figurine had gone missing the previous week. The investigation showed that Resident 1 provided a description of the staff member who was allegedly involved in taking their ceramic figurine and its estimated value. It also showed that Resident 1's representative initially reported the similar allegation to Staff B [Social Services Director] on 02/07/2025. Further review of the report showed that the incident was reported to the State Agency on 02/18/2025, 10 days after the allegation was initially reported to Staff B. In an interview on 03/13/2025 at 11:12 AM, Resident 1 stated that that they reported to the facility about their missing [NAME] ceramic carriage figurine, and they suspected that one of the night nurses, whose name begins with the letter T, and who worked night shift might have taken it. Resident 1 further stated that their representative had also reported similar allegation approximately a week prior to 02/14/2025. Review of the nursing staff schedule from 02/15/2025 to 02/19/2025, showed that the facility allowed Staff C, Registered Nurse, to continue to work and provide care to residents during the investigation of Resident 1's allegation of misappropriation of property. In an interview on 03/13/2025 at 3:08 PM, Staff A, Director of Nursing Services, stated that Staff C was not suspended and continued to work while the investigation was ongoing. Staff A further stated that they were unaware that suspending Staff C during an investigation was required. Reference: (WAC) 388-97-0640 (2)

Based on interview and record review, the facility failed to thoroughly identify, assess, monitor and provide timely interventions for possible side effects related to anticoagulant (blood thinner) therapy for 1 of 6 sample residents (Resident 1) who received blood thinner medications. Failure to complete thorough assessments and consistent monitoring for possible side effects while on anticoagulation therapy resulted in harm for Resident 1 who had severe lower left quadrant (LLQ) abdominal pain related to unidentified abnormal bleeding and a subsequent severe decline in condition with loss of life. Findings included . The National Institute of Health (NIH) website [www.NIH.gov] described an ileus as a failure of normal intestinal movement in the absence of mechanical obstruction. The NIH further described an intestinal obstruction as the interference of the normal passage of contents through the gastrointestinal tract. The NIH site showed it was difficult to identify/diagnose an obstruction from ileus on the basis of an abdominal x-ray alone. The NIH indicated that studies such as Computed Tomography (CT-scan) was necessary to identify obstruction versus ileus, identifying the site of obstruction, and differentiating between partial and complete obstruction. The NIH indicated that an abdominal assessment for bowel distention, listening for bowel sounds, pain (description, location, migration, intensity, frequency) and palpation was necessary in the early diagnostic process. The NIH also showed information regarding retroperitoneal hematoma (RPH), defined as bleeding into the abdominal cavity. The report showed that patients did show clinically apparent signs and symptoms until a substantial amount of blood loss had occurred. In several studies, abdominal pain seemed to be the most common complaint, along with pain in the back, flank, and hip. The main diagnostic test for RPH was a CT-scan. The NIH website indicated that RPH was not readily detectable on an abdominal x-ray or ultrasound. Review of the manufacturer's website (www.[MEDICATION(S)].com) for [MEDICATION(S)], an injectable blood thinning medication showed that one of the adverse side effects (s/e) of the medication was hematomas (bleeding/abnormal collection of blood outside of a blood vessel), including RPH. The website indicated that an unexplained drop in blood pressure should lead to a search for a bleeding site. The website also indicated there was a high risk of bleeding with the use of [MEDICATION(S)] and it was important to monitor patients for signs and symptoms of bleeding. Review of the facility policy titled, Bowel Care Management, revised [DATE], showed All residents' bowel and bladder status is assessed on admission, quarterly, annually and with a significant change of condition. The policy showed the care manager or designee was responsible for conducting this assessment and developing a care plan as needed. The policy showed the charge nurse would assess the resident's status by checking the abdomen, bowel sounds/tones and a digital exam. Review of the facility policy titled, Pain Management, revised [DATE], showed that each resident had the right to have pain prevented or controlled adequately. The policy also showed that residents with acute pain would be assessed through interviews and documentation including: 1. Description of pain, intensity, usual time of occurrence and exact location; 2. Related diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 3. Interview of the resident or family; and 4. Overall effect the pain has on the resident's psychosocial and activity status. Review of the facility policy titled, Medication Administration: Anticoagulant Therapy, revised on [DATE], showed that any order for Anticoagulation therapy will be monitored closely. The policy also stated the following: 1. Each resident will have an individualized care plan with appropriate interventions for monitoring the Anticoagulant therapy; and 2. The resident will have a weekly skin check by the licensed nurse/Charge nurse to monitor for any new bruises/discolorations potentially related to the Anticoagulant therapy. The policy did not indicate monitoring for pain associated with bleeding, monitoring for drops in blood pressure (BP) to rule out active bleeding nor did it reflect the frequency for s/e monitoring. RESIDENT 1 Resident 1 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's Admission Minimum Data Set (MDS) assessment, dated [DATE], showed the resident was cognitively intact. Review of a nursing admission assessment, dated [DATE], showed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . It was also noted the resident had previously received an oral blood thinning medication that was discontinued due to the development of a hematoma on his buttocks (that occurred prior to admitting to the facility). Review of the resident's electronic Physician's orders, dated [DATE], showed [MEDICATION(S)] was labeled with a Black Box warning. The electronic order contained a black box icon within the order that showed a pop-up warning when hovered over by computer mouse. The pop-up warning (Issued by the Food and Drug Administration) showed the medication had adverse side effects, such as bleeding that could lead to death, and therefore required frequent monitoring for possible adverse side effects(s/e). The physician's order for [MEDICATION(S)] did not show any directions for nursing staff to monitor the resident for possible medication side effects. Review of the resident's care plan, initiated on ,d+[DATE], showed it did not identify that the resident was on Anticoagulation therapy, and did not include any goals or interventions, as directed by the facility policy for Anticoagulation therapy. Review of the [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the [DATE] Treatment Administration Record (TAR) did not show any documentation that the nursing staff had monitored the resident for any s/e related to the [MEDICATION(S)]. Review of a nursing note, dated [DATE] at 11:31 AM, showed that during a skin assessment on [DATE], nursing had found a purple bruise on the right forearm that extended to the right upper arm. The note indicated the bruise was probably due to the resident pulling himself up in bed. The note stated the attending physician was aware and would follow up on their next visit. There was no documentation to show the nurse had further assessed the resident or performed ongoing monitoring for s/e related to the [MEDICATION(S)]. Review of a nursing note, dated [DATE] at 4:45 PM, showed the resident's right forearm was bruised, swollen, and painful with the resident describing the pain as a nine on a pain scale from one to ten (ten being the highest). The note showed the resident was given an ice pack and pain medication. There was no documentation to show a thorough pain assessment was done to find possible causes, pain quality, migration or if an assessment was done to rule out the possibility that the resident was exhibiting s/e's from the [MEDICATION(S)]. Review of a nursing note, dated [DATE] at 2:38 PM, showed the resident's right forearm appeared swollen with yellow/brownish colored bruising. The note stated the resident was given pain medication with continued monitoring. The note did not state what other measures were taken to find possible causes of the pain, describe what type of monitoring was to be done or include any documentation to show blood thinning s/e assessment or monitoring was completed to rule out the possibility that the resident was exhibiting s/e's from the [MEDICATION(S)]. Review of a nursing note, dated [DATE] at 9:16 AM, showed Resident 1 had a new complaint of left hip pain with facial grimacing which the resident rated as a pain level of nine out of ten. The note indicated the resident had told staff that he could not move his left leg and asked to go to the hospital. The attending physician was notified and ordered a onetime dose of pain medication that was given to the resident. The note did not indicate whether the resident was interviewed to give a more indepth description of his pain such as when the pain started, pain quality, pain migration, visual assessment of the pain location or whether the pain medication was effective. There was no documentation showing completion of an indepth assessment for possible s/e of the blood thinner medication or of consistent monitoring to rule out the resident was exhibiting s/e's to the [MEDICATION(S)]. Further record review showed there were no other notes regarding the resident's condition until later in the evening at 11:49 PM, over 14 hours later. Review of the nursing note, dated [DATE] at 11:49 PM, showed the resident was on alert to monitor for inappropriate behaviors. The note documented the nurse had walked into the resident's room to administer medications and found the resident was naked from the waist down. The note showed the resident told the staff that he had pain that felt like he had been sitting on his testicles all day, and gestured for the nurse to look at his private area. The note indicated the nurse attempted to assess the area, but the note did not describe any findings of an assessment. An antibiotic injection was given to the resident, and an x-ray of the left hip and abdomen was ordered and done earlier in the shift. The note also indicated the resident was given two enemas. The note did not show whether the nurse's attempt to assess the resident was completed nor did it show that a thorough pain assessment was done. The note also did not indicate whether a neurolgical assessment was done to rule out any changes in the resident's mental status or if an abdominal/pelvic assessment was completed for any visual abnormalities or possible causes, whether any vital signs taken [such as blood pressure or pulse for internal stability] nor did the note indicate why the resident was given two enemas. There were no other notes regarding the resident's condition until the next day on [DATE] at 12:58 PM, over 14 hours later. Review of a nursing note, dated [DATE] at 12:58 PM, documented the resident was having continued LLQ pain and indicated the x-ray results showed a small ileus obstruction. The note showed the resident had been constipated for several days, and was given an enema the night before that yielded an XL [extra large] bowel movement. The note showed a slight tender mass could be felt on the resident's LLQ of their abdomen and that the resident had reported continued pain in his LLQ. The note stated the physician was notified who ordered that another enema was to be given. [Review of the bowel movement flow sheets from [DATE] to [DATE] showed the resident had large formed/normal bowel movements and did not document the resident had constipation.] The [DATE] nursing note did not show that the physician was given information on the resident's description of the pain such as pain quality, pain migration, visual assessment of the pain location or if the enemas given prior were effective on relieving the resident's pain. The note also did not include any documentation to show a thorough abdomen assessment was completed or if any vital signs were obtained. This information could have been collected to give the physician a clearer picture of the resident's clinical condition. Review of the x-ray report, dated [DATE], showed the Radiology Physician concluded that the x-ray findings may have represented a colonic Ileus. The report indicated that further evaluation with IV (Intravenous) and oral contrast-enhanced CT-scan of the abdomen and pelvis would be warranted for persistent clinical concern and/or worsening symptoms. Review of a nursing note on [DATE] at 7:00 PM showed that around dinner time there were first responders/paramedics in the resident's room because the resident had called 911. The note stated the first responders received report from the floor nurse, assessed the resident and found the resident to be stable and that it was unnecessary to transport him to the hospital. Review of a nursing note on [DATE] at 10:36 PM showed the resident was on alert monitoring for inappropriate behaviors. The note showed the x-ray results were faxed to the Physician and the resident received another enema that yielded a small bowel movement. The Physician was then notified of this event. Review of a nursing note on [DATE] at 9:05 AM showed that a Nurse Assistant (NA) called the floor nurse to the resident's room. The note showed that when the floor nurse entered the resident's room, the resident's head was hanging to the right side of the bed with dried blood coming out of the resident's nose. The resident's legs were hanging to the left side of the bed. The floor nurse determined that the resident was unresponsive without breathing or a pulse and instructed staff to call 911. The paramedics then arrived who pronounced the resident already deceased . Family and Physician were then notified. In an interview on [DATE] at 5:01 PM, the resident's family member stated the family had requested for an autopsy to be performed on Resident 1. The family member said that the autopsy revealed the resident did not have a bowel obstruction, but died from an internal abdominal bleed [in the area suspected of a bowel obstruction]. The wife stated that the medical examiner who performed the autopsy told them that the resident might have been still alive if he had gotten early medical treatment. On [DATE] at 9:26 AM, Staff A, the Medical Examiner who performed the autopsy on the Resident 1, stated the results of the autopsy showed the resident never had a bowel obstruction, but died from a RPH (abdominal bleed). Staff A stated that the resident was having symptoms two days prior to his death and said the resident would not have died from the abdominal bleed if he had received early diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the autopsy report reflected Staff A's findings. On [DATE] at 11:49 AM, Staff B, Radiology Physician [from the company that issued the x-ray results], stated the resident's x-ray findings of colonic Ilieus was not a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] On [DATE] at 5:09 PM, Staff C, Licensed Practical Nurse (LPN), stated a resident taking a blood thinner medication would need to be assessed for signs and symptoms such as bleeding, bruising, altered level of consciousness (ALOC) and changes in vital signs, such as blood pressure (BP) to assess hemodynamic changes. Staff C stated if there was any monitoring done, it would be documented in the progress notes. Staff C could not state how often monitoring was done. On [DATE] at 5:23 PM, Staff D, Registered Nurse (RN), stated monitoring for a resident taking a blood thinner was usually ordered by the Physician and charted in the MAR/TAR. Staff D stated signs and symptoms of blood thinning medication were bleeding gums, blood in stool and bruising. Staff D did not state how often monitoring was to be done or monitoring signs and symptoms. Staff D did not mention monitoring resident BP or pain associated with bleeding. On [DATE] at 5:39 PM, Staff E, LPN, stated residents on a blood thinner were at risk for bleeding such as bloody stools and bruising. When asked what they would do if a resident on a blood thinner suddenly had LLQ pain, Staff E stated they would call the doctor. Staff E did not mention if they would do anything else such as checking BP or doing a thorough pain assessment. On [DATE] at 1:07 PM, Staff F, RN, stated residents taking a blood thinner were monitored once weekly during skin checks. Staff F stated other bleeding episodes would be documented in the progress notes. Staff F stated they would know if a resident was bleeding internally by changes in level of consciousness and vital signs such as blood pressure. Staff F stated the risk for bleeding was low with a resident getting [MEDICATION(S)]. Staff F did not mention assessing for pain associated with bleeding. On [DATE] at 1:15 PM, Staff G, LPN, stated residents on a blood thinner were monitored once weekly during skin checks or as needed with bleeding episodes. Staff G stated monitoring was usually documented in the electronic medical record but stated they did not know why some residents were being monitored for anticoagulation s/e's and others were not. Staff G stated they would know if a resident on anticoagulation therapy, was bleeding by bloody stool/urine or nosebleeds. Staff G stated if a resident was bleeding they would call the Physician then send the resident out to the hospital for further evaluation. Staff G made no mention of monitoring BP or pain associated with bleeding. On [DATE] at 2:12 PM, Staff H, LPN, stated facility residents on a blood thinner were monitored once weekly during skin checks that was documented on the TAR. Staff H stated as a charge nurse, they expected to see anticoagulation monitoring in the care plan and would know if there was active bleeding by bruising. When asked if there was other signs and symptoms they would look for, Staff H was not able to answer. On [DATE] at 2:47 PM, the Director of Nursing Services (DNS) stated the reason Resident 1 was not sent out to the hospital was because when it was found that their symptoms were unrelieved and worsening, the Physician was notified who gave orders that the nursing staff followed. The DNS stated after the resident called 911, the paramedics who arrived received report from the nurses about the resident's condition then deemed the resident was non emergent. When asked how staff were monitoring residents on anticoagulation therapy, the DNS stated it was done once weekly with skin checks or when there was an issue of bruising or bleeding. The DNS stated monitoring depended on Physician's orders to monitor that was documented in the TAR by nursing staff. The DNS was then notified of the investigation findings. In a telephone interview on [DATE] at 3:15 PM, Staff I, facility Medical Director, stated the reason they did not send Resident 1 to the hospital was because the nurses reported that Resident 1 was doing fine. Staff I stated they did not know why the resident died and said that perhaps the resident had a [CONDITION(S)]. The resident's symptoms of LLQ pain were persistent to the point that Resident 1 called 911 and asked to be taken to the hospital. It was not clear as to why the resident's request to be further evaluated at the hospital did not happen, even though the resident was still having severe pain. The primary Physician had been given the results of the x-ray that contained the Radiology Physician's recommendation for the resident to be evaluated by CT-scan, if symptoms/clinical condition got worse. The nursing notes showed the physician was notified regarding the resident's decline in condition. There was no documentation indicating that the facility considered further evaluation by a CT- scan, as recommended by the Radiology Physician. In addition, the facility's anticoagulation therapy policy, resident's care plan, and MAR/TAR did not include any direction for staff to assess and monitor for the blood thinning medication's side effects and did not indicate that staff followed the black box warning issued for the medication. The resident's blood pressure was last checked on [DATE], 9 days prior to the resident's death. Lastly, interviews showed the nursing staff were not able to state adequate assessment/monitoring, potential side effects for residents taking anticoagulant (blood thinning) medications. Reference (WAC) [DATE] (1)

Based on observation, interview and record review, the facility failed to ensure a resident received adequate supervision and assistance to prevent accidents for one of two residents (Resident 1) reviewed for accidents and incidents. Failure to ensure that the facility's certified Health Care Center Nursing Assistants (HCCNAs) consistently provided the direct care (extensive assistance from 1-2 persons with transfers) for Resident 1 as indicated in the resident's care plan resulted in Resident 1 experiencing pain during and after a transfer by a personal Aide and requesting to be taken to a hospital due to the increased pain & swelling, with a subsequent [DIAGNOSES REDACTED]. Findings included . Resident 1 was admitted to the Nursing Facility on 04/26/2019, for rehabilitation after a fall which resulted in a fracture. Prior to admission to the Skilled Nursing Facility (SNF), the resident resided in an independent apartment within the same Continuing Care Retirement Community. The Minimum Data Set (MDS) assessment, dated 05/03/19, showed the resident needed extensive assistance from two staff for most Activities of Daily Living such as bed mobility, transfers, dressing, toileting and hygiene. However, the care plan, initiated 05/09/19, showed Resident 1 needed extensive assistance from one or two staff members. The care plan directives stated the resident needed extensive assistance from 1-2 persons with transfers and the assistance was provided by Health Care Center Nursing Assistants (HCCNA's). A progress noted entry, dated 07/04/19 at 1:58 AM, showed that Resident 1 complained of knee pain of six (out of a scale of ten maximum). The RN (Registered Nurse) administered a dose of Tylenol and offered an ice pack, advised resident's personal aide (Aide C) to switch to heating pack after 15 min (minutes) if pain does not decrease. Aide verbalized understanding. A second entry, dated 07/04/19 at 4:49 AM, showed the resident's pain was was ten out of ten at 3:30 AM, and noted 1+ [MEDICAL CONDITION] (swelling) was noted in the right leg. The RN documented the Resident 1 requested a transfer to the hospital, the staff notified the family, an ambulance arrived at 4:00 AM, and Resident 1 was transported to the hospital accompanied by Aide C. The progress notes documented Resident 1 readmitted from the hospital on [DATE], after being diagnosed with [REDACTED]. An observation on 07/12/19 at 3:00 PM showed Resident 1 was in her room with Aide F. When asked about the leg injury, Resident 1, did not provide any information and suggested contacting her family member. Aide F stated she was employed by Mirabella Home Health Agency and was a private caregiver for Resident 1. During an interview on 07/15/19 at 5:00 PM, the resident's representative was asked about the resident's injury. The representative stated that Resident 1 reported to the emergency room staff that she (Resident 1) bumped her knee on the toilet during a transfer. The representative stated Resident 1 had private caregivers while in the nursing home 24 hours a day, and Aide C, who was caring for Resident 1, transferred the resident to bed around 9 PM and would not have transferred the resident to the toilet during the night. On 07/16/19 at 1:15 PM, Resident 1 was in her room and Aide F was present. Aide F stated she provided assistance with ADL's and turned the call light on if she needed help from Health Care Center Nursing Assistant (HCCNA), CNA's, who worked in the Skilled Nursing Facility. Aide F said Resident 1 had recently returned from the hospital with a fractured leg and since her return to the facility required a mechanical lift, which required two person assist with transfers. Aide F stated that prior to the injury, Resident 1 was weight bearing and she transferred the resident with one staff member. Review of the hospital evaluation showed a 07/04/19 x-ray report that indicated this could represent an old fracture. Acute fracture is considered less likely but not entirely excluded. Additional testing was completed (CT scan dated 07/04/19) which showed it was likely a non-displaced fracture of tibia. The facility's Accident/Incident reporting log was provided for review on 07/12/19. There was no evidence an investigation into the circumstances precluding the substantial injury had been completed nor had the state hotline been notified of the substance injury of unknown origin. (See F607 regarding the facility policy for the prevention of abuse and neglect was not consistently implemented.) A completed copy of the investigation was provided by the Director of Nursing (DNS) on 07/16/19. An investigation note, dated 07/12/19, showed the caregiver (personal aide), Aide C, had transferred the resident from wheelchair to bed on 7/3/19 at 9:10pm. The note indicated that during the transfer, the resident's knee buckled while attempting to sit on the bed, but the resident had not made any complaints at the time. The investigation also included an 7/8/19 email to the facility DNS from Staff D, the (Mirabella) Home Health Manager which summarized a (telephone) statement from Aide C. The statement showed (that on 7/3/19 at 9:10 PM) Aide C was transferring the resident from wheelchair to the bed, but when the resident stood up to turn and sit on the bed, somehow the resident's knee gave in. Aide C made the resident sit on the bed and the resident told Aide C she had pain on the leg. There was no indication on the statement that this pain was immediately reported to the RN. The email statement showed that Aide C (later) reported the resident's complaint of pain to the RN at about 1:30 AM, on 07/04/19, but the statement was not clear as to whether Aide C reported the transfer incident to the RN. During an interview on 07/16/19 at 10:30 AM, Staff D, the Human Resource Director (HRD) reviewed Aide C's employee file. Staff D stated that Aide C was employed by the MHHA (Mirabella Home Health Agency) and was not a Health Care Center Nursing Assistant (HCCNA). The facility failed to ensure that Health Care Center Nursing Assistants (HCCNA) provided direct care to Resident 1. In addition Aide C failed to recognize and report a change in condition in a timely manner, including complaints of pain during a transfer or any problem with the transfer. The incident was not reported by Aide C until 07/08/19, after the MHHA manager contacted Aide C by phone to obtain a statement (when the incident investigation was initiated). Reference (WAC) 388-97-1060 (3)(g)

Based on observation, interview and record review the facility failed to provide the necessary supervision and follow the facility's policy regarding mechanical lift (sit to Stand) transfers for 1 of 2 Residents (1). Failure to follow Resident 1's plan of care which required two person assist with a mechanical transfer resulted in a fall with harm for Resident 1 who sustained a fracture and experienced pain. Findings included: The facility's policy showed that during the use of a mechanical lift, two staff members need to be present to ensure safety of the resident. RESIDENT 1 Resident 1 was admitted in (YEAR) with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] showed that she required 2 person extensive assistance with bed mobility and transfers. The Plan of Care (P[NAME]) for transfers directed staff to use a mechanical lift (sit to stand) with a 2 staff person assist. The facility's incident report dated 06/28/18 showed that Resident 1 required 2 staff to transfer using a sit to stand lift. The report showed that when the resident fell , only one staff (NAC) was present during the time of transfer. The report documented the incident could have been avoided if NAC had followed the P[NAME] and had 2 staff present during the transfer. On 7/20/18 at 2:15 P.M., during an interview and observation with Resident 1 and spouse, the spouse stated Resident 1 requires staff assistance for turning in the bed as she is not able to roll or move in bed by herself. Resident 1's spouse stated that when one nursing assistant (NAC) transferred her from the chair to bed by herself, the staff (NAC) lost control, and Resident 1 fell . Resident 1's spouse stated that the fracture happened when she fell . The nursing progress notes showed that after the fall on 6/28/18, Resident 1 experienced pain in her hip. The nursing notes showed that the pain was not relieved with medication, so an x-ray was ordered which showed a [MEDICAL CONDITION] (femur). During an interview with the Director of Nursing (DNS) on 7/20/18, she stated that the NAC had failed to follow Resident 1's P[NAME] that directed staff to have 2 person assist with mechanical transfers. She stated that the NAC had transferred Resident 1 by herself and did not follow facility policy which requires 2 staff to be present during all mechanical lift (sit to stand) transfer. Reference: (WAC) 387-97-1060 (3) (g)

Based on observation, interview and record review it was determined the facility failed to provide necessary care and services to prevent pressure ulcers for one (#1) of three residents reviewed for facility acquired pressure ulcers. The facility's failure to provide care related to an orthopedic boot caused harm to Resident #1 who developed an unstageable pressure ulcer on the left heel. Findings include: According to The National Pressure Ulcer Advisory Panel, unstageable pressure ulcers are wounds that have eschar (tan, black, or brown) or slough (yellow, tan, gray, green or brown) tissue present. The anatomic depth of soft tissue damage cannot be visualized or palpated in the wound bed. RESIDENT #1 Record review revealed Resident #1 initially admitted to the facility on [DATE] for rehabilitation after surgical repair of a fractured left tibia (leg) with external fixation. The 10/03/16 comprehensive assessment indicated the resident was severely cognitively impaired and required extensive assistance from two staff to change positions in bed. The skin section of the assessment identified the resident was at risk for pressure ulcers and had no current ulcers. On 10/10/16, Resident #1 was sent to the emergency room for an acute treatment of [REDACTED]. On 10/20/16, Resident #1 admitted back to the facility from the hospital with a healing fractured left leg and external fixation. Record review revealed Resident #1 did not have any pressure ulcers on readmission. Observation of Resident #1's left heel on 12/23/16 at 12:00 p.m. and 01/06/17 at 10:00 a.m. revealed an unstageable pressure ulcer with scant drainage. Observation on 12/23/16 at 12:00 p.m. and on 01/06/17 at approximately 10:00 a.m., Resident #1 was observed grimacing while Licensed Staff provided care to the left foot. On interview, Resident #1 stated she was experiencing pain at a level eight (on a scale from one to ten, with ten being the worst pain imaginable) to the affected area. Record review revealed on 11/22/16, Resident #1 went to an Orthopedic Surgeon for a follow up appointment. While at the doctor's office, the doctor ordered and placed an orthopedic/ therapeutic boot to the resident's left foot to prevent foot drop. Resident #1 returned to the facility wearing the therapeutic boot. Review of an incident investigation report, dated 12/12/16, revealed Resident #1 was noted with black eschar to the left heel (unstageable pressure ulcer) measuring 4 centimeters (cm) x 3 cm. The incident report noted Staff C (Licensed Nurse) attempted to remove the therapeutic boot while providing care. It appeared it was the first time the boot had been removed, three weeks after it's placement. In an interview on 12/23/16 at approximately 2:00 p.m., when Staff C, who was present at the time of Resident's #1's readmission, was asked about the care instructions for the therapeutic boot, he stated that the doctor' office did not send the resident with any care instructions or physician's orders [REDACTED]. When asked how he, or other staff cared for the therapeutic boot in the absence of written care instructions, Staff C did not respond. He stated he was not Resident #1's regular nurse. Review of Resident #1's medical record did not include documentation of doctor's follow up narratives and/or physician's orders [REDACTED]. Review of nurse's progress notes, Treatment Administration Records (TAR), and Care Plans (CP) did not include care instructions related to the therapeutic boot, nor was there any indication the boot was ever removed or checked for proper placement or fit. There was no indication staff assessed the risk factors presented by the boot nor that interventions were developed / implemented to reduce those risk factors. In addition, there was no monitoring of the resident's skin that was not readily observable to staff, due to the boot. Review of the nurse's progress notes revealed no documented evidence facility licensed staff attempted/made reasonable efforts to follow up with the provider related to care instructions for the therapeutic boot. In addition, there was no indication staff requested orders related to the care of the boot from the resident's medical provider at the facility. In an interview on 01/06/17 at approximately 11:00 a.m., when Staff B, Director of Nursing, was asked to provide evidence of how staff cared for the therapeutic boot since it was placed on 11/22/16 to 11/22/16 the day unstageable pressure ulcer was discovered), Staff B was unable to provide any information. When Staff B was asked to provide documented evidence staff had followed up with the Orthopedic Surgeon, or any medical provider, to obtain care instructions related to the boot, she was unable to provide any documentation and stated I don't know. The failure to provide necessary care and services to prevent pressure ulcers caused harm to Resident #1, who admitted without pressure ulcers but developed an unstageable pressure ulcer on the left heel due to the lack of care related to the therapeutic boot.