Every finding on record at Mountain View Rehabilitation and Care Center

Based on interview and record review, the facility failed to ensure a system in which resident's records were complete, accurate, and accessible, for 1 of 1 resident (Resident 36) reviewed for accurate and complete medical records. The facility failed to ensure the residents' medical records contained weekly laboratory results and accurate documentation about appointments placed residents at risk for medical complications, unmet care needs, and for diminished quality of life. Findings included .<APPOINTMENTS>Review of an oncology clinic note dated 10/16/2025 at 11:04 AM, documented Resident 36 scheduled an appointment on 10/29/2025 at 2 PM. Review of the facility providers' notes dated 10/21/2025 at 9:39 AM, 10/24/2025 at 8:52 AM, documented to follow up with oncologist (cancer specialist) on 10/29 at 2 PM.Review of an oncology clinic note dated 10/29/2025 at 2:24 PM, Resident 36 was no show for the visit, and the clinic was not notified of the reason.Review of Resident 36's Electronic Medical Record (EMR) on 10/29/2025 showed no documentation about if Resident 36 attended the appointment or what the reason of missing the appointment was. In an interview on 01/08/2026 at 12:53 PM, Staff C, Licensed Practical Nurse/Resident Care Manager, stated Resident 36 had an appointment on 10/29/2025 and the resident went but there was no documentation.In an interview on 01/07/2026 at 10:59 AM, Staff A, administrator, stated they would ask the nurse about if Resident 36 went for the appointment.On 01/08/2026 at 5 PM, Staff A provided two staff statements by Staff D, Receptionist and Staff H, Licensed Practical Nurse, dated 01/08/2026, documented that on 10/29/2025, Resident 36 canceled the appointment themself due to not feeling well, this information was not documented in the resident's clinic record.In multiple interviews on 01/07/2026 at 2:43 PM, 01/08/2025 at 2:33 PM, and 01/09/2026 at 1:55 PM, Resident 36 stated they never canceled appointment themselves, and they were not aware of the appointment was cancelled. Resident 36 stated they always wanted to go for appointments to get their cancer treated. <LABORATORY RESULTS>Resident 36 admitted to the facility on [DATE] with diagnoses to include malignant extensive stage lung cancer (end stage lung cancer has spread to other parts of the body), metastasis to liver (cancer has spread to the liver). According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 11/27/2025, the resident was cognitive intact.Review of Resident 36's January 2026 Medication Administration Record (MAR), documented a physician order of weekly laboratory. Review of Resident 36's laboratory results in Electronic Medical Record (EMR), no laboratory results found from 10/24/2025 to 11/19/2025, and from 11/21/2025 to 12/18/2025.In an interview on 01/12/2026 at 12:35 PM, Staff G, Medical Record Director, stated all laboratory results were uploaded to EMR.In an interview on 01/12/2026 at 12:40 PM with Staff C, Licensed Practical Nurse/Resident Care Manager (RCM), and Staff B, Director of Nursing, Staff C stated they would look for the laboratory results during the above time periods. No further information provided. Reference WAC 388-97-1720 (1)(a)(i)(ii)(iii)(iv)(2)(l)

Based on interview and record review the facility failed to ensure residents received the necessary care and services to attain or maintain their highest practicable level of well-being for 2 of 2 residents (Resident 82 and 94) reviewed for quality of care. These failures placed all residents at risk of developing wounds, worsening wounds and other skin conditions and diminished care. Findings included.<COMPRESSION STOCKINGS>Resident 82 admitted to the facility on [DATE] with diagnoses to include history of stroke, history of falling, and orthostatic hypotension (a form of low blood pressure that happens when standing after sitting or lying down). Review of Resident 82's Medication Administration Record (MAR) from 01/01/2026 through 01/06/2026 showed a physician's order dated 01/02/2026 directing nursing staff to apply compressing stockings to both their lower extremities in the morning and remove at night for orthostatic hypotension. During an observation on 01/06/2026 at 11:48 AM Resident 82 was observed lying in their bed, their legs uncovered with no compression stockings. During an observation on 01/07/2026 at 9:41 AM Resident 82 were observed lying in their bed, their legs uncovered with no compression stockings. In an interview on 01/08/2026 at 4:15 PM Staff M, Registered Nurse, stated Resident 82 wore compression stockings for orthostatic hypotension. When asked if Resident 82 was wearing compression stockings, Staff M entered the resident's room and asked to see their legs. Resident 82 was wearing protective sleeves, loose fitting, and bunched up around their ankles. Staff M stated Resident 82 was wearing skin protective covers rather than compression stockings. Staff M searched Resident 82's room for compression stockings, none were found. Resident 82 stated they would get some compression stockings for them. Review of Resident 82's progress notes, dated 01/02/2026 through 01/08/2026 showed no documentation of refusals to wear compression stockings. <SAGE BOOTS>Resident 94 admitted to the facility on [DATE] with diagnoses to include multiple pressure wounds and failure to thrive. Review of Resident 94's discharge summary from the hospital dated 01/02/2026 documented that they were to wear sage boots (heel protection boots for pressure relief) to both their feet to offload (relieve pressure) their heels. Review of Resident 94's Treatment Administration Record (TAR) documented a physician order dated 01/07/2026 for daily and as needed heel protectors at all times one time a day for wound care. Review of Resident 94's care plan dated 01/02/2026 documented they had heel and ankle ulcers with interventions to include foam boots as tolerated for wound healing. During an observation on 01/06/2026 at 9:56 AM Resident 94 was observed lying in bed, foam boots at the foot of the bed, and not worn. During an observation on 01/07/2026 at 9:13 AM Resident 94 was observed lying in bed, foam boots at the foot of the bed, and not worn. In an interview on 01/07/2026 at 9:40 AM Resident 94 stated a someone had walked through their room and made the comment that they should be wearing their boots all the time. In an interview on 01/08/2026 at 1:42 PM Staff N, Nursing Assistant Certified, stated they rely on the care plan and information from other staff to care for residents in the facility. Staff N stated Resident 94 had boots for their feet and were to wear them at night, but it was up to the resident if they wanted to wear them. In an interview on 01/12/2026 at 10:20 AM Staff B, Director of Nurses, stated there was a physician order for Resident 94 to wear foam boots starting 01/02/2026. Staff B stated there were no documented refusals for Resident 94 to wear the foam boots. Reference WAC 388-97-1060(1)(3)(c)

Based on observation, interview, and record review, the facility failed to ensure developed interventions (fall mats and call lights) were in place to minimize the risk for injury during a fall for 1 of 2 sampled residents (Residents 26) reviewed for accident hazards. This failure placed residents at risk for potential injury, negative outcomes and decreased quality of life.Findings included .Review of the facility policy titled, Fall Best Practice Guidelines dated 3/2016 documented the facility would:* Identify an action plan or approaches to be taken to prevent further falls based on newly identified facts or risk factors.* Update the resident Care Plan to reflect new action plans or approaches to prevent new falls. * Update resident care guide. * All residents will be reviewed at a minimum of two additional time by the fall intradisciplinary team weekly meetings to assess and document in the medical record whether the intervention had been successfully implemented or if further recommendations were required. Resident 26 admitted to the facility on [DATE] with diagnoses to include vascular dementia (a decline in thinking skills from reduced blood flow to the brain), history of falls, and leg fracture.Review of Resident 26's incident reports related to falls documented:- On 07/15/2025 fall documented on the Kardex (guide derived from the care plan directing staff on how to care for a particular resident), dated 07/22/2025, Resident 26 required fall mats at bedside. Resident 26 was educated on the importance of using their call light for assistance.- On 07/21/2025 fall documented on the Kardex, dated 07/24/2025, Resident 26 required fall mats at their bedside.- On 09/03/2025 fall documented on the Kardex, dated 09/09/2025, Resident 26 required fall mats at their bedside.- On 09/28/2025 fall documented on the Kardex, dated 10/01/2025, Resident 26 required fall mats at their bedside. Resident 26 was educated on the importance of using their call light for assistance.Review of Resident 26's care plan on 01/08/2026 documented they were a fall risk. Interventions included maintaining Resident 26's bed in a low position, anticipating their needs, ensuring the call light was within reach and floor mats at the bedsideDuring an observation on 01/05/2026 10:37 AM, no floor mats were observed at Resident 26's bedside. Observed Resident 26's call light laying on the floor behind their bed out of their reach.During an observation on 01/06/2026 at 1:59 PM and 01/07/2026 at 10:01 AM, Resident 26 was observed lying in their bed with no floor mats at their bedside.During an observation on 01/08/2026 at 1:15 PM, Resident 26 was observed lying in their bed, their meal in front of them on an overbed table, their call light out of reach on the floor, and no floor mats at their bedside.During an observation on 01/09/2026 at 11:28 AM, Resident 26 was observed lying in their bed, their call light out of their reach, draped over their wheelchair several feet away from the bed.In an interview on 01/07/2026 at 11:42 AM Staff O, Nursing Assistant stated they know how to care for residents by reviewing their Kardex and care plan in addition to obtaining information from therapy or the nursing staff. When asked if Resident 26 was a fall risk, Staff O stated they had not worked with them for a while and they did not have the strength to get up anymore.In an interview on 01/09/2026 at 2:16 PM Staff Q, Nursing Assistant Certified (NAC) stated Resident 26 required two-person assistance for transfers, becomes agitated and annoyed and required a calm approach. Staff Q stated Resident 26 was a fall risk just by the way they maneuvered their body while in bed. When asked what fall interventions were in place for Resident 26, Staff Q stated their bed was in the low position. Staff Q stated they had worked for the facility for 2 months and had not seen Resident 26 with fall mats at their bedside.In an interview on 01/09/2026 at 11:28 AM Staff P, NAC stated Resident 26 was moved a lot in the last several months and they may have had fall mats in the other rooms. Staff P stated Resident 26 was no longer a fall risk given increase in their pain and not using their wheelchair anymore.In an interview on 01/08/2026 at 2:54 PM Staff A, Administrator, stated the clinical resource manager had been in the facility the day before and discontinued Resident 26's intervention for fall mats at bedside. Staff A stated the intervention was a year old and it should have been resolved a while ago. When asked how and when the fall mats were determined no longer appropriate, Staff A did not provide a response.Reference WAC 388-97-1060 (3)(g)

Based on observations and interviews, the facility failed to ensure treatment carts and medication carts were locked for 1 of 1 treatment carts (Treatment Cart 1) and 1 of 4 medication carts (Medication Cart C). These failures placed residents at risk for having access to treatment supplies and medication not prescribed to them, missing medication, and access to medication by unauthorized individuals. Findings included .<Unlocked Medication Cart C>On 01/05/2026 at 11:55 AM Medication Cart C was observed unlocked and unattended. Staff R, Registered Nurse, was observed to enter room [ROOM NUMBER]. Several facility staff walked by Medication Cart C while unlocked and unattended. Staff R returned to Medication Cart C at 11:58 AM.In an interview at 11:55 AM Staff R stated they had not realized their medication cart was left unlocked and locked the cart. Staff R stated the expectation was to have their medication cart locked when unattended to prevent anyone from taking medication and misusing it. <Unlocked Treatment Cart 1>On 01/09/2026 at 11:17 AM Treatment Cart 1 was observed to be unlocked. The top drawer of the treatment cart contained antifungal cream tubes, alcohol preparation pads, and prescribed wound gel for a resident. The second drawer contained spray wound cleanser, the third drawer contained tweezers and wound supplies (pads, dressing supplies), The fourth drawer contained bottles of iodine, gloves, and sanitizing wipes.In an interview on 01/09/2026 at 11:20 AM Staff S, Licensed Practical Nurse, stated they had not recently used the treatment cart, did not know that it was unlocked, and that it should be locked after use. Staff S locked the treatment cart.Reference WAC 388-97-1300 (2)

Based on interview and record review, the facility failed to identify the resources needed and provide the necessary care and services the resident requires during day to day operations according to the facility assessment (document describing resident population and needs to determine staff and other resources necessary to competently care for residents). The facility failed to provide care and treatment for chemotherapy for 1 of 1 resident (Resident 36). This failure placed residents at risk of unmet medical needs and delays in care, treatment and service needs. Findings included.Review of the facility's policy titled, Facility Assessment, 2025/2026, revised date 08/22/2025, documented the facility is licensed to provide care for 82 residents. The actual maximum number of residents allowable may be less at times to accommodate for safe resident care needs (e.g., infection isolation). The facility assessment documented Services and Care we offer based on Residents' needs included Cancer Treatments (Chemotherapy/Radiation).<RESIDENT 36>Resident 36 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include malignant extensive stage lung cancer (end stage lung cancer has spread to other parts of the body) and metastasis to liver (cancer has spread to the liver). According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 11/27/2025, documented Resident 36 was cognitively intact. Review of a hospital consultation note dated 07/10/2025 at 9:44 PM, documented Resident 36's chemotherapy treatment would consist of six cycles of chemotherapy up to six months, which could be given every 21 days for the initial three days of the cycle.In an interview on 01/05/2026 at 1:49 PM, Resident 36 stated they were supposed to have chemotherapy, but the facility told them they did not take care of residents or provide transportation for residents who required chemotherapy. In an interview on 01/07/2026 at 2:43 PM, Resident 36 stated they were not aware they could not do chemotherapy before being admitted to the facility and they always wanted to get their chemotherapy. Resident 36 stated they were not aware the facility canceled their chemotherapy appointments. In an interview on 01/08/2026 at 9:15 AM, Collateral Contact (CC) 1, Resident 36's Caregiver, stated the facility had not allowed the resident to have chemotherapy or have port placement since admitted to the facility in July 2025. CC1 stated the facility informed them that the nurses in the facility could not take care of a port or take care of Resident 36 when they returned from chemotherapy treatments. In an interview on 01/07/2025 at 10:20 AM, Staff D stated they did not schedule appointments or make transportation for residents who required chemotherapy. Staff D stated Resident 36 could not have chemotherapy while residing in the facility due to the need for quarantine and a private bathroom.In an interview on 01/07/2026 at 10:24AM, Staff F, admission Coordinator, stated when Resident 36 admitted to the facility, they communicated with the oncologist to pause the chemotherapy with the plan to resume after they discharged . Staff F stated the reason they needed to pause the chemotherapy was due to the required precautions and given Resident 36 was residing in a three-person shared room without a private bathroom they were unable to accommodate treatments. In an interview on 01/08/2026 at 2:44 PM, CC3, RN at oncology clinic stated the facility told them Resident 36 was not allowed to have chemotherapy while residing in the facility and could not provide care or transportation for chemotherapy. In an interview on 01/11/2026 at 6:40 PM, CC4, Family member of Resident 36 stated the resident was told after admission to the facility that the resident could not receive any chemotherapy because the facility was not equipped, not certified and not qualified to take care of residents who required chemotherapy. In an interview on 01/13/2026 at 9:23 AM, CC5, Home and Community Services Social Worker stated there were three different staff (two facility social workers and one business office) who told them the Resident 36 could not stay in the facility for chemotherapy, could not accommodate residents with chemotherapy and could not provide transportation. CC5 stated they were told by facility staff they had no private bathrooms and could not handle urine accommodated with the chemotherapy treatment and Resident 36 had to choose between receiving chemotherapy and being discharged . In an interview on 01/08/2026 at 3:51 PM, Staff A stated the facility would arrange transportation, make appointments and provide care for residents who wanted chemotherapy.No associated WAC

Based on interview and record review, the facility failed to honor resident rights related to providing care and treatment for chemotherapy for 1 of 1 resident (Resident 36). This failure placed residents at risk of unmet medical needs, emotional upset, and diminished quality of life. Findings included.<RESIDENT 36>Resident 36 admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses to include malignant extensive stage lung cancer (end stage lung cancer has spread to other parts of the body) and metastasis to liver (cancer has spread to the liver). According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated [DATE], the resident was cognitively intact. In an interview on [DATE] at 1:49 PM, Resident 36 stated they were supposed to have chemotherapy, but the facility told them they did not take care of residents with chemotherapy and did not provide transportation for chemotherapy. In an interview on [DATE] at 2:43 PM, Resident 36 stated they were not aware they could not do chemotherapy before being admitted to the facility and they always wanted to get their chemotherapy. The resident stated they were not aware the facility canceled their chemotherapy appointments. In an interview on [DATE] at 2:33 PM, Resident 36 stated they were supposed to have six cycles of chemotherapy, but they only received two while they were in the hospital in July and August last year. The resident stated they wanted to be discharged to another place which could provide chemotherapy care. In an interview on [DATE] at 9:15 AM, Collateral Contact (CC) 1, Resident 36's Caregiver, stated the facility had not allowed the resident to have chemotherapy or have port placement since admitted to the facility [DATE]. CC1 stated the facility stated the nurses in the facility could not take care of the port or take care of the resident when they returned from chemotherapy treatments. Review of a hospital consultation note dated [DATE] at 9:44 PM, documented Resident 36's chemotherapy treatment would consist of six cycles of chemotherapy up to six months, which could be given every 21 days for the initial three days of the cycle. Review of a hospital case manager note dated [DATE] at 8:23 AM, showed Resident 36 would need outpatient chemotherapy for three days every 21 days. Review of a facility provider note dated [DATE] at 9:33 AM, documented Resident 36 to follow up with oncologist for next cycle every 21 days. Review of a facility provider note dated [DATE] at 9:13 AM and a progress note dated [DATE] at 11:30 AM, documented Resident 36 to follow up with oncologist on [DATE] at 11:00 AM and [DATE] at 12:45 PM, [DATE] at 11:00 AM for labs, [DATE] at 11:00 AM, [DATE] at 10:00 AM, at [DATE] at 2:20 PM for infusions. Review of an oncology clinic provider visit note dated [DATE] at 1:24 PM, the oncologist documented Resident 36 was to return on [DATE] for cycle two infusion and to follow up for port placement. Review of a facility provider progress note dated [DATE] at 11:35 AM, documented Resident 36 was scheduled for port placement on [DATE] for chemotherapy. Review of an oncology clinic note dated [DATE] at 3:46 PM, documented the facility called and canceled all Resident 36's appointments and the resident would be told to call and reschedule everything once they discharged from the facility. Review of Resident 36's Electronic Medical Record (EMR) showed there was no documentation the resident was notified of any above appointment cancellations or changes. Review of a telephone encounter note dated [DATE] at 12:00 PM, documented the facility requested to push back Resident 36's chemotherapy schedule until after they discharged from facility on [DATE] due to the resident could not attend chemotherapy appointments on rehabilitation therapy days per insurance authorization. Review of a hospital note dated [DATE] at 3:35PM and [DATE] at 11:26 AM, documented Resident 36 had not been able to follow up for outpatient chemotherapy after being admitted to SNF since [DATE] and the chemotherapy appointment was initially scheduled on [DATE] and pushed back by the facility till [DATE] and then all appointments cancelled by the facility. Review of an oncology clinic note dated [DATE] at 7:34 AM, documented the provider ordered to contact the facility and scheduled cycle three chemotherapy on [DATE]. The following note dated [DATE] at 9:56 AM, documented the facility requested to schedule the resident out by two weeks to allow the resident to receive physical therapy and occupational therapy. The note documented Resident 36 had future appointments scheduled for [DATE] at 4:00 PM, [DATE] at 11:00 AM, [DATE] at 3:00 PM, [DATE] at 3:20 PM, [DATE] at 4:00 PM. In a follow up interview on [DATE] at 2:44 PM, CC3, Registered Nurse in oncology clinic, confirmed Resident 36 did not go to any of the above appointments. Review of an oncology clinic note dated [DATE] at 11:04 AM, documented the clinic staff called and spoke with the facility to schedule an appointment for Resident 36 on [DATE]. The facility declined to schedule the available appointment on [DATE] at 4:00 PM related to transportation availability and rescheduled for [DATE] at 2:00 PM. Review of an oncology clinic note dated [DATE] at 2:24 PM, documented Resident 36 was a no show for their appointment on [DATE] at 2:00 PM. Review of Resident 36's Electronic Medical Record (EMR) for [DATE] revealed no documentation about if Resident 36 attended the appointment scheduled that day and/or what the reason for missing the appointment was. Review of an oncology clinic note dated [DATE] at 12:19 PM, documented the facility stated they could transport the Resident 36 to their office for office visits but not for treatment and there was no anticipated discharge date for them. Review of an oncology clinic provider visit note dated [DATE] at 9:42 AM, documented the facility could not make the resident for chemotherapy appointment since last cycle on [DATE] in the hospital and the resident wanted to resume the chemotherapy as soon as possible. Review of an oncology clinic note dated [DATE] at 4:03 PM, documented they contacted the facility and spoke with Staff D, Receptionist, to schedule port placement and to resume chemotherapy treatment appointments for Resident 36. Staff D stated that none of their residents while in their care were able to do chemotherapy and they could not accommodate. Staff D stated there was no expected discharge date for the resident and no appointments were scheduled Review of CC5, Home and Community Services staff's note dated [DATE] at 10:01 AM, documented Resident 36 were told by the facility that they could not remain in the facility as they were not able to handle cancer residents with chemotherapy and the resident stated it had to do with transportation. Review of CC5's note dated [DATE] at 11:41 AM, documented CC5 was told by three different staff in the facility directly that Resident 36 could not remain in the facility if the resident wanted to continue with the chemotherapy due to the facility not having a private room and being to handle the radiation in their body. It documented that Resident 36 had not stated their choice of going to Adult Family Home and the resident's first choice would be to remain in the facility and have their chemotherapy. In an interview on [DATE] at 10:20 AM, Staff D stated they did not schedule appointments or make transportation for residents who required chemotherapy. Staff D stated while the resident in the facility they could not have chemotherapy due to quarantine and need for a private bathroom. Staff E, Registered Nurse/RCM stated the admission coordinator always talked with the hospital case manager so they know that the facility could not do chemotherapy while the resident in the facility. In an interview on [DATE] at 10:24AM, Staff F, admission Coordinator, stated when Resident 36 admitted to the facility, they communicated with the oncologist to pause the chemotherapy and to reestablish treatment after they discharged from the facility. Staff F stated the reason they needed to pause the chemo was due to precautions needed (a private room and bathroom) and the resident was currently residing in a three-person shared room without a private bathroom. In an interview on [DATE] at 10:59 AM, Staff A, Administrator stated they were waiting for the oncology clinic to call and schedule an appointment for a port placement. Staff A stated the resident did not want to go through full treatment and did not want to go out of the building to any appointments prior to [DATE]. Staff A stated the facility had been monitoring labs as requested by the Resident 36's oncologist and they went to the oncologist appointment on [DATE] with their daughter. In a follow up interview on [DATE] at 11:32 AM, Resident 36 stated since admission their plan was to go to chemotherapy appointments and there was never a period of time that they did not want to go to chemotherapy or any other appointment. Resident 36 stated their daughter had died years ago and they had not taken them to any appointments. Resident 36 stated they were not aware of the facility cancelling their chemo appointments and the facility kept telling them they could not provide transportation and could not take care of them after receiving chemotherapy treatments. In an interview on [DATE] at 2:20 PM, CC2 (Scheduler at oncology clinic) and CC6 (Scheduling Supervisor at oncology clinic) stated they called the facility to schedule a port placement for Resident 36, and they were told by Staff D, the facility could not accommodate someone who was receiving chemotherapy. In an interview on [DATE] at 12:53 PM, Staff C, Licensed Practical Nurse (LPN)/Resident Care manager (RCM) stated Resident 36 went to the oncology appointment on [DATE] and they were still waiting for the oncology clinic to send the port placement appointment. Staff C stated they had not yet heard anything from the clinic, and they had not followed up with the clinic. Staff C stated they were not aware of any appointments being cancelled and they were not aware Resident 36 had wanted to go chemotherapy. In an interview on [DATE] at 2:44 PM, CC3 stated Resident 36 had not received any chemotherapy treatments while residing in the facility. CC3 stated they had reached out to the facility multiple times to schedule appointments, but the facility did not assist them, and they even had trouble getting calls back from the facility. CC3 stated the facility told them Resident 36 was not allowed to have chemotherapy when they were in the facility, and the facility could not provide care or transportation for chemotherapy. CC3 stated they had made multiple attempts to call the facility to schedule port placement after the appointment on [DATE] but nobody answered the phone. CC3 stated they wanted to know when Resident 36 would be discharged as they had already been told the facility could not accommodate them with port care. CC 3 stated the facility canceled all appointments for Resident 36's chemotherapy appointments between July and [DATE] and it wasn't until they were admitted to the hospital on [DATE] that they received chemotherapy treatment. CC3 stated the oncology clinic staff attempted to schedule additional chemo appointments after the resident was readmitted to the facility on [DATE] but the facility declined and reported there was no transportation available after 4:00 PM. CC3 stated they rescheduled the appointment for the morning time but the resident did not show for the appointment on [DATE] and the clinic was not notified of the reason. In an interview on [DATE] at 3:51 PM, Staff A stated Resident 36 did not go to any chemotherapy or oncology appointments because the resident admitted to the facility to get rehabilitation therapy to improve their strength before they received chemotherapy treatments. Staff A stated the hospital provider placed rehab therapy before the resident could receive further chemotherapy. Review of the hospital record provided by Staff A, dated [DATE], contained no documentation that the provider ordered to postpone or cancel Resident 36's chemotherapy, rather documented they discussed with Resident 36 and their child about the treatment plan which included chemotherapy every 21 days for the initial three days and consisted of six cycles up to six months. In an interview on [DATE] at 3:51 PM, Staff A stated there was care conference with Resident 36 could not discharge on [DATE] and to schedule chemotherapy after discharge. Review of the occupational therapy (OT) treatment note provided by Staff A, dated [DATE], documented Resident 36 reported plan to discharge on [DATE] due to upcoming chemo treatment and likely to regress with chemo, and Resident 36 was concerned about complete chemo treatment. When asked if Resident 36 went any chemotherapy after [DATE], Staff A stated the facility communicated with the oncology clinic, but the clinic never attempted to schedule chemotherapy, and the resident received chemotherapy in the hospital when admitted on [DATE] due to critical and abnormal laboratory results. When asked why Resident 36 could not receive chemotherapy prior to hospital admission or after being readmitted to the facility since [DATE], Staff A stated the resident had terminal cancer. When asked if Resident 36 wanted to receive chemotherapy treatments, Staff A again stated the resident had terminal cancer. In an interview on [DATE] at 9:23 AM, CC5 stated that besides Resident 36, there were three different staff (two facility social workers and one business officer) who told them the resident could not stay in the facility for chemotherapy and the facility could not accommodate residents with chemotherapy and could not provide transportation. CC5 stated they were told the facility had no private bathroom and could not handle urine accommodated with the chemotherapy treatment and Resident 36 had to choose between receiving chemotherapy and being discharged . CC5 stated Resident 36 did not want to leave the facility but they had to leave because the resident wanted to have chemotherapy. CC5 stated Resident 36 got overwhelmed and the resident had to believe what the facility told them. In an interview on [DATE] at 6:40 PM, CC4, Resident 36s family member stated the resident was told after admission to the facility, that they could not receive any chemotherapy because the facility was not equipped or not certified or not qualified to take care of residents receiving chemotherapy and they were not able to take care of residents when they came back. CC4 stated Resident 36 was supposed to have six cycles of chemotherapy over six months and was supposed to have completed those six treatments by now. CC4 stated Resident 36 always wanted to receive chemotherapy and the resident pursued but the facility just told them they could not send them. CC4 stated the facility let the resident believe they could not return to the facility after chemotherapy treatments, that was why the resident should schedule their chemotherapy after they discharged from the facility.In an additional follow up interview on [DATE] at 1:55 PM, Resident 36 stated they had not received permission to cancel their chemotherapy appointments while at the facility. Resident 36 stated they required chemotherapy treatments when they were admitted to the facility since [DATE] and they had not received any chemotherapy while they resided in the facility. Resident 36 stated I was told three times while at the facility I was not allowed to have chemotherapy, that there was no transportation and they could not care for me after my chemotherapy. Resident 36 stated they were confused as to why they could not have chemotherapy and remain at the facility. Resident 36 stated the oncologist had planned for six chemotherapy treatments, comprised of three days in a row and off 21 days and the only time they had received treatments were the two times they were admitted to the hospital. Resident 36 stated their wishes were to have their chemotherapy treatments and when asked if they ever declined the resident stated, I'm not a dummy I wanted to get that over with, they were frustrated that they could not get their treatments, stating This is my life. Reference WAC 388-97-0180(1-4)

Based on interview and record review the facility failed to notify the responsible party when a medication order had been changed for 1 of 1 (Resident #1) residents reviewed for a change of condition. The failure to not inform the resident representative of a high-risk medication change placed them at risk not to be informed of the risks and benefits and violated a resident right to be involved in health care decision making. Findings included . Review of a facility policy titled, Notification-Physician or Responsible Party, revised date May 2016, showed that the responsible party was to be notified if there was a change in resident's treatment and the notification was to be made within 24 hours. Definitions: - Antipsychotic medication- a class of psychiatric medications used to treat psychosis and affect a person's mood, thinking and behavior. Side effects can cause drowsiness. - Psychosis- a state where a person loses touch with reality, often experiencing hallucinations (seeing or hearing things that aren't there) and/or delusions (holding false beliefs that are not shared by others) Resident 1 was admitted to the facility on [DATE]. Review of the Minimum Data Set Assessment (assessment of conditions and care needs), dated 02/28/2025, showed resident had moderately impaired cognitive ability. Review of Resident 1's physician order history for antipsychotic medication use, documented Resident 1 was admitted on risperidone (an antipsychotic medication) 0.5miligram(mg) twice daily. On 03/12/2025, the dose of risperidone was increased to 0.5mg once a day and 1mg at bedtime. On 03/19/2025, the dose of risperidone was increased to 1mg twice a day. Review of the clinical record showed no documentation that the responsible party had been notified of the medication changes on 03/12/2025 or 03/19/2025. During an interview on 05/30/2025 at 3:34 PM, Staff B, Resident Care Manager/Registered Nurse, reported that the responsible party for Resident 1 was very concerned with the use of medications that could cause drowsiness. Staff B reported they had processed the risperidone dose order change on 03/12/2025. Staff B reported they did not notify the responsible party when they processed the order. Staff B reported they did not see documentation in the clinical record that the responsible party had been notified. During an interview on 05/30/2025 at 3:41 PM, Staff A, Director of Nursing Services, reported the provider had reviewed Resident 1's medications due to agitation and had increased the dosage of the risperidone. Staff A reported they had processed the risperidone dose order change on 03/19/2025. Staff A stated they did not see documentation that the responsible party had been notified of the medication dose increase. Reference WAC 388-97-0320 (1)(c)

Based on observation, interview, and record review, the facility failed to ensure adequate indications for use of an antipsychotic medication (medications that affect the mind or behavior) for 3 of 6 residents (Residents 5, 179 and 380), failed to ensure residents were monitored for adverse consequences of psychotic medication use for 2 of 6 residents (Residents 45 and 380), failed to ensure behaviors were monitored for 2 of 6 residents (Residents 45 and 380) and failed to obtain consents timely for 1 of 6 residents (Resident 179) reviewed for unnecessary medications. These failures put the residents at risk for experiencing adverse side-effects from unnecessary medication use. Findings included . As referenced in the Food and Drugs/Drug (FDA) Safety Information, anti-psychotic medications have serious side effects and can be especially dangerous for elderly residents. The use of anti-psychotic medications without an adequate rationale, or for the sole purpose of limiting or controlling expressions or indications of distress without first identifying the cause, there was little chance that they would be effective, and they commonly cause complications such as movement disorders, falls with injury, stroke, and increased risk of death. The FDA Boxed Warning, which accompanied, second-generation anti-psychotics stated, Elderly patients with dementia-related psychosis treated with atypical anti-psychotic drugs are at an increased risk of death. <RESIDENT 179> Resident 179 admitted to the facility on [DATE] with diagnoses to include mild neurocognitive disorder due to known physiological condition with behavioral disturbance (condition caused by an underlying medical condition). Review of Resident 179's quarterly Minimum Data Set (MDS- an assessment tool) assessment, dated 09/27/2024, showed the resident was rarely or never understood with severe cognitive impairment. The resident was coded not to have had any mood, behavior concerns or signs of psychosis such as hallucinations (perceptual experiences in the absence of real external sensory stimuli) or delusions (misconceptions or beliefs that are firmly held, contrary to reality). The resident was not receiving any antipsychotic medication. Review of Resident 179's physician's orders showed the resident began receiving Hydroxyzine (anti-anxiety medication) every 8 hours as needed for anxiety and agitation initiated on 03/24/2024 and Seroquel (anti-psychotic medication) at bedtime for agitation initiated on 11/11/2024. Review of the Atypical Antipsychotic consent form dated 12/03/2024 for Seroquel, showed Staff G, Social Services Supervisor obtained verbal consent for this medication on 12/04/2024, 23 days after the medication was administered. The indication for the antipsychotic use was listed as confusion, anxiety, and depression, which were not appropriate indications for antipsychotic medication use. Review of Resident 179's clinical record showed a consent form for Vistaril/Hydroxyzine dated 06/24/2024 that did not include a diagnosis/indication for use of the anti-anxiety drug. The consent was obtained 3 months after the resident began receiving Vistaril/Hydroxyzine. Review of Resident 179's psychotropic care plan showed Seroquel was used related to behavior management. In an observation on 01/02/2025 at 2:34 PM, Resident 179 was asleep and reclined in their wheelchair at the nurse's station. In an observation on 01/03/2025 at 9:14 AM, Resident 179 was asleep in their wheelchair at the nurse's station. In an observation on 01/06/2025 at 9:40 AM, Resident 179 was sitting in a tilt in space wheelchair that was positioned upright. Resident 179 was observed to be restless and pushed off with their right hand from the nurse's station counter and moved their right leg to the side. Resident repetitively moved their right arm and leaned to the right and back. Resident was pushing up on the wheelchair arm with a look of discomfort. In an observation on 01/07/2025 at 8:19 AM, Resident 179 was reclined in their wheelchair, positioned slightly against the wall at nurse's station. The resident was asleep, and their right slipper was on the floor. In an observation on 01/07/2025 at 9:48 AM, Resident 179 remained in their wheelchair asleep, lightly snoring. In an interview on 01/08/2025 at 1:54 PM, Staff J, Registered Nurse (RN) stated consents need to be obtained prior to administration of psychotropic medications. Staff J stated Resident 179 could be agitated and restless at times and they could administer Seroquel for the resident's depression. In an interview on 01/09/2025 at 9:15 AM, Staff A, Administrator stated they had a performance improvement plan in place for this as they identified psychotropic management as an issue. Staff A stated the expectation was that the interdisciplinary team review orders, care plans and consents during their weekly psychotropic meetings. No additional information was provided. 44110 <RESIDENT 380> Resident 380 admitted to the facility on [DATE], with diagnoses that included paranoid schizophrenia (chronic mental illness that affects a person's thoughts, feelings, and behaviors) and anxiety. The MDS assessment, dated 01/01/2025, showed the resident had mild cognition impairment. Review of Resident 380's physician orders dated 12/26/2024 showed an order for Seroquel (antipsychotic) 25 milligram (mg) tablet one time a day, and 50 mgs at bedtime. Review of Resident 380's physician order dated 12/26/2024 showed the resident was to be monitored for anti-psychotic target behaviors. The order showed a blank space for what those target behaviors were. The order was not individualized or personalized and did not reflect an area to monitor the efficacy of the interventions used. Review of Resident 380's current care plan on 01/02/2025, showed it did not direct staff to monitor the efficacy of the antipsychotic medication. In an observation and interview on 01/02/2025 at 10:07 AM, Resident 380 was observed sitting in their wheelchair next to their bed. When asked how the resident was, Resident 380 burst into a loud wail, and started to cry and threw themselves across the over the bed table and started crying hysterically and stating they are sending me up repeatedly. A staff member, Staff K, Nursing Assistant Certified (NAC) entered the room and stated they were looking for the nurse. Staff K stated they were not aware of the resident's behavior as this was the first time working with the resident, but that the resident did appear confused. In an observation on 01/02/2025 at 1:33 PM, Resident 380 was observed sitting in their wheelchair in their room with their head resting on a pillow that was placed on top of the over the bed table. Resident immediately burst into tears, and stated it just not good, resident was unable to elaborate any further and continued to cry. Review of Resident 380's clinical record on 01/06/2025 at 8:59 AM, showed the resident had been moved to another room on 01/05/2025 due to the resident being paranoid and believed their roommate was accusing them of stealing personal items. Review of a fall investigation for Resident 380, showed the resident had a witnessed fall with therapy on 01/02/2025. The witness statement from the therapist stated they were discussing therapy interventions with the resident when the resident began talking off topic about random subjects, and occurrences from the past. The therapist documented they attempted to redirect the resident; however, the resident became agitated, screaming no one was telling them the truth. The therapist documented attempts to de-escalate the resident were unsuccessful and the resident fell from the wheelchair. In an interview on 01/07/2025 at 11:24 AM, Staff X, Licensed Practical Nurse (LPN) stated they are instructed to monitor resident behaviors and document in the EMAR system. Staff X stated that the Resident Care Managers (RCMs) are the ones that ensure the monitoring was individualized and personalized to each resident. In an interview on 01/07/2025 at 2:42 PM, Staff F, LPN/RCM stated the admitting nurse, which was usually one of the RCM's was responsible for ensure the psychotropic behavior monitoring was personalized to the resident with proper monitoring of episodes and interventions. Staff F confirmed that Resident 380 was lacking the target behaviors for the behavior monitoring orders, and there was no way to monitor the effectiveness of the interventions used. Review of Resident 380's electronic medical record administration (EMAR) on 01/08/2025 showed the resident had been administered both medications as ordered every day since their admission on 12/26/2024. The behaviors displayed on 01/02/2025 and 01/05/2025 were not documented in the medical record for monitoring of the anti-psychotic medication. In an interview on 01/09/2025 at 9:20 AM, Staff A, Administrator stated they needed to complete more education with the staff on ensuring the orders are complete. 47047 <RESIDENT 45> Resident 45 admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, post-traumatic stress disorder (PTSD), and major depressive disorder. In a review of Resident 45's Medication Administration Record (MAR) dated January 2025 showed they had a physician order dated 11/23/2024 for duloxetine (an anti-depressant medication) to treat major depressive disorder and hydroxyzine (an antianxiety medication) to treat anxiety. There was no monitor in place for adverse consequences or behaviors related to the use of duloxetine and no monitor in place for adverse consequences for the use of hydroxyzine. Review of Resident 45's care plan dated 12/08/2024 showed they were at risk for depression and mood problems related to antidepressant use and anxiety. Interventions for depression included observation for side effects of anti-depressant medication. Interventions for anxiety included to administer medications as ordered and monitor and document side effects and effectiveness. Review of Resident 45's electronic medical record from 11/23/2024 through 01/05/2025 showed no documentation or monitor for adverse consequences related to the use of an antidepressant and anti-anxiety medication. Review of Resident 45's Kardex (resident specific guide for nursing assistants to provide care) dated as of 01/06/2025 directed nursing assistants to monitor, document, and/or report to the physician ongoing signs and symptoms of depression unaltered by antidepressant medications. In an interview on 01/07/2025 at 11:50 AM Staff G, Social Services Supervisor, stated the admitting nurse adds any monitors needed for residents who had psychoactive medications. Staff G stated they try to review residents every 30 days to ensure monitors are in place. In an interview on 01/07/2025 at 12:45 PM Staff A, Administrator, stated there was not a monitor in place for Resident 45's antidepressant use and a monitor was put into place that day. In an interview on 01/08/2024 at 2:34 PM Staff B, Director of Nursing Services, stated the nursing aides are not to assess or monitor as those are nursing tasks and are responsible for personal care only. 51312 <RESIDENT 5> Resident 5 admitted to the facility on [DATE] and readmitted on [DATE]. During the record review on 01/06/2025, Resident 5's provider orders included an 'antipsychotic drug to be administered for dementia.' In an interview on 01/08/2025 at 1:56 PM, Staff O, LPN, stated that an antipsychotic drug was used for schizophrenia behavior issues, not dementia. In an interview on 01/08/2025 at 2:17 PM Staff B, DNS, stated that the order was in the process of being changed on 01/08/2025. In an interview on 01/07/ 2025 at 1:43 PM, Staff A, Administrator stated that dementia is not a proper diagnosis for an antipsychotic medication. Refer to WAC 388-97-1060(3)(k)(i)(4)

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, and homelike comfortable environment. The facility failed to provide necessary housekeeping and maintenance of resident rooms, bathrooms, and hallways; failed to ensure comfortable sound levels were maintained, failed to ensure resident rooms were individualized with items to provide a homelike environment, and failed to ensure residents were afforded adequate living space. These failures placed residents at risk for a diminished quality of life. Findings included . Review of the facility policy titled homelike environment dated 2024 showed the facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: Cleanliness and orderly environment in rooms Privacy Curtains. Comfortable (minimum glare) yet adequate (suitable to the task) lighting; Inviting colors and decor; Personalized furniture and room arrangements; Pleasant, neutral scents; Comfortable temperatures; and Comfortable noise levels. <COMFORTABLE SOUND LEVELS> Residents 8, 13, and 53 were roommates in a 3 bed room. Resident 13 admitted [DATE] and was alert and oriented. Resident 13 was in the window bed. Resident 53 admitted [DATE] and according to the 11/04/2024 Quarterly Minimum Data Set (MDS) assessment (a required tool), Resident 53 was cognitively impaired and required extensive assistance for care. Resident 53 was in the center bed. Resident 8 admitted [DATE] and was alert and oriented. Resident 8 was in the door bed. In an observation on 01/02/2025 at 9:51 AM Resident 53 was in their bed yelling out in a repetitive distressed manner. Several staff responded in attempts to determine Resident 53's need and just after staff would exit the room, Resident 53 would resume repetitive yelling. In an interview and observation on 01/02/2025 at 10:51 AM, Resident 53 was yelling and banging on the side of their bed. Resident 13 was lying in their bed with headphones on and stated this goes on all day and all night and they had not slept well since they admitted . Resident 13 stated they ask the nurses, can you do something? and one nurse finally gave them a paper (grievance form) they could fill out but stated they felt that the staff should do that; they were frustrated and tired and felt like someone should be doing something more for them (Resident 53). In an interview and observation on 01/03/2025 at 12:59 PM, Resident 8 was lying in bed with the privacy curtain closed between their bed and the middle bed and stated (Resident 53) yells, the nurses come in and out constantly, and as soon as they leave it starts over, (Resident 53) will start yelling again and nobody cares. Resident 53 was observed to begin grabbing the privacy curtain and pulling it open while yelling out. Resident 8 stated there was an agreement about the privacy curtain and that yesterday (Resident 53) had it open and today was their day to have it closed and (Resident 53) is not following the agreement. <HOMELIKE ENVIRONMENT> In an observation on Resident 53's personal space on 01/03/2025 at 1:04 PM, the resident was in the center bed with both privacy curtains pulled on either side of them. The privacy curtains were pale yellow solid colored curtains. The space where resident 53's bed was measured just over 68 square feet. The resident had no personal wall space other than behind their head which was not visible to them. In front of them on the wall there was a TV mounted close to the ceiling and the only other item in view was an institutional Personal Protective Equipment plastic rolling cart against the wall which was stacked with bed pads and a package of cleansing wipes. Residents 8 and 13 (on either side of the resident) preferred the privacy curtains closed, which resulted in Resident 53 being in a small, enclosed space when the privacy curtains were closed. In an interview and observation on 01/03/2025 at 1:04 PM, Resident 53 was pulling on the privacy curtain to attempt to open it and yelling repetitively. Resident 8 grabbed the privacy curtain and began pulling it back to closed stating (they) want it open and I want it closed, this is all the time, it is my curtain too. Both residents had a grip on the privacy curtain attempting to pull it in opposite directions. Staff R, Certified Nursing Assistant, attempted to intervene, and attempted to close the curtain as Resident 8 requested, but stated (Resident 53) won't let go, they want it to be open. Staff R called for assistance from management and social services. Review of the resident records on 01/03/2025 showed no documentation of resident preferences related to personal space or privacy curtains. Review of the grievance log on 01/03/2025 for the prior 6 months showed no documented grievances related to room or room mate concerns for either resident. Applying the reasonable person concept, a reasonable person would desire or expect some personalization for a homelike environment such as space for personal items or decoration and control over their limited personal space, such as being able to have the privacy curtains open or closed, when desired, and for the facility to intervene and mitigate on behalf of each resident when incompatibility was evident. 51312 <RESIDENT ROOMS> In an observation on 01/02/25 at 9:52 AM, room [ROOM NUMBER]'s flooring next to resident 5's bed was sticky. The wall under the residents' TVs had scraped areas along the entire wall with exposed drywall and multiple nail-sized holes. In an observation on 01/03/25 at 12:39 PM, room [ROOM NUMBER]'s flooring next to resident 5's bed was sticky. Resident 5's overhead light had a thick layer of dust on it. There was no trash bag in resident 5's trash can. <FACILITY> In an observation on 01/02/25 at 10:16 AM of the hallway for rooms 1-28, showed the ceiling was dusty around the vents, there was dust on the wall around the fire door, and the utility room doors in the hallway had areas around the doorknobs that were discolored and splotchy. The light fixtures had black globs with wings inside of them. The walls and ceiling had multiple spots that were dark and had particulate matter on them. In an observation/interview on 1/3/2025 at 2:04 PM, Staff A, Administrator, stated the stains on the wall by room [ROOM NUMBER] was ketchup, the discolored and splotchy spots on the utility room door was old tape residue, the dark areas splattered on the walls and the ceiling was more food. Staff A stated the walls adjacent to the fire door, the personal protective equipment containers, and the light fixtures were dusty, and the staff was going to have a dusting party. During resident counsel on 01/06/25 1:00 PM, Resident 330 stated the facility was dirty and needed to be deep cleaned. 44110 In an observation on 01/02/2025 at 11:09 AM, surveyor observed gnats at the nurse's station. In an observation and interview on 01/02/2025 at 2:14 PM, Resident 16 was lying in bed talking to surveyor when they started to swat at the air. Resident 16 then said there are always gnats flying around, then pointed to a bug catcher (long strip with sticky adhesive with pictures of bugs on it) attached to the wall next to the resident's head of the bed. Resident 16 said the gnats are horrible, and that was why they had the bug catcher. In an observation on 01/06/2025 at 9:25 AM, room [ROOM NUMBER] had three residents listed as occupants in the room. In the room each resident's personal space was separated by a fabric privacy curtain that hung from the ceiling. The resident (Resident 380) that had their bed in the middle of the room (they had other residents on either side of them), their bed was observed to be pushed next to the resident's space near the door to allow for the resident to sit in the chair to eat breakfast. The privacy curtain between the two residents was observed to be snagged as it was wedged between the two beds with no individual space between the resident's belongings and beds. In an observation on 01/06/2025 at 2:05 PM, Fire Marshall was asked to measure the space for the resident that was in the middle of the room in room [ROOM NUMBER]. The Fire Marshall measured the width of the room from wall to wall which measured 11.6 feet, and then measured between the two privacy curtains, which measured 5.9 feet. The privacy curtains were observed to be pushed in on both sides of the middle resident's personal space, which decreased the space for the resident to have their belongings. The total square footage of usable space for Resident 380 was 68.44 square feet, less than the 80 square feet that was required for a home like environment. In an observation on 01/07/2025 at 8:56 AM, room [ROOM NUMBER] was observed that the middle bed and the bed near the door had less than 6 inches of space between the two beds and was only separated by a fabric privacy curtain. It was observed that both residents were in their beds. In an observation and interview on 01/07/2025 at 1:09 PM, room [ROOM NUMBER], which presented with three residents in the room separated by only fabric privacy curtains, Resident 533 was lying in the bed in the middle spot. Resident 533 was asked if we could measure their space, and they agreed and then stated its really narrow in here, not a lot of space. The space was 11.6 feet in width and 6 feet in length, total square footage of 69.6 feet, less than 80 square feet to provide a home like environment. In an interview on 01/08/2025 at 10:00 AM, Staff W, Maintenance Supervisor stated they were aware of the gnat problem in Resident 16's room. They stated they hung up the bug catcher to deter the gnats. In a joint interview on 01/09/2025 at 9:20 AM, Staff A, Administrator and Staff B, Director of Nursing Services, Staff A stated they agreed to the bug catcher for Resident 16, per a grievance request. Staff B stated they try not to store food in the resident's room. Staff A stated they were aware of the concern for lack of personal space in the three person rooms. 51551 <BATHROOM CLEANLINESS> In an observation on 01/02/2025 at 9:42 AM, in the bathroom between rooms [ROOM NUMBERS], the sink had yellowish rust stains and had large amount of dark hair. The drain was partly clogged and the water drainage was slow. The toilet high rise seat was soiled with multiple brown substances. There were two square grey contaners,not in plastic bags and not labeled, on the floor and a female urinal, not in plastic bag and unlabeled, on the top of the toilet water tank. In an observation on 01/02/2025 at 10:02 AM, in the bathroom between rooms [ROOM NUMBERS], there was a piece of feces floating and multiple yellowish rust stais in the toilet bowel. There were one basin, two bed pans, one urinal, and one big container piled together on the floor under the sink, not were in plastic bags nor labeled. There were two toothpastes and one toothbrush on the floor in between the sink and toilet bowl. There was a hair brush on the edge of the sink that was not labeled with a resident name. There was a bottle of periwash spray on the back of the toilet tank that was not labeled with a resident name. In an observation on 01/02/2025 at 3:01 PM, the bathroom between room [ROOM NUMBER] and 36 looked the same as what it was at 10:02 AM. In an observation on 01/03/2025 at 8:59 AM, in the bathroom between rooms [ROOM NUMBERS], there was a denture cup in the sink that had no resident name. There toilet bowl contained yellow fluid. There was a bottle of periwash spray on the back of the toilet tank that was not labeled with a resident name. In an observation on 01/03/2025 at 9:02 AM, in the bathroom between rooms [ROOM NUMBERS], there was a female urinal on top of the toilet tank, not in a plastic bag or labeled. There were two grey square containers on the floor below the sink. There were still multiple brown spots on the toilet high rise seat. In an observation and interview on 01/03/2025 at 12:08 PM, in the bathroom between rooms [ROOM NUMBERS], Staff B observed the bathroom with surveyor. There were a bottle of peri wash spray that had no resident name and a bottle of odor eliminator spray on the top of the toilet tank. There was a denture cup in the sink that did not have a resident name. Staff B stated they were not sure whom these items belonged to. Staff B stated they expected any toileting items (bedpan/urinal) in the bathroom needed to be in a plastic bag and labeled with resident's names. Staff B stated they were encouraging staff to not to leave any grooming items in the bathroom. In an observation on 01/08/2025 at 10:20 AM, in the bathroom between rooms [ROOM NUMBERS], there was a basin on the floor under the sink. 47047 <PRIVACY CURTAINS> In an observation on 01/02/2025 at 9:52 AM, room [ROOM NUMBER]'s privacy curtain was visibly soiled with multiple areas of brown particulate matter. In an observation on 01/02/2025 at 10:16 AM, room [ROOM NUMBER]'s privacy curtain was visibly soiled with multiple areas of particulate matter. In an observation in 01/03/2025 at 1:08 PM room [ROOM NUMBER]'s privacy curtain was visibly soiled with multiple brown stains toward the bottom of the curtain. In an observation on 01/03/2025 at 1:45 PM room [ROOM NUMBER]'s privacy curtain between the beds was visibly soiled with a brown stain, circular in shape, near the middle of the curtain. In an observation on 01/03/2025 at 1:08 PM room [ROOM NUMBER]'s privacy curtain between the beds was visibly soiled with brown matter in circular patterns near the middle of the curtain. In an interview on 01/03/2025 at 1:08 PM Staff BB, Housekeeper, stated they knock on door and identify themselves before entering. Staff BB stated they empty the trash, make sure that there is nothing on the floor, pick up dirty linens and send to the soiled linens, and mop and sweep floor. When asked if how they manage cleaning of soiled curtains, Staff BB stated they make a note in their notebook and inform their supervisor of it. Staff BB entered room [ROOM NUMBER] and stated they had not seen the soiled curtain and would make a note to tell their supervisor. In an interview on 01/03/2025 at 1:14 PM Staff R, Housekeeping Supervisor, stated the housekeepers tell them when a privacy curtain was soiled and required to be changed. Staff R stated at least monthly they complete a check of all the privacy curtains to ensure cleanliness. Staff R stated they were only informed of room [ROOM NUMBER] that needed their privacy curtain changed. In an interview on 01/03/2025 at 1:27 PM Staff A, Administrator, stated soiled privacy curtains would be changed that day. Staff A stated privacy curtains were done during their deep cleaning schedule and an inservice would be completed with staff. In an observation on 01/08/2024 at 2:00 PM room [ROOM NUMBER]'s privacy curtain remained soiled, in the same spot as observed on 01/03/2025, on the curtain between the beds, circular in shape and near the middle of the curtain. 42927 During a phone interview on 01/02/2025 at 2:01 PM, Collateral Contact 1(CC1), Resident 229's family member, stated Resident 229's privacy curtains were dirty. CC1 stated everytime they visit Resident 229 complains about the privacy curtain being dirty. During an interview and observation on 01/02/2025 at 2:54 PM, Resident 229 stated there were dead bugs on the privacy curtain. Observed two pea sized areas of brown particulate matter and a large area of dried brown splatter along the bottom of the privacy curtain on the right side of the bed. There were various small spots of dried liquid on the privacy curtain on the left side of the bed. During an observation on 01/03/2025 at 9:37 AM, the privacy curtains around Resident 229's bed still had the areas of brown particulate matter and dried splash spots. During an interview and observation on 01/03/2025 at 12:12 PM, Staff B observed the brown particulate matter on the privacy curtain. Staff B stated they did not know what the particulate matter was, but the privacy curtain needed to be changed. Staff B was not aware of how often the privacy curtains were changed or if they were washed when soiled. Refer to WAC 388-97-0880

Based on interview and record review, the facility failed to ensure the Resident Assessment Instrument (RAI), an assessment of a resident's needs, strengths, goals, and preferences, were completed within the required timeframes and/or included thorough summaries of the Care Area Assessments (CAA's), an assessment of a specific resident care or medical issue, to holistically analyze the plan of care for 9 of 22 residents ( 4, 5, 20, 55, 51, 62, 66, 70 and 179) reviewed for comprehensive assessments. This failure placed the residents at risk of not having appropriate services provided based on the resident's individualized needs and placed all other residents at risk of their needs and preferences not met. Findings included . Review of the facility's policy, Resident Assessment and Associated Processed, revised/reviewed August 2024, showed CAA's will be made of the residents needs, strengths, goals, life history and preferences using the RAI and will include at least the following: Identification and demographic information Customary routine Cognitive patterns Communication Vision Mood and behavior patterns Psychological well-being Physical functioning and structural problems Continence Disease diagnosis and health conditions Dental and nutritional status Skin conditions Activity pursuit Medications Special treatments and procedures Discharge planning Documentation of summary information regarding additional assessment performed on the care areas triggered by the completion of the MDS Documentation of resident participation in the assessment process Review of the facility policy titled, Resident Assessment and Associated Process, revised August 2024, showed a comprehensive assessment and completion of the CAA process will be conducted within 14 days of admission. A significant change in status assessment will be completed within 14 days of identification. Review of the RAI manual, Version 1.19.1, dated October 2024, showed that a Significant Change in Status Assessment (SCSA) was required to be performed within 14 days of when a resident enrolled in a hospice program. <RESIDENT 70> Resident 70 admitted on [DATE] with diagnoses to include edema, heart failure ad Gastro -Esophageal Reflux Disease. The admission MDS assessment, dated 10/20/2024, included the following triggered CAA's: cognitive loss, psychosocial wellbeing, activities, Activities of Daily Living (ADL), pressure ulcer (PU), nutritional status, urinary, falls, pain, and return to the community. Review of the MDS assessment, dated 10/24/2024, showed the psychosocial well-being, activities and return to community CAA's did not contain comprehensive summaries or analysis that included the current goals, preferences, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's CP was needed. <RESIDENT 179> Resident 179 admitted on [DATE] with diagnoses to include diagnoses to include stroke with hemiparesis (inability to move one side of body) and hemiplegia (paralysis on one side of the body), mild neurocognitive disorder with behavioral disturbances , depression and limitation of activities. The Annual MDS assessment, dated 06/27/2024, included the following triggered CAA's: cognitive loss, communication, urinary incontinence and indwelling catheter, psychosocial wellbeing, , mood, activities, falls, nutrition, dehydration/fluid maintenance, pressure ulcer/injury and psychotropic drug use. Review of the admission MDS assessment, dated 06/27/2024, showed the psychotropic drug use, cognitive loss, mood, CAA's did not contain comprehensive summaries or analysis that included the resident's current goals, preferences, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's CP was needed. <RESIDENT 20> Resident 20 admitted on [DATE] with diagnoses to include post-traumatic stress disorder, autistic disorder, bipolar disorder and anxiety disorder. The Annual MDS assessment, dated 12/16/2024, included the following triggered CAA's: psychotropic drug use, cognitive loss/dementia, behavioral symptoms, psychosocial wellbeing, nutrition, and pressure ulcers. Review of the Annual MDS assessment, dated 12/16/2024, showed the psychosocial CAA did not contain comprehensive summaries or analysis that included the resident's current goals, preferences, limitations, strengths or needs for the specific care areas, which were necessary to determine if updates to the resident's CP was needed. The CAA's had documentation of Resident 20's history of depression and autism, but no assessment of how those diagnoses affected the specific care areas. In an interview on 01/07/2024 at 1:47 PM with Staff H, Licensed Practical Nurse (LPN)/MDS Coordinator stated the CAA's should be completed with a summary. Staff H stated that Staff B, Director of Nursing and they audit the CAA's to ensure completion. In an interview on 01/09/2025 at 9:48 AM, Staff G, Social Services, stated they had been in their position for a year and a half and were responsible for the cognition, psychotropic meds and psychosocial wellbeing CAA's for the facility. Staff G stated they identified issues with the CAA's a couple months ago and they started training on the CAA process. Staff G stated they did not complete the areas that were necessary for Resident's 20, 70, 179. Staff G stated Resident 5's nutrition and unnecessary medication CAA's were blank. Staff G stated Resident 4's MDS was not completed timely. Staff G stated they requested training from their complaint nurse last night. 51312 <RESIDENT 5> Resident 5 was admitted on [DATE] and readmitted on [DATE]. A record review of Resident 5's MDS, dated [DATE], showed that the resident had blank triggered CAAs in the areas of pain, activities, and psychotropic medications. In an interview on 01/07/2025 at 1:46 PM, Staff H, stated that they were unaware they were required to fill out CAAs and thought they could just refer to the care plan. 51551 <RESIDENT 4> Resident 4 admitted to the facility on [DATE] and were not receiving hospice services. Review of the Hospice Certification and Plan of Care showed Resident 4 elected their hospice benefit on 11/01/2024. Review of Resident 4's MDS assessments, showed a SCSA dated 11/19/2024 was completed on 12/03/2024, 33 days after hospice service started. <RESIDENT 62> Resident 62 admitted to the facility on [DATE] and were not receiving hospice services. Review of Hospice Certification and Plan of Care showed Resident 62 elected their hospice benefit on 08/06/2024. Review of Resident 62's MDS assessments, showed a SCSA dated 08/19/2024 was completed on 09/05/2024, 31 days after hospice service started. In an interview on 01/07/2025 at 1:46 PM, Staff H stated a SCSA was required when a resident started hospice benefit. In a joint record review and interview on 01/08/2025 at 4:11 PM, Staff B and Staff H stated Resident 4 and 62 were on hospice and their SCSA were completed late. <RESIDENT 66> Resident 66 admitted to the facility on [DATE]. Review of Resident 66's admission MDS assessment dated [DATE], showed the assessment completion date was 09/08/2024, 16 days after admission. Review of CMS (Centers for Medicare and Medicaid Services) MDS 3.0 NH (nursing home) Final Validation report dated 09/10/2024, showed a warning message that Resident 66's assessment care areas were completed late, more than 13 days after admission. Review of Resident 66's Medicare discharge assessment dated [DATE], showed the assessment completion date was 10/10/2024, 16 days after Medicare services ended. Review of CMS MDS 3.0 NH Final Validation report dated 10/11/2024, showed a warning message that Resident 66's Medicare discharge assessment was completed late and the completion date was more than 14 days after Medicare services ended. Review of Resident 66's discharge assessment dated [DATE], showed the assessment completion date was 10/13/2024, 18 days after discharge. <RESIDENT 61> Resident 61 admitted to the facility on [DATE]. Review of Resident 61's comprehensive admission assessment dated [DATE], showed the assessment completion date was 07/18/2024, 18 days after admission. <RESIDENT 55> Resident 55 admitted to the facility on [DATE]. Review of Resident 55's quarterly MDS assessment, dated 08/31/2024, showed the assessment completion date was 09/16/2024, 17 days after MDS date. Review of CMS MDS 3.0 NH Final Validation report on 09/17/2024, showed a warning message that Resident 55's assessment was completed late, more than 14 days after MDS date. In a joint record review and interview on 01/08/2025 at 4:11PM, Staff B and Staff H stated the validation reports showed the assessments were completed late for Residents 66, 61 and 55. Staff B stated they were aware of the late MDS assessments. 47047 Reference: (WAC) 388-97-1000 (b)(c)(ii)(2)(f)(g)(p)(3)(a)

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASRR) accurately reflected the current status for two of seven residents (Residents 45 and 50) and failed to ensure two of seven residents (Resident 5 and 56) were referred for level two evaluations. These failures placed the residents at risk for inappropriate placement and not receiving timely and necessary services to meet mental health care needs. <RESIDENT 50> Resident 50 admitted to the facility 11/01/2023 with diagnoses that included depression and [NAME] Syndrome (genetic condition in which a male has an extra X chromosome which may delay developmental milestones). In a review of Resident 50's provider progress note dated 11/02/2023 showed they had a diagnosis of depression and was taking an psychoactive (medication that can alter thoughts/behaviors) medication for treatment. In a review of Resident 50's care plan, dated 11/06/2023, showed they were prescribed a medication to treat their depression with the goal to reduce the medication at the review date. Interventions included a monitor for behaviors associated with their depression, specifically pacing, wandering, disrobing, inappropriate response to verbal communication, and violence/aggression towards staff/others. In a review of Resident 50's completed level one PASRR, dated 10/26/2023 showed they had not shown serious mental illness indicators, had a serious mental illness or intellectual disability related conditional indicators. In an interview on 01/07/2025 at 10:21 AM, Staff G, Social Services Supervisor, stated they review PASRR's with Staff A, Administrator. Staff G stated the director of admissions reviewed the PASRR prior to a resident's admission. Staff G stated they look for any errors or any missing diagnoses on the PASRR received prior to admission and if any errors were found would complete a new and updated PASRR. Staff G stated that Resident 50, upon admission, had not carried the diagnoses of depression or [NAME]'s syndrome. Staff G stated that PASRR's are reviewed for all residents quarterly and with significant changes for accuracy. In an interview on 01/07/2025 at 12:45 PM Staff A, Administrator, stated Resident 50's PASRR was completed, and the diagnosis of depression was added later. Staff A stated [NAME] Syndrome was not a qualifying diagnosis to indicate an intellectual disability per their discussions with the PASRR coordinator. Staff A stated a new PASRR had been completed to address Resident 50's diagnosis of depression. <RESIDENT 45> Resident 45 admitted to the facility on [DATE] with diagnoses that included adult failure to thrive, post traumatic stress disorder, and major depressive disorder. In a review of Resident 45's electronic medical record on 01/06/2024 showed no completed level one PASRR. Reviewed Resident 45's PASRR Level 2 Invalidation assessment dated [DATE] showed they did not require a level two evaluation as they were discharged from the nursing facility. Review of Resident 45's Level 2 Invalidation assessment dated [DATE] showed that resident was admitted to a different nursing facility and contained conflicting information regarding their diagnoses and indicators of serious mental illness. In an interview on 01/07/2025 at 10:21 AM, Staff G, Social Services Supervisor stated they review PASRR's with Staff A, Administrator. Staff G stated the director of admissions reviewed the PASRR prior to a resident's admission. Staff G stated they look for any errors or any missing diagnoses on the PASRR received prior to admission and if any errors were found would complete a new and updated PASRR. Staff G deferred to Staff A, Administrator related to Resident 45's level one PASRR. In an interview on 01/07/2025 at 12:45 PM Staff A, Administrator stated Resident 45 had a completed level one PASRR, was part of the admission record, and would provide the PASRR once located. No other information was provided or received. In review of Resident 45's medical record on 01/09/2025 a level one PASRR was uploaded on 01/07/2025. The level one PASRR was dated 04/25/2024 and showed Resident 45 was discharged to a different nursing facility. 51551 <RESIDENT 56> Resident 56 admitted to the facility on [DATE] with diagnoses to include depression. Review of Resident 56's provider admission visit note dated 07/30/2024, showed Resident 56 was taking an antidepressant every day for depression. Review of Resident 56's Minimum Data Set (MDS, assessment of care needs) assessments dated 08/04/2024, showed Resident 56 was taking an antidepressant. Review of Resident 56's Level I PASRR dated 07/18/2024, Section IA showed Resident 56 had serious mental illness indicators which included anxiety and depression. Section IV indicated a level II evaluation referral was required for serious mental illness. Review of Resident 56's medical record showed no Level II PASRR was completed prior to the Resident 56's admission to the facility. In an interview on 01/06/2025 at 4:01 PM, Staff A stated there was no PASRR level II evaluation done for Resident 56. 51312 <RESIDENT 5> Resident 5 was admitted on [DATE] and again on 12/11/2024. During an interview on 01/07/2025 at 1:28 PM, Staff G, stated that only Staff A reviews PASARR. During an interview on 01/06/2025 at 4:00 PM Staff A, stated that Resident 5's PASSAR was in their email and it showed an invalidation for PASSR Level II. During a review of Resident 5s records showed they were referred for a PASARR level II 19 days after initial admit to the facility. WAC 388-97-1915 (1)(2)

Based on interview, and record review, the facility failed to ensure three (5, 20, and 50) of six residents reviewed for unnecessary medications, staff failed to followed provider orders in regard to weights and blood sugar (the amount of glucose in your blood) monitoring. These failures placed residents at potential risk of a decline in medical status and quality of life-related to unmet care needs. Findings included . <BOWEL MONITORING> <RESIDENT 20> Resident 20 admitted to the facility on [DATE]. Review of Resident 20's physician's orders showed the resident received Milk of Magnesia (laxative), twice daily and Docusate Sodium (stool softener) once a day for constipation. Review of Resident 20's bowel record showed the resident had no bowel movements (BM) from 12/29/2024 at 9:51 PM until 01/06/2025 at 9:59 PM. Review of Resident 20's progress notes from 12/29/2024 through 01/09/2025 showed no documentation about the constipation, abdominal assessment, or new order for Lactulose (laxative) twice daily ordered on 01/06/2025. In an interview on 01/08/2025 at 1:54 PM, Staff J, Registered Nurse (RN) stated the electronic health record showed them when a resident had not had a BM for 3 days then they would look to see what bowel medications they could administer to them. Staff J stated the nurses were to assess their interventions until the resident had a bowel movement. Staff J stated Resident 20 did not go to the bathroom on their own so if there was no BM documented, they had not had a BM. Staff J reviewed the residents bowel documentation from 12/30/2024 through 01/06/2024 and stated the resident had not had any BMs, so the nurses kept giving them laxatives and laxatives and now they finally had a very, very large BM. <WEIGHT MONITORING> <RESIDENT 20> Resident 20 admitted to the facility on [DATE]. Review of the Weight Committee Interdisciplinary Team (IDT) note dated 11/29/2024, showed Resident 20 had active orders for weekly weights indefinitely. Review of Resident 20's October 2024 Medication Administration Record (MAR) showed no weight entry documented for 10/31/2024. Review of Resident 20's November 2024 MAR showed no weight entry documented for 11/07/2024. Review of Resident 20's December 2024 MAR showed no weight entry documented for 12/10/2024 and 12/17/2024. In an interview on 01/08/2025 at 12:32 PM, Staff L, Licensed Practical Nurse (LPN) stated residents were to be weighed the first three days after admission, then once a week for the first month then the weights are scheduled once a monthly after that. In an interview on 01/08/2025 at 1:46 PM, Staff K, Nurse Aide Certified (NAC) stated some resident's weights were obtained weekly, some daily on admit or monthly. Staff K stated they were told by nurses when to weigh the residents. 47047 Review of the facility policy titled, Diabetes Mellitus Resident/Washington State dated 05/2007; revised 03/2015; 04/2016 showed the facility would recognize and assist in the treatment of complications commonly associated with diabetes notify the resident's physician when blood sugar were out of range per orders, insulin needing to be held, and monitor blood sugar as needed for any change in behavior or symptoms of hyper/hypoglycemia. <RESIDENT 50> Resident 50 admitted to the facility 11/01/2023 with diagnoses that included Type II Diabetes Mellitus (DM, a common disease that occurs when the body doesn't use insulin properly, resulting in high blood sugar levels) and high blood pressure. In an interview on 01/02/2025 at 2:44 PM Resident 50 stated their blood sugar levels were often high, were allowed to get too high, and were a concern to them. Review of Resident 50's care plan as of 01/06/2025 showed no identified focus area related to their diagnosis of type 2 diabetes mellitus. Review of Resident 50's recorded blood glucose (BG-measure of glucose in the blood) for December 2024 showed no entries for the following dates: 12/11/2024, 12/12/2024, 12/13/2024, 12/14/2024, 12/19/2024, 12/20/2024 12/21/2024, 12/22/2024, 12/27/2024, 12/28/2024, 12/29/2024, 12/30/2024, 12/31/2024 and 01/01/2025 through 01/05/2025. Review of Resident 50's MAR for December 2024 showed discontinued physician orders as of 12/10/2024 for Insulin Glargine Subcutaneous Solution 100 UNIT/Milliliter (ML) Inject 31 unit subcutaneously at bedtime for DM hold if BG below 90 and Insulin Glargine Subcutaneous Solution 100 UNIT/ML Inject 44 unit subcutaneously one time a day for DM hold if BG below 90. On 12/10/2024 the MAR showed new orders; Lantus Subcutaneous Solution 100 UNIT/ML Inject 40 unit subcutaneously at bedtime for diabetes Lantus Subcutaneous Solution 100 UNIT/ML Inject 44 unit subcutaneously in the morning for diabetes mellitus type 2 insulin dependent. The MAR showed Resident 50 had not received any insulin at bedtime as ordered on 12/10/2024 and no blood glucose values were documented. The December 2024 MAR included orders as needed for HYPERGLYCEMIC PROTOCOL: Notify physician Immediately if BG is above 400 parameters or too high for meter to read for insulin coverage adjustment. Call Medical Director if unable to reach other physicians. Recheck BG as directed by physician. The December 2024 MAR included as needed orders for HYPOGLYCEMIA PROTOCOL BG below 60: If resident alert, offer fast acting carbohydrate (such as 4 ounces (oz) orange juice, 4 oz Apple Juice, 4 oz, water with two teaspoons sugar added, 1 Tube Glucose Gel, or 3 Glucose Tablets). Check BS every 15 minutes and repeat steps one and three as necessary until BG is above 90. Notify physician of occurrence. Document what is given and notify physician as needed. There were no documented instances on the MAR. Review of Resident 50's provider progress note dated 12/10/2024 showed their blood glucose levels were reviewed from 12/07/2024 through12/09/2024, their insulin was increased, and the plan was to continue to monitor closely. Review of Resident 50's progress note dated 01/06/2025 showed they complained to an aide they felt they had low blood sugar, and their BG was checked and noted to be elevated at 304. In an interview on 01/08/2025 at 11:32 AM Staff S, LPN, stated the protocol for diabetic management with residents who had orders for insulin included a prompt in the electronic medical record to check BG prior to administering which was not dependent on the use of long acting or short acting insulins. Staff S stated Resident 50's insulin was administered in the morning and the BG was checked prior to them being administered insulin. In joint interview on 01/08/2025 at 11:51 AM with Staff F, LPN/Resident Care Manager (RCM) was asked for the policy on insulin management and blood glucose checks, but no information was provided. Staff I, Corporate Registered Nurse, stated there was a direction in the body of Resident 50's insulin order to check BG and then stated it did not look like they had BG checks because they were on a long-acting insulin. Staff I stated they would review Resident 50's clinical record to find information regarding the missing BG checks and would provide additional information. No additional information was provided. In an interview on 01/08/2025 at 2:34 PM Staff B, Director of Nursing stated there was typically supplementary documentation in electronic medical record to document BG based on the physician order. When asked about Resident 50's missing BG checks, Staff B stated Resident 50 had an order for the supplementary document cues to check BG prior to administration of the insulin until they had undergone changes in their insulin dose on 12/10/2024. Staff B stated they would need to speak with the provider to get additional information as to why the BG checks were not added to the supplemental documentation. Staff B stated Resident 50's care plan did not need to contain information about their diagnosis of type two diabetes mellitus and their insulin use because nursing assistants provided personal care to residents only and would not be assessing any symptoms of diabetes. 51312 <RESIDENT 5> Resident 5 was admitted to the facility on [DATE] with a readmitted [DATE]. Review of Resident 5's admission physician orders showed an entry dated 12/11/2024 for weights for three days, and then once a week for four weeks. Review of Residents 5's December 2024 MAR showed that the first weights were completed on 12/13/2024, the second on 12/14/2024, and the third on 12/21/2024. In an interview on 01/08/2025 at 10:19 AM, Staff X, LPN, stated aids were to be notified when a resident needed weight by looking at the KARDEX (worksheet that includes a summary of patient information and tasks). Staff X stated that when a resident had dramatic weight loss, nursing should notify nutrition services and assess the resident's needs. In an interview on 01/08/2025 at 10:45 AM, Staff CC, NAC, stated that when residents are admitted to the facility from the hospital, weights are to be taken 3 days in a row; if a resident has a dramatic weight loss, the nurse should be notified. In an interview on 01/08/2024 at 12:10 PM, Staff F, LPN/RCM, stated aides should be told by nursing staff when a weight was required on a resident. If there are drastic weight changes, staff should automatically re-weight residents. In an interview on 01/08/2025 at 1:56 PM, Staff O, LPN stated nursing staff would tell aides when residents should be weighed, and if there is a drastic change in weight, nursing should notify the provider and try to figure out why it changed. In an interview on 01/08/2025 at 2:17 PM Staff B, stated provider orders for Resident 5 were not followed and that weights should have been verified. Refer to WAC 388-97-1060(1)(2)(b)(3)(h)(i)(4)

Based on interview and record review, the facility failed to review and revise care plans for 1 of 3 residents for falls (179), and 1 of 5 residents for nutrition (20). The failure to review and revise care plans by the interdisciplinary team after each assessment placed the residents at risk for unmet care needs, feelings of boredom, agitation and a diminished quality of life. Findings included: Review of the facility policy titled, Fall Best Practice Guidelines dated 08/2024 showed a post fall assessment/evaluation including recommendations and care plan changes will be completed for all residents who have experienced a fall. The care plan will be completed/updated to include newly identified factors that may have contributed to the fall. The facility will develop an action plan or approaches to be taken in an attempt to prevent further falls based on newly identified facts or risk factors. The facility is to update the resident care guide. <RESIDENT 179> Resident 179 admitted [DATE] with diagnoses to include stroke with hemiparesis (inability to move one side of body) and hemiplegia (paralysis on one side of the body) neurocognitive disorder with behavioral disturbance, seizure disorder, limitation of activities due to disability and impaired mobility. Review of the clinical record showed the resident had 15 falls since admission (06/21/2024, 07/01/2024, 07/16/2024, 07/24/2024, 07/27/2024, 08/31/2024, 09/18/2024, 10/12/2024, 10/17/2024, 11/03/2024, 12/06/2024, 12/10/2024, 12/19/2024, 12/25/2024, and 01/06/2025. Review of the 07/01/2024 at 5:27 AM fall investigation included an additional intervention to check the resident's position and check for incontinence every two hours. These interventions were not added to the care plan. Review of the 08/31/2024 at 5:27 AM fall investigation included an additional intervention to check the residents position every 30 minutes and check for incontinence every 2 hours. These interventions were not added to the care plan. Review of the 10/12/2024 6:45 AM fall investigation included an additional intervention to check the residents position every 30 minutes and check for incontinence every hour. These interventions were not added to the care plan. <RESIDENT 20> Resident 20 admitted on [DATE] with diagnosis to include diabetes. Review of the December 2024 Medication Administration Record showed the resident received Ozempic from 10/24/2024 until it was discontinued on 12/12/2024. Review of the expected weight loss care plan showed the resident was receiving Ozempic (medication prescribed to assist with weight loss). In an interview on 01/08/2025 at 1:54 AM, Staff J, Registered Nurse said that care plans were revised by the resident care managers. In an interview on 01/09/2025 at 9:15 AM, Staff A stated care plans were to be reviewed and updated as needed and also quarterly. No additional information was provided. Reference: (WAC) 388-97-1020 (5) (b)

Based on interview and record review, the facility failed to ensure a resident with a hearing impairment had a base line care plan developed and implemented to provide effective and person-centered care for 1 of 1 resident (Resident 380) reviewed for base line care plans. This failure placed residents at risk of not being informed of their initial plan for delivery of care and services and placed them at risk for unmet needs and possible complications. Findings included . Resident 380 admitted to the facility 12/26/2024, with diagnoses that included paranoid schizophrenia (chronic mental illness that affects a person's thoughts, feelings, and behaviors) and anxiety. The Minimum Data Set (MDS) Assessment (an assessment tool), dated 01/01/2025, showed the resident had mild cognition impairment and had moderate difficulty hearing with no devices. Review of Resident 380's nursing admission assessment dated [DATE], showed the resident had difficulty hearing with no devices to assist. Review of Resident 380's nursing progress notes dated 12/28/2024, 12/30/2024, 01/02/2025, 01/03/2025, and 01/04/2025 showed nursing documentation that the resident had difficulty hearing. Review of Resident 380's care plan on 01/02/2025, showed no focus area for the residents hearing impairment. In an interview on 01/02/2025 at 10:07 AM, Resident 380 was observed sitting in their wheelchair next to their bed. Resident responded to a question I cannot hear very well. The resident was asked if they used hearing aids with an elevated voice, they stated they were not here at the facility. In an interview on 01/07/2025 at 10:32 AM, Staff D, Nursing Assistant Certified (NAC) they determine what level of care to provide to each resident based on the care plan. In an interview on 01/07/2025 at 10:46 AM, Staff E, NAC stated the staff will self-report to each other, however ultimately, they we rely on the care plan for determining the needs of the residents. In an interview on 01/07/2025 at 2:42 PM, Staff F License Practical Nurse (LPN)/Resident Care Manager (RCM) stated that the nursing manager who completes the admission was the responsible for starting the base line care plan. Staff F stated, they use the admission nursing assessments, the discharge report from the discharging facility, the residents' medications, their diagnoses, and needs to build the base line care plan. Staff F, confirmed after reviewing Resident 380's admission nursing assessment, and the MDS that the resident was documented had moderate difficulty with their hearing. Staff F confirmed the resident's hearing impairment was not included in their base line care plan. In an interview on 01/09/2025 at 9:20 AM, Staff A, Administrator stated that the nursing admission assessment was a template, and the nurse was supposed to individualize the interventions for the resident as needed. Staff A stated they do not complete a base line care plan the nurses build the care plan from the start of the admission. Refer to WAC 388-97-1020(3)

Based on interview and record review, the facility failed to identify a Significant Change in Status for 1 of 3 sampled residents (Resident 229) reviewed for hospice services. Failure to identify and complete a Significant Change in Status (SCSA) assessment placed residents at risk for inadequate care planning and a diminished quality of life. Findings included . Review of the Long-Term Care Facility Resident Assessment Instrument, User's Manual, V1.19.1, dated October 2024, showed that a SCSA was required to be performed within 14 days when a resident enrolled in a hospice program. Review of the facility policy titled, Resident Assessment and Associated Process, revised August 2024, showed significant change in status assessments must be completed within 14 days of identification. Resident 229 admitted on [DATE] and were not receiving hospice services. Review of a Hospice Certification and Plan of Care showed Resident 229 elected their hospice benefit on 12/20/2024. Review of Resident 229's Minimum Data Set (MDS, assessment of care needs) assessments since admission showed no SCSA had been completed. In an interview on 01/07/2025 at 1:46 PM, Staff H, Licensed Practical Nurse/MDS Coordinator, stated a SCSA was required when a resident started hospice benefit. In a joint interview on 01/08/2025 at 4:11 PM, Staff B, Director of Nursing, and Staff H stated Resident 229 was on hospice and a SCSA had not been done. Staff H stated they were not sure why the SCSA was not done. Refer to WAC 388-97-1000(3)(b)

Based on observation, interview, and record review, the facility failed to provide assistance with 2 of 3 dependent residents including meal assistance for resident (4) and bathing for resident (179) reviewed for activities of daily living (ADL's). Facility failure to provide resident's, who were dependent on staff for assistance with hygiene including eating assistance and showers placed residents and others at risk for embarrassment, poor hygiene, unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy, Activities of Daily Living , revised July 2015, showed the policy was that nursing assistants will provide assistance with ADL's based on the resident's individualized plan of care. These interventions will be on the Kardex, which Is accessed in Point of Care (POC). <RESIDENT 179> Resident 179 admitted [DATE] with diagnoses to include stroke with hemiparesis (inability to move one side of body) and hemiplegia (paralysis on one side of the body) neurocognitive disorder with behavioral disturbance, seizure disorder, limitation of activities due to disability and impaired mobility. Review of the Quarterly Minimum Data Set assessment, dated 09/27/2024, showed Resident 179 did not reject care. Review of the care plan showed the resident required maximum assistance of one staff for bathing as necessary two times a week. Review of Resident 179's shower records, dated 12/30/2024 through 01/07/2025, showed the resident did not receive showers twice weekly. The resident received a shower on 12/30/2024 and the next shower was 01/07/2025 at 1:59 PM. In an interview of 01/09/2025 at 9:15 AM, Staff A, Administrator stated their expectation was showers were provided as the resident preferred and at least once a week. 47047 Resident 4 admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease (a progressive disease that destroys memory and other mental functions), dysphagia (difficulty swallowing food or liquids), and need for assistance with personal care. <EATING> In an observation on 01/02/2024 at 11:15 AM Resident 4 sat a a round table with three other residents. Observed Staff D, Nursing Assistant Certified (NAC) assisting another resident at the same table as Resident 4. Observed Resident 4 with their meal in front of them until 11:30 AM when Staff T, NAC arrived to assist them. In an observation on 01/03/2024 at 8:55 AM Resident 4 was laying in their bed, low position, and lights off with her breakfast meal tray sitting on their overbed table. Observed Staff U, NAC enter Resident 4's room and stated they were there to assist Resident 4 with their breakfast. In an interview on 01/03/2024 at 9:40 AM Staff U, NAC stated they did not know when Resident 4's breakfast tray was brought to them. Staff U stated they were not sure what time the breakfast trays arrived on the hall and asked Staff S, Licensed Practical Nurse (LPN), when they arrived. Staff S stated they thought trays arrived at 7:30 AM. Staff U stated breakfast trays typically arrive on the hall between 7:30 AM and 8:00 AM. Staff U stated they were Resident 4's assigned NAC. Staff U stated another NAC had delivered Resident 4's tray to their room. When asked if Resident 4 is able to feed themselves without assistance, Staff U stated they needed assistance, and their hands were shaky. Staff U stated Resident 4 required one to one feeding assistance from an aide. When asked why Resident 4 had not been assisted until 8:55 AM they stated they did not believe Resident 4 had waited that long. Staff U stated when they have a resident who required one on one assistance, they leave their meal in the meal cart until they are ready to assist them to eat. Staff U stated Resident 4 had pancakes, eggs, cream of wheat, and orange juice and did not eat their meal until they were assisted by them. Review of Resident 4's care plan dated 02/20/2019 showed they required assistance from staff for their activities of daily living (ADL) and care. Resident 4's care plan showed they required set up assistance to eat. Review of Resident 4's Kardex (resident specific guide that nursing assistants how to provide care) as of 01/08/2025 showed they required set up assistance to eat. Review of Resident 4's Annual MDS dated [DATE] showed they received set up assistance with eating. Review of Resident 4 progress notes dated 09/04/2024 showed resident required assistance with meals. Review of documentation completed by NAC's for eating for January 2025 showed Resident 4 was dependent on staff for eating 14 out of 24 opportunities. In an interview on 01/08/2025 at 4:06 PM Staff B, Director of Nursing Services, stated Resident 4 required maximum assistance. When asked about assistance Resident 4 required for eating, Staff B stated per nursing aide documentation, they were dependent on staff for eating. Staff B stated they did not know if Resident 4 could participate in any ADL and would need to research it further. Staff B stated care plans are changed and updated as facility assessments are done and through any changes in the resident's condition. <CALL LIGHT> On 01/03/2025 at 9:35 AM observed Resident 4's call light clipped to the lower left portion of their pillowcase, out of reach of the resident, and hanging past the mattress close to the floor. On 01/08/2025 at 11:49 AM observed Resident 4 lying in bed, their call light on the floor, several feet from their bed. On 01/08/2025 at 4:17 PM observed Resident 4's call light on the floor in the same spot as 11:49 AM. Resident 4 was not in their room. On 01/09/2025 at 9:00 AM Resident 4 was observed sleeping in their bed and the call light was out of reach; observed hanging on the wall. In an interview on 01/08/2024 at 4:17 PM Staff V, Registered Nurse, stated Resident 4 used their call light at times. Staff V stated Resident 4 should have their call light clipped to their sheet and always be within reach of the resident. Review of Resident 4's care plan dated 03/04/2019 directed nursing to have the call light within reach of the resident. Refer to WAC 388-97-1060(1)(2)(c)

Based on observation, interview, and record review the facility failed to provide respiratory care consistent with professional standards of practice for 1 of 1 residents (Resident 45) reviewed for respiratory care. Failure to follow provider's orders for oxygen (O2) therapy placed the resident at risk for unmet needs, potential negative outcomes and a diminished quality of life. Findings included . Review of the facility policy titled, Oxygen Administration dated 05/2007, revised 04/2016; 07/2019 showed it was the policy of the facility that oxygen therapy is administered as ordered by the physician or as an emergency measure until the order could be obtained. Resident 45 admitted to the facility on [DATE] with diagnoses that included pulmonary fibrosis (a lung disease that causes scaring in the lungs making it difficult to breathe) and congestive heart failure (CHF-a chronic condition in which the heart doesn't pump blood as quickly as the body needs). In an interview on 01/02/2025 at 2:12 PM Resident 45 stated the concentrator (a medical device that administers O2) settings for their O2 should be set to 3 liters per minute (lpm). Resident 45 stated they do not change the settings on their concentrator and the concentrator was in the bathroom to decrease the noise it makes. In an observation on 01/02/2025 at 2:12 PM Resident 45 was wearing a nasal cannula (device used to deliver supplemental oxygen through the nose) plugged into the concentrator which was in the bathroom. The settings on the concentrator were set at 3.5 lpm. In an observation on 01/06/2025 at 9:57 AM Resident 45 was in their bed, lying flat, wearing a nasal cannula attached to the concentrator, the concentrator set at 3.5 lpm. In a review of Resident 45's care plan dated 11/24/2024 showed they had oxygen therapy related to a diagnosis of CHF; interventions included the application of O2 by nasal cannula at 3 lpm continuously to keep their O2 saturations (amount of O2 in the blood) above 88 percent (%). In a review of Resident 45's progress note dated 01/03/2025 showed they refused their O2, wanted the concentrator in the bathroom, had a O2 saturation of 85%, and was given 4 lpm of O2 to increase their saturations. Review of Resident 45's January 2025 Treatment Administration Record (TAR) showed they had a physician order dated 12/11/2024 for O2 by nasal cannula at 3 lpm continuous. In an interview on 01/07/2025 at 2:15 PM Staff AA, Registered Nurse, stated when there is an order for O2 a concentrator is obtained for the resident, made sure there is an O2 sign placed on their door, checked O2 settings every shift, and checked O2 saturations every shift. Staff AA stated the functioning of the concentrator is checked every shift and the settings are checked to make sure they are set per the physician order. In an observation and interview on 01/07/2025 at 2:33 PM Staff F, Licensed Practical Nurse/Resident Care Manager stated Resident 45's physician orders for O2 was 3 lpm. Observed Staff F review the settings on Resident 45's concentrator and stated the settings were set to 3.25 lpm. Observed Staff F adjust the setting on Resident 45's concentrator to 3 lpm. In an interview on 01/08/2025 at 10:30 AM Staff A, Administrator, stated Resident 45 adjusted their settings on their concentrator and the care plan and notes had been updated. No other information was provided or obtained. Refer to WAC 388-97-1060(3)(j)(vi)

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing form was accurately completed with actual hours worked for each shift for 5 of 6 days (01/02/2025, 01/03/2025, 01/06/2025, 01/07/2025, and 01/08/2025), reviewed for sufficient and competent staffing. This failure placed the residents and residents' representatives at risk of not being fully informed of the current staffing levels. Findings included . In observations on 01/02/2025 at 9:46 AM, 11:06 AM, 1:55 PM, and 3:05 PM, the facility's daily nursing staffing form posted did not show the actual hours worked for nursing staff. In observations on 01/03/2025 at 9:11 AM, 12:06 PM, and 2:48 PM, the facility's daily nursing staffing form posted did not show the actual hours worked for nursing staff. In observations on 01/06/2025 at 9:48 AM, 12:33 PM, and 3:02 PM, the facility's daily nursing staffing form posted did not show the actual hours worked for nursing staff. In observations on 01/07/2025 at 10:50 AM, and 2:27 PM, showed that the facility's daily nursing staffing form posted did not show the actual hours worked for nursing staff. In an interview on 01/07/2025 at 2:28 PM, Staff C, Staffing Coordinator stated they were responsible for posting the daily staffing at the nurse's station daily. Staff C stated that they update the sheet with the actual hours worked the following day with the exact hours worked based on the time punches. A request for the previous last seven days was requested. In observation on 01/08/2025 at 8:55 AM, showed that the facility's daily nursing staffing form posted did not show the actual hours worked for nursing staff. In an interview on 01/08/2025 at 9:47 AM, Staff C stated they had been able to locate the sheets for the daily actual staffing hours. Staff C was asked again when they update the actual section of the daily sheet, Staff C stated the following day when they can calculate the total time punches from all the staff. Staff C was asked if they were aware that the section (on the staffing sheet) for actual hours worked was to be updated at the beginning of each shift. Staff C stated they were not aware that was required. In an interview on 01/09/2025 at 11:10 AM, Staff A stated that the daily staffing posting was updated every 12 hours, as they had some staff that worked 12-hour shifts. Staff A was advised that on all observations during the survey period, and that there had been no updates observed to the daily staffing sheet, nor did the staffing coordinator understand the requirement that they were to update in real time after each shift. No further information was provided. No associated WAC

Based on interview, and record review, the facility failed to address emotional and psychosocial well-being through assessment, care plan development and implementation for one of two residents (53), reviewed for individualized behavioral health needs. This failure placed residents at risk of unmet emotional and psychosocial health needs, unwanted behaviors, and a decreased quality of life. Findings included . Resident 53 admitted [DATE] with diagnoses which included a stroke and aphasia (effect of a stroke causing difficulty with verbal expression and/or comprehension) and dementia without behavioral disturbance. The resident's most recent entry following a hospitalization was 11/29/2024. According to the most recent Quarterly Minimum Data Set (MDS- an assessment tool) assessment dated [DATE], showed Resident 53 did not participate in the cognitive interview documented as rarely or never understood, with short term and long-term memory problems, no verbal or physical behaviors directed toward others and no other behaviors (not directed toward others) which included verbal/vocal symptoms such as screaming or other disruptive sounds. Review of Resident 53's care plan on 01/03/2024 showed the facility would: - Monitor/report/document signs and symptoms of depression and obtain mental health consult as needed. - Stop and return if agitated. - Avoid isolation. - Monitor and document effectiveness of communication and indicators of distress. - Refer to psychiatry. Review of resident 53's progress notes dated 11/29/2024 through 01/03/2024 showed one progress note on 12/27/2024 stating the resident yelled intermittently throughout the shift and one note on 12/28/2024 stating the resident yells out at times. Review of the task documentation for nursing assistants on 01/03/2024 showed no option for nursing assistants to document behavioral symptoms for Resident 53. Review of the Medication and Treatment Administration records since Resident 53's re-admission on 11/29/2024 showed there was a space for nurses to document target behaviors for the resident's antidepressant medication which included agitation, aggression, psychosis, and inappropriate behaviors. The monitor showed day shift and evening shift had an option to chart the number of instances of target behavior but there was no option to specify which behavior was exhibited. Night shift had only check marks with no specific data of any kind. The monitor showed on 12/05/2024 there were three instance of target behavior (unspecified), one instance on 12/06/2024, one instance on 12/17/2024, and one instance on 12/23/2024. There were no corresponding progress notes for those dates to specify what behavior was exhibited or any interventions attempted. Review of Resident 53's administration record further included as needed documentation of interventions for staff to implement, which included: activity, adjust room temperature, back rub, change position, give fluids, give food, redirect, refer to nurses' notes, remove from environment, return to room, toilet, and other. There was no documentation of any interventions attempted since 11/29/2024. In an observation on 01/02/2025 at 9:51 AM Resident 53 was in their bed yelling out in a repetitive distressed manner. Several staff responded in attempts to determine Resident 53's need and just after staff would exit the room, Resident 53 would resume repetitive yelling. In an interview and observation on 01/02/2025 at 10:51 AM, Resident 53 was yelling and banging on the side of their bed. Resident 13 (Resident 53's roommate) was lying in their bed with headphones on and stated this goes on all day and all night since they admitted on [DATE]. Resident 13 stated they were frustrated and tired and felt like someone should be doing something more for them (Resident 53). In an observation on 01/02/2025 at 10:53 AM, Resident 53 was calling out in a distressed manner chanting ah ah ah ah ah. In an observation on 01/02/2025 at 10:58 AM, Resident 53 yelling hello, hello. In an observation on 01/03/2025 at 8:56 AM, Resident 53 was sitting upright in bed yelling out hello, hello, holding their right hand up in the air, hand in flexed position and pushing on the overbed table. Staff P, Certified Nursing Assistant, responded and lowered the table and the resident was observed to nod. In an observation on 01/03/2025 at 9:14 AM, Resident53 was yelling hello, hello no call light on, the call light was observed clipped on the top of corner of the resident's mattress. In an observation and interview on 01/03/2025 at 9:16 AM, began yelling hello, hello. Staff Q, Certified Nursing Assistant, entered the room and was observed talking to the resident. Staff Q exited the room and stated Resident 53 does not like to get out of bed. Staff Q stated the staff can usually figure out what the resident is asking for but sometimes they get upset. It is typically the same kinds of things like wanting water or moving their table or changing their television channels. Staff Q stated this is normal for the resident; to yell out . they are used to it. In an interview on 01/03/2025 at 9:25 AM, Resident 53 was observed to use their bed controller to self-adjust the head of their bed. In an observation on 01/03/2025 at 9:26 AM, Resident 53 began yelling hello, hello. Staff P, Certified Nursing Assistant responded and assisted the resident to change the TV channel, Resident 53 was observed to laugh and smile at the TV. Staff P stated Resident 53 just yells out, (they) can use their call light, but they won't use it. It can be right next to their hand, but they won't use it, stated Staff P. Resident 53 again yelled out hello, Staff P stated, like that .they will just yell. Staff P stated they did not know if there was a place to chart Resident 53's disruptive behavior. In an interview and observation on 01/03/2025 at 12:59 PM, Resident 8 was lying in bed with the privacy curtain closed between their bed and the middle bed and stated (Resident 53) yells, the nurses come in and out constantly, and as soon as they leave it starts over, (Resident 53) will start yelling again and nobody cares. Resident 53 was observed to begin grabbing the privacy curtain and pulling it open while yelling out. Resident 8 stated there was an agreement about the privacy curtain and that yesterday (Resident 53) had it open and today was their day to have it closed and (Resident 53) is not following the agreement. Staff R, Certified Nursing Assistant, attempted to intervene, and attempted to close the curtain as Resident 8 requested, but stated (Resident 53) won't let go, they want it to be open. Staff R called for assistance from management and social services. In an interview and observation on 01/03/2025 at 1:04 PM, Resident 53 was pulling on the privacy curtain to attempt to open it and yelling repetitively. Resident 8 grabbed the privacy curtain and began pulling it back to closed stating (they) want it open and I want it closed, this is all the time, it is my curtain too. Both residents had a grip on the privacy curtain attempting to pull it in opposite directions. In an interview on Staff A on 01/03/2025 at 1: 10 PM, Staff A stated they were reaching out to the family of Resident 53 to facilitate a room change for Resident 53 to a more compatible roommate. Staff A stated the family of Resident 53 had not been agreeable to a mental health consultation earlier on. In an interview on 01/09/2025 at 08:45 AM, Staff A and Staff B, Director of Nursing Services were made aware of the lack of consistent assessment, monitoring, documentation and evaluation of interventions related to Resident 53's behaviors and Staff A stated they had received approval from the resident's family to pursue behavioral health support. Refer to WAC 388-97-1060 (3)(e)

Based on observation, and interview the facility failed to ensure one of four medication carts had unsecured medications. In addition, the facility failed to ensure medications were secured and not accessible to residents for two of two (70 and 75) residents. These failures placed residents at risk for unauthorized access to medications and biologicals, and potential drug misuse. Findings included . Review of the facility policy titled, Storage if Medications dated May 2022 showed Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Review of the facility policy titled, Bedside Medication Storage effective May 2022 showed bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgment of the facility's interdisciplinary resident assessment team. <MEDICATION CART A> In an observation and interview on 01/08/2025 at 1:56 PM, Staff O, LPN left an insulin pen unattended on the cart under the computer screen. The pen had medication in it but is not labeled with a resident name. At 1:58 PM, Staff O returned to the cart and was alerted to the unattended unlabeled insulin pen. Staff O said they would look at all the insulin lids in the drawer in order to find out who has a missing lid in the drawer. Was looking for that. Found it and put a pen in a drawer with resident label. <UNATTENDED MEDICATIONS> <RESIDENT 70> In an observation on 01/02/2025 at 10:27 AM, Resident 70 was in bed and located on their nightstand to their right were artificial eye drops, nasal spray, Walgreens oral throat spray, antifungal powder, and Diclofenac Sodium External Gel (Topical pain reliever). Resident 70 stated Those are just medications the nurses can use if they need to after they assess me. I put the Diclofenac gel on my knees to help the pain. Review of the physician's orders showed no orders for the eye drops, nasal spray, antifungal powder. In an observation on 01/03/2025 at 10:29 AM, the resident was in bed and the eye drops, nasal spray, Walgreens oral throat spray, antifungal powder, Diclofenac Sodium External Gel, remained in the same location at bedside. In an observation on 01/06/2025 at 8:35 AM, the resident was in bed watching TV and the eye drops, nasal spray, Walgreens oral throat spray, antifungal powder, Diclofenac Sodium External Gel remained in the same location at bedside. In an observation on 01/07/2025 at 8:20 AM, the resident was in bed on their right side and the eye drops, nasal spray, Walgreens oral throat spray, antifungal powder, Diclofenac Sodium External Gel remained in the same location at bedside. In an observation on 01/08/2025 at 9:08 AM, the resident was in bed watching TV and the eye drops, nasal spray, Walgreens oral throat spray, antifungal powder, Diclofenac Sodium External Gel remained in the same location at bedside. In an observation on 01/09/2025 at 8:52 AM, Resident 70 was in bed asleep on their side with the medications still present. Review of the clinical record showed there was no self-medication program assessment, physician order or self-medication administration care plan for Resident 70. <RESIDENT 75> In an observation on 01/02/2025 at 11:27 AM, Resident 75 was resting in bed. There was Albuterol inhaler on their overbed table. Resident 75 said they kept the inhaler there for when they need it. In an observation on 01/03/2025 at 9:38 AM, Resident 75 was in bed and the Albuterol inhaler remained in the same location on the overbed table. In an observation on 01/06/2025 at 10:01 AM, Resident 75 was in bed asleep. The Albuterol inhaler was partially covered with a napkin. In an interview and observation on 01/06/2025 at 12:50 PM, Resident 75 was in bed watching TV with the Albuterol inhaler at bedside. The resident said they used the inhaler several times a day and wanted to keep it at bedside, to so they didn't have to wait 40 minutes for it when they needed it. They stated, When I need it, I need it. The resident said staff told then to put the inhaler away, but they wanted to keep it nearby. In a similar observation on 01/06/2025 at 2:28 PM, Resident 75 was resting in bed with the inhaler on their overbed table. Review of the clinical record showed there was no self-medication program assessment, physician order or self-medication administration care plan for Resident 75. In an interview on 01/08/2025 at 12:32 PM, Staff L, Licensed Practical Nurse said there were no residents on self-medication programs. In an interview on 01/08/2025 at 1:54 PM, Staff J, Registered Nurse said they had no residents on self-medication program. Staff J said if a resident were on Self Medication Program, the nurses would need to talk to the provider, assess the resident and care plan if they were safe to self-administer their medications. Staff J said they would not leave the medications in the room with the resident. They would bring the resident the medications when they would be taking the meds. In an interview on 01/09/2025 at 9:15 AM, Staff A, Administrator was notified Resident 75's Albuterol inhaler at bedside and Resident 70's medications at bedside. Staff A said family was supposed to be picking up Resident 70's medications. Staff A said the expectation was residents should be assessed for self-medication program; the care plan should reflect that, and the medications should be safely stored. Reference: (WAC) 388-97-1300 (2)

Based on interview and record review the facility failed to ensure one of three residents (1) reviewed for abuse were free from abuse. The facility failed to re-educate all staff on abuse and neglect following the abuse, re-educate staff on how to manage residents exhibiting behaviors, and to monitor the resident for signs of psychosocial harm. Based on the reasonable person concept this failure would have caused psychosocial distress to Resident 1 who was verbally abused by a staff member while experiencing respiratory distress and placed other residents at risk for staff to resident or resident to resident abuse. Findings included . Review of the facility Abuse Prevention & Investigation policy, revised 4/2019, Each resident has the right to be free from abuse. Residents must not be subjected to abuse by anyone, included but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members, legal guardians or surrogates, friends or any other individual. Also, Any employee determined to be guilty of abuse; neglect or mistreatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Review of provider progress note dated 04/22/2022, Resident 1's chest x-ray showed pneumonia, heart failure, and fluid build-up in their lungs. The resident was alert to self only and was noted to be agitated, irritable, and confused. The resident was placed on end-of-life comfort measures. Review of all progress notes on 04/22/2022, revealed no documentation of the verbal abuse or monitoring for psychosocial distress related to staff yelling at them. There was no documentation in the progress notes indicating Resident 1's son had been notified of the verbal abuse and their response to the notification. Review of the progress note on 04/22/2022 at 10:30 PM, revealed the resident had passed away. Review of a facility investigation dated 04/22/2022, revealed Staff A, Nursing Assistant (NA), was overheard telling a resident to stop yelling and that there was nothing more they could do for them. Upon investigation, Staff B, Registered Nurse, observed Staff A standing at the end of Resident 1's bed yelling at the resident to be quiet. The resident was observed to not be yelling and was in distress stating they could not breathe. Staff A was removed from the resident's room. The facility substantiated verbal abuse. The investigation did not include any documentation of staff re-education for management of residents with behavioral issues. Staff A returned to her previous position as a NA following completion of the investigation. Further review of the facility investigation showed the Director of Nursing Service (DNS) indicated abuse/neglect in services were completed for staff. Review of sign-in sheets for All-Staff in-service dated 04/25/2022, which included Abuse/Neglect education, revealed only 22 staff signatures. Review of the staff Covid-19 matrix dated 05/20/2022 revealed the facility had 95 employees. Requested of the DNS education provided to Staff A prior to the abuse incident, regarding handling residents with behaviors/difficult residents. On 05/26/2022, the DNS provided certificates of completion for training on abuse and neglect, effective communication, and dementia care: normal aging versus dementia/Alzheimer's; all dated in October 2021. There was no documentation of handling residents with behaviors/difficult residents. In an interview on 05/20/2022 at 12:15 PM, the DNS stated Staff A was permitted to continue working at the facility after suspension for the investigation of verbal abuse. In an interview on 05/25/2020 at 12:38 PM the DNS stated they thought they re-educated most staff on abuse and neglect after Resident 1's verbal abuse investigation. The DNS stated for staff who did not attend the abuse and neglect training at their all-staff meeting on 04/25/2022, the facility would catch them on their next day at work and if that did not happen would make phone calls. After showing the DNS the sign-in form for the in-service, they brought another sign-in form dated 04/15/2022, which was prior to the incident on 04/22/2022. The DNS stated they did not re-educate all NA staff on providing care for residents with behavior issues. Reference WAC: 388-97-0640 (1)

Based on observation, interviews, and record reviews, the facility failed to ensure that two of four residents (49 and 51) reviewed for pressure ulcers received care and services to prevent, monitor, and treat pressure injuries. This failure resulted in both residents' deep tissue injuries to progress into advanced stages of pressure ulcers resulting in gangrene and amputation of Resident 49's right above the knee lower extremity, constituting an immediate jeopardy. Refer to initial comments page for information pertaining to immediate jeopardy identified on 04/21/22. Findings included . Review of the facility's policy titled Skin monitoring and management dated 06/2016, indicated it is the policy of this facility that: 1. A resident who enters the facility without pressure injury does not develop pressure injury .and a resident having pressure injuries receives necessary treatment, and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. On 04/21/2022 at 6:20 PM, Staff E, the Oversight Administrator (OA), Staff F, Chief Officer of Operations (COO), and Staff I Registered Nurse (RN)/Clinical Resources, were notified that the facility's failure to ensure Resident 49 was provided care and services to prevent them from sustaining a PU constituted immediate jeopardy at F686-J: Treatment/Services to Prevent/Heal Pressure Ulcers. The immediate jeopardy was determined to first exist on 01/03/2022, when the facility discovered Resident 49 had sustained a deep tissue injury that became worse and infected, resulting in an amputation. The facility presented an acceptable plan for removal of the immediate jeopardy on 04/22/2022 at 4:55 PM. The survey team validated through observations, interviews, and document review, that the facility immediate jeopardy was removed on 04/23/2022 at 10:45 AM following the facility's implementation of the plan for removal of the immediate jeopardy. The deficient practice remained at a G (isolated with actual harm) scope and severity following the removal of the immediate jeopardy. RESIDENT 49 Review of Resident 49's undated Admission Record located in Resident 49's electronic medical record (EMR) under the Profile tab, indicated Resident 49 was initially admitted on [DATE] with a readmission on 03/10/2022. Resident 49's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 49's quarterly Minimum Data Set (MDS), located in the EMR under the tab MDS, with an Assessment Reference Date (ARD) of 10/25/2021, (prior to resident's pressure ulcer), revealed a Brief Interview for Mental Status (BIMS) score of 14 out of 15, which indicated Resident 49 was cognitively intact. This MDS assessment revealed Resident 49 did not exhibit any behaviors, including the rejection of care and was assessed as being at risk for developing pressure ulcers/injuries. There were no pressure ulcers/injuries documented at the time of this MDS assessment. This MDS assessed Resident 49 as requiring extensive assistance of one person for bed mobility and transfers. Review of Resident 49's Care Plan located in Resident 49's EMR under the Care Plan tab, revealed Resident with history of pressure area to her right heel and potential for further pressure ulcer development related to impaired mobility, bladder incontinence, history of malnutrition, refusals of showers/bathing at times, muscular [CONDITION(S)], [CONDITION(S)], and history of [CONDITION(S)] ([CONDITION(S)]) with left-sided hemi (paralysis of one side of the body) -date initiated: 08/23/2019, revised history of deep tissue injury (DTI) to right medial heel related to her putting pillow at foot of bed causing increased pressure to area- resolved 05/21/2020. Revision: refusal to wear off-loading boots; right medial blister 02/2019- resolved 02/24/2021, and right heel boggy 02/24/2021. Interventions includes . float heels, has pressure reducing mattress on her bed . needs monitoring/reminding/assistance to turn/reposition, notify nurse immediately of any new areas of skin breakdown: Redness, Blisters, Bruises, discoloration noted during bath or daily care . Off-loading boot on right heel at all times when in bed . resident to be followed by [a contracted wound care service] for assessment and treatment recs to wound . and weekly head to toe skin at risk assessment. Review of Resident 49's quarterly MDS located in the EMR under the MDS tab, with an ARD date of 01/14/2022 (after the identification of a deep tissue injury) revealed a BIMS score of 11 out of 15, which indicated Resident 49 was moderately cognitively impaired. The assessment revealed the resident did not have any behaviors, including the rejection of care and skin conditions indicated the resident has a pressure ulcer/injury . Review of Resident 49's Physician Orders, Progress Notes, Treatment Administration Record (TAR), wound care notes located in Resident 49's EMR for the Months of January, February, and March 2022 revealed the following orders were not completed on the noted dates: -01/27/22 Right heel wound: Cleanse with NS, pat dry, apply iodasorb (a medication used for wound treatment) to wound bed, secure with super absorbent dressing every dayshift for DTPI. This was not completed on dates: 01/29/2022, 01/30/2022, 02/10/2022, 02/19/2022, 02/22/2022, and 02/27/2022. - Offload bilateral heels at all times(sic) while in bed every shift. This was not completed on dates: 01/17/2022(nights), 01/23/2022 (days) 01/29/2022(days) and 01/30/2022 (days), 02/02/2022 (nights), and 02/27/2022 (nights); - Offloading boots to bilateral heels at all times(sic) while in bed. Document compliance every shift for Right heel wound. This was not completed on dates: 01/17/2022 (nights), 01/23/2022 (days), 01/29/2022(days), 01/30/2022 (days), 02/02/2022 (nights), and 02/27/2022 (nights); and - Left heel treatment: Cleanse with NS, pat dry, paint with [MEDICATION(S)]. Ensure black off-loading boot is in place! Every-day shift for boggy and unblanchable (assessment sign to indicate pressure injury) heel. This was not completed on 02/19/2022. Review of the Licensed Nurse (LN)-Skin Evaluation dated 01/06/2022, located in Resident 49's EMR under the Assessment tab, revealed Weekly skin assessment done . [CONDITION(S)] and blanching noted on both heels and resident is encouraged to offloading heels, no new open area or new impairment noted. Review of Resident 49's LN-Skin Evaluation dated 01/19/2022, located in Resident 49's EMR under the Assessment tab, revealed . Right heel also has a healing wound covered with dressing and a brace over it. No other open skin and other skin issues noted. Review of Resident 49's LN-Skin Evaluation dated 01/26/2022, located in Resident 49's EMR under the Assessment tab, revealed wound nurse changed this patient's right heel dressing as ordered by the doctor on weekly wound rounds . otherwise this patient's skin is warm dry and intact without open areas. Review of Resident 49's LN-Skin Evaluation dated 02/02/2022, located in Resident 49's EMR under the Assessment tab, revealed .Right heel also has a healing wound covered with dressing and a brace over it. No other open skin and other skin issues noted. Skin warm dry with good turgor. Review of Resident 49's LN-Skin Evaluation dated 02/16/2022, located in Resident 49's EMR under the Assessment tab, revealed resident's skin is clean, dry and intact, adequate skin turgor and elasticity, resident is assessed by wound team for right heel wound and dressing is changed by wound team, no new skin impairment and open area noted, wound care team management (WCTM). Review of Resident 49's LN-Skin Evaluation dated 02/24/2022, located in Resident 49's EMR under the Assessment tab, revealed Weekly skin assessment completed, resident's skin is clean, dry and intact, adequate skin turgor and elasticity, resident is assessed by wound team for right heel wound and dressing is changed by wound team, [MEDICATION(S)] is applied at left heel, no new skin impairment and open area noted, WCTM. Review of Resident 49's LN-Skin Evaluation dated 03/02/2022, located in Resident 49's EMR under the Assessment tab, revealed Weekly skin assessment completed, resident's skin is clean, dry and intact, adequate skin turgor and elasticity, resident is assessed by wound team for right heel wound and dressing is changed by wound team, [MEDICATION(S)] is applied at left heel, Resident's right heel wound is getting worse exudate drainage and Eschar noted . Review of Resident 49's Progress Notes dated 03/03/2022, located in Resident 49's EMR under Progress notes, revealed resident has DTI (deep tissue injury) right heel and left heel wound infection, right heel wound condition got worse as unstageable pressure ulcer with necrosis and eschar, (practitioner notified), ordered to transfer the resident to hospital as resident need aggressive treatment . Review of practitioner's Progress Note dated 03/24/2022, located in Resident 49's EMR, under Misc. tab, revealed .initially presented to [medical center] on 03/03/2022 for worsening of chronic bilateral heel pressure ulcers. In the emergency room (ER), patient received antibiotics and intravenous fluids, and admitted for further care. During the hospital course the patient was treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . During hospital course, patient underwent right above knee amputation (AKA) .family has elected to place resident on Hospice care. During an interview with Licensed Practical Nurse (LPN) Staff J, on 04/21/2022 at 1:18 PM, Staff J was asked what does it mean when she does not initial a box on the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] ? Staff J stated, that means the order was not done, basically if not documented, not done. Staff J was asked if Resident 49 has ever refused care, such as, repositioning, off-loading boots, etc.? Staff J stated, No, not that I am aware of. During an interview conducted with the Advanced Registered Nurse Practitioner (ARNP) Staff G on 04/21/2022 at 1:34 PM, Staff G was asked what her expectations were of nursing related to wound care and wound care prevention orders? Staff G stated, I would expect the order to be completed, and if it can't be done, then it needs to be documented why not. Staff G was questioned concerning Resident 49's wound care and if the treatment were not completed what would be the outcome? Staff G stated, if a dressing change is not completed there is always an increased risk of infection to the wound. During an interview with the registered nurse (RN) Staff O on 04/21/2022 at 2:24 PM, Staff O stated she had researched the orders and dates of missing documentation and confirmed the care and treatments were not completed. RESIDENT 51 Review of Resident 51's Admission Record, located in the EMR under the Profile tab, revealed Resident 51 was admitted to the facility on [DATE] with a primary diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 51's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 03/24/2022 revealed a Brief Interview for Mental Status (BIMS) was not conducted. No behavioral disturbances or refusal of care was noted on the MDS. Resident 51's self-performance functional status included extensive assistance/one-person physical assistance with bed mobility, toileting, bathing, personal hygiene, and transfers; dressing required extensive assistance/two-person physical assistance. Resident 51 was incontinent of bowl and bladder upon admission. This MDS indicated Resident 51 was at risk of pressure ulcers but did not have any pressure ulcers upon admission. Review of Resident 51's admission skin assessment, dated 03/18/2022 located in the EMR under the Assessments tab revealed the resident was admitted with altered mental status post [MEDICAL RECORD OR PHYSICIAN ORDER] . General skin condition was noted to be normal with bilateral heels soft, mushy. No redness or open area noted. Review of Resident 51's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Float heels while in bed; Monitor q [every] shift for further impairment every shift. Review of Resident 51's baseline care plan dated 03/19/2022 included an ADL (activities of daily living) Self Care Performance section which indicated Resident 51 required two-person maximum assistance with bed mobility . offload bilateral heels while in bed, pressure relieving mattress, and encourage to turn and reposition. Review of Resident 51's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's progress notes indicated weekly skin checks were performed, treatment records indicated heels were floated, however during three observations on 04/19/2022 at 10:52 AM, 04/22/2022 at 9:52 AM, and 04/22/2022 at 4:48 PM the resident was not wearing foam boots as prescribed. Observation on 04/19/2022 at 10:52 AM revealed Resident 51 lying in her bed with her eyes closed lying on her back. Foam boots were not in place to bilateral feet as ordered by physician. Observation on 04/22/2022 at 9:52 AM revealed Resident 51 was in her bed, with head of bed at approximately 30-40 degrees, appeared comfortable, awake and watching television. Foam boots were not in place to bilateral feet as ordered by physician. Interview on 04/22/2022 at 2:33 PM with LPN Staff HH confirmed Resident 51 was lying on her back with head of bed elevated approximately 45 degrees. Staff HH confirmed Resident 51 was not wearing foam boots to bilateral feet and confirmed Resident 51's foam boots were sitting on their wheelchair in the resident's bedroom. Observation on 04/22/2022 at 4:48 PM revealed Resident 51 was lying in bed with the head of bed at approximately 50 degrees with foam boots sitting on the wheelchair next to the closet, resident was feeding herself finger foods. Interview on 04/19/2022 at 11:24 AM with Licensed Practical Nurse (LPN) Staff FF stated the resident is non-compliant with turning and repositioning as well as being bedbound (not able to get up on their own). Interview on 04/19/2022 at 11:28 AM with Resident 51 revealed the resident was not able to state if she had any skin breakdown due to [CONDITION(S)] (difficulty understanding and formulating language due to stroke). Interview on 04/20/2022 at 1:33 PM with Certified Nursing Assistant (CNA) Staff CC stated that the CNA's encourage Resident 51 to transfer to their chair, but the resident refuses and staff are instructed to turn and reposition every two to three hours every shift. Interview on 04/20/2022 at 2:12 PM with Resident Care Manager Staff BB stated Resident 51 was more accepting of care currently than she was upon admission (03/18/2022). Staff BB confirmed that CNAs are expected to turn and reposition bedbound residents every two to three hours and as needed. Interview on 04/22/2022 at 2:58 PM with Resident Care Manager Staff BB reviewed Resident 51's EMR entries and confirmed that Resident 51 had an order dated 04/13/2022 for foam boots to be worn at all times while in bed; additionally, she stated the resident will not keep on the foam boots they kicks them off. During an interview with the Director of Nursing Services (DNS) Staff K on 04/21/2022 at 1:42 PM, Staff K was asked what is expected of the nursing staff related to physician orders? Staff K stated, it is expected that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] ? Staff K stated, it would be expected to be documented if a resident refuses treatment. Reference: (WAC) 388-97-1060 (3)(b)

Based on observations, interviews and record review, the facility failed to 1) meet the needs or wants of residents, 2) ensure there was sufficient numbers of nursing staff to provide care and services, 3) ensure all residents received showers per their preference, 4) answer call lights timely, and 5) ensure residents were provided timely incontinent care/toileting assist for five of six residents (1, 2, 5, 6, & 11) reviewed for care concerns. These failures resulted in harm related to anxiety, feelings of frustration and vulnerability, unmet care needs, discomfort/pain, and a diminished quality of life. Findings included . Review of the Facility assessment dated [DATE] showed under Staffing Plan, that the facility considered both census numbers and acuity levels that impact staffing needs and staffed accordingly. The plan also included the facility hires and schedules staff for average census (62) and if necessary, the facility has contracts in place for temporary agency personnel. Resident 1 In an interview on 03/18/2022, at 11:30 AM, Resident 1 stated call light response was very slow and said their roommate would end up in the bathroom with the emergency light on, calling out for help. Resident 1 stated their roommate would attempt to self-transfer stating their bottom hurt from sitting so long. Resident 1 stated they worried the roommate would fall so kept telling the roommate to stay put until staff came. Resident 1 stated it was often an hour wait for call light response, and stated both the roommate and themself put their call lights and the bathroom emergency light on to try to get help, but it still took a long time for response. Resident 1 also stated they had migraines and it was very important to get medication quickly or the pain worsened and they developed nausea and vomiting. They stated at times it had taken 45 minutes to get the medication. Resident 1 stated they just wanted a shower twice a week, call light response within about 15 minutes, and migraine medication within about 15 minutes. RESIDENT 2 In observations and interviews on 03/18/2022 at 12:17 PM, Resident 2's family members stated the facility does not seem to have enough staff to feed the resident. They stated the resident was unable to feed themself, and when they arrived at mealtimes there was a tray of uneaten cold food in front of the resident. They stated the resident could only eat with their fingers and when they visited they always had to clean under her nails. The resident stated nobody helped feed her. The resident was observed unable to manipulate utensils adequately to feed herself. She was observed to have debris under her nails. Resident 5 In an interview on 03/18/2022, Resident 5 stated about call light response, it takes forever, I wonder and wonder why nobody comes to help. Resident 6 In an interview on 03/18/2022 at 1:28 PM, Resident 6 stated call light response time had been as long as two hours, and stated often it was close to an hour to get staff response. Resident 6 stated staff is in a constant rush all night; I think night shift is short-staffed. Resident 6 stated they have had to wait two hours on night shift for pain medication, and the pain just got worse the longer I waited. RESIDENT 11 Resident 11 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In a telephone interview on 03/28/2022, Resident 11 stated call light response was terrible during her stay at the facility. The resident stated one morning they needed to use a bedpan and it took just under an hour to respond to the call light and place the bedpan. The resident stated it took another hour to remove the bedpan and was a very uncomfortable experience. Resident 11 stated there were numerous times they waited two hours for call light response, and at times someone would answer the light, say they would get someone to help and nobody would return. Resident 11 stated they were incontinent due to failure of staff to respond to call light in a timely manner. The resident stated they always knew when they needed to toilet, however was dependent on staff to place the bedpan, and by the time staff would come they would be soaked and uncomfortable, sometimes required a linen change as well. The resident stated NA's told them they had 15-18 residents assigned to them, multiple call lights on and stated they didn't know where to start. The resident stated she heard residents called the front desk from their cell phones to request care and they would hear other residents call out for help and become so angry and started swearing. The resident also stated they waited a long time after admit for bathing. Resident 11 stated it felt like total chaos being at the facility. STAFF INTERVIEWS In an interview on 03/18/2022 at 2:45, Staff A, Licensed Practical Nurse stated residents were offered showers twice a week, but the staff did get behind. When asked about timeliness of pain medications and other as needed medications, Staff A stated these medications should be a priority and given as soon as possible. In an electronic communication (e-mail) on 03/22/2022, the DNS stated although their was not a call light policy, the expectation was for call lights to be answered as timely as possible, and within 15 minutes In a telephone interview on 03/30/2022 at 12:32 PM, Staff F, NA stated they had been the only NA on the night shift on 03/12/2022 and there had been just two NA's on 03/11/2022. They described the experience as hell. Staff F stated there was no way to do all resident care, so most did not get changed, re-positioned, or checked regularly. Staff F stated this situation did not occur frequently; usually there were three NA's on night shift, however even with three NA's it was very difficult if not impossible to get all residents who needed repositioned and incontinent care every two to three hours. In an interview (date and time omitted to maintain anonymity), Anonymous Staff A (AS-A) stated they had been told by other staff to look past changing residents who cannot verbalize their needs on the long term care hall when they were busy. AS-A stated it was often evident at the start of their shift that residents had not been changed in a long time, and stated with one of the residents, urine had been dripping from the wheelchair to the floor and sheets were stained yellow with urine. AS-A stated this problem was more frequent on the days they were short-staffed. In an interview (time and date omitted to maintain anonymity), Anonymous Staff B (AS-B) stated staff on prior shifts were often so busy they provided care for the residents who were more vocal, and the residents who were unable to voice their needs were left in saturated and/or soiled briefs. In a telephone interview (time and date omitted to maintain anonymity), Anonymous Staff C (AS-C) stated the facility had issues with staffing. Staff AS-C stated the staffing shortage resulted in delayed call light response and missed showers. AS-C stated recently they were short-staffed primarily on evening and night shifts, but also occasionally on day shift. In a telephone interview (time and date omitted to maintain anonymity), Anonymous Staff D (AS-D) stated when there were call-outs, they were very short-staffed, and when there were not call-outs they were told they were staffed to census. AS-D stated it was difficult to believe they were staffed appropriately when NA's were assigned 15-16 residents each and could not possibly provide the necessary resident care. AS-D stated nobody wanted to come in and work when there were call-outs due to being asked so frequently and knowing the work-load was heavy. AS-D stated there were long waits for call light response in spite of trying their best. AS-D stated many residents who could not express their needs and required extensive assistance were not provided sufficient care due to staffing. They stated there was just not enough time to turn, change, offer liquids, feed, and provide other care every two to three hours, therefore often those residents had received cares just once each shift. AS-D stated they heard from other staff to just leave those long term care residents who could not express their needs to the last and provide care for those who were able to request. In a telephone interview on 04/04/2022 at 1:17 PM, an anonymous Provider (AP) stated they were concerned with low staffing at the facility. The AP stated their observations of the impact of insufficient staff included observations of residents with poor hygiene and medication errors. FAMILY/RESPONSIBLE PARTY INTERVIEWS In a telephone interview on 03/28/2022 at 11:00 AM, an anonymous family member (FM-1) stated the facility often appeared short staffed. They stated during visits they had observed their mother's roommate put the call light on and staff did not answer for a long time, so numerous times they approached staff on that resident's behalf and tried to get them to assist the resident. The family member stated one night the nurse stated there was not enough staff to help. In a telephone interview on 03/24/2022 at 12:40 PM, a resident's family member (FM3) stated when they were visiting at the facility they witnessed it taking a very long time for call light response, even a couple of hours. FM3 stated sometimes staff would walk by and say they would be right back but it still took a long time. FM 3 stated going to the nurse was ineffective. FM3 stated that due to the lengthy waits for call light response, their mother had been incontinent. They stated they felt the facility had not had enough staff to care for the residents. In a telephone interview on 03/30/2022 at 11:30 AM, an anonymous resident representative (FM4) stated it seems there was not enough staff. FM4 stated they were recently at the facility and overheard residents calling out for staff and it appeared nobody responded. FM4 stated while at the facility, it just appeared there was not enough staff to provide care for all their residents. FM4 stated some of the incidents were concerning and hoped incidents that happpened were not the usual and that maybe the facility was just short staffed on the particular day. SCHEDULES NURSING SCHEDULE Review of nursing schedule for 03/11/2022 revealed only two nurses and two NA's worked on the night shift. Review of resident roster dated 03/11/2022 showed the census was 57. Review of the nursing schedule for 03/12/2022 revealed only two nurses and one NA worked on the night shift. Review of the resident roster dated 03/12/2022 showed the census was 58. In an interview on 04/04/2022 at 11:41 AM, the Director of Nursing Services (DNS) acknowledged the facility had staffing issues for NA's. The DNS stated on the night shift in March 2022 when there was only one NA, that they had not been informed of the situation until the following day. The DNS acknowledged resident care could not have been completed on all residents. Reference (WAC): 388-97-1660(1)(a)(c)(i)(ii)(iii) Related Citations: F-557 483.10(e)(2) and, F-558 483.10(e)(3)

Based on observations, interviews and record review, the facility failed to provide care in a manner that promoted resident respect and dignity for one of three residents (3) reviewed. According to the reasonable person concept, failure to provide incontinent care for this cognitively impaired resident in a timely manner would have reasonably resulted in embarrassment, humiliation, diminished self-worth, and psychosocial harm. Findings included . Resident 3 admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease and major depressive disorder. Review of the resident's annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had both short and long term memory impairment. The resident was always incontinent of bowel and bladder and required two person assist with toileting. Review of the resident's urinary Care Area Assessment (CAA's) dated 02/08/2022, revealed the resident was totally incontinent and at risk for urinary tract infections, skin breakdown, and impaired dignity. Care staff was to provide extensive to total assistance with incontinent care and anticipate all needs. Review of the resident's orders showed the resident was prescribed [MEDICATION(S)] (a water pill) on 09/18/2020. Review of the resident's care plan showed Resident 3 was incontinent and required staff to complete all incontinent cares with extensive assist of one person. The resident was to be checked and changed every two hours and as needed. In an observation on 03/18/2022 at 12:37 PM, Resident 3 was observed sitting in their tilt-in-space wheelchair which was reclined slightly. The resident was wearing a mask and was faced towards the wall at the foot of the bed, positioned between their bed and roommate's bed. There was a slight odor of urine/stool coming from the resident. In a subsequent observation at 1:02 PM, the resident continued with odor of urine and stool. At 1:26 PM, the odor was noted to be stronger; at 1:50 PM, the odor of urine and stool remained strong, and at 2:20 PM the odor was stronger. At 3:12 PM the odor remained strong and Resident 12 (resident's roommate) repeatedly requested this surveyor put the resident to bed and change her. At 3:35 PM, the odor continued and there was no noted change in the resident's position from the initial observation. On 03/18/2022 at 3:35 PM, the surveyor approached Staff F, NA who stated they were the assigned NA for the evening shift. Staff F stated the day shift NA reported they had just turned and changed Resident 3. Staff F came to the resident's room and stated they noted the odor immediately and stated they would get assistance to change the resident. In an interview and observation on 03/18/2022 at 3:52 PM, Staff G, NA arrived to assist Staff F transfer and change Resident 3. When the NA's stood the resident up from the wheelchair, the wheelchair cushion and the back of Resident 3's pants were soaking wet and very odorous of urine and stool. When the resident's brief was removed, the resident was observed to have stool from their upper thighs to low back. Staff G stated this happened often with residents who could not speak for themselves, they get left for the next shift. Review of a facility investigation dated 03/18/2022 regarding care concerns for Resident 3 reported by the surveyor, revealed the facility did not report to the hotline until 03/21/2022 at 11:38 AM. Additionally, the facility investigation timeline was inaccurate as compared to the surveyors firsthand observations and documentation. Review of Resident 3's progress notes from 03/18/2022 through 03/22/2022 showed no documentation of monitoring for physical or psychological impact related to care issues until 03/22/2022. Social services documented on 03/22/2022 that a visit was made to resident for follow-up regarding care and noted the resident showed no signs of distress. On 03/18/2022 at 4:05 PM the Director of Nursing Services (DNS) was informed of concern for care of long term care residents who could not voice their needs, and specifically for Resident 3. The surveyor informed the DNS of the observations of urine and stool odor for over three hours and the findings when the resident was provided care. The DNS was informed there was no appearance the resident had been repositioned during the observation period. The DNS stated they would initiate an investigation. Reference (WAC): 380-97-0180(1) and (2) Related citation: F-725 483.35(a)(1)(2)

Based on interview and record review, the facility failed to ensure one of three sample residents (#2), reviewed for nutrition, received weight monitoring as planned, and implementation of timely interventions, to maintain adequate nutrition. This failure resulted in actual harm for Residents # 2, who experienced avoidable signifant weight loss, and placed Resident #2 at risk for ongoing weight loss and poor nutrition. Findings included . Review of facility policy titled Nutrition Status Policy/Procedure dated 03/2016, showed to purpose of the policy was to establish a consistent process for obtaining, verifying and recording weights. The policy directed staff that all residents, upon admission, will have an admission weight obtained within 24 hours. Residents will then have weights obtained weekly times 4 weeks. If the resident's weight is stable, they will be weighed thereafter or until a change of condition is indicated otherwise. RESIDENT #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident discharged to the hospital and was admitted on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was severely cognitively impaired and required extensive assistance of one staff member for eating. Review of the resident's weights showed: - 12/10/19, weight on admission was 130 pounds - 12/20/19, showed a weight of 117.2 pounds - 12/27/19, showed a weight of 112.4 pounds - 12/30/19, showed a weight of 110.4 pounds which was a total of 15.08% weight loss in 20 days. Resident #2 was discharged to the emergency roiagnom on [DATE]. Review of LN-Skin Evaluation-PRN/Weekly, dated 12/14/19, documented: A.1. Site 50) Left heel pressure Suspected Deep tissue injury- 3 cm long by 3 cm wide. Site 52) Left toe (s)- Purplish area right, Stage N/A, 2 cm long by 0.5 cm wide. 2. Additional comments: Noted during routine care. Iodine applied and heel boot provided to offload pressure from both feet. Review of Nutritional Risk assessment dated [DATE], showed that Staff D, Registered Dietician (RD), recommended vitamin and nutritional supplements. The assessment did not show that Resident #2 had any changes in weight or skin concerns. Review of current physician orders [REDACTED]. During a joint interview/record review on 01/07/20 at 3:25 PM, with Staff B, Resident Care Manager (RCM)/Registered Nurse, stated The expectation is that recommendations are followed up on timely, within 48 hours. The RCM confirmed that the recommendations made for Resident #2 on 12/18/19 were not implemented until 12/30/19, and stated That is way too long, Not sure how that happened. During a joint interview/record review on 1/28/2020 at 03:00 PM, Staff D, RD, stated that when she completed the nutrition evaluation on 12/18/19, she was unaware that the resident had a current pressure ulcer or weight loss. Staff D, confirmed that the dietary recommendations made on 12/18/19, were not implemented until 12/30/19, stating I expect that recommendations are carried out within 24 hours. During a joint interview/record review on 1/28/19 at 3:36 PM, the DNS stated Dietary recommendations should be processed within 48 hours or as soon as we can get a hold of doctors. The DNS stated that all new admits should have weights done every day for 3 days to get baseline. She also stated If a resident refuses a weight, then that should be documented and the provider notified, but that staff should be re-approaching to try to get the weight obtained. The DNS verified that Resident #2 did have significant weight loss and the dietary recommendations were not carried out until twelve days after they were made. Reference WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to prevent the development of pressure ulcers/pressure injuries and implement timely interventions necessary to prevent the development of a facility acquired pressure ulcer, for one of four residents (#2) reviewed for pressure ulcers (PU). These failures caused harm to Resident #2 who developed an avoidable facility acquired deep tissue injury to the left heel and placed Resident #2 at risk for diminished quality of life. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin. Intact skin with localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration, these may indicate deep pressure injury. Deep Tissue Pressure Injury (DTI): Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable). A review of the facility policy titled, Skin Care Policy / Procedure dated June 2016, showed The purpose of this policy is that the resident does not develop pressure injury unless clinically unavoidable, and that the facility provides care and services to: 1. Promote the prevention of pressure injury development; 2. Promote the healing of pressure injuries that are present (including prevention of infection to the extent possible); and 3. Prevent the development of additional, avoidable pressure injury. The policy directed facility staff to: 1. Assessment: (a) Complete Initial Admission Record and Braden Scale to identify risk and to identify any alterations in skin integrity noted at the time. (d) All risk factors identified on assessment should be documented in the resident's clinical record and, when appropriate, be addressed through a care plan designed to minimize the possibility of skin breakdown. (e) Develop comprehensive care plan if indicated following evaluation/assessment. Care plans must be individualized and designed to meet the needs of the particular resident for whom they are being developed. (g) Assessment of wounds identified after admission: A licensed nurse will assess/evaluate a resident's skin at least weekly. Areas of breakdown, excoriation, or discoloration, or other unusual findings must be documented in the nursing notes or on one of these forms (Pressure Injury/Non-Pressure Injury/ weekly / PRN skin assessment/evaluation. (h) A licensed nurse will assess/evaluate at least weekly each area of alteration/injury, whether present on admission or developed after admission, which exists on the resident. 2. Prevention: In order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan: (b) Monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition. (d) Use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, wedges, pillows, etc.) 3. Documentation: (a) Pressure Injury, Non-pressure ulcer, / weekly /PRN skin assessment/evaluation forms: If the clinical assessment/evaluation indicates a change in condition or decline in the assessing/evaluating nurse will notify the physician and create a narrative note documenting that notification. (b) Weekly Skin check: Licensed nurse should document skin evaluations in accordance with this policy and document on the skin assessment/evaluation weekly/PRN form. 6. Communication of changes: (a) Any changes in the condition of the resident's skin as identified daily, weekly, monthly, or otherwise, must be communicated to: the resident/responsible party; the physician; others as necessary to facilitate healing. RESIDENT #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident discharged to the hospital and was admitted on [DATE]. Review of the facility's report titled Grievance Log dated 12/20/19, showed the resident's family member reported that on 12/20/19 the family member was told by the facility that the resident had multiple wounds on her legs and was unable to discharge home because of these wounds. The family member observed the wounds, stating They're huge, huge wounds, absolutely horrific. The family member further stated I was never contacted about these injuries, that the facility is calling pressure wounds. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was severely cognitively impaired and required extensive to total assistance of two staff members for bed mobility and toileting. In a review of the facility's LN- Initial Admission Record, dated 12/10/19, showed the resident admitted to the facility with a Stage 1 to the Coccyx area- blanchable. The definition listed on the admission record showed Stage 1- intact skin with non-blanchable (impaired blood flow to area) redness. Review of the admission nursing progress note, dated 12/10/19, stated Pressure Injury Stage 2 to Coccyx. Review of nursing progress note dated 12/14/19, stated Suspected deep tissue injury (DTI) on the left heel and a dark purplish area under the big toe nail. Noted during routine care. Iodine applied and heel boot provided to offload pressure for both feet. The skin integrity care plan was revised on 12/24/19 to reflect the resident's current skin breakdown. Interventions listed included: -Barrier cream to coccyx every shift; Float heels while in bed; Turn every 2 hours (initiated on admit) -treatment for [REDACTED]. -Apply thick foam boot to bilateral lower leg at all times for skin prevention (initiated on 12/18/19, 4 days after discovery of wounds) -Monitor coccyx and left buttock area (initiated on 12/19/19) -Air mattress (initiated on 12/20/19, 6 days after the discovery of the wounds) -Resident to be followed by United Wound Healing for wounds (initiated on 12/23/19, 9 days after the discovery of the wounds) The pressure ulcer (PU) care plan was initiated on 12/22/19 to reflect pressure areas on left heel and left buttocks and potential for further PU development related to risk factors, 8 days after the discovery of the deep tissue injury to the left heel. Review of admission orders [REDACTED] 1. Barrier cream to coccyx every shift and as needed for incontinence/skin prevention 2. Float heels while in bed every shift for skin prevention 3. Turn every 2 hours and as needed for pressure relief/skin prevention Review of LN-Skin Evaluation-PRN/Weekly, dated 12/14/19, documented: A.1. Site 50) Left heel pressure Suspected Deep tissue injury- 3 cm long by 3 cm wide. Site 52) Left toe (s)- Purplish area right, Stage N/A, 2 cm long by 0.5 cm wide. 2. Additional comments: Noted during routine care. Iodine applied and heel boot provided to offload pressure from both feet. Further review of Weekly skin assessments, dated 12/18/19 and 12/25/19, showed that the facility was inconsistent in documenting the locations and types of skin concerns that had been observed. Review of a physician progress notes [REDACTED]. - Left lower leg swelling present - Left hip dressing is clean and dry There was no mention that the resident had any other skin concerns. Review of Nurse Practitioner note dated 12/19/19, under physical exam/Skin section documented the presence of left hip surgical wounds, a full thickness wound to the left lateral leg (unclear cause), a DTI to the left heel and a Stage 2 PU to the right buttock. Review of a facility investigation dated 12/18/19, stated the resident had an open area to the left buttocks, redness to her coccyx, and a left hip surgical site. The Director of Nursing Services (DNS) conclusion stated that this skin breakdown was reasonably related to the resident's condition and risk factors. No abuse or neglect identified. This investigation showed that the DNS's findings were inconsistent with the current skin issues of Resident #2, including the deep tissue injury to the left heel. During a joint interview/record review on 01/08/2020 at 7:30 AM, Staff A, Licensed Practical Nurse/Wound Nurse, stated that she is responsible for reviewing all residents with major wounds weekly and documenting the assessments in the clinical records. Staff A confirmed that she assessed Resident #2 on 12/18/19 and documented her findings in the resident's clinical record. Staff A also stated that the resident was assessed again on 12/25/19, however that assessment was not documented in the clinical record. Review of weekly wound tracking forms completed by wound nurse dated 12/18/19 and 12/25/19, showed that the forms did not have any information on them related to Resident #2. During a joint record review/interview on 01/07/20 at 12:00 PM, the DNS stated The expectation is that nurses notify management immediately for all new skin issues so that the areas can be immediately assessed and treatments implemented. The DNS also confirmed that there was not an investigation completed for the left heel DTI discovered on 12/14/19 because she was unaware of the issue until the resident discharged to the hospital on [DATE]. Review of Medication Administration Record [REDACTED] - Air mattress (Order date 12/22/19), 8 days after discovery of left heel DTI - Treatment to left lateral lower extremity and left great toe wound (Order date 12/21/19). - Treatment to left heel DTI (Started on 12/19/19), 5 days after discovery of the injury. During an interview on 01/07/2020 at 11:05 AM, Staff B, Resident Care Manager (RCM)/Registered Nurse (RN), stated that the staff member who first observed the wounds on Resident #2 did not report them to management, the doctor or family representative and that the employee received a verbal warning regarding their failure to notify. Staff B further stated that the facility held an in-service for the nursing staff on 12/19/19 regarding notification of changes. During a joint interview/record review on 01/07/20 at 12:00 PM, the Director of Nursing (DNS), stated that the nurse who first observed the deep tissue injury on the left heel of Resident #2 on 12/14/19, failed to notify anyone and so she was unaware this issue was present prior to the resident discharging on 12/31/19. The DNS further stated that the facility and physician related the wound on the left lateral leg to resident's [DIAGNOSES REDACTED]. During an interview on 01/07/20 at 2:30 PM, Staff C, Nursing Assistant (NA), stated We would document in their charts if we reposition someone or float their heels. Staff C stated That would all be charted every shift if that's what is on their Kardex. Review of task documentation flow sheet for the NAC's titled Pressure Reducing Devices/ Floating Heels dated December 2019, showed missing documentation and holes in the charting every day on the flow sheets. During a joint interview/record review on 01/28/20 at 3:36 PM, the DNS stated that she met with Resident #2's family on 12/20/19, for concerns related to her wounds. The DNS stated I don't believe the family was aware of skin issues the resident had prior to that meeting. The DNS verified that the task documentation for the Nursing Assistants titled Floating Heels, had multiple holes and missing documentation for 12/2019. Reference WAC 388-97-1060 (3) (b)

Based on observation, interview and record review, the facility failed to provide care and services necessary to maintain good grooming and personal hygiene for 1 of 1 dependent residents (41) reviewed who was unable to carry out their own activities of daily living. Failure to change absorbent briefs timely to ensure the resident didn't sit in urine-soaked clothing, to offer a urinal prior to breakfast, to routinely reposition the resident in bed when he was unable to do on his own, to trim toenails, and to wash hands and face and to comb hair during morning care all resulted in an extended pattern of unmet necessary care and services. Findings included . Resident 41 originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set assessment, dated 05/25/18, he had no unhealed pressure ulcer, was frequently incontinent of urine and always incontinent of bowels, had severe cognitive impairment, and required extensive 2-person assist with bed mobility, transfers, dressing and toilet use and 1-person assist with personal hygiene, and had total dependence for bathing. Review of a care journal/notes submitted by the resident's medical representative revealed the following: - (MONTH) 1 - the morning shift CNA (certified nursing assistant) noticed a pressure wound on his right heel; - (MONTH) 3 - CNA was changing resident's briefs and walked away to get another wash cloth and when she came back he was on the floor . when the medical representative arrived (at the emergency department), her first sensation was nausea, and he smelled horrendous; - (MONTH) 5 - notes from meeting the resident's Power of Attorney and the Medical Representative both had with the facility Director of Nursing Services (DNS) and Staff H, Social Services Director. There were concerns regarding toileting the resident and having urine soaked clothing. The resident's medical representative asked for briefs to be time-stamped with a sharpie and the facility stated they could not do that. Medical representative asked for a urinal to be offered daily for 15 minutes a minimum of 5 days for trial and only 1 CNA has followed through. Upon opening the daily laundry bags on (MONTH) 28, 29, 30, 31 - (clothes) in daily laundry bags were soaking wet from the knee's of the pants up to the neck of his shirts, Resolution: move him next to the nurses station; - (MONTH) 9, 10, 11 Wet laundry again; - (MONTH) 14- Met with Staff H asking for a Record Review by the medical director, and asked for a meeting with DNS and the Administrator to discuss the following concerns: the regular rotation of CNA's, lack of supervision on the weekends, improperly moving the resident by using only one staff member trying to deadlift resident up in bed, and not adhering to the standard of care practices; - (MONTH) 22 - Wednesday, Thursday, and Fridays clothes wet from shoulders to knees; and - (MONTH) 23 - received message from Staff H .I texted her letting her know of the wet clothes and would be in Monday to talk with Administrator. Review of a Comments, Grievances and Compliments Card, dated 06/15/18 revealed the resident's medical representative had verbalized as she washed the residents clothes she observed his clothes were wet with urine and she would like him checked/changed more frequently. The facility resolved the grievance by reviewing and updating the care plan and KARDEX (care directive for nursing assistants) for toileting needs every two hours. This care plan update was reviewed with staff. The facility stated the grievance was resolved on 06/18/18. Review of a text message on the medical representative's cell phone (to the Staff H, SSD), dated (MONTH) 23 (Saturday) which revealed (Resident's) clothes Wednesday, Thursday and Friday are soaking wet from mid back to knee. He smells. I need him showered and changed per the standard of care. I will be addressing this Monday with (Administrator). Review of a Comments, Grievances and Compliments Card, dated 06/25/18 revealed the resident's medical representative had met with Staff H, SSD, the DNS, and the Administrator, regarding clothing wet with urine 3 out of 5 days, the medical representative alleged the resident was not being changed during the day frequently enough. Resolution included DNS and Administrator to provide increased daily observation/checks and support, assessing for alternate brief support, started binder for check & change program, and all care staff education in-service. In an interview on 06/27/18 at 2:17 PM, the resident was interviewed/observed in his room. Resident 41 could not say words; he kept repeating 2, 2, 2 . Resident 41 was able to move his head Yes/No, with what seemed to be appropriate responses. We tried for him to write, he could not write his name or any other words legibly. He was sitting in a wheelchair wearing tennis shoes on both feet, and his right arm was resting on a padded table device. The resident was asked if he could move his right arm or right leg, he looked like he was trying to, but nothing moved then he shook his head No. He indicated he needed two staff to turn him, not one, which he indicated was due to back pain. Resident 41 indicated staff did offer him a urinal, but he was not sure if it was regular or not. Asked about being wet with urine, he indicated he had laid in urine, he was unable to provide any specifics, but he indicated it had happened a lot. In an interview on 06/28/18 at 8:58 AM, the resident's medical representative stated: - repositioning was a problem as he wasn't being repositioned, she would try to reposition him, she said she was at the facility all of the time and she never saw him being repositioned and his heels were never floated, she said she would float his heels with a pillow under his feet and she did side-to-side turning, she stated he had no air mattress and no boots (soft/pressure relieving) until after the heel pressure ulcer was discovered; -she stated on (MONTH) 9th, she and her husband (the resident's Power of Attorney) visited, the resident was slid way down in bed so his head was by the mobility bars, his drawsheets (linen residents lay on, used for repositioning) were way up his back, a female nursing assistant had given him a bear hug and tried to boost him up in the bed on her own which caused the resident to wince, she said nobody came for a long time so she went out in the hall and later 2 nursing assistants came and boosted him up in bed. She said he was wet with urine, so (she) washed him and placed clean clothes on him; - she said she had asked for a urinal trial, he was successful 1 out of 3 times, but only 1 nursing assistant had been offering him the urinal; - she didn't think 1 nursing assistant could safely turn him for incontinent care, because he had bad back pain; and -the resident would be wet (with urine) or need repositioning, and she would do it when she was there, I would be here all day and no one would come in and check on him. I would go stand in the hall to try to find someone to help. She said her and her husband would come in and he (the resident) would be laying in clothes soaked in urine, or he would be slouched down in bed so far that his head would be down by the side rail, his legs would be froglegged and they couldn't believe their eyes. She stated they had talked to facility staff and were told they would fix the issues, they thought things (care) would get better and it would be the same think over again. In an observation on 06/29/18 at 7:16 AM, observed Staff I, NA (Nursing Assistant) perform incontinent care (resident had been incontinent of stool) and morning cares prior to breakfast. Staff I was providing care independently. Staff I first cleaned the front of the resident's groin/genitalia, then bent down and leaned across the resident's uncovered groin and turned the resident towards him, he braced the resident's uncovered groin area against his shirt top while he leaned over him and cleaned feces, contaminating his own clothing. After the incontinent care, Staff I got another staff member to help transfer the resident to his wheelchair. Staff I did not offer the resident the use of a urinal as per his plan of care. Staff I did not offer to help wash the resident's hands or face and he did not offer to help the resident brush his teeth. The resident was taken to breakfast. In an interview on 06/29/18 at 7:58 AM, Staff G, Licensed Practical Nurse, the DNS, and the Administrator were interviewed regarding the incontinent care/morning cares observation. The DNS stated that Staff I should have turned the resident to his right, not his left, that way the resident could have assisted by holding the mobility bar. The DNS stated the resident should have received his morning cares before going to breakfast. The DNS stated they should have offered the resident his urinal. We jointly reviewed the residents 'check and change' toileting documentation, it was filled out very inconsistently and the documentation did not make sense, there were 3 columns, 1st column check wet/dry, 2nd column changed (incontinent briefs) Yes/No, 3rd column Name/time. Some of the findings we discussed included: - 06/26/17 - at 12:30 AM, 2:00 AM, 4:00 AM, 6:00 AM, he was noted to have been wet in column 1, in the 2nd column staff wrote in No offer urinal, there was no documentation his briefs had been changed; - 06/28/18 - there was documentation of 13 times that date that he was wet with urine (column 1), yet there was no corresponding documentation in column 2 that he had been changed; and - there were multiple times on the form where staff were not documenting their names on the form, just the times the resident was checked. After reviewing the check and change binder and documentation irregularities we noted, the DNS stated We will have to look at that. In an interview on 06/29/18 at 12:42 PM, the DNS was asked if the facility had done an alternate brief support assessment (this was listed as a resolution activity on the 06/25/18 grievance form), she stated Yes, she was asked for a copy, but this was never provided during the survey. Review of a Comments, Grievances and Compliments Card, dated 07/03/18, revealed the resident's clothes were soaking wet from mid back to knees, Have filed numerous complaints to Staff H. In an observation on 07/05/18 at 11:01 AM, the resident's medical representative was observed trimming the resident's toenails which were observed to be quite long, the toenails on the big toes were observed to extend out beyond the toes approximately ¼ inch. During the observation, Staff T, an Administrator from a related facility, came into the room to show the resident's medical representative a new kind of briefs that they thought would contain the resident's urine better. In an interview on 07/05/18 at 6:32 PM, the resident's medical representative was asked about the circumstances related to how she got the Social Services Directors' cell phone number so she could be able to text her, she stated she had been given the personal cell phone numbers of Staff H and for the Administrator, because of all of the issues like the fall and the wet laundry so that she could contact them any time. On 07/06/18 at 9:53 AM, reviewed the documentation in the resident's check and change binder, there was no documentation made after 07/05/18 at 10:00 PM. The DNS was asked about the lack of documentation after 10:00 PM. On 07/06/18 at 10:37 AM, the DNS provided a copy of a different form titled Voiding Pattern Assessment. The DNS was asked if staff were supposed to be using this other form, she answered No. The DNS stated that night shift staff member, Staff S, NA, had not yet been educated on the resident's check and change program. However, review of an In-service Program Sign-in Sheet (regarding training to improve care), dated 06/26/18, revealed Staff S had signed the attendance roster for that training. The form Voiding Pattern Assessment form did not have documentation the resident's incontinent briefs were changed, even though there was documentation 9 times that he was wet. There was also no documentation on day shift 07/06/18 from the start of the shift until the forms were copied at 9:53 AM. In an interview on 07/09/18 at 7:39 AM, the resident's medical representative stated the DNS and Staff H told her they would not be labeling the date/time on the resident's incontinent briefs for staff reasons, because they didn't know how they would get that word out to the staff. She said she had asked what could be done to try to track his briefs changing times and they didn't offer up any solutions. The medical representative stated she had trimmed the resident's toenails because she had been asking the CNAs and Staff U, LPN/Resident Care Manager, who she said Resident 41's told her it would be done during shower time, but that never happened and it needed to be done, so she did it. The medical representative was going to be asking for another care plan meeting because care just wasn't being done consistently. She said the DNS kept saying she would take care of everything, but there really was no routine. In an interview on 07/09/18 at 8:10 AM, an Ombud from the Washington State Long-term Care Ombudsman Program stated she had recently had a meeting with the facility Administrator and Staff H regarding staff behaviors. She stated the Administrator kept saying Resident 41 was getting the best possible care because We're in survey. Resident 41 was unable to speak or write. Based on the Reasonable Person Concept, a reasonable-person in a similar position like Resident 41's position would likely have felt dehumanized after experiencing this pattern of unmet care needs. Reference: (WAC) 388-97-1060 (2)(c) Related citations: CFR 483.10 (j)(1)(2)(4), F585 - Grievances CFR 483.25 (b)(1), F686 - Treatment/services to prevent/heal pressure ulcer CFR 483.35 (a)(1)(2), F725 - Sufficient nursing staff CFR 483.70 (i)(1)(5), F842 - Resident records

Based on observation, interview and record review, the facility failed to consistently supervise nursing staff to ensure necessary care and services were provided to prevent and heal a pressure ulcer for 1 of 1 sample residents (41) reviewed for pressure ulcers. The facility also failed to ensure staff used appropriate resident handling techniques to minimize risk of shear and friction injury for 2 of 2 sample residents (41 and 52) assessed to be at risk for pressure injuries. These failed practices caused harm when staff failed to develop and implement an individualized repositioning program using appropriate resident handling techniques for Resident 41 who had a stroke and was unable to move one side of his body. The facility failed to use enough staff for repositioning Resident 41 to avoid further injury from friction and shearing, failure to update the care plan and KARDEX and failure to supervise nursing and nursing assistant care and documentation which all contributed to Resident 41 developing an avoidable pressure ulcer within 2 weeks of admission that had not yet healed. Findings included . Record review of the facility's policy titled Skin Care Policy/Procedure, revised date 06/2016, revealed: - A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and a resident having pressure injuries received necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing; - Pressure injury: .The injury occurs as a result of intense and / or prolonged pressure or pressure in combination with shear; - PREVENTION: In order to prevent the development of skin breakdown or prevent existing pressure injuries from worsening, nursing staff shall implement the following approaches as appropriate and consistent with the resident's care plan; - Reposition the resident; - Use pressure relieving/reducing and redistributing devices (including but not limited to low air loss mattresses, pillows, etc .; - CNA's (certified nursing assistants) will review electronic Kardex (care directive for nursing assistants) to view care plan interventions; - Licensed Nurse (LN) to document presence of pressure reducing devices on Treatment Administration Records (TAR) as ordered; - Use transfer techniques which minimize friction and skin tears/shear .; and - MONITORING: Daily via medication administration and treatment administration records, confirm all orders have been implemented as ordered. FACILITY MATRIX Review of the facility matrix, dated 06/26/18, revealed the facility provided the survey team with a matrix that was coded as not having any facility-acquired pressure ulcers (any stage) or any worsened pressure ulcers (any stage). RESIDENT 41 The resident originally admitted to the facility on [DATE] for rehabilitation after a stroke. His [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set assessment, dated 05/25/18, he had no unhealed pressure ulcer, was at risk of developing a pressure ulcer, had severe cognitive impairment, and required extensive 2-person assist with bed mobility, transfers, dressing and toilet use. Review of a LN Initial Admission Record, dated 05/18/18, the day of admission revealed the resident had no pressure ulcers. Review of a care journal submitted by the resident's Medical Representative, undated, revealed on 06/01/18, when she came into the resident's room, she noticed that he had an air mattress. The medical representative's statement indicated she asked staff about the air mattress and was told they had noticed a pressure wound on his right heel. The care journal indicated on 06/09/18 she witnessed 1 nursing assistant attempt to dead lift the resident up higher in bed hurting him. The journal indicated the pads were bunched up underneath the resident. When the nursing assistant left the room, no one came, so the medical representative stood in the hall until she could get assistance. Eventually two nursing assistants came and boosted the resident up in bed, they were shown the bunched up pads and they barely attempted to fix and left. In an observation/interview on 06/26/18 at 12:15 PM, the resident was wearing a special boot device on his right foot. There was a kickstand (used to hold the foot up to relieve pressure on the lateral heel pressure ulcer ) that was not being utilized, it was folded back in the storage position behind the achilles area. The resident's Medical Representative pointed to a sign on the wall with instructions on how the kickstand device was to be deployed. She stated a therapist had put the sign on the wall because staff were not deploying the kickstand properly. Review of a sign on the wall in the resident's room regarding a right foot boot kickstand revealed there was a picture of a boot with the kickstand deployed, and a handwritten note with an arrow to the kickstand, the note stated Kick stand out sticking out on R-circled (Right) side when in bed. The date on the bottom of the sign was 06/15/18. In an observation on 06/26/18 at 1:51 PM, the resident was in bed wearing the special heel protector boot on the right foot, the kickstand device was not being used, there was no boot on the left foot. In an observation on 06/26/18 at 3:45 PM, the resident was in bed wearing the special heel protector boot on the right foot, the kickstand device was being utilized, there was no boot on the left foot. In an interview on 06/28/18 at 8:58 AM, resident's Medical Representative, stated when she came into the facility on [DATE], a nurse told her they had found a right heel pressure ulcer. She stated resident repositioning was a problem because staff weren't doing it. She stated staff were not floating the resident's heels. She stated the resident had no air mattress and no protective boots until after a pressure ulcer had been discovered. She stated after the pressure ulcer was found, staff were to put on a special boot with a kickstand that was used to relieve pressure from the pressure ulcer. She stated staff were not consistently deploying the kickstand to relieve the pressure on the pressure ulcer, and that two weeks earlier, Staff A, (Occupational Therapist), had put a sign on the wall to remind staff, and to show staff how to properly deploy the kickstand. She stated on 06/09/18 she and her husband, the resident's POA (Power of Attorney) came in to visit and found the resident had slid way down in the bed so that his head was situated by the mobility bar and the draw sheets (linen a resident sits on that is used to pull them up in bed) underneath him were way up his back. She stated a female nurse aide attempted to boost the resident up in bed by herself by giving him a bear hug, the resident winced, the aide apologized and left the room. She stated they waited a long time and nobody came to reposition the resident up in bed, so she went and stood in the hall until she could get help from two nursing assistants. She stated one staff member was not enough to reposition him because he had pain issues with his bad back. She spoke of a pattern of coming to visit and the resident would be wet with urine, slouched down in bed, and his legs were frog-legged, she stated she and her husband could not believe their eyes. She stated they had talked to facility staff about his care, they thought it would get better, and then it would be the same thing again. Review of Occupational Therapy Treatment Encounter Notes, dated 05/31/18, revealed Pt (patient) at high risk for skin breakdown due to inability (sic) to reposition himself due [MEDICAL CONDITION](stroke). Review of Braden Scales for Predicting Pressure Sore Risk revealed: -05/18/18 - Moderate risk (date of admission) -06/01/18 - Low risk (the date the facility discovered a heel pressure ulcer) -06/04/18 - High risk (the date the resident returned from the hospital with an unstageable right heel pressure ulcer). Review of progress notes revealed staff called 911 after the resident had a fall on 06/03/18. The progress notes indicated the resident returned to the facility on [DATE]. Review of hospital records, dated 06/04/18, revealed hospital staff documented the resident had an unstageable right heel pressure ulcer that was present on admit to the hospital. Review of a physician's progress note, dated 06/05/18 at 1:46 PM, revealed Resident 41 had a decubitus (pressure) ulcer of right heel. The physician documented the pressure ulcer was a stage II (partial-thickness skin loss, presenting as a shallow open ulcer, the wound bed is viable, pink or red, and may also present as an intact or open/ruptured blister), on the affected side (of his stroke), the plan included offloading, skin prep to the wound to toughen the skin, and a wound consult was ordered. Review of the resident's care plan, print date 06/27/18, revealed the resident had an actual impairment to skin integrity related to an [MEDICAL CONDITION](stroke). Review of the Focus area details indicated an entry dated 06/04/18 that read readmitted with rt (right) heel DTI (Deep Tissue Injury). Related interventions included: - Air mattress to bed to assist with skin prevention/integrity, set to resident's comfort/weight, on 240 setting/189.0 lbs, with static normal pressure cycle. Assure that mattress is properly inflated every shift; - Apply Multi-Podis Boot to Right Lower Leg for positioning when in bed and Ensure Kick Stand Out to Right side when resident in bed; - Encourage offloading heels and bony prominence's; - Encourage repositioning every 2-3 hours; - Float heels with foam boots at all times; - Foam boots to both heels; - Keep right arm elevated on a pillow at all times due to neglect; - Resident may have the Podis boot picture on the wall for family and staff monitoring for proper positioning; and - Right elbow elevated with pillow at all times. Due to neglect and inability to reposition independently. In an interview on 06/27/18 at 1:29 PM, Staff D, Nursing Assistant (NA), stated the resident can turn to his right, and he can turn a little bit to his left, and that he has pain in his lower back when he turns. Staff D stated he had one boot for his right foot, which had the kickstand device. Staff D stated he had no boot for his left foot at all. In a follow-up joint interview at 1:47 PM, Staff D stated she found a pair of foam boots in the closet. Staff D stated maybe the resident didn't like them. Staff E, Licensed Practical Nurse (LPN), reviewed the resident's care plan which revealed Float heels with foam boots at all times, and another intervention for foam boots to both heels. Staff D & E were unable to provide any information why those care plan interventions were not being implemented, even though review of the TAR records revealed Staff E had signed off on them 13 times so far in (MONTH) that foam boots to both of his heels was being done. In an interview at 2:17 PM, interviewed/observed the resident in his room. He could not say words, he kept repeating 2, 2, 2 . But he was able to nod his head Yes/No, with what seemed to be appropriate responses. We tried for him to write, he could not write his name or any other words legibly. He was sitting in a wheelchair wearing tennis shoes on both feet, and his right arm was sitting up on a padded table device. The resident was asked if he could move his right arm or right leg, he looked like he was trying to, but nothing moved then he shook his head No. He indicated he needed two staff to turn him, not one, which he indicated was due to back pain. He was asked to push the call light button, which he did. He indicated No, when asked if staff had ever used the foam boot on his left foot In an observation on 06/27/18 at 2:41 PM, Staff B & C, NA's, transferred the resident into bed. They asked the resident if he wanted to wear his right foot special boot, he indicated No. Staff B stated the boot hurt him. They did not place any boot on either foot. Afterwards the resident was observed lying flat in bed with his heels and the back of his legs lying flat against the bed. No floating of the heels was done. In an observation at 3:30 PM, the resident was lying in bed, there were no protective boots on or floating of the heels. In an interview at 3:30 PM, Staff B stated she had not yet let the nurse know the resident was not wearing his protective boots. Review of the KARDEX (care directive for nursing assistants), print date 06/27/18, revealed it did not have any information regarding the foam boots, but there were entries under the skin section that directed staff to encourage offloading the resident off of his heels and bony prominence's; apply multi-Podis Boot to Right Lower Leg for positioning and to be on all times while in bed, keep right arm elevated on a pillow at all times due to neglect and an air mattress. The air mattress was to be set at a specific setting (on 240 setting/189 lbs) with static normal pressure cycle. Staff were to assure that mattress is properly inflated every shift. Review of the 06/27/18 progress notes revealed an entry timed 2:57 PM, Res refused to apply boot. There was no documentation why he had refused, which boot, or what foot they were referring to. In an interview on 06/27/18 at 3:15 PM, the Director of Nursing Services (DNS) was interviewed about staff not following the care plan to have foam boots to both of his heels due to the [MEDICAL CONDITION], and to float heels with foam boots at all times, and to encourage offloading heels and bony prominence's. The DNS replied the care plan wasn't updated. In an interview on 06/28/18 at 1:18 PM, Staff A was asked about the sign she had placed on the wall regarding proper right foot boot kickstand deployment, she stated the kickstand on the boot wasn't being consistently used, so she put the sign up, she didn't know if it was because staff weren't always putting it out, or if it was something else, but she thought putting the sign up as a reminder might help. Staff A was asked how many staff were necessary to boost the resident up in bed, she thought two for safety reasons and because he's (the resident) a big guy. Staff A didn't know if it was really safe for only one staff to turn the resident either, because he had an air mattress and he could slip and slide on it. In an interview on 06/28/18 at 1:34 PM, Staff F, Physical Therapy Assistant, stated the resident could be impulsive, so bed mobility with one person may be a challenge. In an interview on 06/28/18 at 2:29 PM, Staff E, LPN, was asked how she checked the proper settings on the resident's current air mattress because both the KARDEX and the care plan, copy dates 06/27/18, revealed the air mattress settings were to be at 240-setting/189 lbs, and to assure these setting every shift. Staff E stated the air mattress didn't have numbers like that, so she wasn't quite sure what was meant by that. Staff E reviewed the resident's orders and determined the air mattress with those specific settings had been changed to a different bolster air mattress on 06/04/18, she said that order to check those settings every shift should have been discontinued on 06/04/18 when the new mattress with different types of settings was implemented. Review of (MONTH) (YEAR) TARs, print date 06/28/18, revealed an order for [REDACTED]. Review of the TARs revealed Staff E, had signed off as doing it 14 times in that same time period. There was also no way the NAs could have been following KARDEX directives to check the same settings every shift for the same time period. Review of the (MONTH) (YEAR) TARs, print date 06/28/18, revealed an order for [REDACTED]. These foam boots were found in the resident's closet on 06/27/18. In an interview on 06/28/18 at 2:46 PM, the DNS was asked about the TARs being signed off that the LNs had checked the accurate settings, the DNS stated it looked like the mattress got changed and the paperwork didn't, she stated I am going to address that. In an interview on 06/28/18 at 2:57 PM, the DNS was asked why the resident's pressure ulcer wasn't reported on the facility matrix and whether or not the pressure ulcer was facility-acquired, she called someone on the phone, then stated they had mis-coded the matrix and that it was a facility-acquired pressure ulcer. The DNS stated No, when asked if they had conducted an investigation to try to figure out the possible causes for the resident's pressure ulcer. The DNS stated No, when asked if the facility had considered that using only 1 NA for turning and incontinent care may have been contributory to his developing a pressure ulcer considering shearing. The DNS was asked if she saw any problem with only 1 NA performing incontinent care on a 189 lb man with [MEDICAL CONDITION] and confusion, she stated she didn't think so. In an observation on 06/29/18 at 7:00 AM, the resident was observed lying in bed. His right arm was not elevated on pillows per the care plan. The right foot was observed turned to the right, could not see the kickstand. The blankets were directly on his feet and tucked down at the foot of the bed between the mattress and the foot of the bed. There were 3 pillows on his side of the privacy curtain, one under his head, and two sitting in a chair next to his bed. In an interview on 06/29/18 at 7:11 AM, Staff G, LPN, stated she had just been in the room checking on the resident. Staff G was asked if the kickstand was deployed properly, she checked, it wasn't, it was turned back behind the resident's right Achilles area, it was not working as designed. Staff G did not provide any information. Review of the (MONTH) (YEAR) TARs revealed the resident had a right 2nd toe old skin abrasion that staff were monitoring. In an observation on 06/29/18 at 7:16 AM, Staff I, NA, was observed providing incontinent care, by himself, for the resident who had a bowel movement, Staff I cleaned the front of the resident's groin/genitalia, then he leaned across the resident's uncovered groin/genitalia to get hold of him for turning, he turned the resident towards him and braced the resident's groin area against the front of his scrub shirt, while he leaned over the resident and cleaned the bowel movement. Staff I was asked to take a quick look at his shirt and how it was being contaminated by contact with the resident's groin, he stated Well, I have to do it like that so he doesn't fall out of bed. In an interview on 06/29/18 at 7:47 AM, Staff I was asked how he knew how many staff the resident required for incontinent care, bed mobility, etc . He said he looked at the KARDEX; we looked at the KARDEX in the computer Kiosk on the wall and it only had information for 2 staff for transfers, no staffing requirements were listed for bed mobility or toileting; he was unable to provide any information why the KARDEX didn't have staff requirements for the other areas. In an interview on 06/29/18 at 7:58 AM, Staff G, LPN, was asked about the resident's right arm not being on pillows per the plan of care earlier that morning after she had just been in the room checking on him. She didn't know why. In an observation on 06/29/18 at 1:26 PM, the resident's right heel pressure ulcer was observed to be approximately 1 x 2 centimeters, with no appreciable depth, it had a red scab. Review of a Pressure Reducing Devices 30-day look back report, print date 06/27/18, revealed from 05/29/18 - 06/27/18, there was no documentation in the floating heels column, or the PRAFO Boots(Pressure Reducing Ankle Foot Orthotic Boots) columns. Review of the resident's clinical record revealed after he developed a right heel pressure ulcer he needed a wound consult and ongoing treatments to promote healing. RESIDENT 52 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his admission MDS, dated [DATE], he had moderate cognitive impairment, and required 2-person extensive assist with bed mobility, transfers, dressing and toilet use, and was at risk for developing pressure ulcers. He was care planned that he required 2-person staff assist with bed mobility and toileting. Review of a Resident Occurrence Report, dated 06/23/18, revealed a solo nursing assistant was doing incontinent care, and used such excessive force when turning the resident that he was injured during handling. This failure to use safe and gentle resident handling techniques that minimized shear and friction in a resident at risk for pressure ulcers is indicative of a failure by the facility to recognize the risks and hazards inherent in caring for elderly residents at risk for skin injuries. In summary, the facility failed to have effective processes in place to prevent, then to heal a pressure ulcer. The facility failed to provide nursing staff supervision of resident care, to provide administrative oversight, and there was a lack of effective, consistent, and sustained implementation of the care plan that resulted in the resident experiencing a pressure ulcer that had not yet healed. Comprehensive review of Residents' 41 & 52 care and services regarding skin at-risk issues revealed there was a lack of appreciation by the facility's nursing leadership regarding the risks and hazards associated with preventative skin care of the elderly. Reference: (WAC) 388-97-1060 (3)(b) Related citations: CFR 483.10 (j)(1)(2)(4), F585 - Grievances CFR 483.24 (a)(2), F677 - ADL care provided for dependent residents CFR 483.25 (d)(1)(2), F689 - Free of accident hazards, receives supervision/devices CFR 483.35 (a)(1)(2), F725 - Sufficient nursing staff CFR 483.70 (i)(1)(5), F842 - Resident records

Based on observation, interview and record review, the facility failed to ensure they provided an environment that was free from accident hazards over which the facility had control and they failed to provide supervision and care planned care and assisted devices for 2 of 3 residents (41 & 52) reviewed for avoidable accidents. Resident 41 was harmed when a solo nursing assistant left him alone on his side during incontinent care without the use of his care-planned assistive device, when the nursing assistant left the room to get/wet wash cloths necessary to complete the incontinent care, and he fell out of bed and required emergent transfer to the hospital. Resident 52 experienced harm when a solo nursing assistant used excessive force while turning a resident during incontinent care and he .rolled him too far propelling him into a wooden nightstand near the bed, resulting in an arm laceration and facial bruising/swelling, and a near fall, this resident's care planned assistive devices were also in the down position during the care. Both residents had been assessed by the facility as requiring 2 staff for bed mobility & toileting. Findings included . Review of the facility Matrix, a document completed by staff to provide surveyors with current information regarding residents, dated 06/26/18, revealed the facility failed to submit an accurate matrix to the survey team. Review of the Matrix instructions, dated 01/2018, revealed facilities were to report: Fall(s), Fall(s) with Injury, Fall(s) with Major Injury: Resident(s) who have fallen in the facility in the past 90 days or since admission and have incurred an injury or not . Resident 41's fall information on the facility Matrix was blank. RESIDENT 41 The resident originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment, dated 05/25/18, he had severe cognitive impairment, and required extensive 2-person assist with bed mobility, transfers, dressing and toilet use. Review of a Physical Therapy Treatment Encounter Note, dated 06/01/18, he required fall precautions. In an interview on 06/25/18 at 3:23 PM, the resident's medical representative stated the resident was either dropped or had a fall when a nursing assistant had left him on his side to go into the bathroom, and when the nursing assistant came back out of the bathroom, he was on the floor. She stated he was paralyzed on his right side and he was left lying on his left side (good side) and the air mattress went off and he ended up on the floor. She stated he was a full-assist for care, so she did not understand how staff could have left him on his side and let him fall. She stated he was found to have a brain bleed at the hospital, but the doctor told her he didn't know if the brain bleed was from being treated with aspirin and [MEDICATION NAME] (blood thinning medication being used to treat his stroke) or due to the fall. Review of a Resident Occurrence Report, dated 06/03/18, revealed the resident had a non-witnessed fall on 06/03/18, sustained a small laceration on the top of the right hand, seemed to have pain in a few areas, and was sent out to the hospital for further evaluation to rule out further injury. The incident investigation findings were that the fall was Reasonably related to condition/event. The report indicated action taken included staff training, care plan revision, and first aid. The investigation form indicated the side rails were down (he had 1 right-sided mobility/assistance bar, he was turned away from it). The report indicated the assist handle was in place so the resident could assist in his cares as much as possible. The report indicated the nursing assistant was changing the resident's briefs and the resident started to have a bowel movement, the nursing assistant left the room for a minute . Training included nursing assistants to gather materials prior to entering room. The nursing assistant's statement indicated her immediate action to keep the resident safe was to Put the bed low in position & called the nurse. The care plan revision made was Ensure when providing incontinent care all items are in the room prior to providing care. Asking for assistance if needed. Review of the training documentation revealed 5 nursing assistants were in-serviced. The subjects covered part of the training included To prevent future re-occurrence. Please ensure that you have all necessary supplies prior to completing task. You may also ask for assistance as needed. The training form had sections for Reaction from Participants, and Summary and Conclusions, both were left blank. The facility did not substantiate abuse/neglect. The incident investigation did not state whether the resident's plan of care was being followed by staff. The incident investigation did not indicate why the assist/mobility bar was in the down position, even though it had been planned so he could assist in his care as much as possible. The incident investigation did not indicate why the resident had been turned onto his left side, away from the care planned assist device that had been planned so he could assist with bed mobility. The incident investigation did not indicate why the nursing assistant's immediate action was to put the bed in a low position after the resident had already fallen. The incident investigation report did not include size, depth, color, pain, or bleeding, of the wound, even though page 1 of the report had a place for it to be filled in. Review of the resident's care plan and KARDEX (care directive for nursing assistants), print dates both 06/27/18, revealed no documentation as to how many staff were required for bed mobility or toileting. The KARDEX indicated the bed was to be in the low position for safety. The care plan indicated he had a right-sided assist handle to assist with bed mobility and he needed extensive assist with turning and repositioning. In an interview on 06/28/18 at 2:57 PM, the Director of Nursing Services (DNS) was interviewed about the fall and the related investigation. The DNS stated she did not know why the mobility bar was left down when the nursing assistant left the room and the resident fell . The DNS stated they contributed the resident at high risk of falling because of his stroke, his impaired balance, his impaired mobility and his impaired cognition, so they ordered the use of the mobility bar. The DNS stated she did not know why the nursing assistant didn't call other staff for assistance, she stated She could have called for help, but she didn't. The DNS was asked if it was facility practice to do incontinent care with only 1 nursing assistant, she stated Well, it can be done with 1 aide, sometimes they can use extra help with BM (bowel movement). The DNS was asked what they determined to be the root cause of the fall, she stated the care giver wasn't there when he fell , I look at it like he was in bed maybe he attempted to change positions, he was laying on his good side, his left side, and we think he attempted to change positions. The DNS was asked how the fall was reasonably related to his condition, which they concluded in the investigation, she stated he had a stroke which made him at high risk for falls. She was asked if it's reasonable related to his condition to have a fall because he had a stroke? She stated Well, it was unfortunate. The DNS stated he did not have fall mats because they didn't think he needed them. The DNS was asked if residents ever had BMs during pericare, she stated Yes, every day .the resident may not have realized the staff was going to come back to take care of him. I think he was confused, her (the aide) had good intentions. The DNS was asked about the care plan revision to have all necessary supplies in the room prior to doing the care, and wasn't that already an expectation, the DNS stated Yes, they should have everything to be ready. The DNS was asked if the NA that left the resident alone to get more washcloths should have had more washcloths in the room without leaving, she did not provide any information. The DNS was asked if they had considered that using only 1 NA for the care may have been contributory to the fall, she replied No. The DNS denied the facility had a shortage of wash cloths. Review of the emergency department records, admitted [DATE], revealed the patient had a mechanical fall with a closed head injury ., The patient remembers the fall and thinks that he bumped his head, Final Impression: 1. Fall, initial encounter, 2. Closed head injury, initial encounter, 3. Petechial hemorrhage (a type of [MEDICAL CONDITION] resulting in bleeding). In an observation on 06/29/18 at 7:16 AM, Staff I, NA, was observed providing incontinent care, by himself, for the resident who had a bowel movement, Staff I cleaned the front of the resident's groin/genitalia, then he leaned across the resident's uncovered groin/genitalia to get hold of him for turning, he turned the resident towards him (away from the assist device) and braced the resident's uncovered groin area against the front of his scrub shirt, while he leaned over the resident and cleaned the bowel movement. Staff I was asked to take a quick look at his shirt and how it was being contaminated by contact with the resident's groin, he stated Well, I have to do it like that so he doesn't fall out of bed. In an interview on 06/29/18 at 7:47 AM, Staff I was asked how he knew how many staff the resident required for incontinent care, bed mobility, etc . He said he looked at the KARDEX; we looked at the KARDEX in the computer Kiosk on the wall, and it only had information for 2 staff for transfers, no staffing requirements were listed for bed mobility or toileting. He was unable to provide any information why the KARDEX didn't have staff requirements for bed mobility or toileting. In an interview on 07/02/18 at 2:36 PM, the DNS stated the resident's care plan should have been updated earlier, only 1 aide has been doing his care for a long time, and we did not have a problem, why would we need 2 aides now? In an interview on 07/02/18 at 2:53 PM, the DNS stated the facility was putting all residents that had air mattresses on 2 person care now. In an interview on 07/06/18 at 8:20 AM, the resident indicated he had a fall the night prior. In an interview on 07/06/18 at 8:22 AM, the resident's medical representative stated she had come into the facility the evening prior because the resident had another fall. She said on entering the resident's room, his roommate was yelling help, help, help. She stated staff had told her Resident 41 fell trying to self-transfer himself from the wheelchair to the bed. She said she asked him if that was how he fell , because he was trying to transfer himself to the bed, and he indicated it was not, and that he kept pointing to the clock. The medical representative thought the issue was something with his new roommate. Review of the facility's incident investigation, received via email on 07/09/18, revealed the facility's findings were the source was established and it was reasonably related to his condition/event. RESIDENT 52 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his admission MDS assessment dated [DATE], he had moderate cognitive impairment, and required 2-person extensive assist with bed mobility, transfers, dressing and toilet use. According to his care plan, he was at risk for falls. In an interview on 06/26/18 at 2:50 PM, the residents' daughter stated he had a fall 2 days earlier and sustained some facial and arm injuries. She said that staff told her he didn't fall completely, she said she asked her dad and he said he did in fact fall. The daughter stated she didn't think the staff member was being truthful because of the bruising and that her dad said he did fall, and the daughter found his cap on the floor. The daughter said staff told her he almost fell when they were turning him in bed. The daughter was very upset, she stated she had researched the facility prior to him coming, and people said residents fall here a lot. In an observation/interview at 3:35 PM, the residents' daughter showed the surveyor yellow/purple bruising and some swelling under his left eye, and there were 2 dressings on his left arm, the daughter stated that all of that happened in the fall. Review of a Resident Occurrence Report, dated 06/23/18, revealed the nature of the occurrence was Injury during handling, and actions taken were care plan revision and first aid. The only injury documented was a left elbow abrasion 1.5 centimeters (cm) by 1.5 cm, with S/f (superficial) depth, with serous drainage. The side rails were documented to be down, but this was determined by the facility to be not pertinent to occurrence. Staff phone interview notes with the nursing assistant Staff C, NA, that performed the care, revealed the resident had gotten done using a urinal, a solo nursing assistant was turning the resident side to side due to bowel movement and the resident got too close to the edge of the air mattress and he grabbed him before falling, while doing it, the resident hit his left arm on the night stand causing abrasion. Staff C's witness statement included a question, What do you think is the probable cause of the incident? Staff C's answer was I rolled him too far. The incident investigation Action: 1. Wooden nightstand moved further away from bed, and 2. Ensure assist rails up so resident can increase participation with ADLs (activities of daily living). The question what could prevent this from recurring? was answered Treatment applied to left elbow. Training: verbal training with the nursing assistant. Review of the care plan revision that was made revealed Use caution during transfers and bed mobility to prevent striking arms, legs, and hands against any sharp or hard surface. The attached care plan revealed he was care planned to have 2 staff to assist with toileting and repositioning and turning in bed and that there were bilateral assist rails for resident to assist with his bed mobility. Review of the nursing assistant training provided by the facility after Resident 41 fell , dated 06/04/18, revealed Staff C had not attended. Review of the KARDEX, print date 06/29/18, revealed Transfers: requires 2p (person) assist with transfers. Bed mobility: requires 2p extensive staff participation to reposition and turn in bed. Bilateral assist rails for resident to assist with his bed mobility. Toilet use: requires 2p extensive staff assist. Review of the care plan, print date 06/29/18, revealed he required 2-person extensive assist with toilet use, 2-person assist with bed mobility to reposition and turn in bed, and 2-person extensive assist with transferring. In an interview on 06/29/18 at 1:01 PM, the DNS was asked about only 1 staff providing incontinent care when they had assessed the resident as requiring 2 staff and then the resident got injured, she stated it could have something to do with the nursing assistant and how they work too. In an interview on 06/29/18 at 1:36 PM, Staff J, LPN/MDS assessment coordinator, was asked how the MDS assessment correlated to resident care and resident care plans, she indicated the care plan was based on the snapshot in time when they gathered information for the MDS. Staff J was asked about the resident's status and how staff would know how many staff were needed for his care, she stated Well, if staff refer to current care plan, it states he needs 2 persons for bed mobility and toileting. In an observation of wound care on 07/02/18 at 3:26 PM, the resident was observed to have an unhealed wound on his left arm that was approximately 1 x 0.5 x 0.1 inches and was red/raw. In an interview on 07/03/18 at 3:37 PM, the residents' daughter stated she was still very worried about falls at the facility, she stated she had seen a resident fall in front of the nursing station about an hour earlier. She was concerned staff weren't being truthful because her dad told her he had fallen to the ground, she had told the nurse that, but the nurse denied it. She said Falls are a big problem at the facility. She said after the first fall she found his cap on the floor, the cap he wears all the time. ANONYMOUS RESIDENT INTERVIEW In an interview on 07/03/18, a resident (AR1) was interviewed and he/she wanted to remain anonymous. This resident stated falls and staffing were a problem at the facility and he/she stated they had overheard staff talking about falls and near falls and they could tell by conversations that they were not going to report some of the fall incidents. This resident stated there was not enough staff at the facility to prevent falls and have call lights answered timely. In summary, the facility failed to provide care in accordance with the resident's care plans, both residents were assessed as requiring 2-person assist with bed mobility and toilet use, yet in both incidents, incontinent care was being done by 1-person, both residents were injured. The facility investigative process and root cause analysis process was substandard, in both incidents the facility analysis process showed a lack of appreciation or understanding of the risks and hazards associated with bed mobility in elderly cognitively and physically impaired residents. The facility failed to consider whether staff providing care had done so in accordance with their plans of care; specifically, only 1-staff was providing care in each incident, and in each incident, the assist handles/mobility bars were in the down position, so the residents' could not assist, which was why they were implemented. Both incidents were very similar, the residents were both incontinent of stool, they were both new admits within the last month, they both had air mattresses, they were both assessed as needing 2-staff for care, they both received care by only 1-staff, staff had put both resident's assist devices into the down position and inaccessible to the residents, in both incidents staff failed to ask for assistance, in both of the incidents the stories related to the family/representative by the residents were different than what the facility documented. Both incidents were avoidable accidents caused by staff failure to provide care in accordance with the resident's care plans. Systemically, it is failed practice for facility leadership not to utilize a facility-centered approach to evaluate and analyze similarities between resident incidents, risk factors and hazards, and to utilize this information to promote safety throughout it's environment and among staff, and to utilize this information to make adjustments in staffing, supervision and training, and to communicate to staff best practices to mitigate hazards to residents. Reference: (WAC) 388-97-1060 (3)(g) Related citations: CFR 483.10 (a)(1)(2)(b)(1)(2), F550 - Resident rights/exercise of rights CFR 483.10 (j)(1)(2)(4), F585 - Grievances CFR 483.24 (a)(2), F677 - ADL care provided for dependent residents CFR 483.25 (b)(1), F686 - Treatment/services to prevent/heal pressure ulcer CFR 483.25 (d)(1)(2), F689 - Free of accident hazards, receives supervision/devices CFR 483.35 (a)(1)(2), F725 - Sufficient nursing staff

Based on interview and record review the facility failed to ensure services that were provided met professional standards for 1 of 1 resident (1) with a gastrostomy tube. Failure to identify the need for timely and effective interventions to protect the skin and/or contain the gastric drainage resulted in harm of a chemical burn to Resident 1's skin. Findings include: The most common type of feeding tube is the gastrostomy (G) tube. [DEVICE]s are placed through the abdominal wall into the stomach. RESIDENT 1 Resident 1 had a gastrostomy feeding tube (PEG) inserted on 3/2/17 and started with small volumes of enteral feedings (TF). The nursing notes from 3/3/17 to 3/10/17 documented the drainage continued from the gastrostomy site (stoma area) even though dressing changes were frequently being done. The drainage from the stoma (opening) was described as yellow/brown and on 3/9/17. The Licensed Nurse (LN) documented that the drainage was profuse and the dressing (duoderm) was not adequate to protect Resident 1's abdominal skin from the irritation of the drainage which came in contact with her abdominal area. The irritation caused excoriation (redness) of the skin. The LN also documented Resident 1 had felt pain and burning sensation from the copious drainage. The Advanced Registered Nurse Practitioner (ARNP) seen Resident 1 on 3/7/16. The ARNP's note documented the PEG tube was leaking around site and the plan was to protect her skin, run TF slowly and to make an appointment to have the PEG looked at. On 4/7/17 at 1:55 p.m., during an interview with the ARNP who saw Resident 1 on 3/7/17 stated the leakage from the stoma (opening) site was not normal and when she assessed her skin, the redness was localized only around the stoma (opening) and not the abdomen. Review of Treatment Administration Record (TAR) sheets showed there was directions beginning 3/2/17 at 4:31 p.m. to monitor peg tube site for s/sx infection or bleeding and notify MD if present every shift for peg tube. This was signed by all shifts all days until discharged to hospital. During an interview with the Director of Nursing (DNS) on 3/27/17 she stated she had assessed Resident 1's skin around the stoma when it was inserted on 3/2/17 and the skin was not irritated but there was drainage from the stoma. On 4/13/17 during an interview with a family member s/he stated the drainage from the gastrostomy tube was horrible and her whole stomach was beet red from the drainage. The family member stated Resident 1 cried out in pain due to stomach buring from the excessive drainage from the GT. The hospital note dated 3/10/17 documented Resident 1 had developed leakage around the G tube (PEG) at the SNF and was noted to have [MEDICAL CONDITION] tissue damage around the tube from gastric fluid leakage. The hospital's surgical team evaluated the skin breakdown and documented there is full thickness skin and soft tissue loss due to the gastric tissue. It appears it is secondary to sensitivity from gastric acid. For approximately 2 inches surounding in all dimensions it appears there are 3rd [MEDICAL CONDITION](chemical) and beyond this local skin irritation. Even though the drainage from the stoma continued and the dressing was not adequate to protect Resident 1's skin, there was no documented evidence that LN B, C, D or E had further collaboration with the physician to evaluate other interventions or revise the plan of care to avoid further skin irritation and breakdown for Resident 1. Reference: WAC 388-07-1620 (2) (b)(i) (ii) 6 (b)(i)

Based on interview and record review, the facility failed to recognize the need for necessary interventions due to leakage from a gastrostomy tube for 1 of 1 residents (1). Failure to identify the need for medical intervention resulted in harm to Resident 1 who sustained [MEDICAL CONDITION] gastrostomy site leakage. Findings include: The most common type of feeding tube is the gastrostomy (G) tube. [DEVICE]s are placed through the abdominal wall into the stomach. A small amount of leakage of secretions from the stoma is considered normal. These secretions are usually tan or clear in color, and may become crusty when they dry. Leakage of formula or stomach contents from the tube site (around the tube or button) is more concerning because nutrients may be lost, and the acid from stomach contents may damage skin. Leakage of formula or stomach contents is not considered normal. RESIDENT 1 Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed she required extensive assistance of two persons for most activities of daily living (ADLS) and her admit nursing assessment revealed she had no skin breakdown. The nursing progress notes written by Licensed Nurses (LNs) were reviewed and showed: A nursing note entry by LN B, a Licensed Practical Nurse (LPN) on 03/04/17 at 1:59 p.m., documented the gastric tube (GT/PEG) continues with yellow/brown drainage, clean dressing applied. Additionally, LN B documented she assessed Resident 1 on 3/5/17 and indicated she was receiving enteral feeding per the PEG and tolerated 120 cc/ml. and that the gastrotomy (GT) continues with yellow/brown drainage from insertion site. On 3/6/17 at 11:43 p.m., LN C documented Resident 1 had tolerated tube feeding (TF) with no adverse affect but the insertion site continued with yellow/brownish drainage and would continue to monitor. On 3/7/16, the ARNP assessed Resident 1. The ARNP's note documented the PEG tube was leaking around site and that the plan was to protect the skin, to run TF slowly and to make appointment to have the PEG looked at. On 3/8/17 LN D documented Resident 1 had moisture associated skin damage (MASD) around the stoma of the GT from the copious drainage and described the skin to be very red and macerated. LN D indicated numerous dressing changes were required in addition to using linens to help contain and absorb the copious drainage. LN D notified the hospital (radiology) who instructed her to adjust the tube to tighten the stoma seal. Additional documentation revealed Resident 1 indicated she was having abdominal pain and felt a burning sensation due to the copious drainage and the stoma was inflamed and appears painful This entry indicated radiology recommended the ARNP see the resident and if concerned about her skin or the tube leaking, call tomorrow for a appointment. A nursing note entry for 3/9/17 at 3:32 p.m. documented the ARNP was made aware of the profuse drainage from the PEG site. The note revealed a new order to decrease further maceration (skin irritation) of periwound (around stoma) was obtained and an order for [REDACTED]. Another nursing note by LN B for 3/9/17 at 4:05 p.m. documented the GT site continued to cause excoriation due to the excessive drainage and at 11:03 p.m., LN C documented that the PEG insertion site continued with drainage which was yellow/brownish in color. On 3/10/17, the notes documented the GT site continues to have excessive drainage and that the site noted with quarter size opening and excoriation to abdominal area due to gastric juices and that Resident 1 was attempting to pull out the PEG. The note indicated Resident 1 was sent to the hospital (radiology) for GT evaluation d/t drainage. Review of treatment administration (TAR) sheets showed there was directions beginning 3/2/17 at 16:31 Monitor peg tube site for s/sx infection or bleeding and notify MD if present every shift for peg tube. This was signed by all shifts all days until discharged to hospital. There was no description in the nursing notes of site. The hospital note dated 3/10/17 documented Resident 1 had developed leakage around the G tube (PEG) at the SNF and was noted to have [MEDICAL CONDITION] tissue damage around the tube from gastric fluid leakage. The hospital's surgical team evaluated the skin breakdown and documented there is full thickness skin and soft tissue loss due to the gastric tissue. It appears it is secondary to sensitivity to gastric acid. For approximately 2 inches surounding in all dimensions it appears there are 3rd [MEDICAL CONDITION](chemical) and beyond this local skin irritation. On 3/27/17 during an interview with LN D, she stated the drainage from the PEG site was so bad that staff used pillow cases and linens to help absorb the excessive drainage from the PEG site. LN D stated the dressing (duoderm) which was ordered would not adhere and/or stick to the skin as the drainage continued under the dressing and lifted off causing the surrounding skin to became irritated. On 3/24/17 during a family interview, the family member stated the PEG tube site was leaking and the drainage was so much that staff were placing rags to help contain the drainage. The family member stated licensed staff missed the boat and Resident 1 sustained 3rd [MEDICAL CONDITION] to bile on her abdomen which caused skin damage. On 4/7/17 at 1:55 p.m., during an interview with the Advanced Registered Nurse Practitioner (ARNP) who saw Resident 1 on 3/7/17. The ARNP stated the PEG tube was leaking, which was not normal and the leakage was just around the stoma (opening), and redness was around the stoma. The facility's Skin Care Policy/Procedure indicated that comprehensive skin review should occur on an as needed basis though the activity of the interdisciplinary team. The policy directed staff to communicate skin changes as identified daily, .to resident's physician, or others as necessary to facilitate healing and if the resident is not able to or chooses not to participate in the care plan relative to prevention of skin breakdown, the nursing staff shall communicate with the resident's physician to discuss an appropriate intervention or response. There was no documented evidence that the LNs recognized the need to intervene to avoid the complications due to the inability to contain the copious drainage or revise interventions (dressing) in order to protect her skin from a chemical burn even when Resident 1 experienced pain and a burning sensation on her skin from the drainage. Reference: WAC 388-97-1060 (3) (f)