Every finding on record at North Valley Hospital

Based on interview and record review, the facility failed to ensure an anti-inflammatory medication (medication that reduces inflammation and pain), taken in conjunction with an anticoagulant (blood thinning) medication, was administered according to medical provider orders for 1 of 3 Residents (Resident 1). This failure resulted in the medication being administered in excess which may have contributed to bruising and placed the resident at risk for additional bleeding and worsening of their overall condition. Findings included:According to Medscape Drug Reference Database, https://reference.medscape.com/drug-interactionchecker, copyright 1994-2026, Eliquis (an anticoagulant medication) and Naproxen (an anti-inflammatory medication) have a serious interaction, as both medications decrease the ability of the body to form clots in the blood and can lead to excess bleeding. The database stated concurrent use of the two medications should be avoided or include dosage modifications. Record review showed Resident 1 admitted to the facility on [DATE] with a diagnosis of atrial fibrillation (irregular beating of the heart that can lead to the production of blood clots that then can break away from the heart and cause a heart attack or stroke). Resident 1 also took Eliquis daily to decrease the risk of stroke or heart attack.Review of progress note dated 12/02/2025, Staff C, Medical Doctor, indicated Resident 1 had pain in their knee and shoulders and could start Naproxen 250 mg BID (two times per day) for 2 weeks (for 14 days), and to initiate Naproxen 250 mg BID for short course if renal and gastrointestinal status allow. The progress note showed Staff B's, Resident Care Manager, initials on the top right corner with the date 12/10/2025.Record review of Resident 1's Medication Administration Record (MAR) showed on 09/10/2025 an was order entered for the Eliquis to be taken one time daily, and that the medication was to be administered daily until the resident discharged . The MAR showed on 12/02/2025 an order was entered for Naproxen two times daily and did not have an end date. Review of the MAR showed Naproxen was then administered two times daily until they discharged from the facility on 02/25/2026.Further record review showed a skin check was completed on 02/23/2026 at 8:35 PM after facility staff found significant dark blue/purple bruising to Resident 1's inner thighs, buttock and perineal region (external sexual organs located between legs). Record review of a skin assessment written on 02/24/2026 measured the bruising: right upper inner thigh 3 centimeters (cm) by 3cm, right upper inner thigh 7 cm by 4 cm, left upper inner thigh 8 cm by 4 cm, perineal area - did not measure.During an interview on 03/05/2026 at 3:10 PM, Staff B stated they entered the order for Naproxen into the MAR for Resident 1 on 12/02/2025. Staff B confirmed they entered the order without an end date. They also stated it was their initials on the MD progress note from the same date, indicating they had reviewed the MD note. Staff B could not recall why an end date had not been entered as ordered by Staff C.In an interview on 03/05/2026 at 3:10 PM, Staff A, Director of Nursing, confirmed Resident 1 was taking Eliquis on admission and started taking Naproxen on 12/02/2025. The Naproxen was to end after two weeks, but was entered into the MAR without an end date and Resident 1 continued to receive the medication until the resident discharged from the facility on 02/25/2026. Staff A stated the interaction between the two drugs could have caused the bruising identified on 02/23/2026.Reference: WAC 388-97-1060(3)(k)(i)

Based on observation and interview, the facility failed to follow food code regulations to prevent the potential of foodborne illness by not correctly performing hand hygiene when indicated during the lunch meal service for 2 of 2 dietary staff (Staff D and E). This failure placed residents at risk for food-borne illnesses.Findings included.On 02/26/2026 from 11:28 AM to 12:12 PM, dietary staff were observed preparing plates of food for the resident's lunch. Staff D, Dietary Aide, plated the main dish with utensils, while wearing gloves. Staff D was observed unlatching and opening the door of the heated food cart twice and opened the cooler door to remove needed items. Staff D did not change gloves, wash their hands or use hand sanitizer after touching the handles and resumed plating the food with the same gloves. Staff E, Cook, was observed placing slices of cheesecake on a plate, adding caramel drizzle and apple topping. Staff E touched the handle of the cooler, removed items from the cooler, then touched the cheesecake (to nudge it to the center of the plate) and squeezed the caramel bottle while wearing the same gloves. Staff E changed gloves during food service, but they did not do hand hygiene with the glove changes. Neither Staff D or Staff E washed their hands at the sink until the food service was completed or used hand sanitizer during any of the glove changes, as required.During an interview on 02/26/2026 at 12:12 PM, Staff E stated they should change gloves after touching anything other than the serving utensils. Staff D agreed and said they should have changed gloves after touching the cooler handles. When asked if they needed to wash hands or use hand sanitizer at any time, they both stated that they should have done so whenever they changed gloves.During an interview on 02/27/2026 at 2:55 PM, Staff C, Registered Dietician, stated they expected dietary staff to perform hand hygiene (either wash hands or use hand sanitizer) with every glove change, and they should change gloves after touching other surfaces during meal preparation.Reference: WAC 388-97-1100(3), 2980

Based on interview and record review, the facility failed to ensure pharmacy recommendations were followed up on for 1 of 5 sampled residents (Resident 3), reviewed for unnecessary medication. This failure placed the resident at risk for experiencing adverse side effects from receiving medication at a higher dose, and for being on a medication for a longer duration than medically necessary. Findings included. <Resident 3> Review of the annual assessment dated [DATE], documented Resident 3 had diagnoses which included Parkinson's disease, a progressive brain disorder that caused problems with movement, balance, and coordination. Review of the Order Summary Report, dated 05/16/2023, showed that Resident 3 was prescribed Carbidopa-Levodopa, a medication used to treat the symptoms of Parkinson's disease. Review of the Pharmacy consultation Report, completed on 09/29/2025, documented Resident 3 received Carbidopa-Levodopa during flexible medication times, a window of time when medications were administered. The report stated in order to provide better management of the symptoms, it was recommended the medication be administered at specific times and not flexible medication times. Review of the Medication Administration Records (MAR) showed the months of October 2025 and November 2025 documented the Carbidopa-Levodopa continued to be administered during flexible medication times. No documentation was found in the resident's record to show the physician had been informed of the 09/29/2025 pharmacy recommendations. The 11/24/2025 Pharmacy Consultation Report repeated the 09/29/2025 recommendation to have the Carbidopa-Levodopa changed to a specific administration time. Review of the December 2025 MAR showed on 12/26/2025, the administration time for the Carbidopa-Levodopa had been changed to a specified time, almost three months after the initial pharmacy recommendation. In an interview on 02/27/2026 at 10:27 AM, Staff B, Resident Care Manager, stated the facility had identified some issues with timely follow-up with regard to the pharmacy recommendations. Reference (WAC) 388-97-1300(4)(c)

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Failure to ensure expired foods were discarded for 3 of 3 refrigerators, 1 of 1 dry storage areas, opened dates were placed on food items in the refrigerator and freezer and performed hand hygiene when indicated. The facility further failed to consistently monitor refrigerator and dish washer temperatures. These failures placed residents at risk for food-borne illnesses. Findings included . <Expired/undated food> During an initial tour of the kitchen on [DATE] at 11:17 AM, the dry storage area revealed a nut mix that was made on [DATE] with no expiration date, a can of trail mix with no expiration or open date, two boxes of brown rice that expired on [DATE], five bags of instant mashed potatoes that expired on [DATE], and a bag of opened toasted seeds that had no open or expiration date. The refrigerator in the main kitchen contained three packages of cheese and a large container of wilted grapes with no open or expiration date, a pan of bacon, five crescent rolls, onions, celery and cabbage that had no expiration date. The freezer contained a homemade cheesecake, a cake and a dessert in a bowl with no expiration date, a bag of opened tater tots, three opened bags of vegetables with no open or expiration date, a bag of opened strawberries that were unsealed and four frozen bananas with no open or expiration date. In an interview on [DATE] at 11:17 AM, Staff I, Dietary Manager, stated food needed to be dated for quality and safety. During an observation on [DATE] at 11:09 AM, the refrigerator in the dining room revealed three boiled eggs that expired on [DATE], and an opened package of cheese slices with no open or expiration date. The refrigerator in the snack room revealed a bag of frozen cookies and a bag of mixed berries with no date or expiration date, a container of muffins that were made on [DATE] with no expiration date, and French toast made on [DATE] with no expiration date. <Dining Room Observation> During observation on [DATE] at 11:57 AM, Staff M, Dietary Aide, wore a pair of purple gloves, walked across the common hall from kitchen counter in the large assisted dining room into the small dining lounge to deliver an uncovered plate of food to Resident 24. Without removing their gloves or performing hand hygiene, Staff M walked back across the common hall to the kitchen counter in the large assisted dining room. At 11:59 AM, Staff M walked back to the small dining lounge to deliver and set up an uncovered plate of food for Resident 38. Without removing their gloves or performing hand hygiene, Staff M approached the kitchen counter in the large assisted dining room. Staff M delivered an uncovered plate of food for Resident 4. At 12:01 PM, Staff M picked an item off the floor with their right hand, removed their right glove, did not perform hand hygiene and applied a new glove. At 12:04 PM, Staff M delivered an uncovered plate of food to Resident 37. At 12:08 PM, without removing their gloves or performing hand hygiene, Staff M obtained coffee for Resident 23. In an interview on [DATE] at 12:24 PM, Staff N, Licensed Practical Nurse, acknowledged food should always be covered when transporting. In an interview on [DATE] at 12:34 PM, Staff C, Resident Care Manager, stated food should be covered when transported down the hall to prevent potential bacterial contamination. In an interview on [DATE] at 3:31 PM, Staff B, Director of Nursing, acknowledged staff did not cover food when transporting food from the assisted dining room kitchen counter across the common hallway and delivering to the small dining lounge because the common hall was considered part of the dining room area. <Food Temperatures> During observation of tray line on [DATE] at 11:26 AM, Staff O, Cook, had plated a chicken breast on a plate that they had removed from a heated cart and was going to serve the chicken to a resident. When Staff O was asked to check the temperature of the chicken breast prior to serving it, the temperature was 133 degrees which had not met the requirement of 165 degrees. Staff O then requested another chicken breast from the kitchen. Staff O had checked the temperatures of the cold items, the salad was 46 degrees, cottage cheese 41.5 degrees and the strawberries were 43.1 degrees. Cold foods needed to be less than 41 degrees. Staff O was going to serve the above foods after the temperatures had been obtained and were found to be to warm. In an interview on [DATE] at 12:31 PM, Staff O stated it was important to serve food at the appropriate temperature to prevent illness. <Sanitary Practices> During an observation of tray line on [DATE] at 11:57 AM, Staff O was plating food, turned toward the counter and rested their gloved hands on the surface, wearing the same gloves they opened the door of the heated cart, opened the refrigerator, got a sandwich, took the plastic wrap off the sandwich and grabbed the sandwich with the same unclean gloves and put it on the resident's plate. In an observation on [DATE] at 12:26 PM, Staff O was wearing gloves and had plated food. Staff O, wearing the same gloves, opened the refrigerator, grabbed a drink for a resident, and went back to plating food without performing hand hygiene or changing gloves. At 12:27 PM, Staff O wearing the same gloves, opened the refrigerator, took out a sandwich, picked it up and placed it on a plate, hand hygiene was not performed, and gloves were not changed. In an interview on [DATE] at 12:31 PM, Staff O stated they should have done hand hygiene after touching things and prior to touching the resident's sandwich and this was important to prevent the spread of germs. During an interview on [DATE] at 1:03 PM, Staff I stated hand hygiene should have been completed after touching things and prior to the food being served. <Refrigerator temperatures> In an observation on [DATE] at 11:20 AM, the refrigerator in the snack room had a [DATE] temperature log that hung on the refrigerator. The log stated the temperature was to be between 36 to 46 degrees, instructed staff to record the temperature and initial, and they needed to document what action had been taken if the temperature was out of range. The November log showed the temperature had been monitored 4 out of 15 days. The temperature was out of range on all four days and there was no documentation of what had been done to correct the out-of-range temperatures. In an interview on [DATE] at 1:03 PM, Staff I stated the kitchen aides were supposed to monitor the refrigerator temperatures and discard expired food. Staff I stated this was important, so the food did not go bad. <Dishwasher temperatures> During a second observation of the kitchen on [DATE], the dishwasher temperature log instructed staff to monitor the temperature in the morning, at noon and in the evening. The [DATE] log had four omissions in which the temperature was not monitored. A review of the [DATE] temperature log showed seven omissions, and the [DATE] log showed 22 omissions. In an interview on [DATE] at 1:01 PM, Staff I, Dietary Manager, stated it was important to monitor the dishwasher temperatures to ensure the dishes were sanitized and clean. Reference: WAC [DATE] (3), 2980 47328

Based on observation and interview the facility failed to ensure damaged paint and drywall was repaired timely after a water leak in 1 of 3 halls, reviewed for environment. In addition, the facility failed to ensure hazardous chemicals were secured in 1 shower room. This failure placed residents at risk of potentially avoidable accidents, lack of dignity and diminished quality of life. Findings included . <Shower Rooms> During an observation on 11/12/2024 at 1:42 PM, the shower room on the east hall was unlocked. The shower room had an unlocked cabinet that was at eye level. The cabinet contained two bottles of disinfectant cleansers that said to keep out of reach of children. A similar observation was made at 3:37 PM, the same day. There were no residents wandering or near the area. In an interview on 11/12/2024 at 4:04 PM, Staff K, Nursing Assistant, stated the cabinets were supposed to be locked. Staff K was shown the unlocked cabinets in the shower room and acknowledged the cleaning solutions should have been locked up. Staff K added they had never seen a resident come into the shower room unattended. During an interview on 11/12/2024 at 4:08 PM, Staff L, Registered Nurse, stated all chemicals were kept locked up because they are toxic and would be harmful to the residents. In an interview on 11/12/2024 at 4:09 PM, Staff B, Director of Nursing, confirmed the chemicals should have been locked up and this was important because cognitively impaired residents could ingest them. <Paint and Drywall> During observation on 11/15/2024 at 5:37 AM, a large section of ceiling and wall near the two dining rooms had large pockets of puffed-up paint going down the wall. When touched, the paint was filled with air pockets. During observation on 11/15/2024 at 5:43 AM, the ceiling in the hall between the two dining rooms had a large area of sagging drywall in the center of the hall. A section of ceiling above a light fixture and an electrical outlet had a large section of uneven bumpy drywall with dried brown discolored drip streaks going down the wall. The wallpaper at the bottom of wall near the floor was bubbled up and wrinkled, the trim along the bottom was not flush against the wall or floor tiles. During observation on 11/15/2024 at 5:52 AM, a large section of sagging drywall with a holes at the base were noted in the ceiling outside room [ROOM NUMBER]. During observation and interview on 11/16/2024 at 12:24 PM, the various sections of drywall and paint damage were observed with Staff N, Licensed Practical Nurse. Staff N acknowledged it appeared as if the paint and drywall damage were a result of a water leak and was unsure how long the wall and/or drywall were in disrepair. During observation and interview on 11/16/2024 at 12:33 PM, the various sections of drywall and paint damage were observed with Staff G, Registered Nurse. Staff G was unsure how long the wall and/or drywall were in disrepair and informed maintenance. In an interview on 11/16/2024 at 1:24 PM, the various sections of drywall and paint damage were observed with Staff J, Maintenance Assistant. Staff J acknowledged there was a water leak over a year ago that resulted in the discolored brown streaks down the wall, sagging ceiling drywall damage, and bubbled up paint down the walls but the damage still had not been repaired. In an interview on 11/16/2024 at 5:04 PM, Staff B, Director of Nursing, acknowledged paint and drywall damage repairs from the water leak over a year ago, were not completed timely. Reference: WAC 388-97-3220 (1) 46115

Based on interview and record review the facility failed to ensure Level I Preadmission Screening and Resident Review (PASRR, an assessment to ensure individuals with serious mental illness or intellectual/developmental disabilities were not inappropriately placed in nursing homes for long term care) was accurately completed for 1 of 6 sampled residents (Resident 6), reviewed for PASRR. In addition, the facility failed to routinely ensure residents with a positive Level I PASRR were referred for Level II PASRR evaluations, as required for 2 of 6 sampled residents (Resident 6 and 31). This failure placed the residents at risk for not receiving the care and services appropriate for their needs. Findings included . <Resident 6> According to the admission assessment, dated 04/14/2024, Resident 6 admitted to the facility on [DATE] with diagnoses including chronic pain. The assessment further showed Resident 6 did not demonstrate any behaviors or signs and/or symptoms of depression. Review of the 05/15/2023 PASRR showed Resident 6 had no serious mental illness indicators identified, and a Level II evaluation was not indicated. Review of the 05/16/2023 provider documentation showed Resident 6 took antipsychotic (medications used to treat symptoms of psychosis [mental disorder that cause abnormal perceptions and thoughts]) medications for visual hallucinations (false perception of an object or event that seems real but not) and antidepressant medication for moderate recurrent major depression. Review of the 05/17/2023 mood care plan showed Resident 6 received medication for depression and instructed staff to administer medications as ordered, documented behaviors and interventions attempted, monitor and document medication side effects. Review of provider orders showed an active 07/27/2023 order for Resident 6 to be administered an antidepressant and a 08/29/2023 order for Resident 6 to be administered an antipsychotic daily. Review of the 04/12/2024 neurologist (doctor that specializes in conditions that affect the brain and nerves) progress notes showed Resident 6 was to continue taking an antipsychotic due to a history of severe hallucinations. According to the quarterly assessment, dated 10/13/2024, over the last two weeks Resident 6 felt down, depressed, or hopeless several days. Resident 6's PASRR was not redone, and Resident 6 was not referred for a Level II evaluation, as required. Further review of the antipsychotic medication use care plan revised 10/31/2024 showed Resident 6 took medications related to a history of experiencing frightening hallucinations and instructed staff to administer medications as ordered, monitor and document medication side effects. <Resident 31> According to the admission assessment, dated 04/02/2024, Resident 31 had diagnoses including depression and psychotic (severe mental illness that causes a person to lose touch with reality and have difficulty relating to others) disorder. Review of the 03/15/2023 PASRR showed Resident 31 had mood disorders, but a Level II evaluation was not indicated. According to the quarterly assessment, dated 09/29/2024, showed over the last two weeks Resident 31 felt down, depressed, or hopeless half or more days. Resident 31 had severe cognitive impairment. Resident 31's PASRR was not redone, and Resident 31 was not referred for a Level II evaluation, as required. Review of March 2024 through November 2024 nursing progress notes showed no documentation Resident 31 was referred for a PASRR Level II evaluation, as required. In an interview on 11/15/2024 at 12:48 PM, Staff E, Social Service Director, explained the facility typically received PASRRs prior to admission but if none was received Staff E completed a PASRR prior to a resident's admission. Staff E further stated a PASRR was redone if/when a resident had a change of condition. Staff E explained a positive Level I PASRR required a referral for a Level II evaluation from an assessor, but they had not referred any residents for a Level II PASRR evaluation in several years. Staff E stated if or when a Level II PASRR referral was submitted it would be documented in a progress note and care planned. Staff E reviewed Level I PASRRs for Resident 18 and Resident 31. Staff E acknowledged Resident 18 and Resident 31 were not referred for a Level II PASRR, as required. In an interview on 11/16/2024 at 5:04 PM Staff B, Director of Nursing, stated they expected staff to follow the appropriate PASRR process. Reference WAC 388-97-1915 (1)(2)(a-c)

Based on observation and interview the facility failed to ensure standard precautions were maintained and hand hygiene was performed when indicated during 2 of 2 medication pass observations. This failure placed residents at risk of contracting communicable diseases and diminished quality of life. Findings included . Review of the facility policy titled, Hand Hygiene-Infection Prevention revised August 2024, showed hand hygiene was performed by using alcohol-based hand rub (ABHR) or washing hands with soap and water when visibly soiled or when contact with suspected infectious stools. The policy further showed staff should perform hand hygiene before and after contact with a resident, after contact with blood, body fluids, visibly contaminated surfaces, after contact with objects in the residents rooms, after removing personal protective equipment (PPE, gloves, gown, face mask), and before meals. The Centers for Disease Control and Prevention website, CDC.gov - with regard to standard precautions showed, standard precautions are based on the principle that all blood, body fluids, secretions, excretions except sweat, nonintact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include: hand hygiene, use of gloves, gown, masks, eye protection, or face shield, depending on the anticipated exposure. <200 Hall> During observation on 11/15/2024 at 6:28 AM, Staff N, Licensed Practical Nurse (LPN), did not perform hand hygiene and dispensed medications for Resident 4. Staff N entered Resident 4's room without performing hand hygiene, touched the bed, bedside table, and administered medications to Resident 4. Staff N used ABHR when exiting the room. During observation on 11/15/2024 at 6:39 AM, Staff N, LPN, did not perform hand hygiene and dispensed medications for Resident 3. Staff N entered Resident 3's room washed their hands with soap and water prior to applying a pair of gloves. Staff N obtained a drop of blood to check Resident 3's blood sugar, without changing gloves or performing hand hygiene, Staff N administered an injection. In an interview on 11/16/2024 at 12:24 PM, Staff N, stated hand hygiene was cleansing hands with ABHR or washing with soap and water. Staff N stated hand hygiene was to be performed before and after resident care. Staff N explained staff should perform hand hygiene when indicated to prevent the spread of bacteria and potential infection. In an interview on 11/16/2024 at 12:34 PM, Staff C, Resident Care Manager, explained hand hygiene should be performed by using ABHR or washing with soap and water at various times including between residents and after glove removal. Staff C acknowledged gloves should be changed and hand hygiene performed between residents. Staff C expected staff to perform hand hygiene when indicated because it was the number one way of preventing infection. In an interview on 11/16/2024 at 3:31 PM, Staff B, Director of Nursing, explained hand hygiene should be performed at various times including before applying gloves and after glove removal. Staff B stated they expected staff to perform hand hygiene when indicated. 46115 <100 Hall> During an observation on 11/15/2024 at 8:17 AM, Staff G, Registered Nurse, administered an insulin injection into Resident 36's abdomen. The abdomen was not cleansed with an alcohol wipe prior to the injection and gloves were not worn. During an interview on 11/15/2024 at 8:25 AM, Staff G stated they should have worn gloves and cleansed the resident's abdomen prior to the injection, and this was important for infection control. In an interview on 11/16/2024 at 4:10 PM, Staff B, Director of Nursing, stated the expectation was for nursing to have cleansed the injection site prior to administration and to have worn gloves. Reference WAC 388-97-1320 (1)(c )

Based on observation, interview, and record review the facility failed to ensure the Minimum Data Set (MDS, assessment tool) accurately reflected the status of 1 of 11 sampled residents (Resident 31), reviewed for resident assessment. This failure placed residents at risk of inaccurate monitoring of resident status over time, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Extended Care Resident Assessment revised August 2024, showed the facility would accurately conduct a comprehensive assessment for each resident upon admission and periodically thereafter. The assessment would include a dental status assessment by a Registered Nurse (RN) to the condition of the teeth, gums, and other structures of the oral cavity that may affect a resident's nutritional status, communication abilities, or quality of life. The assessment was to include the need for, and use of, dentures or other dental appliances. The policy showed the assessment would be completed within 14 calendar days after admission. Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.18.11 revised October 2023, showed the RAI consisted of three basic components: the Minimum Data Set (MDS), the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three component of the RAI yields information about a resident's functional status, strengths, weaknesses, and preferences, as well as offered guidance on further assessment once problems were identified. The MDS must be accurate as of the assessment reference date (ARD). According to the admission assessment, dated 04/02/2024, Resident 31 admitted to the facility on [DATE] with diagnoses including cancer and muscle wasting. The assessment further showed Resident 31 was dependent on staff for oral hygiene and no oral or dental status concerns were identified. Resident 31 had severe cognitive impairment. Review of the 03/27/2024 nursing admission assessment showed Resident 31 had a partial denture, no mouth pain or chewing problems. The assessment showed no documentation regarding Resident 31's own teeth or their status. Review of the 03/28/2024 personal hygiene care plan showed Resident 31 was dependent on staff assist for oral care. No documentation was found regarding Resident 31's own teeth or their status. Review of the 04/29/2024 provider note showed Resident 31 had periodontal (infection of tissue that hold teeth in place) disease and referred Resident 31 for a dental evaluation and treatment. During observation on 11/13/2024 at 9:21 AM, Resident 31 laid in bed with a thick layer of white debris along their bottom teeth. When Resident 31 smiled and exposed their upper teeth, Resident 31 had some missing upper teeth and jagged discolored front teeth. During an interview on 11/15/2024 at 10:55 AM, Staff F, Nursing Assistant, stated Resident 31 had their own teeth but was missing some. Staff F was unsure if Resident 31 had broken or jagged teeth. In an interview on 11/15/2024 at 11:18 AM, Staff G, Registered Nurse, stated Resident 31 had their own teeth but they were not in very good shape. In an interview on 11/16/2024 at 12:44 PM, Staff C, Resident Care Manager, stated an MDS was an assessment tool to comprehensively collect data about a resident and should accurately reflect a resident's status as of the ARD. Staff C further stated if an MDS was inaccurate it could potentially affect a resident because the assessment helped drive clinical care for residents. Staff C reviewed Resident 31's medical record. Staff C acknowledged the admission nursing assessment for oral/dental was not filled out completely and the 04/02/2024 admission MDS did not accurately reflect Resident 31's dentation status as of the ARD. In an interview on 11/16/2024 at 3:55 PM, Staff B, Director of Nursing, reviewed Resident 31's medical record. Staff B acknowledged the 04/02/2024 admission MDS did not accurately reflect Resident 31's dental status as of the ARD and should have. Reference WAC 388-97- 1000 (2)(k) Refer to F656 and F791 for additional information.

Based on observation, interview and record review, the facility failed to determine a resident had a significant change in their physical condition for 1 of 11 sampled residents (Resident 27) reviewed for comprehensive assessments. This failure placed the resident at risk for unidentified care needs and a lack of revisions to their plan of care. Findings included . A review of the 06/16/2024 quarterly assessment documented Resident 27 had diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and dementia with anxiety. Resident 27 had severe cognitive impairment, required partial/moderate assistance to eat, and substantial/maximum assistance for toileting, dressing, personal hygiene, and mobility in and out of bed. A review of the active 07/14/2022 comprehensive care plan documented Resident 27 had an ADL (activities of daily living) self-care deficit. The resident required set-up assistance for eating, supervision to extensive assistance for personal hygiene and dressing, extensive assistance for toileting and bed mobility, and 2-3 staff assistance for a stand and pivot method of transfers. Staff were to use a mechanical lift as needed. On 09/08/2024, the quarterly comprehensive assessment was completed and documented that Resident 27 required substantial/maximum assistance for eating and was totally dependent on staff for completion of their ADLs. A significant change assessment had not been completed for Resident 27. Changes were not made to the Resident 27's plan of care. On 11/12/2024 12:04 PM and 11/14/2024 at 11:53 AM, Resident 27 was observed in the dining room at lunch. The resident had a staff member seated next to them that fed the resident. Resident 27 had drinks that had lids on them with straws. Staff held the glass to Resident 27's mouth so they could drink. On 11/13/2024 at 12:10 PM Resident 27 was observed in their room. The resident was in their wheelchair with a mechanical lift sling around them that was connected to the mechanical lift (a machine that hoists a resident out of their seat or bed using a sling; the resident is passive when transferred, the staff and machine bear the weight of the resident). Staff P, Nursing Assistant, (NA) was present and waited for a second staff to assist the transfer. During an interview on 11/16/2024 at 9:35 AM, Staff P stated they had been employed at the facility for just over 2 months. They stated when they first started, Resident 27 was able to be transferred using a stand and pivot method, but currently had to use a mechanical lift. They stated Resident 27 used their arms slightly when putting on a top but did not assist dressing with their legs. Staff P stated they did not attempt to seat the resident on a commode; they were unsure if Resident 27 was able to support their trunk. During an interview on 11/16/2024 at 10:44 AM, Staff Q, NA, stated Resident 27 required total assistance. The resident required a mechanical lift for transfers and was unable to follow instructions such as when helping reposition or rolling the resident in bed. The resident also required staff to feed them, so they stayed right next to the resident at meals. During an interview on 11/16/2024 at 11:43 AM, Staff C, Resident Care Manager, stated the interdisciplinary team had discussed Resident 27's status but did not recall why a significant change assessment had not been done. Staff C stated a significant change assessment was important so it could be determined if a resident required more support services and so staff knew the appropriate level of care they needed to provide. During an interview on 11/16/2024 at 4:10 PM, Staff B, Director of Nursing, stated their internal audits had identified that the comprehensive assessment process had some areas that needed improvement, and they planned to continue working to improve the assessment process. Reference: WAC 388-97-1000(3)(b)

Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan that included dentation status and needs for 1 of 11 sampled residents (Resident 31), reviewed for care planning. This failure placed residents at risk of unmet care needs and diminished quality of life. Findings included . According to the admission assessment, dated 04/02/2024, Resident 31 admitted to the facility on [DATE] with diagnoses including cancer and muscle wasting. The assessment further showed Resident 31 was dependent on staff for oral hygiene and no oral or dental status concerns were identified. Resident 31 had severe cognitive impairment. Review of the 03/27/2024 nursing admission assessment showed Resident 31 had a partial denture, no mouth pain or chewing problems. The assessment showed no documentation regarding Resident 31's own teeth or their status. Review of the 03/28/2024 personal hygiene care plan showed Resident 31 was dependent on staff assist for oral care. No documentation was found on goals or interventions developed regarding Resident 31's dentation status. Review of the 04/29/2024 provider note showed Resident 31 had periodontal (infection of tissue that hold teeth in place) disease and referred Resident 31 for a dental evaluation and treatment. No documenation was found in Resident 31's care plan regarding periodontal disease goals or interventions. Review of March 2024 through November 2024 nursing progress notes showed on 05/29/2024 Resident 31 did not allow their partial denture to be removed during oral care. On 09/06/2024 staff had difficulty removing extra food debris from Resident 31's lower teeth. During observation on 11/13/2024 at 9:21 AM, Resident 31 laid in bed with a thick layer of white debris along their bottom teeth. When Resident 31 smiled and exposed their upper teeth, Resident 31 had some missing upper teeth and jagged discolored front teeth. In an interview on 11/15/2024 at 10:55 AM, Staff F, Nursing Assistant, stated Resident 31 had their own teeth but some were missing. Staff F further stated Resident 31 was dependent on staff assist for oral care but sometimes refused oral care by turning their head and pushing away. In an interview on 11/15/2024 at 11:18 AM, Staff G, stated Resident 31 was dependent on staff for oral care. Staff G further stated Resident 31 had their own teeth, but they were not in very good shape. In an interview on 11/15/2024 at 11:36 AM, with Staff C, Registered Nurse Care Manager, and Staff D, Registered Nurse Care Manager. Staff C explained a dentation assessment included oral care needs, denture and natural tooth status. Staff C stated dentation was assessed upon admission using the nursing admission assessment which helped create a resident's care plan. Staff C stated Resident 31 had some of their own teeth and an upper partial denture. Both Staff C and Staff D reviewed Resident 31's medical record. Staff D acknowledged Resident 31's care plan showed no documentation regarding Resident 31's dental status but should have. In an interview on 11/16/2024 at 3:55 PM, Staff B, Director of Nursing, reviewed resident 31's medical record. Staff B acknowledged Resident 31's record did not accurately reflect Resident 31's dentation status and should have. Reference WAC 388-97-1020 (1), (2)(a)(b) Refer to F636 and F791 for additional information.

Based on observation, interview, and record review, the facility failed to consistently provide grooming for 1 of 2 sampled residents (Resident 30), reviewed for activities of daily living. This failure placed the resident at risk for not being groomed according to their preferences, and a diminished quality of life. Findings included . According to the 09/29/2024 annual assessment, Resident 30 was cognitively intact and needed supervision/set up assistance from staff for ADL's (activities of daily living), such as personal hygiene. Per the 10/11/2023 care plan, Resident 30 had impaired vision and needed assistance with ADL's. Review of the personal hygiene task from 10/16/2024 through 11/13/2024 documented Resident 30 required partial to total assistance and had not refused cares. Review of the bathing task from 10/16/2024 to 11/13/2024 documented Resident 30 required partial to total assistance and had refused to be bathed twice. In an observation and interview on 11/12/2024 at 1:13 PM, Resident 30 was lying in their bed and stated they could not see well. Resident 30's nails were unclean with a brown substance underneath them. Subsequent observations of Resident 30 having unclean nails with brown matter under them were made on 11/13/2024 at 9:22 AM, 1:21 PM and 2:22 PM, 11/14/2024 at 09:22 AM and 1:05 PM and 11/16/2024 at 8:59 AM. During an interview on 11/14/2024 at 11:16 AM, Resident 30 stated they used their fingers to eat with and staff had not cleaned under their nails after meals. In an interview on 11/16/2024 at 9:36 AM, Staff H, Nursing Assistant, stated nail care was completed after showers and should have been completed after meals for residents that ate with their fingers to prevent bacteria. During an interview on 11/16/2024 at 9:52 AM, Staff B, Director of Nursing, stated nail care was completed with showers and confirmed nail care should have been provided after meals and this was important because nails can harbor bacteria. Reference: WAC 388-97-1060 (2)(c)

Based on interview and record review the facility failed to ensure residents administered psychotropic (drugs that alter brain function and could cause changes in mood, behavior, awareness, thoughts, or feelings) medications were adequately monitored and had indications for medication use documented in their medical record for 1 of 5 sampled residents (Resident 18), reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary medication and a diminished quality of life. Findings included . Review of the facility policy titled, Psychotropic Drug Monitoring revised August 2023, showed the facility would assess and monitor resident who received psychotropic medications in order to assist the physician in evaluating effectiveness of drugs, to prevent drug induced impairment, to ensure that residents did not receive these drugs unless therapy was necessary to treat a specific condition as diagnosed and documented in the clinical record and to ensure residents receiving these drugs received gradual dose reductions (GDR) and behavioral interventions in an effort to discontinue these drugs. The policy instructed staff to document behaviors observed in a progress note and notify social service staff and nurse management staff who would initiate behavior monitoring with specific targeted behaviors. Behavior monitoring was to be continued for the duration of the drug therapy. According to the quarterly assessment dated [DATE], Resident 18 had diagnoses including dementia, depression, Bipolar disorder (mental illness that caused changes in energy, thinking, behaviors, sleep and extreme mood swings) and post-traumatic stress disorder (PTSD, anxiety disorder that could develop after someone experienced or witnessed a traumatic event). The assessment further showed Resident 18 took antidepressant and antipsychotic (medications used to treat symptoms of psychosis [mental disorder that caused abnormal perceptions and thoughts]) medications. Resident 18 did not show signs and/or symptoms of depression or exhibit any behaviors which was unchanged from the previous assessment. Review of the 04/25/2024 hospital discharge orders showed Resident 18 was to be administered an antipsychotic and an antidepressant 100 milligrams (mg) daily. Review of the 04/26/2024 mood care plan showed Resident 18 took an antidepressant and antipsychotic medication and instructed staff to administer medications as ordered, document behaviors and interventions attempted, monitor and document signs and/or symptoms of depression. Review of April 2024 through May 2024 medication administration records showed no documentation Resident 18 experienced behaviors or signs and/or symptoms of depression. Review of April 2024 through July 2024 nursing progress notes showed Resident 18 pleasantly interacted with staff and residents, was cooperative with cares, and did not demonstrate mood or behavior concerns. On 04/30/2024 Resident 18's antipsychotic was decreased. Resident 18 had no change in mood or behavior related to decrease of their antipsychotic medication. On 05/09/2024 the provider gave further orders to decrease the antipsychotic slowly because Resident 18's Bipolar disorder was clinically stable at that time. Resident 18 had no mood or behavior changes observed. On 05/16/2024 Resident 18 reported feeling unmotivated, asked about an antidepressant, the provider increased Resident 18's antipsychotic back to the previous dose and increased their antidepressant to 150mg. No documentation was found to show behaviors or other signs and/or symptoms of depression Resident 18 experienced. On 07/09/2024 Resident 18's antidepressant was increased again, to 200mg. Review of the 05/07/2024 provider progress note showed Resident 18 did not demonstrate any behavior issues and took an antipsychotic medication for their Bipolar disorder. The provider's plan was to wean the antipsychotic medication slowly and monitor Resident 18. Review of the 06/04/2024 provider progress note showed nursing staff reported Resident 18's emotions were more labile and increased the antipsychotic back to the original dose. Review of May 2024 through August 2024 'task' behavior monitoring showed Resident 18 experienced behaviors on 05/12/2024, 06/02/2024, and 07/24/2024. Review of the 07/09/2024 provider progress note showed nursing staff reported Resident 18 was isolating and staying in [their] room more. Resident 18 requested an increase to their antidepressant. The provider increased Resident 18's antidepressant to 200mg. Review of the 05/01/2024, 07/28/2024, and 10/27/2024 depression questionnaires showed Resident 18 did not show signs and/or symptoms of depression. In an interview on 11/16/2024 at 2:15 PM, Staff E, Social Service Director, stated resident behaviors were monitored in the medication administration record, in the 'tasks', and documented in nursing progress notes. Staff E explained a psychotropic medication GDR was considered a failure based on the resident's behavior or depressive symptom changes. Staff E did not recall what behavioral changes Resident 18 experienced when their antipsychotic was reduced. In an interview on 11/16/2024 at 2:37 PM, Staff C, Resident Care Manager, stated resident's were placed on alert charting when a medication was reduced to monitor their tolerance. Staff C further stated Resident 18 was anxious when their medication was reduced and requested their medications back. In an interview on 11/16/2024 at 3:48 PM, Staff B, Director of Nursing, reviewed Resident 18's medical record. Staff B acknowledged Resident 18's behaviors should have been documented in further detail in their record. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review the facility failed to assist the resident in obtaining routine dental care as required for 1 of 1 sampled residents (Resident 31), reviewed for dental services. This failure placed residents at risk of unmet dental care needs and diminished quality of life. Findings included . Review of the facility policy titled, Physician Referrals revised November 2024, showed the facility would provide person-centered care by ensuring timely and appropriate referrals to external health care providers, community resources, and other specialized services. The policy further showed a referral was warranted if the facility was not able to meet a resident's needs within its scope of practice or available resources. Staff were to document the identified need the resident's medical record and update the resident's care plan to reflect any changes resulting from the referral. The policy further showed the facility would maintain records of all referrals, including the reason for the referral, consent forms, communication logs, and follow-up outcomes. According to the admission assessment, dated 04/02/2024, Resident 31 admitted to the facility on [DATE] with diagnoses including cancer and muscle wasting. The assessment further showed Resident 31 was dependent on staff for oral hygiene and no oral or dental status concerns were identified. Resident 31 had severe cognitive impairment. Review of the 03/27/2024 nursing admission assessment showed Resident 31 had a partial denture, no mouth pain or chewing problems. The assessment showed no documentation regarding Resident 31's own teeth or their status. Review of the 03/28/2024 personal hygiene care plan showed Resident 31 was dependent on staff assist for oral care. No documentation was found regarding Resident 31's dentation status. Review of the 04/29/2024 provider note showed Resident 31 had periodontal (infection of tissue that hold teeth in place) disease and referred Resident 31 for a dental evaluation and treatment. Review of provider orders as of 11/14/2024 showed no provider order for a dental evaluation or treatment. Review of March 2024 through November 2024 nursing progress notes showed on 05/29/2024 Resident 31 did not allow their partial denture to be removed during oral care. On 09/06/2024 staff had difficulty removing extra food debris from Resident 31's lower teeth. No documentation was found showing Resident 31 had been seen or evaluated by a dentist as requested by the provider on 04/29/2024. During observation on 11/12/2024 at 12:34 PM, Resident 31 had a thick layer of white debris along their lower teeth. During observation on 11/13/2024 at 9:21 AM, Resident 31 laid in bed with a thick layer of white debris along their bottom teeth. When Resident 31 smiled and exposed their upper teeth, Resident 31 had some missing upper teeth and jagged discolored front teeth. In an interview on 11/15/2024 at 10:55 AM, Staff F, Nursing Assistant, stated Resident 31 had their own teeth but some were missing. Staff F further stated Resident 31 was dependent on staff assist for oral care but sometimes refused oral care by turning their head and pushing away. In an interview on 11/15/2024 at 11:18 AM, Staff G, Registered Nurse, stated provider notes were reviewed by nursing staff and nurse care managers processed any referrals requested by a provider. In an interview on 11/15/2024 at 11:36 AM, with Staff C, Resident Care Manager, and Staff D, Resident Care Manager. Staff C stated nurse managers reviewed provider documentation and followed up as needed on orders and/or referrals. Staff C further stated Resident 31 had some of their own teeth and an upper partial denture. Both Staff C and Staff D reviewed Resident 31's medical record and both staff stated they were unable to recall if Resident 31 had been seen by a dentist. Staff C contacted Resident 31's representative via phone. Resident 31's representative acknowledged Resident 31 had not been seen by a dentist since they admitted to the facility. In an interview on 11/16/2024 at 3:55 PM, Staff B, Director of Nursing, reviewed Resident 31's medical record. Staff B stated they expected staff to follow-up and process provider referrals. Reference WAC 388-97-1060 (3)(j)(vii) Refer to F636 and F656 for additional information.

Based on observation and interview, the facility failed to maintain kitchen equipment in a safe and clean operating condition for 1 of 1 stove hoods when reviewed. This failure placed staff at risk of injury, residents at risk of consuming contaminated food products and a diminished quality of life. Findings included . In the initial observation of the kitchen on 11/12/2024 at 12:05 PM, a section of the hood of the stove was falling and had an approximately four-inch gap from the hood to the ceiling. The stove hood had grease built up all along the edge of the opening. During a second tour of the kitchen on 11/15/2024 at 12:39 PM, the stove hood remained unchanged from the initial tour of the kitchen. In an interview and observation of the stove hood on 11/15/2024 at 1:01 PM, Staff I, Dietary Manager, stated the stove hood should have been closed and was cleaned quarterly in the past and was now cleaned twice a year. Staff I stated they had not been told about the stove hood hanging down and maintenance should have been notified. During an interview on 11/16/2024 at 1:27 PM, Staff J, Maintenance Assistant, stated they were notified about the stove hood on 11/15/2024. Staff J stated staff notified maintenance of needed repairs by calling a work request line and the expectation was that they be notified as soon as possible. Staff J added they thought this possibly happened when the stove hood was cleaned in October. Reference: WAC 388-97-2100

Based on interview and record review, the facility failed to develop comprehensive, person-centered care plans for 3 of 14 sampled residents (Residents 31, 5 and 2), reviewed for care planning. Failure to establish care plans that addressed care needs for the management of diabetes mellitus, (a chronic, metabolic disease that results due to the body not being able to break down sugar (glucose) for the body's cells to use for energy), blood thinning medications, and hydration placed residents at risk for unmet care needs and worsening of medical conditions. Findings included . <Resident 31> Per the 07/04/2023 quarterly assessment, Resident 31 had diagnoses which included diabetes mellitus and atrial fibrillation (an irregular and rapid heartbeat). Review of the Order Summary Report from 10/06/2022 through 09/30/2023 showed on 10/06/2022, the physician prescribed oral medication to treat the diabetes and a blood thinning medication to treat the atrial fibrillation. The 10/11/2022 care plan showed the nutrition care plan informed the nursing staff that the resident had diabetes, but no other information or interventions specific to the resident's care needs related to the diabetes (such as monitoring for signs and symptoms of high or low blood sugar, and what staff needed to do when it occurred) were found. Further review of the care plan showed no interventions related to the use of the blood thinning medication (such as monitoring for signs and symptoms of bleeding) were found. In an interview on 09/15/2023 at 10:15 AM, Staff K, Nursing Assistant, stated a resident's care plan informs the nursing staff what specific care needs the resident had, and if the information was not on the care plan, then the staff would not know what the resident needed. In an interview on 09/15/2023 at 12:00 PM, after discussion and review of Resident 31's care plan, Staff D, Resident Care Manager, stated the care plan should have included interventions related to diabetes and the use of blood thinning medications. <Resident 5> Review of the physician's orders dated 07/18/2023, showed the physician ordered a fluid restriction related to a diagnosis of hyponatremia (a condition that occurs when the level of sodium in the blood is too low). Review of Resident 5's care plan dated 01/19/2021, and last revised on 08/31/2023, showed there was no care plan for hyponatremia or a fluid restriction. In an interview on 09/14/2023 at 3:21 PM, after discussion and review of Resident 5's care plan, Staff D, Resident Care Manager, stated the care plan should have included hyponatremia and a fluid restriction. <Resident 2> Per the 06/25/2023 quarterly assessment, Resident 2 had diagnoses which included diabetes mellitus and peripheral vascular disease (a condition affecting the blood vessels outside of the heart and brain which can cause blood clots to form). Review of the Order Summary Report from 04/20/2022 through 09/30/2023 showed the physician prescribed multiple medications to treat the diabetes and a blood thinning medication to treat the peripheral vascular disease. The 10/11/2022 care plan showed the nutrition care plan informed the nursing staff that the resident had diabetes, but no other information or interventions specific to the resident's care needs related to the diabetes (such as monitoring for signs and symptoms of high or low blood sugar, and what staff needed to do when it occurred) were found. Further review of the care plan showed no interventions related to the use of the blood thinning medication (such as monitoring for signs and symptoms of bleeding) were found. In an interview on 09/15/23 11:30 AM Staff O, Nursing Assistant, stated the nursing staff referred to a resident's care plan to know the care needs for each resident and to know if there had been any changes. In an interview on 09/15/23 at 12:02 PM with Staff D, Resident Care Manager, the care plan of Resident 2 was discussed and reviewed, and Staff D acknowledged the care plan did not contain interventions for diabetes and the blood thinner. They stated the care plan should have included interventions related to diabetes and the use of blood thinning medications. Reference: (WAC) 388-97-1020 (2)(a) 46115 47728

Based on observation, interview, and record review, the facility failed to ensure 2 of 2 residents (Resident 5, 8), reviewed for use and care of a urinary catheter (a flexible tube that passes through the urethra and into the bladder to drain urine), received appropriate care and services to maintain dignity. These failures placed the residents at risk for diminished quality of life. Findings included . Facility policy titled Preventing Catheter Associated Urinary Tract Infections, last revised 08/2023, showed to maintain cloth covers over catheter bag when resident is in bed, up in chair, wheelchair, front wheel walker, etc. for dignity. <Resident 5> Per review of the 08/27/2023 quarterly assessment, Resident 5 had diagnoses which included neurogenic bladder, (a condition in which you lack bladder control due to a brain, spinal cord, or nerve problem), and utilized a urinary catheter. On 09/11/2023 at 9:22 AM, Resident 5 was observed lying in bed with the catheter drainage bag on the bed, not covered by a privacy bag. Additional observations of the catheter without a privacy bag were observed on 09/11/2023 at 9:49 AM, 09/11/2023 at 2:27 PM, 09/12/2023 at 9:24 AM, 09/13/2023 at 9:32 AM, 09/13/2023 at 11:06 AM and 09/13/2023 at 2:31 PM. <Resident 8> Per review of the 06/11/2023 quarterly assessment, Resident 8 had diagnoses which included benign prostatic hyperplasia (a condition in which the prostate gland is enlarged), urinary retention and utilized a urinary catheter. On 09/11/2023 at 2:40 PM, Resident 8 was observed sitting in their wheelchair with the catheter bag underneath without a privacy bag. Additional observations of the catheter without a privacy bag were observed on 09/12/2023 at 9:22 AM, 09/12/2023 at 12:05 PM, 09/13/2023 at 9:26 AM, 09/13/2023 at 11:04 AM, 09/13/2023 at 12:05 PM, 09/13/2023 at 2:39 PM, and 09/14/2023 at 9:34 AM. In an interview on 09/14/2023 at 10:10 AM, Staff G, Nursing Assistant, stated catheters are placed in a privacy bag, so they are not exposed. In an interview on 09/14/2023 at 2:31 PM, Resident 8 stated they preferred the catheter bag to be covered, and if wasn't that would be bothersome. In an interview on 09/15/2023 at 8:44 AM, Staff D, Resident Care Manager, stated catheters should be placed in privacy bags to provide dignity for the residents. Reference: WAC 388-97-0180 (1-4)

Based on observation, interview and record review, the facility failed to ensure a resident that had significant weight loss was reassessed and their weights monitored for 1 of 3 sampled residents (Resident 11) reviewed. Also, the provider was not notified of Reisdent 11's weight loss. This failure placed residents at risk for further undesired weight loss, and a decline in their health. Findings included . According to a quarterly assessment completed on 07/30/2023, Resident 11 had diagnoses including adult failure to thrive, dementia and psychotic disorder. Resident 11 was severely cognitively impaired, had delusions, and rejected care. Resident 11 required extensive assistance of one for eating and had weight loss not on a prescribed weight loss regimen. A review of the resident weights showed the following weights for Resident 11: -5/2/2023 180.1 pounds (lbs.), -7/3/2023 169.4 lbs., -8/1/2023 167.8 lbs., -9/6/2023 163.0 lbs., a 9.5% loss in 4 months. A progress note by Staff E, former Registered Dietician (RD), completed on 07/25/2023 documented Resident 11's weight loss was expected given recent episodes of intense delusions that impacted Resident 11's intake to the point that they were not eating or drinking. It further noted that some weight loss was desirable, but the rate and means of current weight loss was not intended. There was no new nutrition intervention added at that time but Resident 11 was to be put on weekly weights and have their intake monitored. The 07/30/2023 Staff E quarterly Nutritional Risk assessment showed Resident 11's goal weight was 180-195 lbs., they ate and drank 50-75% of their meals and fluids, and currently received no nutrition supplements. The goal was to prevent significant weight loss and the plan was to switch to weekly weights and to offer a calorie rich snack or a supplemental nutritional drink if the resident refused their meal. The 04/27/2020 comprehensive care plan showed Resident 11 had nutritional risk related to progressing dementia and left side blindness. Interventions included to provide a general diet of small portions and thin liquids, finger foods, and orient to the plate and utensils; offer water frequently and monitor intake. On 07/31/2023, the care plan was updated to include offering the resident a supplemental nutritional drink or a calorie-rich snack. A provider order was entered on 08/01/2023 for Resident 11 to be weighed every week. Further record review showed there were no further RD assessments or progress notes regarding the resident's nutritional status, Resident 11 was not weighed weekly for monitoring, and Resident 11 continued to lose weight. In addition, Resident 11 was seen by their provider on 07/07/2023 and 09/05/2023, and the provider progress notes did not mention their weight loss or additional nutritional interventions. On 09/06/2023, an order was added for Resident 11 to receive a nutritional supplemental drink as a meal three times a day if the resident refused their meal. Resident 11 was observed during the lunch meal service on 09/11/2023 at 11:48 AM and again on 09/13/2023 at 11:54 AM in the dining room. Staff sat next to Resident 11, placed bites of food on their fork, then Resident 11 lifted the fork to their mouth and ate. They were assisted in this manner for the entire meal. During an interview on 09/14/2023 at 11:38 AM, Staff F, Nursing Assistant (NA), stated residents were weighed monthly by the restorative aide. Staff F stated some residents were to be weighed weekly and there was a list of those residents, but they did not assist with the weekly weights. Staff F stated Resident 11 went to the dining room for most meals, but if not, they gave the resident a can of their supplement and the resident drank it well. During an interview on 09/15/2023 at 9:36 AM, Staff G, NA, stated most residents were weighed monthly but a few were weighed weekly. Staff G was unsure which residents were weighed weekly, and stated unless they were told by the restorative aide, Staff G did not know who needed weighed. During an interview on 09/15/2023 at 10:27 AM, Staff H, RD, stated they worked remotely and had to rely on staff updates to do their assessments. Staff H spoke with Staff D, Resident Care Manager (RCM) most weeks but was not able to visualize the residents, and this added difficulty to the assessments. Staff H was made aware of any resident's weight loss from a flag that appeared in the electronic medical record. Staff H did not know who was responsible for notifying the provider of a resident's weight loss. Staff H stated weekly weights were recommended for Resident 11 in July of 2023, but they had not been done. Staff H stated they had not reassessed Resident 11 and weight loss warranted a full reassessment. During an interview on 09/15/2023 at 12:42 PM, Staff D, RCM, stated they had discussed Resident 11's weight loss with Staff H the week prior. They discussed slow progressive weight loss versus weight loss related to missing meals. They agreed Resident 11 was overweight to begin with, but missing meals was not the way to lose weight. Resident 11 had developed an extensive rash. Before the rash, Resident 11 rarely missed a meal and ate in the dining room. The weekly weights had not happened, and the provider had not been notified. Staff D stated it was missed. Reference: WAC 388-97-1060(3)(h)

Based on observation, interview and record review, the facility failed to develop goals and interventions to manage a resident's chronic pain or implement existing pain interventions for 1 of 1 sampled residents (Resident 24) reviewed. This failure placed residents at risk for unmet comfort needs and decreased quality of life. Findings included . Resident 24 was admitted with diagnoses including Alzheimer's disease (progressive disease that destroys memory and other mental functions), cervicalgia (neck pain) and low back pain. A quarterly comprehensive assessment completed 07/09/2023 showed the resident was severely impaired cognitively and had frequent moderate pain that made it hard to sleep at night but did not interfere with daily activities. A 07/06/2023 quarterly pain assessment documented Resident 24 had frequent moderate pain that made it hard to sleep. The comments showed Resident 24 complained of frequent neck, lower back, shoulder and right hip pain. No as needed pain medications had been given. A review of provider orders showed the resident had the following medications ordered to be given at scheduled intervals: -Voltaren 1% gel (a pain reliever applied to the skin), apply 4 grams to right hip once daily; and -acetaminophen 650 milligrams (mg) twice a day for low back pain. The resident also had medications and interventions ordered that could be used as needed: -rice buddy warm pack to affected area every 4 hours for 20 minutes as needed; -Voltaren 1% gel to lower back twice daily as needed; -hydrocodone 5-325mg every 6 hours for moderate pain as needed; -hydrocodone 5-325mg, one half tablet every 6 hours for mild pain as needed; and -acetaminophen 650mg every 6 hours for pain as needed. Additionally, an order was entered on 08/23/2023 for physical therapy to do an evaluation and treat for low back pain. The 05/05/2022 comprehensive care plan did not have any care areas initiated, goals established, or interventions developed related to Resident 24's chronic pain. A review of the September 2023 medication and treatment administration records (MAR/TAR) showed Resident 24 had not been given any as needed medications or used the rice buddy for their pain. There were no entries created in the MAR/TAR for staff to document that the resident's pain was monitored. Review of the vital signs portion of the record where a resident's rating of their pain was documented (using a standard pain scale, rated from 0 to 10 by a resident, zero meaning no pain and ten meaning severe pain) had no entries for Resident 24's ratings of pain since 08/30/2023. The Nurse Assistant care card (KARDEX, care instructions for direct care givers) active at the time of the survey did not include interventions to alleviate the resident's pain. On 09/11/2023 at 10:55 AM, Resident 24 was observed lying on their bed. The head of the bed was elevated, and the resident had slid down so that their feet were flat against the foot board. When asked, Resident 24 stated they were not having a good day; their head, back and feet hurt. Resident 24 stated they supposed the nurse gave them medicine to help, then raised their hands in an oh well type of motion. During an interview on 09/11/2023 at 2:19 PM, Resident 24's family representative stated the resident generally had aches all over; they were unsure what therapies Resident 24 used to help alleviate their pain, but stated the resident was still able to function. On 09/13/2023 at 9:27 AM, Resident 24 was lying on their bed. When asked if the resident was having any pain, Resident 24 used their hands and started at the top of their head and moved their hands down to their stomach and stated, It starts up here, then goes down to here. Resident 24 stated if they told the staff they were hurting, staff gave them things to do but they were unable to state what those things were. On 09/15/2023 at 9:22 AM, Resident 24 was lying on their bed, the head of the bed was elevated, and Resident 24 had slid down so their feet were flat against the foot board and their neck was bent forward. Resident 24 stated their aches came and went. As Resident 24 talked, they reached their right hand around to the left side and rubbed their neck. During an interview on 09/14/2023 at 11:46 AM, Staff F, Nursing Assistant (NA), stated they could reposition a resident or position them with pillows if they complained of pain, but nurses provided warm or cold packs, so those types of interventions were not on the KARDEX. If a resident complained of pain, they notified the nurse. During an interview on 09/14/2023 at 3:18 PM, Staff N, Physical Therapist, stated if Resident 24 complained of pain, it was usually in their lower back, and then Staff N did therapy activities with Resident 24 that the resident could complete from their bed. Staff N stated they were not aware if Resident 24 was given pain medication before their therapy sessions, but Staff N did not think so. Staff N thought part of the pain might have been caused by being in bed, which made the resident achy so Staff N tried to get the resident out of bed as much as possible. During an interview on 09/15/2023 at 9:44 AM, Staff G, NA, stated Resident 24 did complain about hurting and would just state all over. If there were interventions, that information would be in the care plan, and Staff G stated they had access to the care plans but they usually just tried to get the resident out of bed. During an interview on 09/15/2023 at 1:02 PM, Staff D, Resident Care Manager, stated Resident 24 absolutely needed pain management; if they were unable to rid the resident of their pain, then a goal for Resident 24 might have been to improve their quality of life. Staff D stated the care plan did not have a goal, and therefore was not complete. Staff D stated Resident 24 was able to help set their goals and would be included in that. Reference: WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure 1 of 1 sampled residents (Resident 5), reviewed for use and care of a supra pubic urinary catheter (a surgically created connection between the urinary bladder and the skin used to drain urine from the bladder in individuals with obstruction of normal urinary flow), received appropriate care and services to minimize the risk of associated urinary infections. These failures placed the residents at risk for infection. Findings included . Per review of the 08/27/2023 quarterly assessment, Resident 5 had diagnoses which included neurogenic bladder, (a condition in which you lack bladder control due to a brain, spinal cord, or nerve problem), and utilized a suprapubic urinary catheter (defined above). Review of catheter care plan showed interventions for catheter care were implemented on 01/20/2021 and instructed the nursing staff to place the catheter drainage bag below the bladder. On 09/11/2023 at 9:22 AM, and 09/13/2023 at 11:06 AM, Resident 5 was observed lying in bed with the catheter drainage bag and tubing on the bed, same level as the bladder. This allows the urine to flow back into the bladder. On 09/11/2023 at 2:27 PM, Resident 5 was observed lying in bed with the catheter bag on the floor without a barrier. Additional observation of the catheter lying on the floor were made on 09/12/2023 at 9:24 AM and 09/13/2023 at 2:31 PM. In an interview on 09/14/2023 at 10:10 AM, Staff G, Nursing Assistant, stated catheters are to be placed below the level of the bladder and should not touch the floor. In an interview on 09/15/2023 at 8:44 AM, Staff D, Resident Care Manager, stated the catheter should be positioned to allow the urine to drain into the bag. Staff D added the catheter or tubing should not touch the floor as this could cause an infection. Reference: WAC 388-97-1320 (2)(a)

Based on interview and record review, the facility failed to ensure in-service training for 1 of 6 nursing assistants (Staff L) included dementia management, as required. These failures placed residents with dementia at risk for receiving care from inadequately trained staff. Findings included . Record review of the Facility Assessment, dated 07/25/2023, showed required in-service training for nursing assistants must include dementia management, and care of the cognitively impaired, for those staff providing services to individuals with cognitive impairments. Review of Staff L's employee record showed they were hired on 09/27/2021. The review of the training/education records showed Staff L did not complete the yearly training regarding dementia management, and care of the cognitively impaired resident as required since being hired. In an interview on 09/15/2023 at 12:46 PM, Staff D, Resident Care Manager, stated yearly training including dementia training was done when hired and yearly in January for all employees. During an interview at 1:00 PM, Staff B, Director of Nursing confirmed training was done as stated by Staff D; At 1:28 PM, after discussion and review of Staff L's record, Staff B confirmed the required dementia training had not been completed. Reference (WAC): 388-97-1680 (2)(a-c)

Based on observation, interview, and record review, the facility failed to implement measures to prevent skin breakdown, for a resident at risk for skin breakdown, for 1 of 3 sample residents (1), reviewed for pressure ulcers. This failure resulted in actual harm for Resident 1, who developed an avoidable unstageable pressure ulcer (the depth of the open area cannot be visualized) on the back of their lower right calf. Findings included . According to a quarterly assessment dated [DATE], Resident 1 was severely cognitively impaired and required the extensive assistance of one to two people with all of their activities of daily living, including repositioning in bed. Per the assessment, the resident was at risk for developing pressure ulcers, but did not currently have any. Resident 1's 12/17/2021 care plan to prevent skin breakdown showed the resident was at risk for developing a pressure ulcer injury secondary to the resident being largely immobile. A review of the record showed on 02/08/2023 the resident was found to have a fracture of the right leg. The investigation determined the cause to be pathological (caused by an underlying disease). The orders upon the resident's return from the hospital on 02/14/2023 showed the resident was to wear a leg immobilizer (a type of brace that provides support to keep the leg straight and promote healing). Per a 03/01/2023 progress note, the resident was noted to have a new unstageable pressure ulcer (the depth could not be visualized) measuring 3.0 cm. (centimeters) by 4.0 cm., on the back of their right lower leg. On 03/08/2023 at 2:35 PM, the resident's right calf was observed wrapped with a clean gauze dressing, as the resident was being transferred into their wheelchair to be transported to a wound care visit off-site so it could not be visualized. Record review of a note from 03/08/2023 from an outside wound care provider, showed the resident had an unstageable pressure ulcer on their right posterior (back side) leg. The area measured 3.5 cm. by 3 cm. and was 80% covered with slough/eschar (a collection of dead skin tissue within a wound). In an interview on 03/08/2023 at 2:40 PM, Staff A, Director of Nursing, stated that the resident had a full leg immobilizer (see above definition) in place, when the pressure area developed at the spot where the immobilizer pressed against the lower rear calf of the resident. They further stated the provider who ordered the leg immobilizer did not give clear direction on when, or if, the immobilizer could be removed, and no further instruction was requested from that provider. They further stated that there were no orders to check for pressure areas developing on the lower end of the brace, where the pressure area developed. Staff A was not able to show nursing staff had contacted the provider for instructions related to the immobilizer. Reference: WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure two of seven sample residents (#32, 14), 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 # 14, who experienced avoidable severe weight loss, and placed Resident #32 at risk for ongoing weight loss and poor nutrition. Findings included: According to the State Operations Manual, revised 11/22/17, suggested parameters for evaluating unplanned weight loss include 5% (percent) loss in one month, 7.5% loss in three months, and 10% loss in six months as significant weight loss. Weight loss greater than these amounts is severe. 1. Per the resident assessment dated [DATE], Resident #14 had [DIAGNOSES REDACTED]. The resident's care plan, last updated on 07/08/19, showed the resident was at nutritional risk related to an extremely slow eating pace. A goal for meal completion within 1 hour, was established on the resident's care plan. Interventions included; allow increased eating time, staff cues and reminders, and staff to assist with food and fluid intake as needed. Per physician orders [REDACTED]. A review of the facility's weight tracking record showed the resident weighed 153 lbs. on 05/13/19. The record showed as of 07/09/19, the resident's weight was down to 138 lbs- a severe 15 lb weight loss. The record showed the resident's weight was not obtained in June, as ordered. In an interview on 07/12/19 at 11:12 AM, Staff D, Registered Dietician (RD), stated that she was alerted electronically through the facility computer program of resident weight loss. She further stated she had just become aware of Resident #14's weight loss, two days prior to the interview. Staff D stated that even though the resident was at risk for nutritional deficiencies, she had determined monthly weights were appropriate for her. Staff D stated that the resident had not had any chewing, or choking problems, but her diet had been changed to pureed foods in (MONTH) (YEAR), in an effort to increase intake. She stated that the resident had taken a very long time to eat regular texture foods. In addition, she acknowledged a weight had not been obtained in June, which had allowed the resident's weight to plummet without detection, or intervention, for 2 months. In an observation on 07/12/19 at 11:43 AM, the resident was seated in the assisted dining room for a facility barbeque. The resident had a plate in front of her with three small scoops of pureed food. Each serving appeared to be a quarter cup or less in size. The rest of the resident's plate was empty. In addition, the resident had a glass dish to the side with approximately a half cup of pureed cookie in it. The resident ate very well during the observation, consuming 100% of her meal. Observations of the lunch serving line in the kitchen on 07/12/19, showed a scoop had been used to serve the pureed meals that held 1.33 ounces, or approximately 3 tablespoons of food per scoop. In a follow up interview on 07/16/19 at 11:32 AM, Staff D stated that the resident didn't have a meal monitor in place as she had been consuming nearly 100% of her pureed meals recently. In addition, she stated that the resident used to have an order for [REDACTED]. The RD stated that the facility had recently switched from regular fruit juices to diet juices, such as Crystal Light, in an effort to prevent excess caloric intake from beverages. She stated that she thought the resident may benefit from returning to the higher caloric fruit juices. See F-800 for additional information regarding the facility serving incorrect portion sizes for pureed diets. 2. Per the 03/04/19 admission assessment, Resident #32 had [DIAGNOSES REDACTED]. Additionally, the resident had no difficulty swallowing, no known weight loss, and was able to feed herself independently once the meal was set up. A nutrition assessment, also dated 03/04/19, showed the resident had a good appetite, and the goal was to maintain her current weight. A review of the electronic weight summary showed the resident's admission weight was 178.8 pounds (lbs) on 02/21/19. On 04/02/19 the resident was 169.2 lbs, a 5.37% unplanned weight loss. Review of the progress notes, from 04/02/19 to 05/01/19, showed the weight loss, as well as a decrease in appetite, was noted on 04/08/19, and a meal monitor was activated to assess the resident's intake. The resident continued to report a decreased appetite despite offers peanut butter and jelly sandwiches when the resident did not eat the main meal. Per the electronic weight summary on 05/01/19 the resident had lost additional weight, and was re-weighed for accuracy. On 05/04/19 the resident was 160.6 lbs, a 10.18% unplanned body weight loss in less than three months. No further weights were recorded prior to the resident's hospitalization for an unrelated medical condition on 05/20/19. Laboratory test results dated 02/22/19 and 05/25/19 showed the resident's [MEDICATION NAME] (a laboratory test that may indicate malnutrition, normally 3.4 to 5.0 grams per decaliter (g/dL)) dropped from 3.3 g/dL on admission to 2.5g/dL. Observation on 07/11/19 at 12:22 PM showed Resident #32 was in the dining room, and had eaten 100% of her lunch and was assisted back to her room via wheel chair. At 12:49 PM the same day, the resident stated she was aware of her weight loss on her initial stay in the facility, and stated it was because she didn't like the food, though staff would offer her a peanut butter and jelly sandwich. She was not able to recall if staff had spoken with her about interventions to address the weight loss. In an interview on 07/11/19 at 1:59 PM, Staff M, Nursing Assistant, stated the resident no longer needed assistance, but when she was first admitted to the facility, she required encouragement to eat and slept often. When asked about interventions to address the resident's poor appetite and weight loss, Staff M stated a protein powder had recently been tried, and Staff D, Registered Dietician, was talking about a supplement that day. In an interview on 07/12/19 at 10:37 AM, Staff D stated resident weights should be closely monitored on admission to establish a baseline, and confirmed that was not done, though she did not know why. She stated she was not alerted to Resident #32's weight loss or decreased appetite prior to an automated alert of weight loss greater than 5% by the computer system on 04/08/19. Per Staff D, the resident should have been transitioned to weekly weights at that time, for increased monitoring. Staff D stated the resident's weight was currently stabilizing (after readmission 06/10/19), and had current interventions of: diet change to include more options, snacks between meals, cottage cheese with breakfast, and liquid nutritional supplements. In a follow up interview on 07/16/19 at 11:22 AM, Staff D stated interventions to prevent weight loss and nutritional compromise were not attempted until 05/01/19, after the resident had severe weight loss. On 07/16/19 at 3:18 PM, Staff C, Resident Care Manager, stated the resident was overweight on admission and was initially pleased with the weight loss. She stated she was aware of the resident's poor appetite, and thought it might be related to depression, as the resident would request specific food items, then only take a few bites. Staff C stated the resident was now on an antidepressant medication. Reference: (WAC) 388-97-1060(3)(h)

Based on interview and record review, the facility failed to ensure two of six residents (#32 & 19), reviewed for medication management, were free from significant medication errors. This resulted in actual harm for Resident #32, who required emergent treatment to reverse a critically high level of potassium in the blood, and placed Resident #19 at risk for harm from low blood sugar levels. Findings included . 1. Review of Resident #32's care plan, initiated 02/22/19, showed the resident had heart failure and an irregular heartbeat, and took medications which placed her at risk for changes in her potassium level. Per the (MONTH) 2019 Medication Administration Record [REDACTED]. According to Medscape Reference (https://emedicine.medscape.com/article/ 3-overview), blood potassium concentration greater than approximately 5.0-5.5 mmol/L in adults is too high ([MEDICAL CONDITION]). Levels higher than 7 mmol/L (millimoles per liter) can lead to significant medical consequences, and levels exceeding 8.5 mmol/L can quickly be fatal. Many individuals with [MEDICAL CONDITION] have no symptoms. Weakness and fatigue are the most common complaints, and patients may report difficulty breathing, chest pain, palpitations (feelings of having a fast-beating, fluttering or pounding heart), and muscle paralysis. Review of a 05/31/19 laboratory test showed the resident's blood potassium level was high, at 5.7 mmol/L. Further review showed the test result was sent to the resident's physician via facsimile (fax). No physician response to the elevated potassium was found in the resident's record. Per the (MONTH) and (MONTH) 2019 MARs, the resident continued to receive the potassium supplement twice a day, through 06/04/19, except for the evening of 06/03/19 when the resident refused it. Review of the progress notes, from 05/31/19 to 06/04/19, showed the resident was increasingly weak and fatigued. There was no evidence the elevated potassium level was considered as a possible contributing factor, or that the physician was contacted for follow up, prior to 06/04/19. Further review of the progress notes showed on 06/04/19 the resident reported sudden chest pain. Her pulse was faint, and her blood pressure was too low to safely give medication. The resident was transported to the emergency department for further evaluation. Review of the hospital discharge summary, dated 06/11/19, showed the resident had a blood potassium level of 8.0 mmol/L at the emergency department, and required insulin and intravenous fluids to treat the elevated levels. In an interview on 07/12/19 at 9:52 AM, Staff F, Licensed Practical Nurse, stated laboratory test results received by the facility were faxed to the physician by the nurse working at the medication cart, and the nurse was responsible to follow up with the physician if no new orders were received. Per Staff F, if a resident had a high potassium level, the nurse should review the medication list, and if the resident was receiving a potassium supplement, the Resident Care Manager should be notified to follow up. In an interview on 07/16/19 at 3:18 PM, Staff C, Resident Care Manager, confirmed Resident #32 continued to receive her potassium supplement twice daily after the lab result which showed the potassium level was high. Per Staff C, the potassium should not have been administered until staff heard back from the physician. Staff C stated she was not on duty on 05/31/19, and she was not sure why staff did not follow up with the physician, however the resident had additional urgent medical conditions staff were assisting her with at the time. In a follow up interview on 07/17/19 at 9:01 AM, Staff C stated she had noted the elevated potassium level on 06/03/19, assessed the resident's change in condition, and reported it to the physician. On 06/04/19, Staff C received orders to discontinue several medications, including the potassium, and orders to perform additional laboratory tests. Per Staff C, the resident had chest pain and required emergency treatment, before the new orders were processed. 2. Per the facility assessment dated [DATE], Resident #19 had [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Per a physician's orders [REDACTED]. The order showed if the resident's blood sugar was below 100, the insulin was to be held, and not administered to the resident. A review of the Medication Administration Records (MAR's) for (MONTH) and (MONTH) 2019 showed on 06/25/19 , the resident was given insulin in the evening, even though her blood sugar was below 100. On 06/29/19, the resident was given insulin injections in the morning and evening. Her blood sugar on both occasions was below 100. On 07/02/19, the resident was again given insulin in the morning, when her blood sugar was below 100. These errors placed the resident at risk for episodes of [DIAGNOSES REDACTED] ( a very low level of blood sugar). In an interview on 07/17/19 at 10:48 AM, Staff C acknowledged the insulin had been given outside the physician ordered parameters, and stated that the medication should have been held due to the resident already having low blood sugar levels. Reference: (WAC) 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to assess, monitor, and intervene in a timely manner, for 1 of 2 sampled residents (#1), reviewed for recent facility acquired fractures. This failed practice resulted in actual harm to the resident, who had delayed treatment related to a [MEDICAL CONDITION] humerus (arm). Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review, the resident was staff assessed to be moderately impaired in cognition, required extensive assistance from one staff member for toileting, personal hygiene, and transfers, and used a sit-to-stand lift (a lift which helps residents stand and transfer). According to the record, on 10/18/16, the resident was placed on the toilet by Staff A (Certified Nurse Assistant), using a sit-to-stand lift. The resident was left unattended for approximately 3 to 5 minutes, at which time she experienced a possible vasovagal response (loss of consciousness which causes your heart rate and blood pressure to drop suddenly). The resident was placed in bed by Staff A and another nurse assistant. The record did not show that Staff B (Registered Nurse), who had been notified of the resident's change in condition, by Staff A, had assessed the resident, taken vital signs, or notified the physician. A review of the facility investigative report, dated 10/19/16 at 6:00 p.m., revealed the evening shift on 10/19/16, had found a substantial sized bruise on the resident's upper left arm which measured 6 cm (centimeters) by 7 cm. The bruise was determined to be of unknown origin and no changes to the care plan were made in regards to transfers or the use of the sit-to-stand lift. Further record documentation revealed on 10/21/16, Staff F (Resident Care Manager) attempted to assess the bruise however, the resident was fully dressed in a long sleeve shirt, and therefore she did not visualize the bruise. Staff F stated in the documentation that gentle range of motion was done with the resident's left arm and no signs or symptoms of pain was observed with the resident. She requested that Staff B attempt to visualize the bruise later in the day after lunch or notify the evening shift if she was unable to assess the bruise. On 10/22/16, a late entry by the nurse into the clinical record, revealed the evening shift nurse re-checked the resident's left upper arm. Documentation showed the bruise now measured 11 cm by 13 cm and was solid purple. The next nurses progress note in the clinical record, which was dated 10/25/16, revealed the bruise had grown in size and was now 18 cm in length and covered the entire circumference of the arm to below the elbow. The resident was now showing signs and symptoms of pain when staff attempted to reposition her in bed, and when range of motion was attempted, the resident flinched. It was at this time the staff notified the physician and an x-ray was ordered. An x-ray was obtained the same day which documented the resident had a comminuted fracture (a fracture of at least areas of a bone) of the left humurus (arm). The physician ordered the resident's arm to be placed in a sling and the care plan was changed to use the Vanderlift (full body lift) when attempting to transfer the resident and a pillow to support her arm. A review of the medication record revealed the resident had continued to recieve Tylenol 1000 mg (milligrams) two times daily. There was no further documentation of any ongoing pain assessment for dementia residents. On 10/27/16 the resident's condition deteriorated. Tylenol was now being administered per the rectum two times daily however, it was documented not for pain but for an increase in temperature. an order for [REDACTED]. During an interview on 11/02/16 at 1:58 p.m., Staff B was asked if she had assessed the resident on 10/18/16, when she had a change in her condition. She stated, No, I just laid eyes on her. She further stated, In retrospect, I should have charted that something happened, obtain vitals and labs if needed. I just didn't think she had any injuries. Staff B was asked if she assessed the bruise on 10/21/16 per Staf F's request. She stated, No, I did not go look at it. Staff B was asked if the staff continued to use the sit-to-stand lift for transfers. She stated yes. During an interview on 11/02/16 at 3:42 p.m., Staff E (Registered Nurse) if she had been notified of a change in the resident's condition or bruise prior to 10/19/16. She stated, No, nothing from the day shift was told to us .zero information. During an interview on 11/03/16 at 9:40 a.m., Staff G (Director of Nursing) was asked if the staff continued to use the sit-to-stand lift for transfers until 10/15/16. She stated as far as she was aware, yes. She then stated to this surveyor, she was aware the facility had failed to perform a nursing assessment after a non-responsive episode, failed to visualize a bruise, clarifying the origin of the bruise, and signing off of an investigation before thoroughly completing the investigation.

Based on observation, interview, and record review, the facility failed to perform timely care and services, in response to increased pain and difficulty with mobility, for 1 of 6 sample residents (#1), reviewed for a change in condition, after a fall. This failed practice resulted in actual harm to the resident, who had delayed treatment, and increased pain, related to a [MEDICAL CONDITION]. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review, the resident had mild cognitive impairment, and required limited to extensive assistance with most activities of daily living. The resident had mild generalized pain, received Tylenol three times daily, and as needed. According to the record, on 12/03/15, the resident walked utilizing a walker. At 8:30 a.m. that morning, she fell in the dining room. After the fall, the resident was able to walk to the bathroom, and complained of mild generalized pain. The resident had no bruising, or other signs of injury. Review of the facility investigation revealed on 12/04/15 during the night shift, the resident was guarded with mobility, complained of generalized pain, and received an as needed dose of Tylenol. Additional review of the facility investigation revealed during the day shift on 12/04/15, the resident was unable to walk well, and used a wheelchair for mobility (rather than a walker, as she had previously done). She complained of pain during transfers. Staff A reported the resident's pain to Staff C at the end of the day shift. Staff C reported to Staff D, the evening shift nurse, the resident was complaining of left hip pain, and might need an x-ray. On 12/04/15 during the evening shift, there was no evaluation of the resident's mobility prior to getting her up for an activity, and again for dinner. Staff D did not attempt to consult with the physician at that time, to determine if additional evaluation, including obtaining x-rays, and/or having the resident stay in bed until results were known, should be considered. Per the facility investigation, after assisting the resident to dinner, Staff E reported the resident's reports of pain to Staff F, the Resident Care Manager (RCM). Staff F evaluated the resident, and the resident grabbed her left leg when she attempted to stand. The physician was immediately notified. Per record review, a left hip x-ray was obtained, after the physician was contacted the evening of 12/04/15, and showed a mildly displaced (bone out of alignment) [MEDICAL CONDITION]. Resident #1 was then transferred to the hospital for surgery. During interview on 01/06/16 at 1:15 p.m., the resident stated she was not in pain. When asked if she was receiving the care she needed, she stated she thought so, but didn't know for sure. During a telephone interview on 01/08/16 at 11:00 a.m., Staff E stated there was a delay in notifying the physician, and requesting an x-ray on 12/04/15, but she didn't think the symptoms indicated a hip injury until later in the day. The facility's failure to evaluate changes in mobility, including pain with movement, and consult with the resident's physician prior to getting the resident out of bed for meals/activities on 12/04/15, placed the resident at risk for increased pain, and a delay in treatment for [REDACTED].