Every finding on record at Othello Post Acute

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, food was not covered, labeled, dated or discarded when expired for 2 of 3 refrigerators. The facility failed to perform hand hygiene when indicated during the meal service and did not maintain food at acceptable temperatures for service. These failures placed residents at risk for foodborne illnesses.Findings included . <Expired/undated/uncovered food>During an initial tour of the kitchen on 01/06/2026 at 10:33 AM, the main refrigerator in the kitchen contained nine bowls of cooked apples with cinnamon that were uncovered and had no date. An observation on 01/06/2026 at 10:48 AM of the refrigerator in the employee lounge that held the resident's food revealed a bowl of food for Resident 18 that was to be used by 12/20/2025, and another bowl without a date. There were also seven ice cream bars in the freezer for Resident 18 that had no date. Resident 35 had a bag of tamales that were dated 12/28/2025, and a pizza pocket with no date. In an interview on 01/06/2026 at 10:33 AM, Staff H, Dietary Manager, stated food that was in the refrigerator had to have a date and be covered for food safety. In an interview on 01/06/2026 at 10:48 AM, Staff H stated when food was brought in from family members it was taken to the kitchen, dated and placed in the refrigerator. Staff H stated it was important to date the food to prevent illness. <Food Temperatures>During an observation of the lunch meal service on 01/26/2026 at 10:36 AM, Staff Y, Cook, had checked the temperatures of the cold items. The milk was 48 degrees Fahrenheit (F), coleslaw 44.3 degrees F, and the peaches were 42 degrees F, all above the recommended food temperature of 41 degrees. Staff H instructed staff to discard the coleslaw, while they removed the milk from the resident trays. There were four glasses of milk left on the trays. At 11:44 AM, the cart with the milk was ready to be served to the residents. When Staff H was asked about the milk, they pulled the milk from the resident trays and stated it did not meet the required temperature. A plain piece of fish was prepared for a resident, and the temperature was 141 degrees F, not 145 degrees as required. At 12:00 PM, the fish was placed on the cart to be served to the resident. When Staff I, Cook, was asked about the fish, they stated the temperature needed to be 145 degrees. In an interview on 01/09/2026 at 1:40 PM, Staff H stated food needed to be served at the appropriate temperatures to prevent the growth of bacteria. <Hygiene>In an observation on 01/09/2026 at 12:08 PM, Staff I, with gloved hands, pushed the meal cart that other staff members had touched through the door to the dining room. Staff I put a piece of fish on a plate and touched it with the same gloved hands to prevent it from falling off the plate. Staff I then grabbed a hamburger bun with the same gloved hands and placed a slice of cheese on it. At 12:10 PM Staff I removed their gloves, no hand hygiene was performed, and they checked the temperature of a glass of milk. Staff I then put on a new pair of gloves without hand hygiene being performed. In an interview on 01/09/2026 at 1:36 PM, Staff I stated they should have removed their gloves after touching the meal cart, washed their hands and put on new gloves prior to touching the food and it was important to prevent cross contamination. Staff I added they should have also washed their hands and put on new gloves after checking the temperature of the milk, prior to going back to the meal service. In an interview on 01/09/2026 at 1:40 PM, Staff H stated hand hygiene needed to be performed after touching things and new gloves were to be worn to prevent cross contamination. Reference: WAC 388-97-1100 (3), 2980

Based on observation, interview and record review, the facility failed to ensure care plans were updated timely for 3 of 3 sampled residents (Residents 6, 7 and 47), reviewed for individualized plans of care. This failure created the potential for resident needs to go unaddressed, and potential related adverse events. Findings included. <Resident 6> A quarterly assessment dated [DATE] documented Resident 6 had diagnoses that included low back pain and infection of the bone of the right foot and ankle. Resident 6 was able to make their needs known, occasionally experienced pain they rated as moderate intensity, and received regularly scheduled and as needed opioid (narcotic) pain medications daily. During an interview on 01/07/2026 at 9:52 AM, Resident 6 was observed to be visibly uncomfortable; their brow was furrowed, and they made a face when moving in their bed. Resident 6 stated they had a long history of lower back pain. The resident stated they had a pain pump (a device implanted under the skin that delivers a steady dose of pain medication) and the medication in the pump was now morphine (an opioid pain medication), a change from fentanyl (an opioid pain medication). Resident 6 stated they also received pain pills that could be given every 4 hours. The 08/18/2025 care plan documented Resident 6 had potential and actual pain. Staff were to administer medications as ordered, and complete a pain assessment on admission, quarterly, and with new complaints of pain. On 10/14/2025, the care plan was updated for staff to encourage different pain-relieving methods, such as positioning or relaxation, observe and report changes in usual routine, monitor/record and report to the nurse complaints of pain or requests for pain treatments, observe for side effects of pain medication and report occurrences to the provider. The care plan had no goals, interventions, or monitoring developed regarding the resident's use of a pain pump. The 08/08/2025 admission physician assistant progress note documented Resident 6 previously managed their pain using a pain pump; the pump was not in use, and the resident's pain was to be managed with oral pain medication given as needed. The 12/16/2025 physician progress note documented Resident 6 was to be seen at the nearby pain clinic and their pain pump was to be refilled. There were no provider notes in Resident 6's record that detailed the pain clinic visit or any instructions regarding the use of the pain pump. A review of provider orders documented Resident 6 could receive 5 milligrams (mg) of oxycodone, an opioid pain medication, every 4 hours as needed for moderate pain and 10 mg. every 4 hours for severe pain. Resident 6 could also take 650 mg. of acetaminophen every 6 hours as needed for pain. Staff were to assess the resident's pain every shift. There were no provider orders regarding the pain pump, what medication and dose were infusing, or what management of the pump was indicated. During an interview on 01/09/2026 at 1:33 PM, Staff K, Physician Assistant, stated Resident 6 was seen by the provider at the pain clinic on 12/16/2025, but Staff K was unable to see a provider note from that visit in the resident's record. Staff K stated they requested a copy from the pain clinic provider. Staff K stated the pain clinic would manage the resident's pain pump and the clinic would likely see the resident at least quarterly. During an interview on 01/10/2026 at 8:38 AM, Staff B, Director of Nursing, (DON), stated if there are new interventions needed in a plan of care, the care plan was to be updated within 24-28 hours. Staff B stated they were aware Resident 6 had been to the pain clinic and had their pain pump refilled in December 2025 and the care plan should have been updated to address the pump. Staff B stated the resident was at risk for being over sedated if staff were unaware the resident had a pain pump in use. Staff B stated they were waiting for notes from the provider at the pain clinic to add to the resident's record. <Resident 7> The 12/11/2025 significant change assessment documented Resident 7 had diagnoses that included traumatic brain injury (brain injury as a result of an external trauma), difficulty swallowing, and gastroparesis (delayed movement of food from the stomach to the small intestine). Resident 6 was severely cognitively impaired, was dependent on staff for all aspects of their care and received their nutrition through a feeding tube (a tube inserted through the abdomen into the intestine that bypassed the mouth, esophagus and stomach). On 01/06/2026 at 2:54 PM, Resident 7 was observed positioned in a tilting-style wheelchair. The resident was extremely thin; their cheekbones and collar bones protruded, and their arms and legs were thin with no visible muscle mass or tone. The resident was unable to follow any commands with purpose and had a very moist, harsh cough. Suction equipment to clear the resident's oral cavity of any secretions was present in the room for use as needed. A review of Resident 7's provider orders showed that on 05/30/2025, Resident 7 was to have nothing by mouth. Further review of the record documented Resident 7 had multiple hospitalizations beginning 06/12/2025 related to self-removal of their feeding tube, vomiting of bloody emesis, nausea, continued vomiting, aspiration pneumonia and bleeding in the intestines. A review of the care plan documented the following active care areas: -11/05/2024 Activities of daily living (ADL) self-care deficit; for EATING: the resident is totally dependent with eating at meals and snacks. Position upright at 90 degrees while seated in chair, make sure the resident swallows 2 times after every bite or given a drink with a spoon and is to remain upright for 30 minutes minimum after eating or drinking. -06/17/2025 The resident was at high risk for aspiration (when food entered the lungs instead of being swallowed) related to decreased cognitive status and tube feeding; staff were to encourage fluid intake and follow aspiration precautions such as head of bed elevated and upright position when eating. -06/18/2025 The resident was at nutritional risk related to gastroparesis and difficult swallowing; the resident was to have nothing by mouth, monitor and record food and fluid intake. During an interview on 01/10/2026 at 9:48 AM, Staff B, Director of Nursing reviewed Resident 7's record and stated Resident 7 was not safe to swallow and went to strict nothing by mouth (NPO) status when their feeding tube was inserted. Staff B acknowledged references to eating and drinking should have been resolved in the resident's care plan when the resident was determined to be strict NPO. Staff B stated there was a risk for a mistake to be made if those references remained on the resident's care plan. <Resident 47> The 12/18/2025 admission assessment documented Resident 47 had diagnoses including bilateral knee fractures and had surgical repair. The resident was cognitively intact and made their needs known. The 12/26/2025 physician order documented Resident 47 had been prescribed enoxaparin (a blood thinning medication, anticoagulant, used to prevent and treat serious blood clots after surgery) daily for prophylaxis. Review of the care plan showed no documentation Resident 47 was prescribed a blood thinning medication and possible adverse effects to monitor for such as bruising and bleeding. Further record review showed there were no side effect monitors in the medication administration or treatment administration records (MAR/TAR). In an interview on 01/09/2026 at 2:10 PM, Staff J, Nursing Assistant, stated they knew what care to provide the residents with by reading their care plan. Staff J stated if a resident was at risk for bleeding/bruising it would say on the care plan. In an interview on 01/09/2026 at 1:57 PM, Staff C, Registered Nurse, stated when a resident received anticoagulant medication there was a monitor in the MAR or TAR for bruising and bleeding. Staff C stated the medication needed to be on the resident's care plan in the event of an injury that caused bleeding. In an interview on 01/09/2026 at 3:10 PM, Staff B, Director of Nursing, stated Resident 47's anticoagulant medication should have been on their care plan, and it was important because nursing staff needed to be aware of what to monitor them for as they might have bleeding. Reference: WAC 388-97-1020(2)(c)(d)

Based on interview and record review, the facility failed to obtain consent for psychotropic medications (medications that affect the mind, mood, and emotions) prior to administration of the first dose, as required, for 1 of 5 sampled residents (Resident 47), reviewed for unnecessary medications. This failure placed the resident and representative at risk of not being fully informed of the risks and benefits of medications and making a fully informed choice about their medical care. Findings included .A 12/18/2025 admission assessment documented Resident 47 had diagnoses including depression and anxiety. Resident 47 was cognitively intact and took medication for depression. The 12/12/2025 nutritional care plan documented Resident 47 had depression. There were no instructions to nursing staff regarding the antidepressant medication. On 12/12/2025, a provider order was given to administer mirtazapine (a medication used to treat depression) daily.A review of Resident 47's medical record showed no informed consent was completed for their mirtazapine. Per the December 2025 medication administration record, Resident 47 received their first dose of mirtazapine on 12/26/2025.In an interview on 01/09/2026 at 1:57 PM, Staff C, Registered Nurse, stated the consent for psychotropic medications needed to be obtained within three to five days of administering the medication. When asked why it was important to obtain consent prior to administering the medication, Staff C was unsure. In an interview on 01/09/2026 at 2:26 PM, Staff D, Registered Nurse, stated psychotropic medication consents needed to be obtained prior to the first dose. During an interview on 01/09/2026 at 3:10 PM, Staff B, Director of Nursing, stated the consent should have been signed prior to the administration of the medication and this was important because the resident needed to be informed of the risks and benefits so they could make an informed decision. Reference WAC 388-97-0300(3)(a), -0260, -1020(4)(a-b).

Based on interview and record review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR, an assessment done to identify if potential nursing facility residents required services to support any behavioral health needs once admitted to the nursing facility) was completed after a 30-day hospital exempted stay expired for 2 of 5 sampled residents (Residents 6 and 34), reviewed. This failure placed the residents at risk for inappropriate placement, and/or not receiving timely and necessary services to meet their behavioral health needs. Findings included . The Medcaid.gov Preadmission Screening and Resident Review retrieved at https://www.medicaid.gov/medicaid/long-term-services-supports/institutional-long-term-care/preadmission-screening-and-resident-review documented the PASRR process required that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment called a Level I screen prior to facility admission to determine whether they might have severe mental illness (SMI) or intellectual disability (ID). Those individuals who tested positive at Level I were then evaluated in depth, called a Level II PASRR. The results of this evaluation determined need for behavioral health services, appropriate setting, and recommendations for services to inform the individual's plan of care. <Resident 6> Review of the record showed Resident 6 was admitted to the facility on [DATE] and had diagnoses that included depression and post-traumatic stress disorder (PTSD, a mental health condition caused by experiencing an extremely stressful event that caused emotional distress or physical reactions). A PASRR Level I screen completed on [DATE] documented Resident 6 screened positive for severe mental illness; however, the Level II evaluation was not indicated at that time related to an exempted hospital discharge (when the resident was expected to reside at the facility for less than 30 days). The form documented the additional assessments were to be completed if the resident remained at the facility after the 30-day exemption expired. Further record review showed Resident 6 did not discharge from the facility after 30 days expired and still resided at the facility. Resident 6's record had no documentation that a Level II PASRR was completed after the 30-day hospital exemption expired. <Resident 34> Review of the record showed Resident 34 admitted to the facility on [DATE] and had diagnoses which included depression and anxiety. The [DATE] Level I PASRR screen for Resident 34 was positive for severe mental illness. The Level II PASRR was not indicated at that time due to meeting the guidelines for an exempted hospital stay. The form documented the additional assessments were to be completed if the resident remained at the facility after the 30-day exemption expired. Further record review showed Resident 34 did not discharge from the facility within 30 days or less as expected and was currently still a resident at the facility. Resident 34's medical record had no documentation that a Level II PASRR was completed after the 30-day hospital exemption expired. During an interview on [DATE] at 3:52 PM, Staff E, Social Service Director, stated they were responsible for the PASRR process at the facility. They acknowledged Residents 6 and 34 should have been referred for Level II PASRR evaluations after their exempted hospital stay was completed. Staff E stated the evaluations were important so recommendations for the residents' mental health needs could be implemented. Reference: WAC 388-97-1915(1)(2)(a-c)

Based on observation, interview, and record review, the facility failed to ensure oxygen and nebulizer delivery equipment was maintained as ordered and oxygen was administered per provider orders for 1 of 2 sampled residents (Resident 34), reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection. Findings included .Per the 10/29/2025 admission assessment, Resident 34 had diagnoses which included chronic obstructive pulmonary disease (COPD, a progressive lung disease that blocked airflow and made it hard to breathe), and respiratory failure. In an observation on 01/06/2025 at 11:52 AM, Resident 34 was lying in bed asleep. The resident wore oxygen that was set at 4 liters (L) and the tubing was dated 12/17/2025.The 10/23/2025 physician order documented Resident 34 had been prescribed oxygen at 3L continuously for shortness of breath and the tubing was to be changed weekly.The December 2025 medication administrator record (MAR) and January 2026 MAR showed nursing staff initialed weekly that the oxygen tubing had been changed and Resident 34 received 3L of oxygen daily.Subsequent observations of Resident 34's oxygen tubing dated 12/17/2025 were made on 01/06/2025 at 1:41 PM. On 01/07/2026 at 8:54 AM the oxygen tubing was dated 01/06/2026. Subsequent observations on 01/09/2026 at 9:29 AM and 1:44 PM, and 01/10/2026 at 8:24 AM showed Resident 34 was on 4L of oxygen, not 3L as ordered. In an observation on 01/06/2026 at 1:41 PM, Resident 34 was lying in bed asleep. On their tray table was a small volume nebulizer (SVN, turns liquid medication into a fine, breathable mist for people with lung conditions such as COPD) and the tubing and equipment was dated 11/25/2025. The 10/23/2025 physician order instructed nursing to administer Ipratropium-Albuterol (DuoNeb, opens airways during times of difficult breathing) three milliliters via inhalation every six hours as needed for shortness of breath.The December 2025 and January 2026 MAR's showed Resident 34 received the Albuterol-Ipratropium via SVN on a consistent basis. Subsequent observations of Resident 34's SVN equipment dated 11/25/2025 were made on 01/07/2026 at 8:54 AM, 12:39 PM, and 2:45 PM, 01/08/2026 at 8:57 AM, 01/09/2026 at 9:29 AM and 1:44 PM, and 1/10/2026 at 8:24 AM. Review of Resident 34's medical record showed no documentation to clean or change the nebulizer equipment. In an interview on 01/09/2026 at 4:03 PM, Staff F, Registered Nurse, stated oxygen tubing was changed weekly, and they did not think there was a monitor for the SVN equipment. Staff F stated it was important to change the oxygen tubing and SVN equipment to prevent bacterial growth as it was a direct path into the lungs. In an interview on 01/10/2026 at 8:46 AM, Staff G, Licensed Practical Nurse, stated it was important to follow provider orders for oxygen because the residents could retain too much carbon dioxide. When Staff G was asked how many L's of oxygen Resident 34 was prescribed, they stated 3L. Staff G entered Resident 34's room and verified the resident was on 4L of oxygen and the SVN tubing was dated 11/25/2025. Staff G exited Resident 34's room without correcting the oxygen flow rate. In an interview on 01/10/2025 at 9:08 AM, Staff B, Director of Nursing, stated SVN equipment and oxygen tubing was changed weekly and documented on the MAR. Staff B stated it was important to change the SVN equipment and oxygen tubing to prevent bacteria. Staff B stated if the equipment and tubing were not changed it could possibly lead to a respiratory infection. Staff B stated Resident 34 should have received 3L of oxygen and it was important for their respiratory status and to follow the provider's orders. Staff B acknowledged there were no orders to maintain the SVN equipment. Reference: WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and use of assistance devices when consuming hot beverages, and to consistently assess hot beverage temperatures for safety prior to serving to prevent accidents for 1 of 3 sample residents (Resident 1). Resident 1, who was severely cognitively impaired, experienced harm when they were provided a cup containing a hot beverage that had not been checked for temperature without a lid and unsupervised which the resident spilled in their lap and resulting in a third-degree burn.According to the American Burn Association, thinner skin of older adults burns faster and deeper, and a serious burn can occur within five seconds of exposure to a liquid at a temperature of 140 degrees Fahrenheit (F).Per the assessment dated [DATE], Resident 1 was severely cognitively impaired, required assistance with activities of daily living including set up of food and drink before eating and/or drinking, and had diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (loss of strength or paralysis in the right side of the body due to a stroke, lack of sufficient blood flow to the brain), and aphasia (a language disorder that affects a person's ability to communicate).Review of the care plan dated 06/02/2025, documented Resident 1 was to be encouraged to drink hot cocoa while seated at a table in the dining room, and that Resident 1 required supervision and possible assistance when consuming hot beverages.Review of the facility incident investigation, showed Resident 1 was seated in their wheelchair in the hallway when Staff A, Nursing Assistant (NAC) gave the resident a cup of hot cocoa from the snack cart that came from the kitchen a short time before. Staff A walked down the hallway away from the resident. Into another resident's room and heard Resident 1 scream and saw the resident had spilled the hot cocoa on their lap.Review of Resident's 1's electronic medical record, showed they sustained a burn to their right and left thighs on 7/26/2025 at 6:01pm when they spilled hot cocoa on their lap. Staff B, Registered Nurse (RN) documented the burn initially resulted in reddened skin and on 07/28/2025 a blister developed on the back of the right thigh.Review of progress note dated 07/28/2025, Staff C, Physician Assistant (PA), documented Resident 1 had third degree burns (damage to the top and middle layers of skin and the fatty layer) on their inner thighs with a blister between right thigh and buttocks, approximately 6 centimeters (cm) x 2 cm in size, because of having spilled hot cocoa on their lap on 07/26/2025.During an interview on 07/29/2025 at 3:15pm, Staff D, evening cook, stated the evening snack cart was scheduled to go out at 7:00pm but often was taken out early. They stated they didn't check the temperatures of the hot liquids on evening snack, Staff D explained that temperatures of the hot liquids were required.In an interview on 07/29/2025 at 3:24pm, Staff E, Dietary Manager, stated the evening snack cart hot liquids temperatures are supposed to be checked and stated there was no record of the temperature checks for the evening snack cart. They also stated Resident 1 had a large mug with a heavy lid that would not come off if dropped and it was supposed to be used when giving Resident 1 hot liquids. They stated it had not been used on 07/26/2025, when the resident spilled hot liquid on their thighs.Review of the care plan showed no documentation, prior to 07/30/2025, that Resident 1 used a particular mug for hot beverages.Review of the Facility's July 2025 hot liquids temperature log documented hot liquids were not to be served unless the temperature was within 123-155 degrees F. The temperature log the facility provided for July 2025 started with July 19th, 2025, only documented 10:00am and 3:00pm snack cart temperatures. Further review from 07/19/2025 through 07/27/2025, showed all temperatures for hot water and hot coffee were documented 158 degrees F or higher.Reference: WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure laboratory services were obtained as ordered and followed-up timely, for 1 of 3 sampled residents (Resident 2), reviewed for laboratory (lab) services. This failure placed the resident at risk for delayed treatment, and a decline in condition. Findings included . Review of the October 2024 progress notes for Resident 2 showed on 10/07/2024 the resident complained of urinary symptoms including a burning sensation during urination and urinary frequency. The notes showed the medical provider was notified and an order for a urinalysis (UA; laboratory test of urine to detect a wide range of disorders including urinary tract infections) was obtained. Review of Resident 2's UA lab report dated 10/08/2024 showed multiple abnormal results were identified. The lab report was not signed by a provider and/or nursing staff to show it had been reviewed. Review of the October 2024 provider notes showed the resident was seen by a Nurse Practitioner on 10/09/2024. The note did not include information regarding the UA results obtained the previous day. On 10/10/2024 at 10:11 AM a representative for Resident 2 reported the resident had concerns about a UTI and had not heard the results yet. Additional review of the provider notes showed on 10/17/2024 the resident was seen by a Physician Assistant who documented the UA results from the previous week were concerning for a urinary tract infection (UTI). Another UA was ordered with directions to perform additional testing if the new UA had abnormal results. Review of Resident 2's October 2024 Medication Administration Record (MAR) showed an order to obtain a UA on 10/17/2024 or 10/18/2024. The MAR was blank/not signed on either day. In a telephone interview on 10/29/2024 at 1:23 PM Resident 2 stated they had been discharged home from the facility with several medical issues that were unaddressed. The resident stated they were unable to recall if facility staff followed-up with them regarding their UTI. In an interview on 10/29/2024 at 2:36 PM Staff C, Registered Nurse, stated the medical providers were responsive to staff concerns but the provider who answered the phone and/or visited the residents were not always the same, so it was hard to ensure continuity of care. Staff C stated they had not been at the facility during the past few weeks and were unable to provide any additional information about follow-up with the provider(s) for Resident 2's UA results and/or whether the re-ordered UA had been obtained. In an interview at 3:35 PM the same day with Staff B, Director of Nursing, and Staff A, Infection Preventionist, Staff B stated lab results were received by nursing staff who were then responsible to ensure the provider received the results. Staff A stated the UA on 10/08/2024 was received by the facility the same day and staff should have notified the provider of the abnormal results by phone right away. Staff A stated they did not know if a second UA was obtained when the provider ordered it on 10/17/2024 and/or if the resident received follow-up information on their health status. Reference: (WAC) 388-97-1620(2)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 1 of 1 medication storage rooms. The facility further failed to maintain temperatures to ensure medications were properly stored. This failure placed residents at risk for receiving compromised or ineffective medication. Findings included . During an observation of the medication room on 10/10/2024 at 7:18 AM, with Staff I, Registered Nurse, revealed a vial of hepatitis vaccine that had expired on 08/24/2024. The refrigerator in the medication room was 50 degrees and contained Covid-19 and Prevnar (a vaccine that protects against pneumonia) vaccines and a vial of Tubersol (medication injected under the skin to determine exposure to Tuberculosis). The temperature log posted on the wall stated the temperature should be between 36-46 degrees. Review of the refrigerator temperature logs documented the temperature had not been monitored since July 2024 and was monitored nine times that month. In an interview on 10/10/2024 at 7:18 AM, Staff I stated the temperature of the vaccines should be monitored to ensure the temperature was appropriate to maintain viability of the vaccines. During an interview on 10/10/2024 at 7:35 PM, Staff B, Director of Nursing, confirmed the temperature of the refrigerator should have been monitored to ensure the viability of the vaccines and the hepatitis vaccine should have been discarded. Reference: WAC 388-97-1300 (2)

Based on observation, interview and record review, the facility failed to repeatedly review care plan intervention effectiveness and timely revise ineffective interventions for 3 of 14 sampled residents (Residents 3, 6, and 12), reviewed for care planning. This failed practice placed residents at risk of unmet care needs and diminished quality of life. Findings included . Review of the facility policy titled, Care Planning revised May 2023, showed the care plan should contain description of services to be provided to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Individualized care plan interventions would be added with a date to indicate when the intervention was started. The policy further showed the care plan was to be reviewed upon admission, quarterly and with significant changes in condition. <Resident 3> Review of the quarterly assessment, dated 09/28/2024, showed Resident 3 admitted to the facility on [DATE] with diagnoses including chronic liver failure and high blood pressure. Resident 3 had no pressure injuries or no intravenous (IV) access. Resident 3 was cognitively intact and able to clearly verbalize their needs. Review of the care plan revised 06/24/2024 showed Resident 3 had a laceration to their right shin and instructed staff to complete treatments per provider orders and monitor for signs and/or symptoms of infection. The care plan revised 08/30/2024 showed Resident 3 had a pressure injury to their buttocks and instructed staff to keep skin clean, monitor bony prominences for signs of skin breakdown and provide wound care per provider orders. The care plan initiated on 09/11/2024 showed Resident 3 used a perimeter mattress (mattress with a raised or defined edge) for safety and instructed staff to ensure proper positioning with proper body alignment when in bed. The care plan revised 09/16/2024 showed Resident 3 had IV access and instructed staff to follow enhanced barrier precautions (EBP, infection control measures used to reduce the spread of drug-resistant organisms) for infection control, provide IV site care, and notify the provider if signs and/or symptoms of infection were observed. Review of provider orders showed a 08/19/2024 order for Resident 3 to use a protective barrier cream twice daily to their buttocks for itchy and dry skin. A 09/25/2024 order showed Resident 3 was to use an alternating air mattress with bolsters to promote pressure relief and comfort. Review of the 09/07/2024 through 10/05/2024 weekly skin evaluations showed Resident 3 had no pressure injuries to their buttocks nor a laceration to right shin. Review of September 2024 through October 2024 nursing progress notes showed on 09/26/2024 Resident 3 removed their IV access line, and it was not reinserted. Observation on 10/07/2024 at 9:46 AM showed an enhanced barrier precaution sign posted on Resident 3's room door with a plastic black storage container full of personal protective equipment (PPE, gowns, gloves, masks, eye protection) right outside of the room. Observation on 10/08/2024 at 8:51 AM, showed the enhanced barrier precaution sign was no longer posted on Resident 3's room door and the black storage container containing PPE had been removed. During observation and interview on 10/08/2024 at 9:18 AM, Resident 3 laid in bed wearing a short sleeve hospital gown, on top of an alternating air mattress, and did not have IV access to either arm. Resident 3 stated they only had a rash to their buttock that staff treated with a barrier cream and denied other skin issues. Similar observation were made on 10/09/2024 at 9:43 AM. In an interview on 10/10/2024 at 11:24 AM, Staff E, Nursing Assistant (NA), stated care plans should be updated with a resident's needs because staff referred to them to determine a resident's care needs. Staff E stated Resident 3 no longer had IV access, no longer required a bandage to their buttocks, and used a barrier cream for skin integrity. In an interview on 10/10/2024 at 12:09 PM, Staff B, Director of Nursing (DNS), stated care plans were reviewed as needed, quarterly, and with changes of condition. Staff B further stated care plans should accurately reflect a resident's care needs, if not updated accurately then staff might not know what care a resident needed and the facility might not meet a resident's care needs. Staff B reviewed Resident 3's records. Staff B stated Resident 3's right shin laceration and buttock pressure injury had resolved, Resident 3 no longer had IV access, and Resident 3 used an alternating air mattress for pressure reduction not a perimeter mattress. Staff B acknowledged Resident 3's care plan did not reflect their current needs. <Resident 6> Review of the admission assessment, dated 09/11/2024, showed Resident 6 admitted to the facility on [DATE] with diagnoses including dementia (loss of cognitive function- thinking, remembering, and reasoning that interferes with a person's daily life), and hemiplegia (paralysis on one side of the body) following a stroke. The assessment further showed Resident 6 sustained one injury fall since admission and used a chair that prevented rising. Resident 6 had two unhealed pressure injuries with dressings applied to their feet and was on isolation or quarantine precautions. Review of provider orders dated 09/10/2024 showed Resident 6 was to be on EBP due to wounds on their buttocks and both legs. A 09/13/2024 order showed Resident 6 was to use a Broda (low to the ground chair with tension seating with a back that reclined) chair for safety and positioning related to profound weakness. Review of the 09/11/2024 facility fall incident report showed Resident 6 was seated in their WC, leaned forward, and fell out of the chair hitting their head. The incident summary showed the WC was switched to a Broda chair and the care plan was updated. Review of the 09/10/2024 skin care plan showed Resident 6 had wounds to their buttock, both legs and instructed staff to follow EBP. The 09/12/2024 falls care plan showed Resident 6 had a history of falls and instructed staff to place Resident 6's bed in the low position when occupied, keep frequently used items within reach, and use a Broda chair for safety and positioning. Review of September 2024 nursing progress notes showed on 09/10/2024, Resident 6 was on EBP due to pressure injuries to their buttocks and both legs. On 09/13/2024 Resident 6 began to use a tilt in space type WC (chair height wheelchair that swiveled to elevate the legs and recline the back). Review of 09/22/2024 through 10/06/2024 weekly skin evaluations showed Resident 6 had no pressure injuries to their buttocks or legs. Observation on 10/07/2024 at 9:46 AM, showed an EBP sign posted on Resident 6's room door with a plastic black storage container full of PPE right outside of the room. Similar observation were made on 10/08/2024 at 8:48 AM. Observation on 10/08/2024 at 2:19 PM, showed the EBP sign was no longer posted on Resident 6's room door and the black storage container containing PPE had been removed. During an observation on 10/09/2024 at 9:44 AM, Resident 6 sat in a tilt in space type WC, not a Broda. Similar observations were made on 10/09/2024 at 10:36 AM, 10/10/2024 at 7:53 AM and 10:16 AM. In an interview on 10/11/2024 at 8:08 AM, Staff F, NA, stated Resident 6 did not have skin issues. In an interview on 10/11/2024 at 8:22 AM, Staff D, Licensed Practical Nurse (LPN), stated Resident 6's skin issues resolved. Staff D further stated Resident 6 sustained a fall September 2024 and their WC was exchanged. In an interview on 10/11/2024 at 10:57 AM, Staff B, DNS, reviewed Resident 6's record. Staff B stated Resident 6 no longer had skin issues. Staff B acknowledged Resident 6's care plan showed they used a Broda chair but it had been exchanged for a tilt in space type WC so they could better participate in therapies and increase their independence. Staff B acknowledged Resident 6's care plan was not up to date. <Resident 12> Review of the quarterly assessment, dated 09/16/2024, showed Resident 12 had a diagnosis of severe dementia with severe cognitive impairment. Resident 12 had not sustained any falls since admission, reentry or the prior assessment. Review of the 06/10/2024 self-care deficit care plan showed Resident 12 required total assistance of two staff for bed mobility. The care plan revised 06/10/2024 showed Resident 12 was at risk for falls out of bed and instructed staff to place the bed in the lowest position when occupied and place fall mats on both sides of the bed. A fall intervention initiated 01/16/2024 instructed staff to position Resident 12 in the center of the bed, the intervention was revised/reworded on 10/02/2024 to ensure Resident 12 was positioned in the center of the bed. Review of the 09/27/2024 facility fall incident report showed Resident 12 rolled out of bed onto the floor. The incident summary showed the care plan was updated to ensure Resident 12 was positioned in the center of the bed. In an interview on 10/11/2024 at 8:14 AM, Staff D, LPN, explained the facility process when a fall occurred and stated a new fall intervention should be implemented immediately to prevent incident recurrence because the sooner the intervention the better the [fall] prevention. In an interview on 10/11/2024 at 11:07 AM, Staff B, DNS, reviewed Resident 12's record. Staff B acknowledged Resident 12's fall intervention to position them in the center of the bed was initially initiated January 2024 and not a new intervention after sustaining a fall out of bed September 2024. Reference WAC 388-97-1020 (5)(b) Refer to F880 for additional information.

Based on interview and record review, the facility failed to repeatedly implement the bowel management protocol when indicated for 2 of 5 sampled residents (Resident 7 and 16), reviewed for bowel management. This failure placed residents at risk of medical complications, unmet care needs, and diminished quality of life. Findings included . Review of the facility policy titled, Management of Constipation revised November 2023, defined constipation as three or more days without a bowel movement (BM) characterized by a decrease in frequency and/or passage of hard, dry stools. The policy showed BMs would be documented and monitored in the electronic medical record. When a resident was identified with no/small BM documented for 64 hours the nurse would assess the resident and determine if the bowel protocol would be initiated. The policy further showed the standard bowel protocol to relieve constipation with a provider order may include administration of 1) Milk of Magnesia (MOM, liquid laxative) after eight shifts of no BM, 2) Bisacodyl (stimulant laxative) suppository, if no results from MOM, and 3) Fleets enema (liquid laxative inserted rectally), if no results from the suppository. <Resident 7> Review of the quarterly assessment, dated 07/11/2024, showed Resident 7 had a diagnosis of neurogenic bladder (nerves and muscles of bladder do not work together). The assessment further showed Resident 7 experienced constipation and bowel continence was not rated because the resident did not have a BM during the seven-day assessment observation period. Review of the nutrition risk care plan implemented 09/14/2022 showed Resident 7 experienced constipation and instructed staff to monitor BMs and follow provider orders for bowel interventions. The 07/13/2024 self-deficit care plan showed Resident 7 required extensive assistance of 2 staff for toilet use. Review of provider orders showed Resident 7 was to take an opioid pain medication routinely three times daily, was not on routine bowel medications, and had active orders for: - 02/27/2024 Docusate to be given every 12 hours as needed for constipation - 02/27/2024 MOM to be given as needed for constipation if no BM after three days. - 02/27/2024 Bisacodyl suppository to be given every 24 hours as needed for constipation, if no results from MOM after 12 hours. - 02/27/2024 Fleet enema to be given every 24 hours as needed for constipation, if no results from suppository after four to six hours. The provider was to be notified if no results from the enema. Review of Resident 7's July 2024 through October 2024 bowel record showed: - July: 07/07/2024 large (after 6 days without a BM), 07/13/2024 extra-large (after 5 days without a BM), 07/24/2024 large and small (after 4 days without a BM) - August: 08/08/2024 medium (after 7 days without a BM), 08/11/2024 extra-large (after 3 days without a BM), 08/16/2024 extra-large (after 5 days without a BM), 08/20/2024 large (after 4 days without a BM), 08/23/2024 extra-large (after 3 days without a BM), 08/27/2024 large (after 4 days without a BM), 08/30/2024 extra-large (after 3 days without a BM) - September: 09/06/2024 extra-large (after 7 days without a BM), 09/11/2024 large (after 5 days without a BM), 09/16/2024 large (after 5 days without a BM), 09/28/2024 small - October: 10/02/2024 large (after 4 days without a BM), 10/04/2024 large, no BM documented through October 9th (5 days without a BM) Review of Resident 7's July 2024 through October 2024 Medication Administration Record showed: - July: MOM was administered on 07/12/2024 with effective results and 07/23/2024 with results documented as unknown. - August: MOM was administered on 08/19/2024, 08/27/2024, and 08/30/2024 with all results documented as unknown. - September: MOM was administered on 09/10/2024 with unknown results and on 09/17/2024 with effective results - October: MOM was administered on 10/09/2024 Review of July 2024 through October 2024 nursing progress notes showed Resident 7 took routine opioid pain medication possibly affecting bowel regularity. The notes showed no documentation the provider was notified of Resident 7's history of recurrent constipation. <Resident 16> Review of the 08/11/2024 quarterly assessment documented Resident 16 had diagnoses including kidney disease and depression. Resident 16 was cognitively impaired, required moderate assistance of staff for toileting, was occasionally incontinent of bowels, and had constipation. The 05/04/2023 care plan showed Resident 16 had an alteration in bowel elimination; staff were instructed to assist with periods of incontinence and provide pericare after each incontinence episode. Resident 16 had the following provider orders: -09/12/2024 Senna 8.6 milligrams (mg) one tablet twice daily for constipation, -08/01/2023 MOM 30 milliliters (ml) as needed for constipation, give at bedtime if no bowel movement on day 3, -08/01/2023 Dulcolax suppository once every 24 hours as needed for constipation if no results from MOM after 12 hours, -08/20/2024 Fleet enema 7-19 grams (gm) /118 ml once every 24 hours as needed if no results from Dulcolax in 4-6 hours. If no results from enema notify provider. A Physician Assistant progress note written on 09/11/2024 documented Resident 16 was seen at the request of nursing for constipation, going two to five days between bowel movements. The plan was to increase the Senna from once daily to twice daily and they would continue to monitor this. A nursing progress note written on 09/17/2024 documented Resident 16 complained of constipation. Review of the September 2024 MAR showed the Senna was increased and given twice daily, and the resident was given MOM on 09/17/2024 for no bowel movement. Review of the October 2024 MAR showed the Senna was given twice daily with no omissions, and there were no administrations of the as needed MOM, Dulcolax, or Fleet enema. A review of the 30 day look back of Nursing Assistant Bowel documentation from 09/11/2024 to 10/09/2024 showed the following: - From 09/11/2024 to 09/16/2024, Resident 16 had no bowel movement, a period of 6 days. -On 09/17/2024, the resident had one small and one medium bowel movement after administration of MOM. -From 09/22/2024 to 09/29/2024, the resident had no bowel movement, a period of 7 days. Resident 16 had received no as needed medications to relieve their constipation. -From 10/06/2024 to 10/09/2024 the resident had no bowel movement, a period of 3 days, and received no as needed medications to relieve their constipation. In an interview on 10/10/2024 at 11:28 AM, Staff E, Nursing Assistant, stated BMs were documented in the resident's electronic medical record and an alert would pop up if/when a resident did not have a BM documented for three days. Staff E further stated the typical bowel protocol consisted of oral laxative administration if no BM after three days, a suppository if no results, then an enema if no results from the suppository. Staff E stated potential complications from unresolved constipation could include a bowel obstruction that could require surgical intervention. Staff E acknowledged Resident 7 suffered from routine constipation for a while and would have rock hard stools after receiving as needed bowel medications. In an interview on 10/10/2024 at 11:58 AM, Staff B, Director of Nursing, stated BMs were documented in the electronic health record. Staff B explained the facility bowel protocol consisted of administration of MOM if no BM for three days, administration of suppository on day 4, then administration of an enema on day five, and the provider was to be notified if there were no results from the enema or if a resident experienced routine constipation issues. Staff B acknowledged Resident 7 had an extensive constipation history, routinely went five to seven days without having a BM, and stated the residents did not have the bowel protocol implemented when indicated. Reference WAC 388-97- 1060 (1) This is a repeat citation from 03/27/2024 46033

Based on interview and record review, the facility failed to consistently implement appropriate interventions to reduce fall hazards and monitor for intervention effectiveness for 1 of 3 sampled residents (Resident 4), reviewed for falls. This failure resulted in Resident 4 sustaining repeated falls and placed residents at risk for avoidable accidents, significant injury, and diminished quality of life. Findings included . Review of the facility policy titled, Fall and Injury Prevention and Management Care Plan revised 01/2023, showed the facility would revise a resident's care plan and/or center practices to attempt to determine causall factors that may have led to a fall, to prevent future occurrences and reduce the likelihood of another fall. The facility was to assess risk factors and hazards to identify potential interventions to implement. Review of the facility policy titled, Fall Injury Management- Post Fall or Injury revised 01/30/2023, documented proper action following a fall included: assessing for injury, determining potential cause, or contributing factors, addressing potential contributing factors, revising the care plan and/or center practices to reduce the likelihood of another fall, and communicating a fall to the physician and the resident representative in a timely manner. The policy instructed staff to initiate and complete a fall incident report, complete a fall risk assessment, determine potential causes to the fall, review and revise fall interventions, and communicate changes and/or interventions to staff. Per the 09/21/2024 admission assessment, Resident 18 admitted on [DATE], had diagnoses which included chronic obstructive lung disease (COPD, a group of lung diseases that make it difficult to breathe), kidney disease and diabetes, was cognitively intact and made needs known. The assessment documented Resident 18 had sustained a non injury fall since their admission to the facility. The assessment additionally documented resident was on Hospice (end of life care) related to end stage COPD. Per the 09/23/2024 care plan, Resident 18 was at risk for falls related to anxiety and deconditioning secondary to end stage respiratory failure. The nursing staff was instructed to encourage the resident to use their call light and ensure it was within reach, keep needed items within reach, ensure resident was wearing non-skid socks or shoes when ambulating or mobilizing in wheelchair, and to offer to assist resident to the bathroom prior to bed. Review of the 10/07/2024 fall risk assessment documented Resident 18 was at high risk for falls because they had a history of falling and overestimated/forgot their limitations. Review of September 2024 through October 2024 accident and incident log and nursing progress notes documented Resident 18 sustained 9 falls in 23 days on: 09/21/2024 at 7:30 PM, 09/30/2024 at 11:29 PM, 10/02/2024 at 10:33 AM, 10/02/2024 at 5:15 PM, 10/05/2024 at 6:30 AM, 10/05/2024 at 7:03 PM, 10/06/2024 at 12:15 AM, 10/07/2024 at 10:58 AM and 10/08/2024 at 4:15 AM. Review of the facility incident report for the unwitnessed fall that occurred on 09/30/2024 at 11:29 AM documented Resident 18 was found on the floor next to their bed, was not wearing their oxygen, had a skin tear on their right forearm, bruising and swelling to left hand and knee. Resident 18's oxygen saturation was checked, and it was 50% (the normal oxygen saturation for someone with COPD is 88-92%.) The 09/30/2024 progress note at 11:51 AM, documented Resident 18 was on Hospice, ambulated without waiting or calling for assistance and did not have their oxygen on. An intervention was added to the care plan on 10/01/2024 to place a sign in Resident 18's room to remind them to call for assistance. Review of the facility incident report for the unwitnessed fall that occurred on 10/02/2024 at 10:30 AM documented Resident 18 was found on the floor in front of their bed, was not wearing their oxygen, had a skin tear on their left forearm, very confused, and unable to answer questions appropriately. Resident 18's oxygen saturation was checked, and it was 70%. The fall was related to attempting to get out of bed to ambulate, anxiety, and unawareness of their limitations. Per the incident report the resident admitted to the facility, was alert, oriented, able to make needs known, wore oxygen and their saturations stayed in the 90's. Since their admission, Resident 18 had a significant change in condition, increased confusion, anxiety, unable to answer questions appropriately and make needs known and the resident had several falls over the last weeks. Fall mats were placed on each side of the bed to decrease risk of injury if another fall occurred. Review of the facility incident report for the unwitnessed fall that occurred on 10/02/2024 at 5:15 PM documented Resident 18 was found on the floor in front of their bed, was not wearing their oxygen, very confused, and unable to answer questions appropriately. Resident 18's oxygen saturation was checked, and it was in the 70's. The fall was related to attempting to get out of bed to ambulate, anxiety secondary to air hunger and decreased oxygen saturations and unawareness of their limitations. Review of the facility incident report for the fall that occurred on 10/05/2024 at 6:30 AM documented Resident 18 was found on their knees on the floor next to their bed. Family was in the room and had attempted to transfer the resident into their wheelchair. Resident 18 received a large bruise on their left knee and a skin tear on their left forearm. On 10/08/2024, the family was educated that Resident 18 was to be transferred by staff using a hoyer lift (a device that lifts the resident). Review of the facility incident report for the fall that occurred on 10/06/2024 at 12:15 AM documented Resident 18 was found sitting on their wheelchair foot pedals, very confused and anxious secondary to respiratory distress and low oxygen saturations. Resident 18 had attempted to stand unassisted from their wheelchair, staff member reacted quickly but was unable to keep the resident in their chair and had to assist them to a seated position on the floor. A self-releasing seatbelt was added to Resident 18's wheelchair. Review of the facility incident report for the unwitnessed fall that occurred on 10/07/2024 at 10:58 AM documented Resident 18 was found lying on the floor next to the bed, was not wearing oxygen, confused, and had a skin tear to their right forearm. Resident 18's oxygen saturation was checked, and it was 81%. The resident was placed in their wheelchair and placed in front of the nurse's station for increased supervision and a medication review was completed. The fall was related to Resident 18 had attempted to ambulate, poor safety awareness and unawareness of limitations. A sign was added to remind resident to call for assistance. Review of the facility incident report for the unwitnessed fall that occurred on 10/08/2024 at 4:15 AM documented Resident 18 was found lying on the floor near the end of the bed. Resident 18 was placed back in their wheelchair and brought to the nurse's station for better supervision. Resident 18's care plan was updated to place resident in activities or at the nurse's station to provide interaction and closer supervision when awake. During an observation on 10/07/2024 at 2:35 PM, Resident 18 was tilted back in their wheelchair, very fidgety, calling out, confused, and their family kept telling them they needed to stay in their wheelchair. Resident 18 observed multiple times trying to get out of their wheelchair unassisted. Resident 18's family spoke to the nurse and the nurse had explained how the resident continued to try to get out of their chair and bed. In an observation and interview on 10/07/2024 at 3:15 PM, Resident 18 was sitting in their wheelchair, had purple and green bruising over their arms and their entire left hand was covered in bruises. Resident 18's family stated some of the bruises were from a dog where she used to live but had fallen twice the day before and fell about every other day. Resident 18's family stated the facility did not have 1:1 supervision for the resident when they were not there. During an observation on 10/07/2024 at 3:49 PM, Resident 18 had a fall mat on the right side of their bed only, not the left side also as care planned. In an observation on 10/08/2024 at 10:10 AM, Resident 18 was sitting on the edge of the bed with no oxygen on and stated they needed to put their make up on. A staff member entered the room and stated they were going to go get help and left. Resident 18 stood up and began walking, very unsteadily, surveyor yelled to staff that Resident 18 was going to fall. Staff B, Director of Nursing and an unnamed staff member ran down the hall. Resident 18 had grabbed onto their wheelchair and leaned over it. The staff arrived in the resident's room and stated they needed more help. The surveyor went and got a nurse, and the resident was assisted into their wheelchair. During an observation on 10/09/2024 at 1:20 PM, Resident 18 was in their room tilted back in their wheelchair. There was no supervision provided as care planned. In an observation on 10/10/2024 at 7:54 AM, Resident 18 was sitting in the hall near the nurse's station, had pulled their oxygen off, and was attempting to get out of the wheelchair. There was no staff at or near the nurse's station to provide supervision. At 8:00 AM, two nursing assistants arrived and picked Resident 18's nasal cannula off the floor. The resident was anxious and kept trying to get out of their wheelchair. At 8:03 AM, Resident 18 was wheeled to their room without oxygen on. At 8:06 AM, Staff B, Director of Nursing, stated the resident was restless and was waiting for the nurse to get them a mask for oxygenation and pain medication. At 8:09 AM, Staff C, Registered Nurse, entered the room and Resident 18's oxygen saturation was 44-45% on room air. At 8:12 AM, the nurse placed the oxygen mask on the resident. During an observation on 10/10/2024 at 1:27 PM, Resident 18 was asleep in bed with only one prong of their nasal cannula in their nose, no supervision was being provided. The bed was not in low position and the fall mat was not on the left side of the bed on the floor. At 2:55 PM, the same observation of the bed and fall mat were made. In an observation on 10/11/2024 at 7:10 AM, Resident was lying in bed asleep, no supervision was being provided. The resident was not wearing oxygen, and the bed was not in low position. In an interview on 10/11/2024 at 8:41 AM, Staff E, Nursing Assistant, stated high fall risk residents would have floor mats, be placed at the nurse's station for increased supervision or have 1:1 supervision. Staff E added that Resident 18 was a high fall risk, and they were able to provide safety for them when they had 1:1 supervision. During an interview on 10/11/2024 at 9:01 AM, Staff D, Licensed Practical Nurse, stated they checked the residents during rounds to ensure their oxygen was being worn and they educated the residents on risks of not doing so. Staff D stated if oxygen saturations were too low it could lead to hypoxia (a deficiency in the amount of oxygen reaching the body's tissues) which could lead to shortness of breath and death. Staff D stated increased supervision or 1:1 supervision was provided for residents that have repeated falls. Staff D stated Resident 18 would have benefited from having 1:1 supervision related to confusion, depression and end of life status and they had mentioned it to the hospice nurse two days ago and they were looking into that. Staff D stated some of Resident 18's fall possibly could have been prevented with 1:1 supervision. Staff D added that some of Resident 18's falls could have occurred from low oxygen saturation and the resident was educated but confused. In an interview on 10/11/2024 at 9:22 AM, Staff B stated checks were completed to ensure residents were wearing their oxygen and low oxygen saturations could lead to respiratory issues. Staff B stated the cause of Resident 18's falls were related to increased anxiety, restlessness and end of life status. Staff B stated Resident 18's bed should have been kept in the lowest position and fall mats on each side of the bed. Staff B added Resident 18 would have benefited from 1:1 supervision, and it possibly could have prevented some of their falls and injuries and would have also helped with Resident 18 wearing their oxygen. Reference WAC: 388-97-1060 (3)(g)

Based on observation and interview the facility failed to ensure rooms containing sharps, chemicals, and tools were secured in 3 of 4 shower rooms and 1 of 22 resident rooms (room [ROOM NUMBER]), and failed to ensure a wheelchair and seatbelt were maintained in a clean manner for Resident 2 reviewed for physical environment. This failure placed residents at risk of potentially avoidable accidents, lack of dignity and diminished quality of life. Findings included . <Shower Rooms> During observation on 10/07/2024 at 10:35 AM, the shower room at the end of the hall between room [ROOM NUMBER] and room [ROOM NUMBER] was unlocked. The shower room had 2 unlocked cabinets that were at eye level. One cabinet contained a gallon of pink shampoo. The second cabinet contained a multi-purpose cleanser in a spray bottle and a small box containing 14 disposable razors. A similar observation was made at 12:39 PM, the same day. In an interview on 10/07/2024 at 12:46 PM, Staff L, Nursing Assistant (NA), stated the facility did not lock the shower rooms but the cabinets were supposed to be locked. Staff L was shown the unlocked cabinets in the shower room and acknowledged the shampoo and multi-purpose cleanser should have been locked up. Staff L further stated disposable razors were not to be stored in the shower room. During an inspection of the nursing units on 10/07/2024 at 9:56 AM, the shower room next to resident room [ROOM NUMBER] was observed. Signage on the door showed the room was in use, however, after knocking, the door was not locked and was opened. The room was mostly bare, except for a large bathtub, and a large black tool chest was positioned against the wall. The tool chest drawers were unlocked and contained power tools, screwdrivers, drill bits, nails, screws, and other sharp objects. There were no residents wandering near or trying to enter the shower room. On 10/07/2024 at 10:14 AM, the door to the shower room remained unlocked; there were no residents or staff in the hall. On 10/07/2024 at 10:15 AM, Staff J, Maintenance Manager, was observed entering the shower room. When interviewed, they stated staff and residents no longer used the shower room, they had been using it for the last 6 months to store their tools. The drawer contents and small sharp objects were observed, and Staff J stated they could see where leaving the shower room and the tool chest unlocked could present a risk for the residents if they got into the tools. Staff J locked the tool chest at that time. During an observation on 10/07/2024 at 9:31 AM, the shower room towards the end of the hall between the nurse's station and room [ROOM NUMBER] was open, and accessible to residents and the public. The shower room had two plastic cabinets secured to walls on opposite sides of the room. One cabinet was without a lock and freely opened, and the other cabinet had a lock in place with a key attached to it. The cabinet without a lock contained the following items: an opened 10 pack of disposable razors, used bar of soap, hair shampoo, body wash, antiseptic skin cleanser, roll of plastic bags, and two boxes of gloves. The same observation was made at 12:33 PM. In an interview on 10/07/2024 at 10:32 AM, Staff F, Nursing Assistant, stated that the shower room was used to shower residents and the facility stored items such as disposable razors, shower chairs and disinfectants. Staff F also stated that the shower room should be locked. In an interview and observation on 10/07/2024 at 12:42 PM, Staff D, Licensed Practical Nurse, observed the opened shower room door and disposable razors in the unlocked cabinet. Staff D stated they were not aware that the razors were in the cabinet, and the cabinet should have been locked. Staff D confirmed that the shower room should be locked because residents could get into it. At this time it was observed the cabinet that had the lock and key was now opened and contained a bottle of peroxide disinfectant. Staff D stated chemicals should have been locked up. < room [ROOM NUMBER]> During observation on 10/07/2024 at 10:15 AM, a project work being done sign was observed on the room door. The door was closed but unlocked, no staff were in the room. Upon entering the room, a closed can of paint approximately 1/4 full was sitting on a bedside table to the right near the room entrance. On the bathroom floor there was a caulking gun with a tube of caulk, two [NAME] spatulas, a tape measure, and a blue folded item that looked like a pocketknife. In an interview on 10/07/2024 at 10:17 AM, Staff J, Maintenance Manager, stated painting and repairs were being done in room [ROOM NUMBER]. Staff J was shown the blue folded item that looked like a pocketknife. Staff J identified the item as a folded-up box cutting knife and acknowledged it should not have been left in the room unsecured or unattended. Staff J further stated they could not lock room [ROOM NUMBER] when work was being done related to safety issues. In an interview on 10/10/2024 at 11:55 AM, Staff B, Director of Nursing, stated chemicals, razors, tools and potentially dangerous items should be secured for resident safety. In an interview on 10/11/2024 at 12:53 AM, Staff A, Administrator, acknowledged chemicals, razors, and tools should have been locked up for resident safety. <Resident 2> Per the 08/07/2024 quarterly assessment, Resident 2 had diagnoses which included a traumatic brain injury and quadriplegia, had severe cognitive impairments and was dependent for all cares. Review of a 02/20/2024 comprehensive care plan documented Resident 2 was wheelchair bound, at risk for falls and wore a lap belt related to poor trunk control and spasticity. In an observation on 10/08/2024 at 9:38 AM, Resident 2 was observed in their room sitting in their wheelchair. The wheelchair and lap belt was unclean with food debris on it. Subsequent observations of the wheelchair and lap belt with food debris were made on 10/08/2024 at 2:02 PM, 10/10/2024 at 7:44 AM, and 10/11/2024 at 7:12 AM. During an interview on 10/11/2024 at 7:13 AM, Staff F, Nursing Assistant, stated night shift was responsible for cleaning the wheelchairs and it was important for hygiene and dignity. In an interview on 10/11/2024 at 9:16 AM, Staff B, Director of Nursing, stated the nursing assistants were responsible for cleaning the wheelchairs and lap belts weekly and as needed. Staff B added this was important because of bacteria and to maintain the resident's dignity. Reference WAC 388-97- 3220 (1) 46033 46115 50027

Based on observation, interview, and record review, the facility failed to honor a resident's choice for community outings for 1 of 4 sampled residents (Resident 4), reviewed for resident rights. This failure placed residents at risk of violations to their resident rights, unmet social needs, and diminished quality of life. Findings included . Review of the facility policy titled, Leave of Absence revised July 2023, showed a cognitively intact resident may leave the facility independently or family and/or friends may take a cognitively impaired resident from the facility when approved by the interdisciplinary team. A logbook would be used to track departures and returns of residents on the unit. The policy outlined the procedure for a leave of absence for a resident with cognitive impairment, an intended absence from the facility for a period in excess of eight hours in a day, and an intended absence beyond midnight. The policy directed staff to refer to the missing person procedure if a resident had not returned from their leave of absence within two to four hours of the anticipated return time. Review of the facility policy titled, Resident Rights dated August 2022, showed residents would be informed of their rights upon admission and resident rights were to be reviewed with the resident and/or their representative at least annually or as often as needed. A list of resident rights would be posted in the facility. The policy showed staff would be educated on resident rights upon hire and yearly thereafter. Review of the facility undated Resident [NAME] of Rights showed residents had the right to interact with members of the community both inside and outside the facility and make choices about aspects of their life that were significant to them to enhance their quality of life. The bill of rights further showed residents had the right to participate in social, religious, and community activities that did not interfere with the right of other facility residents. Review of the quarterly assessment, dated 07/08/2024, showed Resident 4 had diagnoses including abnormal posture and cerebral palsy (group of disorders that affect movement, balance, and posture). The assessment further showed Resident 4 used a motorized wheelchair (WC), was able to wheel/maneuver at least 50 feet with two turns and wheel at least 150 feet independently. Resident 4 was cognitively intact and able to clearly verbalize their needs. Review of the 10/03/2024 activity care plan showed Resident 4 enjoyed strolling around the facility in their motorized WC and was able to make independent choices regarding their leisure time. The 01/18/2024 limited physical mobility care plan showed Resident 4 was able to use their motorized WC independently. Review of the 07/11/2024 elopement risk evaluation showed Resident 4 was alert and oriented to person, place, time, and situation, had no history of elopement attempts and was identified as not at risk for elopement. Review of September 2024 through October 2024 nursing progress notes showed on 09/18/2024 at 12:39 PM Resident 4 became agitated and yelled throughout the hall. Resident 4 was upset because they wanted to go to the store in their motorized WC independently. Resident 4 was notified they could not go to the store independently for safety reasons and needed an escort, Resident 4 became very upset, began cursing and hollering again. At 1:55 PM the same day, Resident 4 screamed at staff in the hall and expressed they wanted to go to the store alone. Review of the 10/03/2024 quarterly nursing evaluation showed Resident 4 was alert and oriented to person, place, time, and situation, had no exit seeking behaviors and was identified as not at risk for elopement. Review of the 10/04/2024 social service quarterly evaluation showed Resident 4 had no change in cognitive status in the last quarter. During observation on 10/07/2024 at 11:27 AM, Resident 4 drove and maneuvered their motorized WC without safety concerns. Similar observations were made on 10/07/2024 at 2:49 PM, 10/09/2024 at 10 AM and 11:35 AM, and on 10/11/2024 at 7:58 AM. In an interview on 10/07/2024 at 2:32 PM, Resident 4 stated they were recently informed they needed an escort to leave the facility because of events from another sister facility. Resident 4 stated they were previously allowed to sign out and leave the facility independently, Resident 4 began to raise their voice as they explained they had lived in the area for [AGE] years, had never gotten lost, had not experienced a fall or accident when out in the community previously, and did not have difficulty driving or maneuvering their motorized WC. Resident 4 stated I feel I am in prison because of the new rule. In an interview on 10/11/2024 at 8:10 AM, Staff F, Nursing Assistant, stated they had not seen residents go on personal outings independently, they typically had an escort, even if they were cognitively intact. In an interview on 10/11/2024 at 8:28 AM, Staff D, Licensed Practical Nurse, stated residents were not allowed to go on community outings without a companion. Staff D further stated Resident 4 was cognitively intact, could drive/maneuver their motorized WC without safety concerns and had not experienced any accidents. Staff D acknowledged Resident 4 wanted to go on community outings independently but still required an escort for their safety. In an interview on 10/11/2024 at 8:44 AM, Staff H, Social Service Director, explained resident rights. Staff H stated residents could go on community outings independently depending on their cognitive status and transportation method. Staff H further explained if a cognitively intact resident chose to go on a community outing in their WC, then the facility would ask them to have a companion for their safety but if they had other transportation arrangements then they could go out independently. Staff H stated Resident 4 was able to drive and maneuver their motorized WC without safety concerns and had a history of following the rules related to leaves of absence. Staff H further stated Resident 4 would need an escort if they chose to leave the facility in their motorized WC, for their safety. In an interview on 10/11/2024 at 10:47 AM, Staff B, Director of Nursing, stated residents could go on community outings depending on their cognition and transportation method. Staff B stated they were concerned about Resident 4 going on community outings because of traffic. Staff B was unsure if Resident 4 had been assessed for WC mobility in the community. Staff B acknowledged requiring Resident 4 to have an escort on community outings without justification could be a resident right issue. In an interview on 10/11/2024 at 11:25 AM, Staff G, Director of Therapy, stated residents were required to pass a motorized WC assessment that included a drive test to ensure they could safely navigate around others inside and outside the facility, prior to being allowed to use the motorized WC. Staff G acknowledged Resident 4 had not been recently assessed for WC mobility. In an interview on 10/11/2024 at 12:43 PM, Staff A, Administrator, acknowledged Resident 4 was required to have an escort to go on community outings because of traffic and the community environment. Refer to WAC 388-97-0900 (1)-(4)

Based on observation, interview and record review, the facility failed to provide necessary services to support activities of daily living (ADLs) for 2 of 4 sampled residents (Residents 1 and 22) reviewed. Specifically, Resident 1 was not receiving restorative nursing services as careplanned, and a robust system was not implemented for Resident 22, who had communication challenges after suffering a stroke. Findings included . The Facility Assessment Tool dated 08/15/2024 documented Othello Care Center resident population might require and would be provided Restorative Nursing care. <Resident 1> The 08/09/2024 quarterly assessment documented Resident 1 had diagnoses including quadriplegia (paralysis that affected all four extremities and the body from the neck down), was cognitively intact and able to make their needs known. Resident 1 was dependent on staff for their ADLs and had no minutes of active or passive restorative range of motion completed. The care plan updated on 03/22/2023 documented Resident 1 had an alteration in physical mobility related to their quadriplegia; staff were instructed to cue the resident to perform active range of motion (AROM, where the resident carries out the movement) exercises for their head and neck of turning side to side, placing their left side to their left shoulder, and right side to their right shoulder, and moving the chin to the chest for 2 sets of 10 repetitions during cares for 15 minutes. Staff were also to perform passive ROM (PROM, where staff complete the movement for the resident) for both upper and lower extremities for 10 repetitions each, for 15-30 minutes 6-7 times per week. On 10/09/2024 at 11:49 AM, Resident 1 was observed seated in their electric wheelchair. The resident used their head to push on levers that operated the wheelchair. The resident had limited spastic movements of their arms. Resident 1 stated staff used to help move their arms and stretch them, but this had not happened in a long time. Resident 1 could not remember when the stretches had been done last and wondered why it had stopped. On 10/10/2024 at 10:09 AM, Staff E, Nursing Assistant (NA) and Staff N, NA, were observed transferring Resident 1 from their bed to their wheelchair using a mechanical lift. Resident 1 was totally dependent on the NA's for how they were positioned in their wheelchair, and their arms and legs had to be positioned on the appropriate supports. When asked, Staff E and Staff N stated therapy completed and documented the stretches and PROM for Resident 1. The NAs did not complete those tasks. During an interview on 10/10/2024 at 1:26 PM, Staff G, Director of Therapy, stated there were no restorative aides at present and they were trying to bring back the restorative nursing program. During an interview on 10/11/2024 at 2:16 PM, Staff A, Administrator, stated it was their plan to bring back the restorative nursing care. It was important for the residents so they could maintain their functionality. 50027 <Resident 22> The quarterly assessment, dated 08/31/2024, documented Resident 22 had diagnoses including stroke and aphasia (the inability to understand or express speech). Resident 22 had no speech, rarely expressed ideas and wants, and sometimes understood simple, direct communication. Resident 22's cognition was severely impaired, although oriented to their location. The resident's preferred language was Spanish and they needed an interpreter to communicate with health care staff. The care plan, dated 05/26/2024, documented Resident 22 had an alteration in communication related to aphasia and was Spanish speaking only. Staff were instructed to allow Resident 22 adequate time to respond, ask yes/no questions, face resident when speaking, identify the resident's primary mode of communication, observe non-verbal cues that would indicate needs or understanding (e.g., nodding, facial grimacing, shaking head), and use visual aids to demonstrate daily cares. During an observation on 10/08/2024 at 9:13 AM, Resident 22 was in their room. They were seated in their wheelchair and watched the Spanish-language channel on television. There were two identical signs posted in English on the walls (above their television and left side of the bed) that read as followed: Please Call, Don't Fall .Your safety is Important to us. If you need to get up, use the call button for assistance. There was an Activities Monthly Calendar and Menu printed in English posted on the bathroom door. During an observation on 10/09/2024 at 11:53 AM, Resident 22 was in their room watching television on an English-language channel. The resident initiated communication with the surveyor verbalizing words and phrases that were not understood, in addition to using hand gestures (i.e., pointing). The surveyor had to ask yes/no questions several times to determine that the resident wanted the television remote. Resident 22 confirmed with a head nod and used the television remote to change to a Spanish-language channel. On 10/10/2024 at 9:45 AM, an observation and interview were conducted with Resident 22 in their room using an interpretation service over the phone for translating in Spanish. The resident communicated using gestures and single word phrases when speaking. The interpreter stated they could not understand Resident 22 when they spoke. The resident gestured that it was difficult to express to staff what their basic wants and needs were. Resident 22 stated that they did not receive speech therapy, but desired to so that they could improve their communication skills. Review of the speech therapy record, from 05/29/2024 to 10/07/2024, documented Resident 22 was not provided skilled services for aphasia until 07/22/2024, then received speech therapy 11 of 32 sessions planned and had no refusals. Further review showed a decline in Resident 22's expressive language skills when there was a lapse in treatment. There was no documentation of other communication tools attempted nor implemented. During an interview on 10/11/2024 at 10:44 AM, Staff O, NA, stated it took a long time to understand what Resident 22 wanted or needed during ADLs which impacted how long it took to provide the resident care. During an interview on 10/11/2024 at 1:35 PM, Staff P, Speech-Language Pathologist, confirmed they minimally treated Resident 22's communication skills. Staff P stated that Resident 22 understood limited English and they engaged with them speaking primarily Spanish. Staff P confirmed that the signs in Resident 22's room should be posted in Spanish. Staff P also stated they had not implemented any other communication tools for Resident 22. Staff P confirmed that Resident 22 would benefit from other communcation tools. During an interview on 10/11/2024 at 2:36 PM, Staff B, Director of Nursing, stated it was important for Resident 22 to have a better mode of communication so the facility could meet their needs. Reference: WAC 388-97-1060 (2)(a)(v) See F688 for additional information.

Based on observation, interview and record review, the facility failed to maintain respiratory equipment in a clean manner for 2 of 2 sampled residents (Residents 8 and 18) reviewed for respiratory care. This failure placed the residents at risk for illness and decreased quality of life. Findings included . <Resident 8> A review of the 08/28/2024 five day assessment documented Resident 8 had diagnoses including heart failure (the heart pumps ineffectively so does not meet the needs of the body) and pneumonia. The resident was moderately impaired cognitively and was dependent on supplemental oxygen. Provider orders instructed staff to wash the oxygen concentrator (the machine that delivers oxygen) filter if recommended by the manufacturer every Wednesday on night shift. A review of the September and October 2024 Medication Administration Records (MARs) documented the filter on the oxygen concentrator had been cleaned every Wednesday, with no omissions. On 10/07/2024 at 3:29 PM, Resident 8 was observed in their room, seated in an easy chair. Resident 8 was wearing oxygen and stated they had to wear it all the time. An oxygen concentrator was observed on the floor by the bed. The mesh filter on the side of the concentrator was covered in layers of lint and dust. The color of the filter was unable to be seen because the dust covered it so thickly. On 10/08/2024 at 9:07 AM, the concentrator filter was observed and had been cleaned. During an interview on 10/11/2024 at 3:00 PM, Staff A, Administrator, stated they had seen how dirty the filter on Resident 8's oxygen concentrator was and had cleaned it themself. They were surprised to learn the MAR showed the filter had been cleaned weekly. Staff A expected staff to clean the filters as ordered. <Resident 18> According to the 09/21/2024 admission assessment, Resident 18 had diagnoses including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), was cognitively intact and wore oxygen. The 09/16/2024 comprehensive care plan documented Resident 18 had chronic respiratory failure related to COPD and received oxygen as ordered by the physician. A review of Resident 18's record revealed there were no orders to clean the oxygen filter. The October 2024 MAR documented the oxygen filter was to be changed every six months. During an observation on 10/07/2024 at 3:43 PM, Resident 18 was observed sitting in their wheelchair. The back of the oxygen concentrator had an air filter that was covered in a thick layer of dust and debris. In an interview on 10/11/2024 at 9:01 AM, Staff D, Licensed Practical Nurse, stated the oxygen filters were checked weekly and changed if they needed to be. In an interview on 10/11/2024 at 9:22 AM, Staff B, Director of Nursing, stated the oxygen filters were to be cleaned weekly and as needed. Staff B added this was important because unclean filters could cause respiratory issues. Reference: WAC 388-97-1060(3)(j)(vi) 46115

Based on observation, interview and record review, the facility failed to develop treatment goals and care-planned interventions after a resident developed a pressure ulcer for 1 of 3 sampled residents (Resident 1) reviewed for pressure ulcers. This failure placed the resident at risk for further deterioration of their skin, unintended health consequences and decreased quality of life. Findings included . Edsberg, L. E., Black, J. M., [NAME], M., [NAME], L., [NAME], L., & Sieggreen, M. (2016). Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System; Journal of Wound Ostomy Continence Nurs, 43(6), 585-597 retrieved 10/21/2024 from https://npiap.com/page/PressureInjuryStages defined a stage 2 pressure injury as a partial-thickness skin loss, the wound bed is pink or red, moist and may also present as an intact or ruptured serum-filled blister. A review of the quarterly assessment dated [DATE] documented Resident 1 had diagnoses including complete quadriplegia-paralysis of the body from the neck down. Resident 1 was cognitively intact, was dependent on staff for all their activities of daily living (ADLs) and was at risk for pressure ulcers. The care plan revised 05/21/2024 documented Resident 1 had potential for alteration in their skin integrity related to quadriplegia; interventions included to perform weekly skin checks, identify/document potential causative factors and eliminate/resolve where possible, and to notify the charge nurse immediately if any skin breakdown was noted during care. A weekly skin evaluation dated 09/26/2024 showed no skin concerns were identified for Resident 1. A Physician Assistant (PA) progress note dated 10/02/2024 documented Resident 1 complained of a blister to the outer aspect of their right fifth finger (the pinky finger), had never had this before and was unsure how it happened. The note further documented nursing had provided wound care with padding and tape to keep the area safe and appeared to be related to pressure from their hand resting on the wheelchair. The PA determined the pressure injury was unavoidable due to Resident 1's quadriplegia that resulted in decreased movement and sensation. Further record review showed there were no orders or interventions added to Resident 1's treatment plan regarding the pressure ulcer that had developed on their pinky finger. Weekly skin checks completed on 10/03/2024 and 10/10/2024 showed no skin concerns were identified for Resident 1. On 10/07/2024 at 2:37 PM, Resident 1 was observed in their room seated in their electric wheelchair. A blister similar in size to a fingerprint was observed on the outer upper portion of the resident's right pinky finger. The top part of the blister near the fingertip contained fluid, and the lower portion was collapsed but intact. When the resident's hand was in a resting position on the arm support, the same area of their finger rested against the side of the armrest. The armrest was constructed of a firm black material and had no additional padding on it. Resident 1 stated they had no sensation in their fingers and they had not had any bandages or treatments regarding their finger. On 10/09/2024 at 11:49 AM and 10/10/2024 at 10:09 AM, the resident's pressure sore was observed. The fluid in the upper portion had decreased in size, and the skin remained intact, but appeared dried without elasticity. During an interview on 10/11/2024 at 12:09 PM, Staff B, Director of Nursing, stated Resident 1 was high risk for skin breakdown. Staff B stated skin checks were completed weekly at night so the resident's hands may not have been looked at closely. Staff B stated that when providers visited the residents, they did not always know who was seen or if there were any new findings that needed to be followed up on. Staff B stated interventions needed to be put in place so that Resident 1's pressure sore did not get worse. Reference: WAC 388-97-1060(3)(b)

Based on observation, interview, and record review the facility failed to implement interventions to prevent reduced range of motion (ROM) and/or prevent further decrease in ROM for 1 of 3 sampled residents (Resident 12), reviewed for limited ROM. This failure placed residents at risk of contracture (permanent tightening of muscles, tendons, ligaments, or skin that limits movement in a joint or body part) development, unmet care needs, and diminished quality of life. Findings included . Review of the facility undated procedure titled, Contracture Program showed it was used to determine if a resident would benefit from, or required contracture prevention or management which may include passive range of motion (PROM), active range of motion (AROM), positioning, splint and/or brace assistance through the restorative nursing program. The procedure referred staff to a nursing assistant textbook for AROM and/or PROM procedure guidance. Review of the facility policy titled, Restorative Nursing dated December 2022, showed the facility's restorative nursing program enabled residents to attain or maintain their highest practicable level of physical, mental, and psychosocial functioning. The restorative nursing program consisted of two options, restorative improvement and restorative maintenance. Restorative improvement was based on a reasonable expectation of improvement in function, restorative maintenance was based on the achievement of highest functional level and prevention of functional decline. Resident would be assessed for restorative services upon discontinuation of therapy services, quarterly, with significant changes and/or as needed. The policy instructed staff to determine a resident's willingness and ability to participate in a restorative nursing program, document refusals in the resident medical record, and re-evaluate at least quarterly. If a restorative program was initiated, it was to be documented in the electronic medical record, daily participation documented, progress reviewed with the interdisciplinary team and during care conferences, program and/interventions revised as needed based on individual resident needs. Review of the quarterly assessment, dated 09/16/2024, showed Resident 12 had diagnoses including dementia. Resident 12 was dependent on staff to complete all of their activities of daily living (ADL's). The assessment further showed Resident 12 had range of motion impairment to both upper extremities and did not receive AROM, PROM or require splint or brace assistance. Resident 12 had severe cognitive impairment. Review of the care plan initiated 06/14/2022 showed Resident 12 had limited physical mobility related to dementia and instructed staff to monitor, document, and report signs and/or symptoms of contracture development or worsening and refer to therapy as needed. Review of the quarterly assessment, dated 03/16/2024, showed Resident 12 had no range of motion impairment to either upper extremity and did not receive AROM, PROM or require splint or brace assistance. Review of the 03/26/2024 quarterly nursing evaluation showed Resident 12 had no impairment to either upper extremity but was dependent on staff assistance to complete their ADLs. Review of the 06/13/2024 quarterly nursing evaluation showed Resident 12 had impairment to both upper extremities and had begun to curl into themselves at wrists and hands. Review of the annual assessment, dated 06/16/2024, showed Resident 12 had range of motion impairment to both upper extremities and did not receive AROM, PROM or require splint or brace assistance. Review of the 06/25/2024 provider progress note showed Resident 12 had a contracture to their left upper extremity and was only able to move their hand slightly. During an observation on 10/07/2024 at 2:38 PM, Resident 12 had their right hand clamped shut in a fist with no rolled up washcloth, palm protector, splint or brace in place. Similar observations were made on 10/08/2024 at 8:46 AM, 2:23 PM, and 3:46 PM. In an interview on 10/07/2024 at 3:34 PM, Resident 12's family member stated Resident 12 typically did not have a rolled-up washcloth, palm protector, splint or brace in place and was unsure if staff assisted Resident 12 with hand stretching exercises. In an interview on 10/11/2024 at 8:03 AM, Staff F, Nursing Assistant, stated Resident 12 had not been able to open their hands for a while and did not have or use any type of palm protector or hand splints. In an interview on 10/11/2024 at 8:14 AM, Staff D, Licensed Practical Nurse, acknowledged Resident 12 had hand contractures that had progressed over time and was dependent on staff assist to perform their ADLs. Staff D further stated Resident 12 did not have or use any hand splints or braces. In an interview on 10/11/2024 at 10:05 AM, Staff G, Director of Therapy, reviewed Resident 12's therapy records. Staff G stated Resident 12 was last seen by therapy in April 2024 for wheelchair positioning. Staff G was unsure if Resident 12 had hand contractures and acknowledged therapy had not worked with Resident 12 on contracture prevention or management. Staff G further stated a ROM restorative nursing program could have prevented contractures. In an interview on 10/11/2024 at 11:07 AM, Staff B, Director of Nursing, stated if a resident had contractures, they would involve therapy so a plan of care could be developed to prevent further contracture development or worsening. Staff B acknowledged Resident 12's hands have been clamped shut for at least six months. In an interview on 10/11/2024 at 1:53 PM, Staff A, Administrator, stated they would submit a therapy referral if a ROM issue was observed. Reference WAC 388-97- 1060 (3)(d), (j)(ix) See F676 for additional information.

Based on observation, interview and record review, the facility failed to ensure a resident received consistent showers for 1 of 3 dependent sampled residents (Resident 2), reviewed for activities of daily living (ADL's). This failure placed the resident at risk for not being bathed per their preferences and poor hygiene. Findings included According to the 08/07/2024 quarterly assessment, Resident 2 had severe cognitive impairments, needed total assistance from staff for ADL's, such as bathing, and it was somewhat important to them to choose between a bed bath and a shower. In an interview on 10/07/2024 at 12:12 PM, Resident 2's guardian stated the resident had been bathed twice in the shower room and that was by them. The guardian added they would like the resident to be bathed in the shower room and staff had never attempted to do so to their knowledge. Per the 02/20/2024 care plan, Resident 2 was to be kept neat, clean, and well-groomed daily and required total dependence for bathing. Review of the bathing documentation from 09/09/2024 to 10/05/2024 documented Resident 2 had been given a bed bath on 09/09/2024, 09/13/2024, 09/21/2024, 10/04/2024 and 10/05/2024. In addition, the documentation showed the resident had not refused to be bathed. During an observation on 10/07/2024 at 12:12 PM, Resident 2's hair was greasy. Subsequent observations of Resident 2 with greasy hair were made on 10/08/2024 at 9:38 AM and 12:01, 10/09/2024 at 9:35 AM and 11:43 AM, 10/10/2024 at 7:44 AM and 1:29 PM, and 10/11/2024 at 7:12 AM. In an interview on 10/11/2024 at 9:16 AM, Staff B, Director of Nursing, stated showers were to be given twice weekly and this was important for hygiene and to promote health. Staff B added the staff were hesitant to give Resident 2 a shower because they had involuntary spastic movements of their limbs and should have assessed Resident 2 for a different type of bath chair so they could have showers. Reference: WAC 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to have the practitioner reevaluate the continued use of antipsychotic medication (a type of medication used to treat symptoms of psychosis) as required after 14 days of use for 1 of 5 sampled residents (Resident 18) reviewed for unnecessary medications. These failures placed the residents at risk for unintended medication side effects and a decreased quality of life. Findings included . According to the 09/21/2024 admission assessment, Resident 18 had diagnoses which included chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), respiratory failure and diabetes, was cognitively intact, able to make their needs known and received Hospice services. A review of the 09/2024 physician's orders documented Resident 18 was prescribed haloperidol lactate (an antipsychotic medication) as needed (PRN) for agitation. The 09/27/2024 comprehensive care plan had the following care areas: -Hospice Care/End of life needs; interventions were to provide end of life care as needed to meet the needs of the resident and alert the provider with changes in resident's status. -the resident had a psychosocial well-being problem related to anxiety; interventions were to provide the resident assistance/supervision/support to identify precipitating factors/stressors, provide opportunities for resident and family to participate in care, and when conflict arose, remove resident to a calm safe environment that allowed them to vent/share feelings. A review of the resident's medication administration records (MAR) for 09/2024 and 10/2024 documented the resident received haloperidol lactate on 09/22/2024, 10/02/2024, 10/04/2024, 10/05/2024, 10/06/2024, 10/07/2024, 10/08/2024 and 10/09/2024. Resident 18's records did not include progress notes or assessments from the resident's providers for 09/2024 or 10/2024 for the continued use of the haloperidol lactate for more than 14 days. In an interview on 10/11/2024 at 9:01 AM, Staff D, Licensed Practical Nurse, stated PRN psychotropic medications needed to be reassessed by the providers after 14 days. During an interview on 10/11/2024 at 9:22 AM, Staff B, Director of Nursing, was not able to provide documentation that Resident 18 had been reassessed for the continued use of the PRN haloperidol lactate after 14 days. Staff B added it was important that the resident be reassessed to know if the resident still needed it and whether is was beneficial to them. Reference: WAC 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Three medication errors were identified for 2 of 10 sampled residents (Residents 23 and 176), observed during 30 medication administration opportunities that resulted in an error rate of 10%. This failure placed residents at risk of receiving subtherapeutic effects of their medications, possible adverse side effects, and diminished quality of life. Findings included . Review of the undated facility policy titled, Medication Administration showed staff would check for the right medication, right dose, right dosage form, right route, right resident, and right time prior to administering medication. Staff were to perform hand hygiene, gather appropriate equipment for medication administration, perform necessary assessments as needed prior to medication administration, and read the medication administration record (MAR) for the ordered medication, dose, dosage form, route, and time. If there was a discrepancy between the medication label and the MAR, staff were not to administer medications and check with the provider for clarification. The policy further instructed staff to follow the MAR and document medications administered into the MAR as soon as medications were given. Review of the facility policy titled, Physician's Orders revised February 2023, showed clinicians could take verbal, telephone, and electronic orders from a provider. The policy explained the required components of an order and instructed staff to transcribe verified ordered into the electronic health record, leaving them in a queue for a second licensed nurse to review for accuracy. <Resident 176> During a medication administration observation on 10/10/2024 at 7:18 AM, Staff C, Registered Nurse (RN), prepared, dispensed, and administered numerous oral medications to Resident 176 including Aspirin (over the counter medication that reduces pain, fever, inflammation, and blood clotting) safety coated (prevents stomach upset) and Geri-Mox regular strength liquid antacid. Review of the 10/01/2024 provider orders documented Resident 176 was to be given chewable, not safety coated aspirin daily for heart health. There was no provider order for the resident to receive Geri-Mox liquid antacid. In an interview on 10/10/2024 at 10:29 AM, Staff C stated they administered Geri-Mox to Resident 176 because the resident had reported stomach pain earlier. Staff C was informed an order for Geri-Mox or liquid antacid was not seen in Resident 176's medical record. Staff C stated Geri-Mox was part of the provider standing orders but should be entered into the resident's record so staff could follow up on the medication effectiveness and prevent potential double dosing the medication. Review of the facility undated standing order protocol showed standing orders were a guide for nurses and providers. The standing orders could be implemented following an appropriate nursing assessment of the resident and transcription into the electronic health record. For heartburn/bloating/stomachache staff could initiate orders to administer one over the counter chewable antacid tablet every eight hours as needed, if no relief after one day staff could give liquid antacid four times daily as needed. Further review of Resident 176's provider orders showed no order for over the counter chewable antacid tablets, as per the standing order protocol guidance. <Resident 23> During a medication administration observation on 10/10/2024 at 7:27 AM, Staff C prepared, dispensed, and administered numerous oral medications and gave an insulin injection to Resident 23. No topical patches for pain relief were dispensed, applied or offered to Resident 23. Review of the 09/17/2024 provider orders documented Resident 23 was to have a Lidocaine patch applied daily for pain. In an interview on 10/10/2024 at 10:27 AM, Staff C, when asked, stated they had not applied a lidocaine patch to Resident 23. Staff C stated Resident 23 frequently refused the Lidocaine patch but was unsure if the provider was notified so the order could be discontinued. In an interview on 10/10/2024 at 10:56 AM, Staff B, Director of Nursing, stated the facility standing order protocol was a guide and orders needed to be transcribed into the resident's electronic health record. Staff B stated they expected staff to document medications as administered in the MAR. In a follow-up interview on 10/10/2024 at 11:43 AM, Staff B stated they expected staff to administer medications as ordered by the providers. Reference WAC 388-97-1060 (3)(k)(ii)

Based on interview and record review, the facility failed to ensure a physician ordered foot care referral for a podiatrist was followed up on, and a change in foot wound condition was reported to the medical provider for 1 of 3 sampled residents (Resident 1), reviewed for wound care. Resident 1 experienced harm when they required additional surgery and amputations to their foot. These failures constituted Past Non-Compliance (the facility was not in compliance at the time the situations occurred; however, there was sufficient evidence that the facility corrected the non-compliance after they were identified) at harm level. The facility immediately implemented and completed a plan of correction which was verified by surveyors. The plan of correction included a review of the previous 72 hours of progress notes to identify any residents with a change of condition and reporting any identified changes to the medical provider, a skin sweep of the entire facility resident population to ensure wounds were accurately documented and appropriate referrals and/or wound care orders were implemented, education to licensed nurses on completion of skin and wound assessments and reporting changes of condition to the appropriate medical provider, and audits to ensure solutions were sustained. Findings included . Review of the facility policy titled, Documentation-Skin Conditions, dated 02/24/2024 showed licensed nurses would perform weekly skin and wound assessments, identified skin conditions would be referred to the wound consultant if available, staff would document the wound assessments including measurements and recommendations for treatment, and assessments would be communicated to the medical provider. Review of the admission assessment dated [DATE] showed Resident 1 admitted with diabetic foot ulcers (one to the left heel and one to the left 5th toe) which required dressing changes from staff, was mildly cognitively impaired, and rejected care one to three days of the assessment period. Review of the 03/11/2024 Skilled Nursing Facility Transfer Orders showed Resident 1 was to have follow-up appointments with wound care, vascular surgery, and podiatry. The facility was to follow the recommendations of the wound team for treatment of their diabetic foot wounds. Review of a wound care provider note dated 03/18/2024 showed Resident 1's foot wounds were measured, biofilm (a slimy layer of microorganisms) over the wound was removed, and a wound culture (laboratory test to diagnose and treat bacterial infections) was performed. Per the note, the resident had last been seen by a podiatrist prior to their admission to the facility and a follow-up with podiatry was recommended. No additional wound care provider notes were found in the resident's record after 03/18/2024. Review of the March 2024 Medication Administration Record showed the resident received an antibiotic from 03/21/2024 to 03/31/2024 due to a positive wound culture. Review of a facility Weekly Skin Evaluation form dated 04/01/2024 showed the resident's foot wounds were measured again and the left toe wound had increased in size and had black/dead tissue covering the wound. Per the form, the physician was not notified of the change. No additional evaluations of the resident's wounds were found in the resident's record after 04/01/2024. Review of the March and April 2024 progress notes showed Resident 1's follow-up appointment with their vascular surgeon was rescheduled from 03/25/2024 to 05/06/2024. No documentation related to a podiatry follow-up was found in the progress notes. Additionally, the notes showed no notification to the wound care team, the vascular surgeon, and/or a podiatrist about the decline in the resident's wound on or after 04/01/2024. Per the progress notes the resident was hospitalized on [DATE] related to significant changes to the resident's left toe wound and a decrease in blood flow to the foot. Review of the hospital records dated 04/11/2024 showed the resident admitted to the hospital with sepsis (a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs) and gangrene to the left foot. Per the hospital record, the resident required intensive monitoring, intravenous antibiotics, and additional surgeries to treat their condition. In an interview on 04/25/2024 at 12:57 PM, Staff B, Podiatrist, stated Resident 1 was not referred to their services while the resident was in the facility. Staff B stated their last scheduled visit in the facility was prior to the resident's admission, and they did not do emergency appointments, so the facility would have needed to schedule the resident with a local podiatrist, per their admission orders. In an interview at 1:31 PM the same day, Staff C, Registered Nurse (RN), confirmed Resident 1 was not seen by the wound care provider one to two weeks after their appointment on 03/18/2024, as recommended. Staff C stated they were not aware if a provider was notified of the decline to the resident's wound identified on 04/01/2024. In an interview at 2:08 PM, Staff D, RN, stated Resident 1 was cooperative with wound care and was anxious about the healing of their wounds. Staff D stated they assessed the resident's wound on 04/01/2024 and noted the wound was larger and had darker tissue in the wound bed after they were no longer receiving antibiotics, which should have been reported. Staff D stated they did not know if the resident had any follow-up appointments with wound care, vascular surgery, and/or a podiatrist. In an interview at 2:25 PM, a representative for Resident 1 stated after the resident was transferred to the hospital on 04/10/2024, they required two surgeries and amputation of a portion of the left foot due to the infection (gangrene). Per the representative, the resident had just transferred out of the hospital and was still suffering from post-operative delirium (a state of serious confusion, disorientation and inattention that may result in hallucinations, delusions, difficulty communicating and/or understanding of what is occurring). In an interview on 04/25/2024 at 4:08 PM, Staff A, Director of Nursing, stated when a resident completed an antibiotic, they should be evaluated to determine if it was effective. Staff A stated they reviewed Resident 1's medical record on 04/01/2024 and did not see any notes that would indicate the antibiotic was not effective as Staff D's assessment of the wound was completed later in the day. Staff A stated they were unaware of the order to refer the resident to podiatry upon admission and did not have additional information regarding notification of a medical provider of the decline to the resident's wound. At 5:04 PM the same day, Staff A stated the facility had completed an investigation after Resident 1's hospital admission on 04/10/2024 and identified failures related to documentation of wound care, completion and documentation of routine wound assessments, notification of changes in resident conditions to the medical provider, and follow-up with ordered referrals. Staff A stated the facility had implemented a plan of correction that included a review of the previous 72 hours of progress notes to identify any residents with a change of condition and reporting any identified changes to the medical provider, a skin sweep of the entire facility resident population to ensure wounds were accurately documented and appropriate referrals and/or wound care orders were implemented, education to licensed nurses on completion of skin and wound assessments and reporting changes of condition to the appropriate medical provider, and audits to ensure solutions were sustained. This was Past Non-Compliance at harm level and is no longer outstanding. The deficiency was corrected on 04/22/2024. Reference WAC 388-97 -1060 (3)(j)(viii)

Based on observation, interview, and record review, the facility failed to thoroughly investigate the cause(s) of falls and assess the need for additional effective interventions for 2 of 3 sampled residents (Resident 1 and 3), reviewed for accident hazards. This failed practice resulted in actual harm to Resident 3 who was not provided supervision following a decline in health status and experienced a hip/pelvic and coccyx (tailbone) fracture that required hospitalization and surgery, and placed Resident 1 at risk for additional falls, injury secondary to falls, and diminished quality of life. Findings included . <Resident 3> Review of the 09/27/2023 quarterly assessment showed Resident 3 had a diagnosis of Parkinson's disease (a chronic degenerative disease of the nervous system that affects both the motor system and non-motor systems) and was moderately cognitively impaired. Additionally, the resident required substantial staff assistance for transfers and toileting, partial assistance for bed mobility, and supervision in their wheelchair. Review of Resident 3's care plan for falls, revised 08/07/2023, showed staff were to ensure the resident's call light was in reach, encourage the resident to use their call light and respond promptly, ensure commonly used items were in reach, ensure appropriate foot wear was used while ambulating or in the wheelchair, remind the resident to lean back if they were leaning forward, and place fall mat when the resident was in bed. Review of an 11/09/2023 facility fall investigation showed Resident 3 rolled out of bed onto their fall mat at 10:15 AM that day and reported no injury. The investigation did not include the resident's statement regarding what led to the fall, nor did it include statements from staff who had last seen the resident and/or provided care. The investigation did not include potential environmental factors that may have contributed to the fall (such as lighting, noise, resident footwear, placement/nearness of the resident's wheelchair, position and/or use of the call light, staffing levels, etc.) and did not show an assessment to detemine the need for new interventions to prevent further falls. Review of an 11/15/2023 facility fall investigation showed Resident 3 was found on the floor face down next to their bed, on the side further away from the in-room bathroom, at 7:13 PM that day. The resident statement showed they reported they needed to go to the bathroom. There was no documentation of when staff last saw and/or assisted the resident with care including toileting, nor did it include potential contributing environmental factors. Per the investigation the resident had recently recovered from COVID-19 (a viral illness) which caused an increase in confusion for the resident and had bloodwork and urine cultures pending. The listed interventions were to use a manual wheelchair and education to use the call light for assistance. Review of an 11/22/2023 facility fall investigation showed Resident was found on their knees next to the bed in their room at 7:54 PM that day. The resident reported they got up from their bed to use the bathroom. There was no documentation showing when staff last saw and/or assisted the resident with toileting or environmental factors. The investigation documented the resident had recently recovered from COVID-19 and had increased confusion, and staff were waiting on results of a urine culture. The report also showed education and redirection were not effective. No interventions to prevent further falls due to the resident's increased confusion were listed. Review of an 11/24/2023 facility fall investigation showed Resident 3 was found on the floor mid-way between their bed and the bathroom at 8:17 PM that day. There was no documentation showing when staff last provided assistance with care including toileting, and/or information whether the resident was last in their wheelchair or bed, or any other potential contributing environmental factors. The investigation showed the resident had a new onset of right hip pain following the fall. Review of hospital records dated 12/07/2023 showed Resident 3 was hospitalized for a hip fracture and required a full exam under anesthesia in the operating room by orthopedic surgeon to evaluate the extent of their injury. The hospital records also showed the resident had a tailbone fracture and blood clot in the veins of the fractured leg. Observation on 12/19/2023 at 2:39 PM showed Resident 3 lying in bed in their room, which was at the end of the hallway furthest away from the nurse's station. The resident's bed was close to the window/wall and their roommate was in the bed closer to the doorway and bathroom. A fall mat was next to the bed and the wheelchair was several feet away from the bed and turned away from the resident. A call light was clipped onto the resident's gown. In an interview on 12/19/2023 at 3:28 PM, Staff C, Registered Nurse, stated Resident 3 had increased confusion at nighttime which led to increased falls. Staff C stated they had requested to move the resident closer to the nurse's station but there was not a closer bed available. Staff C stated Resident 3 utilized a urinary catheter and staff suspected a urinary tract infection but were having trouble with receiving results during the time of the resident's falls. When asked what new interventions were attempted to address the resident's fall risk related to their increased confusion Staff C stated the previous interventions (fall mat and education/redirection) were ineffective and was unable to provide information of new fall prevention measures attempted. Staff C confirmed the resident had a fracture related to their falls in November and stated the resident had just returned to the facility that day. In an interview at 4:26 PM the same day, Staff A, Director of Nursing, stated if facility staff did not include enough information in a fall report they would follow up with questions to the staff. When asked about the missing details of Resident 3's fall investigations Staff A acknowledged the investigations were not thorough and stated they were new to the position and still learning about investigations and documentation. Staff A stated Resident 3's falls were attributed to a decline in their Parkinson's, their recent COVID-19 diagnosis, and a urinary tract infection. Staff A confirmed call light education was not an effective intervention for a confused resident. Staff A stated they also educated staff about doing more frequent checks on the resident but did not document the education to direct care staff (including date of the education and specific timeframes on what frequent checks entailed). Staff A was also asked about the trend in falls at night (three of the resident's falls occurred between 7:13PM and 8:17 PM) and interventions attempted. Staff A stated they were attempting to set up a neurology appointment to address the resident's condition but did not list any direct intervention (such as increased supervision, a toileting program, etc.). See F-880 and F-776 for additional information. <Resident 1> Review of the 09/14/2023 quarterly assessment showed Resident 1 was dependent on staff for toileting, required substantial assistance for transfers and mobility, and partial assistance for locomotion in their manual wheelchair. Review of the care plan for falls revised on 09/18/2023, showed staff were to encourage Resident 1 to remain in areas of high visibility when in their wheelchair and to not leave the resident in their wheelchair in their room unattended. Review of a 10/20/2023 facility fall investigation showed the resident was found on the floor in front of the bathroom in their room at 3:07 PM that day and was incontinent of bowel. The resident reported they were attempting to stand up from their wheelchair when they lost strength and fell to the floor. The investigation did not include staff statements documenting when and where the resident was last seen, when toileting assistance was provided, and/or any possible contributing environmental factors. No interventions to prevent further falls were listed. Review of a 12/12/2023 facility fall investigation showed Resident 1 was found on the floor near their bed at 1:20 PM by their roommate, who used their call light to alert staff. The wheelchair was noted to be behind the resident with the brakes unlocked. The resident was provided education of the need to request assistance with transfers and responded, I know. Per the investigation, the resident showed potential to attempt to self-transfer again. In an interview on 12/19/2023 at 12:32 PM Staff D, Nursing Assistant, stated Resident 1 required staff assistance for transfers to the bed and bathroom and liked to do as much as possible for themself. Staff D stated Resident 1 sometimes stayed up in their wheelchair in their room to look at items on their dresser, and the most recent fall occurred when the resident was alone in their room. When asked about fall precautions for Resident 1, Staff D stated to keep the bed low and call light in reach. Staff D did not include the care plan interventions to not leave the resident unattended in their wheelchair while in their room or to encourage the resident to stay in areas of high visibility. In an interview at 12:44 PM the same day Staff B, Registered Nurse, stated Resident 1 would attempt to stand and transfer to the bed in their room if they were left alone and if they were awake staff needed to frequently check on them and redirect them away from their room. Per Staff B, the resident liked to be in the puzzle room chair and would not self-transfer when distracted with an activity they liked. In an interview at 1:39 PM the same day Staff A, Director of Nursing, stated there was a lack of thoroughness for Resident 1's October 2023 fall investigation and stated residents always wore socks so Resident 1 probably had appropriate footwear at the time of the incident. Staff A stated the resident was not being specifically monitored for any conditions at the time of the fall so there was no available documentation showing when staff last checked on the resident prior. When asked about interventions to prevent further falls, Staff A stated staff were educated to provide frequent checks, but the education was not documented (details regarding the date of the education provided, the expected frequency of checks, and whether that education included reminders of care plan interventions were not provided). Staff A also stated a referral to physical therapy was requested after the resident's most recent fall. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review the facility failed to timely obtain and implement a physician order for X-ray services for 1 of 3 sampled residents (Resident 3), reviewed for diagnostic testing. This failure resulted in actual harm for Resident 3, who sustained a blood clot secondary to a fracture, which required medical intervention. Findings included . Review of the facility's Mandated Reporting Log from 10/19/2023 to 12/19/2023 showed Resident 3 experienced five falls during the month of November. Review of the November 2023 progress notes showed the following: - On 11/24/2023 Resident 3 had an unwitnessed fall in their room. The resident complained of pain to their right hip following the fall but had no other signs of injury. The medical provider was notified and advised staff to monitor for hip injury. - On 11/25/2023 Resident 3 had another unwitnessed fall. - Resident 3 complained of tenderness and/or pain to the right hip and leg daily from 11/27/2023 through 11/30/2023. - On 11/29/2023 a provider ordered an X-ray for Resident 3. - On 11/30/2023 a mobile diagnostic imaging company was in the facility to obtain an X-ray of Resident 3's hip. No results were included in the note. Review of the December 2023 progress notes showed Resident 3 continued to complain of right hip pain until the resident was sent to the hospital following receipt of X-ray results showing a pelvic fracture on 12/05/2023 (11 days after the resident started complaining of pain and six days after the X-ray was ordered). Review of the hospital notes dated 12/07/2023 showed multiple acute (sudden or new) deep vein thromboses (DVT; blood clot) were identified on ultrasound of the right leg upon admission to the hospital. The DVTs were attributed to the amount of time that elapsed since the initial injury and would require a blood thinner for no less than three months. In an interview on 12/19/2023 at 3:28 PM Staff C, Registered Nurse (RN), stated Resident 3 continued to complain of new onset right hip pain for several days after their fall so the provider ordered an X-ray. Staff C confirmed an X-ray was obtained on 11/30/2023 but it took time to receive the results. Per Staff C, facility nurses were responsible for following up on results, and they had asked both Staff B, RN, and Staff A, Director of Nursing, for results, but the facility did not hear back prior to 12/05/2023. On 12/19/2023 at 4:15 PM Resident 3 was observed lying in bed in their room. The resident stated they did not remember the falls that led to their injury but remembered pain to their hip and tailbone that felt like a nail file. The resident stated it felt like it took a month to get an X-ray and they did not know why one was not obtained earlier. In an interview at 4:26 PM the same day Staff A stated the facility had identified issues with the system for receiving results from diagnostic testing (such as X-rays), and stated facility nurses were to follow up on missing results. When asked what follow up was done related to Resident 3's X-ray results, Staff A stated there was a weekend between the date the X-ray was done and the date the facility received the results, and that the facility sent the resident to the hospital immediately upon receiving results on 12/05/2023. Reference: (WAC) 388-97-1620 (6)(a)(b)(i)

Based on interview and record review, the facility failed to ensure one of three sample residents reviewed for falls (#19), was provided adequate supervision, and that care planned interventions were followed to prevent falls. This failed practice resulted in actual harm to Resident #19, who fell while unattended, and sustained a serious head injury. Findings included . Review of the resident's [DATE] admission assessment showed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The assessment also showed the resident had wandering behaviors daily, that the resident was not steady moving from a seated position to a standing position, and was only able to stabilize with staff assistance. There was no documentation in the admission assessment showing the resident had sustained falls, prior to admission to the facility. Per review of the resident's care plan dated [DATE], and last revised on [DATE], the following interventions were in place related to fall prevention: -bed in low position. -fall mats next to bed on floor. -keep wheelchair locked at bedside when in bed. -tab alarm on at all times (a personal alarm that clips onto clothing, to alert staff if a resident attempted to stand without assistance). -winged mattress on bed (a mattress with raised edges, to prevent falls out of bed). -the resident's location was to be monitored by an employee during waking hours, with a 1:1 staff attendance (a revision made on [DATE]). A review of the facility's investigation reports for the resident showed the following: -[DATE] at 6:42 PM. The resident was found sitting on the floor in front of her bed. The resident stated she had gotten up to ambulate, became unsteady, and slid to the floor. The resident stated that she hit the back of her head during the fall. Neurological checks were completed, and the resident's care plan was modified to include: staff to offer and provide assistance with toileting before/after meals and prior to laying down, encourage her to be up in the dining room for meals for increased supervision and socialization, and continue to use the tab alarm. -[DATE] at 3:06 AM. During a skin assessment a purple faded bruise was found to the right side of the resident's forehead. It was discovered the resident was found sitting on the floor next to her bed on [DATE] between 7:30 and 8:00 PM. The bruise to the resident's forehead was noted at that time. The resident told staff she had fallen out of her bed. Neurological checks were completed, and the resident's care plan was modified to include: placing the bed in a low position, placing fall mats next to the bed, and keeping the wheelchair locked at the bedside. -[DATE] at 2:38 PM. The resident's wandering and behaviors escalated after an altercation with another resident in the facility. She was placed with a 1:1 sitter during day and evening shift (i.e. during waking hours). -[DATE] at 2:45 PM. The resident was found on the floor in the TV room. The resident was lying on her left side in front of an armchair. Her wheelchair was locked next to the chair. She was non-responsive to both verbal and tactile stimulation. She was transported by ambulance to the emergency room . The hospital's emergency department note dated [DATE] showed a CT scan (a CT scan takes images of an area of the body at different cross-sections - also known as a CAT scan) was completed, and the resident was diagnosed with [REDACTED]. The note showed a telephone consultation was done with a neurosurgeon at another hospital. Per the note, the surgeon recommended no surgical intervention, due to the resident's advanced disease process, and the massive size of the bleed in the resident's brain. Review of a progress note dated [DATE] at 8:23 PM, showed the resident returned to the facility around 3:00 PM by ambulance on a stretcher. The note documented .brain bleed is ongoing, res(ident) may not make it long. The progress note showed the resident was changed from a full code to Do Not Resucitate (DNR), and was placed on comfort care. The resident remained on comfort care measures, exhibited an overall decline in condition, and died on [DATE]. The facility's incident investigation related to the fall on [DATE] showed the resident had been placed on increased supervision on [DATE], related to her wandering behaviors. The supervision included having a staff member sitting with the resident at all times, during the day and evening shifts (waking hours). According to the investigation Staff N, Nursing Assistant (NA), stated she had been .helping out with (the resident) for the last couple of days. Staff N stated that she left the resident unattended, and asleep in an armchair on [DATE] at 2:00 PM. She then left the resident, and went to tell Staff L and Staff M, NA's, she was leaving for an appointment. Staff N stated that she asked them to keep an eye on the resident, until someone came to watch her on the evening shift. Per the investigation, Staff L confirmed she had been made aware the resident was sleeping in a chair in the TV room. She stated that she found the resident laying on the ground in front of the armchair at around 2:30 PM, or 30 minutes after she was informed the resident was alone in the TV room. Staff M also confirmed she had been made aware that Staff N was going to leave, but said she was told someone else was going to come in and watch the resident that evening. The facility investigation also showed Staff K, Activities Director, was interviewed and stated that she was scheduled to watch the resident the evening of [DATE]. She stated that she was outside for an activity with other residents at around 2:00 PM the day of the fall, and had been told by Staff H, NA, that Staff M was with the resident, .or I would have gone in. In follow-up interviews with Staff H, K, L, M, and N, they all agreed that the resident was supposed to have 1:1 staff sitting with her during day and evening shifts, and verified no one was sitting with the resident at the time she fell on [DATE]. In addition, Staff L confirmed the resident was supposed to have a tab alarm on her at all times, and the tab alarm was not on the resident when she found her on the floor. Staff L stated there was no way to hook the tab alarm onto the armchair she was in. On [DATE] at 1:50 PM, Staff H stated that it was her understanding that Staff K was supposed to be sitting with the resident on the evening of [DATE]. She further stated that initially she was going to watch the resident for the evening shift, but she had to leave for an appointment, so Staff K was going to sit with the resident. On [DATE] at 12:56 PM, Staff K acknowledged she had initially agreed to sit with the resident at the end of her shift, but Staff H had agreed to take over for her. She stated Staff H told her she had to leave and wouldn't be able to sit with the resident, but that Staff L and M were with the resident. On [DATE] at 2:05 PM, Staff L stated that Staff K was supposed to be sitting with the resident at the time of the resident's fall. On [DATE] at 2:13 PM, Staff M stated that it was her understanding that Staff K was .taking care of her (the resident) for the evening shift. Per the interviews, there was no clear communication between the staff, to ensure the resident was not left alone. In a follow-up interview on [DATE] at 3:04 PM, Staff B, Director of Nursing, confirmed the resident had been placed with a 1:1 sitter during the day and evening shift, related to her behaviors. She stated that the sitters were supposed to sign off with each other at the end of their shift, to ensure the resident was not left alone. She acknowledged the resident had been left alone sleeping in an armchair in the TV room when she fell on [DATE]. In addition, she stated that she had not observed a tab alarm on the resident when she examined her after the fall. On [DATE] at 4:21 PM, Staff A, Administrator, confirmed the resident was supposed to have a 1:1 sitter with her during waking hours due to her wandering behaviors, and acknowledged a sitter was not present with the resident when she fell on [DATE]. Reference (WAC) [DATE](3)(g)