Every finding on record at Pacific Care and Rehabilitation

Based on interview and record review, the facility failed to ensure physician and/or treatment orders were updated and/or complete for 1 of 1 sampled resident (Resident 6) reviewed for pressure ulcer/injury (an area of damaged skin and soft tissue due to prolonged pressure, usually over a bony prominence). This failure placed residents at risk of unmet care needs, an inaccurate physician treatment plan, and a diminished quality of life.Findings included.Resident 6 was admitted to the facility on [DATE]. The Admission/Medicare - 5 day Minimum Data Set, an assessment tool, documented Resident 6 was moderately cognitively impaired and had a pressure ulcer. In an interview on 07/06/2026 at 2:10 PM, Resident 6 said staff did wound care and changed the patch to her pressure area daily.Record review of Resident 6's physician orders, dated 06/02/2026, showed an order for Santyl Ointment (a prescription medication that removes dead tissue from skin ulcers), apply to per additional directions topically every day for wound care. The order did not specify where to apply the Santyl Ointment.Record review of Resident 6's July 2026 Electronic Medication Administration Record (EMAR) showed Resident 6 had Santyl Ointment applied topically to the groin (body area where the lower part of the abdomen meets the upper thighs) on 07/01/2026, 07/02/2026, and 07/03/2026, and topically to the coccyx (tailbone area) on 07/04/2026, 07/05/2026, 07/06/2026, 07/07/2026, 07/08/2026, and 07/09/2026.Record review of Resident 6's physician orders, dated 06/30/2026, documented, TREATMENT COCCYX: Cleanse area with NSS [normal saline solution], apply skin prep to peri wound, apply Santyl.day shift every Tue [Tuesday], Thu [Thursday], Sat [Saturday] for pressure injury.In an interview on 07/09/2026 at 10:10 AM, Staff C, Resident Care Manager/Licensed Practical Nurse (LPN), said Resident 6's wound care with Santyl Ointment was not done daily. Staff C said Resident 6's wound care was done on Tuesday, Thursday, and Saturday. When asked Staff C about the order for Santyl Ointment daily, dated 06/02/2026, Staff C said this order was for the pharmacy. Staff C said they had to have a separate order for the pharmacy, or the pharmacy would not send the medication. When asked about the documentation in the July 2026 EMAR for Santyl applied daily to the groin and/or the coccyx, Staff C said they should not be putting Santyl on Resident 6 daily. Staff C said there was no skin issues on Resident 6's groin. Staff C said Resident 6's daily Santyl order was not updated to match the treatment order, dated 06/30/2026, for three days per week and it should have been. In an interview on 07/09/2026 at 11:13 AM, Staff D, LPN, said Resident 6's wound care was supposed to be done daily with normal saline, Santyl, and a foam dressing.In an interview on 07/09/2026 at 11:19 AM with Staff B, Director of Nursing/Registered Nurse (RN), and Staff E, Clinical Resource Nurse/RN, Staff B said the pharmacy wanted a separate order for Santyl Ointment. Staff B said Santyl Ointment should not have been applied daily to Resident 6. Staff B said when the treatment order for Resident 6 changed on 06/30/2026 to Tuesday, Thursday, and Saturday, the Santyl order should have been updated from daily to match the treatment order and it was not. Staff B said Resident 6 did not have any skin issues on her groin area. Staff B stated, It is not clear, the order needs to be clarified. The site should be clear in the order for Santyl of where it goes to. Reference WAC 388-97-1060 (1)(3)(b)(k)

Based on observation and interview, the facility failed to provide care and services in a manner that maintained and promoted dignity for 1 of 15 sampled residents (32) when staff stood next to her while assisting with eating her meal. This failure placed residents at risk for diminished self-worth, self-esteem, and feelings of embarrassment. Finding included . Resident 32 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, a required assessment tool, dated 02/06/2025, showed Resident 32 was severely cognitively impaired. On 05/19/2025 at 12:43 PM, Staff F, Nursing Assistant (NA), was standing up next to Resident 32 while assisting the resident with eating. At 12:44 PM, Staff F walked away and returned moments later. Staff F stood in front of Resident 32 and assisted her with eating. At 12:48 PM, an unidentified NA brought a chair into the dining room and placed it next to Staff F. Staff F sat down in the chair. On 05/22/2025 at 8:19 AM, Staff F said they were supposed to be sitting next to the resident when assisting a resident with their meals. When asked why she was standing when she assisted Resident 32, Staff F said there were not enough chairs in the dining room that day. Staff F said she tried to get assistance from someone by radio to bring her a chair. At 8:59 AM, Staff B, Director of Nursing and Registered Nurse, stated staff should be ideally at eye level when assisting residents. Reference WAC 388-97-0180 (2) .

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was completed accurately to reflect a resident's health status and/or care needs for 1 of 5 sampled residents (31) reviewed for unnecessary medications. This failure placed residents at risk for inaccurate and/or unmet care needs and a diminished quality of life. Findings included . Resident 31 was admitted to the facility on [DATE]. The Annual MDS assessment, dated 04/10/2025, documented Resident 31 was severely cognitively impaired and was taking an antipsychotic (used to manage the symptoms of psychosis, where individuals experience a loss of contact with reality) medication. Record review of Resident 31's Electronic Health Record (EHR) physician orders and medication administration record did not show Resident 31 was prescribed or taking an antipsychotic medication. On 05/22/2025 09:37 AM, Staff C, MDS Nurse and Registered Nurse (RN), said when she completed the MDS, she coded medications in the MDS a resident was taking per the classification of the drug. After looking at Resident 31's Annual MDS, dated [DATE], Staff C said it was coded Resident 31 was taking an antipsychotic medication. After looking at Resident 31's EHR, Staff C said she did not see an antipsychotic medication prescribed or taken by Resident 31. Staff C said the MDS was miscoded. At 10:06 AM, Staff B, Director of Nursing and RN, said it was her expectation the MDS was completed to accurately reflect the resident and medications taken by the residents. Reference WAC 388-97-1000 (2)(n) .

Based on observation, interview and record review, the facility failed to develop a person-centered care plan addressing medication self-administration for 1 of 3 residents (21) reviewed for medication administration. This failure placed residents at risk of un-met care needs and a diminished quality of life. Findings Included . Facility policy entitled, Self Administration of Medications, revised on 05/2016, documented .9. Appropriate notation of these determinations will be placed in the residents care plan. Resident 21 was admitted to the facility on [DATE]. The admission /Medicare - 5 Day Minimum Data Set assessment, dated 04/10/2025, documented Resident 21 was alert and oriented. Review of Resident 21's care plan did not show documentation of self-administration of medications focus and/or interventions. On 05/20/2025 at 8:36 AM, Resident 21 was observed to have a pill organizer container with four compartments with medication in each compartment. Resident 21 said the medications in the pill organizer were his Parkinson's medications. On 05/21/2025 at 9:57 AM, Staff G, Resident Care Manager and Licensed Practical Nurse, said Resident 21 was evaluated for medication self-administration and was deemed appropriate to self-administer his Parkinson's medications. When asked if a care plan was in place for medication self- administration, Staff G said there was no care plan and she had just put in a new care plan addressing medication self- administration. At 2:50 PM, Staff B, Director of Nursing and Registered Nurse, said it was the expectation that there would be a care plan initiated when Resident 21 was assessed and deemed appropriate for medication self-administration. Reference WAC 388-97-1020 (1)(2)(d) .

Based on observation, interview and record review, the facility failed to ensure oxygen and/or nebulizer (a medical device that turns liquid medication into a fine mist that can be inhaled through a mouthpiece or mask) tubing was changed and/or bagged for 1 of 3 residents (14) reviewed for respiratory care. This failure placed residents at risk of respiratory infections, worsening health complications, and a decreased quality of life. Findings Included . Record review of the facility's policy entitled, Oxygen Administration, revised 04/2016, documented .INSTRUCTIONS FOR TUBING AND HUMIDIFIER CHANGES: . 2. Oxygen tubing is to be replaced every seven (7) days or when visible soiled . Resident 14 was admitted to the facility on [DATE] with multiple diagnosis to include chronic obstructive pulmonary disease (COPD, a progressive lung disease that makes it difficult to breathe) and acute and chronic respiratory failure with hypoxia (a low level of oxygen in the blood). The Quarterly Minimum Data Set assessment, dated 02/14/2025, documented Resident 14 was alert and oriented and was on oxygen therapy. A physician's order, dated 08/10/2024, documented Resident 14 was prescribed, CHANGE O2 [oxygen] TUBING WEEKLY every night shift every Wed [Wednesday]. A physician's order, dated 08/10/2024, documented Resident 14 was prescribed, CHANGE O2 AND SVN [small volume nebulizer] TUBING Q [every] WEEK - DATE ALL TUBING AND PLACE IN ZIPLOCK BAG WHEN NOT IN USE every night shift every Wed. Record review of Resident 14's respiratory status care plan, dated 08/23/2024, documented an intervention, NEBULIZER TO BE RINSED WITH COOL WATER AFTER EACH USE & STORED IN A BAG ON NIGHT STAND. On 05/19/2025 at 3:24 PM, Resident 14 was observed lying in bed with oxygen running at 2 lpm (liters per minute) per nc (nasal cannula). The oxygen tubing was observed with tape on it, dated, 5/7, 12 days ago. A nebulizer machine was observed on the nightstand with the nebulizer tubing and mouthpiece propped up against the mattress on the right side of the bed. The nebulizer tubing and mouthpiece were undated and uncovered with no bag observed. Resident 14 said the nebulizer mouthpiece just stayed there. On 05/20/2025 at 10:59 AM, Resident 14 was observed lying in bed with oxygen running at 2 lpm per nc. The oxygen tubing was observed with tape on it, dated, 5/7, 13 days ago. A nebulizer machine was observed on the nightstand with the nebulizer tubing and mouthpiece undated and uncovered with no bag observed. On 05/21/2025 at 10:19 AM, Resident 14 was observed lying in bed with oxygen running per nc. The oxygen tubing was observed with tape on it, dated, 5/7, 14 days ago. A nebulizer machine was observed on the nightstand with the nebulizer tubing and mouthpiece undated and uncovered with no bag observed. At 10:22 AM, Staff D, Licensed Practical Nurse (LPN), said oxygen and nebulizer tubing was changed by night shift once a month and as needed. Staff D said the tubing was labeled and dated when it was changed. At 10:30 AM, Staff E, Resident Care Manager and LPN, said oxygen and nebulizer tubing was changed weekly and should be labelled and dated when changed. Staff E said nebulizer tubing was kept in a bag when not in use. Staff E went to Resident 14's room to observe the oxygen and nebulizer tubing. Staff E said the oxygen tubing should have been changed last Wednesday (seven days prior) and it was not. Staff E said the nebulizer tubing should have been dated and kept in a bag, and it was not. At 1:45 PM, Staff B, Director of Nursing Services and Registered Nurse, said it was her expectation oxygen and nebulizer tubing was dated and changed weekly, and kept in a bag when not in use. Reference WAC 388-97-1060 (1)(3)(vi) .

Based on interview and record review, the facility failed to ensure residents had the ability to exercise self-determination related to aspects of life in the facility that were significant to the resident, including health care decisions and accessing outside providers of health care services consistent with their interests, for 1 of 5 sampled residents (Resident 1) reviewed for self determination. This failure placed residents at risk for not being able to choose treatment options outside the facility, decreased autonomy, powerlessness, and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE]. The 5-day admission Minimum Data Set assessment, dated 05/14/2024, documented the resident was moderately cognitively impaired. A discharge planning note, dated 07/19/2024, documented, ALF LN [Assisted Living Facility Licensed Nurse] in to see [Resident 1] today, though did not complete an eval as [Resident 1] was not feeling well. ALF LN will attempt again next week. On 08/14/2024 at 1:28 PM, Family Member 1 (FM1) said on 07/19/2024 he had a meeting with Resident 1 and Collateral Contact 1 (CC1, Registered Nurse), a nurse from an assisted living facility, in the resident's room. FM1 said Resident 1 had vomiting and diarrhea. FM1 said CC1 told him she thought Resident 1 needed to go to the ER (emergency room ). FM1 said he agreed Resident 1 should go to the hospital. FM1 said the nurse on duty, Staff C, Registered Nurse, asked if he wanted Resident 1 to go to the hospital and FM1 told Staff C yes. FM1 said Staff C asked Resident 1 if she wanted to go to the hospital and the resident said yes. At 2:55 PM, Staff C said she contacted the provider on 07/18/2024 to relay Resident 1's complaints of nausea and GI (gastrointestinal) pain. Staff C said the provider told her to give ibuprofen, a pain medication, three times a day for the pain, and send the resident to the ER if the pain persists. Staff C said on 07/19/2024, FM1 was visiting with Resident 1 and she told the resident and FM1 about gallstones that were seen on Resident 1's recent imaging. Staff C said FM1 and Resident 1 talked about treatment options and decided to wait until a provider saw her on Monday, 07/22/2024. Resident 1's electronic medical record did not show documentation of the discussion between Staff C and Resident 1 or FM1. On 08/15/2024 at 9:10 AM, CC1 said she went to the facility on [DATE] to perform an assessment for placing Resident 1 in an assisted living facility. CC1 said Resident 1 was in her room, in a wheelchair, and told CC1 she did not feel well. CC1 said during her assessment Resident 1 could not keep her eyes open. CC1 asked FM1 if this was normal behavior for her and FM1 said it was not. CC1 said she told FM1 that she thought the resident should go to the hospital and FM1 agreed. CC1 said she informed Staff D, Social Services Director, that she could not complete her assessment as Resident 1 was not feeling well. CC1 said at that time she told the facility she thought the resident needed to go to the hospital. Resident 1's electronic medical record did not show documentation of a transfer to the hospital on 07/19/2024. On 08/28/2024 at 11:25 AM, Collateral Contact 2 (CC2), an on-call provider service staff member, said there was a call made from the facility to their on-call provider on 07/19/2024. CC2 said the provider was informed the resident wanted to go to the hospital. CC2 said the provider told the nurse to send the Resident 1 to the hospital. At 11:49 AM, Staff D, Social Services Director, said she recalled the conversation with CC1 regarding Resident 1. Staff D said CC1 told her Resident 1 was not feeling good and CC1 thought Resident 1 needed to go to the hospital. Staff D said she informed either the Resident Care Manager or the floor nurse, but could not remember which one. At 11:52 AM, Staff E, Infection Preventionist and Registered Nurse (RN), said she was the manager of the day as Staff A, Administrator and Staff B, Director of Nursing Services and RN, were out of the facility for the week. Staff E said if there was a change in condition the nurse would assess the resident, call the provider and obtain orders, and tell the resident what they said, then ask the resident if they wanted to go to the hospital. Staff E said the facility could not force a resident to go to the hospital, and the opposite was true, that if the resident wanted to go to the hospital they could go. After reviewing Resident 1's electronic medical record, Staff E could not find documentation the resident was transferred to the hospital on 07/19/2024. Staff E said there should be a progress note if a resident transferred out of the facility. Staff E said the expectation if a resident wished to go to the hospital was to notify the provider and start facilitating the resident transfer. On 08/29/2024, an undated written response provided by the facility, showed the provider on call on 07/19/2024 documented, This letter is in response to an on-call response on the night of 07/19/2024 for patient [Resident 1] at Pacific Care and Rehabilitation facility. Call was received at [12:22 PM] on the secure app from nurse . stating, family is asking to send patient to ER. I responded to the call at [12:35 PM] with instructions but was not recorded on the sign-out for unknown reasons. I always capture responses on the signed out for documentation that will require further follow-up/evaluations, but I cannot recall why it was not captured for this phone call. For this type of call, I would have triaged the patient based on vital signs and current condition, give my recommendations to proceed with family wishes. At the time of this letter, I cannot recall the details of the response to this call. Reference WAC 388-97-0900 (1)-(4)

Based on interview and record review, the facility failed to ensure residents received timely hearing services to maintain their ability to hear adequately and effectively for 1 of 2 sampled residents (5) reviewed for hearing treatment and services. This failure placed residents at risk for frustrations, decline in communication, and a diminished quality of life. Findings included . Resident 5 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 01/23/2024, documented the resident was cognitively intact, had moderate difficulty hearing, and had no hearing aids. A nursing note, dated 10/19/2023, documented, [Resident 5] is congenial, a little hard of hearing, but loves to visit. A social services summary, dated 10/23/2023, documented, Hearing: none, no devices, denies issues, son would like apt [appointment], will schedule. A social services summary, dated 01/23/2024, documented, Hearing: none, no devices, denies issues, son would like apt, will schedule. On 04/01/2024 at 1:35 PM, Collateral Contact 1, family member, said Resident 5 required hearing aids for communication. On 04/03/2024 at 1:08 PM, Staff D, Social Services Director, said Staff G, Social Services Assistant, usually scheduled resident hearing appointments. Staff D said residents were asked upon admission and quarterly about needing hearing-related services. Staff D said she discussed Resident 5's hearing appointment with Staff G, but Staff D did not see a hearing appointment scheduled on the calendar. Staff D said she expected Staff G to make an appointment for hearing services within a day or two of hearing about the need. At 1:54 PM, Staff G said she was responsible for scheduling resident hearing appointments in the facility. Staff G said she would hear about hearing needs from nurses on the floor or from reviewing care conference notes. Staff G said residents were offered hearing services upon admission and she would fill out a form and call local hearing places to schedule an appointment. Staff G said Resident 5's hearing appointment was put in today (04/03/2024, 163 days after the 10/23/2023 note indicating the facility was scheduling a hearing appointment). Staff G said the 10/23/2023 appointment was on her follow-up list, but she was not able to follow-up on the appointment. Staff G said she would not consider Resident 5's hearing appointment to be made timely. At 2:06 PM, Staff A, Administrator, said the social services department was responsible for scheduling hearing appointments in the facility. Staff A said hearing needs were assessed upon admission and quarterly thereafter. Staff A said his expectation was for hearing appointments to be scheduled as soon as possible. Staff A said he did not think Resident 5's hearing appointment was made in a timely manner. Reference WAC 388-97-1060 (3)(a)

Based on observation, interview, and record review, the facility failed to provide prompt dental services for 1 of 2 sampled residents (51) reviewed for dental services. This failure places residents at risk for continued dental problems and a diminished quality of life. Findings included . Resident 51 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 02/25/2024, showed the resident was cognitively intact. The Dental Assessment, dated 02/08/2024, documented Resident 51 had top and bottom partials. The assessment showed the bottom partials were ill fitting. The assessment's findings indicated Resident 51 would like to see dentist regarding bottom partial. On 04/01/2024 at 11:37 AM, Resident 51 was observed to have some missing teeth. Resident 51 said her bridge was loose. Resident 51 said she thought the facility was working to get her into seeing someone, but was not sure. On 04/03/2024 at 10:43 AM, Staff G, Social Services Assistant, said she received a list of what residents' needed from nursing staff. Staff G said she was not aware Resident 51 needed to have partials looked at because it had not been communicated to her. Staff G said she did not a get a copy Resident 51's Dental Assessment so could only rely on what was provided to her from a list. Reference WAC 388-97-1060 (3)(j)(vii)

Based on observation and interview, the facility failed to ensure medications were kept secure in 1 of 2 sampled medication carts (F-Hall) reviewed for medication storage. This failure placed residents at risk of misappropriation of medication and a diminished quality of life. Findings included . On 05/03/2023 at 1:57 PM, the F Hall medication cart, located across the hall from room [ROOM NUMBER], was observed to be unlocked. No nursing staff were within view of the medication cart. Staff D, Resident Care Manager and Registered Nurse (RN), was shown the unlocked medication cart and immediately locked the cart. Staff D said the cart should have been locked. Staff D said she expected the medication carts to be locked when the nurse was away from the cart. At 2:14 PM, Staff D said the cart was reported to have a problem locking. At 2:46 PM, Staff D said if a medication cart was having troubles locking, it was supposed to stay in a location where it could be seen by the nurse, or kept within view of the nurse's station, at all times. On 05/04/2023 at 2:05 PM, Staff D said the cart was brought to their attention to be having problems locking on 05/02/2023. At 4:13 PM, Staff B, Director of Nursing Services and RN, indicated a medication cart should be kept within sight of the nurse at all times if staff knew it was having a problem locking. Reference WAC 388-97-1300 (2)

Based on observation and interview, the facility failed to ensure residents had a safe environment when unlocked razors, nail clippers and other toiletries were kept in an unlocked cabinet behind an unlocked door for 1 of 1 clean utility rooms reviewed for safe, comfortable, homelike environment. This failure placed residents at risk for accidents, injuries and a diminished quality of life. Findings included . On 05/01/23 at 9:46 AM, clean utility door was observed to be unlocked. Toiletry items (razors, nail clippers, shaving cream, shampoo, hand sanitizer, lotion, deodorant, denture supplies) were in an unlocked cabinet within reach of residents. 19 razors were counted. On 05/02/2023 at 10:00 AM, razors, nail clippers and toiletries were observed in the same unlocked cabinet. On 05/03/2023 at 8:14 AM, razors, nail clippers and toiletries were observed in the same unlocked cabinet. On 05/05/2023 at 9:20 AM, after seeing the unlocked clean linen room and the unlocked cabinet with the toiletry items, Staff E, Registered Nurse and Resident Care Manager, said most residents would not be able to get to the razors, but they still needed to be locked up. At 9:25 AM, after notifying maintenance, Staff E was told they would be putting a lock on the cabinet. Reference WAC 388-97-3220 (1)

Based on observation, interview and record review, the facility failed to ensure activities of daily living (ADLs) were provided for dependent residents including bathing for 1 of 3 sampled residents (212) reviewed for ADL care. This failure placed residents at risk for poor hygiene, health complications and a diminished quality of life. Findings included . Resident 212 was admitted to the facility on [DATE]. The 5-Day Minimum Data Set, an assessment tool, dated 12/03/2022, documented Resident 212 was cognitively intact and required extensive assistance with ADLs. Resident 212's bathing record, dated 05/03/2023 to 05/08/2023, documented one shower was provided on 05/03/2023 and one sponge bath was provided on 05/05/2023, seven days after being admitted . Resident 212's progress notes, dated 04/26/2023 to 05/08/2023, did not document a shower refusal or a reason for a shower not being offered. On 05/01/2023 at 11:12 AM, Resident 212 said she would like to shower, and had not received a shower since her admission on 04/26/2023. Resident 212 said she preferred to shower at home every two to three days. On 05/05/2023 at 11:02 AM, Staff C, Certified Nursing Assistant, said residents were offered a shower twice a week. Staff C said she would look for documentation of Resident 212's showers. At 1:34 PM, Staff B, Director of Nursing Services and Registered Nurse, said residents were offered showers twice per week, unless residents requested a different schedule. Staff B stated, We go by room numbers. [Resident 212] is on the schedule for Tuesdays and Fridays. Staff B was unable to provide documentation Resident 212 received a bath prior to 05/03/2023. On 05/08/2023 at 11:18 AM, Staff B said new residents are offered showers upon arrival. Staff B was unable to provide documentation Resident 212 was offered a shower upon arrival. An email from Staff A, Administrator, dated 05/10/2023, documented the Administrator was not able to find documentation of Resident 212 receiving a bath or a shower prior to 05/03/2023. Reference WAC 388-97-1060 (2)(c)

Based on interview and record review, the facility failed to ensure laboratory testing was completed following physician's orders for 1 of 5 sampled residents (33) reviewed for quality of care regarding unnecessary medications. This failure placed residents at risk for an inaccurate physician treatment plan and a diminished quality of life. Findings included . Resident 33 was admitted to the facility on [DATE] with diagnoses including hyperlipidemia (high cholesterol). The quarterly Minimum Data Set, an assessment tool, dated 03/10/2023, showed the resident was severely cognitively impaired. The Electronic Health Record (EHR) documented Resident 33 had physician orders, dated 12/13/2021, for BMP [Basic Metabolic Panel, a blood test for a general metabolism overview] Q6 [every 6] Months, December/June. Physician's orders, dated 12/13/2021, documented, TSH [Thyroid Stimulating Hormone, a blood test to measure the thyroid hormone] Q12 [every 12] Months (December); CMP [Comprehensive Metabolic Panel, a blood test to measure 14 different substances in your blood including liver and kidney health] Q12 [every 12] Months (December); and LIPIDS [a blood test used to monitor risk of cardiovascular disease] Q12 Months (December). Resident 33's EHR showed no documentation of a BMP or a Lipid blood test. Resident 33's EHR showed the last CMP blood test was completed on 01/31/2022, one month and two weeks past due as ordered by the physician every 12 months. On 05/08/2023 at 9:57 AM, Staff E, Resident Care Manager and Registered Nurse (RN), said the process for laboratory testing, was the order shows up on the MAR (Medication Administration Record) for three days in the month they were due. Staff E said the facility drew their own labs. Staff E said there should have been a CMP and Lipids test done in December 2022. Staff E said she did not see any recent BMP, CMP, or Lipids lab tests done and no refusals documented. Staff E stated, He didn't have lipids. We missed the lipids. [Resident 33] has not had a BMP drawn either. At 11:11 AM, when asked about Resident 33's ordered labs, Staff B, Director of Nursing Services and RN, stated, Yes. We missed them. Reference WAC 388-97-1060 (4)

Based on observation, interview and record review, the facility failed to ensure respiratory care and services were provided in accordance with professional standards of practice when oxygen (O2) was ordered without a dosage, route, or parameters for titration for 2 of 3 sampled residents (34 & 56) reviewed for respiratory care. This failure placed residents at risk for receiving care and services that were not physician ordered, unmet care needs and a diminished quality of life. Finding included . The facility policy entitled Oxygen Administration, revised 04/2016, noted, It is the policy of this facility that oxygen therapy is administered, as ordered by the physician or as an emergency measure until the order can be obtained. 1) Resident 34 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxemia (a condition where you do not have enough oxygen in the tissues of the body and can develop over time). On 05/01/2023 at 4:10 PM, Resident 34 was observed receiving 2-liters per minute (LPM) of oxygen via a nasal canula (NC - flexible tubing that sits inside the nostrils and delivers O2). Resident 34's Electronic Health Record (EHR) showed an order written on 03/31/2023 for oxygen with out the amount of LPM and route to receive it. The order noted, may titrate to keep O2 sats [saturation] above 90% every shift. The order did not indicate parameters for titration. On 05/04/2023 at 2:21 PM, Staff F, Licensed Practical Nurse (LPN), said an oxygen order should tell you how many liters to give. When asked what to do if the order did not specify how much to give, Staff F stated, You need to call the doctor to get clarification. When asked what they would do if a resident's O2 saturation went below 90% when on oxygen, Staff F stated, I would say you bring up the O2 sats to above 90% and call the doctor. At 2:47 PM, Staff H, LPN, said the order would say two liters, three liters, four liters. It depends on the diagnosis. When asked what to do if the order did not specify how much to give, Staff H said you need to call the doctor to get clarification. When asked what they would do if the resident's O2 sats go down below 90% while on oxygen, Staff H said they would keep monitoring to make sure the resident was not in distress. If it was still low, they would notify the doctor. On 05/05/2023 at 8:45 AM, when asked how much oxygen to give based on an order, Staff E, Registered Nurse (RN) and Resident Care Manager (RCM), said if the order was specific, it would say. If the order was not specific and was to keep saturation above 90, they would start at 2-LPM. If the order did not specify how much to give, they would start at 2-LPM and check again in 20 to 30 minutes. When asked what they would do if a resident's O2 saturation went below 90% while on oxygen, Staff E stated, It depends. Most of the time we will bump up the oxygen and then check their symptoms to see what's going on. At 9:34 AM, when asked about the expectations when an oxygen order did not have specific parameters and starting dose, Staff B, Director of Nursing Services and RN, stated, We don't make that decision. That's the doctor's order. When asked about if a resident was on oxygen and was not at 90 percent, Staff B said increase oxygen if they have an order to increase the oxygen. If not, monitor their symptoms and call the doctor. After reviewing Resident 34's order, Staff B stated, That's not good. 44739 2) Resident 56 was admitted to the facility on [DATE] with diagnoses including idiopathic pulmonary fibrosis (condition in which the lungs become scarred and breathing becomes increasingly difficult) and chronic obstructive pulmonary disorder (condition that blocks airflow and make it difficult to breathe). The quarterly Minimum Data Set, an assessment tool, dated 04/26/2023, documented the resident was cognitively intact and required oxygen. Resident 56's physician's orders, dated 01/10/2023, documented, Titrate oxygen to keep sats >90% as needed for shortness of breath related to pneumonia, acute and chronic respiratory failure, chronic obstructive pulmonary disease, and dependence on supplemental oxygen. No liters per minute, route of oxygen delivery, or parameters for titration were ordered. On 05/02/2023 at 9:59 AM, Resident 56 was observed receiving oxygen by a nasal canula, (tube that runs from the oxygen concentrator to the resident's nose). The concentrator was set to deliver oxygen at 3-liters per minute. On 05/03/2023 at 9:11 AM, Resident 56 was observed receiving oxygen by nasal canula at 3-liters per minute. On 05/04/2023 at 9:04 AM, Resident 56 was observed receiving oxygen by nasal canula at 3-liters per minute. On 05/05/2023 at 9:00 AM, Resident 56 was observed receiving oxygen by nasal canula at 3-liters per minute. At 9:07 AM, Staff E, RN and RCM, said Resident 56 did not have specific orders because O2 saturations tended to fluctuate and O2 needed to go between 2 and 4 liters per minute. Staff E said documentation of liters per minute should be in progress notes or where O2 saturations were documented. Record review of progress notes and O2 saturations rates documentation did not show liters of oxygen delivered per minute. Oxygen orders were rewritten, dated 05/05/2023, showed oxygen @ 2-5 LPM via NC/Mask continuous/PRN [as needed] may titrate to keep O2 sats above 90% as needed for shortness of breath related to pneumonia, acute and chronic respiratory failure, chronic obstructive pulmonary disease and dependence on supplemental oxygen. Reference WAC 388-97-1060 (3)(j)(iv)

Based on observation, interview, and record review, the facility failed to ensure adequate care and services were provided to promote wound healing when pressure reduction interventions were not implemented, antibiotic orders were not implemented and daily wound dressings were not performed for two of three sampled residents (38 & 39) reviewed for pressure ulcers. This failure placed residents at risk for wound complications, infection, delayed healing, increased pain, and a decreased quality of life. This failure caused harm to Resident 38 when interventions were not implemented and the wound became infected. Findings included . Facility Policy Titled Skin Care Policy/Procedure dated 06/2016 documented: --A resident who enters the facility without pressure injury does not develop a pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; AND --A resident having pressure injuries receives necessary treatment and service to promote healing, prevent infection, and prevent new avoidable pressure injuries from developing. --CNA's will review electronic Kardex to view care plan interventions. --Licensed Nurse to document presence of pressure reducing devices on Treatment Administration Record (TAR) --Confirm all orders have been implemented as ordered. 1) Resident 38 was readmitted to facility on 07/08/2021. The admission Minimum Data Set (MDS), an assessment tool, dated 07/11/2021, documented Resident 38 was severely cognitively impaired, was dependent on two staff for bed mobility and transfers, was at risk for development of pressure injuries, and required the use of a pressure relieving device for bed and wheelchair. The MDS showed the resident had no documented wounds upon readmission to the facility on [DATE]. The Licensed Nurse (LN) Initial Admission Record, dated 07/08/2021, documented, Left heel is callused with dry skin it is protected with a foam dressing and a sock placed over it. A Braden Scale (a tool used to assess risk of developing a pressure injury), dated 07/08/2021, showed Resident 38 was at moderate risk for developing pressure injuries. The pressure ulcer care plan, dated 07/08/2021, documented the resident had a potential for pressure injury due to decreased mobility and fragile skin. LN Skin Assessment, dated 07/27/2021, documented resident had slight redness remains to heels and right great toe. Skin intact, warm, dry. Mucous membranes pink and moist. A progress note, dated 08/07/2021, documented While assisting getting resident into bed this eve this writer noted left heel is soft and boggy, red and dry [definition of deep tissue injury]. Heels floated, skin otherwise intact and in good condition. Placed on alert. The care plan, updated 08/08/2021, documented Resident 38 had a Stage 3 pressure ulcer to her left heel. Interventions included an air mattress, report improvements and declines (worsening) to the MD (physician), float heels, and heel protector while in bed. A Physician order, dated 08/08/2021 documented, Heel protectors, bilateral, when in bed, every shift for pressure ulcer. A Physician order, dated 08/08/2021, documented, Air mattress-check placement and function every shift for promotion of skin integrity. A local wound healing provider (LWHP) note, dated 08/18/2021, documented the L (left) heel wound as unstageable measuring 2 centimeters (cm) x 2 cm x 0.1 cm. Additional orders included pressure relief/offloading, reposition, low air loss mattress, offloading, and wheelchair cushion. LWHP notes showed the following wound measurements: On 09/08/2021, 0.5 cm x 0.5 cm x 0.1 cm. On 09/22/2021, 1.8 cm x 1.5 cm x 0.1 cm. On 10/06/2021, 2 cm x 2 cm x 0.2 cm. A culture and sensitivity (C&S) report (test to determine antibiotic effectiveness), dated 10/13/2021, documented the L heel wound was positive for heavy growth of Proteus Mirabilis (an antibiotic resistant bacteria), heavy growth of Staphylococcus Aureus (an antibiotic resistant bacteria), and heavy growth of Enterococcus (an antibiotic resistant bacteria). LWHP notes showed the following wound measurements: On 10/20/2021, 2.2 cm x 1.8 cm x 0.2 cm On 11/17/2021, 2 cm x 0.6 cm x 0.2 cm On 12/08/2021, 0.5 cm x 0.5 cm x 0.1 cm On 01/05/2022, 2 cm x 1 cm x 0.2 cm A LWHP note, dated 02/02/2022, documented the left heel measured 3 cm x 2 cm x 0.1 cm. Offloading boots were added to treatment recommendations. A LWHP note, dated 02/09/2022, documented the left heel wound measured 3.3 cm x 2 cm x 0.1 cm. A new C&S of the wound and X-ray was ordered to rule out [CONDITION(S)] (infection of the bone). A LWHP note, dated 02/16/2022, documented the left heel wound measured 3.0 cm x 4.5 cm x 0.1 cm. [MEDICATION(S)], an antibiotic, by mouth was ordered for 21 days. Resident 38's February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . A LWHP note, dated 02/23/2022, documented Resident 38's left heel wound measured 3.5 cm x 4.6 cm x 0.1 cm. On 02/28/2022 at 10:16 AM, Resident 38 was observed seated in her wheelchair at the side of her bed. Resident 38's left heel was resting flatly on the footrest. An offloading boot or heel protector was not in place. On 03/01/2022 at 4:11 PM, Resident 38 was observed seated in her wheelchair at the side of bed. Resident 38's left heel was resting on the strap of her footrest. An offloading boot or heel protector was not in place. On 03/02/2022 at 8:24 AM, Resident 38 was observed in bed on a foam mattress with pillows behind her knees. The resident's knees were flexed, and her heels were touching the bed. There was not a heel protector or offloading boots in place. At 8:28 AM, Staff S, Advanced Registered Nurse Practitioner, said she had been [MEDICATION(S)] the wound. The wound was an unstageable; and after debridement, it was a Stage 3. At 8:32 AM, Staff P, Resident Care Manager (RCM) and Registered Nurse (RN), was observed removing a sock, gauze, and foam dressing from Resident 38's left foot. A foul odor was noted during the dressing change. Pillows were placed under resident's knees, but her heels were still touching the bed. No heel protector or offloading boot was in place. At 9:22 AM, Resident 38 was observed lying in bed on a foam mattress, knees flexed and pillows behind knees, heels on the foam mattress, and no heel protector or offloading boots in place. No heel protectors or offloading boot were visible in the room. When asked about heel boots for Resident 38, Staff E, Nursing Assistant (NA) said Staff R, Certified Occupational Therapy Assistant (COTA), was working with her and she would put on the boots. At 9:33 AM, Staff R was observed providing assistance to Resident 38. Staff R then took Resident 38 to the therapy gym. There were no heel protector or offloading boots in place. At 11:07 AM, Resident 38 was observed in her wheelchair, at her bedside, with a sock on her L foot, resting flatly on footrest. No heel protectors or offloading boots were in place. A LWHP note, dated 03/02/2022, documented a change to wound care orders to daily dressing changes. The note referenced Resident 38 taking [MEDICATION(S)]. The February 2022 and March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 38's March 2022 Treatment Administration Record (TAR) documentation showed wound care was not provided on 03/03/2022, 03/05/2022, and 03/07/2022. On 03/03/2022 at 5:24 AM, Resident 38 was observed with pillows under her knees, knees flexed and left heel on foam mattress. No heel protectors or offloading boots were in place. At 5:35 AM, Staff Q, Nursing Assistant (NA), said she checked and repositioned Resident 38 throughout the night. Staff Q said she used a pillow to elevate Resident 38's heels so there was no pressure. At 6:00 AM, Staff N, Licensed Practical Nurse (LPN), said Resident 38's pressure ulcer interventions included dressing changes, float her heels, pain medication if needed and making sure there was no pressure on the heels. At 11:42 AM, Staff N said Resident 38 did not have an air mattress. Resident 38's January 2022, February 2022 and March 2022 TAR documentation showed facility staff entered a check for monitoring placement and function of air mattress, indicating an air mattress was in place. (An air mattress was not observed.) At 12:33 PM, Staff P said Resident 38 did not have an air mattress, because her heels were always floated, so the resident's heels did not touch the bed. Staff P said the wound was not improving. At 12:36 PM, Staff B, Director of Nursing Services and RN, said Resident 38's offloading boots were supposed to be on all the time unless therapy was working with her, or they were in the wash. On 03/04/2022 at 8:09 AM, Staff B said she had never seen Resident 38 without her boots, unless they were being washed; and staff were to use pillows if boots were not available. Staff B said she believed when Resident 38 moved rooms, the air mattress did not come with her. Staff B said Resident 38 moved some time in January 2022. Staff B said she would expect staff to notify someone that the mattress was not in place. Staff B said she did not think not having the mattress would have a negative impact on wound healing. At 10:57 AM, an air mattress was observed being delivered to Resident 38's room. At 1:57 PM, Staff P, RCM and RN, said she printed the LWHP notes and entered any new orders into the electronic medical record. After reviewing the LWHP note, dated 02/16/2022, where [MEDICATION(S)] was ordered; Staff P stated, I didn't see that. She told me there was no change. At 2:10 PM, Staff B said her expectation was for orders to be implemented as soon as they receive them. A progress note, dated 03/07/2022 at 8:49 AM, documented, Preliminary wound culture results received 03/06/2022 growing Proteus Mirabilis along with 3 other Isolates yet to be identified on the culture. The lab is further testing the Proteus Mirabilis for potential ESBL [highly resistant to oral antibiotics]. Due to the potential for culture growing ESBL +, resident was placed in Contact precautions pending final culture results. The March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] On 03/07/2022 at 10:32 AM, Resident 38's room was observed with a contact precaution cart outside the room. At 1:08 PM, Staff N said Resident 38 was not scheduled for wound care today. At 2:40 PM, Staff B said Resident 38's dressing was ordered to be changed daily. Staff B said the order currently in the electronic record was from 02/25/2022 and was for every other day on evening shift. Staff B said she would expect the order to have been updated on 03/02/2022 to daily dressing changes. 2) Resident 39 was admitted to the facility on [DATE]. A quarterly MDS, dated [DATE], indicated Resident 39 required extensive assistance of two staff for bed mobility, was at risk for pressure ulcers/injuries and needed pressure reducing devices for bed and wheelchair. A care plan addressing residents' risk for pressure ulcers, initiated 12/15/2020 and updated 01/05/2022, documented the resident required pressure relieving/reducing devices in bed and wheelchair. On 03/01/2022 at 8:12 AM, Resident 39 was observed sitting up in bed. No therapeutic mattress was observed. A progress note, dated 03/01/2022 at 12:31 PM, documented therapy staff reported a red, soft area to resident's right heel. The physician was notified, and orders for a therapeutic mattress and foam boots to both heels were ordered. On 03/02/22 at 3:43 PM, Resident 39 was observed lying in bed. No therapeutic mattress was observed. On 03/03/22 at 11:31 AM, Resident 39 was observed lying in bed. No therapeutic mattress was observed. Staff N said when a therapeutic mattress was ordered, it usually took a few days to arrive; but could take more. Staff N said in the meantime, they placed foam boots and floated heels with pillows. Navy blue therapeutic boots were observed to both feet, which were lying directly on the mattress without pillows floating heels. At 11:34 AM, Staff P said the mattress had been ordered and should be arriving that day. On 03/04/22 at 9:22 AM, Resident 39 was observed lying in bed on a therapeutic mattress. Navy blue therapeutic boots were observed to both feet, which were lying directly on the mattress without pillows floating heels. At 9:25 AM, Staff N was observed placing navy blue therapeutic boots on both feet of Resident 39, and placing a pillow laterally beneath the lower portion of the resident's calves. Staff N stated, There, their floated. The navy blue moon boots were touching the bed. On 03/07/22 at 11:14 AM, after reviewing Resident 39's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff N said she thought the RCM put an order in the treatment record. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to ensure care and services were provided in a manner that maintained and promoted dignity when assistance was not provided in a timely manner and when staff failed to ask permission before entering resident rooms for two of two sampled residents (10 & 26) reviewed for resident rights. This failure placed residents at risk for lack of privacy, embarrassment and a diminished quality of life. This caused harm to Resident 10 when he was not assisted and he had to drive his wheelchair through the facility in soiled clothing. Findings included . <Timely Assistance> The facility's policy entitled, Resident Rights, dated 10/04/2016, documented residents have the right to a dignified existence. Residents have the right to be treated with respect and dignity, including the right to, Reside and receive services in the facility with reasonable accommodation of your needs and preferences except when to do so would endanger your or other residents' health or safety. Resident 10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS), an assessment tool, dated 12/17/2021, documented the resident was cognitively intact and totally dependent on staff with toileting and personal hygiene. On 02/28/2022 at 10:28 AM, Resident 26 said he pushed his call light for Resident 10, the resident across the hall when Resident 10 yelled out for help. Resident 26 said he had his door to his room open most of the time, and he knew how long it took for the staff to come and help Resident 10. Resident 26 said it sometimes took over an hour before staff came to assist Resident 10. The resident said the longest he could remember Resident 10 waiting for staff to help him was an hour and a half, 90 minutes. At 4:03 PM, Resident 10 said he often had trouble with long call light wait times. Resident 10 said he specifically recalled an incident approximately one week ago during lunch when he put his light on and asked to be laid down in bed to have a bowel movement. Resident 10 said his Nursing Assistant (NA) responded, said she would get help (to get him a bedpan), and did not return. During lunch, Resident 10 indicated he coughed during his meal which caused Resident 10 to be incontinent of feces and urine in his brief, which leaked urine around his suprapubic catheter from coughing so hard. Resident 10 said he was at his sink cleaning up, and overheard someone comment he would have to wait to be laid down in bed and changed because staff were still feeding residents. Resident 10 said that was when he went up to the business office to ask for staff to lay him down and clean him up. Resident 10 stated, How did it make me feel? It made me cry. I had to go down the hallway wet, in crappy pants. On 03/03/2022 at 8:39 AM, Staff L, Business Office Manager, said she was very familiar with Resident 10, and she did recall the incident he described. Staff L said it took place about one to two weeks ago. Staff L said Resident 10 had come into her office to ask her to get someone to help him get cleaned up because he had been incontinent of urine and feces. Staff L said she had to get on her radio and call someone to come help Resident 10 get cleaned up. Staff L said Staff M, NA, came off her lunch break to help Resident 10 get back to bed so he could get cleaned up. Staff L said she knew Resident 10 was upset because of his demeanor and the way he spoke to her. Staff L stated, I could hear it in his voice, he was upset. I don't know if he was crying, but I think he was on the verge of crying or he had been crying. At 12:55 PM, Staff M, NA, said she was on her break, and she heard over her radio a staff member needed to come assist Resident 10 back to bed. Staff M said she did not respond to the radio because she was on a break. Staff M said 10-15 minutes went by and no staff member had come to assist Resident 10 get back to bed. Staff M said she then heard Staff L come on the radio asking for assistance to get Resident 10 back to bed. Staff M said Resident 10 told her someone had initially come into his room, said they would get some help for him, and never returned. Staff M said Resident 10 was visibly upset. Staff M said she knew he was upset because he had tears in his eyes and he is not afraid to tell you he is upset. On 03/04/2022 at 8:55 AM, Staff B said it was everybody's job to answer call lights and she would like to see the call lights responded to in under 10 minutes. Staff B said if a resident needed care when meal service was happening, she expected staff to find out if the resident had an urgent need. If not, let the resident know staff would assist them as soon as possible. After discussing the incident about Resident 10, Staff B stated, Unfortunately, for [Resident 10] to be in the hall like that; yes, it is a dignity issue. <Asking Permission Before Entering Resident Rooms> 1) Resident 10 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was cognitively intact. Resident 10's electronic medical record showed a document entitled Resident Rights, Statement of Acknowledgment, signed by Resident 10 and a facility representative on 12/23/2021. The document showed Resident 10 and the facility were mutually aware of the facility's Resident Rights Policy. On 02/28/2022 at 3:03 PM, Resident 10 said he had a lot of issues with staff just walking into his room without knocking or asking permission to enter. Resident 10 stated, This is my home, and I would not walk into their home without their permission or without knocking. At 4:53 PM, Staff X, Licensed Practical Nurse, was observed knocking on Resident 10's door and then walked into the room without asking for permission to enter the room. 2) Resident 26 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 26 was cognitively intact. Resident 26's electronic medical record showed a document entitled Resident Rights, Statement of Acknowledgment, signed by Resident 26 and a facility representative on 02/01/2022. The document showed Resident 26 and the facility were mutually aware of the facility's Resident Rights Policy. On 02/28/2022 at 10:35 AM, Resident 26 said the NAs did not knock and introduce themselves, especially on the weekends. Resident 26 said just because his door was open did not excuse them from knocking and asking permission to enter his home. Resident 26 said it was a problem all over the facility, not just his room. At 1:00 PM, Staff T, Physical Therapist, was observed walking into Resident 26's room, said Hello [Resident 26], and did not knock or ask for permission to enter his room. On 03/02/2022 at 4:08 PM, Staff B, Director of Nursing Services and Registered Nurse, said all facility staff were trained on resident rights and should knock on the door to a resident room and wait for permission prior to entering the room. Staff B said her expectation was for staff to knock and wait for permission prior to entering the room even if the door to the resident's room was open. Staff B stated, Yes, I do consider that a dignity issue. [The residents] have a right to know who is entering their room and why. Reference WAC 388-97-0180 (2) and -1060 (1)

Based on observation and interview, the facility failed to ensure 1 of 5 staff members wore hairnets while in the kitchen, 2 of 5 staff members performed hand hygiene when entering the kitchen to obtain hot beverages, and 1 of 2 staff members observed for meal preparation touched eating surfaces of utensils and tops and inside surfaces of glasses during meal prep. These failures place residents at risk for food-borne illness and cross contamination. Findings included . On 03/03/2022 at 5:13 AM, Staff DD, Cook, was observed preparing breakfast without a hairnet on. At 5:49 AM, Staff DD place a hairnet on on their head. At 5:50 AM, Staff EE, Dietary Aide, was observed setting up glasses by touching the tops and inside of drinking surfaces of the glasses and touching the eating surfaces of utensils while wrapping them in napkins. At 7:44 AM, Staff GG, Housekeeping staff member, was observed entering the kitchen and obtaining a hot beverage from the coffee dispenser. Hand hygiene was not performed, and a hairnet was not donned. At 8:58 AM, Staff FF, Nursing Assistant, was observed entering the kitchen and obtaining a hot beverage from the coffee dispenser. Hand hygiene was not performed, and a hairnet was not donned. At 9:00 AM, Staff H, Dietary Manger, said staff should not enter the kitchen and cross the red line without applying a hairnet and washing their hands. Staff H said she would be educating the staff to make sure they were aware not to touch the tops and insides of glasses and the eating surfaces of utensils. Reference WAC 388-97-483.60(i)(2)

Based on observation, interview, and record review, the facility failed to ensure staff-maintained infection control practices were used to prevent the spread of infection and disease by placing a meal tray from a quarantine room onto a clean meal carts, failed to ensure hand hygiene was completed during one of two dining observations and during three of three medication administration observations, failed to disinfect shared equipment, failed to wear correct personal protective equipment (PPE) when going into a quarantine room, and failed to regularly test water for Legionella, a potentially dangerous bacteria that grows in water. These failures placed residents at risk of infections and a decreased quality of life. Findings included . <Shared Equipment> 1) On 03/01/2022 at 10:25 AM, Staff E, Nursing Assistant (NA), was observed entering room [ROOM NUMBER] with a mobile vital signs machine. A container of disinfecting wipes was not observed on the machine. At 10:28 AM, Staff E was observed exiting room [ROOM NUMBER]. The vital signs machine was not disinfected before being parked in the hallway. At 10:31 AM, Staff E said he did not know what the process for disinfecting resident equipment was after leaving a resident room. At 1:01 PM, Staff E said red top wipes were used to wipe down resident equipment. 2) On 03/01/2022 at 3:01 PM, Staff BB, NA, was observed pushing a Hoyer lift into room [ROOM NUMBER]. At 3:14 PM, Staff BB was observed coming out of room [ROOM NUMBER] with the Hoyer lift. Staff BB plugged the hoyer lift into the outlet next to room [ROOM NUMBER]. Staff BB did not disinfect the Hoyer lift prior to walking away. There were no disinfecting wipes observed in room [ROOM NUMBER]. At 3:18 PM, Staff BB stated, Equipment should be cleaned before you use it, cleaned after you use it, and then put it where it is supposed to be. Staff BB said the only kind of equipment she would need to clean like that would be the Hoyer lift. When asked if she followed the process with disinfecting the Hoyer lift, Staff BB stated, No, I cleaned it before. I did not clean it after. On 03/02/2022 at 2:14 PM, Staff F, Infection Preventionist and Registered Nurse (RN), said she performed an in-service education yesterday regarding disinfecting shared resident equipment. Staff F said shared resident equipment should be disinfected between resident use. Staff F said the facility used [MEDICATION(S)] red top wipes, which were located in the nurses medication cart and in the soiled utility room. On 03/03/2022 at 11:35 AM, Staff A, Administrator, said shared equipment should be cleaned when the equipment comes out of a resident room. <Legionella Water Program> A facility policy entitled Legionella Water Management Program, dated 09/24/2018, documented, Do quarterly Legionella test using a field test kit. Rotate location of testing each quarter. Document results. The policy showed it had not been updated since creation on 09/24/2018. On 03/02/22 at 3:41 PM, the facility Legionella water treatment program was reviewed with Staff G, Maintenance Director, showing the last water test for Legionella bacteria appeared to be on 01/16/2021. There was no documentation of previous water tests. Staff G said he performed water testing for Legionella once a year. On 03/03/22 at 11:35 AM, Staff A, Administrator, said the facility tested for Legionella bacteria annually, and would bleach the outdoor fountain four to five times a year. The facility was unable to provide documentation of the fountain bleaching or regular water testing. Staff A said he would be changing the Legionella water testing from annually to quarterly. When asked if the legionella water testing policy had been reviewed annually, Staff A stated, Apparently not. It was created in 2018. <Meal Cart> On 02/28/2022 at 11:40 AM, Staff Z, Hospitality Aide (HA), was observed to don PPE and entered a resident room (quarantine) through a zipper entry. Staff Z was handed a lunch tray from Staff AA, HA. Staff Z walked to the resident and placed the tray on the bed side table. The resident and Staff Z exchanged some words. Staff Z picked up the tray and walked it back to the zipper entry. Staff Z asked Staff AA to take the tray. Staff AA took the tray and placed it at the bottom of the clean food cart. The food cart had several meal trays still needing to be delivered to resident rooms. On 03/01/2022 at 8:29 AM, Staff F said if a meal tray went into a quarantine room and came out, it should be put on a dirty food cart. At 9:12 AM, Staff H, Dietary Manager, said if a meal tray went into a resident room, regardless of touching any surfaces, the tray should be put on the dirty tray cart by the kitchen. The tray should not go on the clean cart. It would be considered contaminated. <Hand Hygiene> The facility's policy and procedure entitled, Medication Administration, dated 07/2014 and revised 04/2016, documented: 1. Prepare/stock medication cart 2. Wash hands 3. Begin the medication pass 4. Wash your hands or use alcohol gel between residents On 03/03/2022 at 6:35 AM, Staff D, RN, was observed administering medications to Resident 33. Staff D changed her gloves in between administering the oral medications and putting on the topical ointment and did not perform hand hygiene in between glove changes. At 6:51 AM, Staff D was observed entering Resident 10's room. Staff D put on gloves to flush the resident's catheter. Staff D was observed removing her gloves and donning a clean pair of gloves prior to placing barrier cream on Resident 10's tailbone. Staff D did not perform hand hygiene in between glove changes. At 7:05 AM, Staff D was observed preparing to administer insulin to Resident 33. Staff D put on clean gloves without performing hand hygiene. On 03/07/2022 at 11:27 AM, Staff D said she was not aware she had not washed her hands in between changing her gloves. Staff D said she changes gloves so often during the day, she does not think about it. <PPE> On 03/02/2022 at 1:15 PM, room [ROOM NUMBER] was observed to be enclosed in plastic and taped on three sides, with a zipper running from top to bottom down the middle of the doorway for entry and exit of the room. The room had a sign taped to the door frame, Quarantine Precautions. There was a plastic cart on wheels by the entryway of the room containing PPE. On 03/03/2022 at 1:18 PM, Staff CC, Laundry Staff, was observed exiting room [ROOM NUMBER] without wearing PPE. At 1:30 PM, Staff JJ, Laundry Staff, told Staff CC she needed to be wearing a gown when she saw Staff CC exiting room [ROOM NUMBER] without wearing PPE. Staff CC said she knew and waved her hand back at Staff JJ. At 2:14 PM, Staff B, Director of Nursing Services and RN, said all staff had been trained in standard infection control practices and those specific to COVID-19. Staff B said her expectation was for staff to follow all infection control practices. Staff B stated, [Staff CC] has been taught infection control practices and she knows the expectations; and laziness is not an excuse. At 3:30 PM, Staff CC said she had been trained in infection control practices. Staff CC stated, It is imperative we protect ourselves and do not engage in cross contamination. To me, dirty laundry is all contaminated. Whether it is dirty or not, it doesn't matter. We are supposed to gown up with gown, gloves, goggles, and mask; and before leaving the room remove it all and do your hands. Staff CC said she went into room [ROOM NUMBER] to look for dirty laundry. Staff CC said she knew room [ROOM NUMBER] was an isolation room and did not gown because she was only taking a quick peek. When asked what PPE she was wearing, Staff CC said she was not wearing any PPE. A cart with PPE was observed outside room [ROOM NUMBER]. Reference WAC 388-97-1320 (1-3)

Based on interview and record review, the facility failed to ensure a written notice of transfer was provided to the resident and/or the resident's representative describing the reason for the transfer for one of two sampled residents (26) reviewed for hospitalization . This failure placed residents at risk of not being informed of their condition, unmet care needs and a diminished quality of life. Findings included . Resident 26 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 01/18/2022, showed the resident was alert and oriented and was able to make needs known. The medical record documented Resident 26 discharged from the facility on 10/14/2021, to an acute hospital, and returned on 10/18/2021; and the resident discharged from the facility on 12/03/2021, to an acute hospital, and returned on 12/09/2021. Resident 26's medical record did not show documentation the resident was provided a written notice of transfer. On 03/03/2022 at 10:28 AM, Staff D, Licensed Practical Nurse, said she would do the electronic Transfer form, a form for documenting transfer outside the facility. Staff D said the documentation was given to the emergency medical transport (EMT) staff. At 10:36 AM, Staff C, Resident Care Manager, said when a resident was transferred to the hospital, they put together a packet of information and sent it with the EMTs. At 10:58 AM, Staff B, Director of Nursing Services and Registered Nurse, said when a transfer packet was put together, it included a notice of transfer. Staff B said a copy was supposed to be given to the resident to give to the hospital. Reference WAC 388-97-0120 (2)(a,b,c & d)

Based on interview and record review, the facility failed to ensure a written bed-hold notice was provided to the resident or resident's representative at the time of transfer to the hospital for one of two sampled residents (26) reviewed for hospitalization . This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Resident 26 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 01/18/2022, showed the resident was alert and oriented and was able to make needs known. The medical record documented Resident 26 discharged from the facility on 10/14/2021, to an acute hospital, and returned on 10/18/2021. The medical record did not show documentation that contact was made to the resident or family regarding the bed-hold. The medical record documented Resident 26 discharged from the facility on 12/03/2021, to an acute hospital, and returned on 12/09/2021. The medical record did not show documentation that contact was made to the resident or family regarding the bed-hold. On 03/03/2022 at 10:36 AM, Staff C, Resident Care Manager, said a packet of information was put together to include a bed-hold. Staff C said if the resident was alert, they would discuss the bed-hold with the resident. If the resident was confused at that time of transfer, they would send the bed-hold to the hospital with the emergency medical transportation (EMT). At 10:44 AM, Staff HH, Admissions Coordinator, said his responsibility was to contact the resident while the resident was at the hospital. Staff HH said he would try to get a verbal consent from the resident. Staff HH said he documented all communication on the bed-hold form and gave it to the Business Office. At 10:56 AM, Staff L, Business Office Manager, said the bed-hold was offered by the nurse prior to transfer or if the resident was admitted to the hospital. Staff L said her responsibility was to file and maintain the completed bed-hold form. When asked if she had copies of the bed-holds for Resident 26's transfers to the hospital in October 2021 and December 2021, Staff L said she did not have bed-holds for those dates. At 10:58 AM, Staff B, Director of Nursing Services and Registered Nurse, said the bed-hold was done before the resident left the facility, or it was faxed if they were not alert when they were being transferred. Reference WAC 388-97-0120 (4)(a,b & c)

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening and Resident Review (PASARR), a screening tool used to identify mental health needs, was accurate for one of six sampled residents (16) reviewed for PASARR. This failure placed residents at risk for not receiving specialized mental health services, unidentified needs and a decreased quality of life. Findings included . Resident 16 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Significant Change Level 1 PASRR was completed on 11/10/2020, and a referral for a Level 2 evaluation was indicated. The Level 2 evaluation, dated 11/30/2020, recommended, Refer for psychiatric consult to assess response to recently initiated [MEDICATION(S)] [an antipsychotic medication] . A referral for a psychiatric consult was not found in Resident 16's medical chart. On 03/03/2022 at 8:41 AM, Staff Y, Social Services Supervisor, said if the PASARR Level 2 recommendation was a psychiatric consult, she would ask the resident if they would like services. Staff Y said if the resident accepted, they would start the process; but if the resident said no, she would follow up on a later date. Staff Y said she would hope she documented the conversation in the progress notes. At 8:47 AM, Staff Y said there was not documentation of a conversation with Resident 16 in the progress notes. Reference WAC 388-97-1915 (4)

Based on observation, interview and record review, the facility failed to promptly identify and implement interventions to prevent weight loss and failed to ensure residents received adequate oral fluid intake for 1 of 5 sampled residents (#1) reviewed for nutrition and hydration. This failure placed residents at risk for impaired nutrition, impaired hydration, and a decline in health status. This caused harm to Resident #1 when she experienced a 12.28% weight loss in 18 days and was hospitalized for [REDACTED]. Findings include . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 03/15/19, documented Resident #1 had severe cognitive impairment and required supervision with eating. The MDS documented Resident #1 rejected care 1 to 3 days during the assessment period, weighed 171 pounds, and had no identified weight loss in the past 6 months. The Registered Dietician Nutritional Risk Review, dated 03/12/19, documented Resident #1's weight was 171.6 pounds (#). The Usual Body Weight (UBW) was blank. The document noted Resident #1's meal and snack intake were varied and might not be adequate to meet needs for weight management. A nutritional supplement, Ensure, was added to her diet. The Dietary Admission Evaluation, dated 03/12/19, did not show documentation of the resident's UBW, ideal weight range, and weight history. The evaluation showed the foods the resident liked included eggs, juice, pork, poultry, beef, fruit, and cottage cheese. A review of Resident #1's Weight Summary showed the following: On 03/08/19, weight was 171.6#. On 03/10/19, weight was 171.0#. On 03/11/19, weight was 170.8#. On 03/26/19, weight was 150.0#, a 12.28% weight loss in 18 days. Progress notes, dated 03/09/19 to 03/29/19, documented Resident #1 frequently refused medications and meals, and experienced intermittent episodes of nausea and vomiting. Resident #1 was started on an oral appetite stimulant. Resident #1's care plan, dated 03/21/19, documented Resident #1 was at risk for dehydration due to poor/inconsistent fluid intake requiring encourage extra fluids throughout the day. The care plan did not document an individualized approach to address Resident #1's ongoing refusal of meals, recent weight loss, and personal food preferences. Progress notes, dated 3/29/19, documented Resident #1 was admitted to the hospital for [DIAGNOSES REDACTED]. The Emergency Department Report, dated 03/29/19, documented Resident #1 was observed with dry mucous membranes and required intravenous fluids. Resident #1's care plan, dated 04/07/19, documented Resident #1 had nutritional problems requiring regular diet, regular textures, and thin liquids; and to offer meal replacements if the resident ate less than 50% of her meals. On 04/09/19 at 7:00 PM, Resident #1 was observed interacting with staff. Staff C, Nursing Assistant, was observed encouraging Resident #1 to go eat ice cream in activities. Resident #1 was resistant at first, but then went with Staff C to the activity. At 7:10 PM, Staff C said getting Resident #1 to eat was challenging at each meal so they offered her food alternatives and she was eating cheese a lot lately. Staff C said she was unsure if Resident #1 had lost weight. On 04/10/19 at 10:05 AM, the resident's case manager, said she observed staff decline to assist the resident with meals because she doesn't eat anyway. The individual said Resident #1 lost 20 pounds and was admitted to the hospital. At 11:50 AM, Staff D, Nursing Assistant, said Resident #1 would often say she was not hungry so they offered other food alternatives, such as cheese. Staff D said she was unaware of Resident #1 losing weight and did not know what foods Resident #1 liked and disliked. At 2:13 PM, Staff E, Registered Nurse, said Resident #1 would often refuse to take her medications and had poor food and drink intake. Staff [NAME] said she was unsure if Resident #1 had lost weight, and stated, she can't imagine she hasn't. At 2:34 PM, Staff F, Dietary Manager, said they tracked weight loss each Monday, and she was sure they had discussed Resident #1's weight loss. When asked to provide the tracking for Resident #1, Staff F was able to provide the meal preference card, but no other weight loss tracking documentation. Staff F said Resident #1's likes and dislikes were on her meal preference card, but she was not responsible for updating care plans with nutrition and hydration needs. On 04/11/19 at 11:45 AM, Resident #1 was observed without having water or beverages in her room. Resident #1's family representative (FR) said she had not been asked about Resident #1's food preferences. The FR said Resident #1 had no issues eating prior to coming to stay at the facility. At 1:21 PM, Staff D said Resident #1 did not have water or fluids in her room. Staff D said Resident #1 should have a water pitcher in her room. At 1:31 PM, Staff A, Director of Nursing Services, said Resident #1 should have water in her room and should have an UDW on her assessment. At 2:28 PM, Staff B, Registered Nurse and Staff Development, said there was no UDW addressed on the nutritional assessment, the care plan lacked an individualized plan including food preferences, and no notification of weight loss was sent to dietary. Staff B said dietary staff did note updates on the care plan. Staff B said former Care Managers completed this task, but they no longer worked here. Staff B said this was overlooked. Reference WAC 388-97-1060 (3)(h)(i)

Based on observation, interview and record review, the facility failed to prevent the development of a pressure ulcer/pressure injury for 1 of 4 sampled residents (#2) reviewed for pressure ulcers. This failure placed residents at risk for development of pressure ulcers and a diminished quality of life. This caused harm to Resident #2. Findings include: Review of the facility's Skin Care Policy and Procedure and Skin Monitoring and Management (revised 06/2016), documented, It is the policy of this facility that: (1) A resident who enters the facility without pressure injury does not develop pressure injury unless the individual's clinical condition or other factors demonstrate that a developed pressure injury was unavoidable; and (2) A resident having pressure injuries receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable pressure injuries from developing. The Skin Monitoring and Management policy documented to complete Weekly skin check conducted by a licensed nurse. All residents will have a head to toe skin check performed at least weekly by a licensed nurse. Resident #2 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, a comprehensive assessment tool, dated 12/28/17, documented Resident #2 had moderately impaired cognition and required extensive assistance for activities of daily living, and had no pressure ulcers on admission to the facility. The resident's care plan, initiated 12/27/17, documented to complete weekly skin checks and that the resident required one staff participation in repositioning. The (MONTH) (YEAR) Treatment Administration Record did not show documentation for weekly skin checks. Review of the facility incident log documented, on 12/30/17 at 01:30 AM, Resident #2 had a blister on her heel. A nursing note, dated 12/30/17 at 05:55 PM, documented, (Nursing) was called into resident's room by therapy depart(ment) to look at resident's heel (due to) her complaining of pain in right heel. Upon examination pt (patient) has a 4 cm x 2.8 cm blister that is intact. On call Dr. contacted by phone. Daughter informed in person. A Care Plan, initiated 12/31/17, noted Resident #2 has actual impairment to skin integrity r/t intact blister bottom right heel (clear fluid filled). The Care Plan Goal stated, Skin injury of the intact 4 cm x 2.8 cm blister will be healed by review date. Interventions included, Encourage good nutrition and hydration in order to promote healthier skin; float heels; and slipper grip socks when out of bed. On 12/30/17 at 11:11 PM, nursing documented, Client has intact blister R (right) heel. Foot floated on pillow in bed. On 12/31/17, an order was written for nursing to apply skin prep to the bottom of Resident #2's right heel three times a day for skin integrity, and to float heels while in bed for skin integrity. Nursing documented Resident #2's right heel blister was intact on 01/01/18 at 03:11 PM and 01/02/18 at 06:33 AM, and on 01/03/18 at 07:40 AM documented, R(ight) heel blister intact at this time. DC (discontinue) alert charting at this time. On 01/03/18, the treatment order was changed to apply [MEDICATION NAME] to bottom of right heel three times a day for skin integrity, and to place pressure relieving boots while in bed every shift for wound healing. On 01/07/18 at 4:47 PM, nursing documented, Resident #2 .continues with [MEDICAL CONDITION] (swelling) to bilateral feet and ankles, more the right than left On 01/07/18 at 6:00 PM, nursing documented Resident #2 had [MEDICAL CONDITION] in bilateral feet. Elevating feet while in bed. On 01/09/18 at 10:54 AM, a Weekly Skilled Review note documented the use of pressure relieving boots while Resident #2 was in bed. On 01/12/18 at 04:06 PM, a Skin/Wound Note documented, Rt. Heel 2.5 cm diam(eter) with skin intact. Underlying color is dark brown. No pain with palpation. Painted with [MEDICATION NAME]. Heel relieving cushion in place and heels floated off of bed. On 01/19/18 at 04:32 PM, a Skin/Wound Note documented, Rt. heel currently 4.5 x 3.5 black, boggy, with skin intact. Painted with [MEDICATION NAME] and loose fitting socks applied .Heels elevated on pillows. On 01/22/18 at 04:15 PM, Resident #2's affected heel was observed with approximately a silver-dollar-sized circular area, skin appeared to be dark purple/black. LN was observed to apply [MEDICATION NAME] to area and apply pressure relieving boots to Resident #2's feet. Resident #2 denied pain in the heel at that time. On 01/22/18 at 5:15 PM, when asked about the blister on Resident #2's heel, the DNS stated, That one was acquired in-facility. Reference WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to provide adequate care and monitoring for 1 of 4 sampled residents (#1) reviewed for urinary catheter use. This failure placed residents at risk for development of a catheter injury and a diminished quality of life. This caused harm to Resident #1. Findings include . Review of the facility's Catheter Care Policy and Procedure (revised 06/2016) documented each resident with an indwelling catheter will receive catheter care daily and as needed, and use of a catheter strap to avoid tension on and in-and-out movement of the catheter. Resident #1 was readmitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The Minimum Data Set, a comprehensive assessment tool, dated 11/30/17, documented Resident #1 had moderate cognitive impairment, and required extensive assistance with activities of daily living. Review of Resident #1's care plan, dated 11/03/17, documented Resident #1 has pressure ulcer or potential for pressure ulcer development r/t (related to) disease process, hx (history) of ulcers, immobility, vascular insufficiency. A Care Plan, dated 11/20/17, documented Resident #1 had an indwelling catheter placed on 11/18/17 related to [MEDICAL CONDITION] and a history of urinary obstruction (inability to urinate). The goals identified documented, Will show no s/sx (signs or symptoms) of urinary infection through review date (02/07/18) and Will remain free from catheter-related trauma through review date (02/07/18). An physician order, dated 11/20/17, documented Resident #1 was to receive catheter care every shift and prn (as needed) every shift for [MEDICAL CONDITION]. A Weekly Skin Evaluation, dated 01/02/18 at 9:04 AM, documented, No new skin issues. Skin is warm, pink and dry. No open areas or s/sx infection . A nursing note, dated 01/02/18 at 08:56 PM, documented, While CNA (Certified Nursing Assistant) was giving peri/cath cares called LN (Licensed Nurse) into room. Noted penis with 4 x 2 cm opening with cath(eter) showing, then above that area 2 x 2 open area with cath showing, then head of penis split 3 cm. No drainage, slight redness from peri care and c/o (complaint of) discomfort only when washed. A nursing note, dated 01/02/18 at 9:07 PM, documented, Called (physician) notified him of open areas on penis, no new orders. Called Nursing director they are having wound rounds in am .Placed on alert to monitor and family notified. A nursing note, dated 01/03/18 at 04:12 AM, documented, . The end of penis is split open with catheter displaced and on posterior end of penis, with a smaller hole midway of penis. No pinkness, drainage. Foley (catheter) intact and draining medium color urine. Complaint of pain when touched. A nursing PRN Skin Evaluation, dated 01/03/18 at 6:25 AM, documented, .Posterior penis with 4x2 cm medial full thickness wound, proximal wound 2x2 cm full thickness and glans penis 3 cm full thickness - exudate scant serous, no redness, no pain. A Skin/Wound Note, dated 01/13/18 at 8:15 AM, documented, Noted penis with 4 x 2 cm opening with cath showing, then above that area 2 x 2 open area with cath showing, then head of penis split 3 cm. No drainage, no redness or signs of infection noted, rsd (resident) denies pain to area, referred to urologist for urgent need. Will update MD - and monitor on alert. A progress note, dated 01/03/18 at 8:50 AM by Resident #1's wound care provider, documented, .New wounds on patient's posterior proximal penis/[DIAGNOSES REDACTED]. Patient has foley catheter is in place which caused erosion of the patient's penile head. Just inferior to catheter erosion are 2 open areas that expose the patient's urethra allowing visualization of inserted catheter. Uncertain of what the causation of the two openings are other than possible soft tissue necrosis (death) due to bacteria or atrophy from catheter. No s/sx of infection at [DIAGNOSES REDACTED]. No pain at openings. No treatment necessary, but recommend urgent urology consult. Under Treatment Goals of the 01/30/18 progress note, the wound care provider documented, Healing is expected to be delayed due to identified factor(s): dementia/Impaired Cognition, Diabetic complicating factors, Impaired Mobility. The patient's wound(s) has fair healing potential; however slow progress is expected secondary to comorbidities. On 01/04/18, the urologist documented Resident #1 had severe penile erosion - glans to distal penile shaft approx. 4 cm split mid shaft - ventral erosion with catheter exposed. No evidence of [MEDICAL CONDITION] (skin inflammation). Evidence of poor catheter management. Recommend suprapubic (surgically placed catheter for long-term use) tube placement. On 01/04/18, nursing noted Resident #1's catheter stopped draining, thick yellow discharge was noted around the catheter and the resident developed pain in his left lower quadrant. A nursing transfer form, dated 01/04/18 at 10:11 AM, documented Resident #1 was sent to the hospital emergency room for evaluation of penile erosion/possible infection. At the hospital, Resident #1's catheter was removed and a new one placed. On 01/05/18, Resident #1's primary care physician (PCP) documented Resident #1's had (1) an ulcer of urethral meatus, (2) [MEDICAL CONDITION] (kidney infection), and (3) [MEDICAL CONDITION] (potentially life-threatening infection) without septic shock. The PCP documented Patient suddenly developed a splaying of his penis that appears related to foley pressure necrosis. On 01/22/18 at 01:15 PM, Licensed Nurse (LN) A said catheter care was usually provided by the CNAs, and nursing documents that it was done. When asked how nursing verifies catheter care was done, LN A said the CNAs communicate with the LNs. LN A stated Resident #1's catheter care was provided by LNs due to an active treatment order to apply ointment to the open areas. LN A said Resident #1 was scheduled to have a suprapubic catheter surgically placed later that week. At 1:40 PM, Resident #1's wound was observed while LN A provided catheter care and applied ointment per treatment orders, dated 01/17/18. When asked about pain at the site, Resident #1 stated it only hurt when they take care of it. Resident #1 rated his pain level at 08/10, and LN A gave the resident medication for pain. At 03:53 PM, LN B stated she was the nurse caring for Resident #1 when the wounds were first reported by the CNA during catheter care. LN B stated when she looked at the site, she saw the two erosions and then the split. LN B said, I was shocked. Yeah, I was shocked. I said, 'Is that his catheter?' You shouldn't be able to see it there. At 5:15 PM, the Director of Nursing Services (DNS) stated she had never seen anything like this before. The DNS stated she disagreed with the urologist's statement that the erosion was related to poor catheter care. WAC Reference 388-97-1060 (3)(c)

Based on observation, interview and record review, the facility failed to ensure hazardous chemicals and/or supplies were labeled and stored securely in 3 of 4 shower rooms, 2 of 2 soiled utility rooms and 1 of 2 central supply rooms; and that Safety Data Sheets (SDS) were accessible to staff. Failure to ensure residents were protected from accessing hazardous chemicals and/or supplies and staff having access to information on how to treat if exposure occurred placed residents at risk of injury. This failure resulted in an immediate jeopardy on 7/25/17. Findings include: On 7/25/17 at 9:33 a.m., the soiled utility room across from the Dietary Services office was noted to have a key pad entry lock and opened without entering a code. On the counter, just inside the door, was a spray bottle with a disinfectant label and another spray bottle with bleach written on it. There was no indication of the dilution of bleach or what to do if ingested or skin contact occurred. At 9:35 a.m., the shower room across from Room 48 was observed to be unlocked and had a cabinet on the wall with a key hanging from the side that was broken off. The cabinet was unlocked and contained a spray bottle with bleach water written on it. At 9:40 a.m., the shower room across from Room 44 was observed to be unlocked. The cabinet on the wall was unlocked and contained a spray bottle with bleach water written on it. At 9:57 a.m., the soiled utility room near Room 12 was observed to be unlocked. Two spray bottles were on the counter. One bottle was labeled disinfectant spray and the other had bleach written on it. At 10:15 a.m., the central supply room on E hall was observed to be unlocked. Razors, periwash, shaving cream and body wash were easily accessible at waist height. At 10:17 a.m., the shower room across from Room 15 was observed to be unlocked. The cabinet on the wall was unlocked with a broken key hanging next to it. The cabinet had a spray bottle with bleach written on it in pen. All of the unlocked doors had lever type handles that were easy to use and the doors opened easily. On 7/25/17 at 9:58 a.m., Laundry Worker (LW) A stated bleach bottles were kept in the locked cabinets in the shower rooms and disinfectants were in the soiled utility rooms At 9:59 a.m., Housekeeper (HSK) A stated cleaning supplies like bleach were labeled and locked in the shower rooms and only staff should have access to them. At 10:01 a.m., Nursing Assistant (NA) B stated some cleaning products were kept in the shower rooms and that everything was labeled and behind locked doors. She stated the shower rooms were not kept locked but there was a locked cabinet in there and the soiled utility rooms were locked. NA B also stated there was a hazmat book at the front desk. At 10:04 a.m., Licensed Nurse (LN) B stated the shower rooms were left unlocked and there may be some body wash left out but everything else should be left in the locked cabinet. LN B stated, Chemicals are locked in the soiled utility room so they are not accessible to residents. At 10:09 a.m., NA C stated the shower rooms were normally kept unlocked and the chemicals used to clean the shower chairs should be locked in the cabinet. When asked where cleaners were stored, NA C said, We keep a bottle of bleach water in the dirty utility room. It's behind a locked door. At 10:16 a.m., the Director of Nursing Services (DNS) stated the utility room doors should be locked. She reported there was a knob on the back of the key pad that could be turned to unlock it and staff should not unlock them. The DNS stated the shower room doors should be locked and if locks were broken maintenance should be notified right away to fix it. She stated the bleach was not labeled adequately and the SDS binder (contains information on how to manage spills and/or exposure to chemicals) was placed in the cupboard for staff to access. At 10:10 a.m., HSK B stated the soiled utility rooms had a key pad that kept them locked at all times and only staff should have access to them. At 10:55 a.m., when asked for the SDS for the facility, LW A went to the front nurse's station and was not able to locate them. LN B looked and was not able to locate the SDS binder. LW A stated, It's always been there .it's in a burgundy binder. I don't know where it went. Copies were provided from the SDS binder in the maintenance director's office. At 11:02 a.m., the DNS provided documentation the facility had 8 residents that had been assessed to be cognitively impaired and independent with mobility. Six of the eight resident rooms were within close proximity (within 2 rooms or closer) of the unsecured chemicals or supplies. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to provide the necessary care and services for adequate pain and Foley catheter management for 2 of 5 sampled residents (#72 & 108) reviewed for pain and urinary catheter use. These failures resulted in harm to Resident #72 when the facility did not provide ordered pain relieving measures to the resident for 6 days which resulted in increased and unrelieved pain, and resulted in harm to Resident #108 when the facility did not provide adequate catheter care and monitoring that resulted in pain, blood in the urine and signs of an abrasion. Findings include: 1) Resident #72 was admitted to the facility on [DATE]. The resident's Minimum Data Set (MDS), an assessment tool, dated 6/28/17, indicated the resident was cognitively intact and required two person extensive assistance with activities of daily living. On 7/25/17 at 5:14 p.m., Resident #72 was observed with a pained facial expression, squinted eyes and was groaning. When asked if she was having pain, the resident said her back hurt. At 5:15 p.m., when asked about the resident's pain, Licensed Nurse (LN) A said she had given Resident #72 Tylenol and would have to look to see how soon she could get more. At 5:25 p.m., the resident was observed with squinted eyes, groaning and said her back was hurting. The nurse was informed of the resident's pain. LN A told Resident #72 she would give her Tylenol as soon as she could. The resident's care plan included interventions for an alteration in comfort due to chronic back pain and decreased mobility. Planned interventions included repositioning, Tylenol and [MEDICATION NAME]es for her lower back. Review of the resident's Medication Administration Record [REDACTED]. Medication notes indicated the facility was waiting for the pharmacy to deliver the medication during that time. Resident #72's MAR indicated [REDACTED]. A pain level of 1-3 was considered mild pain; 4-5 was considered moderate pain; 6-9 was considered severe pain and 10 was considered excruciating pain. The MAR indicated [REDACTED]. A follow up note indicated the Tylenol had been ineffective to control the resident's pain. During the evening shift, it was documented the resident was experiencing moderate pain. On 7/24/17, the resident was experiencing moderate pain during the day shift. On 7/25/17, the resident was experiencing moderate pain on night shift. On 7/26/17, the resident was experiencing moderate pain on day shift and mild pain on night shift. On 7/27/17 at 1:51 p.m., when asked about Resident #72's [MEDICATION NAME]es, LN C said, We ran out. We were waiting for insurance approval. All we can do is advocate for the resident and call the doctor. LN C said he was unsure if anyone called the doctor to report the resident was without the medication and request an alternate medication. At 2:10 p.m., when asked about the resident's physical signs of and expressions of pain observed on 7/25/17 and the unavailability of the [MEDICATION NAME]es, LN A said, Oh, I didn't know it had been that long. That's too bad. At 2:15 p.m., LN D stated there had been communication between nursing and the pharmacy regarding the [MEDICATION NAME]es and there was no documentation anyone had called the doctor before July 26th to request a different type of patch or alternate medication. At 2:30 p.m., the Director of Nursing Services (DNS) said the doctor should have been called for an alternate medication sooner. On 7/28/17 at 10:44 a.m., the resident's family member said she noticed an increase in Resident #72's pain during the week she was without the patches and stated, the resident has been pretty uncomfortable and has been asking us to rub her back. 2) Resident #108 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], showed the resident had moderate cognitive impairment and required staff assistance with all activities of daily living. The urology consult and referral report, dated 7/18/17, showed Resident #108 was referred to an urologist due to Pain in groin, bladder and hematuria (blood in urine). The Urologist's findings included the resident's urine was blood tinged and the Foley catheter tubing was secured with significant traction to left leg - No slack. The glans (rounded portion of a penis) showed early signs of ventral erosion (type of abrasion). The provider documented the blood in the urine was most likely from prostatic irritation during transfers due to amount of tension on catheter. The Urologists recommendations/orders included: 1. Secure catheter with slack in tubing, no traction. 2. Alternate leg to secure catheter daily - this will reduce risk of further erosion. And 3. Monthly catheter changes and [MEDICATION NAME] (an antibiotic) with each catheter change. Review of the resident's order details, July Medication Administration Record [REDACTED]. Chart review showed the resident's urinary and foley catheter related care plans had not been updated to include the urologists new orders/recommendations. On 7/27/17 at 2:30 p.m., Licensed Nurse (LN) C stated it was the LN's responsibility to check each shift for correct leg strap placement and enough give in the catheter tubing so it would not be tugged on. At 4:20 p.m., LN G said upon returning from a doctor's visit, a resident's LN should look at the orders/recommendations and place them in the computer, notify the pharmacy, family or responsible party of any changes and update the resident's care plans (CP's) and Kardex (summary of care needs) for staff. At 4:37 p.m., the Director of Nursing Services (DNS) indicated there was a system for staff to follow through with consults to make sure things were done. The DNS said the LN who got the consult paperwork was to update the resident's CP. The drop was with the initial nurse not putting the orders in and the follow-up for double checking orders on the consult by the DNS and/or the RCM. The DNS identified the biggest fail in the system was there was no back up system in place if someone who needed to be involved in the process was out of the facility. Reference WAC 388-97-1060 (1)

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 discharged Residents (#1), who was identified at risk for skin breakdown and who developed pressure injuries in the facility, was assessed, monitored, evaluated and treated in a timely manner. Failure to assess, monitor, evaluate, prevent and/or promote prompt healing of existing pressure injuries resulted in harm to Resident #1. Findings include: discharged Resident #1 was admitted to the facility from the hospital on [DATE] after a fall at home where she incurred pubic and sacral bone fractures. Additional conditions included altered mental status, urinary tract infection [MEDICAL CONDITION] and [MEDICAL CONDITION]. The resident required extensive assistance with transfers, mobility and dressing/grooming. She was assessed at moderate risk for skin breakdown. According to hospital transfer records dated 11/24/15, the resident had redness to her coccyx at the time of transfer to the facility. The facility's admission assessment indicated no skin issues. On 5/26/16 review of the record indicated the resident was sent to the physician's office for a routine visit on 1/13/16. The physician documented finding 2 pressure ulcers-Allevyn (special dressing), one dressing to each (left and right) buttocks--needs better dressing--needs daily checks plus prevention . On 1/19/16, the resident's coccyx wound measured 1.5 x 1 cm and the resident was placed on an air bed and cushion to her wheelchair. On 1/26/16 the injury was determined to be unstageable; measured 2 x1 cm with slough (Slough (dead tissue) is indicative of Stage III or Stage IV pressure ulcers and when a large amount of slough is present and obscures the wound bed, the wound is unstageable). On 2/2/16, the coccyx area measured 2 x 2 cm with blackish/brown slough/eschar (dead tissue) to wound bed and continue to wait for MD response in regards to wound clinic referral in previous week . The skin assessment dated [DATE] at 7:35 a.m. and 10:55 a.m., indicated the physician was notified of the odor to the coccyx wound. At 3:20 p.m., the nursing note (NN) indicated the resident was found to have cloudy, foul urine odor and wound on coccyx noted to have an odor and the right elbow was found to have a small open area with a screw visible (from previous surgery in 2012). On 2/4/16 at 4:00 p.m., the NN indicated the unstageable pressure ulcer measured 2 x 2 x 0.2 depth with increased drainage and odor and a right elbow screw was found exposed in an area 0.5 cm diameter with serous drainage, hard redness surrounding the area. The resident had a low grade temperature of 99.4. The record indicated the physician agreed to send the resident to the emergency room (ER) for evaluation on this day and wrote a note to make sure that the ER looked at the resident's elbow, buttocks and checked the urine. According to the ER records, the resident arrived on 2/4/16 at 4:03 p.m. and was found with profound [MEDICAL CONDITION] (decline in alertness/lethargy) since this past Monday (2/1/16). And, Today the patient was found to be very unresponsive and to have a very swollen [DIAGNOSES REDACTED]tous (red) and warm appearing right elbow . The resident had a low grade fever of 100.4 and blood pressures that trended downward from 139/68 to 96/50 .due to [MEDICAL CONDITION] secondary to UTI and infected elbow and toxic metabolic [MEDICAL CONDITION] (decreased alertness). The resident had a white blood count of 14,000 (reference range was 3.6 - 10.8) and a temperature of 100.4 indicating infection. The ER physician note indicated: The patient has an unstageable pressure wound to her coccyx .likely Stage III or Stage IV .full thickness with some superficial skin breakdown to this area measuring 4 cm x 3.5 cm (double the size of the facility measurements) with surrounding redness and black eschar .wound clinic consulted .will debride (remove dead tissue) coccyx and place a wound V.A.C. (device/therapy that delivers negative pressure (a vacuum) at the wound site through a patented dressing, that helps draw wound edges together, remove infectious materials to promote healing). The note continued: .appears to have a pressure ulcer on the olecranon (boney prominence of the elbow) and pus . The resident's urine showed white cells that were too numerous to count (reference range 0-5) indicating infection. The toxic [MEDICAL CONDITION]ly due to the infections .she is dehydrated and will continue IV (intravenous) fluids . The hospital records indicated the resident underwent [REDACTED]. The resident was ordered to receive high dose IV (intravenous) antibiotics daily for 4 weeks and was scheduled for frequent wound clinic visits. On 5/26/16 at 3:30 p.m., during interview with Licensed Nurse (LN) A and the Director of Nursing Services (DNS), they were unable to provide documentation to indicate staff found the coccyx wounds prior to the resident's routine visit to the physician and there were no records found to indicate the physician had been contacted related to the wound clinic referral dated 1/26/16 and/or if the physician responded to the request. Failure to recognize and assess the need for timely care/treatment of [REDACTED]. At the time of this current investigation, the facility had taken corrective measures and no current violations of F 314 Pressure Sores was evidenced.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were protected from physical abuse including rough handling for 1 of 4 current sampled residents (#82) reviewed for abuse. This failure placed residents at risk for exposure to potentially rough handling and a diminished physical, mental and psychosocial well-being. This failure resulted in harm to Resident #82 when she sustained bruises on her right wrist and hand. Findings include: Resident #82 was admitted to the facility on [DATE] with multiple diagnoses. The resident's Minimum Data Set, an assessment tool, dated 07/20/15, indicated the resident was alert and oriented, and required extensive assistance with activities of daily living. On 09/09/15 at 3:41 p.m., Resident #82 was observed with bruising on her right wrist and hand. The discoloration was in the location of the right wrist of approximately 7-8 centimeters (cm) wide and 7-8 cm long wrapping around the wrist on top of the hand. The discoloration was purple and red in color, and in the shape of finger tips on the inside of the wrist. When asked about the bruising on the resident's wrist and hand, Resident #82 stated, Some of the young ones (staff) get frustrated easily, and will sort of yank the old people around. The resident said sometimes she felt disrespected. On 09/10/15 at 3:45 p.m., Resident #82's wrist and hand were observed and the discolored areas were more visible with the same shape and color as observed on 09/09/15. When asked what happened to her wrist and hand, the resident said a staff member was trying to turn her over. The resident indicated due to her size, they were having a difficult time and grabbed her wrist, and that is how the bruise happened. Resident #82 said, They got ahold of my arms and yanked me over. The resident stated, One time I was breathing my nebulizer, and they (staff) said I don't need to do that now, and one of them snatched it out of my hand. That is how I got one of the bruises on my hand, they grabbed my arm and yanked it from me. Resident #82 said, I talked to (the Director of Nursing Services (DNS)), and she said she would talk to all the staff and tell them to be gentler. The resident did not want to identify the staff members who were working with her, and stated she didn't want to be a tattle-tell. On 09/11/15 at 10:15 p.m., a progress note documented, Note text: Bruise noted on right wrist-reddened in color. 7 x 8.5 cm. No c/o (complaints of) pain or discomfort. Husband and MD (physician) notified of bruise. Placed on alert status. On 09/14/15 at 10:09 a.m., when asked about the bruising to Resident #82's wrist and hand, the DNS indicated she was working on an incident report regarding the bruising. On 09/23/15 at 10/20 a.m., the DNS stated the bruise came to her attention when a surveyor asked her about the bruise toward the end of the day on 09/11/15, and an investigation was started. There was no evidence the facility recognized the bruising to the right wrist and hand of Resident #82 could have been due to the rough handling by staff.

Based on interview and record review, the facility failed to ensure necessary care and services were provided for 1 of 5 Residents (#1). Failure to identify, review and act on an assessment and evaluation from a physician resulted in overlooking a referral for a vascular consult. This failure placed the resident at actual delay in treatment. Findings include: All interviews took place on 12/12/2014 unless otherwise stated. Resident #1 was admitted to the facility 6/24/2014. He had [DIAGNOSES REDACTED]. These blisters would fill with blood tinged fluid and had a high risk of becoming necrotic areas. The resident had a history of [REDACTED]. Resident #1 also had [DIAGNOSES REDACTED]. Resident #1, according to the Minimum Data Set (MDS - assessment tool) was alert but could not make his own health care decisions. The resident was dependent on staff members for all care needs. Documentation indicated the resident's family visited the resident frequently and participated in the resident's care. On 11/13/2014 a physician evaluated the resident's feet and documented abnormal findings to include temperature changes, [MEDICAL CONDITION] of the left foot, ulcerations and eschars (scabs) to right foot, absent pulses on both right and left feet. Advanced changes were also noted to include absent hair growth, palor, thin, shiny skin, and redness. Recommendations included a vascular consult. The facility did not review the 11/13/2014 evaluation and recommendations when it arrived to the facility (date unknown). Interview with a Licensed Nurse Staff member (#A) stated the process of making a referral would include Social Services coordinating the appointment and transportation to complete the referral. The Social Services Staff member stated the referral was not reviewed. Interview with Licensed Nurse Staff (#B) revealed the document from the physician arrived to the facility (date unknown) and was filed in the resident's record without it being reviewed by a Licensed Nurse. The referral was not made. The resident did not have a vascular consult. A facility document (dated 12/7/2014) indicated two newly developed necrotic areas were found upon assessment on the 1st and 2nd toes of Resident #1's left foot. The resident was transported to a hospital for evaluation and treatment of [REDACTED]. .