Every finding on record at Panorama City Conv & Rehab CTR

Based on observation, interview, and record review, the facility failed to monitor medical devices to prevent pressure related injuries for 2 of 4 residents (Residents 3 and 7) when reviewed for pressure injuries. Resident 3 experienced harm when they developed avoidable pressure ulcers to both heels and their left calf, related to lack of monitoring of a medical device (E-Z boot - plastic splint designed to stabilize the foot and ankle, preventing rotation and contracture with a soft, fleece-lined interior, non-skid base, and hook-and-loop velcro closure - also called a podus Boot). This failure placed residents at further risk for avoidable pressure injuries. Findings included. Review of the facility policy titled Management of Braces and Splints last reviewed 01/06/2026, showed Braces and splints shall be used only with appropriate clinical justification, proper authorization, and ongoing monitoring to prevent complications such as (including but not limited too) skin breakdown. It further showed Orders must include: Type of brace or splint, Body part affected. Purpose/medical indication, Schedule for use (e.g., wear times, removal times) and any specific precautions or care instructions.Review of the electronic health record (EHR) showed Resident 3 was admitted to the facility on [DATE] with diagnosis of left hip fracture. The resident was able to make needs known. Review of the admission minimum data set assessment (MDS) dated [DATE] showed Resident 3 was at risk for pressure injury and had no current pressure injuries. Resident was not identified as having an orthotic device/brace. Review of the care plan showed an entry for risk for pressure ulcer, dated 10/08/2025, with two interventions documented for a Braden skin assessment and to apply barrier cream to peri area.Review of the EHR showed a progress note, dated 11/07/2025, showed Was notified by staff of pressure injuries to both heels with the left heel injury larger with skin around it not blanching with a round hard area in the middle. [Resident 3] was wearing [their] own shoes at the [time] with [them] complaining that the orthotic [sole inserts] both makes them very tight and puts pressure on [their] heels. [They] also has been wearing [E-] Z boots in bed with them fitting poorly and having been found to be put on improperly at times.Review of the provider orders showed Resident 3 was prescribed an antibiotic on 11/18/2025 for a wound infection to the left lower leg.Review of the skin assessment, dated 12/18/2025, showed a new medical device related pressure injury to the left lower leg that was red and non-blanchable (did not change color when pressed) this was not related to the orthotics, what was the medical device that caused the injury to the left lower leg, the E-Z boot.Review of the wound care providers consultation, dated 01/06/2026, showed a medical device related pressure injury to the left lower leg that was covered in eschar (hard, black, dead or dying tissue).Review of the skin assessment, dated 01/22/2026, showed a medical device related pressure injury to the left calf with a start date of 12/18/2025. The document showed slough (white or yellow dead tissue) was present and drainage.Review of the care plan showed an entry for pressure injury left heel and lower leg dated 01/16/2026, with interventions for referral to wound provider, there was no care plan entry found in the EHR for E-Z boots.Review of the provider orders on 01/22/2026 showed no orders in place to monitor and manage the E-Z-boot.During an interview and observation on 01/26/2026 at 10:58 AM, Resident 3 stated they wore a boot on the left ankle when in bed and they didn't fit good. Resident 3 said they used to wear the sole inserts inside their shoes but the shoes were too tight and caused the heel wound. There was a hard plastic boot device with a soft insert noted on the bedside table (E-Zboot). The resident had on the right shoe; the resident was wearing a sock with the left foot resting on a pillow. When asked if the resident had pain Resident 3 stated yes, my leg hurtsDuring an interview on 01/26/2026 at 11:07 AM, Staff H, Certified Nursing Assistant (CNA) stated Resident 3 was wearing the E-Z boot that morning when she got her out of bed and she removed it. When asked where they find out when to put the boot on or take it off Staff H stated its should be on the Kardex (care directions). Staff H reviewed the Kardex with this surveyor and stated the boot was not on the Kardex.Resident 7Review of the EHR showed Resident 7 admitted to the facility on [DATE] with a diagnosis of severe malnutrition. The resident was able to make needs known.During an interview and observation on 01/23/2026 at 9:52 AM, Resident 7 sat in their wheelchair at the bedside, a left ankle brace and right finger splint was observed, Resident 7 stated they wear the ankle brace so they can walk and the finger brace to help straighten their finger. The resident removed the finger brace and a red area was noted to the knuckle.Review of the EHR on 01/23/2026 showed no care plan / Kardex entry for the ankle brace or the finger splint and no provider orders for when to put them on, take them off or check the skin under them.During an interview on 01/26/2026 at 11:19 AM, Staff I, CNA, stated they helped Resident 7 put the ankle brace on every morning and it should be on the Kardex.During an interview on 01/26/2026 at 9:33 AM, Resident 7 stated they had been wearing the foot brace and finger splint for a couple weeks. Resident 7 stated staff did not take them off during the day.During an interview on 01/26/2026 at 9:19 AM, Staff J, Resident Care Manager, stated it was their expectation that braces and splints be included in the ADL care plan / Kardex and Resident 3's E-Z boot and Resident 7s brace and splint should have orders for when to put them on and take them off and to monitor for skin breakdown. During an interview on 01/26/2026 at 11:35 AM, Staff K, Director of Rehabilitation Services stated the therapy department provided a wear schedule and recommendations when a resident was given a brace or a splint and it should be added to the care plan and orders for staff to follow. During an interview on 01/26/2026 at 1:04 PM, Staff B, Director of Nursing Services stated it was their expectation that braces or splints have orders in place for when to put them on and take them off and to check the skin under them and if the CNAs were placing them or taking them off it should be included in the care plan or Kardex.Reference WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to ensure the dishwasher was cleaning dishes at required temperatures for 1 of 1 kitchen dishwashers reviewed under kitchen task. This failure created the potential to expose residents to unsanitary conditions and increased risk of foodborne illness. Findings included .On 01/26/2026 at 9:55 AM, during a kitchen observation, review of the Food Services Department Daily Dish Machine Temerature Log documented, Wash Cycle must reach a temperature of 150-160 degrees Fahrenheit. Rinse Cycle must reach a temperature of no less than 180 degrees. Please report temperature outside of the required range to your Supervisor immediately. The flowing days were listed outside the required temperature ranges:01/05/2026 PM Wash 145 degrees01/10/2026 AM Rinse 179 degrees01/11/2026 AM Rinse 172 degrees01/12/2026 AM Rinse 179 degrees01/13/2026 PM Rinse 145 degrees01/14/2026 PM Rinse 145 degrees01/18/2026 AM Rinse 179 degrees01/18/2026 PM Rinse 145 degrees01/19/2026 PM Rinse 145 degrees01/20/2026 AM Wash 142 degrees01/20/2026 PM Rinse 145 degrees01/21/2026 PM Rinse 145 degrees01/22/2026 PM Rinse 145 degreesAnd were missing entries on 01/23/2026 PM, 01/24/2026 PM and 01/25/2026 AM. On 01/26/2026 at 9:59 AM, Staff D, Food Service Manager, confirmed the required temperature for the wash cycle was 150-160 degrees and the rinse cycle was greater than 180 degrees. Staff D said if it was outside the range staff should have notified the supervisor. When asked about the out of required ranges/missing temperatures, Staff D said they had not been notified of any out of range temperatures and staff should have notified them. When asked how would staff know if the dishes had been adequately cleaned, Staff D said they would not know. Reference WAC 388-97-1100 (3), -2980

Based on interview and record review, the facility failed to implement an effective Antibiotic Stewardship Program, to promote appropriate use of antibiotics, reduce the risk of unnecessary antibiotic use and decrease the development of adverse side effects and antibiotic resistance for 3 of 3 residents (Residents 3, 5 and 130) when reviewed for antibiotic stewardship. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics. Findings included.Review of the facility policy titled Antibiotic Stewardship last reviewed 01/5/2026, showed The facility practices the core elements of antibiotic stewardship, outlined by the Centers for Disease Control and prevention. The nurse will utilize McGeer constitutional infection criteria protocol to determine if it is necessary to treat with antibiotics and notify the provider of the results of diagnostics to ensure the resident is taking the appropriate antibiotic or if the antibiotic needs to be discontinued or changed. In the event that the prescribing physician orders an antibiotic without identification of infection criteria the provider will be requested to identify rationale for ordered antibiotic.Review of the facility documentation of McGeer criteria for urinary tract infection (UTI) showed a positive urine culture would have 100 thousand Colony forming units (CFU) of no more than two organisms and reports of fever, pain with urination, hematuria (blood in urine), incontinence (unable to prevent leaking urine), urgency and/or frequency.Resident 3Review of the electronic health record (EHR) showed Resident 3 was admitted to the facility on [DATE] with diagnosis of left hip fracture. The resident was able to make needs known.Review of the EHR showed Resident 3 had reported pelvic pain and was prescribed Cipro (an antibiotic) on 01/02/2026 through 01/06/2026 for a UTI.Review of the lab results for urine collected on 12/30/2025 showed 10-25 thousand CFU of a bacteria and 25 - 50 thousand CFU of yeast.Review of the infection tracking dated 12/31/2025 showed in order to meet criteria for antibiotic use there should be at least 100 thousand CFU of no more than two microorganisms, UTI should be diagnosed when there are localizing genitourinary signs and symptoms and a positive urine culture result. Further reviews showed the resident had no genitourinary symptoms.Review of the EHR on 01/26/2026 showed no documentation of an antibiotic time out or the rationale for continued use of the antibiotic.Resident 5Review of the EHR showed Resident 5 admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with a diagnosis of pubic bone fracture. The resident was able to make needs known.Review of the urinalysis lab report dated 12/16/2025 showed 10 to 20 thousand CFU of an organism, provider had notated on the lab slip likely not a UTI on 12/19/2025.Review of the infection tracking dated 12/17/2025 was blank and not assessed for criteria.Review of the EHR showed the resident had reported pelvic pain and was having increased agitation and was prescribed an antibiotic on 12/18/2025. The resident was sent to the emergency room on [DATE] and was found to have a pelvic fracture and a UTI and returned to the facility on [DATE].Review of the provider orders showed a new order for antibiotic therapy with a start date of 12/23/2025 through 12/30/2025.Review of the EHR on 01/26/2026 showed no documentation of an antibiotic time out or the rationale for continued use of the antibiotic.Resident 130Review of the EHR showed Resident 130 admitted to the facility on [DATE] with a diagnosis of multiple sclerosis (disease that affects the central nervous system). The resident was able to make needs known.Review of the provider's orders showed an order for Bactrim (an antibiotic) for 7 days with a start date of 11/20/2025.Review of infection tracking for Resident 130 dated 12/19/2025 showed did not meet criteria for antibiotic use.Review of the EHR showed a provider order for an antibiotic dated 12/20/2025. Progress note review showed this order was phoned in by an outside provider on 12/19/2025.Review of the EHR on 01/23/2026 showed no infection tracking/assessment was completed and no urine lab tests were included in the EHR for this antibiotic.Review of the EHR on 01/26/2026 showed no documentation of an antibiotic time out or the rationale for continued use of the antibiotic.During an interview on 01/27/2026 at 1:18 PM, Staff G, Registered Nurse/Infection Preventionist (RN/IP) stated Resident 130 was having an increase in behaviors and was prescribed the antibiotic on 12/19/2025 and a urinalysis was not done. Staff G stated all new antibiotics should have been reviewed for appropriateness. Staff G stated they did not have access to review labs done outside of the facility and should so they can review for appropriateness. There should be an antibiotic time out and documented rationale for continued use of antibiotics.During an interview on 01/27/2026 at 12:24 PM, Staff B, Director of Nursing Services stated it was their expectation that the Infection Preventionist and Providers follow their antibiotic stewardship policy. Reference WAC 388-97 -1620(2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure psychotropic medications (any drug that alters the brain affecting mood, behavior, perception and thought processes) were regularly monitored and documented on and gradual dose reduction (GRD, psychotropic medication decrease) had adequate indication for noncompletion for 2 of 5 sampled residents (Resident 40 & 85) reviewed for unnecessary medication. This failure placed residents at risk of unnecessary medication usage and a diminished quality of life. Findings included .Resident 40 Resident 40 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS), dated [DATE], documented Resident 40 was severely cognitively impaired. A physician's order, dated 11/22/2025, for Trazadone (antidepressant) 12.5 milligrams was prescribed for insomnia. A physician's order, dated 01/15/2026, for Trazadone (antidepressant) was increased to 25 milligrams daily for insomnia. The electronic health records (EHR) showed no documentation of side effect monitoring or target behavior monitoring for the medication. On 01/26/2026 at 9:04 AM, Staff C, Nurse Manager/Licensed Practical Nurse, reviewed January 2026's Medication Administration Record (MAR) and the Treatment Administration Record (TAR) and confirmed Resident 40 had received the medication and the increase in January 2026. Staff C was asked to find the side effect and target behavior monitoring for the medication. Staff C reviewed the EHR and confirmed there was no documentation of side effect and target behavior monitoring and said there should have been. On 01/26/2026 at 9:17 AM, Staff B, Director of Nursing Services (DNS), said to administrator a psychotropic medication, the facility must obtain a diagnosis, order, follow up and side effect and target behavior monitoring must be in place. Staff B reviewed January 2026's MAR and TAR. When asked if there should have been side effect and target behavior monitoring, Staff B would not answer the question directly but said they would have to check on that because the justification for use was insomnia, not mental health. No further answer was provided. Resident 85Resident 85 was admitted to the facility on [DATE]. Review of the Annual MDS, dated [DATE], showed the resident was cognitively intact with clear comprehension and expressed/communicated needs without difficulty. The MDS Pain Assessment Interview, showed Resident 85 received as needed (PRN) pain medication, no routine pain medication, and experienced pain/hurting rarely or not at all during the assessment period. Record review showed Resident 85 had the following orders for pain control.a) Duloxetine (an antidepressant) 60 milligrams (mg) at bedtime for pain related to polyneuropathy (disease affecting peripheral nerves in both sides of the body, causing weakness, numbness, and pain), dated 07/01/2025.b) Acetaminophen 650 mg every four hours PRN for pain from 1-10 on a scale to 10. A Consultant Report dated 10/02/2025, showed the pharmacist identified Resident 85 had received duloxetine 60 mg daily for polyneuropathy, since the previous dose increase on 07/01/2025. Due to Resident 85's creatinine clearance (lab test that measures how well ones kidneys are filtering waste from the blood) of 28 milliliters per minute ( ml/min, normal creatinine clearance levels for women typically range from 70 - 115 ml/min) performed on 08/14/2025, the pharmacist recommended the provider consider tapering the duloxetine to 40 mg at bedtime for one week, then 30 mg at bedtime for one week, then 20 mg at bedtime for one week and then discontinue. The rationale provided was to avoid accumulation of duloxetine and its metabolites (the substances a medication is broken down into through metabolism). The pharmacist documented that the use of duloxetine should be avoided in patients with severe kidney disease. On 10/06/2025 the provider declined the pharmacist's recommendation and cited a prior failed GDR of Resident 85's duloxetine. At the bottom of the consultant report a facility nurse documented Resident 85 had a failed GDR on 07/01/2025. A nurses note, dated 05/09/2025 at 1:59 PM, documented the provider approved a pharmacy recommendation to perform a GDR of Resident 85's duloxetine and wrote an order to decrease the duloxetine from 60 mg at bedtime to 40 mg, secondary to poor kidney function. The note documented that Resident 85 was placed on alert charting to monitor their response to the dose reduction. Review of the April and May 2025 MARs showed Resident 85's duloxetine was decreased from 60 mg to 40 mg at bedtime on 05/09/2025 as ordered. Review of Resident 85's PRN acetaminophen use showed it was administered six times during the 16 days that preceded the dose reduction (04/23/2025, 04/26/2025, 04/28/2025, 04/29/2025, 05/01/2025 and 05/07/2025) and four times in the 22 days after the 05/09/2025 GDR of the duloxetine. Review of the June 2025 MAR showed Resident 85 was administered PRN acetaminophen 12 times in 30 days. Nurses' documentation showed the acetaminophen was effective in managing Resident 85's pain. Review of the nurses' notes/provider notes from 05/09/2025 - 06/30/2025 (52 days) showed there was no documentation that Resident 85 had complained of increased or poorly controlled pain, or that the PRN acetaminophen was ineffective in managing their break-through pain A nurses' note, dated 07/01/2025 at 1:01 PM, documented Resident 85's GDR of duloxetine had failed, and their previous dose of duloxetine 60 mg at bedtime would be reinstated. On 01/27/2026 at 11:11 AM Staff B, DNS, was asked to provide the documentation /assessments that the facility's interdisciplinary team used to determine Resident 85's GDR of duloxetine had failed. On 01/27/2026 at 11:53 AM, Staff B, DNS, provided a Social Services note, dated 06/30/2025, that documented during a care conference on 06/30/2025, the resident reported increased neuropathy pain at night. The note indicated the Unit Manager would notify the provider. On 01/27/2026 at 11:53 AM, Staff B, DNS, also provided a fax communication form addressed to the provider, dated 06/30/2025, which stated the following [Resident 85] is reporting increased pain since the GDR of her duloxetine from 60 mg QD [every day] to 40 mg QD. She would like her previous dose of 60 mg reinstated after this failed attempt at dose reduction. Further review of the document showed it was signed by the provider on 07/01/2025, who hand wrote on it Agreed. On 01/27/2026 at 1:10 PM, Staff B, DNS, was asked if they could find any documentation in the EHR, given Resident 85 was placed on alert charting for staff to assess, monitor, and document their response to the GDR, that would support the facility's determination that Resident 85 had a failed GDR of their duloxetine (e.g., nurses notes, interdisciplinary notes, pain assessments/ monitors, provider notes/assessments, or provider communications etc.), or whether Resident 85's one time statement that they had increased neuropathy pain at night, provided during a care conference 52 days after the GDR of the duloxetine, was the sole determinant used to conclude and document in the record that Resident 85 had a failed GDR of their duloxetine, Staff B, DNS, said he felt Resident 85's statement that they had increased neuropathy pain at night, request that the previous duloxetine dose of 60 mg be reinstated, and the fact the provider ordered the duloxetine to be increased back to 60 mg at bedtime, was enough to show that it was a failed GDR. Reference WAC 388-97-0620 (1)(a)

Based on interview and record review the facility failed to ensure care and services were provided in accordance with professional standards for 1 of 6 residents (Resident 49) when reviewed for bowel management. This failure placed the residents at risk for medical complications, poor clinical outcomes and a decreased quality of life. Findings included.Review of the electronic health record (EHR) showed Resident 49 admitted to the facility on [DATE] with diagnoses of dementia (a group of symptoms that effects memory) and adult failure to thrive. The resident was able to make needs known.During an interview on 01/23/2026 at 10:06 AM, Resident 49 stated they were given medicine to soften their stools and staff didn't tell them what they were getting. Resident 49 stated they had been having loose stools every day and did not want the medicine.Review of the EHR showed Resident 49 had been documented as having 14 soft stools and eight loose stools over the prior 24 days. Review showed the resident had two extra-large loose stools on 01/17/2026.Review of the provider's orders showed an order for Loperamide (a medicine to help with loose stools) three times daily as needed for loose stools. An order for magnesium oxide (a medication known to promote bowel movements) daily and an order for Senna (a laxative medication) twice a day for constipation and to hold (not give) for loose stools and notify the provider.Review of the January 2026's medication administration record (MAR) showed the resident had refused the evening dose 18 times and refused the morning dose twice in last 24 days.Review of the EHR showed no documentation that the provider was notified of Resident 49's loose stools or refused medications. There was no documentation that the medications were held.During an interview on 01/26/2026 at 9:39 AM, Staff L, Licensed Practical Nurse (LPN) stated they would talk with the resident and find out why they were refusing and would notify the provider. If the resident was having loose stools, they would hold the bowel medications and let the provider know.During an interview on 01/26/2026 at 9:16 AM, Staff J, Resident Care Manager stated it was their expectation that the staff should hold bowel medications and notify the provider if a resident was having loose stools or refusing medication consistently.During an interview on 01/26/2026 at 1:09 PM, Staff B, Director of Nursing Services stated it was their expectation nursing staff would have held bowel medications, notified the provider and documented in the EHR using an SBAR (SBAR, a form to communicate to providers that outlines situation, background, assessment, and request) if a resident was having loose stools and refusing their bowel medications.Reference WAC 388-97 -1060(1)-(3)

Based on interview and record review, the facility failed to report allegations of abuse and injuries of unknown origin timely to the State Agency for 2 of 3 residents (Resident 1 & 2) reviewed for abuse and injuries of unknown origin. This failure placed residents at risk for repeated incidents, unmet care needs and unidentified abuse and/or neglect. Findings included .<Resident 1>Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (A stroke) and neurological disorder. The Minimum Data Set (MDS), an assessment tool, dated 05/18/2025, documented Resident 1 had moderate cognitive impairment and was dependent on staff with some activities of daily living (ADLs).Progress notes, dated 06/13/2025, documented during a physician's examination, Resident 1 was found with healing fractures of the right second, third, fourth, and fifth ribs. No source of the injury was identified in the progress notes.The facility investigation, dated 06/13/2025, was blank.The facility submitted the allegation to the State Agency on 06/19/2025.On 07/18/2025 at 1:20 pm, Staff B, registered nurse and Director of Nursing, verified the allegation was not reported timely and said allegations should be reported within 24 hours. <Resident 2>Resident 2 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease. The MDS, dated [DATE], documented Resident 2 had moderate cognitive impairment and was dependent on staff with some ADLs.Progress notes, dated 06/10/2025, documented at noon of the same day Resident 2 reported an allegation of sexual abuse by staff. Resident 2 reported a staff member told the resident he loved the resident, stating they were beautiful then showed Resident 2 his penis.Progress notes, dated 06/11/2025 at 5:13 pm, documented after completing investigation, [Resident 2's] accusation was called in to the state.On 07/18/2025 at 1:20 pm, Staff B said all staff are mandated reporters and the allegation should have been reported timely. Staff B said allegations should be reported within 24 hours to the State Agency. Reference WAC 388-97-0640(5)(a) (6)(c)

Based on interview and record review, the facility failed to complete a thorough investigation to rule out abuse or injuries of unknown origin for 2 of 3 residents (1 & 3) reviewed for abuse or injuries of unknown origin. Failure to conduct a thorough investigation placed the residents at risk for unidentified abuse or neglect, poor clinical outcomes and a decreased quality of life. Findings included .<Resident 1>Resident 1 was admitted to the facility on [DATE] with diagnoses including cerebral vascular accident (A stroke) and neurological disorder. The Minimum Data Set (MDS), an assessment tool, dated 05/18/2025, documented Resident 1 had moderate cognitive impairment and was dependent on staff with some activities of daily living (ADLs).Right shoulder dislocationThe facility investigation, dated 05/14/2025, documented Resident 1 was found to have an anterior subluxation of the glenohumeral joint (a dislocation of the shoulder). Resident 1 required surgery for the injury. The investigation did not reveal a source of the injury. The investigation did not include interviews from the resident, staff who cared for the resident, or other residents.Right rib fracturesProgress notes, dated 06/13/2025, documented Resident 1 was found healing fractures of lateral right second, third, fourth, and fifth ribs during a physician's examination. No source of the injury was identified in the progress notes.The facility investigation, dated 06/13/2025, was blank. The investigation did not reveal a source of the injury. The investigation did not have a summary of the timeline of the injury. The investigation did not include interviews from the resident, staff who cared for the resident, or other residents.On 07/18/2025 at 1:20 pm, Staff B, registered nurse and Director of Nursing, said he never thought of interviewing other residents with allegations such as Resident 1's. Staff B said there should be staff interviews. <Resident 3>Resident 3 was admitted to the facility on [DATE] with diagnoses including dementia and mood disturbances. The MDS, dated [DATE], documented Resident 3 had moderate cognitive impairment and was dependent on staff with some ADLs.The facility investigation, dated 06/19/2025, documented Resident 3 reported a staff member made comments about the resident's body calling them fat and saying the resident had a big, beautiful booty. The investigation did not include interviews with a sample of residents for whom the named staff member provided care.On 07/18/2025 at 1:20 pm, Staff B said the investigation should include interviews with sample residents. Reference WAC 388-97--0640 (6)(a)(b)

Based on observation, interviews and record review, the facility failed to provide the two staff person assistance and use of a gait belt for transfers as required according to the plan of care for 1 of 3 sampled residents (Resident 1) reviewed for falls. Resident 1 experienced harm when they fell and sustained a head laceration when staff transferred them without a second staff person to assist and properly support resident with a gait belt. This failure placed residents at risk for falls with injury, pain and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease and kidney disease. The quarterly minimum data set (MDS) an assessment tool, dated 02/26/2025, documented Resident 1 has moderately impaired cognition and was dependent on staff for all activities of daily living (ADLs). The Care Directive, dated 08/13/2024, documented Resident 1 required a sit-to-stand (a device which mechanically assists a resident to stand) for morning cares. Resident 1 required two staff, using a gait belt, for transfers throughout the day. The facility investigation, dated 03/23/2025, documented Resident 1 was on the floor in their bathroom. Staff responding noted there was no wheelchair, walker, gait belt or sit-to-stand near the bathroom. The resident was observed on the floor in the bathroom, laying on her back on the right side. Blood was coming out of the resident's head. 911 was called and the resident was transported to the hospital. Resident 1 required eight staples to a laceration on the head, measuring 2 x (by) 5 centimeters (cm). The resident had bruising to the right shin measuring 4 x 3.5 cm, to the left shin measuring 4 x 3.5 cm, and right forehead measuring 6 x 7 cm. The root cause of the fall was related to Staff E, nursing assistant (NA), not following the care plan, not using a gait belt, and use of only one staff to transfer Resident 1. On 05/12/2025 at 1:53 PM, Staff D, NA, said Resident 1 required the sit-to-stand in the morning due to difficulty with weakness. Staff D said two staff were always required when using the sit-to-stand. Staff D said if Resident 1 did walk, staff always needed to use a gait belt with two staff persons. Staff D said sometimes, Resident 1 would get stubborn and this was why it was important to have two staff persons. Staff D said Resident 1's care plan explained the resident's mobility needs. Staff D said Resident 1 did not have a history of falls except for the incident on 03/23/2025. On 05/12/2025 at 2:03 PM, Resident 1 was observed to be assisted with walking from a chair to a recliner. Two staff assisted the resident, using a gait belt. The resident was observed to be resistive to staff. The staff were observed to reposition the gait belt to gain a better grip on the resident. Resident 1 continued to be resistive towards staff. On 05/12/2025 at 2:09 PM, Staff C, Licensed Practical Nurse and Unit Manager, said Resident 1 had pain and just generally struggled to get moving in the morning. Staff C said they decided it would be best to use the sit-to-stand in the morning. The resident should otherwise have two staff and a gait belt for transfers. Staff C said Resident 1 had not had any recent falls accept for the incident on 03/23/2025. Staff C said the resident fell because Staff E did not follow the care plan. Staff C said this resulted in bruising and a laceration to Resident 1's head for which the resident required staples to close. There were no prior incidents with Staff E aside from tardiness/lateness. Staff C said they though Staff E's ongoing lateness made it difficult to keep up with the work and daily schedule. On 05/12/2025 at 3:02 PM, Staff A, Administrator, said he would expect staff to follow the care plan. Staff A said Staff E was terminated from the facility due to the incident. On 05/14/2025 at 1:46 PM, Staff B, Director of Nursing and Registered Nurse, said the care plan was in place and Staff E had what he needed for the job. Staff E was terminated from the facility. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure resident assessments accurately reflected their health status and/or care needs for 1 of 7 sampled residents (Residents 1) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. The failure to accurately assess residents with a pressure ulcer (PU, a wound which develops due to prolonged pressure to the body) placed residents at risk for pain and discomfort, diminished quality of life and unidentified and/or unmet care needs. Findings included . Resident 1 admitted to the facility on [DATE] with a left hip fracture. The Admission MDS, dated [DATE], showed Resident 1 was admitted without a PU. Hospital Discharge notes, dated 09/19/2024, documented Resident 1 sustained a PU to the hip from a wrap dressing applied to the resident's hips while hospitalized . Skin Evaluation form, dated 09/19/2024, documented Resident 1 had a PU to the hip. On 01/17/2025 at 3:31 PM, Staff C, licensed practical nurse and MDS coordinator, said Resident 1 was admitted with a PU. Staff C said this was coded incorrectly on the MDS and would require a correction of the coding. Staff C said she was unsure why this was missed since it was clearly documented the resident had a PU. At 3:44 PM, Staff B, Registered Nurse and Director of Nursing, said the MDS should reflect the resident's status. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to review, revise and implement a comprehensive plan of care to include resident specific information for 1 of 7 sampled residents (Residents 1) reviewed for care plans. The failure to establish care plans that were individualized, accurately reflected assessed care needs and provided direction to staff, placed residents at risk to receive inappropriate and inadequate care to meet their individualized needs. Findings included . Resident 1 admitted to the facility on [DATE] with a left hip fracture. The admission Minimum Data Set (MDS, an assessment tool), dated 09/25/2024, showed Resident 1 was dependent on staff with some activities of daily living. Skin Evaluation form, dated 09/19/2024, documented an assessment of Resident 1's skin, identifying the resident with a pressure ulcer (PU) to the hip. According to Skin Evaluation Forms on 09/24/2024 and 10/03/2024, Resident 1 continued to have a PU to the hip. The care plan, dated 09/19/2024, document Resident 1 had fragile skin with redness to the hip and no open areas. The care plan showed staff would apply barrier cream with each incontinent episode. No revisions to the care plan were made to reflect a PU during the resident's stay. At 3:44 PM, Staff B, Registered Nurse and Director of Nursing, said Resident 1 had a PU. Staff B said there were some interventions implemented to help prevent the skin breakdown, but these interventions were not specific to residents with PUs. Staff B said the care plan did not reflect the status of Resident 1's skin. Staff B said appropriate interventions related to a PU should have been included on the care plan. Reference WAC 388-97-1020(1), (2)(a)(b)

Based on observation, interview and record review, the facility failed to ensure food products were labeled with a prepared or use by date, staff performed hand hygiene and glove changes during meal preparation and service, and that the high temperature (Hi-temp.) dishwasher washer met the minimum wash and rinse temperatures required for proper cleaning and sanitization of resident dishware and utensils. This failure placed residents at risk for food borne illnesses. Findings included . <Hi-Temperature Dishwasher Temperature Log> Observation of the facility's Hi-temp. dishwasher on 10/15/2024 at 7:39 AM, showed there was a laminated sign and a dishwasher temperature log where staff were to record the wash and rinse cycle temperatures of the dishwasher three times a day. The October 2024 dishwasher temperature log showed for proper sanitization of dishware/ utensils, the wash cycle must reach 150 - 160 degrees, and the rinse cycle needed to reach 180 degrees Fahrenheit (df). The log contained instruction to staff to PLEASE report temperatures out of the required range to your supervisor immediately. Review of the laminated instruction sheet attached to the front of the dishwasher, showed it provided staff the following direction !!!!!!PLEASE READ!!!!!! Read wash temp and rinse temp and record, with initials, every day. This is extremely important in complying with health code standards. Review of the facility's Hi-temp. dishwasher testing log on 10/15/2024 at 7:53 AM, showed staff recorded dishwasher rinse cycle temperatures that failed to meet the minimum required temperature of 180 df on the following dates: Breakfast Rinse Temperatures - 10/01/2024= 175 - 10/02/2024= 178 - 10/03/2024= 177 - 10/08/2024= 178 - 10/09/2024= 179 - 10/10/2024= 177 - 10/12/2024= 178 Lunch Rinse Temperatures - 10/01/2024= 178 On 10/15/2024 at 7:39 AM, Staff P, Dietary, said on the above referenced occasions, dietary staff recorded dishwasher rinse cycle temperatures below the minimum required rinse temperature of 180 degrees. Staff P said if the dishwasher wash or rinse cycles failed to meet the minimum required temperature, staff were to report it immediately to their supervisor, who in turn would inform the Sous Chef. Staff P said the Sous Chef was who contacted the vendor about any dishwasher issues/concerns. When asked if contact with the vendor was documented somewhere, Staff P said the vendor provided the facility with documentation of their communication. At 10:47 AM, when asked if there was any documentation showing staff notified their supervisor of the eight rinse cycle temperatures that failed to reach the minimum temperature of 180 degrees or otherwise took any action to address the issue, Staff P stated, No, I don't think so. No further documentation was provided. <100 Hall Oxygen Room Refrigerator> Observation of the resident refrigerator in the 100-hall oxygen room on 10/14/2024 at 11:26 AM, showed there was four undated and unlabeled containers filled with a red gelatin-like substance. On 10/15/2024 at 10:10 AM, Staff O, Dietary Manager, stated, Food prepared by the facility needs to be labeled with the date it was prepared, or a use by date. 46793 <1st Floor Dining Room Steam Table> On 10/09/2024 at 11:43 AM, Staff F, Dietary Aide, was observed touching food (beef pot pie) with gloves on, then proceeded to move around the kitchen area touching environmental surfaces (cupboards handles, countertop and food carts), looking for cookies. Staff F did not change his gloves before moving onto the next plate. At 11:45 AM, Staff F was observed touching food (beef pot pie) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 11:46 AM, Staff F was observed touching food (beef pot pie) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 11:47 AM, Staff F was observed touching food (beef pot pie) with gloves on Staff F did not change the gloves before moving onto the next plate. At 11:49 AM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 11:50 AM, Staff F was observed touching food (beef pot pie) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 11:52 AM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 11:54 AM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 11:55 AM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 11:55 AM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 11:56 AM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 11:57 AM, Staff F was observed leaving the dining room with a food cart and gloves on. At 12:00 PM, Staff F was observed returning to the kitchen no longer wearing gloves. Staff F donned new gloves without washing hands. At 12:03 PM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 12:05 PM, Staff F was observed touching food (beef pot pie) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 12:06 PM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 12:06 PM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 12:08 PM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 12:08 PM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 12:09 PM, Staff F was observed touching food (crab patty) with gloves on. Staff F did not change the gloves before moving onto the next plate. At 12:10 PM, Staff F was observed wiping his gloves on his apron. At 12:11 PM, Staff F was observed changing his gloves and did not complete hand hygiene. At 12:25 PM, when asked when should hand hygiene/changing gloves be completed, Staff F said before temping food and taking off your gloves. When asked what measures were in place to prevent cross contamination of food, Staff F said using different utensils and checking the food tickets for allergies. When asked if touching food was acceptable, Staff F said no. After reviewing the documented times Staff F had touched the food, Staff F stated, I didn't realize I was touching the food. It must have been subconsciously. When asked if he should have been touching the food, Staff F said no. Reference WAC 388-97-1100(3); -2980

Based on interview and record review, the facility failed to ensure person centered side effect and target behavior monitoring was identified for psychotropic medications (drug taken to exert an effect on the chemical makeup of the brain and nervous system) for 4 of 5 sampled residents (Resident 74, 46, 42 & 3) reviewed for unnecessary psychotropic medications. This failure placed residents at risk for receiving unnecessary medications, adverse side effects, falls, injury and a diminished quality of life. Findings included . The facility policy entitled Psychoactive Medication, revised 04/07/2024, documented, POLICY: Specific behaviors are identified for each resident that affect the resident's quality of life. 9. Side effects must be listed on the Medication Treatment Record (TAR) for each group of medications. Side effects are documented daily on the MAR . 10. Care Pal must be developed around the behaviors the resident is currently exhibiting. Identify only the behaviors that can realistically be changed and includes possible causes for these behaviors. Interventions should be specific for each behavior. 15. The Monthly Behavior Monitoring POC [Point of Care] must be instituted for each resident receiving anti-psychotic or anti-anxiety. POC should identify the specific behaviors the psychoactive medication is prescribed for. 1) Resident 74 was admitted to the facility on [DATE] with diagnoses including depression (a mental health condition that involves a prolonged low mood or loss of interest in activities). The Quarterly Minimum Data Set (MDS, an assessment tool) documented Resident 74 was cognitively intact and prescribed an anti-depressant medication. Resident 74's electronic health record (EHR) did not show Resident 74 had person-centered side effect or target behavior monitoring for the anti-depressant medication. On 10/15/2024 at 2:19 PM, Staff D, Unit Manager, said before administering any psychotropic medication, a physician's order, consent, an assessment (completed by Social Services), and side effect and target behavior monitoring were required. When asked about the side effect and target behavior monitoring for Resident 74, Staff D said she could not find any. Staff D said Resident 74 should have side effect and target behavior monitoring. At 2:53 PM, Staff B, Director of Nursing Services, said consent, diagnosis, an assessment, non pharmological interventions and orders should all be in place before administering a psychotropic medication. When asked about side effect and target behavior monitoring for Resident 74, Staff B said Resident 74 should have had side effect and target behavior monitoring. On 10/16/2024 at 12:21 PM, Staff E, Social Services, said the facility had a tracking system for all residents on a psychotropic medication. After opening Resident 74's electronic health record (EHR) and showing a list of Patient Health Questionnaire-9 (PHQ-9, a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression) questions, Staff E said all resident have this questionnaire. When asked where this document generated from, Staff E stated, I don't know. After opening the mood tracking tab, Staff E said all residents have mood tracking too. When asked where the questions were pulled from, Staff E said the MDS. When asked to provide Resident 74's person centered side effect and target behavior monitoring for the anti-depressant, Staff E stated, I don't know if I would have any additional behavioral tracking for her. We don't have any for her. When asked if there should have been individualized side effect and target behavior monitoring for Resident 74's anti-depressant medication, Staff E said yes. 42960 2) Resident 42 was admitted to the facility on [DATE] with diagnoses including Major Depressive Disorder (a serious mood disorder that can affect how people feel, think, and behave) and dementia (a chronic condition that causes a decline in mental functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life). The Quarterly MDS, dated [DATE], documented Resident 42 was severely cognitively impaired. Resident 42's physician orders listed orders for Venlafaxine (antidepressant) 75 mg[milligrams] by mouth Daily for Depression and Seroquel (antipsychotic) 25 mg by mouth at bedtime for distressing delusions [a belief that is clearly false and that indicates an abnormality in the affected person's content of thought] and aggressive behaviors toward others. Resident 42's Care plan listed a Behavior Category with specific behaviors exhibited yelling, agitation, and delusions/hallucinations. Resident 42's Daily Charting listed Mood - staff observations of Hallucinations (seeing, hearing, smelling, feeling something that is not there). On 10/16/2024 at 1:19 PM, Staff B said they expected there to be more specifics in the daily tracking, such as what was disturbing them and how it was affecting them. 50392 3) Resident 46 was admitted to the facility 05/27/2024 with diagnoses including depression and anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, and fear). The Quarterly MDS, dated [DATE], documented Resident 46 was cognitively intact and was prescribed an anti-depressant. Resident 46's EHR documented Resident 46 did not have person-centered target behavior monitoring for the anti-depressant. 37044 4) Resident 3 was admitted to the facility on [DATE]. Review of the Annual MDS, dated [DATE], showed the resident was moderately cognitively impaired, had diagnoses of non-Alzheimer's dementia and depression disorder, demonstrated verbal and physical behavioral symptoms towards others (e.g., hitting, kicking, scratching etc.) on one to three days during the assessment period, and received antipsychotic medication. Resident 3 physician's orders documented a 07/17/2024 order for Seroquel (an antipsychotic) three times a day for dementia with behavioral disturbances. A dementia with behaviors care plan, revised 07/28/2024, identified the target behaviors for the use of Seroquel as hallucinations, delusions or withdrawals. Review of Resident 3's EHR did not show documentation of Resident 3 experiencing hallucination, delusions or withdrawals. On 10/16/2024 at 10:34 AM, when asked if Resident 3 had ever had hallucination, delusions or withdrawals Staff M, Unit Manager, stated, No, not hallucinations or withdrawals; but the delusion would be her misguided belief that she can walk. When asked whether a dementia diagnosis with behaviors, with an identified target behavior of having a misguided belief they could walk was an adequate indication for use of an antipsychotic medication, Staff M said the reason Resident 3 was started on Seroquel was due to the resident demonstrating verbal and physical behaviors towards others, but said those were not identified as the targeted behaviors for the use of Seroquel. The October 2024 Treatment Administration Record (TAR) showed the target behaviors for the use of Seroquel were identified as: a) Declining staff care/medications; b) Being argumentative and making false statements towards staff when redirected regarding declining care. c) Being tearful and argumentative with husband; d) Fixed beliefs regarding her mobility capabilities. No non-pharmacological behavioral interventions were identified. The targeted behaviors were also resident rights (e.g. declining care and/or medications, filing complaints or allegations against staff, being argumentative with husband etc.). The TAR behavior monitoring did not identify verbal and physical behaviors towards others as a targeted behavior for the use of Seroquel. On 10/16//2024 at 10:41 AM, when asked if a resident had a right to decline care and/or medications, to file complaints, to make allegations against staff, or to be argumentative with their husband, Staff M stated, Yes. When asked if those were appropriate targeted behaviors for the use of an antipsychotic medication, Staff M said the reason the Seroquel was initiated was for verbal and physical behaviors towards others. Staff M said the care planned targeted behaviors for the use of Seroquel did not match the TAR targeted behaviors for the use of Seroquel; and neither included verbal/physical behaviors towards others as a targeted behavior. Review of the October 2024 TAR showed on 10/02/2024 and 10/03/2024 staff documented a + to indicate Resident 3 had demonstrated a targeted behavior for the use of Seroquel, but there was no indication which targeted behavior was demonstrated. On 10/16//2024 at 10:41 AM, when asked what targeted behavior Resident 3 demonstrated on 10/02/2024 and 10/03/2024, Staff M said they did not know because the charting did not identify what targeted behavior was demonstrated. Staff M indicated it was important to identify a resident's specific targeted behaviors that a psychotropic medication was initiated to treat, because staff monitor for increases or decreases in the frequency of the targeted behaviors to evaluate the effectiveness of the medication and need for continued use. Staff B said having different targeted behaviors identified on the care plan and TAR for the use of Seroquel, and neither one identifying verbal/physical behaviors towards others as the targeted behaviors detracted from the ability to effectively monitor the effectiveness of the medication and need for continued use. Reference WAC 388-97-1060 (3)(k)(i)

Based on observation, interview and record review, the facility failed to ensure intravenous (IV) access devices were assessed, maintained and monitored in accordance with professional standards of practice when IV orders did not include routine monitoring of IV insertion sites, weekly changes of IV dressings and needleless injection caps and an initial and then weekly measurements of IV catheters external length and the resident's arm circumferences for 1 of 1 sampled residents (Resident 74) reviewed for IV therapy. This failure placed residents at risk for loss of vascular access, infection, and other potential negative health outcomes. Findings included . The facility policy entitled Midline Catheter Dressing Change, revised June 2024, documented Guidance 1. Sterile dressing change using transparent dressing is performed: 1.1 Upon admission 1.1.1 If transparent dressing is dated, clean dry and intact the admission dressing change may be omitted and scheduled for 7 days from the dated on the dressing label 1.1.1.1 Upper arm circumference and external catheter length measurements must still be completed as part of the initial assessment. 1.2 At least weekly 2 1.3 If the integrity of the dressing has been compromised (wet, loose, or soiled). Resident 74 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) documented Resident 74 was cognitively intact. The Midline Insertion Record, dated 10/03/2024, documented the Int (Internal) length (tubing) 10 centimeters (cm) and no external length. Resident 74's Comprehensive Care Plan showed no documentation pertaining to the Midline IV including maintenance and/or monitoring of the IV access site. On 10/10/2024 at 10:21 AM, Resident 74 said the Midline IV had been placed in the right arm after determining they were positive for an infection and required IV antibiotics. Resident 74 said the IV (transparent) bandage had not been changed since it was inserted. Observation of the transparent bandage showed no date for when the bandage was received. Dried blood was observed at the insertion site and along both sides of the IV tubing, under the transparent dressing. The October 2024 Medication and Treatment Administration Records (MAR/TAR) showed there was no documentation the facility staff had: a) Monitored the IV insertion site for signs and symptoms of infection or infiltration. b) Performed weekly midline dressing changes. c) Measured the midline external length weekly. d) Measured the resident's right arm circumference weekly. On 10/15/2024 at 2:19 PM, Staff D, Unit Manager, said care and maintenance of a Midline IV included every shift, looking at the insertion site and the dressing, making sure there were no signs or symptoms of infection, and looking at the skin for damage or bruising. Every shift should be flushing the IV with saline as per ordered. When asked about measurements, Staff D said staff should be measuring the external length of the tubing to assure the tubing is not being pulled out. After reviewing the Midline Insertion Record, dated 10/03/2024, in the electronic health record (EHR), Staff D said there was no external length on the report, therefore staff would not know what to measure. Staff D said the missing length should have been caught and she could not show where staff had been documenting the external length. Staff D said needleless injection caps were changed on any blood draw and when the tubing was changed. When asked about the observation of the soiled bandage, Staff D said Resident 74 was having issues with bleeding and the bandage should have been changed. At 2:53 PM, Staff B, Director of Nursing Services, said the expectation for maintenance and monitoring for Midline IV's was for staff to be following doctor's order (flushes), checking the site for signs and symptoms of infection, and changing dressings as required. Staff B said this should be done daily. After reviewing Resident 74's EHR, Staff B said he could not locate where the external measurement documentation was. Staff B said the external measurements should be documented. Staff B said he could not locate information regarding if the needleless injection caps had been changed. When asked about the observation of the soiled bandage, Staff B said if the integrity of the bandage was compromised, then the bandage should have been changed. Reference WAC 338-97-1060 (3)(j)(ii)

Based on interview, and record review, the facility failed to ensure services provided met professional standards of practice when physician orders were not followed and the provider was not notified when medications were held for 1 of 5 sampled residents (Resident 40) reviewed for unnecessary medications. This failure placed residents at risk for medication errors, adverse side effects, delayed review of their medication regimen and unmet care needs. Findings included . Resident 40 was admitted to the facility on [DATE]. Review of their physician orders showed an 08/26/2023 order for Metoprolol (a blood pressure medication) twice daily for high blood pressure, with direction to hold the medication for a systolic blood pressure (SBP) less than 110 or a pulse (P) less than 60. Review of the September 2024 Medication Administration Record (MAR) showed facility nurses administered Resident 40's Metoprolol outside of the physician's ordered parameters on the following occasions: a) 09/22/2024 at 8:00 AM- P=50; medication was administered. b) 09/05/2024 at 8:00 AM- P=55; medication was administered. c) 09/10/2024 at 8:00 AM- P=59; medication was administered. d) 09/20/2024 at 8:00 PM- SBP=109; medication was administered. On 10/16/2024 at 2:12 PM, Staff L, Unit Manager, said facility nurses administered Resident 40's Metoprolol outside of the physician ordered parameters, and it was the expectation that nurses administered medication in accordance with physician's orders. The September 2024 MAR showed Resident 40's Metoprolol was held eight times for a SBP less than 110 or a P less than 60. The September 2024 MAR showed the resident had a 03/07/2022 order for Imdur (an antianginal medication, treats chest pain by relaxing/widening blood vessels), twice daily, with direction to hold for a SBP less than 110. The MAR showed facility nurses held the medication eight times in September 2024. Review of Resident 40's electronic health record did not show documentation the provider was informed of the held medications. On 10/16/2024 at 2:17 PM, Staff L said nurses should notify the provider when they hold medications. Documentation was requested showing the 16 above referenced occasions, in which the resident's Imdur and Metoprolol were each held on eight occasions in September 2024. No further documentation was provided. Reference WAC 388-97-1620(2)(b)(i)(ii)

Based on observation and interview, the facility failed to ensure appropriate hand hygiene was used during dining tray pass for 1 of 3 sampled rooms (room [ROOM NUMBER]) reviewed for dining and 1 of 2 sampled residents (Resident 74) reviewed for transmission based precautions. This failure placed residents at risk for facility acquired or healthcare associated infections and related complications and a diminished quality of life. Findings included . <Dining> On 10/09/2024 at 11:46 AM, Staff H, Certified Nursing Assistant (CNA), was observed passing a food tray to an unknown Resident in room [ROOM NUMBER]. Staff H knocked on the door of room [ROOM NUMBER] and put the food tray down on the bedside table, then assisted placing a shirt saver (garment to protect clothing from food spills) on an unknown resident, touching resident clothing in the process. No hand hygiene was observed after placement of shirt saver and before exiting room and getting a new tray for the next resident. At 11:50 AM, Staff H said she washed her hands at the beginning of tray pass and if she got a resident out of bed, but not when setting up trays. At 12:30 PM, Staff B, Director of Nursing Services, said if staff were touching residents or their food, they should be performing hand hygiene after contact. Staff should wash their hands with soap and water. <Transmission Based Precautions> On 10/16/2024 at 11:27 AM, Staff G, CNA, was observed providing care to Resident 74. Staff G was wearing gloves during care and once gloves became soiled, she removed soiled gloves and took new gloves out of a box of gloves and put them on. No hand hygiene was observed between glove changes. At 11:45 AM, after providing additional care to Resident 74, Staff G removed soiled gloves and took new gloves out of a box of gloves and put them on. No hand hygiene was observed between glove changes. At 12:00 PM, Staff D, Unit Manager, said when gloves were soiled, staff should take off soiled gloves and perform hand hygiene before putting clean gloves on. Reference WAC 388-97-1320 (1)(c)

Based on observation, interview, and record review, the facility failed to ensure residents were free from avoidable accidents during a resident transfer for 1 of 3 residents (Resident 1) reviewed for accidents. Resident 1 experienced harm when facility staff did not follow the resident's individualized care plan fpr safe transfers and the resident sustained a fracture requiring hospitalization . This failure placed residents at risk for injury and a diminished quality of life. Findings included . <Facility Policy> Review of the facility's policy Mechanical Lift Usage, revised 05/08/2017, showed residents that require maximum to total assistance with transfers were not to be lifted without the aid of a mechanical lift. Those residents who did not bear weight or were unable to hold on to the lift bar were to be lifted with Hoyer lifts (lifts that utilize a sling and lift the resident's entire body). The specific lift used by the resident would be written on the resident's care plan and nursing care directives. <Resident 1> Resident 1 was admitted to the facility on [DATE] with diagnoses including multiple sclerosis (the body attacks protective covering of nerves), hemiplegia (weakness to one side of the body) and hemiparesis (abnormal feeling on one side of the body) following a stroke. The Admission Minimum Data Set (MDS), an assessment tool, dated 03/10/2024, showed Resident 1 had cognitive impairment, was dependent on staff for toileting and bathing and used a wheelchair (w/c) for mobility. Resident 1's care plan, dated 04/25/2024, showed Resident 1 required two-person dependent (fully dependent on two people) assistance with a Hoyer lift for all transfers from w/c to bed and bed to w/c. The care plan documented, do not attempt two-person dependent assist for toileting. Due to Hoyer lift status, resident will use bedpan for toileting. Investigation/follow-up documentation for an incident regarding Resident 1 on 05/06/2024, dated 05/09/2024, showed Collateral Contact (CC) 1, resident's family member, reported that a staff member had transferred Resident 1 onto the toilet resulting in left shoulder pain. The investigation documented, at the time of the event, the care plan read to use a mechanical lift for toileting. Staff C, Nursing Assistant, brought the sit-to-stand machine [lift device that requires some weight bearing by the resident) into room to see if that would work for Resident 1 and it became clear this would not work because Resident 1 was unable to participate with transfers and could not bear weight. Resident 1 was unable to grip the handles with her left hand and Resident 1 was then helped to bed. The investigation showed, fracture appears to have occurred while on the sit-to-stand lift. Resident 1 reported increased pain while on the sit-to-stand. Resident 1's radiology report, dated 05/07/2024, showed an acute fracture (result of traumatic injury that causes a clean break) at the proximal left humeral neck (near the arm/shoulder joint). Resident 1's interdisciplinary note, dated 05/08/2024 at 8:42 PM, showed the resident returned to the facility from the hospital via stretcher with a sling to their left arm. Resident 1's hospital record, dated 05/08/2024, showed Resident 1 was seen in the emergency department for fracture of the left upper arm and was discharged back to the facility with pain medication and instructions to follow up with an orthopedic surgeon. On 05/22/2024 at 11:20 AM, during an interview, CC 1 said Resident 1 had used a bedpan for toileting as the resident's left arm and leg were non-functional and there had always been two staff to assist Resident 1 with toileting prior to the incident. CC 1 said they were present during the transfer with Resident 1. Resident 1 was in a w/c and wanted to go to the toilet so CC 1 asked Staff C to find another staff member to help toilet the resident and Staff C said they would get a lift because the other staff were busy. Staff C came into Resident 1's room with a different lift [the sit-to-stand] and attempted to put the resident in the lift. CC 1 said Resident 1 complained this was hurting and Staff C placed Resident 1 back in the w/c, left the room and then returned with another staff member. Staff C lifted Resident 1 up from the w/c without a gait belt and placed her on the toilet. After Resident 1 was finished toileting, Staff C, again, lifted Resident 1 without a gait belt and placed the resident back in the w/c. CC 1 said they reported the incident to a staff member and the facility ordered an x-ray and found there was a fracture. Resident 1 was sent to the hospital and returned to the facility with a sling to their left arm. CC 1 said the facility used ice and pain medication to relieve the resident's pain. On 06/06/2024 at 12:05 PM, during an interview, Staff C said on 05/06/2024 they had transferred Resident 1 to the bathroom and back to the resident's w/c and did not use the mechanical lift as directed on the resident's care plan. Staff C said it was not the appropriate way to transfer the resident, as the care plan had indicated the resident required a Hoyer lift with two staff members. Staff C said Resident 1 did tell CC 1 their arm hurt after the transfer. On 06/11/2024 at 4:10 PM, Director of Nursing, Registered Nurse, Staff B said when transferring a resident that required the use of Hoyer lift, two staff were required to be present. Staff B said staff could retrieve resident information from the care directive in the resident's room or from the care plan. Staff B said Resident 1 required a Hoyer lift for transfer and Staff C did not use the correct lift to transfer the resident and Resident 1 sustained a fracture, was transferred to the hospital for medical care but did not require surgical intervention. Reference WAC 388-97-1060(3)(g)

Based on interview and record review the facility failed to follow professional standards of practice during medication administration for 3 of 6 residents (Residents 5, 6 & 7) reviewed for medication administration. This failure to ensure services provided met professional standards of practice placed residents at risk for diversion of medication, medication errors and adverse outcomes. Findings included . <Policy> Review of the facility's policy, Medication Assessment and Documentation, dated 09/10/2015, showed medications were listed on the Medication Administration Record (MAR) and the licensed nurse would initial the MAR after the medication had been administered. <Resident 5> Resident 5 was admitted to the facility on [DATE] with diagnoses including an infection related to an orthopedic prosthetic and arthritis. Resident 5's MAR, dated 05/03/2024, showed the following medications were prepared, administered and signed by Licensed Practical Nurse (LPN), Staff F: 1. CoQ-10 100 mg (milligrams)(vitamin like substance) capsule by mouth 2. Florastor 250 mg (probiotic) capsule by mouth 3. PreserVision AREDS-2 250 mg-90 mg-40 mg-1mg (supplement for eyes), one capsule by mouth 4. Famotidine 10 mg (medication to treat acid reflux) tablet by mouth 5. Miralax 17 gram (laxative) oral powder. Mix with 8 ounces of preferred beverage by mouth 6. Metoprolol Succinate ER 50 mg (medication to treat high blood pressure) tablet extended release (take with 25 mg/ total 75 mg) by mouth 7. Metoprolol Succinate ER 25 mg tablet extended release (take with 50 mg/ total 75 mg) 8. Calcium Carbonate (mineral supplement) 600 mg (1,500 mg)-vitamin D3 200-units tablet by mouth 9. Lisinopril 10 mg (medication to treat high blood pressure) tablet by mouth <Resident 6> Resident 6 was admitted to the facility on [DATE] with diagnoses including diabetes (inability to control blood sugar), hypertension (high blood pressure) and narcolepsy (disruption of sleep/wake cycles). Resident 6's MAR, dated 5/3/2024, showed the following medications were prepared, administered, and signed by LPN, Staff F: 1. Glimepiride 1 mg (medication to treat diabetes) tablet by mouth 2. Jardiance 25 mg (medication to treat diabetes) tablet by mouth 3. Folic Acid 400 mcg (vitamin) tablet by mouth. 4. Acetaminophen 500 mg (pain medication) 2 tablets by mouth 5. Vitamin B-12 1,000 mcg tablet by mouth 6. Ferrous Bisglycinate 25 mg (iron supplement) 2 capsules by mouth 7. Furosemide 80 mg (medication for excess fluid) tablet by mouth 8. Potassium Chloride 99 mg (supplement) 1 capsule by mouth 9. Carvedilol 3.125 mg tablet (medication to treat high blood pressure) by mouth 10. Modafinil 200 mg (stimulant) tablet by mouth (give with 100 mg for total of 300 mg) 11. Modafinil 100 mg tablet by mouth (give with 200 mg for total of 300 mg) 12. Famotidine 20 mg (medication for stomach issues) tablet by mouth 13. Biotin 8,000 mcg (vitamin) 1 capsule by mouth 14. Senna 8.6 mg (laxative) tablet by mouth 15. Florastor 250 mg capsule by mouth 16. Venlafaxine ER 75 mg capsule, extended release (give with 150 mg dose to total 225 mg) 17. Venlafaxine ER 150 mg (antidepressant) capsule, extended release (give with 75 mg dose to total 225 mg) <Resident 7> Resident 7 was admitted to the facility on [DATE] with diagnoses including diabetes and anemia (reduction in red blood cells or iron) Resident 7's MAR, dated 5/3/2024, showed the following medications were prepared, administered, and signed by LPN, Staff F: 1. Miralax 17 gram (laxative) oral powder packet mixed with 6-8 ounces of juice or water by mouth. 2. Senna 8.6 mg tablet by mouth 3. Ferrous Sulfate 325 mg (iron supplement) tablet by mouth 4. Finasteride 5 mg (medication for enlarged prostrate) by mouth 5. Mometasone inhaler 2 puffs (steroid) into lungs 6. PreserVision AREDS 4,296 mcg-226 mg-90 mg capsule by mouth 7. Singular 10 mg (medications to treat allergies) by mouth 8. Glimepiride 1 mg (medication to treat diabetes) tablet by mouth 9. Men's Multi Plus Prostate Support Vitamin 1 tablet by mouth 10. Buprenorphine HCL 8 mg (narcotic medication) by mouth or sublingual 11. Sodium Chloride 1,000 mg by mouth 12. Hydrochlorothiazide 50 mg (medication to treat excessive fluid) by mouth 13. Prosource 1 pack by mouth On 05/16/2024 at 2:58 PM, by telephone interview, Staff F, LPN said they were assigned to administer medications to residents for A wing. Staff F said Staff D, LPN/Unit Manager would ask for certain residents' medications. Staff F would prepare and sign for the medications and Staff D would take the medications to the residents for administration. On 06/07/2024 at 1:15 PM, Staff E, LPN said they were assigned to administer medications on Unit A and Staff D/Unit Manager would come to the medication cart and ask for the medication for certain residents. Staff E said they would prepare the medication themselves and then Staff D would take the medications to the resident's room. [Staff D] means well, but I don't like it. I am assigned to the cart. On 06/11/2024 at 12:25 PM, Staff J, Registered Nurse, Unit Manager said, the general approach is the same nurse will prepare and administer the medication to the resident. Staff J became aware it was happening on A wing and discussed with Staff B, Director of Nursing/Registered Nurse about revising the medication administration policy. Staff J said it had only happened in a pinch when they were short staffed, I have done it myself a handful of times. On 06/11/2024 at 1:05 PM, Staff I, Registered Nurse, Unit Manager said the nurse that prepared the medication should administer the medication to the resident. On 06/11/2024 at 2:30 PM, Staff D said it had been their regular practice to help nurses on A wing who were behind on the medication pass. Staff D said the nurse assigned to the medication cart would prepare the medications for certain residents and Staff D would take the medications to that resident for administration. Staff D said it had occurred with Staff E, F, G and H. Staff D said on 05/03/2024 in the AM, Staff F/LPN prepared the medications and signed the eMAR for medications for Residents 5, 6 and 7 and Staff D administered the medications to the residents. Staff D said they did not follow the 5 rights of medication administration as the medications were prepared by Staff F and administered by Staff D and the right resident, drug, dose, time and route were not verified by the nurse preparing the medications. On 06/11/2024 at 4:00 PM, Staff B said they had become aware Staff D was administering medications to residents that had been prepared by other nurses on A Wing. Staff B said they were unable to provide a policy related to that practice. Staff B said they had sent an email to all licensed nurses to stop the practice. Reference WAC 388-97-1620(2)(b)(i)(ii)

Based on observation, interview and record review, the facility failed to have a system in place that ensured effective communication, collaboration, and coordination of care occurred between the facility and the hospice provider for 2 of 2 residents (Resident 8 & 19) reviewed for hospice services. The facility's failure: to designate a member of their inter-disciplinary team (IDT) to be responsible for communication and collaboration with hospice staff; to obtain and maintain a current copy of residents' hospice plans of care; to identify and communicate what services/disciplines (registered nurse, chaplain, certified nursing assistant, massage therapist etc.) hospice would provide each resident and at what frequency; and to obtain hospice staffs' visit notes, detracted from the effective coordination of care and placed residents at risk for not receiving necessary care and services. Findings included . Review of the facility's Nursing Facility Services Agreement contract, reviewed 05/04/2022, showed hospice was responsible for providing services related to a resident's terminal illness, as specified in the resident's individualized plan of care. Hospice shall coordinate with the facility to develop a plan of care for each hospice patient and furnish a copy of the plan of care, including services to be provided and anticipated frequency of visits. Review of the facility's Coordination of Hospice Services policy, dated 09/01/2023, showed the facility and hospice provider would coordinate a plan of care that would identify the care and services each entity would provide. The facility would coordinate with hospice, and identify, communicate, follow and document all interventions put into place by hospice and the facility. The facility would maintain communication with hospice as it related to residents' plans of care and services. 1) Resident 8 admitted to the facility on [DATE]. Review of the significant change Minimum Data Set (MDS, an assessment tool), dated 06/22/2023, showed the resident had a terminal diagnosis and received hospice services. A 06/21/2023 hospice intake document showed Resident 8 started on Hospice services on 06/21/2023. On 11/07/2023 at 10:39 AM, Resident 8's significant other said there had been some miscommunications between hospice and the facility. She indicated the facility and hospice had different ideas about how to manage and treat Resident 8's wounds and stated, I was kind of getting caught in the middle, so I kind of said you two [facility staff and hospice staff] get together and figure it out. Review of Resident 8's electronic health record (EHR) showed no copy of the resident's initial hospice plan of care was present. A 07/26/2023 hospice plan of care update, dated 07/26/2023, was received by the facility via fax on 07/28/2023 at 4:47 PM. Review of the plan of care showed for the 06/21/2023 -09/18/2023 certification period, hospice would provide Resident 8 with: one Chaplain visit every 30 days for 90 days and one as needed visit; one Medical Social Worker visit every 30 days for 90 days and four as needed visits; a skilled nursing visit every week for 12 weeks; and a hospice aide to provide the best personal hygiene throughout the course of Resident 8's changing condition as evidenced by the Resident and/or family verbalizing satisfaction with hospice aide services during aide supervision every 14 days.The anticipated frequency of hospice aide visits was not identified. No current hospice plan of care or visit notes from any hospice discipline, other than skilled nursing, was found in Resident 8's EHR. On 11/13/2023 at 9:52 AM, when informed about the miscommunication between the facility and hospice related to Resident 8's wound care, Staff J, Nurse Manager, confirmed that the facility wanted to change Resident 8's treatment orders to better manage odor and drainage and that hospice initially was not in agreement. Staff J indicated they agreed to have the resident seen by a third party wound care service and subsequently agreed on treatment orders. At 9:53 AM, when asked what services/disciplines hospice was providing Resident 8, the anticipated frequency of those visits, if the visits had occurred and whether the facility had documentation of them Staff J, Nurse Manager, said they did not know if Resident 8 had received visits from the hospice Chaplain, Medical Social Worker, or hospice aide as outlined in the coordinated hospice plan of care, Staff J stated, [Hospice representatives] do not check in with me all of the time. When asked if there was a current hospice plan of care or documentation (e.g., hospice sign-in log, visit notes etc.) from hospice disciplines, other than skilled nursing, in Resident 8's EHR, Staff J said they could not find any. On 11/13/2023 at 9:36 AM, when asked if the facility had designated a member of their inter-disciplinary team (IDT) to be responsible for communication and collaboration with hospice staff, Staff B, Director of Nursing, indicated that they had not. 49451 2) Resident 19 was admitted to the facility on [DATE] with diagnoses including parkinson's disease (a brain disorder that causes unintended or uncontrolled movements, such as shaking, stiffness and difficulty with balance and coordination) and dementia (a condition that affects the way a person's brain is working). Review of Resident 19's hospice order, dated 10/04/2023, showed a stage 2 pressure ulcer with wound treatment to the coccyx (tailbone area). Apply a light layer of prescription cream after each episode of incontinence. The hospice nurse was to assess at each visit. (visit frequencies two times per week). Review of Resident 19's EHR showed no hospice documentation of Resident 19's pressure ulcer/wound assessments from 10/04/2023 through 11/06/2023. On 11/08/2023 at 11:26 AM, Staff E, Nurse Manager/ Licensed Practical Nurse, said hospice had completed the wound assessments and wound treatments two times a week on Resident 19's pressure ulcers. Staff E said she was not aware wound reports were not sent by hospice and were not incorporated in Resident 19's EHR. No associated WAC

Based on observation, interview, and record review, the facility failed to ensure refrigerator temperatures were maintained within acceptable ranges for 3 of 6 unit refrigerators (A, E, & F-Wing Snack Rooms) reviewed for food service. This failure placed residents at risk of food-borne illness and a diminished quality of life. Findings included . Review of the record log titled, Food Services Department Daily Refrigerator/Freezer Temperature Checks, showed refrigerator temperatures must stay between 35 and 39 degrees Fahrenheit and staff were to report temperatures outside of the required range to their supervisor immediately. Review of the September 2023, October 2023, and November 2023 temperature logs showed refrigerator temperatures were recorded at over 41 degrees Fahrenheit (F) on the following dates: 1) A-Wing Snack Room September 2023: 7th 43 degrees F. October 2023: 5th 43 degrees F, 10th 42 degrees F, 13th 42 degrees F, 16th 45 degrees F, 17th 42 degrees F, 20th 43 degrees F, 24th 43 degrees F, 27th 43 degrees F, 29th 42 degrees F. November 2023: 1st 45 degrees F, 2nd 45 degrees F, 3rd 42 degrees F, 5th 44 degrees F. 2) E-Wing Snack Room September 2023: 1st 42 degrees F, 7th 44 degrees F, 14th 46 degrees F, 15th 44 degrees F, 22nd 44 degrees F, 28th 44 degrees F, 29th 44 degrees F. October 2023: 2nd 42 degrees F, 4th 42 degrees F, 5th 42 degrees F, 12th 46 degrees F, 20th 42 degrees F, 21st 42 degrees F, 22nd 42 degrees F, 23rd 42 degrees F, 26th 44 degrees F, 27th 48 degrees F, 28th 44 degrees F, 29th 42 degrees F. November 2023: 3rd 44 degrees F, 4th 42 degrees F, 5th 42 degrees F. 3) F-Wing Snack Room September 2023: 1st 42 degrees F, 3rd 42 degrees F, 6th 42 degrees F, 8th 42 degrees F, 10th 42 degrees F, 14th 42 degrees F, 15th 42 degrees F, 17th 42 degrees F, 20th 42 degrees F, 22nd 42 degrees F, 24th 42 degrees F, 27th 42 degrees F, 29th 42 degrees F. October 2023: 1st 42 degrees F, 6th 42 degrees F, 8th 42 degrees F, 10th 42 degrees F, 12th 43 degrees F, 14th 42 degrees F, 19th 42 degrees F, 21st 42 degrees F, 23rd 42 degrees F, 26th 42 degrees F, 29th 42 degrees F. November 2023: 2nd 42 degrees F, 5th 42 degrees F. On 11/08/2023 at 10:07 AM, Staff H, Dietician, said housekeeping checked the unit snack refrigerator temperatures daily and reported to their supervisor at that time if the temperature was out of range. Staff H said she would audit the temperatures monthly to make sure they had correct temperatures and would follow up if needed. At 1:31 PM, Staff I, Housekeeper, said she checked the temperatures on the unit snack refrigerators every day and wrote the result on the log. When asked who she reported the results to if the temperature was out of range, Staff I said she didn't tell anyone the results. Staff I said the kitchen checked the logs. At 1:35 PM, Staff G, Dietary Services Manager, said housekeeping checked the temperatures on the unit refrigerators daily when they cleaned them. Staff G said if the temperature was out of range, housekeeping would tell the nurses or him, and he would tell the Environmental Services Supervisor. Staff G said he was not notified of any temperatures greater than 41 degrees this month. At 2:08 PM, when asked if there was a process for follow up documentation for the same day a fridge was out of range, Staff H stated, No, not really. At 4:32 PM, Staff A, Administrator, said it was his expectation refrigerator temperatures out of range were reported and addressed. On 11/09/2023 at 11:04 AM, Staff G said they needed to have an in-service with housekeeping staff on how to read refrigerator temperatures and what to do when the temperature was out of range. Staff G said they needed to find a better process. Reference WAC 388-97-2980 (1)

Based on observation, interview, and record review, the facility failed to ensure residents had access to their call lights for 1 of 1 sampled residents (Resident 18) reviewed for environment. This failure placed residents at risk of unmet care needs and diminished quality of life. Findings included . Resident 18 admitted to the facility on [DATE]. The annual Minimum Data Set, an assessment tool, dated 09/06/2023, documented Resident 18 was moderately cognitively impaired. Resident 18 is blind in her right eye. On 11/06/2023 at 12:34 PM, during an interview, Resident 18 said she was blind in her right eye and could not see the call light when it was clipped to the curtain on her right side. The call light was observed clipped on the curtain, at eye level and on the right side of Resident 18's bed. On 11/09/2023 at 9:29 AM, Resident 18's call light was observed clipped on the curtain, at eye level and on the right side of Resident 18's bed. At 3:41 PM, Resident 18's call light was observed clipped on the curtain, at eye level and on the right side of Resident 18's bed. On 11/13/2023 at 9:04 AM, Resident 18's call light was observed clipped on the curtain, at eye level and on the right side of Resident 18's bed. The curtain was observed pulled back and the call light was positioned between the folds of the curtain. At 9:14 AM, Staff C, Licensed Practical Nurse (LPN), said staff try to anticipate the needs of residents with visual impairments. Staff C said they would normally clip call lights to the left side of the resident or to their bed, so they have easy access to the call light. Staff C was observed searching Resident 18's area, including in and under the bed and between the blankets but was unable to locate the call light. Resident 18 was observed sitting in her wheelchair when Staff C asked them where the call light was. Resident 18 stated, I never know where that thing is. Staff C continued to search and located the call light hidden between the folds of the curtain on the right side of Resident 18's bed. When asked about Resident 18's right-sided blindness, cognitive impairment and the location of the call light, Staff C said the location was inappropriate and the call light would be moved. Staff C asked Resident 18 where she wanted the call light. Resident 18 said the left side. At 12:15 PM Staff B, Director of Nursing Services, said he expects staff to accommodate resident choices and preferences for residents with visual impairments to the best of their abilities. After the incident with the hidden call light was explained, Staff B said the call light should have been moved, it was not a good spot. Reference: (WAC) 387-97-0860 (2)

Based on observation, interview, and record review, the facility failed to ensure residents were free from accident hazards including fall with injury for 1 of 3 sampled residents (1) reviewed for accident hazards. This failure placed residents at risk for injury, pain and a diminished quality of life. This failure caused harm to Resident 1 when the resident was transferred without a gait belt, had a fall with injury and sustained a left hip fracture. Findings included . Resident 1 was admitted to the facility on [DATE]. The Minimum Data Set, an assessment tool, dated 12/12/2022, documented the resident was cognitively intact, required extensive assistance from two staff members for bed mobility and transfers, and extensive assistance from one staff for ambulation (walking). Resident 1's care plan, initiated 09/12/2022, included transfer interventions initiated on 10/20/2022 for one-person limited assistance with gait belt and FWW (front wheel walker) for ambulation. A nursing note, dated 12/24/2022 at 11:21 PM and modified on 12/29/2022 at 7:15 AM, documented, This LN [Licensed Nurse] heard a loud noise coming from [Resident 1's] room and immediately went to investigate to ensure [the resident] was safe. The note showed upon entering the resident's room, the resident was found on the floor, in a sitting position with both knees slightly bent. A Certified Nursing Assistant (CNA) was next to the resident. When assessing the area surrounding Resident 1, there was not a safety device in place such as a walker and the resident was not wearing a gait belt. The CNA said Resident 1 lost his balance during a transfer, falling to the floor and landing with most of his weight onto his left knee when falling onto his left side. The resident said the left knee took the brunt of the fall when landing on his left side. The resident complained of left knee pain when being assessed for Range of Motion (ROM) and the resident was unable to do much ROM due to left knee starting to hurt, so immediately stopped. Resident 1 complained of pain and tenderness to left knee when palpated. The resident refused to try to bend the left knee due to pain. The resident had no other complaints of pain during the assessment. The note showed the nurse was unable to fully assess for weight bearing status at that time. A Hoyer lift was used to transfer the resident from the floor and back to bed. After being transferred to bed, a thorough head to toe assessment was completed. The left side of the resident was checked down to the hip. The Left Lower Extremity (LLE) and left knee with no redness, bruising, or swelling noted at that time. The MD (physician) was notified of the fall with a request for an immediate x-ray of the left knee due to pain, unwillingness to try to move LLE and not being able to bear weight. New orders were received as follows: 1. Routine 2-view x-ray to left knee to rule out fracture. 2. Apply ice packs as tolerated for pain and swelling. Resident 1 refused PRN (as needed) Tylenol 650 milligram (mg) offered for pain management, and stated, It doesn't hurt when I am not moving. The resident allowed staff to apply ice pack to left knee. Vitals signs (VS) were stable. The note showed staff called and requested a knee x-ray. Resident 1 was placed on alert status to monitor for latent injuries or complaint of new or uncontrolled pain. The note documented WCTM (will continue to monitor). A nursing note, dated 12/25/2022 at 11:13 PM, documented, .latent bruising noted to left hip area . 1. Flat bruise, reddish purple in color 3.5cm [centimeter] x 4.5cm to lateral lower left hip. 2. Flat bruise dark purple in color 4.5cm x 5.5 cm to lateral left hip. No complaint of pain by the resident. MD informed . A nursing note, dated 12/26/2022 at 9:00 AM, documented, [At 8:30 AM] resident complained of left femur [thigh bone] discomfort, unable to lift leg. Left pedal pulse [top of foot] palpable. Discomfort to lateral left femur with palpation. LLE color good. VS stable. Unable to bear weight on left leg. [At 8:35 AM] MD notified. Orders received for: 1) STAT [immediate] 3 view pelvis 2) STAT 2 view Left femur. [At 8:40 AM] [X-ray provider] notified. A nursing note, dated 12/26/2022 at 12:55 PM, documented, [At 11:10 AM], resident has been experiencing increased pain. Tylenol insufficient [for] controlling pain. Left foot continues to abduct [move]. Call to MD. New order received, 1. Oxycodone 5 mg [milligram] Q [every] 6 hours PRN [for] pain level 4-10. MD faxed script to [pharmacy] . 2. Tylenol for pain level 1-3. 3. If resident would like to be seen by an MD may go to [hospital] or Urgent Care. [At 11:40 AM] [X-ray provider] here for x-rays. Resident visibly uncomfortable. Had Tylenol on board. Awaiting oxycodone script. A radiology report, dated 12/26/2022 at 1:21 PM, documented the resident was found to have a Displaced left sub capital hip fracture [neck of thighbone]. A nursing note, dated 12/26/2022 at 10:22 PM, documented, MD contacted this afternoon with radiology results, order given to send [Resident 1] to ED [emergency department] for further evaluation. [Emergency Contact 1] notified via phone call . Ambulance company contacted for pick up; arrived around 4:40 PM. Resident left facility at 4:43 PM . enroute to [hospital] . An Orthopedic Consult Note, dated 12/27/22 at 10:29 AM, documented Resident 1 extremity with left hip shortened and externally rotated and pain with ROM; diagnosed with a left displaced femoral neck fracture with planned surgical repair. A Facility Incident Investigation Note, dated 12/27/2022, summarized Staff D, CNA, responded to Resident 1's call light. The resident was sitting in his recliner and was ready to go to bed, but needed to use the bathroom. The CNA did not place a gait belt on the resident, gave the resident his walker and was standing in front of him. The resident became unsteady and fell on to the left knee and hip. A Facility Incident Investigation Note, dated 12/30/2022, documented on 12/28/2022 at 11:00 AM, Staff B, Director of Nursing Services, interviewed Staff D. When asked why Staff D did not use a gait belt, Staff D stated, To be honest, I didn't think about it. When asked if Staff D was aware the resident's care plan and facility policy including the use of a gait belt for all transfers, Staff D stated, Yes. The facility Investigation concluded the fall was related to the [CNA]'s failure to use a gait belt during transfer/ambulation to ensure resident safety causing the resident to fall to the ground and sustain a left sided lower extremity fracture. On 01/11/2023 at 10:54 AM, Resident 1 was observed laying in a face side up position in bed with head of bed elevated. When asked about his fall, Resident 1 said he was getting ready for bed and stated, The aid was ahead of me, and I didn't have a strap on. She was watching me. When asked if staff usually use a gait belt to transfer him, the resident stated, Usually. Resident 1 appeared visibly tired and requested I come back another time so he could take a nap. At 2:59 PM, Resident 1 was observed laying in bed in a face side up position. The resident asked this investigator to come back another time as he was very tired still. On 01/17/2019 at 12:38 PM, Resident 1 was observed sitting in his recliner and was just finishing eating lunch. When asked about the fall, the resident said he was going to bed. Resident 1 said he got up with his walker and told the CNA to keep an eye on me. I am a little unstable. Resident 1 stated, [The CNA] was walking in front of me, about 3-4 feet, instead of behind me, so when I fell there was no one to help me. When asked if the CNA had used a gait belt, Resident 1 stated, No, she did not. When asked about his injuries, Resident 1 stated, I was hoping I was ok, my hip was pretty sore, and everyone said hopefully it was just bruised . but the pain was really bad if I had to be moved or pushed. Resident 1 said he remained in bed from the time of the fall until he went to the hospital two days later. Resident 1 said he did not recall staff offering transport to the ER for evaluation. Resident 1 said he now had to be transferred using a Hoyer (mechanical) lift. At 2:05 PM, Staff C, Licensed Practical Nurse and Nurse Manager, said staff knew how resident transfers were to be completed by a care guide hung in the resident closet and access in the point of care tablets. Staff C said gait belts were used for all resident transfers unless they were independent. Staff C said Resident 1 was to be transferred with a gait belt and walker when ambulating. Staff C said she did not believe Staff D was using a gait belt at the time of Resident 1's fall. Staff C said she monitored that care plans were being followed by observations and audits. Staff C said Resident 1 was now transferred via Hoyer lift. On 01/19/2023 at 10:42 AM and 1:01 PM, Resident 1 was observed laying in a recliner, visiting with family. At 1:40 PM, Staff B said staff were assessed for skills with initial hire skills checklist and annually. Staff B said Staff D was a newly hired CNA, but had completed orientation and skills checklist. Staff B said the facility policy was for all residents to be transferred using a gait belt. Staff B said Staff D had been terminated for the failure to use a gait belt when transferring Resident 1 as well as lack of concern or remorse. On 01/20/2023 at 3:09 PM, Staff D, CNA, said she had completed the orientation at the facility, usually provided care for 10-12 residents and knew the transfer status of the residents was in the closet. Staff D said she failed to place a gait belt on Resident 1 prior to the transfer, and stated, It totally slipped my mind. Staff D said she attributed this to feeling rushed and trying to care for all of the residents. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure a safe environment as free from accident hazards as possible and that adequate supervision was provided for 1 of 3 sampled residents (#1) reviewed for accidents; additionally the facility failed to ensure adequate supervision of NA A who made an unauthorized change to a resident's wheelchair. These failures caused harm to the resident when Resident # 1 was able to exit the facility without staff being alerted resulting in injury to the resident. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set, a comprehensive assessment tool, dated 12/1/26 documented Resident #1 has difficulty with short and long term memory, has impaired decision making, and requires supervision and cueing. Resident #1's care plan dated 9/30/16 documents Wanderguard attached to wheelchair due to history of wandering. On 1/21/17 at approximately 3:00 p.m., NA A left her assigned duty station on the second floor. She went to Resident #1's room on the first floor and exchanged the residents wheelchair for another wheelchair while Resident #1 was asleep. Resident #1's wanderguard (device used to alert staff when resident is near exits) was not transferred from the old wheelchair to the new wheelchair. NA A's witness statement dated 1/21/17 documents I switched over the wheelchair .the wanderguard wasn't taken off of the old chair and put on the new chair. The Facility's incident report dated 1/24/17 documents on 1/21/17 Resident #1 was found at approximately 9:15 p.m., outside, in the staff parking lot just outside the employee entrance. Resident #1 had fallen off the sidewalk onto the pavement and the wheelchair was tipped over on top of the resident. Resident #1 was noted to have a large laceration to the right side of the forehead with significant bleeding. Resident #1 also complained of pain to the right knee and had blood dripping from the nose. Emergency Department records document Resident #1 was diagnosed with [REDACTED]. Resident #1 required 15 staples, 2 simple sutures, and 1 purse-string suture to close a significant laceration to the forehead. On 2/9/17 at 10:03 a.m., Licensed Nurse (LN) A stated that Resident #1 was seen at the nursing station by multiple staff around 9:00 p.m., and was noticed to be missing around 9:15 p.m LN A demonstrated the path Resident #1 likely took to exit the building. LN A indicated that Resident #1 self-propelled their wheelchair from the nursing station across the hall and through an unlocked, unalarmed door into a stairwell. Resident #1 then self-propelled down a short hallway to the employee entrance/exit to the parking lot. This door was also unlocked and unalarmed. Once Resident #1 exited the building the angle of the ramp was too steep for a controlled decent. LN A stated that if Resident #1's wheelchair had a wanderguard attached staff would have been alerted as soon as Resident #1 was near the exit door. LN A indicated, without a wanderguard attached to the wheelchair the resident was able to leave the building without sounding an alarm. LN A stated that NA A was practicing outside of their scope of practice when she left her assigned duty area and replaced Resident #1's wheelchair. On 2/9/17 at 3:12 p.m., the Administrator (ADM) indicated that the door Resident #1 went through had the wanderguard system in place and would have alarmed but not locked the door. ADM stated that NA A was terminated for failure to comply with Panorama policies and procedures. The facility failed to adequately supervise NA A who made an unauthorized exchange of a resident's wheelchair resulting in a significant injury. The facility failed to provide adequate supervision for Resident #1 who left the building undetected and suffered a significant injury as a result.

Based on record review and interview it was determined that the facility failed to provide ordered medication, [MEDICATION NAME] (a medication that regulates the rhythm of the heart), for 1 of 2 residents reviewed. This failure resulted in Resident #1 developing chest pain and being hospitalized . Findings include: Resident #1 was admitted [DATE] at 5:30 p.m. with multiple [DIAGNOSES REDACTED]. Record review shows on March 12th resident did not receive 8:00 p.m. dose of [MEDICATION NAME]. Record review shows on March 13th resident did not receive 8:00 a.m., 2:00 p.m., and 8:00 p.m. dose of [MEDICATION NAME]. On 4/5/16 at 11:30 a.m., Nurse (A) stated she was aware that resident needed [MEDICATION NAME]. She stated it was not available in her cart, she had not seen it listed as available in the E-Kit (Emergency Medication Kit provided by facility) and had called pharmacy in Tukwilla to order it. On the morning of March 14th resident developed chest pain and had a rapid heart rate. He was transferred to the hospital for care.

Based on observation, interview and record review, it was determined the facility failed to monitor and evaluate the impact of the interventions or revise the interventions as appropriate for 1 of 3 current sampled residents (#94) reviewed for pressure ulcers. This failure caused harm to resident #94 when the resident developed an unstageable pressure ulcer (full thickness wound where the depth of the wound is unable to be visualized due to a layer of dead tissue) after admission. Findings include: "Pressure ulcers (PUs) (also called bedsores, decubitus ulcers are caused by pressure against the skin that limits blood flow to the skin and nearby tissues) occur frequently in...nursing home older adults and are serious problems that can lead [MEDICAL CONDITION] (potentially life-threatening complication of an infection) or death" and "the Braden Scale is the standard assessment tool used for predicting development of PUs" (Hartford Institute for Geriatric Nursing, Issue Number 5, Revised 2012). Resident #94 was admitted from the hospital on [DATE] with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), an assessment tool, dated 12/18/14, indicated the resident had no pressure ulcers and was at risk for pressure ulcer development. The MDS indicated the resident required extensive assist of two-persons with bed mobility and transfers from the bed to the wheelchair. Resident #94 did not exhibit rejection of care per the admission MDS and review of nursing assistant daily charting from admission through 01/08/15. The Care Area Assessment (CAA) identified risk factors and indicated to see care plan, treatment administration record (TAR), and routine care protocol for interventions. The CAA indicated new skin issues would be referred to the MD (physician) and registered dietician (RD). A Braden (an assessment to measure risk of skin breakdown), dated 12/11/14, indicated high risk for skin breakdown. An admission skin assessment, dated 12/11/14, did not identify any redness or skin issues to the resident's back. The National Pressure Ulcer Advisory Panel defines a stage one pressure area as "intact skin with non-bleachable redness of a localized area usually over a bony prominence." Nurses Note, dated 12/16/14, documented "...redness to lower back (related to) patient lying in bed..." On 12/17/14 , a Skin Assessment Form documented, "patient has persistent redness to lower back vertebral column (related to) pressure from being in bed. Patient encouraged to get out of bed for meals at minimum. Patient not able to lay on side (related to) fractures. Geomat (a special bed cushion) in place." Nurses Notes, from 12/17/14 to 12/24/14, documented daily ongoing redness to the resident's back. A Nurses Note, dated 12/25/14, documented "...redness to vertebral column remains. Small scab noted on back." A Nurses Note, dated 12/26/14, noted "...spine remains red with scabbed area to lower back..." A Skin Assessment Form, dated 12/27/14, documented the "(patient) has open area on mid/lower back that has partially opened with top layer of skin is off. The lower part is hematoma (localized swelling that is filled with blood) in appearance. The area was cleaned and covered with non adherent dressing." A Skin Assessment Form, dated 12/31/14, documented the resident's "open area to lumbar back is open 2.5 cm (centimeters) by 1.5 cm, wound is dark brown in color, unstageable, entire spine is red. Applied Allevyn (a foam bandage) dressing to entire spine. Continue to monitor and assess." Per Resident #94's Alteration in Skin Integrity Care plan, the interventions of "dressing as ordered" and "turn and reposition frequently" began on 01/05/15. A Skin Assessment Form, dated 01/06/15, documented the "wound to back is open and white slough (tissue in the process of separating from the viable portions of the body and is usually light colored, soft, moist, and at times stringy). Peri-wound is red." Measurements on the form were 2.5 cm by 2.0 cm. The facility's Skin Integrity Policy, dated 09/06/12, stated an "E-Z graph will be used to document pressure ulcers and stasis ulcers." An E-Z graph form was not created for this wound until 12/27/14 after documentation of redness was noted from 12/16/14 to 12/26/14. The Skin Integrity Policy documented the physician was to be notified of skin integrity issues and a physician order [REDACTED]. On 01/06/15, a physician order [REDACTED]. No documentation was found in the medical chart prior to 01/06/15 of a physician order [REDACTED]. The wound care nurse consultation, dated 01/06/15, documented recommendations including "positioning to minimize pressure to area" and "hydrogel to facilitate debridement (the removal of damaged tissues) of the lesion." The wound care nurse documented it was "somewhat perplexing as to source of pressure as this area more indented than protruding. Suspect supine (on back) positioning in high fowlers position (head of bed elevated as high as possible)." On 01/08/15 at 8:57 a.m., the resident was observed sitting in bed with the head of bed elevated to 70 degrees (high fowler's position). Per Resident #94's Skin Integrity care plan, the interventions of "float spine and encourage (patient) to lay on sides as much as possible" and "Nutricare (a nutritional supplement) with ice cream (three times a day) between meals to promote healing" began on 01/08/15. On 01/08/15 at 12:22 p.m., the resident's back was observed with Licensed Nurse (LN) B with an approximately quarter sized open area to the lower back with yellow slough throughout entire wound bed. A smaller open area (<1 cm) was noted just above the larger area. The area surrounding the wound was dark red and raised at the edges with redness up along the length of the spine. On 01/08/15 at 4:46 p.m., the Resident Care Manager (RCM) A stated, "I remember going in and saying we really needed to put Allevyn all up and down her back. This was before (the wound) opened up." No documentation could be located in the TAR or nurses' notes indicating an Allevyn dressing was applied until 12/27/14 when the area progressed from redness/small scab to an open wound. RCM A indicated the resident had an in-facility X-ray of her ribs and sternum on 12/27/14 and had to be "laid on a flat plate (hard board used during x-rays)." She indicated that the worsening of the pressure ulcer noted on 12/27/14 could have been related to the resident having to lay on the hard surface during the X-ray. The facility could not provide any documentation that the x-ray was investigated as a cause of injury to the resident. On 01/08/15 at 4:56 p.m., LN C stated the area started out pink and indicated "we tried to get her out of bed, rotate her. It just slowly got worse." On 01/09/15 at 9:55 a.m., RCM A indicated the resident was placed on an airbed (specialized mattress to relieve pressure) around 12/18/14. RCM A indicated she was now requesting an order from the physician to culture the wound (check for infection) because "it has an odor to it." Additional documentation, provided by the facility on 01/13/15, showed on 01/09/15 "note sent to MD to report odor, maceration (softening and break down of skin resulting from prolonged exposure to moisture), and deterioration of wound, new order received for C&S (culture and sensitivity) and Bactrim (an antibiotic) started. MD came in to see resident and examine wound." Resident #94 was admitted to the facility with no open area or redness to her back. The facility staff noted persistent redness to the resident's back for 11 days before the wound opened up. The facility failed to implement alternate interventions to mitigate the development of pressure ulcers for Resident #94. The facility failed to notify the resident's physician until 01/06/15, when the wound was classified as unstageable.