Every finding on record at Pine Ridge Post Acute

Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 2 Freezers (Kitchen Freezer), 2 of 3 Refrigerators (Kitchen Walk-in Refrigerator & Olympic Dining Room Refrigerator), 1 of 2 Dry Storage Room (Kitchen Mini Storage), and 1 of 3 Staff (Staff M), reviewed for food services. The failure to label, cover, and discard food items past the use by date and perform hand hygiene placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.Findings included.Review of the facility's policy titled, Dietary: Food Storage, revised on 07/25/2024, showed, Leftover food items are stored in appropriate containers so that the interior temperature of the food chills quickly to [less than or equal to] 41 F [degrees Fahrenheit-temperature scale]. They are covered, labeled, and dated. The policy showed, Non-corrosive [refers to materials, liquids, or substances that do not cause damage] containers with tight-fitting lids should be used to store non-perishable food items.Opened food items in dry storage should be stored in a closed container to prevent contamination.All stored items should have an expiration date or a purchase/delivery date. The policy further showed, To ensure food is rotated properly, food without a product date shall be dated on delivery.Review of the facility's policy titled, Resident Food from Outside Source, dated on 08/01/2024, showed, Refrigerated food items from an outside source is stored in a container with the following information on it: Date product was received, Name of product type (i.e. [example], meat casserole, cookies, salad), Resident name and room number. The policy showed, Refrigerated foods that are unlabeled or undated, when noted, is discarded. The policy further showed, Refrigerated products are discarded on the following schedule: Commercially prepared products, in their original containers, is used before the manufacturer's expiration or use by date.Review of the facility's policy titled, Hand Hygiene, revised on 12/15/2021, showed, Hand hygiene is the primary means of preventing the transmission of infection and should be performed as soon as possible after hands become contaminated and frequently during the working day. The following is a list of some situations that require hand hygiene:.b) When hands are visibly soiled (hand hygiene with soap and water);.f) Before and after eating or handling food (hand hygiene with soap and water);.u) After removing gloves or aprons; and/or before applying; .KITCHEN FREEZERObservation of the Kitchen Freezer on 03/17/2026 at 8:45 AM, showed one uncovered/unlabeled rectangular tray and one uncovered/unlabeled round tray of an unknown food item.In an interview and joint observation on 03/17/2026 at 8:47 AM, Staff G, Assistant Dietary Manager, stated that they labeled food items in the kitchen. Staff G stated that leftover food was good for three days and prepped food was good for seven days. Staff G stated that it would be labeled with the name of the food item, the preparation date and the use by date. Staff G stated that they would expect food items to be labeled and that the food item should be covered unless it was hot food that was cooling down. A joint observation of the Kitchen Freezer showed one uncovered/unlabeled rectangular tray and one uncovered/unlabeled round tray of an unknown food item. Staff G stated that it was left over cake from yesterday [03/16/2026] and that it should have been covered/labeled. KITCHEN WALK-IN REFRIGERATORObservation of the Kitchen Walk-in Refrigerator on 03/17/2026 at 8:33 AM, showed the following:-One uncovered and unlabeled tray that contained five plates of an unknown dessert.-One uncovered and unlabeled tray that contained an unknown dessert in small bowls. -One half full uncovered and unlabeled tray that contained an unknown dessert. -One full unlabeled metal tray that contained an unknown dessert covered in plastic wrap. -Three unlabeled sandwiches wrapped in plastic wrap.In a joint observation and interview on 03/17/2026 at 8:55 AM with Staff G showed threeunlabeled sandwiches. Staff G stated that it should been labeled. Further observation showed one uncovered and unlabeled tray that contained five plates of an unknown dessert, one uncovered and unlabeled tray that contained an unknown dessert in small bowls, one half full uncovered and unlabeled tray that contained an unknown dessert and one full unlabeled metal tray that contained an unknown dessert covered in plastic wrap. Staff G stated that the metal tray contained banana bread that was from yesterday [03/16/2026] and that it should have been labeled. Staff G stated that the other trays were [NAME] Cheesecake for today's (03/17/2026) dessert. Staff G further stated that they should have been covered and labeled.In a follow up observation of the Kitchen Walk-in Refrigerator on 03/20/2026 at 8:46 AM, showed the following:-One full uncovered metal tray labeled Jello with UB [use by] 03/20/26 [03/20/2026]. -One unlabeled and uncovered metal tray that contained an unknown food item. -One unlabeled metal tray that contained an unknown dessert in small bowls and one bowl of mixed salad greens.In a joint observation and interview on 03/20/2026 at 9:28 AM with Staff G showed one unlabeled and uncovered metal tray that contained an unknown food item and one unlabeled metal tray that contained an unknown dessert in small bowls and one bowl of mixed salad greens. Staff G stated that the metal tray contained cake that was made yesterday and that it should have been labeled. Staff G stated that the metal tray with small bowls were leftover dessert from yesterday [03/19/2026] and that it should have been labeled. Further joint observation showed one full uncovered metal tray labeled Jello with UB 03/20/26. Staff G stated that the Jello should have been covered. OLYMPIC DINING ROOM REFRIGERATORObservation of the Olympic Dining Room Refrigerator on 03/20/2026 at 2:38 PM showed the following items:-One container of organic lemonade with please enjoy by 03/11/2026 labeled for room [ROOM NUMBER].-One unopened container of salsa labeled [resident's first name] dated 02/11/2026. In an interview and joint observation on 03/20/2026 at 3:13 PM, Staff G stated that the dietary aides maintained the unit refrigerators. A joint observation of the Olympic Dining Room Refrigerator showed one container of organic lemonade with please enjoy by 03/11/2026 and one unopened container of salsa dated 02/11/2026. Staff G stated that they should have been discarded and that if it's [it is] out of date, it's out of regulations.KITCHEN MINI STORAGE Observation of the Kitchen Mini Storage on 03/20/2026 at 8:38 AM, showed the following:-One opened container of whole celery seed with best by date of 03/05/25 [03/05/2025].-One opened container of poultry seasoning with no use by or expiration date. -One opened container of granulated garlic with no use by or expiration date. -One opened container of parsley flakes with no use by or expiration date. -One opened container of steak seasoning with no use by or expiration date.-One opened container of whole basil leaves with no use by or expiration date.-One opened container of whole bay leaves with no use by or expiration date.-One opened container of coarse ground black pepper with no use by or expiration date.-One opened container of whole thyme leaves with no use by or expiration date.-One opened container of salt with no use by or expiration date.-One opened container of Beef base with the lid not fully closed.In an interview and joint observation on 03/20/2026 at 9:18 AM, Staff G stated that they expected food items to be labeled with an expiration or use by date. Staff G stated that they reused some of the spice containers and that dietary staff would label them with the use by date. Staff G stated that food items past the use by or expiration date would be discarded. A joint observation of the Kitchen Mini Storage showed one opened container of whole celery seed with a best by date of 03/05/25. Staff G stated that it should have been thrown away. Further joint observation showed an opened container of poultry seasoning, granulated garlic, parsley flakes, steak seasoning, whole basil leaves, whole bay leaves, coarse ground black pepper, whole thyme leaves and salt with no use by or expiration date. Staff G stated that they should have had a used by date and that anything that had been opened should have had a use by date. A joint observation showed an opened container of Beef base with the lid not fully closed. Staff G stated that the lid should have been closed. FOOD HANDLING/HAND HYGIENESTAFF MObservation and interview on 03/20/2026 at 10:51 AM, showed Staff M, Cook, was in the preparation station pureeing beef stroganoff in a blender with gloves on. When Staff M was done, they took their used equipment to the dishwasher, placed it on a dishwashing tray and ran the dishwasher. Staff M removed their gloves and waited by the dishwasher to finish. Staff M did not perform hand hygiene after removing their gloves. When the dishwasher was done, Staff M took the clean equipment back to the preparation station. Staff M applied gloves and poured carrots into a blender and pureed it. When Staff M was done, they poured the pureed carrots into a metal container and added a thickening agent. Staff M then placed the container of pureed carrots inside the steamer. Staff M removed their gloves and pushed a cart full of used kitchen equipment to the dishwashing station. Staff M did not perform hand hygiene. Staff M placed carrots into a food processor. When Staff M was done, they poured the minced carrots into a metal container and then took all the equipment they had used to the dishwashing station. Staff M went back to the preparation station, took a rag from a red bucket and wiped down the preparation table. When Staff M was done, they placed the rag back into the red bucket, took the metal container of minced carrots, placed it inside the steamer and performed hand hygiene. In an interview on 03/20/2026 at 11:08 AM, Staff M stated that they would perform hand hygiene when they went from dirty to clean and between glove use. Staff M further stated that they should have performed hand hygiene when going from dirty to clean task and when they removed their gloves. In an interview on 03/20/2026 at 2:31 PM, Staff G stated that staff were to perform hand hygiene when they entered the kitchen, before preparing food, after handling dirty dishes/garbage and between glove use. Staff G stated that Staff M should have performed hand hygiene between glove use, when handling food, and after doing dirty dishes. In an interview on 03/24/2026 at 3:11 PM, Staff C, Infection Preventionist, stated that they would expect dietary staff to perform hand hygiene when entering the kitchen, handling food/spills and when their hands were visibly dirty. Staff C further stated they would expect dietary staff to perform hand hygiene from a dirty to clean task and between glove use. In an interview on 03/25/2026 at 9:16 AM, Staff A, Administrator, stated that they would expect staff to follow their food storage/labeling and hand-washing policy.Reference: (WAC) 388-97-1100 (3).

Based on observation, interview, and record review, the facility failed to ensure there were sufficient dietary support to serve meals on time for 1 of 1 kitchen, reviewed for food service. This failure placed the residents at risk of delayed mealtimes, frustration, and a diminished quality of life. Findings included . Review of the facility's policy titled, Food and Nutrition Services, revised in October 2017, showed, Meals and/or nutritional supplements will be provided within 45 minutes of either resident request or scheduled meal time, and in accordance with the resident's medication requirements. Review of the Dining Meal Times posted outside the kitchen showed that lunch in the dining room was from 11:00 AM to 12:00 PM and room trays were from 11:30 AM to 12:00 PM. In an observation and interview on 03/20/2026 at 1:15 PM showed Staff M, Cook, prepared the last tray for lunch. Staff M stated that they were done with all the meal trays. When asked what time they would finish the tray line, Staff M stated between 12:30 PM to 12:45 PM and that it depended on the food. When asked if lunch was late, Staff M stated that it was late and that lunch was scheduled to be served from 11:00 AM to 12:00 PM. Staff M stated that meals had to be on time. Staff M further stated that they needed another person to work the kitchen when their assistant was off. A joint record review of the facility's document titled, Dining Meal Times and interview on 03/20/2026 at 2:26 PM with Staff G, Assistant Dietary Manager, showed that breakfast in the dining room was from 7:00 AM to 8:00 AM, breakfast room trays were from 7:30 AM to 8:00 AM, lunch in the dining room was from 11:00 AM to 12:00 PM, lunch room trays were from 11:30 AM to 12:00 PM, dinner in the dining room was from 5:00 PM to 6:00 PM and dinner room trays were from 5:30 PM to 6:00 PM. Staff G stated that meals would be delivered as stated in the meal time schedule. Staff G stated that if lunch was going out at 1:15 PM and the meal time was scheduled for 11:00 AM to 12:00 PM, it was not on time. Staff G stated that there were a cook and a dietary aide doing the tray line and that it was a lot of work for two staff. Staff G further stated that they expected meals to be served on time. In an interview on 03/25/2026 at 9:16 AM, Staff A, Administrator, was asked if they expected staff to provide meals per the facility's scheduled meal times, Staff A stated, generally speaking that's [that is] what we strive for, but things can happen that would cause it to be delayed. Staff A further stated that they would expect to have enough dietary staff to prepare meals on time. Observation on 03/17/2026 at 12:51 PM showed the meal cart was delivered to the 300 hall. At 1:05 PM another meal cart was delivered to the 400/500 hall. In an interview and observation on 03/19/2026 at 12:32 PM, Resident 91 stated that lunch was supposed to come now and stated that they had been waiting for twenty minutes. Observation at 12:57 PM showed Resident 91's meal tray delivered to them. In an interview on 03/20/2026 at 12:58 PM, Staff X, Registered Nurse, stated that lunch trays were usually delivered around 12:00 [PM] to 12:30 [PM]. When asked if the meal trays were here now, Staff X stated, no. Observation on 03/20/2026 at 1:05 PM showed the meal cart was delivered to the 300 hall. At 1:15 PM another meal cart was delivered to the 400/500 hall. A joint record review and interview on 03/24/2026 at 9:52 AM with Staff G showed the Dining Meal Times for lunch room trays was scheduled from 11:30 AM to 12:00 PM. Staff G stated that they would expect the meal trays to be delivered to the 400/500 hall from 12:00 PM to 12:15 PM. Staff G stated that it would be helpful to have additional staff in the kitchen. Staff G further stated that the lunch room trays should be delivered between 11:30 AM to 12:00 PM. In an interview at 03/25/2026 at 12:09 PM, Staff A stated that they expected the meal trays to be delivered to residents within the scheduled mealtimes. When asked if they expected lunch meal trays to be delivered as late as 1:15 PM, Staff A stated, no. Reference: (WAC) 388-97-1160 .

Based on observation, interview, and record review, the facility failed to develop and/or consistently implement care plans for 4 of 16 residents (Residents 11, 24, 4 & 8), reviewed for comprehensive care plans. The failure to develop a care plan for dementia (loss of memory and cognitive functioning that impairs day-to-day life) and implement care plans for call lights, hearing aids and dining assistance placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, revised in March 2022, showed, A comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs. It further showed, A comprehensive, person-centered care plan for the resident should be developed by the interdisciplinary team (IDT), with input from the resident, and his/her family or legal representative. The Comprehensive person-centered care plan should be developed within the seven (7) days of the completion of the required MDS [Minimum Data Set-an assessment tool] assessment. (Admission, Annual, or significant change in status), and should be completed within 21 days of admission. RESIDENT 11Review of the admission MDS dated [DATE] showed Resident 11 was readmitted to the facility on [DATE] and had a diagnosis of dementia with other behavior disturbance. Further review of the MDS showed that the question, Will Cognitive Loss/Dementia-Functional Status be addressed in the care plan? was marked yes. Review of the comprehensive care plan printed on 03/19/2026 showed no person-centered care plan with resident specific interventions that addressed Resident 11's dementia. In an interview on 03/24/2026 at 10:19 AM, Staff J, Certified Nursing Assistant (CNA), stated that they looked at the resident's care plan on how to care for them. Staff J stated that Resident 11 had dementia, that they were sometimes confused and had behaviors. In an interview on 03/24/2026 at 10:25 AM, Staff D, Resident Care Manager (RCM), stated that they expected residents with dementia to have a person-centered care plan with specific interventions. Staff D further stated that Resident 11 had dementia and that they would have expected them to have had a dementia care plan. In an interview on 03/25/2026 at 9:09 AM, Staff N, MDS Coordinator, stated that if the question, Will Cognitive Loss/Dementia-Functional Status be addressed in the care plan? was marked, yes in the MDS, they would have expected a care plan addressing the resident's cognitive loss/dementia. A joint record review of Resident 11's annual MDS dated [DATE] showed that the question, Will Cognitive Loss/Dementia-Functional Status be addressed in the care plan? was marked yes. A joint record review of Resident 11's comprehensive care plan showed that the resident had a cognitive impairment care plan that was initiated on 03/24/2026. When asked if there should have been a care plan prior to 03/24/2026, Staff N stated, yes and that they did not see any dementia/cognitive loss care plan that was initiated prior to 03/24/2026. In an interview on 03/25/2026 at 10:51 AM, Staff B, Regional Director of Clinical Services, stated that they would have expected residents with dementia to have a person-centered care plan with specific interventions and that Resident 11 should have had a care plan. RESIDENT 24Review of a face sheet printed on 03/25/2026 showed that Resident 24 was readmitted to the facility on [DATE]. Review of Resident 24's risk for falls care plan intervention initiated on 11/10/2023 showed, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observations on 03/18/2026 at 9:08 AM, on 03/23/2026 at 9:26 AM and on 03/25/2026 at 8:12 AM, showed Resident 24 lying in bed. Their call light was wrapped around the call light port on the wall and was not within Resident 24's reach. In an interview and joint observation on 03/25/2026 at 8:29 AM, Staff O, CNA, stated that they looked at the care plan on how to care for residents and that they followed the care plan. A joint observation showed that Resident 24's call light was wrapped around the call light port on the wall and was not within their reach. When asked if Resident 24's call light should be within reach, Staff O stated, Always no matter what, that's [that is] unreachable for them. In an interview and joint record review on 03/25/2026 at 8:35 AM, Staff I, Registered Nurse (RN), stated that they expected the CNAs to follow the residents' care plan and that they would expect the resident's call light to be within reach. A joint record review of Resident 24's care plan showed, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Staff I stated that Resident 24 did not use their call light. In an interview on 03/25/2026 at 8:43 AM, Staff D stated that they expected staff to follow the residents' care plan and that they had access to the Kardex (care guide for CNAs). Staff D stated that they expected the resident's call light to be placed within reach. When asked if Resident 24 used their call light, Staff D stated yes, I believe so. Staff D further stated that they would have expected staff to follow Resident 24's care plan and expected their call light to be within reach. In an interview on 03/25/2026 at 10:48 AM, Staff B stated that they expected staff to follow the resident's care plan and expected the resident's call light to be placed within reach. RESIDENT 4Review of the admission MDS, dated [DATE], showed that Resident 4 used hearing aids. Review of Resident 4's hearing care plan, revised on 01/05/2026, showed the intervention to apply hearing aid to both ears. It further showed, Ensure hearing aid or other hearing appliance is in place and in working order. Observation on 03/19/2026 at 11:58 AM showed Resident 4 was not wearing their hearing aids. Resident 4 stated I have some and that they were unsure where the hearing aids were and it had been quite a while since they had used them. In another observation on 03/20/2026 at 10:26 AM showed Resident 4 was not wearing their hearing aids. In an interview, joint record review, and joint observation on 03/23/2026 at 9:25 AM, Staff L, CNA, stated that they would help residents that needed assistance for placing their hearing aids. Staff L stated that Resident 4 was hard of hearing and I haven't [have not] seen a hearing aid. Staff L stated that they would follow resident's care plans. A joint record review of Resident 4's hearing care plan, showed the intervention to apply hearing aid to both ears. It further showed, Ensure hearing aid or other hearing appliance is in place and in working order. Staff L stated that they had never done it [applied hearing aids] for her. A joint observation showed that Resident 4 was not wearing any hearing aids. Staff L stated that Resident 4 was not wearing any hearing aids and that they did not see any hearing aids in their room. In an interview, joint record review, and joint observation on 03/23/2026 at 9:40 AM, Staff H, Licensed Practical Nurse, stated that they followed resident care plans. A joint record review of Resident 4's hearing care plan, showed the intervention to apply hearing aid to both ears. It further showed, Ensure hearing aid or other hearing appliance is in place and in working order. Staff H stated that they did not know if Resident 4 used hearing aids and that she hears me. A joint observation showed Resident 4 was not wearing their hearing aids. Staff H found hearing aids in the top drawer of Resident 4's nightstand and asked Resident 4 if they wanted to use the hearing aids. Resident 4 stated yes. Staff H placed the left hearing aid in Resident 4's ear and asked Resident 4 if they could hear them. Resident 4 stated yes and that they wanted to use both hearing aids. Staff H told Resident 4 that the right hearing aid was broken and stated that they would let Resident 4's family know. In an interview and joint record review on 03/25/2026 at 9:25 AM, Staff F, RCM, stated that if a resident used hearing aids they expected staff to offer them daily. Staff F stated that even if it seemed like a resident could hear without the hearing aids that they expected staff to still offer the hearing aids. Staff F stated that they expected staff to follow resident's care plans. A joint record review of Resident 4's hearing care plan, showed the intervention to apply hearing aid to both ears. It further showed, Ensure hearing aid or other hearing appliance is in place and in working order. Staff F stated that they expected staff to offer Resident 4 their hearing aids. In an interview on 03/25/2026 at 11:49 AM, Staff B stated that if residents had hearing aids they expected staff to offer them every day. Staff B stated that if a resident needed help to place the hearing aids, they expected staff to help them. Staff B further stated that they expected staff to follow resident's care plans and if it said to place hearing aids for a resident, they expected staff to do so. RESIDENT 8Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition. The policy further showed that the appropriate care and services would be provided to residents in accordance with their plan of care including dining. Review of Resident 8's ADL care plan revised on 02/28/2026, showed an intervention for Eating: 1:1 [one to one] Feeding Assist. Observation on 03/23/2026 at 8:30 AM, showed Staff S, CNA, assisted Resident 8 set up their breakfast tray on their bedside table. At 8:32 AM, Staff S was no longer in Resident 8's room and Resident 8 was eating unsupervised. At 8:46 AM, Resident 8 was lying in bed with their eyes closed and their breakfast in front of them. At 9:02 AM, Staff S returned to Resident 8's room, woke them up and asked them if they were done with their meal and took the tray out of the room. In an interview and joint record review on 03/23/2026 at 9:10 AM, Staff S stated that they would check the residents' Kardex or care plan to see how much assistance a resident needed with their ADLs. Staff S stated that they were expected to follow the care plan. Staff S stated that Resident 8 could feed themselves, but she needs to be supervised, or sometimes needs to be fed, and that if the resident was unable to do it, they would assist them. Staff S stated that a 1:1 feeding assist meant that they would have to stay with the resident for the entirety of the meal to assist them. A joint record review of Resident 8's Kardex showed they were a 1:1 feeding assist. Staff S stated that Resident 8 did need assistance with feeding at times because they fell asleep or were unable to feed themselves. On 03/25/2026 at 8:12 AM, Staff R, RN, stated that staff were expected to follow the resident's care plan. On 03/25/2026 at 8:33 AM, Staff F stated that they would expect staff to follow the residents' care plan. Staff F further stated that Resident 8 was a 1:1 feeding assist as they had struggled with meal intake since admission and would have expected staff to stay with them during their meal. On 03/25/2026 at 10:06 AM, Staff B stated that they expected staff to follow a resident's care plan. Reference: (WAC) 388-97-1020 (1)(2)(a)

Based on observation, interview, and record review, the facility failed to ensure respiratory services were provided according to professional standards of practice for 3 of 4 residents (Residents 39, 21 & 83), reviewed for respiratory care. The failure to follow physician orders for oxygen (O2) therapy and to properly store O2 equipment placed the residents at risk for respiratory infections and related complications.Findings included .Review of the facility's policy titled, Respiratory Treatment, revised on 06/22/2022, showed, The licensed nurse is responsible to check residents O2 therapy each shift to validate that the regulator is set for the appropriate liter flow.When oxygen is not in use, the cannula [NC-flexible tubing with a prong (one of two small, curved plastic or silicone tips) that sits inside the nose and delivers O2] (mask) and tubing is to be stored in a bag. The policy showed that the administration of other types of respiratory treatments such as Continuous Positive Airway Pressure (CPAP- a device that keeps the airways open during sleep) are completed per physician's order and manufacturer recommendation of equipment operations. The policy further showed, Use the manufacturer guidelines to develop cleaning and care maintenance treatment orders.Place mask and tubing in bag after it has dried. If not stored in a bag, the mask is cleaned prior to each use to prevent any contamination. In addition, the policy showed that should an oxygen mask and CPAP mask be noted on the floor, the mask is cleaned prior to placement on the resident.RESIDENT 39Review of a face sheet printed on 03/18/2026 showed that Resident 39 readmitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a progressive lung disease that causes air flow blockage and breathing-related problems).Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 02/06/2026, showed that Resident 39 received O2 therapy.Review of Resident 39's physician orders showed an order for continuous O2 at three liters (a unit of measurement) a minute (3 L/min) via NC every shift for O2 use related to acute respiratory failure with hypoxia (a condition where the lungs cannot deliver enough O2 to the blood, leading to dangerously low O2 levels in the body) with a start date of 05/16/2025.Observation on 03/18/2026 at 1:43 PM, showed Resident 39 was lying in bed with one prong inside their right nostril (nose) and the other prong was outside of their nostril. Resident 39's O2 tubing was not plugged onto the O2 concentrator and that the O2 concentrator was set at 1.5 L/min. At 1:49 PM, Staff J, Certified Nursing Assistant (CNA), entered the resident's room and gave them water. Staff J applied gloves, assisted the resident and left the room. Staff J did not adjust Resident 39's NC and did not plug their O2 tubing onto the O2 concentrator.On 03/18/2026 at 1:57 PM, Resident 39 stated that they had to use O2 all the time.Observation on 03/18/2026 at 2:15 PM, showed Staff K, CNA, entered Resident 39's room and asked Resident 39 if there was anything they could help them with. Resident 39 stated they did not need help and Staff K left the resident's room. Staff K did not adjust Resident 39's NC and did not plug their O2 tubing onto the O2 concentrator.In an interview and joint observation on 03/18/2026 at 2:28 PM, Staff K stated that they checked the residents' Kardex (care guide for CNAs) and care plan when caring for residents. Staff K stated that when caring for resident receiving oxygen, they made sure that the resident was connected to the O2 concentrator and that the NC was applied and working properly. Staff K stated that they would check when they entered the resident's room to see if the resident was wearing their NC and that the O2 concentrator was turned on. Staff K stated that they would ask the resident if they could feel the O2. Staff K stated that they would store the NC in a bag and would place it inside the drawer of the resident's bedside table when not in use. Staff K stated that they made sure that it was not on the floor. When asked who ensured that the resident was receiving the correct O2 level, Staff K stated the nurse. A joint observation showed that Resident 39's O2 tubing was not plugged onto the O2 concentrator and that they had one prong inside their right nostril and the other prong was outside of their nostril. Staff K stated, It [O2 tubing] has to be connected [to the O2 concentrator] and that Resident 39's NC needed to be adjusted.In an interview, joint record review and joint observation on 03/18/2026 at 2:49 PM, Staff I, Registered Nurse, stated that they would change the residents NC if it was visibly soiled or if it fell on the floor and that they would place it in a plastic bag when not in use. Staff I stated that nurses ensured that residents received the right O2 and that we follow the order. A joint record review of Resident 39's physician orders showed an order for continuous O2 at 3 L/min. Staff I stated that they checked the resident's O2 every shift, when the residents' had trouble breathing and as needed. A joint observation of Resident 39's O2 concentrator showed that it was set at 2.5 L/min. Staff I stated that it should have been at 3 L/min and that it should have been connected to the O2 concentrator at all times. Staff I further stated that staff should have adjusted Resident 39's NC if they noticed that it was not applied properly. RESIDENT 21Review of the admission MDS dated [DATE] showed that Resident 21 was admitted to the facility on [DATE] and had a diagnosis of acute and chronic respiratory failure with hypercapnia (the inability of the respiratory system to maintain normal gas exchange, leading to elevated carbon dioxide [helps maintain the body's acid-base balance] levels in the blood. Further review of the MDS showed that Resident 21 received O2 therapy.Review of Resident 21's March 2026 Medication Administration Record showed an order for continuous O2 at 2 L/min via NC every shift for O2 use with a start date of 03/06/2026.Observation on 03/17/2026 at 2:29 PM showed that Resident 21's NC was hung on top of their night stand drawer and was not stored in a bag. Observation on 03/18/2026 at 2:21 PM showed Resident 21's NC was lying on top of their night stand and was not stored in a bag.In a joint observation and interview on 03/18/2026 at 2:32 PM with Staff K showed that Resident 21's NC was lying on the floor. Staff K stated that it should not have been on the floor and that it should have been stored in a bag.RESIDENT 83Review of the admission MDS dated [DATE] showed that Resident 83 was admitted to the facility on [DATE] and had a diagnosis of obstructive sleep apnea (a condition in which breathing stops involuntarily for brief periods of time during sleep). Further review of the MDS showed that Resident 83 used a CPAP.Review of Resident 83's respiratory care plan showed an intervention for CPAP on at 9:00 PM and off at 7:00 AM dated 03/18/2026.Observation on 03/17/2026 at 10:54 AM showed that Resident 83's CPAP mask was lying on top of their night stand and that it was not stored in bag. Resident 83 stated that staff did not store their CPAP mask in a bag.Observation on 03/18/2026 at 10:09 AM showed that Resident 83's CPAP mask was inside the top drawer of their night stand and was not stored in a bag. Resident 83 stated that a staff had placed it there.Observation on 03/23/2026 at 9:15 AM showed that Resident 83's CPAP mask was lying on top of their night stand and was not stored in a bag. In an interview and joint observation on 03/23/2026 at 10:30 AM, Staff H, Licensed Practical Nurse, stated that they would clean the CPAP mask, let it dry and store it in a plastic bag when not in use. A joint observation showed that Resident 83's CPAP mask was lying on top of their night stand and was not stored in a bag. Staff H stated that Resident 83's CPAP mask should have been stored in a bag.In an interview on 03/23/2026 at 1:08 PM, Staff E, Resident Care Manager (RCM), stated that if a resident was on continuous O2, staff were to ensure that the NC was properly in place and stored in a plastic bag when not in use to prevent contamination. Staff E further stated that the CPAP mask would be stored in a bag when not in use. Staff D, RCM, stated that the NC should be stored in a bag when not in use and if it was found on the floor, they would replace it with a new one. Staff E stated that they would expect Resident 39 to receive the right O2 liter and would expect the CNA or nursing staff to ensure their O2 tubing was plugged. Staff E stated that they would expect staff to adjust Resident 39's NC and notify the nurse. Staff E further stated that they would expect Resident 83's CPAP mask to be stored in a bag when not in use.In an interview on 03/25/2026 at 10:35 AM, Staff B, Regional Director of Clinical Services, stated that respiratory equipment should be stored in a plastic bag when not in use. Staff B stated that Resident 21's NC should have been stored in a plastic bag and that if it was on the floor, staff should have replaced it. Staff B stated that if staff noticed that Resident 39's O2 tubing was not plugged onto the O2 concentrator, they would expect the CNA to alert the nurse that the resident's O2 tubing was unplugged. Staff B stated that they would expect the CNA to adjust the resident's NC if it was not applied properly. Staff B further stated that Resident 83's CPAP mask should have been stored in a bag when not in use. Reference: (WAC) 388-97-1060 (3)(j)(vi).

Based on observation, interview, and record review, the facility failed to ensure Contact Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) practices were followed for 2 of 5 (Staff H & V), and failed to ensure hand hygiene/glove use practices were followed for 4 of 6 staff (Staff V, L, H & I), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included. Review of the facility's policy titled, Transmission Based Precautions [measures put in place to prevent spread of infection by staff wearing Personal Protective Equipment (PPE-use of gown, gloves, mask and/or face shield) before entering a resident's room or environment], revised in May 2023, showed, It is the policy of this facility to implement Transmission-Based Precautions.for residents known to be, or suspected of being, infected with infectious agents. Review of the Centers for Disease Control Prevention online article titled, Transmission-Based Precautions, dated 04/03/2024, showed, Use Contact Precautions for patients [residents] with known or suspected infections that represent an increased risk for contact transmission. It further showed that putting on PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens [germs that can cause disease]. Review of the facility's policy titled, Hand Hygiene, revised on 12/15/2021, showed, Hand hygiene is the primary means of preventing the transmission of infection and should be performed as soon as possible after hands become contaminated and frequently during the working day. It further showed that hand hygiene is required after removing gloves.and/or before applying. CONTACT PRECAUTIONSSTAFF HObservation on 03/17/2026 at 12:17 PM, showed Staff H, Licensed Practical Nurse, entered Resident 84's room (contact precautions room) without wearing a gown or gloves. Observation on 03/19/2026 at 10:34 AM showed Staff H entered Resident 84's room without wearing a gown or gloves. In an interview and joint observation on 03/19/2026 at 10:43 AM, Staff H stated that they would know if a resident was on contact precautions by the signage at the resident's door, during report, and in a resident's medical records. Staff H stated that they used a gown and gloves when providing care for a resident on contact precautions. When asked if they needed to wear a gown and gloves prior to entering a resident's room on contact precautions, Staff H stated that I use a gown when giving care and I didn't [did not] give care to Resident 84. A joint observation of the signage by Resident 84's door showed that everyone must wear a gown and gloves before room entry. Staff H stated, my mistake. STAFF VObservation on 03/20/2026 at 9:04 AM, showed Staff V, Certified Nursing Assistant (CNA), entered Resident 84's room without wearing a gown and gloves. In an interview on 03/20/2026 at 9:10 AM, Staff V stated that they would look at the sign if a resident was on isolation precautions. Staff V stated that Resident 84 was on contact precautions. Staff V stated that they were unsure when they needed to wear PPE for contact precautions and would ask a nurse. In a follow up interview at 9:20 AM, Staff V stated that they have to wear gown and gloves every time they enter a contact precautions room. When asked if they wore a gown and gloves when they entered Resident 84's room, Staff V stated, no. In an interview on 03/25/2026 at 8:30 AM, Staff C, Infection Preventionist, stated that they expected staff to follow the signage at residents' rooms if they were on contact precautions. Staff C stated that they expected staff to wear a gown and gloves prior to entering a contact precautions room. HAND HYGIENE/GLOVE USESTAFF VObservation on 03/20/2026 at 10:04 AM, showed Staff V wearing gloves while changing Resident 4's brief and providing peri-care (the daily cleansing of the private areas to maintain hygiene and comfort). When they were finished, Staff V touched Resident 4, their blanket, sheets, call light, and their clean brief. Staff V did not change gloves between dirty to clean tasks. In an interview on 03/20/2026 at 10:30 AM, Staff V stated that they would change gloves after changing a resident's brief/providing peri-care and touching clean items. When asked if they had changed their gloves between changing Resident 4's brief/providing peri-care and touching Resident 4, their blanket, sheets, call light, and their clean brief, Staff V stated, I made a mistake. In an interview on 03/25/2026 at 8:30 AM, Staff C stated that they expected staff to change their gloves when going between a clean and dirty area, on the body or in the room. Staff C stated that they would expect staff to change their gloves after changing residents' briefs and before touching the residents and their linens. Staff C further stated that staff should perform hand hygiene between glove changes. In an interview on 03/25/2026 at 11:49 AM, Staff B, Regional Director of Clinical Services, stated that their expectation if a resident was on contact precautions was that staff should read the signage and follow it. Staff B stated that they expected staff to wear a gown and gloves prior to entering a contact precautions room. Staff B further stated that they expected staff to change their gloves between dirty and clean tasks and that they should perform hand hygiene between glove changes. STAFF LObservation on 03/23/2026 at 9:56 AM, showed Staff L, CNA, wearing a gown and gloves. Staff L followed Resident 83 to the bathroom and assisted them to sit on the toilet. Staff L closed the bathroom door, stood outside and waited for Resident 83 to finish. When resident called out for Staff L's help, Staff L entered the bathroom and provided Resident 83 with peri-care. When Resident 83 was done, Resident 83 walked back to bed and Staff L followed Resident 83 from behind. Staff L lifted Resident 83's legs up in bed, gave Resident 83 their call light, bed remote control and repositioned their pillow. Staff L did not remove their gloves and perform hand hygiene from dirty to clean tasks. In an interview on 03/23/2026 at 10:20 AM, Staff L stated that they would perform hand hygiene before and after glove use and from dirty to clean tasks. Staff L further stated that they should have removed their gloves and perform hand hygiene. In an interview on 03/24/2026 at 3:18 PM, Staff B stated that they would have expected Staff L to have removed their gloves and perform hand hygiene especially with peri-care. STAFF HObservation on 03/23/2026 at 8:30 AM, showed Staff H applied gloves and applied diclofenac external gel (medication for pain) to Resident 89's left knee. When Staff H was done, they removed their gloves and applied new gloves. Staff H applied Resident 89's knee brace and immediately removed It. Staff H informed Resident 89 that they were going to come back and that they wanted the medication on their knee to dry. Staff H did not perform hand hygiene between glove use. In an interview on 03/23/2026 at 9:01 AM, Staff H stated that they would perform hand hygiene before and after giving medications and between glove use. Staff H further stated that they should have performed hand hygiene between glove use. STAFF IObservation on 03/24/2026 at 12:35 PM, showed Staff I, Registered Nurse, applied gloves and wiped the cap of Resident 92's insulin (medication for high blood sugar) with alcohol wipes, and drew the medication with a syringe (a tube with a needle used to inject medications in the body). When Staff I was done, they removed their gloves and locked the medication cart without performing hand hygiene. Staff I knocked on Resident 92's door, applied gloves without performing hand hygiene and administered Resident 92's insulin. In an interview on 03/24/2026 at 12:47 PM, Staff I stated that they would perform hand hygiene before/after giving medications and before/after glove use. Staff I further stated that they should have perform hand hygiene before and after glove use. In an interview on 03/25/2026 at 10:32 AM, Staff C stated that they would have expected staff to perform hand hygiene prior to applying gloves to administer an injection. Staff C further stated that Staff I should have performed hand hygiene prior and between glove use. In an interview on 03/25/2026 at 10:46 AM, Staff B stated that they expected staff to perform hand hygiene from dirty to clean tasks and between glove use. Staff C further stated that they expected Staff H and Staff I to perform hand hygiene between glove use. Reference: (WAC) 388-97-1320 (1)(a)(c) .

Based on observation, interview, and record review, the facility failed to ensure expired medical supplies and medications were discarded for 2 of 2 medication rooms (East & [NAME] Medication Room), and for 2 of 4 medication carts (Cart 3 & Cart 1). In addition, the facility failed to store medications properly for 1 of 2 unit refrigerators (Snohomish Den Refrigerator), reviewed for medication storage and labeling. These failures placed the residents at risk of receiving compromised and ineffective medications, and unauthorized access to medications.Findings included . Review of the facility's policy titled, Medication Storage, dated in January 2023, showed, Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The policy further showed that outdated, contaminated, discontinued, or deteriorated medications were immediately removed from stock and disposed of according to procedures for medication disposal. EAST MEDICATION ROOMIn a joint observation and interview on 03/20/2026 at 9:41 AM with Staff F, Resident Care Manager, showed three Medline (brand name) Safety Syringes (a tube with a needle used to inject medications in the body) with an expiration date of 03/04/2026 and one syringe with an expiration date of 02/03/2026. Staff F stated that the syringes expired and should not have been in the medication storage room. In another joint observation of the refrigerator showed four boxes of Actemra (prescription medicine that treats inflammatory conditions) for Resident 9 with an expiration date of January 2026. Staff F stated that Resident 9 was a current resident and that the expired medication should not be in the refrigerator. WEST MEDICATION ROOMIn a joint observation and interview on 03/20/2026 at 10:19 AM with Staff U, Registered Nurse (RN), showed a Tresiba insulin degludec pen (medication for high blood sugar) with an open date of 10/26/2025. Staff U stated that it was expired and that the resident who it belonged to had discharged . An additional joint observation showed a flu (contagious respiratory illness) vaccine injection box dated 05/02/2024. Staff U stated that it was expired and would not use it. MEDICATION CART 3In a joint observation and interview on 03/20/2026 at 10:47 AM with Staff T, RN, showed one opened container of Calcium 600 plus D 10 micrograms (a unit of measurement) tablets (supplement) with a best before date of February 2026 and one glargine insulin pen (medication for high blood sugar) with an open date of 02/08/2026. Staff T stated that the best before date for the Calcium supplement had passed and that it had already been a month for the insulin pen. Staff T further stated that both medications should not have been in the medication cart. CART 1In a joint observation and interview on 03/20/2026 at 11:33 AM with Staff I, RN, showed a lispro insulin pen (medication for high blood sugar) for Resident 74 with an open date of 02/18/2026. Staff I stated that it had been more than 28 days and would discard it. In a phone interview on 03/25/2026 at 9:14 AM with Staff BB, Consultant Pharmacist, stated that lispro and glargine insulin pens were good for 28 days after opening and the Tresiba insulin degludec pen was good for 56 days after opening. Staff BB stated the facility could either destroy the medication in house after that or could send it back to the pharmacy if it was hazardous. On 03/25/2026 at 10:14 AM, Staff B, Regional Director of Clinical Services, stated that they expected medication to be stored appropriately per guidance, not expired, and secured safely. Staff B further stated they did not expect to have medication from October 2025 in the medication room and that the facility was able to destroy those medications in house and if not would return them to the pharmacy. SNOHOMISH DEN REFRIGERATORObservation of the Snohomish Den Refrigerator on 03/20/2026 at 2:46 PM, showed one opened box of Gel Pack Instant and Reusable Cold or Heat Therapy labeled [room] 218 and one unlabeled flower pill box. In an interview and joint observation on 03/20/2026 at 3:13 PM, Staff G, Assistant Dietary Manager, stated that dietary aides managed the unit refrigerators and that they would not expect non-food items to be stored in the refrigerators. A joint observation of the Snohomish Den Refrigerator showed one opened box of Gel Pack Instant and Reusable Cold or Heat Therapy labeled 218 and one unlabeled flower pill box. Staff G opened the flower pill box and stated that they were pills or vitamins. Staff G stated that they would not have expected them to be stored in the refrigerator. At 3:24 PM, Staff G took the box of Gel Pack Instant and Reusable Cold or Heat Therapy and the flower pill box and showed it to Staff F. Staff F opened the flower pill box and stated that they would not have expected it to be stored in the refrigerator and that we would not utilize that fridge [refrigerator] for medication purposes at all. Staff G further stated that the box of Gel Pack Instant and Reusable Cold or Heat Therapy and the flower pill box should not have been stored in the Snohomish Den Refrigerator. In an interview on 03/25/2026 at 12:24 PM, Staff B stated that they would not expect the residents medications to be stored in the unit refrigerators. Staff B stated that the box of Gel Pack Instant and Reusable Cold or Heat Therapy and the flower pill box should not have been in there. Reference: (WAC) 388-97-1300 (2) .

Based on interview and record review, the facility failed to ensure the COVID-19 (a highly transmissible infectious virus that causes respiratory illness and in severe cases can cause difficulty breathing and could result in impairment or death) vaccine was offered and/or provided for 2 of 5 residents (Residents 9 & 32), reviewed for immunizations. This failure placed the residents at risk for contracting the COVID-19 virus and related complications.Findings included.Review of the facility's policy titled, SARS-CoV-2 (COVID-19), dated 08/01/2024, showed, Center residents are offered recommended COVID-19 vaccinations upon admission and as eligible per CDC [Centers for Disease Control and Prevention] recommendations.Review of the CDC online document titled, Staying Up to Date with COVID-19 Vaccines, dated 11/19/2025, recommended a 2025-2026 COVID-19 vaccine for people ages 6 months and older. It further showed that getting the 2025-2026 COVID-19 vaccine is especially important if you.are living in a long-term care facility.RESIDENT 9Resident 9 readmitted to the facility on [DATE].Review of the document titled, Informed Consent-Immunization, signed on 12/29/2025, showed that Resident 9's representative signed the consent form for Resident 9 to receive the COVID-19 vaccine.Review of Resident 9's Electronic Health Record (EHR- medication administration record, progress notes, miscellaneous, and immunizations tab), showed no documentation that Resident 9 received the COVID-19 vaccine.In an interview and joint record review on 03/25/2026 at 8:30 AM, Staff C, Infection Preventionist, stated that they expected the COVID-19 vaccine to be offered to residents upon admission and would look at when to offer per CDC recommendations. Staff C stated that if a resident consented to receive the COVID-19 vaccine they would expect them to receive it. A joint record review of the document titled, Informed Consent-Immunization, signed on 12/29/2025, showed that Resident 9's representative signed the consent form for Resident 9 to receive the COVID-19 vaccine. Staff C stated the document showed that they [Resident 9] wanted the vaccine. A joint record review of Resident 9's EHR showed no documentation that Resident 9 received the COVID-19 vaccine. Staff C stated that there was nothing after 12/29/2025 that showed Resident 9 received the COVID-19 vaccine.In an interview and joint record review on 03/25/2026 at 11:49, Staff B, Regional Director of Clinical Services, stated that if a resident signed a consent to receive the COVID-19 vaccine they would expect it to be given. A joint record review of Resident 9's EHR showed the document titled, Informed Consent-Immunization, signed on 12/29/2025, showed that Resident 9's representative signed the consent form for Resident 9 to receive the COVID-19 vaccine. Staff B stated they would keep looking to find if Resident 9 received the COVID-19 vaccine and if they could not find anything it would be considered not given. No further documentation was provided.RESIDENT 32Resident 32 was admitted to the facility on [DATE].Review of the immunization tab showed that Resident 32 declined the COVID-19 vaccine on 10/18/2023 and on 10/04/2024.Review of Resident 32's EHR showed no documentation that they had been offered the COVID-19 vaccine after they declined on 10/18/2023 and on 10/04/2024.In an interview and joint record review on 03/25/2026 at 8:30 AM, Staff C stated they would expect to offer the COVID-19 vaccine even if a resident had previously declined it. A joint record review of Resident 32's EHR showed the last time Resident 32 was offered the COVID-19 vaccine was on 10/04/2024. Staff C stated, I would expect for her to have been offered since then.In an interview and joint record review on 03/25/2026 at 11:49 AM, Staff B stated that they expected the COVID-19 vaccine to be offered to residents upon admission and if they were long term residents they would offer again. A joint record review of Resident 32's EHR showed the last time Resident 32 was offered the COVID-19 vaccine was on 10/04/2024. Staff B stated, doesn't [does not] look like it was offered in 2025. Staff B stated that it should have been offered in 2025, but we did not.Reference: (WAC) 388-97-1620 (2)(b)(i)(ii).

Based on observation, interview, and record review, the facility failed to ensure feeding assistance was provided for 1 of 1 resident (Resident 8), reviewed for activities of daily living. This failure placed the resident at risk of unmet care needs and a diminished quality of life.Findings included.Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, showed, Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition. The policy further showed that the appropriate care and services would be provided to residents in accordance with their plan of care including dining.Review of Resident 8's ADL care plan revised on 02/28/2026, showed an intervention for Eating: 1:1 [one to one] Feeding Assist.Observation on 03/23/2026 at 8:30 AM, showed Staff S, Certified Nursing Assistant, assisted Resident 8 set up their breakfast tray on their bedside table. At 8:32 AM, Staff S was no longer in Resident 8's room and Resident 8 was eating unsupervised. At 8:46 AM, Resident 8 was lying in bed with their eyes closed and their breakfast in front of them. At 9:02 AM, Staff S returned to Resident 8's room, woke them up and asked them if they were done with their meal and took the tray out of the room.In an interview and joint record review on 03/23/2026 at 9:10 AM, Staff S stated that they would check the residents' Kardex (quick reference tool for resident care) or care plan to see how much assistance a resident needed with their ADLs. Staff S stated that they were expected to follow the care plan. Staff S stated that Resident 8 could feed themselves, but she needs to be supervised, or sometimes needs to be fed, and that if the resident was unable to do it, they would assist them. Staff S stated that a 1:1 feeding assist meant that they would have to stay with the resident for the entirety of the meal to assist them. A joint record review of Resident 8's Kardex showed they were a 1:1 feeding assist. Staff S stated that Resident 8 did need assistance with feeding at times because they fell asleep or were unable to feed themselves.On 03/25/2026 at 8:12 AM, Staff R, Registered Nurse, stated that staff was expected to follow the resident's care plan.On 03/25/2026 at 8:33 AM, Staff F, Resident Care Manager, stated that they would expect staff to follow the resident's care plan. Staff F further stated that a 1:1 feeding assist would include assisting the residents eat their meal and providing reminders to eat while being observed. Staff F further stated that Resident 8 was a 1:1 feeding assist as they had struggled with meal intake since admission and would have expected staff to stay with them during their meal.On 03/25/2026 at 10:06 AM, Staff B, Regional Director of Clinical Services, stated that they expected staff to follow a resident's care plan. Staff B further stated that a 1:1 feeding assist meant that staff were actively assisting the residents eat their meal and that it was important for their nutrition.Reference: (WAC) 388-97-1060 (2)(c).

Based on observation, interview, and record review, the facility failed to provide services to maintain hearing methods to carry out the Activities of Daily Living (ADL) for 1 of 1 resident (Resident 4), reviewed for communication. This failure placed the resident at risk of not being able to hear and/or communicate and a diminished quality of life.Findings included.Review of the facility's policy titled, Activities of Daily Living (ADL), Supporting, revised in March 2018, showed that Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs).Review of the admission Minimum Data Set (an assessment tool), dated 12/30/2025, showed that Resident 4 used hearing aids.Review of Resident 4's hearing care plan, revised on 01/05/2026, showed the intervention to apply hearing aid to both ears. It further showed, Ensure hearing aid or other hearing appliance is in place and in working order.Observation on 03/19/2026 at 11:58 AM showed Resident 4 was not wearing their hearing aids. Resident 4 stated I have some and that they were unsure where the hearing aids were and it had been quite a while since they had used them.Observation on 03/20/2026 at 10:26 AM showed Resident 4 was not wearing their hearing aids.In an interview and joint observation on 03/23/2026 at 9:25 AM, Staff L, Certified Nursing Assistant, stated that they would help residents that needed assistance for placing their hearing aids. Staff L stated that Resident 4 was hard of hearing and I haven't [have not] seen a hearing aid. A joint observation showed that Resident 4 was not wearing any hearing aids. Staff L stated that Resident 4 was not wearing any hearing aids and that they did not see any hearing aids in their room.In an interview and joint observation on 03/23/2026 at 9:40 AM, Staff H, Licensed Practical Nurse, stated that they did not know if Resident 4 used hearing aids and that she hears me. A joint observation showed Resident 4 was not wearing their hearing aids. Staff H found hearing aids in the top drawer of Resident 4's nightstand and asked Resident 4 if they wanted to use the hearing aids. Resident 4 stated yes. Staff H placed the left hearing aid in Resident 4's ear and asked Resident 4 if they could hear them. Resident 4 stated yes and that they wanted to use both hearing aids. Staff H told Resident 4 that the right hearing aid was broken and stated that they would let Resident 4's representative know.In an interview on 03/25/2026 at 9:25 AM, Staff F, Resident Care Manager, stated that if a resident used hearing aids they expected staff to offer them daily. Staff F further stated that even if it seemed like a resident could hear without their hearing aids that they expected staff to still offer the hearing aids.In an interview on 03/25/2026 at 11:49 AM, Staff B, Regional Director of Clinical Services, stated that if residents had hearing aids they expected staff to offer them every day. Staff B further stated that if a resident needed help to place their hearing aids, they expected staff to help them.Reference: (WAC) 388-97-1060 (2)(b).

Based on interview and record review, the facility failed to ensure a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) was completed for 1 of 16 residents (Resident 8), reviewed for significant change of condition. The failure to complete an SCSA within 14 days of a significant change of condition placed the resident at risk for delayed care planning, unmet care needs, and a diminished quality of life. Findings included .Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1 dated October 2025, showed that an SCSA is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team determined that a resident meets the significant change guidelines for either major improvement or decline. The RAI manual showed, A SCSA is appropriate if there are either two or more areas of decline or two or more areas of improvement. Further review of the RAI manual showed that an SCSA would be completed 14 days after determination that a significant change in a resident's status occurred (determination date + [plus] 14 calendar days).Review of the facility's policy titled, Change in a Resident's Condition or Status, revised in February 2021, showed a significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by staff, impacted more than one area of the resident's health status, required interdisciplinary review and/or revision of the care plan, and was ultimately based on the judgment of the clinical staff and guidelines outlined in the RAI. The policy further showed if a significant change in the resident's physical or mental condition occurred, a comprehensive assessment would be conducted as outlined in the MDS RAI manual.Review of the dietary note dated 12/26/2025 showed Resident 8's current weight was 146.9 pounds (lbs.) and had a significant weight loss of 7.4 percent (%) in 30 days related to variable intake.Review of Resident 8's Nutritional Risk Assessment (Admission/Annual), dated 01/23/2026, showed they readmitted to the facility with a diagnosis of above the knee (right knee) amputation (removal of a limb or extremity). The assessment further showed that Resident 8 had a significant weight loss of 10% x [times] 90 days, partially related to loss of limb and to variable intake.Review of the admission MDS dated [DATE], showed that Resident 8 did not have weight loss. It further showed that Resident 8 had functional limitation in range of motion (limitation that interfered with daily functions or placed the resident at risk of injury in the last seven days) to their lower extremity on one side.Review of the quarterly MDS dated [DATE], showed that Resident 8 did not have weight loss. The MDS further showed Resident 8 had functional limitation in range of motion to both sides of their lower extremities.Review of the document titled, Weight Summary, showed Resident 8 weighed 164.5 lbs. on 10/30/2025 and 136.2 lbs. on 01/29/2026, which indicated a significant weight loss of 17.2% in three months.Review of Resident 8's Activities of Daily Living (ADL) care plan revised on 02/28/2026, showed, Resident has actual decline in ADL and remains at risk and requires assistance related to amputation, pain, recent surgery, weakness.On 03/25/2026 at 8:17 AM, Staff N, MDS Coordinator, stated that they followed the RAI manual. Staff N stated that Resident 8 had a significant weight loss and was not on a physician prescribed weight loss regimen. Staff N further stated that Resident 8 had impairments to both lower extremities and that they should have done an SCSA.On 03/25/2026 at 10:14 AM, Staff B, Regional Director of Clinical Services, stated that they would expect staff to complete an SCSA when it met the requirements in the RAI manual. Staff B stated that if a resident had significant weight loss and a decline in range of motion, they would expect an SCSA to be completed and that it should have been completed for Resident 8.Reference: (WAC) 388-97-1000 (3)(b).

Based on interview and record review, the facility failed to ensure clinical records were complete and accurate for 1 of 4 residents (Resident 13), reviewed for advance directives. This failure placed the resident at risk for medical complications and unmet care needs.Findings included.Review of the facility's policy titled, Advance Directives, reviewed in [DATE], showed a definition for Physician Orders for Life-Sustaining Treatment (POLST) that stated, This document, signed by an authorized health care professional, is a medical order that records residents' treatment wishes so that emergency personnel know what treatments to provide in the event of a medical emergency.Review of Resident 13's POLST form dated [DATE], showed Resident 13's code status (instructions to their medical team about what to do if a resident had no pulse and was not breathing) was Attempt Resuscitation/CPR (Cardiopulmonary Resuscitation-emergency lifesaving procedure performed when the heart stops beating).Review of Resident 13's comprehensive care plan printed on [DATE] showed that Resident 13's code status was Do Not Attempt Resuscitation (DNAR).Review of a Physical Therapy note dated [DATE] showed under Precautions that Resident 13's code status was DNAR.In an interview and joint record review on [DATE] at 12:08 PM, Staff V, Certified Nursing Assistant, stated that they knew what a resident's code status was by checking the resident's care plan. A joint record review of Resident 13's Electronic Health Record (EHR), showed that Resident 13's code status was Attempt Resuscitation/CPR. Another joint record review of Resident 13's comprehensive care plan showed that Resident 13's code status was DNAR. Staff V stated that they are different and that they did not match.In an interview and joint record review on [DATE] at 12:15 PM, Staff U, Registered Nurse, stated that they looked for a resident's code status on the main page of a resident's EHR. A joint record review of Resident 13's EHR showed that Resident 13's code status was Attempt Resuscitation/CPR. Staff U stated that the resident's code status should match everywhere, including the resident's care plan.In an interview on [DATE] at 12:28 PM, Staff F, Resident Care Manager, stated that they expected staff to know what a resident's code status was by looking in a resident's EHR, POLST binder, and a resident's care plan.In an interview and joint record review on [DATE] at 12:34 PM, Staff W, Director of Rehabilitation, stated that a resident's code status was documented under precautions in residents' therapy notes. A joint record review of the Physical Therapy note dated [DATE], showed under Precautions that Resident 13's code status was DNAR. A joint record review of Resident 13's EHR showed that Resident 13's code status was Attempt Resuscitation/CPR. Staff W stated that Resident 13's code status in therapy notes needs to be updated.In an interview on [DATE] at 11:49 AM, Staff B, Regional Director of Clinical Services, stated that they expected a resident's code status to be consistent between what the POLST form stated and a resident's comprehensive care plan. Staff B further stated that they expected resident records to be accurate.In an interview on [DATE] at 12:09 PM, Staff A, Administrator, stated that they expected resident records to be accurate.Reference: (WAC) 388-97-1720 (1)(a)(i)(ii).

Based on interview and record review, the facility failed to provide a copy of the transfer/discharge notice to the State Long Term Care Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations) office with the required information for 2 of 4 residents (Residents 8 & 9), reviewed for hospitalizations. This failure placed the residents at risk for not having opportunities to make informed decisions about their transfer.Findings included.Review of the facility's policy titled, Notice of Transfer or Discharge, reviewed in April 2025, showed, The center sends a copy of the notice to the State Long term Care Ombudsman.RESIDENT 8Review of the discharge Minimum Data Set (MDS-an assessment tool), dated 01/15/2026, showed that Resident 8 was admitted to the facility on [DATE] and discharged to an acute hospital on [DATE].RESIDENT 9Review of the discharge MDS dated [DATE], showed that Resident 9 was admitted to the facility on [DATE] and discharged to an acute hospital on [DATE].Review of the discharge MDS dated [DATE], showed that Resident 9 discharged to an acute hospital on [DATE]. On 03/24/2026 at 2:31 PM, Staff P, Medical Records Director, stated they were responsible for notifying the Ombudsman either via fax or email when a resident was hospitalized or discharged from the facility. Staff P stated that they had recently started sending over a copy of the notice of transfer/discharge when they were notified that it was required. Staff P further stated that they had not sent out a copy of the notice of transfer/discharge to the Ombudsman for Resident 8 and Resident 9 and that they should have.On 03/25/2026 at 12:34 PM, Staff A, Administrator, stated that they understood that the regulation was to send a copy of the notice of transfer/discharge to the Ombudsman.Reference: (WAC) 388-97-0120(2)(c)(5).

Based on interview and record review, the facility failed to determine on admission if a resident had an advance directive (a written instruction, such as a living will or durable power of attorney for health care) for 1 of 4 residents (Resident 1), reviewed for advance directives. This failure placed the resident and/or their representative at risk of losing their right to have their preferences honored to receive care according to their choice.Findings included.Review of the facility's policy titled, Advance Directives, reviewed in March 2025, showed, During the admission process, the facility will identify if the resident has an advance directive.if the resident does, a copy will be requested and kept in the resident's medical chart, accessible to the physician and care staff.Resident 1 was admitted to the facility on [DATE].Review of Resident 1's Electronic Health Record (EHR) showed no documentation that the facility identified if Resident 1 had an advance directive.In an interview and joint record review on 03/20/2026 at 2:34 PM, Staff Z, Social Services Director, stated that they would document if a resident had an advance directive in an admission note. I would say if they have one or not. When asked if Resident 1 had an advance directive, Staff AA, Social Worker, stated that they were Resident 1's Social Worker and then began looking through Resident 1's EHR. Staff AA stated that there was no documentation that showed if Resident 1 had an advance directive.In an interview and joint record review on 03/25/2026 at 12:09 PM, Staff A, Administrator, stated that they expected that it would be discussed at admission if a resident had an advance directive. Staff B, Regional Director of Clinical Services, stated that they would expect documentation if a resident had an advance directive or not. A joint record review of Resident 1's EHR showed no documentation that the facility identified if Resident 1 had an advance directive. Staff B stated that there was no documentation that showed that the facility identified if Resident 1 had an advance directive.Reference: (WAC) 388-97-0280 (3)(a).

Based on observation, interview, and record review, the facility failed to ensure call lights (an alerting device for staff to assist residents in need) were within reach for 2 of 2 residents (Residents 87 & 24), reviewed for accommodation of needs. This failure placed the residents at risk for delayed care, accidents/falls, and a diminished quality of life. Findings included. Review of the facility's policy titled, Answering the Call Light, revised in October 2010, showed, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. RESIDENT 87Review of the admission Minimum Data Set (an assessment tool), dated 03/18/2026, showed that Resident 87 required substantial/maximal assistance [helper does more than half the effort] for sitting to standing. Observation on 03/17/2026 at 8:58 AM, showed Resident 87 in their bed and their call light laying on the chair next to their bed and was not within reach. Resident 87 stated that they were unsure where their call light was and they were looking around their bed for it. At 9:05 AM, Staff Y, Certified Nursing Assistant (CNA), entered Resident 87's room to speak with the resident and take their meal tray. The call light remained on the chair next to Resident 87's bed and was not within reach. Another observation on 03/18/2026 at 1:20 PM, showed Resident 87 in their bed and their call light on the floor and was not within reach. At 1:34 PM, Staff Y entered Resident 87's room to take their meal tray. When Staff Y left the room, the call light remained on the floor. In an interview and joint observation on 03/18/2026 at 1:48 PM, Staff Y stated that when they left a resident's room, they would check that the call light was within reach. A joint observation of Resident 87's room showed the call light on the floor and not within reach of Resident 87. Staff Y stated, I did not check [the call light] when I picked up the meal tray. In an interview on 03/25/2026 at 9:25 AM, Staff F, Resident Care Manager (RCM), stated that they expected the call light to be within reach of residents and that staff should be checking call light placement prior to leaving the residents' room. In an interview on 03/25/2026 at 11:49 AM, Staff B, Regional Director of Clinical Services, stated that they expected staff to check prior to leaving residents' room that the call light was within reach. RESIDENT 24Review of Resident 24's risk for falls care plan intervention initiated on 11/10/2023 showed, Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Observations on 03/18/2026 at 9:08 AM, on 03/23/2026 at 9:26 AM and on 03/25/2026 at 8:12 AM, showed Resident 24 lying in bed. Their call light was wrapped around the call light port on the wall and was not within Resident 24's reach. In a joint observation and interview on 03/25/2026 at 8:29 AM with Staff O, CNA, showed that Resident 24's call light was wrapped around the call light port on the wall and was not within reach. When asked if Resident 24's call light should have been within reach, Staff O stated, Always, no matter what, that's [that is] unreachable for him. In an interview on 03/25/2026 at 8:35 AM, Staff I, Registered Nurse, stated that they would expect the resident's call light to be within reach. In an interview on 03/25/2026 at 8:43 AM, Staff D, RCM, stated that they expected call lights to be placed within the resident's reach. When asked if Resident 24 used their call light, Staff D stated, yes, I believe so. Staff D further stated that they would have expected Resident 24's call light to be within reach. In an interview on 03/25/2026 at 10:48 AM, Staff B stated that they expected residents' call lights to be placed within reach. Reference: (WAC) 388-97-0860 (2)

Based on interview and record review, the facility failed to ensure the survey result binder included the results for 4 of 4 complaint surveys (03/14/2025, 04/07/2025, 05/14/2025 & 07/10/2025) that resulted in citations since the last annual survey. This failure prevented residents, residents' representatives and visitors from exercising their right to review past survey results and the facility's plan of correction.Findings included.Review of the state inspection survey results binder on 03/25/2026 at 11:45 AM showed that it did not include the results for the complaint surveys and plan of corrections from 03/14/2025, 04/07/2025, 05/14/2025, and 07/10/2025.In an interview and joint record review on 03/25/2026 at 12:09 PM, Staff A, Administrator, stated that they expected the survey results binder to include surveys, complaints, and revisits. A joint record review of the survey binder showed the following complaint survey results and associated plans of corrections were missing for 03/14/2025, 04/07/2025, 05/14/2025, and 07/10/2025. Staff A stated that the results should have been in the survey results binder and available for residents and families.Reference: (WAC) 388-97-0480(1)(b)(c).

Based on interview and record review, the facility failed to ensure a fall incident was thoroughly investigated for 1 of 3 residents (Resident 1), reviewed for abuse investigations. This failure placed the residents at risk for repeated incidents, unidentified abuse, and inappropriate corrective actions. Findings included . Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, revised in September 2022, showed, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. The policy further showed, The individual conducting the investigation as a minimum: .d. interviews the person(s) reporting the incident; . f. interviews the resident (as medically appropriate) or the resident's representative; . h. interviews staff members (on all shifts) who have had contact with the resident during the period of the alleged incident; i. interviews the resident's roommate, family members, and visitors; . l. documents the investigation completely and thoroughly. Review of Resident 1's face sheet printed on 05/13/2025, showed they admitted to the facility with diagnoses that included, Alzheimer's Disease (a brain disorder that gradually impairs memory, thinking, and other cognitive abilities) and vascular dementia (a form of memory loss caused by decreased blood flow to the brain, leading to damage and loss of brain cells). Review of Resident 1's admission Minimum Data Set (an assessment tool) dated 12/22/2024, showed Resident 1 had severe cognitive impairment. Review of Resident 1's Cognitive Impairment care plan initiated on 01/01/2025, showed Resident exhibits cognitive loss related to dementia. Review of Resident 1's Order Summary Report printed on 05/13/2025, showed an order dated 01/14/2025 to, OK [okay] to send to ER [emergency room ] to eval [evaluate] for head injury, bleed r/t [related to] recent fall, hematoma [a localized collection of blood outside of blood vessels, typically caused by injury], skull fracture per [Collateral Contact 1 (CC1)] request. Review of Resident 1's hospital ER note dated 01/14/2025, showed, patient [resident] had a fall yesterday and he was on Eliquis [blood thinner medication] and was brought to the ER today for evaluation. The [CC1] states that he was with the patient yesterday around noon time and states that he had to leave the room to take care of something and he was only away for 8 minutes however states that when he returned back, patient was facedown on the ground. He states that he tried to help the patient up and the patient could not stand by himself and states that he could not, had to ask staff around to help him assist him back to the bed. He states that the swelling around the patient's face and forehead have gotten worse and he asked the facility to send the patient to the ER to be evaluated. Patient currently states that he has no complaints or symptoms but states that when he touches the front of his head, hurts . He cannot remember how he fell . An additional hospital ER note dated 01/14/2025 showed, In regards to today's visit, due to fall yesterday and concern for inadequate care, patient's [CC1] wanted him [to be] brought in for a CT [Computed Tomography scan- a medical imaging test that uses X-rays and a computer to create detailed images of the body] . The note showed, [CC1] was [trying] to get the patient back up on his own into the bed for about 10 minutes and reports that he had no assistance from staff at the facility. The note further showed Resident 1 had a mild nasal fracture (break in one of the bones of the nose) and frontal (forehead) scalp hematoma. Review of Resident 1's hospital ER provider note dated 01/14/2025, showed, Moderate sized hematoma to right side of forehead w/ [with] tenderness to palpation [touch] over affected area, supraorbital [a bony elongated opening located above the orbit (eye socket) and under the forehead] ecchymosis [a discoloration of the skin resulting from bleeding underneath, typically caused by bruising] present around bilateral eyes, slight swelling over bridge of the nose. Review of Resident 1's investigation report dated 01/13/2025, showed the following: -SSD [Social Service Director] reported to this nurse [resident] fell . This nurse immediately assessed [resident]. [The resident] was found in bed with right forehead hematoma and pain. -Resident 1 stated, I turned on my right side, and fell out of bed. -Under section, Injuries Observed at Time of Incident, there was a hematoma to the top of scalp. -Under section, Mental Status, a check mark indicated Resident 1 was orientated to person and place. An additional note under mental status at time of incident indicated the resident was, alert to self, forgetful of time place and situation. -Under section, Injuries Report Post Incident, a bruise to Resident 1's face and localized tissue edema (swelling) to the top of their scalp was noted. -Resident 1 had dementia, was alert, and had decreased cognition. The investigation conclusion further showed Resident 1 was alert to self, sometimes place time and situation but forgetful, and that Resident 1 was at risk for falls related weakness, unsteady gait and decreased mobility. -The root cause of the fall was determined to be the resident repositioning to the right side of bed and falling out. The investigation further showed Resident 1, was sent out to ER per [CC1] request to eval [evaluate] for injuries, and Right forehead hematoma swelling increased and bruising noted on nose area, provider and [CC1] updated and was sent to ER [on] 1/14/25 [01/14/2025]. Res not yet returned from ER visit, no update from [resident's CC1]. [Resident] was last toileted [at] 10:35 [am] and last seen 12:30 [pm] lying in bed. Floor was dry, not cluttered . [Resident] mood/behavior was monitored while working with staff, no changes noted, plan of care was being followed by staff, thus abuse and neglect ruled out. -a witness statement dated 01/13/2025 from a Certified Nursing Assistant stated they last saw Resident 1 around 10:45 AM in their room sleeping. The statement showed that Resident 1 was last toileted at 10:35 AM and Lay down, at 12:30 PM. The statement showed that Staff C was the nurse that checked Resident 1. The statement further showed under the question, What did you do to help the resident? Assist back to bed obtain VS [vital signs- reflect essential body functions, including heartrate, breathing rate, temperature, and blood pressure]. Further review of Resident 1's Investigation Report dated 01/13/2025 did not show an interview from the social services director that reported that Resident 1 had a fall or how they knew that Resident 1 had a fall. The report did not show an interview from CC1 who was at the facility [visiting] on 01/13/2025. The report did not show how Resident 1 was found by the staff that assisted them back into their bed after the fall. The report showed conflicting statements regarding Resident 1's cognition, and did not include other staff interviews that encountered Resident 1 on 01/13/2025. On 05/05/2025 at 11:33 AM, Staff D, Registered Nurse (RN), stated that if a resident had a fall, they would check on the resident, their positioning, complete a nursing assessment, check for major injuries, and if safe to do so assist them back into their bed. On 05/05/2025 at 12:10 PM, CC1 stated that on 01/13/2025 they had been visiting Resident 1. CC1 stated that they stepped away from Resident 1's room for less than ten minutes, and when they returned, they could hear someone calling out for help. CC1 stated that they turned the resident to their side and were unable to physically assist Resident 1 back into bed, so they asked an [unknown] staff in a nearby room to assist Resident 1 back to bed. CC1 stated that they asked [unknown] staff to send Resident 1 to the hospital on the same day. CC1 stated that Resident 1 had three huge lumps, on their head. CC1 further stated that an [unknown] charge nurse came to assess the resident 20 minutes later. On 05/13/2025 at 12:48 PM, Staff C, RN, stated that the social worker reported to them that Resident 1 had a fall. Staff C stated that when they went to assess the resident he was already in bed with a hematoma on their forehead. Staff C stated that Resident 1 stated they had fallen when they turned to their side. Staff C stated that CC1 knew first about Resident 1's fall and had informed the social worker. On 05/13/2025 at 5:14 PM, Staff A, Director of Nursing, stated that based on the investigation, the social worker reported that Resident 1 had a fall to Staff C. When asked if they would expect there to be an interview included from the social worker, Staff A stated, not necessarily, as they notified nursing right away and there would have been additional information. Staff A further stated that if CC1 was in the room and stated they got the resident back into bed then they would expect to interview CC1. On 05/14/2025 at 3:44 PM, Staff C stated that they would expect an investigation to be thoroughly investigated. Staff C stated that they completed the investigation for Resident 1's fall and that they did not recall which social worker reported the fall. Staff C stated that they did not know how the social worker became informed of Resident 1's fall [which was a different statement from Staff C's interview on 05/13/2025 at 12:48 PM]. When asked how abuse and neglect could be ruled out if the reporter was not interviewed, Staff C stated, you can ask the social worker, and that they did their assessment and checked on Resident 1 when they were notified. On 05/14/2025 at 4:34 PM, Staff B, Assistant Director of Nursing, stated they would expect an investigation to be thoroughly investigated. When asked how the social worker became informed of Resident 1's fall, Staff B stated, I cannot really answer that question. I would have to ask her. Staff B further stated that they assumed someone must have informed them most likely the resident or the family. On 05/14/2025 at 5:03 PM, Staff A stated that they would be ruling out abuse and neglect when interviewing the residents. When asked if they would expect to follow their abuse and neglect policy and interview the resident's representative, Staff A stated, sure, and that it really depends on the nature of the incident for abuse and neglect. Staff A further stated that they did not suspect abuse with Resident 1's fall and that they thought CC1 placed Resident 1 back into bed. Reference: (WAC) 388-97-0640 (6)(a)

Based on observation, interview, and record review, the facility failed to revise an elopement care plan for 1 of 1 resident (Residents 1), reviewed for care plan revision. This failure placed the resident at risk for additional elopements, unmet care needs, and a diminished quality of life. Findings included . Review of the quarterly Minimum Data Set assessment (MDS-a required assessment) dated 01/16/2025 showed Resident 1 admitted to the facility on [DATE]. The MDS assessment further showed the resident had moderately impaired thinking and used a wheelchair for mobility. Review of the admission elopement risk assessment dated [DATE] showed the resident was at risk of elopement. Review of the facility's investigative report dated 02/24/2025 showed that on 02/24/2025 at 3:00 AM, the local law enforcement called the facility and informed the nurse on shift that Resident 1 was found at a store approximately 11/2 miles away from the facility in a gown and with a wheelchair that had the name of the facility on it. Resident 1 was returned to the facility at 3:30 AM by the local law enforcement. A device (wander alarm) was then placed on Resident 1 to alert staff when Resident 1 approached the monitored doors that exit the facility. Review of the care plan initiated on 02/24/2025 showed, Check placement of the wander alarm every shift. Location: Left Ankle. Observation and interview on 03/10/2025 at 4:17 PM with Staff D, Licensed Practical Nurse, showed the wander alarm was not on the left ankle of Resident 1, the wander alarm was observed fastened to the left arm of the wheelchair that Resident 1 sat on. Interview with Staff D at this time stated the wander alarm was checked every shift to make sure it was still in place and worked properly. Staff D then stated that the wander alarm had been moved from the left ankle to the arm of the wheelchair because Resident 1 did not want it on their ankle anymore. Staff D further stated that the care plan should have been updated when the wander alarm was moved from Resident 1's left ankle to the arm of their wheelchair. In an interview on 03/10/2025 at 4:28 PM, Staff E, Resident Care Manager, stated the care plan should have been updated when the wander alarm was moved from Resident 1's left ankle to the arm of Resident 1's wheelchair. In an interview on 03/10/2025 at 4:45 PM, Staff B, Assistant Director of Nursing Services, stated the care plan and the location of the wander alarm should be the same, the care plan should have been updated when the wander alarm was removed from Resident's 1 left ankle. Reference (WAC): 388-97-1020 (5)(b)

Based on interview and record review, the facility failed to provide the necessary supervision resulting to an elopement for 1 of 1 resident (Resident 1), reviewed for accident hazards. This failure placed the resident at risk for additional elopements, injuries and pain. Findings included . Review of the quarterly Minimum Data Set assessment (MDS-an assessment tool), dated 01/16/2025 showed Resident 1 admitted to the facility on [DATE]. The MDS assessment further showed the resident had moderately impaired thinking and used a wheelchair for mobility. Review of the admission elopement risk assessment dated [DATE] showed the resident was at risk of elopement. Review of the care plan dated 10/15/2024 showed Resident 1 was at risk of elopement/exit seeking/wandering related to mild thinking impairment, a history of elopement attempts, mood or behavior disorders and noncompliance. Review of the facility's investigative report dated 02/24/2025 showed that on 02/24/2025 at 3:00 AM, the local law enforcement called the facility and informed the nurse on shift that Resident 1 was found at a store approximately 11/2 miles away from the facility in a gown and with a wheelchair that had the name of the facility on it. Resident 1 was returned to the facility at 3:30 AM by the local law enforcement. The investigative report documented that Resident 1 reported that they used their wheelchair to go to a local store, went down a curb near the store, fell and was helped up by a couple that wheeled them to the store, the local law enforcement was notified. Resident 1 was assessed for injuries when they returned to the facility and a bruise/scratch was noted on their left knee, pain medication (Tylenol) was administered for pain relief. A device (wander guard) was then placed on Resident 1 to alert staff when Resident 1 approached the monitored doors that exit the facility. In an interview on 03/10/2025 at 3:09 PM Resident 1 stated they left the facility alone and went to the store. Resident 1 stated that they tried to roll their wheelchair over a curb next to the store, fell over the curb, out of their wheelchair and a man and a woman that they did not know helped them to get back into their wheelchair and then pushed them in their wheelchair the rest of the way to the store, then the local law enforcement was called who brought them back to the facility. Resident 1 further stated they hurt their knee when they fell out of their wheelchair, and the nurse gave them pain medication to stop the pain. In an interview on 03/14/2025 at 1:01 PM, Staff C, Certified Nursing Assistant, stated they thought Resident 1 was at risk for elopement because they would sit by the door of the facility, and it looked like they wanted to leave the facility. In an interview on 03/14/2025 at 4:17 PM, Staff D, Licensed Practical Nurse, stated Resident 1 was at risk for elopement and that they had recently eloped from the facility, a wander guard had been placed on Resident 1 to notify the staff when Resident 1 got close to the doors that exit the facility. In an interview on 03/14/2025 at 3:39 PM, Staff E, Resident Care Manager, stated Resident 1 was at risk for elopement and was not safe to leave the facility unsupervised. In an interview on 03/14/2025 at 3:41 PM, Staff B, Assistant Director of Nursing Services, stated that Resident 1 had a decline in their thinking ability but was able to enter the code that opened the door and left the facility. Staff B stated that the investigation dated 02/24/2025 showed when the staff reviewed the facility's surveillance camera Resident 1 was seen leaving the facility at 12:47AM unsupervised, and that they were not safe to be out in the community unsupervised. In an interview on 03/14/2025 at 4:04 PM, Staff A, Administrator stated that Resident 1 was not safe to leave the facility unsupervised, especially at 1:00 AM. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure the dishwasher temperature was checked and the sanitizing solution was tested routinely in accordance with professional standard for food service safety for 1 of 1 kitchen, reviewed for food services. These failures placed the residents at risk for food borne illness and a diminished quality of life. Findings included . Review of the facility policy titled, Dishwashing, adopted on 08/01/2024, showed, It is the policy of this center that dishes and other multi-use eating, preparation and serving items are cleaned and sanitized properly after each use. The policy further showed to log and check for proper temperatures. In an interview and joint observation on 12/16/2024 at 10:39 AM with Staff I, Dietary Director and Staff K, Dietary Aide, stated that they checked the dishwasher temperature and the sanitizer ppm [or PPM- parts per million - unit of measure for concentration] three times a day [breakfast, lunch and dinner]. Staff K stated that they logged daily the dishwasher temperature and the sanitizer ppm in separate columns using one form for each month. Joint observation showed the December 2024 Dishwasher Temperature/Sanitizer Log form was blank for 12/15/2024. Joint observation of the form showed the dinner columns for the dishwasher temperature and sanitizer ppm were blank on 12/14/2024. Staff K stated that the dishwasher temperatures were not logged. Staff K further stated that they ran out of test strips and were not able to test the sanitizing solution. In an interview on 12/16/2024 at 10:50 AM, Staff I stated that they had a low-temperature dishwasher which used chemicals to sanitize dishware. Staff I stated that they expected the staff to check the dishwasher temperature and conduct testing of the sanitizer three times a day and to log the information on the form. In an interview on 12/18/2024 at 10:07 AM, Staff A, Administrator, stated that they expected staff to check the dishwasher temperature and to test the sanitizing solution per the facility process. Reference: (WAC) 388-97-1100 (3)

Based on interview and record review, the facility failed to ensure adequate monitoring were conducted for use of diuretics (medications that help move extra fluid and salt out of the body) for 2 of 7 residents (Residents 3 & 26), anticoagulants (medication that prevent blood clot) for 3 of 7 residents (Residents 26, 28 & 10), and antibiotic (medication that treats infections) for 1 of 7 residents (Resident 11), reviewed for unnecessary medications. These failures placed the residents at risk for receiving unnecessary medications, adverse side effects, and related complications. Findings included . A review of the facility's policy titled, Medication Administration General Guidelines, revised in January 2023, showed the last step in the process was to observe residents for medication actions/reaction and record in the nurse's notes as appropriate. The policy further showed that any noted adverse consequence should be reported to the prescriber and/or attending physician. A review of the facility's policy titled, Medication Therapy, revised in April 2007, showed that all medication orders will be supported by appropriate care processes and practices. The policy further stated that the medical director and consultant pharmacist shall collaborate to address issues of medication prescribing and monitoring with the practitioners and staff. RESIDENT 3 A review of Resident 3's face sheet showed they admitted to the facility on [DATE]. A review of the December 2024 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed Resident 3 had an order for furosemide (a diuretic medication) 20 milligrams (mg-a unit of measurement) to treat congestive heart failure (CHF-when the heart is unable to pump blood efficiently to the body). The MAR did not show Resident 3 was adequately monitored for diuretic use. A review of the nursing progress notes from 11/16/2024 to 12/16/2024 did not show Resident 3 was not adequately monitored related to diuretic use. In a joint record review and interview on 12/17/2024 at 2:26 PM with Staff P, Licensed Practical Nurse (LPN), showed the December 2024 MAR did not show Resident 3 was monitored for diuretic use. Staff P stated that residents on diuretics were monitored for adverse side effects for three days after initiating the medication. In an interview on 12/17/2024 at 2:35 PM with Staff D, Resident Care Manager (RCM) and Staff C, RCM, Staff C stated that residents taking diuretics were placed on alert charting at the start of the medication. Staff D stated that for residents with CHF, they would monitor their weight if it were included with the physician order. In an interview on 12/17/2024 at 2:40 PM, Staff B, Assistant Director of Nursing, stated that they did not feel monitoring of diuretic use should be included in the MAR/TAR. Staff B stated that they expected diuretics to be monitored at the initiation of the medication and would be on alert for 72 hours. RESIDENT 26 A review of the Resident 26's face sheet showed they admitted to the facility on [DATE]. In a joint record review and interview on 12/17/2024 at 2:04 PM with Staff Q, Registered Nurse, showed Resident 26's December 2024 MAR had an order for furosemide 20mg to be given once daily and apixaban (an anticoagulant) 5 mg to be given twice a day. Staff Q stated that Resident 26's diuretic use was not monitored and that monitoring side effects for anticoagulants were not charted in the MAR/TAR. Staff Q stated that apixaban was included in the care plan and not in the MAR/TAR for everyday monitoring. A review of the nursing progress notes from 11/16/2024 to 12/16/2024 did not show Resident 26 was being monitored for anticoagulant use and/or diuretic use. In an interview on 12/17/2024 at 2:35 PM, Staff C stated that monitoring for anticoagulant use was included in the comprehensive care plan. Staff C stated that when residents start diuretic medications, they would be placed on alert charting for 72 hours. Staff C further stated that they would monitor a resident's weight if the physician ordered it. In an interview on 12/17/2024 at 2:40 PM, Staff B stated that they did not feel adverse side effect monitoring for diuretics and anticoagulants should be on the MAR/TAR. Staff B stated that diuretic use and anticoagulant use were included in the comprehensive care plan. Staff B further stated that when residents receive an order for a diuretic or anticoagulant medication, the resident would be placed on alert charting for 72 hours. RESIDENT 28 A review of Resident 28's face sheet showed they admitted to the facility on [DATE]. A review of the December 2024 MAR showed Resident 28 had an order for apixaban to be given twice a day to treat atrial fibrillation (an irregular and often very rapid heart rhythm). Resident 28's MAR/TAR had no documentation to show monitoring for anticoagulant use was conducted. A review of the nursing progress notes from 11/16/2024 to 12/15/2024 did not show Resident 28 was monitored related to anticoagulant use. In a joint record review and interview on 12/17/2024 at 2:04 PM with Staff Q, showed Resident 28's December 2024 MAR had a written order for apixaban (an anticoagulant) to be given twice a day to treat atrial fibrillation (an irregular and often very rapid heart rhythm). Further review of the MAR revealed no documentation to show monitoring was conducted related to anticoagulant use. Staff Q stated they did not find charting specifically for anticoagulant use. In an interview on 12/17/2024 at 2:19 PM, Staff Q stated that they had just spoken to their RCM and was told apixaban was not added in the MAR/TAR for everyday monitoring. Staff Q further stated that the apixaban was added in the care plans. In an interview on 12/17/2024 at 2:35 PM, Staff C stated that anticoagulant use was usually care planned and would not be in the MAR/TAR. Staff C further stated that Resident 28 was alert and was able to report any bleeding or excessive bruising. In an interview on 12/17/2024 at 2:40 PM, Staff B stated that they did not expect monitoring for anticoagulant side effects would be included in the MAR/TAR because it was in the care plan. Staff B further stated that when they receive a new order for apixaban, they would place the resident on alert charting for three days. 47218 RESIDENT 10 Resident 10 admitted to the facility on [DATE]. Review of the November 2024 and December 2024 MAR/TAR showed Resident 10 had an order for apixaban to be given twice a day for atrial fibrillation. The MAR/TAR did not show Resident 10 was being monitored related to anticoagulant use. Review of the nursing progress notes from 11/04/2024 to 12/12/2024 showed no documentation that Resident 10 was adequately being monitored related to anticoagulant use. On 12/16/2024 at 3:06PM, Staff T, LPN, stated that anticoagulant medications needed to be monitored for bleeding and bruising every shift and were placed on alert for 72 hours when the anticoagulant was started. Staff T stated that there were no orders to monitor for adverse side effects of anticoagulant use. In a joint interview on 12/16/2024 at 3:22 PM with Staff D and Staff F, Regional Clinical Nurse, Staff D stated that staff monitors for side effects of bleeding for anticoagulants through residents' care plans, not in the MAR or TAR. Staff F stated that staff documented side effects of anticoagulant use by exception and that the facility did not require adverse side effects monitoring were documented every shift. In an interview on 12/16/2024 at 4:09 PM, Staff B was asked for documentation to show that Resident 10 was being adequately monitored related to the anticoagulant use. Staff B stated, nurses know to monitor for signs and symptoms of bleeding, and that the facility monitors anticoagulant side effects in residents' care plans. RESIDENT 11 Resident 11 admitted to the facility on [DATE]. Review of the November 2024 and December 2024 MAR/TAR showed Resident 11 was on doxycycline (an antibiotic) 100 mg twice a day since 11/25/2024 without a stop date. Review of the nursing progress notes from 11/25/2024 to 12/18/2024 showed no documentation that Resident 11 was adequately monitored related to antibiotic medication use. On 12/18/2024 at 9:27 AM, Staff T stated they monitor for side effects of antibiotic use and that if there were no side effects, they were not documented. Staff T further stated that antibiotic side effects were monitored through the duration of the antibiotic treatment. On 12/18/2024 at 2:03 PM, Staff E, RCM, stated that Resident 11 was on antibiotics since admission. Staff E stated that there was no active monitoring for adverse side effects for the antibiotic use. Staff E further stated that residents on antibiotics had a care plan for antibiotic use and for monitoring of side effects. Joint record review and interview with Staff E showed Resident 11 did not have a care plan for antibiotic use. Staff E stated that there should have been a care plan for Resident 11's antibiotic use with interventions of monitoring adverse side effects. On 12/18/2024 at 2:22 PM, Staff B stated that side effects to antibiotic use were documented by exception and the monitoring of the side effects were included in the residents' care plans. Joint record review and interview with Staff B showed Resident 11 did not have a care plan for antibiotic use and/or to monitor for side effects to anticoagulant use before 12/18/2024. Staff B stated that Resident 11 should have had a care plan for monitoring side effects of antibiotic medication. Reference: (WAC) 388-97-1060 (3)(k)(i) (4)

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for abuse investigations was free from misappropriation of property. Resident 1, who had impaired thinking and lacked the ability of a reasonable person to provide informed consent for either purchases made by staff member or designations to bank accounts, experienced harm when they suffered a substantial loss of monetary funds after staff accessed their financial accounts for personal gain without permission and placed other residents at risk for financial exploitation. Findings included . Review of the facility policy titled, Abuse-Screening, Training, Identification, Investigation, Reporting and Protection, dated 01/2023 showed, it is the policy of this center to prevent and prohibit all types of abuse and misappropriation of property, protect our residents from abuse. Further review of the facility policy showed, Misappropriation of residents property is defined as the illegal or deliberate use of resident's resources for the personal profit or gain of another person; or spending resident funds without the resident's consent, or if the resident is not capable of consenting, spending resident funds for items or services from which the resident cannot benefit or appreciate, or spending resident funds to acquire items for use in common areas when such purchase is not initiated by the resident. Review of the quarterly Minimum Data Set assessment (MDS-an assessment tool) dated 01/25/2024, showed Resident 1 readmitted to the facility on [DATE] with a diagnosis list that included dementia (loss of memory and intellectual functioning [mental ability that included reasoning, planning, and understanding complex ideas]). Further review of the 01/25/2024 MDS assessment showed a Brief Interview for Mental Status (BIMS [an assessment that measured orientation and thinking ability]) was conducted. The BIMS assessment used a points system that ranged from 0 to 15 points; 0 to 7 points suggested severely impaired thinking. Resident 1 scored 00 on the BIMS assessment. Review of the electronic record showed Resident 1 started Hospice Services (specialized care that provides comfort and support for residents that were near the end of life) on 10/14/2023 for multiple diagnoses that included poor nutrition. Review of an investigation summary dated 01/03/2024 showed, Staff C, Activity Director, informed the Administrator [Staff A], that they were asked by Staff D, Social Service Assistant (SSA) to reconcile bank statements for Resident 1. Staff C then reported that they felt uncomfortable because Staff D did not provide supporting documentation for the charges on the bank statements. Further review of the investigation summary showed Resident 1 was interviewed on 01/03/2024 and on 01/04/2024 and was not able to elaborate or respond to questions asked about their bank statements. On 01/04/2024 during the interview, Resident 1 drifted in and out of awareness. Review of the investigation summary dated 01/03/2024, showed Staff D was interviewed about Resident 1's bank statements and charges on their account/debit card. Staff D stated, they had access to Resident 1's card off and on, but 100% of the time since the end of November 2023 and has had access to Resident 1's account since the beginning but can't remember the exact date, maybe March of 2023. Staff D stated they had no idea how their name got added to Resident 1's bank account as Payable on Death. Staff D was asked to provide receipts from all transactions from Resident 1's financial account from 08/25/2023 that included cash withdrawals from automatic cash machines and other transactions made from Resident 1's financial account. Staff D was unable to provide receipts for all the transactions that were made. Additional review of the investigative summary dated 01/03/2024 showed Staff C was asked by Staff D to be a witness and to initial the bank statements because a state authority/service would review Resident 1's case. Staff C then stated that the statements dated back to July 2023 and noted there was some strange and out of character orders for a patient on Hospice. Staff C noted the bank statements had Payable on Death and Staff D's first and last name was listed on it. Staff C informed Staff A, and Staff A requested Staff E, Business Office Manager (BOM) be informed. Staff C and Staff E reviewed Resident1's financial statements and noticed several rides share transactions, cash withdrawals and department store purchases. A facility investigation was initiated, and law enforcement was notified. Review of a law enforcement report dated 02/01/2024 showed a spreadsheet for all purchased items made on Resident 1's account from 08/25/2023 to12/21/2023: the total charged/withdrawals included an online purchase for $891.15, automatic cash machine withdrawal for $600.00; food for $261; online food delivery for $39.96; food for $66.63; a department store purchase for $138.07, online food delivery for $484.85. Eight of these orders were delivered to the home of Staff D. The report documented other verified charges made from Resident 1's financial account and that the case was ongoing. Observation on 01/25/2024 at 2:42 PM, showed Resident 1 was in bed, eyes open and nonresponsive to name or questions asked. Observation on 02/08/2024 at 12:02 PM, showed Resident 1 was in bed, eyes closed. Opened eyes when name was called, unresponsive to questions asked. In an interview on 02/08/2024 at 12:22 PM with Staff C, stated that Resident 1 did not take any ridesharing [ride share - a way for multiple riders to get to anywhere they are going by sharing only one car] and was not capable of taking ride share rides. Staff C stated that Staff D spent a lot of time with Resident 1 and kept their name and phone number on the dry erase board in Resident 1's room as a contact person. An interview on 02/08/2024 at 1:53 PM with Staff F, Social Worker (SW), stated that Staff D spent a lot of time with Resident 1, Staff F stated that Staff D did a lot of hands-on care that they did not do for other residents. An Interview on 02/08/2024 at 2:15 PM with Staff G, SW, stated that receipts should have been brought back and kept each time something was purchased for Resident 1. Staff G stated Resident 1 would have been furious and would not have consented to all the purchases made if they had the ability to know what happened to their financial accounts. An interview on 02/08/2024 at 3:46 PM with Staff H, Assistant Director of Nursing, stated that they did think Resident 1 was able to give consent for Staff D to make the purchases from their bank account. An Interview on 02/08/2024 at 3:54 PM with Staff A, stated that a receipt should have been kept for each purchase made for Resident 1. Staff A stated misappropriation of Resident 1's funds by Staff D was substantiated by the facility. Further review of the investigation summary dated 01/03/2024, showed misappropriation of Resident 1's financial accounts by Staff D was substantiated. Reference: (WAC) 388-97-0640 (3)(d)

Based on observation, interview, and record review, the facility failed to implement written abuse and neglect policies and procedures related to the required resident protection, reporting and investigation of abuse and neglect allegations for 2 of 3 residents (Resident 2 and Resident 1) reviewed for abuse and neglect. These failures caused harm to Resident 2 and Resident 1 and placed other residents at risk for harm and abuse and/or neglect. Findings included . A review of the facility policy titled, Abuse-Washington dated and revised on 02/2019 showed the facility would protect residents from abuse, report and investigate allegation of abuse to appropriate reporting authority. The policy directed the facility staff to: 1. The facility should utilize incident/accident investigation policy and procedure to investigate concerns and incidents. The investigation would include the following: a. The alleged incidents of abuse and neglect must be thoroughly investigated. The investigation was done to determine what occurred and what changes to the provision of care and services was needed. b. A thorough investigation was completed through a systemic collection and review of evidence/information that describes and explains an event or a series of events. It seeks to determine if abuse and neglect occurred, and how to prevent further occurrences. 2. All staff members are considered mandatory reporters, and such are obligated to report using the Washington State Abuse Hotline. 3. Allegation of abuse or neglect will be reported to The Department of Social and Health Services (DSHS) following Washington State Guidelines (Purple Book). 4. Administrative personnel will immediately remove staff member involved in said incident from their duties. The staff member will be sent home until administrative personnel can complete a thorough investigation of reported incident. RESIDENT 2 Resident 2 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 2's admission Minimum Data Set (MDS) assessment dated [DATE] showed the resident had cognitive impairment and needed two person staff assistance with bed mobility and transfers. On 06/22/2022 at 9:30 AM, Resident 2's family member (FM1) stated that she had serious concerns with Resident 2's overall condition including the facility's lack of care and action towards their concerns. FM1 stated that she had met with several staff members including Staff H, Registered Nurse (RN)/Resident Care Manager (RCM), Staff I, RN/RCM and Staff A, Administrator about several care concerns including incidents of rough handling from staff during care that she personally observed a few times. FM1 stated that she reported an allegation of abuse/rough handling towards Resident 2 on 05/30/2022 to Staff I, RN/RCM. FM1 stated that she had a meeting with Staff I and told him that she had witnessed an (unknown) male caregiver to be very rough when providing care to Resident 2 to the point where Resident 2 was grinding his teeth and was moaning in pain. FM1 stated that Staff I's only response to her was what was the color of the alleged perpetrator's skin and if the same staff had worked with Resident 2 again. FM1 stated she had not heard from Staff I or anyone after that and Resident 2 continued to experience the same problem on several occasions. FM1 also stated that there was another incident she witnessed during the week of 06/09/2022 to 06/13/2022 (not able to recall specific date and time) where she witnessed another (unknown) female Nursing Assistant Certified (NAC) to be very rough during care to the point where Resident 2 was loudly moaning and teeth gritting so she had to intervene and asked the NAC what she was doing because she was hurting Resident 2. FM1 stated that she reported this right away to Staff H who told her that she would follow-up with her concerns. However, FM1 stated she had not heard from Staff H again on what the facility would do to protect Resident 2 and to make sure that he would not experience the same rough treatment and abuse from staff. FM1 stated that she was not happy on how the facility just simply ignored her concerns of abuse, so she met with Staff A for almost an hour on 06/14/2022. FM1 stated that she told the Administrator the concerns about rough handling of staff to Resident 2 that she personally witnessed and reported to staff members, including other concerns with care such as Resident 2's unrelieved/uncontrolled pain, long call light wait times that would take at least 30 minutes to almost 1-2 hours to get help from staff and the concerns with Resident 2 being left in bed until at least 11:30 AM on 3 different occasions without being cared for by staff. According to FM1, Staff A even gave her his cell phone number after the meeting so she could contact him directly if they continue to experience the same problems. However, FM1 stated she did not receive any follow-up on what was done to address her concerns and that Resident 2 continued to experience the same problem even until now, to the point where Resident 2 no longer felt safe to be in the facility. On 06/22/2022 at 10:00 AM, Resident 2 stated he experienced rough handling and was hurt by staff while at the facility. Resident 2 also stated that he felt pain and that the incident of rough handling was an on-going experience for him. According to Resident 2, he did not feel safe in the facility and was grateful that his family member was coming to visit daily. On 06/22/2022 at 11:55 AM, during a follow-up meeting with Resident 2 and FM1, FM1 stated that she visited Resident 2 on 06/19/2022 at approximately 11:15 AM, and noticed that Resident 2 was still in bed, had incontinent odor with his brief wet of urine, and had not had his morning medications for the day. FM1 stated she sent a message via text to Staff A of these concerns and Staff A told her that he would get someone to check on Resident 2. However, FM1 stated she again did not receive any follow-up or report on what happened and what was done to all her concerns. FM1 stated she had enough and was tired of being ignored so she decided that she would just transfer Resident 2 to another facility and leave. During the meeting, Resident 2 once again told the surveyor that he did not feel safe in the facility because of what he experienced with staff during care. A review of the text messages between Staff A and FM1 dated 06/19/2022 at 11:24 AM, showed that Staff A and FM1 had the above written conversation concerning Resident 2, including the response from Staff A that he would send a staff person to check on the resident. On 06/22/2022 at 12:05 PM, Staff A stated he remembered having a meeting with FM1 concerning Resident 2. However, Staff A stated he could not recall receiving any concerns related to care and services or abuse and neglect. Staff A confirmed and stated that he provided his cell phone number to FM1 and acknowledged receiving the text message on 06/19/2022. According to Staff A, he did not think of the text message as an allegation of neglect, but he did ask a staff member to follow-up on Resident 2. Staff A stated he did not have any record of what was done at that time. Staff A was not able to provide any documentation that he or the facility had investigated or followed up on the concerns reported by FM1. On 06/22/2022 at 1:45 PM, during a meeting with Staff H and FM1, Staff H stated and confirmed that she received the concern from FM1 regarding the allegation of rough handling against a caregiver. However, Staff H stated she did not follow the facility's abuse and neglect policy including the need to protect the resident from the alleged perpetrator, the required reporting, and investigation of the allegation of abuse/neglect. According to Staff H, she reported the allegation to Staff I but she could not recall the specific date and time of when this occurred. On 06/22/2022 at 2:10 PM, Staff I stated he could not recall having any report from Staff H regarding any abuse or neglect allegation from Resident 2 or FM1. However, Staff I stated that he could recall receiving concerns from FM1 in the past, but he could not remember the details of these concerns. Staff H further stated that there was no documented evidence of any follow-up, or action taken (if any) to address the concerns reported by FM1. A review of the facility's incident investigation reporting log and grievance log from 05/01/2022 to 06/22/2022 showed no evidence that the facility had investigated any of Resident 2 or FM1's concerns as required and as directed by the facility's abuse and neglect policy. A review of Resident 2's clinical records showed no documented evidence that any staff member including Staff I, Staff H, and Staff A, had followed up and assess Resident 2 for any physical or psychosocial harm related to the allegations of abuse and neglect of care reported by FM1. On 06/22/2022 at 2:30 PM, both Staff A and Staff B, RN, Staff Development Coordinator (SDC) stated that all allegations of abuse and neglect should have been followed up on immediately, reported and investigated as required by their own abuse policies and procedures and the regulations. RESIDENT 1 Resident 1 was a long-term care resident at the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's quarterly MDS assessment dated [DATE] showed the resident had intact cognition and needed two-person extensive assistance with bed mobility, transfers, toileting, and personal hygiene needs. On 06/22/2022 at 10:30 AM, Resident 1 stated he had serious care concerns regarding the care and services at the facility. Resident 1 stated he had bad skin problem to his penis, scrotum, and groin area that was causing him awful pain and discomfort. Resident 1 also stated that his skin problem was on and off because he had to sit on his own urine and wait for a long time about one to two hours, sometimes longer before he could get incontinent care and assistance from staff. According to Resident 1, the pain on his groin area was the worst because it had a burning sensation and staff had told him that he had huge skin cracks that were draining and were very red. Resident 1 stated he reported this concern related to neglect of care to staff, including Staff A on a regular basis, but he was ignored and did not hear any follow-up or feedback from the facility. Resident 1 stated he also had reported the concerns with call lights and neglect of care to staff including the staff's refusal to get him out of bed and provide incontinent care around 05/01/2022 (could not recall specific date/time) and again last week (the week of 06/13/2022 to 06/19/2022), but the resident could not recall specific date or time including when he reported concerns about his missing clothes and problems with the TV remote control. Resident 1 further stated that he continued to experience the same problem daily, including today. Resident 1 further stated, he was angry and felt helpless and just don't know what to do anymore. Resident 1 stated he felt neglected and it was not right to be treated badly by the facility. Resident 1 stated he was embarrassed and humiliated to be sitting on his own waste for hours and not getting timely assistance from staff on an ongoing basis. According to Resident 1, no one had checked on him today and offered to have a brief change, so he had been waiting and sitting in his urine since 7:00 AM that day. Resident 1 further stated, this was the reason why he kept having itchy, burning, painful rashes in between his legs and scrotum area. On 06/22/2022 at 10:45 AM, Staff C, RN, stated she had not provided any type of incontinent care to Resident 1 since the beginning of her shift at 6:00 AM. Staff C also stated that Resident 1 had no skin issues and did not have any treatment orders for any skin breakdown. On 06/22/2022 at 11:00 AM, Staff D, NAC, stated he had not cleaned or provided any perineal care to Resident 1 that day. Staff D also stated that Resident 1 had redness and rash to his scrotum and peri area, but he also had not seen it that day. Staff D offered no explanation as to why he had not provided personal hygiene care or incontinent care to Resident 1 since the start of his shift at 6:00 AM. On 06/22/2022 at 11:15 AM, a joint skin observation with Staff C, Staff D, and Staff B, showed Resident 1 had redness to the penis and both the scrotum extending to the bilateral (both) groin area. Staff B also measured the open areas on both the right and left groin area measuring 3 centimeter (cm) in length, 0.5 cm wide and 0.1 cm deep. Staff B stated he would classify the wound as a Moisture Association Skin Damage (MASD) due to its clinical presentation and description. Resident 1 had a soiled brief (urine) during the observation and reported and complained of burning pain to the groin area. (See also F684 - Quality of Care for more information.) A review of the facility's incident investigation reporting log and grievance log from 05/01/2022 to 06/22/2022 showed that Resident 1 had filed grievances on 05/01/2022, 06/09/2022, and 06/14/2022, which were assigned and processed by Staff A. The grievance on 05/01/2022 showed that the resident complained that staff did not/refused to get him out of bed when he wanted to. The grievance was processed and resolved on 05/05/2022 by Staff A. There was no documented evidence that the concerns related to neglect of care was followed up on or investigated by the facility as directed by the abuse and neglect policy. On 06/22/2022 at 1:25 PM, Resident 1 showed a notation of when he met with Staff A to report his concerns with care. The dates matched the facility's grievance reporting log including the areas of concerns that was reported by Resident 1 except that the long wait for call lights, and the staff(s) refusal to change him on time were on Resident 2's notation but not on the facility's reporting logs. On 06/22/2022 at 1:30 PM, Staff A stated he could not recall getting any concerns from Resident 1 that was related to abuse and/or neglect of care. However, Staff A stated that he had remembered and processed other concerns from Resident 1 but could not recall the call light concerns including any allegations of abuse or neglect of care. Staff A stated that if any allegations of abuse or neglect were reported to him or any facility staff, the facility would immediately report and investigate the allegations as needed and as required by their policy and the regulations. Reference: (WAC) 388-97-0640 (1) (2)(a)(b) (5)(a) (6)(a)(b)

Based on observation, interview, and record review, the facility failed to comprehensively assess, monitor, and treat skin breakdown for 1 of 3 residents (Resident 1) reviewed for non-pressure skin condition. Additionally, the facility failed to implement written policies and procedures related to the treatment and management of skin breakdown for Resident 1. These failures caused harm to Resident 1 who developed a Moisture Associated Skin Damage (MASD), experienced pain, and placed other residents at risk for harm and unmet care needs. Findings included . Moisture Associate Skin Damage or MASD is defined as an inflammation and erosion of skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate (discharge), [MEDICATION(S)] or saliva. A review of the facility policy titled, Skin at Risk/Skin Breakdown dated 01/2003 and revised on 09/2020 directed facility staff (Licensed Nurses) to complete a full body skin assessment/evaluation to all residents at least weekly. The policy also directed facility staff to: A. Upon discovery of newly identified skin impairment, the licensed nurse will document skin impairment that includes measurement of size, color, presence of odor and exudates. B. The license nurse will document presence of pain associated with the skin impairment. C. Notify the physician and obtain a treatment order if needed. D. Notify the resident or resident representative of the skin condition and treatment plan. E. Evaluate environment, mobility equipment, functional and cognitive ability, medication, laboratory results to identify interventions to promote healing and resolution of skin impairment. F. Document skin findings on the skin form. Resident 1 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident had intact cognition and needed two-person extensive assistance with bed mobility, transfers, toileting, and personal hygiene needs. A review of Resident 1's care plan dated 10/04/2021 and revised on 06/15/2022 showed that the resident had the potential for skin integrity impairment related to decreased mobility and current medical conditions. The care plan showed that the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . The care plan directed facility staff to notify licensed nurses for any new skin issues observed. On 06/22/2022 at 10:30 AM, Resident 1 stated he had serious care concerns regarding the care and services at the facility. Resident 1 stated he had serious skin problem to his penis, scrotum, and groin area that was causing him awful pain and discomfort. According to Resident 1, the pain on his groin area was the worst because it had a burning sensation and that staff had told him that he had huge skin cracks that were draining and were very red. Resident 1 stated he felt neglected and it was not right to be treated badly by the facility. According to Resident 1, no one had checked on him that day and offered to have a brief change, so he had been waiting and sitting in his urine since 7:00 AM. Resident 1 further stated, this was the reason why he kept having itchy, burning, painful rashes in between his legs and scrotum area. (See also F607 - Develop/Implement Abuse/Neglect policies for more information). On 06/22/2022 at 10:45 AM, Staff C, Registered Nurse (RN) stated Resident 1 had no current skin issues or breakdown to his groin and perineal area. Staff C stated that Resident 1's physician order sheet and treatment administration record (TAR) showed no orders for any treatment and that she was not aware of any skin breakdown that would require any treatment. On 06/22/2022 at 11:00 AM, Staff D, Nursing Assistant Certified (NAC) stated he had not cleaned or provided any perineal care to Resident 1 that day. Staff D also stated that Resident 1 had redness and rash to his scrotum and peri area, but he had not seen it today. Staff D offered no explanation as to why he had not provided personal hygiene care or incontinent care to Resident 1 since the start of his shift at 6:00 AM. On 06/22/2022 at 11:15 AM, a joint skin observation with Staff C, Staff D, and Staff B, RN/Staff Development Coordinator (SDC), showed Resident 1 had redness to the penis and both the scrotum extending to the bilateral (both) groin area. Staff B also measured the open skin areas on both the right and left groin area measuring 3 centimeter (cm) in length, 0.5 cm wide and 0.1 cm deep. The skin was open with a pink/red, color appearance. The wounds and the scrotum area had pink cream applied to it. Staff B stated he would classify the wound as an MASD due to its clinical presentation. Staff B also stated that it appears the wound had been present for a while and that staff had been applying cream to the affected areas. Resident 1 reported and complained of burning pain to the groin area during the observation. On 06/22/202 at 11:45 AM, during a joint record review of Resident 1's clinical records (skin assessments, physician order sheet, medication and treatment administration records, care plans, nursing, and physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff B stated that even the physician was not aware of Resident 1's skin condition. Staff B was not able to provide an answer or explanation as to why the facility had no record of the skin breakdown despite staff's knowledge of the skin issue and evidence of cream being applied to the wounds. On 06/22/2022 at 1:20 PM, Staff F, NAC, stated she had work with Resident 1 recently (mostly day shift) and had applied barrier cream to the resident's scrotum and groin area. Staff F stated she had observed redness to the groin area and that nurses were aware of the skin issues. On 06/22/2022 at 2:00 PM, Staff G, NAC, stated he had work with Resident 1 recently (mostly evening shift) and had applied barrier cream to the resident's scrotum and groin area. Staff G stated he had observed redness and rash to the groin area and that he had reported the skin issues to the nurse in the past. Staff G stated the resident would sometimes complain of pain to the area especially when being cleaned and when the cream was being applied. A review of Resident 1's weekly skin check/evaluation dated 06/21/2022 (1 day before) completed by Staff E, RN, showed Resident 1 had no skin issues or breakdown. However, on 06/22/2022 at 2:10 PM, during a joint interview with Staff B and Staff E, Staff E stated he did not assess and complete the skin check for Resident 1 and offered no explanation as to why he marked that the skin check was done and documented no skin issues without completing and doing the task. On 06/22/2022 at 2:30 PM, both Staff A and Staff B stated that Resident 1's skin condition should have been assessed, care planned and monitored in the clinical records. Both Staff A and Staff B stated they were not sure why Staff E would just mark that he completed the skin check and documented no skin issues without performing the task. A review of the physician order sheet dated 06/22/2022 showed the physician ordered three different treatment orders for Resident 1 including hydrocortisone cream (steroid), [MEDICATION(S)] cream (antifungal) and [MEDICATION(S)] cream (skin protectant) for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Reference: (WAC) 388-97-1060 (1)(3)(b)

Based on interview, record review and policy review, the facility failed to ensure three of four residents (#1, #3, #4 ) were free of significant medication errors. Failure to administer medications per facility guidelines and standard of practice resulted in harm to Resident #1 who required medical interventions, and placed Resident #3 and Resident #4 at risk for possible complications. Findings included . The facility's policy on specific procedures for all medications, undated, showed licensed nurses were to identify residents before administering a medication. The policy on preparation and general guidelines for medication administration showed: Residents are identified before medication is administered. Methods of identification include checking identification band, checking photograph attached to medical record, calling resident by named, and if necessary, verifying resident identification with other facility personnel. The facility's policy regarding preparation and general guidelines for controlled medications, undated, showed that when a controlled medication (narcotic) is administered, the licensed nurse (LN) administering the medication immediately enters the following information on the accountability record (narcotic log) and the Medication Administration Record [REDACTED]. Medical definition of narcotic: drug (as [MEDICATION NAME], or [MEDICATION NAME]) that in moderate doses dulls the senses, relieves pain, and induces profound sleep, but in excessive doses causes stupor, coma, or convulsions. [MEDICATION NAME] ([MEDICATION NAME]) is an opioid antagonist used for the complete or partial reversal of opioid overdose, including respiratory depression. RESIDENT #1 Resident #1's quarterly Minimum Data Set (MDS) assessment, dated 06/23/2019, showed that Resident 1 was alert. The Medication Administration Record [REDACTED] Resident #1 had a room-mate (Resident #2) who received routine narcotics for pain management. Resident #2's MAR for (MONTH) 2019 showed that he was to receive routine MS([MEDICATION NAME]) ER(extended release) 90 milligrams (mg) by mouth daily at 7:00 [NAME]M. (three) 30 mg tablets, for a total 90 mg dose. The narcotic log for Resident 2 showed on 09/10/2019 at 7:30 AM., LN A had signed the log indicating the 3 tablets of MS ER were obtained from Resident 2's individual narcotic medication. Resident #1's MAR for (MONTH) 2019 showed that he was not on any narcotic medication. The MAR indicated [REDACTED].M. [MEDICATION NAME] (a muscle relaxant) a 5 mg tablet. The facility's investigative report, dated 09/10/2019, showed a medication error had been identified and Resident #1 had received 90 mg of [MEDICATION NAME] (MS) ER. The report showed the Licensed Nurse (LN A) had inadvertently administered Resident #2's medication ([MEDICATION NAME] 90 mg dosage) to Resident #1. The facility's report concluded that the LN failed to adhere to policy to ensure safe medication pass/management at bedside. The physician's note, dated 09/10/2019, showed Resident #1 was seen for possible ingestion of his roomate's (Resident #2) [MEDICATION NAME] (MS). The note showed Resident #1 informed the physician that he felt strange, anxious, fuzzy, nauseous and vomited twice. The physician's note showed a medication ([MEDICATION NAME]) was ordered for the nausea/vomiting, and that a dose of [MEDICATION NAME] was administered to Resident #1 without any change in symptoms. The physician's plan, due to possible accidental ingestion of [MEDICATION NAME], was to transfer Resident #1 to the emergency room for confirmation of narcotic (MS) ingestion. Review of Resident #1's (MONTH) 2019 MAR indicated [REDACTED]. The nursing progress note, dated 09/10/2019 at 8:30 AM, by LN A showed Resident #2 (Resident #1's room-mate) had informed LN A that he had not received his morning MS. LN A documented she then discussed medication pass with Resident #1, who told LN A that he believes there was medications he did not recognize. The nursing progress note showed that Resident #1 was alert and oriented, and was placed on alert due to possible medication error. Another nursing progress note, dated 09/10/2019 at 1:01 P.M., showed there was a possible medication error this AM, suspected that Resident #1 consumed 90 mg MS ER dose that was meant for roommate (Resident #2). Resident #1 shows sign and symptoms of drowsiness with vomiting and was administered [MEDICATION NAME] precautionary, a cool washcloth was placed on his forehead to further assist with nausea. During an interview with Resident #1 on 10/02/19 at 2:16 P.M., he stated that a plastic medication cup was left on his bedside table by the licensed nurse (LN A) so he thought they were his medications, and took them. Resident #1 stated that he vomited after taking the wrong medications which LN A left for him. During an interview with Resident #1's family on 10/2/2019 at 2:30 PM, she stated that LN A had given the wrong medication to Resident 1 on 09/10/2019 and the toxicology report obtained at the hospital showed positive for narcotic (opioids) and that he does not take narcotic medications. The family member stated that when the medication error occurred, LN A was upset about the medication error, and was crying her eyes out. During an interview with the Medical Director (MD) on 10/2/2019 at 3:17 PM, she stated that Resident #1 had received the wrong medication, a narcotic (MS). The MD stated that Resident #1 was not receiving any narcotic medications and was narcotic naive(not chronically receiving opioids on a daily basis), so [MEDICATION NAME] (narcotic antagonist) was ordered, in addition to a medication for Resident #1's vomiting/nausea. During an interview with the Director of Nursing (DNS) on 10/2/2019 at 4:10 PM, she stated that Resident #1 had become lethargic and vomited after administration of the wrong medication (MS). The DNS stated that the LN A had informed nursing management regarding the medication error. During an interview with LN A on 10/7/2019 at 2:30 P.M., LN A stated that Resident #1 had been administered his room mate's narcotic medication (MS). She stated that upon her discovery of the medication error, she notified the nurse manager (RCM). Resident #1 was transported to the hospital emergency room (ER) for evaluation on 09/10/2019. The emergency room triage note showed possible given extra pills this morning at 07:30 [NAME]M., patient's roommate (Resident #2) was missing his MS ER. Resident #1 believes he may have been given Resident #2's MS. Resident 1 stated that he had vomited three time and was given [MEDICATION NAME] and [MEDICATION NAME] (for nausea/vomiting). The emergency room report, dated 09/10/2019, showed that the reason for the visit was overdose (accidental) and nausea. The emergency room note showed Resident #1 received medication for nausea ([MEDICATION NAME]) and that the toxicology (urine) report dated 09/10/2019 showed positive for opiate (narcotics). RESIDENT #3 Resident #3 was admitted to the facility from the hospital on [DATE]. [DIAGNOSES REDACTED]. The hospital transfer sheets showed the physician's transfer prescription orders listed 32 medications which were sequentially numbered on the physician's prescription orders. The prescribed medications for Resident 3's DM, included a long acting insulin (Toujeo 300 units/ml) 60 units at HS (night time), and a short acting insulin (Humalog) 15 units before meals in addition to a sliding insulin scale before meals. The medications for his [MEDICAL CONDITION] included [MEDICATION NAME] daily (AM), aspirin daily and atorvastation daily for cholesterol. Daily [MEDICATION NAME] ([MEDICATION NAME]) was prescribed for anxiety and trazadone for [MEDICAL CONDITION]. Other medications included multivitamin, iron and tylenol. The MAR for (MONTH) 2019 showed 22 omissions from 09/09/2019 to 09/11/2019 as follows: --Long acting insulin for two evening doses (09/09/19 and 09/10/2019 and Trazadone for [MEDICAL CONDITION] were not administered per MAR, --No documented evidence that the daily 09/10/19 and 09/11/19 doses of blood pressure medication ([MEDICATION NAME]), ASA, or cholesterol medication (atorvastation), [MEDICATION NAME] (anxiety medication), iron ([MEDICATION NAME] sulfate) or multivitamin had been administered. Additionally, the Tylenol order (three times a day) was not administered on the evening of 09/09/2019, 09/10/2019 (three doses) or the two prescribed doses on 09/11/2019. The facility's medication error report investigation for the medication omission, dated 09/11/2019, showed that 10 medications were not confirmed by facility staff upon admission of Resident #3. The report showed the root cause was due to the medication packet received upon arrival did not match orders previously received prior to admission. The report showed that LNs involved in admission process needed to follow policies/procedures for medication upon admission. Additionally, the report showed that LN B was provided education in regards to checking medication admission orders [REDACTED]. During an interview on 10/07/2019 at 4:00 PM, LN B stated that she had put the physician's orders [REDACTED]. During an interview on 10/07/2019 at 4:03 PM, the Director of Nursing (DNS) stated all omission medication errors were corrected on 09/11/2019. The DNS stated that the paper work that Resident #3 brought with him on admit differed from the fax/email received from the hospital. RESIDENT #4 Resident #4 was readmitted to the facility on [DATE] after hospitalized from [DATE] to 09/06/2019. The hospital discharge orders, dated 09/06/2019, showed Resident #4 was to be on antibiotics ([MEDICATION NAME]) due to a history of an intestinal infection (C- Difficile). The hospital transfer orders showed Resident #4 was to be administered [MEDICATION NAME] three times (TID) from 09/05/2019 to 09/19/2019. The MAR for (MONTH) 2019 showed that the oral [MEDICATION NAME] had not been administered three times a day on 09/06/19, 09/07/19 and 09/08/2019, and the morning dose was not administered on 09/09/2019. The MAR indicated [REDACTED]. The facility medication error report, dated 09/08/2019, showed the medication ([MEDICATION NAME]) was missed when being entered on Resident #4's Medication Administration Record [REDACTED]. During an interview on 10/07/2019 at 4:40 PM, the Director of Nursing (DNS) stated that Resident #4 did not receive her antibiotic dose from 09/06/2019 to 09/08/2019. The DNS stated the medication omission error was recognized on 09/09/2019 and corrected, and that on 09/09/2019 the [MEDICATION NAME] medication was administered the afternoon of 09/09/2019. Reference: WAC 388-97-1060 (3)(k)(iii)

Based on observation, interview, and record review, the facility failed to consistently assess, monitor and provide individualized resident centered care for 1 of 3 residents post-operatively. Failure to ensure continuity of care for a post-operative resident resulted in pain and swelling of Resident 1's lower extremity with a subsequent transfer to the hospital for evaluation. Findings included . The facility policy for alert charting, revised 02/2019, showed that staff were to document vital signs every shift, the reason for admission and adjustment to the facility, and an assessment for pain every shift for 72 hours. The facility's policy for Care Plan-Kardex/Baseline Care Plan, revised 02/2019, showed that the policy of the facility was to develop a care plan that directed care givers to have accurate information available to them so as to properly care for residents. Total knee replacement is a common and often painful orthopaedic operation. Femoral nerve block (FNB) is an [MEDICATION NAME] technique that blocks sensation to the knee to reduce pain following surgery. FNB is given as a single injection or as continuous infusion of numbing medication in the groin area. The nerve block for pain after total knee replacement can last for 12-24 hours. Medication continuously delivered through a tiny plastic tube (nerve catheter) placed next to the nerve can last for 2-3 days. (https://www.cochrane.org/ ./ANAESTH_femoral-nerve-blocks-acute-postoperative-pain). RESIDENT 1 Resident 1 admitted to the facility on [DATE] after a total left knee replacement. The hospital referral/discharge record, dated 05/13/19, showed that Resident #1 received pain medications (narcotic) and had a peripheral nerve catheter (FNB) for the management of knee pain; and to reduce swelling, ice was to be applied to the knee and a compression antiembolism socking (TED) used. The referral notice showed that Resident 1 was being administered narcotic pain medications for post-op knee pain up to 6 times a day. Resident 1's admission pain assessment, dated 05/15/19, showed that Resident 1 stated that she had no pain, but had experienced pain in the last 5 days. The nursing admit assessment showed that Resident 1 had swelling of her affected left lower leg, and that she denied experiencing pain at the time of this assessment, but informed the Licesed Nurse (LN) that she had pain in the last 5 days. A care plan for pain included: --Anticipate resident's need for pain relief and respond immediately to a complaint of pain. The Plan of Care and/or Treatment Administration Record for (MONTH) 2019 did not show any interventions to relieve the left leg swelling or care regarding the PNB/catheter. A nursing progress note, dated 05/16/19 at 7:21 PM, showed that Resident 1 had a dressing on her left knee and a pain pump was in place, however no other pain regimen was noted with admission orders [REDACTED] The kardex used by nursing assistants (NACs) did not show specific interventions in regard to left leg positioning due to swelling. Another nursing progress note, dated 05/15/19 at 8:31 PM, showed that Resident #1's narcotic medication order(s) had not been with (did not come with) the resident on admit. The family member inquired about the order. The LNs notified the hospital and an entry on 05/15/19 at 8:30 P.M. showed that a hospital LN would bring the written prescription for the narcotic pain medication to the facility, so that the facility could then send the medication prescription order to the pharmacy. Resident 1's initial Care Plan for pain, dated 05/15/19, showed the LNs would identify and record previous pain history and manage her pain. The Care Plan also indicated the staff would identify previous responses to [MEDICATION NAME](pain medication) including pain relief, side effects, and impact on function, administer [MEDICATION NAME] as ordered, and administer pain medication a half hour before treatments or care. There was no documented evidence that an initial care plan was initiated to include possible ice application, use of TED hose, or inspection of the post-op site and the infusion site for the peripheral catheter. The Medication Administration Record [REDACTED]. An entry on the 05/15/19 had a check mark for pain. However, there was no documented evidence that pain management interventions were implemented. On 05/28/19 at 1:47 PM, the facility provided a fax which showed that Resident 1 had exhibited pain at 9:59 PM on 5/15/19. Record review showed Resident 1's physician was not notified regarding the need for an order for [REDACTED]. During an interview on 05/24/19 at 2:53 PM, LNA, a Registered Nurse, who had provided care for Resident 1 during her initial admit on 05/15/19, stated that the resident had a block above the incision, and LNs needed to offer her pain medications as the resident would not ask on her own. LN A stated that when Resident 1's leg locked up and became swollen due to limited movement, she was transferred to the hospital on [DATE] for evaluation. LN A stated that the hospital removed her infusion catheter. During an interview on 05/24/19 at 3:28 PM, LN B, a Registered Nurse, stated LNs are to document every 8 hours on new admissions and the care plan needs to reflect all interventions that LNs and staff needed to ensure a post-op resident had in place. During an interview on 05/24/19 at 2:45 PM, Resident 1 was observed in bed. She stated that there was a mix-up with her pain medication on admit. She stated she had an medication infusion pump in her groin area, and that an LN called the hospital about pain medication. When asked the resident about her pain when she was admitted on [DATE], she stated that she had pain and that the staff had not applied any ice to her knee which she had been receiving at the hospital post-operatively to prevent swelling. Resident 1 stated her left leg then became swollen and she was unable to move her leg, so she was transferred to the hospital. During an interview on 05/24/19 at 4:35 PM, the administrator stated that the hospital did not provide a prescription for the narcotic pain medication for Resident 1 and there was a delay in providing continuity of care. During an interview on 06/05/19 at 10:45 AM, the Director of Nursing stated that the LNs did not ensure that Resident 1's narcotic pain medication order was obtained until 05/16/19 which delayed continuity of care, and stated that the LNs had not developed a post-operative individualized plan of care based on assessment. Reference: (WAC) 388-97-1060(1)

Based on interview and record review, the facility failed to comprehensively assess and implement an individualized plan of care for pressure relief for one of three residents (#1) with pressure ulcers. Failure to ensure pressure relieving measures were in place for Resident 1 resulted in the development of a painful and avoidable pressure ulcer. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Unstageable Pressure Injury: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar (necrotic/dead tissue). Deep Tissue Pressure Injury (DTI): Persistent non-blanchable deep red, maroon or purple discoloration. Pain and temperature change often precede skin color changes. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The facility's policy revised 02/2018 indicated that a resident who entered the facility without pressure ulcer/injury did not develop a pressure ulcer/injury. The policy also directed Licensed Nurses (LNs) to complete weekly skin assessments. RESIDENT 1 Resident 1 was admitted to the facility on [DATE] for rehabilitation. [DIAGNOSES REDACTED]. Resident 1 discharged home on[DATE] with home care services. The admit skin at risk assessment form dated 02/06/2019 showed that Resident 1 was at risk for skin breakdown due to limitated sensation and mobility, and activity status was checked as bedfast (confined to bed all or most of time). The admit nursing assessment dated [DATE] showed that Resident 1 had no current skin issues, but had a history of [REDACTED]. The admit skin grid for skin problems dated 02/06/2019 showed that a Licensed Nurse (LN) documented that inner aspect of both ankles had discoloration, and was described as a dark pink discoloration. The discoloration on the right ankle measured 7.0 centimeters (cm) by 5.5 cm in size and the discoloration of the left ankle measured 3.5 cm by 4.0 cm in size. The Initial In Room Care Plan (IRCP) dated 02/06/2019 showed that he required two person assistance with bed mobility and transfers, and was at high risk for skin issues. Even though Resident 1 informed the LNs that he had a history of [REDACTED]. The admit Minimum Data Set Assessment ((MDS) dated [DATE] showed that Resident 1 required two person assistance with bed mobility and transfers. The MDS showed that he received an ointment to feet, and had no pressure ulcers. The Treatment Administration Record (TAR) for (MONTH) 2019 showed that after the admit skin assessment (02/06/2019), the next weekly skin assessment was not performed until 02/17/2019 (11 days later). Additionally, the admit skin grid dated 02/06/2019, that showed the discoloration of both ankles, had no further skin assessment documented to indicate whether these areas had remained unopen, stable or deteriorated. The TAR for (MONTH) (YEAR) showed that the weekly skin assessment performed by Licensed Nurses (LNs) on day shift showed no new skin issues (no pressure areas on heels). The skin assessment completed on the day shift 03/03/2019 showed no skin issues. A nursing progress note, dated 03/03/19 at 11:36 PM, showed that Resident 1 complained of left heel pain. The LN documented res (resident) reports having a history of similar wound on heels, . most probably a P/U (pressure ulcer). The heel was described as a dark spot with a blanchable area, half a centimeter by half centimeter in size. Foot placed on a pillow. The skin grid form dated 03/03/19 showed that the pressure ulcer on the left heel was not present on admission, had 30% necrotic (dead) tissue in the wound base, was staged as unknown, and had no drainage. The Managing Acute Care Change (MACC) form dated 03/03/19 showed that Resident 1 had deep tissue destruction (DTI) and that staff were to elevate his left heel on a pillow and encourage frequent position changes in bed. The initial Consultant Wound Nurse's (CWN) note dated 03/08/19 revealed that Resident 1 had a pressure ulcer on his left heel that measured 1.5 centimeter (cm) by 1.2 cm in size with sero-sanguineous (thin liquid, bloody) drainage. The facility's skin grid for pressure ulcer dated 03/08/2019 described the wound as a DTI. The wound bed contained eschar (dead tissue) and had sero-sanguineous drainage. The clinical record showed that on 03/08/19, an order was received to apply a float heel boot to the LLE (left lower extremity) at HS (night time) and remove in AM (morning). The Care Plan for risk of pressure ulcers, dated 02/14/19, showed no interventions for avoiding pressure on Resident 1's heels until the development of a pressure ulcer on his heel. During an interview on 03/29/2019 from 10:50 AM to 11:16 AM with the Resident Care Manager (RCM A), a registered nurse, stated there were no preventive measures or care plan developed for pressure relief. RCM A stated weekly skin assessments were to be completed. On 04/16/2019 at 1:30 PM, the Director of Nursing (DNS) stated weekly assessments were not documented and interventions to avoid pressure on Resident 1's heels were not implemented until the development of the pressure ulcer/injury. WAC reference 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to effectively assess, monitor and implement necessary interventions to maintain adequate fluid hydration for 2 of 3 residents (20, and 19) at risk for dehydration. This failure placed the residents in Immediate Jeopardy (IJ) for severe dehydration and death by not effectively monitoring and providing interventions in the event of; physical signs and symptoms of dehydration, monitoring of intake and output (I&O), abnormally high lab values that were indicative of dehydration, decreased fluid intake and urinary output as well as gastrointestinal (GI) fluid loss. Through interviews conducted and Progress notes reviewed, showed Resident 20 had acquired [MEDICAL CONDITION] (A bacteria that causes severe diarrhea) on or around 03/25/18 and also had significant weight loss. Resident 20 was discharged to the hospital on [DATE] and passed away on 04/25/18. Additionally, the nursing facility and Hospice failed to collaborate and work together to develop a coordinated plan of care for 1 of 1 residents (24) reviewed for Hospice Care. Findings included . Lippincott Manual of Nursing Practice Defined Diarrhea as loose or watery stool and if left untreated, could lead to severe dehydration and hospitalization s. Causes of diarrhea included [MEDICAL CONDITION] infection. The text stated signs and symptoms of dehydration in the elderly included dry mucous membranes, dry skin, weight loss, decreased urinary output and abnormal labs such as elevated BUN, Potassium and sodium. The text stated in order to achieve fluid balance, required monitoring of fluid intake and urinary output, weighing the patient daily and monitor pertinent labs. RESIDENT 20 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was to receive nothing by mouth (NPO) to reduce the risk of PNA and therefore required the use of a Gastric tube ([DEVICE]) for nutrition and hydration. The resident's most recent Minimum Data Set (MDS), showed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) and was able to make his needs known. Review of the facility policy titled Nutrition Risk Review revised on 06/17, stated a weekly meeting consisting of the Director of Nursing (DNS), Resident Care Manager (RCM) and Dietician would review assessments completed on residents who were identified as having a nutritional risk to discuss resident status, make referrals to other health professionals and plan appropriate, individualized interventions. Items reviewed in the weekly meetings included the following: 1. Hydration 2. Pertinent Labs 3. Tube feedings 4. Food and fluid intake 5. Significant/patterned weight changes 6. [MEDICATION NAME] nutrition and Intravenous (IV) fluids 7. Physical condition Review of the facility policy titled Intake and Output revised on 06/17, stated I&O's would be instituted to monitor any condition per physicians order or nursing judgment. Review of the facility policy titled Naso-gastric/[DIAGNOSES REDACTED] or naso-jejunal Feeding Tube revised on 06/17, stated it was the facility policy residents receiving tube feedings needed to have intake monitored that would be completed and documented by the licensed nurse at the end of every shift. However the policy also stated Output will not be monitored unless ordered by a Medical Doctor (MD). Review of the resident's care plan dated 3/8/18, identified the resident at risk for dehydration related to the use of an indwelling [DEVICE] and NPO status. The care plan goals stated, Signs and symptoms of dehydration would be recognized and treated. Interventions on the care plan included the following: Assess for dehydration, change in mental status, decreased urine output, dry cracked lips, dry mucous membranes and sunken eyes. The care plan further stated to report abnormal labs indicative of dehydration (elevated hemoglobin, hematocrit, potassium, chloride, sodium, [MEDICATION NAME], blood urea nitrogen {BUN}). Care planned interventions also stated I&O if indicated. However review of the clinical medical record showed the resident did not have any restrictions for fluid intake and was never placed on I&O monitoring as indicated by the nutritional care plan and nursing judgment for implementing I&O's was never initiated as stated by the I&O facility policy. Review of the physician's orders dated 4/11/18 showed orders to flush [DEVICE] with 100ml water every 4 hrs to maintain tube patency and for additional hydration. The order for [DEVICE] flushes was increased to 150ml every 4 hrs on 4/17/18. Review of the resident's daily fluid output flowsheet from 2/23/18 to 04/24/18 showed urinary output documented on most days as small, medium or large during this period. However on some days the flowsheets showed a documented daily urinary output ranging from 240ml to 400ml per day. The flowsheets reviewed for bowel movements from 03/22/18 showed the resident was having loose stools that were also described as having a foul odor. Review of the resident's labs showed normal lab reference ranges for normal BUN were 7-25mg/dl. Normal ranges for combined BUN/Creatinine were 12-20mg/dl. As mentioned earlier, these lab results showed the residents kidney and hydration status, so the higher the result outside the normal reference range was indicative of dehydration. Review of the residents BUN and BUN/Creatinine levels from 2/23/18 to 04/25/18 were as follows: Date BUN BUN/Creatinine (Combined) 03/20/18 21 Unavailable 04/17/18 32 64 04/20/18 38 54 04/24/18 74 57 04/25/18 82 63 These results also showed there was no laboratory monitoring for potential dehydration from 3/20/18 to 04/17/18. Which was also the time the resident was NPO, having loose stools from [MEDICAL CONDITION] infection, receiving 100ml of fluid flushes through his [DEVICE] every 4 hrs, did not have effective I&O monitoring, documentation or communication of low fluid output to an MD or qualified healthcare professional. The lab results also showed the resident was positive for [MEDICAL CONDITION] up until his discharge and death. In an observation on 4/10, 4/11 and 4/12 of (YEAR), the resident was observed to have dry cracked and peeling lips. On 4/13/18 at 9:49 AM, the resident was observed to have dry cracked lips, sunken eyeballs and dry looking flaky skin. In an interview on 4/13/18 at 2:06 PM, Staff W, Nurse's Aide (NA) stated NA's document resident I&O's in the computer. She stated fluids were monitored for residents who were NPO and the nurses kept track. She stated she could tell when a resident was dehydrated by dry skin, chapped lips and mood changes. In an interview at 2:29 PM, staff G Registered Nurse (RN) stated the nurses were responsible for monitoring I&O's for resident's on tube feedings. Staff G stated the nurses monitored fluid intake by how much fluid was left in the IV bag that was used for tube flushes and stated the residents on tube feedings, got most their fluids from the tube feedings. She stated if the resident needed more fluids they obtained an order to give a bolus to increase fluid intake. Regarding a resident admitted to the facility with a [DEVICE] and monitoring I&O's, she stated it was not the facility policy to document I&O's but stated according to standards of practice it would be good to document. She also stated the nurses' aides measured the resident's urine with a urinal, and then documented the amount in milliliters (ml) in the computer. In a joint observation of the resident's output flowsheet regarding how the aides were documenting output, she stated the flowsheet was not an effective way of determining accurate output. She elaborated by saying, You can't determine the amount and stated she would notify the DNS to have the NA's start documenting urinary output in milliliters. At 3:08 PM, Staff Y RN stated, the resident got continuous feedings all day with fluid flushes for extra hydration. She stated the resident was not showing signs of dehydration as evidenced by normal vital signs and the resident had not shown any other signs of dehydration. In an observation on 04/17/18 at 12:47 PM, observed the resident being assisted by Staff AA, Occupational Therapist (OT). The resident's skin appeared to be whitish in color, when Staff AA was asked why she stated, I put lotion on his face, he is extremely dehydrated and I wanted to hydrate his skin a little. Upon visual inspection of the resident it was noted that he had sunken eyeballs, frail appearance with dry looking flaky skin and dry cracked lips. In an interview on 04/18/18 at 2:34 PM, Staff J stated a resident with a G tube should have strict monitoring of fluid output that included measuring output in ml's. He stated signs and symptoms of dehydration where dry skin, dry mucous membranes and stated he thought the resident was well hydrated. When he was shown the resident's daily urinary output of 240ml-400ml, he stated it was indicative of dehydration. He was then asked if the urinary output amount were a red flag and warranted communication with doctor or a qualified health care professional and stated Yes At 4:17 PM, Staff G and Staff C RN stated a resident who was positive for [MEDICAL CONDITION], on a [DEVICE] and NPO should have strict monitoring for I&O's. Both staff members agreed that dry mucous membranes, sunken eyeballs and dry flaky skin were positive signs for dehydration. They also stated other positive signs of dehydration were elevated BUN and decreased urinary output. When asked if Resident 20 appeared to be dehydrated Staff C stated We just drew some labs and he has an elevated BUN and yes, he is dehydrated. When Staff G was shown the daily urinary outputs of 240ml-400ml she was asked if that was adequate urinary output and stated, Not really. She further stated there was no communication to a physician or qualified healthcare professional regarding the resident's low urinary output. Review of the Physician's Assistant (PA) progress note dated 4/18/18 showed the PA evaluated the resident for follow up labs and dehydration. Then an order to start IV infusion of fluids was initiated in response to notification of the residents abnomal BUN. In an interview on 04/26/18 at 2:52 PM Staff BB, NA, stated he had taken care of the resident up until the discharged from the facility. He also stated the resident did not appear to be dehydrated. He stated the resident was still on contact precautions for [MEDICAL CONDITION] and was still having very loose stools up until he discharged . At 3:26 PM, the DNS stated Resident 20 who was NPO, on tube feedings and on [MEDICAL CONDITION] precautions with active diarrhea should have been on I&O's to monitor fluid intake and output. When she was asked to provide a policy for when nurses needed to implement I&O's, she stated no there was none or she had not seen one. She further stated I&O's would have been a good way to monitor the resident's hydration. Regarding any communication of dehydration concerns to a doctor she stated the only documentation she could find was the fluid flushes that were increased by the dietician from 100ml to 150ml every 4 hours. She then reviewed the labs and stated the resident might have been dehydrated and the Dietician was responsible for monitoring the resident's fluid and hydration status. Review of hospital records obtained showed on 04/24/18 the resident was admitted to the hospital with [REDACTED]. (For more information regarding Malnutrition, please see F692). RESIDENT 19 The resident re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident also had a feeding tube and was receiving tube feedings for nutrition and hydration. Review of the residents care plan dated 12/15/17 identified the resident with a risk for dehydration. Goals included Signs and symptoms of dehydration will be recognized and treated. Interventions included assess for dehydration (Change in mental status, decreased urinary output, elevated potassium, chloride, sodium, blood urea nitrogen). Review of the resident's laboratory results for BUN and Potassium and sodium from 03/01/18 to 04/24/18 were as follows: 03/01/18 showed a high Potassium level of 5.9 and a critical high BUN of 128 03/04/18 showed a high Potassium level of 5.8 and a Critical High BUN of 150 04/10/18 showed a high BUN of 69 04/16/18 showed a critical high BUN of 100 04/24/18 showed a critical high sodium level of 156, critical high potassium level of 6.6 and a critical high BUN of 185 The lab results shown above were all considered to be indicative of dehydration. However review of the nursing and physician progress notes [REDACTED]. Review of the results above also showed critically high levels that were an immediate threat to the resident's life without any documented immediate interventions. The progress note dated 04/24/18, showed the resident was sent to the emergency room for further evaluation as a result of critical lab results that were communicated to a healthcare provider. Review of the resident's hospital admission note dated 04/24/18, showed the resident's admitting [DIAGNOSES REDACTED]. Dehydration, [MEDICAL CONDITION] (High potassium levels), [MEDICAL CONDITION] (High sodium levels), [MEDICAL CONDITION] (life threatening low blood pressure), Shock due to systemic infection and Acute [MEDICAL CONDITION]. In an interview on 05/01/18 at 1:56 PM, Staff R Regional Nurse Consultant stated the resident was admitted to the hospital with [REDACTED]. On 04/26/18 at 5:45 PM, an Immediate Jeopardy was called related to Resident's 19 and 20 hydration statuses. Staff R and the DNS were notified of the IJ, were shown the findings and results of the investigation, who both agreed that ineffective monitoring and communication of the resident's hydration status resulted in the immediate Jeopardy. When Staff R was notified of the death of Resident 20 the day before and also learned about Resident 19 hospitalization , she was asked if she thought the reasons for the IJ were justified concerning the events that led to the IJ and stated Yes, I agree. Summary To summarize this investigation, it was evident Resident 20 was at risk for dehydration as stated in the care plan which also gave clear instructions on what the nursing staff should have assessed, monitored and reported any abnormalities. Ultimately the resident's [MEDICAL CONDITION] infection and active diarrhea placed the resident at even a higher risk for dehydration and was not included in the care plan for goals and interventions. Based on the observations made, the resident presented with physical signs and symptoms of dehydration that was noted by the Occupational Therapist, but not by any of the nursing staff that was active in his daily care. Interviews conducted showed the nursing staff knew the physical signs and symptoms of dehydration but failed to acknowledge the existing signs and symptoms, therefore did not use nursing judgement to implement the monitoring and effective documentation of I&O's. As a result there was a failure to document and report critical information to an MD or qualified healthcare provider until the dehydration was advanced coupled with worsening infection and ultimately death. These failures also applied to Resident 19 who had multiple critical lab values that were not well documented or reported until the resident's physical condition worsened and resulted in a hospitalization .

Based on observation, interview and record review, the facility failed to ensure and provide consistent, appropriate respiratory care and adequate oxygen therapy for 1 of 2 residents (19) who required oxygen therapy. In addition, the facility failed to provide oxygen therapy interventions based on the physician orders, professional standards and nurse scope of practice. These failed practices resulted in an Immediate Jeopardy situation on 04/18/18, and placed Resident 19 in harm, severe respiratory distress, obstruction of oxygen airflow, and potentially death related to lack of air/oxygen. Findings included . Resident 19 was admitted to the facility on [DATE] for [MEDICAL CONDITION] (blood infection) and rehabilitation therapy. The resident had multiple hospitalization s and emergency room visits during her stay at the facility, with the most recent on 04/16/18 for a replacement of a feeding tube. In a review of the most recent Minimum Data Set assessment, dated 02/16/18, showed the resident required staff assistance with activities of daily living. In a review of the most recent care plan, showed the resident had no respiratory and/or oxygen plan of care. The in room care plan consideration sheet, showed oxygen section was blank and not filled out. In a review of the Physician order [REDACTED]. In a review of the resident radiology report dated 04/18/18, showed the resident had bilateral lower lobe pneumonia and cardiomegaly (enlarged heart). During a joint observation with Staff D, Licensed Practical Nurse (LPN), on 04/18/18 at 8:15 AM, the resident was observed in her room. The resident presented with severe respiratory distress. The resident had deep rapid breathing, shortness of breath, and the resident was using accessory muscles of respiration including the muscles of the neck. The resident's face and lips color were pale and bluish, and showed signs of cyanosis (bluish or grayish color of the skin due to lack of circulation or inadequate oxygenation). The resident had both hands splinted, and was not able to use the call light to call for help. Staff D, LPN, assessed the resident, repositioned the resident head, but was not able to stabilize the resident breathing and condition. Staff D, LPN, summoned for help after her initial assessment. At 8:25 AM, Staff C, Resident Care Manager and Registered Nurse (RCM and RN), came to the room to assess the resident and provided assistance to Staff D. Both staff members attempted to obtain the resident's vital signs including oxygen saturation but was not at a detectable level at that time. At this time, the surveyor noticed that the resident oxygen tubing was pinched between the bathroom door and the door frame. The bathroom door was fully closed. The surveyor alerted Staff D, to check the resident tubing and check for patency while pointing at the oxygen tubing. Staff D immediately opened the bathroom door, unkinked and straightened the oxygen line. Shortly after the oxygen line was unkinked, the resident saturation reading showed 79%. Staff C, increased the oxygen from 2 lpm to 4 lpm. Staff C did not review the resident current medical condition/diagnoses, and did not contact the physician prior to increasing the resident oxygen level. The resident continued to show signs of respiratory distress with minimal improvement. During this time, Staff D was asked when was the last time a staff member was in the room to check on the resident. Staff D stated, she was told by the CNA that the resident was having trouble breathing about 30 minutes ago. At approximately 8:30 AM, the resident saturation reading was at 97%. The resident breathing had improved from labored deep breathing to even respiration and not labored. Both Staff D and Staff C, were asked if they were aware of the resident oxygen tubing being pinched or kinked, both staff were not able to provide an answer. Staff C, stated, they placed the oxygen concentrator in the bathroom so it can be more quiet in the room. When asked if the staff should be more aware of the risk of getting the oxygen tubing pinched or kinked because of the location of the concentrator, Staff C stated, Yes. Both the staff members were not aware that the oxygen tubing was pinched and kinked between the door and the door frame. At 8:35 AM, Staff A, Administrator, and Staff B, Director of Nursing (DNS), were both informed of the immediate safety concerns for Resident 19. Both Staff members acknowledged the safety risk and the likelihood of the oxygen tubing getting pinched or kinked because of the location of the oxygen concentrator. At this time, the resident respiratory condition was stabilized, and the resident was not showing any signs of respiratory distress. In an interview with Staff B, at 8:39 AM, the DNS stated the oxygen tubing should have been looked at and monitored by staff closely. According to Staff B, the resident was dependent to staff, and would not be able to call for help, and alert staff if her oxygen tubing was kinked or pinched. Staff B was asked about the action of Staff C, to increase the resident oxygen from 2 lpm to 4 lpm without contacting the doctor and reviewing the resident records to review any potential contraindication for high flow oxygen therapy. Staff B stated, Yes it is ok. When asked if Staff C could have caused more harm by increasing oxygen to the resident, and if that practice was not under the current professional and nurse's scope of practice, Staff B, stated, Yes. In a follow-up meeting with Staff A, and Staff B, at 10:51 AM, Staff A reported that the resident nostrils was also clogged by secretions upon assessment by the nurse, and this may have contributed to the respiratory distress Resident 19 had experienced that morning, and it was ok to have the oxygen line pinched between the door and the door frame because it does not affect the flow of oxygen to the resident. The facility's lack of awareness and knowledge of Resident 19's health condition, risk and vulnerability, and the lack of care planning to direct staff regarding the respiratory and oxygen therapy needs placed Resident 19 at serious harm and jeopardy. The facility's failure to recognize the risk and danger of lack of oxygen to a dependent resident, and the facility's failure to educate and train licensed nurses regarding emergency airway assessment, management and nurse's scope of practice placed the residents of the facility at risk for serious harm and immediate health and safety concerns. Reference (WAC) 388-97-1060 (3)(j)(vi)

Based on observation, interview and record review the facility failed to implement infection control standards of practice for Intravenous (IV) medication administration through a central line for 1 of 2 residents (4). Additionally the facility failed to identify risks associated with the use of a central line, goals and interventions to prevent IV catheter associated complications. This failure placed the resident in Immediate Jeopardy (IJ) from a sustaining IV catheter/central line associated infections, as a result from IV tubing that fell to the ground, was not properly disposed of, prior to the administration of an IV medication through the contaminated tubing and into the resident's indwelling central line. This failure also compromised the quality of care to the resident, as well as diminished health and overall well-being. A verbal plan to remove the IJ was stated by the facility and accepted on 04/10/18. Findings included . IN (YEAR) the CDC (Centers for Disease Control. www.cdc.gov), stated the primary sources for most pathogens causing catheter-associated bloodstream infections, where the catheter insertion site or the catheter hub. Contamination could result from the patients' own flora or from healthcare workers' hands during insertion or manipulation, or both which may also include contamination from surfaces. RESIDENT 4 The resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. According to the resident's most recent Minimum Data Set ((MDS) dated [DATE], showed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) and was able to make needs known. Review of the facility policy titled Infusion Therapy Policies and Procedures for Long-term Care stated Change continuous primary and secondary IV administration sets every 24-72 hours, immediately upon suspected contamination or when integrity of the product has been compromised. Review of the resident's care plan initiated on 03/19/18 did not identify the resident having a central line goals and interventions to address and prevent complications associated with the central line. In an observation on 04/10/18 at 10:02 AM, observed Staff V, Licensed Practical Nurse (LPN) preparing an IV medication that was to be administered through the resident's central line. As Staff V was getting ready to connect the IV tubing tip to a hub on the central line, she dropped the line to the floor, picked it up, used an alcohol pad to wipe the tip, and then proceeded to connect the tip to the resident's central line hub. Staff V then proceeded to run the IV medication through the central line for about 15 sec before the line stopped as a result of an occlusion. Staff V exited the room to find help with the infusion. In an interview on or at around 10:15 AM, Staff V stated she did not know what the policy was on what to do if IV tubing or tubing tip became contaminated. She stated she would find out and follow up with the surveyor. In a follow up interview at 11:10 AM, Staff V stated she spoke to the Staff C, Resident Care Manager (RCM) who stated there was no facility policy for what to do when an IV line/tubing was dropped. She further stated she was told by RCM that they were only required to change IV tubing if the line fell to the ground and was visibly soiled. At 11:35 AM, Staff C stated she was not sure if the facility had a policy on dropped IV lines because the facility had centralized policies but stated she would find out. Regarding dropped IV lines she stated We expect the nurses to use their judgment, they should clean it with alcohol and change the tubing if it is visibly soiled. At 12:25 PM, the DNS stated the expectation for a nurse who dropped an IV line on the ground, needed to practice aseptic technique. She stated aseptic technique involved cleaning the line with alcohol and changing the tubing if the tip touched the floor. She also stated they were required to change the line only when visibly soiled. In an interview at 3:13 PM, the Administrator, DNS and Staff U, Regional Nurse Consultant all agreed the IV tubing should have been changed upon touching the ground and hand hygiene practiced prior to connecting to the resident's central venous catheter. Summary On 04/10/18 an Immediate Jeopardy was called related to infection control with IV medication administration through a resident central line. A verbal removal plan was accepted by the surveyors on 04/10/18. Reference (WAC) 388-97-1320 (2)(b)

Based on observation, interview and record review the facility failed to thoroughly investigate incidents/allegations for 2 of 2 residents (10 & 50 ). Failed to develop and implement appropriate interventions for 1 of 1 residents (50), and failed to report to state agency as required, for 2 of 2 residents (10 & 5). These failed practices caused harm to Resident 50 and Resident 10, in the form of fear and mental anguish, and placed other residents at significant risk for harm, injury, diminished quality of life and unmet care needs. Findings included . RESIDENT 50 Resident 50 admitted to the facility on [DATE] for rehabilitation therapy with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment dated [DATE], showed the resident had intact cognition, required staff assistance with bed mobility, transfers, toileting and locomotion. During an interview and observation on 04/09/18 at 11:00 AM, the resident stated, They hurt me, they won't listen during transfers, I need to use a siding board. They will transfer me roughly, and it hurts. It takes 1-2 people or 3 sometimes. I experience severe pain. The resident added, I am in pain every day and, I have to wait for 1-2 hours, and nobody will come for help. According to the resident, I have to literally cry and beg for help, and Staff are rude and not helpful. The resident stated that the most recent episode was last week. He went on to say, Yes, they are all aware of this. I have told the staff my problem, every day. Observation showed the resident was grimacing and tearful at the time of the interview. During a record review and interview at 1:50 PM, Staff B, Director of Nursing (DNS), stated, she was not aware of the allegation regarding Resident 50. A copy of the facility investigation log and grievance log from 10/01/17 to 04/09/18 were reviewed and showed there was no concerns or allegations documented. Staff B stated, they would immediately conduct an investigation and follow up with the resident. In a follow-up record review and interview on 04/16/18 at 9:39 AM, Staff B, DNS, provided a copy of the full investigation report related to the allegation of abuse and neglect. Staff B stated, the facility was not able to substantiate the resident's allegations based on resident interviews and follow up. A review of the investigation summary and conclusion documented, the resident's call light and needs were addressed timely and the resident was happy with the care he was receiving. This conclusion was based on Social Service's interviews with other residents. The report continued to say, there was no evidence found to support mistreatment, Neglect, mistreatment, and/or abuse to this resident .have all been ruled out by this IDT (interdisciplinary team). The conclusion also showed, the only report of rude staff was, of an outburst, at the nursing station, was by a state investigator, who was heard raising his voice at staff. There was no supporting documents attached in the investigation, and the investigation questions did not address the resident's pain and the care of staff during transfer. There was no documentation of direct staff interviews, and there was no evidence of screening or review of employee personal files completed as part of the investigation. Review of progress notes dated from 03/19/18 to 04/09/18, showed a note dated 04/04/18 at 15:56 PM, completed by Staff G, Resident Care Manager, Registered Nurse (RCM/RN), who documented, the resident was noted to be screaming and moaning in pain while being helped to get dressed for an appointment. The resident was assisted by 3 staff members to safely transfer from bed to wheelchair. The note also documented the resident was screaming with pain, given scheduled pain meds with no apparent relief. During an interview and record review with the resident at approximately 9:55 AM about the above progress note. The resident stated, This was exactly what happened. The resident confirmed the allegation he made was during an encounter on the morning of 04/04/18. The resident further stated, I just hope these people don't come back here and do the same thing and hurt me. The resident stated he had fear, related to, staff causing him pain again during transfer. In an interview at approximately 10:05 AM, Staff G, RCM, stated she remembered what happened on 04/04/18. Staff G stated the resident was in severe pain, at that time, was crying and screaming while being helped by the aide. Staff G added, That is when I went to the room. Staff G further stated, when asked if the resident made any allegations of abuse or neglect. She stated I don't believe so. Staff G also stated that she was aware of the recent allegation of abuse, Staff B, DNS, did not talk to her about the incident or progress notes. In a follow-up record review and interview on 04/16/18 at approximately 10:15 AM, Staff B, DNS, stated she was not aware of the progress note dated 04/04/18, as she did not review it as it was not part of the investigation. According to Staff B, she did not review progress notes before the date the incident was reported to her. She only read the on-going notes from 04/09/18 to current. Staff B added, I guess I have to do more investigation follow-up to rule out abuse and neglect. In a follow-up interview with the resident at 2:22 PM, stated, things have changed since the surveyor had reported his concerns to the facility. The resident further stated, he was afraid that when the survey was over, things will go back to normal and the staff who was rude and rough to him will again hurt him. In an interview on 04/20/18 at 12:46 PM, Staff M, Social Services was asked about the investigation and interviews she had completed related to Resident 50's allegation of abuse. Staff M stated, I'm really sorry, It was'nt my intention to put that statement in, they (Administration) made me do it. You know me this is not how I work. The investigation did not focus on the allegation made by the resident. In a follow-up record review at approximately 1:00 PM, showed there was no documentation or follow-up to the reported abuse/neglect. The facility failed to report to the state agency, the investigation was incomplete, for the allegation of abuse and neglect reported by Resident 50. RESIDENT 10 Resident 10 admitted to the facility on [DATE] for rehabilitation therapy with [DIAGNOSES REDACTED]. The record showed the resident had a major fall at the facility, sustained multiple rib fractures, and was hospitalized from [DATE] to 04/10/18. The resident was readmitted for continued rehabilitation therapy and pain management. In a review of the most recent Minimum Data Set (MDS) assessment dated [DATE], showed the resident, had intact cognition, and required staff assistance with bed mobility, toileting tasks, transfers, locomotion in unit and personal hygiene. During an interview and observation on 04/16/18 at 9:05 AM, the resident stated, I had a bad fall last week and had few broken ribs. The resident further stated, I had severe pain right up to 10,000. The resident stated, she went to the bathroom and fell . I had a big mess. Diarrhea all over the place. The resident added, she felt really embarrassed and humiliated about her diarrhea problem, on what happened that day. The resident stated, she had been having a problem with diarrhea for few days and particularly on the night of the accident. She had gone to the toilet about 3 times and If it wasn't because of the diarrhea, I would have not gone to the bathroom. A review of the hospital discharge summary report dated 04/10/18, showed the resident was seen in the emergency department on 04/09/18 after a mechanical fall and complained of left chest pain. The report showed the resident had been having diarrhea and was trying to get to the bathroom when she fell . The hospital report showed the resident had suffered multiple rib fractures related to the incident. During a record review and interview at 9:50 AM, Staff B, DNS, stated the resident's fall was unwitnessed. According to Staff B, the resident was alert and oriented, and this was an isolated case. The investigation indicated the root cause of the fall was because the resident self-ambulated and did not call for staff, before toileting. Staff B was not aware that the resident had diarrhea before the accident. Staff B added, Resident 10 was independent with toileting and that this incident was not reported to the state agency as required. Review of the investigation summary report provided by Staff B, showed no documentation related to the resident's diarrhea, and incontinent episodes prior and during the fall. The investigation summary did not included enough information to rule out the cause of the incident, and was missing information related to what had contributed to the resident fall or if there was staff neglect. Additionally, in an interview on 04/26/18 at 9:50 AM with Resident 10 stated: last Saturday, just a few days ago, two aides beat the hell out of me. I was asleep in bed; I woke up when they straddled my legs and beat the hell out of me. I told them to stop, but they continued to pummel me. Later, they said they were checking for a UTI (urinary tract infection). I have had so many UTI's I could have told them if they had just asked me. I kept telling them to stop. They would not stop. I don't feel safe here, I live in fear. Record review of the facility investigation log dated (MONTH) (YEAR) revealed an entry dated 04/23/18 for an allegation of abuse. In an interview on 04/26/18 at 2:30 PM with Staff B, DNS, said the resident reported the allegation to staff on 04/21/18. She also said she did not know about the allegation until 04/23/18 when she overheard the resident talk about it. The DNS then said the staff did not start an investigation or report the allegation to the State agency. She then said she initiated an investigation and reported it to the state agency, two days after the resident reported the allegation to staff. In a follow-up record review of the completed investigation, the resident made an allegation against two female nurses' aides. She identified one of the nurses' aides by name. The resident refused care and Staff CC, (female nursing assistant named in the allegation) continued to provide care against the wishes of the resident. Staff CC's, employment at the facility was terminated. There was no documented statement or follow-up in the completed investigation on the other alleged female nursing assistant mentioned in the allegation. In a follow-up interview on 04/26/18 at 4:10 PM with Staff B, DNS, she needed to re-educate the staff on abuse, neglect, resident rights and guidelines for reporting to the State agency. RESIDENT 5 Resident 5 admitted to the facility on [DATE], the [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] indicated the resident required staff assistance to complete activities of daily living. Record review of the nursing progress note dated 03/06/18 revealed bruises were noted by staff on the resident's right hip, lower back and right side of the resident's bottom (buttocks). The sizes of the bruises were documented as 17 centimeters (cm) by 8cm; 9 cm by 3 cm; 6 cm by 3 cm. Record review of the incident-reporting log dated (MONTH) 01, (YEAR) to (MONTH) 09, (YEAR) revealed no logged incident related to the bruises. In an interview on 04/19/18 at 11:21 AM with Staff C, Registered Nurse/Resident Care Manager (RCM), she said was unaware that the resident had bruises at that time. She also said the resident should have been placed on alert charting to monitor the bruises and an incident investigation should have been completed to rule out abuse. She was unable to find documentation that the bruises were monitored. In an interview on 04/20/18 at 01:51 PM, Staff B, DNS she said her expectations would have been for the nurses to complete an investigation to rule out abuse. Reference (WAC) 388-97-0640 (6)(a)(b)(c)

Based on observation, interview, and record review, the facility failed to comprehensively assess the increased risk for skin breakdown, and implement timely interventions necessary to prevent the development of a facility acquired pressure ulcer, for 2 of 2 residents (246 and 19), reviewed for pressure ulcers. These failed practices caused harm to Resident 246 and Resident 19, who developed pressure ulcers with partial and full thickness skin loss and pain. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin. Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable, Stage 3 or Stage 4). RESIDENT 246 Resident 246 was admitted to the facility on [DATE] for rehabilitation therapy. The resident [DIAGNOSES REDACTED]. In a review of the facility's admission assessment, showed the resident was admitted to the facility with no skin issues/concerns. The resident was identified to be at high risk for developing a pressure injury. In a review of the most recent Minimum Data Set (MDS) assessment dated [DATE], showed the resident was dependent to staff with toileting task, and required extensive assistance from staff with bed mobility, transfers and personal hygiene. In a review of the resident in-room care plan (staff directives) dated 03/29/18, and care plan dated 04/09/18, showed the resident had no skin care plan to address the resident increased risk for skin breakdown and how to minimize the risk and prevent the development of pressure injury. In an interview with the resident family member/power of attorney (POA) on 04/09/18 at 8:45 AM, stated, the resident was having diarrhea problem recently, and that he was concern about the resident's skin rash and bedsore. According to the POA, they were really concerned because the resident was admitted with no skin issues from the hospital and now, couple of days since admission to the facility, the resident developed redness and bedsores related to her bowel and bladder incontinence, and for waiting a long time in wheelchair. The POA stated, the facility staff were just simply putting a cream to the resident buttock area, yes, they were all aware of it. I observed them put the cream. During a joint observation and interview with Staff D, Licensed Practical Nurse (LPN), Staff E, Certified Nursing Assistant (CNA), and the resident POA on 04/10/18 at 9:39 AM, showed the resident had severe redness to the perineum area expanding to the coccyx/sacrum (tail bone), and bilateral buttocks area. The above area showed severe excoriation and denuded skin. The Sacrum and the buttocks area had open skin, with moderate amount of serosanguineous drainage (drainage with both blood and the liquid part of the blood-serum), with red wound bed. Staff D was asked how she would describe the skin issues observed to the resident. Staff D stated, Redness and excoriation with open skin to the buttocks and sacrum. Pressure Ulcer. The resident was grimacing and had teary eyes during the observation. The resident reported pain during the observation. During an observation and interview with the resident and family member/POA (power of attorney) on 04/11/18 at 10:00 AM, stated, the resident had developed the severe redness and bedsores here in the facility. According to the POA, it was most likely related to the pressure from sitting to long in the wheelchair, and the resident had to sit in her diarrhea for a long time before she can get help. The resident had no pressure reducing cushion in her wheelchair and was using a regular mattress in bed. In an interview with the resident POA on 04/12/18 at 10:25 AM, stated, he had given and signed a consent for the facility to have an overlay air mattress (softer mattress) and cushion in her wheelchair. There was no overlay mattress observed at this time. During an interview and record review with Staff C, Resident Care Manager and Registered Nurse (RCM and RN), on 04/13/18 at 2:23 PM, stated, the first time she was notified of the skin concerns for Resident 246 was on 04/09/18 at approximately 5:00 PM. According to Staff C, she was on her way home when she was notified by the evening shift nurse that there was a serious skin concern to the resident that was observed by the surveyor. Staff C acknowledged that there was a delay in care and communication because the specialized mattress was requested on 04/10/18, and the order was placed on 04/11/18. It was not until 04/12/18 when the mattress was placed. Staff C stated, These should have been all in place on admit. She was clearly at risk for pressure ulcer. In a review of the clinical documentation with Staff C, stated, she had assessed 3 open areas on Resident 246. One in the Sacrum, and one on right and left buttock area. Staff C was asked on how the facility had documented the open skin areas she observed to the resident. Staff C stated, We are calling it moisture associated skin damage, MASD. When asked by a clarifying questions on why the facility was calling it MASD instead of a pressure injury, based on the definition of pressure ulcer as defined by NPUAP, and the open areas were located at a bony prominence area (sacrum, right and left buttocks), Staff C stated, yes, it should have been called a pressure ulcer/injury based on the definition, location and possible cause of the skin breakdown. In a review of the progress notes dated 04/13/18 at 5:31 PM, showed the facility Physician gave an order to initiate Tylenol 1000mg every 8 hours as needed for pain management. It was followed by a progress note at 5:58 PM that showed the resident was referred to United Wound Healing for wound consultation and treatment for [REDACTED]. In summary, the resident was admitted to the facility with known multiple risk factors including, impaired mobility related to stroke, weakness, diabetes and incontinence. The facility had assessed the resident to be high risk for developing pressure injury, however failed to implement timely preventative measures and interventions to address and minimize these risk to prevent the development of facility acquired pressure injury. The resident plan of care was not developed in accordance to the resident needs and risk factors present. The clinical records showed no documentation that the facility had provided the necessary care, services and interventions to minimize the risk, and prevent the development of a facility acquired pressure injury. RESIDENT 19 Resident 19 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the most recent MDS revealed Resident 19 had impaired cognition, and was unable to make needs known. In a review of the facility record skin grid for pressure, venous, arterial, and diabetic ulcers five wounds were documented for Resident 19. Wound 1 On 02/14/18 a stage 3 pressure ulcer was noted on the coccyx with 25 percent granulation and 75 percent epithelization, the formation of granulation tissue into an open wound. On 02/22/18 the wound was listed as stage 4 with 75 percent slough and 25 percent granulation. The wound was revealed to have the same description on 03/01/18, 03/18/18, and 03/15/18. On 03/29/18 a wound vac was listed as being on the wound and draining. Wound 2 The second wound was labeled as full thickness on the right hip. The wound was listed as scar tissue and not a pressure ulcer. Wound 3 On 03/08/18 the right heel wound was marked as unstageable deep tissue injury, DTI, with 100 percent granulation. On 03/15/18 the wound was marked as an unstagaeable DTI with 100 percent granulation. On 03/29/18 the wound was marked a stage 3 pressure ulcer with 25 percent eschar and 75 percent granulation. On 04//05/18 the wound was marked as a stage 3 pressure ulcer with 100 percent epithelization. Wound 4 On 03/08/18 a DTI was noted on the left heel with 100 percent epithelization and a purple color. On 03/15/18 the wound was listed as DTI with 100 percent eschar and a deep purple color. On 03/29/18 the wound was listed as DTI with a black color and 100 percent necrotic tissue. On 04/05/18 the wound was listed as a stage 3 pressure ulcer with 100 percent granulation and a pink color. Wound 5 On 03/02/18 the area behind the left ear was marked as a stage 2 pressure ulcer. On 03/08/18 the wound was marked as a stage 1 pressure ulcer with 100 percent granulation. On 03/15/18, 03/29/18 and 04/05/18 the wound was marked as a stage 4 pressure ulcer with 100 percent granulation. A Review of the progress notes dated 03/01/18 revealed Resident 19 has open area on left ear, blotted and cleaned with normal saline, applied topical ABO skin prep on surrounding areas. Aids instructed to not turn Resident 19 where she was lying on left ear. Sheet placed in MACC (Managing Acute Change of Condition), Skin sheet completed. In a review of the care plan printed on 04/10/18 it was revealed that the right ear monitoring and care plan had been entered on 03/30/18. The pressure ulcers for both left and right heels had been care planned on 03/30/18. In a review of the record United Wound Healing multi wound chart for a visit on 03/08/18 it was revealed that the right posterior heel was listed as a pressure ulcer stage 3. Further review of the record did not reveal a care plan prior to 03/30/18 for pressure ulcers to the ear, and the left and right heel. In an interview on 04/18/18 02:34 PM Staff J Licensed Practical nurse, LPN. Staff J LPN stated that a deep tissue injury was charactarized as closed. Staff J then stated identifying if a wound had eschar or epithelization would not be possible on a closed injury. In an interview on 04/18/18 at 03:05 PM Staff C RCM RN stated that a deep tissue injury, DTI, was characterized by black or purple discoloration to skin that was not necessarily a wound but would be along a bony prominence. It would not be open. Staff C RCM RN then stated you would not see epithelization and granulation on a DTI as it is closed. The skin would be black. You cannot identify what is underneath without removing the top layer. Staff C RCM RN stated that a DTI would be a pressure ulcer if it opened. Staff C RCM RN stated the facility documents based on how the nurse practitioner documents as we do our rounds. We go with the Nurse practitioner, ARNP, Director of Nursing, DNS, and the RCM's and measure the wounds. We take the assessments and update the skin grids based on what was noted at the time. Staff C RCM RN stated that the heels and ear for resident 19 opened in the facility. In an interview on 04/18/18 at 03:05 PM Staff G RCM RN stated Resident 19 had one pressure ulcer on each heel and one on her bottom. Her right hip was one she came with originally from a surgery. The resident had a tendency to lie on her ear. The wound team does weekly wound rounds. In an interview on 04/20/18 at 01:33 PM Staff B director of nursing DNS stated a DTI would be purple and closed. Staff B DNS then said You would not be able to see epithelization, eschar or granulation on a closed wound. Staff B DNS stated documentation was done off of what the wound nurse states. The wound nurse does a report and shows measurements. she recommends treatment. We make a note about any new treatments. We would ask her if there was a discrepancy in the room. In an observation and interview on 04/19/18 at 02:44 PM a skin issue was observed Left foot between the big toe and 2nd toe. Staff G RCM RN stated, it was a pressure ulcer caused by the big toe. It will be marked as a stage 1. In an observation and interview in 04/19/18 it was revealed the left ear pressure ulcer was a stage IV and developed in house. Staff C RCM RN stated the Neck was stiff and contracted. She stated the care plan was not specific on how to off-load. Staff G RCM RN stated it was quite hard to turn the residents neck. The resident was not able to hold or turn her neck/face to the other direction without staff assistance. Staff C RCM/RN stated It was not noticeable from the beginning when the pressure ulcer was first noticed. The observation revealed the wound as full thickness skin loss, minimal odor, serosanguineous discharge at a moderate amount. Further reveiw of the record on 04/20/2018 did not reveal any new pressure ulcer listed on the residents care plan, or progress notes. Reference (WAC) 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to comprehensively assess and ensure 2 of 5 residents (246, and 10) received appropriate care and services necessary to maintain and/or regain bowel and bladder functions, and prevent incontinent related complications. These failed practices resulted in harm to Resident 246 and Resident 10. Resident 246 developed severe complications from incontinence to include severe rash, moisture associated [MEDICAL CONDITION], pressure ulcer and pain. Resident 10 suffered harm in the form of embarrassment, humiliation, diminished quality of life and had contributed to a major fall accident that resulted in severe pain and multiple rib fractures. Additionally, the facility failed to secure an indwelling foley catheter tube (a tube inserted into the bladder that drains urine from the bladder into a bag outside the body) for Resident 8. Failure to secure the tube caused harm to Resident 8 as evidenced by Resident 8's hospitalization for hematuria (blood in the urine). Findings included . RESIDENT 246 Resident 246 was admitted to the facility on [DATE] for rehabilitation therapy. The resident [DIAGNOSES REDACTED]. In a review of the most recent Minimum Data Set (MDS) assessment dated [DATE], showed the resident was dependent to staff with toileting task, and required extensive assistance from staff with bed mobility, transfer and personal hygiene. The resident was identified to be incontinent of bowel and bladder, and no trial of toileting program was attempted or initiated since admission or since incontinence was noted in the facility. In a review of the resident's in-room care plan dated 03/29/18, showed the resident was incontinent of bowel and bladder. The care plan also showed, the resident needed 2 person assist with toileting, transfer and locomotion in unit. In a review of the facility's admission assessment, showed the resident was admitted to the facility with no skin issues/concerns. In an interview with the resident family member/power of attorney (POA) on 04/09/18 at 8:45 AM, stated, the resident was incontinent of bowel and bladder and used brief for incontinent management. The POA further stated, the resident was having diarrhea problem recently, and that he was concern about the resident's skin rash and bedsore. According to the POA, they were really concerned because the resident was admitted with no skin issues from the hospital and now, couple of days since admission to the facility, the resident developed redness and bedsores related to her bowel and bladder incontinence, and for waiting a long time in wheelchair. The POA stated, the facility staff were just simply putting a cream to the resident buttock area, yes, they were all aware of it. I observed them put the cream. During an observation at 2:10 PM, the resident was in bed. A bowel and urine odor was present within 5 feet distance to the resident. The resident was asked if she was wet, and needed to be changed. The resident stated, Yes. The resident was not able to call for help or use the call light. It was not until 3:05 PM until a staff member entered the resident room and offered to change the resident. During a joint observation and interview with Staff D, Licensed Practical Nurse (LPN), Staff E, Certified Nursing Assistant (CNA), and the resident POA on 04/10/18 at 9:39 AM, showed the resident had severe redness to the perineum area expanding to the coccyx/sacrum (tail bone), and bilateral buttocks area. The above area showed severe excoriation and denuded skin. The Sacrum and the buttocks area had open skin, with moderate amount of serosanguineous drainage (drainage with both blood and the liquid part of the blood-serum), with red wound bed. Staff D was asked how she would describe the skin issues observed to the resident. Staff D stated, Redness and excoriation with open skin to the buttocks and sacrum. Pressure Ulcer. The resident was grimacing and had teary eyes during the observation. The resident reported pain during the observation. In an interview and record review with Staff D at 9:45 AM, stated, the resident had zinc oxide cream treatment to be applied every shift to her perineum, buttock and sacral area initiated and ordered on [DATE]. According to Staff D, she was not sure why the zinc order was just put in yesterday because the resident had the rash for a while. Staff D stated, the resident was not on a toileting program to address bowel and bladder incontinence. In an interview with Staff C, Resident Care Manager and Registered Nurse (RCM and RN), on 04/13/18 at 2:23 PM, stated, the resident was incontinent of bowel and bladder, and no trial of toileting program was attempted or initiated since admission or since incontinence was noted in the facility. According to Staff C, the resident developed the rash and open areas to her perineum, buttocks and sacrum in the facility. In a joint interview with Staff C, RCM, and Staff B, Director of Nursing (DNS), at 2:55 PM, Staff B stated, the resident was incontinent of bowel and bladder, and no trial of toileting program was attempted or initiated since admission or since incontinence was noted in the facility. According to Staff B, the facility was aware that the resident was at high risk of developing complications related to incontinence and should have care planned the resident needs better to minimize these risks. During an observation and interview on 04/19/18 at 8:38 AM, the resident was in the room with incontinent of bowel odor present. The resident was asked if she needed to be changed. The resident stated, Yes. When asked how she feels about having a bowel movement in her brief, the resident stated, Bad, feel sorry, and sad. The resident was grimacing, tearful and verbalized pain to her perineum and buttock area. RESIDENT 10 Resident 10 was admitted to the facility on [DATE] for rehabilitation therapy. The resident [DIAGNOSES REDACTED]. The resident was recently hosptalized on [DATE] following a major fall with multiple rib fractures. The resident was readmitted back to the facility on [DATE] for continued rehabilitation therapy and pain management. In a review of the most recent Minimum Data Set (MDS) assessment dated [DATE], showed the resident had intact cognition, and required staff assistance from staff with bed mobility, toileting tasks, transfers, locomotion in unit and personal hygiene. The resident was identified to be incontinent of bowel and bladder, and no trial of toileting program was attempted or initiated since admission or since incontinence was noted in the facility. In a review of the resident bowel and bladder in the past 90 days, showed the resident was frequently incontinent of bowel and bladder. In a review of the resident's bowel and bladder care plan initiated on 11/17/16, showed the resident was incontinent of bowel and bladder. There was no goals/interventions on how the facility will manage, improve and initiate a trial of a toileting program. During an interview and observation with the resident on 04/16/18 at 9:05 AM, stated, I had a bad fall last week and had few broken ribs. The resident further stated, I had severe pain right up to 10,000. The resident shared the circumstances of the fall to the surveyor. The resident stated, she went to the bathroom and fell . I had a big mess. Diarrhea all over the place. The resident added, she felt really embarrassed and humiliated about her diarrhea problem, her incontinence and on what happened that day. The resident stated, she's been having diarrhea problem for few days now, and particularly the night of the accident, she had gone to the toilet about 3 times already. If it wasn't because of the diarrhea, I would have not gone to the bathroom. According to the resident, she can still feel the urge to urinate and go to the bathroom. She just needed help for safety. The resident was observed alone in the facility conference room without any staff around, and no call alert system within the resident reach. At 9:20 AM, Staff H, Certified Nursing Assistant (NAC) arrived in the conference room and checked on the resident. Staff H was asked regarding the resident's bowel and bladder continence. Staff H stated, the resident was incontinent of bowel and bladder, and was not on a scheduled toileting program. During a record review and interview with Staff B, Director of Nursing (DNS) at 9:50 AM, stated, the resident fall was unwitnessed. According to the Staff B, the resident was alert and oriented, and this was an isolated case. The investigation root cause was because of the resident self-ambulating and not calling for staff before toileting. Staff B was not aware of the resident diarrhea concerns before the accident. Staff B added, Resident 10 was independent with toileting. No, she was not on any toileting program. In a review of the investigation summary report provided by Staff B, showed no documentation related to the resident diarrhea problem, and incontinent episodes prior and during the fall. In an interview with Staff I, Therapy Director/Occupational Therapist, on 04/18/18 at 3:50 PM, stated, the resident needed extensive assistance from staff in toileting task due to the incontinent problems. According to Staff I, the resident was not on any toileting program. In a review of the hospital discharge summary report dated 04/10/18 showed the resident was seen in the emergency department on 04/09/18 after a mechanical fall and complained of left chest pain. The report showed that the resident had been having diarrhea and was trying to get to the bathroom when she fell . The hospital report showed the resident had suffered multiple rib fractures related to the incident. In summary, there was no documentation that the facility had identified, comprehensively and accurately assessed, or treated/addressed Resident 246's and Resident 10 bladder and bowel incontinence which resulted to the resident's feeling of self-humiliation, sadness, and embarrassment that a reasonable person will feel during a bowel/bladder accident. Resident 246 and Resident 10's bowel and bladder incontinent issues were not accurately care planned, not person centered to identify the resident's strengths, goals and were missing interventions to address the root cause of the incontinent problem. There was no documentation in the medical record that the facility had attempted, initiated or considered a trial for bowel and bladder retraining to further improve or restore continence. In addition, there was no documentation in Resident 246 and Resident 10's medical record from admission to 04/19/18 that a facility physician, or a specialist had identified, assessed, or provided any treatment or services to achieve or maintain as much normal bowel and bladder function as possible for both Resident 246 and Resident 10. RESIDENT 8 Resident 8 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. In interview on 04/10/18 at 10:40 AM with the resident said, I went to the hospital because my catheter tube was not secured to my leg. They taped the tubing to my leg with a bunch of tape. One day when I sat up on the edge of the bed, I felt a pop, I looked down, and there was a couple of drops of blood in my catheter tubing. I laid back down in my bed, and noticed solid blood on my bedding; the nursing assistant changed my pad. The Nurse came in my room and said I was on a medication that thinned my blood, that is was common and not to freak out. I bleed for five days, and then I told them I needed to go to the hospital. That was when my downward trend started. I wanted to go back home, I worked hard in therapy so I could get strong enough to go home. By no fault of my own, I had to go to the hospital. I got depressed. I should be at home; it is hard for me to do anything for myself right now. Record review of the hospital report dated 01/11/18 revealed the resident was admitted to the hospital on [DATE] for hematuria and discharged back to the facility on [DATE]. In interview on 04/16/18 at 02:54 PM with Staff EE, Restorative Aide, (RA), she said the resident was really focused and worked hard until he went to the hospital. She also said the resident was able to walk from his bed to the bathroom door in his room with assist. She then said she did the resident's restorative program on the days he did not have therapy scheduled. Staff EE also said she tried to motivate the resident to do his exercises when he came back from the hospital because he refused a lot. She then said he could barely stand now. In an interview on 04/20/18 at 11:08 AM with Staff G, RCM, said, maybe if we had care planned earlier and strapped his catheter tube with a catheter strap; instead of tape we could have prevented him from going to the hospital. In an interview on 04/20/18 at 12:05 PM with Staff B, DNS, I would expect a catheter strap, not tape to be used. Reference (WAC) 388-97-1060 (3)(c)

Based on observation, interview and record review the facility failed to obtain weekly weights as ordered by the Physician to maintain ideal body weight while on tube feedings for 1 of 3 residents (20) reviewed for nutrition. This failure resulted in significant weight loss that caused harm by preventing the resident from receiving adequate nutrition to maintain an ideal body weight, hydration and recover from an existing infection of ([MEDICAL CONDITION], bacteria that causes diarrhea) that was acquired in the facility. All of which were never resolved while he was a resident in the facility and may have contributed to the resident's death a day after he was discharged to the hospital. Findings included . The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was to receive nothing by mouth (NPO) to reduce the risk of PNA and therefore required the use of a Gastric tube ([DEVICE]) for nutrition and hydration. The resident was also on contact precautions for active [MEDICAL CONDITION] infection. The resident's most recent Minimum Data Set (MDS) showed the resident scored a 12 on the Brief Interview for Mental Status (BIMS) and was able to make his needs known. Review of the facility policy titled Nutrition Risk Review revised on ,[DATE], stated a weekly meeting consisting of the Director of Nursing (DNS), Resident Care Manager (RCM) and Dietician would review assessments completed on residents who were identified as having a nutritional risk to discuss resident status, make referrals to other health professionals and plan appropriate, individualized interventions. Items reviewed in the weekly meetings included the following: 1. Significant/patterned weight changes 2. Tube feedings 3 Food and fluid intake 4. Pertinent Labs 5. Hydration 6. [MEDICATION NAME] nutrition and Intravenous (IV) fluids 7. Physical condition Review of the residents care plan dated [DATE] identified the resident with an alteration in ability to tolerate adequate oral nutrition, related to recent Aspiration Pneumonia, Dysphagia. Goals included resident will tolerate TF (Tube Feedings) and maintain adequate nutrition throughout stay with no significant unplanned weight loss or gain. Pertinent Interventions included the following: Weights: weekly as needed unless otherwise indicated. Lab: Per provider orders if indicated and intake and output per P[NAME] if indicated. The care plan did not identify the resident to have [MEDICAL CONDITION] or active diarrhea. Therefore goal and interventions for nutritional concerns that could affect weight loss were not initiated. The care plan also did not state who staff should report to for any issues. Review of the residents MDS dated [DATE] for active [DIAGNOSES REDACTED]. However that was not reflected on the resident's care plan for goals and interventions. Review of the physicians order dated [DATE] showed weights were to be obtained once a week every Monday. Review of the resident's vital signs flowsheet for weights showed the resident was weighed upon admission to the facility on [DATE] at 122lbs. The resident was not weighed again until [DATE] at 142.7 lbs then again on [DATE] at 145.7lbs. This was a net gain of 23.7lbs in less than a month. Further review showed another weight taken on [DATE] at 108.2lbs this resulting in net weight loss of 37lbs in 8 days. Weights taken after that up until the resident discharged from the facility varied between ,[DATE]lbs. The flowsheet also showed weights were not recorded weekly as ordered by the MD or as directed by the care plan. Review of the clinical record showed there was no immediate report to an MD or qualified health care professional regarding the rapid weight gain and weight loss to address possible Nutrition or Hydration concerns. In an observation on [DATE] at 9:46 AM, the resident was observed to have a feeding tube ([DEVICE]) however appeared to be very thin, weak and had deliberate movements. Upon interviewing the resident he stated he had lost weight and stated he was on tube feedings for medical reasons. Based on this information the resident was selected to be included as part of the resident survey sample. In an interview on [DATE] at 2:18 PM, Staff W, Nurses Assistant (NA) stated she had not noticed the resident had lost any weight. She stated if any of the residents had lost weight she reported to the nurse, kitchen and Dietary manager. At [DATE] at 2:38 PM, Staff G stated if a resident was not getting enough nutrition she would call the dietician or doctor to get an order to increase the feeding rate. She stated Resident 20 had lost weight and the dietician, MD (Medical doctor) were all aware. When asked what were the causes of the weight loss she stated she would look into the residents chart and get back to surveyor with more information. [DATE] 09:41 AM, Staff DD dietician stated for residents with special needs such as [MEDICAL CONDITION], Pressure ulcers or other ailments she stated she made nutritional adjustments as needed. She stated with any weight loss associated with tube feedings, she consulted with the (interdisciplinary team) IDT team that included the Director of Nursing Services (DNS), the Administrator, nursing staff and the doctor. Regarding her general impression of the resident she stated We finally got his weight stable. She stated the resident started with a weight of 122lbs upon admission. When asked what the resident's weekly weight monitoring was, she stated she was not sure as they were not being done. Staff DD stated she had asked nursing for the weights and did not know what the barrier was and further stated she had communicated the need for weekly weights to nursing and it was documented in her notes. When asked how she was monitoring the resident's weight in order make adjustments to the tube feedings, she stated I cannot comment. Regarding any communication to a Doctor about this issue, she stated there was none. When she was asked to provide any documentation about her concerns with her not getting the weights she stated she would have to look in the dietary log book. During the same interview and joint review of the dietician's notes with the surveyor, showed there was no documented communication of the Dietician not receiving weekly weights in order to manage the resident's tube feedings and nutritional progress. When she was made aware of the weight discrepancy where the resident's weight went from 122 lbs to 142 to 145 then to 108 lbs within a short time, she stated there must have been an error. When asked what she did about the discrepancy, she stated it was documented in the progress notes. A joint review of the progress notes with the Dietician and surveyor, the notes did not show a reason for any weight discrepancy or what was done to address the documented rapid weight gain and weight loss. Staff DD also stated she did not know why the resident had lost weight. When asked if the resident's weight loss was a result of the lack of weight monitoring, she stated it was possible. When she was asked if there was a breakdown in communication with nursing regarding the resident's weight loss monitoring she stated It appears there is. At 10:25 AM, the DNS stated the Dietician made recommendations to nursing. She stated the Dietician communicated the dietary recommendations or concerns in the Nutrition Assessment Review (NAR). The DNS was asked about the resident's weekly weights and stated I do not remember any specific communication form the Dietician about not getting residents weights. If it would have been documented it would have been in our notes. In a joint review of the notes with the surveyor and the DNS, showed there was no communication of the dietician not receiving the resident's weekly weights in order to monitor the resident's nutritional progress while he was receiving tube feedings. She stated That is correct that if it was not documented in the notes then it was not documented. When she was made aware of the resident's rapid weight gain and weight loss she stated We discussed the weight discrepancy in the NAR. However the DNS was unable to show why there was a weight discrepancy and stated the weight loss was severe. When asked if the doctor was aware of the significant weight loss she stated Yes, but I don't know why it was not documented that we discussed the discrepancy. According to the DNS, the doctor signed off on the weights once a month. Summary Review of the hospital admission and discharge records showed on [DATE], the resident was admitted to the hospital for a syncopal event (passing out) and was diagnosed with [REDACTED]. The resident was NPO, had [MEDICAL CONDITION] infection and received tube feedings. These elements greatly increased the residents risk for malnutrition and significant weight loss. The failure to effectively monitor the resident's weight as ordered, prevented the necessary adjustment of the tube feedings to ensure adequate nutritional intake for normal body functions, ability to fight infection and maintain an ideal body weight. Additionally all of the factors mentioned in this report as well as the failure to report any of these concerns to a medical doctor or qualified healthcare professional contributed to residents death on [DATE]. Reference (WAC) [DATE] (3)(h)

Based on observation, interview and record review the facility failed to ensure proper assessment and care of tube feeding for 1 of 2 residents (19) reviewed for tube feedings. This failure caused harm by multiple trips to the emergency room and placed the resident at greater risk for harm related to improper tube feeding related complications. Findings included . Resident 19 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the residents Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 19 was not alert and oriented and unable to make needs known. In a review of the the resident's most recent care plan dated 02/20/18, revealed the interventions included to asssess tube feedings for aspiration (Fluid in lungs), elevate head of bed 30 degrees, monitor blood work per provider orders if indicated, verify tube patency (unobstructed) before administering feeding or medications and if tube should become clogged follow provider orders for unclogging. A review of the physicians orders dated 02/27/18 showed the resident received continuous nutrition by tube. In a record review a progress note dated 02/14/18 revealed TF (tube feeding) machine kept alarming throughout shift. Tube was clogged and staff unable to unclog. Resident 19 was sent to the emergency room (ER) to have tube unclogged. In a record review a progress note dated on 02/19/18 revealed tube accidentally dislodged. Resident sent to the ER to replace tube. In a record review a progress note dated on 02/23/18 revealed tube feed was having clogging after med pass. Smaller syringe was used to clear the line. In a record review a progress note dated on 03/07/18 revealed tube feed was clogged and tried to unclog. Resident was sent to the hospital. In a record review a progress note dated on 03/11/18 revealed, Residents tube is clogged again at this time, This registered nurse, RN, was attempting to admin. Medications through her tube when it clogged (Had removed feeding, flushed well with 50 ml water then went to admin med with syringe and it wouldn't pass through.) Notified physician who advised to send to ER for declogging. Notified transport for pick up in 20 minutes. Notified son by phone. In a review of the record a progress note dated 04/11/18 revealed resident was transported out to the hospital. The facility received a call from the lab with a result of abnormal low blood results. Resident 19 was to receive a blood transfusion. Record review of the hospital records revealed a blood transfusion was completed on 04/11/18. The clinical record from the hospital revealed the resident received additional [MEDICAL CONDITION] on 03/21/18 and 01/25/18. In a record review a progress note dated on 04/14/18 at 10:00 AM revealed Resident 19 was sent to the hospital for feeding tube, PEG tube, leakage. At 11:10 PM a note revealed resident returned to the facility at 04:30 PM. Tube feed was continued and the tube dislodged resident returned to the ER at 11:10 PM to have the tube replaced. A follow up note on 04/15/18 at 02:59 AM revealed the resident returned to the facility around 02:45 AM. In a record review a progress note dated 04/16/18 revealed residents [DEVICE] came out after medication administration and water flush. Resident 19 went to the hospital to have the tube replaced and returned on 04/16/18. Additional review of the clinical record failed to reveal provider specific orders for unclogging the tube. In an interview with Resident 19's son by phone on 04/10/18 at 09:20 AM it was stated the tube was clogged several times. She went to the hospital to get it unclogged about a month ago. In a joint interview on 04/18/18 at 2:34 PM, Staff J, Licensed Practical Nurse (LPN) stated the expectation of staff during a clogged tube feed was to notify the doctor for orders on how to follow up. Staff J (LPN) stated, a reason the tube might be clogged was from medications not being crushed enough. If it was clogged during medication pass I would call the doctor to see what we were allowed to do. He stated the facility had a declogger to be used if the doctor said it was ok. Staff J LPN then stated he was not sure why it kept getting clogged or dislodged. Staff J (LPN) said, dislodging could cause a gastrointestinal (bleed in the stomach) bleed. In an interview on 04/20/18 at 10:31 AM Staff D (LPN) stated the Resident had low red blood cells. Staff D said I am not able to see any assessment related to her blood loss. In an interview on 04/18/18 at 03:05 PM, Staff G RCM/RN stated the expectation for a clogged tube was to stop the feeding. She stated nursing staff should refer to the policies and procedures they received in orientation. Staff G RCM/RN stated the tube can clog if medications are not well crushed. In an interview on 04/18/18 Staff C RCM/ RN stated that the tube has clogged multiple times and over the weekend clogged again. She stated medications were administered together and the interactions could cause potential clogging. Staff C RCM/ RN stated that improper technique, improper placement or not flushing the line were additional reasons the tube can clog. Staff C RCM/ RN stated it would be beneficial for the care plan to include the causes for the clogged tube. Staff C RCM/ RN said I am not seeing anything in the care plan regarding a cause. The causes haven't been identified and we haven't identified the risks. There hasn't been anything identified to avoid future clogging. In an interview on 04/20/18 at 11:32 AM Staff G RCM/RN stated to prevent reoccurrence of [MEDICAL CONDITION] a proper care planning should been done to help prevent it. The expectation was that it should be care planned for follow up in regards to repeat occurrences. I would expect it to be care planned to watch for signs and symptoms in regards to chronic low blood count. Staff G said It is not currently on her care plan to monitor. In a joint interview on 04/20/18 at 01:33 PM Staff B Director of Nursing Services(DNS) stated that the tube could have kept clogging from improper medication crushing. Staff B DNS then stated that there has been no care plan for the tube clogging or dislodging. Staff B said I think as it is a recurrent issue, it should be care planned. Staff B said I do not really have an answer for what the facility expectation for follow up with her bleeding. There would be an expectation for there to be something when monitoring the blood levels. I would not expect her to be care planned. We alert charted after she came back both times. We cannot monitor every patient. Reference (WAC) 388-97-1060 (3)(f)

Based on interview and record review, the facility failed to provide adequate pain treatment and management for 1 of 2 residents (Resident 50) reviewed for pain management. This failure caused harm to Resident 50, and resulted to an uncontrolled pain, and diminished quality of life. Findings included . RESIDENT 50 Resident 50 was admitted to the facility on [DATE] for rehabilitation therapy. [DIAGNOSES REDACTED]. In a review of the facility's admission pain screening and comprehensive assessment dated [DATE], showed the resident was in pain on admit related to the above fractures. The assessment form was not completely filled out and missing information's on how the facility will continuously assess and monitor the resident pain, what was the resident goal for pain management, and how the facility will manage and re-evaluate the resident pain. In a review of the Minimum Data Set (MDS) assessment dated [DATE], showed the resident had intact cognition, and required staff assistance with bed mobility, transfers, toileting and locomotion. The MDS also showed that the resident had presence of severe pain frequently, and that pain had limited the resident's day to day activities. In a review of the resident's pain care plan dated 04/06/18 (18 days after admission), showed the resident had pain related to pelvic and olecranon fractures. Interventions included, pain assessment on admission and as needed, and to monitor the resident pain until pain management plan was established. In a review of the progress notes from admission to 04/04/18, showed the resident had complained of pain on a daily basis. The resident complained of uncontrolled pain throughout these period. The resident was observed and documented to be, tearful/emotional when his pain becomes too much on 03/20/18, pain moderately managed with scheduled and prn (as needed) [MEDICATION NAME] on 03/25/18, Resident states pain is not relieved with current pain medication regime, c/o (complained of) pain started after 0930 lasted till noon, scheduled oxy ([MEDICATION NAME]) and prn x1 given with slight relief on 03/26/18, the resident cried and complains pain after took scheduled [MEDICATION NAME] on 03/31/18 and 04/02/18, and res (resident) noted to be screaming and moaning in pain on 04/04/18. In a review of the Physician orders [REDACTED]. There was no clear instruction on how will the staff/licensed nurses on which pain medication to give or administer if and when the resident complain of pain. The documentation showed no follow-up assessment and evaluation of pain, and that all pain medications were either administered, and or charted late. The MAR indicated [REDACTED]. During an interview and observation with the resident on 04/09/18 at 11:00 AM, stated, They hurt me, they won't listen during transfers, I need to use siding board, but they won't listen. They will transfer me roughly, and it hurts. It takes 1-2 people or 3 sometimes. But it's a rough transfer. I experienced severe pain. The resident further stated, I am in pain everyday here and I have to beg please don't let me be in pain anymore. The resident was grimacing and tearful at the time of interview. During a follow-up interview and observation with the resident on 04/11/18 at 8:50 AM, The resident stated, I still remember those painful transfers and you bet, I will forever take that with me because I was in pain for weeks but thank you for saving me. The resident was tearful during the interview. In a review of the progress notes completed by Staff B, Director of Nursing (DNS), at 2:57 PM, documented, Resident was up in WC (wheelchair) for lunch and began to complain of too much pain . He stated, this always happens, I always have so too much pain. In an interview with the resident wife on 04/13/18 at 8:55 AM, stated, she witnessed and observed the days and weeks that the resident was in pain. During a follow-up interview and observation with the resident at 9:40 AM, the resident was observed receiving his pain medication. The resident stated, I am in severe pain everyday. The resident was tearful and crying. The resident further stated, I cried and moan everyday because of pain. I am afraid to get pain again. There is no position or place to relieve the pain. The nurses don't listen. There is no sleep at all, I haven't had a sleep since I got here. In an interview with Staff B, DNS, at 10:41 AM, stated, she was not aware of the resident uncontrolled pain in the past, but she was aware that the resident was in tears and crying because of pain from time to time. In summary, the facility failed to comprehensively and accurately assess, monitor the effectiveness and revise pain interventions resulted in harm, severe and uncontrolled pain to Resident 50. The lack of timely follow-up and interventions for effective pain management caused fear and diminished quality of life. Reference (WAC) 388-97-1060 (1)

Based on observations, interviews and record reviews the facility failed to provide medical use, monitoring of side effects and to conduct dose reduction with the use of an antipsychotic (medications used to treat psychiatric conditions) medication for 3 of 5 residents (5, 11 and 21) reviewed for unnecessary medications. Resident 11 was harmed in the event of experiencing side effects of an antipsychotic medication such as inability to swallow, slurred or muffled speech and abnormal tongue movements with no clinical indications, side effect monitoring and effective dose reduction.These failures placed 2 of the 3 residents (5, and 21) at risk for harmful side effects with no clinical indications or dose reductions for the medications. These failures diminished the resident's quality of life. Findings included . Review of a medical journal regarding [MEDICATION NAME] issued by the Mayo Clinic (www.mayoclinic.org) on 03/01/17 stated the following signs and symptoms should be reported to Physician immediately while taking the medication; inability to swallow, abnormal involuntary movements of the tongue and face, disturbance in speech and language, sore throat and impaired ability to walk. The Food and drug administration (FDA, www.FDA.gov) stated Neurolepti[DIAGNOSES REDACTED] (NMS) was a serious side effect of the medication that could cause death with symptoms that included confusion, excessive sweating, changes in heart rate and blood pressure. RESIDENT 11 The resident admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. According to the Minimum Data Set ((MDS) dated [DATE] and 11/15/17, the resident scored a 14 on the Brief Interview for Mental Status (BIMS) and was able to make his needs known. Subsequent MDS assessments showed a decline in the resident's mental status where he scored a BIMS of 6 on the 01/1/18 and 02/14/18 assessments. The resident was taking an antipsychotic medication along with taking 3 other anti-depressant medications. Review of the facility policy titled psychoactive Medications revised on 06/17 stated the following: 1. The physician will be notified with all pertinent findings 2. The responsible party will be notified 3. Non pharmacological interventions will be attempted prior to psychoactive medication usage. Review of the resident's care plan dated 10/12/17 for [MEDICAL CONDITION] Drug Use, identified the resident at risk for mental status change/[MEDICAL CONDITION] related to the use of the [MEDICAL CONDITION] medication [MEDICATION NAME]. The care plan stated The resident will be free from mental status change and or [MEDICAL CONDITION] related to the use of [MEDICAL CONDITION]. Interventions included: 1. The interdisciplinary team (IDT) to meet with the Pharmacist on a monthly basis to discuss effectiveness, adverse side effects and lowest effective dose. 2. Non pharmacological interventions will be tried and documented in the progress note prior to giving any PRN [MEDICAL CONDITION] medications. The date on the care plan showed it was initiated on 10/12/17 which was 31 days after the resident admitted to the facility. The care plan did identify monitoring of side effects the resident was at risk for, any goals or appropriate interventions to address concerns while the resident was taking the medication. Review of the [MEDICAL CONDITION] Drug assessment dated [DATE], indications for medication use: Refusal of medications and care, uncooperative, manic behaviors, aggression and restlessness. Review of the progress notes reviewed showed upon admission the resident started complaining of difficulty swallowing. This went on for some time and the notes stated the resident was becoming increasingly agitated feeling that nothing was being done to help him. The notes stated he started using profanity and would throw things in the room out of frustration. The notes stated the resident also started having audible slurring and muffled speech. In the progress notes staff members stated they could not understand what he was saying. It was also documented throughout the progress note the resident was confused which was a change in mental status from when the resident admitted to the facility. The resident then started to have throat pain and increased saliva production noted and reported to nursing by a family member and the resident would constantly ask for Tylenol for pain relief. As a result the resident started refusing his medication and refused to eat resulting in significant weight loss. The progress notes showed the Medical Director (MD) was aware but diagnosed the resident with Dysphagia (Difficulty swallowing) with plans to do an endoscopy. The MD then prescribed a medication to treat reflux disease. Review of the Psychoactive Drug Review showed a Gradual Dose Reduction on 10/23/18 decreased his [MEDICATION NAME] intake to once a day at bedtime. On 11/30/17 the review showed the [MEDICATION NAME] was increased to twice daily related to preservation and increased in delusions. The progress note did not show documentation of the resident having episodes of delusions. In an interview on 04/19/18 at 2:38 PM, the resident stated, In an attempted interview on the responded in a muffled voice and was not easily understood. Upon further observation noted the resident to be speaking muffled with his tongue seemingly in the way. In an interview on 04/20/18 at 8:34 AM, Staff H, Nurses Assistant (NA), stated she had noticed the resident had trouble speaking. She stated He does sound kind of muffled sometimes, but I don't know why. She then stated It might be his tongue. In an interview on 04/20/18 at 11:33 AM, Staff C and Staff G, both Registered Nurses (RN) stated the DNS, the Resident Care Manager and Pharmacist and were involved in the [MEDICAL CONDITION] review meeting. Both staff members stated they discussed resident medications and recommendations were made by the Pharmacist for reductions and increases in medications. Staff C stated the meetings occurred once a month where other concerns were discussed. She stated side effects from [MEDICATION NAME] included increased saliva and drooling. At 12:53 PM, Staff M Socia Services Assistant and the DNS stated aggression was not an indication for taking the medication [MEDICATION NAME]. Staff M stated there were no appropriate indications for the antipsychotic medication usage. The DNS stated a GDR (Gradual Dose Reduction) was attempted, failed then the medication was increased for delusions. When asked to describe side effects of the medication, Staff M stated involuntary tongue movements, excess saliva or drooling. Staff M stated increased saliva. Summary Review of the entire progress note showed monthly [MEDICAL CONDITION] meetings were conducted by the Director of Nursing Services, Social Services Director and MD, but did not include any discussion on possible adverse side effects the resident might have been having from taking the medication [MEDICATION NAME]. The resident exhibited clinical signs and symptoms of the medication side effects. The progress note did not show the facility attempted non-pharmacological interventions prior to the use of the medication and failed to include side effect monitoring and interventions in the care plan. Over time it appeared the resident was becoming increasingly agitated that may have been highly influenced by the side effects of the medication. Without side effects monitoring and interventions the facility failed to find absolute root cause of his behaviors that could have been resolved otherwise. RESIDENT 5 Resident 5 was admitted to the facility 12/28/17, the [DIAGNOSES REDACTED]. Record review of the admission Minimum Data Set assessment dated [DATE] showed the resident was cognitively impaired and required assistance for activities of daily living. Record review of the physicians order dated 12/28/17 revealed an order for [REDACTED]. Further review of the physicians orders revealed an order dated 04/04/18 for [MEDICATION NAME] (Benzodiazepine medication) every 8 hours as needed. There was no documented [DIAGNOSES REDACTED]. Record review of the Medication Administration Record [REDACTED]. Record review of the medical record showed no documented non pharmalogical interventions prior to the administration of the [MEDICATION NAME]. In an interview on 04/19/18 at 11:21AM with Staff C, Registered Nurse/Resident Care Manager, stated they should have tried non pharmological interventions before they gave the [MEDICATION NAME]. She also stated all the medications should have diagnosis, that way the nurses know why they are giving the medications. RESIDENT 21 Resident 21 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the recent resident's Minimum Data Set (MDS) assessment, dated 03/07/18 documented the resident was cognitively intact. A review of the physician orders revealed Resident 21 was receiving the [MEDICAL CONDITION] medications [MEDICATION NAME], Busiprone, and [MEDICATION NAME]. In a review of the MDS dated [DATE] a gradual dose reduction GDR was not attempted. In a review of the Psycotropic Medication Review dated 01/31/18, 02/28/18, and 03/28/18 revealed no GDR attempted for [MEDICAL CONDITION] medications. The form dated 03/28/18 revealed some refusals of [MEDICAL CONDITION] medications. In an interview on 04/19/18 at 11:16 AM Staff G RCM RN stated a GDR for Resident 21 was not attempted. None has been attempted since she admitted . In a joint interview on 04/20/18 at 01:10 PM, Staff B DNS stated a GDR has not been attempted for Resident 21. Staff B stated that the DNS, mental health and pharmacist review the resident. Staff B DNS said There is no reason a GDR has not been attempted. A GDR should be attempted based on the lack of behaviors and sometimes refusing psych meds. Reference (WAC) 388-97-1300 (1),(b),(i),(iv,)(2),(4),(iii),(d)

Based on record review and interview, the facility failed to recognize, comprehensively assess, evaluate treatment, and revise the effectiveness of bowel interventions for 1 of 1 resident (Resident 1), reviewed for bowel care and management. Additionally, the facility failed to monitor Resident 1's bowel record to effectively treat and prevent bowel related complications. These failed practices resulted in serious harm, severe pain, and had contributed to the development of fecal impaction (severe form of constipation),[MEDICAL CONDITION] (severe blood infection) and death of Resident 1. Findings included . According to the United States Library of Medicine National Institute of Health and National Center for Biotechnology Information (NCBI), Fecal impaction (FI) is a common gastrointestinal (GI) disorder, and a source of significant patient discomfort with potential for major morbidity especially in the elderly population. FI is defined as the inability to evacuate large hard inspissated (thickened) concreted stool or bezoar (a small stony concretion) lodged in the lower GI tract. Symptoms associated to FI includes abdominal pain and distention, nausea, vomiting, and anorexia. According to the Food and Drug Administration (FDA) medication information guide, the following adverse reactions/side effects of using Opioids and Benzodiazepines were the following: nausea, constipation, vomiting, headache, [MEDICAL CONDITION], poor balance, coordination, dizziness, and somnolence. Review of the Policy and Procedure for Bowel Protocol The Protocol directed staff to: 1. At the beginning of each shift, the Licensed Nurse will pull the 7 day Matrix Resident Bowel Management Report and identify residents that have not had a BM for 3 days. 2. Residents who have not had a bowel movement in three days will be given Milk of Magnesia. 3. If no bowel movement by the following shift, a Ducolax suppository is given. 4. If resident continues without bowel movement by the next shift a fleets enema will be given. 5. Residents who are noted as having small bowel movements will be assessed for constipation. 6. Residents who are having diarrhea and or loose stools will be assessed for constipation/fecal impaction. 7. If resident exceeds four days without a bowel movement, the Licensed Nurse will complete an abdominal assessment and the physician will be notified for further orthers. Resident 1 Resident 1 was admitted to the facility on (MONTH) 28, (YEAR) for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. In a review of the resident's Minimum Data Set (MDS) assessment dated [DATE], identified the resident to be cognitively intact and needed one-person assistance for bed mobility, transfers, toileting and personal hygiene needs. In a review of the resident's Physician orders [REDACTED]. a. [MEDICATION NAME] 5mg tablet (Opioid based-Narcotic Pain Medication) every 8 hours routinely. b. [MEDICATION NAME] 5mg tablet every 4 hours as needed for pain. c. [MEDICATION NAME] (also known as [MEDICATION NAME], a benzodiazepine) 0.25mg Three times a day routinely. d. [MEDICATION NAME] 0.25mg as needed. e. [MEDICATION NAME] 5% Patch (pain patch) for 12 hours daily. The Physician orders [REDACTED]. a. [MEDICATION NAME] 17 grams daily. Start date: [DATE], Last date Administered: [DATE], four days after admit. b. Senna 17.2 mg twice per day. Start date: [DATE], Last date Administered: [DATE] c. Milk of Magnesia (Magnesium [MEDICATION NAME]) suspension 400mg/5mL - give 30mL as needed for no BM (bowel movement) in 3 days. d. [MEDICATION NAME] (also known as [MEDICATION NAME]) 10mg (milligram) suppository per rectum as needed for no BM on shift following Milk of Magnesia Dose. e. Fleet Enema (Sodium [MEDICATION NAME]) 1 enema per rectum as needed for no BM on shift following suppository application. In a review of the facility's admission note dated [DATE], 1 day after admit, revealed that the facility was informed that the resident hadn't had a BM for 5 days prior to discharge from the hospital. The note showed the nurse on duty had offered MOM (Milk of Magnesia), a bowel medication, but the resident had refused. The resident refused the MOM, but the facility did not take any actions, to educate the resident, offer other alternatives, contact the physician or develop interventions to monitor the resident bowel movements. In a review of the resident Bowel monitoring record from [DATE] to [DATE] showed the resident had documented BM's for the following dates; [DATE] (7 days after last BM), [DATE], [DATE] ([MEDICATION NAME] was stopped), [DATE] (6 days after last BM), and [DATE] (5 days after the last BM). Even though physician's orders [REDACTED]. In a review of the nursing progress notes dated [DATE] at 4:10 PM, documented, Resident presenting this shift with the inability to pass bowel movement, expressed to this licensed nurse that he had passed two medium sized bowel movements the prior day, (there were no BMs documented). The resident's abdomen was distended and non-tender to touch, hyperactive bowel sounds were present in all 4 quadrants (four parts of the abdomen) prior to implementing standing order bowel regimen. After initiation of the regimen, resident reported having a small sized bowel movement (not documented) and some relief as well. MD (Medical Doctor) notified of these results and scheduled for the following: STAT (immediately) abdominal x-ray supine and upright, STAT CBC (complete blood count test) and CMP (complete metabolic panel test). Continue with plan of care. In a review of the resident Care Plan dated [DATE] (created 14 days after admit, showed the resident was at risk for constipation and impaction related to the use of an opioid medication. Interventions included: a. Staff would monitor resident for symptoms of constipation such as no bowel movement for 3 days, hard stools, straining to have bowel movement, complaints of stomach upset, nausea, bloating, and distention. b. Resident would have a PRN (as needed) bowel protocol in place upon admission to the facility. Licensed nurse to start a bowel protocol per physician order [REDACTED]. In a review of the nursing progress notes dated [DATE] at 11:22 PM, documented, Pt (patient) c/o (complain of) severe gastric and abd (abdominal pain), has rebound tenderness on LLQ (left lower quadrant). X-ray done at bedside, result showed that the client is constipated. BS (bowel sound) auscultated on all 4 quadrants. Pt shares that he passed some gas, and passing gas increased his comfort level, scheduled and PRN [MEDICATION NAME] given to help with pain, ineffective. In a review of Physical Therapy notes dated [DATE] at 3:17 PM, showed that the resident refused therapy due to constipation. The daughter requested no PT session today due to constipation and lack of sleep last night. They reported pt. (patient) has been very exhausted and would like to rest in bed. They also reported the patient would be have an x-ray and blood draw. Alerted nursing of patient's complaints of pain in anus. In a review of Occupational Therapy (OT) notes dated [DATE] at 4:30 PM, showed OT liaised with nursing re: patient's complaints of severe pain in stomach. In a review of the Abdominal X-ray result taken on [DATE] at 6:55 PM, revealed the resident had moderate to severe constipation with fecal rectal impaction. Review of the blood test showed the resident had an elevated white blood cells (WBC) of 14.92 (normal value 3.80 to 11.00), a possible indication of a systemic infection, and an elevated BUN (blood urea nitrogen), which was an indication of possible dehydration. In a review of the nursing progress notes dated [DATE] at 12:57 AM, documented, Resident is uncomfortable night, he has substantial ab (abdominal distention). Suppository 1 given approx. (approximately) 11pm, suppository 2 given 0055 (12:55 AM). Additional orders for 2 enemas as warranted and so far resident has had small amounts of BM (incontinent) in brief . Additional order given when resident asked for PRN (as needed) [MEDICATION NAME] 5mg b/c (because of) ab px (abdominal pain). MD notices that additional narc can increase constipation so additional order of: Doss 400mg and 4 Senna tabs (tablets). This LN gives [MEDICATION NAME] 5mg and just mentioned meds at approx. 0040 (12:40 AM). Normal Saline (intravenous) order as well. Resident has large BM shortly after 2ND (second) suppository given. Resident reports px (pain) relief in abdomen, he is still quite distended . Resident states he continues to have abdominal discomfort. Concern for HR (heart rate) has not increased over course of shift however 115 BPM (beats per minute) . Second Large BM EOS (end of shift). In a review of the nursing progress notes dated [DATE] at 7:10 PM (8 hours after discharge), documented, Resident presented this morning with increased abdominal distention compared to yesterday despite passing 2 large bowel movements after receiving two suppositories on night shift. This licensed nurse performed an assessment on the resident at the beginning of the shift with the following results: Alert and oriented x 3, increased distention present, firm and tender, normoactive (normal) bowel sounds in all 4 quadrants. PA (Physician assistant) in to assess resident in the morning, believed it to be possible small bowel obstruction or diverticulitis, written order to send resident out to ER for work up (focus being on potential CT scan), daughter with resident from ,[DATE] (8:00 AM to 11:07 AM) when resident was picked up by the fire department for transport to ER (emergency room ). In a review of the Medication Administration Record, [REDACTED]. There was no evidence in the clinical records, that the elevated WBC was addressed or treated by the facility. During a phone interview on [DATE] at 11:42 AM, the resident family member stated, she had visited Resident 1 regularly at the facility. According to the resident family member, she had noticed Resident 1 having increased abdominal distention, and severe abdominal pain on [DATE], and appeared to her as 9 months pregnant, and his skin was shiney and he looked sick. The family member stated that the facility was informed of these concerns, they did not act, so she had called the doctor herself about 8 or 9 pm. The MD did not answer the phone until the third time she called. The MD stated that she would write an order for [REDACTED]. During a phone interview on [DATE] at 2:05 PM, the resident POA (Power of Attorney and registered nurse) stated, the resident was on routine Narcotics and Benzodiazepines. According to the POA, the facility had knowledge of Resident's 1 risk of constipation from admission to the nursing home, and the resident had continuously reported difficulty passing bowel movement to the facility staff. According to the POA, the doctor was aware of the resident concerns with bowel problems since [DATE]. The POA further stated, she was not sure why Resident 1 was not on a routine bowel medications while at the facility, given that the resident was taking medications, that would clearly affect and decrease bowel activity. In an interview at 3:52 PM, Staff K, Physician Assistant (PA), stated, he did assess Resident 1 on [DATE]. According to Staff K, Resident 1 had an x-ray result that confirmed fecal impaction. Staff K further stated, Resident 1 was in severe pain at the time of transfer and he ordered the resident sent to the hospital because the facility could not manage the resident's change of condition in the facility. In summary, the facility had failed to accurately monitor and assess Resident 1's bowel condition. The facility failed to put necessary and timely interventions to prevent and minimize the risk of bowel related complications. The facility had failed to monitor the effectiveness of interventions and revised as needed to meet the resident needs. Resident 1 transferred to the hospital on [DATE] at approximately 11:00 AM, related to severe abdominal distention, severe abdominal pain, and severe constipation. The resident was treated in the hospital for fecal impaction, peritonitis (inflammation of the lining and inner wall of the abdomen/abdominal organs), [MEDICAL CONDITION]. The resident expired on [DATE], related [MEDICAL CONDITION] and complications related to severe constipation and fecal impaction. A Review of the POS [REDACTED]. The report went on to say the resident was found to have peritonitis (inflammation of the peritoneum, typically caused by bacterial infection either via the blood or after rupture of an abdominal organ.) and the colon was distended, feces filled, and dusky appearing. The colon did have a full thickness necrosis suggestive of stercoral ulceration (is an ulcer of the colon due to pressure and irritation resulting from severe, prolonged constipation due to large bowel obstruction), a consequence of constipation. Recent opioid therapy is the most likely initiating event and underlying cause of death. See also F 684, Services Provided Meet Professional Standards This is a repeat citation from [DATE] at F 309 Quality of Care for bowel management. Reference: WAC [DATE](1)

Based on observation, interview and record review the facility failed to ensure safe storage of medications preventing public access, and medicines in a cup that were left unattended on top of a medication cart. Additionally the facility failed to secure and lock 2 of 2 medication carts and 1 of 2 treatment carts that contained hazardous materials such as surgical scissors, tweezers and topical medications. All of which placed 1 of 3 ambulatory residents (2) with Dementia, in Immediate Jeopardy (IJ) for accidental ingestion, self-harm, harm to others and overall compromise to resident safety. On 03/29/17, the Administrator and DNS were notified of the Immediate Jeopardy (IJ) related to the observation of medications left unattended on a medication cart as well as medication and treatment carts left unlocked and unattended. A verbal removal was given by the administrator and accepted by the surveyors and a written removal plan was accepted on 04/02/18. Findings included . In a review of a Center for Medicare Services (CMS) article found at (www.cms.gov) titled CMS Review of Current Standards of Practice for Long-Term Care Pharmacy Services in Long-Term Care Facilities stated Medication carts must be supervised at all times by the nurse administering medications. When medication carts are not in use, they must be stored in a designated locked area with all drawers locked. RESIDENT 2 Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observations showed the resident was ambulatory via wheelchair and was seen in multiple areas that included nurses stations where medication and treatment carts were located and left unattended and unlocked. Review of the resident's progress notes showed multiple documented episodes where the resident was agitated, verbally and physically aggressive towards staff, pulling out her Urinary Catheter, confused and picking up random objects. Review of the resident's care plan dated 03/22/18 stated Resident experiences wandering (moves with no rational purpose, seemingly oblivious to needs or safety). In an observation on 03/29/18 at 9:10 AM, a medication cart in the 200 hall had a medicine cup sitting on top of the cart with approximately 8-9 medications in it and was unattended. The top drawer of the cart was pulled open by the surveyor that showed the medication cart was left unlocked and unattended. Upon further inspection of another cart in the 300 hall, the surveyor was able to pull open a second drawer of a treatment cart that was unlocked and unattended. In an interview on 03/29/18 at 1:46 PM, Staff H, Registered Nurse (RN) was asked if she was aware the treatment cart located in the 300 unit where she was working that day was unlocked. She stated No. She stated she became aware as soon as the surveyor had opened the cart. When she was asked if the cart should have been locked she stated Yes. When asked why it was not locked she stated I don't know why, the night shift is responsible for locking the cart. When she was made aware of the ambulatory residents in the facility with Dementia that could have accessed the contents of the cart and if she thought there was a risk for those resident's for injury she stated Yes. In a joint visual inspection at 3:46 PM, of the treatment cart that was observed unlocked earlier that morning with Staff J (RN), revealed the cart was left unlocked. Opening the top drawer revealed an open box of surgical scissors, nail clippers and tweezers. There were also bottles of barrier cream, alcohol pads, peroxide and tubes of [MEDICATION NAME] located in other drawers of the cart. When Staff J was asked who was responsible for making sure the carts were locked, he stated I am new, I am not sure. Another nurse Staff P (RN), stepped in said We are all responsible for making sure the carts are locked. In an observation at 3:44 PM, a second medication cart that contained various medication was found unlocked and unattended as evidenced by Surveyor opening the top drawer of that cart. In an interview at 3:45 PM, Staff E (RN), stated she was orienting the staff member who had left the pills on top of the medication cart. Staff E stated the pills should not have been left unattended and the carts should have been kept locked at all times. In an interview at 3:58 PM, Staff G (RN), stated that he was aware he had left pills on top of the medication cart and that it was unlocked and unattended. When he was asked if the pills should have been left on top of the cart he stated They should not have been left there. When he was asked if the cart should have been locked he stated Yes. In an interview on 03/30/18 at 11:58 AM, Staff F, Resident Care Manager (RCM) stated the expectation for nurses who dispensed medication from the medication carts was to have the medication carts locked and medications attended to at all times. WAC Reference: 388-97-1060(3)(g),1060(3)(g)

Based on observation, interview and record review, the facility failed to timely and accurately document the resident's condition, comprehensively assess, care plan, evaluate treatment, and revise the effectiveness of bowel and pain interventions for 1 of 1 Residents (1) in accordance with professional standards. Failure to timely document, adequately assess, plan care, manage pain and follow current standards of nursing practice resulted in harm for Resident 1 and resulted in a diminished quality of life. Findings included . Nursing standards indicate: Standards of nursing conduct or practice. (2) The nursing process is defined as a systematic problem solving approach to nursing care which has the goal of facilitating an optimal level of functioning and health for the client . It consists of a series of phases: Assessment and planning, intervention and evaluation with each phase building upon the preceding phases. (ii) Standard II Delegation and Supervision: The registered nurse is accountable for the safety of clients receiving nursing service . (3) The following standards apply to registered nurses and licensed practical nurses: (a) The registered nurse and licensed practical nurse shall communicate significant changes in the client's status to appropriate members of the health care team. This communication shall take place in a time-period consistent with the client's need for care. Communication is defined as a process by which information is exchanged between individuals through a common system of speech, symbols, signs, and written communication or behaviors that serves as both a means of gathering information and of influencing the behavior, actions, attitudes, and feelings of others; and (b) The registered nurse and licensed practical nurse shall document, on essential client records, the nursing care given and the client's response to that care; and (c) The registered nurse and licensed practical nurse act as client advocates in health maintenance and clinical care. Bowel monitoring and documentation RESIDENT 1 The resident admitted to the facility on [DATE] at approximately 4:11 PM. There was no documentation on evening shift, night shift and day shift. A Licensed nurse did not document until over 22 hours later after admit, on [DATE] at 2:39 PM in regards to the resident's condition. In addition, there was no care plan developed for the resident until [DATE] to address his medical needs. Without a care plan there were no interventions developed to instruct direct care staff on how to care for the resident. In a review of the facility's admission note dated [DATE], revealed the facility was informed by the hospital the resident had not had a BM for 5 days prior to his discharge from the hospital. The admission progress note showed the nurse on duty had offered MOM (Milk of Magnesia), a bowel medication, but the resident refused. There was no thorough documented assessment of the resident's bowel condition. There was no documentation that the nurse attempted a second time or provided education to the resident as to why he should take the MOM or that any other interventions were implemented. The first documentation of the resident having bowel movement in the clinical record was [DATE], (7 days with no BM). A review of the resident's Physician orders [REDACTED]. Both medications could potentially affect and decrease bowel activity. A review of the resident bowel monitoring record from [DATE] to [DATE], showed the resident had BMs documented for the following dates; [DATE], [DATE], [DATE], [DATE] (6 days later), and [DATE] (5 days later). Even though there was more than 3 days between, per the facility policy, the facility did not take any action or complete an assessment of the resident's bowel status. In a further review of bowel, record documentation showed that on [DATE], Staff A, Director of Nursing (DON) documented at 6:13 PM the resident had a Large size bowel movement on [DATE]. Staff B, Minimum Data Set (MDS) nurse documented 2 seconds later at 6:15 PM, the resident had a Large size bowel movement on [DATE]. There was no supporting documentation of either bowel movement by licensed staff. On [DATE], a family member submitted copies of the facility's progress notes to the Department . The progress notes showed they were printed on [DATE] at 5:05 PM. Approximately 68 minutes after records were printed for the family member, and a day after the resident was discharged from the facility, and had expired the two above BM's were documented. In an interview with Staff A, Director of Nursing (DON), on [DATE] at 12:30 PM, Staff A stated No she had not worked on the cart/floor nor had she provided any direct personal care for Resident 1 or taken him to the bathroom or toileted Resident 1 during the entire month of (MONTH) (YEAR). On [DATE] at 4:15 PM, in an interview and record review of the bowel documentation with Staff A, DON, and Staff D, Regional Nurse Consultant. The bowel report showed two late entries both documented on [DATE] for [DATE] and [DATE]. Staff A stated, I don't know where the information came from and there was no supporting documents to support the entry she had put in to Resident 1's clinical record. In an interview on [DATE] at 1:00 PM, Staff B, Minimum Data Set Nurse stated No she had not worked on the cart/floor or had provided any direct personal care, taken Resident 1 into the bathroom or toileted Resident 1 during the entire month of (MONTH) (YEAR). Staff B stated No. she did not have any supporting documents to support the documentation she had put in to Resident 1's clinical record, Staff B further stated, I really don't know why I documented a BM, or if it was accurate or not. Fall Resident 1 In an interview on [DATE] at 11:42 AM, the resident's family member stated the resident had a fall on [DATE]. In addition, the family member stated that the documentation of the incident in the progress notes was not accurate. There were no progress notes documented at the time of the fall that showed there was a fall nor an incident investigation immediately started. Staff H, entered the first progress note as a late entry the next day at [DATE] at 8:25 PM, 24 hours after the fall. Staff H also documented on a fall investigation report, the fall occurred on [DATE] at 8:00 pm. The report also showed that she notified the family on [DATE] at 5:20 PM, 2 hours and 10 minutes prior to the fall per facility policy. The facility failed to ensure licensed staff timely and accurately documented the resident's condition, comprehensively assessed; care planed, evaluated treatment, and revised the effectiveness of bowel interventions in accordance with professional standards. Refer to F684 - Quality of Care for more information.

Based on observation, interview and record review the facility's administration failed to effectively use its multidisciplinary resources to maintain or sustain facility compliance with federal regulatory requirements related to staff trainings, hazards, quality of care, reporting of disruptions of services, effective grievance processes and professional standards were used and implemented to follow policies and procedures in order to meet the needs of the residents. These failures resulted in an immediate jeopardy (IJ) situation related to Hazards, Quality of care, harm in form of severe pain / death and had the potential to impact all residents quality of life. Findings included: 1. Free of Accident Hazards/supervision/devices (Refer to F689) The administration and multidisciplinary staff failed to secure medications that were left unattended on top a medication cart. Furthermore the same cart, 1 other medication cart and a treatment cart were also found unlocked and unattended. This compromised safety for ambulatory residents with Dementia. 2. Quality of care (Refer to F684) The administration and multidisciplinary failed to implement Bowel function preventative measures for a resident at risk for constipation that resulted in bowel impaction and hospitalization . This is a repeat harm level citation from 1/18/17 at F 309 Quality of Care for bowel management. 3. Professional Standards (Refer to F658) The facility administration and multidisciplinary staff failed to provide residents with high quality of care and services to meet professional standards of care. 4. Grievances (Refer to F585) The facility administration and multidisciplinary staff failed file and investigate a resident grievance to ensure resident complaint resolution. This is a repeat citation from 1/18/17 and was re-cited on the Post survey dated 3/23/17 both at F 166 Right to Resolve Grievances. 5. Reporting of Alleged violations (Refer to F609) The facility administration and multidisciplinary staff failed to report a call light system outage as part of the Systems services reporting protocol. 6. Transfer Agreement (Refer to F843) The facility administration failed to ensure a current Transfer Agreement was in place. Verification of this document was never provided after multiple requests. 7. Abuse, Neglect and Dementia Training (Refer to F943) The facility administration failed to ensure Nursing Assistant Certified (NAC) trainings included all of the required components required by state and federal regulatory criteria. In an interview on 03/29/18 at 5:20 PM, the Administrator verbalized removal plans for the two IJ's and an ongoing plan to monitor and implement interventions to prevent the above mentioned from reoccurring. The facility Administration failed to educate staff with return demonstrations, perform internal audits/monitoring to ensure nursing staff followed standards of practice, facility policies and procedures, by responding and investigating grievances, locking medication carts to ensure public safety, following bowel protocols, reporting to the Department and providing quality nursing care. WAC Reference: 388-97-1620 (1)

Based on interview and record review, the facility failed to consistently assess, monitor and ensure timely interventions were in place to prevent and promote healing for 2 of 4 residents (2 & 3). Failure to thoroughly assess and implement timely interventions resulted in harm for Resident 3 who experienced pain and deterioration of a pressure ulcer and not following Resident 2's prescribed plan of care placed the resident at risk for delay in wound healing. Findings included: The skin policy and procedure stated that upon admit residents would be assessed to determine their risk for pressure ulcers (PU) and within 8 hours of admission, a Licensed Nurse (LN) would examine the resident's entire body to determine if skin impairment is present. The policy indicated resident's body assessments would be performed weekly and documented on the Treatment Administration Record (TAR). The policy indicated that when a newly identified skin impairment (excoriation, pressure sore), the LN would document skin impairment that included measurements, notify the physician, obtain a treatment order and document findings on the skin grid. The procedure directed the LN to evaluate and identify interventions to promote healing/resolution of skin impairment. RESIDENT 3 Resident 3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial admission Minimum Data Set (MDS) assessment dated [DATE] indicated the resident did not have any skin issues. By [DATE] a significant change MDS assessment was completed and indicated that the resident had an unstageable pressure ulcer that measured 3.5 centimeters (cm) X 2 cm X 1 cm deep. The assessment also indicated that the pressure ulcer had Eschar (dead skin). Both MDS assessments identified the resident as being at a high risk of developing pressure ulcers. Neither MDS indicated that the resident had a condition or chronic disease that may have resulted in a life expectancy of less than 6 months. The resident expired on [DATE]. The nursing admit note written by LPN D, dated [DATE], documented Resident 3 required one person assist with ADL (activities of daily living), she was continent of urine and bowel, walked occasionally, and was not at risk for pressure sore development according to the Braden scale (a tool used to predict pressure sore risk) even though the MDS indicated she was at high risk. The physician admit note dated [DATE], indicated Resident 3's request was to be made comfortable and to continue with skilled therapy to increase endurance, mobility and strength. Social Services documented on [DATE] at 3:55 p.m. that PT reported to her, that Resident 3 was experiencing pain in the tail bone, preferred to remain in bed, and requested a cushion for her wheelchair as she was able to self-propel in her wheel chair. There was no documentation that this was reported to nursing, that an assessment or observations were made of the resident's tailbone by nursing staff. On the same day, [DATE] at 11:18 p.m., an LPN A, documented that the resident complained of pain on her tail bone. The intervention was to give her pain medication. There was no documentation that an skin assessment was done or that anyone had observed the area. Six days later on [DATE] at 4:41 a.m., LPN B, documented that she was notified by a nursing assistant (NAC) regarding an open area on Resident 3's tailbone. The LN documentation that there was a dark area that measured 3 cm in length by 2.5 in width and the full length of the total wound was 8 cm including the surrounding pink skin of the wound with some of the skin peeling. The LN cleansed the wound, applied a dressing and would have the day shift nurse contact the physician and family. There was no documented evidence that the LPN B had initiated a Skin Grid form or evaluated the plan of care. On the same day, [DATE] at 8:07 a.m. the RCM documented that there was an area of previously observed loss of superficial skin r/t moisture [MEDICAL CONDITION] (MASD) from incontinence from her bottom down the left buttock crease. Area on the tailbone appeared dark because of shadowing from wrinkle skin folds. The area down the left buttock crease was healing. The RCM documented that she spoke to resident because she tends to want stay in bed and not move. The RCM had removed the dressing, applied zinc oxide but did not document that another dressing was applied and the MD (physician) made aware. Even though the RCM documented that the MD was made aware, the MD documented on the same day that the resident had no rash. In addition, the RCM documented on [DATE], a different assessment than LPN B and concluded it was not a PU, but MASD, there was no documented evidence as to how she received MASD, if a prior assessment had been done to identify she was at risk for MASD or if interventions had been put into place to prevent the skin breakdown. In addition, there was no skin grid initiated to track the progression and/or decline of the skin breakdown on the bottom or buttock area until 6 days later on [DATE]. On [DATE], 6 days later, RN A documented at 6:03 a.m., Resident 3 has a black area on bottom. RN A assessed the area to be an unstageable pressure ulcer that measured 3.5 cm by 2 cm and 1cm deep, the wound bed was black with inner gray slough, red excoriation noted below wound which appeared to have been caused by shearing, cleansed with NS, applied foam dressing and [MEDICATION NAME]. The plan was to keep off her bottom, and turn side to side. On [DATE], RN A documented, the resident and family were informed of unstageable pressure ulcer on the tailbone, and the family requested a follow up with the wound center as soon as possible and an air mattress was applied. During an interview on [DATE], the Director of Nursing (DNS) stated the facility used the local hospital's wound clinic however there was no documented evidence regarding whether the follow-up for Resident 3's pressure ulcer had been initiated. RN A documented on the Skin Grid form on [DATE] that Resident 3 had an unstageable pressure ulcer which measured 3.5 centimeters (cm) by 2 cm in size with a depth of 1 cm. The wound base contained necrotic tissue and was described to be black and gray and had no drainage. An assessment for the [DATE] air mattress was completed to prevent skin breakdown. On [DATE] the Physician's Assistant (PA) documented that the resident's tailbone ulcer was worsening, continue with wound care and will monitor closely. On [DATE], Resident 3 complained of unbelieving pain to coccyx area. On [DATE], LPN C documented that the resident's wound drainage was green with a foul odor, and Resident 3 was incontinent of both bowel and bladder, and required extensive assist of 2 persons for repositioning. On [DATE] at 4:06 p.m., LPN C documented the wound was oozing grey/green drainage with foul odor. The LPN reported the condition to the PA, who ordered a urinary catheter, blood work and 2 different intravenous antibiotics. The LNs' managing acute conditions form dated [DATE] indicated due to Resident 3's infected wound (pressure ulcer), the LNs were to assess and document and the goal was that the wound would heal without complications. On [DATE] the RCM documented Rapid development of ulcer to her coccyx. Pear-shaped ulcer over her coccyx covered in slough, therefore unstageable. Peri wound area is pink, blanchable. Slough is soft, dark grey to almost black in the center, there is musty, decaying odor present. Overall assessment is indicative of a possible Kennedy ulcer . treatment . on LAL (low air loss mattress). There were no measurements. There was no MD/PA documentation to support this statement. According to the National Pressure Ulcer Advisory Panel, a Kennedy ulcer is characterized by rapid onset and rapid tissue breakdown, has a sudden onset. The physician (MD) visit on the next day, [DATE] documented the resident has severe chronic pain, has a worsening coccyx ulcer, (was not identified as a Kennedy ulcer) to continue with wound care, and will monitor closely and the MD note for [DATE] documented Resident 3's pressure ulcer, a Stage 4 was worsening, to monitor closely, change diet to high protein, and increase med plus (high calorie supplement). Even though the MD indicated Resident 3 required additional protein for wound healing, there was no documented evidence the Registered Dietitian was notified to evaluate nutritional needs. The only RD assessment and evaluation was completed on A nursing note for [DATE] documented Resident 3 was crying out in pain due to severe coccyx and hip pain. A nursing note ([DATE]) revealed the wound was extending and worsening with possible starting of tunneling or undermining and had copious foul odor noted from decaying flesh and on [DATE], Resident 3 was refusing to get out of bed and hospice was pending. The Treatment and Medication Administration Records (TAR/MAR) for [DATE] indicated Resident -- received routine oral narcotic medication every 4 hours while awake and routine topical patch every 72 hours. The TAR indicated that not until [DATE] was staff to monitor wound on coccyx every shift, place dressing to protect site, cleanse with normal saline and reposition the resident side to side while in bed to offload pressure on tailbone. On [DATE], RN A documented on the skin grid the wound measured 4 cm by 3 cm in size with moderate yellow purulent drainage with odor. RN A also indicated the ulcer was unstageable and described it as a Kennedy ulcer. There was no Physician documentation to support this diagnoses. A Care plan for at risk for pressure ulcers dated [DATE] due to incontinence and impaired mobility and weakness, document nursing would conduct a weekly skin inspection, use the facility mattress for pressure reduction when in bed and provide moisture barrier product to perineal area is indicated. Even though Resident 3 was assessed to have skin breakdown on [DATE], there was no documented evidence that the Plan of Care was updated and measurement of the pressure ulcer was measured according to policy in order to evaluate whether there was deterioration or improvement of the wound. On [DATE], Resident 3 was referred to hospice for pain management and wound care. The hospice note dated [DATE] documented Resident 3 had a Stage 4 pressure ulcer on the sacrum (coccyx). The Skin Grid dated [DATE] also showed an air mattress was in place for the unstageable pressure ulcer. However an order was not noted until [DATE] for the specialty Low air Loss mattress. The [DATE] assessment for the alternating mattress was due to Resident 3's poor mobility and declining condition. On [DATE], Resident 3's clinical record was reviewed with the Director of Nursing (DNS). The DNS stated LNs had not completed weekly measurement and/or documented wound measurement to evaluate the wound. The DNS was unable to provide any further information and that the LNs used the Lippincott manual for the staging of wounds. Even though the resident initially complained of tailbone pain on [DATE], she was not assessed until [DATE]. When it was determined she had skin breakdown, the initial skin assessment sheet was not started until [DATE]. The next entry did not occur until, 22 days later on [DATE], even though the directions on the sheet stated complete weekly. The facility did not timely or thoroughly assess, monitor or timely put interventions in place to prevent or heal a pressure ulcer. This caused the resident pain, became infected and caused the resident to have a decline in condition. RESIDENT 2 Resident 2 was admitted to the facility on [DATE] with a pressure sore on the sacral area, which was a Stage 4 (Stage 4 is a Full thickness tissue with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed.) In an interview on [DATE], a LN who wished to remain anonymous, stated Resident 2 was admitted with a stage 4 pressure ulcer on his bottom. The Facility admission assessment acknowledged this wound, but did not assess the wound. There were no measurements or any other description of the wound present. The treatment order was not being followed, as the product was unavailable and the MD had not been notified. The order for a low-air-loss mattress was not followed until [DATE]. These were part of Resident 2's admit/transfer orders. The LN stated due to not having the supply of [MEDICATION NAME], the order had to changed. Resident expired on [DATE]. An initial nursing assessment was not completed until [DATE] (2 days later). Also an assessment for an the air mattress was not completed until [DATE]. The admit orders revealed that wound care was to turn the resident every 2 hours. They were to place the bed in a flat position for lifting up to reduce sheer force and they were to utilize a waffle cushion. Perform skin checks paying close attention to all bony prominences. The wound was to be cleansed with normal saline and the dressing to be applied was a [MEDICATION NAME] dressing. Then cover with a foam dressing. The dressing change was to be done three times weekly and as needed. Resident 2 was to have a low air loss (LAL) bed. Review of supply lists did not show the facility had received [MEDICATION NAME] dressing for the resident. In an interview on [DATE], the Director of Nursing (DNS) stated the facility had a supply of pressure relieving mattresses (LAL) and wheelchair cushions. If a resident requires these devices, they are put in place prior to a resident's admission if they have a pressure ulcer. Resident 2's Treatment Administration Record (TAR) for [DATE] indicated a [MEDICATION NAME] dressing was to be used with a foam dressing three times weekly. There was no documented evidence that this dressing was applied on [DATE]. A skin grid form for other skin problems under initial identification dated [DATE] documented a sacrum PU, Stage 4. The wound was marked as being full thickness with tunneling. The wound measured to be 6.7 centimeter (cm) by 2.0 cm in size with moderate amount of serosanguinous drainage. The wound bed was red with redness around the surrounding area. The physician's noted for [DATE] documented that Resident 2 complaints of sacral pain which was constant. The pain was worse with movement and when turned every two hours the resident tended to roll over onto his back, when staff returned to check on him. A nursing progress note dated [DATE] documented an order was obtained from the physician for an air mattress. The assessment/condition/care form was updated and an order for [REDACTED]. The next wound measurement was documented on [DATE] and had declined and measured 7 cm by 3 cm with a depth of 2 cm, and had sero-sangeous drainage. There was no assessment regarding the status of the tunneling of the wound or whether the response to treatment was effective for wound healing. The comment on the grid form section indicated Resident 2 had a LAL mattress in place and was to be turned every two hours. On [DATE] Resident 2's care consideration plan used by nursing assistants (NACs) (dated [DATE]) was reviewed. This documentation revealed the resident had a sacral decubitus, was to be turned side to side every two hours and had a LAL mattress on bed (no date). Resident 2's care plan obtained on [DATE]. The Care Plan revealed he was at risk for pressure ulcer due to moisture and impaired mobility. On [DATE], the Care Consideration Sheet was requested and reviewed with the Director of Nursing. The [DATE] form provided did not reveal that a LAL was in place, only a air mattress. Resident 2's care plan obtained on [DATE]. The Care Plan revealed he was at risk for pressure ulcer due to moisture and impaired mobility. During an interview on [DATE] with the Resident Care Manager (RCM) regarding the dressing supply, she stated the order was changed to alginate as the [MEDICATION NAME] is a similar dressing. Alginate dressings are designed to interact with sodium in wounds to create an ionic exchange and help jump-start the healing process. [MEDICATION NAME] Wound Dressings are designed to help wounds heal while providing antimicrobial protection against a broad spectrum of pathogens for an extended period of time. [MEDICATION NAME] and alginate are two different types of dressing with different properties. On [DATE], the Director of Nursing provided no additional information regarding the supply of [MEDICATION NAME] and stated the TAR did not indicate whether the dressing changes had been completed in addition to weekly assessment not being performed per policy. Reference WAC: [DATE](3)(b)

Based on interview and record review, the facility failed let residents remain and not discharge residents due to Medicaid payment type for 2 of 2 residents reviewed for discharge (84 & 101). This failure resulted in Resident 101 being sent home before the family was ready, able to care for the resident and services were set up to support the resident and caused Resident 84 (using reasonable person) psychosocial transfer trauma harm who was sent to an adult family home in which the family did not like and even though the family wanted her to remain in the facility. Findings include: Resident 84 In an interview on 1/11/17 at 8:46 am, the Home and Community Services (HCS) case manager stated that Resident 84 was converting to Medicaid funding, but the family wanted her to stay long term at the facility. The family was told by the nursing facility that since Medicare Coverage was ending they needed to move from the facility, because Medicaid long term care residents. During the adult family home (AFH) assessment the family had asked the facility if Resident 84 could stay and the facility declined. The facility did not give the Resident a 30 day notice with reasons why the resident could not stay. In an interview on 1/12/17 at 3:30 pm, Resident 84's daughter in law stated that right from the beginning the family was told that Resident 84 could not stay long term care, because they only took short term care residents. They were also told by the Social Services Director (SSD) that when Resident 84's Medicare time was up, Resident 84 could not remain in the facility. The daughter in law stated that no 30 day notice was given to the family. In an interview on 1/12/17 at 4:00 pm, Resident 84's husband stated that the facility told him that that the resident's Medicare was running out. He did not want to move her, but staff told him that she could not stay. He does not like the AFH setting that Resident 84 is currently living. The AFH provider is always complaining to him, because she is running her wheel chair into the walls and furniture. He stated that one of the Therapists came to the AFH and told him that the facility was going to start taking Medicaid clients. He went to the facility right away and spoke with the DNS. The DNS told him that she was going to talk to her boss, but the DNS never called him back. On 1/13/17 at 12:15 pm, the DNS stated that when Resident 84's husband came into the facility and asked if Resident 84 could return, the DNS told the Admissions Coordinator about Resident 84 wanting to return. The Admissions Coordinator told the DNS that Resident 84 could not return. In an interview on 1/13/17 at approx. 2:30 pm, the Social Services Director (SSD) was asked about conversations with Resident 84's husband and the sister-in-law not wanting Resident 84 to leave. She stated that she spoke with them, but it was not documented. She stated that the facility felt that Resident 84 would do better in a smaller environment, because all she did was self-propel around the facility. In a review of the medical record there was no evidence of a 30 day notice or as to why the needs of the resident could no longer be met by the facility the resident was discharged to an AFH on 9/26/16. Resident 101 Resident 101 was admitted on [DATE] after having a stroke. She was non weight bearing and flaccid on right side. The record showed the resident was discharged on [DATE]. On 1/10/17 at 8:47 am, the HCS case manager stated that the facility contacted her on Weds, 12/21, during the holiday breaks, and stated that Resident 101 was discharging on 12/28 and asked if the CM could do an assessment before they left. When she met with the family they were apprehensive of the discharge and did not feel that she was ready to go. The facility told the family that they did not have long term care beds and that her insurance would stop on paying on 12/28/16 so she had to discharge. When she was first contacted by the facility she requested that the discharge be delayed, but the facility told the case manager that her managed care insurance was ending so the resident had to leave. The case manager stated that the facility did not allow straight Medicaid clients to remain in the facility so she did not attempt to argue about how Medicaid funding would continue to fund the resident. In an interview on 1/13/17 at 11:10 am, Resident 101 and her son stated they felt the discharge was rushed and the son did not feel that the resident was ready to come home yet. They were told that the managed care company funding was ending and the resident could not stay at the facility. Both residents were not allowed to remain in the facility, they were not given 30 day notices as to why their needs could not be met in the facility, even though the family of Resident 101 did not want to be rushed and the family of 84 wanted her remain in the facility, they were both discharged even though they had Medicaid funding as a backup funding resource. See also F 208 for additional information

Based on observation, interview and record review the facility failed to provide necessary care and services for 2 of 20 (163 and 169) sample residents including failure to follow treatment orders for daily weights and failure to evaluate, monitor and follow facility's policy and physician's orders [REDACTED]. Findings include: RESIDENT 169 Resident 169 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In review of the admission Minimum Data Set (MDS) assessment dated [DATE] under Bowel Patterns the question Constipation present? was answered No. In review of the admission orders [REDACTED]. Milk of Magnesia, (laxative) was to be administered at bedtime of the 3rd day of no bowel movement (BM); a [MEDICATION NAME] suppository was to be administered by the morning of the 4th day if no BM; and a Fleet's enema was to be given on the afternoon of the 4th day if no BM. No Milk of Magnesia (MOM), [MEDICATION NAME] suppository, or Fleet's enema was documented as given on the December 2016 MAR. The facility's Bowel Protocol policy and procedure stated that bowel records are reviewed daily on a designated shift, residents who have not had a bowel movement in 3 days will be given MOM. If no bowel movement by the following shift a [MEDICATION NAME] suppository should be given. If the resident continues without bowel movement by the next shift a Fleet's enema would be given. If a resident exceeds 4 days without a bowel movement the physician would be notified for further orders. In review of the resident's Intake and Output Report and Vitals Report a large bowel movement was documented on 12/17/16. No further bowel movement was documented until 12/23/16. Review of the progress notes dated 12/17/16 -12/22/16 revealed no bowel movement was documented. On 12 22/16 at 1:13 PM the nurse documented in the progress note the resident as alert/stable. Given PRN (as needed) mom (Milk of Magnesia) for no BM. Will continue to monitor POC (plan of care). At 2:25 PM the nurse documents the resident makes the facility BM report. Refuses MOM and says he is not constipated. Staff to monitor the issue of BM. Added to 24 hour report. In a progress note at 4:13 PM the resident complains of heartburn and feels the cause of his discomfort is that he needs to have a BM. When asked if he wanted a bedpan the resident just laughed. The note went on to state the resident's daughter ran from the room at 2:30 PM yelling he is throwing up blood . It was documented by nurse the resident was in no apparent distress holding emesis basin with small amount liquid, red, but not appearing as blood and some mucus. Order for [MEDICATION NAME] obtained from physician and administered at 2:50 PM. The progress note stated the resident continued to complain of having to move his bowels but resident is a swing Hoyer lift, so the brief or a bedpan are the only options. At 7:45 PM it was documented the resident vomited about 100 millilters (ml) of coffee-ground appearing vomitus. Daughter was present. Resident was alert, conversant, reporting no pain. 911 was called and resident sent to the hospital. The physician was notified. In review of the clinical record the physician had not been notified the resident had had no BM since 12/17/16. Review of the hospital's emergency department record revealed a progress note dated 12/22/16 at 11:39 PM documenting the patient has been disimpacted by the PA. Abdominal imaging showed a large stool (BM) burden throughout the colon. Correlate with possibility of constipation In review of the preliminary care plan dated 12/14/16 constipation was not listed as a potential problem secondary to narcotic use. Constipation was added to the care plan on 12/22/16 after the resident was already impacted. In an interview on 01/10/17 at 1:08 PM with the resident he stated I went to the hospital last month for my bowels. The medicine got me plugged up. I don't know if they were giving me stuff for it didn't work I guess. Doing ok now though. In an interview on 01/11/17 at 7:11 AM with Staff C, Resident Care Manager, she stated the bowel protocol was standard for all residents as stated in their policy. If that doesn't work the physician should be notified. If the physician was notified it would be documented in the progress notes. When asked why the protocol was not followed and the resident developed an impaction she stated oh, I didn't know he had an impaction. She was not sure why the protocol had not been followed. I will look for more documentation. No further information was presented. In an interview on 01/13/17 at 1:46 PM with Staff Q, Licensed Nurse, she stated that if the bowel protocol did not work or the resident refused it should be documented on the MAR and the physician notified. The physician notification would be documented in the progress note. In an interview on 01/13/17 at 11:00 AM with the DNS concerning care planning for the resident she stated that the care plan is updated with an Acute Change in Condition form which then goes in the notebook at the nurse's station with the preliminary care plan. This alerts the nurses for what they should be monitoring. She was not sure why the bowel management was not on the preliminary care plan or why the impaction was not added. RESIDENT 163 Resident 163 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. In an interview with the resident on 01/10/17 at 1:11 PM he stated: I have a appointment with my doctor, my kidney's don't work that well anymore and my body starts to fills up with fluid. Record review on 01/12/17 revealed physician's orders [REDACTED]. The weight was also scheduled to be done daily. Further review of the record revealed two weights since day of admission, with one documented refusal by the resident on 01/08/17. In an interview with the Director of Nursing Services, on 01/12/17 at 1:57 PM, she said: they weren't done daily, those are the only weights that are on record.

Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 3 sample residents (1, 2). Failure to administer medications to the correct resident resulted in harm for Resident 1 who required hospitalization due to [MEDICAL CONDITION] (low blood pressure) and placed Resident 2 at risk for possible side effects due an incorrect dose of narcotic medication. Findings include: The facility's medication administration error policy and procedure revealed that a significant medication error is defined as one which causes the resident discomfort or jeopardizes his or her health and safety. [MEDICAL CONDITION] is the medical term for low blood pressure (less than 90/60). When blood pressure drops suddenly and the brain is deprived of an adequate blood supply this can lead to dizziness or lightheadedness. RESIDENT 1 Resident 1 was admitted on [DATE] for treatment of [REDACTED]. The physician's orders [REDACTED]. Resident 1's charted vital signs revealed his blood pressure (BP) ranged from above 140 systolic and above 80 diastolic. (140/80). The physician's notes dated 10/3 and 10/4/16, documented medication would not be started for Resident 1's elevated BP but would just monitor at this time. During an interview on 10/20/16 with the Director of Nursing (DNS), she stated that on 10/6/16, Resident 1 had been administered the wrong medications and received his room-mates medications. The medications administered to Resident 1 in error included [MEDICATION NAME] (a diuretic), [MEDICATION NAME] (heart medication), [MEDICATION NAME] (blood pressure medication),[MEDICATION NAME](cardiac dilation) and [MEDICATION NAME] (blood thinning). The DNS also stated prior to administering medications, licensed nurses (LNs) should identify individual residents by looking at their picture to ensure the correct medications are administered to the correct residents. The medication error report dated 10/6/16, documented Resident 1 was administered the wrong medications on the morning of 10/6/16. The report revealed LNA had given all his roommates medications to Resident 1 resulting in [MEDICAL CONDITION] and medical attention in the ED(emergency room ). The hospital's history and physical dated 10/6/16, documented when Resident 1 went to his scheduled appointment with the ID doctor, he was found to be hypotensive (low blood pressure) with a blood pressure of 60/40, mildly light headed and was immediately sent to the emergency department (ED). The ED note revealed he was admitted due to [MEDICAL CONDITION], likely a combination [MEDICATION NAME] and assessed to have some acute kidney (kidney) injury which may be attributable to renal hypoperfusion (due to low blood pressure). A hospital note dated 10/6/16 at 8:52 a.m., revealed Resident 1 was admitted for blood pressure stabilization as his blood pressure remained low, orthostatic to the 70's after he received intravenous infusion (IV) fluids. The hospital note documented he had a known foot infection that will need antibiotics and doesn't normally take BP (blood pressure) meds (medications). The ED notes stated the resident was admitted related to his [MEDICAL CONDITION]. The blood pressure recordings revealed the following readings: 87/50 at 09:00 a.m., 89/55 at 10:00 a.m., 77/55 at noon (12:01p.m), 97/65 at 01: 09 p.m., 85/58 at 01:31 p.m., 94/55 at 02:00 p.m., and was admitted to the hospital at 2:30 p.m. On 10/20/16 at 3:03 p.m., Resident 1 was interviewed and stated he was not happy about getting the wrong medications and LNA should have identified my face. During an interview on 11/1/16 at 10:33 a.m., with LN B, she stated the physician was notified regarding Resident 1 being administered the wrong medications. LN B stated she was concerned as Resident 1 was not on blood pressure medications. LN B stated she had accompanied Resident 1 to his scheduled appointment as he needed to be watched. RESIDENT 2 Resident 2's pain assessment dated [DATE], revealed that she was receiving routine and as needed (prn) medications for back pain. A physician's orders [REDACTED]. The physician's orders [REDACTED]. The Medication Administration Record [REDACTED]. A medication error report for 10/9/16 indicated two medication errors. The first error regarding the narcotic patch was not removing the patch per physician's orders [REDACTED]. The report documented LN D had applied a 50 mcg patch instead of the ordered 25 mcg dose and LN C had not removed the patch on day 3 (72 hours). A nursing note entry dated 10/9/16 by LN D documented she had applied a 50 mcg patch in error. LN D documented she used a narcotic patch from another resident's narcotic patch and placed another resident's patch on Resident 2. Review of Resident 2's MAR for October 2016 revealed LN D had not documented any administration or removal of the 50 mcg narcotic patch. On 10/20/16 the narcotic logs and medication error reports were reviewed with the Director of Nursing (DNS). The DNS stated LN D used another resident's medication and had not documented the administration or removal of the narcotic patch on Resident 2's MAR. The DNS stated LNs had not followed the physician's orders [REDACTED].

Based on interview and record review, the facility failed to follow the standards of professional practice regarding medication administration and documentation. Failure to administer medications according to the rights of administration for 2 of 3 sample residents (1, 2) resulted in hospitalization for Resident 1 and placed Resident 2 at risk for possible side effects. Findings include: Nursing 2016 Drug Handbook 36th edition, describes the eight rights of medication administration as: 1. The Right drug 2. The Right patient 3. The Right dose 4. The Right time 5. The Right route In addition to the traditional five rights of individual practice, best-practice researchers have added three additional rights. 6. The Right reason 7. The Right response 8. The Right documentation WRONG MEDICATIONS ADMINISTRATION TO WRONG RESIDENT Resident 1's physician's orders [REDACTED]. During an interview on 10/20/16 the Director of Nursing (DNS), stated that on 10/6/16, Resident 1 had been administered the wrong medications. Resident 1 had been administered his room-mates medications. The medications administered to Resident 1 in error included a diuretic, a heart medication, a blood pressure medication, a cardiac medication and a blood thinning medication. The DNS stated one of the ways residents are identified is by using their picture to ensure the correct medications are administered to the correct residents. The facility's medication error report dated 10/6/16, showed Resident 1 had been given the wrong medications that belonged to his roommate. On 10/6/16, Resident 1 was transported to the emergency room (ER) for evaluation. The hospital note documented he was admitted for [MEDICAL CONDITION] after being administered incorrect medications at the facility. On 10/20/16 at 3:03 p.m., Resident 1 was interviewed and stated he was not happy about getting the wrong medications and LN A should have identified my face. The DNS stated LN B pointed out Resident 1 to LN A however LN A had not followed the procedure for identifying the resident prior to medication administration. The DNS stated Resident 1 had questioned LN A about the nasal medication (nasal) which was not his prescribed medication. WRONG DOSE OF MEDICATION: Review of the facility's medication error report dated 10/9/16, indicated LN D applied the wrong dose of narcotic medication. LN D applied a 50 mcg patch instead of the ordered 25 mcg dose on Resident 2. A nursing note entry dated 10/9/16 by LN D documented the patch 50 mcg placed in error, the 25 mcg patch had not been received from pharmacy so she used a discharged resident's patch. On 10/20/16 the narcotic logs, medication error reports and Medication Administration Records were reviewed with the Director of Nursing (DNS) relating to Resident 2's medication error report. The DNS stated LN D had used another resident's narcotic medication for Resident 2. RIGHT DOCUMENTATION: A nursing note entry dated 10/9/16 by LN D documented the patch 50 mcg placed in error, the 25 mcg patch had not been received from pharmacy so she used a discharged resident's patch. The MAR for October revealed LN D had not documented the administration or removal of the narcotic patches on Resident 2's MAR. The DNS stated LNs had not followed the physician's orders [REDACTED]. physician's orders [REDACTED]. A physician's orders [REDACTED]. The order was to administer a narcotic patch ([MEDICATION NAME] 25 mcg/hr) every 72 hours (3 days). The LN did not transcribe on the MAR indicated [REDACTED]. Review of the narcotic logs, medication error reports and Medication Administration Records on 10/20/16 with the Director of Nursing (DNS) relating to medication errors regarding Resident 2's narcotic patch. The DNS stated a LN had not transcribed the physician's orders [REDACTED]. Delay in narcotic patch removal, application of an incorrect dose and use of another resident's medication patch placed Resident 2 at risk for possible complications.