Every finding on record at Redmond Care and Rehabilitation Center

Based on interview and record review, the facility failed to ensure physician orders for pain management and/or post-surgery staple removal were carried out for 2 of 4 Residents (Residents 1 & 2), reviewed for quality of care. These failures placed the residents at risk for discomfort and a diminished quality of life.Findings included.Review of the facility's policy titled, Medication and Treatment Orders, revised in April 2014, showed Orders for medications and treatments will be consistent with principles of safe and effective order writing [giving instructions for patient [resident] care in a way that is clear, complete, and impossible to misunderstand].RESIDENT 1Review of Resident 1's face sheet showed she was admitted to the facility on [DATE] with diagnoses that included orthopedic (related to the bones, joints, and muscles) aftercare and left knee osteoarthritis (a type of arthritis - inflammation or damage in the joints).Review of Resident 1's hospital document titled, After Visit Summary, dated 12/09/2025, showed Resident 1 admitted to the facility with a medication list that included Acetaminophen [Over the Counter (OTC- does not require a prescription) pain medication] 500 mg [milligrams - a unit of measurement], take 2 [two] capsules by mouth every 8 [eight] hours.Review of a facility document titled, LN [Licensed Nurse] Pain Management Review, dated 12/09/2025 showed Resident 1 was assessed for pain and that she endorsed having pain or discomfort to her left knee in the past five days. Further review showed, Goal/Recommendations included Initiate plan of care for pain.Review of a facility document titled, Order Summary Report, showed Resident 1 had a physician's order for Acetaminophen Oral Capsule 500 MG - Give 1000 mg by mouth three times a day for pain, with a start date of 12/10/2025 (one day after Resident 1 admitted to the facility).Review of a nursing progress note written on 12/09/2025 at 2:31 PM, showed Resident 1 arrived at the facility. Further review showed Resident 1 had listed allergies of codeine and tramadol (opioid - a class of drugs used to treat pain) medications.Review of Resident 1's Medication Administration Record (MAR) for December 2025 showed Acetaminophen was scheduled for administration at 8:00 AM, 2:00 PM and at 8:00 PM daily, starting on 12/10/2025. It did not show documentation of Resident 2 receiving pain management on 12/09/2025.Review of nursing progress notes showed documentation of Resident 1's initial medical provider encounter on 12/10/2025. It showed, [Resident 1] Seen today for my initial visit with patient [resident] as new admit to SNF [Skilled Nursing Facility] and prior to patient opting to leave AMA [Against Medical Advice]. It further showed, [Resident 1] Says very unhappy with care she has received so far since her admission yesterday afternoon. Says had to wait several hours last night for her pain med [medication] and ice for her knee.In an interview on 02/02/2026 at 8:30 AM, Resident 1 stated she arrived at the facility at 2:00 PM on 12/09/2025 and that I was on [Acetaminophen] every 8 hours because I was allergic to opioid medications. Resident 1 further stated I had no pain medication, no [Acetaminophen].I asked for [Acetaminophen], and that I needed that pain medication, I had a fresh injury.In an interview on 12/13/2026 at 12:45 PM, Staff C, Licensed Practical Nurse, was asked what the facility's process was for administering medications to a newly admitted resident and Staff C stated, I refer to the MAR.pain medication, we need to pay attention to and follow the physician orders. Staff C further stated that OTC medication was always available, in the medication carts and medication supply room.In an interview and joint record review on 02/13/2026 at 12:49 PM, Staff B, Resident Care Manager, stated that physician orders for medication and treatment were continued at the facility when a resident admits from a hospital and that We get a discharge summary from the hospital.these orders don't [do not] need to be signed off by the in-house [medical] provider because we are just continuing the orders. When asked about the facility's process for OTC medications for newly admitted residents, Staff B stated, We supply a lot of OTC medication, so there shouldn't [should not] be any lag with those, we could give the next dose. A joint record review of Resident 1's MAR for December 2025 did not show documentation of Resident 1 receiving pain medication upon admission to the facility on [DATE]. Staff C stated, It [Resident 1's Acetaminophen] should have been given.In an interview on 12/13/2026 at 1:20 PM, Staff A, Director of Nursing, stated When there is routine and as needed [orders for pain medication], we follow the doctor's order.RESIDENT 2Review of Resident 2's face sheet showed she was admitted to the facility on [DATE] with diagnoses that included injury of head due to a fall, subsequent encounter.Review of Resident 2's document titled, [Hospital Name] Discharge Summary, dated 12/15/2025, showed SNF [Skilled Nursing Facility] follow-up action items, included Requires staple removal, 4 [four] staples (to be removed from scalp on 12/19 [12/19/2025]).Review of a Resident 2's facility document titled, Order Summary Report, showed a physician's order to Remove 4 staples on scalp, dated 12/15/2025 and to start on 12/19/2025.Review of Resident 2's December 2025 Treatment Administration Record (TAR) showed documentation of Resident 2's scalp staples were marked removed on 12/19/2025. It further showed Staff D, Registered Nurse, documented the removal of Resident 2's scalp staples.Review of a nursing progress note dated 12/23/2025, showed Resident 2 was transferred to the hospital for evaluation of critical laboratory results (abnormal medical test results), diarrhea (watery stools) and vomiting.Review of Resident 2's hospital document titled, Emergency Department Encounter, dated 12/23/2025, showed Right scalp wound with dried blood and staples in place.In an interview and joint record review on 01/07/2026 at 2:35 PM, Staff D was asked if she recalled removing scalp staples for Resident 2 on 12/19/2025, and Staff D stated, I remember her .I had to ask for help because she refused.we had to re-schedule the next day.I think was able to remove a couple before she was like no.I do remember the first time, it was two [staples], she said stop after two [staples]. Staff D further stated that she could not recall the total number of staples removed from Resident 2's scalp. When asked if an additional treatment order would be carried out after Resident 2's initial refusal on 12/19/2025, and Staff D stated Yes, I believe so. A joint record review of Resident 2's December 2025 TAR did not show documentation of additional scheduled scalp removal treatments after 12/19/2025. When asked if it was possible that all four staples were not removed from Resident 2's scalp as ordered, Staff D stated, I remember looking and feeling as much as she would allow us to.A joint record review on 02/13/2026 at 12:53 PM with Staff B showed Resident 2's Hospital Discharge summary, dated [DATE], included the instruction, SNF follow-up action items, included Requires staple removal, 4 staples [to be removed from scalp 12/19/2025]. Staff B stated that the treatment order would be carried out according to Resident 2's hospital discharge summary. A joint record review of Resident 2's document titled, Emergency Department Encounter, dated 12/23/2025, showed Right scalp wound with dried blood and staples in place. Staff B stated, The expectation is for all the staples to be removed, but she did have refusal of care and maybe she didn't [did not] let us remove all of the staples, and that we would try again. Further joint record review of Resident 2's December 2025 TAR and December 2025 nursing progress notes did not show documentation of additional scheduled scalp removal treatments after 12/19/2025. Staff B stated, There's [There is] no additional notes about staples.In an interview on 12/13/2026 at 1:20 PM, Staff A stated they expected staff would Assess for pain, assess the site and make sure everything was removed.Reference: (WAC) 388-97-1060 (1)-(3)(k).

Based on observation, interview, and record review, the facility failed to ensure food items were handled appropriately in accordance with professional standards of food safety for 32 of 75 residents (Residents 11, 3, 34, 128, 4, 178, 66, 28, 30, 33, 55, 182, 17, 51, 59, 36, 63, 74, 230, 183, 231, 44, 49, 7, 72, 52, 1, 13, 26, 53, 68 & 61), reviewed for food services. This failure placed the residents at risk of food-borne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Procurement, Storage, and Distribution, revised on 07/08/2022, showed that the facility would store, prepare, distribute, and serve food in accordance with professional standards for food safety. The policy further showed that the facility would follow proper sanitation or food handling practices to prevent the outbreak of foodborne illness. Observation on 06/11/2025 from 11:32 AM to 12:34 PM, showed Staff G, Cook, with gloves on touched the meal cart, meal tickets, and the preparation table area. Using the same gloves, Staff G, started to place fresh parsley on the residents' plates for Resident 11, Resident 3, Resident 34, Resident 128, Resident 4, Resident 178, Resident 66, Resident 28, Resident 30, Resident 33, Resident 55, Resident 182, Resident 17, Resident 51, Resident 59, Resident 36, Resident 63, Resident 74, Resident 230, Resident 183, Resident 231, Resident 44, Resident 49, Resident 7, Resident 72, Resident 52, Resident 1, and Resident 13. At 12:30 PM, Staff G washed their hands and put on new gloves, touched the meal cart, meal tickets, preparation table area, and a bag of bread. While wearing the same gloves, Staff G continued to place fresh parsley on the residents' plates for Resident 26, Resident 53, Resident 68 and Resident 61. In an interview on 06/11/2025 at 12:36 PM, Staff G stated that their process for serving food items was to use serving utensils to place food items on residents' plates. Staff G stated that they did not use a serving utensil and/or a serving tong to place fresh parsley on the residents' plates and that they should have. In an interview on 06/11/2025 at 12:37 PM, Staff H, Dietary Supervisor, stated they expected food items to be served using serving utensils. Staff H stated that Staff G should not have touched fresh parsley with gloved hands to place them on residents' plates after touching the meal carts, meal tickets, meal trays, serving/preparation table, and the bag of bread. Staff H further stated that Staff G should have used a serving utensil to place the fresh parsley on the residents' plates. Reference: (WAC) 388-97-1100 (3) .

Based on interview and record review, the facility failed to ensure an advance directive (a written instruction, such as a living will or Durable Power of Attorney [DPOA] for health care [a document delegating to an agent the authority to make health care decisions in case the individual delegating the authority subsequently becomes incapable to do so]) was obtained for 1 of 3 residents (Resident 14 ), reviewed for advance directives. This failure placed the resident and/or their representative at risk for losing their right to have their preferences honored to receive or refuse/discontinue care according to their choice. Findings included . Review of the facility's policy titled, Advance Directives and Associated Documentation, revised in April 2025, showed that Prior to, upon, or immediately after admission, a facility staff member shall .inquire whether they [residents] have completed an Advance Directive and if they had they should Obtain [a] copy of the Advance Directive .documents and place in the resident health record. Review of the facility's document titled, Advance Directive Receipt, dated [signed by Resident 14] on 08/28/2024, showed that Resident 14 marked that they had an advance directive and would provide a copy. Review of Resident 14's electronic health record under the miscellaneous tab reviewed on 06/08/2025, showed documentation that Resident 14 had a financial DPOA on file and did not show that there was a copy of Resident 14's advance directive. In an interview on 06/10/2025 at 9:15 AM, Resident 14 stated that they had an advance directive and that they thought they had provided a copy to the facility. In an interview and joint record review on 06/10/2025 at 9:18 AM, Staff K, Social Services, stated that the facility would ask residents at admission if they had an advance directive and would request a copy of their paperwork. A joint record review of Resident 14's DPOA document showed that it was a financial DPOA. Staff K stated, there's no mention of medical; I think this is for her finances. In an interview and joint record review on 06/10/2025 at 3:42 PM, Staff M, Patient Advocacy Resource, stated that Resident 14's DPOA paperwork on file was financial. A joint record review of Resident 14's progress notes from 08/24/2025 through 06/09/2025, showed no documentation that there was follow up to obtain Resident 14's DPOA for healthcare. Staff M stated there were no progress notes showing that this was followed up on. Staff M further stated that they spoke with Resident 14 today [06/10/2025] and confirmed that Resident 14 had a DPOA for healthcare and they would be reaching out to get a copy of the paperwork to have on file. In a follow-up interview on 06/13/2025 at 9:42 AM, Staff K stated, it should be documented better and it could be documented in a progress note, when they followed up with a resident and/or their representative to get a copy of their advance directive. Staff K further stated that it was unclear based on the provided documentation that there was any follow-up to obtain Resident 14's advance directive paperwork before 06/10/2025. In an interview on 06/13/2025 at 11:39 AM, Staff A, Administrator, stated that a financial DPOA was not an advance directive. Staff A stated that if a resident said they had an advance directive, then we would need to get a copy and that it should be in the resident's medical record. Staff A further stated that they expected follow-up to be done as often, until it is received and that there should be documentation of the follow-up in a progress note. Reference: (WAC) 388-97-0280 (3)(a)(d) .

DISCHARGE STATUS RESIDENT 76 Review of the nursing progress notes printed on 06/09/2025 showed Resident 76 discharged home on [DATE]. Review of the discharge MDS dated [DATE] showed Resident 76 was admitted to the facility on [DATE] and was discharged on 03/15/2025. Further review of the MDS showed Resident 76 was marked they were discharged to the hospital in Section A2105 (Discharge Status). Section A2105 should have been marked discharge to Home/Community. In an interview and joint record review on 06/11/2025 at 11:09 AM, Staff D stated that they follow the RAI manual for completion of MDS assessments. A joint record review showed Resident 76's MDS dated [DATE] was marked discharged to the hospital. Staff D stated the MDS was marked discharged to the hospital and [Resident 76] did not go there. A joint record review of the progress notes dated 03/15/2025 showed Resident 76 discharged home. Staff D stated that Resident 76's discharge MDS was not accurate and that it should have been marked discharged to home/community. In an interview on 06/11/2025 at 11:15 AM, Staff B stated they expected MDS assessments to be completed accurately according to the RAI MDS Manual. Staff B further stated that Resident 76's MDS should have been marked to have discharged home and that their MDS was inaccurate. Reference: (WAC) 388-97-1000 (1)(b) Based on interview and record review, the facility failed to ensure resident assessments were completed accurately for 3 of 21 residents (Residents 19, 12, & 76), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments were coded on the MDS regarding diagnosis, medication use, and discharge status placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life. Findings included . According to 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 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). DIAGNOSIS RESIDENT 19 Review of admission MDS dated [DATE], showed Resident 19 was not marked for dementia (a progressive condition that affects the brain) in Section I (Active Diagnosis - under I4800). Review of Resident 19's face sheet printed on 06/09/2025, showed Resident 19 had a diagnosis of dementia. Review of physician's progress notes dated 04/01/2025, showed Resident 19 had a diagnosis of dementia during the look-back-period (04/01/2025 to 04/07/2025). In an interview and joint record review on 06/12/2025 at 1:53 PM, Staff D, MDS Coordinator, stated they would follow the RAI Manual for MDS accuracy. A joint record review of Resident 19's physician progress notes dated 04/01/2025, showed Resident 19 had a diagnosis of dementia and was taking a medication for it. A joint record review of Resident 19's admission MDS dated [DATE], showed that dementia was not marked in Section I. Staff D stated Resident 19 should have been marked for dementia and that their MDS was not accurate. MEDICATION USE RESIDENT 12 Review of Resident 12's admission MDS dated [DATE], showed Resident 12 was not marked for antianxiety (medication for anxiety [having excessive/persistent worry and fear]) in Section N (Medications - under N0415B1 [taking, or receiving an antianxiety] and N0415B2 [indication noted-reason why the resident is taking it]) during the look-back period (05/21/2025 to 05/27/2025). Review of May 2025 Medication Administration Record (MAR) showed Resident 12 received an antianxiety medication on 05/22/2025, 05/23/2025, 05/25/2025, and 05/26/2025 during the look-back-period. A joint record review and interview on 06/12/2025 at 1:53 PM with Staff D, showed Resident 12 was not marked to have received an antianxiety medication during the look-back-period. A joint record review of Resident 12's May 2025 MAR showed they were administered an antianxiety during the look-back-period. Staff D stated that antianxiety should have been marked in Resident 12's assessment and that their MDS was not accurate. In an interview on 06/12/2025 at 3:00 PM, Staff B, Director of Nursing, stated that they expected the MDS to be completed accurately for Resident 19 and Resident 12.

Based on observation, interview, and record review, the facility failed to implement a care plan for 1 of 5 residents (Resident 3), reviewed for comprehensive care plans. The failure to implement the care plan for communication placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised in April 2025, showed that the facility will develop and implement a comprehensive person-centered .care plan for each resident that will include resident's needs, goals and desired outcomes. Review of a hearing clinic visit note dated 04/24/2024, showed that hearing instruments [hearing aids] were recommended for Resident 3. An additional visit note dated 05/24/2024, showed that Resident 3's representative reported that when the device is in her ear, she is able to hear him better. Review of the communication care plan printed on 06/08/2025, showed an intervention for left sided hearing [aid] kept in charger at bedside. Needs staff to place and remove. An observation on 06/08/2025 at 2:41 PM, showed Resident 3 with no hearing aids in their ears. Resident 3's representative stated that Resident 3 was hard of hearing, that they had hearing aids, and they aren't [are not] charged. Resident 3's representative further stated that the hearing aids had not been put in for a while. Additional observations on 06/09/2025 at 10:45 AM, on 06/10/2025 at 8:51 AM, at 11:48 AM, at 1:12 PM, on 06/11/2025 at 11:27 AM, and at 1:35 PM, showed Resident 3 had no hearing aids in their ears. In an interview and joint record review on 06/11/2025 at 1:38 PM, Staff I, Registered Nurse, stated that resident's care plans should be followed. A joint record review of Resident 3's communication care plan showed, left sided hearing [aid] kept in charger at bedside. Needs staff to place and remove. Staff I stated they were responsible for placing the hearing aid for Resident 3. Staff I stated, aides [CNA-Certified Nursing Assistant] can put them in and we [nurses] double check. A joint observation showed no hearing aids in Resident 3's ears. Staff I asked Staff L, CNA [who was also in the resident's room], where Resident 3's hearing aid was and Staff L stated, I don't [do not] know and she hasn't [has not] been using the hearing aid for a while. She doesn't [does not] like them. In an interview and joint record review on 06/12/2025 at 2:22 PM, Staff F, Resident Care Manager, stated that they expect staff to read it [care plans] and follow the care plan. Staff F stated that if the care plan said for staff to help place and remove hearing aids for a resident, then staff should follow the care plan. A joint record review of Resident 3's communication care plan showed that it had been updated on 06/12/2025 and now showed instructions that Resident 3's representative would be the one to charge the hearing aid. It further showed that Resident 3's representative or staff could place the hearing aid. Staff F stated, I [just] updated it [the care plan]. In an interview on 06/13/2025 at 11:16 AM, Staff B, Director of Nursing, stated that they expected staff to follow resident's care plans. Staff B further stated that they expected the licensed nurse to put on Resident 3's hearing aid if that was what the care plan showed. Reference: (WAC) 388-97-1020(2)(a) .

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 3), 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, revised on 04/03/2025, showed, A resident's abilities in ADL's do not diminish unless circumstances on the individual's clinical condition demonstrate that diminution [decline] was unavoidable. This includes the resident's ability to .use speech, language, or other functional communication systems. Review of Resident 3's quarterly Minimum Data Set (an assessment tool) showed that Resident 3 had minimal difficulty with hearing (difficulty in some environments, for example when a person speaks softly or the setting is noisy). Review of a hearing clinic visit note dated 04/24/2024, showed that hearing instruments [hearing aids] were recommended for Resident 3. An additional visit note dated 05/24/2024, showed that Resident 3's representative reported that when the device is in her ear, she is able to hear him better. Review of Resident 3's physician orders dated 05/17/2024, showed an order for, Left hearing aid on in the morning, off at night, or when uncomfortable every day and evening shift. It further showed instruction for the LN [Licensed Nurse to] put it ON [at] 0700 [7:00 AM] and take it OFF [at] 1800 [6:00 PM]. An observation on 06/08/2025 at 2:41 PM, showed Resident 3 with no hearing aids in their ears. Resident 3's representative stated that Resident 3 was hard of hearing, that they had hearing aids, and they aren't [are not] charged. Resident 3's representative further stated that the hearing aids had not been put in for a while. Additional observations on 06/09/2025 at 10:45 AM, on 06/10/2025 at 8:51 AM, at 11:48 AM, at 1:12 PM, on 06/11/2025 at 11:27 AM, and at 1:35 PM, showed Resident 3 had no hearing aids in their ears. In an interview and joint record review on 06/11/2025 at 1:38 PM, Staff I, Registered Nurse, stated that nurses were responsible for placing hearing aids for residents that needed help with ADLs. Staff I stated that Certified Nursing Assistants (CNAs) could place them and that nurses would check to make sure they had been placed for the residents. Staff I stated that Resident 3 was hard of hearing and had one hearing aid. A joint record review of Resident 3's physician orders showed, Left hearing aid on in the morning, off at night, or when uncomfortable every day and evening shift. It further showed instruction for the LN [to] put it ON [at] 0700 and take it OFF [at] 1800, ordered on 05/17/2024. Staff I stated that the CNA had placed the hearing aid for Resident 3 today [06/11/2025]. When asked if they had confirmed hearing aid placement, Staff I stated, I thought so, I guess I didn't [did not]. A joint observation showed no hearing aids in Resident 3's ears. Staff I asked Staff L, CNA, where the hearing aid was and Staff L stated, I don't [do not] know and she hasn't [has not] been using the hearing aid for a while. She doesn't [does not] like them. Resident 3's representative stated that it had been a couple weeks since the hearing aid had been charged or placed for Resident 3. Staff I stated, I thought it was in. My mistake. In an interview on 06/12/2025 at 2:22 PM, Staff F, Resident Care Manager, stated that nurses were responsible for placing hearing aids for residents that needed help with ADLs. Staff F stated that CNAs could also help place resident's hearing aids and the nurses should be checking if it's [it is] in place. In an interview and joint record review on 06/13/2025 at 11:01 AM, Staff B, Director of Nursing, stated that if residents needed help with ADLs, including help placing hearing aids, staff should help them. Staff B stated that nurses were responsible for placing hearing aids for residents that needed help with ADLs. A joint record review of Resident 3's physician orders, showed an order for, Left hearing aid on in the morning, off at night, or when uncomfortable every day and evening shift. It further showed instruction for the LN put it ON [at] 0700 and take it OFF [at] 1800. Staff B stated that they expected the licensed nurse to put [it] on [hearing aid] at seven AM for Resident 3. Reference: (WAC) 388-97-1060(2)(b) .

RESIDENT 14 An observation on [DATE] at 11:27 AM showed an opened bottle of biotin (a vitamin supplement) on Resident 14's nightstand. Resident 14 stated I try to take it [biotin] every day. Additional observations on [DATE] at 9:28 AM, on [DATE] at 9:17 AM, and at 1:12 PM, showed an opened bottle of biotin on Resident 14's nightstand. An interview and joint observation on [DATE] at 12:12 PM, Staff I, RN, stated that supplements were considered medications and that medications should be stored in a locked medication room or medication cart. When asked if medications could be stored at a resident's bedside, Staff I stated, No, [it] has to be in the cart. A joint observation showed an opened bottle of biotin on Resident 14's nightstand. Staff I stated that they were unsure if the opened bottle of biotin should be there. In an interview on [DATE] at 12:17 PM, Staff F, stated that medications should be stored in locked medication carts. Staff F further stated that if a resident was able to self-administer medications they could be kept at bedside and it's [it is] supposed to be in a locked drawer. In an interview on [DATE] at 12:50 PM, Staff B stated that medications should be stored in a locked medication room or medication cart. Staff B further stated that if a resident was able to self-administer medications then they should be stored in the drawer [in the resident's room] and should be locked. Reference: (WAC) 388-97-1300(2) Based on observation, interview, and record review, the facility failed to ensure drugs were properly labeled, and/or expired supplies were removed/discarded in accordance with current accepted professional standards for 2 of 5 treatment cart and/or medication cart (C Wing Treatment Cart and B Wing Medication Cart), and failed to properly store a supplement for 1 of 1 resident (Resident 14), reviewed for medication storage and labeling. These failures placed the residents at risk for receiving compromised or ineffective medications, unsafe medication administration, and potential adverse side effects. Findings included . Review of the facility's policy titled, Storage of Medications, revised in [DATE], showed, The facility shall store all drugs and biologicals in a safe, secure, and orderly manner. The policy further showed, Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals shall be locked when not in use, and trays or carts used to transport such items shall not be left unattended if open or otherwise potentially available to others. C WING TREATMENT CART A joint observation and interview on [DATE] at 10:04 AM, with Staff F, Resident Care Manager (RCM), showed an opened urea (moisturizes and softens rough and callused skin areas) care treatment cream that did not have an open date. Further joint observation of the urea cream showed a period after opening symbol (a graphic symbol on cosmetic and toiletry product packaging that indicates how long the product remains safe and effective after it has been opened) of 24 M (months), and it had no expiration date. Staff F stated that the urea cream was good for two years once it had been opened. Staff F further stated that they would expect there to be an open date once the medication had been opened. B WING MEDICATION CART A joint observation and interview on [DATE] at 10:20 AM with Staff I, Registered Nurse (RN), showed medication for Resident 2 labeled Gabapentin (used for facial pain) 100 mg (milligrams-a unit of measurement) capsules with an expiration date of [DATE]. Staff I stated that expired medication should not be in the medication cart and that it should have been wasted or discarded. On [DATE] at 12:50 PM, Staff B, Director of Nursing stated expired medication should not be stored in the medication cart. Staff B further stated when a treatment cream was opened, they expected staff to label it with an open date.

Based on observation, interview, and record review, the facility failed to ensure hand hygiene/glove use practices were followed for 1 of 4 staff (Staff J), reviewed for infection control. This failure placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Infection Prevention and Control Program, revised in April 2025, showed that facility personnel will handle, store, process, and transport linens so as to prevent the spread of infection and the facility will use effective methods for the safe storage, transport and disposal of garbage, refuse and infectious waste. An observation on 06/08/2025 at 9:20 AM, showed Staff J, Certified Nursing Assistant, took soiled material in a plastic bag from room [ROOM NUMBER] to the soiled utility room. It further showed Staff J wearing gloves on both hands while they carried the plastic bag in the hallway and touched the soiled utility room door handle with their soiled gloved hand. Additional observations on 06/08/2025 at 9:50 AM and 11:58 AM showed Staff J carried soiled material in a plastic bag through the hallway to the soiled utility room while wearing gloves on both hands. It further showed Staff J used their soiled gloved hand to touch the soiled utility room door handle, put the soiled material in the soiled utility room, removed the soiled gloves in the hallway and put in the garbage container in the hallway, and then performed hand hygiene. In an interview on 06/08/2025 at 12:21 PM, Staff J stated that their process for carrying soiled linens or soiled material was to put on gloves, put [soiled material] in a plastic bag, tie it up, put in [the] soiled utility room, take off [their] gloves and do hand hygiene. Staff J stated that they wore gloves while carrying the soiled material in the hallway, because [they were] holding something contaminated. Staff J further stated that they touched the soiled utility room door handle with their soiled gloves. In an interview on 06/13/2025 at 9:40 AM, Staff C, Infection Preventionist, stated that they expected staff to transfer soiled items to the soiled utility room by putting [soiled items] in a bag, take off [their soiled] gloves, perform hand hygiene, pick back up [the soiled items] and take to the soiled utility room. Staff C stated that staff should not wear gloves in the hallway unless they were cleaning equipment. Staff C further stated that staff should not touch door handles while wearing [soiled] gloves. In an interview on 06/13/2025 at 11:01 AM, Staff B, Director of Nursing, stated that staff should not wear gloves in the hallway while carrying soiled items to the soiled utility room and they should not touch the soiled utility room door handle with their gloves. Staff B further stated that these practices were a risk for spreading infection. Reference: (WAC) 388-97-1320(1)(a) .

Based on observation, interview, and record review, the facility failed to ensure showers or bathing were consistently provided for 1 of 4 residents (Resident 1), reviewed for Activities of Daily Living (ADLs). This failure placed the resident at risk for poor hygiene, decreased self-esteem, and a diminished quality of life. Findings included . Review of the facility's policy titled, Activities of Daily Living, revised in July 2015, showed that nursing assistants would provide assistance with ADLs based on the resident's individualized plan of care. Review of the admission Minimum Data Set (an assessment tool) dated 02/05/2025 showed Resident 1 required partial/moderate assistance with showers. Review of the shower schedule updated on 02/24/2025 showed Resident 1 was scheduled for showers on Thursday evenings. Review of the February 2025 bathing task showed that Resident 1 did not get showers on 02/27/2025 and 03/06/2025. The last time the resident had a shower was on 02/17/2025 and again on 03/18/2025 [before lunch], almost a month of not having a shower. On 03/18/2025 at 10:09 AM, Resident 1 stated I have not had a shower in a while. It would be nice to have a shower. During an interview and joint record review on 03/18/2025 at 10:22 AM, Staff C, Certified Nursing Assistant, stated that residents were provided shower according to their shower schedule. A joint record review of the shower schedule dated 02/24/2025 showed Resident 1 was scheduled for showers on Thursday evenings. Staff C stated that Resident 1 would have their showers on Thursdays by evening shift staff. On 03/18/2025 at 10:40 AM, Staff D, Registered Nurse, stated that residents had shower schedule, and that Resident 1 was scheduled for showers on Thursday evenings. On 03/18/2025 at 11:12 AM, Staff E, Resident Care Manager (RCM), stated they expect staff to document when resident was provided showers and/or when showers were refused. Joint record review of the February 2025 and March 2025 bathing task showed that Resident 1 did not have showers on Thursday 02/27/2025 an 03/06/2025 and no documentation to show that Resident 1 refused showers. Staff E stated Resident 1 did not get showers as scheduled and that there were no shower refusals. On 03/18/2025 at 1:15 PM, Staff B, RCM/Infection Preventionist, stated that Resident 1's shower should have been scheduled to a different day when Resident 1's dialysis (treatment that helps remove extra fluid and waste products from a person's blood when the kidneys are not able to) schedule changed to evenings. Reference: (WAC) 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to ensure foods stored were labeled/dated and discarded after the expiration date or use by date in accordance with professional standards for food safety for 1 of 3 freezers (Kitchen Walk-In Freezer) and 2 of 2 refrigerators (Kitchen Walk-In Refrigerator and Residents' Refrigerator), reviewed for food services. This failure placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages) and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Safety, dated 2018, showed, The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded, the individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared, the discard day or date may not exceed the manufacturer's use-by-date. KITCHEN WALK IN FREEZER Joint observation and interview on 06/03/2024 at 8:44 AM with Staff H, Nutrition Service Manager, showed 10 bags of vegetable mix, three bags of carrots and 10 bags of broccoli with no delivery date and use by date. Staff H stated that the facility's policy was to put the delivered date and use by date on the day of the arrival. Staff H stated that vegetable mix, carrots, and broccoli were not labeled with delivery date and use by date and should have been. KITCHEN WALK IN REFRIGATOR Joint observation and interview on 06/03/2024 at 8:20 AM with Staff H, showed 20 packets of tartar sauce with use by date of 06/01/2024 and one package of roast beef with no use by date. Staff H stated that there should have been a use by date and proceeded to write the use by date of 06/20/2024 on the roast beef. Staff H further stated that tartar sauce should have been discarded on or after the use by date. RESIDENTS' REFRIGATOR Joint observation and interview on 06/10/2024 at 1:51 PM with Staff H, showed Resident 17's left over lunch dated 06/09/2024 was in the Residents' Refrigerator located in the room between the Social Services office and Evergreen Room (Conference Room). Staff H stated that the left-over foods could be kept for three days. Staff H further stated that the left-over food should have had a use by date on it and proceeded to write 06/12/2024 on Resident 17's food. On 06/11/2024 at 8:51 AM, Staff A, Administrator, stated that it was their expectation for the kitchen staff to maintain food safety per the State and Federal guidelines. Reference: (WAC) 388-97-1100 (3)

Based on interview and record review, the facility failed to employ a qualified social worker that met the educational requirements and supervised social work experience for one year in a health care setting for 2 of 2 social workers (Staff J & P), reviewed for social worker qualifications. This failure placed the residents at risk for unmet social services care needs, and a diminished quality of life. Findings included . Review of the facility's document titled, Job Description Social Services Manager, dated November 2021, showed under section Education and/or Experience, an employee, Must have, as a minimum, a bachelor's [a type of undergraduate degree] degree in social work or a bachelor's degree in a human services field including but not limited to sociology [study of social life and change], special education, rehabilitation counseling [focused on helping people with disabilities], and psychology [study of mind and behavior]. The document further showed the employee, Must have, as a minimum, 1 [one] year of experience as a Social Worker, preferably in a hospital, long-term care facility, or other related health care facility. Review of the Facility Assessment, updated on 04/05/2024, showed the facility was licensed to provide care for 139 residents. STAFF J Review of the facility staff list showed Staff J, Social Services Director, was hired on 06/05/2023. Review of Staff J's resume showed they had an associate (academic qualification below a bachelor's degree) degree in communication. On 06/12/2024 at 10:15 AM, Staff J stated they had an associate degree in communication and that they did not have a bachelor's degree. STAFF P Review of the facility staff list showed Staff P, Social Services Director, was hired on 09/18/2023. Review of a copy of Staff P's bachelor's degree, dated 01/24/2018, showed Staff P had a degree in leisure [involving recreational occupation] and hospitality management [focus on aspects of business]. On 06/11/2024 at 10:08 AM, Staff P stated that there were two social workers for the building. Staff P stated that they had graduated with a bachelor's degree in leisure and hospitality management and that they had previously worked as a dental assistant. Staff P further stated that they had started to work as a social worker in the United States in September of 2023. On 06/11/2024 at 1:47 PM, Staff A, Administrator, stated that Staff P's bachelor's degree was not in any of the categories related to social work. On 06/12/2024 at 10:16 AM, Staff P stated that it had not been a year since they started working as a social worker for the facility and that their bachelor's degree was not in a human services field including, sociology, gerontology (study of the aging process), special education, rehabilitation counseling, or psychology. On 06/12/2024 at 11:05 AM, Staff A stated the facility had 139 certified beds. Staff A stated that Staff P started working in September 2023, and that they did not have a year experience. Staff A further stated that Staff J had the one year experience but did not have a bachelor's degree. Reference: (WAC) 388-97-0960 (2)(a)(b)

Based on interview and record review, the facility failed to ensure allegation of abuse was reported to the State Agency for 1 of 3 residents (Resident 237), reviewed for abuse allegations. This failure placed the resident at risk for potential unidentified abuse and lack of protection from abuse. Findings included . Review of the facility's policy titled, Abuse Prevention & [and] Investigation, revised in July 2015, showed, It is the policy of the facility that all suspected, alleged, or actual cases of resident abuse, including injuries of unknown origin, shall be thoroughly and completely investigated and reported according to State and Federal regulations. Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition), showed injuries of unknown source means any injury sustained by a resident where the source of the injury was not observed directly by staff, or the resident is not able to report/inform how the injury occurred. It further showed, Substantial injuries of unknown source, even if they do not appear to be due to abuse or neglect, must be reported to the Department; because the injuries may have resulted from failure to take preventative measures. Resident 237 admitted to the facility on [DATE] with diagnosis that included dementia (a cognition that affects thinking, memory, reasoning, personality, mood, and behavior). Review of the facility's January 2024 incident log dated 01/16/2024, showed Resident 237 had a left shoulder suspicious fx [fracture - a partial or complete break in a bone]. It further showed under the heading hotline notified (yes/no) was N [not notified]. Review of the facility's investigation report dated 01/19/2024, showed Resident 237 was found lying on their back by the entry door of their room with left temporal (head) bleeding and complained of left shoulder/back pain on 01/16/2024. Resident 237 was sent to the emergency room and returned to the facility the same day with an x-ray result concerning for fracture in the scapula (shoulder blade). It further showed that Resident 237 was unable to say what she was trying to do. Additionally, the investigation report showed that Staff R, Licensed Practical Nurse, reported that Resident 237 was unable to recall what had happened. Review of the nursing progress notes dated 01/17/2024, showed Resident 237 returned from the hospital with a diagnosis of a closed fracture of the left upper arm, facial laceration, and injury of the head. On 06/06/2024 at 2:53 PM, Staff R stated that Resident 237 was not able to state what had happened on 01/16/2024. In an interview and joint record review on 06/10/2024 at 9:46 AM, Staff K, Assistant Director of Nursing, stated their policy for reporting of unobserved falls with substantial injury depended on if they ruled out abuse or neglect. Staff K stated it was not usually called in to the State Agency because they knew what had happened and ruled out abuse. Joint record review of the January 2024 incident reporting log showed that Resident 237's incident dated 01/16/2024 under the heading hotline notified (yes/no) was an N. Staff K stated N meant that it was not reported to the State Agency. Staff K stated Resident 237 stated they had a fall but was unable to give the details of what had happened. On 06/10/2024 at 10:58 AM, Staff A, Administrator, stated that they followed the Purple Book for guidelines for abuse reporting. Staff A stated if a resident had a serious unknown substantial injury, they would report it to the State Agency within the required timeframes. Reference: (WAC) 388-97-0640 (5)(a)

Based on observation, interview, and record review, the facility failed to implement care plans for 2 of 18 residents (Residents 5 & 42), reviewed for comprehensive care plans. The failure to implement care plans for restorative care (to maintain a person's highest level of physical, mental, and psychosocial function to prevent decline that impact quality of life) and communication/sensory placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy titled, Restorative Care, revised in May 2016, showed, Restorative Care will be provided to each resident according to his/her individual needs and desires as determined by assessment and interdisciplinary care planning. RESIDENT 5 Resident 5 admitted to the facility on [DATE]. Review of the quarterly Minimum Data Set (an assessment tool) dated 04/11/2024, showed Resident 5 had Range of Motion (ROM - the amount of movement a joint or body part can make in a specific direction) impairment on both sides of their upper and lower extremities. Review of the activities of daily living care plan printed on 06/04/2024, showed an intervention for Resident 5, AROM [Active Range of Motion - moving joints entirely by the individual performing the exercise] of shoulders, elbows, hips, knees, and ankles .will be performed in order to maintain strength and ROM for 15 mins [minutes] at least 3x [times]/week. Review of the facility provided document titled, Restorative Nursing showed the following documentation of the days Resident 5's received AROM in May 2024: - 05/06/2024 to 05/12/2024: Two days - 05/13/2024 to 05/19/2024: One day - 05/20/2024 to 05/26/2024: Two days - 05/27/2024 to 05/31/2024: Zero days In an interview and joint record review on 06/05/2024 at 12:01 PM with Staff I, Certified Nursing Assistant, stated they worked as a restorative aide, and they provided restorative exercises for Resident 5 on Mondays, Wednesdays, and Fridays and that they documented in the Electronic Health Record (EHR). Joint record review of Resident 5's EHR, showed the last time the exercises were documented was on 05/24/2024. Staff I stated, I probably didn't document when I did the exercises. On 06/05/2024 at 2:12 PM, Staff O, Director of Rehabilitation, stated their expectation was that staff should be doing the ROM exercises [as stated] in the care plan. In an interview and joint record review on 06/06/2024 at 1:28 PM, Staff K, Assistant Director of Nursing, stated they expected Staff I to make sure she's doing the program in the care plan and documenting that it was done. Joint record review of the facility provided document titled, Restorative Nursing, did not show that Resident 5 had received AROM three times a week as was written in the care plan. Joint record review of Resident 5's care plan showed Resident 5 should have AROM exercises three times a week. Staff K stated that the care plan had been followed 50 percent of the time and that it did not meet their expectation. Staff K further stated that the care plan/program should be followed. 48899 Resident 42 admitted to the facility on [DATE]. Review of Resident 42's communication care plan initiated on 05/17/2023, showed Resident 42 was at risk for a communication problem r/t [related to] hearing deficit with interventions that included referral to audiology (testing and management of hearing and balance problems) for hearing consult as ordered and social services to follow up with hearing aids. Review of the nursing progress note dated 05/17/2023 to 06/07/2024, showed no documentation that the facility implemented Resident 42's communication care plan to referral to audiology and social services to follow up with hearing aids. On 06/04/2024 at 8:23 AM, Resident 42 stated that they were supposed to have hearing checkup at least annually. Resident 42 further stated that the facility did not arrange that for me and I have been telling them, but they did not listen. Sometimes I have hearing difficultly, and I am supposed to have hearing aid but did not get nothing. No body helped me with the appointment for about a year. Joint record review and interview on 06/07/2024 at 12:49 PM with Staff F, Licensed Practical Nurse Supervisor, showed no documentation that Resident 42's communication care plan was implemented. Staff F stated that there should have been a follow up on Resident 42's hearing needs. In an interview and joint record review on 06/07/2024 at 12:57 PM with Staff P, Social Services Director, stated that they did not help Resident 42 with their audiology appointment. Joint record review of the nursing progress notes from 05/17/2023 to 06/07/2024 with Staff P, showed no documentation that social services followed up with Resident 42 regarding their hearing aids. Staff P stated that they should have followed up with Resident 42's hearing concerns and implemented their care plan. On 06/10/2024 at 2:57 PM, Staff K stated that staff should have implemented the care plan. Reference: (WAC) 388-97-1020 (3)

Based on interview and record review, the facility failed to follow up on hearing services for 1 of 2 residents (Resident 42), reviewed for communication and sensory. This failure placed the resident at risk for ineffective communication, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy titled, Resident Rights, revised in 11/23/2016, showed residents have rights to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the center. Review of the facility's policy titled, Hearing Impaired Resident, revised in February 2018, showed staff will assist the resident or representative with locating available resources, scheduling appointments, and arranging transportation to obtain needed services. Resident 42 admitted to the facility on [DATE]. Review of Resident 42's communication care plan initiated on 05/17/2023, showed that Resident 42 was at risk for a communication problem r/t [related to] hearing deficit with interventions that included referral to audiology (testing and management of hearing and balance problems) for hearing consult as ordered and social services to follow up with hearing aids. Review of the nursing progress notes dated 04/23/2024, showed that Resident 42 reported difficulty hearing and that the Nurse Practitioner was notified of Resident 42's concern. It further showed that Resident 42 declined the assessment by the Nursing Practitioner and that they would follow up as indicated. Review of the nursing progress notes dated 04/23/2024 to 06/07/2024 showed no documentation that the facility staff followed up on Resident 42's difficulty hearing. On 06/04/2024 at 8:23 AM, Resident 42 stated that they were supposed to have hearing checkup at least annually. Resident 42 further stated that the facility did not arrange that for me and I have been telling them, but they did not listen. Sometimes I have hearing difficultly, and I am supposed to have hearing aid but did not get nothing. No body helped me with the appointment for about a year. In an interview and joint record review on 06/07/2024 at 12:01 PM with Staff F, Licensed Practical Nurse Supervisor, stated that when Resident 42 reported difficulty hearing, the Nurse Practitioner was notified to assess, or order oil drop to soften the resident's ear a little bit. Staff F stated that if it was not effective the Nurse Practitioner would place an order for audiology. A joint record review of the nursing progress notes from 04/23/2024 to 06/07/2024, showed Resident 42's hearing assessment was not completed. Staff F stated the assessment was not completed and the audiology referral was not made. In another joint record review and interview on 06/07/2024 at 12:49 PM with Staff F, showed Resident 42 had recommendations (orders) from their speech and hearing consultant visit dated 03/02/2023 and that the recommendations (orders) were not implemented. Staff F stated that for Resident 42's hearing consultant's recommendations, there should have been a follow up. Joint record review and interview on 06/07/2024 at 12:57 PM with Staff P, Social Services Director, showed the nursing progress notes dated 03/24/2023 to 06/07/2024 did not show documentation that the facility followed up with Resident 42's hearing aids. Staff P stated that they did not help Resident 42 with their audiology appointment and that they should have followed up on it. On 06/07/2024 at 1:00 PM, Staff Q, Nurse Practitioner, stated that I tried to evaluate him after he reported his hearing difficulty, but he refused. I did not do another attempt to evaluate until today. Staff Q further stated Resident 42 agreed for evaluation and that an audiology referral was done today. On 06/10/2024 at 2:57 PM, Staff K, Assistant Director of Nursing, stated that the facility's process was that when there was a report/concerns from residents about hearing issue we notify the Nurse Practitioner to make sure they assessed them. Also, if residents need referral, we have to make sure that was done. Staff K further stated that if residents had a recommendation from hearing consultants, the facility should follow up. On 06/11/2024 at 8:51 AM, Staff A, Administrator, stated when residents had concerns with hearing the facility tries to resolve it ASAP [as soon as possible]. Reference: (WAC) 388-97-1060(3)(a).

Based on observation, interview, and record review, the facility failed to maintain an environment free of accident hazards for 1 of 3 residents (Resident 76), reviewed for accident hazards. The failure to monitor and assess a sliding door as an exit, and to ensure a fence/gate that led to a parking lot and street was secured/locked, placed the resident at risk for elopement [form of unsupervised wandering that leads to a resident leaving the facility], injury, and a diminished quality of life. Findings included . Review of the facility's policy titled, Elopement/Unsafe Wandering, revised in January 2022, showed, This facility is committed to promoting resident autonomy [ability to make own decisions] by providing an environment that remains as free of accident hazards as possible. The policy further showed the facility would provide a safe environment for all residents through appropriate assessment and interventions to prevent accidents related to unsafe wandering or elopement. Resident 76 admitted to the facility on [DATE]. Review of Resident 76's admission Minimum Data Set (MDS- an assessment tool), dated 05/09/2024, showed the resident had impaired cognition. Review of Resident 76's Restraint/Enabling Device/Safety Device Evaluation, dated 05/29/2024, showed the resident was evaluated to be, forgetful follows visitors/family exit doors, and that the device recommended was a wanderguard (a system in which a resident at risk for elopement /wanderer wears a bracelet, sensors that monitor doors, and alarm in real time), that alerted staff when the resident was by an exit door. Review of Resident 76's Elopement/Wandering Evaluation dated 06/01/2024, showed the resident was at high risk for elopement, was ambulatory with an assistive device (mobility aid), and had intermittent (sudden) confusion. Further review of the evaluation showed Resident 76's wandering was, aimless w/[with] potential to go outside, active exit seeking behavior. Review of Resident 76's elopement risk/wanderer care plan initiated on 06/04/2024, showed the resident had, Impaired safety awareness, Resident wanders aimlessly, following visitors going out the door. Review of Resident 76's physician order printed on 06/06/2024, showed an order for Wanderguard to (R [right] ankle): check for placement and function, initiated on 05/29/2024. Observation on 06/05/2024 at 12:55 PM, showed Resident 76 was walking independently using a walker in front of the facility parking lot with a visitor. Observation on 06/06/2024 at 3:21 PM, showed Resident 76 was in their room with a visitor. Their room had a sliding glass door wide open with the sliding screen door in place. Further observation showed the sliding door had no wanderguard trigger alarm box (part of the wanderguard alarm system that is placed on door/exit). Observation outside of Resident 76's room sliding door on 06/06/2024 at 3:54 PM, showed a grassy area with an uneven cement blocks pathway, and led towards the fenced gate that was wide open. Further observation showed the unsecured gate led to a parking lot towards a busy road. Joint observation and interview on 06/06/2024 at 4:43 PM with Staff L, Licensed Practical Nurse, showed Resident 76 had a wanderguard on their right ankle. Resident 76's visitor had left for the day. Resident 76's room glass sliding door was wide open and the screen sliding door was in place. Further joint observation showed Staff L walked through the sliding door with a wanderguard bracelet and no alarm was heard and that there was no [NAME] trigger alarm in the resident's room. Staff L stated that normally they would have one [trigger alarm] on the sliding door but they did not see one. Joint observation outside of Resident 76's room sliding door on 06/06/2024 at 4:46 PM with Staff L, showed a cement blocks pathway that was uneven. Staff L stated it could place the resident at risk for falls, and the gate was open to the parking lot/street, and could be potential for harm, or a very bad injury. In an interview and joint record review on 06/10/2024 at 10:03 AM, Staff B, Director of Nursing, stated that the wanderguard was important because it alerted staff that the resident was by an exit door and the alarm would trigger. Staff B stated that it would prevent elopement and injury as a consequence. Staff B further stated that Resident 76 was ambulatory, forgetful, and when family came to visit them, Resident 76 would follow them to the door. Staff B stated that Resident 76 was confused and that they scored high risk for elopement. Joint record review of Resident 76's admission MDS dated [DATE], showed resident had a brief interview for mental status (tool used to assess cognitive status) score of 0 (zero - indicating severely impaired cognition). Staff B stated that Resident 76 had impaired cognition. In another joint record review and interview on 06/10/2024 at 10:17 AM with Staff B, showed a physician order for a wanderguard was initiated on 05/29/2024. Staff B stated that was when the resident was determined to be at risk for elopement because they were seen by the exit door following a visitor. Joint observation and interview on 06/10/2024 at 12:20 PM with Staff D, Maintenance Director, showed there was no trigger alarm for Resident 76's previous room (room [ROOM NUMBER]-C). Staff D stated there was no alarm on the sliding door and that on 06/06/2024, they had been asked to place an alarm on and that they had been asked to block the doors. Another joint observation and interview on 06/10/2024 at 12:25 PM with Staff D, showed the outside environment of Resident 76's previous room had a cement block pathway that was uneven. Staff D stated that the gate was probably left opened [on 06/06/2024] and that it was supposed to stay closed. Staff D further stated this placed the resident at risk for a fall or injury. In an interview on 06/10/2024 at 1:46 PM, Staff K, Assistant Director of Nursing, stated that a wanderguard and trigger alarm were important because it alerted the staff when a resident was trying to leave the building. Staff K stated that Resident 76 was ambulatory and that they were at risk for elopement. Staff K stated that Resident 76 had impaired cognition and that they tended to follow their visitor. Staff K stated that there was no alarm on Resident 76's sliding door and that the gate should have been closed. Staff K further stated that staff would not be alerted right away without a wanderguard trigger alarm. In an interview and joint record review on 06/11/2024 at 1:59 PM with Staff A, Administrator, stated that the trigger alarm notified staff when the resident was coming close to an exit and that it was audible. Joint record review of Resident 76's elopement/wandering evaluation dated 06/01/2024, showed the resident was at high risk for elopement. Staff A stated the assessment did not specify whether the resident was assessed for the ability to open their sliding door. Staff A further stated that the gate door was opened on 06/06/2024 and that they typically have it closed. In an interview on 06/12/2024 at 8:53 AM, Staff M, Occupational Therapist (OT), stated that Resident 76 had made a lot of progress in terms of Activities of Daily Living (ADLs - activities related to personal care) and that Resident 76 was currently at a supervision level for daily tasks. Staff M stated that this was mainly because Resident 76 was impulsive with their movements and was very quick to stand up and with turning. Staff M stated that Resident 76's daily tasks included dressing, going to the bathroom, getting in and out of bed, and transfers. Staff M stated that Resident 76 was able to ambulate independently in their room, familiar area, or short distances and that they were at risk for elopement. Staff M further stated that Resident 76 had no restrictions in their hands that affected them functionally, and was able to manipulate their utensils for meals or the toilet paper in the restroom and that in terms of dexterity (skill in performing tasks, especially with the hands) they had recently done a cognitive exam, consisting of putting strings into different holes, and that the resident had no problem with completing the tasks. Joint record review and interview on 06/12/2024 at 9:08 AM with Staff M, revealed Resident 76's OT notes dated 05/16/2024, showed, Cues for proper body mechanics and pacing due to impulsive mvmt [movement] and decreased safety awareness. Staff M stated the resident got up fast, and turned quickly, and had decreased safety awareness putting them at risk for falls. Joint record review and interview on 06/12/2024 at 10:04 AM with Staff N, Physical Therapist (PT), showed Resident 76's PT notes dated 06/02/2024, Resident 76 was able to ascend and descend steps, for a total of eight stairs using bilateral (both) handrails at supervision assist. Staff N stated that the stairs were approximately six to seven inches tall. At 10:07 AM, another joint record review of PT notes dated 06/06/2024, showed gait training had occurred in the hallway/gym/room and the resident used no assistive device for 200 feet (ft - a unit of measurement) and outdoor gait training on uneven surfaces for 500 ft at supervision assist. Staff N stated the resident was currently able to ambulate with no assistive device. Staff N further stated that on 06/06/2024, it was the first time they had evaluated the resident specifically for opening the glass sliding door. On 06/12/2024 at 10:51 AM, Staff A, stated that there was no specific documentation for Resident 76's ability to open the sliding door [prior to 06/06/2024]. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to maintain, label/date, and properly store oxygen nasal cannula (flexible tubing that sits inside the nose and delivers oxygen) for 1 of 1 resident (Resident 47), reviewed for respiratory care. This failure placed the resident at risk for unmet care needs, respiratory infections, and related complications. Findings included . Resident 47 admitted to the facility on [DATE] with diagnosis that included chronic obstructive pulmonary disease (a condition that blocks airflow and makes it difficult to breathe). Review of Resident 47's physician orders showed the following: - Apply oxygen via nasal cannula three liters [a unit of measurement] per minute continuous to keep saturation (amount of oxygen in the blood) above 90 percent every shift dated 5/15/2024. - Change oxygen tubing and humidifier every Sunday on night shift dated 5/19/2024. Observation on 06/03/2024 at 11:14 AM, showed a portable oxygen tank on the back of Resident 47's wheelchair, the nasal cannula was laying on top of their wheelchair cushion unlabeled and was not stored in a bag. Resident 47 stated they had used it with therapy earlier in the day. At 2:03 PM, Resident 47's nasal cannula was laying on their wheelchair cushion unlabeled and was not stored in a bag. Observation on 06/04/2024 at 10:17 AM, showed on the back of Resident 47's wheelchair was a portable oxygen tank with the nasal cannula laying on top of their wheelchair cushion unlabeled and was not stored in a bag. Observation on 06/05/2024 at 8:21 AM, showed a portable oxygen tank and nasal cannula laying on top of Resident 47's wheelchair cushion with an unlabeled nasal cannula stored in a bag. Resident 47 stated they told staff to store the nasal cannula in a bag. In an interview and joint observation on 06/05/2024 at 9:03 AM, Staff G, Licensed Practical Nurse (LPN), stated they would change the nasal cannula weekly, label/date and store it in a bag when not in use. Joint observation showed Resident 47's portable oxygen tank and nasal cannula was laying on top of their wheelchair cushion with the unlabeled nasal cannula stored in a bag. Staff G stated that it should have been labeled. Staff G further stated that the nasal cannula should be stored in a bag when not in use. On 06/05/2024 at 2:31 PM, Staff F, LPN Supervisor, stated that the oxygen nasal cannula was labeled and changed weekly and stored in a bag when not in use. Staff F further stated that Resident 47's nasal cannula should have been labeled and stored in a bag when not in use. On 06/05/2024 at 2:56 PM, Staff N, Physical Therapist, stated that they would use a new nasal cannula each time they saw the resident and would discard it after their therapy session. Staff F stated that the nasal cannula tubing should have been discarded after therapy was done with their session. On 06/06/2024 at 2:39 PM, Staff K, Assistant Director of Nursing, stated that therapy should have discarded the nasal cannula after their session with Resident 47. Staff K further stated that the nasal cannula should be stored in a bag when not in use. On 06/06/2024 at 3:17 PM, Staff O, Director of Rehabilitation, stated that their process was to use a new nasal cannula each time they worked with a resident and would discard the nasal cannula after their session. Staff O further stated Resident 47's nasal cannula should have been discarded after their therapy session. Reference: (WAC) 388-97-1060 (3)(j)(vi)

Based on observation, interview, and record review, the facility failed to ensure hand hygiene practices were followed before and after resident care and during meal tray pass for 1 of 13 staff (Staff I) reviewed for infection control. This failure placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Hand Hygiene, revised on 02/21/2022, showed, Use an alcohol-based hand rub .or, alternatively, soap .and water for the following situations, before and after direct contact with residents and after contact with objects in the immediate vicinity of the resident. Observation on 06/03/2024 at 12:15 PM, showed Staff I, Certified Nursing Assistant, brought a meal tray into Resident 1's room, touched the fork and knife, and assisted in cutting Resident 1's food. Staff I then left Resident 1's room without performing hand hygiene and went to the kitchen, touched the kitchen door, and left the kitchen with a new fork. Staff I entered Resident 1's room and handed the new fork to Resident 1. Staff I did not perform hand hygiene prior to re-entering Resident 1's room. Staff I then helped Resident 5 (Resident 1's roommate) get their meal tray set up, touched items on the bedside table, and left Resident 5's room and did not perform hand hygiene. Staff I then entered Resident 46's room and touched their bedside table. On 06/03/2024 at 1:43 PM, Staff I stated they should perform hand hygiene after touching resident's items and going between residents. Staff I stated they should have performed hand hygiene when leaving the resident's room and entering the room. On 06/10/2024 at 10:04 AM, Staff S, Infection Preventionist, stated they expected staff to perform hand hygiene every time they help a resident and between resident rooms. On 06/12/2024 at 8:24 AM, Staff K, Assistant Director of Nursing, stated Staff I should have performed hand hygiene before coming out [of resident's rooms] and going in. Staff K further stated they expected Staff I to perform hand hygiene after leaving one resident's room and before going into the next resident's room. Reference: (WAC 388-97-1320 (1)(c)

Based on observation, interview, and record review, the facility failed to ensure foods stored were properly covered, labeled/dated, discarded after the expiration date, or use by date and ensure ready-to-eat food was handled appropriately in accordance with professional standards for food service safety. These failures placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the following facility provided policies titled: 1. Food Safety, dated 2018, showed, The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded, the individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared, the discard day or date may not exceed the manufacturer's use-by-date. 2. Safe Food Handling Practices - King County updated in November 2022, showed, to Develop good serving procedures to protect food and customers, avoid touching the food contact surfaces of .plates or tableware .Food service workers are required to use utensils to handle ready-to-eat foods. 3. Policy and Procedure for Use of Gloves, undated (unknown when this policy was initiated/revised), showed, Gloves are to be worn and changed frequently to minimize handling of food and food contact surfaces .Gloves will be removed or changed frequently when: handling different food items .before touching non-food items. KITCHEN WALK-IN REFRIGERATOR On 05/16/2023 at 6:06 AM, a joint observation of the main kitchen walk-in refrigerator, walk-in freezer and dry storage room with Staff I, Nutrition Services Manager, showed the following food items with no use by date: - a container of chili dated 05/11/2023. - a container of sweet and sour sauce dated 05/11/2023. - a container of beans in storage container dated 05/12/2023. - a container of cheese sauce that was not fully sealed dated 05/12/2023. - three bags of bagels with best by date of 05/02/2023. KICHEN WALK-IN FREEZER - a bag of bell peppers that was not sealed or dated. - a bag of sausages that was opened but not dated. - a bag of fried steaks that was opened but not dated. DRY STORAGE ROOM - one box of parsley flakes with best by date of 08/18/2022. On 05/16/2023 at 6:06 AM, Staff I stated that they would throw away the above items that were found in the refrigerator and stated, it has a 3-day shelf life. On 05/20/2023 at 1:21 PM, Staff I stated that they label/date food items when they receive it from the vendor and when they open it, they add the open and use by date. Staff I stated that their process was to seal any opened food items, wrap it up and label it with a date. KITCHEN MEAL PREPARATION On 05/19/2023 at 11:43 AM, a joint observation and interview with Staff I, showed, Staff M, Cook, was observed handling plates, utensils, plate warmers and then touching cooked foods on the plate with gloved hands. Staff M was observed touching chicken, carrots, fish, and broccoli when these food items were placed on a plate and arranged them. Staff I stated that they should not be touching cooked food even if they were using gloves. Staff M was also observed to be touching/pressing down the center of the plate surfaces with gloved hands multiple times. Staff I stated that they should not be touching the center of the plate. Staff M was observed using the same gloves throughout lunch service. On 05/20/2023 at 1:49 PM, Staff A, Administrator, stated that everything must be labeled, all food items must be stored in a safe manner and in a tight packaging to maintain freshness. Staff A stated, anything in the fridge is good for 3 days, then staff throws it out. Staff A stated that they expect staff to handle cooked foods with utensils, use gloves and change their gloves when soiled. Reference: (WAC) 388-97-1100 (3)

Based on interview and record review, the facility failed to ensure bed-hold notices were provided at the time of transfer to the hospital for 3 of 4 residents (Residents 29, 124 and 26) reviewed for hospitalization s. This failure placed the residents at risk of lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled, Admission/Discharge/Transfer - Bed Hold, revised in November 2016, showed that a copy of bed hold notification shall be provided to the resident and/or their representative in a language they can understand at the time of admission, transfer to the general acute hospital and start of the resident's therapeutic leave. RESIDENT 29 Resident 29 admitted to the facility on [DATE]. Review of Resident 29's progress notes in the resident's Electronic Health Record (EHR) showed that Resident 29 was sent to the hospital on 04/15/2023. No bed-hold notice was in Resident 29's EHR. RESIDENT 124 Resident 124 admitted to the facility on [DATE]. Review of Resident 124's progress notes in the EHR showed Resident 124 was sent to the hospital on 04/25/2023. No bed-hold notice was in Resident 124's EHR. On 05/19/2023 at 2:42 PM, Staff C, Admissions Coordinator, stated that they were responsible for bed hold notices. After reviewing Resident 29's and 124's EHR, Staff C stated that there was no documentation to show a bed hold was offered to the residents or their representatives at the time of their hospital transfer or thereafter. On 05/21/2023 at 8:53 AM, Staff A, Administrator, stated that their expectation was that bed hold notices were provided to the resident and/or their representative at the time of transfer to the hospital per facility's policy. 47680 RESIDENT 26 Resident 26 admitted to the facility on [DATE]. Review of Resident 26's EHR showed they were transferred to the hospital on 04/28/2023 and readmitted back to the facility on [DATE]. Further review of the EHR showed no indication that a bed hold notification was provided to Resident 26 or their representative. On 05/18/2023 at 10:55 AM, Resident 26 stated that they did not get notification about a bed hold when they were discharged to the hospital. On 05/19/2023 at 1:10 PM, Staff C stated that if a resident was discharged to the hospital, they would call the resident, or their representative of a bed hold and that they would document it in the bed hold notification form. Additionally, Staff C stated that they could not remember if they called the resident or their representative regarding a bed hold. On 05/21/2023 at 10:14 AM, Staff A acknowledged that the facility staff did not notify the resident or their representative of a bed hold. Reference: (WAC) 388-97-0120 (4)(a)(b)(c)

Based on interview and record review, the facility failed to accurately assess 1 of 4 residents (Resident 71) reviewed for hospitalization s. The failure to ensure accurate assessment regarding discharge status resulted in inaccurate information in the resident's clinical record and placed the resident at risk for unidentified care needs. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, Version 1.17.1, dated October 2019, showed: Accuracy of Assessment means that the appropriate, qualified health professionals correctly document the resident's medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate RAI (i.e., comprehensive, quarterly, annual, significant change in status). Resident 71 admitted to the facility on [DATE]. Review of Resident 71's clinical records showed a nursing note that stated Resident 71 discharged to home on 02/20/2023. Review of the discharge Minimum Data Set (MDS) assessment dated [DATE] showed Resident 71's was coded for discharge status to acute hospital. On 05/19/2023 at 2:00 PM, Staff D, MDS Nurse, stated that Resident 71's discharge MDS assessment should have been coded as discharge to the community. Reference: (WAC) 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to provide adequate resident supervision and failed to ensure care plans were implemented to minimize the risk of avoidable fall incident for 1 of 3 residents (Resident 1) reviewed for supervision. This failure caused harm to Resident 1 who suffered facial and forehead injuries from the fall incident. Findings included . Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses list included stroke with ride sided weakness and dementia (memory problem). A review of Resident 1's admission Minimum Data Set (MDS) assessment dated [DATE] showed the resident had impaired cognition and needed one person assistance with locomotion (how resident moves between locations) on/off unit, and with eating. A review of Resident 1's admission Fall risk assessment dated [DATE] showed the resident was a high risk for fall. The assessment showed the resident was disoriented, had history of falls, and was on high-risk medications that could increase the likelihood of fall. A review of Resident 1's hospital discharge summary note dated 06/08/2022 showed that the resident's dementia had worsened after the recent stroke and hospitalization . The note showed the resident was evaluated by speech therapy and recommended a one-on-one staff supervision with eating due to impulsivity with bolus size, and talking with bolus in oral cavity. A review of Resident 1's care plan dated 06/08/2022 showed Resident 1 was a high risk for fall due to her current medical conditions and needed one on one staff supervision/assistance with eating. A review of the facility's incident reporting log for June 2022 showed the resident had a fall incident on 06/10/2022 at 5:41 PM that resulted in physical injury [hematoma- bleeding outside of blood vessels]. On 08/26/2022 at 2:00 PM, Staff B, Director of Nursing (DNS) stated and confirmed that Resident 1 had a fall on 06/10/2022 at 5:41 PM in the main dining room. Staff B stated that the fall incident happened during mealtime (dinner). Staff B also stated there was no staff member present to supervise the resident when the incident happened and that the staff assigned to feed and supervise Resident 1 (Staff C, CNA) left the resident unattended in the dining room to deliver another resident's tray across the hallway. Staff B further stated that Resident 1 was sent to the emergency room following the fall incident and sustained physical injury including hematoma of the forehead. A review of the incident investigation report dated 06/10/2022 showed that on 06/10/2022 at 5:41 PM, the resident was found lying in the dining room floor with hematoma on the right forehead. The incident report showed that Staff C was assigned to Resident 1 to supervise and assist the resident with eating but left the resident in the dining room to deliver another resident's meal tray (outside/away from the dining room). The incident report also showed there was no other staff member present to provide any type of supervision to Resident 1 while Staff C was away from the dining area. The written statement provided by Staff C dated 06/10/2022 showed the last time she visually checked Resident 1 was at 5:30 PM that day and that Resident 1 was still eating and drinking prior to and/or at the time of fall. A phone interview on 08/29/2022 at 8:05 AM, Resident 1's family member (FM1) stated that Resident 1's fall could have been avoided if the facility staff did not leave Resident 1 unattended/unsupervised in the dining room during mealtime. FM1 also stated that Resident 1 experienced severe pain and had sustained serious facial and head injuries because of the incident and that Resident 1's face was severely injured and bruised and appeared to have a huge black eye that extend to her ear/neck area. On 08/26/2022 at 3:15 PM, both Staff A, Administrator and Staff B stated that Resident 1's fall on 06/10/2022 was not witnessed by any staff member, and that the resident was left unattended by Staff C to provide care and deliver a meal tray to another resident (away from the dining room). Staff B stated that Resident 1 was care planned to receive one on one staff supervision during meals and while eating. A review of the hospital's emergency department discharge summary note dated 06/10/2022 showed Resident 1 was seen and evaluated after a fall and sustained traumatic hematoma of the forehead and dehydration (water/fluid loss and/or the absence of sufficient amount of water in the body). Reference: (WAC) 388 - 97-1060 (3)(g)

Based on record review and interview, the facility failed to ensure one of three residents (#2) who received anti-coagulant medication(s) (blood thinning medications) was free of significant medication errors. Failure to ensure (oral) anticoagulant therapy was consistently provided for Resident 2 resulted in the resident receiving an intravenous infusion (IV) of an anti-coagulant medication to obtain therapeutic blood levels to prevent possible blood clots. Findings included . RESIDENT 2 Resident 2 was admitted to the facility on [DATE] for an infection with antibiotic therapy and a [DIAGNOSES REDACTED]. The physician's orders [REDACTED]. The admit physician's orders [REDACTED]. (An INR (International Ratio) is a lab value used to establish baseline parameters for [MEDICATION NAME], a medication used to reduce blood clotting, and should be monitored regularly.) Resident 2's [MEDICATION NAME] Flow Sheet (INR) showed that the therapeutic target range for the INR was 2.0 to 3.0 due to the chronic [MEDICAL CONDITION] diagnosis. The [MEDICATION NAME] Flow Sheet showed that on 06/15/19 Resident 2's INR was 1.7. Documentation on the Medication Administration Record(MAR) for (MONTH) 15, 2019 showed an LN's signature (initials) to indicate the INR reading had been done, as well as the INR reading of 1.7. The MARs for (MONTH) and (MONTH) 2019 showed documentation that Resident 2 was being monitored for possible side effects (SE's) of anticoagulants every shift. The (MONTH) 2019 E-MAR (Electronic Medication Administration Record) showed that the LNs had administered [MEDICATION NAME] 4 mg on (MONTH) 14, 15 , 16, and 17, 2019. A physician assistant's (PA) note, dated 06/18/19, showed that Resident 2's medical [DIAGNOSES REDACTED]. During an interview on 07/30/19 at 1:40 PM, with the medication nurse, LN A, a registered nurse, LN A stated that when a resident was on a blood thinner ([MEDICATION NAME]), the INR is checked by the LN on night shift. LN A stated when the INR was obtained, the LN would initial that the INR was performed and enter the INR value(reading) on the MAR indicated [REDACTED]. A (MONTH) 18, 2019 entry on the (MONTH) 2019 MAR indicated [REDACTED]. The nursing progress notes showed that Resident 2 had a change in condition on 07/20/19 with shortness of breath (SOB). The physician was notified and a chest x-ray was performed. The chest x-ray showed pleural effusion(condition in which excess fluid buildup around the lung). Resident 2 was started on an oral antibiotic, however Resident 2 requested to be sent to the hospital for further evaluation. A facility investigative report, dated 07/21/19, showed that the hospital had called the facility regarding Resident 2's [MEDICATION NAME] dose and INR levels. Facility review of the medical record showed Resident 2 had not received blood thinning medication since 06/17/19 (33 days without [MEDICATION NAME]) and that the last recorded INR was 1.7 by the facility was on 06/15/19. The hospital's emergency room (ER) note dated 07/20/19 showed that Resident 2 had a history of [REDACTED]. However the medication list received from the facility only showed that Resident 2 had been administered daily aspirin. The note read, [MEDICAL CONDITION] Embolism ( PE) is a consideration because patient has [MEDICAL CONDITION] and was suppose to be on [MEDICATION NAME]/[MEDICATION NAME]. Her current INR 1.1 (not a therapeutic goal for [MEDICAL CONDITION]) so the plan is to provide a [MEDICATION NAME] (anticoagulant) infusion (intravenous) for presumption of PE. The note showed that pharmacy would be regulating the dose of anticoagulation(s) to obtain a therapeutic INR goal of 2-3. During an interview on 07/30/19 at 10 :50 A.M., Staff Development Coordinator (SDC), a registered nurse, stated that Resident 2's physician had been notified on 06/15/19 regarding Resident 2's INR of 1.7 who gave an order to continue oral [MEDICATION NAME] 4 mg daily and recheck the INR by night shift on 06/18/19. The SDC stated that the LN had signed the MAR for (MONTH) 18, 2019 indicating that she had drawn the inhouse lab (INR), however there was no documented INR result recorded. Additionally, the LN had not reported the INR result to the day shift LN in order to obtain a physician's orders [REDACTED]. SDC stated that the original order for oral [MEDICATION NAME] 4 mg from 06/14/19 to 06/17/19 does not continue until a INR was drawn in order to evaluate the medication dose according to the INR level and a new physician's orders [REDACTED]. During an interview with the Director of Nursing on 07/30/19 at 4:45 PM, she stated that the LN on night shift (06/18/2019) was not able to recall whether Resident 2's INR had been obtained and that the day shift LN for 6/18/2019 did not recall receiving an INR result or [MEDICATION NAME] dose from shift report. The DNS stated that the medication error was identified when the hospital had contacted the facility on 07/21/19 regarding Resident 2's INR levels and [MEDICATION NAME] dosing. The facility did not identify the medication omission until the hospital anticoagulant clinic contacted the facility on 07/21/2019 to check what the INRs readings had been since admission (6/14/19). Reference: WAC 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to ensure that residents were free from significant medication errors for 1 of 1 residents (#1). Failure to clarify and accurately transcibe medication orders resulted in incorrect dosage and excess duration of medications. This failure resulted in Resident 1 transfer to the hospital for treatment of [REDACTED]. Findings included . RESIDENT 1 Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident 1's hospital transfer orders, dated 04/05/2019, showed Resident 1 was to receive medications (insulins) for DM as follows: -Insulin [MEDICATION NAME] (long acting insulin) 100unit/mL injection SQ(subcutaneous). The dose to be administered was 14 units (U) every morning. -Insulin [MEDICATION NAME] (fast acting insulin also known as [MEDICATION NAME] insulin) U-1000 unit/ml injection into the skin daily with lunch. The order showed that the fast acting insulin dose was to be based on Resident 1's blood sugar (BS) reading via a sliding scale. Another hospital transfer order, dated 04/05/2019, for an electrolyte (Potassium Chloride) showed: -Potassium Chloride (KCL) SA (Sustained Action) 10 milliequivalent (MEQ) tablets; Administer 20 MEQ by mouth daily. Review of the Medication Review Report (Medication orders), dated 04/05/2019, which was signed by the facility physician and two Licensed Nurses (LN) showed the following orders: -The long-acting [MEDICATION NAME]dose was decreased to 7 U every morning. (The 14 U dose was discontinued). -The fast-acting [MEDICATION NAME]sliding scale order showed that the LN transcribed the order as to be given before meals (rather than just with lunch). -KCL ER (extended release tablet) 10 MEQ; Give 1 tablet by mouth one time a day for [DIAGNOSES REDACTED] (low potassium). During an interview on 05/09/2019 at 10:36 AM, a Medication Nurse (LN A) was asked about the process of putting physician orders [REDACTED]. LN A stated that an order was entered in the order detail section, and then the order was printed and faxed to the pharmacy. LN A stated that when a medication order was entered, the order was generated and showed up on the Medication Administration Record [REDACTED] Resident 1's (MONTH) 2019 MAR indicated [REDACTED] -Discontinue the [MEDICATION NAME] Insulin 14 units. The order date was 04/05/2019 at 12:54 PM. -The new (reduced dose) of Insulin [MEDICATION NAME] to 7 units subcutaneous one time a day. Order date was entered 04/05/2019 at 1:34 PM. -The sliding scale insulin ([MEDICATION NAME]) was dated 04/05/2019 at 12:45 PM, and directed LNs to administer before meals (3 times a day instead of the hospital order of only with lunch). -The KCL order showed an entry date of 04/05/2019 at 1:03 PM. The order showed 10 MEQ, give one tablet one time a day. The pharmacy's interchange/formulary forms, used to communicate to facility LNs that a drug substitution/formulary change was made for a prescribed physician's medication, were reviewed. These forms, dated 04/05/2019 at 7:38 PM, showed that Basaglar Insulin was being substituted for the [MEDICATION NAME] Insulin (both long acting insulins), and Humalog Insulin was being substituted for the [MEDICATION NAME] Insulin as the sliding scale fast-acting insulin. The pharmacy's interchange form showed that the [MEDICATION NAME] ([MEDICATION NAME]) 14 U was discontinued. The interchange form showed that pharmacy was going to substitute the [MEDICATION NAME] (brand) insulin with Basaglar, and the new order read as Basaglar inject 14 Units SQ every morning. The pharmacy form's insulin order Units sent to the facility remained at 14 units instead of 7 units. The pharmacy's interchange form showed that the [MEDICATION NAME]([MEDICATION NAME]) per sliding Scale once a day with lunch was substituted to Humalog injection SQ per sliding scale once daily with lunch. During an interview on 05/09/2019 at 11:39 AM, the Staff Development Coordinator (SDC), a registered nurse, stated that when the pharmacy substituted Basaglar insulin for the [MEDICATION NAME]and the Humalog insulin for the [MEDICATION NAME]to sliding scale per formulary, the LN who received the medication changes per pharmacist/formulary, would discontinue the original physician's orders [REDACTED]. The MAR for (MONTH) 2019 showed that when the LN received and signed the pharmacy's formulary changes for the insulin, 14 units [MEDICATION NAME] to Basaglar 14 U, the LN discontinued the facility physician's orders [REDACTED]. In addition, when the LN discontinued the [MEDICATION NAME] sliding scale insulin before meals and changed the sliding scale order to Humalog to continue as before meals. There was no documented evidence that the LN attempted to clarify the dose for the long-acting insulin with the physician (14 units versus 7 units) or whether the sliding scale order was to be with lunch or before all meals. This was not in accordance to the physician's orders [REDACTED]. Review of Resident 1's BS readings on the MAR indicated [REDACTED]. Resident 1 received an incorrect dose of long acting insulin for 15 days. Review of the MAR for (MONTH) 2019 showed that the LNs were checking Resident 1's BS before meals and administering short acting insulin (Humalog) according to the BS level, even though the hospital physician's orders [REDACTED]. Review of the clinical record on 05/09/2019 showed that the LNs had administered 14 Units of the long acting insulin daily (basaglar) and administered before meal insulin in relationship with Resident 1's blood sugar readings. The MAR for 4/20/19 showed that the LN administered 3 units of Humalog (short acting) insulin before breakfast for an elevated blood sugar level (297) and then before lunch time (10:30-11:30), the LN documented that Resident 1's BS was 69. The facility's investigative report for the medication errors dated 4/20/19 for the insulin showed that LN attempted to give Resident 1 her noon medications and apple juice, but the resident spit out her noon medications and food. The report showed that the family was present and informed the LN that her mother did not look right and was slow to reply. The family member was informed about the BS of 69. Per the facility's investigative report, the family member refused to have the LN recheck the BS, requested transfer to the hospital, and the family called 911 (emergency system EMS). The facility's investigative report for the insulin dose error (Long Acting Insulin) showed there was no documented evidence that the facility had noted the inaccuracies regarding the sliding scale administration of insulin. The hospital records dated 04/20/19 showed that medics obtained a BS reading of 40 during the emergency medic transport and administered glucose by mouth to Resident 1. The hospital emergency room note dated 4/20/19 at 2:20 PM showed that Resident 1's glucose (BS) was in the 30's. A laboratory report for 2:09 PM showed at BS of 35 (normal 65-9 mg/dl). The ER physician's note showed that Resident 1 required 50% [MEDICATION NAME] (sugar) and the BSs came back up to 80 to low 100. Per telephone interview on 05/09/2019 at 1:00 PM, the Director of Nursing (DNS) stated the LN who received Resident 1's medications and insulin (Basaglar), along with the interchange form, transcribed the Basaglar Insulin 14 units onto the MAR indicated [REDACTED]. The DNS stated that the LN just entered the 14 units of basaglar insulin (interchange formula) without questioning the dosage of 14 Units when 7 units had been ordered. KCL MEDICATION Resident 1's hospital notes for 04/05/2019 showed that the potassium level was 3.6 (normal level). Resident 1's transfer medication orders showed that she was to receive Potassium Chloride (KCL) SA (sustained action) 10 mEq tablet; the dose to be administered was 20 MEQ (Take 20 MEQ by mouth daily). The facility's signed physician orders [REDACTED]. The Medication Administration Record [REDACTED]. The facility's investigative report for the incorrect dose of KCL dated 04/21/2019 showed that the incorrect dose entry was due to transcription error, and that LNs were provided education how reading and entering correct doses into electronic system and verification of medications orders on admission. During an interview and record review on 05/09/2019 at 3:10 PM, the SDC stated that LNs fax both the hospital transfer orders and the facility-generated orders that are on the MARs to the pharmacy. The SDC stated that the hospital order (4/5/2019) showed Resident 1 was to be on a sliding insulin scale only at noon time, but the LN transcribed the sliding scale to be before every meal without clarification from the physcian . Additionally, even when the pharmacy's formulary/interchange read sliding scale before noon, another LN who received the medications from pharmacy and signed the interchange form did not clarify the order. In addition, SDC stated that the LN signing for the pharmacy interchange for the 14 units of long-acting insulin ([MEDICATION NAME]/Basaglar) failed to clarify the dosage and deleted the 7 Unit long acting insulin dose. Reference: WAC 388-97-1060 (3)(k)(iii)

Based on observation, interview and record review, the facility failed to consistently assess, monitor, provide adequate supervision, and develop, implement and/or revise individualized care plan interventions for 3 of 4 residents (41, 30, 14) reviewed for range of motion (ROM) services. This failure contributed to harm for Resident 41 who had worsening hand contractures with pain and placed Resident 30 and Resident 14 at risk for decline in lower extremity function or walking. Findings included . Review of the facility policy titled Restorative Care, revised on 05/2016 stated the following: 1. Restorative care will be provided to each resident according to his/her individual needs and desires as determined by assessment and interdisciplinary care planning. 2. The resident will receive services to attain and maintain the highest possible mental/physical functional status and psychosocial well being defined by the comprehensive assessment and plan of care. 3. Nursing assistants will document using P[NAME] (Point of care) which will include the type of program and the number of minutes that the resident spent performing program elements. (Type of programs in P[NAME]: Active range of motion, passive range of motion, splints/braces, prosthesis). RESIDENT 41 The resident admitted to the facility on [DATE] with [MEDICAL CONDITION]'s Disease (Inherited disease that causes involuntary movements). The Minimum Data set (MDS) assessments from 01/30/18 to 02/16/19 showed the resident received active Range of motion (AROM) exercises, but did not receive hand splinting. Documentation on 09/26/18 showed the resident had developed bilateral hand contractures that left him dependent on staff for eating and drinking. An Occupational Therapy (OT) Evaluation and Plan of Treatment, dated 12/26/17 - 01/25/18, showed the resident was evaluated by OT for increasing difficulty with self-feeding. The evaluation showed there were no functional limitations due to contractures. The documentation showed the resident could self-feed minimally, and was able to eat 60% of his meal by stabbing food with a utensil in his left hand and bringing food to his mouth. The evaluation showed OT would address this issue by using compensatory techniques and adaptive equipment for the resident to become more independent with self-feeding tasks. No pain was noted during the OT evaluation period. The OT discharge note stated the resident's prognosis to maintain current of function was good with consistent staff follow-through. The note stated that a restorative and functional maintenance program was not indicated. Review of another OT Evaluation and Plan of Treatment dated 09/26/18 - 10/23/18 (9 months later), showed the resident was evaluated by OT for worsening contractures. The evaluation stated the resident had bilateral hand contractures with functional limitations. The OT notes, dated 10/1/18, showed that warm moist towels had to be applied to both hands to decrease the resident's discomfort and pain. It was noted the resident grimaced during Passive range of Motion (PROM) secondary to increase in tone. The short-term treatment plan goals were that the resident would tolerate wearing hand splints for 2 hours, and the long-term goal was the resident would tolerate wearing the hand splints for 4 hours. During this evaluation, the resident was fitted with new hand splints and the resident communicated that the new splints were comfortable. The note again stated that a Restorative and Maintenance program was not indicated. Review of the OT Evaluation and Plan of Treatment notes, dated 03/05/19 - 03/11/19, showed the resident was being evaluated because the resident's family had reported an increase in his hand contractures. The evaluation showed the resident now had functional limitations due to the contractures that impacted all functional activities, and that skilled therapy was needed. The note showed, Passive range of motion of wrist and digits (fingers) to apply splint properly for optimal results. The note also stated the resident had severe tone (muscle and joint tightness) and had a decrease in his range of motion in his wrist and fingers. The OT discharge note showed the resident was able to wear the hand splints for 6 hours. The note concluded by stating a Restorative and Maintenance program was not indicated. The resident's care plan did not include information regarding his bilateral hand contractures with hand splinting, or contain goals and specific interventions, such as monitoring for and reporting any further decline in hand function, or information on the frequency and amount of time the hand splints were to be worn each day. The associated Kardex, the daily care plan guide used by the Nursing Assistants (NAs) also did not identify or list interventions needed to address the resident's worsening hand contractures. Review of the resident's restorative logs from 02/13/19 to 04/04/19, showed the resident received active range of motion (AROM) with approximate average of 15 minutes daily. The log also showed zero daily minutes or hours for splint placement during this period. No other records were available to show splint placement. Observation on 04/01/19 at 9:56 AM showed the resident was lying in bed. His right hand was contracted and he was not wearing a hand splint. During a dining observation on 04/01/19 at 12:33 PM, the resident was being fed by a staff member in the main dining room. The resident had bilateral hand contractures, and was not wearing hand splints. Another observation on 04/02/19 at 8:42 AM showed the resident was wearing a right hand splint on his (R) forearm; the resident's wrist and hand were not within the splint (not splinted). An observation on 04/04/19 at 10:28 AM showed the resident had bilateral splints to both forearms and wrists. Upon closer observation, the splints had a curved portion that was designed to fit in the palm of the resident's hand. The curved portion of both splints was resting on the resident's wrists, rather than fitted into the resident's palms. In a joint observation and interview on 04/04/19 at 10:31 AM, Staff V, OT stated that he was the one who educated the NAs on the restorative needs of the resident. He stated that the hand splints had been recently ordered for the resident. Joint observation of the resident's hands showed the hand palm portion of the splints were resting on the resident's wrists. When Staff V was asked whether that was the correct splint placement, he stated, No and said that the palm portion of the splint was supposed to be sitting in the resident's hand. Staff V then tried to place the splints in the correct position, but stated he could not because the resident's hand contractures were too severe. In a joint observation and interview at 10:42 AM, Staff Y, NA was asked if the splints were placed correctly on the resident's hand. Staff Y stated, No, the resident pushes the splints out of his hand because he has severe pain every time we place the splints on him. He stated the resident usually grimaced when he had pain, and said that the resident grimaced whenever he tried place the splints to the correct position. Staff Y then asked the resident if he was hurting, and the resident blinked twice. Staff Y stated, He usually blinks twice for Yes and once for no. Staff Y stated that Resident 41 has been having contracture pain for a long time when placing the splints. He stated he had recently reported this to the Staff F, Licensed Practical Nurse (LPN) who stated she reported this to Staff C, Resident Care Manager (RCM). During an interview on 04/04/19 at 12:19 PM, Staff C, RCM, stated he was notified of the resident's contracture pain a while back. He stated that he believed the resident's severe contractures were due to the resident's [DIAGNOSES REDACTED]. During an interview on 04/05/19 at 9:57 AM, Staff W, NA, stated that the resident had been wearing the splints for more than six months, and stated the contractures had gotten worse with pain. In an interview at 2:21 PM, Staff X, Physical Therapy (PT) stated that there currently was no one overseeing the facility's restorative program. She stated the nurses were responsible for completing the quarterly assessments, and that she and the Rehabilitation director updated the residents' care plans. She stated that currently, any issues with a resident's restorative program would be referred back to PT for reassessment and evaluation. In an interview on 04/08/19 at 11:09 AM, Staff W, NA stated that it was difficult to perform restorative care for residents as they (NAs) already had a full work load. Staff W stated that it was sometimes difficult to get to all residents who were on a restorative program, especially when they were short-staffed. During an interview on 04/08/19 at11:24 AM with Staff W, NA, and Staff P, NA, the NAs stated that they typically provided daily care to 9 or 10 residents a day. They stated that with all their routine tasks, it was difficult to also do the residents' restorative programs. In an interview on 04/09/19 at 9:38 AM, Staff Y, NA, stated that doing restorative program was a challenge in the midst of all of his other tasks. Staff Y stated there were a lot of days when they were shortstaffed and he could not perform restorative on his residents. At 1:14 PM, Staff C, RCM was made aware of the aides not consistently placing Resident 41's hand splints correctly, not documenting resident refusals to wear the splints due to pain, and not documenting that the splints were placed. He stated he understood that lack of NA documentation was an issue that he would work with the DNS to correct. He also agreed that not placing the splints correctly placed the resident at higher risk for functional decline. RESIDENT 30 Resident 30 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident 30 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderately impaired cognition. The MDS also showed the resident required the extensive assist of one staff member for bed mobility, transfers, and toileting, and required limited assist of one staff member with eating. The resident's care plan, revised on 12/18/18, for ADL Self Care Performance Deficit r/t (related to) weakness, impaired physical mobility, directed staff to provide Nursing Rehab: bilateral hip, knee, ankle AROM (Active Range of Motion) in all planes - 2 sets x 10 to maintain functional strength and decrease risk of contractures. Review of (MONTH) 2019 restorative flowsheet showed the resident refused the bilateral lower extremity (both legs) AROM exercises for 16 days. During an interview and joint record review on 04/05/19 at 01:46 PM, Staff Q, Resident Care Manager (RCM)/Licensed Practical Nurse (LPN) stated that the resident was referred to physical therapy on 01/03/19. Staff Q stated that they do not have specific staff to do residents' restorative programs. Staff Q stated that the assigned nursing assistant (NA) was supposed to do the resident's restorative program, and the nurse on the floor monitored it. Staff Q reviewed the resident's clinical record and stated that Resident 30 was refusing to do his restorative program. In a second interview on 04/05/19 at 01:59 PM, Staff Q stated that the resident was on antibiotic for an upper respiratory infection that started on 03/11/19. Staff Q stated that PT was assessing the resident quarterly to determine whether the restorative program was still effective. During an interview on 04/10/19 at 11:50 AM, Staff L, Director of Rehabilitation (DOR) stated PT did an initial evaluation of the resident on 01/11/19 and that the resident was discontinued from therapy on 03/05/19. Staff L stated that she did joint mobility screens every four months for every new resident, and for any resident who would qualify for Part B (Medicare) services. Staff L stated, I don't do the nursing quarterly assessment for restorative. During an interview on 04/10/19 at 12:00 PM, Staff V, Physical Therapy (PT) provided the resident's PT Discharge Summary, dated 03/05/19, for review. The documentation showed, Discharge Recommendations: discuss with pt (patient) about possible restorative program once she has decreased pain in shoulder and hip. She would benefit from a continuation. Restorative Program Established/Trained= Not indicated at this time. Staff V later stated that the resident was reporting shoulder and hip pain, and that Resident 30 had been assessed by PT for a walking program, which was unrelated to the resident's current AROM restorative program. During a joint interview with Staff Q, RCM/LPN and Staff AA, Quality Improvement Resource (QIR)/Registered Nurse on 04/10/19 at 02:03 PM, Staff Q had asked Staff AA for help where to find the restorative assessment. At 02:34 PM, Staff Q was unable to provide clinical documentation that Resident 30's AROM restorative program goal and progress was evaluated and assessed periodically by a licensed nurse. RESIDENT 14 Resident 14 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an observation on 04/03/19 at 2:11 PM, the resident was observed sitting in his wheelchair in the entrance of his room. Resident 14 was asked if he needed help from the staff what would he do and he was unable to answer. Review of most recent Quarterly Minimum Data Set ((MDS) dated [DATE], the resident scored a 4 on the Brief Interview for Mental Status (BIMs) and was determined to be severely cognitively impaired. It also showed a decline from MDS dated [DATE], Section G (functional status): in the activity of walking in room and corridor going from supervision to activity only occurred once or twice. Review of the resident's Quarterly MDS dated [DATE], showed the resident scored a 15 on the BIMs and was determined to be cognitively intact. During a joint interview/record review on 04/10/19 at 2:02 PM, with Staff D, MDS Coordinator, RN, confirmed that the resident did have a significant change between MDS dated [DATE] and 01/04/2019, confirmed that resident had a decline in ambulation and a change in cognition. Staff D also stated that this change was not captured before as a significant change because His cognition is always going up and down. During a joint interview/record review on 04/09/19 at 11:25 AM, Staff L, Director of Rehab, stated that therapy was not currently working with resident and the last dates of service were in (MONTH) of (YEAR), when the resident was evaluated for his new tilt in space wheelchair. Staff L, stated that the restorative nursing program was run by the nursing department and therapy only initiates programs or makes changes to existing programs as needed, when requested by nursing. Review of PT notes dated 06/12/18 through 07/02/18 showed that on date of discharge from PT (07/02/18), resident was ambulating 150 feet with stand by assistance and close wheelchair follow. Review of nursing progress notes dated 10/24/18, showed resident was found ambulating independently in the hall with his walker. During a follow up interview on 04/10/19 at 11:39 AM, Staff L, stated that the IDT fall committee did not feel that with the resident having a decline in functional ability, change in cognition and numerous falls warranted a therapy referral, stated We didn't pick him back up for therapy because he just keeps falling, we did other interventions like moving his room closer to nurses station, put anti-rollback brakes on his wheelchair, alarms on his bed & chair, things like that. Staff L, stated that when the resident first admitted to the facility he was walking with contact guard assistance but had become very lethargic and the restorative nursing program currently had him on a walking program. Review of the restorative nursing documentation for (MONTH) (YEAR) through (MONTH) 2019, showed resident was scheduled to receive two Restorative nurse programs including: 1. Group Exercises seated left/right hip, knee, ankle, AROM with two pounds in all planes as tolerated to maintain functional strength. 2. Resident to ambulate 150 ft. using front wheeled walker with gait belt and close wheelchair follow. Contact guard assistance to maintain functional mobility. Ambulation distance fluctuates with resident motivation. Review of current care plan showed the resident will participate in nursing restorative program 6 days per week: ambulating 150 feet with contact guard assist, front wheeled walker and close wheelchair follow beginning 08/16/2018, over a month following the intervention. Review of the restorative nursing documentation dated (MONTH) (YEAR) through (MONTH) 2019, showed that resident was participating minimal times per month (varies distances) with both programs and refusing multiple times every month. The documentation on the flow sheets was inconsistent and had multiple blanks in the documentation every month, appearing as through the restorative programs had not been consistently completed. During an interview on 04/09/19 at 1:48 PM, Staff Y, NAC, stated he had only been working in the facility 2 months. Staff Y stated that there were not specific restorative aides so floor nursing assistants were responsible for the programs for their assigned residents during their shifts. Staff Y, stated that he did not feel comfortable walking Resident 14 by himself because the resident was so unsteady on his feet. Reference (WAC): 388-97-1060 (3)(d)

Based on interview and record review, the facility failed to provide the necessary supervision during a mechanical lift transfer for 1 of 3 residents (1). Failure to follow facility policy for mechanical lift transfer and plan of care resulted in harm for Resident 1 who required emergent transfer to hospital and sustained a fracture of his neck. Findings included: The facility's policy for mechanical lift (sling lift) read: this is a 2 person procedure (minimum) and may require 3 staff members to complete for safety. RESIDENT 1 Resident 1 was a long term resident and had a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident 1 had severe cognitive impairments, required a 2 person assist with transfers and bed mobility, had impairment and weighed 213 pounds. The current Plan of Care (P[NAME]) and Kardex directed staff to have 2 staff participation with transfers. The P[NAME] read hoyer (mechanical lift) for transfers, 2 person total assist. During an interview with the Director of Nursing (DNS) on 7/13/18 at 9:45 A.M., she stated the facility policy for a hoyer (mechanical) transfer lift for Resident 1 was not followed. The DNS stated the nursing assistant, Staff B, did not wait for a second staff member to assist with Resident 1's hoyer lift transfer. The DNS stated Staff B had informed her that the strap came off the hoyer hook, while Resident 1 was suspended up in the lift, and he fell to the floor. A facility report dated 7/12/18, documented Resident 1 fell down from hoyer lift during transfer. The report showed that the immediate action taken was to ensure there was always two staff present for hoyer lifts and to check that the straps were connected to the swing correctly. The report showed that Staff B was by herself during the mechanical lift. As the lift was raised, Resident 1 was shaky and Staff B did not know how the hoyer hook came off, allowing Resident 1 to slide out of the sling onto the floor. The report showed 911 (emergency system) was activated and Resident 1 was sent to the hospital for evaluation. The hospital emergency room note showed Resident 1 had a bump (hematoma) on the back of his head, and an x-ray showed a fracture of his neck (cervical). WAC: Reference 388-97-1060 (3)(g)

Based on observation, record review and interviews, the facility failed to ensure residents' environment was free from hazards to avoid accidents for 2 of 4 residents at risk for accidents (#1, #2). The facility staff placed carafes filled with hot beverages in the hallway easily accessible to residents, and Resident #1 sustained a first-degree burn while pouring the hot water. When the facility did not provide adequate supervision for a resident at risk for falls, Resident #2 sustained a left [MEDICAL CONDITION]. These practices resulted in serious harm to the residents. Resident #1 has lived at the facility since 2011. Resident #1 was alert and able to propel herself in the wheelchair. According to the resident's record and an investigative facility report, she was propelling herself in the hallway 12/14/2017 at approximately 2:00 p.m. Resident #1 was seen by a Certified Nursing Assistant (CNA) holding the hot water pitcher, and the water spilled on her left knee area. The resident sustained [REDACTED]. Resident #1 complained of pain at a 7 out of 10 scale. When staff asked her what happened, the resident replied, I don't know but it hurt. The facility staff placed an environmental hazard in the hallway that residents could have access to and caused injury. Additionally, staff failed to evaluate the hot beverage temperatures to determine the risk potential to residents prior to placing it in the hallway. According to the investigation report by facility staff, after the incident occurred, staff immediately checked the temperature of the hot water in the carafe after the resident was burned. Staff documented the temperature of the water to be 176 degrees Fahrenheit (F). According to the facility's policy dated 4/2017, Temperatures of hot beverages at point of service will be maintained at 140 degrees F or less. The Dietary Department will monitor hot beverage temperatures in the dining room. The facility staff failed to have a system in place to identify or monitor the environmental risk of hot beverages to eliminate the risk or reduce the harm from it. After the burn incident occurred, staff implemented an auditing system to monitor the hot beverage temperature at each meal to ensure it was at 140 degrees F or less. The audit took place for 7 days 12/14-12/20/2017. Observation of the coffee pots on 1/10/2018 at 11:00 a.m. filled with coffee located in the kitchen on a cart near the kitchen entry door, found the temperatures were checked by the Dietary Manager (DM), and noted to be 149 degrees F and 157 degrees F. Further observations on 1/10/2018 at 11:05 a.m. revealed three coffee carafes filled with hot beverages behind the nursing station. The Dietary Manager (DM) checked the temperatures of the beverages; they were 149 degrees F, 145 degrees F and 96 degrees F. Two coffee pots were observed located on top of the food cart in the hallway at 11:45 p.m. The DM checked the temperatures of the hot beverages and they were both 140 degrees F. The DM stated, The coffee is now at 140 degrees but after we place the lid back on the pot, the temperature will rise again after 30 minutes. The Director of Nursing (DON) was interviewed on 1/10/2016 at 12 p.m. about the beverage temperatures. The DON stated we need a better system in place to make sure beverage temperatures are where they should be. Facility staff did not have a system in place to ensure hot beverage temperatures were at the appropriate levels before serving them to residents or allowing them access to the hot beverages. Resident #2 According to the resident's record, Resident #2 had lived in the facility since December 2017 after a right hip surgical repair. The resident had multiple complex [DIAGNOSES REDACTED]. The resident required extensive assistance from staff with transfers and bed mobility. According to the medication record and progress notes dated 1/1/2017, Resident #2 had been receiving [MEDICATION NAME] (a narcotic) which could increase the resident's risk of falling. The note also indicated that the resident was forgetful, confused and resident has been a little lethargic last couple of days. The facility failed to recognize and identify the increased need for safety monitoring to ensure Resident #2's safety when there was a known added risk of lethargy documented. According to the facility progress notes dated 1/2/2018, the resident was found on the bathroom on the floor; she had fallen and sustained now a left [MEDICAL CONDITION]. Resident #2 had walked to the bathroom unassisted by staff. The facility staff failed to provide adequate supervision for Resident #2 after it was documented that she was lethargic, forgetful and confused. Refer to WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure that care was provided according to the plan of care for one (Resident #2) of 5 sampled residents. Failure to follow the plan of care resulted in injury to the Resident. Findings include: Resident # 2 was a [AGE] year old female who suffered from progressive dementia, [MEDICAL CONDITION], pneumonia, weakness, and weight loss. She was known to have suffered fractures in the past. She was assessed to be at risk for falls. Her care plan stated "Requires one (person) extensive assist to transfer with stand machine and two person extensive assist with manual transfer." On 05/22/2013 at 11:05 AM the LN (Licensed Nurse) was called to the shower room where she found the Resident lying on top of the CNA's (Certified Nursing Assistant) lap. The Resident complained of severe pain to her left lower extremity. The nursing note stated the "sit/ stand machine was not used for transfer. Resident is a two person assist for transfer." The Resident was assessed by the nurse, transferred to her bed, and given pain medications. The Resident was sent to the hospital where she was diagnosed with [REDACTED]. The facility investigation conducted on 05/23/2013 revealed the CNA who was assisting the Resident used the sit/ stand machine to place the Resident in the shower chair and then placed the machine out in the hallway. After the shower, the CNA stated she could not find the machine. The Resident was asked to stand and hold on to the metal support bars. She became weak and was falling. The CNA stated the wheelchair was behind her but was unlocked as she was trying to transfer the Resident into the chair. She stated she was holding the Resident and did a "controlled guided fall" to the floor. The Resident was lying on the floor with both legs bent. The investigation also revealed the CNA stated she had given showers to this Resident before and knew to use the Sit to Stand machine or two person transfer. She stated she "didn't do it this time because she tried to be in a hurry, too fast, get everything done." The investigation also revealed the CNA did not seek assistance from other staff. The CNA staff member was aware of the fall precautions to be used with this resident. She failed to follow these known safety precautions causing the Resident to suffer a fall which resulted in a femur fracture. In separate interviews on 07/03/2013 and 07/18/2013 with Staff A, Staff Development Coordinator and Staff B, Director of Nursing, both verified that the CNA had not followed the established care plan for safe transfer of this Resident. This is a repeated deficiency previously cited on 03/15/2012.

Based on observation, interview and record review the facility failed to have a system in place to ensure four residents (#18, 88, 142, and 251) at risk for pressure sores had preventive measures in place to prevent pressure sores taken from of a Stage II sample of 40. Once those pressure ulcers developed for Residents (#18, 88, 142, and 251 ) the facility did not review or revise interventions to promote the healing of those pressure sores. This failure to provide interventions timely and consistently to prevent or heal pressure ulcers caused physical harm to Resident # 18, 88, and 251 and placed another resident (#142) at risk for worsening of pressure ulcers. Findings include: Federal guidelines define a pressure ulcer as any lesion caused by unrelieved pressure which results in damage to underlying tissue(s). An unstageable pressure ulcer is defined by the National Pressure Ulcer Advisory Panel (NAUAP) as a "Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined." A Stage IV pressure ulcer is defined by NAUAP as a "Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling." RESIDENT #251 Resident #251 was admitted to the facility on [DATE] from an acute care setting with multiple complex medical diagnoses. When admitted , she had no pressure sores. The resident's Minimum Data Set Assessment (MDS), dated [DATE], indicated the resident required extensive two person physical assistance from staff for all activities of daily living such has bed mobility, transfers, toileting, and personal hygiene. According to the Braden Scale for predicting pressure sore risk, dated 02/23/12, Resident #251 was identified as being at high risk for skin breakdown and development of pressure sores. Clinical record review on 03/06/12 at 03:15 p.m. revealed Resident #251 had a care plan with no directives for staff to follow to monitor and/or prevent skin breakdown although she had been identified as a high risk resident. A review of the Cardex (a care plan located in resident room closet for care giving staff to follow specific interventions) dated 02/24/12 also had no indications the resident was identified as high risk for skin break down nor did it contain preventative measures to relieve pressure on areas prone to the development of pressure ulcers. An interview with Staff N, charge nurse, on 03/07/12 at 11:30 a.m. indicated Resident #251 developed facility acquired unstagable pressure ulcer in her left heel on 03/02/12. The clinical record review on 03/07/12 at 12:00 p.m. revealed Resident #251 was admitted on [DATE] with no pressure ulcer and by 03/02/12, eight days later, staff observed a 2.8 cm by 3.0 cm unstagable pressure ulcer developed on her left heel. Further, as discussed below, it took another ten days (03/12/12) until the facility was fully implementing the care plan interventions. The following observations of Resident #251 were made and reflected the lack of pressure relieving interventions applied by the facility: On 03/05/12 at 2:00 p.m. the resident was observed to be up in a chair with her both heels touching the foot rest. Resident #251 had no socks, no shoes and no pressure relieving device in place. On 03/06/12 at 10:00 a.m. the resident was observed on the bed and it was noted her heels touched the mattress nor were her legs elevated with a pillow nor was any pressure relieving device applied; On 03/07/12 at 11:30 a.m. resident was observed in bed and noted her heels directly on the mattress. No pressure relieving devices were present to relieve pressure on her heels. An interview with Staff I, resident caregiver, on 03/07/12 at 11:30 a.m. stated " I don't know if we need to elevate her legs or not, you see there is nothing in the cardex for me to follow so I didn't elevate her leg or uses those boots. I have been working with her since her admission; I did not know I have to use anything to relief pressure." On 03/07/12 at 3:00 p.m. the wound was observed with Staff N present and it was noted to be 3.0 cm by 3.0 cm with a full thickness tissue loss in which the base of the ulcer was covered by dark eschar in the wound bed. The wound was dry, intact and the eschar tissue was firmly attached to the wound bed. When Staff N was questioned about staff's knowledge on what to do to prevent skin breakdown, Staff N replied "I am not sure whether it is in Cardex or not. I didn't do her admission. Usually on admission day we do a Braden scale and if she is at risk we do some interventions to prevent skin breakdown and update the cardex for the aide to be on the same page with everyone. I am doing weekly skin check today; I will update the care plan and the Cardex today." An interview with Staff O, Rehabilitation Manager, on 03/08/12 at 10:30 a.m. She stated "I have been directly working with the resident and she is in our case load. I was not aware she has an actual wound. No one report to me that. I will see her today and see if we can get linard splint or some kind of boots." An interview with the resident on 03/12/12 at 2:30 p.m. she indicated " I don't have any problem to wear the boots therapy give me last week or put pillow under my legs. I understand my heels have to be off of the mattress. I can't do it. They don't do it every day for me. Some day they do some day they don't. They didn't do it for me today." As noted above, on 03/12/12 at 02:30 p.m. the resident was observed in bed and it was noted her heels touched the mattress, her legs were not elevated with a pillow nor were pressure relieving devices applied. Therapy provided boots were noted in resident closet. An interview with Staff P, the nurse on duty on 03/12/12 at 02:40 p.m., she confirmed the resident observation of no pressure relieving devices put on. She stated "I work in evening shift, my shift just started. The day shift nurse did not tell me anything about her (Resident #251) or why the care plan not followed. I will do it now." Despite multiple observations and verification of pressure ulcers prevention interventions by multiple facility staff over the survey period, the facility staff failed to take action consistently as directed by facility protocols, resident individual care plan and guidelines to prevent pressure ulcers until 10 days (03/02/12 to 03/12/12) after the pressure ulcer was identified by the facility staff to promote healing of existing pressure sore. These failures led to the finding of actual harm to Resident #251. RESIDENT #88 Resident #88 was re-admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. Clinical record review reveled there was no admission assessment on 09/25/11 when the resident was readmitted after a three day acute care setting stay. However, a quarterly skin assessment, dated 09/28/12, noted the resident did not have any open ulcers. Review of his Minimum Data Set assessment (MDS) dated on 10/01/11 identified he required extensive assistance with one person physical assist for bed mobility, transfer, and toilet use. An interview with Resident #88 on 03/09/12 at 10:00 a.m. indicated "I have been having difficulty performing my daily routine related to weakness, and immobility almost a year." Despite his multiple medical conditions such as uncontrolled diabetes and weakness, the facility failed to perform skin risk assessment at the time of his readmission to determine the resident's risk of skin breakdown and to implement preventative interventions. According to a 10/09/11 nursing progress note entry and weekly skin assessment resident was noted to have 1.0 cm by 1.8 cm unstagable left heel pressure ulcer with the edges bleeding slightly and small area of maceration. Care plan was revised and pressure relieving devices were implemented after pressure sore developed. Further review of nursing progress note and weekly skin assessment indicated resident developed another pressure ulcer on his right medial foot (1st metatarsal) on 01/29/12. The weekly skin assessment described the wound as having 25% eschar, 75% slough and edges slightly macerated. Resident #88 was referred to physical therapy for assessment of a pressure relieving device consult. There was no other entry prior to 01/29/12 regarding the right foot wound condition or appearance. On 03/09/12 at 11:20 a.m., Resident #88's right medial wound was observed in the presence of Staff E. The wound was noted to be 50% slough, 25% eschar, and 25 % granulation tissue. On 03/08/12 at 7:15 a.m., the resident was observed in bed and it was noted the head of the bed to be elevated 30 degrees and both the resident's left and right foot were touching the foot board. There was no pressure relieving device noted at the foot of the bed to protect the resident's feet against the footboard. The resident was interviewed on 03/08/12 at 7:15 a.m. regarding the bed and the wound. Resident #88 stated "I don't have any feeling down my leg, you know I have diabetes. I don't feel anything down there. I didn't even feel I am touching the foot board. I guess the bed is a little short for me . . . Whenever I raise the head of bed, I tend to slide down. You know I am a tall guy. I used to be 6'4" but I've shrunk a little bit now. Somebody has to do something here. I am tired of getting bed sores in my leg; one after another one. I am going to lose my legs soon." The above observation was confirmed with Staff E on 03/08/12 at 7:35 a.m. Staff E stated "I am sorry the night aide must have forgot to put the pillows and elevate his legs. I will ask the maintenance guy if he has a long bed. It might be okay if the head of bed was lowered a little bit down and put pillow under his legs." When Staff E was interviewed about about the pressure sore, Staff E replied "We've got to do something about it. I will be on top of it from now on." Clinical record review revealed the doctor order for Physical Therapy evaluation and treatment for [REDACTED]. There was an 10 day delay in implementation from the physician order [REDACTED]. On 03/08/12 at 9:45 a.m., the Therapy Manager, Staff O, was interviewed. Staff O stated "Therapy team was not notified till 2/10/12 and we started right away. I know it is not acceptable to delay for 10 days." On 03/09/12 at 11:00 a.m., Resident #88 was observed to be up in the wheel chair, by his bed side. When checking the overlay mattress in the bed, it was noted the overlay mattress on top of the existing regular mattress was flat and deflated (no air) and the pump was working. This observation was confirmed with Staff E, charge nurse. Staff E stated "I think something is wrong with it." When she asked how often she checked the overlay mattress, she replied "I don't usually check it. When the aide noted some problem during the bed linin change they will report to the nurse. We don't have any system to check it whether it is working or not more often. So I can't really tell you how long it was not working." Clinical record review indicated there was no evidence staff had been checking proper functioning of the overlay mattress on the bed to ensure this pressure relieving device was working. Further clinical record review on 03/09/12 at 11:45 a.m. reveled the physical therapy evaluation and treatment did not evaluate how to reduce pressure on Resident #88's heels while resident was in bed. This despite the fact the resident developed two pressure ulcers on his feet and the doctor ordered specifically a therapy consult for pressure relieving devices regarding Resident #88's wound. Despite the resident being at high risk for skin problems on admission related to his medical [DIAGNOSES REDACTED]. These failures led to actual harm to Resident #88. RESIDENT #18 Resident #18 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. The last annual MDS assessment, dated 10/27/11, indicated the resident needed extensive assistance with most activities of daily living except walking. The assessment indicated the resident needed physical assistance from one staff to walk and noted the resident had a Stage I pressure ulcer on her left foot. The Care Area Assessment (CAA's) completed at the time of the assessment noted the resident had a persistent area of redness on the left foot which "is closely monitored." Review of the medical record showed there was no care plan intervention in place. The next MDS, dated [DATE], indicated the resident had a significant change in condition. It also indicated Resident #18 was no longer ambulating and identified a Stage IV pressure ulcer which was 1.2 by 1.0 cm on the left second toe. Review of the CAA's completed at the time of this assessment indicated the resident had developed a Stage II pressure ulcer on the second toe and because of the wound, the resident had stopped walking. During an interview conducted on 03/06/12 at 10:40 am, Staff E reported the resident had two unstageable pressure ulcers, one on the left second toe and another on the metatarsal at the base of the great toe (the bony prominence on the medial aspect) of the right foot. When asked how the resident developed the wounds, the Staff E reported the resident's shoes did not fit. She indicated a podiatrist had evaluated the resident, but she could not recall the last time the consultant provided the service. Review of the progress notes found on 01/13/12 the resident was pulling away from the staff when they attempted to put her shoes and socks on. They noted at the time the reddened area. Staff also indicated area was sensitive to touch and felt warm. The entry indicated the physician would be notified. On 01/16/12 the physician evaluated the resident for a report of "swelling and a black colored toe ulcer" which appeared to be skin-to-skin contact. Treatment orders for the unstagable pressure ulcer and an order stating "no closed toe shoes" were initiated by the physician on 01/16/12. On 03/13/12 a copy of the care directives, guidelines established for the nursing assistants, were obtained from the resident closet. The directives did not identify any specific directives concerning the order the staff should not place closed toed shoes on the resident. The directives had last been updated on 1/23/12. Further review of the progress notes revealed on 02/21/12, a second unstageable pressure ulcer on the right metatarsal (medical aspect of the bony prominence) on the great toe was identified. The wound was noted to be 0.8 by 0.9 cm. and was described as black eschar. The physician was notified by fax and a dressing to cover the wound was applied. The progress note entry directed staff to "keep the right shoe off" to relieve pressure even though a physician order [REDACTED]. On 03/13/12 at 10:30 a.m., during an additional interview, Staff E , was asked about the resident shoes. She then obtained a pair of black colored walking shoes from Resident #18's closet. When asked, she reported the left shoe was not worn after the development of the left toe ulcer. Staff E, however, stated the right shoe was being put on Resident #18 by staff. During a subsequent interview at 1:30 p.m. Staff F, also reported the right shoe was used after the left toe ulcer was found. During review of the care plan on 03/09/12, the information concerning the directive not to wear closed toes shoes was not found. Under the section identifying what kind of assistance the resident needed with dressing, the directives stated "Staff assist with socks and shoes during am care." There was no evidence the care plan was updated to accurately reflect the physician order [REDACTED]. On 03/09/12 at 9:00 a.m., Staff E. completed wound care. The left toe had intact skin with a visible blackened area on the lateral aspect of the second toe. The right foot had an open area. The licensed nurse measured the length and width, noting it was 0.5 by 0.5 cm in circumference. The wound appeared to have a depth of 0.5 cm, but the depth was not measured by the nurse during the observation. The wound was noted to have yellow colored drainage which the nurse described as serosanguineous fluid (containing blood and serum) Resident #18 was observed to wince in apparent pain when the nurse swabbed the area on the right foot to clean and dress the wound. Not ensuring the physician order [REDACTED].#18 who developed a second unstageable pressure ulcer on the medial aspect of the metatarsal on the right foot. RESIDENT #142 Resident #142 was reviewed as a closed record for the development of pressure ulcers during his admission. He was admitted to the facility 09/16/11. Among his admission [DIAGNOSES REDACTED]. Resident #142 was discharged [DATE] with a new Stage II pressure ulcer to his right buttock which developed on 10/03/11 while residing in the facility. During the admission process on 09/16/11, the resident was administered a Braden Score assessing the resident's potential for the development of a pressure ulcer. His score was 16; at "High Risk." Review of the medical record shows a Care Plan initiated 09/16/11. A review of relevant portions of the care plan reflected no specific or generalized pressure relieving measures being taken until after the right buttocks pressure ulcer developed. According to the care plan, interventions dated 10/03/11 and 10/04/11 of "Resident is to be turned side to side every 2 hours" and "Resident uses an A/P mattress" were put in place. The care plan focus of "Resident has pressure ulcer to right upper buttocks . . . The resident has Left malleolar ulcer" care plan were created and initiated by the facility on 10/04/11. The care plan was put in place on 10/04/11 after the right buttocks pressure ulcer had developed but not at admission to address his pressure ulcer on his ankle and to prevent further development of pressure ulcers. Resident #142 went 17 days without measures in place to prevent the further development of pressure ulcers potentially resulting in the development of a second pressure ulcer.