Every finding on record at Regency Canyon Lakes Rehab and Nursing Center

Based on observation, interview, and record review, the facility failed to ensure 2 of 5 residents (Residents 6 and 16) were free of unnecessary medications due to lack of parameters on identical narcotic medications that consisted of two different dosages and frequencies. This failed practice placed residents at risk of receiving medications incorrectly, subtherapeutic (lower than that usually prescribed to treat a disease effectively) or excessive treatment, and adverse side effects. Findings included. Resident 6 Review of the residents' medical records showed they admitted [DATE] with diagnoses to include respiratory failure with hypoxia (when the lungs cannot deliver enough oxygen to the blood), heart failure, and diabetes (increased sugar in the blood). The 06/10/2026 comprehensive assessment showed Resident 6's cognition was moderately impaired. During review of Resident 6's July 2026 Medication Administration Records (MAR), showed the resident had two narcotic (a drug that relieves pain and induces drowsiness, stupor, or insensibility) medication orders; one for liquid Morphine Sulfate (a brand of pain medication) 20 milligrams per every one milliliter (mg/ml, units of measure), give 10 mg every one hour as needed (PRN) for pain, and the second order was for liquid Morphine Sulfate five mg every one hour PRN pain. Neither order showed parameters for pain levels so Nursing staff would know whether to administer the five mg or the 10 mg dose. Resident 16 Review of the resident's medical records showed they admitted [DATE] with diagnoses to include osteomyelitis (an infection in a bone that can cause pain, swelling, and fever) in their spine and Chronic Obstructive Pulmonary Disease (a chronic lung disease that makes it difficult to breathe). The 07/02/2026 comprehensive assessment showed Resident 16's cognition was moderately impaired and received routine and as needed (PRN) pain medication. Review of Resident 16's July 2026 MARs showed they had two narcotic pain medication orders; one for Oxycodone (a brand of narcotic pain medication) five mg, take half of a tablet every four hours as needed for pain, and a second order for Oxycodone five mg, take one tablet every 4 hours as needed for pain. The orders showed no pain level parameters to show Nursing staff which dose to administer and at what level of pain. During an interview on 07/15/2026 at 12:57 PM, Staff C, Resident Care Manager, stated the orders should have had pain level parameters on each medication order to determine which dose the resident should have received. Staff C stated they had overlooked that Resident 16 had the same pain medication orders with two different dose strengths and the medications should have had pain level parameters on each order. During an interview on 07/15/2026 at 4:37 PM, Staff B, Assistant Director of Nursing, along with Staff A, Administrator, stated when there were two pain medications that were the same, with the same time frequency, and two different dose strengths, there should have been pain level parameters to determine which dose was appropriate to administer. Reference WAC: 388-97-1060 (3)(k)(i)

Based on interview and record review, the facility failed to ensure grievances (resident and/or resident representative concerns that can be voiced or written) conveyed during resident council meetings (a meeting of the facility's residents to communicate concerns, request improvements and keep up to date of the facility's activities/events) underwent prompt resolution through to their conclusion or appropriately updated on the grievance progress/conclusion for 4 of 5 residents (Resident 22, 348, 350, 349) reviewed for the grievances process. This failure placed residents at risk for unresolved concerns and unmet care needs. Findings included . Review of the facility policy titled, Grievances Procedure, revised October 2021, showed the facility would .have a process in place for identification, investigation and follow-up of resident/resident representative grievances in a timely manner. The policy showed that grievances would be documented on the grievance logbook and analyzed for identifiable trends within the facility. <Resident 22> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including a bladder infection, diabetes and long-term kidney disease. The 01/06/2025 comprehensive assessment showed the Resident 22 had moderately impaired cognition but was able to make their needs known. <Resident 348> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including a left leg fracture. The 02/17/2025 comprehensive assessment showed that Resident 348 was cognitively intact and able to make their needs known. The resident was discharged from the facility on 02/24/2025. <Resident 350> Review of the resident's medical record showed they were admitted to the facility on [DATE] for rehab following surgery. The 11/19/2024 comprehensive assessment showed that Resident 350 was cognitively intact and able to make their needs known. The resident was discharged from the facility on 01/15/2025. <Resident 349> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including Multiple Sclerosis (a disease where the body attacks its own nervous system that can cause involuntary muscle spasms and muscle stiffness) and a neurogenic bladder (complication controlling bladder functions). The 12/16/2024 comprehensive assessment showed that Resident 349 was cognitively intact and able to make their needs known. The resident was discharged from the facility on 01/27/2025. Review of the facility's grievance logbook for January 2025 through March 2025 showed that grievances expressed through resident council meetings were not documented on the grievance log for January, February or March 2025. During an interview on 04/08/2025 at 9:01 AM Staff F, Activities Director, stated they were charged with coordination of the resident council meetings and documented the meeting minutes since December 2024. Staff F stated that for all grievances we try to solve right then and there, but that some of the grievances Staff F would have to convey to the Director of Nursing Services (DNS) who would fill out a form. Staff F stated they did not bring the resident's grievances to the facility's grievance officer, Staff D, Social Service Director (SSD) for January 2025 through March 2025 nor had they filled out the facility's official grievance form with resident specific information. During the continued interview on 04/08/2025 at 9:01 AM, Staff F stated that during the January 2025 resident council meeting Resident 350 had a grievance about a Nursing Assistant (NA) with an attitude and Resident 349 had a grievance about an NA that refused to help clean the residents face, but specifics regarding the resident's names and conversations were not documented. Staff F stated that during the February 2025 resident council meeting, Resident 348 had a grievance around medications not being administered timely and that Resident 22 had the same grievance during the March 2025 resident council meeting. Staff F stated that specifics regarding the resident's names and conversations were not documented. Staff F stated they did not have documentation that follow-up was completed for any of the residents. Staff F stated the correct grievance process had not been followed. During an interview on 04/08/2025 at 9:53 AM, Staff D, SSD, stated that all grievances were to come to them so they could be documented on the grievance log, ensure that an investigation was completed, that follow-up was done, which included, grievances during resident council meetings so that patterns/trends could be identified. Staff D stated they were not aware of Resident 22, 348, 350 or 349's grievances from the January through March 2025 resident council meetings. Staff D stated they could not ensure the correct process of a grievance resolution through to its conclusion was conducted for Residents 22, 348, 350 and 349. During an interview on 04/08/2025 at 10:48 AM, Staff B, DNS, stated grievance concerns conveyed by Staff F from the January 2025 through March 2025 resident council meetings were not towards any one resident or staff member and Staff B saw the grievance as a whole and not specific. Staff B stated they did not know the names of the specific residents that had conveyed the grievances during the January 2025 through March 2025 resident council meetings. Staff B stated they did not interview the specific residents or follow-up with the residents on the grievance resolution/conclusion. During an interview on 04/09/2025 at 8:08 AM, Staff A, Administrator, stated they had realized that grievances from the resident council meetings were not being documented on the facility grievance log. Staff A stated they did not know that Residents 22, 348, 350 and 349 were involved in the specific grievances from January 2025 through March 2025 resident council meetings. Staff A stated the correct process was not followed for the Resident 22, 348, 350 and 349's grievances. Reference: WAC 388-97-0460(2)

Based on interview and record review, the facility failed to review and validate the Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] are not inappropriately placed in nursing homes for long term care) had the required Level 2 referral sent when residents had a positive Level 1 PASARR and were an exempted hospital discharge in the facility for more than 30 days or had a change in condition in which a new Level 1 PASARR would require completion for 2 of 5 residents (Resident 24 and 2) reviewed for PASARR. This failure placed the residents at risk of not receiving the mental health care and services appropriate to their needs. Findings included . Review of the Department of Social and Health Services, Dear Nursing Home Administrator Letter, guidance titled, Clarification to the Pre-Admission Screening and Resident Review (PASARR or PASRR) Level 1 Screening Process, dated 07/06/2024, showed a positive Level 1 PASARR screen (that would then require a referral for a Level 2 PASARR) was Any of the questions in Section 1A (1, 2, and/or 3) are marked Yes: or sufficient evidence of SMI is not available, but there is a credible suspicion that a SMI may exist; and the requirements for exempted hospital discharge do not apply . Additionally, if requirements for exempted hospital discharge were met but the residents stay changed from less than 30 days to exceeding 30 days, then the facility's responsibility would be to send out positive Level 1 screenings to be evaluated. <Resident 24> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnosis including chronic obstructive pulmonary disease (a lung disease causing restricted airflow and breathing problems) and anxiety (a feeling of worry, nervousness, or fear, often in anticipation of something unpleasant). The comprehensive assessment dated [DATE] showed Resident 24 had a mildly impaired cognition and an anxiety disorder. Review of Resident 24's PASARR, dated 02/21/2025 showed Resident 24 had a positive SMI for a mood disorder. Further review showed Resident 24's PASARR was marked exempt from requiring a Level 2 evaluation due to a physician certifying that Resident 24 would be requiring less than a 30 day stay in the nursing facility. Additionally, the required Level 2 evaluation had not been completed as of 04/08/2025 (46 days after Resident 24's admission). During an interview on 04/08/2025 at 12:52 PM, Staff D, Social Service Director (SSD), stated when a resident was admitted with an exemption marked on the PASARR for a stay of less than 30 days, and the stay was likely going to be longer, the social service assistant would be responsible for sending out for the Level 2 required screening prior to the 30-day mark. During an interview on 04/09/2025 at 9:50 AM, Staff I, Social Service Assistant, stated they were unable to confirm whether Resident 24's PASARR had been sent out for the required Level 2 screening. During an interview on 04/10/2025 at 9:53 AM, Staff B, Director of Nursing Services, stated the process for sending out the required Level 2 PASARR screening for a resident who came into the facility exempt was that social services were to send it prior to the 30-day mark. Staff B stated that it was not completed for Resident 24. 43280 <Resident 2> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses including heart complications, depression, and anxiety. The comprehensive assessment dated [DATE] showed Resident 2 was readmitted on [DATE] with a significant change (a deterioration or improvement in the physical or mental conditions of a resident) in their health status. Review of Resident 2's PASARR, last completed on 10/25/2021 by Staff D, SSD, showed the resident had SMI of depression and anxiety, and no Level 2 was required at the time the assessment was completed (no Level 1 PASARR had been updated after the resident's change in condition on 12/30/2024). During an interview on 04/09/2025 at 2:32 PM, Staff D, stated the facility's process was to complete a new Level 1 PASARR if a resident had a physical or mental change in their condition. Staff D stated they were not aware Resident 2 had a change in condition around the 12/26/2024 significant comprehensive assessment. Staff D stated the correct process was not followed and that a new Level 1 PASARR should have been completed and a referral sent for a Level 2 PASARR evaluation. During an interview on 04/09/2025 at 3:20 PM, Staff A, Administrator, stated the correct process was not followed regarding Resident 2's change in conditions and a new Level 1 PASARR should have been completed/sent out for an evaluation. Reference: WAC 388-97-1975(5)(7)

Based on interview and record review the facility failed to: 1) identify and monitor individualized targeted behaviors (ITB's), and implement non-pharmacological (methods used to improve health and/or manage a residents conditions without the use of medications) interventions before prescribing a psychotropic medication (a group of drugs that affect brain activities associated with mental processes and behavior), 2) monitor for adverse side effects (unwanted, uncomfortable, or dangerous effects that a drug may have, that can lead to a decline in an individual's mental or physical condition); and 3) ensure appropriate justification for the use of a psychotropic medication for 1of 5 residents (Resident 19), reviewed for unnecessary medications. This failure placed residents at an increased risk of medical complications, unnecessary side effects, and a deterioration in their mental and physical health. Findings included . Review of the facility's policy titled, Behavior Management/Psychoactive Medication Overview, dated February 2025, showed that residents with mood or behavior symptoms will be assessed to determine potential causes. Assessment of data, observation, resident interviews, and staff feedback will be used to develop a behavior/mood management care plan. Psychotropic medications may be used for behavior/mood management when other non-pharmacological interventions have been unsuccessful and should be used as a last resort. Routine monitoring for adverse side effects and ITB monitoring will be documented on the resident's medication administration record (MAR). <Resident 19> Review of the resident's medical record showed Resident 19 was admitted on [DATE] with diagnoses including a fracture of the left hip joint and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities). Review of the most recent comprehensive assessment, dated 03/22/2025, showed the resident's cognition was moderately impaired and no hallucinations (a false perception where you see, smell, taste or feel things that appear to be real but only exist in your mind) or delusions (a strongly held false belief that conflicts with reality) were present. Review of the physician's orders dated 03/20/2025 (2 days after admission) showed that Seroquel (a specific psychotropic medication commonly used to treat mental health conditions like hallucinations) was ordered to be given to Resident 19 at bedtime for hallucinations. Further review showed that no orders were placed to monitor ITB's nor non-pharmacological interventions to show whether the psychotropic medication was appropriate or effective. Additionally, there were no orders for monitoring adverse side effects related to psychotropic medication. Review of a progress note dated 03/20/2025 showed Staff G, Registered Nurse, documented a new order for Seroquel to address disturbances related to dementia. Staff G documented the provider had spoken to Resident 19's representative (RR) about Resident 19's status. However, no further documentation regarding the psychotropic medication was found in the record from 03/20/2025 to 04/09/2025. During an interview on 04/09/2025 at 11:49 AM, Staff G stated the process for starting any psychotropic medication included placing the resident on alert charting for monitoring of ITB's specific to the residents, to justify the need for the medication. Staff G stated once a psychotropic medication was started, orders would be placed to monitor a residents ITB's, any adverse side effects, and to update the care plan. Staff G stated that the Resident Case Managers (RCM) were responsible for following up on any psychotropic medication orders or changes to ensure the process was followed. Additionally, Staff G confirmed this process was not followed for Resident 19 when the new order for a psychotropic medication was received. During an interview on 04/09/2024 at 1:08 PM, Staff H, RCM, stated the process for starting any psychotropic medications included placing the resident on alert charting for at least three days to monitor specific ITB's, non-pharmacological interventions attempted and any adverse side effects to show the medications effectiveness. Additionally, Staff H stated all nursing staff were responsible for documenting in the resident's medical record. Staff H stated they were not aware that Resident 19 was hallucinating or that the resident had been started on Seroquel. Staff H stated a daily report of all new medications were provided and Staff H was unsure of how Resident 19's psychotropic medications got missed. During an interview on 04/09/2025 at 4:07 PM, the facilities medical provider, stated they were informed by nursing staff that Resident 19 was hallucinating reportedly seeing children out the window and not sleeping well. The provider also stated they had discussed the hallucinations with Resident 19's RR and expected the behaviors to be documented in the medical record, along with alert charting for any adverse side effects, ITB's, non-pharmacological interventions and evaluation of the medication's effectiveness. However, this was not done for (Resident 19). During an interview on 04/09/2025 at 2:28 PM, Resident 19's RR recalled the facility's medical provider spoke with them and stated they had given permission for the Seroquel medication to be started. However, the RR did not remember why the psychotropic medication was being started, and that Resident 19 was acting differently at the time. During an interview on 04/10/2025 at 9:43 AM, Staff B, Director of Nursing Services, stated they expected nurses transcribing psychotropic medication orders to ensure there was adequate justification for use of the medication, initiated ITB's, monitored for any adverse side effects, and implemented alert charting. Additionally, Staff B stated the process was not followed correctly on the implementation of Resident 19's psychotropic medication. Reference: WAC 388-97-1060(3)(k)(i)

Based on observation, interview and record review, the facility failed to ensure nursing staff implemented appropriate infection control practices in the prevention of urinary tract infections (a condition were pathogens like bacteria enter through the urinary meatus [a passage or opening leading to the interior of the body] and infect the kidneys or bladder) with residents indwelling urinary catheter (IUC, a tube placed in the bladder which drains urine out into a collection bag) care for 1 of 2 resident (Resident 17), reviewed for infection control. This failure placed the residents at risk of developing an IUC associated UTI and unmet care needs. Findings included . <Resident 17> Review of the resident's medical records showed they were admitted on [DATE] with diagnoses including stroke, neuromuscular dysfunction of the bladder (complication controlling bladder functions) and obstructive reflux uropathy (an obstruction in the urinary tract causing urine to back up into the kidneys). The 03/10/2025 comprehensive assessment showed that Resident 17 had moderately impaired cognition and an IUC. Review of Resident 17's care plan showed the resident had a suprapubic catheter (a specific type of IUC that is inserted through a small incision in the abdomen) in place as was to receive IUC care every shift by nursing staff. Observations on 04/07/2025 at 1:09 PM showed Staff E, Nursing Assistant (NA) and Staff G, NA, performing an incontinence brief change and IUC care on Resident 17. Staff E and Staff G performed hand hygiene and put on gloves prior to starting the resident's care. Staff E started perineal care (cleaning and maintenance of the private areas of the body) on the resident's buttocks and a small wound that had a scant amount of blood was noted. Staff E utilized the same wipe, that had just been soiled from wiping the resident's perineal area, to wipe the blood from the resident's wound. Staff E did not perform hand hygiene or put on new gloves and then assisted in turning and replacing the old, soiled brief with a new clean one. Staff E proceeded to clean the resident front perineal area with the same soiled gloves and then move onto the resident's IUC care without performing a glove change or hand hygiene. During an interview on 04/07/2025 at 1:45 PM, Staff G, NA, stated their process for perineal care would be to remove their soiled gloves and perform hand hygiene after completing care on the resident buttocks area and after care of the resident's frontside perineal area. Staff G stated they would then put on new gloves to continue with IUC care. During an interview on 04/07/2025 at 1:49 PM, Staff E stated they should have completed hand hygiene/changed gloves in between each area of the resident's perineal care and then before moving onto Resident 17's IUC care. Staff E stated they did not follow the correct infection control process for IUC care and could have potentially contaminated the residents IUC. During an interview on 04/09/2025 at 3:42 PM, Staff C, Infection Preventionist, and Staff B, Director of Nursing Services, stated that Staff E did not follow the correct infection control process for Resident 17's IUC care and that hand hygiene/change in gloves should have been performed in between each area of the resident's body to prevent the potential spread of infectious pathogens. Reference: WAC 388-97-1320(1)(a)(c)

Based on interviews and record review, the facility failed to ensure 1 of 3 residents (Resident 1), reviewed for medication administration, was free from a significant medication error. Resident 1 experienced harm when Staff A (Registered Nurse) did not follow standard practices for medication administration when they administered multiple medications, belonging to another resident, to Resident 1. This resulted in Resident 1 becoming unresponsive with low blood pressure (BP) and low blood glucose (BG) levels, necessitating an emergency transfer to the emergency room and admission to the hospital. The facility corrected the deficient practice prior to the initiation of the abbreviated survey on 12/26/2024. This failure was past non-compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) was corrected by the facility on 12/18/2024 and is no longer outstanding. The facility removed the immediacy by: - Resident 1 was immediately assessed by the Nurse Practitioner (NP) and action was taken to address their medical needs. The NP remained in the facility and was present at the time Resident 1 was sent to the emergency room . Staff was monitoring the resident closely for changes in their condition. There were no other residents affected. - Staff A and all Licensed Nurses received education on 12/17/2024 regarding the rights of medication administration, and verifying the resident by name and picture or name and date of birth. - A performance review was conducted on Staff A on 12/17/2024. - Residents were interviewed regarding their medications for any concerns, timeliness of administration, and receiving all the medications that were ordered by the physician. - A Skills Checklist was performed on Staff A on 12/18/2024. - Random medication pass audits will be completed weekly for 8 weeks. The results of the audits would be reviewed through the facility Quality Assurance Performance Improvement Committee process at the end of January 2025 with the final results being discussed in April 2025. Findings included . Review of the facility policy titled, General Dose Preparation and Medication Administration, revised on 11/15/2024, showed prior to the administration of medication, facility staff should take all measures required by facility policy and applicable law, including but not limited to the following: 1) Verify each time a medication is administered that it is the correct medication, at the correct dose, at the correct route, at the correct time, for the correct resident. 2) Confirm that the Medication Administration Record reflects the most recent medication order. During medication administration, facility staff should perform the following: 1) Verify resident identification using resident's picture in the computer and at the entrance to their room. 2) Provide the resident with any necessary instructions, including the medication use and possible side effects. <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included arthritis and chronic respiratory disease. Review of Resident 1's comprehensive assessment, dated 11/19/2024, showed they had moderate impaired cognition. Review of a Progress Note, dated 12/16/2024, showed Resident 1 required moderate assistance with one staff for walking, turning in bed and transfers; maximum assistance with one staff for dressing and toilet use; and set up assistance for eating. The resident was able to make their needs known. Review of an assessment by the NP, dated 12/17/2024, showed Resident 1 had a significant medication error involving 12 medications; which included three medications to reduce BP, three medications used in the treatment of diabetes to lower BG, one medication to prevent blood clotting, one medication to reduce swelling, one medication to treat depression and anxiety, one medication to treat a condition where the thyroid gland does not produce enough thyroid hormone, one medication to treat irritable bowel syndrome, and one potassium medication to help nerves and muscles work properly. The resident did well throughout the morning without any acute changes. At lunch time the resident became unresponsive. Their eyes were open, lips were blue (caused by low oxygen levels in the blood), and was unable to answer questions and follow instructions. The resident's BG level was found to be in the 60's (normal BG levels would be 125 or lower), thus a medication to treat low BG was given. Their systolic BP (measures the pressure of the blood pushing against the artery wall - normal reading was less than 120) was in the 60's. Emergency Medical Services (EMS) was called to transport Resident 1 to the emergency room . Review of hospital records, dated 12/17/2024, showed intravenous (via a vein) fluid was given to Resident 1 for treatment of their low BG and low BP. Due to the resident's persistent low BG and slightly low BP they were admitted to the hospital. On 12/26/24 at 11:44 AM, Staff A, stated they only worked one to two days a month at the facility, and had not met Resident 1 until the day of the medication error (12/17/2024). Staff A stated they had looked at the picture of Resident 1 on the computer, which looked similar to the resident whose medications were given to Resident 1. They stated they had not properly identified the resident, nor had they identified the medications to Resident 1, in a rush. Upon Staff A's return to the medication cart after the administration of medications to Resident 1, they immediately became aware of the medication error as Resident 1's room number was different. Staff A stated they immediately notified their supervisor of the medication error. On 12/27/2024 at 10:07 AM, Resident 1 stated that during the medication administration on 12/17/2024 they had told Staff A the 11-12 medications looked strange to them. Staff A had responded, they change them occasionally. Resident 1 stated the medications were hard to recognize in the small medication cup so they took all the medications. They stated they did not know anything about the medications and Staff A did not describe any of them. Resident 1 then went to lunch and ate 25-50% of their meal. They stated that during lunch they began having vision problems and did not feel good. Following lunch they were taken by staff to the end of the hall. Resident 1 did not recall anything further until they were hospitalized . Resident 1 was discharged from the hospital three days later on 12/20/2024. Reference (WAC) 388-97-1060(3)(k)(iii)

Based on observation, interview and record review, the facility failed to provide timely care and services and perform assessments for 1 of 3 residents (Resident 1) reviewed with indwelling urinary retention catheters. Resident 1 experienced harm when they had prolonged bladder pain due to urinary retention with a delay in treatment. The facility corrected the deficient practice prior to the initiation of the abbreviated survey on 09/04/2024. This failure was past non-compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) and was corrected by the facility on 08/29/2024 and is no longer outstanding. The facility removed the noncompliance by: - Resident 1 was immediately assessed by a LN and action was taken to address their medical needs. The physician was notified, and orders received to continue to monitor resident. - Staff A and Staff B, involved in the care and assessment of Resident 1, were suspended and then terminated for failure to assess a change of condition in accordance with professional standards. There were no other residents affected by that practice. - All LNs had received education regarding change of condition related to catheter care, maintenance and output monitoring on 08/23/2024. - Audits would be conducted weekly through the clinical meeting process to ensure residents with catheters were voiding without difficulty. Results of the audits would be reviewed through the facility Quality Assurance Performance Improvement Committee process monthly for three months to ensure compliance with plan of correction and further develop a plan if needed. First audit was completed and reviewed. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses which included Parkinson's disease (chronic, progressive brain disorder that affected the nervous system and caused motor and non-motor symptoms) and urinary retention (a condition that occurred when someone was unable to empty their bladder completely). The resident was transferred to the hospital on 08/07/2024 for heart and kidney problems. They were readmitted to the facility on [DATE] with an indwelling urinary retention catheter due to urinary retention. Review of Resident 1's comprehensive assessment, dated 08/16/2024, showed they had moderately impaired cognition. Review of their plan of care, dated 08/12/2024, showed they required moderate assistance by one staff for grooming/personal hygiene; moderate assistance by one staff for transfers using a Stedy lift (manual sit-to-stand transfer aid that enabled one caregiver to transfer residents); maximum assistance by one staff for toilet use, dressing and turning in bed; and one staff to set up for meals. Review of physician's orders, dated 08/12/2024, showed staff were to irrigate the catheter as needed if plugged or leaking. Review of the facility investigation, dated 08/22/2024, showed Resident 1 voiced they had a hard time getting assistance during the early morning hours of 08/22/2024, despite asking for help on several occasions. The investigation determined the resident's urinary output was not adequate during the evening shift (2:00 PM to 10:00 PM) of 08/21/2024 and during the night shift (10:00 PM on 08/21/2024 until 6:00 AM on 08/22/2024). The indwelling urinary retention catheter had become plugged and limited the resident's output. Staff A, Registered Nurse (RN) on the evening shift of 08/21/2024, failed to recognize the decreasing urinary output and document their assessment in the resident's medical record. In addition, Staff A failed to utilize tools such as the bladder scanner (portable ultrasound device used to measure the volume of urine within the bladder) or irrigate the resident's catheter to ensure their assessment was thorough and accurate. Staff B, Licensed Practical Nurse, on the night shift ending at 6:00 AM on 08/22/2024, failed to perform any assessment, or provide the necessary care and services to the resident. Review of Resident 1's August 2024 Medication Administration Record showed no pain medication was administered to the resident on the evening shift of 08/21/2024 through the night shift ending at 6:00 AM on 08/22/2024. On 09/04/2024 at 10:40 AM, Staff C, Nursing Assistant (NA), stated they had worked with Resident 1 from 6:00 AM to 10:00 PM on 08/21/2024. At 4:00 PM on 08/21/2024 the resident began complaining of pain in their urethra, (tube which allowed urine to pass outside the body). When Staff C checked the resident's catheter between 6:30 PM to 7:00 PM they observed a build-up of pink-red sediment from the insertion site down five inches of the catheter. The catheter collection bag was emptied at 8:30 PM on 08/21/2024 for a total of 75 milliliters (ml's) of dark brown, foul smelling urine. Staff C stated they notified Staff A at that time as usually Resident 1 had large amounts of urinary output. Between 8:30 PM to 10:00 PM the resident had no additional urinary output. Staff C stated when she cared for the resident earlier that day between 6:00 AM to 2:00 PM there was a total of 1800 ml's of urine as the resident usually drank large amounts of water. Staff C stated she had discussed Resident 1's complaints of pain and changes in their urinary output at least twice with Staff A during the evening shift. Staff A had responded to Staff C stating the only thing they could do for Resident 1 was to order a urinalysis (UA) to be done. On 09/04/2024 at 12:15 PM, Staff A, stated they had worked between 6:00 PM to 10:00 PM on 08/21/2024. They were doing a medication administration pass at 8:00 PM when Staff C came to them stating Resident 1 was complaining of burning with urination. Staff A saw Resident 1 at 8:30 PM that evening and they stated it was burning but denied pain. Staff A stated they palpated the resident's abdomen and had no concerns and no complaints of pain by the resident. The catheter was draining amber colored urine. Staff A stated they informed Resident 1 they would get a physician's order in the morning for a UA to be done to rule out a urinary tract infection. Staff A put a note in the provider book regarding the need for a UA to be done and informed Staff B during shift report at 10:00 PM on 08/21/2024. The provider would get the note the following day. Staff A stated they had been informed by Staff C of the resident's low urinary output. Staff A stated they had not contacted the provider, nor had they documented their assessment in the resident's medical record. Despite Resident 1's complaints of burning with urination Staff A stated they had not administered pain medication to the resident as they had not complained of pain. On 09/04/2024 at 11:37 AM, Staff D, NA, stated they cared for Resident 1 from 10:00 PM on 08/21/2024 to 6:00 AM on 08/22/2024. Staff D stated at 11:00 PM on 08/21/2024 there was only 10 to 20 ml's of urine in Resident 1's catheter bag. At 2:00 AM on 08/22/2024 the resident complained of abdominal pain. The resident's abdomen was hard at that time and there was no additional urinary output. Staff D stated Resident 1 agreed to take Tylenol. Staff D informed Staff B of the resident's hard abdomen, minimal urine output and the need for pain medication. Staff D also stated to Staff B that something was not right, with Resident 1. Staff B was to give Resident 1 Tylenol and stated maybe a bladder scan should be done. When Staff D returned to the resident's room between 3:30 AM to 4:00 AM Resident 1 was in so much pain, had tears in their eyes and felt helpless. Staff D stated everything they told Staff B was being disregarded. Resident 1 had no further urine output. Resident 1 stated the Licensed Nurse (LN) never came to their room despite them putting their call light on between 3:00 to 4:00 AM. At 4:00 AM the resident stated, I'm going to die here. A total bed change was done at 4:00 AM as the resident had urinated around the catheter soiling the bed sheets. The resident had used their call light two to three times and asked if the LN was going to do anything about their concerns. Staff D again reported to Staff B that something was not right with the resident. Staff D stated they were not aware of Staff B ever being in the resident's room during the shift, nor was pain medication administered to the resident. On 09/04/2024 at 12:04 PM, Staff B, stated the only thing that was reported by Staff A in shift report at 10:00 PM on 08/21/2024 was Resident 1 was having burning with urination and a UA was to be done. At 3:45 AM on 08/22/2024 Staff D informed them the resident only had 100 ml's of urine output, to which Staff B responded they would perform a bladder scan on the resident. At that time another resident had fallen to which Staff B had responded. Staff B stated they then administered medications to residents at approximately 4:30 AM, forgetting about the need to perform a bladder scan on Resident 1. At 5:20 AM on 08/22/2024 Staff E, RN, arrived to work and performed a bladder scan on the resident which showed 600 ml's to 700 ml's in the resident's bladder. Staff E also put a new catheter in the resident. Staff B stated they were aware of the resident's low urinary output but stated they had not complained of any pain. Staff B stated they had gotten side tracked, when a resident had fallen. Staff B stated they had not administered any pain medication to the resident. On 09/04/2024 at 10:30 AM, Staff E, stated at 5:30 AM on 08/22/2024 they were told by Staff B Resident 1 had bladder pain and painful urination and a UA needed to be obtained. Staff B stated they received that information in shift report at 10:00 PM on 08/21/2024 from Staff A. Staff E stated they were approached by Staff D at 6:15 AM on 08/22/2024 that they had informed Staff B three to four times during their shift that Resident 1 was having bladder pain and no urinary output on the evening and night shifts. Staff D also reported they had touched the resident's abdomen and it was rock hard. Staff E stated they immediately went to assess Resident 1 and observed their abdomen was very distended and rock hard. The resident appeared miserable, had tears in their eyes and was in a lot of pain. Staff E performed a bladder scan on the resident with the first reading of 1066 ml's and the second reading showed 977 ml's of urine. Staff E observed a dark brown sediment in six inches of the catheter tubing from the insertion site. The catheter appeared to be plugged thus a new catheter was inserted with a total of 1700 ml's of urine obtained (normal bladder capacity ranges between 400 and 600 ml's). The resident was immediately relieved of pain with the new catheter. The resident informed Staff E they had put their call light on several times on the previous evening and night shifts with no one addressing their concerns. On 09/04/2024 at 2:45 PM Resident 1 stated to questions regarding their catheter, they remembered the pain through the night, were concerned about their stomach becoming distended and hard, remembering it felt like they were going to die and no one seemed to pay any attention to them. Despite their pain they did not recall receiving any pain medication. Resident 1 was observed lying in bed at the time of the interview. Their indwelling urinary retention catheter was draining clear, yellow urine. Reference: WAC 388-97-1060(1)

Based on observation and interview the facility failed to provide a safe, functional, and sanitary (the conditions that affect hygiene and health) environment for residents and staff for 1 of 1 shower room (SR 1), reviewed for a comfortable environment. This failure placed residents and staff at an increased risk for not feeling safe and secure with their environment. Findings included . Observations of the [NAME] hallway SR1 on 05/08/2024 at 7:43 AM showed the main wall had numerous scuff/scrape marks spanning along the entire lower half of the 20 foot (ft, a unit of measure) wall, where three mechanical lifts had been stored. Multiple gouges and tears could be seen in the sheet rock and paint chips from the wall were noted on the floor. The actual shower had three missing tile pieces, two broken trim/edging sections at the entrance to the shower, and a black substance that could been seen all around the inside perimeter of the shower. Additionally, a 1/2 ft by 1/2 ft section of wall/sheet rock had been cut out around the shower's cover and valve (controls the flow of water and turns the shower on/off) with the top half of the valve sunk into the wall. During an interview on 05/10/2024 at 11:31 AM, while observing SR1, Staff C, Maintenance Supervisor, stated that all shower rooms were operational and being used. Staff C stated they had been attempting to adjust the shower valve to increase the showers water pressure, did not finish the sheet rock behind the valve, and was not sure how the shower valve had sunk back into the wall. Staff C was shown the black substance around the inside perimeter of the shower along with the missing section of tile and trim. Staff C was not sure what the black substance was, but stated the shower was not in proper working order and the missing section of tile/trim, the shower valve, and the numerous scrape/gouge marks on the main wall all need to be fixed. During an interview on 05/10/2024 at 11:40 AM, after showing observations of SR1, Staff A, Administrator, stated that it all needed to be fixed, that it was not a comfortable environment for the residents, and they would be working to correct it. Reference: WAC 388-97-3220(1)

Based on interview and record review the facility failed to provide adequate supervision to ensure the directed plan of care for two-person staff assistance with transfers and use of assistive devices were followed for 1 of 3 residents (Resident 1) reviewed for avoidable accidents and/or falls. These failures caused harm to Resident 1 when they were transferred off the toilet by one staff member, not utilizing a gait belt (an assistive device placed around the resident's waist to safely transfer the resident), and fell in the bathroom. Resident 1 sustained a sacral (large triangular bone at the bottom of the spine) fracture at the time of the fall which resulted in pain and a decline in their activities of daily living (ADLs). Past Noncompliance was identified at CFR 483.25(d)(2), F689 Free of Accident Hazards/supervision/devices, at a scope and severity level of G and corrected by the facility on 07/05/2023. Findings included . Resident 1. Review of the resident's medical record showed they were admitted to the facility on [DATE], five days following hospitalization after a fall, with a new diagnosis of a stroke (blood flow to the brain is blocked) with left sided weakness. Review of the resident's comprehensive assessment, dated 6/24/2023, showed they had moderate cognitive impairment; required extensive assistance by two staff for turning in bed, transfers, dressing, and toilet use; and extensive assistance by one staff member for personal hygiene. Review of the resident's plan of care, dated 06/21/2023, showed the resident required extensive assistance by two staff for transfers and was at risk for falls. Review of a Progress Note, dated 06/24/2023 at 9:33 PM showed the resident fell in the bathroom when they were being transferred to their wheelchair from the toilet. The resident stated they grabbed the bars on the wall of the bathroom, stood up and lost their balance landing on their left hip and hitting their head on the wall. On initial assessment by the Licensed Nurse (LN), the resident was able to move their arms and legs without difficulty. Forty-five minutes later the resident began to complain of left hip pain. The physician was called, and orders were received to transport the resident to the emergency room . Hospital records, dated 06/25/2023, showed the resident had a nondisplaced (bone cracks or breaks but retains its proper alignment) fracture of the sacrum. The resident was readmitted to the facility on [DATE] from the hospital. Review of the facility investigation report, dated 06/24/2023 at 6:30 PM, showed Staff A, Nursing Assistant (NA), transferred the resident from the toilet to the wheelchair by themselves, and had not utilized a gait belt during the transfer. The resident's plan of care required two staff for transfers. Review of the June 2023 and July 2023 Medication Administration Records showed narcotic medication was ordered on 06/29/2023 (readmitted ) for the resident every four hours as needed for pain. The resident received their first dose at 8:00 PM on 06/29/2023 for a pain level of eight (pain level of 0 to 10 with 0 being no pain, and 10 being severe pain) to their buttocks area. Narcotic pain medication continued to be administered one to two times per day for pain between 06/29/2023 through 07/07/2023. In an interview on 07/06/2023 at 3:20 PM, Staff B, Director of Nursing, stated that all staff had to utilize gait belts during transfers of residents. In an intreview on 07/07/2023 at 9:00 AM, Staff C, Director of Rehab/Physical Therapy Assistant, stated that the resident was flaccid (neurological condition shown by weakness or paralysis) from their left shoulder to the left hand. Prior to the resident's fall on 06/24/2023, they required two staff to assist with transfers using a gait belt. The resident could use their right am to grab the bar on the bathroom wall to assist with transfers. One staff was required to be on the resident's left side and the other would be behind them on the right side. Due to the resident's left-sided weakness from their stroke, they leaned extensively to the left side. All staff were required to use gait belts during all resident transfers. Following the resident's fall which resulted in a sacral fracture, they no longer used the bathroom but rather used a bedpan in bed. In an interview on 07/07/2023 at 9:35 AM Staff D, Registered Nurse, stated they were right outside the resident's room when they heard a thump and a scream. The resident was lying in a corner on the bathroom floor. There was no gait belt used by Staff A. Staff D stated the resident was supposed to have two NAs assisting them off of the toilet. In a telephone interview with the resident's representative, Collateral Contact, on 07/10/2023 at 2:16 PM showed the resident had much pain due to their fall on 06/24/2023 and continued to have pain. The CC stated the resident had difficulty sitting up due to the pain. The facility implemented the following interventions by 07/05/2023, which corrected the deficiency: - Staff A provided education by administrative staff on 06/28/2023 and completed facility training with the Director of Rehab on 06/27/2023. - The facility implemented a system for auditing nursing assistants regarding the use of gait belts and appropriate knowledge of the residents' plans of care regarding ADLs. Audits were to be completed three times per week for four weeks, then weekly for three months. Audits were to be continued as planned. - Provided education on 06/30/2023 to all nursing staff on gait belts and the use of the residents' plans of care regarding ADLs Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to periodically test the sanitizing agent used to ensure proper sanitation of food preparation surfaces in accordance with professional standards for food service safety, for one of one kitchen reviewed for food service safety. This failure placed all residents, staff, and visitors that ate from the facility's kitchen at risk for food borne illnesses and the spread of infectious diseases. Findings included . Review of the March 1, 2022, Washington State Retail Food Code, showed the concentration of the sanitizing solution must be accurately determined by using a test kit or other device. Review of the Pureforce Food Contact Quat Sanitizer product label instructions for use, dated 2012, showed the concentration of sanitizer used in the solution for sanitizing stationary, hard, nonporous surfaces, such as sinks and countertops, should be mixed at a ratio of 0.25 - 0.68 ounces of Food Contact Quat Sanitizer product per gallon of water, to achieve a concentration of 150 - 400 parts per million ([ppm] - a unit of measurement that is used to ensure proper dilution) active quat. During an interview on 04/20/2023 at 9:50 AM, Staff M, Dietary Manager, stated that they used the buckets of sanitizing solution to sanitize the preparation (prep) areas in the kitchen. They stated that the solution used to be tested , they had a testing kit that contained test supplies and forms to complete, but it was stored in an inconvenient location and was now lost. During an interview on 04/20/2023 at 9:53 AM, Staff L, Cook, stated that they used the solution with a clean rag to clean the prep areas of the kitchen. They stated that they used to test the solution but had not done it for a while. A concurrent observation and interview on 04/20/2023 at 9:55 AM, showed a bucket of sanitizing solution in the sink in the dishwasher area of the kitchen. Staff K, Dietary Aide (DA), stated that they were never trained to test the sanitizing solution and had not seen any forms or testing supplies. During an interview on 04/20/2023 at 12:38 PM, Staff M, stated that they could not find the testing logs for the sanitizing solution. They stated that testing was done, and staff knew how to test, but the log had been lost and no one reported the missing log. Staff M stated that they expected that the sanitizing solution in the buckets would have been tested every 2 hours. During an interview on 04/21/2023 at 10:56 AM, Staff M stated that they used the sanitizing solution in the buckets to wipe down all the areas that were soiled during meal prep. During an observation and interview on 04/21/2023 at 11:59 AM, showed Staff N, DA, in the dishwasher area of the kitchen with Staff M present. There was a bucket of sanitizing solution in the sink. Staff N stated that they had just started their shift and was not sure if the solution had been changed. Staff N performed a test on the solution, which showed the solution passed at 200 ppm. They emptied the bucket and refilled it from the automatic solution delivery device. Staff N then performed a test on the clean solution which passed at 400 ppm. During the same observation and interview, Staff M stated that the testing of the solution was a failed system. Record review showed sporadic testing of the sanitizing solution with the last documented test in December of 2022. During an interview on 04/21/2023 at 11:34 AM, Staff A, Administrator, stated that they understood the failure and was looking into purchasing new buckets that continuously monitored the sanitizing solution. Reference: WAC 388-97-1100(3)

Based on observation, interview, and record review, the facility failed to ensure standard infection prevention and control precautions were implemented by seven of ten staff (H, D, O, I, Q) observed during dining and meal tray delivery to residents, and one of two staff (J) observed during wound care dressing changes. These failures placed residents and staff at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of the facility's policy titled, Centers for Disease Control and Prevention (CDC), Hand Hygiene in Healthcare Settings, dated 01/30/2020 showed that all staff should implemented hand hygiene to help reduce the spread of infections to others. Further review showed that staff should perform hand hygiene for situations like, before contact with a resident or a resident's immediate environment, before handling clean or soiled dressings, before moving from a contaminated body site to a clean body site during resident care, after contact with objects in the immediate vicinity of a resident, after removing gloves, and before/after eating or handling food. Additionally, CDC's procedures for hand washing included, lathering the hands with soap, and rubbing them together for a minimum of 15 to 20 seconds. Dining Observation on 04/17/2023 at 11:41 AM showed Staff H, Nursing Assistant (NA), in the dining room serving salad to residents. Staff H was observed serving salad from a large bowel into a smaller salad bowl with utensils and assisted residents in setting up the bowl so that they would be able to eat. Staff H had bare hand contact with their own clothes, resident's used drinking cups and utensils when they were assisting each of the four residents, and did not perform hand hygiene during or after serving residents their food. During an interview on 04/19/2023 at 11:22 AM, Staff H stated that they should have performed hand hygiene in-between each resident when there were serving them salad and theyforgot. During a concurrent observation and interview on 04/18/2023 at 12:00 PM, Staff D, NA, delivered a meal tray to a room. Staff D arranged items on the resident's bedside table, cut up the resident's food, buttered the biscuit, handled the resident's silverware, then exited the room without performing hand hygiene. Staff D proceeded to obtain another resident tray from the delivery cart without performing hand hygiene. Staff D stated that they usually washed their hands before and after meal delivery for each room but had spaced it out that day. Staff D had bare hand contact with the resident's personal items and food throughout the observation. During a concurrent observation and interview on 04/18/2023 at 12:02 PM, Staff O, NA, delivered a meal tray to a resident's room. Staff O performed meal set up, then exited the room without performing hand hygiene. They proceeded to obtain another room tray from the delivery cart without performing hand hygiene. Staff O stated that they always washed their hands before and after delivering trays. Staff O further stated, I forgot and need to go do that now. Observation on 04/19/2023 at 7:44 AM showed Staff I, NA, was in the dining room delivering meal trays to residents. Staff I was observed delivering/setting up three different resident meal trays, touched multiple items/surfaces which included one resident's arm/sleeve and another's wheelchair, and did not perform hand hygiene in-between each resident. During an interview on 04/19/2023 at 8:23 AM, Staff I stated that they should have been performing hand hygiene in-between passing out/setting up trays for residents and was not aware that they had touched multiple surfaces in-between passing out meal trays to residents. During an observation and subsequent interview on 04/21/2023 at 8:06 AM, Staff Q, NA, delivered a food tray to a resident's room. Staff Q did not perform hand hygiene upon entry or exit of the resident's room. Staff Q proceeded to obtain another food tray from the cart and delivered it to Resident 22 in another room. Staff Q set the tray on the bedside table, removed the lids to food and drink containers and left the resident's room with the resident's coffee. Staff Q took the uncovered cup of coffee, with their bare hands, to the physical therapy room and heated it up in the microwave, placed a lid on the cup and carried the cup of coffee back down the hall to the resident's room with their palm over the cup of coffee. No hand hygiene was performed during any part of the process. Staff Q explained that when staff delivered trays to residents in halls, they were to take off the food covers, and place clothing covers on the residents, if requested. Staff Q stated that they forgot to perform hand hygiene during tray delivery. Wound Care Resident 15. Review of the resident's medical records showed that they were admitted on [DATE] after knee surgery for rehabilitation and had developed a wound that required a daily dressing change. Observations on 04/18/2023 at 11:56 AM showed Staff J, Registered Nurse (RN), at Resident 15's bedside for a dressing change on a newly identified wound on the resident's right lower leg in addition to a scheduled daily dressing change on their bottom. Staff J set up a cloth pad under the resident's right leg where multiple soiled gauze pads were observed. Observations on Staff J's dressing changes sequence of events were: 04/18/2023 at 11:59 AM after removing the resident's soiled gauze dressings Staff J doffed (to take off) their soiled gloves and then proceeded to perform hand washing (without lathering or scrubbing their hands and washed for less than five seconds) at the sink in the resident's room, then donned (to put on) a new pair of gloves. 04/18/2023 at 12:03 PM after cleaning the residents leg wound, Staff J doffed gloves and performed hand washing (without lathering or scrubbing their hands and washed for less than five seconds) at the sink in the resident's room for the second time. 04/18/2023 at 12:08 PM Staff J changed gloves (after finishing cleaning the wound and had contact with the soiled/contaminated gauze pads) and did not perform hand hygiene before donning new gloves. Staff J then proceeded to open clean dressing supplies that were used to cover the wound and wrap the resident's leg. Additionally, Staff J changed and wrapped the resident's leg with the clean dressing without removing the soiled gauze pads that were still under the resident's leg and did not have a separate clean and dirty space. During an interview on 04/20/2023 at 10:33 AM, Staff J, stated that they did not follow the correct process for hand washing and should have lathered and scrubbed their hands for 20 seconds. Further, Staff J stated that they had not followed the correct process for the clean dressing change on the resident's leg. Staff J stated they should have removed the soiled dressings from the area under the resident's leg before applying the clean dressing. Additionally, Staff J stated that they should have performed hand hygiene in-between each glove change and forgot to do it. During an interview on 04/20/2023 at 1:56 PM, Staff B, Director of Nursing Services, stated that they expected all staff to perform hand hygiene in between each resident meal tray delivery, handling of food or entering/exiting resident's rooms. Staff B also stated that Staff J had not followed the correct standard infection control process for wound care and dressing changes and that they would expect all staff to perform hand washing by lathering the hands with soap and scrubbing them together for 20 seconds. Additionally, Staff B would expect all staff to perform hand hygiene in between every glove change. Reference: WAC 388-97-1320(1)(c)(2)(b) 45117 46722

Based on observations, interviews, and record review, the facility failed to ensure clinical appropriateness for safe self-administration of medication for two of two residents (5 and 192), reviewed for medication administration. Additionally, the facility failed to obtain a physician's order for self-administration of medications for the residents and did not update the individualized care plan. Failure to complete a self-administration assessment and obtain a physician's order placed the residents at risk for medication errors and adverse medication interactions. Findings included . Resident 5. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, stroke, and GERD (gastro-esophageal reflux disease - a digestive disease in which stomach acid or bile irritates the food pipe lining). The 02/20/2023 comprehensive assessment showed the resident required extensive assistance of one to two staff members for Activities of Daily Living (ADLs). The assessment also showed the resident had a moderately impaired cognition. An observation on 04/17/2023 at 10:03 AM showed the residents over the bed table contained a bag of cough drops, a container of Vicks Vaporub (a topical ointment that temporarily relieves cough), and a bottle of Rolaids (antacid medication to neutralize stomach acid and relieve acid indigestion). A bedside table showed a bottle of Advil ([NSAID] a non-steroidal anti-inflammatory medication that treats fever and mild to severe pain), a bottle of TUMS (antacid), a bag of cough drops, and a container of Tucks Medicated Pads (a pad saturated with medication to relieve the itching and burning associated with hemorrhoids). Additional observations on the following dates showed the same observations: 04/18/2023 at 8:56 AM; 04/20/2023 at 7:52 AM; 04/21/2023 at 7:55 AM. During an interview on 04/21/2023 at 8:33 AM, Staff C, Nursing Assistant (NA), stated that they provided cares for Resident 5. They stated that sometimes resident family members brought in medications for the residents. Staff C stated that if they found medications in a resident room, they let the licensed nurses know. They stated they were not aware of any medications in any resident rooms. During an interview on 04/21/2023 at 8:37 AM, Staff E, Licensed Practical Nurse (LPN), stated that the process for a resident to keep medications at the bedside included obtaining a physician's order. Staff E stated they were responsible for passing medications to Resident 5 and were not aware of any medications kept at the bedside. During an interview on 04/21/2023 at 8:40 AM, Staff F, Registered Nurse (RN), stated that the process for allowing medications at the bedside included placing a call to the physician to ask if its ok. They stated that they would not put in an order for medications at the bedside but might put in a progress note. During an interview on 04/21/2023 at 8:43 AM, Staff G, Patient Care Coordinator (PCC), stated that they were the PCC for Resident 5. They stated that the process for a resident to keep medications at the bedside for self-administration included completion of a medical assessment form to make sure the resident was appropriate for the self-administration. Once the assessment was completed, they would obtain a physician order and place the self-administration order on the Medication Administration Record (MAR). Staff G stated they did not know the resident had medications at the bedside. During a second interview at 9:30 AM, Staff G stated that there was also a prescription bottle of Ondansetron (a medication to prevent nausea and vomiting) that came from an outside pharmacy. Observation showed the bottle was labeled with the name of the drug and a quantity of 20. There were 11 pills left in the bottle. Review of the resident's medical record showed that there was a lack of assessment, no physicians order, and no care area on the individualized care plan for safe self-administration of the medications . Resident 192. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses including a right hip fracture, mild cognitive impairment, and a need for personal care assistance. The 4/13/2023 comprehensive assessment showed the resident required assistance of one staff member for ADLs. The assessment also showed the resident had a mildly impaired cognition. An observation on 04/17/2023 at 12:50 PM showed a bottle of Refresh eye drops on the residents over the bed table. Review of the medication label showed the medication was filled at an outside pharmacy. The bottle was half full. Additional observations on the following dates showed the same bottle of eye drops on the bedside table: 04/18/2023 at 8:40 AM; 04/20/2023 at 9:20 AM; 04/21/2023 at 8:29 AM. During an interview on 04/17/2023 at 12:50 PM, the resident stated that their doctor stated that they could have their eye drops in their room because they needed them frequently. During an interview on 04/21/2023 at 8:34 AM, Staff D, NA, stated that they were aware of the eye drops in the resident's room. During an interview on 04/21/2023 at 8:43 AM, Staff G stated that they were the PCC for the resident and were not aware of the eye drops at the bedside. They further stated that there was no assessment or physicians order for that resident to keep medications at the bedside. Review of the resident's medical record showed that there was a no assessment, no physicians order, and no care area on the individualized care plan for safe self-administration of the medications. During an interview on 04/21/2023 at 9:57 AM, Staff B, Director of Nursing Services (DNS), stated that if medications were found in a resident's room, it would be reported to the licensed nurses, a physician order would be obtained, and a self-medication assessment would be performed. During a follow-up interview at 11:34 AM, Staff B stated that the facility did not have a policy on self-administration of medications. They stated that they ensure that an assessment had been done and that a physician's order had been obtained. It should have been on the Medication Administration Record. Reference: WAC 388-97-0440, 388-97-1060(1)(3)(l)

Based on observation, interview, and record review, the facility failed to ensure the right to make choices regarding frequency of bathing and food preferences for five of 10 residents (18, 6, 25, 27, 28), reviewed for self-determination. The facility's failure to accommodate residents choices placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . Frequency of Bathing Resident 18. Review of the resident's medical record showed the resident was admitted to the facility on [DATE] and according to the 08/07/2021 admission Minimum Data Set (MDS, an assessment tool), showed the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment showed that the resident required one-person physical assistance with bathing. Resident's 18 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the resident's care plan, dated 08/03/2021, and Kardex (individualized directives for resident care) both showed the resident was to have a shower two times a week. During an interview on 09/07/2021 at 12:57 PM, Resident 18, stated that staff did not provide bathing according to their preferences and that they have only had three showers since their admission to the facility. Additionally, the resident stated that they would like to make sure a shower was given prior to the next doctor appointment because they did not want to go when they were dirty and not looking good. Review of the resident's shower record showed Resident 18 got showers on Mondays and Thursdays. Review of the Resident's Task Bathing Record, showed the resident received a shower on 08/23/2021, 08/26/2021, and on 09/02/2021. On 09/13/2021 the day of the resident's doctor appointment, the resident refused a shower. During a concurrent observation and interview on 09/14/2021 at 9:02 AM, (the day after the resident's doctor appointment) showed Resident 18 had oily hair. The resident stated that they did not get a shower prior to going to the doctor's office and that they would have liked one but was informed by staff that it was too late for a shower and to make it to the doctor's appointment on time. Resident 6. Review of the resident's medical record showed Resident 6 had diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was able to make their needs known. The care plan, dated 07/06/2021, showed the resident needed extensive one-person assistance for bathing and the resident wanted two showers a week. The Kardex also showed the resident was to receive two showers a week. The shower schedule showed that the resident was to receive a shower on Wednesdays and Saturdays. Review of the Resident's Task Bathing Record, showed that since admission the resident received a shower on 08/18/2021, 09/02/2021, 09/08/2021, and on 09/11/2021 (four out of the eight scheduled showers). During a concurrent observation and interview on 09/09/2021 at 9:51 AM, Resident 6 stated that they would like to get two showers a week, and for some reason I only get one shower a week. Resident 6 also stated that they do not get told if they are not going to get a shower, it just doesn't happen. The resident stated that there have been times that they did not even get one shower in a week. The resident also stated that they need their hair washed at least one time a week or their hair gets oily looking. The resident's hair was oily and unkempt during the interview. Resident 25. Review of the resident's medical record showed the resident was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Resident's MDS, dated [DATE], showed the resident was able to make their needs known and it was very important to choose between a tub bath, shower, bed bath or sponge bath. The care plan, dated 08/23/2021, and Kardex showed the resident was to receive showers two times a week and as needed. During an interview on 09/09/2021 at 9:51 AM, Resident 25, stated that they wanted two showers a week at least and would really like a shower everyday but I know that's not possible. Additionally, the resident stated that there were times they were not given their showers and did not know when it was not going to happen. Review of the Resident's Task Bathing Record, showed in the past 30 days the resident received a shower on 08/18/2021, 08/29/2021, 09/05/2021, 09/08/2021, and 09/11/2021 (five out of the eight scheduled showers). Resident 27. Review of the resident's medical record showed the resident admitted to the facility on [DATE] following a hospitalization and was dependent on staff for showers. According to the 08/28/2021 admission MDS, the resident was able to make their needs known and expressed that choices about bathing was Very Important. During an interview on 09/07/2021 at 10:37 AM, the resident stated they did not recall having received a shower since admission to the facility. The resident stated that they would like a shower but had not been informed of when their showers would occur. Review of the resident's care plan, dated 09/07/2021, showed the resident required extensive assistance for showering and was to receive showering twice weekly and as necessary. Review of Resident 27's shower record from 08/24/2021 through 09/13/2021 showed the resident was provided a shower on one occasion since admission, which occurred on 09/03/2021 (one out six scheduled showers). Resident 28. Review of the resident's medical record showed the resident admitted to the facility on [DATE] after a knee replacement. According to the 08/31/2021 admission MDS, the resident was cognitively intact and expressed that choices about bathing was Very Important. During an interview on 08/07/2021 at 2:48 PM, the resident stated I've only had one shower .I'd like to have them twice per week. The resident further stated that staff had not informed them of when showers would occur and that they just came and got me. Review of Resident 28's shower record from 08/26/2021 through 09/13/2021 showed the resident received only two showers, one on 09/03/2021 and the second on 09/09/2021 (two out of the five scheduled showers). During an interview on 09/09/2021 at 12:17 PM, Staff P, Nursing Assistant (NA), stated that they most often worked as a designated shower aide, but because of openings on the schedule they had been pulled to work floor shifts as an NA. Staff P stated that the residents were not getting showers as often and that showers were being missed. During an interview on 09/13/2021 at 12:42 PM, Staff C, Registered Nurse/Resident Care Manager, stated that based on room assignment, residents were to receive at minimum of two showers weekly. Staff C acknowledged that the residents had not been receiving showers as scheduled. Food Preferences Resident 6 and 25. During a concurrent interview on 09/09/2021 at 9:51 AM, both Resident 6 and 25 stated that they were not provided information about what the alternate food choices were for lunch/dinner. Both residents stated that they would like a menu where they could choose what they were going to eat for their meals (between the regular and alternate meals). Additionally, Resident 25 stated, I'll know (what meal it is) when it gets here regarding meals and what food was being served. Resident 25 stated the menus they received were not dated, and did not list an alternate meal choice. The resident also stated that it was very difficult to determine what meal was being served so that the resident could make a choice. During an interview on 09/10/2021 at 9:29 AM, Staff E, Dietary Manager, stated that the residents received a four-week cycle of menus (menus were not dated). Additionally, Staff E, stated that the only place that an alternate food choice was displayed was located at the front entrance (an area that was not frequented by residents). Reference: WAC 388-97-0900 (1) (3)

Based on observation, interview, and record review, the facility failed to develop a comprehensive system for notifying residents of the grievance process, how to report a grievance, and/or how to anonymously report their concerns for two of two residents (6, 25) reviewed for grievances. Further, the facility failed to complete a grievance form, investigate, and resolve a grievance for three of three residents (25, 28,129) reviewed for new grievances. This failure placed the residents at risk of unresolved concerns and diminished quality of life. Findings included . Grievance Process Review of the facility's Grievance Procedure, dated November 2016, showed that it was the policy of the facility to identify, investigate and follow-up with resident grievances in a timely manner and that Grievances are resolved immediately, when possible, by the individual receiving the grievance .when immediate resolution is not possible, the grievance is routed to the Grievance officer. The policy did not include how residents could file a grievance in writing and/or anonymously. Review of the March, April, May, June, July, and August 2021 grievances showed two grievances in the past six months, both were lost clothing on 06/14/2021, and 06/24/2021. On 09/07/2021 at 2:00 PM, observations of the most frequently used resident common areas, which included, main activity area, east/west hallways, and resident dining areas, failed to show postings notifying residents of the grievance process. On 09/09/2021 at 9:51 AM, a meeting with a group of resident council representatives was conducted. Residents 25 and 6 stated that they were not aware of the grievance process in the facility or how or where to file a grievance. Residents 25 and 6 also stated that they were not aware of who the Long-Term Care Ombudsman was or how to make contact. Resolve a Grievance During the 09/09/2021 resident council meeting at 9:51 AM, Resident 25 stated that they had a grievance regarding a room change. Resident 25 stated that they wanted to stay in their room, and they had called a family member to talk with the facility so they would not have to move rooms. The resident further stated that when they admitted to the facility, they were assured that they would not have to change rooms. Resident 25 had the family member call the facility so the facility would not know that the resident was the one complaining. During an interview on 09/14/2021 at 10:48 AM, Staff D, Social Service Director, stated that there was not a room change for Resident 25, but a roommate was being moved into Resident 25's room. They talked with Resident 25 and the resident was fine with a new resident being placed in their room. Staff D stated that they felt this was a non-issue, so they did not complete a grievance form. Resident 28. Review of the medical record showed the resident admitted from the hospital on 08/26/2021 following a knee replacement surgery. Review of the resident's 08/31/2021 admission assessment showed the resident was cognitively intact. During an interview on 09/07/2021 at 2:50 PM the resident stated that this morning at 6:00 AM, they were in pain and had asked for their as needed (PRN) pain medication. The resident stated that the medication was not administered until 9:00 AM. Resident 28 stated they thought the staff delayed bringing the pain medication at 6:00 AM because it was more convenient for them to give it with other routine medications and stated, I should not have to wait that long. During an interview on 09/08/2021 at 10:15 AM, Staff C, Registered Nurse/ Resident Care Manager, when informed of the resident's complaint, stated that they were not aware of the resident's complaint regarding a delay in administration of the PRN pain medication. Staff C stated that they would conduct an investigation. Review of the facility's grievance concern/complaint log from 09/07/2021 through 09/14/2021 showed no grievances were received from Resident 28. During an interview on 09/14/2021 at 10:30 AM, Staff C stated that a grievance had not been logged, regarding Resident 28's complaint. Staff C stated that their involvement in any nursing complaint was only to conduct an investigation and to follow up with floor staff as needed. Staff C stated a grievance procedure was not initiated for the resident. Resident 129. Review of the medical record showed the resident admitted on [DATE] following knee surgery. Review of the 08/31/2021 admission assessment showed the resident was cognitively intact. During a concurrent interview and observation on 09/07/2021 at 2:30 PM, the door to the resident's room showed a sign which indicated that the resident was on droplet precautions and that the door was to remain closed at all times. Additionally the sign instructed staff to wear Personal Protective Equipment (PPE) to include gown, gloves and mask when in the resident's room. The resident was observed in bed, stated that they had felt very isolated, could not have visitors and was not able to walk the hallways due to quarantine restrictions. Further, the resident was informed by the facility that they would be off quarantine on 09/09/2021. Resident 129 stated that they were so relieved that the quarantine was almost over and they would be allowed get out of their room, walk the halls and have visitors. Review of a 09/08/2021 Out of Facility Risk Assessment showed the resident had an appointment at an outpatient clinic and due to potential exposure time and social distancing factors, the assessment showed the resident scored at a higher risk activity and would be placed in quarantine for an additional 14 days. During an interview on 09/09/2021 at 12:29 PM, Staff D, Social Services stated that the resident's risk had been assessed and a determination was made for additional quarantine days. Staff D stated that the resident was not very happy with the decision. During an interview on 09/09/2021 at 2:03 PM, Resident 129 stated it's ridiculous, they came in this morning, and told me I'm back on quarantine. The resident stated that during the appointment at the clinic, social distancing was maintained and that everyone wore masks. I was looking forward to just getting out into the hallway and walking, I feel so isolated. The resident stated that when they voiced their frustration to Staff D, they were told it was out of the facility's hands. During an interview on 09/15/2021 at 11:10 AM, Staff I, Regional Vice President/Acting Administrator, stated that they needed to do a better job on grievances, and did not realize there were only two grievances in the past six months and if they would have known that they would have looked into it. During an interview on 09/15/2021 at 11:45 AM, Staff B, Director of Nursing Services, stated that the facility utilized the grievance/complaints concerns to determine trends and areas needing improvement. Staff B stated that the facility was implementing changes to the grievance process, as they had not been adequately capturing resident complaints and concerns. Reference: WAC 388-97-0460

Based on observation, interview, and record review, the facility failed to ensure food was served in an attractive manner, flavorful, and at an appetizing temperature for three of three meals observed during the survey period. In addition, eight of 22 residents (3, 13, 15, 19, 20, 230, 28, and 26) who ate in their rooms, reported dissatisfaction with the meals served. Failure to ensure food was served in an attractive, palatable, and at an appetizing temperature placed residents at risk for a decreased nutritional experience. Findings included . Resident 3. Review of the resident's medical record showed they were admitted on [DATE] with diagnoses to include compression fractures of the upper back and malnutrition (not eating a diet with proper amount of nutrition or calories). Review of the 06/21/2021 comprehensive assessment showed the resident had some impairment of memory but was alert and able to make their needs known. The resident was underweight and had difficulty swallowing liquids. The resident's liquids had to be thickened to a nectar consistency. Resident 3 needed set-up assistance with their regular diet. During an observation and interview on 09/07/2021 at 11:45 AM, the resident was served a palm size piece of cooked chicken, roasted potatoes cut in small wedges, and sliced cooked carrots. The resident stated the chicken was tough and had no flavor and didn't taste good and was uneatable. Additionally, the resident stated they cannot wait to get home and eat some real food. During an interview on 09/07/2021 at 3:18 PM, the resident stated the food at the facility was terrible and the facility did not provide condiments like salt, pepper, or ketchup. Resident 13. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses of a traumatic head injury, paralysis to left side of the body, and right eye [CONDITION(S)]. Review of the 07/21/2021 comprehensive assessment showed the resident required extensive assistance from staff with meals. The resident was able to make their needs known but had some memory impairment. During an observation on 09/07/2021 at 12:00 PM, the resident was being assisted with eating the lunch meal which included chopped up chicken, carrots, and a dessert. During an interview on 09/07/2021 at 1:40 PM, the resident stated they were unable to tell the difference in what kind of meat they had eaten and that there was no good flavor, no seasoning, and no sauces. The resident stated there were no choices or alternatives if the meal was not hot or did not taste good. Resident 13 stated that the usual snacks were peanut butter sandwiches, and that the food was cold at breakfast. They stated they would just like some Cinnamon Toast Crunch cereal. During an observation on 09/08/2021 at 8:10 AM, the resident was served a breakfast cereal and stated it was supposed to be hot cereal but was cold. There was no alternative offered. Resident 15. Review of the resident's medical record showed they admitted to the facility on [DATE] with diagnoses to include end stage kidney disease with [CONDITION(S)] (machine acts as a kidney filter to remove waste and other toxins from the body), and multiple other medical issues. Review of the 07/26/2021 comprehensive assessment showed the resident had trouble hearing and usually understood what was said, they were alert, oriented, and could make their needs known. The resident required set up assistance during meals. Review of the 08/04/2021 informed consent form showed the resident did not want a pureed textured diet and wanted regular textured foods. The 08/04/2021 consent form included risk for not following the pureed textured diet and signed by Resident 15, Staff C, Registered Nurse/Resident Care Manager (RN/RCM), and Staff G, Physician Assistant (PA). During an interview on 09/08/2021 at 9:45 AM, the resident stated the food was terrible and had no taste. The resident stated that the meals were supposed to be regular texture, not pureed. During an observation of the 09/09/2021 at 8:48 AM the resident was up in a tilt and space wheelchair with a breakfast tray, which included a mound of brownish molded blob in the center of the plate with a syrupy light brown liquid around it. The oatmeal was lumpy and congealed (jello like consistency). There were blue cups with fluid and plastic straws. The resident did not eat but 25% of the meal. During an interview on 09/09/2021 at 8:50 AM, the resident stated they did not know what the food was and said it was terrible, cold, unappealing, could not eat it, and did not want pureed food. An unknown Nursing Assistant (NA) came into the room to take the residents tray away and did not know the resident diet, and then stated someone else gave them the tray. The NA then placed the uneaten food on the resident's tray to the meal cart. An alternative food choice was not offered. Review of the 09/08/2021 diet order showed the resident was on a regular, pureed texture diet. Liquids were a thin consistency with a high protein liquid supplement with all meals. Resident 19. Review of the medical record showed the resident admitted on [DATE] with diagnosis of stroke with right sided paralysis. Review of the 08/07/2021 comprehensive assessment showed the resident was alert, oriented and could make their own decisions and required set up only with meal trays. During an interview on 09/07/2021 at 11:19 AM, the resident stated the food was not very good and there was no variety or flavor. The resident stated they informed Staff E, Dietary Manager (DM), they wanted oatmeal for breakfast with fresh fruit. The resident stated that the eggs were terrible and cold. During an observation on 09/07/2021 at 12:05 PM, the resident's lunch consisted of a small strip of chicken, a small cut wedge of sliced roasted potatoes (four small pieces), a quarter cup of cooked carrots and a fruit cup for dessert. The resident stated that the meat had no flavor and no seasoning. There were no condiments or salt and pepper on the resident's meal tray. The resident was on a regular diet. During an observation on 09/08/2021 at 12:10 PM, the resident was served a lunch tray which consisted of a sausage like, brown, crusted meat, brown tater tots, diced red beets and diced peaches for dessert along with milk, and other fluids. During an interview 09/08/2021 at 12:12 PM, the resident stated that the food was unappealing and was bland, and ugly color. The resident took a bite of the brown crusted meat and stated it was tough and had no flavor. Resident 20. Review of the medical record showed they were admitted to the facility on [DATE] with diagnoses to include diabetes (too much sugar in the bloodstream), dementia (impaired ability to think, remember and it interferes with everyday activities), and heart disease. During an observation and interview on 09/08/2021 at 12:00 PM, the resident had no main dish on their lunch tray. The resident stated they asked the staff to get rid of the tray of food because it was disgusting and made them ill to look at it. Resident 230. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include high blood pressure, heart disease and difficulty walking. The resident was alert, oriented and able to make their needs known. Review of the 08/30/2021 comprehensive assessment showed the resident required extensive assistance with most activities of daily living except, eating which the resident was independent. The resident was on a regular diet. During an interview on 09/07/2021 at 11:45 AM, the resident stated they ordered the fish with vegetable for lunch. The resident stated that they were the last person served lunch and dinner because they were at the cut off point for the dietary staff because they switch to another cart, so they get served last. The resident stated that lunch started at 11:30 AM but I do not get served until 12:10 PM or as late as 12:20 PM. During a 09/07/2021 observation the resident was served lunch at 12:10 PM. The lunch tray consisted of a palm sized piece of chicken, small portion of cooked carrots, and small wedged roasted potatoes. The resident stated they didn't order chicken but ate it anyway. The resident stated that they keep their own condiments at bedside, since the facility did not provide them (salt and pepper). Resident 230 stated the vegetables were so over cooked that they just crumble when using a fork to eat them. The resident stated the chicken was dry and tasteless and used their salt and pepper to supply some seasoning to the chicken. During an interview on 09/08/2021 at 9:16 AM, the resident stated that they requested oatmeal because by the time the food arrived to them it's usually cold to lukewarm. They stated the food had no taste and at breakfast this morning the oatmeal was lumpy, and they had no brown sugar to add to the oatmeal. During an observation on 09/09/2021 at 12:04 PM, the resident's plate had breaded steak links that were crusted with brown tater tots and diced red beets. The resident then pulled out some other food that they kept in their drawer. A test tray was requested from the kitchen for lunch on 09/08/2021 at 11:30 AM, for the lunch meal. The lunch test tray was placed on the meal cart at 11:51 AM. The test tray for lunch consisted of crusted brown links of steak fingers, brown tater tots and diced up red beets, peaches, and milk. The tray presentation was not appealing as the color of the food was brown with red beets on a white plate. The food was tested for temperature palatability which the tater tots, steak fingers and beets were lukewarm, and the milk and diced peaches were warm. During an interview on 09/09/2021 at 11:00 AM, Staff F, Registered Dietician, stated that they come to review the residents' dietary information in the facility every other week. Staff F stated that they had access to the facility information and did review off-site per the computer. The Dietician stated that Staff E, Dietary Mananger, was the person who interviewed the residents for likes and dislikes and they communicated changes with each other. Staff F stated they were unaware of the residents' concerns of food palatability of food served, lack of resident's choices of menu items, and alternative menu choices. Resident 28. Review of the resident's medical record showed they admitted to the facility on [DATE] for rehabilitation following a knee replacement surgery. Review of the 08/31/2021 admission assessment showed the resident was alert, oriented, and could make their needs known. The resident required set up assistance during meals. During an interview on 09/07/2021 at 2:52 PM the resident stated that the food was bland, not seasoned and that breakfast was not good as the burrito was dry. The resident stated that they never knew what was going to be served and that they just ate what was put in front of them. Further, the resident was not aware that there were alternate choices and did not know that snacks were available. Resident 26. Review of the resident's medical record showed that the resident was admitted on [DATE] for rehabilitation following a fracture of the calf bone in the lower leg, Review of the resident's comprehensive admission assessment, dated 08/23/2021, showed the resident's cognition was moderately impaired and ate meals independently with set-up help only. During an interview on 09/07/2021 at 10:57 AM, Resident 26 stated, Food is just that, food. The food here has no flavor, and I just eat it because they put it in front of me. Reference WAC: 388-97-1100 (1)(2)

Based on observation, interview, and record review the facility failed to develop and implement a dementia care plan with individualized interventions for one of two residents (12) reviewed for dementia. This failure placed the resident at risk for unmet physical, mental, and psychosocial needs and a diminished quality of life. Findings included . Resident 12. Review of the resident's medical record showed the resident admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's comprehensive assessment, dated 07/24/2021, showed the resident had severe cognitive impairment, with dementia as an active diagnosis. Review of the Resident 12's elopement assessment, dated 07/20/2021, showed they were not at risk for elopement. Review of the resident's care plan, dated 07/24/2021, showed Resident 12 had a generalized dementia care plan with interventions that were not specific to the resident. Furthermore, the care plan did not show individualized elopement/wandering interventions. A concurrent observation and interview on 09/08/2021 at 9:19 AM, showed Resident 12, pushing their wheelchair in the room. The resident stated that they enjoyed visiting and they were on their way out to do that. In addition, the resident stated that they would like the opportunity to socialize while enjoying a meal, it's a give and take thing and .socializing is how we have always done it. We have always been very social like that. An observation on 09/13/2021 at 11:19 AM, showed Resident 12 was self-propelling in the main hallway,when they asked Staff R, Nursing Assistant (NA), if they could go visit their sister and brother. Staff R stated to the resident, No, not right now, you need to go back to your room for right now. An observation on 09/13/2021 at 11:25 AM, showed Resident 12 (with a surgical mask on) self-propelling down the main hallway, headed for the front lobby door. Further observations showed Staff U, Housekeeping Supervisor, intervened and talked with the resident about returning to their room for lunch. The resident then declined eating lunch and stated that they were going to visit their sister and brother. Staff U stated to the resident that they needed to go back to their room for lunch and Staff U then escorted resident back to their room. During an interview on 09/13/2021 at 11:30 AM, when asked why Resident 12 was escorted back to their room, Staff U, Housekeeping Supervisor, stated, to keep track of her. An observation on 09/13/2021 at 11:45 AM, showed Resident 12 (with a surgical mask on) out of their room, self-propelling down the main hallway toward the front entrance. As Resident 12 was passing the therapy room, Staff V, Physical Therapist (PT), redirected and escorted the resident back to their room. An observation on 09/13/2021 at 12:16 PM, showed Resident 12 eating lunch alone in their room, with their back toward the door, looking out the window. A concurrent observation and interview on 09/14/2021 at 10:44 AM, showed Resident 12 (with a surgical mask on) out of their room and again heading down the main hallway toward the facility's front lobby door. Resident 12 stated that they were going to look out the window of the front door. The resident stated, there are never any activities in this place. As Resident 12 passed the therapy room, Staff W, Occupational Therapy Assistant (OTA), escorted the resident back to their room. An observation on 09/14/2021 at 11:07 AM, showed the resident again in the main hallway, outside of the private dining room. Staff V, PT, came out of the therapy gym and pushed the resident's wheel chair to assist the resident back to their room. During an interview on 09/15/2021 at 9:40 AM, Staff V, PT, stated Sometimes we escort (Resident 12) back to their room so that they can be accounted for. We do this to keep track of the resident because they tend to wander into other resident rooms. During an interview on 09/15/2021 at 10:04 AM, Staff W, OTA, stated that Resident 12's cognition was so bad that we pretty much take her back to her room to keep track of her because she is all over the place, and to keep her safe. Furthermore, Staff W stated that they wouldn't be surprised if the resident would make it out of the front door. During an interview on 09/15/2021 at 11:03 AM, Staff Y, NA, stated that Resident 12 had wandered into other resident's rooms and attempted to elope multiple times, as they pointed toward the East exit door, where the resident has attempted to exit the building. During an interview on 09/15/2021 at 12:00 PM, Staff B, Director of Nursing Services, stated, We take her back to her room for a safety thing because she is a fall risk. Staff B stated that they were not aware that the resident had made multiple attempts to elope or that they had wandered into other resident rooms. Reference: WAC 388-97-1040(1) (a-c)

Based on observation, interview and record review, the facility failed to ensure one of one staff member (Staff O) reviewed for proper use of personal protective equipment (PPE) with infection control guidelines and standards of practice related to donning (to put-on) an N95 respirator (facemask that provides a seal and helps protect the lungs from harmful particles) during conduction of COVID-19 (a highly infectious virus) specimen collection for staff within the facility. This failure placed facility staff and residents at risk for the potential spread of the COVID-19 virus. Findings included . Record review of the facility's policy titled, COVID Reopening policy, revised 07/06/2021, showed, Resident and staff testing conducted as required at 42 Code of Federal Regulation 483.80 (h) (see QSO [Quality Safety & Oversight] 20-38-NH Revised). Review of the Center for Medicare and Medicaid Services QSO 20-38-NH, revised 04/26/2021 showed, During specimen collection, facilities must maintain proper infection control and use recommended personal protective equipment (PPE), which includes an N95 or higher-level respirator (or face mask if a respirator is not available) . Review of the Center for Disease Control and Prevention (CDC) guidelines titled, Respirator On/ Respirator Off, dated 06/09/2020, showed, check the seal to protect yourself from COVID-19 .Do not allow facial hair, jewelry, glasses, clothing, or anything else to prevent proper placement or to come between your face and the respirator. Further review showed that this process ensured proper seal of the N95 face mask, which prevented COVID-19 from passage through the sides of the N95 mask. During an interview on 09/13/2021 at 12:21 PM, Staff B, Director of Nursing Services (DNS), stated that the facility was not low on any PPE supplies. An observation on 09/13/2021 at 2:23 PM, showed, Staff O, Licensed Practical Nurse/Resident Care Manager (LPN/RCM), was the only staff conducting COVID-19 specimen collection/testing on all facility staff that day. Staff O was further observed to be wearing an N95 mask with their facial hair sticking out approximately an inch from the bottom half portion of the mask during conduction of a staff specimen collection (therefore did not ensure a proper seal with the N95 mask). During an interview on 09/13/2021 at 2:23 PM, Staff O, LPN/RCM, stated that they had been fit tested and that despite their facial hair sticking out of their mask, they still had a good seal. During an interview on 09/13/2021 at 3:04 PM, Staff B, DNS, confirmed that Staff O did not have a proper seal on their N95 face mask during their conduction of routine facility staff testing for COVID-19. The DNS agreed that the length of Staff O's facial hair did not fall within the parameters of the CDCs guidelines for facial hairstyles that would allow a proper seal of a respirator. No associated WAC reference.

Based on interview and record review, the facility failed to ensure the Pre-Admission Screening And Resident Review (PASARR) assessment was accurately completed for one of five residents (2), reviewed for PASARR. This failure placed the resident at risk for not receiving timely and necessary specialized services to meet their mental health care needs. Findings included . Resident 2. Review of the medical record showed the resident admitted on [DATE] with diagnoses to include [CONDITION(S)] (A temporary mental state characterized by confused thinking and reduced awareness of surroundings), dementia and depression. Review of the 06/15/2021 admission assessment showed dementia/[CONDITION(S)] documented under the mental status section. The nursing assessment also showed that the resident was taking an antidepressant medication for depression along with an antipsychotic medication for [CONDITION(S)]. Review of the facility's [CONDITION(S)] medication consent, dated 06/15/2021, listed [MEDICATION(S)] (a medication that can be used to treat depression) and [MEDICATION(S)] (a medication that can be used to treat [CONDITION(S)]). Review of the admission comprehensive assessment, dated 06/19/2021, also showed that the resident had an active diagnoses of dementia. Review of the PASARR, dated 06/15/2021, showed no serious mental illness indicators, no diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The PASARR was last reviewed by a hospital social worker prior to the resident's admission to the facility. During an interview on 09/14/2021 at 9:02 AM, Staff D, Social Services Director, stated that they were responsible for reviewing and/or changing PASARR's to reflect a resident's current status. If a PASARR was incomplete or incorrect on admission, Staff D explained they were responsible for updating them. I must have overlooked that one. Reference: WAC 388-97-1915 (1)

Based on observation, interview, and record review the facility failed to provide individualized behavior monitoring for the use of [CONDITION(S)] (any medication capable of affecting the mind, emotions, and behavior) medications for two of five residents (2, 26) reviewed for unnecessary medication use. This failure placed residents at risk to receive an incorrect dose and duration of [CONDITION(S)] medication and increased the risk for unmet psychosocial needs. Findings included . Behavior Monitoring Review of the facility's, Behavior Monitoring/[CONDITION(S)] Medication Policy, revised July 2018, showed that The nurse manager or social services enters target behaviors in the description box of the order. The same policy showed Behavior monitoring is used as part of the [CONDITION(S)] Medication Review process in order to determine effectiveness of [CONDITION(S)] medications in alleviating symptoms and timing of gradual dose reduction (GDR) attempts (stepwise tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the medication can be discontinued altogether). Resident 2. Review of the resident's medical record showed the resident admitted to the facility on [DATE], with diagnoses to include [CONDITION(S)] (a temporary mental state characterized by confused thinking and reduced awareness of surroundings), a fracture affecting the spinal column, and depression. Review of the resident's comprehensive admission assessment, dated 06/19/2021, showed the resident's cognition was severely impaired. Review of the physician's orders, dated 06/16/2021, showed that the resident was taking [MEDICATION(S)] (a medication that can be used for [CONDITION(S)]) and [MEDICATION(S)] (a medication that can be used for depression). Review of the resident's care plan, dated 06/15/2021, showed a care plan focus for medication therapy for the use of an antidepressant and an antipsychotic medication. The care plan also showed interventions that included to monitor and record target moods/behaviors related to (depression or [CONDITION(S)]) and document per facility protocol. Review of the facility's [CONDITION(S)] Medication Review, dated 07/12/2021, showed the resident was not fearful of care staff .resident was angry and wouldn't allow staff in her room . The mentioned target behaviors were not listed in the care plan or the Electronic Medication Administration Record (EMAR). During an interview on 09/15/2021 at 11:50 AM, Staff D, Physician Assistant Certified (PA-C), stated that the resident admitted with a diagnosis of [CONDITION(S)], and that they had significant pain. Staff D stated once the resident's pain improved, a GDR of the [MEDICATION(S)] was attempted, and resident responded ineffectively. Staff D also stated that the resident's behaviors worsened as evidenced by cussing, yelling, paranoid of staff poisoning them, they didn't want staff in their room, combative with care, and accusatory of spouse having an affair with staff. Staff D stated that their expectations of the Licensed Nurses (LN's) were to monitor all residents on [CONDITION(S)] medications for target behaviors, adverse medication effects, and to notify them of any negative response. Review of the resident's June 2021 through 09/14/2021 EMAR, showed an order to monitor for Delusions/[CONDITION(S)]. There were no individualized target behaviors listed for direct care staff to monitor. Resident 26. Review of the resident's medical record showed the resident was admitted to the facility on [DATE], with diagnoses to include a fracture of the calf bone in the lower leg, depression, and [CONDITION(S)] (a condition in which constant sleep is disturbed frequently for a long duration of time). Review of the resident's comprehensive admission assessment, dated 08/23/2021, showed the resident's cognition was moderately impaired. Review of the physician's orders dated 08/19/2021, showed the resident was taking [MEDICATION(S)] (a medication that can be used for depression) and [MEDICATION(S)] (a medication that can be used for depression/[CONDITION(S)]). Record review of Resident 26's [CONDITION(S)] Medication review, dated 08/31/2021, showed [MEDICATION(S)] was being given for a diagnosis of [CONDITION(S)] and the target behaviors that were being monitored were the number of hours slept. Additionally the records showed, hours of sleep are being monitored on the EMAR?, and the response was check marked as yes, (even though no hours of actual sleep were documented). Review of the resident's care plan, dated 08/18/2021, showed a care plan focus for medication therapy for the use of an antidepressant medication. The care plan also showed interventions that included to monitor and record target moods/behaviors related to [MEDICATION(S)] and [MEDICATION(S)] and document per facility protocol. Review of Resident 26's August and September 2021 EMAR, showed an 08/26/2021 order to Document number of hours of sleep every shift for use of [MEDICATION(S)]. The documentation did not show the number of hours of sleep, only the LN's initials. During an interview, and observation on 09/07/2021 at 10:57 AM, showed Resident 26 was falling asleep during the interview. Resident 26 stated they didn't sleep well and they were really tired. An observation on 09/13/2021 at 2:49 PM, showed the resident was sleeping with no arousal or response to the knock on the door. During an interview on 09/14/2021 at 10:23 AM, the resident stated that they were sleepy, and they couldn't sleep last night. The resident then stated, that because they were not sleeping well it affected their activities during the day. I feel down and tired all the time. During an interview on 09/14/2021 at 10:30 AM, Staff R, Nursing Assistant, stated that they report to the nurse how many hours a resident slept on their shift. Staff R explained it was their uderstanding that the nurse responsible for documenting the number of hours the residents had slept on each shift. During an interview on 09/14/2021 at 10:36 AM, Staff L, LN, stated that (on the process of monitoring for effectiveness of medications used for [CONDITION(S)]) that they would ask the Night shift LN or the Nursing Assistants about how the resident slept through the night. Staff L stated We each do this on our shift, we document in the orders that asks for the effectiveness of the medication. Staff L stated, If not effective, we let the health care provider know and they would review the record and the LN's can give their input to her as well. During an interview on 09/14/2021 at 10:53 AM, Staff O, LN, explained during the night shift, the LNs documented hours slept and then the LNs during the day monitor and record the hours slept in the EMAR. Staff O stated that Staff G, PA-C, monitored if the medication was new and determined whether the medication was effective. We don't monitor the effectiveness of a medication, that's the PA's job to do. During an interview on 09/14/2021 at 2:40 PM, Staff B, Director of Nursing Services (DNS), stated the LNs did not monitor for the effectiveness of [CONDITION(S)] medication because the PA-C addressed that. The DNS also stated there was not a process to monitor the effectiveness for every resident on a [CONDITION(S)] medication and they only monitor the resident's target behaviors on a case-by-case basis. Staff B further explained the LNs monitored hours slept and if a resident was on a [CONDITION(S)] medication long-term, the facility would not monitor. When there was an order to monitor and document the number of hours the resident slept each shift, the LNs would be expected to have documented the actual number of hours slept. Reference: WAC 388-97-1060 (3)(k)(i)

Based on observation and interview, the facility failed to ensure three of four soiled linen rooms (east, west and main) and one of one laundry room in the facility were mechanically vented to remove odors and reduce the risk of cross contamination. This failure placed the residents at risk of lack of good air circulation and a diminished quality of life. Findings included . On 12/12/19 between 9:48 AM and 10:30 AM, the laundry process was observed with Staff K, Housekeeping Director, and Staff L, Maintenance Director. The facility was observed to utilize a three room laundry process. The first room was a soiled linen holding room, which was accessed via a door from the hallway. The room contained a hopper, hand washing sink and several barrels of soiled laundry. The second room contained commercial grade washers and dryers. The third room was where the laundry sorted, folded, and prepared for distribution. Additionally, the facility had three soiled linen holding rooms located on the east, west and south resident occupied wings. During the observations, Staff L tested the ventilation in each of the rooms by holding a tissue up to the vent and if the tissue stuck, it confirmed the negative draw/ventilation was working properly. During the test of the ventilation in the washer and dryer room and the adjacent soiled linen room, Staff L stated that he heard the fan motor running but was unable to get the tissue to stick to the vent. He acknowledged the two rooms were not venting out properly. Observations and interview continued on the east, west and south wing soiled rooms which showed two of the three rooms did pass the tissue test, which Staff L indicated were not working properly. Staff L stated that he had not been tasked with ensuring the ventilation in those rooms were properly working and was not aware that the fans were not functioning. During an interview on 12/12/19 at approximately 11:00 AM, Staff A, Administrator, acknowledged the four rooms were not venting properly. Reference WAC 388-97-0880(2)

Based on interviews and record review the facilty failed to recognize, comprehensively assess, evaluate treatment, and revise the effectiveness of bowel interventions for one of four residents (#1) reviewed for bowel care and management. Additionally, the facility failed to monitor the resident's bowel record to effectively treat, prevent bowel related complications, and consult with the physician. These failed practices resulted in actual harm to Resident #1 as they contributed to the resident's change in condition, and need for hospitalization , due to a severe fecal impaction and rupture of the bowel. Findings included: Resident #1. Review of the resident's medical record showed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Progress Notes (PNs), dated [DATE], showed the resident was readmitted from the hospital following [DIAGNOSES REDACTED]. He displayed cognitive deficits, and required extensive assistance with all activities of daily living. Progress Notes, dated [DATE], showed the resident's intake was inadequate, but had increased over the last several days. The resident refused meals frequently, thus was receiving nutritionally enhanced meals, an appetite stimulant medication, and nutritional supplements. In addition, the Speech Therapist was working with the resident. The resident's Bowel Movement (BM) Report between [DATE] to [DATE] showed the following: ,[DATE] - medium, loose/diarrhea stool ,[DATE] - ,[DATE] (eight days) - no stools ,[DATE] - small, loose/diarrhea stool ,[DATE] - no stools ,[DATE] - small, putty like stool ,[DATE], 29 (two days) - no stools ,[DATE], 31 - small, loose/diarrhea stool ,[DATE], 2, 3 (three days) - no stools ,[DATE] - small, loose/diarrhea stool ,[DATE]- ,[DATE] (six days) - no stools ,[DATE] - small, formed stool ,[DATE] - no stools Review of physician's orders [REDACTED]. 1) Milk of Magnesia (MOM) - give 30 milliliters if no BM for three days 2) [MEDICATION NAME] stool softener capsule if no BM for four days 3) [MEDICATION NAME] suppository if no BM for five days 4) Fleets enema if no BM for six days There were no routine laxatives ordered by the physician. Despite the above physician's orders [REDACTED]. 1) MOM only given on ,[DATE], ,[DATE], ,[DATE] 2) No [MEDICATION NAME] capsules given 3) [MEDICATION NAME] suppository given once on ,[DATE] 4) Fleets enema given once on ,[DATE] Review of a Skilled Service Note, dated [DATE] at 3:13 PM, by Staff A, Registered Nurse (RN), showed a fleets enema was given for constipation with very, minimal results. At 11:43 PM on [DATE] Staff B, RN, documented the resident was groaning in pain when up in the wheelchair and did not verbalize where it hurt. He refused meals, liquids, and medications; and was drowsy during the evening shift. Progress Notes, dated [DATE] during the dayshift, showed the resident was alert and seated in his wheelchair at the nursing station. At approximately 8:05 AM Staff C, RN, heard a Nursing Assistant stating the resident's name over and over to wake him up. The resident's eyes were closed and he was unresponsive. The resident was immediately put to bed and emergency services were called. He was transported to the emergency room (ER) at approximately 8:15 AM. Hospital records, dated [DATE] and [DATE], showed the resident had a severe fecal impaction between the lower portion of the sigmoid colon (lower portion of the large intestine) and upper portion of the rectum with perforation (rupture) of the bowel. An assessment of the resident's abdomen in the ER showed tenderness over a large area, rigid, no bowel tones, clear evidence of acute abdomen. The resident expired at the hospital on [DATE]. Per telephone interview with Staff A on [DATE] at 2:16 PM, he stated he administered a Fleets enema to the resident on [DATE] during the dayshift as the resident was on a bowel program (Fleets enema was to be administered if no BM for six days). The results from the enema consisted of a very small formed stool with mostly liquid from the enema. Prior to the enema the resident's abdomen was distended (swollen) and he had his hand on his abdomen moaning. The resident was unable to verbalize his needs. Staff A stated upon assessment of the abdomen there were no bowel tones in the lower left quadrant, and hypoactive bowel tones on the right side. The resident was not eating or drinking during that shift. Staff A stated he passed on in report to the evening shift regarding the enema and the abdomen being firm. On [DATE] at 3:42 PM Staff B stated during a telephone interview, she was aware the resident had received an enema during the dayshift of [DATE]. On the evening shift of [DATE] he was noted to be moaning, thus staff got him up in a wheelchair. He would open his eyes but would not verbalize his needs. The resident refused the evening meal, healthshake, and all medications that evening. He dribbled a small of stool which was not documented as it wasn't anything. Staff B stated she passed on to the night shift nurse the resident might need something else for his bowels. Per telephone interview on [DATE] at 2:00 PM with the resident's physician, he stated he was unaware of the resident's problems with constipation, and changes in his abdomen, as noted per above interview with Staff A. Review of Progress Notes and Skilled Services Notes between [DATE] to [DATE] showed despite the resident's significant problem with constipation (21 of the 27 days without a BM), there was no documentation which showed staff was performing thorough abdominal assessments with the exception of bowel tones being present on 16 of the possible 81 shifts, and abdomen being soft and nontender on [DATE] and [DATE]. In addition, staff did not consult with the physician regarding changes in the resident's condition on [DATE], and ongoing problems with constipation, and lack of effectiveness of the prescribed laxatives. Reference (WAC) [DATE](1)

Based on interview and record review the facility failed to ensure one of three (#1) residents reviewed for accidents received adequate interventions and supervision to prevent falls. In addition, failure to thoroughly investigate the cause of unwitnessed falls and ensure interventions were provided and modified for fall prevention, resulted in repeated falls with injury. Findings included: Resident #1. Per the medical record the resident was admitted to the facility on [DATE] and discharged on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's most recent comprehensive assessment, dated 02/03/19, showed she had severe cognitive impairment and required extensive assistance of one to two caregivers for all care provided. Review of Resident #1's careplan showed, in part, the resident had multiple problems on admission which posed as indicators for an increased risk of falls. The problems included impaired cognition; antipsychotic, antidepressant and diuretic medication use, frequent incontinence of urine, chronic pain, behavioral symptoms of wandering, eloping and anger and a history of falls. Resident #1's care plan showed the risk for falls problem was initiated on 01/03/19 with the following interventions in place: anticipate and meet the resident's needs, be sure the residents call light is within reach and encourage to use it and needs prompt response to all requests for assistance. On 1/09/19 the care plan was updated to include the following interventions; do not leave resident unattended in the library as there is no call light available, educate family/resident/caregivers about safety measures and what to do if a fall occurs, identify and address causes of fall risk as appropriate, notify physician for changes in medical condition, acute illness and potential adverse drug reactions. Review of Resident #1's nursing progress notes, skilled assessment notes and the facility's incident reports showed the resident had six falls between 01/05/19 and 02/04/19 of which two required emergency room assessments and four resulted in pain and/or injury. On 01/05/19 at 8:10 PM, Resident #1 had an unwitnessed fall and was found on the floor in the facility library. She complained of left leg pain and swelling was observed to the leg. Resident #1 was sent to the emergency room for evaluation and returned to the facility with no significant injury found. Resident #1 stated she was trying to transfer chairs when she fell and the facility determined the fall was the result of an attempted self transfer though there was no documentation to show there was an analysis and evaluation of the fall to prevent recurrence. In addition, there was no documentation any interventions were put in place in an attempt to prevent future falls until 01/09/19, four days after the fall. On 01/13/19 at 2:30 PM, Resident #1 had an unwitnessed fall in her room and was found sitting on the floor. She stated to one staff member she was trying to get to the bathroom when she fell . Resident #1 was assessed by the nursing staff as having no injuries though stated in the report, As resident has dementia and staff cannot rule out head strike, neurological checks (neuro) were initiated. The facility determined Resident #1's fall was the result of self transferring and walking without assistance though there was no documentation to show there was an analysis and evaluation of the fall to prevent recurrence. In addition, the incident report stated the careplan would be updated to include leaving her in a supervised area when out of bed to increase oversight and decrease risk of recurrent falls. There was no noted new interventions documented in her careplan since 01/09/19. On 01/25/19 at 1:45 PM, Resident #1 had an unwitnessed fall in another resident's bathroom and was found sitting on her bottom on the floor after another resident alerted nursing. She was assessed by nursing staff and no injuries were found though she complained of left knee pain. The facility determined Resident #1's fall was the result of self transferring though there was no documentation to show there was an analysis and evaluation of the fall to prevent recurrence. In addition, neuro checks were not initiated to rule out the possibility of a head injury and no new interventions were added for fall prevention to her careplan since 01/09/19. On 01/27/2019 at 6:30 AM, Resident #1 had an unwitnessed fall in her bathroom and was found sitting on the floor. She stated she did not recall how she fell and denied hitting her head. Nursing staff assessed Resident #1 had no injuries and initiated neuro checks to rule out a head injury. The facility determined Resident #1's fall was the result of self transferring though there was no documentation to show there was an analysis and evaluation of the fall to prevent recurrence. In addition, Resident #1's incident report stated the careplan had been updated to include leaving her in a supervised area when out of bed to increase oversight and decrease the risk of recurrent falls. There were no new interventions documented to the care plan since 01/09/19, despite the fact Resident #1 had three more falls since the careplan was last updated with any interventions for fall prevention. On 02/03/19 at 12:45 PM, Resident #1 had an unwitnessed fall in her bathroom and was found sitting on the floor bleeding from a 2.5 cm. laceration to her left eye brow. She stated she did not know how the fall occurred. The wound was dressed and neuro checks were initiated to rule out a head injury. The facility determined the fall was the result of attempting to self transfer though there was no documentation to show there was an analysis and evaluation of the fall to prevent recurrence. In addition, Resident #1's incident report stated nursing assistants are to offer toileting following meals and then take her to the nurses station. There were no new interventions documented to Resident #1's careplan since 01/09/19, despite now having had five previous falls since admission. On 02/04/19 at 6:50 PM, Resident #1 had a witnessed fall attempting to stand up from her wheelchair in the hallway. She was found lying on her left side and complaining of severe pain to her right arm. She stated to staff I broke my arm. Resident #1 was sent to the emergency room for evaluation and was found to have a fractured radius in her right arm. A splint and sling were placed on the resident and she returned to the facility. A cast was placed to the fractured arm on 02/07/19. Review of Resident #1's careplan showed the interventions to place a concave mattress on her bed to help resident distinguish boundaries and to place the resident in a supervised area when out of bed were initiated on 02/04/19. In an interview with the Director of Nursing and the Administrator on 02/21/19 at 2:30 PM, they stated it was the responsibility of the resident's nursing case manager to investigate and assess the cause of falls and to update the careplan after each fall with interventions to prevent reoccurrences. WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to provide ongoing comprehensive pain assessments for one of one resident (#27) with moderate to severe pain continuing for approximately six weeks. This lack of assessing the pain comprehensively resulted in harm to the resident due to the staff's failure to recognize the severity of the medical issue, the continuation of pain, and failure to consult with the physician when the pain medicine was not controlling the pain. Findings included: The facility used the standard Subjective Pain Scale of 1 to 10 to identify the pain levels as: 1 to 3 described as minor pain from barely noticeable to tolerable; 4 to 6 described as moderate pain from distressing to intense; 7 to 10 described as severe pain from very intense to unimaginable. Resident #27. Per medical record review, she was admitted [DATE] and was of advanced age. [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Additionally, a scheduled anti-anxiety medication ([MEDICATION NAME]) was ordered on [DATE]. On the 09/10/18 admission to the facility, a pain assessment was completed during which the resident said she had frequent pain for the last five days of the right hip and left arm. She told the nurse an acceptable pain level between zero and ten would be a four (moderate pain). She identified effective pain interventions had been positioning, rest, and quiet environment. Further, the 09/10/18 comprehensive admission assessment showed the resident had frequent pain which limited day-to-day activities and was at a level four of ten. A surgical wound was present and she was also assessed as cognitively intact. When the 30-day Medicare assessment was completed on 10/08/18, the resident's pain remained the same as the above admission assessment showing no improvement; continuing with moderate, frequent pain limiting day-to-day activities. The 10/02/18 nursing progress note showed the resident had told her nurse, I panic and then went on to explain when she realized it was time to either change her brief or go to therapy she would become worried that she would not be able to get comfortable again. She did not want to get addicted to drugs. The reports from therapy was that the resident became anxious which impaired her course of progression. The physician ordered [MEDICATION NAME] in the morning to help with anxiety during therapy. Review of the resident's (YEAR) Medication Administration Records (MAR) revealed a 1 to 10 subjective pain scale assessment tool was to be completed prior to giving the resident [MEDICATION NAME]. A) The (MONTH) record showed the pain levels had been completed 46 times in 21 days with all between moderate and severe levels- severe was documented 16 times with highest level a nine; B) The (MONTH) record showed an increase in the pain levels and the number of times [MEDICATION NAME] was requested: the pain level was reported by the resident as severe 30 of the 58 times in 23 days with the highest level continuing at level nine. Review of the monitoring of the [MEDICATION NAME]'s effectiveness on the Medication Administration Record showed there was documentation by nurses of either effective, ineffective, or a pain scale number between 0 and 4 (identifying moderate pain continued). Review of the daily Medicare Skilled Services Notes, located on a specific form and filled out by licensed nurses, showed a lack of completion of the requested information for pain assessments. An example included: On 10/22/18, the resident had a 7 of 10 pain level that was continuous sharp pain in left arm and right hip. However, the form showed the need for a description of intensity and frequency for each pain site, activity level tolerance, interference with activities of daily living, and effectiveness of pain medications provided the resident throughout the period of the daily assessment. Therefore, the assessment was not complete. On 10/21/18 at 12:10 PM, the resident was seated in a wheelchair with her legs bent at the knees in an approximate ninety degree angle. Her right foot was on a small, flat pillow situated on a footrest. The resident was constantly readjusting her leg using her hands to move it slightly back and forth, and rubbing her thigh. The resident said she had a pain pill recently and was hoping it will stop the pain. She stated she had a broken right leg, left shoulder, two toes and had a concussion from a fall in her bathroom at home. She said she had occupational and physical therapy, and one of their staff told her she had to keep her leg bent down like now, but she would like it elevated to reduce the pain. She continued to frequently reach down to reposition the leg and foot. She stated she had two broken toes which were painful also, and now the therapist wanted her to start to self-propel the wheelchair; she was unsure if she would be able. The resident had a sling on her left arm to reduce the stress on her broken shoulder. The resident said it helped but she did not like it too tight on her neck; she could readjust it as she needed, which she then moved it slightly. The resident stated she was claustrophobic and things around my neck bother me causing me to panic. On 10/22/18 at 3:06 PM, the resident was observed in bed on her back rubbing her upper right thigh. She grimaced and said she was in a lot of pain. Her friend visiting said she had asked for a pain pill for the resident and was told she would get it soon, but that had been a while ago and no one had come yet. The resident's friend stated she had adjusted a pillow under her leg for comfort, but that did not help. On 10/23/18 at 11:33 AM, Staff U, Registered Nurse (RN), Patient Care Coordinator, stated the effectiveness of medications were reviewed when he completed the comprehensive assessment after admit and quarterly. He showed on the medication administration record (MAR) where there was the pain level documented by the nursing staff. He pointed out the [MEDICATION NAME] was documented as effective. On 10/23/18 at 12:00 PM, the resident was laying on her back in bed with her head elevated to approximately a 30 degree angle. She had one sheet covering her lower body, her left shoulder sling in place, and her two small neck pillows positioned underneath her neck. The resident had her eyes shut but awoke when spoken to. She stated she was in a lot of pain; she did not know if it was time for her pain pill again, but she needed one. On 10/23/18 at 12:54 PM, Staff J, RN, stated she had given the resident medication for pain at 9:20 AM and it would not be given again until 1:20 PM. She knew the resident was in pain. She reviewed the MAR and stated there was not any non-pharmaceutical interventions listed to try to decrease the pain. When asked about monitoring and documenting the resident's pain after the [MEDICATION NAME] was given, Staff J stated she put in numbers between 1 to 10, but other nurses put in an E for effective or I for ineffective. She acknowledged there was no assessing and documenting how long the pain medication was effective after it was given. She was aware the resident had pain but said it seemed the medication was relieving the pain at times. She stated she only worked a couple of days a week and did not know who was assessing the resident's pain management. On 10/23/18 at 1:13 PM, the resident remained in bed on her back with slight elevation in the head of her bed. She stated she had not been able to eat much lunch; she had no appetite. She continued to make facial grimaces and move or rub her right leg during the conversation. She was asked if she was in pain now and said it was probably an eight; she was hurting but could not have her pain pill until 1:20 PM. She really wanted to take a nap but had not been able to because of the pain; she hurt too much now to sleep. She stated the therapist had come in earlier morning and worked with her which always created a lot of pain, and from then on, she was hurting. When asked if other measures were taken to help with the pain, she said there were none. She was going out to the doctor's appointment tomorrow to see why her pain was so bad. She stated she was going to tell the doctor the current pain medication had all the effectiveness of an aspirin. On 10/24/18 at 09:08 AM, Staff S, Rehabilitation Director, stated during the therapy sessions, the resident was afraid to walk and she did not like to be touched. While in therapy, he said there were different pain interventions tried by therapists. There was some success with soothing music during the sessions, which distracts her from her fear and anxiety that she has a lot of. The therapists did talk with nursing to give the resident pain medication about 45 minutes before therapy, but that didn't work. However, when asked if he had informed nursing about other interventions such as music, the Rehabilitation Director said he had not. Review of the 10/02/18 plan of care revealed the resident's pain relief goal for her [MEDICAL CONDITION] and arm was for the pain to continue at a moderate level of four. Staff were to notify the physician if interventions were unsuccessful, and were to identify and address underlying causes of pain. On 10/23/18 at approximately 1:00 PM, following an interview regarding the lack of routine comprehensive assessments with the Director of Nursing, she completed a pain assessment on 10/24/18 and consulted with the physician. A skeletal muscle relaxant was ordered. On 10/24/18 at 2:20 PM, Staff H, RN/Charge Nurse, stated the resident had been out to the orthopedic surgeon's appointment that morning. The physician had determined there was something wrong with the resident's right hip; it was not healing. The orthopedic surgeon was now sending the resident to another orthopedic surgeon who was known for taking the complicated cases. Although the subjective pain scale was completed routinely, nursing staff did not objectively assess the pain and document the data and analyze it in an attempt to evaluate the existing pain and the cause. Also, non-pharmaceutical interventions were not developed to manage or prevent the pain. Thus, the pain continued and increased in severity over a period of approximately six weeks. Reference: WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to provide timely, effective interventions for the treatment of [REDACTED].#2) reviewed with pressure ulcers. Failure to implement timely treatment caused the resident to have recurrent stage two pressure ulcers on her right buttock which constituted actual harm. Additionally, the facility failed to ensure licensed nurses routinely monitored and documented skin conditions for two of four resident's (#2, 17) reviewed for the prevention of pressure ulcers. Findings included: The National Pressure Ulcer Advisory Panel (2016) defines the pressure injury stages as follows: *Stage One injury a non-blanchable red intact skin * Stage Two injury partial -thickness skin loss with exposed dermis, the wound bed is viable, pink or red, moist, and also present as an intact rupture serum blister *Stage Three injury full thickness skin loss, in which fat is visible *Stage Four injury full -thickness skin and tissue loss with exposed muscle, tendons, and ligaments * Unstageable Pressure injury obscured full -thickness skin and tissue loss, in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar *Deep tissue Pressure Injury persistent non-blanchable deep red, maroon or purple discoloration or non-intact skin. Resident #2. Per the medical record her initial admit was 09/11/14. On 12/30/18 the resident was discharged to the hospital due to influenza and was readmitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The facility 11/2015 Braden Scale Policy showed, .this facility to assess residents' risk for development of pressure ulcers, initiate care plan interventions to prevent pressure ulcer development, implement ulcer preventions and periodically evaluate effectiveness of interventions in accordance with the Braden Scale. The Skin-at-Risk Program Overview Policy, dated 11/2015, documented the facility was to ensure that residents who enter the facility without a pressure ulcer do not develop pressure ulcers unless their clinical condition demonstrates the pressure ulcer was unavoidable and that residents who enter the facility with a pressure ulcer receive appropriate care and services to promote healing and prevent infection. The policy also included the Licensed Nurse (LN) would complete weekly skin checks and document in the residents record if a new skin condition was present. Once a pressure ulcer was identified the LN would complete Weekly measurements of the pressure ulcer, venous ulcers, arterial ulcers and diabetic/neuropathic ulcers will be documented on the WEEKLY ULCER EVALUATION . The documentation was to include length, width, depth, undermining, tunneling, pain, amount and type of drainage, condition of wound bed and wound edges. Nursing progress notes, dated 01/02/18, showed Resident #2 was admitted following hospital stay for influenza. The resident's comprehensive assessment dated , 01/09/18, showed she was cognitively impaired and she was at risk for development of pressure ulcers; however, during the assessment, the resident did not have any pressure ulcers. An Initial Non-Pressure Skin Condition Assessment, dated 01/30/18, Showed the resident had a 2.2 centimeter (cm) by 1.8 cm open area on right buttock. Appears to be related to shearing. The edges were intact. Two weeks later, a Weekly Skin Ulcer Measurement Wound Evaluation, dated 02/14/18, showed the skin shearing (friction) on the right buttock has deteriorated to a 0.8 cm by 0.3 cm, 0.05 cm deep pressure ulcer. Wound bed is red with edges intact . There was no further documented (MONTH) (YEAR) Weekly Skin Ulcer Measurement Wound Evaluation in the resident's medical record. A month later on 03/13/18, The Weekly Ulcer Measurement Wound Evaluation showed, Nearly resolved stage 2 ulcer. Skin has covered wound and is intact with edges attached . The 03/20/18 Weekly Skin Ulcer Measurement Wound Evaluation documented the pressure ulcer on the right buttock had healed. Nursing progress notes, dated 08/18/18, showed a nursing assistant reported skin breakdown (to) coccyx area, resident already have a treatment order. Recurring issue. Monitoring order in place. The 08/18/18 nursing progress note did not describe the specific site or measurements of the resident's open area. On 10/22/18 at 10:29 AM, the resident was observed to be toileted by Staff L, Nursing Assistant (NA). The NA stated she had worked in the facility for seven years and was familiar with the resident. The NA assisted the resident with toileting. While the resident was being toileted she stated My bottom hurts. I have had these sores on my bottom off and on. The resident had a small dark scab on her right mid-buttock area and pink circular nickel size on her left buttock. The NA stated she had not noticed it before, but she does have open areas on her bottom off and on. On 10/24/18 at 8:50 AM, Staff I, Patient Care Coordinator (PCC), stated he was not aware the resident had pressure ulcers on her bottom, no one reported to me or I would have assessed the resident. He added he was aware she had a history of [REDACTED]. On 10/24/18 at 8:56 AM, the resident's family member stated the resident does not move much now as she likes to sit in her recliner most of the day. She added she was aware of the resident's sores on her bottom. Sometime this summer someone from the therapy department met with me and explained to me that there was a concern that she might have skin breakdown (on her bottom) as the recliner she sits on did not have a good cushion and it was not a good fit for her. My mom has had sores on her bottom off and on for the past three to four months. She added she believed that the sores on the resident's bottom were due to the way she sits in the recliner, she tends to slide in the chair and the fabric on the chair is rough and the fabric puckers on the seat. On 10/24/18 at 9:33 AM, Staff O, Occupational Therapist (OT), stated he had met with the resident's family member this past Spring and had shared his concerns about the resident developing skin breakdown due to the recliner. The cushion on the recliner has lost it ability to absorb the pressure from the coccyx area. He added the resident is not sitting correctly in the recliner, she does not sit upright in the recliner. He added he agreed with the resident's family member the fabric on the recliner was rough to the touch. He added I did recommend a new recliner for the resident. He was not able to recall if he had informed the nursing department about his concerns regarding the resident's recliner. The 03/08/18 Occupational Treatment note showed the OT worked with the resident on her positioning in the recliner and lift chair. The OT recommended a new chair as her current tilt chair due to the seat cushion being too firm. On 10/24/18 at 9:55 AM, Staff K, Registered Nurse (RN), stated the resident does have an order for [REDACTED]. Sometimes I apply the cream and sometimes I give it to the nursing assistants for them to apply the cream. When asked what his weekly skin checks included, he stated the assessment of visible skin and I ask the NAs who toilet the residents to come and get me so I can see the resident's buttocks. On 10/24/18 at 10:35 AM Staff J, RN, stated she had assessed the resident's skin last week and did not recall seeing any skin issues, we check the visible skin for bruises and sores. On 10/24/18 at 10:40 AM, Staff M, NA, stated she had provided care to the resident about a week ago and had not seen a new skin problem, she has had skin problems on her bottom off and on, but did not recall seeing a new skin problem. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) instructed the nursing staff to check the resident's skin and add a plus sign if new skin condition present and a negative sign if no new skin condition was present. The skin assessments were completed on 10/3/18, 10/10/18, and 10/17/18 all indicated no new skin conditions present. The (MONTH) (YEAR) TAR included a physician order [REDACTED]. Additionally, the order included to monitor skin breakdown near coccyx, keep area clean and apply [MEDICATION NAME] cream as needed. The TAR was initialed on a daily (10/1-23/18) basis by the Licensed Nurses indicating it had been done by them. On 10/24/18 at 1:30 PM Staff H, Charge Nurse, stated when a resident has a skin breakdown, I am to be notified , the nurse will assess the skin breakdown and the physician is notified. She added she had not been notified of the current skin breakdown on the resident's buttocks nor of the (MONTH) 18, (YEAR) open area on the resident's coccyx. On 10/25/18 at 3:30 PM, Staff N, Nurse Consultant, acknowledged the lack of a system for assessing and monitoring residents' pressure ulcers. The Braden Scale for Predicating Pressure Sore Risk dated 07/05/18 showed the resident at risk for skin breakdown related to decreased mobility and occasional incontinence, and did not include sheering related to her recliner. Resident #17. Review of the 09/05/18 annual comprehensive assessment showed the resident had severe cognitive impairment and was totally dependent on two staff to reposition in bed. The resident had an indwelling catheter and was always incontinent of bowel. The resident had [DIAGNOSES REDACTED]. On 10/23/18 at 10:30 AM, Staff R, NA, stated they only got the resident up for meals because of the sores on her bottom. On 10/23/18 at 11:15 AM Staff F, and Staff Q, both NAs, provided personal care for the resident and transferred her to the wheelchair for lunch. During cares, the resident was turned on her left side to expose her buttocks. Her bilateral buttocks had hardened appearing skin approximately 5 by 3 (centimeters) cm on right buttock and 4 by 1.5 cm on left buttock. During the observation, Staff Q pointed to a spot on the right buttocks and stated that spot bled last week. Both NAs stated the resident's bottom had always looked this way and there would be spots that would open and close periodically. Staff F stated that the nurses have told them not to scrub the thickened area of skin because it is very fragile and the nurse would come and spray something on it to clean it. Shortly after this, Staff K, RN, arrived with some [MEDICATION NAME] (a skin protectant product that provides a physical moisture barrier) to apply to the resident's buttock. When asked how often he documented the appearance of the resident's skin, he stated he did not, the PCC (Patient Care Coordinator) would look at resident's skin weekly and document. The resident was then prepared to transfer from her bed to her wheelchair using a mechanical lift and sling. After the resident was transferred to her wheelchair, the staff left the sling under her and Staff F stated they would remove the sling in the past but the resident seemed uncomfortable when it was removed and replaced, so now we leave it (the lift sling) under her. The same day at 11:30 AM Staff I, PCC, stated he had not seen Resident #17's buttocks because thickened skin areas were not pressure ulcers. Most likely the charge nurse had seen it and documented in the record. On 10/23/18 at 11:35 AM, Staff H, RN and Charge Nurse, stated she had not seen the resident's buttocks for a couple of months and was not aware of any monitoring or documentation of the resident's scar tissue on her buttocks. She acknowledged the scar tissue from previous pressure ulcers increased the residents risk for recurrence. She stated she would assess the resident when she laid down after lunch. Review of Staff H's 10/23/18 progress note, after the nurses assessment of Resident #17, showed the following: Has new skin issues on top of old scare (sic) tissue on bil(ateral) buttocks. MD aware ordered continue [MEDICATION NAME], and monitor for changes. Therapies eval seating in (wheelchair). Scarring on bil(lateral) buttocks has areas of scarring that's is (sic) protruding. LT (left) buttocks is only bumpy from scarring no discoloration or open areas, only scarring seen. On residents (sic) RT (right) buttocks there are two areas of protruding skin tags on top of scare (sic) tissue or scar tissue growing. Area on top protrudes out aprox. 0.7cm with a tiny superficial open area at its (sic) tip aprox. 0.1 cm in dia(meter). The other area is just below this and also protrudes out aprox 0.3 cm in diam(eter) with a non open blood filed (sic) area at its (sic) tip as if it was pinched together while setting in (wheelchair). All areas are hard as scare (sic) tissue builds Review of the resident's care plan showed a skin problem last revised on 11/08/17 that showed the resident was a risk for skin issues and breakdown related to recurring yeast infections and excoriation on bilateral buttocks. The goal was to maintain or develop clean and intact skin by the review date. Interventions included to evaluate wound per protocol. Redness to groin and scabbed area to left buttock identified 11/16/17. Reposition/turn resident every 2-3 hours while up in chair and while in bed to provide pressure relief. A 09/05/18 Braden scale (a tool to assesses a resident's risk of developing a pressure ulcer) showed a score of 14 indicating the resident was at moderate risk for skin breakdown related to frequent moisture, poor mobility. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. And an order on 10/09/17 to apply [MEDICATION NAME] cream to bilateral buttocks for redness in bony prominences every shift after peri-care. Further, both of these orders were being signed as completed each shift by the nurses. Weekly skin checks revealed no changes. If a new condition was present, the nurse was to document in a progress note and initiate skin documentation form. For the month of (MONTH) (YEAR), Resident #17's skin check was documented with negative on the 4th by Staff K, RN, and the 18th by Staff T, RN. On 10/25/18 at 11:50 AM, Staff K stated he first saw the residents scar tissue about a month ago, however, he did not document the change in the resident's record. On 10/25/18 12:15 PM, Staff T, stated per phone interview that she did not recall seeing scar tissue on Resident #17's buttocks when she did her skin check. Review of the resident's medical record for the past year did not show documentation of the thickened skin/scar tissue on the resident's bilateral buttocks. Reference: WAC 388-97-1060(3)(b)