Every finding on record at Regency Olympia Rehabilitation and Nursing Center

.Based on interviews and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 3 sampled residents (Resident 1) reviewed for quality of life. This failure placed residents at risk for compromised health outcomes and a diminished quality of life.Findings included. Resident 1 was admitted to the facility on [DATE] with multiple diagnosis to include a right hip fracture. The 5-day Minimum Data Set, an assessment tool, dated 02/20/2026 indicated Resident 1 was cognitively intact.Record review of Resident 1's skilled transfer orders dated 02/13/2026, showed physician orders to schedule a follow up appointment with the orthopedic provider for staple removal in two weeks.In an interview on 04/20/2026 at 11:19 AM, Resident 1 said that she had not been out to see the orthopedic surgeon since admission. Resident 1 said she had her staples in for a long time recently having them removed which was painful.Record review of Resident 1's electronic health record showed that the staples to Resident 1's right hip were removed on 04/08/2026 (51 days) after admission.In an interview on 04/20/2026 at 11:50 AM, Staff B, Director of Nursing/Registered Nurse said that the transfer orders did not get carried out due to an oversight. Staff B said the appointment and staple removal should have been done per the physician's transfer orders.In an interview on 04/24/2026 at 11:38 AM, Staff A, Administrator, said she would expect the admission/transfer orders to be completed as instructed.Reference WAC 388-97- 1060 (1)-(3)

Based on interview and record review, the facility failed to fully address lab results as reported by laboratory services for 1 of 1 resident (Resident 31) reviewed for death. This failure placed residents at risk for adverse side effects and a diminished quality of life. Findings included .Resident 31 was admitted to the facility on [DATE] and passed away on 03/08/2026. The admission /Medicare - 5 Day minimum data set, an assessment tool, dated 02/27/2026, documented Resident 31 was severely cognitively impaired. Record review of Resident 31's electronic health record showed a physician's order, dated 03/05/2026, for CBC (complete blood count) with Platelets, BMP (Basic metabolic panel, a blood test measuring kidney health, electrolyte balance; essential minerals including sodium, potassium, calcium, magnesium, chloride, and phosphate, fluid status, and blood sugar levels).Record review of Resident 31's laboratory results, dated 03/07/2026, indicated, Mild Hemolysis [blood sample destruction] Present; Some results may be affected Interference present; unable to result BMP panel. BUN [Blood Urine Nitrogen measure in the blood]/ CREAT [creatinine, waste product in the blood] resulted only.In an interview and record review on 04/09/2026 at 1:04 PM, Staff E, Licensed Practical Nurse, said when lab (laboratory) results were received, nurses were expected to review the results and report them to the provider. Staff E reviewed Resident 31's Lab report dated 03/07/2026 and said it was the expectation that the report of mild hemolysis should have been reported to the provider but wasn't. In an interview and record review on 04/10/2026 at 9:36 AM, Staff B, Director of Nursing/Registered Nurse, reviewed Resident 31's lab report dated 03/07/2026 and said it was the expectation that the lab report indicating blood sample hemolysis should have been reported to the provider and the BMP should have been re-drawn. Reference WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to provide care and services in a manner that promoted dignity related to uncovered indwelling urinary catheter (a tube inserted into the bladder that drains urine into a bag outside of the body) bags for 1 of 2 sampled residents (Resident 21) reviewed for dignity. This failure placed residents at risk for embarrassment, diminished self-worth, and a decreased quality of life.Findings included. Record Review of the facility's policy titled, Indwelling Urinary Catheters, date revised April 2018, documented, .8. Residents with catheter bags will have them covered or use of bags that provided dignity while in bed with visibility from hallway, out of their room or in community. Resident 21 was admitted to the facility on [DATE]. The Modification of Admission/Medicare - 5 day Minimum Data Set, an assessment tool, dated 01/13/2026, documented Resident 21 was moderately cognitively impaired and had an indwelling catheter. Record review of Resident 21's physician orders, dated 01/09/2026, documented, LN [licensed nurse] to ensure, catheter system is secured, catheter strap in place, covered appropriately (privacy bag). Record review of Resident 21's Indwelling Urinary Catheter care plan, date revised, 03/06/2026, documented an Intervention, Maintain dignity at all times (leg strap, bag cover). In an observation on 04/06/2026 at 10:54 AM, Resident 21 was observed sitting in his wheelchair in the dining room with the catheter drainage bag hanging under the wheelchair, uncovered, with urine visible in the bag. In an observation on 04/06/2026 at 11:04 AM, Resident 21 was observed sitting in his wheelchair in the living room near the fireplace with the catheter drainage bag hanging under the wheelchair, uncovered, with urine visible in the bag. In an interview on 04/06/2026 at 2:37 PM, Staff G, Certified Nursing Assistant, said urinary catheter bags were supposed to be covered for privacy. In an interview and observation on 04/06/2026 at 2:43 PM, Staff E, Licensed Practical Nurse, said urinary catheter bags should be covered with a blue bag cover when residents were in bed and anytime in the facility. When asked to look at Resident 21's catheter drainage bag, hanging under his wheelchair uncovered in the hallway, Staff E said Resident 21 did not have a cover on the catheter bag and there should have been. In an observation on 04/07/2026 at 8:46 AM, Resident 21 was observed sitting in his wheelchair in the hallway outside the dining room. A blue privacy bag was hanging under the wheelchair bunched up. Resident 21's catheter drainage bag was observed hanging under the wheelchair, uncovered with urine visible in the bag, not placed in the blue privacy bag. In an interview on 04/07/2026 at 2:05 PM, Staff B, Director of Nursing/Registered Nurse, said it was her expectation urinary catheter bags were covered for privacy. Reference WAC 388-97-0180 (2)

Based on interview and record review, the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering psychotropic medications (a medication capable of affecting the mind, emotions, and/or behaviors) for 2 of 6 sampled residents (Residents 5 & 4) reviewed for unnecessary medications and/or medication consent. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications, and a diminished quality of life.Findings included. Record Review of the facility's policy titled, Behavior Management/Psychotropic Medication Overview, date revised July 2025, documented, .10. Resident or representative must be fully informed, and consent will be obtained when psychotropic medications are initiated or dosage increased. Resident 5 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/19/2026, showed Resident 5 was severely cognitively impaired and was taking an antipsychotic (a class of psychotropic medications used to treat symptoms of various mental disorders) medication. Record review of Resident 5's physician orders, dated 09/18/2025, showed Resident 5 was prescribed Seroquel (an antipsychotic medication) oral tablet 25 mg (milligrams), give 0.5 (one half) tablet two times a day, which was increased from 25 mg tablet, give 0.5 tablet once daily at bedtime. The September 2025 Electronic Medication Administration Record (EMAR) showed Resident 5 received an increased dose of Seroquel beginning 09/19/2025. Review of Resident 5's Electronic Health Record (EHR), did not show documentation of an informed consent completed for the increased dose of Seroquel. In an interview on 04/08/2026 at 3:15 PM, Staff H, Registered Nurse (RN), said they needed to obtain consent from a resident's responsible party to give psychotropic medications. Staff H said consent was also needed for a change in dose of psychotropic medication. In an interview on 04/08/2026 at 3:33 PM, Staff D, Resident Care Manager/Licensed Practical Nurse, said consent was needed for new psychotropic medications. Staff D said if there was a change in dose of psychotropic medications, a new consent was not needed. In an interview on 04/08/2026 at 3:43 PM, Staff B, Director of Nursing/RN, said consent was needed for psychotropic medications. Staff B said if changes were made to the medication, they should notify the responsible party, get consent and document a progress note for any changes. In a joint interview on 04/09/2026 at 10:25 AM, Staff B and Staff I, Regional Nurse/RN, said there was no documentation of consent for the increased dose of Seroquel for Resident 5 in September 2025 and there should have been. Resident 4 was admitted to the facility on [DATE]. The Significant Change MDS, dated [DATE], showed Resident 4 was moderately cognitively impaired. Record review of Resident 4's physician orders, dated 04/06/2026, showed Resident 4 was prescribed Seroquel oral tablet 25 mg, give 0.5 tablet every 12 hours as needed. The April 2026 EMAR showed Resident 4 received Seroquel on 04/06/2026. Review of Resident 4's EHR did not show documentation of an informed consent completed for administration of Seroquel. In a joint interview on 04/09/2026 at 1:10 PM, Staff B and Staff I said Resident 4 should have had an informed consent completed prior to starting the Seroquel and did not. Reference WAC 388-97-0260 (1)(a)(b)

Based on interview and record review, the facility failed to monitor for adverse side effects (ASE) of antianxiety medication (a class of drugs used to treat anxiety [a mental health condition that causes fear, a constant feeling of being overwhelmed, and excessive worry about everyday things]) and/or failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [a class of drugs primarily used to treat mental health conditions such as hallucinations and delusions]) and/or failed to place a stop date order of 14 days for PRN (as needed) psychotropic medication (a medication capable of affecting the mind, emotions, and/or behaviors), and failed to ensure resident specific target behaviors were monitored prior to administering antianxiety medication for 3 of 6 sampled residents (Residents 3, 4, and 25) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side-effects, medical complications, and a diminished quality of life.Findings included . Record review of the facility policy, titled, Behavior Management/Psychotropic Medication Overview, revised July 2025, documented, .11. Adequate monitoring and reevaluation of psychotropic medications for side effects and adverse consequences will be implemented upon initiation of the medication and the need for tapering as indicated, to include: .Documentation in the eMAR [electronic medication administration record] every shift for a minimum of 14 days and then as needed. The AIMS test will be used to monitor for specific side effects associated with antipsychotic medication. Resident 3 was admitted to the facility on [DATE]. The 5-day Minimum Data Set (MDS), an assessment tool, dated 03/13/2026, indicated Resident 3 was alert and oriented and had a diagnosis of anxiety disorder. Record review of Resident 3's electronic health record (EHR) showed a Physician's order, dated 03/27/2026, for clonazepam (an antianxiety medication) oral tablet 1 MG (milligram) to give 0.5 (one half) tablet orally three times a day for anxiety. Record review of Resident 3's March and April 2026 EMAR did not show documentation of facility monitoring ASE while Resident 3 was receiving clonazepam. In an interview and record review on 04/10/2026 at 9:19 AM, Staff B, Director of Nursing/Registered Nurse (RN), reviewed Resident 3's EHR and said there was no monitoring in place. Staff B said it was the expectation that Resident 3 was monitored for ASE while she was receiving clonazepam. Resident 4 was admitted to the facility on [DATE]. The Significant Change MDS, dated [DATE], showed Resident 4 was moderately cognitively impaired. Record review of Resident 4's physician orders, dated 04/06/2026, showed Resident 4 was prescribed Seroquel (an antipsychotic medication) oral tablet 25 mg, give 0.5 (one half) tablet every 12 hours as needed. The April 2026 EMAR showed Resident 4 received Seroquel on 04/06/2026. Review of Resident 4's EHR did not show documentation of an AIMS test completed for the administration of Seroquel. Record review of Resident 4's physician orders, dated, 04/07/2026, documented, LORazepam [an antianxiety medication] Concentrate 2 MG/ML [two milligrams per milliliter] Give 0.5 ml by mouth every 6 hours as needed for Anxiety. The April 2026 EMAR showed resident 4 received Lorazepam on 04/08/2026. Further review of Resident 4's physician orders did not document a stop date of 14 days for PRN Lorazepam. In an interview on 04/08/2026 at 3:33 PM, Staff D, Resident Care Manager/Licensed Practical Nurse (LPN), said an AIMS test should be completed when there was a new order for Seroquel. In a joint interview on 04/09/2026 at 1:10 PM with Staff B and Staff I, Regional Nurse/RN, Staff B and Staff I said Resident 4 should have had an AIMS test prior to starting Seroquel and she did not. Staff B and Staff I said Resident 4 should have had a stop date for the PRN Lorazepam and there was not. Resident 25 was admitted to the facility on [DATE] with multiple diagnoses to include anxiety disorder. The Quarterly MDS, dated [DATE], documented Resident 25 was alert and oriented. Record review of Resident 25's physician orders, dated 03/24/2026, documented, LORazepam Oral Tablet 1 MG (Lorazepam) Give 1 tablet by mouth every 6 hours as needed for anxiety, and LORazepam Oral Tablet 1 MG (Lorazepam) Give 2 tablet by mouth every 6 hours as needed for anxiety. Record review of Resident 25's April 2026 EMAR showed Resident 25 received 2 tablets of Lorazepam, three times per day, on 04/02/2026, 04/03/2026, 04/04/2026, and 04/07/2026. Record Review of Resident 25's EHR did not show documentation that Resident 25 exhibited symptoms or behaviors, warranting the administration of 2 tablets as opposed to 1 for all four dates. In an interview on 04/09/2026 at 09:18 AM, Staff E, LPN, stated He is prescribed lorazepam every 6 hours, but can take two. Staff E said the amount of medication had been effective when resident exhibited symptoms of hitting himself, or when Resident 25 reported increased mental anguish. Staff E said symptoms should have been documented on the EMAR, but was unable to provide such documentation for the dates requested. In an interview on 04/09/2026 at 10:12 AM, Staff D said Resident 25 was administered 2 tablets instead of 1 due to his verbal outburst and history of hitting himself. Staff D said nurses used their judgment and clinical observations when deciding whether to administer 1 tablet or 2 tablets. Staff D was unable to provide documentation of Resident 25's behaviors warranting the administration of 2 tablets opposed to 1, and stated, I would trust the nurses make good judgement without writing it out. In a joint interview on 04/09/2026 at 2:15 PM, Staff I and Staff B said the facility's current anxiety monitor for Resident 25 was insufficient and did not capture all of Resident 25's behaviors indicating when and when not to administer 2 tables. Staff I stated, the best practice is to document rationale. Reference WAC 388-97-1060 (3)(k)(i)(4)

Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I, a screening tool used to identify mental health needs, was requested upon a significant change of condition for 1 of 6 residents (Resident 7) reviewed for PASRR. This failure placed the residents at risk of unidentified mental health needs, and a diminished quality of life.Findings included . Record Review of the facility's policy titled, Pre-admission Screening and Resident Review WA (PASRR), revised June/2024, documented, .6. The PASRR will be reviewed and updated as indicated with significant changes in resident's physical or mental condition. The state mental health authority will be notified of the changes affecting the resident's physical or mental condition. Resident 7 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS, an assessment tool), dated 01/28/2026, showed Resident 7 was moderately cognitively impaired and was exhibiting signs of physical and mental decline. Record review of Resident 7's Level I PASRR, dated 01/28/2026, documented Resident 7 did not require a Level II PASRR. Record review of Resident 7's EHR (Electronic Health Record), documented Resident 7 was assessed for change of condition on 01/28/2026. Record review of Resident 7's EHR did not show documentation that a new Level I PASRR was completed upon Resident 7's significant change of condition. In an interview on 04/09/2026 at 2:31 PM, Staff J, MDS Coordinator, said Resident 7 started to experience overall decline in the areas of food intake, cognition, mood, participation in activities and ADL care, and behaviors to include hallucinations and delusions. In an interview on 04/09/2026 at 2:37 PM, Staff I, Regional Nurse/Registered Nurse, said it was the facility's practice to send new PASRR referrals following a significant change in condition. Staff I said Resident 7's condition had changed significantly, but a new PASRR referral was not completed. Staff I stated, new PASRR should have been done, with a new referral. Reference WAC 388-97-1915 (4)

Based on interview and record review, the facility failed to adequately monitor residents' heart rate (HR) for 1 of 5 residents (Resident 3) reviewed for unnecessary medications. This failure placed residents at risk for adverse side effects and a diminished quality of life. Findings included.Resident 3 was admitted to the facility on [DATE]. The 5-day Minimum Data Set, an assessment tool, dated 03/13/2026, indicated Resident 3 was alert and oriented and had a diagnosis of chronic atrial fibrillation (irregular heart rhythms that do not revert to normal rhythm on their own).Record review of Resident 3's electronic health record (EHR) showed a Physician's order, dated 03/09/2026, for Digoxin (medication used to manage irregular heart rhythms) Oral Tablet 125 MCG (micrograms) to give 1 tablet orally in the morning for atrial fibrillation.Record review of Resident 3's EHR showed Resident 3's HR was 58 bpm (beats per minute) on 03/13/2026, 56 bpm on 03/20/2026, 59 bpm on 03/23/2026, 57 bpm on 03/27/2026 and 51 bpm on 04/09/2026. Record review of Resident 3's electronic medication administration record (EMAR) showed Resident 3 received Digoxin on 03/13/2026, 03/20/2026, 03/23/2026, 03/27/2026 and 04/09/2026 despite a HR of below 60 bpm.In a joint interview and record review on 04/10/2026 at 9:32 AM, Staff B, Director of Nursing/Registered Nurse (RN) and Staff I, [NAME] Nurse/RN, said nurses assessed Resident 3's HR prior to administering Digoxin. Staff B said it was the expectation that licensed nurses would assess Resident 3's HR prior to administering Digoxin, hold the medication if Resident 3's HR was below 60 bpm and notify the provider. Staff B and Staff I reviewed Resident 3's EHR and EMAR and said Resident 3 had received Digoxin on 03/13/2026, 03/20/2026, 03/23/2026, 03/27/2026 and 04/09/2026 while her HR was below 60 bpm. Staff B said Digoxin should not have been administered with the HR below 60 and provider should have been made aware. Reference WAC 388-97-1060 (3)(k)(i)

Based on observations, interviews and record review, the facility failed to ensure that pressure ulcers were appropriately identified, and physician orders were obtained for 1 of 4 (Resident 1) residents reviewed for quality of care. This failure resulted in Resident 1 developing pressure wounds and not receiving appropriate medical interventions.Findings included. Review of the facility's Pressure Ulcer Prevention Guidelines, dated March 2014, documented, It is the policy of this facility to implement care and services to prevent residents from developing pressure ulcers. 1. Pressure ulcer prevention interventions include 4 major approaches: a. Minimizing pressure.b. Managing moisture. c. Prevention of friction and shear [skin tearing or damage].d. Maintaining adequate nutrition and hydration.Review of the facility's policy Skin at Risk program, dated April 2018, documented, Procedure 4. An appropriate treatment order will be obtained from the resident's physician and implemented when a wound is identified. Resident 1 admitted to the facility on [DATE] after a hospitalization. Resident 1's 5-day Minimum Data Set (MDS), an assessment tool dated 09/08/2025 indicated Resident 1 was cognitively intact. The 5-day MDS indicated Resident 1 admitted to the facility with no pressure ulcers. Review of Resident 1's care plan, created 09/03/2025, provided no indication of an open area/non-blanchable redness [a condition where skin shows a persistent redness after pressure is released indicating underlying tissue damage] to sacrum/buttocks.Review of Resident 1's Electronic Health Record (EHR), dated 09/09/2025 at 12:47 PM, showed Staff C, Registered Nurse, documented in the progress notes New skin condition - sacrum. Small skin tear with non-blanchable redness to sacrum/buttocks. Registered Nurse cleansed area and applied zinc barrier cream with a 6x6 bordered gauze. No charting found to indicate the Physician was notified of a new skin wound. Review of Resident 1's Treatment Administration Record (TAR), dated September 2025, showed no treatment was implemented for the assessment, care, or monitoring of the Small skin tear with non-blanchable redness to sacrum/buttocks.During an observation on 09/29/2025 at 4:08 PM, Staff D Licensed Practical Nurse (LPN) undressed Resident 1's wounds to assess. Resident 1 had a pressure ulcer measuring approximately 1.5 centimeters x1.0 centimeters to left medial sacrum. In an interview on 10/09/2025 at 1:24PM Staff C said that she noticed the area on Resident 1's sacrum and applied zinc-based cream and a dressing to the area. Staff C said that she had the Resident Care Manager (RCM) look at the wound also. Staff C said she did not request an order from the doctor for ongoing treatment as she assumed the RCM would do that. Staff C said there should have been notification and an order from the doctor.In an interview on 010/09/2025 at 12:40 PM, Staff B, Registered Nurse and Director of Nursing said an open area or injury would be investigated for cause. Staff B was unable to provide an investigation for the injury to Resident 1. WAC 388-97-1060 (3)(b)

Based on observations, interviews and record review, the facility failed to ensure that allegations of abuse were reported timely for 1 of 2 [Resident 1] sampled residents reviewed for abuse/neglect. This failure placed residents at risk for potential verbal and physical abuse, and a diminished quality of life. Findings included. Review of the facility's Abuse/Neglect/Misappropriation/Exploitation policy dated 10/2022, documented that Individual mandatory reporters must immediately report to the Abuse Hotline when there is reasonable cause to believe an incident is abuse, neglect or exploitation. Resident 1 was admitted to the facility on [DATE] for rehabilitation following a hospitalization. The Quarterly Minimum Data Set, an assessment tool, dated 07/08/2025, indicated that Resident 1 was mildly cognitively impaired.Review of Resident 1's Electronic Health Record (EHR) dated 07/25/2025, at 2:33 AM, showed Staff D, Licensed Practical Nurse (LPN) documented in the progress notes Resident 2 was raising her voice, yelling, cursing at spouse telling him to lay down or she will leave. CNAs [Certified Nursing Assistants] repeatedly assisted Resident 1 to lay back down in bed and cover him with a blanket. At this time, Resident 2 continues to yell at Resident 1 to stay in bed. Continue to assist as needed.Review of Resident 1's EHR, dated 07/26/2025 at 1:01 AM, showed Staff D documented in the progress notes Upon arrival for night shift it was overheard that Resident 2 was yelling loudly at room Resident 1 because he spilled some Pepsi on his pants. This continued for approximately 30 minutes. Went to check on residents and Resident 2 reported that she was not happy with Resident 1 and how he had spilled Pepsi. Asked residents if the door could be closed for the privacy of conversation. Resident 2 apologized for the loudness and arguing.Review of Resident 1's EHR, dated 07/31/2025 at 3:49 AM, showed Staff D documented in the progress notes [Resident 2] Continues to be awake most of the night off and on yelling at roommate, [Resident 1] to be quiet and go to sleep and put feet back in bed.In an interview on 08/27/2025 at 11:10 AM Staff C, Social Services, said she was made aware of a potential allegation of verbal and possibly physical abuse which occurred during the night shift on 08/14/2025. Staff C said the dayshift nurse had received the information during the morning report. Staff C said the nurse responsible did not intervene or interview either resident when the incident occurred during the night shift.In an interview on 08/27/2025 at 11:25 AM Staff B, Director of Nursing and Registered Nurse, said the night shift nurse left a note in her box describing an incident of potentially both verbal and physical abuse that happened during the night. Staff B said that Staff D was a long-term employee of the facility and should have known better and both intervened and reported the concern of abuse.In an interview on 09/09/2025 at 3:25 PM Staff A, Administrator, said Staff D was a seasoned nurse and knew the process to report abuse allegations. Staff A said staff D should have intervened and reported the concern for verbal and potential physical abuse. WAC 388-97-0640 (5)

<Resident 12> On 05/20/2025 at 12:41 PM, Resident 12 was observed standing in the bathroom holding onto the safety bar. Without performing hand hygiene, Staff F applied gloves and removed the dirty dressing on the resident's buttocks. Staff F then changed gloves without performing hand hygiene. Staff F cleansed the buttocks area, patting it dry, then said she forgot the wound treatment as she removed her dirty gloves leaving the room without completing hand hygiene. Upon returning to the room, Staff F applied clean gloves without performing hand hygiene, applied the wound treatment and clean dressing. Staff F then removed the dirty gloves and left the room without completing hand hygiene. At 1:10 PM, when asked about performing hand hygiene during a dressing change with wound care, Staff F said to do hand hygiene when changing gloves. Staff F said she might have forgotten to do so each time during Resident 12's dressing change. Reference WAC 388-97-1320 (1)(a)(c)(3) Based on observation, interview, and record review, the facility failed to ensure appropriate Personal Protective Equipment (PPE) use was implemented during linen sorting and washing machine cleaning in 1 of 1 facility laundry areas, failed to ensure PPE was used during personal care for 1 of 1 sampled resident (Resident 14), failed to ensure safe hand hygiene practices were implemented during dressing changes for 2 of 3 sampled residents (Residents 12 and 124), failed to develop a complete Water Management Program to reduce the risk of Legionella (a family of micro-organisms which are naturally found in water bodies) growth and spread in the facility, and failed to create an Infection Prevention and Control Program based on a facility and community-based infection control (IC) risk assessment. These failures placed residents at risk of potential contaminants being passed from staff to residents, worsening wound infections, and developing Legionnaires disease (a severe form of pneumonia, a lung infection, caused by a bacterium known as Legionella), and diminished quality of life. Findings included . <Laundry Area> On 05/23/2025 at 11:12 AM, Staff P, Housekeeping Assistant, said they wear gloves and a mask when sorting dirty laundry and loading laundry into the washing machine. At 11:18 AM, Staff P was observed while demonstrating and verbalizing areas of the facility washing machine to sanitize prior to removing clean laundry from the washing machine. Staff P did not demonstrate or verbalize the need to clean the interior rim of the washing machine door. At 11:36 AM, Staff Q, Maintenance Director, said staff were not currently required to wear a clothing protector device when sorting or loading dirty linens into the washing machine. When asked how laundry staff protect their clothing from potential contamination, Staff Q said it would make sense for staff to wear some kind of cover when sorting dirty laundry and placing it into the washing machine to reduce the risk of exposure. Staff Q said he would expect staff to sanitize the interior rim and the washing machine door before staff unload clean clothes from the washer to reduce risk of potential contamination. <PPE Use During Direct Contact Care> Review of Resident 14's Minimum Data Set assessment, dated 04/29/2025, showed the resident was admitted to the facility on [DATE] with an existing feeding tube (a medical device used to provide nutrition to people directly into the stomach). On 05/20/2025 at 3:30 PM, Resident 14 was observed with a roommate and a sign for Enhanced Barrier Precautions (EBP-an intervention designed to reduce transmission of multi-drug resistant organisms in nursing homes) attached to the room door. The sign directed staff to wear a mask, gown and gloves when providing direct contact care for the resident(s) on EBP. At 3:32 PM, Staff L, Nursing Assistant (NA) and Staff M, NA, were observed not wearing gowns while turning Resident 14 onto her left side. Staff M's uniform pants and top were observed to come into direct contact with Resident 14 as Staff M supported the resident, who had been turned onto the left side so staff could provide personal care. When asked if Resident 14 was on EBP, Staff L and Staff M both said they did not know what EBP was. Staff L removed her gloves, performed HH, went to the door, read the EBP sign, and told Staff M they should have been wearing gowns. At 4:41 PM, Staff B, Registered Nurse (RN) and Director of Nursing Services, said she would expect staff to put on gown and gloves prior to entering Resident 14's room to provide personal care and when a resident was on EBP. <Infection Control Program> Review of the facility Infection Control Program, provided by Staff B, did not show documentation supporting the completion of a required facility and community-based IC risk assessment. On 05/23/2025 at 10:14 AM, Staff B said they could not provide the requested IC facility and community-based risk assessment. Staff B said they were not involved in making an IC risk assessment and would check with the corporate office to see if they could provide one. At 4:05 PM, the facility provided documents did not include the IC facility and community-based risk assessment. <Water Management Program> Review of the facility's Water Management Program showed the following incomplete or missing required components: --Specific control measures or acceptable ranges for each of the program identified areas where hazardous conditions could exist. --What specific corrective actions the facility would take to get conditions back to within the facility's program identified control measure acceptable ranges. --Contingency responses for how the facility would respond to unexpected problems or corrective actions to take to bring control measures into the determined acceptable range for that control measure. --Procedures to show how the facility would confirm their water management program was effectively controlling the hazardous conditions throughout the building water systems. --Identification of type of sample collection, specimen transport methods and which lab the facility would use to perform stated Legionella testing. -- How the facility would communicate information on the water management program to staff. On 05/23/2025 at 11:36 AM, Staff Q said he would review the Center for Disease Control's Legionella Water Management Toolkit and complete items that were missing from their program. At 4:55 PM, Staff A, Administrator, asked for clarification on what concerns were identified with the facility water management program. Staff A said they would check with the corporate office and see if they could provide an existing completed plan. <Lack of Hand Hygiene During Wound Care> RESIDENT 124 On 05/19/2025 at 8:52 AM, Resident 124's wound dressing change was observed. Staff C, Resident Care Manager, cleansed Resident 124's wound area and did not change gloves or perform hand hygiene (HH) prior to working with clean dressing material. Staff F, RN, cleansed around the resident's wound area and did not perform HH prior to cutting the packing foam to be inserted into the resident's wound. The end of one piece of foam was observed to have touched an area of the resident's bottom sheet, which had four light brown nickel-sized areas from unknown substance on it. This piece of foam was then packed into the resident's wound. Scissors used to cut the clean dressing packing and other materials were laid directly on the resident's bottom sheet three times and directly on the resident's bedspread twice during the dressing change process. Staff F then changed gloves and did not perform HH prior to applying the clear dressing over Resident 124's packed wound. At 12:46 PM, Staff F said when doing a wound dressing change HH should be done between dirty and clean processes. Whenever gloves are changed, HH should be done. When asked where clean dressing supplies should be placed, Staff F said there was supposed to be a barrier used and they were set on the bed during this dressing change. At 12:59 PM, Staff C said gloves should be changed when you go from a dirty to a clean process and HH should be done before and after the dressing changes. On 05/20/2025 at 4:52 PM, Staff B said she expected nurses to perform HH and change gloves, anytime they go from a dirty to a clean processes. Staff B said there should be a clean area to lay dressing supplies and scissors on and equipment should be cleaned in between dirty and clean processes and/or before moving to a different area or wound.

Based on interview and record review, the facility failed to identify and report potential allegations of abuse and/or neglect to the State Survey Agency as required for 2 of 3 sampled residents (Resident 5 and X). This failure placed residents at risk for further abuse and/or neglect and a diminished quality of life. Findings included . Review of the facility's policy entitled Abuse/Neglect/Misappropriation/Exploitation, revised 10/2022, showed the facility would ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials [including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities] in accordance with State law through established procedures. RESIDENT 5 Review of Resident 5's quarterly Minimum Data Set (MDS) assessment, dated 02/26/2025, showed Resident 5 was admitted with diagnoses including stroke (a medical emergency that occurs when blood flow to the brain is disrupted) and depression. The MDS showed the resident had limited movement on both sides of the upper and lower body, requiring up to maximum assistance with Activities of Daily Living (ADLs) and the resident was able to make needs known. Review of the facility grievance log, dated December 2024 through May 2025, showed on 01/16/2025, Resident 5 filed a grievance. Review of the facility's Grievance Form, dated 01/16/2025, showed Resident 5 reported A male CNA [Certified Nursing Assistant] was helping me get ready in the morning and he was really rough getting me dressed. He left a bruise on my arm. The allegation of abuse was investigated as a grievance. Review of the facility reporting incident log, dated December 2024 through May 2025, showed Resident 5's allegation of potential abuse had not been logged or called in to the State Survey Agency. RESIDENT X Review of Resident X's MDS assessment, dated 12/06/2024, showed Resident X was admitted with diagnoses including a spinal fracture and depression. The MDS showed the resident had limited movement on both sides of his body, was incontinent of bowel and bladder, was totally dependent on staff for toileting care, and was able to make needs known. Review of the facility's Grievance Form, dated 02/25/2025, showed Resident X reported he was incontinent of bowel. He asked a family member to get the Nursing Assistant (NA) to assist. A NA came in and told the resident they would have to wait to be changed because their NA was on break and this was not the NA's section. The NA left the room without providing toileting care. The resident remained in his soiled brief until his assigned aid returned from break. The allegation of neglect was investigated as a grievance. Review of the facility reporting incident log, dated February 2025, showed Resident X's allegation of potential neglect had not been logged or called in to the State Survey Agency. On 05/22/2025 at 11:44 AM, Staff B, Director of Nursing Services, said the allegations had not been logged or call in to the State Survey Agency as required. Reference WAC 388-97-0640 (5)(a), (6)(a)(c) .

Based on interview and record review, the facility failed to develop a trauma trigger (a psychological stimulus that prompts recall of a previous traumatic event) assessment for 2 of 2 sampled residents (Residents 17 and 12) reviewed trauma informed care. This failure placed residents at risk for unidentified trauma triggers, behaviors, re-traumatization and a diminished quality of life. Findings included . <Resident 17> Record review of Resident 17's admission record, undated, showed she was admitted to the facility on [DATE]. The facility matrix (documented used to identify pertinent care categories), undated, showed Resident 17 had a diagnosis of Post Traumatic Stress Disorder/Trauma (PTSD). Resident 17's care plan, dated 03/16/2025, showed a focus problem, Potential alteration in psychosocial well-being related to survivor of traumatic event . The care plan had a goal that, Triggers of traumatic event will be minimized . Record review of Resident 17's Psychosocial History and Discharge Plan, effective 03/21/2025, showed the resident had a history of trauma, and documented a trauma informed care plan was developed with a goal to minimize the triggers of the traumatic event. On 05/21/2025 at 11:04 AM, Staff C, Resident Care Manager, said she was unable to find a list of triggers. On 05/22/2025 at 2:00 PM, Staff B, Director of Nursing Services, said trauma triggers would be listed on the [NAME] (a computer program developed from a resident's care plan with instructions for nursing assistants to follow and document resident care) under the Behavior and Mood section. Staff B said she did not see any specific triggers listed. <Resident 12> Record review of Resident 12's admission Record, undated, showed an original admission date to the facility of 12/20/2024 with diagnoses including depression (feeling of loneliness, sadness), and hallucinations (seeing or hearing things that are not there). Record Review of Resident 12's Psychosocial History and Discharge Plan, effective 04/08/2025, showed the resident had a history of trauma. Record review of Resident 12's care plan, revised 04/18/2025, showed a focused problem, Potential alteration in psychosocial well-being r/t [related to] survivor of traumatic event (specify). The care plan showed a goal, Triggers of traumatic event will be minimized . On 05/22/2025 at 2:15 PM, Staff B said the trauma triggers for this resident were not listed. Reference WAC 388-97-1060 (1)(3)(e) .

Based on observations and interviews, the facility failed to ensure treatment carts were locked for 1 of 1 treatment carts (Treatment Cart 1), and failed to ensure medication dosages were accurately labeled for 1 of 6 sampled residents (Resident 14) reviewed for medication storage. This failure placed residents at risk for having access to treatment supplies not prescribed and receiving incorrect doses of medications. Findings included . <Unlocked Treatment Cart> On 05/19/2025 at 9:25 AM and 9:57 AM, Treatment Cart 1 was observed to be unlocked. The treatment cart contained a total of 18 containers of antifungal powder and creams (treatment for fungal skin problems), 2 tubes of hydrocortisone 1 percent (%) cream (treats skin problems), 3 tubes of lidocaine ointment 5% (treatment for skin pain), 2 tubes of zinc oxide paste (protects the skin from moisture), 3 tubes of estradiol vaginal cream 0.01% (treats vaginal dryness, and irritation), 2 containers of clobetasol propionate 0.05% (treats severe skin irritations), and 5 containers of Thera-Honey gel (provides moisture for wound healing). The cart also contained wound care supplies. On 05/20/2025 at 1:22 PM and 1:33 PM, Treatment Cart 1 was observed to unlocked and contained the above mentioned medications and medical supplies. On 05/20/2025 at 1:35 PM, Staff F, Registered Nurse, said medications ought to be locked up. Staff F observed that Treatment Cart 1 was unlocked. On 05/21/2025 at 12:33 PM, Treatment Cart 1 was observed to be unlocked and contained the above mentioned medications and medical supplies. On 05/22/2025 at 2:47 PM, Staff B, Director of Nursing Services and Registered Nurse, said the expectation was for the treatment cart to be locked. <Medication Labeling> The admission Record, undated, showed Resident 14 was admitted to the facility on [DATE]. Review of Resident 14's May 2025 Medication Administration Record (MAR) showed an order for Lisinopril Oral Tablet 20 milligrams (mg), Give 0.5 tablet via PEG Tube (a feeding tube inserted through the skin, directly into the stomach) two times a day. Review of Resident 14's Lisinopril Bubble Pack Medication Card, stored in the medication cart, showed an order for Lisinopril 10 mg tablet, give 1 tablet via tube twice daily. On 05/22/2025 at 10:23 AM, after removing Resident 14's AM dose of Lisinopril from the medication bubble pack, Staff F, Licensed Practical Nurse, was asked to review the provider order and the medication card order. Staff F said the orders should match and did not. Staff F said there was a potential for a dose error because one indicated to give ½ a pill and the other indicated to give a whole pill. On 05/23/2025 at 11:03 AM, Staff A, Administrator and covering for Staff B, said the MAR order and Medication dispensing card orders should match. Reference WAC 388-97-1300 (2) .

Based on interview and record review, the facility failed to ensure urinary tract infection related antibiotic initiation practices were based on Center for Disease Control and Prevention (CDC) approved criteria. This failure placed residents at risk of receiving or not receiving necessary antibiotics and a diminished quality of care. Findings included . The facility's Antibiotic Stewardship Policy, revised 04/2023, did not identify what urinary tract infection qualifying symptom criteria was to be used to assist providers in determining if resident symptom presentation met criteria threshold to initiate use of an antibiotic. On 05/23/2025 at 10:14 AM, Staff B, Registered Nurse and Director of Nurses Services, said the facility created an SBAR (a structured communication tool used to facilitate clear and concise communication) tool the nurses used to report urinary tract infection related symptoms and concerns to a resident's provider. When asked what antibiotic initiating criteria the SBAR contained, Staff B stated, McGeer's criteria. Review of CFR 483.80(a)(3) showed the facility's Antibiotic Stewardship Program shall assess residents for any infection using standardized tools and criteria (e.g. SBAR tool for urinary tract infection assessment using Loeb minimum criteria for initiation of antibiotics). Review of CFR 483.80(a)(2)(i) Showed McGeer criteria was used to count true case events (diagnosed infections) and to estimate the actual incidence/prevalence of disease. No Associated WAC .

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness (SMI), Intellectual Disabilities (ID), and related conditions are not inappropriately placed in nursing homes for long-term care) Level I form was completed accurately and Level II PASARR referrals were made for 2 of 5 sampled residents (Residents 8 & 9) reviewed PASARR screening. These failures placed residents at risk of not receiving specialized mental health services and a diminished quality of care. Findings included . Review of the facility's policy entitled Pre-admission Screening and Resident Review WA [PASARR], revised June 2024, showed, Level II PASRR evaluations are required for all nursing facility residents identified to have indicators of SMI/ID during the Level I screening or at any time during residency in the nursing facility, and for any resident with confirmed SMI or ID who presents with significant changes in their cognitive or physical conditions. RESIDENT 8 Review of Resident 8's admission Record, undated, showed the resident was admitted to the facility on [DATE] with diagnoses including depression (feeling of loneliness, sadness), anxiety disorder (having excessive/persistent worry and fear), and insomnia (having trouble sleeping at night and/or staying asleep). Review of Resident 8's Level I PASARR, dated 02/20/2025, showed the diagnoses of depression and anxiety disorder. There was no documentation in the resident's electronic health record that a referral for a Level II evaluation was made. RESIDENT 9 Review of Resident 9's admission Record, undated, showed the resident was admitted to the facility on [DATE] with diagnoses including depression and insomnia. Review of Resident 9's Level I PASARR, dated 02/20/2025, showed the diagnosis of depression. There was no documentation in the resident's electronic health record that a referral for a Level II evaluation was made. On 05/22/2025 at 9:23 AM, after review of the medical record for Resident 8 and Resident 9, Staff A, Administrator, said referral for a Level II evaluation should have been made for Residents 8 and Resident 9. Reference WAC 388-97-1975 (1) .

Based on observation, record review and interview, the facility failed to implement physician's orders for a heart and a breathing medication during medication administration for 1 of 6 sampled residents (Resident 11) reviewed for services provided meet professional standards. This failure placed residents at risk for adverse outcomes for a heart rate below 60, mouth irritation, and a diminished quality of care. Findings included . <Heart Medication> On 05/22/2025 at 8:06 AM, during a medication administration observation, Resident 11's physician's order showed to administer a heart medication, give one tablet orally in the morning for heart failure. Check apical pulse (pulse at the heart) prior to administering medication. If below 60 hold medication and call the physician. Staff F, Registered Nurse, said she would hold the medication because the resident's pulse was 45 beats per minute this morning. Record review of Resident 11's April 2025 Medication Administration Record (MAR) showed on 16 out of the 30 days the pulse was below 60 and one day was documented X. Record review of Resident 11's May 2025 MAR showed on 7 out of the 22 days the pulse was below 60. On 05/22/2025 at 3:10 PM, when asked if the physician was notified regarding the pulse below 60 beats per minute, Staff F stated, No, and reviewed the physician's order. <Breathing Medication> On 05/22/2025 at 8:21 AM, Resident 11 was observed during another medication administration. The physician's order showed to administer 2 puffs of an inhaler for better breathing, two times a day. Then rinse mouth with water after use. Do not swallow. Staff F did not have the resident rinse their mouth with water as ordered. At 8:23 AM, Staff F said she should have had Resident 11 rinse their mouth with water and spit it out. At 2:42 PM, Staff B, Director of Nursing Services, said the expectation for administering medications was to follow the physician's orders. After reviewing the April 2025 and May 2025 physician orders and MAR for Resident 11's heart medication and asked how many times Resident 11's pulse was under 60 for each of these two months, Staff B said there were several days the resident's pulse was under 60 and there was no documentation the physician was notified. Reference WAC 388-97-1060 (3)(a)(k) .

RESIDENT 14 Review of the admission Record, undated, showed Resident 14 was admitted to the facility on [DATE], with diagnoses including a sudden interruption of blood flow to the brain, muscle weakness affecting one side of the body and/or paralysis of one side of the body, and language disorder caused by brain damage. Review of Resident 14's Skin Integrity/Pressure Injury Care Plan, dated 05/18/2025, showed interventions included, Encourage resident to offload/reposition frequently for ongoing pressure relief. On 05/27/2025 at 2:38 PM, Staff B, Registered Nurse and Director of Nursing Services, said this would not be something Resident 14 could do entirely on her own. Reference WAC 388-97-1020 (1)(2)(d) Based on observation, interview and record review, the facility failed to ensure person centered care plans were completed to address all aspects of care including individualized goals and approaches for eating and for assistance with turning and repositioning for 2 of 14 sampled residents (Resident 4 & 14) reviewed for care plans addressing resident needs. These failures placed residents at risk for inconsistent and/or inadequate care and treatment and diminished quality of care. Findings included . RESIDENT 4 Review of the admission Record, undated, showed Resident 4 was admitted to the facility on [DATE] with diagnoses including dysphasia (difficulty swallowing food or liquids) and cerebral vascular disease (stroke). The quarterly Minimum Data Set (MDS) assessment, dated 02/28/2025, showed the resident required a mechanically altered diet (thickened liquids). On 05/19/2025 at 11:00 AM, Resident's 4 room was observed with signs giving the following instructions to caregivers: --[Resident 4's] get up Schedule: Monday, Wednesday, Friday: Please ensure that [Resident 4] is getting up into a wheelchair on the following days. These are the minimum days patient should be getting up and if they would like to get up on other days, please encourage this. Thank you. --No Straws --Knobbed Cup Only Please On 05/21/2025 at 8:55 AM, Staff K, Nursing Assistant, said the information on the signs posted in the room directing resident care were not in the Kardex (a computer program developed from a resident's care plan with instructions for nursing assistants to follow and document resident care). On 05/22/2025 at 1:30 PM, Staff I, Nursing Assistant, said there were no instructions for nursing assistants to follow in the Kardex regarding Resident 4 using a knobbed cup, not using straws and nothing about Resident 4's preferred schedule for getting in and out of bed. On 05/23/2025 at 2:30 PM, Staff E, Corporate Regional Nurse, said the directives for nursing assistants to follow posted on the walls in Resident 4's room were not on the care plan or Kardex and needed to be updated.

Based on observation, interview and record review, the facility failed to accurately assess the dental status on the Minimum Data Set (MDS) assessment for 1 of 3 sampled residents (Resident 17) reviewed for assessment accuracy. This failure placed residents at risk for unmet dental and nutritional needs and a diminished quality of life. Findings included . Record review of Resident 17's admission Record document, undated, showed she was admitted to the facility on [DATE] with diagnoses of failure to thrive, poor calorie intake and malnutrition. On 05/19/2025 at 10:33 AM, Resident 17 said her dentures were outdated. The resident was observed pointing to her front top dentures and said her two front teeth were missing. The resident said she needed to have her dentures fixed and then she might be able to eat and chew better. Record review of Resident 17's care plan, dated 03/18/2025, showed the resident had an oral hygiene performance deficit due to full upper and lower dentures. The MDS, dated [DATE], showed Resident 17's dental section coded as no broken or loosely fitting full or partial dentures. On 05/23/2025 at 3:22 PM, Staff N, MDS Coordinator, said she did not recall if Resident 17 had missing teeth or dentures. Reference WAC 388-97-1000 (1)(b) .

Based on observation, interview and record review, the facility failed to provide toileting, repositioning, and pressure relieving devices for 1 of 4 sampled residents (Resident 14) reviewed for activities of daily living for dependent residents. This failure placed residents at risk for skin impairment including developing a pressure injury (PI) and a diminished quality of life. Findings included . Per the admission Record, undated, Resident 14 admitted to the facility on [DATE], with diagnoses including a stroke (a sudden interruption of blood flow to the brain). Review of Resident 14's Braden Scale (an assessment tool that measures risk for pressure injury), dated 04/25/2025, scored the resident as 14, moderate risk for PI development. The Braden Scale noted the resident had redness in the peri area and buttocks and required staff assistance with all locomotion and bed mobility. Resident 14's Skin Integrity Care Plan, dated 04/25/2025, included a goal of, The resident will not have avoidable skin impairment through the next review date, and an intervention of, Provide pressure relieving devices in bed and/or wheelchair. Review of Resident 14's admission Minimum Data Set (a standardized assessment tool measuring health status in nursing home residents), dated 04/29/2025, showed the resident required assistance from staff for activities of daily living including bed mobility, transfers, eating and toileting. A Skilled Charting Evaluation form, dated 05/18/2025, documented Resident 14 required staff assistance with bed mobility, transfers, eating, and toileting (Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.}. On 05/19/2025 at 10:13 AM, Resident 14 was observed laying on her back in bed. An air mattress or other pressure relieving device was not observed on the bed. A provider order, dated 05/19/2025 (24 days after being identified as a moderate risk for developing a pressure ulcer on the Braden Scale), requested an Air Mattress be placed on Resident 14's bed between 2:00 PM and 10:00 PM that day to promote skin integrity. On 05/20/25 at 11:43 AM, Resident 14 and her Resident Representative (RR) were observed in the facility gathering room. Resident was on her back in her partially reclined wheelchair (WC). At 12:14 PM, Resident 14 was observed in the same position as previously observed with the RR at her side. The RR said no staff had come to take Resident 14 to the bathroom or reposition her in the previous half hour. At 12:15 PM through 3:30 PM, Resident 14 was continuously observed with her WC in the same location and the resident in the same position as previously observed. No toileting or repositioning was offered by staff during this period of time. At 3:30 PM, Staff L, Nursing Assistant (NA), and Staff M, NA, were observed taking Resident 14 to her room and placing the resident in bed. At 3:35 PM, Staff L and Staff M were observed providing personal care for Resident 14 showing a red, blotchy, non-raised rash that covered Resident 14's lower abdomen and mid-to-lower back area. On 05/27/2025 at 2:38 PM, Staff B, Director of Nursing Services, said Resident 14 was not on a turning or toileting check and change schedule. Staff B said she would expect staff to perform a check and change and reposition Resident 14 at least every two hours. Reference WAC 388-97-1060 (2)(c) .

Based on interview and record review, the facility failed to provide restorative nursing services including a restorative stretching program for 1 of 2 sampled residents (Resident 10) reviewed for maintaining activities of daily living. This failure placed residents at risk for avoidable decline in function and a diminished quality of life. Findings included . The admission record, undated, showed Resident 10 was admitted to the facility on [DATE]. The quarterly Minimum Data Set assessment, dated 03/11/2025, showed the resident was cognitively impaired and required substantial to maximum assistance with bed mobility and transfers. A Restorative Program Referral Form, dated 05/12/2025, documented, Stretching program-while in chair, straighten left lower leg (LLE) extremity as far as tolerable. Hold for 45 seconds-1 minute. Repeat X5 [five times] or to a maximum tolerance. On 05/22/2025 at 11:39 AM, Staff B, Director of Nursing Services, said one resident in the facility, Resident 10, was on a restorative program. Staff B said Nursing Assistants (NAs) were responsible for the restorative program and the charge nurse oversaw the care and services. On 05/23/2025 at 9:24 AM, Staff F, Registered Nurse, stated, We do not have a restorative nursing program here. No one I know is on a restorative nursing program . At 9:57 AM, Staff G, Rehab Director, said referrals from therapy were given to nursing. Staff G stated, I let them know what we recommend. [Resident 10] is on a restorative nursing program for her left leg. At 10:15 AM, Staff H, Nursing Assistant (NA), said for Resident 10 a brace was used on her left arm. At 11:13 AM, Staff I, NA, said for Resident 10 on her weak left arm, we wash and dry her arm and hand, and we put lotion on her hands making sure the hand is clean and dry. Staff I stated, I do apply a splint to her left arm. At 11:37 AM, Staff E, Corporate Regional Nurse, was unable to provide documentation for a restorative nursing program for Resident 10's left lower leg. Staff E stated, We need to clean this up a little bit. Reference WAC 388-97-1060(2)(a)(v). .

Based on interview and record review, the facility failed to ensure timely action was taken when a resident's indwelling urinary catheter (a small flexible tube inserted into the bladder to drain urine) showed abnormal urine characteristics indicating an infection for 1 of 1 sampled resident (Resident 1) reviewed for catheter care. This resulted in Resident 1 experiencing harm when the potential infection was not treated/evaluated timely and the resident required a transfer to the hospital where she was diagnosed with a kidney infection. This failure placed residents at risk of acquiring catheter associated infections, delay in care, pain and a diminished quality of life. Findings included . Review of the facility's Catheter Care Policy and Procedure, revised 04/2018, documented residents with long term indwelling catheter use will have care plan interventions developed to prevent complications including urinary tract infections and urethral irritation. Section 6 noted residents with indwelling urinary catheters will have interventions in place to maintain urinary drainage including, G. Monitor urine drainage for four odor, sediment, color change or hematuria [blood in urine]. Resident 1 was admitted to the facility on [DATE] with diagnoses including type 2 diabetes without complications, retention of urine, and diarrhea. The Minimum Data Set assessment, dated 10/28/2024, documented Resident 1 was alert and oriented, and was dependent on staff for activities of daily living associated with catheter care. Physicians' orders, dated 10/24/2024, documented the following: --Indwelling catheter: 16FR [French indicates the diameter], 10cc [cubic centimeter] balloon, to gravity drainage. Change Monthly and PRN [as needed] every day shift starting on 10/24/2024. --Change catheter bag and tubing as needed. --Monitor for signs and symptoms of skin breakdown related to catheter tubing/strap every shift. --LN [License Nurse] to ensure, catheter system is secured, catheter strap in place, covered appropriately (privacy bag) and catheter care was provided every shift and as needed. --Irrigate catheter as needed if plugged or leaking. Resident 1's admission assessment, dated 10/24/2024 at 12:48 PM, documented a 16FR catheter with a 10cc balloon was in place for diagnosis of urinary retention. Catheter was patent (open and draining freely) and draining clear urine. The facility form Skilled Charting Evaluation, dated 10/25/2024 at 1:46 PM, was initiated for Resident 1 and showed Section E of the form was designated to the assessment of urinary status. Sections 5a., 5b., and 5c. were designated to describe urine characteristics for color, clarity, and odor consecutively. The Skilled Charting Evaluation, dated 10/25/2024, showed no characteristics were documented. The Skilled Charting Evaluation, dated 10/26 at 8:31 PM and 10/27/2024 at 8:30 PM, showed urine characteristics were described as yellow, clear, and no odor. The Skilled Charting Evaluation, dated 10/28/2024 at 10:15 AM, 10/29/2024 at 11:54 AM, 10/30/2024 at 8:06 AM, and 10/31/2024 at 10/35 AM, showed urine characteristics were not documented. Physician order, dated 11/01/2024 at 2:00 PM, noted the following: Encourage fluid intake. Monitor urine for color, sediment, and blood. May collect U/A (urinalysis, a urine test) C&S (culture and sensitivity involves a urine sample checked type of bacteria and the recommended antibiotic treatment) if symptomatic. This order was for every shift for two weeks with a start date of 11/01/2024. Lab work, dated 11/01/2024, for BMP (basic metabolic panel)/CBC with diff (complete blood count with diff measures the number and types of cells in the blood) showed no elevated white blood cell count. The Skilled Charting Evaluation, dated 11/01/2024 at 1:50 PM and 11/02/2024 at 8:24 PM, showed urine characteristics were described as dark yellow, sediment in catheter tubing, and no odor. A Nurse Progress Note, dated 11/02/2024 at 4:41 AM, documented no blood was noted in urine. A small amount of sediment was noted. Resident 1 was encouraged to drink water. Resident 1 had no complaints of discomfort. A Nurse Progress Note, dated 11/02/2024 at 11:13 PM, documented sediment was noted in amber colored urine, but no blood noted. Resident 1 encouraged to drink more fluid. A Nurse Progress Note, dated 11/03/2024 at 4:48 AM, documented no blood noted in urine. Some sediment noted. Urine was a light tea color. Resident 1 had no discomfort. No signs or symptoms of a urinary tract infection. Foley catheter was draining. Resident 1 was afebrile (free of fever). The Skilled Charting Evaluation, dated 11/03/2024 at 8:56 PM, showed urine characteristics were described as tea colored, clear with sedimentation, and no odor. A Skilled Charting Evaluation for 11/04/2024 was not located in the medical chart. The Skilled Charting Evaluation, dated 11/05/2024 at 2:05 PM, 11/06/2024 at 3:33 PM, and 11/07/2024 at 10:25 AM, showed urine characteristics were not documented. A Skilled Charting Evaluation for 11/08/2024 was not located in the medical chart. The Skilled Charting Evaluation, dated 11/09/2024 at 4:06 PM, showed urine characteristics were not documented. The Skilled Charting Evaluation, dated 11/10/2024 at 9:20 PM, showed urine characteristics were described as amber in color, with mucous, and strong odor (per their policy and procedures, and standard nursing practice this would indicate a change of condition and the need to notify the provider). A Skilled Charting Evaluation for 11/11/2024 was not located in the medical chart. The Skilled Charting Evaluation, dated 11/12/2024 at 10:50 AM, 11/13/2024 at 10:27 AM, and 11/14/2024 at 4:15 AM, showed urine characteristics were not documented. Lab work, dated 11/13/2024, for BMP was physician reviewed and showed no signs and symptoms of dehydration. A Skilled Charting Evaluation for 11/15/2024 was not located in the medical chart. The Skilled Charting Evaluation, dated 11/16/2024 at 3:33 PM, showed urine characteristics were not documented. The Skilled Charting Evaluation, dated 11/17/2024 at 9:38 PM, 11/18/2024 at 11:05 PM, and 11/19/2024 at 11:19 AM, showed urine characteristics were described as amber in color, clear with sediment, and strong odor (per their policy and procedures, and standard nursing practice this would indicate a change of condition and the need to notify the provider). The Skilled Charting Evaluation, dated 11/20/2024 at 9:35 AM and 11/21/2024 at 12:25 PM, showed urine characteristics were not documented. A Skilled Charting Evaluation for 11/22/2024 was not located in the medical chart. Resident 1's October 2024 and November 2024 Medication Administration Record did not show any new medications were ordered for urinary infections from 10/24/2024 to 11/23/2024. The Skilled Charting Evaluation, dated 11/23/2024 at 4:32 PM, showed urine characteristics were not documented. A Progress Note, dated 11/24/2024 at 10:33 AM, documented Resident 1 was sent to the emergency department due to complaints of pain to bladder, no output in urinary drainage bag since start of shift (6:00 AM), and inability to flush catheter or reinsert after removing. The Skilled Charting Evaluation documentation for 11/24/2024, charting completed on 11/24/2024 at 4:24 PM, showed Resident 1's urine characteristics were not documented. Section 6 dedicated to notable changes to bladder function documented the following: No urine output. Staff unable to flush catheter. Staff unable to reinsert catheter after removal due to pain and swelling of the urethra. Sent to Emergency Department for evaluation. Section M noted resident sent to hospital due to urinary retention. Has foley catheter. Attempted to change but unable to reinsert the catheter. Resident reported increased pain to the bladder and vaginal area. Resident visibly in distress; crying and inconsolable. A Progress Note, dated 11/24/2024 at 6:20 PM, documented staff was informed by hospital Resident 1 had been admitted for a kidney infection. A Progress Note, dated 12/01/2024, documented Resident 1 was discharged to her family's home on hospice services. On 01/13/2025 at 3:18 PM, Staff C, Registered Nurse (RN), said if Resident 1 was on Medicare there should be daily Medicare documentation that talks about urine color, consistency, and odor. Staff C said she thought there had been an order to collect a U/A with culture and sensitivity if indicated. Staff C said she was not sure if a U/A with culture and sensitivity was obtained. At 4:48 PM, Staff B, Director of Nursing Services and RN, said staff had not identified signs and symptoms of a urinary tract infection and she did not think a U/A with culture and sensitivity had been obtained. Reference WAC 388-97-1060 (3)(c)

Based on interview and record review, the facility failed to ensure a resident received adequate supervision when the care plan required two person assistance with turning in bed, and only one staff assisted the resident, for one of three sampled residents (#1) reviewed for falls. This failure placed residents at risk for falls, fractures and a diminished quality of life. This resulted in harm to Resident #1 when the resident sustained [REDACTED]. Findings included . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 03/20/2020, documented Resident #1 had impaired cognition and required extensive assistance of two persons for activities of daily living (ADLs) including bed mobility and transfers. The Care Plan for ADL Self-Care Performance Deficit and/or Limited Physical Mobility, dated 12/19/2019, documented the resident was non-weight bearing related to history of stroke. The care plan noted the resident was totally dependent on two staff to turn and reposition in bed as necessary. A nursing note, dated 03/30/3030 at 9:04 AM, documented on 03/30/2020, at approximately 8:10 AM, the Resident Care Manager (RCM) heard a call for immediate help and responded to Resident #1's room. The floor nurse and two Certified Nursing Assistants (CNAs) were present. Resident #1 was observed on the floor laying on his right side in between his bed and the foot of his roommate's bed. A facility Radiology Results Report, dated 03/30/2020 at 8:14 PM, documented Resident #1 had an acute right knee fracture involving the patella (kneecap). The facility incident investigation, completed by Staff C, former Director of Nursing Services, dated 04/01/2020 and revised 04/06/2020, documented the resident's care plan showed Resident #1 was a two-person assist for bed mobility. A witness statement, dated 04/06/2020, written by Staff D, CNA, documented she had asked for help but everyone was busy so she changed Resident #1 by herself. Staff D documented she turned him on his side and then Resident #1 fell off the bed. On 07/08/2020 at 3:12 PM, Staff E, Licensed Practice Nurse (LPN), said an aide called her into Resident #1's room, and she saw the resident laying on the floor, on his right side, in between the beds. Staff E said Resident #1's head was kind of under his roommate's bed. Staff E said her first impression was how could he fall. On 07/14/2020 at 1:53 PM, Staff F, LPN and RCM, said Resident #1 was totally dependent on staff for bed mobility. When asked about the resident's fall, Staff F said Staff D did not use a second person. Staff D rolled the resident to one side, he got too far to the edge, and weight and gravity took over. Staff F said Staff D was a good CNA; she just made a mistake. On 07/15/2020 at 1:30 PM, Staff D said she was providing care to Resident #1. Staff D said the resident was turned on his side and she normally had the supplies right there, but they were on the resident's nightstand. Staff D said she reached over to grab the supplies; and when she turned back, Resident #1 was going off the bed. Staff D said she could not do anything about it. Staff D said she will never do it again; she will wait for help. On 07/23/2020 at 10:35 am, Staff A, Administrator, said the care plan was not followed when care was provided by a staff person working alone. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to treat residents with respect and dignity when a resident was care planned to urinate in a trash can and when plastic utensils were given to a single resident for meals for 1 of 3 sampled residents (#2) reviewed for dignity. This failure placed residents at risk for embarrassment, diminished self-esteem and a lack of a safe, homelike dining experience. This caused psychosocial harm to Resident #2. Findings include . Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 09/12/18, indicated the resident was severely cognitively impaired without behaviors, and required limited assistance with transferring, mobility and toileting. The MDS showed the resident was on a diuretic (a medication causing increased urination) and was continent of bladder. <Trash Can> Resident #2's Activities of Daily Living (ADL) Care Plan, dated 07/07/18, showed TOILET USE: The resident requires SBA (stand-by-assist) w/gait belt; supervision by 1 staff for restroom use; toileting. An incident investigation report showed Resident #2 had a toileting-related fall on 11/15/18 at 12:45 AM. The incident investigation note, dated 11/20/18, documented, Based on his cognitive impairment and considering his preference, the DNS (Director of Nursing Services) gave the resident (in addition to the trash can he had already available with a plastic bag-liner) an empty trash can to urinate in at any time daily .his care plan had been updated to include his preference of staff to validate the empty garbage next to his bed and empty the contents accordingly. Resident #2's Falls Care Plan, dated 11/20/18, documented, keep trash can without the plastic bag liner available at bedside for resident to use as a urinal for bladder continence; toileting. An incident investigation report showed Resident #2 had a toileting-related fall on 11/22/18 at 6:00 PM. The incident investigation note, dated 11/27/18, documented keeping a trashcan with the liner out for him to urinate in. Resident #2's Bladder Incontinence Evaluation, dated 11/27/18 at 9:43 PM, documented the resident required supervision transferring on/off the toilet. Resident #2's Kardex, a tool used by staff to direct resident care, reviewed on 12/05/18, documented keep trash can without the plastic bag liner available at bedside for resident to use as a urinal for bladder continence; toileting. On 12/05/18 at 3:42 PM, Resident #2 said he felt really small when asked how he felt when he did not urinate in the toilet, and demonstrated by holding his straightened index finger approximately ½ inch above his straightened thumb. On 12/10/18 at 10:10 AM, Staff Q, Certified Nursing Assistant (CNA), said Resident #2 has had to urinate in the trash can on two occasions while she was on duty; once when Resident #2 could not get into the shared locked bathroom and once when Staff Q was assisting another resident. At 11:47 AM, Staff C, Registered Nurse, (RN), stated, (Resident #2) was constantly found urinating in the garbage can. At 3:25 PM, Staff A, Administrator, stated the trashcan was the resident's preference and was not a typical intervention. Staff A said the intervention was reviewed at stand-up meetings with the entire Inter-Disciplinary Team involved. <Plastic Silverware> On 12/06/18 at 8:32 AM, Resident #2's breakfast tray was observed to have an individualized dietary-needs slip which documented under Special Notes: PLASTICWARE. A progress note, dated 10/09/18 at 12:49 PM, documented, CNA informed this LN (Licensed Nurse) that resident is refusing to eat lunch and is upset. This LN went in to see resident and resident stated, 'I will not eat until I get a real fork and spoon, no plastic.' Resident had plastic utensils delivered d/t (due to) incident this AM .Resident then calmly stated 'that's fine, I'm just not going to eat and I'm going to call channel 7 news tomorrow. Review of Resident #2's (MONTH) (YEAR) Medication Administration Record [REDACTED]. A progress note, late entry, dated 10/10/18 at 8:30 AM, documented, Was notified by NAC and assigned nurse that resident was waving and running after staff out of his room using a butter-knife that he had been served with his breakfast .Resident did allow DNS to confiscate his butter-knife. DNS then notified kitchen to only serve plastic utensils with all meals in consideration of resident's level of agitation displayed. The facility grievance log showed no documentation about this incident. The facility accident/incident log showed no documentation about this incident. Resident #2's ADL Care Plan, dated 10/11/18, showed may only have plastic utensils to use for meals r/t hx (related to history) of aggressiveness/agitation w/silverware against staff. Resident #2's Kardex, reviewed on 12/05/18, documented may only have plastic utensils to use for meals r/t hx of aggressiveness/agitation w/ silverware against staff. On 12/03/18 at 1:02 PM, Resident #2's daughter said the resident told her he was eating pork chops with plastic ware. On 12/05/18 at 3:42 PM, Resident #2 said staff wouldn't let me eat with a fork. I had to eat with a plastic fork. When asked how he felt about using the plastic silverware, Resident #2 said about that low, and demonstrated by holding his straightened index finger approximately ½ inch above his straightened thumb. Resident #2 stated, Have you ever tried to eat a pork roast with plastic? Resident #2 said visitors who were walking in the hallway, looked in and saw him eating with the plastic utensils. The resident was observed with a sad expression on his face. On 12/10/18 at 11:41 AM, Staff B, DNS/RN, said Resident #2 was care planned for plastic silverware because of a resident to staff incident around 10/10/18. Staff B stated, I am not seeing an investigation and there is no grievance. Staff B said the plastic silverware care plan is still in place, and at this time he should be getting plastic. At 3:28 PM, Staff A, Administrator, said Resident #2 was to use the plastic utensils as a temporary intervention and temporary care plan. When asked if Resident #2 should still be using plastic utensils, Staff A stated, No. Reference WAC 388-97-0180(1-4)

Based on observation, interview and record review, it was determined the facility failed to ensure 8 of 11 current and/or former/discharged sampled residents (#1, 2, 3, 4, 5, 6, 7 & 8), identified at risk for skin breakdown and who developed pressure sores and/or had wounds that increased in size, were assessed, monitored, evaluated and treated according to accepted standards of practice, were evaluated for the impact of the implemented interventions and/or revised treatment needs as appropriate for the residents in a timely manner. This failure placed residents at risk for increase skin breakdown and dimished quality of care. Failure to recognize, assess, monitor, evaluate, prevent and/or promote prompt healing of existing pressure ulcers resulted in harm to Resident #1, 2, 3, 4, 5, 6, 7 & 8 Findings include: Review of the facility's Skin at Risk Program Overview indicated: It is the policy to ensure this facility to ensure 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 residents who enter the facility with a pressure ulcer receive appropriate care and services to promote healing and prevent infection. An appropriate treatment order will be obtained and implemented when a pressure ulcer is identified .Weekly measurements .daily wound monitoring/documentation .Optimal care plans developed and implemented .Documentation includes length, width, depth, undermining, tunneling, pain, amount and type of drainage, condition of wound bed and wound edges . 1) Resident #1 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Review of facility weekly ulcer reports indicated the resident had none listed the week of 03/28/16-04/04/16. The resident's initial ulcer assessment, dated 02/29/16, indicated Resident #1 had a pressure wound measuring 1x0.5x0.25cm on her coccyx (tailbone) region. There was no further ulcer assessment documentation of this wound. On 03/31/16 observation of Resident #1, with the Director of Nursing Services (DNS) and Licensed Nurse (LN) A, showed the resident's buttocks were purple with a healing stage II pressure wound. 2) Resident #2 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the resident's MDS, indicated the resident was at risk to develop pressure ulcers. Review of the facility weekly ulcer reports indicated the resident had a stage III pressure wound on her coccyx (tailbone region) on 02/29/16 measuring 2 x 1.6 cm, increasing from 0.9 x 0.4 x 0.3cm the week prior; and a 0.1 x .01cm stage II pressure wound on her left buttock fold., the week prior it was noted to not be measured. On 03/14/16, a nurses note showed LN B noted, Area on coccyx has healed. Tx not necessary at this time will alert day nurse to notify dr. On 03/25/16,a nurses note showed LN C noted, Resident's reddened buttocks has now opened along crack and right buttock. Will continue with current tx in place. On 03/31/16, observation of Resident #2, with the DNS and LN A, showed the resident had a 2.5 x 1.3cm stage II pressure wound on her coccyx. Resident #2 also had complaints of itching and irritation in her groin area. Resident #2's care plan indicated the resident was admitted with impaired skin integrity and the facility will evaluate wounds per protocol, and provide additional peri-care as needed and provide lotions or barrier creams to promote comfort and protect the skin. 3) Resident #3 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's MDS indicated the resident was at risk to develop pressure ulcers. Review of the facility weekly ulcer reports showed the resident has had an ongoing stage IV pressure wound on his mid-spine and was being followed by a wound care clinic. The weekly ulcer report noted on the week of 02/29/16-03/07/16 the resident had a stage IV pressure wound on his mid-spine measuring 0.9 x 0.2 x <0.1cm, increased from the prior week that had measured 0.7 x 0.1 x 0.2cm. On 03/31/15, observation of Resident #3, with the DNS and LN A, showed the resident had an open wound to his spine measuring approximately 1 x 0.1 x 0.1cm. The resident had a stage II pressure wound on his left scapula (shoulder blade) measuring 1 x 2cm, and a stage I pressure ulcer on his left elbow measuring 0.5 x 1cm. The pressure ulcers to his scapula and elbow were not documented on any ulcer weekly form or skin assessment. During this observation Resident #3 had an inflamed and reddened scrotum and left groin. The resident stated, It's very tender and feels like sand paper (while the nurse cleaned the area). When the resident was rolled onto his side for cleaning he had dried feces on his left side. Nursing Assistant (NA) A indicated, during this observation, Resident #3's catheter had been leaking urine for sometime and urine gets in there. On 03/31/16 and 04/01/16, Resident #3 was observed to sit in his tilt in space wheelchair and lean to his left side. The resident was observed to sit in his wheelchair near the nurse's station for at least four hours. Record review of Resident #3 was care planned for a stage IV pressure ulcer to mid-spine and was admitted with impaired cognition and mobility with poor skin turgor. The resident's care plan goal noted, wounds will heal with current treatment. Resident's #3's interventions were for the resident to be repositioned every 2 hours and provide incontinent care after each episode. 4) Resident #4 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. Review of the facility weekly ulcer report for the week of 02/22/16-02/29-16 indicated the resident had macerated (reddened area) on his right buttock measuring 1.3 x 1.1cm. On the weekly ulcer report for the week of 02/29-03/07/16 indicated Resident #4 had a blister on his right buttock measuring 1.9 x 1.6cm. Record review showed a non-pressure skin condition assessment was done on 02/22/16 on Resident #4. No further documentation was found for this skin condition for Resident #4 since the date indicated. On 03/31/16, observation of Resident #4's skin, with the DNS and LN A, showed on the right ischial (upper buttock region) had a 2.7 x 5.5cm stage I pressure ulcer with a 0.4 x 0.4 purple dot, and a 0.2 x 0.2cm reddened coccyx. On the resident's right shin he had an 8 x 4.8cm reddened area that was outlined with a faded pen. The resident had dried feces in his right groin region. 5) Resident #5 admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. There was no documentation the resident had any skin wounds. On 04/01/16, with LN D, it was observed the resident had a stage I abrasion on his coccyx measuring 1.5 x 1.5cm. 6) Resident #6 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of skin assessments, dated 07/21/15, 07/28/15, 08/11/15, and 10/21/15, showed the resident had no skin breakdown. The resident was discharged on [DATE]. Resident #6's discharge nursing progress note indicated, left buttock with small dry discoloration, 1cm x 1cm, barrier cream applied. Resident #6's care plan noted she was at risk for impaired skin integrity related to diabetic [MEDICAL CONDITION], impaired mobility, and bowel and bladder incontinence. Interventions were for the resident's skin condition to be monitored per protocol, and provide additional peri-care as needed and provide lotions and barrier creams to promote and protect the skin. 7) Resident #7 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Record review of the resident's MDS indicated the resident was at risk to develop pressure ulcers. Review of the facility weekly ulcer report indicated no documentation on any skin conditions for Resident #7. On 03/31/16, a skin observation, with the DNS and LN A, showed the resident had a reddened, blanchable area to her coccyx. 8) Resident #8 was admitted on [DATE] with multiple [DIAGNOSES REDACTED]. The resident discharged to the hospital on [DATE] and returned to the facility on [DATE] with a stage II pressure wound to her left buttock measuring 1.2 x 1.5 x <0.1cm. Resident #8's care plan indicated it had not been updated since 01/27/2016, and did not address the newly formed pressure ulcer to her coccyx. Review of the resident's assessments indicated she had not had a full skin assessment since she returned from the hospital. On 03/31/16, a skin observation, with the DNS and LN A, showed the resident had a 4x4 dressing on her coccyx that was soiled with feces. The resident and DNS both indicated this was the same dressing from the hospital. On 03/31/16 at 2:19 p.m., LN E indicated she was not sure who did the skin assessments. LN E said the former DNS used to do them and was not sure who did them now. LN E indicated she did not normally do them due to time constraints. At 2:23 p.m., LN F indicated all the licensed nurses should be doing skin assessments. LN F said it was her understanding the DNS was the one that was supposed to be doing the weekly skin assessments. An interview with a confidential informant indicated they felt there was not enough nursing assessments or skin assessments being done on residents, and they felt this was putting the resident's at risk for skin breakdown. The confidential informant indicated there needed to be much better nursing assessments of wounds then there is now. On 04/01/16 at 1:33 p.m., the DNS indicated she was hired the beginning of February 2016 and she was having another Registered Nurse (RN) doing the skin checks. The DNS said the RN quit and the knowledge of skin assessments went with him. The DNS indicated the skin checks had not been fully done since the end of February due to confusion. The DNS indicated she did an audit on 03/25/16 of who needed full skin checks due to not being consistent on skin checks, and knew they needed to be done, but had not yet gotten them done. Failure to recognize, assess, monitor, evaluate, prevent and/or promote prompt healing of existing pressure ulcers placed the residents at risk for skin breakdown and worsening of pressure and non-pressure skin conditions. This failure resulted in harm to Resident #1, 2, 3, 4, 5, 6, 7 & 8, and was determined to represent substandard care in the facility. .

Based on observations, interview and record review, it was determined the governing body failed to ensure the facility was operated in a manner to maintain compliance with regulations related to sufficient nurse staffing and resident quality of care. This failure resulted in harm to 8 of 11 current and discharged /former sampled residents (#1, 2, 3, 4, 5, 6, 7 & 8), and placed the care and needs of residents at risk for a decrease in their quality of care and quality of life and failure to reach their highest level of function. Findings include: The governing body failed to ensure the facility was effectively administered to ensure there were sufficient qualified staff to avoid negative outcomes for the 8 of 11 residents reviewed for pressure ulcers. Refer to 42 CFR 483.75 F-490, Effective Administration, Resident Well-Being for facility was not administered effectively to utilize resources to attain and/or maintain the highest practicable well-being of residents in the facility and failed to have sufficient qualified nursing staff and address staff knowledge to meet resident needs. This failure resulted in harm to 8 of 11 current and/or discharged residents (#1, 2, 3, 4, 5, 6, 7 & 8) and placed the specific needs of residents at risk to not reach their highest level of function and a diminished quality of care and quality of life.

Based on observation, interview and record review, it was determined the facility was not administered in a manner to effectively use its resources to attain and/or maintain the highest practicable well-being of each resident. Failure to access sufficient qualified nursing staff and address staff knowledge to meet resident needs resulted in harm for Resident #1, 2, 3, 4, 5, 6, 7 & 8, and placed the individualized and specific needs of residents at risk for failure to reach their highest level of function and a decrease in quality of care quality of life. Findings include: The facility administrator failed to ensure the facility resources were sufficient to ensure the residents with risk of skin breakdown received the appropriate assessments and treatment for [REDACTED]. Please refer to the following: 1) Refer to 42 CFR 483.25(c) F-314, Quality of Care/Treatment/Services to Prevent/Heal Pressure Sores for facility failure to ensure 8 of 11 current and former/discharged sampled residents (#1, 2, 3, 4, 5, 6, 7 & 8) who were identified as at risk for skin breakdown and who developed sores in the facility were assessed, monitored, evaluated and treated by qualified personnel and in accordance with accepted standards of practice and resulted in harm to these residents. 2) Refer to 42CFR 483.30(a) F-353, Nursing Services, Sufficient Nursing Staff per Care Plans for facility failure to ensure sufficient, qualified nursing staff were available to provide care and services to residents in the facility to help them attain and/or maintain their highest practicable level of function and impacted their well-being and quality of care and resulted in harm to 8 of 11 current and former/discharged sampled residents (#1, 2, 3, 4, 5, 6, 7 & 8). 3) Refer to 42 CFR 483.30(b)(1) F-354, Nursing Services, Registered Nurse (RN) Schedule for failure to ensure RN coverage for at least eight (8) hours a day, seven (7) days a week for three (3) days in March 2016 (3/6, 3/13 & 3/20) placing residents at risk of not receiving timely and necessary assessments and monitoring of direct care and services by sufficient qualified nursing staff to provide and supervise resident quality of care.

Based on observation, interview and record review, it was determined the facility failed to have sufficient nursing staff to provide and supervise care for residents with complex health care needs and to ensure residents were assessed, monitored and treated for [REDACTED].#1, 2, 3, 4, 5, 6, 7 & 8) reviewed for pressure ulcers. This failure placed residents at risk for not attaining and/or maintaining the highest practicable physical, mental and psychosocial well-being in accordance with resident assessments, care plans and professional standards of practice and impacted their well-being and quality of care. Findings include: On 03/31/15 at 2:19 p.m., Licensed Nurse (LN) E said she was not sure who did the skin assessments for residents. LN E said the former Director of Nursing Services (DNS) used to do them. LN E indicated she was not sure who did them now. LN E said she did not normally do them due to time constraints. At 2:23 p.m., LN F said she understood the DNS was the one that was supposed to be doing the weekly skin assessments. On 04/01/16 at 1:33 p.m., the DNS said she was hired the beginning of February 2016, and she was having another Registered Nurse (RN) complete the skin checks. The DNS said that RN quit and the knowledge of skin assessments went with him. The DNS said the skin checks had not been done since the end of February. The information is more detailed in the following citations: 1) Refer to 42 CFR 483.25(c) F-314, Quality of Care/Treatment/Services to Prevent/Heal Pressure Sores for facility failure to ensure 8 of 11 current and former/discharged sampled residents (#1, 2, 3, 4, 5, 6, 7 & 8) who were identified as at risk for skin breakdown and who developed sores/in the facility were assessed, monitored, evaluated and treated by qualified personnel and in accordance with accepted standards of practice and resulted in harm to these residents. 2) Refer to 42 CFR 483.30(b)(1) F-354, Nursing Services, RN Schedule for facility failure to ensure registered nurse (RN) coverage for at least eight (8) hours a day, seven (7) days a week for three (3) days during the month of March 2016 (3/06/16, 03/13/16 & 03/20/16) placing residents at risk of not receiving timely and necessary assessments and monitoring of direct care and services by sufficient qualified nursing staff to provide and supervise care of residents.

Based on observation, interview and record review the facility failed to provide transportation for scheduled physician orthopedic clinic visits to maintain or improve (1 of 1 resident) Resident #1's shoulder fracture that occurred in a motor vehicle accident. Due to a two week delay, Resident #1 experienced a dislocation of the pinned fracture while at the facility and is now subject to increased chance of infection in the shoulder during upcoming surgery. Findings include: Resident #1 was admitted on [DATE] from St Joseph hospital in Tacoma to Olympia Manor in Olympia after a motor vehicle accident that fractured her right pelvis, caused three fractures of her right femur and fractured her left shoulder joint and upper arm. Her right upper leg was in a Striker brace so she was not to be at any more than a 45 degree hip flexion in bed or sitting. Her left shoulder was in an arm immobilizer at all times to keep the fracture aligned. Resident #1 was admitted with scheduled appointments to see her trauma physician and orthopedic physicians in Tacoma. This was scheduled for 6/11/15. On 6/6/15 Resident#1's nursing home physician was in to see her. Resident complained to the physician that her arm felt worse. The physician ordered her transport via ambulance to St. Joseph Hospital to see her trauma physician. Since neither of her specialists was in that day she was returned to the nursing home without being seen. A new orthopedic appointment was made for 6/9/15 in the morning. Because Resident #1 can only sit at a 45 degree angle she would need to be transported via ambulance on a gurney or in a wheel chair that would accommodate a 45 degree hip flexion angle. In interview on 6/17/15, Resident #1 remained concerned about seeing her trauma physician and about her shoulder and arm fractures. She raised her concerns with social services and nursing continually since 6/9/15. On 6/9/15 Resident #1 did not go to her orthopedic appointment. On 6/8/15 nurses notes state: .Bellevue Healthcare cannot get resident's w/c here today and unsure when it will get here. Resident must lay at a certain angle to go to doctor's appt. Resident must go on a gurney if 22 reclining w/c is unavailable. Talked with resident who states she absolutely must go to her appt tomorrow and doesn't understand why she can't go via ambulance as she did on 6/6/15. Discussed with DNS who will call Administrator and try to get authorization to send resident via ambulance tomorrow to Tacoma. Nurse's notes on 6/9/15 revealed Spoke to resident yesterday in notification of ortho-consult change in consideration of facility's anticipation of wheelchair availability. Also spoke to ortho-clinic for Dr. Sno who states that despite appointment needing cancellation today, resident may still keep original appointment date at time of hospital discharge set for 6/11/15. Nurse's notes on 6/10/15 at 09:49 reveals that the wheelchair order will not be delivered by 6/11/15 for the ortho-clinic appointment. The appointment was cancelled by the facility and rescheduled for 6/18/15. On 6/11/15 nurses notes stateVisited with resident who was upset and crying regarding not being able to go to her appointment again because facility not receiving her w/c still. On 6/11/15 a progress note stated discussed with resident who was upset and asked why she could not go via ambulance and told resident she would need to speak with the Administrator who makes that decision. A new appointment was made for 6/18/15 for the ortho-clinic since she already had an appointment on that day with the trauma clinic. In interview of Resident #1 on 6/23/15, she stated that her ortho-physician was unhappy that she had not returned within the two week period as originally planned. She verified that he was concerned over the displaced alignment of her shoulder fractures and felt she was at greater risk of infection at this time of performing surgery than if she had been operated on two weeks earlier. Resident #1 shared her copy of these concerns written in a progress note from her physician with this investigator. On 6/29/15, Resident #1 called this investigator saying tearfully that she could not have surgery on her shoulder because of the infection in her shoulder that was worse than the trauma physician had expected.

Based on observation, interview and record review it was determined the facility failed to ensure all doors that exited the building were secured and/or alarmed and failed to adequately supervise to prevent access to an unsafe area in the facility for 1 of 4 Sampled Residents (#34) reviewed for accidents. As a result, Resident #34 entered a hallway intended only for staff access and fell down a flight of stairs in a wheelchair and sustained a cervical fracture. This injury constituted harm for this resident. Findings include: Resident #34 admitted to the facility on [DATE] following hospitalization . A hospital "Resident Discharge Summary" dated 1/20/14 documented the resident fell at home, had severe osteoporosis, a history of previous surgical repair of a left hip fracture and sustained new non-displaced fractures of pelvic bones, right hip and right upper arm. A facility diagnostic list identified Resident #34 had a history of [REDACTED]. The summary identified the resident did not require surgery and discharged to the nursing home for rehabilitation. A Minimum Data Set (MDS, required assessment tool) dated 1/29/14 identified Resident #34 had moderately impaired vision, had cognitive impairment and did not know the correct year, month or day, required extensive assistance from two staff for bed mobility, transfer, dressing and hygiene and had functional limitation of one side of an upper extremity. The MDS also indicated the resident had difficulty with focusing and inattention, became easily distracted, disorganized thinking and had hallucinations and delusions. On 4/8/14 at 9:08 a.m. Resident #34 wore a neck brace and sat in a wheelchair in the dining room engaged in an activity. On 4/8/14 at 9:18 a.m. Resident #34 wore a neck brace while Staff NA A pushed the resident in a wheelchair down the hall. Staff NA A stopped at a doorway to a bathroom and the resident used both feet to self-propel the wheelchair a short distance inside. On 4/9/14 at 7:50 a.m. Resident #34 wore a neck brace and propelled the wheelchair using both feet to move down the hall into the dining room. Physician orders [REDACTED]. On 3/13/14 the physician increased the dose when the resident continued to have confusion and make paranoid statements and did not redirect easily. On 3/24/14 the physician discontinued the first psychoactive medication and implemented use of a different one. A nursing note dated 3/14/14 documented the physician changed psychoactive medications since the first one prescribed was ineffective to treat agitated behaviors. A "Fall Management" Plan of Care dated 1/22/14 identified risk for falls included a history of falls, fractures, pain, incontinence, dementia, medication use, sensory impairment and had dementia with behaviors. An aide care plan dated 1/23/14 identified the resident used a front wheeled walker only with therapy staff. Nursing notes dated 1/23/14 through 3/26/14 identified Resident #34 exhibited confusion with agitation at times and usually could be re-directed. Notes indicated the resident could make needs known and self-propelled in the facility in a wheelchair. Nursing notes documented the resident attempted to seek a means to exit the facility on 2/19/14; 2/20/14 and 3/13/14. On 3/19/14 staff documented the resident walked in the hall without a walker and poorly understood safety teaching. On 3/20/14 staff documented the resident attempted to exit seek more than 10 times during the shift, twice on 3/21/14 and attempted to exit seek on 3/23/14 and 3/24/14. Facility "Event & Occurrence Reports" identified Resident #34 experienced two falls in the facility since admission. Both times, the resident did not use a call light to summon staff for assistance. On 2/17/14 at 3:20 a.m. an investigation documented Resident #34 slid off the bed onto the floor during an attempt to get up to go to the bathroom. A second facility investigation identified on 2/28/14 at 4:00 a.m. staff found Resident #34 on the floor. The resident reported falling trying to go to the bathroom. The conclusion of the investigation identified the resident had rehab, got stronger and attempted to self-transfer and had confusion at times. A nursing note dated 3/26/14 at 1:00 p.m. documented Resident #34 self-propelled "around facility" in a wheelchair. A facility investigation report dated 3/31/14 identified at 8:15 p.m. on 3/26/14, staff discovered Resident #34 at the bottom of a stairwell that led to the basement (in the facility) and sent the resident to the emergency room . Staff documented in the investigation the resident self-propelled in the wheelchair about 8:00 p.m. during an attempt to enter another resident's room. Staff re-directed the resident to the Fireside Room. Approximately 15 to 20 minutes later, staff looked for the resident and a nurse saw the resident's slipper in the doorway that led to the stairs. Staff located the resident at the bottom of the stairs with head at the bottom and legs extended toward the top of the stairs and the wheelchair turned over. The investigation conclusion stated the resident went through two doors to get to the stairs. All other doors in the facility were alarmed and no resident had gone through those doors before. The day following this incident, the facility added a keypad alarm to the door that led to the area before the door before the stairwell. On 4/9/14 at 10:17 a.m. a door located in front of the nurses' station contained a large "STOP" sign visible at standing eye level and another sign below that which indicated "Staff Only." Sign placement was not at eye level if seated in a wheelchair. Staff MR reported at this time the same sign was on the door before the facility installed the new digital keypad. On 4/9/14 at 10:34 a.m. the RVP reported two aide staff were busy caring for another resident the evening Resident #34 fell . When they were done and went to look for resident they did not locate her. The RVP reported no other residents had wandered through the door in front of the nursing station before. The RVP also reported the facility had residents in the past who were exit seekers. On 4/3/14 at 12:32 p.m. Staff FMD reported the facility just installed the alarm system on the door (in front of nurse station) last Friday (3/28/14). The FMD reported staff entered the door to go downstairs and now the door would alarm when pushed open. On 4/9/14 at 3:40 p.m., The DNS reported facility doors that exited in the front of the building, back hallway, dining room and therapy room all had alarms to signal staff when they were opened. The surveyor and the DNS then looked at the location where Resident #34 fell . Inside the first door in front of the nursing station a short distance down the hall there was a second unlocked and unalarmed door. A short distance past the second door a third door exited the building There was a set of stairs on the right immediately before the third exit door that led to the basement. The DNS identified Resident #34 fell down this flight of stairs. The DNS reported before Resident #34 fell , the facility did not have a lock or alarm on the door in front of the nursing station and just recently added an alarm to the door to alert staff if a resident opened the door. The DNS reported the third door (that exited the facility) remained locked so no one could enter the building from the outside. Resident #34 remained hospitalized from [DATE] following the fall until re-admission to the facility on [DATE]. A hospital "Admission History and Physical" dated 3/27/14 identified the resident's current fall down the stairs resulted in a fracture in a bone located in the upper cervical spine and the resident would need to wear a neck brace for 3 months. A hospital Physical Therapy Evaluation dated 3/27/14 indicted Resident #34 could return to the facility to prior level of functional mobility and needed to wear a neck collar 24 hours a day seven days a week. The report also indicated the resident alert, "pleasantly confused" and followed instructions about 75% of the time. Resident #34 had high risk for falls that included a history of cognitive impairment; recent history of falls resulting in fractures; recent psychoactive medication adjustments; self-propelled in the facility in a wheelchair and pattern of exit seeking. The facility failed to identify the need to alarm a door that led to an unsafe area for residents to alert staff if entered by the resident. Staff failed to provide adequate supervision to ensure Resident #34's safety to prevent the resident from entering this unsafe area. This led to Resident #34 falling down a flight of stairs which resulted in fracture in a bone in the upper neck which constituted harm for this resident. .

Based on observation, interview and record review, the facility failed to have sufficient qualified staffing to provide and supervise care for residents for 18 of 18 current residents (#1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17, &18) out of a census of 24. The facility failed to provide timely and needed care to residents. The care provided was not supervised in a manner to provide consistency in therapeutic approaches to avoid actual harm. Staff did not adequately assess, evaluate, report or document information needed to formulate effective and timely interventions. The harm resulted from a failure to provide care and services to maintain resident's highest practicable well being in the areas of; responding to avoidable changes in skin condition, ensuring dignity of all residents. Findings include: 1) Refer to 42CFR 483.10(n), F-176 Resident Rights: The facility failed to ensure Resident self administration of drugs was deemed safe for Resident #1. 2) Refer to 42CFR 483.25(a) (3), F-312 Quality of Care: The facility failed to ensure care was provided to dependent residents affecting Residents #'s 1,3,4,7,9,11,13,14,15,17 & 18. 3) Refer to 42CFR 483.25(k) (4)(5)(6), F-328 Quality of Care: The facility failed to provide physician managed treatment/care for special needs which caused Resident #1 to sustain physical harm. 4) Refer to 42CFR 483.65(b)(1)(2)(c), F-441 Infection Control: The facility failed to ensure adequate infection control to prevent the spread of infection, for Residents #'s 1 & 5 with the potential to affect all facility residents. 5) Refer to 42CFR 483.75, F-490 Administration: The facility failed to ensure effective administration to provide the highest practicable physical, mental and psychosocial well-being of each resident residing in the facility. 6) Refer to 42CFR 483.75, F-493 Governing Body: The facility failed to ensure effective governing body or desgnated persons legally responsible for the management and operation of the facility to ensure the highest practicable physical, mental and psychosocial well-being of each resident residing in the facility. The facility did not have a plan in place when the repairs to the only facility shower room was not completed for 7 weeks and proper supplies and direction to staff to provide the necessary bathing, showering and shampoo per the resident plan of care. During interviews with residents (1,3,4, 5,7,9,11,12,13,14, & 17) complained of problems with receiving care or assistance from staff due to lack of sufficient staffing. All 11 of these residents gave examples of prolonged waits for assistance or lack of assistance when they requested help from staff either verbally or by activating their call light. On 3/6/14, the Regional Consulting Nurse (RCN) stated the staffing in the building was based off of facility census and what the facility felt was appropriate. The facility failed to take into account the needs of the resident population to ensure their needs were met. .

Based on interview and record review, it was determined the governing body failed to ensure that the facility was operated in a manner to maintain compliance with regulations related to the facility ' s maintenance and meeting the care planned activity of daily living needs of 24 residents related to access to working bathing facilities. When the only shower room in the facility was not immediately repairable, the governing body failed to ensure that it supplied resources sufficient to meet the on-going care planned hygiene needs of 24 of 24 residents. This failure caused a decrease in the quality of life of residents and placed residents at potential risk for developing skin changes. Findings include: On 3/4/14, the facility's shower/bathing room used by all residents in the home was observed non-operational with construction work being done. The contractor working stated he had started the project 1/14/14. The repair was scheduled for one day. The contractor stated the facility shower would be done later that afternoon (3/4/14 at 3:00 P.m.), and operating; but not the tub. The Administrator (ADM) stated there was no facility plan for the residents hygiene needs during the extended construction time. The ADM stated were no issues with the non-operational bathing/shower room for 7 weeks because the residents did not have any concerns regarding the non-operational bathing room because they were clean, and the DNS stated there were no skin issues. There was no plan in place to provide alternate equipment to provide residents with showers, bathing and shampooing once it was clear to administration the repair work was extensive and would not be completed within a week. On 3/4/14, the Facility Maintenance Director (FMD) stated he started employment at the facility on 2/10/14. He stated he brought to the ADM's attention shortly after his arrival at the facility, he could rent a portable shower for the residents but that had not occurred. On 3/5/14, the Social Services Director (SSD) and Minimum Data Set Coordinator (MDS) stated the lengthy unfinished construction of the only facility shower/bathing room was discussed nearly every day in a stand up meeting with department managers. The SSD stated there were grievances filed by residents in regards to the nonfunctioning shower room and/or not receiving bed baths. The facility resident concern/grievance log was reviewed. A resident concern dated 1/16/14 filed by a resident and family member documented the resident wanted a shower, but it was not working. On 1/20/14 the SSD spoke with the ADM and documented a contractor was fixing it, but was "unsure how long it would take to fix." The ADM signed the concern on 1/31/14 but had documented no findings or action recommendations to resolve the concern. On 2/17 and 2/19/14, Resident #3 voiced "frustration" that the shower was still not fixed. The follow up to Resident #3's concern was documented on 2/21/14, recommending the Nursing Assistant (NA) offer a bed bath or bath until the work was completed. The facility action to the concern was documented as discussed in the daily stand up meeting on 2/24/14, and the construction work continued expected to be completed 3/3/14. The ADM signed the concern form on 3/3/14. On 2/28/14, Resident #3 voiced a concern stating she was told 2 days prior she would be given a bed bath, but had never received one. Resident #3 asked for a bed bath again on 2/27/14, and was told by staff she would receive on in the evening, but never did receive one. On 3/3/14, the ADM signed the concern report that day he was aware of the concern. The proposed plan by management was to "just wait until construction was completed." The SSD stated she did not believe the ADM or management team had discussed with the residents the construction of the bathing room. The SSD and MDS staff stated nursing staff were to give residents bed baths, and the issue of residents not having their hair washed for greater than a month was addressed more than a month after construction of the shower remodel had started, when the facility obtained a portable hair washing basin system was implemented. There was no noted proactive response to implement solutions during the repair to ensure residents received showers, baths and shampooing according to each resident plan of care. On 3/6/14, the Resident Council President (RCP) stated the facility had not had a meeting with the residents to inform them of the repair of the bathing room, apprised them of the progress, or sought resident input regarding concerns. During the timeframe from January 2013 to March 6th 2013 the facility had two changes in the Administrative team. The Administrative team present at the time of the investigation was not fully informed of the current facility situation. On 3/18/14, the Corporate Representative (CR) was contacted. She stated the facility, Regional Consultant Nurse (RCN) and Regional Director of Operations (RDO) had notified her several weeks into the project approximately at the end January or beginning of February, that the shower room repair was more extensive, stopped the project and sought approval to continue, which was given. The CR stated the plan by the facility staff, RCN and RDO was to use the tub bath or offer bed baths until the project was completed, but the issue of hair washing was not brought to her attention. Refer to F-490 .

Based on interview and record review, it was determined the facility failed to ensure proper treatment and care for 1 of 1 residents (#1) reviewed for respiratory care. The facility failed to seek and provide physician directed care for suctioning and provision of clean equipment for Resident #1 who was suctioning himself. This failure created potential harm to Resident #1 who improperly used non-sterile suctioning equipment for secretions at his [MEDICAL CONDITION] site in the presence of on-going bleeding at his laryngeal/ trachea stoma. Findings include: Resident #1's most recent admission 2/26/14 from hospitalization for pneumonia with hemoptysis (expectoration of blood from the lungs or trachea), cancer, laryngectomy (removal of the voice box) and a trachea stoma (a hole in the neck that allows breathing). Resident #1 was cognitively intact with no memory problems. Resident #1's trachea stoma site which the resident had for four years, was observed with dried blood and some fresh blood, with no Lary tube (a soft curved tube designed to maintain the breathing airway after a laryngectomy). He took a soiled washcloth with dried amber and dark red colored material from his lap and wiped his trachea stoma site. The medical record was reviewed. The 2/16/14 hospital admission note documented the resident reported multiple symptoms including blood tinged sputum from his tracheal stoma in his neck that persisted for months, and was observed with dried blood at the tracheal stoma site which was abnormal. The resident was diagnosed with [REDACTED].) The hospital discharge orders documented, "[MEDICAL CONDITION] management per protocol; Lary tube placed 2/15/14, is reusable, needs to be cleaned daily, and as needed with sterile water." The nurses note dated 2/26/14, documented Resident #1 had returned from the hospital, with "new Lary tube placed. To be cleaned with sterile water twice daily." On 3/4/14, Resident #1 was observed sitting upright in his bed with a breathing treatment machine and 3 [MEDICATION NAME] of medication to his right on a bedside table. The breathing treatment machine was operating and delivering medication via a mist to the trachea stoma site. On his bedside stand to his left was a clear graduated cylinder with a clear fluid in it, and suction machine connected to a hose with a [MEDICATION NAME] suction catheter tip (a firm plastic tip with a large opening surrounded by a bulb head designed to allow effective oral suctioning without damage to tissue) lying uncovered next to some toiletries. He stated he suctioned himself. He stated the nurses did not like to do it, and with one nurse for all residents in the facility, they did not come in a timely manner so he preferred to do it. "When I can't breathe from a (mucus) plug, I need to be suctioned immediately, I can't wait." Resident #1 stated sometimes the Licensed Nurse (LN) was present during suctioning. He stated he placed the [MEDICATION NAME] catheter tip, sometimes forcing it, down his trachea stoma site as far as he could get it go, to try to get mucus cleared from his airway. Resident #1 stated the [MEDICATION NAME] catheter was the only one provided to him from the staff, but he was never given a sterile catheter. He was aware it was not the correct catheter but, "That's not my biggest worry, I'm only supposed to live a couple of more months, and when I can't breathe that's my biggest worry, not getting air. I know I'm going to die, but until that day, I want to be able to breathe." Resident #1 stated after he returned recently to the facility from staying in the hospital 10 days for pneumonia, and he currently was too tired to empty the collected material in the canister of the suction vacuum. He stated the nursing assistants (NAs) bring him the distilled water, but the NAs are scared of the machine and set up although currently he needed more distilled water "badly." There were no physician orders for suctioning for Resident #1. The Treatment Administration Record (TAR) contained orders dated 2/26/14, documented as "Special instruction, daily as needed, Larytube cleansed daily as needed with sterile water, omitting the discharge order "clean daily" from the hospital and no orders for suctioning. The TAR revealed Resident #1's Lary tube or trachea stoma site had not been cleaned. On 3/5/14, Resident #1 was observed in his bed with the same suction machine as the day prior with collected material in the canister, [MEDICATION NAME] catheter tip and the clear graduated cylinder with the same amount of clear fluid. Resident #1 was observed with dried blood at his trachea stoma site, a washcloth with dried colored material as the day previous. Resident #1 stated the [MEDICATION NAME] was the same one from the previous days. At approximately 2:45 pm, Resident #1 was observed sitting in a chair in the hallway after ambulating with a Physical Therapist (PT). He began to cough expelling air through his trachea stoma, and covered the site with a washcloth. When he finished coughing he appeared fatigued and placed the washcloth on his leg. Observed on the washcloth was a very large amount of sticky amber colored material with an approximate 1 inch diameter blood clot. LN B stated she was aware Resident #1 had suctioning equipment in his room, stating she had assisted Resident #1 when he suctioned himself by putting her finger over the notch on the [MEDICATION NAME] to provide more suction. She stated she had never suctioned Resident #1, but was aware of Resident #1 suctioning himself for "at least 6 months." LN B reviewed Resident #'s1 chart and stated there were no physician orders to suction Resident #1. LN C stated Resident #1 suctioned himself and would place the [MEDICATION NAME] as far as he could down his trachea stoma site. The Director of Nursing (DNS) stated she was not aware that Resident #1 was suctioning himself, with improper equipment or non-sterile equipment. On 3/6/14, the DNS stated the facility defers to the Lippencott Nursing Manual as guidance to care for residents for standards of nursing practice, but there was no facility policy to direct staff how to care for residents with special respiratory needs. On 3/7/14 at 12:10 pm, the physician (MD) managing Resident #1's care was interviewed. The MD stated she was not consulted or notified Resident #1 was suctioning himself, suctioning improperly, bleeding at the site of his trachea stoma, coughing up mucus with blood, or that staff were not administering breathing treatments or adequately monitoring the resident. The MD stated the information was the first time she had heard the resident was suctioning himself with a [MEDICATION NAME] and it was concerning becuase there was no order for the resident to be suctioned. .