Every finding on record at Regency Omak

Based on interview and record review, the facility failed to provide access to medical records within the timeframe required for 1 of 3 residents (Resident 1), reviewed for access to medical records. This failure placed residents and/or their representatives at risk of not being fully informed of services and treatments provided and violated their rights.Findings included . Review of a complaint alleging financial exploitation, dated 07/31/2026, showed Resident 1 had passed away on 02/03/2026. On 06/06/2026, their Next of Kin (NOK), requested their full medical record from the facility. Further review showed the medical records had not been received by Resident 1's NOK and they had not received any further communication from the facility.Record review for Resident 1 on 08/11/2026, showed their NOK was the person who had requested the full medical record from the facility on 06/06/2026.In an interview on 08/11/2026 at 2:40 PM, Staff B, Health Information Director, stated they had received a record request for medical records for Resident 1 on 06/06/2026 (Saturday). Staff B stated on 06/08/2026 (Monday) they had sent the completed medical request form to the facility's legal team to make sure it was alright to release the records to Resident 1's NOK. On 06/09/2026, Staff B received two additional forms from the facility's legal team for the NOK to fill out prior to Resident 1's medical records being released. Staff B stated that they had not had any further communication with Resident 1's NOK and had not forwarded the forms that needed be filled out prior to release of the medical record to resident 1's NOK. In an interview with Staff A, Administrator, on 08/11/2026 at 2:50 PM, they reviewed the emails from 06/06/2026, 06/08/2026 and 06/09/2026. They stated after the 06/08/2026 email they had not been added to the 06/09/2026 email that had been sent to Staff B from the facility's legal team with direction to forward the two forms to Resident 1's NOK to be filled out prior to the resident's medical record being released. Staff A stated the facility rarely received public record requests and they were unfamiliar with the time frame to fulfill these requests. Staff A reviewed the required time frame for requiring access to Resident 1's record, within 24 business hours of a written request, and stated the request had not been completed timely by the facility. Reference: (WAC)388-97-0300(2)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure hand hygiene was performed when indicated during the lunch meal service. The facility further failed to ensure the microwave and ice machine were clean and dishwasher temperatures were maintained at the appropriate temperatures. These failures placed residents at risk for food-borne illnesses and food served from unsanitary conditions.Findings included .<Sanitary Practices>During an observation of tray line on 01/23/2026 at 11:47 AM and 11:52 AM, Staff E, Cook, was plating food with gloved hands. Staff E opened the refrigerator door with the same gloved hands and then placed salad on a plate and touched it with their gloved hands to keep it on the plate. No hand hygiene was performed after Staff E opened the refrigerator door with their gloved hands before handling the food. In an observation on 01/23/2026 at 12:14 PM, Staff E opened the refrigerator with gloved hands, touched meal tickets, then plated a grilled cheese sandwich, picked it up with their same gloved hands and cut it up. At 12:15 PM, Staff E wore the same gloves and picked up a chimichanga and cut it up. <Cleanliness>In an observation on 01/21/2026 at 7:55 AM, the ice machine vent was covered in thick dust debris, and the microwave had splattered food that covered the inside. In an observation on 01/23/2026 at 1:22 PM with Staff F, Dietary Manager, the microwave remained with splattered food that covered the inside and the ice machine continued to have thick dust debris over the vent. Staff F stated staff were not wiping the microwave like they should have been and it was important to keep it clean to prevent germs. Staff D added it was important to keep the ice machine clean because the dust could get into the machine and possibly cause illness. <Dishwasher temperatures>During a second observation of the kitchen on 01/23/2026 at 12:42 PM, Staff F stated the dishwasher was a low temperature dishwasher. A wash cycle was ran and the temperature reached 104 degrees, not 120 degrees as required. Staff F stated they were unsure what the wash temperature needed to be. Staff F stated it was important to wash the dishes at the appropriate temperature to kill bacteria. Staff F ran another wash cycle, and the temperature reached 106 degrees. On 01/23/2026 at 1:35 PM, Staff G, Maintenance Director, brought their dishwasher temperature log to the kitchen. Staff G stated they used a thermometer to monitor the temperature of the dishwasher. At 1:43 PM, Staff G checked the temperature of the water after the wash cycle was completed and got a temperature of 100 degrees. Staff H, dietary aide, had already washed and put away many loads of dishes. At 1:45 PM, Staff G ran another wash cycle, and the temperature was 100 degrees. In an interview on 01/23/2025 at 1:47 PM, Staff H stated they were unsure what the dishwasher temperature needed to be. On 01/23/2026 at 1:48 PM, Staff G shut down the dishwasher and restarted it. Staff G ran another wash cycle, and it was 110 degrees. Staff G then immediately took steps to repair the dishwasher to bring the temperatures to the required levels. Reference: WAC 388-97-1100(3), 2980

Based on observation, interview, and record review, the facility failed to monitor a resident's neurological status (an evaluation completed on a person's alertness, muscle strength, coordination, ability to feel and reflexes) after multiple unwitnessed falls occurred for 1 of 1 sampled residents (Resident 34) reviewed for falls. This failure placed the residents at risk for falls.Findings included .Review of the facility policy titled, Incident Documentation and Investigation revised October 2022 documented neurological checks were to be performed after non witnessed falls occurred. The 09/24/2025 admission assessment documented Resident 34 had diagnoses including Parkinson's disease (a progressive disorder of the central nervous system that impacted movement), a fractured back, and difficulty walking. The assessment further showed Resident 34 had severe cognitive impairment and required partial to moderate staff assistance for transfers. Resident 34 sustained two or more falls since their admission. The 09/22/2025 fall care plan, revised on multiple dates, showed Resident 34 was at risk for falls related to chronic pain, weakness/fatigue, impaired balance resulting in previous falls, impaired decision making, impaired activity tolerance, impaired cognition, chronic dizziness, decreased safety awareness and impulsivity.Review of the facility September 2025 through January 2026 incident report tracking log showed Resident 34 sustained falls on the following dates: 09/19/2025, 09/23/2025, 10/05/2025, 10/07/2025, 10/10/2025, 10/14/2025, 10/23/2025, 10/27/2025, 11/04/2025, 11/17/2025, 12/10/2025, 12/16/2025, 12/18/2025, and on 01/20/2026, for a total of 15 falls during that time period. Review of the facility fall incident investigation reports showed Resident 34 had unwitnessed falls on the following dates and neurological monitoring was not completed:- 09/23/2025 Resident 34 was found on the floor in front of the bathroom door and sustained a skin tear to their elbow and right hip pain. - 10/07/2025 Resident 34 was found in their room on the floor, kneeling beside the bed. - 10/14/2025 Resident 34 was found on the floor near the activities room. - 10/21/2025 Resident 34 was found on the floor in their room. - 10/23/2025 Resident 34 was found on the floor in their bathroom. - 11/17/2025 Resident 34 was found on the floor in their room. - 12/10/2025 Resident 34 was found on the floor in their bathroom. - 12/16/2024 Resident 34 was found on the floor in their room. - 01/20/2026 Resident 34 was found on the floor in the fireside room. In an interview on 01/24/2026 at 11:48 AM, Staff D, Registered Nurse, stated after a fall occurred, they assessed the resident for injury and obtained their vital signs (blood pressure, pulse, respirations and temperature). Staff D stated for unwitnessed falls, they performed neurological checks and documented them on the neurological form. Staff D stated if staff were not present when a resident fell, the nurse on duty assessed the resident to determine if they had hit their head. If a resident hit their head, the nurse initiated neurological checks via the neurological form. If a form had not been initiated, then the resident was assessed only for latent injuries. In an interview on 01/24/2026 at 12:20 PM, Staff B, Director of Nursing, stated neurological checks were performed for unwitnessed falls and documented on a form and scanned into the resident's medical record. Staff B stated neurological assessments should have been completed for Resident 34's unwitnessed falls and this was important because if the resident hit their head, they may have a bleed and need to be hospitalized . Staff B added if the neurological assessment form was not completed, there needed to be a neurological assessment in the progress notes. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to implement care planned interventions related to monitoring during a viral infection for 2 of 3 residents (1 and 2) whose care plans were reviewed. This failure put the residents at risk for worsening of their condition and unmet care needs. Findings included . <Resident 1> Review of Resident 1's medical record showed they tested positive for influenza on 02/19/2025. Review of the resident's care plan showed that on 02/19/2025 a new focus was added for risk of infection due to Influenza. New interventions for the focus included: assess lung sounds, assess sputum or other respiratory discharge, check vital signs and monitor for abnormalities. Review of Resident 1's February 2025 medication administration record (MAR) showed they were administered an antiviral medication from 02/20/2025 through 02/24/2025, for a total of ten doses. Further review of the same MAR did not show orders, or a place to record, the resident's lung sounds, sputum or other respiratory discharge, or when or how often to monitor the resident's vital signs. Review of the vital sign section of Resident 1's chart showed sporadic vital signs recorded. The Resident's oxygen level, pulse, respiration per minute and blood pressure were all recorded on 02/21/2025. The Resident's temperature was recorded on 02/19/2025 at 1:19 AM, again at 5:03 AM and again at 10:42 PM. The next temperature was recorded on 02/21/2025 at 1:31 PM. Review of the progress note section of Resident 1's chart did not show nurse notes with any further vital signs, assessment of lung sounds or sputum from 02/19/2025 through 02/24/2025. <Resident 2> Review of Resident 2's medical record showed they tested positive for influenza on 02/19/2025. Review of the resident's care plan showed that on 02/19/2025 a new focus was added for risk of infection due to Influenza. New interventions for the focus included: assess lung sounds, assess sputum or other respiratory discharge, check vital signs and monitor for abnormalities. Review of Resident 2's February 2025 medication administration record (MAR) showed they were administered an antiviral medication from 02/20/2025 through 02/24/2025, for a total of ten doses. Further review of the same MAR did not show orders, or a place to record, the resident's lung sounds, sputum or other respiratory discharge, or when or how often to monitor the resident's vital signs. Review of the vital sign section of Resident 1's chart showed sporadic vital signs recorded. The Resident's oxygen level, pulse, respiration per minute, blood pressure and temperature were all recorded on 02/20/2025, 02/21/2025 and 02/22/2025. The Resident's temperature was recorded on 02/24/2025. Review of the progress note section of Resident 1's chart did not show nurse notes with any further vital signs, assessment of lung sounds or sputum from 02/19/2025 through 02/24/2025. During an interview on 03/03/2025 at 2:55 PM, Staff C, Nursing Assistant, stated that the nursing assistants collect the resident vital signs during their shift. They stated that the nurse on each shift filled out a form with a list of names, times, and what vital signs needed to be collected, they then attach the form to a clipboard and leave it in a specified area. Staff C further stated that when the vital signs were recorded the Nursing Assistant would leave the clipboard with the nurse and the nurse would then enter the information into each resident record. During an interview on 03/03/2025 at 3:08 PM Staff B, Resident Care Manager, stated that each resident who had a viral infection should have orders on their MAR for vital signs to include which vital signs and how often to collect them. They stated there should also be a place to record the nurse assessment of the resident's lung sounds and sputum, quality and quantity, or if there was none present. They stated that for residents who took an antiviral, the nursing staff would monitor for the length of time the resident took the antiviral and longer if needed. They further stated that they were not aware of a standard process in the facility for how long to monitor the resident and where/when to put the orders for vital sign monitoring or lung assessment. During an interview on 03/03/2025 at 3:32 PM, Staff A, Administrator, stated that they had confirmed with Staff B, that the nurse would fill out a vital sign sheet with who needed vitals and when, and the nurse would get that information from the resident's medical record. They further confirmed that the facility did not keep the paper sheets where the vital signs were recorded and that there was not another location the staff recorded vital signs or the assessment of lung sounds. Reference WAC 388-97-1020(1), (2)(a)(b)

Based on interview and record review, the facility failed to identify what information was conveyed to the hospital at the time of transfer for 1 of 2 sampled residents (Resident 34) reviewed for hospitalization s. This failure placed the resident at risk for a disruptive and ineffective transition from the facility to the hospital setting. Findings included . <Resident 34> Review of 03/17/2024 progress notes showed Resident 34 experienced a change in condition and the staff called the on-call provider who recommended Resident 34 go to the emergency room for an evaluation. Review of Resident 34's medical record showed no documentation the facility communicated to the hospital the minimum required information at the time of the Resident 34's transfer on 03/17/2024, including: The basis for the transfer, the specific resident need(s) that could not be met, facility attempts to meet the resident needs, or the information provided to the receiving facility to include contact information of the practitioner responsible for the care of the resident, resident representative information including contact information, Advance Directive information, all special instructions or precautions for ongoing care as appropriate, comprehensive care plan goals, and all other necessary information, including a copy of the resident's discharge summary, and any other documentation, as applicable, to ensure a safe and effective transition of care. Review of 05/20/2024 and 07/06/2024 progress notes showed Resident 34 experienced a change in condition and the staff transferred the resident to the hospital for emergency care or evaluation. Review of Resident 34's medical record showed no documentation the facility communicated to the hospital the minimum required information at the time of the Resident 34's transfers on 05/20/2024 or 07/06/2024. In an interview with Staff B, Director of Nursing, and Staff E, Corporate Nurse, on 10/10/24 at 11:53 AM. Staff B stated that when a resident is transferred to the hospital, the nurses send with the resident a little discharge packet found at the Nurses Station. Staff B stated the packet has a checklist of what information the staff must send with the resident to the hospital when a change in condition occurs. Staff B stated the nurses also complete a Transfer to Hospital evaluation in resident's electronic medical record which is then forwarded to the receiving hospital. The Transfer to Hospital evaluation shows the resident's vital signs, allergies, reason for transfer, type of assistance or other care information required. The Transfer to Hospital Evaluation provided the staff the opportunity to show if other additional information, like a resident's face sheet, medication list, and a copy of the POLST [Physician Order for Life Sustaining Treatment], was sent. Staff B and E confirmed and acknowledged that the medical record failed to show the minimum required information the staff conveyed to the hospital at the time of Resident 34's transfers. Staff B stated, I don't see what information was sent to the hospital. Reference WAC 388-97-0120.

Based on interview and record review, the facility failed to ensure it completed a notice of bed hold for 1 of 2 (Resident 34) sampled residents reviewed for hospitalization . This failure placed the resident and/or their representative at risk for a lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . <Resident 34> Review of the progress notes showed that on 03/17/2024, 05/20/2024, and 07/06/2024, Resident 34 experienced a change in condition and the staff transferred the resident to the local hospital for emergency care. Record review showed no documentation the facility offered Resident 34 and/or their representative a notice of bed hold at the time of or shortly after the hospital transfers for 03/17/2024 and 05/20/2024. In an interview with Staff B, Director of Nursing, and Staff E, Corporate Nurse, on 10/10/24 at 11:53 AM. Staff E confirmed via record review that the facility did not but should have offered the notice of bed hold to Resident 34 and/or their representative at the time of the hospital transfer and stated, I didn't see it. Reference WAC 388-97-0120 (4).

Based on interview and record review, the facility failed to ensure vaccine consents, medication reviews, and advance directives records were complete and accurate for 3 of the 19 sampled residents (2, 14, 20 and 26) whose records were reviewed. Failure to ensure clinical records were complete and accurate, placed residents at risk of not having their needs met. Findings included . <Resident 2> 1. The 08/06/2024 quarterly assessment documented Resident 2 was able to make their needs known and able to make decisions regarding their care. Review of Resident 2's record showed an updated POLST form, a document that details a resident's wishes for end-of life treatment and resuscitation in the event their heart stops, had been completed on 08/15/2024, was which indicated the resident did not want to be resuscitated, and wished to have comfort measures only. The form included the signature of the resident, but did not have the signature of the medical provider. In an interview on 10/10/2024 at 11:47 AM, with Staff A, Administrator and Staff B, Regional [NAME] President, Staff B stated the POLST form should be signed by the provider as soon as possible. When informed Resident 2's updated POLST was unsigned by the provider, Staff B stated they would check with Medical Records to see if they had one that had not yet been scanned into the resident's record. In a follow-up interview at 10/10/2024 at 11:55 AM, Staff A confirmed that Resident 2's POLST had not been signed, and the provider was contacted to come in and sign the form. 40297 <Resident 14> 1. Review of a 07/21/2024 annual assessment showed Resident 14 admitted to the facility on [DATE] with complex medical conditions. The assessment showed Resident 14 used an antidepressant. Review of 01/17/2024 progress notes showed the provider started Resident 14 on Trazadone [an antidepressant] at bedtime for sleep. Review of a 02/01/2024 progress note showed the staff spoke to the provider, who discontinued the Trazadone and prescribed sertraline (an antidepressant) for depression. Review of 04/18/2024, 07/11/2024, and 10/04/2024 Psychotropic [a drug that affects a person's mental state] Medication Reviews completed by Staff D, Social Services Director, showed Resident 14 received sertraline for insomnia. The Summary and Recommendations section showed the resident received Trazadone for depression and sleepless legs, even though the Trazadone was discontinued on 02/01/2024. The above information was shared with Staff D on 10/10/24 at 10:45 AM. Staff D stated that the medication review should read sertraline and not trazadone and acknowledged, It's not an accurate review. <Resident 26> The 07/23/2024 annual assessment documented Resident 26 had diagnoses which included anxiety, depression, and obsessive-compulsive disorder, a mental disorder that caused recurrent, unwanted thoughts and repetitive behaviors that could not be controlled. The assessment further showed Resident 26 received psychotropic medication. Review of the Order Summary Report from 07/01/2023 through 10/10/2024 showed Resident 2 admitted to the facility on [DATE] with the psychotropic medications, Fluoxetine, Bupropion, and Clonazepam on admission, prescribed to treat the symptoms of depression and anxiety. Additional review showed the Bupropion was discontinued on 09/14/2024. Review of the Psychotropic Medication Reviews, an assessment tool used to monitor dosages, efficacy, side effects and to determine if the psychotropic medication was appropriate for use, documented the following: - On 07/26/2023, the only medication listed was Bupropion, but the resident was also prescribed Fluoxetine and Clonazepam. - On 10/19/2023, the form listed Fluoxetine, Clonazepam, and Bupropion, but the Bupropion had been discontinued on 09/14/2023, almost a month prior to the review. - On 01/12/2024, the only medication listed was Clonazepam, however the resident was still receiving Fluoxetine. In an interview on 10/10/2024 at 12:03 PM with Staff A, Administrator, and Staff B, Regional [NAME] President, the inaccuracy and incompleteness of the Psychotropic Medication Reviews was discussed. Staff B confirmed the reviews should be accurate, and include the correct medication, dosages, and indications for the medications use. Both Staff A and Staff B acknowledged that resident's records needed to be accurate to reflect the resident's status and care needs. <Resident 20> Review of Resident 20's medical record showed an undated COVID-19 Declination Form. This form showed eight statements that either staff or residents were asked to read and check each box as a form of acknowledgment. The form specifically asked the facility to identify whether it was a resident or staff completing the consent, to include their full name, date of birth, and gender. Review of the COVID-19 Declination Form showed no indication whether the name of the individual whose printed name was on the form was a staff or resident, their date of birth, and gender. The form showed none of the eight statements were checked as instructed, which would demonstrate the individual completing the form acknowledged the information in the consent to include, Despite these facts I am choosing to decline the COVID-19 vaccine. The end of the form showed Resident 20's printed name and underneath it a set of initials where the form asked for Signature of the Staff, Resident or Representative. The above findings were shared with Staff G, Infection Preventionist, on 10/10/2024 at 11:23 AM. Staff G stated that the vaccine consent was not complete. Reference WAC 388-97-1720 (2)(a-m).

Based on observation, interview, and record review, the facility failed to destroy a deceased resident's controlled medication timely, in accordance with currently accepted professional standards, in 1 of 1 medication storage rooms. Additionally, the facility failed to ensure that controlled medications were stored in a permanently affixed, locked storage compartment in the medication refrigerator. These failures placed the facility at risk for potential diversion or misappropriation of controlled medications. Findings included . On [DATE] at 3:12 PM, the medication room refrigerator was inspected with Staff F, Registered Nurse/Resident Care Manager (RN/RCM). The refrigerator contained a small, metal box with a padlock. Staff F opened the padlock with the key, and it contained 4 bottles of liquid Lorazepam (a sedative/controlled medication.) One of the bottles was labeled for Resident 1. The metal box was not secured to the refrigerator and could be removed. During a concurrent interview, Staff F stated that Resident 1 had passed away a few weeks ago. They further stated that their Lorazepam should have been destroyed at that time. Staff F stated the medications were secure since they were in a locked box in a locked room. When asked about a permanently affixed box, they stated they did remember that term from the previous survey. Staff F further reported the facility did trial of a few of those boxes, but they were not big enough, so it went by the wayside. Staff F acknowledged the failed practice was a repeat deficiency from the previous year. According to their medical record, the Resident 1 expired on [DATE], 20 days earlier. On [DATE] at 5:05 PM, Staff A, Administrator was informed of the observations in the medication room and acknowledged failed practice related to not destroying controlled medications for a resident who had expired, and not securing controlled medications in a permanently affixed container in the medication refrigerator. Reference: WAC [DATE] (2)

Based on interview and record review, the facility failed to ensure an adequate indication for the use of an antidepressant for 1 of 5 sampled residents (Resident 14) reviewed for unnecessary medications. This failure placed the resident at risk to receive unnecessary medications and/or experience adverse side effects. Findings included . <Resident 14> Review of a 07/21/2024 annual assessment showed Resident 14 admitted to the facility on [DATE]. This assessment showed the staff assessed the resident to have severely impaired cognition, no signs or symptoms of depression, no hallucinations or delusions and that the resident wandered. The assessment showed Resident 14 used an antidepressant, the staff noted an indication for the use of the antidepressant, and the staff did not identify any psychiatric/mood disorder. Review of Resident 14's medical diagnosis list included the diagnoses of dementia without any behavioral, psychotic, or mood disturbances or anxiety, multiple sclerosis [a progressive neurological disorder], and insomnia. Review of a 01/15/2024 Pre-admission Screening and Resident Review [PASRR, an assessment that prevents people with mental disabilities from being inappropriately admitted to nursing facilities] showed Resident 14 was assessed to have no serious mental illness indicators, to include Mood Disorders - Depressive or Bipolar. This screening showed Resident 14 had a diagnosis of dementia but that a neurological disorder was the primary diagnosis. Review of 01/15/2024 progress notes showed Resident 14's representative reported to the staff that the resident historically gets up in the night a lot and has been cognitively and functionally declining at home for a while. Review of progress notes of 01/17/2024 showed the resident continued to be awake most of night and the provider started Resident 14 on Trazadone [an antidepressant] at bedtime for sleep. Record review showed that the dose of Trazadone was doubled on 01/31/2024 and that Resident 14, only slept four hours intermittently that night shift. Review of a 02/01/2024 progress note showed the staff spoke to the provider, who discontinued the Trazadone and prescribed sertraline (an antidepressant) for depression. Review of 02/13/2024 provider notes showed they assessed Resident 14 with worsening cognitive and physical function due to multiple sclerosis and dementia. The provider described the resident experienced agitation and had been up frequently during the night, agitated regarding location, spouse not being present, and confused about details to person, place, and location. Review of 06/21/2024, 08/23/2024, and 09/13/2024 provider notes showed the provider added the diagnosis of Alzheimer's dementia with behavioral disturbance. The provider notes showed no indication for the use of the antidepressant sertraline. Review of 04/18/2024, 07/11/2024 and 10/04/2024 Psychotropic Medication Reviews completed by Staff D, Social Services Director, showed Resident 14 received sertraline for insomnia, and the target behaviors included depression, sadness, behaviors. The Summary and Recommendations section showed the resident received Trazadone [another antidepressant] for depression and sleepless legs, even though Trazadone was discontinued on 02/01/2024. The summaries showed Resident 14 did not struggle with depression. Additional record review showed the staff monitored Resident 14's behaviors for anxiety as evidenced by Agitation/Wandering and the hours of sleep. Review of April, July and October 2024 Medication Administration Records (MAR) showed the staff administered sertraline to Resident 14 for, UNSPECIFIED DEMENTIA, MILD, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY, contrary to the 04/18/2024, 07/11/2024, and 10/04/2024 Psychotropic Medication Reviews that showed the indication for the sertraline was insomnia. In an interview on 10/10/24 at 10:45 AM, Staff D stated that the sertraline was started to address sleep deprivation and anxiety. Staff D acknowledged the diagnosis in the MAR contradicted the indication for the use of sertraline in the Psychotropic Medication Reviews. Staff D directed the surveyor to ask the Resident Care Manager when they were asked if the diagnosis of dementia without behavioral disturbances was an appropriate indication for the use of an antidepressant. In an interview with Staff B, Director of Nursing, and Staff E, Corporate Nurse, on 10/10/24 at 12:36 PM. Staff B stated the current diagnosis, is not the right diagnosis for the sertraline and that the Resident 14 does have behavioral disturbances. We need to change it [the diagnosis]. Reference WAC 388-97-1060 (3)(k)(i).

Based on interview and record review, the facility failed to ensure 1 of 5 sampled residents (Resident 26), reviewed for Pre-Admission Screening and Resident Review (PASARR) [an assessment completed prior to admission into a skilled nursing facility to determine whether a resident with a diagnosis of a serious mental illness needed specialized mental health services] was completed accurately and if indicated, a referral for additional screening had been made. Findings included . <Resident 26> The 07/23/2024 annual assessment documented Resident 26 had diagnoses which included anxiety, depression, and obsessive-compulsive disorder, a mental disorder that caused recurrent, unwanted thoughts and repetitive uncontrollable behaviors. Review of Resident 26's record showed a PASARR level 1 was initiated on 07/06/2024, but the form was incompletely filled out, with Section IV of the form being blank. Additional record review found no other documentation that showed a fully completed PASARR had been done. In an interview on 10/10/2024 at 10:10 AM, Staff D, Social Service Director, stated a PASARR needed to be completed prior to admission, and after review of Resident 26's record, confirmed the PASARR had not been fully completed. Reference (WAC): 388-97-1915 (1)(2)(a-c)

Based on interview and record review, the facility failed to ensure 3 of 5 sampled residents (Resident 2, 26, and 14), reviewed for unnecessary medications, were informed of the potential risks associated with the use of psychotropic medications (medications that can affect the mind, emotions, and behaviors). This failure placed the residents and/or their representative at risk of not being fully informed of the potential risks and benefits of taking the medications. Findings included <Resident 2> The 08/06/2024 quarterly assessment documented Resident 2 had diagnoses which included anxiety and depression. In addition, the assessment documented the resident received psychotropic medication. Review of the Order Summary Report from 01/01/2024 through 10/09/2024 documented on 05/10/2024, the physician had prescribed a psychotropic medication, Fluoxetine, to treat Resident 2's depression. Review of the Medication Administration Records (MARS) from May 2024 through September 2024 showed the resident had received Fluoxetine daily as prescribed. Review of Resident 2's record found no documentation and/or an informed consent form had been completed that explained the risks and benefits of taking a psychotropic medication were discussed, either verbally or written, with the resident and/or their representative prior to the resident receiving the medication. <Resident 26> The 07/23/2024 annual assessment documented Resident 26 had diagnoses which included anxiety, depression, and obsessive-compulsive disorder, a mental disorder that caused recurrent, unwanted thoughts and repetitive behaviors that can not be controlled. The assessment further showed Resident 26 received psychotropic medication. Review of the Order Summary Report from 07/01/2023 through 10/10/2024 documented on 05/24/2024, the physician prescribed a psychotropic medication, Olanzapine, to help treat the symptoms of Resident 26's anxiety and depression. Review of the May through September 2024 Medication Administration Records (MARS) showed Resident 26 received the Olanzapine daily as prescribed. Review of Resident 26's found an informed that included the risk and benefits of taking Olanzapine had been completed on 05/29/2024, four days after the resident received the first dose of the medication. In an interview on 10/10/2024 at 11:40 AM with Staff A, Administrator and Staff B, Regional [NAME] President, Staff B stated it was the expectation that informed consents were obtained before the first dose was given to the resident. When informed no informed consent was found for Fluoxetine for Resident 2, and the informed consent for Resident 26's Olanzapine had been obtained four days after the medication had been given, Staff B stated they would follow up with Medical Records to see if the informed consents had been obtained. In a follow up interview at 1:23 PM, Staff B confirmed no informed consent had been obtained for the Fluoxetine, and the informed consent for the Olanzapine had not been obtained prior to the first dose being given. 40297 <Resident 14> Review of Resident 14's medical record showed the provider ordered sertraline, an antidepressant, on 02/01/2024, for depression. Review of Social Services assessments dated 04/18/2024, 07/11/2024, and 10/04/2024, showed Resident 14 received sertraline for insomnia. Review of Medication Administration Records from February to October 2024 showed the staff administered sertraline to Resident 14 daily. Record review showed no documentation the staff provided and obtained informed consent for the sertraline. In an interview on 10/09/2024 at 10:25 AM, Staff D, Social Services Director, stated that the Resident Care Managers were responsible for obtaining consents for psychotropic mediations prior to administration. Staff D acknowledged there was no consent for sertraline in Resident 14's medical record. Reference WAC 388-97--0300(3)(a), -0260, -1020(4)(a-b).

Based on interview and record review the facility failed to develop and implement a system to evaluate agency/contracted staff competencies in skills and techniques to ensure staff provided necessary care and respond to each resident's individualized needs for 1 of 4 sampled staff (Staff I), reviewed for nursing services. This failure resulted in ineffective communication with Resident 1 that made them feel uncomfortable, placed residents at risk of unmet care needs and diminished quality of life. Findings included . Review of the facility policy titled, Resident Rights dated 11/2016, showed residents had the right to receive care and treatment with respect and dignity that promotes maintenance or enhancement of their quality of life and individuality. Review of the facility policy titled, Abuse/Neglect/Misappropriation/Exploitation dated 10/2017, showed the facility would train employees at orientation, annually, and as needed on what constitutes abuse and neglect, how to report potential abuse, how to recognize signs of staff burn out that may lead to abuse, and how to deal with catastrophic resident reactions. The policy further showed the facility would supervise staff in order to identify inappropriate behaviors such as using derogatory language, rough handling, ignoring residents while providing care, or not attending to resident needs. Review of the facility policy titled, Code of Business Conduct and Compliance Guide dated 2013, showed staff including independent contractors conducting business with the facility, were expected to achieve the highest ethical standards of conduct. The policy showed all staff were to read, understand, and follow the policy daily by being sensitive to and respectful of concerns, values, and preferences of others, including employees, residents and their families. All employees were to undergo annual compliance training that contained any new, updated, revised information, policies, or procedures regarding resident care, billing, documentation, confidentiality, privacy, security, and other pertinent compliance related policies and procedures. The policy further showed the facility established social media policies and procedures for the reasonable use of social media including social networking forums, personal communication devices and other media used by employees in or outside of the facility to ensure rights of all residents, employees, family members, and vendors were protected. Every employee was expected to know what those policies were and to fully comply with them while working for the company. Review of the facility policy titled, Our Culture, Our Values, Our Standards of Performance dated 2017, showed the facility would seek to facilitate open and honest communication to create an environment of mutual respect and understanding. The facility would treat customers, family members, and coworkers with warmth, dignity, and respect by being considerate, responsive and kind during interactions. The policy expected each employee to commit to the facility standards of performance. Review of the quarterly assessment, dated 06/16/2024, showed Resident 1 admitted to the facility on [DATE] with diagnoses including anxiety (feeling of fear, dread, or uneasiness), depression (persistent low mood, loss of interest, and difficulty doing normal activities), and chronic pain. The assessment further showed Resident 1 was cognitively intact, had adequate hearing, understood others, and was able to verbalize their needs. Review of the 04/04/2024 care plan showed Resident 1 had a potential alteration in psychosocial well-being related to being a survivor of a traumatic event and a significant/traumatic health history. The care plan instructed staff to provide active listening, acknowledge non-verbal communication, inform Resident 1 prior to touching them or providing care. The care plan revised 04/30/2024 showed Resident 1 was at risk of experiencing behavioral symptoms related to anxiety, depression, adjustment to their current situation, verbal outbursts with care team members, confabulation, and care concerns. The care plan instructed staff to administer medications as ordered, approach resident in a clam manner, praise positive behaviors or improvements, provide cares in pairs when possible related to frequent care concerns, notify care manager or social services when behaviors occur, explain all procedures before starting and allow resident time to adjust. Review of the 07/07/2024 facility incident report investigation showed Resident 1 felt uncomfortable on 07/05/2024 after Staff I, Licensed Practical Nurse (LPN), made inappropriate comments about Resident 1's body and their body's physical response to the application of a cold pain patch. The 07/08/2024 incident summary note showed Staff I did not deny the alleged conversations with Resident 1 and stated they had always bantered back and forth with Resident 1 in that manner. The summary further showed Staff I's alleged statements were made as initially reported by Resident 1 and unprofessional conduct was substantiated. Review of Staff I's facility personnel file showed no documentation Staff I was evaluated for skills and/or competencies, received any training regarding facility policies and procedures or was given performance expectations. In an interview on 07/09/2024 at 11:34 AM, Resident 1 stated on 07/05/2024 Staff I, LPN, made a comment about Resident 1's body's response to the application of a cold pain patch that made Resident 1 feel uncomfortable. In an interview on 07/09/2024 at 2:27 PM, Staff C, LPN, stated Staff I was not 100% professional when at work and verbalizing unprofessional comments mostly directed towards staff. In an interview on 07/09/2024 at 2:29 PM, Staff D, Social Service Director, acknowledged Resident 1 reported Staff I made a comment, during an application of a patch, that made Resident 1 feel uncomfortable. In an interview on 07/09/2024 at 2:37 PM, Staff B, Director of Nursing (DNS), stated they recently became aware Resident 1 had been having personal communication with Staff I via text messaging (sending short electronic messages between mobile devices). Staff B further stated they informed Staff I of the allegation made by Resident 1 on 07/05/2024 and Staff I did not deny the allegation. In an interview on 08/06/2024 at 10:28 AM, Staff E, Nursing Assistant, stated the facility used agency nursing staff but was unsure how they were trained or how the facility ensured they had the required skills to provide resident care. Staff E stated facility staff received routine education, which included education on abuse and communication. Staff E further stated staff were expected to act professionally and maintain professional boundaries to include communicating with residents professionally and knowing how to appropriately redirect residents with inappropriate behaviors. Staff E acknowledged staff should not act or communicate with residents in a manner that could be perceived as unprofessional, a violation of their resident rights and/or potentially abusive. In an interview on 08/06/2024 at 10:37 AM, Staff F, Registered Nurse, stated nursing staff hired by the facility typically shadowed experienced facility staff and completed a three page check off sheet as part of the new hire process. Staff F further stated the facility used agency nurse staff but was unsure how the facility determined if agency nurses had the appropriate skills prior to being assigned a work assignment and providing direct resident care. Staff F acknowledged staff were expected to act and communicate with residents in a professional, kind, competent, and respectful manner; staff were not to act or communicate with residents in a manner that could be perceived as unprofessional, a violation of their resident rights and/or potentially abusive. In an interview on 08/06/2024 at 10:54 AM, Staff H, Staff Development, stated there were different staff trainings scheduled monthly, training was reviewed during the all-staff meetings with mandated attendance for facility staff and encouraged attendance for agency staff. Staff H acknowledged this was the first year the facility used agency nursing staff and the onboarding process was not well developed. Staff H further stated staff were expected to act and communicate with residents in a professional manner at all times while maintaining professional boundaries such as not exchanging phone numbers and staff should not act or communicate with residents in a manner that could be perceived as unprofessional, violations of a resident's rights, and/or potentially abusive. Staff H further added it was not professional for Staff I to exchange phone numbers with Resident 1. In a follow-up interview on 08/06/2024 at 11:52 AM, Staff B, DNS, stated new facility staff completed a new hire check off sheet during their orientation but was unaware if agency staff completed the same onboarding form. The facility provided staff education on communication styles and professionalism with a pre/posttest that every staff was required to completed. Staff B further stated they expected staff to act and communicate with residents in a professional manner at all times, staff should not have personal relationships with residents, should not share personal information, should not keep resident secrets from the facility, and/or should not befriend residents on social media. Staff B stated Staff I refused to give a statement related to Resident 1's allegation. Staff B acknowledged it was not appropriate for Staff I and Resident 1 to text. In an interview on 08/06/2024 at 12:10 PM, Staff A, Administrator, acknowledged the facility used agency nursing staff but they only received safety orientation that reviewed the facilities emergency preparedness plan, there was no other new hire orientation or skill evaluation completed for agency staff. Staff A stated staff were expected to act and communicate with residents kindly, considerately, respectfully, and professionally. Staff A further added staff were there to provide residents with care that enriched their lives without crossing professional boundaries such as befriending residents on social media or text messaging them; staff were professionals providing a service not resident friends and needed to be mindful of how they communicated with residents. Reference WAC 388-97-1080 (1), 1090 (1)

Based on interview and record review, the facility failed to honor a resident's right to refuse care for 1 of 3 residents (1) investigated for abuse. two staff members insisted that a resident have a shower, despite their initial refusal. This failure placed the resident at risk for feelings of disrespect and decreased self-worth. Findings included . According to an admission assessment, dated 03/04/2024, Resident 1 had diagnoses which included a fractured pelvis and arthritis. The assessment further showed that the resident was able to understand, be understood and required assistance with bathing. A progress note from the social worker, dated 05/30/2024 at 1:43 PM, documented that the resident said they were forced to take a shower on 05/27/2024 and the aides said they smelled like a dog. The nursing assistants identified were immediately suspended, left the facility and appropriate notifications were made. The facility conducted a thorough investigation. A review of Resident 1's Bathing/Shower task in their medical record documented they did have a shower on 05/27/2024. The facility investigation, completed on 05/31/2024, documented that Staff C, Nursing Assistant (NA) and Staff D, NA, did push Resident 1 to take a shower, despite an initial refusal. The investigation further documented Resident 1's roommate overheard an aide say that if the resident didn't shower, they would smell like a wet dog. Resident 1 then got into the shower chair, and allowed Staff C to give the shower, while Staff D stayed in the resident room and changed the bed linens. Staff E, NA was called into the shower room to assist Staff C, if needed. During an interview on 06/12/2024 at 12:30 PM, Resident 1 stated that they were pushed into taking a shower that time, but had not had any more incidents. Resident 1 further stated that the issue was over, and they felt safe with the caregivers. During an interview on 06/12/2024 at 1:45 PM, Staff E, NA stated that if a resident refused care, they checked back later or requested that another staff member offer. If the resident still declined, they should let the nurse know. When asked about the incident with Resident 1, Staff E said that they had been called into the shower room in case Staff C needed help. Staff E further stated that Resident 1 did seem kind of mad, but did not say no and let Staff E help them undress for the shower. Staff E was not aware that the resident had refused the shower in their room. During an interview on 06/12/2024 at 2:00 PM, Staff F, NA, stated that a resident refused care, they would ask again later. Staff F further stated they would try to offer a bed bath, but could not force the resident. During an interview on 06/12/2024 at 2:11 PM, Staff G, Licensed Practical Nurse, stated that they would try to determine why a resident refused care, would offer again and let nursing management know of any refusals. During an interview on 06/12/2024 at 2:18 PM, Staff H, NA, stated they handled refusals of care by reapproaching later. Staff H further stated they encouraged residents to accept care, but could not make them. During an interview on 06/12/2024 at 2:30 PM, Staff B, Director of Nursing, acknowledged that Staff C and Staff D violated Resident 1's rights, and this was failed practice. Reference: WAC 388-97-0180(1-4)

Based on interview and record review, the facility failed to ensure allegations of potential abuse were reported immediately to the State Survey Agency as required, for 1 of 3 sampled residents (Resident 1). This failure placed the resident at risk for abuse. Findings included . A 12/22/2023 admission assessment showed Resident 1 had diagnoses including pneumonia, chronic obstructive pulmonary disease (chronic disease that damages the lungs) and muscle weakness, and that they were cognitively intact. According to a facility report, dated 02/14/2023, Resident 1 discharged from the facility on 02/02/2024. On 02/14/2024 the facility received a call from the discharged resident's medical provider stating that the resident was reporting they were forced to take an enema, despite their refusal, a few days prior to their facility discharge. Record review of Resident 1's medication administration record showed they received a suppository (medication given in the rectum to encourage bowel movements) given by Staff D, Registered Nurse, on 01/26/2024 at 4:15 AM. No enema (liquid inserted into the rectum to encourage bowel movements) was recorded as administered during Resident 1's stay at the facility. In an interview on 02/27/2024 at 10:01 AM Resident 2 stated that they had been roommate with Resident 1 during their stay. Resident 2 stated that Resident 1 had often complained of rough handling by staff during their stay and had overheard Resident 1 tell nursing staff of their concerns related to a rough enema and related to rough handling by staff. In an interview on 02/27/2024 at 11:41 AM, Staff B, Resident Care Manager, stated that they had received multiple complaints from Resident 1 about rough handling by staff, about physical therapy working the resident too hard and that an enema they had received had hurt really bad. They further stated that Resident 1's concerns had been recorded by the facility as grievances and that the allegations had not been reported as possible abuse. Staff B stated that Resident 1's concerns had been talked about in the facility daily huddle with other nursing management staff almost daily, Monday through Friday, during their stay. In an interview on 12/27/2024 at 12:15 PM, Staff C, Social Services Director, stated that during Resident 1's stay at the facility they had reported concerns about staff being rough and had also said therapy was rough. Staff C stated that Resident 1's concerns had been discussed in the facility clinical meetings every day and no one had said anything about a reporting Resident 1's concerns as possible abuse. In an interview on 12/27/2024 at 12:32 PM, Staff A, Director of Nursing, stated that during daily clinical meetings there had been discussion about Resident 1's reporting staff were rough with them. Staff A further stated that Resident 1's allegations of abuse had not been reported to the required State Agency until 11 days after the resident had discharged from the facility. Reference (WAC) 388-97-0640(7)(b)(i)

Based on interview and record review, the facility failed to complete a thorough investigation into allegations of abuse in a timely manner, for 1 of 3 sampled residents (Resident 1). Failure to recognize allegations as possible abuse and failure to immediately investigate allegations, placed the resident at risk for diminished quality of life, and continued possible abuse. Findings include: A 12/22/2023 admission assessment showed Resident 1 had diagnoses including pneumonia, chronic obstructive pulmonary disease (chronic disease that damages the lungs) and muscle weakness, and that they were cognitively intact. According to a facility report, dated 02/14/2023, Resident 1 discharged from the facility on 02/02/2024. On 02/14/2024 the facility received a call from the discharged resident's medical provider stating that the resident was reporting they were forced to take an enema, despite their refusal, a few days prior to their facility discharge. Record review of Resident 1's medication administration record showed they received a suppository (medication given in the rectum to encourage bowel movements) given by Staff D, Registered Nurse, on 01/26/2024 at 4:15 AM. No enema (liquid inserted into the rectum to encourage bowel movements) was recorded as administered during Resident 1's stay at the facility. In an interview on 02/27/2024 at 10:01 AM Resident 2 stated that they had been roommate with Resident 1 during their stay. They were aware that Resident 1 had received a suppository for constipation a few days prior to their discharge and had been in the room when it occurred. They stated that the privacy curtain had been pulled but that Resident 1 was heard to say it hurts repeatedly. Resident 2 further stated that Resident 1 often complained of rough handling by staff during their stay and had overheard Resident 1 tell nursing staff of their concerns related to the rough enema and related to rough handling by staff. In an interview on 02/27/2024 at 11:41 AM, Staff B, Resident Care Manager, stated that Resident 1 had a lot of pain during their stay, and they had made multiple adjustments to their medication to try and manage their pain to tolerable levels. This included the use of opioid narcotics (strong, prescription, pain medications that are known to cause constipation) and that the named resident had been constipated (inability to have a bowel movement) and required a suppository during their stay to manage their constipation. Staff B stated that they had worked closely with Resident 1 to try and make them comfortable during their stay and had received multiple complaints from the resident about being handled roughly by staff, physical therapy working the resident too hard and that an enema they had received had hurt really bad. They further stated that Resident 1's concerns had been recorded by the facility as grievances and that the allegations had not been formally investigated as potential abuse. Staff B stated that Resident 1's concerns had been talked about in the facility daily huddle with other nursing management staff almost daily, Monday through Friday, during their stay. In an interview on 12/27/2024 at 12:15 PM, Staff C, Social Services Director, stated that during Resident 1's stay at the facility they had reported concerns about staff being rough and had also said therapy was rough. Staff C stated that they had tried to get more details from Resident 1 about what had happened but that no formal investigation was completed into the allegations until after the resident had discharged . Staff C reported that Resident 1's concerns had been discussed in the facility clinical meetings every day and no one had said anything about a formal investigation being needed. In an interview on 12/27/2024 at 12:32 PM, Staff A, Director of Nursing, stated that during daily clinical meetings there had been discussion about Resident 1's reporting staff were rough with them. Staff A further stated that they had not seen the allegations as abuse and that the allegations had not been formally investigated until 11 days after the resident had discharged from the facility. Reference: WAC 388-97-0640 (6)(a)(b)

Based on observation, interview, and record review, the facility failed to implement interventions, consistently monitor pressure ulcers, and notify appropriate disciplines once pressure ulcers were identified for 3 of 3 sampled residents (Residents 3, 7, and 29), reviewed for pressure ulcer care. Actual harm occurred for Resident 3, when facility staff did not have preventive protective boots(cushioned devices placed on the feet to protect against pressure) implemented timely, the resident lost a significant amount of weight, developed an additional pressure injury, and the Registered Dietician (RD) was not notified of the resident's wounds. This failure placed the other residents at risk of harm from further deterioration of their skin conditions, and a decreased quality of life. Findings included <Resident 3> Resident 3 had diagnoses including left femur (thigh bone) fracture and paralysis (the loss of the ability to move some or all of your body), after a stroke. A 03/07/2023 quarterly pressure sore risk assessment showed the resident was at high risk for developing pressure ulcers (an injury that breaks down the skin and underlying tissue, related to pressure). A review of the record showed on 05/01/2023 Resident 3 was readmitted to the facility from the hospital after receiving care for a fractured thigh bone. A 05/06/2023 significant change in condition assessment showed the resident required extensive assistance of two staff for bed mobility, was totally dependent for transfers from bed, and used a wheelchair for locomotion. The resident had no weight loss, and weighed 190 pounds (lbs.). Review of the 05/08/2023 RD assessment showed Resident 3 had a 3.7 lb. weight gain from 04/16/2023 and had minimal fluctuations in their weight for past five months. The assessment also showed the resident was at high nutritional risk, and had decreased intake upon their return from the hospital on 05/01/2023 (eating less than 25% of one meal daily). There were no additional RD assessments or interventions documented in the resident's record after their return from the hospital, with a known decrease in intake, and an increased nutritional risk. The comprehensive care plan had the following care areas (with date of initiation listed): -12/12/2018 Risk for nutritional problems; interventions included regular diet, mechanical soft texture, encourage fluids of choice, explain the importance of maintaining the ordered diet, monitor weight per policy, report significant losses or gains to the provider and RD, RD to evaluate and make recommendations, and offer snacks in between meals. On 05/01/2023, the plan was revised to include serve diet as ordered and monitor intake. -05/24/2023 Actual alteration in skin integrity; interventions included to administer treatments as ordered, keep skin clean and dry, encourage good nutrition and hydration, evaluate the environment for causative factors, follow facility protocols, notify licensed nurse (LN) of changes to skin, encourage position changes, ensure pressure is kept off of left outer ankle and refer to the RD as needed. On 05/25/2023, the care plan was updated to include foot protectors on both feet (defined above) at all times while in bed, and on the left foot when up in chair. A review of the resident's weights showed the following: 02/16/2023-193.1 lbs. 04/16/2023-186.7 lbs. 05/02/2023-190.4 lbs. and 05/10/2023-183.2 lbs., a 3.8% loss in 8 days. A review of nursing progress notes showed on 05/15/2023, Resident 3 developed a cellulitis (infection of the skin) on their left lower leg on the outer calf area, and was sent to the local hospital. The resident returned on 05/17/2023. A 05/17/2023 initial skin ulcer/injury measurement and evaluation showed Resident 3 had a stage II pressure ulcer (intact blisters or a shallow open sore) on the left outer ankle that measured 1.0 centimeters (cm.) x 1.0 cm. x 0.0 cm. that was present when Resident 3 returned from the hospital. Additionally, there was a 1.0 cm. x 1.0 cm. suspected deep tissue injury on the same outer ankle. The plan was to monitor the areas until resolved, and if the blisters opened, they were to be treated with a foam dressing. The 05/17/2023 provider orders included elevating the left leg, avoid prolonged pressure to the red areas, regular diet, offer snacks three times a day, and give one multi-vitamin, Vitamin D and Vitamin B-12 daily for nutritional supplement. The 05/24/2023 weekly skin ulcer measurement and evaluation showed Resident 3's left outer ankle stage II pressure ulcer had not changed in size, had no drainage, undermining (skin separation), or tunneling (skin damage underneath a wound, which penetrates deeply underneath the skin). The treatment was updated to add protective booties while in bed and up in a chair. The KARDEX (care instructions for nursing assistants) in effect on 05/24/2023 instructed staff Resident 3 was to wear foot protectors on both feet at all times while in bed and up in a chair, to avoid prolonged pressure to red areas of left leg, ensure pressure was kept off the left outer ankle, and assist the resident with position changes. On 05/24/2023, Resident 3's weight was 178.0 lbs., a 6.5% significant weight loss from 05/02/2023. On 05/24/2023 at 9:07 AM, Resident 3 was observed in their bed. Their left leg was turned outward so that the outer ankle rested on the mattress. There were no protective boots on, and none observed in the room. The resident stated they used to weigh over 200 lbs. but had lost weight recently. The resident was also observed on the following dates: -On 05/25/2023 at 9:27 AM seated in their wheelchair wearing socks and shoes; -On 05/26/2023 at 9:45 AM asleep in their bed, wearing non-skid socks and no protective boots; the left leg was elevated on a pillow. At 11:48 AM the same day, the resident remained in bed, the left leg was no longer resting on a pillow and their ankle was positioned against the mattress. There were no protective boots on. On 05/29/2023 at 10:44 AM, an incident note documented the resident had a new suspected deep tissue injury on the left inner heel, possibly from care or handling. The note showed the resident's heel was limp, and needed to be moved by staff, as the resident did not move it. On 05/30/2023 at 1:14 PM, the resident's left inner heel and outer ankle area were observed with Staff K, Registered Nurse (RN), and Staff C, Director of Nursing Services (DNS). The left outer ankle had an area with a defined border that was not open, had no drainage, and had a grey-ish tint to it on the ankle bone. Staff K stated the area measured 1.7 cm. x 2.5 cm. x 0.0 cm. The left inner heel had a new round purple bruise that measured 3.5 cm. x 4.0 cm. x 0.0 cm. Staff K pressed on the area and stated it was boggy (soft or mushy). During the observation, Staff C stated they did not know where the new pressure on the left inner heel came from because the resident's leg rotated externally. Staff C was unsure if the resident's shoe caused the pressure or possibly their wheelchair. Staff C stated therapy was to evaluate the resident's wheelchair. During an interview on 05/31/2023 at 12:04 PM, Staff L, Nursing Assistant (NA), stated the padded boot was new for Resident 3 and had been added that week, 05/29/2023. Staff L stated they were able to find care planned interventions in the KARDEX on the computer; and stated if there were changes to a resident's care, it showed on a communication board in the computer. Staff L did not remember seeing anything regarding the protective boots for Resident 3 on the communication board. During an interview on 05/31/2023 at 2:17 PM, Staff E, RN, stated Resident 3 had a new area of pressure on their inner heel. Staff E was unsure when the protective boots were brought into the resident's room, but stated it sounded as if there was an opportunity to get the resident the boots sooner. Staff E stated just by looking, it appeared the resident had lost weight, and stated the Resident Care Manager (RCM) notified the provider and the RD if there was significant weight loss, but currently there was no RCM. The RD was to be notified of new skin issues as well, but Staff E was unsure if that happened, and stated if that had not occurred, it was concerning. During a telephone interview on 05/31/2023 at 4:21 PM Staff J, RD, stated they had assessed Resident 3 on 05/08/2023, when they returned from the hospital after being treated for a fracture from a fall. Staff J was unaware the resident was hospitalized on [DATE] but stated normally if a resident left the facility they were reassessed when they returned, and stated that since Resident 3 had just been assessed on the 8th, Staff J probably would have just done a progress note instead. Staff J stated Resident 3 was reviewed during the Nutrition at Risk meetings, but the weight of 178 lbs. on 05/24/2023 had not been recorded in their record before their last meeting. Staff J stated they had not been notified of the resident's wounds when they were identified on 05/17/2023, and stated it sounded like the resident got missed at the 05/24/2023 meeting. They stated if they had been made aware, changes would have been made to Resident 3's nutrition plan of care such as double portions of protein, extra proteins, or a supplemental shake of some kind. 37544 <Resident 29> Per the 04/20/2023 quarterly assessment, Resident 29 needed extensive assistance from one to two staff to complete activities of daily living such as turning in bed and personal hygiene. In addition, the assessment showed the resident was at risk for developing skin issues and had no pressure ulcers or open lesions. Review of the progress notes from 03/01/2023 through 05/31/2023 showed the following: On 05/09/2023 at 3:10 PM, Resident 29 was found to have a blister on their left leg stump (the leg below the knee had been amputated) that had opened. The area was cleaned, a foam type dressing was applied, and the provider was notified; on 05/10/2023 at 12:13 AM, the dressing was removed, the area cleaned, and a new dressing applied; and on 05/12/2023 at 8:19 AM, it was documented the provider acknowledged being notified of the blister. Further review of the progress notes found no additional documentation regarding the blister. The May 2023 Treatment Administration Record (TAR) showed an order dated 05/24/2022 which instructed the licensed nursing staff to check Resident 29's skin every Tuesday, and mark the TAR with a plus sign for new issues or a negative sign to show no new skin conditions had been found. In addition, instruction was given to document a progress note and initiate the skin documentation form when a new skin condition was found. Review of the May 2023 TAR showed on 05/09/2023 the TAR was marked with a negative sign to indicate no new skin issues were found. A progress note, on the same date, documented Resident 29 had a blister on their left leg, which was not there previously. Review of the skin documentation assessment forms showed the form was not initiated for the blister as instructed, nor were other skin assessment forms found that showed the blister was being monitored. Review of the skin care plan showed interventions were implemented on 04/14/2023, but the care plan had not been updated to inform the nursing staff of the blister on the left leg, or what Resident 29's care needs were for the treatment of the blister. In an interview on 05/31/2023 at 9:53 AM, Staff G, NA, stated Resident 29 had a blister on the back of the left leg, but was not sure if it was still there since they had been off work for a few days. In an interview on 05/31/2023 at 2:13 PM, Staff F, RN, stated they were not aware of any skin issues or Resident 29 having a blister. After review of the resident's physician orders, progress notes, skin documentation forms, and TAR, Staff F confirmed there were no orders or additional documentation after the progress note on 05/09/2023 and confirmed skin assessments were supposed to be done weekly and the skin documentation form was to be filled out if any new issues were found. On 05/31/2023 at 2:27 PM, Resident 29 was observed lying in bed watching television. Staff F asked if they could assess the resident's skin and the resident turned to their right side. The back of the left thigh/stump area was assessed, and no dressing or visible open areas were found. In an interview on 05/31/2023 at 2:40 PM Staff C, DNS, confirmed skin assessments were done weekly, and the skin documentation form was to be completed when there were new skin issues found. When informed about the progress note on 05/09/2023 regarding the blister, Staff C stated they would need to follow up. In a follow-up interview on 3:17 PM, Staff C confirmed there was no follow-up monitoring, and the facility process for skin assessments had not been followed. 46115 <Resident 7> Review of the 03/23/2023 significant change in status assessment, Resident 7 required extensive assistance of two staff to turn and reposition them in bed. The assessment showed the resident was at risk for developing skin issues and had no pressure ulcers. Per the record, Resident 7 had a Braden scale (a scale for predicting pressure sore risk) completed on 03/23/2023 and their score was 11, which showed the resident was at high risk for developing pressure ulcers. Resident 7 was noted to have a suspected deep tissue injury on their left heel on 03/28/2023. The left heel injury was not placed on the treatment administration record (TAR) to monitor until 04/06/2023, nine days after the pressure injury occurred. An incident investigation, dated 03/28/2023, showed Resident 7 had a 6.0 cm. x 3.5 cm. blister to the bottom of the left heel, that was painful to the touch. The care plan was updated at that time to float the resident's heels while in bed (for pressure relief to the area). The investigation showed the cause of the blister was due to the resident resting their heels on the bed, decreased nutritional intake, decreased mobility, and recent illness of COVID-19 (a highly contagious respiratory disease). Prior to that date, no interventions were in place to relieve the pressure from Resident 7's heels. During an interview on 06/01/2023 at 11:38 AM Staff J, RD, stated they were unaware Resident 7 had a deep tissue injury/blister to the left heel. Staff J reported if they had been made aware, a multivitamin and Vitamin C would have been added to Resident 7's medications, to aid in skin healing. Staff J additionally added that issues with skin had recently been missed, and stated they should have been notified of Resident 7's pressure injury. During an interview on 05/31/2023 at 2:00 PM Staff C, DNS, stated upon admission a Braden Scale was completed on every resident. Per Staff C, the nursing staff were expected to turn and reposition residents, provide incontinent care, and float heels. They stated that if a pressure ulcer developed, it would be placed on the TAR for monitoring once found. Staff C additionally added the facility was in crisis staffing during the COVID-19 outbreak and repositioning and floating of the heels did not occur on a consistent basis. Reference: WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure the filter for oxygen concentrators (a machine used to convert room air to oxygen) and oxygen tubing were clean/changed in a timely manner, for two of three sampled residents (Residents 91, 17), reviewed for respiratory care. These failures placed the residents at risk for respiratory complications and infection. Findings included . <Resident 91> Per the 05/25/2023 admission assessment, Resident 91 admitted to the facility on [DATE] with diagnoses which included heart failure (when the heart muscle doesn't pump blood as well as it should), circulation problems, lung disease, and needed oxygen due to those conditions. Review of the physician orders showed on 05/19/2023, the resident had been prescribed oxygen to be used continuously, due to the heart and lung conditions listed above. The 05/19/2023 respiratory care plan showed the licensed nursing staff were instructed to clean the oxygen concentrator, and change the oxygen tubing weekly. On 05/23/2023 at 12:35 PM, Resident 91 was observed wearing oxygen while participating in a group activity. An inspection of the oxygen concentrator in the resident's room showed the concentrator was unclean with thick dust stuck to the vent, and the filter was dark with visible dust and debris. Subsequent observations to the oxygen concentrator being unclean and the filter being dirty were made on 05/24/2023 at 9:02 AM, 05/25/2023 at 9:11 AM and 11:58 AM, 05/26/2023 at 7:54 AM, and 05/31/2023 at 9:40 AM. In an interview with Resident 91 on 05/31/2023 at 2:06 PM, they stated they weren't sure when the contractor filter was supposed to be cleaned, or even if there was one. Observation of the concentrator at the time of the interview showed no change in the appearance of the vent and filter. On 05/31/2023 at 2:09 PM, Staff F, Registered Nurse, stated concentrator filters and tubing should be changed weekly, when asked how often oxygen concentrators were cleaned and filters changed. When asked if they would check Resident 91's concentrator filter, Staff F proceeded to open the filter case, and dust particles flew up into the air. Staff F confirmed the filter and vent were dirty. During an interview on 05/31/2023 at 2:36 PM Staff C, Director of Nursing Services (DNS), confirmed oxygen concentrator filters were to be cleaned weekly, and when informed of the observations of Resident 91's concentrator vent and filter being dirty, stated the resident had not been at the facility long. When asked what the facility policy was for cleaning equipment between resident use, Staff C stated there was not a facility policy, but it was a standard of practice and expectation that equipment was cleaned before being used with another resident. In a follow-up interview on 06/01/2023 12:34 PM, Staff C stated after looking at Resident 91's concentrator, it was discovered it was the resident's personal concentrator, and had been brought with them on admission. Staff C acknowledged the filter and vent were dirty, and stated the usual process was to switch to facility equipment when a resident brought in their own equipment, and they were not sure why that didn't occur. 46115 <Resident 17> Per the 03/02/2023 quarterly assessment, Resident 17 admitted to the facility with obstructive sleep apnea (a problem in which your breathing pauses during sleep), hypoxemia (a low level of oxygen in the blood), shortness of breath, and a disorder of diaphragm (the thin muscle below the lungs and heart), and required oxygen due to those conditions. Review of the physician orders showed on 12/18/2020, the resident had been prescribed oxygen to be used continuously due to the diagnoses listed. The respiratory care plan showed the licensed nursing staff were instructed on 09/23/2019 to change the oxygen tubing weekly. There was no direction on cleaning the concentrator, or a physician's order to do so. On 05/23/2023 at 9:25 AM, Resident 17 was observed wearing oxygen with a date on the tubing of 05/16/2023. An inspection of the oxygen concentrator in the resident's bathroom showed the concentrator had thick dust stuck to the vent, and the filter had dust and debris with white spots. Subsequent observations of the oxygen concentrator being unclean and the filter being dirty were made on 05/24/2023 at 9:13 AM, 05/25/2023 at 10:21 AM, and 05/26/2023 9:27 AM. During an observation on 05/30/2023 at 3:14 PM, Resident 17's oxygen tubing that was connected to their concentrator was dated 05/29/2023, 13 days after the tubing was last changed on 05/16/2023. Resident 17's portable oxygen tank tubing had the date of 05/16/2023. There was tubing for the portable oxygen tank lying across a chair with a date of 05/29/2023. Resident 17, when interviewed at that time, stated they needed to change the tubing at some point. During an interview on 05/31/2023 at 10:51 AM, Staff E, Resident Care Manager, stated concentrator filters were to be cleaned weekly. They additionally added that oxygen tubing was also to be changed weekly. During an interview on 05/31/2023 at 11:19 AM, Staff C, DNS, confirmed the oxygen tubing should be changed weekly or sooner if needed. Staff C also stated the concentrators and filters should be cleaned weekly, and that was missed, due to their central supply person being gone. Reference: WAC 388-97-1060 (3)(j)(vi)

Based on observation, interview, and record review, the facility failed to refer a resident for behavioral health services when needed for 1 of 1 sampled residents (Resident 12), reviewed for mood and behavior. This failure placed the resident at risk for worsening depression and a decreased quality of life. Findings included . Resident 12 had diagnoses including stroke and major depressive disorder. A 05/04/2023 quarterly comprehensive assessment showed the resident was cognitively intact, had a mood severity score of 0 (meaning no mood alterations), and received an antipsychotic (a type of medication used to alter the brain chemistry to reduce symptoms of psychosis - a mental disorder), and and an antidepressant (medication to treat depression), daily. The 03/29/2022 comprehensive care plan had the following care areas: -History of suicidal ideation, depression; interventions included do not leave the resident alone if they made suicidal ideation comments unless it was determined they were not at risk, monitor for self-harm/ideation, remove hazardous items from room if they report suicidal thoughts. -Potential for alteration in psychosocial well-being related to survivor of traumatic event; interventions were to acknowledge non-verbal communication, provide community resources/outside referrals for mental health, provide empathy, provide least restrictive environment. Review of the resident's counseling progress notes from 08/2022 to 12/2022 showed the resident was seen last by their counselor in 12/2022. During an interview 05/24/2023 at 10:10 AM, Resident 12 stated they used to get counseling sessions on a laptop computer, and the counseling had not happened in a long time. Resident 12 stated the sessions were helpful just to have someone to talk to, and since they had stopped, the resident stated they felt more withdrawn. During the interview, the resident was still in bed wearing a hospital gown. The resident was also observed sleeping in bed on the following dates and times: -05/24/2023 at 3:38 PM, -05/25/2023 at 9:23 AM, -05/25/2023 at 10:47 AM, -05/26/2023 at 9:05 AM, and -05/30/2023 at 12:38 PM. During an interview on 05/31/2023 at 9:44 AM, the medical records clerk at the local behavioral health clinic stated Resident 12 had received services last in 12/2022. The resident was listed as a no show on 01/04, 01/11, 01/18, and 01/25/2023, so the resident was discharged in 02/2023. They stated there had been no further follow-up since then. During an interview on 05/31/2023 at 11:54 AM, Staff L, Nursing Assistant, stated Resident 12 was quiet, but usually happy. Staff L stated at times the resident got upset and then would shut down and not want to talk and would stay in bed. Staff L stated Resident 12 was more active a few months ago, but had been quieter after one of their friends was discharged from the facility. When the resident was upset, they did not get tearful, they would become more withdrawn. During an interview on 05/31/2023 at 2:07 PM, Staff M, Restorative Aide, stated Resident 12 used to walk the parallel bars and wheel around in their wheelchair, but did not do that much anymore. Per Staff M, the resident had a friend that was discharged a month or two prior, and they stated that was when they noticed a difference in the resident's interactions. The resident was supposed to have restorative care 3-5 days a week, but the resident refused or stated they were too tired. Staff M stated the resident stayed in their room more. During an interview on 06/01/2023 at 11:51 AM Staff D, Director of Social Services, stated they had assessed Resident 12 on 05/05/2023, and the resident had minimal depression at that time. The resident talked about the loss of a daughter and a significant other. Staff D tried to check in with Resident 12 after they'd leave to visit their significant other, because they would come back and be more depressed. Staff D stated the resident's significant other was in a new relationship. The resident's friend that was discharged had been coming to visit, but that had also stopped. Staff D stated they had not thought about trying to re-establish the resident with their counselor. At that time, there was nothing in the works. Reference: WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure expired medications were disposed of timely, in accordance with currently accepted professional standards, in 1 of 1 medication storage rooms. The facility further failed to ensure narcotics were locked in a permanently affixed narcotic container. These failures placed residents at risk for receiving compromised or ineffective medication, and placed the facility at risk for potential diversion or misappropriation of narcotic medications. Findings included . Per observation of the medication storage room, located between the two nursing stations on 05/06/2023 at 8:12 AM with Staff E, Resident Care Manager, and Staff C, Director of Nursing, showed Nutrisource Fiber (medication used to treat constipation) expired on 02/09/2023, a vial of Tubersol (a medication injected under the skin to determine the presence of tuberculosis, that must be discarded after 30 days of use) had been opened with no open date placed on the vial, and three bottles of Magnesium Citrate (a medication used to treat constipation), expired on 03/2023. Additionally, there was a bottle of Lorazepam (a sedative/controlled substance) and Morphine (a narcotic pain medication) for Resident 29, that was placed in the refrigerator and not in the locked narcotic container. During an interview with Staff C, Director of Nursing, on 05/06/2023 at 8:50 PM, they verified that the above medications were all expired and should have been disposed of, and that the narcotics should have been placed in the locked narcotic container. Reference: WAC 388-97-1300 (2)

Based on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Residents 29, 191), reviewed for use and care of a urinary catheter (a flexible tube inserted into the bladder to drain urine into a drainage bag), received appropriate care and services to minimize the risk of associated urinary infections. In addition, the facility failed to ensure hand hygiene and glove changes were performed when indicated in the kitchen by one of three kitchen staff (Staff I), observed during tray line service. These failures placed the residents at risk for infection. Findings included <Urinary Catheters> Per review of the 04/20/2023 quarterly assessment, Resident 29 had diagnoses which included obstructive uropathy, (a condition in which the flow of urine is blocked resulting in the urine backing up into the kidneys, creating the risk of damage to the kidneys and infection), and utilized an indwelling urinary catheter (defined above). Review of catheter care plan showed interventions for catheter care were implemented on 08/04/2022, and instructed the nursing staff to place the catheter drainage bag below the bladder, and to ensure the tubing had no obstructions or kinks. On 05/23/2023 at 9:49 AM, Resident 29 was observed sleeping in bed with the catheter drainage bag hung on the lower bar of the bed, below the bladder. The catheter tubing was positioned downward, but looped back up, which caused the urine to pool into the lower loop of the tubing, and back up the full length of the tubing instead of draining into the collection bag. Additional observations of the catheter tubing positioned in a manner that prevented the urine from draining into the collection bag were made on: 05/23/2023 at 10:43 AM and 3:28 PM, 05/24/2023 at 9:08 AM, 05/25/2023 at 9:17 AM, 10:20AM, 12:05 PM, and 2:19 PM. In an interview on 05/31/2023 at 9:52 AM Staff G, Nursing Assistant, stated the catheter tubing needed to be positioned so the urine could drain into the bag. In an interview at 3:22 PM Staff C, Director of Nursing, stated nursing staff received annual skills training related to catheter care, and confirmed catheter tubing should be positioned to allow the urine to drain into the bag. 46115 Per the 05/17/2023 admission assessment, Resident 191 had diagnoses which included benign prostatic hyperplasia (a prostate gland enlargement that can cause urination difficulty) and neurogenic bladder (lacking bladder control due to brain, spinal cord, or nerve problems). In an observation on 05/23/2023 at 9:05 AM, Resident 191 was observed sitting in their wheelchair with the catheter tubing and bag on the floor. Additional observations of the catheter bag touching the floor were made on 05/24/2023 at 11:57 AM, 05/25/2023 at 12:03 PM, and on 06/01/2023 at 8:39 AM. During an interview on 05/31/2023 at 10:42 AM Staff I, Nursing Assistant, stated the catheter was clipped to the wheelchair or on the side of the bed to prevent it from touching the floor. During an interview on 05/31/2023 at 3:23 PM Staff C, Director of Nursing, stated the catheter was to be kept off the floor as that could lead to an infection. 47728 <Tray Line Observation> The following observations were made of the kitchen staff during the lunch meal preparation and tray line service on 05/31/2023: At 10:36 AM Staff I, Dietary Aide, was wearing gloves and labeling cups with pre-poured liquids for the residents. Staff I opened a drawer under the serving area and took out a used note pad and a pen, placed them on the serving area counter, and began looking through the note pad. Without changing gloves or performing hand hygiene, Staff I then continued to label the cups, touching the rim of the cups with the dirty gloves as they were picked up. At 10:45 AM the same day, while still wearing the same gloves, Staff I wiped down the food serving area with food-safe sanitizer and a cloth. Without performing hand hygiene or changing gloves, Staff I then restocked the condiment trays for the residents. At 11:15 AM, during tray line service, Staff I removed items from the food/drink refrigerators, and without performing hand hygiene or changing gloves, placed the items on the resident's lunch trays that were being set up. In an interview at 11:30 AM with Staff H, Dietary Manager, and Staff I present, Staff H was asked when hand hygiene and gloves should be changed. Staff H stated gloves needed to be changed, After touching something dirty, when changing tasks like going between serving and making sandwiches, after touching a door or cupboard handle. After hearing Staff H's response, Staff I confirmed they didn't do that, and they then performed hand hygiene and changed their gloves. Reference: WAC 388-97-1320 (1)(c), 1320 (2)(a)

Based on observation, interview, and record review, the facility failed to ensure monitoring and timely interventions were in place, to prevent the development of facility-acquired pressure ulcers, for two of three sample residents (#37, 17), reviewed for pressure ulcers. The facility failed to monitor and promptly intervene when a pressure ulcer deteriorated, resulting in actual harm to Resident #37, who was hospitalized with a wound infection. Findings included . 1. Resident #37 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. An annual assessment, dated 10/30/18, indicated the resident was cognitively intact for daily decision-making, required extensive staff assistance for activities of daily living, and had no pressure ulcers. A review of the pressure ulcer care plan, initiated on 05/19/15, showed the resident was at high risk for the development of pressure ulcers, due to multiple chronic disease processes. Interventions included for staff to administer treatments as ordered, and to follow policies/protocols for the prevention/treatment of [REDACTED]. An initial skin ulcer assessment, dated 11/14/18, showed a facility-acquired pressure ulcer on the right ischeal tuberosity (informally known as the sit bones), which measured 4.0 centimeters (cm.) x 3.0 cm., contained 100% granulation tissue (reddish connective tissue), with no signs or symptoms of infection. The wound was documented as unstageable (full thickness tissue loss, in which the base of the ulcer is covered in slough - dead tissue - and/or eschar - dark, crusted tissue - in the wound bed), with a 1.0 cm. x 1.0 cm. dark area in the center of the wound. The physician was notified, and treatment orders were obtained. Weekly skin assessments were reviewed, from the time of the 10/30/18 annual assessment, which showed no pressure ulcers, until the unstageable pressure ulcer was first identified on 11/14/18; no other pressure ulcers were identified. A weekly skin ulcer wound evaluation on 11/23/18 showed the wound had deteriorated, and the slight dark spot in the middle was now a large area of eschar, measuring 5.5 cm. x 4.0 cm. The wound was documented as unstageable, with the wound bed having 20% slough and 80% eschar. There was no documentation of signs or symptoms of infection. The physician was notified, and treatment orders obtained. A weekly skin ulcer wound evaluation on 11/28/18 showed the wound was documented as unstageable, had 100% eschar, and had a foul smelling, purulent (resembling pus) drainage. Staff H, Wound Nurse Practitioner, attempted to obtain a wound culture, but due to the extensive eschar was unable, so antibiotics were ordered. An 11/29/18 nursing progress note showed the resident was started on an antibiotic that day. The note also showed the resident continued to have increased weakness and poor trunk control, as well as the wound continued to have a foul odor. An appointment to see the primary care physician was made, due to the resident's overall decline. A physician office visit note on 11/30/18 showed the resident had a temperature of 99.1, and was showing signs of increased depression. The physician documented that he spoke with Staff H on the phone the day before, regarding the wound. Staff H had stated to him that the resident should be referred to general surgery for [REDACTED]. A nursing progress note, dated 11/30/18, showed the resident had shown signs of depression and disinterest in things during the shift. The note showed the resident had gone to the doctor that day, and when he returned the resident stated, I still don't feel good. A nursing progress note, dated 12/01/18, showed there was a moderate amount of foul smelling drainage from the right ischial tuberosity wound. There was no documentation of the physician or Staff H having been updated/consulted. A 12/02/18 nursing progress note at 2:04 AM, showed the resident was very weak, and it took several minutes for the resident to take his medication. Per the note, the dressing to his bottom was intact, but had a very foul odor. In addition, the resident was very slow to respond to questions, but alert when he finally responded. The note also showed he was very quiet and did not joke or visit at all (with the nurse). There was no documentation that the physician or wound nurse were updated/consulted with regarding his condition. A nursing progress note, dated 12/02/18 at 10:02 AM, showed the wound had a large amount of foul smelling drainage, during a dressing change. There was no documentation the physician or wound nurse were notified. A nursing progress note, dated 12/03/18 at 2:10 AM, showed Resident #37 was slow to respond when spoken to, very weak, and uncomfortable. There was no documentation the physician or wound nurse were notified. According to nursing progress notes on 12/03/18, Staff E, Charge Nurse, observed the wound that morning, and noted that it had deteriorated over the weekend. Per the note, the wound was now red, with increased odor and drainage. Staff E further documented that the resident continued to complain of increased weakness. Staff E discussed this with the resident, who then decided to see a surgeon for a surgical consult. Staff H, Wound Nurse Practitioner, was notified of this, and stated she would discuss it with her colleagues (to decide whether it should be an orthopedic or general surgeon). A return call from the general surgeon's office was received, and an appointment was made for the resident to be seen the next day. There was notification to the resident's primary physician of increasing heart rates, possibly due to a blood pressure medication having been discontinued earlier in the week, but there was no documentation the primary physician was updated/consulted with regarding the deterioration of the wound, and increased weakness, which could potentially be related to the infection of the wound. A progress note, dated 12/03/18 at 2:45 PM, indicated the patient's condition had further deteriorated. He was slurring his speech, and was slow to respond to questions. Per the note, the resident's temperature was 102.3, the pressure ulcer wound had increased in size, and was warm to touch. The patient stated he would like to go to the emergency room for evaluation, and was sent by staff. In an interview and observation on 01/06/19, Resident #37 was observed lying in bed on his left side. He was alert and talkative. He was asked how long he has had the wound. He stated two to three months. He was asked if the wound had been infected. He stated he was not sure, but he had been to the hospital for a week, due to problems with the wound. In an observation on 01/07/19 at 9:56 AM, Staff E, Charge Nurse, provided wound care to the resident's pressure ulcer on the right ischial tuberosity. The wound was observed to be approximately 7.0 cm. x 7.0 cm. in diameter, with a small amount of necrosis (black, dead tissue), on about 10% of the wound. There was a fissure (tunnel) that extended from the wound inward, towards the bones, for approximately 4.5 cm. Staff E stated the wound was improving. In an interview on 01/08/19 at 10:35 AM, Staff E stated the pressure ulcer wound was unstageable when first discovered, and progressed from a small wound to a more severe wound, which required a wound specialist being involved in wound care. Staff E stated they notified the physician on (MONTH) 14th (when it was first discovered), and on (MONTH) 23rd, the physician wrote an order for [REDACTED]. In an interview on 01/09/19 at 1:38 PM, Staff B, Director of Nursing, stated that when a wound is first discovered, staff should contact the provider, follow their orders, measure the wound, and place the resident on alert charting (every shift documentation). Per Staff B, vital signs should be taken every shift, while on alert charting. Staff B was asked, after reviewing documentation from 12/01/18 to 12/03/18, when the resident was transferred to the hospital, if there was any documentation of physician notification/consultation, or monitoring and intervening timely for Resident #37; she stated no. In an interview on 01/09/19 at 3:00 PM, Staff H stated that she provides wound care to the resident weekly, however, she had been on vacation at the time the wound was first discovered (around 11/13/18), until after Thanksgiving. She saw the wound for the first time on11/28/18, when she prescribed the antibiotics. Staff E further stated she had spoken to the general surgeon, and had scheduled the resident to be seen in his office the next day, however, the resident declined rapidly and was sent to the hospital for [MEDICAL CONDITION] (an overwhelming and potentially life-threatening response to infection). 2. Record review revealed a skin assessment dated [DATE], which showed Resident #17 was at high risk for pressure ulcers, due to factors including his decreased mobility, history of stroke, and diabetes. According to his assessment dated [DATE], Resident #17 required extensive assistance with activities of daily living, including bed mobility and transfers. The assessment also showed the interventions to prevent pressure ulcers included a pressure reducing device for his wheelchair (but not bed), and a turning and repositioning program. According to a facility investigation, on 12/11/18, facility staff identified a 0.2 x 0.2 centimeter (cm.) open pressure ulcer (Stage II, involving superficial layers of skin), to the resident's left ankle (within a 3.0 x 3.5 cm. reddened area). The investigation showed the resident stated he thought the wound developed from laying on his left side all the time. The investigation showed new interventions, after the pressure ulcer formed, were to start pressure relieving boots while the resident was in bed, and educate the resident on the importance of relieving pressure off of the left side, to promote healing and prevent pressure areas. Review of the resident's record, including on 01/09/19, showed although the facility staff were aware that the resident favored laying on his left side, and did not participate in the turning and repositioning program effectively, other interventions were not implemented until after the pressure ulcer developed. In an interview on 01/10/19 at 10:57 AM, Staff D, Resident Care Manager, confirmed the resident favored lying on his left side for comfort, and that the pressure relieving boots were not implemented until after the pressure ulcer was identified. WAC reference: 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to provide adequate pain management for 1 of 3 residents (#39), reviewed for pressure ulcers. This failure resulted Resident #39 experiencing pain and discomfort, related to development of a pressure ulcer. Findings include: A review of the facility's comprehensive assessment, dated 02/05/17, revealed the resident had [DIAGNOSES REDACTED]. Resident #39 was staff assessed to be severely impaired in cognition, and had no pain indicators during the assessment period. The assessment further documented the resident required extensive assistance with most activities of daily living, and was mostly non-verbal. An initial wound treatment progress note, dated 02/06/17, revealed the resident had a pressure ulcer to the left hip, and during treatment, the resident did not exhibit any signs of pain or discomfort. Subsequent weekly progress notes documented the resident did not complain of pain during wound treatment. On 03/08/17, Staff K, wound nurse, re-assessed the pressure ulcer, and documented the resident had complained of pain during the wound treatment. There was no indication Staff K obtained an order for [REDACTED]. On 03/15/17, Staff K documented the resident had significant pain during the debridement of the wound (removal of dead tissue), was agitated, and attempted to get out of bed. Staff K did not contact the physician, to obtain an order for [REDACTED]. An observation of the wound and wound treatment was made on 03/22/17 at 1:40 p.m., with Staff J, charge nurse. During the wound treatment, the resident was observed to say, No several times, become agitated, and attempt to get out of bed (indicating she was in pain). Staff J was asked if the resident was medicated for pain, prior to the wound care treatment, and said no. A review of the Medication Administration Record [REDACTED]. (See F-314 for additional information related to pressure ulcers).

Based on observation, interview, and record review, the facility failed to ensure 1 of 3 residents (#39), reviewed for pressure ulcers, received the necessary monitoring and interventions to prevent and promote healing of a facility-acquired pressure ulcer. Resident #39 experienced actual harm, as evidenced by the development and deterioration of a facility-acquired pressure ulcer, with resulting pain. Findings include: A review of the facility's comprehensive assessment, dated 02/05/17, revealed the resident had [DIAGNOSES REDACTED]. She was staff assessed to be severely impaired in cognition, required extensive assistance with repositioning, and was mostly non-verbal. The assessment also identified the resident was wheelchair bound, when she was out of bed, and was at risk for pressure ulcer development. A 01/18/17 physician's progress note, identified a suspected bruise on the resident's left hip, with surrounding redness. A review of the care plan and treatment record during that time, revealed no additional precautions were taken, to prevent the skin alteration from worsening. (See F 280 for additional information related to care planning). A facility investigation, dated 02/06/17, identified the bruised area was now a pressure ulcer, and indicated it may have been a result of the resident's wheelchair frame, and/or her preference for sleeping on her left side. A review of the resident's clinical record, at the time the wound developed into a pressure ulcer, revealed the facility did not immediately put additional interventions in place, to ensure pressure relief in that area. Weekly skin assessments and wound treatments which were performed by Staff K, wound care nurse, were initiated on 02/08/17. The initial wound assessment described the wound as unstageable (indicating possible deep tissue damage). Staff K described the base of the wound as covered with thick brown eschar (dead tissue) and was without odor or signs and symptoms of infection. Documentation indicated the edges of the wound were intact, and there was no redness. The assessment further documented the wound measured 1.3 centimeters (cm.) in length, was of unknown depth, and the resident did not complain of pain during the treatment. On 02/22/17, Staff K reassessed the wound. She documented the wound now measured 1.5 cm. in length x 1.6 cm. in width, with unknown depth. There was a small amount of drainage, however, there was no odor or signs of infection. On 02/28/17, Staff K again reassessed the wound, and documented the wound had now deteriorated, noting it measured 2.3 cm. in length, the base of the wound was covered with yellow, spongy slough (a mass of dead tissue separated from surrounding living tissue), and the edges of the wound were open. The assessment also noted facility staff indicated the resident had been removing the dressing and picking at the wound. The treatment order was changed, to improve [MEDICATION NAME] of the wound, and to prevent infection. Staff K documented she had recommended to staff, Please turn and reposition the resident every 2 hours while she was in bed. A review of the care plan did not show this intervention had been added, which was specifically designed to prevent the resident from picking at the wound, removing the wound dressing, or laying for too long on the left side. On 03/08/17, Staff K documented the wound as unchanged, and indicated the resident continued to take the bandage off the wound and pick at it. Assessment of the wound revealed the depth of the wound now measured 1.2 cm., with a moderate amount of drainage. She further documented the resident had complained of pain during the treatment (see F 309 for additional information related to pain management). On 03/15/17, Staff K documented the pressure ulcer now measured 1.9 cm. in length x 1.8 cm. in width, with unknown depth. The base of the wound was now covered with 100% dead tissue. There was no drainage, odor, or signs of infection. The report also documented the resident continued to remove the dressing from her hip, and picked at the wound during the night. No additional measures were taken by the facility, to prevent the resident from picking at the wound, or removing the dressing. An observation of the wound and wound treatment was made on 03/22/17 at 1:40 p.m. Staff J, charge nurse, removed the dressing to the resident's left hip. The wound was observed to be approximately 3.0 cm. in diameter, of undetermined depth, and with redness noted around the edges of the wound. The wound bed was observed to contain a brownish substance. In an interview on 03/22/17 at 2:00 p.m., Staff J acknowledged the facility had not attempted to implement additional interventions, to prevent the resident from gaining direct access to her wound (apart from changing/adding tape). In an interview on 03/24/17 at 7:53 a.m., Staff L, licensed nurse, stated once the resident was up for the day and dressed, she did not touch the bandage, because she had pants on, and could not access it. She was asked if the resident wore pajama pants at night to prevent the resident from accessing the wound. She stated no. The facility failed to prevent the resident from acquiring a preventable pressure ulcer, and did not put additional interventions in place, after having knowledge of resident behaviors (removing bandage and picking at wound), to prevent if from worsening.

Based on interview and record review, the facility failed to ensure medications were administered as ordered by the physician for 2 of 4 sample residents (#1 & 2). The failed practice resulted in harm to Resident #1 who had to be treated for [REDACTED]. Findings include: 1. Resident #1 had [DIAGNOSES REDACTED]. According to the record, on 5/7/12 the resident went to a physician appointment where he was noted to have a significantly elevated blood clotting time. The physician's office contacted the facility who indicated the resident may have received twice the ordered dosage of blood thinning medication during the preceding week. The resident was treated with Vitamin K to decrease his excessive blood clotting time. Per the facility investigation, orders received on 5/1/12 were transcribed onto the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. During an interview on 5/9/12 at 2:00 p.m., one of the licensed nurses involved stated she did not remember whether she gave the resident a double dose of the medication but that it was possible. 2. Resident #2 had [DIAGNOSES REDACTED]. On 3/29/12 the resident went to a physician's appointment where he was noted to have a decreased blood clotting time. The physician's office contacted the facility who checked the resident's record and determined the resident was not given his blood thinning medication on 3/25/12, 3/26/12, and 3/27/12. Per record review, the facility investigated the medication error of omission and attributed it to a transcription error. The resident required an increased dosage of blood thinning medication to return his blood clotting time to a therapeutic level. During an interview on 5/9/12 at 2:00 p.m., the licensed nurse involved in the error stated she missed the order because she was unfamiliar with the form used by the physician's office.

Based on interview and record review, the facility failed to ensure that 1 of 3 sampled residents (#1) was treated with dignity and respect related to an incident where the resident ' s phone was removed from her reach and her bedroom door was shut for 1 hour. The resident felt " scared " and " claustrophobic " as a result of the incident. This resulted in psychological harm. Findings include: On 1/3/2011, during an interview with Resident #1 she was shaky and tearful. She stated that on 12/22/2010, she asked Staff D to get her out of bed approximately 10:00 pm. Resident #1 stated she was told by Staff D that there was only one other staff member on the floor and she would have to put her call light on and wait until an additional staff member arrived at 11:00 pm. Resident #1 stated she could not tolerate lying in bed for the extra hour due to pain and " begged " Staff D to let her get up. She stated Staff D offered her pain medicine, but she refused, stating all she needed was to get back into her recliner. She stated that Staff D took her phone out of the resident ' s reach and shut her door. The resident stated she became frightened. She stated she was claustrophobic and felt like " she was dying " when the door was shut. She stated about an hour later, Staff D entered the room with the two night shift aides and handed her the phone while stating that she could call her husband if she wanted. Resident #1 stated she told Staff D she had no intention of calling her husband, she was going to call the police to get help getting out of the bed. Resident #1 stated she had no problems with any other staff, only Staff D. She stated that it seemed like Staff D went out of her way to make her wait longer than necessary for assistance. She stated she was " well enough to yell " and was concerned about other residents who could not speak for themselves. Resident #1 stated she was afraid on the nights when Staff D was working that the incident would be repeated. She stated she was fearful of that type of incident repeating itself between 12/22/2010 and 1/3/2011 (the date of the interview), however, she said no other incident had occurred with Staff D. The facility failed to ensure the resident was treated in a dignified manner resulting in psychological harm to the resident.

Based on observation, interview, and record review the facility failed to ensure there was an effective system in place to address unsafe smoking which included accurate assessments and adequate supervision; one of 4 sampled residents (#2) who smoked experienced harm when he burned his chest with a cigarette while smoking. Findings include: Resident #2 had [DIAGNOSES REDACTED]. He had a history of [REDACTED]. Per his record he had short and long term memory loss and modified independence in his cognition. The resident was independent in his electric wheelchair and able to move about in and out of the facility. Despite the potential for unsafe smoking and changes in the resident's condition, the smoking assessment was not consistently updated. For example, on 12/18/09 the physician was notified that the resident had been falling asleep while eating and propelling his electric wheelchair for the past few months. The resident's smoking safety assessment (which was over one year old) did not assess the impact of this behavior on smoking safety. It identified he required supervision by staff when outside smoking and staff would keep his cigarettes and fire materials; but did not include the use of a smoking apron as one of the interventions. On 8/22/10, a nursing assistant was dressing the resident and noted a burn on the resident's chest. Per the facility investigation dated 8/22/10, the facility determined he had burned himself with a cigarette. The resident denied burning himself and did not want any smoking restrictions. Per the investigation the resident had kept his own smoking materials (not allowed per the care plan and smoking assessment). The facility notified the resident's physician and treatment was provided. The facility updated the resident's plan of care after he sustained the burn to ensure he was supervised when smoking and that he had a smoking apron on to prevent future burns. During the onsite investigation on 9/7/10, the resident was observed outside smoking unsupervised at 11:05 a.m. and 1:00 p.m. The resident was observed to not be wearing a smoking apron. Per an interview with administrative staff on 9/7/10, the resident was to be supervised at all times while outside smoking and he was supposed to wear his smoking apron. On 9/27/10 during the onsite investigation, resident #1 was observed outside being supervised while smoking wearing his smoking apron. The facility had updated the resident's assessment. The facility's failure to consistently assess and monitor the resident's ability to smoke safely and ensure that interventions were followed put the resident at risk for burns. The resident sustained [REDACTED].