Every finding on record at Seattle Medical Post Acute Care

Based on interview and record review, the facility failed to ensure a resident with impaired cognition and who had been identified as an elopement (a resident who is unsafe to be alone leaves the facility without supervision) risk, remained safely within the facility premises under adequate supervision for 1 of 3 residents (Resident 1), reviewed for accident prevention. This failure placed the resident at risk of significant hazards, including environmental exposure, potential medical complications, and the risk of being struck by a motor vehicle.A past noncompliance was initiated on 06/29/2026 related to F689 Free of Accident Hazards/Supervision/Devices, for failure to protect Resident 1 from an avoidable elopement. The facility implemented the following interventions that were initiated on 06/29/2026 and corrected by 06/30/2026:-Resident 1 was safely located at a hospital following the elopement.-Resident 1 will be placed on one-to-one supervision in the event of a return to the facility.-The Iidentified security staff was educated on checking the facility elopement book at the beginning of every scheduled shift to identify newly identified residents at risk for elopement or other revisions.-Facility wide audits were conducted to ensure that all residents identified as an elopement risk have been appropriately identified and have appropriate interventions in place.-Alike residents have had their elopement evaluations and care plans reviewed to ensure accuracy.-Facility elopement books have been reviewed and audited for accuracy.-All-staff education on the facility's elopement policy and procedures was completed.-Security personnel/reception have been educated on checking the elopement book at the start of every shift to ensure that they were aware of updates or changes.-Periodic audits of random staff interviews would be conducted to ensure elopement policy and procedure were understood and to ensure compliance with the plan of correction.-Plan for reviewing and reporting of audit findings to the facility's Quality Assurance and Performance Improvement Program meeting scheduled for 07/16/2026, for continued quality improvement.Findings included.Review of a face sheet showed Resident 1 admitted to the facility on [DATE] with diagnosis that included anxiety disorder (a condition where worry, fear or nervousness becomes too strong, happens often, or lasts too long, and it starts to interfere with daily life).Review of an assessment titled, Brief Interview for Mental Status (BIMS - a tool used in nursing homes to measure memory and thinking ability), dated 06/26/2026, showed that Resident 1 was assessed as severely impaired with making decisions regarding tasks of daily life. It further showed that Resident 1 had a BIMS score of five out of 15, which indicated noticeable problems with memory, recall and orientation.Review of an assessment titled, Elopement Risk Evaluation, dated 06/25/2026, showed that Resident 1 was identified as an elopement risk and that Resident 1 has wandered in the past month. It further showed that Resident 1 was assessed to exhibit sign of wanting to the leave.Review of Resident 1's elopement care plan, dated 06/26/2026, showed that Resident 1 was an elopement risk related to impaired cognition and active exit seeking behaviors.Review of an investigation summary report titled, Elopement, dated 06/29/2026, showed that Resident 1 was appropriately identified as an elopement risk.Security guard did not review update to elopement book and inadvertently assisted resident in exiting building. It showed that Resident 1 left the facility around 3:20 AM on 06/29/2026. It further showed that Resident 1 was located at [Name of Hospital], approximately six blocks (11-14 minute walk) from the facility.In an interview on 07/13/2026 at 1:33 PM, Staff B, Resident Care Manager, stated that Resident 1 was identified in the facility's elopement books and that an elopement book was available to all staff including the security guards. When asked if there were hazards to Resident 1 leaving the facility without supervision on 06/29/2026, Staff B stated, Yes [Resident 1] was walking unattended, and that Yes, there were hazards. Staff B further stated, I think the security guard could have paged the floor nurse and said something.In an interview on 07/13/2026 at 1:49 PM, Staff A, Administrator, stated that Resident 1 was Identified as elopement risk due to confusion.we already identified that it was not safe for [Resident 1] to be alone. Staff A further stated, My expectation is that the staff follow the elopement process by reviewing the elopement binder at the start of their shift.Reference: (WAC) 388-97-1060 (3)(g).

Based on interview and record review, the facility failed to provide/administer medication for 1 of 7 residents (Resident 1), reviewed for significant medication error. Resident 1 experienced harm when they did not receive their steroid medication (used to reduce swelling), had a sudden change in condition and was transported/admitted to the hospital where they were diagnosed with adrenal crisis (a serious medical condition caused by a sudden stoppage of steroid medication). This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included . A review of the admission record dated 04/03/2026 showed Resident 1 was admitted to the facility on [DATE] from the hospital with a diagnosis list that included Mucopurulent Chronic Bronchitis (a severe form of bronchitis [inflamed airway tubes in the lungs]). A review of the hospital discharge medication list dated 04/03/2026 showed a physician's order for Methylprednisolone (steroid medication) give 40 milligrams (mg-a unit of measurement) IV (intravenous administration of fluids and/or medications directly into the bloodstream) daily, start taking on 04/04/2026. Review of the April 2026 Electronic Medication Administration Record (EMAR) showed a physician's order for Methylprednisolone 40 mg IV daily, with a start date of 04/04/2026. The EMAR further showed that on 04/04/2026 and 04/05/2026 they were marked 00's [the steroid medication was on order from the pharmacy and were not administered]. Review of a nursing progress note in the electronic medical record dated 04/06/2026 showed Resident 1 had a sudden change of condition and emergency services were called, and Resident 1 was transported to the hospital. Review of the hospital summary report dated 04/06/2026 showed Resident 1 was admitted to the medical intensive care unit of the hospital due to hypotensive shock (a life-threatening emergency that causes inadequate blood flow to vital organs). The hospital summary report further showed Resident 1's hypotensive shock was ultimately thought to be secondary due to adrenal crisis in the setting of not receiving IV steroids at the facility to which they were discharged to on 04/03/2026. In an interview on 05/05/2026 at 11:33 AM with Staff C, Licensed Practical Nurse, stated that if a medication was not delivered from the pharmacy to the facility, they would check the emergency medication kit and depending on the medication that was ordered, the resident may need to be sent to the hospital to prevent a change of condition.A joint record review and interview on 05/05/2026 at 1:50 PM with Staff E, Registered Nurse/Unit Manager, showed a physician's order for Methylprednisolone 40 mg IV daily, with a start date of 04/04/2026. The EMAR further showed the medication had not been administered on 04/04/2026 or 04/05/2026 as ordered. Staff E stated they found out that the medication had not been administered to Resident 1 on 04/06/2026, after they had been transported to the hospital by emergency services for a change of condition. Staff E further stated Resident 1's change of condition and hospitalization could have potentially been caused by the missed steroid medication. A joint record review and interview on 05/06/2026 at 3:27 PM with Staff B, Director of Nursing Services, showed the hospital summary in the electronic medical record dated 04/06/2026, revealed that Staff B concurred [agreed] with the hospital summary that showed Resident 1's shock was ultimately thought to be secondary due to adrenal crisis in the setting of not receiving IV steroids at the facility to which they were discharged to on 04/03/2026. In an interview on 05/06/2026 at 3:43 PM with Staff A, Administrator, stated their expectation was for the nurses to give medications as ordered by the physician. Reference: (WAC) 388-97-1060(3)(k)(iii) .

Based on record review and interview, the facility failed to ensure pharmacy services were provided to meet the needs of 5 of 7 residents (Residents 2, 3, 4, 6 and 7), reviewed for medication administration. The failure to administer and/or document medication administration in accordance with professional standards of practice placed the residents at risk for negative outcomes and a diminished quality of lifeFindings included .Review of the facility policy titled, Medication Administration General Guidelines, dated 01/26 [January 2026] showed, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. The individual who administers the medication dose records the administration on the resident's MAR [Medication Administration Record] immediately following the medication being given. Review of the investigation report dated 04/28/2026 showed it was reported that two identified nurses allegedly did not administer medications as ordered by the physician for Residents 2, 3, 4, 6 and 7. The report further showed that the two identified nurses indicated on the MAR that the medications were administered for Residents 2, 3, 4, 6 and 7. RESIDENT 2 Review of the investigation report dated 04/28/2026 showed Resident 2 had a brain injury that caused a vegetative state (a medical disorder when a person is awake but shows no signs of awareness). The report showed the resident had a diagnosis of heart failure, diabetes (inability to control blood sugar in the body) and high blood pressure among other diagnoses. Further review of the report showed Resident 2 potentially missed their morning medications on 04/25/2026 for Spironolactone (medication used to release excess fluids from the body) 12.5 milligrams (mg-a unit of measurement) Metoprolol (medication used to treat high blood pressure) 50 mg give two tablets, Metformin (medication used to control blood sugar)1,000 mg and Warfarin (medication used to treat heart disease) 1 mg, the investigation report showed the medications were not given to Resident 2. RESIDENT 3 Review of the investigation report dated 04/28/2026 showed Resident 3 had a brain injury that caused a vegetative state and was dependent on staff for all care which included medication management. The report showed Resident 3 potentially missed their morning medication on 04/25/2026 for Levetiracetam (medication used to treat seizures [excessive activity in the brain]) 1,000 mg. Further review of the report showed that the medication was documented as administered on the MAR, however, the investigation report showed the medication was not given to Resident 3. RESIDENT 4 Review of the investigation report dated 04/28/2026 showed Resident 4 had a brain injury that caused a vegetative state and was dependent on staff for all care which included medication management. The report showed Resident 4 potentially missed their morning medication on 04/25/2026 for Lisinopril (medication used to treat high blood pressure) 20 mg. Further review of the report showed that the medication was documented as administered on the MAR, however, the investigation report showed the medication was not given to Resident 4. RESIDENT 6Review of the investigation report dated 04/28/2026 showed Resident 6 had diagnoses that included heart disease and diabetes and was dependent on staff for all care which included medication management. Review of the investigation report dated 04/28/2026 showed Resident 6 potentially missed their medications on 04/25/2026 and 04/26/2026 for Carvedilol (medication used to treat high blood pressure)12.5 mg, Lisinopril 5 mg, Apixaban (medication used to reduce the risk of heart attack) 5 mg and Metformin 1,000 mg. The report further showed that the medications were documented as administered on the MAR, however, the investigation report showed the medications were not given to Resident 6. RESIDENT 7Review of the investigation report dated 04/28/2026 showed Resident 7 had a brain injury and high blood pressure. The report showed Resident 7 was dependent on staff for all care which included medication administration. The report showed Resident 7 potentially missed their medications on 04/25/2026 and 04/26/2026 for Amlodipine (medication used to treat high blood pressure) 5 mg. The report further showed the medication was documented as administered on the MAR, however, the investigation report showed the medication were not given to Resident 7. Review of the investigation summary report/findings dated 05/01/2026 showed that Residents 2, 3, 4, 6 and 7 did not receive their medications as ordered by their physician. In an interview on 05/06/2026 at 1:49 PM with Staff F, Licensed Practical Nurse/Unit Manager, stated they did the investigation report dated 04/28/2026. Staff F stated the investigation report was initiated on 04/28/2026 because it was alleged that two identified nurses were documenting on the MAR that medications were administered, however, it was observed that Residents 2, 3, 4, 6, and 7's medications remained on the medication carts after the identified nurses had documented they administered the medications.In an interview on 05/06/2026 at 3:09 PM, Staff B, Director of Nursing Services, stated Residents 2, 3, 4, 6 and 7's medications were not administered, and it was confirmed that they were not given. Staff B further stated all necessary people/agencies were notified and the identified nurse's employment at the facility had been terminated.Reference: (WAC) 388-97-1060(3)(k)(iii) .

Based on interview and record review, the facility failed to ensure the physician was notified when the facility's pharmacy could not provide medication for 1 of 7 residents (Resident 1), reviewed for significant medication error. The failure to notify the physician when the pharmacy could not provide a steroid medication (used to reduce swelling) placed the resident at risk for unmet care needs and a diminished quality of life.Findings included . A review of Resident 1's admission record dated 04/03/2026 showed they were admitted to the facility on [DATE] from the hospital with a diagnosis list that included Mucopurulent Chronic Bronchitis (a severe form of bronchitis [inflamed airway tubes in the lungs]). A review of the hospital discharge medication list dated 04/03/2026 showed a physician's order for Methylprednisolone (a steroid medication) give 40 milligrams (mg-a unit of measurement) IV (intravenous administration of fluids and/or medications directly into the bloodstream) daily, start taking on 04/04/2026. Record review of the April 2026 Electronic Medication Administration Record (EMAR showed a physician's order for Methylprednisolone 40 mg IV daily, with a start date of 04/04/2026 revealed that on 04/04/2026 and 04/05/2026 they were marked OO's [the steroid medication was on order from the pharmacy and were not administered]. Record review of a nursing progress notes dated 04/04/2026 and 04/05/2026 did not show that the physician had been notified when the medication was on order from the pharmacy and could not be administered to Resident 1. In interview on 05/05/2026 at 11:33 AM with Staff C, Licensed Practical Nurse (LPN), stated that if a medication was not available they would contact the physician and let them know the pharmacy did not deliver the medication and that the medication was not in the facility emergency medication kit. Staff C further stated that the physician might change the medication to one that was in the facility or change the times or dates of the prescribed medication. In an interview on 05/05/2026 at 12:04 PM, with Staff D, LPN, stated that if a medication was not available they would notify the physician to see if the medication could be changed to a medication that was in stock at the facility.A joint record review and interview on 05/05/2026 at 1:50 PM with Staff E, Registered Nurse/Unit Manager, showed a physician's order for Methylprednisolone 40 mg IV daily, with a start date of 04/04/2026 had not been administered on 04/04/2026 and 04/05/2026 as ordered. Review of the nursing progress notes dated 04/04/2026 through 04/05/2026 did not show that the physician had been notified when the medication was not available from the pharmacy or of the missed medication. Staff E stated the physician should have been notified when the pharmacy did not deliver the medication. Staff E further stated the physician would have been able to change the medication order to something that was available in the facility's emergency medication kit, change the route of the medication or maybe the time of the medication. In an interview on 05/06/2026 at 3:27 PM with Staff B, Director of Nursing Services, stated the nurses were expected to notify the physician when the medication was not administered to Resident 1 on 04/04/2026 and 04/05/2026. Staff B further stated the physician may have changed the order to a medication that was available or provided orders to transport Resident 1 back to the hospital until the medication was available in the facility. In an interview on 05/06/2026 at 3:43 PM with Staff A, Administrator, stated the nurses were expected to notify the physician when medications were not administered to the residents. Reference: (WAC) 388-97-0320 (1)(b)Refer to F760 - Residents are Free of Significant Medication Errors

Based on interview and record review, the facility failed to ensure a resident was protected from misappropriation of controlled (narcotic or opioid) pain medication for 1 of 3 residents (Resident 1), reviewed for misappropriation of controlled medications. This failure placed the resident at risk in unmet care needs, ongoing misappropriation of medications, and a diminished quality of life.Findings included.Review of the facility's policy titled, Freedom from Abuse, Neglect.Misappropriation of Resident Property. updated March 2025, showed that an example of misappropriation of resident property included Missing prescription medications or diversion of a resident's medications, including, but not limited to, controlled substances for staff use or personal gain.Review of the facility's investigation summary titled, Allegation of Misappropriation of Property, dated 03/23/2026, showed Staff B, Registered Nurse, documented administration of a controlled substance for Resident 1 and that [Resident 1] had no active [physician] orders for such medication [controlled substance] to be administered. It further showed that Resident 1's Medication Administrator Records did not show documentation related to the administration of the controlled substance and that the Facility suspected potential drug diversion by [Staff B].[Staff B] claimed to have administered a controlled medication to a patient [Resident 1] that had no valid physician order with no documentation whether it was given or not.In an interview on 04/17/2026 at 1:17 PM, Staff A, Director of Nursing, stated that an investigation concerning misappropriation of property involving Staff B resulted from an audit of Resident 1's electronic health records. Staff A stated that misappropriation of property was not ruled out and that .[Staff B] was not able to provide an explanation of where the medication [controlled substance] was. Staff A further stated they expected residents would be free from abuse, including misappropriation of property.Reference: (WAC) 388-97-0640 (2)(a), (3)(c)(d).

Based on interview and record review, the facility failed to ensure residents were free from misappropriation of controlled (narcotic or opioid) medication for 4 of 5 residents (Residents, 1, 2, 3 & 4), reviewed for misappropriation of controlled medications. This failure placed the residents at risk for pain, unmet care needs, ongoing misappropriation of medications, and a diminished quality of life.A past noncompliance was initiated on 02/20/2026 related to F602-Free from Misappropriation/Exploitation, for failure to protect Residents 1,2,3 and 4 from misappropriation of medications. The facility implemented the following interventions, which were initiated on 02/20/2026 and fully corrected by 03/02/2026:-Resident 1 was promptly assessed to rule out ingestion of narcotic medication.-The facility reconciled all narcotic medication inventory logbooks, and residents who received narcotic medications were assessed for pain. Any residents identified as potentially affected by misappropriation were followed up with as required. -The facility's narcotic inventory records were transferred into new logbooks, and the previous books were retired. -Resident 2, Resident 3, and Resident 4 were identified to be potentially affected by misappropriation of narcotic medication through interviews with residents and staff.-All identified residents were assessed and monitored for pain.-The facility arranged for their pharmacy to bill the facility for the identified residents' controlled medications for February 2026. -The identified staff was suspended pending investigation and subsequently terminated due to suspicion of diverting residents' narcotic medications.-Licensed nurses were re-educated on the facility's Abuse, Neglect and Misappropriation policy, as well as the procedures for documentation, receipt, transferred, destruction and endorsement of controlled substances (narcotic medications). -Periodic audits of residents with prescribed narcotic medications were initiated and conducted weekly for a duration of four weeks and then conducted monthly for a duration of two months to ensure compliance with the plan of correction. -Completed audits were reviewed during the facility's Quality Assurance and Performance Improvement Program (QAPI) meeting on 03/23/2026. - Plan for reviewing and reporting to the facility's QAPI future meetings for continued quality improvement.Findings included.Review of the facility's policy titled, Freedom from Abuse, Neglect.Misappropriation of Resident Property. updated March 2025, showed that an example of misappropriation of resident property included Missing prescription medications or diversion of a resident's medications, including, but not limited to, controlled substances for staff use or personal gain.RESIDENT 1 Review of the facility's investigation summary titled, Drug Diversion, dated 02/20/2026, showed Resident 1 did not have an active order for a narcotic medication but he was given a narcotic medication by Staff B, Licensed Practical Nurse, on the night of 02/19/2026 and that he was certain that it wasn't [was not] and he did not ask nor need it. It further showed, A review of [Resident 1's] current physician orders, February 2026 MAR [Medication Administration Record] and facility Narcotic book showed [Staff B] entered the order in PCC [Point Click Care - An electronic health record system] on her own without a provider's authorization. It further showed that Staff B was immediately suspended pending the result of the investigation for potential narcotic diversion, and for entering [physician] orders without a valid [physician] order.RESIDENT 2 Review of the facility's investigation summary titled, Drug Diversion, dated 02/20/2026, showed that Resident 2's February 2026 MAR showed as needed narcotic pain medication was administered on the night of 02/19/2026. It further showed that [Resident 2] stated that he did not ask for [narcotic medication] during the night shift and did not receive any.RESIDENT 3 Review of the facility's investigation summary titled, Drug Diversion, dated 02/20/2026, A review of the narcotic book documentation showed [Staff B] gave two doses of 15 mg [mg-a unit of measurement] of [narcotic medication] on 01/07/2026 and on 01/21/2026 [to Resident 3]. However, in an interview on 02/20/2026 at 10:00 AM, [Resident 3] stated that the nurses (all nurses) only gave her two tablets, and she never asked for three tablets (15 mg).RESIDENT 4 Review of the facility's investigation summary titled, Drug Diversion, dated 02/20/2026, showed that Resident 4 was interviewed on 02/20/2026 and that he stated that he did not receive pain medication from Staff B on 02/15/2026 at 6:00 AM, as requested. It further showed that Resident 4 stated, [Resident 4] remembered asking [Staff B] about it but was told he already took them.In an interview on 04/03/2026 at 12:45 PM, Staff A, Director of Nursing, stated that discrepancies identified in Resident 1's February 2026 MAR and physician orders for narcotic medications prompted the investigation into potential drug diversion involving Staff B. Staff A further stated that as a result of the investigation, it was concluded that Staff B practiced outside her license by putting in a [physician] order with the intent of misappropriating medication. When asked if misappropriation of resident property was not ruled out for Residents 1, 2, 3 and 4, Staff A stated, Yes, the intent of misappropriation was admitted by [Staff B] during the investigation. Staff A stated that they expected residents to be free from abuse, including misappropriation of property, and that facility nurses would follow standards of practice free from professional misconduct.Reference: (WAC) 388-97-0640 (2)(a), (3)(c)(d).

Based on interview and record review, the facility failed to ensure that two-person assistance was provided for bed mobility for 1 of 3 residents (Resident 1), reviewed for accident prevention. This failure to provide adequate supervision during repositioning in bed resulted in harm to Resident 1, who experienced an avoidable accident that caused a head injury requiring hospitalization and was found to have a new Left Frontal Intraparenchymal Hemorrhage (L F IPH - bleeding inside the left front part of the brain), leading to unintended health complications and a reduced quality of life.A past noncompliance was initiated on 01/18/2026 related to F689 Free of Accident Hazards/Supervision/Devices, for failure to protect Resident 1 from an avoidable accident. The facility implemented the following interventions that were initiated on 01/18/2026 and corrected by 01/21/2026:-Resident 1 was promptly transported to the hospital for medical evaluation and treatment.-The identified staff was suspended pending an investigation of the incident.-The identified staff was provided one on one reeducation regarding identifying and following plan of care for each resident before they returned to work.-Care observations of other residents were conducted to ensure staff provided care as determined by the residents' plan of care.-Audits were completed for a 30-day look-back on past falls and injuries to identify other residents affected by the failed practice.-Staff were educated on identifying and following plan of care for each resident as identified in their plan of care. -Periodic audits of resident care observations were initiated and will be conducted weekly for a duration of four weeks and then conducted monthly for a duration of two months to ensure compliance with the plan of correction. -Plan for reviewing and reporting to the facility's Quality Assurance and Performance Improvement Program meeting scheduled for 02/23/2026, for continued quality improvement.Findings included.Review of a face sheet showed Resident 1 admitted to the facility on [DATE] with diagnoses that included aphasia (a condition where a person has trouble speaking, understand words, read, or write) following cerebral infarction (a blocked blood vessel in the brain that causes brain damage), and encephalopathy (a condition that affects normal brain function).Review of Resident 1's Activities of Daily Living care plan, revised on 03/22/2023, showed she was two-person assist dependent for bed mobility due to limited/impaired mobility.Review of Resident 1's quarterly Minimum Data Set (an assessment tool), dated 12/26/2025, showed she was dependent (the assistance of two or more helpers was required for the resident to complete the activity) to complete the task to roll from lying on back to left and right side, and return to lying on back on the bed.Review of a facility provider acute care note dated 01/18/2026, showed Resident 1 chronically received anticoagulant (blood thinner) medication for valvular atrial fibrillation (a condition affecting heart valves and causes an irregular heartbeat).Review of Resident 1's nursing progress note dated 01/18/2026 showed, [Resident 1] fell from the bed and hit the back of her head resulting in a 2 cm [centimeter - a unit of measurement] laceration [cut in the skin], and that Resident 1 was sent to the hospital for further evaluation. It further showed that the progressed note was written by Staff B, Weekend Nurse Manager.Review of hospital records titled, History and Physical - Critical Care, dated 01/18/2026, showed Resident 1 presented to the Emergency Department, after a fall from bed at SNF [Skilled Nursing Facility] found to have new L F IPH that increased slightly in size on 4hr [four hour] repeat scan [CT-Computed Tomography- medical imaging of the brain] with increased ventricles [four small, connected spaces inside the brain that hold and move fluid] size as compared to previous scan in 2019.Review of the facility's investigation summary report dated 01/18/2026, showed Staff B received a statement from Staff C, Certified Nursing Assistant (CNA), regarding Resident 1's incident on 01/18/2026. It further showed, Spoke with CNA about the event. I asked her if she had help while providing care for [Resident 1]. She said no. She stated that she had not turned her she was just trying to reposition her to the middle of the bed. She stated the patient [resident] slid off the side of the bed.Review of a training record, titled, CNA Competency Turning and Repositioning, dated 09/08/2025, showed that Staff C received training to lower head of bed, appropriate. Stand on the opposite side of the bed in which they will turn them. Lower bed rail, as a step in completing a turning and repositioning task.In an interview on 02/09/2026 at 12:52 PM, Staff B stated that Resident 1 was full dependence for bed mobility assistance and that repositioning her in bed required two-person assist to complete the task safely. When asked what contributed to Resident 1's fall out of bed on 01/18/2026, Staff B stated, [Staff C] said, when she went to pull [Resident 1] that's when [Resident 1] slid off the bed, and that I would expect [Staff C] to wait for second person to help. Staff B further stated that they expected staff would follow the resident's plan of care to make sure two-person assist is followed for bed mobility.In an interview on 02/10/2026 at 4:02 PM, Staff C was asked about the circumstances of Resident 1's incident on 01/18/2026, Staff C stated, I noticed she was at the edge of the bed on the left side.I pushed her upper body towards the middle of the bed, then I went around to the right side of the bed and used the draw sheet to pull her towards me. When asked what steps were taken to position the bed before repositioning Resident 1, Staff C stated, I didn't [did not] use any of the controls of the bed before repositioning [Resident 1], and that Resident 1's head of the bed was not lowered from a raised position prior to repositioning her. When asked when Staff C called for help from other staff, Staff C stated, I did not call for help at that moment, I called for help after the incident, when [Resident 1] slid out of the bed. Staff C further stated that Resident 1 slid off the bed from the left side while Staff C was standing on the right side of the bed. When asked if Resident 1's sliding off the bed could have been prevented, Staff C stated, If there was someone else there, then we would have been able to position her together and someone could have acted as a barrier on the side where she slid from, the left side.In a joint record review and interview on 02/11/2026 at 12:21 PM with Staff D, Nurse Practitioner, showed hospital records titled, History and Physical - Critical Care, dated 01/18/2026, showed Resident 1 presented to the Emergency Department, after a fall from bed at SNF found to have new L F IPH that increased slightly in size on 4hr repeat scan with increased ventricles size as compared to previous scan in 2019. Staff D stated, Because of the fall on 01/18/2026, the size of [Resident 1's] ventricles increased in size, showing swelling to the brain, and that Resident 1's anticoagulant medication was held [stopped] because [anticoagulant medication] can cause bleeding. When asked if the Resident 1's fall with a head injury caused the newly found bleeding in her brain, Staff D stated, From the notes, yes, after the fall, [Resident 1] was found to have new bleeding [in the brain].In an interview on 02/11/2026 at 12:32 PM, Staff A, Director of Nursing, stated [Resident 1] fell and ended up in the hospital with an injury, and that the incident happened when [Staff C] saw [Resident 1] sliding off the bed, came in and repositioned [Resident 1], however in the process of correcting [Resident 1's] position, [Resident 1] fell. When asked if Resident 1's 01/18/2026 fall was an avoidable accident, Staff A stated, Yes. Staff A further stated that Resident 1 was assessed to require two-person assistance with bed mobility. When asked if Staff C ensured Resident 1 received adequate supervision in accordance with their plan of care, Staff A stated, No she could have called for a second person.Reference: (WAC) 388-97-1060 (3)(g).

Based on observation, interview, and record review, the facility failed to provide necessary assistance with Activities of Daily Living (ADL) for 4 of 10 residents (Residents 4, 33, 7 & 23) reviewed for ADLs. The failure to provide residents who were dependent on staff for assistance with personal hygiene placed the residents at risk for unmet needs and a diminished quality of life.Findings included. NAIL CARERESIDENT 4Review of Resident 4's comprehensive care plan, revised on 08/05/2025, showed that Resident [Resident 4] will have ADL needs met. It further showed that Resident 4 needed extensive assistance with grooming. Observations on 09/04/2025 at 8:10 AM and on 09/08/2025 at 9:00 AM, showed Resident 4 had brown matter under their nails on their right hand. Observation on 09/09/2025 at 10:30 AM, showed Resident 4 coming back from the shower room. It further showed that Resident 4 had brown matter under their nails on their right hand. In an interview and joint observation on 09/10/2025 at 10:55 AM, Staff X, Certified Nursing Assistant (CNA), stated that CNAs were responsible for cleaning hands, including under nails for dependent residents. Joint observation of Resident 4's hands showed that Resident 4 had brown matter under their nails on their right hand. Staff X stated that the nails on Resident 4's right hand looked dirty. In an interview on 09/10/2025 at 1:34 PM, Staff Y, Registered Nurse (RN), stated that they did not expect there to be brown matter under Resident 4's nails and they should be clean. In an interview on 09/10/2025 at 1:50 PM, Staff F, Resident Care Manager (RCM), stated that they expected staff to help dependent residents with ADLs, including nail care and washing hands. Staff F further stated that they would not expect there to be brown matter under Resident 4's nails after they had a shower. In an interview on 09/11/2025 at 11:30 AM, Staff B, Director of Nursing, stated that they expected staff to provide ADLs for dependent residents, including cleaning their hands/nails. Staff B further stated that they expected them [staff] to provide the needs for the residents if they can't [cannot] do it themselves. RESIDENT 33Review of the significant change in status Minimum Data Set (MDS – an assessment tool) dated 08/20/2025 showed that Resident 33 readmitted to the facility on [DATE] with diagnoses that included persistent vegetative state (a condition where a person is awake but shows no signs of awareness or cognitive function), type 2 diabetes, and contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) of the muscle. It further showed that Resident 33 had functional limitation in range of motion to both sides of their upper extremities and was dependent on staff for personal hygiene. Review of Resident 33's baseline care plan intervention dated 11/09/2022, showed to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. In an interview on 09/04/2025 at 9:52 AM, Resident 33's representative stated that Resident 33 liked their nails short. Observations on 09/04/2025 at 9:26 AM, on 09/05/2025 at 2:38 PM, on 09/08/2025 at 8:59 AM, on 09/09/2025 at 9:34 AM and on 09/10/2025 at 10:35 AM, showed Resident 33's fingernails on both hands were long. In an interview and joint observation on 09/10/2025 at 10:43 AM, Staff S, CNA, stated that they followed the resident's care plan. Staff S stated that they provided nail care as needed and that if a resident had diabetes, the nurses would do it. Joint observation of Resident 33's fingernails showed that they were long on both hands. Staff S stated, They're [they are] really long and that they would notify the nurse. In an interview on 09/10/2025 at 2:24 PM, Staff N, LPN, stated that they provided nail care to residents who had diabetes and that the CNA provided nail care to residents who did not have diabetes. Staff N stated that they provided nail care during skin checks and as needed if they were too long. Staff N stated that they trimmed Resident 33's fingernails and when asked if Resident 33's fingernails were long, Staff N stated, Yes, that's [that is] why I trimmed them. In an interview and joint record review on 09/11/2025 at 8:57 AM, Staff E, RCM, stated that their process for nail care was that they would follow the physician orders and as needed. If a resident did not have an order, they would follow general practice. Staff E stated that the nurses would provide nail care for residents with diabetes and those who did not have diabetes, the CNA would provide them. Staff E stated that staff would assess during care/showers and that if their fingernails were too long, they would ask the residents if they would like nail care to be provided. Staff E stated that nail care would be included in their care plan. Joint record review of Resident 33's care plan showed to check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. Staff E further stated that they would have expected nursing to have provided nail care if Resident 33's fingernails were long. In an interview on 09/11/2025 at 9:44 AM, Staff B stated that they expected nail care to be provided weekly and as needed during bath days. RESIDENT 7 Resident 7 was admitted to the facility on [DATE] with diagnoses to include anoxic brain injury (a severe condition that occurs when the brain is deprived of oxygen for a prolonged period and can lead to cognitive impairment and/or paralysis [medical condition characterized by the loss or impairment of voluntary movement and sensation in one or more parts of the body]) and Type II Diabetes (a condition characterized by persistently high blood sugar). Review of the quarterly MDS dated [DATE] showed Resident 7 had severely impaired cognition and was dependent on staff for ADLs. Review of Resident 7's care plan for ADLs, revised on 09/03/2025, showed interventions for diabetic nail care weekly and as needed, with referral to a podiatrist (foot doctor) if staff were unable to provide the care.Observation on 09/02/2025 at 2:00 PM showed Resident 7's right and left-hand fingernails were long and untrimmed. In an interview and joint observation on 09/09/2025 at 11:10 AM, Staff Z, Licensed Practical Nurse (LPN), stated they followed the resident's care plan and that nurses were responsible for providing weekly diabetic nail care. Staff Z further stated that if they could not trim or file down the nails, they would refer the resident to a podiatrist. A joint observation showed Resident 7's right and left-hand fingernails were long. Staff Z stated Resident 7's fingernails needed to be trimmed or filed down. ORAL CARERESIDENT 23 Resident 23 was admitted to the facility on [DATE] with diagnosis that included diffuse traumatic brain injury (a brain injury that can lead to disability and cognitive issues). Review of the quarterly MDS dated [DATE] showed Resident 23 had severely impaired cognition and was dependent on staff for ADLs.Observations on 09/05/2025 at 8:09 AM and 2:23 PM, and on 09/08/2025 at 9:49 AM, showed Resident 23's mouth was wide open with dry brown crust on their tongue.In an interview and joint observation on 09/08/2025 at 10:32 AM, Staff BB, Respiratory Therapist, stated they were responsible for oral care on all residents on ventilator machines (a medical procedure that uses a machine to assist or replace spontaneous breathing). Staff BB further stated that oral care was provided once a shift and as needed. A joint observation showed Resident 23's tongue had brown crust and dry yellow mucus hanging on the roof of the mouth. When asked if Resident 23's mouth looked clean, Staff BB stated, no.In an interview on 09/10/2025 at 10:05 AM, Staff B, stated staff were expected to follow the care plan and check nails weekly to ensure they were not long and to trim or file them down. Staff B further stated that oral care should have been completed for Resident 23. Reference: (WAC) 388-97-1060 (2)(c) .

Based on observation, interview, and record review, the facility failed to ensure Enhanced Barrier Precautions (EBP-precaution to protect residents from multidrug-resistant organism [a germ that is resistant to medications that treat infections]) practices were followed for 1 of 1 resident (Resident 77), failed to ensure sharps were disposed of properly for 1 of 3 shower rooms (Second Floor Shower Room) and for 1 of 2 clean utility rooms (First Floor Clean Utility Room), reviewed for infection control. In addition, the facility failed to ensure proper hand hygiene/glove use practices were followed for 1 of 3 residents (Resident 2) and for 1 of 3 staff (Staff Q). These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.Findings included. EBPReview of the facility's policy titled, Enhanced Barrier Precautions, revised on 03/26/2024, showed that Enhanced Barrier Precautions (EBP) are used in conjunction with standard precautions and expand the use of PPE [Personal Protective Equipment-gown, gloves, masks] to donning [putting on] of gown and gloves during high-contact resident care activities. It showed that EBP are indicated for residents with indwelling medical devices including tracheostomies (a surgical procedure that creates an airway through the neck). It showed that EBP requires use of gown and gloves during high-contact resident care activities including transferring residents. It further showed that when EBP are implemented, the appropriate notice [is posted] on the room entrance door.so that all personnel will be aware of precautions. Review of Resident 77's comprehensive care plan, revised on 06/05/2025, showed that the resident has a tracheostomy. Observation on 09/03/2025 at 9:28 AM, showed no EBP signage outside Resident 77's room. Observation and interview on 09/05/2025 at 8:27 AM, showed no EBP signage outside Resident 77's room. Staff V, Certified Nursing Assistant (CNA), entered Resident 77's room, without wearing a gown or gloves, while they delivered Resident 77's meal tray. Staff V then assisted Resident 77 to sit up in bed and had contact with the resident's body and clothes. When asked if Resident 77 was on EBP, Staff V stated, there's [there is] no sign. I don't [do not] work over here, so I don't know. Staff V further stated that Resident 77 had a tracheostomy and when asked if they wore PPE when moving Resident 77 from laying to sitting up in bed, Staff V stated, no. In an interview on 09/11/2025 at 8:08 AM, Staff B, Director of Nursing, stated that they expected staff to use gowns and gloves if they were going to have high contact with a resident on EBP, which included repositioning them in bed. Staff B stated that if staff did not see EBP signage and a resident had a tracheostomy, staff should clarify with a nurse. SHARPS DISPOSALReview of the facility's policy titled, Regulated Waste Labeling and Disposal, last revised on 03/24/2025, showed, Regulated waste is labeled and disposed of in accordance with applicable Occupational Safety and Health Administration (OSHA) regulations. Regulated waste is contained, stored and transported in a manner that protects personnel from exposure to blood or other potentially infectious material (OPIM). The policy showed semi-liquid blood or other OPIM contaminated items and contaminated sharps are considered as regulated waste. The policy further showed regulated waste must be placed in containers which are closable and labeled or color coded in accordance with OSHA regulation. SHARPS DISPOSAL-SECOND FLOOR SHOWER ROOMObservation on 09/03/2025 at 11:18 AM, showed the Second Floor Shower Room, had a red sharps container that was not secured and was on the ground. It further showed that the sharps container had an opening on the lid and was filled with used razors; the used razors were accessible through the opening. Joint observation and interview on 09/04/2025 at 2:08 PM with Staff W, CNA, showed the Second Floor Shower Room, had red sharps container that was not secured and was on the ground. It further showed that the sharps container had an opening on the lid and was filled with used razors; the used razors were accessible through the opening. Staff W stated that they disposed of used razors in the red sharps container and described it as open and that the container should be covered. Joint observation and interview on 09/05/2025 at 1:25 PM with Staff C, Infection Preventionist, showed the Second Floor Shower Room, had a red sharps container that was not secured and was on the ground. It further showed that the sharps container had an opening on the lid and was filled with used razors; the used razors were accessible through the opening. Staff C stated that the sharps container should be secured, and it should not be on the floor. Staff C stated it can be an infection risk. In an interview on 09/09/2025 at 1:45 PM, Staff B stated that they expected the sharps container to be secured and has to meet standards, where you can put [sharps] in and can't [cannot] get them back out. SHARPS DISPOSAL-FIRST FLOOR CLEAN UTILITY ROOMObservations on 09/04/2025 at 10:18 AM and on 09/05/2025 at 11:12 AM, showed a full sharp container containing contaminated sharps and used blood draw items stored in the bottom cabinet of the First Floor Clean Utility Room. In an interview on 09/05/2025 at 1:15 PM, Staff T, Licensed Practical Nurse, stated that full sharp containers would be stored in biohazard bin located in the dirty utility room. In an interview and joint observation on 09/05/2025 at 1:28 PM, Staff C stated that a full sharp container would be stored in the biohazard bin located in the dirty utility room and should not be stored in the clean utility room. Joint observation at 1:38 PM showed there was a full sharp container containing contaminated sharps and used blood draw items that was stored in the bottom cabinet of the First Floor Clean Utility Room. Staff C stated that the sharp container should not have been stored in the clean utility room. In an interview on 09/10/2025 at 2:38 PM, Staff B stated that that they expected full sharp containers to be disposed in the biohazard bin located in the dirty utility room and should not have been stored in the clean utility room. HAND HYGIENE/GLOVE USEReview of the facility's policy titled, Handwashing/Hand Hygiene, updated in August 2025, showed, Hand hygiene is performed as soon as feasible, after hands become contaminated and frequently during the working day. Examples of situations when hand hygiene is performed, includes but is not limited to.Before and after handling invasive devices.Before and after dressing change/wound care.After contact with potentially contaminated surfaces or items in the resident's environment.After removing gloves. It further showed, The use of gloves does not replace hand washing/hand hygiene. RESIDENT 2Observation on 09/08/2025 at 2:37 PM, showed Staff R, Respiratory Therapist, applied new gloves and assessed Resident 2's inner cannula (a removable thin tube inside their tracheostomy). Staff R then removed the dressing that was on each side of Resident 2's tracheostomy, took a gauze (a woven cloth used for wound care) and wiped off the secretions that were on Resident 2's neck and tracheostomy. When Staff R was done, they removed their gloves and applied new gloves without performing hand hygiene. Staff R then applied a new dressing on each side of Resident 2's tracheostomy. In an interview on 09/08/2025 at 4:27 PM, Staff R stated that their process was to perform hand hygiene between glove use and that they should have performed hand hygiene between glove use when they provided tracheostomy care. STAFF QObservation on 09/05/2025 at 11:29 AM, showed Staff Q, Housekeeping Aide, cleaning room [ROOM NUMBER] that had an EBP signage by the door. Staff Q had gloves on and emptied the trash cans that were in the room and placed them in a trash can that was outside the room. Staff Q then mopped and swept room [ROOM NUMBER]. Staff Q then removed their gloves and threw them in a trash can outside the room. Staff Q took new trash bags that were tied to the trash can that was outside the room, took new gloves and a broom and brought them to room [ROOM NUMBER]. Staff Q then applied the new gloves and emptied out the trash cans in room [ROOM NUMBER]. Staff Q did not perform hand hygiene between glove use, and between cleaning room [ROOM NUMBER] and room [ROOM NUMBER]. In an interview on 09/05/2025 at 11:46 AM, Staff Q stated that they would perform hand hygiene after cleaning and when they would remove their gloves. When asked why it was important to perform hand hygiene, Staff Q stated, because there's [there is] bacteria [germs]. Staff Q stated that they should have performed hand hygiene after removing their gloves. In an interview on 09/10/2025 at 8:57 AM, Staff P, Housekeeping Supervisor, stated that staff were to perform hand hygiene before entering/exiting resident rooms and between glove use. Staff P further stated that Staff Q should have performed hand hygiene after removing their gloves. In an interview on 09/10/2025 at 9:15 AM, Staff B stated that their process for glove use was for staff to perform hand hygiene before glove use, between dirty to clean tasks and between glove use. Staff B further stated that Staff R and Staff Q should have performed hand hygiene after they removed their gloves. Reference: (WAC) 388-97-1320(1)(a)(c)(4) .

Based on observation, interview, and record review, the facility failed to ensure resident environment were maintained for 3 of 6 rooms (Rooms 111, 314 & 317), for 2 of 3 floors (Third Floor & First Floor Hallway Ceiling), for 1 of 1 resident bed linen (Resident 30), for 3 of 3 elevator jambs (First Floor, Second Floor & Third Floor), and for 1 of 1 bed (Resident 1), reviewed for environment. The failure to ensure resident rooms were maintained, wall fans were properly mounted, condensation from ceiling pipes were prevented, elevator jambs were repaired, bed linens were changed, and/or bed were in good repair placed the residents at risk for a less than homelike environment and a diminished quality of life.Findings included. Review of the facility's policy titled, Preventative Maintenance, dated July 2008, showed that the intention of the policy is to establish a building where the environment is safe and comfortable, essential utilities were delivered without interruption and mechanical systems and equipment operate safely, accurately, and reliably. The policy further showed that all areas of the Center and equipment therein, are inspected and maintained in accordance with the scheduled maintenance system. The maintenance department is responsible for the condition and function of the Center's physical plant including utilities, grounds, and equipment. Review of the facility's job description for Certified Nursing Assistant (CNA), updated in March 2025, showed changing bed linens were included in their job duties. room [ROOM NUMBER]Review of a face sheet printed on 09/08/2025, showed Resident 66 was readmitted to the facility on [DATE] to room [ROOM NUMBER]. In an interview and observation on 09/03/2025 at 12:41 PM, Resident 66 stated they had a concern and asked to have their bathroom assessed. Resident 66's bathroom had a hole in the wall that was between the faucet and the toilet, a hole on the floor and a round raised metal piece attached to the floor. Resident 66 stated that they used the bathroom and that they had tripped on the round raised metal piece that was on the floor. Observations on 09/04/2025 at 2:46 PM, on 09/05/2025 at 2:16 PM and on 09/08/2025 at 4:25 PM, showed Resident 66's bathroom had a hole in the wall that was between the faucet and the toilet, a hole on the floor and a round raised metal piece attached to the floor. Review of the maintenance logbook on 09/10/2025 at 10:30 AM, showed no log for room [ROOM NUMBER]. In an interview and joint observation on 09/10/2025 at 10:49 AM, Staff S, CNA, stated that if something in the facility needed to be fixed, they would put in a request in the maintenance logbook. Staff S stated that if there was no action taken, they would talk to the maintenance department. Staff S stated that Resident 66 used the bathroom and if they were strong, they were able to walk independently to the bathroom. A joint observation of Resident 66's bathroom showed a hole in the wall that was between the faucet and the toilet, a hole on the floor and a round raised metal piece attached to the floor. Staff S stated, I've always seen it and that they were not sure if they had put in a request in the maintenance log and that they thought that someone had already put one in. A joint observation and interview on 09/10/2025 at 10:58 AM with Staff H, Maintenance Director, showed the bathroom in room [ROOM NUMBER] had a hole in the wall that was between the faucet and the toilet, a hole on the floor and a round raised metal piece attached to the floor. Staff H stated that they were notified of it. When asked if they were aware of it before today, Staff H stated that they were not aware and that they expected staff to put in a repair request in the maintenance log. In an interview on 09/10/2025 at 11:21 AM, Staff A, Executive Director, stated that they expected the facility environment to have ongoing maintenance and any issues to be communicated to the maintenance department. Staff A further stated that they expected the holes on the bathroom wall/floor and the round raised metal piece on the bathroom floor to have been communicated in the maintenance log or to the maintenance department. room [ROOM NUMBER]Observation on 09/03/2025 at 8:50 AM, showed a light fixture over the bathroom sink. Two out of the three bulbs in this fixture did not light up when the bathroom lights were turned on. A joint observation and interview on 09/10/2025 at 2:02 PM with Staff H showed the light fixture over the bathroom sink had two of the three bulbs out. Staff H stated that they should have replaced the bulbs if they had been made aware. The bathroom wall facing the toilet showed a deep gauge in the wall, measuring about a one-foot gap between the wall and the bathroom base cover. Staff H stated that this wall damage was probably created by a wheelchair and would be an easy fix. A joint observation showed the bathroom ceiling; dry wall tape was visible around where sheet rock may have been cut out. Staff H stated that this looked like an unfinished roof related fix and that it measured around two by three feet. In another joint observation of the wall in room [ROOM NUMBER] showed dry wall damage in multiple areas that stripped the top layer, measuring from two inches to six inches in length and up to two inches wide. Staff H stated that the damage looked like it was caused by the cord covers that were applied to the wall with adhesive strips. A joint observation showed the window screen in room [ROOM NUMBER] had a tear in the lower right corner. Staff H stated the tear on the screen looked like it was about two feet long. room [ROOM NUMBER]Observation on 09/03/2025 at 9:44 AM, showed room [ROOM NUMBER] had an electric wall fan partially mounted on the wall and was turned on. The top screw on the wall mount was an inch out of the wall causing the fan to tilt downward. A joint observation and interview on 09/10/2025 at 2:02 PM with Staff H, showed an electric wall fan running. The fan was around 16-24 inches in diameter and was anchored on the wall by three screws. The single screw on the top was hanging one inch off the wall, leaning downward. Staff H stated that the fan was not safe and would take care of it first. Staff H stated that no one had alerted them that the fan needed to be fixed. HALLWAY CEILING-THIRD FLOOR AND FIRST FLOORObservation on 09/05/2025 at 8:21 AM, showed there was condensation dripping onto the hand sanitizer dispenser that was mounted outside of room [ROOM NUMBER]. There was a gap at the edge of the ceiling where piping was exposed, and each side of this gap had two-inch black spots that looked like organic matter. Observation on 09/08/2025 at 11:19 AM, showed condensation under the air conditioning unit installed on the upper part of the wall, outside of room [ROOM NUMBER]. A joint observation and interview on 09/10/2025 at 2:15 PM with Staff H, showed there were condensation drops on the hand sanitizer dispenser on the wall outside of room [ROOM NUMBER]. Staff H stated that it was an easy fix and looked like the refrigeration lining (foam insulation with high resistance to water vapor to prevent condensation formation) needed to be replaced. A joint observation and interview on 09/10/2025 at 9:33 AM with Staff H, showed there was condensation under the first-floor air conditioner. Staff H stated that this was manageable and would replace the refrigeration lining. In an interview on 09/11/2025 at 10:00 AM, Staff A stated that they expected the conditions of the general environment to be maintained and cleaned. BED LINENObservation on 09/03/2025 at 9:16 AM, showed the fitted sheet on Resident 30's bed had orange, brown stains on the left side. Just below the stains, was an empty can of Chef Boyardee [brand name for canned pasta] on the floor. Additional observations on 09/09/2025 at 9:34 AM and 09/10/2025 at 9:14 AM showed the fitted sheet on Resident 30's bed had the same orange, brown stains that was observed on 09/03/2025. In an interview on 09/10/2025 at 9:14 AM, Resident 30 stated that the staff had not offered to change their sheets in a while. In an interview on 09/10/2025 at 9:31 AM, Staff GG, CNA, stated that their duties included changing bed linen. In an interview on 09/05/2025 at 2:08 PM, Staff G, Resident Care Manager, stated that care staff duties included changing bed linen. Staff G stated that staff would change the bed linen routinely and when it was soiled. Staff G further stated that they would change their bed linen as preferred and requested by residents. In an interview on 09/10/2025 at 2:49 PM, Resident 30 stated that if they were not in bed, they would not mind if staff came in and changed their bed sheets when they were not in their room. In an interview on 09/11/2025 at 10:00 AM, Staff B, Director of Nursing, stated that they expected that when linen was soiled, it should be changed. ELEVATOR JAMBSObservation on 09/04/2025 at 10:08 AM showed the facility's First Floor and Second Floor elevator jambs paints were scraped, damaged and had multiple scratch marks. In an interview and joint observation on 09/10/2025 at 9:25 AM, Staff H stated that the building's scrapes and scratched paints would be patched and repainted including the elevator jambs. A joint observation of the First, Second, and Third Floor elevator jambs had multiple scrapes and scratched marks. Staff H stated that they had a plan to patch and repaint the elevator jambs. In an interview on 09/11/2025 at 8:40 AM, Staff A stated that they expected the building to be regularly maintained, including repatching and repainting of elevator jambs. RESIDENT 1Observations on 09/04/2025 at 8:05 AM and on 09/05/2025 at 10:40 AM, showed Resident 1's bed with the veneer (thin slice of natural wood) peeling off in multiple areas on the footboard. A joint observation and interview on 09/10/2025 at 10:55 AM with Staff X, CNA, showed Resident 1's bed with the veneer peeling off in multiple areas on the footboard. Staff X stated, it's [it is] coming off, I will tell the nurse. In an interview and joint observation on 09/10/2025 at 11:15 AM, Staff H stated that they keep an eye on them [footboards] and if the veneer was coming off a resident can cut a finger. A joint observation of Resident 1's bed showed the veneer was peeling off in multiple areas on the footboard. Staff H stated that the peeling veneer should come off. Staff H further stated that it [footboard] will be replaced. In an interview on 09/11/2025 at 8:03 AM, Staff A stated, I would not expect the [veneer] to be peeling off. I would expect it to be fixed or replaced. Reference: (WAC) 388-97-0880 (1)(2)

Based on observation, interview, and record review, the facility failed to ensure medical supplies were dated and discarded when expired and/or failed to maintain the required temperatures range for 2 of 2 medication refrigerators (First Floor Medication Refrigerator & Third Floor Refrigerator) and failed to ensure medications were properly stored and secured for 3 of 4 residents (Residents 37, 3 &11), reviewed for medication storage. These failures placed the residents at risk of receiving compromised medications/supplies and related complications. Finding included. Review of the facility's policy titled, Storage of medication, dated 01/23 [January 2023], showed, Outdated ., deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal. Medications requiring refrigeration or temperatures between 2°C ([Celsius- unit of measurement]), 36°F [Fahrenheit- unit of measurement] and 8°C (46°F) are kept in a refrigerator with a thermometer to allow temperature monitoring. A temperature log or tracking mechanism is maintained to verify that temperature has remained within accepted limits. The temperature of any refrigerator that stores vaccines should be monitored and recorded twice daily. FIRST FLOOR MEDICATION REFRIGERATORA joint observation and interview on 09/08/2025 at 1:35 PM with Staff E, Resident Care Manager (RCM), showed expired and undated medical supplies, including ultrasound (medical imaging that used sound wave) gel with an expiration date of 03/25/2025 and cornstarch powder (to prevent skin moisture) with no manufacturer/expiration date. Staff E stated they were expired and should have been discarded. THIRD FLOOR MEDICATION REFRIGERATORA joint observation on 09/08/2025 at 2:10 PM with Staff G, RCM, showed the third-floor refrigerator temperatures were out of range, the freezer read 49° F and refrigerator read 48°F. Further observation showed the ice was melting and water draining into the refrigerator compartment. In an interview and joint record review on 09/08/2025 at 3:07 PM, Staff G stated that they expected the refrigerator temperatures to be within normal range of 34 to 40°F for the refrigerator and 0 to negative 2°F for the freezer. Staff G stated that temperatures in the refrigerator were out of range. A joint record review of the refrigerator temperature logs showed missing temperature logs for 08/09/2025, 08/10/2025, and 08/26/2025. Staff G stated that if the fridge temperature was not logged, it was not completed. Staff G further stated it was their expectation that refrigerator temperatures were checked and documented daily. In an interview on 09/10/2025 at 3:07 PM, Staff B, Director of Nursing, stated it was their expectation that staff would check and record refrigerator temperatures daily and that all expired medications be discarded according to facility policy. MEDICATIONS AT BEDSIDERESIDENT 37Observations on 09/03/2025 at 2:50 PM and on 09/05/2025 at 2:53 PM, showed Resident 37 had one opened bottle of Flonase (medication that reduces swelling in the nose due to allergies), one opened bottle of Mucinex (medication that makes mucus thin and loose making it easier to cough it up), one opened bottle of normal saline nasal spray (saltwater solution that adds moisture to nasal passages to help clear congestion, relieve dryness, and flush out irritants like dust and pollen), and one opened bottle of Derma Daily medications (powder to apply in moist skin) on their bedside table. A joint observation and interview on 09/09/2025 at 1:37 PM with Staff HH, Licensed Practical Nurse (LPN), showed Resident 37 had Flonase, Mucinex, nasal saline spray, and derma daily medication on their bedside table. Resident 37 stated they had possessed the medications for a while and had been using them. Staff HH stated that resident's medication should not be stored at their bedside. In an interview on 09/10/2025 at 2:16 PM, Staff F, RCM, stated that Resident 37 was preparing for discharge to home and had been trained to self-administer medications. When asked if medications were allowed to remain on the bedside table, Staff F stated medications were required to be locked in a safe place, either in the medication cart or in a locked drawer in the resident's room. In an interview on 09/10/2025 at 2:56 PM, Staff B stated it was their expectation that staff would not leave medications at the bedside, would observe the resident take all medications and store medications in the medication cart or locked in the medication drawer. RESIDENT 3Observation on 09/03/2025 at 11:50 AM, showed one opened bottle of Turmeric and Ginger supplement (dietary supplement) on top of Resident 3's nightstand. Resident 3's representative stated that Resident 3 takes them [Turmeric and Ginger supplement] once a day. Additional observations on 09/08/2025 at 10:28 AM and on 09/09/2025 at 8:50 AM, showed one opened bottle of Turmeric and Ginger supplement on top of Resident 3's nightstand. In an interview and joint observation on 09/09/2025 at 10:46 AM, Staff Y, Registered Nurse, stated that medications, including supplements, should be stored in medication carts and locked containers. Staff Y stated that medications should not be at the bedside. Joint observation showed one opened bottle of Turmeric and Ginger supplement bottle on top of Resident 3's nightstand. Staff Y stated that they had seen Resident 3's Turmeric and Ginger supplement bottle before and did not know if Resident 3 was taking them. Staff Y stated that there was no order for the supplement, and it should not be on the nightstand. In an interview on 09/09/2025 at 10:58 AM, Staff F stated that residents could have medications at the beside if they were assessed on properly storing [medications], properly administering [medications], had a [physician's] order, and care plan. Staff F stated that medications at the bedside should be stored in a lock box. Staff F further stated that they would not expect Resident 3 to have a supplement at the bedside. In an interview on 09/09/2025 at 1:35 PM, Staff B stated that they expected medications to be secured and locked. RESIDENT 11Observation on 09/05/2025 at 1:20 PM showed there was an unopened box of lidocaine pain-relief gel patches sitting on Resident 11's dresser and there were clear plastic drawers where other medications were visible which contained the following medications:-one open bottle of cyclopentolate hydrochloride ophthalmic eye drops (treats dry eyes)-one bottle of brimonidine eye drops (treats dry eyes)-one bottle of prednisolone acetate eye drops (treats inflammation of the eyes)-eight Bisacodyl suppositories (for bowel management)-one mini enema kit (for bowel management)-a tube of an over-the-counter muscle rub, greaseless pain-relieving cream (treats muscle pain) In an interview on 09/05/2025 at 1:20 PM, Resident 11 stated that they kept the lidocaine and the pain-relieving creams in their room so that they could instruct staff where to apply them. In an interview on 09/05/2025 at 2:37 PM, Staff U, LPN, stated that there were no residents on the third floor that was on a self-medication administration program and that residents were not to store medications in their rooms. Staff U further stated that Resident 11 had refused to take their prescription eye drops and was not supposed to have them in their room. In an interview on 09/05/2025 at 2:41 PM, Staff G stated that they did not have any residents on self-medication administration program. Staff G stated that Resident 11 would go out and buy their own over the counter medications and eye drops. Staff G further stated that medications stored in resident rooms should be stored in a lockable storage. In an interview on 09/11/2025 at 10:30 AM, Staff B stated that they expected medications to be secured and a self-medication administration assessment to have been completed. Reference: (WAC) 388-97-1300 (2)

Based on observation, interview, and record review, the facility failed to ensure expired food items were discarded for 2 of 4 refrigerators (Kitchen Walk-In Refrigerator & Second Floor Refrigerator) and 1 of 1 dry storage (Kitchen Dry Storage Room), reviewed for food service safety. These failures placed the residents at risk of food-borne illness (caused by the ingestion of contaminated food or beverages).Findings included .Review of the facility's policy titled, Food Storage, updated October 2017, showed, Food products are used within one year unless the manufacturer's expiration date is different.The manufacturer's expiration date, when available, is the use by date for unopened items.KITCHEN WALK-IN REFRIGERATORA joint observation and interview on 09/03/2025 at 9:13 AM with Staff J, Dietary Manager, showed one unopened Darigold (brand name) heavy whipping cream with a best buy date of 08/29/2025. Staff J stated that the heavy whipping cream best buy date was 08/29/2025 and that it should have been discarded.SECOND FLOOR REFRIGERATORA joint observation and interview on 09/03/2025 at 2:43 PM with Staff L, Certified Nursing Assistant, showed an opened thicken apple juice with a used by once open date of 08/29/2025. Staff L stated that the thicken apple juice was to be used by 08/29/2025 and that it should have been discarded.KITCHEN DRY STORAGEA joint observation and interview on 09/05/2025 at 9:21 AM with Staff J, showed two unopened Medplus 2.0 (type of fortified nutritional shake) vanilla flavored supplement with a used by date of 12/28/2024 and 08/24/2025. Staff J stated the two supplements should have been discarded.In an interview on 09/09/2025 at 11:16 AM, Staff A, Executive Director, stated they expected expired or passed the used by date food items in the refrigerators and/or dry storage should have been discarded.Reference: (WAC) 388-97-1100 (3).

Based on observation, interview and record review, the facility failed to accurately assess 4 of 24 residents (Residents 8, 86, 32 & 45), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding prognosis, Pressure Ulcer (PU)/Pressure Injury (PI-bed sore), and mechanical ventilation (a medical procedure that uses a machine to assist or replace spontaneous breathing) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.19.1, dated October 2024, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. As such, nursing homes are responsible for ensuring that all participants in the assessment process have the requisite knowledge to complete an accurate assessment. It further showed to code yes for J1400 (Prognosis [a prediction of the likely outcome or future course of a medication condition or disease]), if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. The Observation Period (also known as the Look-back period) is the time-period over which the resident's condition or status is captured by the MDS and ends at 11:59 PM on the day of the Assessment Reference Date (ARD or assessment period). Review of the facility's policy titled, Resident Assessment Instrument Policy, updated in March 2019, showed that the facility would complete MDS in accordance with state and federal regulations per the RAI manual. RESIDENT 8Review of the hospice certification of illness note dated 07/12/2025, showed that Resident 8's prognosis was six months or less if the disease ran its normal course. Review of Resident 8's Significant Change in Status Assessment (SCSA) MDS dated [DATE], showed that Section J1400, Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 [six] months? was marked no. RESIDENT 86Review of the hospice certification of illness note dated 08/05/2025, showed that Resident 86 had a terminal diagnosis and a prognosis of six months or less if the disease ran its normal course. Review of Resident 86's SCSA MDS dated [DATE], showed that Section J1400 was marked no. In an interview and joint record review on 09/08/2025 at 11:18 AM, Staff D, MDS Coordinator, stated that they followed the RAI manual and that when completing Section J1400 they looked for the physician determination documentation and would mark the MDS based on that document. A joint record review of Resident 8's SCSA MDS dated [DATE], showed that it was marked no for Section J1400. A joint record review of the hospice certification of illness note dated 07/12/2025, showed that Resident 8's prognosis was six months or less if the disease ran its normal course. Staff D stated that the SCSA MDS was not accurate and that they would modify it. A joint record review of Resident 86's SCSA MDS dated [DATE], showed it was marked no for Section J1400. A joint record review of the certification of illness note dated 08/05/2025, showed that Resident 86 had a terminal diagnosis and a prognosis of six months or less if the disease ran its normal course. Staff D stated that Resident 86's SCSA MDS was not accurate. In an interview on 09/09/2025 at 2:22 PM, Staff B, Director of Nursing, stated that they expected the MDS to be completed timely and accurately including the SCSA MDS. RESIDENT 32The RAI manual defines PU/PI as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. For each PU/PI coded on MDS, the RAI manual directed staff to determine if the PU/PI was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. The RAI manual defines PU/PI stages: -Unstageable PU/PI is when the wound's anatomical (body structure) tissues are obscured such that the extent of soft tissue damage cannot be observed or palpated. -Stage 4 PU/PI is a full thickness tissue loss with exposed bone, tendon or muscle. Resident 32 was readmitted to the facility on [DATE]. Review of the admission-readmission nursing evaluation dated 02/19/2024 showed that Resident 32 was readmitted with three stage 4 PU/PI. Review of the SCSA MDS dated [DATE], showed Resident 32 had five unstageable PU/PI coded as acquired at the facility. Review of the quarterly MDS dated [DATE], showed Resident 32 had one stage 4 and six unstageable PU/PI. Further review of the MDS showed the stage 4, and the five unstageable PU/PI were coded as present upon reentry. In an interview and joint record review on 09/10/2025 at 11:02 AM, Staff D stated that they would follow the RAI Manual for MDS accuracy, and they would review skin evaluation, progress notes and wound consultant notes to complete Section M (Skin Conditions) of the MDS. A joint record review of Resident 32's SCSA MDS dated [DATE], showed that Resident 32 had five unstageable PU/PI acquired at the facility. A joint record review of Resident 32's quarterly MDS dated [DATE], showed Resident 32 had seven PU/PI and six out of the seven PU/PI were present on admission. Staff D stated that Resident 32 was refusing wound assessment, and they coded the MDS based on the physician diagnosis list dated 06/10/2025. Staff D further stated that the quarterly MDS dated [DATE] may not be accurate. In an interview on 09/10/2025 at 3:00 PM, Staff B stated that they expected the MDS to be accurate. RESIDENT 45Resident 45 was admitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypercapnia (a medical emergency where the body fails to adequately remove carbon dioxide [gas] from the bloodstream). Review of the admission physician progress notes dated 05/08/2025 showed Resident 45's was admitted with a tracheostomy (an incision on the front of the neck to open a direct airway to windpipe to relieve an obstruction to breathing) requiring ongoing care and cool humidified air. Further review of the note showed Resident 45 was not on a mechanical ventilator. Review of the quarterly MDS dated [DATE] showed Resident 45 was coded to be on a mechanical ventilator. In an interview and joint record review on 09/10/2025 at 9:31 AM, Staff AA, Respiratory Therapist, stated that Resident 45 had a tracheostomy and have never been on a ventilator machine. A joint record review of Resident 45 physician's orders showed no mechanical ventilator order. In an interview on 09/10/2025 at 9:42 AM, Staff D, stated that the resident had a tracheostomy and was never on a mechanical ventilator. Staff D further stated Resident 45 quarterly MDS was inaccurate. In an interview on 09/10/2025 at 10:50 AM, Staff B stated that they expected the MDS to be completed accurately. Reference: (WAC) 388-97-1000(1)(b) .

Based on observation, interview, and record review, the facility failed to provide care and services in a manner that maintains and promotes dignity and respect for 2 of 4 residents (Residents 23 & 55), reviewed for dignity. The failure to knock on the door and introduce themselves before entering, ensure oxygen concentrator (a machine that generates oxygen) was correctly labeled, and provide adequate covering was provided to maintain privacy during transfer placed the residents at risk for lack of privacy, decreased self-worth, potential embarrassment, and diminished quality of life.Findings included.Review of the facility-provided document titled, Notice of Resident Rights under Federal Law, updated in July 2015, showed the center will protect and promote these rights to the best of their ability. The document further showed, The resident has the right to personal privacy. the resident has the right to a dignified existence and self-determination.RESIDENT 23Resident 23 was admitted to the facility on [DATE] with diagnoses that included diffuse traumatic brain injury (a brain injury that can lead to prolonged coma [a state of prolonged unresponsiveness and unconsciousness], disability, and cognitive issues).Observation on 09/04/2025 at 10:49 AM, showed Resident 23's door was closed. Staff K, Certified Nursing Assistant (CNA), opened the door and, together with Staff V, CNA, entered Resident 23's room without knocking on or introducing themselves.Observation on 09/04/2025 at 2:39 PM, showed Staff Z, Licensed Practical Nurse, opened Resident 23's door and entered the room without knocking or requesting permission to enter, and did not introduce themselves.Observation on 09/05/2025 at 8:19 AM, showed Resident 23's oxygen concentrator had another resident's name sticker on it.During a joint observation and interview on 09/05/2025 at 10:31 AM with Staff AA, Respiratory Therapist, showed Resident 23's oxygen concentrator had another resident's name sticker on it. Staff AA stated the name on the concentrator was wrong and should have been labeled with Resident 23's name.Observation on 09/08/2025 at 10:38 AM, showed Staff BB, Respiratory Therapist, opened Resident 23's door and entered without knocking or introducing herself.During an interview on 09/08/2025 at 10:48 AM, Staff BB stated that it was expected for the staff to knock and introduce themselves before entering a resident's room. When asked if they knocked before entering, Staff BB stated, no, but I should have.RESIDENT 55Review of a face sheet printed on 09/11/2025 showed Resident 55 was admitted to the facility on [DATE].Review of the annual Minimum Data Set (an assessment tool) dated 07/09/2025 showed Resident 55 had severe cognitive impairment and was totally dependent on staff for activities of daily living.Observation on 09/05/2025 at 9:24 AM, showed Staff W, CNA, transferred Resident 55 in the hallway using a mechanical lift (a medical device used to safely and efficiently move residents with limited mobility). Staff W covered Resident 55's upper body with a white sheet. When Resident 55 was lifted up using the mechanical lift, the bottom back side of the resident was completely exposed and people in the hallway could see Resident 55's bottom.In an interview on 09/05/2025 at 9:37 AM, Staff W stated they covered Resident 55 with a white sheet and was not aware that their bottom was exposed. When asked if they would normally check to ensure residents were covered before transfer, Staff W stated they normally would, and they did not check at that time.In an interview on 09/09/2025 at 2:00 PM, Staff F, Resident Care Manager, stated staff were expected to knock on the door, introduce themselves, and request permission to enter a resident's room. Staff F further stated that staff were expected to ensure residents were properly covered to provide privacy, and ensure equipment was labeled with the correct resident's name.In an interview on 09/10/2025 at 10:42 AM, Staff B, Director of Nursing, stated it was their expectation that staff knock on the resident s door, introduce themselves, request permission to enter, and inform the residents of what they were going to do. Staff B further stated that respiratory equipment should be labeled with the correct resident's name and that residents should be properly covered to ensure privacy during transfer.Reference: (WAC) 388-97-0880 (1)(a)(b).

Based on interview and record review, the facility failed to provide written notices of transfer/discharge to the resident and/or their representative and failed to notify the Office of the State Long Term Care Ombudsman (an advocacy group for residents), describing the reason for transfers/discharge for 2 or 3 residents (Residents 101 & 8), reviewed for hospitalization and discharge. These failures placed the residents at risk for not having the opportunities to make informed decisions about transfers/discharges. Findings included . Review of the facility's policy titled, Transfer and Discharge, updated in May 2025, showed, When the transfer or discharge is initiated, the resident receives written notice using the Resident Notice of Transfer or Discharge which includes the following items: date of notice is given, effective date of the transfer/discharge, reason for the transfer/discharge, where the resident is to be moved, contact information for the state Long-Term Care Ombudsman . It further stated, The facility sends a copy of the notice to the State Long-term Care Ombudsman. The notice is provided at least 30 days before the transfer or discharge; the following are exceptions: when a resident's urgent medical needs require more immediate transfer. In these cases, notice must be given as soon as practical before or at the time of transfer or discharge. RESIDENT 101Review of Resident 101's admission record printed on 09/04/2025, showed Resident 101 admitted to the facility on [DATE] and discharged to acute care hospital on [DATE]. Review of the nursing progress notes dated 07/17/2025 showed Resident 101 had a change in condition and was transferred to the hospital for further evaluation. Review of Resident 101's electronic health record (EHR) in the progress notes and documents tabs did not show documentation that a written notice of transfer/discharge was provided to Resident 101 and/or their representative. Further review of the EHR did not show documentation that the Ombudsman was notified of Resident 101's transfer/discharge to the hospital. In an interview on 09/08/2025 at 2:04 PM with Staff F, Resident Care Manager (RCM), stated that when residents were transferred/discharged to the hospital, the nurses would do a change of condition (CIC), call report to the hospital, and send a packet with the resident to the hospital. Staff F further stated a paper form of the written notice of transfer/discharge was also completed. A joint record review of Resident 101's EHR in the documents tab did not show documentation that a written notice of transfer/discharge was provided. In an interview on 09/08/2025 at 2:21 PM, Staff I, Social Services Director, stated they would do the written notice of transfer/discharge form and that they would fax the form to the Ombudsman. Staff I further stated they would scan the notice of transfer/discharge form and fax confirmation into the EHR documents tab. Staff I stated there was no nursing home transfer/discharge notice given to Resident 101 and/or their representative when they transferred/discharged to the hospital on [DATE]. In an interview on 09/09/2025 at 11:10 AM, Staff A, Executive Director, stated, they expected staff to provide a written notice of transfer/discharge to the resident and/or their representative when they transferred/discharged to the hospital on [DATE] and to notify the Ombudsman of the transfer and/or discharge. RESIDENT 8Review of the nursing progress note dated 07/03/2025 showed Resident 8 was transferred to the emergency room for further evaluation. Review of Resident 8's EHR did not show documentation that a written notice of transfer/discharge was provided to Resident 8 and/or their representative. Further review of the EHR did not show documentation that the Ombudsman was notified of Resident 8's transfer/discharge. In an interview on 09/09/2025 at 1:27 PM, Staff E, RCM, stated that when residents were transferred to the hospital, they would be given written notice of transfer/discharge along with their discharge packet and that they would send a copy to the resident's representative. Staff E stated that it would be documented in the progress notes that the written notice of transfer/discharge was given and that a copy would be saved under documents in their EHR. Staff E further stated that they did not see any documentation that a written notice of transfer/discharge was provided to Resident 8 and/or their representative and that they were still looking. In a joint record review and interview on 09/09/2025 at 2:00 PM with Staff I, showed the Nursing Home Transfer or Discharge Notice, dated 09/04/2025, revealed that Resident 8 transferred to the hospital on [DATE] and that the notice was provided to Resident 8's representative on 09/04/2025, (63 days after transfer to hospital). A joint record review of the document titled facsimile transmission to the Ombudsman was dated 09/05/2025. Staff I stated that they would have expected a written notice of transfer/discharge to be provided to Resident 8 and/or their representative, and a copy sent to the Ombudsman. In an interview on 09/10/2025 at 10:15 AM, Staff A stated that they expected residents to receive a written notice of transfer/discharge when they were transferred/discharged to the hospital and a copy of the notice to be sent to the Ombudsman. Reference: (WAC) 388-97-0120 (2)(a)(b)(c)(d) .

Based on interview and record review, the facility failed to ensure Level II Preadmission Screening and Resident Review (PASARR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions are not inappropriately placed in nursing homes for long-term care) referral was made for 1 of 7 residents (Resident 77), reviewed for PASARR screening. This failure placed the resident at risk of not receiving the care and services appropriate for their needs.Findings included.Review of the facility's policy titled, PASRR Process Policy and Procedure, revised on 01/01/2025, showed upon admission the admissions coordinator or designee validates the Level I PASRR and, if Level II was indicated, the Social Worker ensures timely referral to a Licensed Mental Health Professional.Resident 77 was admitted to the facility on [DATE] with diagnoses that included schizophrenia (a chronic mental illness that affects a person's thoughts, feelings, and behavior), bipolar disorder (a chronic mental health condition characterized by extreme mood swings between periods of mania [elevated mood] and depression), and major depressive disorder (mental health characterized by persistent low mood and loss of interest or pleasure in thinks once enjoyed doing).Review of Resident 77's Level I PASARR dated 03/14/2025 showed Section 1A (SMI indicator) was marked yes for schizophrenia and mood disorders. Further review showed, No Level II evaluation indicated.In a joint record review and interview on 09/09/2025 at 11:01 AM with Staff I, Social Service Director, showed Resident 77's Level I PASARR from the hospital indicated no Level II was required. Further review showed schizophrenia and mood disorders were marked yes. Staff I stated Resident 77 should have been referred for Level II PASARR evaluation and was not.In an interview on 09/10/2025 at 8:37 AM, Staff B, Director of Nursing, stated they expected PASARR screenings to be completed accurately and a Level II PASARR referral completed. residents further stated that if SMI indicators were marked yes, then the resident should have been referred for Level II evaluation.In an interview on 09/11/2025 at 9:17 AM, Staff A, Executive Director, stated that if Level I PASARR indicated SMI, then the resident should have been referred for a Level II PASARR evaluation.Reference: (WAC) 388-97-1975(1)(2).

Based on observation, interview, and record review, the facility failed to follow hospice (specialized care for people who are nearing the end of their life) physician orders and effectively communicate/coordinate hospice plan of care for 1 of 1 resident (Resident 8), reviewed for hospice services. This failure placed the resident at risk for delayed treatment, unidentified decline, and unmet care needs.Findings included . Review of the facility's policy titled, Hospice - Provision of Care by Outside Providers, updated September 2017, showed, The hospice and center communicate, establish, and agree upon a coordinated Plan of Care (POC) reflecting the hospice philosophy and based on an evaluation of the individual needs of the resident. The POC includes: directive for managing pain and other uncomfortable symptoms, and the care and services the Center and hospice provide in order to be responsive to the unique needs of the resident and his/her expressed desire for hospice care. It further showed, Medications, medical supplies and services are provided as indicated by the agreement for coordination of services. Review of the Significant Change in Status Minimum Data Set (an assessment tool) dated 07/17/2025, showed that Resident 8 received hospice services. Review of Resident 8's terminal dx [diagnosis] care plan initiated on 07/13/2025, showed that Resident 8 was admitted to hospice on 07/12/2025. The care plan further showed the following interventions:- Facility to provide daily care and management, Hospice to provide DME [Durable Medical Equipment], assist with pain management for further delineation of duties refer to Hospice/center care coordination form.- Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Review of the hospice nurse visit note dated 08/26/2025, showed [Staff N, License Practical Nurse] noted pt [patient] has erythema (redness of the skin) and moistened skin under folds of neck. [physician] ordering Nystatin [antifungal medication] powder. Review of the document titled, Hospice Physician Order, with an order date of 08/26/2025, showed, Nystatin powder topical [surface of skin], apply to affected area twice daily for seven days for rash. It further showed, Instructions: Apply to affected area (under folds of neck) twice daily for 7 [seven] days. Review of Resident 8's August 2025 and September 2025 medication administration record did not show an order for Nystatin powder. Observations on 09/03/2025 at 2:02 PM, on 09/04/2025 at 2:43 PM, on 09/05/2025 at 11:10 AM and 09/08/2025 at 2:38 PM, showed Resident 8 had redness on their neck. A joint observation and interview on 09/09/2025 at 10:00 AM, Collateral Contact 1 (CC1), showed Resident 8 was pointing to redness on their neck. CC1 stated that they had informed Staff N about it and that they thought they observed the redness two weeks ago. In a joint observation on 09/09/2025 at 10:34 AM with Staff N showed Resident 8 had redness under their neck folds. When Staff N attempted to lift Resident 8's neck fold to take a closer look, Resident 8 winced and pushed Staff N's hand away. In an interview and joint record review on 09/09/2025 at 11:42 AM, Staff N stated that they communicated with the hospice team and notified them of any changes to the residents and any supplies that the residents needed. Staff N stated that they received hospice physician orders through fax. Staff N stated that they were aware of the redness on Resident 8's neck folds, that they verbally notified the hospice nurse and that they did not receive an order for it. Staff N stated that they did not write a progress note about the communication they had with the hospice nurse. When asked if they followed up with the hospice team, Staff N stated that they did not. Staff N stated that they did not work on the weekends and that they guess no one followed up. A joint record review of the hospice physician note dated 08/26/2025, showed an order for Nystatin powder. Staff N stated, I didn't [did not] know about this until you showed me and that they had never seen it. Staff N further stated that they should have followed up with the hospice team and checked in with Staff E, Resident Care Manager (RCM), but that they did not. In an interview on 09/09/2025 at 1:38 PM, Staff E stated that they would communicate and coordinate with the hospice team with any change in condition of the residents. Staff E stated that the hospice team would fax physician orders to the nurse's station or would get them through medical records. If the fax was not working, they would call the hospice team. Staff E stated that when they received the order, their in-house provider would be notified and then the order would get carried out. Staff E stated that they could either get verbal or faxed orders. Staff E stated that they were not aware of the redness on Resident 8's neck or the Nystatin order dated 08/26/2025. Staff E further stated they would have expected Staff N to have followed up with the hospice team when they did not receive a treatment order. In a phone interview on 09/10/2025 at 2:12 PM, CC2, stated they had verbalized to the facility nurse that the physician was possibly going to write an order for Nystatin for Resident 8 and that it would come, that it would get there. In an interview on 09/11/2025 at 9:45 AM, Staff B, Director of Nursing (DON), was asked how the facility ensured ongoing communication with the hospice team, Staff B stated that what they would like to see was timely and ongoing communication between the facility and the hospice team during in-person visits and through written documentation at a reasonable time frame so that facility representatives (nurse, RCM, DON) could read and review them. Staff B stated that the hospice team checks in with them every time they were in the facility and that the nurse checks in with them as well. Staff B stated that when hospice visits the resident, they expect their visit notes to be sent to medical records through fax or electronic-fax (e-fax) within 24 to 48 hours and that they expected that they should have been communicated in person and writing would just be verification. When asked how they ensured hospice physician orders were carried out, Staff B stated through communication. Staff B stated that their nurses could take verbal orders from their physician or written orders via fax or e-fax and then they would put it in their electronic health record. Staff B stated that if a resident was found or reported to have redness on their neck, they would have expected the nurse to have followed their process which was to assess the resident, communicate their findings to their physician/hospice team and from there, initiate POC if necessary. Staff B stated that Resident 8 needed treatment for their rash and that they expected timely communication, timely treatment and their skin to be evaluated. Reference: (WAC) 388-97-1060 (3)(b).

Based on observation, interview, and record review, the facility failed to ensure staff followed safe transfer practices when using a mechanical lift (a medical device used to safely and efficiently move residents with limited mobility) for 1 of 4 residents (Resident 55), reviewed for accident prevention. This failure placed the resident at risk of falls, injury, and compromised safety.Findings included.Review of a face sheet printed on 09/11/2025 showed Resident 55 was admitted to the facility on [DATE]. Review of the annual Minimum Data Set (MDS - an assessment tool) dated 07/09/2025 showed Resident 55 had severe cognitive impairment and was totally dependent on staff for activity of daily living.Observation on 09/05/2025 at 9:24 AM showed Staff W, Certified Nursing Assistant (CNA), transferred Resident 55 from a shower bed using a mechanical lift without a second person present. Staff DD, Respiratory Therapist Supervisor, was present holding the ventilator (a medical device that assists or takes over breathing for individuals who are unable to breathe adequately on their own) tubing but was not assisting with the transfer.In an interview on 09/05/2025 at 9:33 AM, Staff DD stated they were not trained to use the mechanical lift, and their role was only to manage the ventilator machine tubing.In an interview on 09/05/2025 at 9:37 AM, Staff W stated that normally two staff would assist with a mechanical lift transfer and stated that enough staff were present on the floor but were not utilized.In an interview on 09/09/2025 at 2:00 PM, Staff F, Resident Care Manager, stated that mechanical lift transfers required two trained staff.In an interview on 09/10/2025 at 11:15 AM, Staff B, Director of Nursing, stated that it was their expectation that two staff assisted with mechanical lift transfer and that respiratory therapists were not considered as the second staff.Reference: (WAC) 388-97-1060(3)(g).

Based on interview and record review, the facility failed to obtain registry verification to ensure staff met competency evaluation requirements before allowing to serve as a nurse aide for 1 of 5 nurse aides (Staff M), reviewed for nursing aide registry. This failure placed the residents at risk for potential abuse, neglect, and unmet care needs.Findings included .Review of the facility's policy titled, Screening, updated October 2022, showed, The Center conducts registry checks for all employees before hire, annually, and more frequent as required by state law and regulation.Review of Staff M's personnel records showed they were hired by the facility on 08/01/2025 as a Certified Nursing Assistant. Further review showed Staff M's records did not include documentation from the nurse aide registry.In an interview on 09/10/2025 at 3:38 PM, Staff B, Director of Nursing, stated that Staff M's registry verification was not completed before the employee's start date. Staff B further stated that the facility should have had registry verification before Staff M started working at the facility.In an interview on 09/11/2025 at 8:39 AM, Staff A, Executive Director, stated that their expectation was the facility to obtain staff registry verification prior to hire date.Reference: (WAC) 388-97- 1660 (3)(c).

Based on record review and interview, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 5 residents (Residents 9), reviewed for unnecessary medications. The failure to administer and/or document medication administration in accordance with professional standards of practice placed the residents at risk for negative outcomes and a diminished quality of life.Findings included .Review of the facility's policy titled, Medication Administration General Guidelines, dated 01/24 [January 2024] showed, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. The individual who administers the medication dose, records the administration on the resident's MAR [Medication Administration Record] immediately following the medication being given. In no case should the individual who administered the medications report off-duty without first recording the administration of any medications. The resident's MAR/TAR [Treatment Administration Record] is initialized by the person administering the medication, in the space provided under the date, and on the line for that specific medication dose administration and time.Resident 9 admitted to the facility on [DATE] with diagnoses that included high blood pressure, diabetes (a condition that affects the level of sugar in the blood), chronic arterial fibrillation (a condition where the upper chambers of the heartbeat irregularly and rapidly), and Gastroesophageal Reflux Disease (GERD - condition where stomach acid flows back up into the esophagus [tube that carries food from the throat down to the stomach], causing irritation and discomfort). Review of the quarterly Minimum Data Set (an assessment tool) dated 08/04/2025, showed Resident 9 had impairment in cognition and dependent on staff with all aspects of care.Review of Resident 9's July 2025 MAR showed that the following medications were not administered to Resident 9 on 07/26/2025 and 07/27/2025 and were documented on the MAR as 9 [Other/See Progress Notes]:Lansoprazole (medication for GERD) at 8:00 AMLiquid protein supplement at 12:00 PMLisinopril (blood pressure medication) at 8:00 AMMultiple Vitamins-Minerals (supplement) at 8:00 AMRosuvastatin Calcium (medication that lowers cholesterol [a waxy substance found in the blood]) at 8:00 AMApixaban (blood thinner) at 9:00 AMCarvedilol (blood pressure medication) at 9:00 AMInsulin Glargine (medication that regulates blood sugar) at 8:00 AMMetformin (medication that helps manage blood sugar levels) at 8:00 AMMiraLax (stool softener) at 8:00 AMSenna (stool softener) at 8:00 AMBaclofen (muscle relaxant) at 9 AM and 3:00 PMInsulin Lispro (medication that regulates blood sugar) at 8:00 AM, 12:00 PM and 6:00 PMTylenol (pain medication) at 8:00 AM and 12:00 PMReview of the nursing progress note dated 07/26/2025 and 07/27/2025 did not show why the medications listed above were not administered to Resident 9.In an interview and joint record review on 09/11/2025 at 9:18 AM, Staff B, Director of Nursing, stated that their expectation was for the staff to follow the physician order in medication administration. A joint record review of the July 2025 MAR showed that the above listed medications were not administered to Resident 9 on 07/26/2025 and 07/27/2025 and were documented on the MAR as 9. Staff B stated that their expectation was when a medication was not administered and documented as 9, there should be a nursing note why the medications were not administered. Staff B further stated they would start an investigation into it.Reference: (WAC) 388-97-1300 (1)(b)(ii)(3)(a).

Based on interview and record review, the facility failed to timely provide necessary care and services to prevent the worsening of pressure ulcer/pressure injury (PU/PI-an injury to skin and underlying tissue resulting from prolonged pressure on the skin) and ensure nutritional supplements and recommendations were followed for 1 of 2 residents (Resident 1), reviewed for pressure ulcers. Resident 1 experienced harm when their sacrum (the triangular bone at the base of the spine that connects the lower back to the pelvis [bony structure inside hip]) and left lower leg pressure ulcers worsened/deteriorated due to the delayed implementation of recommended treatments and nutritional supplements. These failures placed the residents at risk for further skin breakdown, worsening pressure ulcers, infection, medical complications, and a diminished quality of life.Findings included .The October 2024 Resident Assessment Instrument (RAI) User's Manual defines PU/PI as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The PU/PI can present as intact skin or an open ulcer and may be painful. The RAI manual defines PU/PI stages:-Stage 1 PU/PI is an observable, pressure related alteration of intact skin with a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the injury may appear with persistent red, blue, or purple hues.-Stage 2 PU/PI is a partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough (dead tissue, yellow/white material in the wound bed) or bruising. -Unstageable PU/PI is when the wound's anatomical (body structure) tissues are obscured such that the extent of soft tissue damage cannot be observed or palpated. -Stage 4 PU/PI is a full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar (a dry, crusty scab or layer of dead tissue that forms on the surface of a wound) may be present on some parts of the wound bed. Often includes undermining (when the skin around a wound separates from the tissue underneath, creating a space or pocket beneath the wound's edges) and tunneling (an underground tunnel extending from a surface wound into the surrounding tissue). The RAI manual further showed that PU/PI at more advanced stages typically require more aggressive interventions, including more frequent repositioning, attention to nutritional status, more frequent dressing changes, and treatment that is more time-consuming than with routine preventative care.Review of the facility's policy titled, Skin Integrity, updated in June 2025, showed, In an effort to maintain the resident's optimal level of skin integrity and promote healing of skin ulcers/pressure ulcers/wounds, the facility has a systematic approach and monitoring process for evaluating and documenting skin integrity. In the event that a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds. Resident 1 admitted to the facility on [DATE] with diagnoses that included traumatic brain injury and persistent vegetative state (also known as post-coma unresponsiveness, is a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings).Review of the facility's admission - readmission Nursing Evaluation dated 05/02/2025, showed Resident 1 was readmitted to the facility with one stage 2 PU/PI on their sacrum measuring 1.5 centimeter (cm - unit of measurement) by 1 cm by 0 cm. The assessment further showed that Resident 1 had two stage 1 PU/PI on their left lower leg.Review of Resident 1's admission Minimum Data Set (an assessment tool) dated 05/08/2025 showed Resident 1 was in a persistent vegetative state with no visible consciousness and that they had one stage 2 PU/PI present on admission. The assessment further showed that Resident 1 was at risk of developing PU/PI and was dependent on staff with all aspects of care. Review of the wound consultant's note dated 05/15/2025 showed that Resident 1's physical examination indicated malnutrition. The note showed that Resident 1 had one unstageable PU/PI to their sacrum measuring 5 [cm] by 4.5 [cm] by 0 [cm]. The note further showed the goal of care was for wound healing, an intervention for daily wound dressing change, and recommendation for 30 mL (milliliters - unit of measurements) of protein supplement twice a day until wound closure. Review of the wound consultant's note dated 05/29/2025 showed that Resident 1's sacrum unstageable PU/PI wound showed, Deteriorating by overall clinical impression, tissue quality. The note showed Resident 1 had two other wounds of unknown origin on their left lower leg. The note further showed a treatment to apply Dakin's (a special cleaning solution that helps kill the germs in a wound) soaked gauze to the sacrum wound daily and recommendation for 30 ml protein supplement twice a day until wound closure. Review of Resident 1's May 2025 Medication Administration Record (MAR)/Treatment Administration Record (TAR) showed there was no documentation that showed the wound consultant's recommendation of protein supplement was implemented. Further review of the MAR/TAR showed no wound care was provided for Resident 1's sacrum wound on 05/19/2025 and 05/27/2025. Review of the wound consultant's note dated 06/05/2025 showed that Resident 1's sacrum wound was a stage 4 PU/PI and was measured 6 [cm] by 9 [cm] by 2 [cm] with wound undermining. The note showed that Resident 1 sacrum stage 4 PU/PI was Deteriorating by overall clinical impression, tissue quality, dimension and with significant amount of palpable (able to be touched or felt) bone. The note further showed that Resident 1's two left lower leg wounds were unstageable PU/PI. Review of Resident 1's June 2025 MAR/TAR showed the wound consultant's treatment recommendation of applying Dakin's-soaked gauze to Resident 1's sacrum wound was started on 06/04/2025 (six days after it was recommended). Further review of the MAR/TAR showed Resident 1 started receiving 30 ml protein supplement on 06/07/2025 (23 days later after it was recommended). Review of the wound consultant's note dated 07/10/2025 showed that Resident 1's sacrum wound was a stage 4 PU/PI and was measured 7 [cm] by 8 [cm] by 1.5 [cm]. The note showed that Resident 1 sacrum stage 4 PU/PI wound has deteriorated and measures larger in size. The note further showed that Resident 1's two left lower leg wounds were stage 4 PU/PI and measured 2.5 [cm] by 1.5 [cm] by 0.2 [cm], and 0.5 [cm] by 0.2 [cm]. Review of the progress note dated 07/11/2025 showed that Resident 1 was sent to hospital due to abnormal laboratory results. Review of the hospital progress note dated 07/13/2025 showed Resident 1 was admitted to the hospital with, Large sacral ulcer with CT [Computed Tomography - a medical imaging technique that uses X-ray to create detailed, cross-sectional images of the body's internal structures] findings suspicious for coccyx [tailbone] osteomyelitis [bone infection].In a phone interview on 07/21/2025 at 10:35 AM, Staff D, Registered Dietitian, stated that it was the responsibility of the Resident Care Manager (RCM) to implement Resident 1's protein supplement recommendations given by the wound consultant. During an interview and joint record review with Staff B, Assistant Director of Nursing, stated that the RCM was responsible for implementing treatment recommendations given by the wound consultant. A joint record review of Resident 1's wound consultant note dated 05/15/2025 showed that there was a recommendation for 30 ml protein supplement twice a day. A joint record review of the May 2025 MAR/TAR showed that no documentation to show the wound consultant's recommendation of protein supplement was implemented. A joint record review of June 2025 MAR/TAR showed Resident 1 started receiving 30 ml protein supplement on 06/07/2025 (23 days later after it was recommended). Staff B stated that there were delays in implementing the wound consultant's treatment recommendations. Reference: (WAC) 388-97-1060 (1)(3)(b).

Based on interview and record review, the facility failed to ensure acceptable parameters of nutrition were maintained, provide nutrition per physician order, maintain accurate documentation of nutritional intake, and recognize significant weight loss for 1 of 2 residents (Resident 1), reviewed for nutrition/weight loss. Resident 1 experienced harm when they had a significant weight loss of 24.1 percent (%) in two months. This failure placed the residents at risk for further decline in their weight, unintended consequences of poor nutrition, unmet care needs and decreased quality of life.Findings included.Review of the facility's policy titled, Nutrition Risk Monitoring and Evaluation guidelines, updated in November 2017, showed that residents nutritional risk factors are evaluated by the Interdisciplinary Team (IDT) on an ongoing basis. Among the guideline's listed nutrition factors to consider are significant weight loss or weight gain, poor skin integrity, unresponsiveness, and enteral feedings (also known as tube feeding, is a way of delivering nutrition to the stomach). The policy further showed that the IDT determines appropriate interventions with ongoing monitoring and evaluation by the Nutrition Hydration Skin Committee.Review of the facility's policy titled, Weights, revised on 10/12/2023, showed, The Center uses weights as one component of data collection needed to evaluate resident's nutritional status, fluid retention, or diuresis [excessive urination]. The policy further showed that residents with significant weight loss/gain (five percent in 30 days, 7.5 % in 90 days, or 10% in 180 days) and residents with multiple pressure ulcers may need to be weighed weekly. The policy further showed, The nurse records validated weights on the Weight Record in the resident's medical record.Review of the facility's policy titled, Enteral Feeding Tube, updated in May 2025, showed, It is the policy of this center that residents receiving tube feedings receive appropriate treatment and services to prevent complications and restore, if possible, normal eating skills.Intake is completed on those residents who are receiving enteral nutrition. This is done by checking the total infused via the enteral feeding pump. This is cleared after the total is evaluated and documented on the MAR [Medication Administration Record] or TAR [Treatment Administration Record]. Resident 1 admitted to the facility on [DATE] with diagnoses that included traumatic brain injury and persistent vegetative state (also known as post-coma unresponsiveness, is a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings).Review of Resident 1's admission Minimum Data Set (an assessment tool) dated 05/08/2025 showed Resident 1 was in a persistent vegetative state with no visible consciousness. The assessment showed that Resident 1 was on a feeding tube and was dependent on staff with total calorie (measurement of the energy content of food) and fluid intake by tube feeding. Review of Resident 1's admission nutrition evaluation dated 05/16/2025 showed, Resident is NPO [nothing by mouth], dependent on enteral nutrition to meet 100% nutrition/hydration needs.Review of May 2025 MAR and TAR showed that Resident 1 had an order for tube feeding of Jevity 1.5 (brand name- a tube feeding formula) at a rate of 65 cubic centimeter (cc - a unit of measurement) per hour for 20 hours which equals to 1300 cc total per 24 hours. Review of the MAR/TAR showed no documentation of the total amount of tube feeding formula infused from 05/02/2025 through 05/16/2025. Further review of the MAR/TAR showed that Resident 1 received a daily total of 520 cc of tube feeding formula from 05/17/2025 through 05/31/2025 (780 cc less formula was administered daily).Review of June 2025 MAR and TAR showed that Resident 1 received a daily total of 520 cc of tube feeding formula from 06/01/2025 through 06/05/2025 (780 cc less formula was administered daily). Review of Resident 1's weights and vitals summary dated 07/15/2025, showed the following documented weights:- On readmission on [DATE], they weighed 144.2 pounds (lbs.).- On 06/20/2025, they weighed 107.2 Ibs. (25.6 % or 37 Ibs. weight loss since readmission).- On 06/29/2025, they weighed 106.6 Ibs. (26 % or 37.6 Ibs. weight loss since readmission).- On 07/10/2025, they weighed 109.4 Ibs. (24.1 % or 34.8 Ibs. weight loss since readmission).Review of the Nutrition Hydration Skin Committee Review dated 07/11/2025 (which was completed 21 days after Resident 1's documented weight loss) showed Resident 1 was reviewed for pressure injuries and weight loss. The review showed Resident 1 had a significant weight loss of 25.5 percent in one month.Review of the progress note dated 07/11/2025 showed that Resident 1 was sent to the hospital due to abnormal laboratory results. Review of the hospital progress note dated 07/13/2025 showed Resident 1 looked cachectic [a state of severe physical wasting and malnutrition. It is characterized by significant loss of body weight, particularly muscle mass] during admission to the hospital. In an interview on 07/21/2025 at 10:11 AM, Staff E, Licensed Practical Nurse, stated that for residents on enteral feeding, the total amount of formula infused via the enteral feeding pump would be read at the end of the administration and would be documented on the resident's MAR/TAR. In a phone interview and a joint record review on 07/21/2025 at 10:35 AM, Staff D, Registered Dietitian (RD), stated that the center's [facility's] nutrition evaluation and weights review would be done during the center's weekly nutrition hydration skin committee meeting. Staff D stated that they would not review the MAR/TAR to calculate the amount of tube feeding formula administered for a resident and they would calculate a resident's estimated nutritional needs based on the order. A joint record review of the electronic health record showed Resident 1's weight record page showed Resident 1 weighed 144.2 Ibs on 05/02/2025, 107.2 Ibs on 06/20/2025, 106.6 Ibs. on 06/29/2025, and 109.4 Ibs. on 07/10/2025. Staff D stated that based on the weights obtained on 06/20/2025, on 06/29/2025, and 07/10/2025, Resident 1 had a significant weight loss. Staff D stated that the nutrition evaluation was not completed until 07/11/2025 (the day Resident 1 transferred out to hospital) because they were waiting for Resident 1 to be reweighed. Staff D further stated that Resident 1 had significant weight loss and Resident 1's reweights and nutritional evaluation, would have been done in a more timely fashion.In an interview and a joint record review on 07/21/2025 at 10:55 AM, Staff B, Assistant Director of Nursing, stated that the center's feeding tube policy was for LNs [Licensed Nurses] to document the amount of formula infused via enteral feeding daily on the resident's MAR/TAR and that was their expectation. A joint record review of Resident 1's May 2025 MAR/TAR showed that Resident 1 had an order for Jevity 1.5 at a rate of 65 cc per hour for 20 hours which equals to 1300 cc total per 24 hours. A joint record review of May 2025 MAR/TAR showed there was no documentation of the amount of formula administered from 05/02/2025 through 05/16/2025. Further review of the May 2025 MAR/TAR showed that Resident 1 received a daily total of 520 cc tube feeding formula from 05/17/2025 through 05/31/2025. A joint record review of June 2025 MAR/TAR showed that Resident 1 received a daily total of 520 cc tube feeding formula from 06/01/2025 through 06/05/2025. Staff B stated that the enteral feeding order was not entered correctly and may be the nurses had mistakenly put the wrong amount [of formula]. Staff B stated that based on the weights obtained on 06/20/2025, on 06/29/2025, and on 07/10/2025, Resident 1 had a significant weight loss. Staff B further stated that due to Resident 1's status, it's really difficult to get an accurate weight.In an interview on 07/21/2025 at 1:15 PM, Staff A, Executive Director, stated that they would expect LNs to follow the tube feeding order and document the amount provided each day. Staff A stated that the RD calculated the calorie intakes via tube feeding and that they would think the RD would review the MAR/TAR for the tube feeding formula amount administered. Staff A stated that they were not sure if the RD was responsible for reviewing the MAR/TAR for the tube feeding formula amount administered but that there should be more follow-up for residents with significant weight loss. Staff A stated that when there was significant weight loss, they would expect nutritional evaluation to be completed on the following day. Reference: (WAC) 388-97-1060 (1)(3)(h).

Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from sexual abuse for 1 of 2 residents (Resident 1), reviewed for sexual abuse investigations. Resident 1 experienced harm, applying the reasonable person concept (how a reasonable person would respond under the same circumstances, a reasonable person in this same situation would be upset, angry, and feel violated), when Resident 2 was observed performing nonconsensual sexual act on Resident 1. This failed practice placed all residents at risk for sexual abuse, psychological harm, and a diminished quality of life. A past noncompliance was initiated on 04/12/2025 related to F600 Free from Abuse and Neglect for failure to protect Resident 1 from sexual abuse. The facility implemented the following interventions that were initiated 04/12/2025 and corrected by 04/14/2025: - Resident 1 was assessed and monitored by licensed nurses. - Resident 2 was placed on one-on-one supervision and removed from the facility by Law Enforcement officials. - The facility conducted an interview of Resident 2's identified previous roommates for possible sexual abuse - Staff education was provided for all staff on the facility's policy of abuse and neglect prohibition, prevention, identification, reporting and investigation. - Weekly audits were completed weekly for three weeks, and the facility had ongoing weekly and monthly audits for two months and the results will be reviewed through the facility's Quality Assurance Performance Improvement Committee process. Findings included . Review of the facility's policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated March 2025, showed, Each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, misappropriation of resident property, exploitation, and any physical or chemical restraint not required to treat the resident's medical condition. The Center [facility] implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members, and others who may have unsupervised access to residents . Sexual Abuse: Non-consensual sexual contact of any type with a resident includes unwanted intimate touching of any kind, especially of breasts or perineal area; all types of sexual assault or battery, such as rape, sodomy [anal or oral intercourse] and coerced nudity . Generally, sexual contact is non-consensual if the resident either appears to want the contact to occur but lacks the cognitive ability to consent; or does not want the contact to occur. Non-consensual contact may include, but is not limited to, situations where a resident is sedated, is temporarily unconscious, or is in a coma [a state of prolonged loss of consciousness]. RESIDENT 1 Resident 1 admitted to the facility on [DATE] with diagnoses that included anoxic brain damage (occurs when oxygen is cut off completely from the brain) and persistent vegetative state (also known as post-coma unresponsiveness, is a chronic disorder in which an individual with severe brain damage appears to be awake but shows no evidence of awareness of their surroundings). Review of Resident 1's annual Minimum Data Set (MDS - an assessment tool) dated 02/14/2025 showed Resident 1 was in a persistent vegetative state with no visible consciousness. The assessment further showed that Resident 1 was dependent on staff with all aspects of care. Observations on 04/18/2025 at 11:17 AM, showed Resident 1 was in bed positioned on their back. Further observation showed Resident 1 was not responsive and with no awareness of self or surroundings. Review of the interdisciplinary note dated 04/12/2025, showed, Today at approximately 3:00 PM, a staff member observed the resident's roommate [Resident 2] to may have been inappropriately performing unwanted sexual act to the resident [Resident 1]. Review of a facility investigation dated 04/12/2025, showed Staff J, Certified Nursing Assistant (CNA), stated that they saw Resident 2 with head/face on Resident 1's private area, while Resident 1's brief was off performing oral sex. Further review of the investigation showed the facility substantiated a resident to resident sexual abuse and Resident 2 was arrested by the Police on 04/12/2025. In a phone interview on 05/02/2025 at 8:00 AM, Resident 1's Collateral Contact 1 (CC1) stated that Resident 1 was not able to consent. CC1 stated that they felt very scared when they were notified about the incident on 04/12/2025. In an interview on 05/02/2025 at 10:14 AM, Staff J stated that on 04/12/2025 around 3:00 PM, when they were entering Resident 1's room, they found Resident 2 by Resident 1's bed. Staff J stated that Resident 2 was bending down at their waist and their head and face were in Resident 1's private area and was performing oral sex, Staff J stated that when they called Resident 2 by name and asked them what they were doing, Resident 2 stopped their action and walked back to their bed. Staff J stated that they observed Resident 1's incontinence brief was unfastened, and their private area was exposed. Staff J further stated they immediately reported it to Staff G, Resident Care Manager. In an interview on 05/02/2025 at 11:01 AM, Staff G stated that on 04/12/2025, when Staff J notified them about the incident, they went to Resident 1's room and observed Resident 1's incontinence brief was open, and their private area was uncovered. Staff G further stated they immediately placed Resident 2 on one-on-one supervision and assessed Resident 1 for injury. RESIDENT 2 Resident 2 admitted to the facility on [DATE]. Review of Resident 2's quarterly MDS dated [DATE] showed Resident 2 was cognitively intact. The assessment further showed Resident 2 was independent with sit- to-stand and able to walk at least ten feet in a room, corridor, or similar spaces. Review of the December 2024 and January 2025 Documentation Survey Report for behavior monitoring and intervention showed that Resident 2 had the following physical/verbal behavioral symptoms: - On 12/11/2024 - threatening others - On 12/18/2024 - scratching others and threatening others - On 12/20/2024 - pacing and wandering - On 12/29/2024 - grabbing others - On 01/03/2025 - wandering - On 01/04/2025 - wandering - On 01/15/2025 - physically aggressive Further review of the January 2025 Documentation Survey Report showed that the behavioral monitoring was discontinued on 01/25/2025. Review of the social service note dated 12/30/2024 showed that the facility's social worker met with Resident 2 related to occurrence of grabbing others. Further review of the note did not show if further behavioral assessment or Resident 2's behaviors directed towards others addressed under Resident 2's care plan. Review of the comprehensive care plan printed on 04/18/2025 showed there was no care plan in place for Resident 2's documented behaviors in December 2024 and January 2025. In an interview and joint record review on 05/02/2025 at 11:53 AM, Staff F, Social Services Director, stated that if a resident exhibited behavior towards other residents/staff, the facility would assess the resident and implement an intervention for the behaviors identified. Staff F stated they were not aware of Resident 2 having documented behaviors directed towards others. Joint record review of the social service note dated 12/30/2024 showed that Resident 2 had exhibited behavior grabbing others. Staff F stated that Resident 2's behaviors were not addressed under their care plan due to there being no behavioral trends, and the resident was not on medications that required behavior monitoring. In an interview on 05/02/2025 at 3:27 PM, Staff B, Director of Nursing, stated that if a resident exhibited physical/verbal behavioral symptoms directed towards others, the provider and their representative would be notified, a follow-up assessment would be completed, the resident would be monitored, and the behavior would be addressed under the resident's care plan. Staff B stated that they were not aware of Resident 2's documented behavioral symptoms. Staff B stated that the behavioral monitoring was discontinued when the resident was sent to hospital, and it was not reactivated when they were readmitted . Staff B further stated that Resident 1 was not able to cognitively consent to sexual activity. In an interview on 05/02/2025 at 3:58 PM, Staff A, Executive Director, stated that residents have the right to be free from any type of abuse. Reference: (WAC) 388-97-0640(1)

Based on interview and record review, the facility failed to ensure the primary care physician was timely notified when medications were not administered for 1 of 4 residents (Resident 1), reviewed for notification of change. The failure to notify the primary care physician when the medication (clozapine-used to treat Schizophrenia [a chronic mental illness characterized by a combination of symptoms that significantly impair a person's thinking, feeling, and behavior]) were not administered caused harm for Resident 1 who had increased anxiety, behaviors, and suicidal ideation requiring hospitalization . A past noncompliance was initiated on 02/26/2025 related to F580 Notify of Changes (Injury/Decline/Room, Etc.) for failure to notify the physician when clozapine was unavailable and/or not provided to the resident resulting in increased behaviors, anxiety, and suicidal ideation requiring hospitalization . The facility implemented the following interventions that were initiated 02/26/2025 and corrected by 02/28/2025: - Resident 1 was evaluated by the physician and was sent to the hospital for further evaluation. - The facility conducted an audit of medication errors from 01/01/2025 through 03/01/2025. No other issues identified. - In-services were held for licensed nurses related to medication administration and what to do if a medication was not available, including who to notify. - Weekly audits were completed weekly for four weeks and monthly for two months and the results will be reviewed through the facility Quality Assurance Performance Improvement Committee process. Findings included . Review of the facility's policy titled, Medication Error Reporting and Adverse Drug Reaction Prevention and Detection, dated 01/2023, showed that Medication Error/Variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional, resident or consumer. It showed that medication errors are considered significant if they require hospitalization . It further showed that In the event of a significant medication error .immediate action is taken, as necessary, to protect the resident's safety and welfare .the prescriber is notified promptly of any significant error. Resident 1 admitted to the facility on [DATE] with diagnosis that included Schizophrenia. Review of the annual minimum data set (an assessment tool), dated 12/11/2024, showed Resident 1 had a tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) and inserts a tube to provide an airway). Review of Resident 1's February 2025 Medication Administration Record (MAR) showed an order for clozapine with instructions to give 200 mg (milligrams-a unit of measurement) .one time a daily for Schizophrenia. It showed that on 02/22/2025, 02/23/2025, 02/24/2025 and 02/25/2025, clozapine was not marked as given and showed it was on order from pharmacy [indicating the medication was unavailable]. Review of the facility's investigation report dated 02/26/2025, showed Staff H, Registered Nurse (RN), was the night nurse on 02/22/2025 and that was the first day the medication [clozapine] was not administered to Resident 1. It showed that Staff H did not notify the physician and did not place the resident on alert monitoring. It showed that Staff G, RN, was the nurse on 02/23/2025, 02/24/20225 and 02/25/2025 and that clozapine was not available on those days to be administered. It further showed that Staff G did not notify the physician or place the resident on alert monitoring. Review of a nursing progress note dated 02/24/2025, showed the resident [Resident 1] appeared anxious, PA [Physician Assistant] gave new order for Hydroxyzine [a medication used to treat anxiety]. Review of a nursing progress note dated 02/26/2025, showed patient [resident] noted walking back and forth on unit new order for Ativan [medication to treat anxiety] 1 mg administered will continue to monitor. Review of another nursing progress note on 02/26/2025, showed patient noted to continue having more anxiety and notified new order for lorazepam [generic for Ativan] 4 mg x 1 [times one] only received medication obtained and administered will continue to monitor. Review of a social services progress note dated 02/26/2025 showed that SW [social work] met with resident this afternoon r/t [related to] reported anxiety. Resident was observed by this SW pacing down the hallway of 1st [first] floor throughout the day and resident endorsed feeling anxious by writing on his notepad when approached by this SW. Review of a social services note dated 02/27/2025 showed that resident was observed pacing down common areas of the facility. It further showed that Resident endorsed continuing to feel anxious at times. Review of a physician note dated 02/27/2024 showed Pt [patient] did not receive his PM [night] clozapine x 4 [four] days and having symptoms of anxiety, insomnia, racing thoughts, and confusion, irritability, pacing up and down the hallways. It showed Medications did not reach until 2/26 [02/26/2025] PM. Review of a nursing progress note dated 03/01/2025, showed Resident has expressed suicidal ideation with altered mental status. On call PCP [Primary Care Physician] notified with order to send to hospital for evaluation and treatment. Review of a hospital note dated 03/01/2025, showed that Resident 1 presents [to the] emergency department with suicidal ideation. It showed, He did express that he was suicidal without a plan. Review of a hospital psychiatry (the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders) note dated 03/02/2025, showed Spoke with nursing staff via phone at [the facility]. Per staff, due to a medication error patient went without Clozapine from 2/22 [02/22/2025] to 2/26 [02/26/2025] so staff psychiatrist restarted Clozapine titration. It showed Resident 1 was requiring Ativan .for agitation including pulling at trach [tracheotomy], psychomotor agitation, thought to be due to decreased Clozapine dose. In an interview on 03/27/2025 at 11:19 AM, Staff E, Licensed Practical Nurse, stated that if a resident's medication was unavailable, they would notify the doctor, call the pharmacy and notify the resident. In an interview and joint record review on 03/27/2025 at 12:00 PM, Staff B, Physician, stated that missing four doses of clozapine would be a big cause for concern. Joint record review of Resident 1's hospital records showed Resident 1 was sent to the hospital on 03/01/2025 for low oxygen, self-decannulation (removal of the tracheostomy) and suicidal ideation. Staff B stated it was very unfortunate those doses were missed. Staff B further stated that they would expect staff to notify the provider as soon as discovered that a medication was missed and no one was notified about the missing doses until [Resident 1] was having behaviors. In an interview on 03/27/2025 at 12:06 PM, Staff C, PA, stated they were notified that Resident 1 was having behavior changes such as not sleeping well, pacing up and down the hallway and he was anxious and agitated and they ordered hydroxyzine starting on 02/24/2025. Staff C stated that nursing called me that morning [02/26/2024] to say [Resident 1] was not getting better, I ordered lorazepam. Staff C said when they got to the clinic on 02/26/2025, the Resident Care Manager (RCM) told me about the missing doses [of clozapine] and then I went to see him. Staff G stated they were not notified about the missing doses of clozapine until 02/26/2025 [four days after missing the first dose]. Staff C further stated that Resident 1 had to go to the hospital because the day he left I was told he had suicidal thoughts and they did tell me he attempted self-decannulation. In an interview and joint record review on 03/27/2025 at 1:39 PM, Staff D, RCM, stated they expected medications to be available for residents and you can't just not give it [the medication] if there's an order, there's steps to take, call pharmacy, have to make the doctor aware. Joint record review of the Resident 1's February 2025 MAR showed clozapine was not given from 02/22/025 through 02/25/2025. Staff D stated that clozapine was not given on 02/22/2025, 02/23/2025, 02/24/2025 and 02/25/2025 and showed that the medication was on order from the pharmacy. Staff D stated they expected licensed nurses to notify the pharmacist and the doctor to ask what to do. Joint record review of Resident 1's progress notes from 02/22/2025 through 02/25/2025 showed no documentation that the physician was notified of the missing doses of clozapine. Staff D stated, if it wasn't documented it didn't happen. Further joint record review of Resident 1's progress notes, showed that Resident 1 had increased behaviors and Staff D stated that most likely because he missed 4 [four] doses of clozapine. Joint record review of a nursing progress note dated 03/01/2025 showed that Resident 1 was sent to the hospital for suicidal ideation. Staff D stated, I didn't know about him having suicidal ideation before, so based off of that it would be a new behavior and that it happened after Resident 1 missed four doses of their clozapine. Staff D further stated Resident 1 had a change in condition due to missed doses of clozapine and stated that suicidal ideation was a negative outcome. In a phone interview on 03/27/2025 at 3:32 PM, Staff A, Director of Nursing, stated that Resident 1 went to the hospital because the facility couldn't manage Resident 1's behaviors and it would be better handled at the hospital. When asked if Resident 1 was having suicidal ideation, Staff A stated, I believe that was mentioned. When asked if Resident 1 experienced a negative outcome due to missing four doses of clozapine, Staff A stated that Resident 1 had increased behaviors. When asked if being hospitalized was a negative outcome, Staff A stated Resident 1 had actively increased behaviors and out of abundance of caution he was sent to the hospital. When asked if this was after Resident 1 missed four doses of clozapine, Staff A stated, yes. Staff A further stated that staff should have notified the provider after the first dose was missed. Reference: (WAC) 388-97-0320

Based on interview and record review, the facility failed to provide an ordered medication, significant to the health of 1 of 4 residents (Resident 1), reviewed for medication administration. This failure caused harm to Resident 1 when their medication (clozapine-used to treat Schizophrenia [a chronic mental illness characterized by a combination of symptoms that significantly impair a person's thinking, feeling, and behavior]) were not administered resulting in increased anxiety, behaviors, and suicidal ideation requiring hospitalization . A past noncompliance was initiated on 02/26/2025 related to F760 Residents Are Free of Significant Medication Errors for failure to provide a medication significant to the health of the resident. The facility implemented the following interventions that were initiated 02/26/2025 and corrected by 02/28/2025: - Resident 1 was evaluated by the physician and was sent to the hospital for further evaluation. - The facility conducted an audit of medication errors from 01/01/2025 through 03/01/2025. No other issues identified. - Staff educations were held for licensed nurses related to medication administration and what to do if a medication was not available, including who to notify. - Weekly audits were completed weekly for four weeks and monthly for two months and the results will be reviewed through the facility Quality Assurance Performance Improvement Committee process. Findings included . Review of the facility's policy titled, Medication Administration General Guidelines, dated January 2024, showed that Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices. Review of the facility's policy titled, Medication Error Reporting and Adverse Drug Reaction Prevention and Detection, dated 01/2023, showed that Medication Error/Variance shall be defined as any preventable event that may cause or lead to inappropriate medication use or resident harm while the medication is in the control of the health care professional, resident or consumer. It showed that medication errors are considered significant if they require hospitalization . Resident 1 admitted to the facility on [DATE] with diagnosis that included Schizophrenia. Review of the annual Minimum Data Set (an assessment tool) dated 12/11/2024, showed Resident 1 had a tracheostomy (a surgical procedure that creates an opening in the trachea (windpipe) and inserts a tube to provide an airway). Review of Resident 1's February 2025 Medication Administration Record (MAR) showed an order for clozapine with instruction to give 200 mg (milligrams-a unit of measurement) .one time a daily for Schizophrenia. It showed that on 02/22/2025, 02/23/2025, 02/24/2025 and 02/25/2025, clozapine was not marked as given and showed it was on order from pharmacy [indicating the medication was unavailable]. Review of the facility's investigation report dated 02/26/2025, showed Staff H, Registered Nurse (RN), was the night nurse on 02/22/2025 and that was the first day the medication [clozapine] was not administered to Resident 1. It showed that Staff H did not notify the physician and did not place the resident on alert monitoring. It showed that Staff G, RN, was the nurse on 02/23/2025, 02/24/20225 and 02/25/2025 and that clozapine was not available on those days to be administered. It further showed that Staff G did not notify the physician or place the resident on alert monitoring. Review of a nursing progress note dated 02/24/2025, showed the resident [Resident 1] appeared anxious, PA [Physician Assistant] gave new order for Hydroxyzine [a medication used to treat anxiety]. Review of a nursing progress note dated 02/26/2025, showed patient [resident] noted walking back and forth on unit new order for Ativan [medication to treat anxiety] 1 mg administered will continue to monitor. Review of another nursing progress note on 02/26/2025, showed patient noted to continue having more anxiety and notified new order for lorazepam [generic for Ativan] 4 mg x 1 [times one] only received medication obtained and administered will continue to monitor. Review of a social services progress note dated 02/26/2025 showed that SW [social work] met with resident this afternoon r/t [related to] reported anxiety. Resident was observed by this SW pacing down the hallway of 1st [first] floor throughout the day and resident endorsed feeling anxious by writing on his notepad when approached by this SW. Review of a social services note dated 02/27/2025 showed that resident was observed pacing down common areas of the facility. It further showed that Resident endorsed continuing to feel anxious at times. Review of a physician note dated 02/27/2024 showed Pt [patient] did not receive his PM [night] clozapine x 4 [four] days and having symptoms of anxiety, insomnia, racing thoughts, and confusion, irritability, pacing up and down the hallways. It showed Medications did not reach until 2/26 [02/26/2025] PM. Review of a nursing progress note dated 03/01/2025, showed Resident has expressed suicidal ideation with altered mental status. On call PCP [Primary Care Physician] notified with order to send to hospital for evaluation and treatment. Review of a hospital note dated 03/01/2025, showed that Resident 1 presents [to the] emergency department with suicidal ideation. It showed, He did express that he was suicidal without a plan. Review of a hospital psychiatry (the branch of medicine focused on the diagnosis, treatment and prevention of mental, emotional and behavioral disorders) note dated 03/02/2025, showed Spoke with nursing staff via phone at [the facility]. Per staff, due to a medication error patient went without Clozapine from 2/22 [02/22/2025] to 2/26 [02/26/2025] so staff psychiatrist restarted Clozapine titration. It showed Resident 1 was requiring Ativan .for agitation including pulling at trach [tracheotomy], psychomotor agitation, thought to be due to decreased Clozapine dose. In an interview on 03/27/2025 at 9:30 AM, Staff F, Consultant Pharmacist, stated that clozapine was a powerful anti-psychotic used to treat schizophrenia. Staff F stated that Clozapine should be taken daily. When asked what would happen if a resident missed four doses, Staff F stated, that would be an issue and would see symptoms like hallucinations, agitation, and delusions in a resident. When asked if missing four doses would be considered a significant medication error, Staff F stated, I think for the most part that would be significant. In an interview on 03/27/2025 at 11:19 AM, Staff E, Licensed Practical Nurse, stated that if a resident's medication was unavailable, they would notify the doctor, call the pharmacy and notify the resident. In an interview and joint record review on 03/27/2025 at 12:00 PM, Staff B, Physician, stated that missing four doses of clozapine would be a big cause for concern. Joint record review of Resident 1's hospital records showed Resident 1 was sent to the hospital on 03/01/2025 for low oxygen, self-decannulation (removal of the tracheostomy) and suicidal ideation. Staff B stated it was very unfortunate those doses were missed. In an interview on 03/27/2025 at 12:06 PM, Staff C, PA, stated they were notified that Resident 1 was having behavior changes such as not sleeping well, pacing up and down the hallway and he was anxious and agitated and they ordered hydroxyzine starting on 02/24/2025. Staff C stated that nursing called me that morning [02/26/2024] to say [Resident 1] was not getting better, I ordered lorazepam. Staff C said when they got to the clinic on 02/26/2025, the Resident Care Manager (RCM) told me about the missing doses [of clozapine] and then I went to see him. Staff C further stated that Resident 1 had to go to the hospital because the day he left I was told he had suicidal thoughts and they did tell me he attempted self-decannulation. In an interview and joint record review on 03/27/2025 at 1:39 PM, Staff D, RCM, stated they expected medications to be available for residents and you can't just not give it [the medication] if there's an order, there's steps to take, call pharmacy, have to make the doctor aware. Joint record review of the Resident 1's February 2025 MAR showed clozapine was not given from 02/22/025 through 02/25/2025. Staff D stated that clozapine was not given on 02/22/2025, 02/23/2025, 02/24/2025 and 02/25/2025 and showed that the medication was on order from the pharmacy. Joint record review of Resident 1's progress notes, showed that Resident 1 had increased behaviors and Staff D stated that most likely because he missed 4 [four] doses of clozapine. Joint record review of a nursing progress note dated 03/01/2025 showed that Resident 1 was sent to the hospital for suicidal ideation. Staff D stated, I didn't know about him having suicidal ideation before, so based off of that it would be a new behavior and that it happened after Resident 1 missed four doses of their clozapine. Staff D further stated Resident 1 had a change in condition due to missed doses of clozapine and stated that suicidal ideation was a negative outcome. In a phone interview on 03/27/2025 at 3:32 PM, Staff A, Director of Nursing, stated that Resident 1 went to the hospital because the facility couldn't manage Resident 1's behaviors and it would be better handled at the hospital. When asked if Resident 1 was having suicidal ideation, Staff A stated, I believe that was mentioned. When asked if Resident 1 experienced a negative outcome due to missing four doses of clozapine, Staff A stated that Resident 1 had increased behaviors. When asked if being hospitalized was a negative outcome, Staff A stated Resident 1 had actively increased behaviors and out of abundance of caution he was sent to the hospital. When asked if this was after Resident 1 missed four doses of clozapine, Staff A stated, yes. Reference: (WAC) 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to ensure that a wound vac (a machine using a suction pump, tubing, and a dressing to remove excess fluids and promote healing of wounds) was not removed prior to a follow-up appointment with a burn clinic for 1 of 1 Resident (Resident 1), reviewed for a skin graft wound (a surgical procedure in which a piece of skin is transplanted from one area to another). Resident 1 experienced harm when their wound vac was removed by the facility and a skin graft was compromised resulting in hospitalization and repeat skin graft surgery. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses that included burns to the upper back, stroke (occurs when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients), status post tracheostomy (a surgical opening made through the front of the neck into the windpipe allowing air to flow in and out, and gastrostomy (a surgical opening made through the abdomen into the stomach where a feeding tube is inserted). Review of Resident 1's hospital document dated 02/14/2024, showed Resident 1 had a Post operative plan: Vac [referring to wound vac] until POD5 [Postoperative day 5) to be removed in clinic. Review of the hospital discharge summary instructions/orders dated 02/16/2024, showed, Wound care: Wound vac at 75 mmHg [millimeters mercury-a unit of pressure] to back until POD 5 [post operative day five]. Follow up with burn clinic on 2/20 [02/20/2024]. Review of Resident 1's physician orders transcribed by the facility, dated 02/16/2024, showed, Remove wound vac prior to [hospital] Burn clinic follow-up appointment 02/20/2024 0500 [5:00 AM]. Review of Resident 1's nursing progress notes dated 02/16/2024, showed Resident [Resident 1] arrived via stretcher transport with AMR [Ambulance Medical Response] . Resident is s/p [status post] skin graft to burn site [upper back area] with donor site of R [right] thigh .Wound Vac in place and functioning without air leak, sponge is compressed. Review of the nursing progress notes dated 02/20/2024, showed Staff C, Registered Nurse (RN), stated the facility removed Resident 1's wound VAC as ordered. The wound care was done as ordered. Pt [patient/resident] is ready for his appointment [burn clinic follow-up]. Further review of the nursing progress notes showed, Staff D, Resident Care Manager, stated, Per RN [Staff C] report, wound vac was removed using proper procedure and technique for wound vac removal for skin graft sites. Resident tolerated well without issues. After chart review, wound care for skin graft donor site and wound vac site were followed as ordered by [hospital]. Resident went out for [hospital] burn clinic follow up at 0745 [7:45 AM, that day], awaiting [waiting] for resident's return to update [hospital] Burn clinic orders. Review of Resident 1's hospital Burn Clinic follow-up notes, dated 02/20/2024, showed Patient underwent outpatient excision and skin grafting of the unstable burn wound on his back with wound vac placement on 02/14/2024 .Unfortunately, patient reports that his wound vac was taken off at the facility and restarted on wet-to-dry dressings. Further review of the Burn Clinic notes showed Resident 1 will require re-grafting of the previously excised wound as he has demonstrated an inability to heal the chronic unstable burn scar prior to the above operation. Plan is to take him to surgery on Thursday, February 22nd [February 22, 2024] and regraft [reapply skin graft] his back wound. We will admit him to the hospital afterwards to over seen the wound care/new graft. Review of Resident 1's hospital's Burn post operative note dated 02/22/2024, showed He [resident] had a graft procedure done on 02/14/2024, but unfortunately the wound VAC device was removed prematurely at the rehabilitation facility and the graft was lost. He returns to the OR [operating room] for a repeat procedure. In an interview on 02/26/2024 at 8:08 AM with Resident 1's Representative (RR1), stated that Resident 1 underwent another skin graft due to the negligence of staff. RR1 stated It wasn't supposed to be removed because that's what the doctor said at [the hospital]. We had a scheduled follow up at the burn clinic on the 20th [February 20,2024] and we had to go back to [the hospital] last Thursday [February 22, 2024] because of another surgery, which for me should have not happened if not for the negligence of the facility. I can just imagine how much pain [Resident 1] is going through. This is unnecessary surgery for him. In an interview on 02/28/2024 at 5:19 PM with Staff C stated that at 5:00 AM on 02/20/2024, a new order showed in the computer to remove the wound vac dressing, and at the same time, the second order showed to remove wound vac dressing and cover with wet to dry dressing and secure with ABD [abdominal] pad. Staff C stated they informed Resident 1 and told them they had orders to remove their wound vac/dressing. Staff C stated they asked Resident 1 to roll on to their left side, gave their Oxycodone [narcotic] pain medication before removing the wound vac and dressing, rolled up to their side, and turned off the wound vac. Staff C stated they washed their hands and put on their gloves, and slowly removed the wound vac dressing. Staff C stated that the skin graft was clinging to the wound vac dressing about 80% [eighty percent] and they could not remove it and a small part about 20% [twenty percent] was hanging on the dressing. Staff C further stated that the loose part of the skin graft that was hanging, I put it back to stick to the wound. Then I covered it [wound] with wet to dry dressing as ordered. During an interview and joint record review on 02/29/2024 at 9:54 AM, Staff D stated that they were the admitting nurse for Resident 1 on 02/16/2024. Staff D stated they reviewed the hospital discharge orders and transcribed (wrote) the wound care orders for Resident 1. Staff D stated that there was no discharge order to remove Resident 1's wound vac. Staff D and the surveyor performed a joint record review of the hospital discharge summary instructions dated 02/16/2024. Staff D stated that the discharge order stated, wound vac at 75 mmHg to back until POD 5 and discussed it with Staff E, Nurse Practitioner (NP), and Staff F, Nurse Consultant that day. Staff D stated, I was directed by the NP to write the order, Remove wound vac prior to [hospital] Burn clinic follow-up appointment 02/20/2024 0500 [5:00 AM], and it showed a discharge instruction, Patient [resident] has been arranged to come back to [the hospital] burn clinic on 02/20/2024, for wound vac takedown. Staff D stated they were not aware of the hospital discharge instructions until they were notified by the Burn clinic on 02/20/2024, that the wound vac should have not been removed. Staff D stated that the Burn clinic called that day, and they stated that not removing the wound vac was in the discharge instructions. In an interview on 02/26/2024 at 11:10 AM with Staff B, Director of Nursing Services, stated that Resident 1's skin graft was removed when Staff C removed the wound vac prior to Resident 1's burn clinic follow up appointment on 02/20/2024. Staff B stated that they started a plan of correction which included in-services for staff regarding wound vac. Staff B further stated that the wound vac should have not been removed. Reference: (WAC) 388-97-1060 (1)

Based on interview and record review, the facility failed to assess and monitor before, during, and after hypodermoclysis (clysis - introduction of large amounts of fluid into the body between skin and muscle) procedure, ensure proper supervision during the procedure, and promptly intervene to address bleeding, in accordance with professional standards of practice for 1 of 1 resident (Resident 1). Resident 1 experienced harm when they were hospitalized to evaluate and treat a critically low blood pressure and an acute kidney injury (sudden and rapid loss of kidney [two bean-shaped organs that filter your blood] function) related to acute blood loss. This failed practice placed other residents at risk for unmet care needs, decline in medical status, and related complications. Findings included . Review of the facility's policy titled, Subcutaneous Hydration [hypodermoclysis], dated August 2016, showed hypodermoclysis may be contraindicated for residents with other conditions where subcutaneous therapy might result in extensive bleeding under the skin. The flow rate should be checked, and the subcutaneous site assessed every hour and PRN (as needed) during infusions (slow injection of a substance into the tissue) and at least once per shift if not in use. Suggested charting includes Resident's condition at initiation of therapy including mental status as appropriate. Assessments for condition of site(s), pulse, BP (blood pressure, is a pressure of the blood in the circulatory system), physical assessment/resident's response to therapy. Resident 1 admitted to the facility on [DATE]. Review of Resident 1's care plan, dated and initiated on 11/27/2023, did not include the resident's diagnosis, condition, current medications (aspirin and ticagrelor [antiplatelet drugs to prevent blood clots from forming, and increases risk for bleeding]) and/or services/procedures (clysis) that would place Resident 1 at risk for bleeding. Review of the significant change in status Minimum Data Set (an assessment tool) dated 01/29/2024, showed Resident 1 had a Brief Interview for Mental status (BIMS) score of 9 indicating moderately impaired cognition, and took an antiplatelet medication. Review of the laboratory result dated 02/03/2024, showed Resident 1's hemoglobin (cells that distributes the oxygen throughout the body) was 7.0 ([normal value for female adult is 10.4 to 15.2 gram/deciliter [g/dl, unit of measurement for medical test]). Review of the progress notes dated 02/03/2024 at 1:38 PM, showed Staff D, Licensed Practical Nurse, documented, Received notification from lab [laboratory] of critical value-Hematocrit [Hemoglobin] 7.0 plus several other abnormal values. Review of Resident 1's physician order dated 02/03/2024, showed to give sodium chloride (salt and water solution) at 500 milliliter (ml, a unit of measurement for volume) perfusion (passage of fluid through the tissue) one time only for dehydration (excessive water loss from the body) for one day, infuse 500 ml at 70 ml per hour via clysis. Review of the February 2024 Medication Administration Record (MAR) showed Resident 1 took aspirin daily in the morning from 02/01/2024 to 02/04/2024, and ticagrelor every 12 hours from 02/01/2024 to 02/03/2024. The MAR showed an order for clysis dated 02/03/2024, missing a signature for administration, on 02/03/2024. In a joint record review and interview on 02/06/2024 at 11:22 AM with Staff C, Resident Care Manager, stated that there was no assessment evaluating the resident's clinical condition and risk factors completed for Resident 1 prior to clysis administration. Review of Resident 1's clinical records showed no monitoring before, during, and after clysis administration and had no documentation for when and who administered them. Staff C stated, I was not here when it was administered. Review of Resident 1's nursing progress notes dated 02/04/2024, showed that at 11:00 AM, post clysis procedure, Resident 1 was soaked with blood on their right upper quadrant (RUQ- upper right part of the abdomen) bandage and on their bedding. At 6:00 PM, Resident 1 had blood oozing from the entry site used for the clysis procedure. The progress note showed that the on-call provider was notified, and Resident 1's blood pressure was 87/47 (hypotension-low BP reading). Resident 1 was transported to the emergency room at 8:20 PM that day and was admitted to the hospital. Review of the hospital records dated 02/04/2024, showed Resident 1's hemoglobin level was at 5.3 [below 7 would require blood transfusion] and BP of 94/51 (hypotension). Resident 1 received a blood transfusion, 2 (two) units of packed red blood cells (PRBC) for acute blood loss. The hospital records showed Resident 1 presented with anemia (reduced blood cell count), hypotension, and new acute kidney injury. In an interview on 02/13/2024 at 9:38 AM, Staff D stated they received clysis training a long time ago, before their hire date. Staff D stated their clysis training was on an animal. Staff D stated a critical lab of hemoglobin 7.0 was received for Resident 1 and the provider ordered clysis for hydration. Staff D stated that clysis was started on Resident 1 at around 5 or 6 PM with no Registered Nurse (RN) supervision on 02/03/2024. Staff D stated they did not complete an assessment before clysis, did not take the baseline BP, did not monitor the clysis site, and did not check Resident 1's BP during and after the clysis procedure. Staff D stated they should have called the provider earlier in AM since Resident 1 was at risk for further bleeding due to blood thinner medications they were taking. Staff D stated Resident 1 was taking aspirin and ticagrelor medications, which placed the resident at risk for further complications related to an already low hemoglobin level. Staff D further stated Resident 1 was sent out [to the hospital] due to low BP. In an interview on 02/14/2024 at 10:20 AM, Staff B, Director of Nursing, stated Resident 1's assessment should have been completed with ongoing monitoring during and after Resident 1's clysis procedure. Staff B stated they expected the MAR to be signed and/or documented as administered and that Resident 1's care plan should have included risks of bleeding, goals, and interventions. Staff B further stated that Staff D should have been supervised by an RN during the clysis administration. Reference: (WAC) 388-97-1060 (1)(3)(ii)

Based on observation, interview and record review, the facility failed to ensure 2 of 3 residents (Residents 1 and 2) reviewed for abuse, were free from abuse. Failure to keep another resident from entering their rooms & attempting to get into bed with them while making a sexual request resulted in psychological harm for Resident 1, and placed both residents at risk for ongoing psychological distress and diminished quality of life. In addition, the facility failed to ensure the alleged abuse was reported and investigated so as to identify possible similar allegations/incidents. Findings included . Review of the untitled facility abuse policy, revised December 2013, stated each resident had the right to be free from abuse, including verbal, mental, sexual, or physical abuse. The policy defined sexual abuse as nonconsensual sexual contact of any type with a resident. The policy also stated sexual contact was nonconsensual if the resident did not want the contact to occur. Resident 1 The resident admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Minimum Data Set (MDS) assessment, dated 5/28/2021, showed the resident was cognitively intact and able to communicate her needs. Review of the resident's care plan, dated 05/04/2021, showed the resident had depression. Goals included the resident would remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood. Interventions included the following: 1. Monitor/document/report as needed any signs and symptoms of depression including: hopelessness, anxiety, sadness, [CONDITION(S)], negative statements, anxious or health related complaints and tearfulness. 2. The resident needs time to talk. Encourage the resident to express feelings. Resident 2 The resident admitted to the facility in March 2021, with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the resident's MDS, dated [DATE], showed the resident was cognitively intact and able to make her needs known. Review of the resident's care plan, dated 6/25/2021, showed the resident had a psychosocial well-being careplan. Goals were that the resident would have psychosocial well-being with interventions, which included that when there was conflict, the resident was to be removed to a calm, safe environment and allowed to vent/share feelings. Resident 3 The resident admitted to the facility in March 2021. The MDS, dated [DATE], showed the resident was cognitively intact and was able to communicate his needs. On 07/21/2021 at 11:09 AM, Reporter A, stated that Staff B, Social Services Director (SSD), had informed them that Resident 3 had approached two female residents while at the facility and attempted to get into their beds with sexual intent. On 07/21/2021 at 1:09 PM, Staff B, SSD, stated that Resident 3 had approached two female residents (Residents 1 and 2) and asked to sleep in their beds on 06/30/2021. Resident 3 was then discharged that same day, 06/30/2021, as Resident 3 had been assessed as independent with activities of daily living and no longer needed skilled services at the facility. Review of the incident log for June 2021, showed the incidents had not been logged, reported to State agencies or investigated. On 07/22/2021 at 11:26 AM, Resident 1 stated that Resident 3 came into her room, got out of his wheelchair, laid on her bed and stated he wanted to have sex with her. Resident 1 stated she was startled, screamed at him to get off her bed, and told him to get out of her room. Resident 1 said she then told Staff C and Staff D, Nursing Assistants (NA), about the incident. When asked how she felt about the incident she stated that she had cried, as the incident brought back memories of her being molested when she was young. She stated she liked being in the facility and generally felt safe but never wanted an experience like that ever again. She stated no one followed-up with her regarding the incident. Review of the resident's progress notes and care plan did not show any documentation regarding the alleged incident. On 07/27/2021 at 9:38 AM, Resident 2 stated she recalled the incident wherein Resident 3 insisted on and told her he wanted to get into her bed for sexual relations. She stated she told the resident that his actions were inappropriate and to back off (which he did). She stated she was not offended, but would have been if he had insisted on it. She stated Resident 3 was trying to see how far he could go, but Resident 1 stated she would not have let him have it if he tried. Review of Resident 2's progress notes and care plan did not show any documentation regarding the incident. In a joint onsite interview on 07/27/2021 at 11:56 AM, Staff C, NA, and Staff D, NA, both stated they were aware of the incident(s). Staff C stated she spoke to Resident 3 and told him his actions were inappropriate. Both stated the incident was reported to a nurse, but could not remember who the nurse was or when the incident happened. At 12:35 PM, Staff E, facility administrator, stated no one had informed her about the incident(s). Staff E stated that if she had known about the incident(s), a facility investigation would have been initiated and the incident would have been reported to the state agencies. The administrator acknowledged that an investigation could have potentially identified other possible victims. At 1:43 PM, Staff B stated that she knew about the incident(s), but did not report it because she stated that when she spoke to Resident 1 about the incident, the resident seemed fine and unaffected by the incident. Reference (WAC) 388-97-0640(1)

Based on observation, interview, and record review, the facility failed to ensure and provide sufficient protection to prevent resident to resident abuse for one of one resident (Resident #1) reviewed for abuse. This failure resulted in physical assault/abuse of Resident #1 by Resident #2 while in the facility. Resident #1 was hit in the face, neck and chest multiple times, sustained scratches and a bruise, which constitutes harm by physical abuse. Findings include . Record review of the facility's policy titled, Abuse and neglect and misappropriation of resident property prohibition policy dated (MONTH) (YEAR), showed that each resident has the right to be free from abuse, including physical and verbal abuse. The Center implements policies and processes so that residents are not subjected to abuse by staff, other residents and others who may have unsupervised access to residents. Abuse is defined in accordance to the State Operating Manual (YEAR), 483.5 as, The willful infliction of injury. Willful is defined in the State Operating Manual (YEAR), 483.5, as used in the definition of abuse. means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Resident #1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. According to the care plan, dated 04/12/19, Resident #1 had impaired cognitive functioning and required assistance with mobility due to her right side weakness. Review of the progress notes, dated 01/03/2020, showed that Resident #1 was found at 4:00 PM with scratches on her right eye, right cheek, and her neck, and a bruise by her left eye. The progress note also showed that Resident #1 appeared distressed after the situation. The facility staff conducted an investigation of the incident. According to the investigative report, dated 01/06/2020, staff were alerted by another resident who told the staff that you should come look at this. The report showed that Resident #1 had scratches on her face, forehead and chest. Additionally, the report showed Resident #1 had a bruise by her left eye and had blood on her face, and seemed scared. The facility investigative report showed that staff determined that Resident #2 had hit and scratched Resident #1 which caused Resident #1's injuries. Observation on 02/04/2020 at 1:00 PM showed Resident 1# lying in her bed. The resident had a healing bruise on her left eye and healing scratches on her chest and face. The resident could not respond to questions due to her cognitive disability. Resident #2 had lived in the facility since (MONTH) 2019 with [DIAGNOSES REDACTED]. Resident #2 had a communication problem related to speaking another language. According to her most recent care plan, dated 11/29/19, the resident was able to communicate her basic needs. Review of a quarterly Minimum Data Set assessment, dated 11/01/19, showed Resident #2 had demonstrated some physical & verbal behavior symptoms directed toward others that significantly interfered with activities and social interactions and significantly intruded on the privacy and activity of others. Resident #2 has since discharged from the facility and was not available for interview. During an interview on 02/04/2020 at 11:00 AM, Staff A, Licensed Nurse (LN) stated that she was the LN on duty on the day of the assault (01/03/2020). Staff A stated that Resident #2 was agitated that day and was blocking people from passing in the hall by positioning her wheelchair in the middle of the hall. Staff A stated that Resident #2 was also pulling at Resident #1's clothing while the residents were seated in the hall between 10:00 AM and 11:00 AM. Staff A stated that she separated the residents by moving their wheelchairs apart and told Resident #2 No, no don't do that. During the interview, Staff A did not state that any other interventions were put in place to protect Resident #1. Staff A also stated that when she was informed by a resident at 4:00 PM that Resident #1 and Resident #2 were in the dining room alone, she went to the dining room and discovered Resident #1 had been injured. Review of the facility investigation report, dated 01/06/2020, showed When asked what happened, Resident #1 pointed at Resident #2. Resident #2 was then asked if she hit or touched Resident #1, and Resident #2 responded by shaking her head to indicate yes. When facility staff determined that Resident #2 had assaulted Resident #1, law enforcement was notified and Resident #2 was arrested by the police. Resident #1 was taken to a hospital after the incident for further evaluation. Review of the hospital discharge note, dated 01/03/2020, showed Resident #1 had a [DIAGNOSES REDACTED]. The facility staff did not prevent and protect Resident #1 from physical abuse when Resident #2 deliberately hit her in the face, neck and chest when the residents were unsupervised. During an interview with the facility Administrator on 02/10/2020 at 10:30 AM, he stated, This was an isolated incident and Resident #2 had never been physically aggressive before. Review of a previous occurrence report, dated 12/07/19 at 4:00 PM, about a verbal resident to resident altercation involving Resident #2 and a different resident, showed Resident #2 came into the dining room wanting to listen to music, but the other resident told her no. Resident #2 became agitated and started pointing, raising her voice, and making threatening gestures at the other resident by drawing her thumb across her throat like she was threatening to cut his throat which scared the other resident. The report showed the other resident was educated to avoid Resident #2. A progress note, dated 12/11/19, showed Resident #2 had a previous verbal incident with resident. Another note, dated 12/11/19, showed, No behavioral issues throughout the night. Review of the most recent care plan did not include any behavioral issues, interventions or goals. Review of a physician note about Resident #1, dated 02/03/2020, showed that since her assault, she has not been sleeping well. Review of the Medication Administration Record, [REDACTED]. Staff interview and record review of the facility investigation showed that Resident #2 found Resident #1 alone and unsupervised in the dining room, and hit Resident #1 in the face, neck, and chest, which was physical abuse. The facility was also aware of Resident #2's previous threatening gestures made toward another resident, and the behavior of pulling at Resident #1's clothes. However, staff did not provide adequate oversight and/or supervision to ensure Resident #1's safety. The facility did not assure the safety of Resident #1 and did not provide sufficient protection to prevent resident-to-resident physical abuse. WAC Reference 483.12 (a) (1) -0640(1)

Based on observation, interview, and record review, the facility failed to provide the appropriate interventions to prevent accidents for one of four residents (Resident #1) in accordance with her care needs. Failure to use two-person extensive assist for bed mobility during provision of care by staff resulted in Resident #1 falling out of bed to the floor and sustaining several fractures. Findings included . Resident #1 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessments ((MDS) dated [DATE] and 2/17/2019, Resident #1 required two-plus persons extensive physical assistance with bed mobility. According to recent progress notes in (MONTH) & (MONTH) 2019, Resident #1 was alert, oriented, able to make her needs known, and could follow commands. Resident #1 had a [MEDICAL CONDITION] (breathing assistance device placed in the front of her neck). According to the facility investigative report dated 2/25/19 for a fall incident that occurred on 2/24/19, the resident was in the process of being changed by a nursing assistant and she fell out of bed to the floor. The nursing assistant (Staff A) present during the fall documented in the investigative report that she (resident) fell when I was giving her care. The bed moved and she tilted over. The resident was sent to the hospital. According to the hospital discharge records dated 2/28/19, Resident #1 sustained a right proximal tibia(lower leg) fracture, a right malleolus(ankle) fracture, and a left humerus(upper arm) fracture. Resident #1 was out of the facility on 3/20/2019, and was not available for interview. The Director of Nursing (DON) employed at the time of Resident's accident that occurred on 2/24/2019 was not available for interview. According to Resident #1's most recent care plan dated 1/22/2019 and revised on 2/22/2019, the resident is low risk for falls r/t (related to) deconditioning. Interventions included: anticipate and meet resident needs, be sure call light is within reach, encourage resident to participate in activities that promote exercise and follow facility fall protocol. The care plan did not reflect the MDS assessment information that the resident required two- person physical assistance with bed mobility. There was no evidence that staff had evaluated and analyzed the resident's care needs related to bed mobility to ensure appropriate interventions were care planned and implemented consistently to maintain her safety. During an interview on 3/27/19 at 3:30 P.M. with the interim DON, he acknowledged that the information was not added to the care plan to reflect Resident #1's mobility care needs on 2/24/19. During an interview with the facility administrator on 3/20/19 at 10:15 A.M. he stated, When the resident fell , that (Staff A) used poor safety judgement, working too fast, and trying to get things done. The Administrator added that facility staff had been in-serviced on Individual service plans (ISP). The administrator provided two documents on 3/20/19 at 11:00 A.M. titled, in-service education summary. The document had no date or time, but contained the signatures of 18 facility staff. In the section of Content or Summary of In-Service, it stated, (ISP) This is a comprehensive, customized care plan based off the resident's interest, needs and desires. You can find these in the resident's closet door, or in PCC. Further review of the in-service document revealed that Staff A had not signed the document to indicate that she had been in-serviced on the process for the ISP. Observation of the closet door of Resident #1 on 3/20/19 at 12:00 P.M. revealed a document titled Visual Bedside Individual Service Plans (ISPs). There was a print date of 2/25/19 (after the fall) at the bottom of the document. No other dates were on the document. The document indicated the resident required two-person assistance with bed mobility. During an interview on 3/27/19 at 1:00 P.M. with a Licensed Nurse, Staff D, she was shown the document called the ISP from the closet door of Resident #1. Staff D stated she was not familiar with the document and had not been inserviced about the updated process. During an interview with the Staff A via telephone on 3/25/19 at 9:00 A.M., Staff A stated, I have worked by myself with the resident since she has been there, around six months. There was never a care plan on her closet door. They (facility staff) placed that paper on her door after she fell . The resident pretty much always could help me turn her, but she lifted her feeding tube when she tried to help, the mattress moved, and she slipped out of bed. During an interview with Staff B, Nursing Assistant, on 3/27/19 at 10:00 A.M. Staff B stated, I have worked with her (Resident #1) before the fall. I have turned her by myself before the fall because she (the resident) could help with her turn in bed, and she understood how to do it. No one was in the room with me before when I turned her. In an interview with Staff C, Nursing Assistant, on 3/27/19 via telephone at 3:30 P.M. Staff C stated, I have worked with her (Resident #1) before. I have turned her by myself because she (the resident) could help with her turn in bed. She was awake, she could hear and see, she can help good. I turned her and she could help. There was no evidence that staff had been monitored to ensure that they were providing care in accordance with Resident #1's assessed needs for two-person bed mobility, as indicated on the MDS, to maintain her safety. Observations were made on 3/27/19 at 10:30 A.M of Resident #1 in her bed, lying on her back, she was awake and gave good eye contact. The resident was able to nod her head appropriately to yes or no questions and moved her mouth with (mouthed) words to respond to questions. The resident also moved her arms to gesture when communicating. During an interview with Resident #1 on 3/27/19 at 10:35 A.M., Resident #1 indicated 'yes' that she did recall the fall from the bed on 2/24/19. She was able to communicate that two caregivers were never in the room when she was being turned in the bed before the fall. She answered yes she could help staff turn her, and moved her arms as she mouthed the words. When asked for documentation on 3/27/19 at 12:30 P.M. to determine what care directive staff were using for Resident #1 on dates 2/22/19, 2/23/19, and 2/24/19, Licensed Nurses Staff D and Staff E were unable to locate those documents in the computer or hard copy medical record. The facility staff failed to ensure the resident was provided the appropriate interventions that were consistent with her identified care needs of two-person assist related to safe bed mobility. This failure caused harm to Resident #1. WAC Reference 388-97-1060 (3) (g)

Based on observation, interview, and record review, the facility failed to comprehensively assess, monitor, develop individualized care plans, and implement timely interventions such as frequent turning and repositioning necessary to prevent the development of avoidable pressure ulcers for four of six residents (10, 66, 92 and 94) reviewed for pressure ulcers. These failures resulted in harm to these residents who developed facility-acquired pressure ulcers with partial and full thickness skin loss with diminished quality of life and health. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages included: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin. Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Presence of blanchable [DIAGNOSES REDACTED] or changes in sensation, temperature, or firmness may precede visual changes. Color changes do not include purple or maroon discoloration; these may indicate deep tissue pressure injury. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible Undermining and tunneling may occur. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Deep Tissue Pressure Injury: Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Review of the facility policy titled Skin Integrity updated in (MONTH) (YEAR) stated the following: 1. The resident's skin integrity is evaluated using the Braden Scale Evaluation (Tool to help predict the risk of pressure ulcer injury) then a plan of care (P[NAME]) is established based on the risks identified. 2. Ongoing evaluation continues weekly with the licensed nurse (LN) completing a full body skin audit. Completion of the skin audit is documented on the Treatment Administration Record (TAR) with initials and either a -(to indicate no skin impairment) or + (indicating presence of skin impairment). 3. The nurse completes a Braden scale/Skin Integrity Evaluation at admission, then weekly for 3 weeks, annually and with significant change. 4. Completes/documents notification to the physician and resident representative. Review of the facility repositioning turn schedule detailed which direction residents should be facing in bed depending on the time of day. The sampled residents 10, 66, 92 and 94 were all assessed as being totally dependent on staff for activites of daily living. Most of the residents who resided on this particular nursing unit were observed to completely immobile, in a vegetative state and dependent on artificial methods of breathing such as ventilator or [MEDICAL CONDITION]. RESIDENT 92 The resident admitted to the facility in (MONTH) 2000 with a [DIAGNOSES REDACTED]. The resident was not able to verbalize his needs and was fully dependent on staff for toileting, repositioning and Activities of Daily Living (ADL's). According to the resident's Minimum Data Set (MDS) for skin dated 10/13/10 showed the resident was not identified to have any pressure ulcers. Review of all MDSs following also did not show the resident as having any pressure sores until the MDS dated [DATE]. This MDS showed the resident had unstaged and unhealed pressure ulcers. The MDS showed skin and ulcer treatments were in place, such as pressure reducing device for bed, and a turning and repositioning program. During the survey period, the resident was observed to have pressure ulcers on the Right (R) hip, Right heel and Sacrum. Review of the resident's most recent Braden scale completed on 07/06/17 showed the resident was at high at risk for developing pressure ulcers due to having limited or unresponsiveness to painful stimuli, skin often moist, being completely immobile and at risk for friction and shearing. Review of the resident's care plan created and revised on 11/06/18, identified the resident to have Actual impairment to skin integrity. Goals included, The resident will have no complications of the sacral decubitus (Pressure Ulcer) through the review period. Interventions stated in the care plan included: 1. Follow facility protocols for treatment of [REDACTED]. 2. The resident needs pressure relieving/reducing mattress, pillows to protect the skin while in bed. The care plan only identified the resident's sacral pressure ulcer, and did not include a turning schedule to relieve pressure off the resident's sacrum. The MDS dated [DATE] had identified pressure ulcers, however there was not a comprehensive pressure ulcer care plan until the creation and revision of the care plan dated 11/06/18 (3 months after the pressure ulcer were identified by the MDS). Review of the resident's point of care (P[NAME]) task sheets from 01/31/19 to 03/01/19, used by nursing assistants (NAs) to document when the NA turned or repositioned the resident while in bed, showed the resident was turned or repositioned on average three times daily. Review of the progress notes dated 09/04/18 showed documentation of 2.5cm (centimeter) in length (L) x 3cm wide (W) sacral open area with yellow slough base at center of wound which is 3mm pit into overall open area. The note stated will follow up with Resident Care Manager (RCM) for a treatment plan. The note did not state the resident's family, Physician or representative were notified of the findings. A follow-up progress note dated 09/24/18 stated Sacral wound now 3cm x 3.5cm x 0.4cm depth with red base and clean edges without undermining. Documentation showed the sacral pressure ulcer was not identified until it was already a Stage 3. Review of a consultant wound specialist (Wound specialist) progress notes showed the resident was first seen by United Wound Care on 03/07/19, seven months after the initial sacral pressure ulcer was documented by the MDS on 08/13/18. The note showed the resident by this time had also developed a Right hip and Right heel pressure ulcer. The note described all three pressure ulcers as exposing muscle, fat or bone. In an observation with Staff W, NA present on 02/25/19 at 11:46 AM, the resident was observed to have pressure ulcers on the Right heel, Right lateral hip and coccyx. The resident was not on a pressure relieving mattress. In an interview on 03/01/19 at 04:29 AM, Staff LL, NA stated the resident had pressure ulcers on the side of his hip, heel and coccyx. He stated they turned the resident every two hours, but the resident was on a regular mattress. He stated an air mattress would have probably helped to prevent new or prevent the worsening of the current ulcers. In an interview and joint observation on 03/01/19 at 4:32 AM, Staff V, Registered Nurse (RN) showed the resident had an approximately 3cm (L) x 3cm (W) x 2cm Deep (D) open area with a foul odor in the room that was stronger closer to the resident. Staff V was observed changing the resident's dressing and stated the pressure ulcers had started in the facility. He stated that the resident at risk due to his comorbidities (multiple diagnoses). Staff V stated that the current interventions in place were to turn the resident every two hours so as to to try and keep the resident off his pressure sores. He stated the resident was not on an air mattress. When he was asked why not, he stated the air mattress was on order and he did not know why there had been a delay in ordering the mattress. He stated the resident could have benefited from an air mattress. In addition, he stated that the resident had never been evaluated by the wound care specialists. In an interview on 03/04/19 at 9:23 AM, Staff Physician 1 stated that frequent turning of an immobile resident was important for both current ulcers and prevention of new pressure ulcers. In an interview on 03/04/19 at 12:45 PM, Staff FF, Resident Care Manager (RCM) stated he had been working in the facility for ten years. When asked how important it was to turn residents as directed by the care plan to prevent the worsening or development of new pressure ulcers, he stated it was very important. Staff FF was also asked if the pressure relieving mattresses would help in the prevention and development of pressure sores, as well as having wound care services initiated for residents who had pressure ulcers and Staff FF stated, Yes. When asked to show where the NAs documented turning the resident (every two to three hours), Staff FF stated we do not document, but use a turn schedule for all residents. When asked if that was effective way of monitoring whether residents were being consistently turned, Staff FF stated, Yes, the NACs know to do it. However a joint visual inspection with Staff FF of the residents on the unit, showed approximately 60 percent of the residents were not facing the direction according to facility's repositioning turn schedule. He was then asked if the turn schedule was effective, he stated, Not as well. He agreed that this was a barrier to pressure ulcer prevention and contributed to worsening ulcers. Staff FF was unable to state the reasons why the resident was not being seen by the wound care specialists or why he was not on a pressure relieving mattress, and agreed it was problem. Staff FF stated he had voiced the needs of the residents for six months with no results. He stated he could not answer to when the resident's pressure ulcers first started and when asked if that was problem or barrier to care he stated, Yes. In an interview on 03/04/19 at 1:52 PM, the Director of Nursing(DNS) and Regional Director confirmed the NAs were not documenting turning the resident's every two hours and agreed this was a problem. They stated the turning schedule was probably not effective in making sure the NAs were turning the residents. The DNS also stated the ball was dropped with the resident not getting a pressure relieving mattress or treatment services with the wound care specialists. In an interview on 03/05/19 at 10:50 AM, Staff PP and Staff OO (NAs) stated they felt that if they had more staff they could provide better care for the residents. They also stated that if something(care) was not done, then that was usually because they were overwhelmed with tasks. In a follow up interview on 03/07/19 at 10:15 AM, Staff V (RN) was asked why there were multiple residents with pressure ulcers. Staff V stated Well you should know as a nurse, if they have complicated medical histories, they are at risk for pressure ulcers. When asked if there were any barriers that he had seen he stated, I don't know you would have to ask the administration, there are no clear cut goals in the policies, I do the best that I can do, beyond that talk to administration. We work hard but there is so much for us to do, sometimes we don't even take breaks. In a telephone interview on 03/19/19 at 10:49 AM, the resident's family member stated Resident 92's pressure ulcers started about 3-4 months ago. He stated that he had first found out about the pressure ulcers when he noticed a urinary catheter on the resident and asked the staff why the resident had the catheter. He was told by the staff that the catheter was to minimize moisture on the skin as the resident was incontinent of urine. He stated he was never notified of the resident's pressure ulcer development. RESIDENT 66 Resident 66 was admitted to the facility on [DATE] following an incident that left him unable to verbalize his needs, and was fully dependent on staff for toileting, repositioning and Activities of Daily Living (ADL's). According to the resident's 10/26/18, showed the resident admitted to the facility with one Stage 2 pressure ulcer on his Left Buttock (no measurements were recorded). The MDS indicated the resident was on a pressure mattress. Review of the residents Braden Scale for Predicting Pressure Sore Risk dated 01/22/19 showed the resident was at high risk for developing pressure ulcers based on the following risks identified: 1. Very limited sensory perception. 2. Completely immobile 3. Had a problem with friction and shear Review of the Facility Weekly Skin Evaluation sheets showed the first recorded measurement of the Left buttock ulcer was on 11/14/18 (26 days after admission): 1.5cm (L) x 2.5cm (W) x 0.1cm (D). The skin sheets dated 11/28/18 showed the Left Buttock pressure ulcer had increased in size to 5.5cm (L) x 2.2cm (W). Also at this time, the skin sheets showed the resident had developed a Right buttock pressure ulcer measuring 3cm (L) x 0.7cm (W) with 100% slough, draining fluid, and described as unstageable. Documentation did not clearly show when the Right buttock pressure ulcer was first discovered or whether it was discovered as a stage 3. Review of the wound specialist progress note dated 11/28/19 showed the Left buttock pressure ulcer as deteriorating, unstageable, obscured with full thickness skin, and tissue loss. The Right buttock pressure ulcer was defined as an unstageable pressure injury, obscured with full-thickness skin, and tissue loss. Skin sheets dated 01/03/19 also showed Resident 66 had developed a pressure ulcer (Described as a Deep tissue Pressure injury with blood filled blister) on his Left hip measuring 4.2cm (L) x 2.5cm (W) (It was unclear how long the resident had the ulcer before it was discovered at that stage). Review of the resident's care plan initiated on 11/20/18 and revised on 01/22/19 identified the resident as having pressure ulcer development related to immobility. The goals included the resident will have intact skin. Interventions included the following: 1. Educate the resident/family/caregivers as to causes of skin breakdown; including transfer/positioning requirements and importance of frequent repositioning. 2. Follow facility policies/protocols for the prevention/treatment of [REDACTED]. The care plan did not include goals and interventions for the air mattress or did not show the resident was on a turning schedule. Review of the resident's point of care (P[NAME]) task sheets that allowed NAC's to document when they turned or repositioned Resident 66 while in bed from 02/10/19 to 03/11/19 showed that the resident was turned or repositioned on an average of 3 times a day. A telephone interview with the resident's family member on 03/20/19 revealed Resident 66 was placed on an air mattress on or around 02/20/19 (Five months after admission to the facility). In an interview on 03/01/19 at 8:50 AM, Staff NN (RN) was asked who determined the air mattress settings to relieve pressure and she stated the unit manager did it. She stated she did not know where the settings were recorded or what were appropriate settings for the residents, and the unit manager was not available as he had been on vacation. In a joint observation of the air mattress pump, Staff NN stated she did not know anything about the air mattress or pump. In an interview on 03/01/19 at 8:56 AM, Staff BB, Licensed Practical Nurse (LPN) stated he did not know the recommended air mattress settings or where the settings were recorded. He stated the physician and RCM determined the settings. He stated the care staff, such as NACs, altered the settings based on the care they give. He stated he would find out. In an interview on 03/04/19 at 12:45 PM, Staff FF, Resident Care Manager (RCM) was asked if there was any documentation on the recommended settings for the air pressure relieving mattresses he stated there was no documentation. He agreed depending on the resident's weight there would be specific settings needed to provide pressure relief and the lack of documentation of the setting was a problem. He was informed that care staff stated they change the settings during care and agreed the mattresses and settings may not be providing pressure relief. In a telephone interview on 03/21/2019 at 11:53 AM, the air mattress manufacturer stated the use of the air mattresses can be for comfort levels based on individual preference. She stated however if the intended use of the mattress is for pressure relieving, then height and weight need to be assessed and a specific setting is determined by a doctor or nurse for pressure relieving therapy. In an interview on 02/28/19 at 2:03 PM, Staff OO (NA) stated she usually turned the resident from side to side every 2 hours. When asked if it was documented she stated No there is no where we document it we just know to do it. In an interview on 03/04/19 at 1:52 PM, the DNS and Regional director, the DNS confirmed NA's were not documenting turning the resident every two hours. The DNS stated there was a problem if NAs were not following the resident's turning schedule, and not having the NAs document when they turn a resident was probably not effective to make sure NAC's were turning the residents. The DNS agreed these issues could be a problem that contributed to the development or worsening of pressure ulcers. The DNS also stated the ball was dropped when Resident 66 did not get a pressure relieving mattress or evaluation and treatment services by the skin consultant United Wound. RESIDENT 94 The resident admitted to the facility in (MONTH) (YEAR) and was in a persistent vegetative state. The resident's MDS dated [DATE] showed the resident was fully dependent on staff for bed mobility such as repositioning and toileting. The resident was on an air mattress. Review of the admission MDS showed the resident admitted to the facility with Right hip Stage 3 pressure ulcer that eventually advanced to a Stage 4. Review of weekly skin sheets showed Resident 94 developed a Left hip pressure ulcer on 07/25/18. The wound measured 1cm (L) x 0.7cm (W) and 2.3cm deep. Physician's orders showed a specialty air mattress was ordered and placed in (MONTH) 2019. An initial evaluation by the wound care specialist occurred on 02/07/19 (eight months after the care plan identified the Right hip wound). Review of Resident 94's care plan initiated on 06/21/18 and revised on 02/13/19 identified the resident with skin integrity impairment to the right hip and had unavoidable skin breakdown and slow healing due to multiple comorbidities and complete dependence for all ADLs. Goals included Heal with treatment. Interventions included the following: 1. As needed evaluation by consulting with MD 2. Air loss mattress, set to 3 for comfort. 3. Treatment as ordered by MD. 4. Weekly skin evaluation. The care plan did not include a turning or repositioning schedule as an intervention to address the resident's immobility and presence of pressure ulcers. The care plan also did not identify goals and interventions for the resident's left hip pressure ulcer. Review of the resident's point of care (P[NAME]) task sheet that allowed NAC's to document when they turned or repositioned the resident while in bed from 02/03/19 to 03/04/19 showed the resident was turned or repositioned on an average of three times a day. Review of the weekly skin sheet dated 06/07/18, showed measurements for the Right trochanter (hip) with measurements of 1.1cm x 0.7cm x 2.1cm. A Left hip pressure ulcer was documented on 08/01/18 with measurements of 1.0cm x 0.7cm x 2.3cm. The resident was first followed by the wound care specialists starting 6/13/18 through (MONTH) (YEAR). The last United Wound note, dated 8/29/18, showed pressure ulcer measurement for the right hip at 0.7cm x 0.3cm x 1.9cm at a Stage 4 pressure injury. The weekly skin sheet dated 2/22/19 showed the resident still had the right hip pressure ulcer at 1.5cm x 1.5cm x 1.5 cm Summary There were several factors that identified the lack of inconsistent care and processes related to pressure ulcer prevention and care. It was established by the facility that turning and repositioning residents who were completely immobile, had a big impact on the prevention of new pressure ulcers and to prevent current ulcers from getting worse. The facility's turning schedule that showed showed all residents were to be turned every two hours was not effectively implemented in ensuring the residents were being turned to prevent worsening or development of new ulcers. The facility also failed to timely identify new pressure ulcers and develop an individualized care plan with timely interventions. Lastly, staff interviews indicated that care staff had little to no knowledge on the appropriate management of therapeutic, pressure-relieving settings for the residents' air mattresses. RESIDENT 10 Review of the facility's Skin Integrity policy updated in (MONTH) (YEAR): .4. The resident's skin is inspected daily with completion of activities of daily living (ADL's). Changes in the resident's skin are reported to the Licensed Nurse (LN). 5. Ongoing evaluation continues weekly with the LN completing a full body skin audit. Resident 10 was readmitted to the facility on [DATE]. The primary [DIAGNOSES REDACTED]. Record review of a significant change in status (MDS) assessment dated [DATE] revealed Resident 10 had impaired memory and was dependent on staff for all care and mobility. The assessment indicated the resident was at risk of pressure ulcer development. Record review of the admission nursing assessment dated [DATE] showed the resident readmitted to the facility with one pressure ulcer (suspected deep tissue injury- SDTI) on the left heel that measured 3.3 cm by 2.5 cm. The assessment also identified Resident 10 as being at high risk for pressure ulcer development. Additional record review of the weekly skin evaluation forms dated 01/29/19, 02/05/19 and 02/11/19 showed one pressure ulcer on the Left heel. There was no other pressure ulcers identified. The pressure ulcer was documented as unstageable, documentation on 01/28/19 documented the left heel pressure ulcer as SDTI. Record review of the risk scale for predicting pressure ulcer development form dated 02/11/19 indicated the resident was at moderate risk of developing pressure ulcers. Further review of the record showed a weekly skin evaluation form dated 02/18/19 which documented a SDTI to the left heel that was blackish, purple and measured 3.0 cm by 2.2 cm. A risk scale for predicting pressure ulcers was dated 02/18/19 indicated the resident was at high risk of pressure ulcer development. Record review of the weekly skin evaluation form dated 02/28/19, revealed a significant increase in size to the pressure ulcer on the left heel from 3.0 cm (on the evaluation 10 days prior) to 3.8 cm on the current evaluation. The evaluation also indicated an increase in width from 2.2 cm to 2.5 cm. In an observation and interview on 03/01/19 at 5:00 AM with Staff JJ and Staff KK (CNA), an unstageable pressure ulcer was observed on the resident's left heel and left ankle. Staff KK said that the area on the resident's left ankle and left heel had been present since he returned from the hospital. Staff KK said the nurses were aware of the area on Resident 10's left ankle and left heel. Staff JJ said that the area on the resident's ankle had been there since he returned from the hospital, and Staff JJ also said we always told the nurse when a resident had a problem with their skin. In an observation and interview on 03/01/19 at 5:21 AM with Staff GG, RN/Corporate nurse he confirmed the resident had an unstageable pressure ulcer on the left ankle. He stated: I need to check into this and get back to you. In an observation and interview on 03/01/19 at 8:58 AM with Staff Q (CNA) stated: it was here (points to the unstageable pressure ulcer on the left ankle) and so was this one (points to pressure ulcer on the left heel) when he came back from the hospital. The nurses know about it. In an observation and interview on 03/01/19 at 8:54 AM with Staff F (LN) stated, skin checks are done every week by the LN. If you find a problem it is documented in the electronic record. The nursing assistants check the skin every day and they will let the nurse know if they see a problem. Then the nurse will go check it, call the doctor to get a treatment and let the family know. He came back from the hospital with those on his ankle and foot. I don't think he has a treatment for [REDACTED]. I know he has something for the heel. It should be the same for both. In an interview on 03/05/19 at 11:49 AM with Staff B, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM) said, the skin checks are done weekly, the nurses check weekly and the nursing assistants check daily while they do care with the residents. If there is a problem then it is documented on the skin sheets. I checked already, it was not documented anywhere. I don't know why the unstageable on his ankle was not documented. In an interview on 03/13/19 at 11:46 AM with Staff GG Registered Nurse (RN)/ Nurse Consultant, no further information was provided. Reference: (WAC) 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to comprehensively assess and ensure that timely and appropriate services/interventions were provided to maintain, increase and/or prevent decrease in range of motion (ROM), for four of four residents (2, 28, 19 & 24) reviewed for range of motion and restorative nursing services. This failure caused harm to Resident 2 and 28 who developed hand/leg contractures, decreased ROM, and placed other residents at risk for developing new contractures and/or worsening of existing contractures. Findings included . The National Stroke Association defines [MEDICAL CONDITION] as weakness or the inability to move one side of the body. Side effects of [MEDICAL CONDITION] include muscle [DIAGNOSES REDACTED] (muscle control disorder characterize by tight/stiff muscles and inability to control those muscles), [MEDICAL CONDITION] (loss of muscle strength) and pain. Rehabilitation treatments, ROM exercises and assistive devices can help improve mobility and recovery. RESIDENT 2 Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident required the assist of two staff members for bed mobility, transfers, toileting and dressing, and required the assist of one staff member with eating and personal hygiene. The MDS also showed Resident 2 had impaired functional limitation in ROM on both sides of upper and lower extremities that interfered with the resident's daily functioning and placed the resident at risk of injury. Review of the care plan revised on 01/25/19 for impaired mobility r/t (related to) [MEDICAL CONDITION] directed staff to assist the resident to wear bilateral (both sides) hand splints seven days a week. Further review of clinical records (care plan, therapy notes, progress notes and restorative flowsheets) showed no record of evidence that Resident 2 was receiving Bilateral Upper Extremity (BUE) and Bilateral Lower Extremity (BLE) restorative exercises; and splints for her bilateral hands. Resident 2's bilateral leg contractures were also not comprehensively assessed by the facility. Further review of Resident 2's restorative flowsheets showed she was seen once by the restorative aid in (MONTH) (YEAR) and no restorative exercises were provided for the month of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) 2019 and (MONTH) 2019. Review of the daily staffing schedules for the month of (MONTH) (YEAR) showed nine days of the month of (MONTH) (YEAR) did not have restorative aides to provide restorative services. During a joint observation on 02/26/19 at 10:45 AM, the resident was observed with limitation of ROM on her bilateral hands, arms and lower legs. Staff F, Licensed Practical Nurse (LPN) tried to stretch out the resident's legs. Staff F was unable to stretch out the resident's bilateral legs and stated, The resident's bilateral hands and bilateral legs has contractures. The left hand is worse than the right. Staff F stated splints were not applied and she was not sure if the resident was on a restorative program. Staff F also stated she was scared to move the resident's legs because they were tight. Resident 2 was not wearing bilateral hand splints on 02/25/19 at 10:34 AM, 02/26/19 at 10:45 AM, 02/27/19 at 09:36 AM and 02/28/19 at 10:04 AM. In an interview on 02/28/19 at 10:04 AM Staff A, Registered Nurse (RN)/Staff Development Coordinator (SDC), was informed Resident 2 had a care plan for splints program for both hands and the resident was observed not on splints. Staff A stated, I will take a look. In another observation on 02/28/19 at 11:13 AM Staff P, Nursing Assistant Certified (NAC) tried to stretch out the resident's legs but was unable to do so because of contractures. Staff P stated that it was hard to straighten the resident's legs and I'm concerned with the resident's tailbone. It's bone to bone. At 11:34 AM, A joint observation was conducted with Staff F, LPN and Staff M, RN who assessed the resident's skin and found a new redness on the resident's left rectal area (gluteal). Staff M stated the resident had a non-blanchable redness (stage 1 pressure ulcer) to her left rectal area measuring 0.3 cm (length) x 0.2 cm (width). The resident left sitz bone (buttock) had a blanchable abrasion measuring 0.6 cm (length) x 0.5 cm (width). At 12:11 PM Staff O, Restorative Aid (RA), stated, I don't know what to tell you, to be honest. I have never seen the splints or hand rolls. I can only bend her knees 23 degrees and cannot anatomically bend her legs straight. Staff O stated he met with therapy once a month but the resident's condition was not discussed and we don't have a system in place about restorative progress. At 02:53 PM, Staff A stated, The resident's BUE and BLE Passive Range of Motion (PROM) exercises was discontinued in (MONTH) (YEAR) and I just started it again. We are going to get the resident a new splint. Staff A also stated she was aware the resident had contractures on both upper and lower extremities. During an interview on 03/04/19 at 10:43 AM Staff B, LPN/Resident Care Manager (RCM), stated that Resident 2 had bilateral hand and leg contractures. The contractures on the resident's legs was worse than the hands. Staff B stated, The therapists are aware to get splints for the hands; we talked about it this morning. During an interview on 03/05/19 at 1:30 PM Staff T, Occupational Therapy (OT)/Director of Rehab (DOR) stated the resident was not on caseload in the last year and nothing was brought to her attention regarding the resident's degree of contractures. Staff T stated the resident already had a wheelchair that was fitted to the resident's contractures. Staff T stated, on 03/01/19, Staff U, OT, wrote a restorative program for the resident, a PROM to BUE and working on PROM to bilateral extremities and I ordered the splint for the hand. In another interview on 03/06/19 at 9:50 AM Staff A stated, No restorative exercises were provided for the resident for the month of (MONTH) (YEAR), (MONTH) 2019 and (MONTH) 2019. The resident's restorative exercises were cancelled for a few months and the resident's condition was not reported to me. RESIDENT 28 Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] showed Resident 28 was provided the assist of two staff members for bed mobility, transfers, toileting and personal hygiene, and received limited assist (received physical help in guided maneuvering of limbs) of one person with eating. The MDS also showed Resident 28 had impaired functional limitation in ROM on one side of upper and lower extremities that interfered with her daily functioning and placed her at risk of injury. Review of the care plan with revised date of 11/28/18 for impaired mobility related to [MEDICAL CONDITION] directed staff to assist the resident with BUE and BLE PROM to all joints/planes 10-15 repetitions four to five times a week. Review of the nursing restorative program flowsheet showed the resident was not consistently seen by the restorative aid four to five times a week as stated in the resident's care plan. The resident's restorative program flowsheet showed Resident 28 was seen six to eight times per month. Below were the restorative flowsheet documentations on how many times the resident was seen by the restorative aid per month in the last six months: September (YEAR): eight times October (YEAR): six times November (YEAR): seven times December (YEAR): six times January 2019: seven times February 2019: seven times Review of the resident's clinical records (care plan, tasks, therapy notes, progress notes) showed no record or evidence that Resident 28's right hand/arm contractures were comprehensively assessed by the facility. During an observation on 02/26/19 at 09:55 AM, Resident 28 was in her room lying in bed. The resident was unable to move her right arm/hand and right leg. The resident's right hand was contracted in a fist. The resident's right hand was squeezing the rolled towel very tightly. At 10:01 AM, Resident 28 was grimacing when Staff Q, NAC tried to stretch out the resident's right hand. Due to the resident's [MEDICAL CONDITION], Resident 28's ability to communicate was limited to making concrete requests and was only able to respond to simple direct communication due to [MEDICAL CONDITION]. The resident stated yes when she was asked if it was painful to straighten out her right hand. During an interview on 02/26/19 at 10:32 AM, Staff S, NAC stated the resident was not on a braces or splints program. During an interview on 02/28/19 at 12:24 PM Staff O, RA stated the rolled towel on the resident's right hand was not effective. Staff O stated, I wish the resident had a nice splint, or a roll guard will be better. It is not enough to provide the resident's restorative exercises on a PRN (as needed) basis. The resident would benefit from more exercises. Staff O also stated the resident had complaints of right hand pain during range of motion exercises but the resident's pain was not consistently reported to LN's (Licensed Nurses) to address the resident's pain prior to restorative exercises. At 12:32 PM Staff C, LPN stated the restorative aid did not approach her prior to the resident's exercise program to address the resident's right hand pain. Staff C stated the resident was on PRN pain medications, which would be provided as needed. At 02:50 PM, Staff A provided a copy of Resident 28's restorative flowsheets for the last six months. The surveyor mentioned the resident's restorative exercises were done six to eight times a month. The care plan was not followed, and there was no assessment for the resident's right hand/arm contractures. During an interview on 03/04/19 at 10:09 AM Staff B, LPN, RCM stated, What I would probably talk to restorative aid (Staff O) about is to check with the nurse before providing restorative. I know that the resident's right hand is contracted and not only the hand but also the whole arm. Staff B stated she would check with therapy what hand splints would be appropriate for the resident. During an interview on 03/05/19 at 01:23 PM Staff T, Occupational Therapy (OT)/Director of Rehab, stated the resident was not on caseload currently or within the last year. Staff T stated, On 03/05/19, OT evaluated the resident for a carrot (positioning device) for the right hand and an elbow splint. At 01:56 PM, Staff T, stated, I am not aware the residents are being seen on a PRN basis, our recommendation is for the restorative aid to see the residents three to five times per week and there are residents who came back from restorative to PT with a decline in function. RESIDENT 19 Resident 19 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] showed the resident was unable to make needs known and was only able to respond to simple direct communication. The resident was provided the assist of two staff members with bed mobility, transfer and toileting and was provided total assistance of one person with eating via tube feeding. During an observation on 02/26/19 at 11:16 AM, the resident was unable to lift or move his right arm and right leg. Staff P, NAC stated the resident could move his left hand and left leg but not the right, and the right hand was stiff. During an interview on 02/28/19 at 11:56 AM Staff F, LPN stated, I cannot answer how often they do restorative on him. During an interview on 03/04/19 at 10:49 AM Staff B, LPN/RCM stated, I need to ask the restorative aid (Staff O). I don't see the resident's restorative (exercises) on the tasks list. During an interview on 03/05/19 at 11:48 AM, the Administrator stated, There is no exercise program on the resident's tasks list. At 1:36 PM Staff T, OT/DOR stated, We provided a restorative program for the resident and I trained the restorative aid (Staff O), it was around (MONTH) 2019 when the resident discharged from therapy. There was no record or evidence that the facility provided restorative exercises for the resident. RESIDENT 24 Resident 24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] showed the resident was able to make self-understood, and able to understand others. Resident 24 received the assist of two staff members with bed mobility, transfer and toileting. Review of the clinical records showed the resident's restorative care plan for PROM to Left Upper Extremity (LUE) was cancelled on 11/02/18. The facility was not able to provide a copy of the resident's restorative flowsheets for (MONTH) (YEAR), (MONTH) 2019 and (MONTH) 2019 because the resident's exercise program was not provided. During an observation on 02/25/19 at 02:01 PM, the resident was unable to move his left arm and left leg. The resident stated that lately he was not receiving his exercises. Resident 24 stated, I need exercises. The longer I lay without exercises the worse it's going to be. During an interview on 02/28/19 at 11:58 AM, Staff P, NAC, stated that she could not recall if the resident was on restorative program and the resident should be on an exercise program because he cannot move his left side. At 11:59 AM Staff F, LPN stated the resident was not receiving restorative exercises. At 02:46 PM Staff A, RN/SDC, stated the restorative reports were blank for (MONTH) (YEAR), and could not be pulled the restorative flowsheet reports for (MONTH) (YEAR), (MONTH) 2019 and (MONTH) 2019 because the resident's restorative program was cancelled on 11/02/18. Staff A stated the resident's restorative program would be reinstated. During an interview on 03/04/19 at 10:45 AM Staff B, LPN/RCM stated that she was not aware the resident's exercises were not being done. During an interview on 03/05/19 at 11:48 AM, the Administrator stated, The resident has not had any restorative exercises for a couple of months now. At 01:28 PM Staff T, OT/DOR, stated there was a restorative program that Physical Therapy (PT) wrote for Resident 24. Staff T provided an undated copy of that restorative program to the surveyor. Staff T stated, I was not aware the resident's restorative program got dropped. In an interview on 03/13/19 at 10:55 AM, Staff O, RA, Staff TT, RA and Staff A who stated they tried to get to complete their resident restorative needs however got pulled away from restorative duties that left residents without the restorative therapies. Staff A, stated they had requested additional restorative aides about four months ago but has not seen any progress since. Reference (WAC): 388-97-1060 (3)(d)

Based on observation, interview and record review, the facility failed to protect 1 of 4 residents who wandered (Resident 1) from abuse. Resident 1 wandered into another resident's room where he was pushed to the floor by the other resident and sustained a [MEDICAL CONDITION], this constitutes harm. Findings include: Resident 1 was admitted to the facility in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. According to the care plan dated 11/10/2018, Resident 1 wanders aimlessly, significantly intrudes on privacy and activities. The care plan also indicated that the resident had impaired decision-making and impaired safety awareness. The interventions documented on the care plan included: Distract resident from wandering by offering pleasant diversions, structured activities, food, and conversation. Resident prefers IPad and watching Netflix. The care plan did not include interventions to monitor for any behaviors of Resident 1 that might provoke a reaction by other residents or other behaviors which included, wandering into other's rooms/space. Resident 1 was discharged from the facility and was not available for observation or interview. In an interview with Staff A on 12/27/18 at 10: 45 AM, it was determined that Resident 1 wandered in the hallway and would go into other resident's rooms, but he was easily redirected. Staff B also stated in an interview on 12/27/2018 at 11 AM, that Resident 1's memory was not that great and he had a poor sense of direction. According to the facility's investigative report dated 12/17/2018, Resident 1 wandered into Resident 2's room at approximately 1:30 PM, Resident 2 pushed Resident 1, who then fell to the floor and sustained a [MEDICAL CONDITION]. The facility's investigative report also indicated that Resident 2 told staff, He didn't respond to him asking him to leave, so he pushed him out. Abuse is defined in accordance to the State Operating Manual (YEAR), 483.5 as, The willful infliction of injury. Willful is defined in the State Operating Manual (YEAR), 483.5, as used in the definition of abuse. means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. An additional staff statement on facility's investigative report revealed, Resident 2 told staff Resident 1 was trying to enter to his room, that's why he pushed Resident 1 from him, and he(Resident 1) fell to the floor. The investigative report review and interview with Staff B on 12/27/2018 at 11 AM indicated that Resident 1 was found on the floor in front of Resident 2's room, complaining that he could not move his left leg. According to a written statement by the Director of Nursing(DON) dated 12/17/2018, an x-ray was obtained and a fracture of left hip was noted. The facility staff failed to the prevent physical abuse of Resident 1 when Resident 2 deliberately got out of bed and pushed Resident 1 which caused him to fall to the floor and caused him injury. During an interview with the DON on 12/27/2018 at 12: PM, she stated, this was an isolated incident and Resident 2 had never been aggressive before; she added that Resident 2 did not mean to hurt Resident 1. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review and staff interviews indicated Resident 2 had no prior history of aggressive behaviors. Resident 2's room was observed on 12/27/2018 at 12:15 PM. Upon entering the room, approximately 4-5 steps had to be taken before Resident 2's bed was visible from around a corner. According to facility staff's investigative report dated 12/17/2018 and Staff B interview on 12/27/2018 at 11 AM, Resident 1 was found on the floor in the doorway of Resident 2's room. Resident 2 was interviewed in his room on 12/27/2018 at 12:15 PM as he sat on his bed. When asked about the incident when a resident was found on the floor in his doorway. Resident 2 stated, That day I was lying in my bed when he (Resident 1) came into my room, I asked him over and over to leave and he would not leave, so I got up out of the bed. Resident 2 did not add more information regarding the topic. According to facility investigation documentation, Resident 2 got out of his bed and deliberately pushed Resident 1 to the floor which caused him to fracture his hip. The facility did not provide timely and consistent interventions, such as distraction or redirection, to assure the safety of Resident 1, and failed to provide sufficient protection to prevent resident-to-resident abuse. WAC Reference 388-97-0640(1)

Based on observation, interview and record review, the facility failed to ensure all required generator testing and generator fuel cleaning procedures were performed to ensure the emergency electrical power system functioned in the event of an electrical loss of power in the facility. This failure placed residents in the facility that were dependent on electrical power at risk for loss of their electrical power systems. On 5/24/2018 the facility had a census of 88 residents. The census included 17 residents on ventilation devices, 20 residents on oxygen concentrators with tracheostomies and 43 residents on tube feedings. According to the State Fire Marshal (SFM) an IMMEDIATE JEOPARDY (IJ) was called on (MONTH) 23, (YEAR) at 5:17 p.m. The IJ was removed on (MONTH) 25, (YEAR) at 11:45 a.m. GENERATOR FUEL CLEANING On 5/24/2018 at 9 a.m., a large light brown truck from an environmental services company was observed outside of the facility in the parking lot performing an activity. Upon entering the facility, the SFM was present. Upon interview with the Maintenance Director on 5/24/2018 at 9:20 a.m. it was determined that the truck outside of the facility in the parking lot was performing the cleaning of the facility's onsite generator underground diesel fuel tank. Further interview with the Maintenance Director on 5/24/2018 at 10 a.m., revealed that the generator diesel fuel testing was performed on 2/20/2018 by a certified lab. The facility received the results of that test on 3/29/2018. The results indicated that the fuel had a 0.30% amount of sediment and water in the fuel; and the allowable industry rate was 0.05%. Upon record review of the inspection documents provided by the SFM authority, the generator fuel had been tested and the results did not meet industry standards in accordance with the Life Safety Code, NFPA 99 and NFPA 110 (See State Fire Marshal Federal Tag K-0918 Electrical System-Essential Electrical System). According to the SFM there was a potential for the facility's generator to malfunction because of this rate of sediment and water in the generator fuel. According to the SFM an IMMEDIATE JEOPARDY was called by the SFM on (MONTH) 23, (YEAR) at 5:17 p.m. The residents in the facility that were dependent on electrical power systems were at risk for no back up power from the generator if the electrical power were to fail in the building. An interview was conducted with the Maintenance Director on 5/24/2018 at 10 a.m., about the generator fuel test results. He stated, he was aware of the fuel testing results in (MONTH) (YEAR) and he informed the administrator of the test results. During an interview with the administrator on 5/24/2018 at 2:30 p.m., he stated he had knowledge of the generator fuel test result in (MONTH) (YEAR). The administrator stated, that he considered the test result as a recommendation not an emergency. There was no evidence that the staff had taken appropriate action to ensure the diesel fuel inside the generator was brought to the approved industry standard. It was not until (MONTH) 24, (YEAR) that the fuel inside the generator was cleaned in order to bring it back to industry standards. The residents in the facility that were dependent on electrical power systems were at risk for not having a generator function in an event of a power failure for approximately 3 months. REQUIRED GENERATOR TESTING During an interview with the Maintenance Director on 5/24/2018 at 11:00 a.m. about the testing of the generator required testing that should be done every month, he replied I did not perform the generator test in April, I did not want the filter on the generator to become clogged, I knew about the test result that was abnormal. Upon review of emergency generator test log documents, it did not indicate that the generator had been tested in (MONTH) or (MONTH) (YEAR). The facility's generator had not been tested and maintained for 2 months in accordance with the Life Safety Code, NFPA 99 and NFPA 110. This failure placed residents in the facility that were dependent on electrical power systems at risk for loss of power.

Based on record review and interview facility staff failed to exercise safety precautions and implement interventions to prevent accidents for 1 of 4 residents (Resident #1) at risk for accidents. Resident #1's safety device helmet was not applied by staff when the resident was up in the chair. The resident fell from the chair and was found by staff face down with his nose bleeding. This practice resulted in harm to Resident #1. Resident #1 was admitted to the facility in (MONTH) of (YEAR). According to facility records, he had prior injuries that affected his brain functions and mobility. Upon review of his admission records, the resident had a history of [REDACTED]. According to Resident #1's current care plan dated 12/14/2017, the resident had physical mobility and cognitive impairments with a goal that he be without injury. The stated intervention documented in all capital letters stated, WHEN OUT OF BED MUST HAVE HELMET ON. According to the facility report, two staff assisted the resident to his tilt and space wheelchair in his room. Both staff left the room at different times and failed to apply Resident #1's safety helmet in accordance with his care plan. The resident was known to be at risk for [MEDICAL CONDITION], falls and injuries and was left unsupervised without his safety helmet in place. The facility staff did not implement a safety focused intervention and apply assistive devices to ensure that Resident #1 to minimize accidents and injuries. According to a statement in the facility, report by Staff A and Staff B left the room and did not ensure the helmet was placed on Resident #1's head in accordance with his care plan. According to a statement in the facility report by Staff B, he indicated he remained in the room after Staff A left, and made the resident's bed then stepped out of the room. Staff B did not ensure the helmet was placed on Resident #1's head in accordance with the resident's care plan, before leaving the room. After approximately 15 minutes later he was told that the resident fell and had no helmet on. Staff B went on to add that he did not have any information of the resident having the helmet on or not. Staff B left the resident unsupervised, without implementing the intervention to apply Resident #1's helmet to reduce hazards and risk in the environment. Staff B or Staff A did not take a reasonable effort to place the helmet device on the resident as directed by his care plan as a safety intervention. Upon review of the facility report summary and progress notes Resident #1 was found on 2/12/2018 at 12 p.m. face down on the floor having minor convulsions. The staff documented that Resident #1 had an actively bleeding nose and he required suctioning. The resident received first aid and, as a cautionary measure, was transferred to the emergency room . The Director of Nursing Services (DNS) was interviewed about the incident on 3/2/2018 at 10:00 a.m. The DNS stated, Staff did not apply his helmet, he (the resident) landed face down and hit his face, his nose was bleeding. Staff were disciplined and trained. The facility did not excercise necessary safety precautions or apply assistive devices consistent with the resident's needs, goals and current professional standards to ensure Resident #1 was free from accidents and injuries, and this constitutes harm. WAC Reference: 388-97-1060 (3) (g)

Based on observation, interview and record review, the facility failed to serve food at the proper temperature for one (#1) of four Residents. Failure to serve food at the proper temperature, caused harm to Resident #1 when a Certified Nurse's Aide (CNA) reheated Resident #1's cup of coffee in the microwave and served the resident overheated coffee, resulting in 2nd [MEDICAL CONDITION] hospitalization . Findings included: Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 01/04/18 at 9:00 a.m., revealed 2nd [MEDICAL CONDITION] the resident's right shoulder and right upper breast area. According to the Incident Investigation Report (IIR) dated 12/31/17, Staff C a Registered Nurse (RN), was in the hallway outside Resident #1's room when she heard Resident #1 yelling for help. A visitor of Resident #1's roommate came out of the room to notify Staff C, Resident #1 had spilled hot coffee on herself and required urgent assistance of staff. According to the IIR dated 12/31/17, when Staff C entered Resident #1's room, she found Resident #1 screaming for assistance. Resident #1 was covered in three layers of beddings and hot coffee had spilled on the covers and the resident was screaming for assistance. Staff C removed bed covers from Resident #1 to expose the affected area to air. According to Staff C's witness statement, Resident #1's skin was reddened and later blistered. Resident #1's physiciah was notified and issued an order to tranfer Resident #1 to the hospital for further evaluation and treatment. During an interview on 12/04/17 at 11:30 p.m., Resident #1 said after Staff D served her a dinner tray on the over bed table, Resident #1 attempted to reach over to grab a cup of coffee, when the dinner tray tipped and the cup of overheated coffee spilled over the left side of her body. Resident #1 stated screamed my lungs out. I felt like I was going to die. In an interview on 01/05/18 at 3:00 p.m., Staff D a Certified Nurse's Aide (CNA) said, Resident #1 had requested that her cup of coffee be reheated. Staff D then heated the cup of coffee in the microwave until it was hot. In an interview, when Staff D was asked if he had known the temperature of the coffee before serving Resident #1, he said No. Review of te facility's food temperature policy and procedure dated October 2017, instructed staff to take temperatures of hot beverages and hot foods prior to service to the residents to ensure hot beverages and food are served to the residents at less than or equal to 150 degrees Fahrenheit (F). In an interview on 01/05/18 at 3:00 p.m., Staff D acknowledged he did not follow the facility's policy to ensure Resident #1's cup of coffee was within safe temperature range for resident consumption (150 degrees F or less). Staff D later stated I have been reeducated to take the hot food/liquid temperature before serving residents. On 01/04/18, at 11:20 a.m., Staff B the Director of Nursing Services (DNS) acknowledged and said staff D should not have served the coffee to Resident # 1 without knowing it's temperature. Staff B further stated that Staff D should have gone to the facility's kitchen to get fresh brewed coffee which is served at safe temperature for resident consumption. On 01/04/18, at 11:45 a.m., in an interview Staff A, the facility's Administrator acknowledged and said, the facility had removed microwaves from all resident dining areas to prevent recurrence and ensure safety of the residents. Failure to serve food at the proper temperature, caused harm to Resident #1 when a Certified Nurse's Aide (CNA) reheated Resident #1's cup of coffee in the microwave and served the resident overheated coffee, resulting in 2nd [MEDICAL CONDITION] hospitalization . Additionally, this placed Resident #1 at risk for diminished quality of life. WAC reference: 388-97-1100 (2)

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (Resident #7) reviewed for pressure ulcers did not acquire a new pressure ulcer while residing at the facility. Additionally, the facility failed to ensure the newly acquired pressure ulcer received treatment based on physician order [REDACTED]. This caused the resident harm. Findings include: RESIDENT #7: The resident's most recent Minimum Data Set ((MDS) dated [DATE] indicated he had [DIAGNOSES REDACTED]. The Care Area Assessment indicated he could understand information better than he could express it. He could use the gesture of putting his thumb up and down to answer "yes" or "no" questions. According to the facility's most recent "Ulcer Evaluation" assessment (Braden Assessment), the facility identified the resident to be at high risk for developing pressure ulcers. On 5/16/11 at 1:00 p.m., The Treatment Administration Record (TAR) was reviewed with Staff R wound nurse who indicated the resident's only ulcers were on his left leg. There was no mention of an ulcer on the resident's buttock by Staff R and there was no documentation on the TAR. During observation of the dressing changes on Resident #7's left leg wounds, no observation or dressing changes were done on the resident's buttock On 5/17/11 at 1:00 p.m., Staff D, the Resident Care Manager and the surveyor noted in the resident's medical record a physician's orders [REDACTED]. The treatment was to clean the areas with normal saline and apply silversorb (wound medication) to the pressure area once daily and to cover it with a dressing. When Staff D was asked if the resident had a pressure ulcer on his buttock, he replied, "Yes." On 5/17/11 at 1:10 p.m., Staff D and surveyor reviewed the TAR for May 2011 which showed there was no physician treatment order listed for the resident's buttock pressure ulcer. Review of the April 2011 TAR showed the treatment had not been administered for 6 days, from 4/19/11, when the order was written, until 4/25/11. Treatment was administered from 4/25/11 to 4/29/11. On 4/30/11 the treatment was documented on the TAR as administered. When Staff D was asked to verify if the resident had a pressure ulcer on his buttock, he replied, "Yes." According to documentation , the dressing changes had not been done as ordered. On 5/17/11 at 1:15 p.m. the ulcer on the Resident #7's buttock was observed with Staff D. The ulcer was observed to be covered with thick white barrier cream used for non ulcerated areas to keep moisture off of the skin. The physician ordered medication and a dressing for the buttock ulcer, but was not present over the wound. The ulcer was observed to be open. When asked if it was a policy to put barrier cream on an open ulcer Staff D replied, "No." Staff D indicated the Nursing Assistants were to report any skin issues to the licensed nurse (LN) and not to put barrier cream on open [MEDICAL CONDITION]. On 5/17/11 at 1:15 p.m., The facility's "Ulcer Evaluation" form was reviewed with Staff D which showed the weekly documentation of dimensions and characteristics of the resident's ulcer on his buttock The ulcer was documented as first found on 4/25/11 on the right buttock and classified on the "Ulcer Evaluation" form as a venous ulcer, not as a pressure ulcer as previously indicated by Staff D. On 4/25/11 the initial ulcer measured 3.2 centimeters (cm) in length, 2.4cm in width; On 5/5/11 it had increased in size to 3.8 cm in length and 4.1 cm in width; On 5/12/11 it stayed the same size and measured 3.8 cm in length and 4.1 cm in width. There was no further documentation of the size and dimensions of the ulcer after 5/12/11. According to documentation, the ulcer was not treated from 4/30/11 to 5/12/11, the ulcerated area increased in size. Review of the TAR also showed the weekly head to toe skin checks had been done on 5/5/11 and 5/12/11. On the TAR, next to "skin issues" was documented under the date a zero with a line through it. The legend next to it indicated this meant there were no skin issues. During the interview at this time, Staff D indicated he was not aware the treatment had not been administered for Resident #7 on his buttock. He indicated he did the recaps each month on the residents on his floor. (Recaps included transferring the previous month's treatment orders to the next month's TAR to ensure nurses administered the physician orders [REDACTED]. Staff D indicated he did the skin measurements for each of the pressure ulcers for this resident and documented them on the Ulcer Evaluation form, but did not verify physician treatment was on the TAR for the wound on the resident's buttock. . .