Every finding on record at Sequim Bay Post Acute

Based on observation, interview, and record review, the facility failed to ensure pressure offloading interventions were implemented consistently to prevent the development and worsening of pressure injuries (also known as pressure ulcers, that occur when soft tissues are compressed between bony prominences and external services) and that wound care was provided consistently as ordered to promote wound healing for 1 of 3 residents (1) reviewed for pressure injuries. Resident 1 experienced harm when they developed a stage 2 (partial thickness loss of skin with expose dermal tissue) pressure injury on their right heel worsened to an unstageable (full thickness skin and tissue loss in which the extent of tissue damage within ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) pressure injury wound that became infected requiring antibiotic treatment. This failure placed residents at risk for pressure wound development, delayed wound healing and a decreased quality of life. Findings included.Review of the facility policy titled, Pressure Injury Prevention and Management Policy, dated June 01, 2025, showed the facility would assess, monitor, and implement appropriate interventions to reduce the risk of pressure injury development. Resident 1 was admitted to the facility on [DATE] for aftercare following a hip fracture and diagnosis including peripheral vascular disease (impaired blood flow to the extremities). The Clinical admission Skin Assessment, dated 01/08/2026, documented the resident had no pressure injuries present on admission. The admission Minimum Data Set (MDS), an assessment tool, dated 01/14/2026, showed the resident was cognitively intact and was at risk for pressure injury. Review of the physician's order, dated 01/09/2026, showed the resident was to wear bilateral AFO's (ankle-foot-orthotics, used to prevent foot drop) during all transfers and when out of bed.Review of the January 2026 Treatment Administration Record (TAR) showed between 01/08/2026 and 01/23/2026 staff documented the AFOs were not in use for 14 of 38 opportunities charted.Review of the Incident report, dated 01/23/2026, showed a clear fluid filled blister to Resident 1's right heel was discovered, the blister measured 4cm (centimeters) x 5cm and was assessed to be a stage 2 (Partial-thickness loss of skin with exposed dermal tissue) pressure injury. The incident report attributed the development of the blister to the residents' use of bilateral AFO's. Review of the physician's order dated 01/23/2026 showed the resident was to wear heel booties to both feet whenever she was in bed.Review of the January 2026 TAR showed the heel booties as documented in place on 7 of 17 opportunities charted.Review of the facility wound care provider note, dated 01/28/2026, showed the Stage 2 Pressure Injury to the right heel was a new wound measured 3.3 cm x 6.2 cm and included dressing change orders for three times weekly and recommendations to offload at all times.Review of the weekly skin assessment, dated 01/29/2026, documented that the resident had no identified skin concerns. Review of the facility wound care provider note, dated 02/04/2026, documented the right heel wound was deteriorating, and now classified as a Stage 3 (full-thickness loss of skin) pressure ulcer measuring 3.7 cm x 7.1 cm x 0.2 cm with 95% necrotic (dying or dead) tissue. Dressing changes were ordered three times weekly.Review of an outside providers physician's order, dated 02/09/2026, showed the resident was to receive daily dressing changes to the right heel ulcer and the heel was to be floated at all times. The order was noted and agreed to by the facility's provider on 02/10/2026. Review of Resident 1's February 2026 Treatment Administration Record (TAR) showed these orders were not implemented.Review of Resident 1's February 2026 TAR showed heel protectors documented in place with only 17 of 56 opportunities charted. Review of the facility wound care provider note, dated 02/25/2026, showed the wound had deteriorated and measured 2.6 x 6.2 x 0.3 cm with 100% necrotic tissue and macerated (skin that has a white appearance and a very soft, sometimes soggy texture) edges to the wound bed. Review of Resident 1's March 2026 TAR showed heel protectors documented in place only 19 of 62 opportunities charted. Review of the facility wound care provider note, dated 03/04/2026, showed the wound had deteriorated and now classified as unstageable with 100% necrotic tissue. Review of the outside wound clinic provider note, dated 03/17/2026, showed the right heel measured 2.6 x 5.8 x 0.2 cm and was believed to be of mixed etiology . as well as pressure leading to the development of these wounds and orders for patient to offload posterior heel at all times-please float heels while in bed, wear heel protectors if possible.Review of the Care conference note, dated 03/20/2026 at 11:00 am, showed the resident verbalized concern for possible wound infection and nursing was to obtain a wound culture. Review of the wound culture results for the right heel, dated 03/23/2026, showed Resident 1 to have MRSA (methicillin resistant staphylococcus aureus) in the wound. Review of the physician's order, dated 03/23/2026, showed the resident was to receive an antibiotic twice daily for 14 days for a MRSA infection. Review of the physician's order, dated 04/07/2026, showed the resident was to receive an antibiotic twice daily for 30 days for a right heel wound infection. On 04/09/2026 at 9:16 am, Resident 1's Power of Attorney (POA - person who makes decision on resident's behalf) said the resident admitted to the facility on [DATE] and did not have the pressure injury on her right heel, Resident 1 was supposed to always wear heel booties and staff did not assist her with that. Resident 1's POA said they visited three times a week and nearly every visit the resident was not wearing heel protectors. The POA said they inquired about how the wound was doing and was told it was healing; when in fact it was not and they had to request the resident to see a different wound care professional. She also had to request a wound culture to diagnose the wound infection. On 04/09/2026 at 12:01 pm, Resident 1 was observed sitting in her wheelchair, the residents' right foot with a dressing in place; the resident was not wearing heel protectors. Two sets of heel protectors were observed on the floor between the dresser and the closet, one larger dark blue pair and one smaller light blue pair. Resident 1 said she did not have the wound when she got there and although staff were good about placing the heel protectors at night after she reminded them, they did not place them during the day. Resident 1 said they were under the impression they were supposed to wear heel protectors at all times. Resident 1 stated, you see I don't have those on, the trouble is one group of people say I am supposed to have them on and the other says I cannot do anything with them on and they take them off, I cannot physically stop them and I need them to help me put them on. That bothers me, it is very stressful, I cannot put them on myself and if they take them off, I cannot put them back on. On 04/20/2026 at 3:35 pm, Staff F, Registered Nurse (RN), said she never saw Resident 1's wound, it was managed by Staff D and the wound care provider. On 4/20/2026 at 3:51pm, Staff E, RN said they were not sure about the status of Resident 1's wound, they had never seen it and did not know if it was getting better or worse, the dressings were usually changed by Staff D, RN and Resident Care Manager (RCM) or the wound care provider.On 04/23/2026 at 1:23 pm, Resident 1 was observed sitting in her wheelchair, the residents' right foot had a dressing in place; the resident was not wearing heel protectors. Two sets of heel protectors were observed on the floor between the dresser and the closet, one larger dark blue pair and one smaller light blue pair.On 4/23/2026 at 1:23 pm, Resident 1's POA said there was nothing in the AFO to cause the pressure. The left one had an insert in it but not the right one, and said, Besides they didn't use them anyway! On 04/23/2026 at 4:19 pm, Staff C, RCM, RN said Resident 1 acquired an unstageable Pressure wound to her right heel due to her wearing AFOs. Staff C said that determination was made by the IDT team during a discussion, she had not looked at the AFO to determine if that was the cause. Staff C confirmed the 02/09/2026 consultant order was noted and agreed to by the facility provider and did not know why the 02/09/2026 order to increase the dressing change to daily and offload heels at all times was not implemented.On 4/23/2026 at 5:21 pm, Staff B, Director of Nursing, RN, said although they were not in the facility at the time the wound developed, it was her understanding the team thought the AFO's were causing friction and that caused the blister. She believed the POA wanted the resident to wear heel protectors at all times, but the facility staff felt it was unsafe for the resident to do so. Staff B was not aware of the 02/09/2026 order to increase the dressing changes to daily and float heels at all times, that was noted and agreed to by the facility provider, stating I am aware now. Staff B said the 03/17/2026 outside wound care orders to offload posterior heel pressure at all times was not put in to add the more specific details. After reviewing the February and March 2026 TAR for placement of heel protectors, Staff B said they were not consistently being placed as ordered. On 04/28/2026 at 11:56 am, Staff D, RN, RCM, said they did not look at the AFO when the wound was discovered to determine if it was the cause of the wound. Reference WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure a resident's representative was notified of significant changes related to the development of a Stage 2 pressure injury (develop when soft tissue is compressed between a bony prominence and an external surface for a prolonged period causing partial-thickness skin loss affecting the epidermis and dermis, but do not expose fat or deeper tissues) for 1 of 3 sample residents (Resident 1) reviewed for notification of changes. This failure placed residents and their representatives at risk of not being able to participate in resident care decisions, delayed medical treatment, and a diminished quality of life. Findings included.Review of the facility policy titled, Change in Condition and Notification Policy, dated 06/01/2025, showed the facility would make notifications regarding the resident's condition, to the resident and resident representative based on the resident's clinical status, decision making capacity and preference. Resident 1 was admitted to the facility on [DATE] for aftercare following a hip fracture and diagnosis including peripheral vascular disease (impaired blood flow to the extremities). The admission Minimum Data Set (MDS) dated [DATE] showed the resident was cognitively intact and felt it was very important to have family and close friends involved in discussions about their care. Review of the Incident report, dated 01/23/2026, showed a clear fluid filled blister to Resident 1's right heel was discovered, the blister measured 4 centimeter (cm) x 5 cm and assessed to be a stage 2 pressure injury. The incident report did not indicate a resident representative was informed of the discovery of the pressure injury. Review of the incident report on 01/28/2026 related to a fall, indicated the Power of Attorney (POA - person who makes decision on resident's behalf)/family would be notified the following shift. Review of the incident report on 02/16/2026 related to a fall, showed the POA/Family was notified via phone call.Review of the incident report on 02/17/2026 related to a fall, showed the POA/family was notified via phone call. Review of the incident report on 02/23/2026 related to a fall, showed the POA/family was notified via phone call. On 04/23/2026 at 1:23 pm, Resident 1 said they would expect the facility to report the wound to her POA.On 04/23/2026 at 1:24 pm, Resident 1 POA said she was not made aware of the wound until she accompanied the resident to their orthopedic appointment on 02/09/2026. On 4/23/2026 at 4:19 pm, Staff C, RCM, RN said resident representatives should be made aware of resident changes such as weight loss, medications, and wounds. Resident representatives should be notified if there was a new stage 2 pressure injury, but they added they might not if the resident was considered alert and oriented. On 04/23/2026 at 5:20 pm, Staff B said they would expect staff to notify the resident representative regarding a new stage 2 pressure injury. Refer to F686Reference WAC 388-97-0320(1)(a) -(d)(2)(a)(b)

Based on observation, interview, and record review the facility failed to include pressure prevention strategies for a newly admitted resident who was at risk for pressure injury (also known as pressure ulcers, bedsores, or decubitus ulcers, occur when soft tissues are compressed between bony prominences and external surfaces) and failed to consistently implement interventions for 1 of 3 residents (Resident 1) reviewed for care planning. This failure places residents at risk of unmet care needs, development of pressure injuries, and decreased quality of life. Findings included.Review of the facility policy titled, Comprehensive Care Planning Policy, dated 06/01/2025 showed the facility would develop, implement, and maintain a comprehensive care plan for each resident based on needs and clinical condition. The care plan would be developed upon admission and based on clinical assessment, .and identified risk. Resident 1 was admitted to the facility on [DATE] for aftercare following a hip fracture and diagnosis including peripheral vascular disease (impaired blood flow to the extremities). The Clinical admission Skin Assessment, dated 01/08/2026, documented the resident had no pressure injuries present on admission. The admission Minimum Data Set (MDS) dated [DATE] showed the resident was cognitively intact and was at risk for pressure injury. The care plan, initiated on 01/09/2026, showed no focus for risk for pressure injury and no pressure prevention interventions until after the resident was found to have developed a stage 2 pressure injury (partial-thickness skin loss affecting the epidermis and dermis, but do not expose fat or deeper tissues) on 01/23/2026. Review of the physician's order, dated 01/09/2026, showed the resident was to wear bilateral AFO's (ankle-foot-orthotics, used to prevent foot drop) during all transfers and when out of bed. Review of the care plan focus for the stage 2 pressure ulcer initiated on 01/23/2026, included the intervention to keep heels off of the bed. Review of the January 2026 Treatment Administration Record (TAR) showed then between 01/09/2026 and 01/23/2026 staff documented the AFO were not in use for 14 of 38 opportunities charted.Review of the physician's order, dated 01/23/2026, showed the resident was to wear heel booties to both feel whenever she was in bed. Review of the facility wound care provider note, dated 01/28/2026 showed the Stage 2 Pressure Injury to the right heel was a new wound measured 3.3 cm x 6.2 cm and included dressing change orders for three times weekly and recommendations to offload at all times. Review of the January 2026 TAR showed heel protectors documented in place only 7 of 17 opportunities charted. Review of a physician's order dated 02/09/2026 showed the resident was to receive daily dressing changes to the right heel ulcer and the heel was to be floated at all times.Review of Resident 1's February 2026 TAR showed heel protectors documented in place only 17 of 56 opportunities charted. Review of Resident 1's March 2026 TAR showed heel protectors documented in place only 19 of 62 opportunities charted. On 04/09/2026 at 9:16 am, Resident 1's Power of Attorney (POA - person who makes decision on resident's behalf) said they visited the resident three times weekly and nearly every time she saw the resident, they did not have heel protectors in place. The POA said they even posted a sign in the resident's room but was scolded by a nurse after the resident fell while wearing heel protectors. On 04/09/2026 at 12:01 pm, Resident 1 was observed sitting in her wheelchair, the residents' right foot with a dressing in place; the resident was not wearing heel protectors. Two sets of heel protectors were observed on the floor between the dresser and the closet, 1 larger dark blue pair and one smaller light blue pair. Resident 1 said they were under the impression they were supposed to wear the heel protectors at all times. Resident 1 stated, you see I don't have those on, the trouble is one group of people say I am supposed to have them on and the other says I cannot do anything with them on and they take them off, I cannot physically stop them and I need them to help me put them on. That bothers me, it is very stressful, I cannot put them on myself and if they take them off, I cannot put them back on. Resident 1 said she did not have the wound when she got there and although staff were good about placing the heel protectors at night after she reminded them, they did not place them during the day. On 04/16/2026 at 3:20 pm, Staff G, Nursing assistant, said she usually placed the heel protectors on when the resident went to bed. When asked if she recalled if the resident had heel protectors on during the day, prior to going to bed the evening before, Staff G said she recalled she only had socks on because they thought the resident had been working with therapy. On 04/23/2026 at 1:23 pm, Resident 1 was observed sitting in her wheelchair, the residents' right foot with a dressing in place; the resident was not wearing heel protectors. Two sets of heel protectors were observed on the floor between the dresser and the closet, one larger dark blue pair and one smaller light blue pair. On 04/20/2026 at 3:25 pm, Staff F, Registered Nurse (RN) said all residents in the facility are at risk for pressure wounds, they know what intervention are in place by the care plan and or orders in the MAR or TAR. Resident 1 was to wear heel protectors when she was in bed only, due to her being a fall risk and that the resident was out of bed the better part of the day and did not feel that pressure was significant during the day. Staff F said she discouraged the use during the day due to the residents fall risk. On 04/20/2026 at 3:51 pm, Staff E, RN, said that residents were assessed for pressure risk when they are admitted and interventions were put into place on the care plan. Staff know what interventions were in place through the care plan and orders on the MAR/TAR. Resident 1 had an order for heel protectors, but when she attempted to transfer it would increase her fall risk, the resident wanted to wear them all the time, Staff E wanted the resident to be safe, and said Resident 1 was not supposed to wear the heel proctors unless she was in bed. On 4/23/2026 at 4:19 pm, Staff C Resident Care Manager, RN said all residents were at risk for pressure injuries, Residents were assessed on admission and intervention such as repositioning and heel protectors were included on the care plan. Documentation for these interventions were usually found on the TAR. On 04/23/2026 at 5:21 pm, Staff B, Director of Nursing Services, RN, said when residents were admitted they were assessed for pressure risk and care plan interventions were added to the care plan. Staff know what interventions were in place for each resident by the care plan, Kardex or orders in the MAR/TAR. Staff B said they ensured the care plan was being followed while out rounding, and during daily meetings. They educated staff and adjusted the care plan as needed. On 04/23/2026 at 11:56 pm, Staff D, RCM, RN, said newly admitted residents were assessed for pressure injury risk and interventions were placed on the care plan. They said interventions such as frequent repositioning or keeping heels off of the bed would be included and care plans were developed by the nursing staff. Staff D said the first interventions were added to Resident 1 on 01/23/2036 after the discovery of the Stage 2 pressure wound. Staff D said she would not have expected any interventions to be on the care plan, as she did not admit with any wounds; everyone should have their heels floated and weekly skin checks. On 04/28/2026 at 12:20 pm, Staff C, RCM, RN, said Staff H initiates the care plan and nursing staff update them. Staff C said there should be interventions on the care plan if the resident was identified at risk for pressure injuries and some intervention included would be frequent repositioning and floating the heels. Staff C did not see any interventions for risk for pressure injury included on Resident 1's care plan. Staff C confirmed the first interventions were placed on the care plan after the discovery of stage 2 pressure injury. On 04/28/2026 at 12:53 pm, Staff B, DNS, RN, said if a resident was at risk for pressure injury they would expect interventions on the care plan such as skin prep to heels, heel boots, and scheduled off-loading. Staff B said the care plans were initially developed by Staff H, reviewed Resident 1's care plan and did not see interventions placed on the care plan until the pressure wound was noted. Staff B could not identify why there was no intervention for pressure prevention on the care plan prior to the discovery of the Stage 2 pressure injury. See also F686 Reference WAC 388-97-1020 (1)(2)(a)(b)

Based on interviews and record reviews the facility failed to follow up on reports of lost items for 1 of 3 residents (Resident 1) reviewed for grievances. This failure places all residents at risk of unmet needs, a diminished quality of life, and potential financial burden. Findings included .Resident 1 was admitted to the facility on [DATE], The admission Minimum data set (MDS), an assessment tool, dated 10/08/2025, showed the resident had moderate cognitive impairment, was dependent on staff for ADLs, medically complex and required the use of corrective lenses. Review of the Resident's Demographics page which included a photo, showed the resident wearing eyeglasses. The care plan focus for Activities, initiated on 10/09/2025 documented the resident wore glasses. The resident discharged from the facility on 12/29/2025. On 02/11/2026 at 10:11 am, CC 1, resident's caregiver, said they reported the resident's glasses missing to facility staff on multiple occasions. The initial occasion was earlier in December, and the nurse referred her to Staff H, Social Services, and they looked through a drawer, and the glasses were not there. At the time of discharge the glasses were still not found and said the discharging nurse told her the glasses were not on Resident 1's inventory list so, then it didn't happen.On 02/11/2025 at 1:58 pm, review of the facility's grievance logs for 10/01/2025 through 01/31/2026 showed no entry for Resident 1's missing glasses. On 02/12/2026 at 1:45 pm, Staff E, Nursing Assistant, said if a resident or family reported something missing, he would tell Social Services, in addition to looking for the item and filling out a grievance form. On 02/12/2026 at 1:51 pm, in a joint interview with Staff C, Social Services Director, and Staff H, Social Services Assistant, Staff H said if someone reported something missing, they would fill out a stop loss form. Staff H said he did not recall anything about Resident 1's missing glasses. Staff C said she did recall hearing they were missing and looking for them but thought they had been found. Staff C said they did not fill out a stop loss form. On 02/12/2025 at 2:06 pm, Staff J, Registered Nurse (RN), said If something was reported to be missing, they would look for it and if it wasn't found they would fill out a grievance form and forward it to Staff A and B. Staff J said they recalled Resident 1 wore glasses but did not recall that they were reported missing. On 02/12/2026 at 4:51 pm, CC2, Case Manager, said they reported to the nursing staff that the residents' glasses were missing on December 4th and again on December 16th. They were never found or replaced. They were able to order another pair of glasses for Resident 1, but he had to pay a Co-pay of $20.On 02/24/2026 at 1:47 pm, Staff D, LPN, said if something was reported missing, they try to look for it and report it to Social Services. Staff D, who was identified as the discharging nurse on Resident 1's Discharge summary, dated [DATE], recalled going over the inventory list specifically but did not recall being made aware of missing glasses or making a statement that they were not on the inventory list. Staff D said Resident 1 did wear glasses and was not aware they were missing, stating Staff C usually handles that. On 02/24/2025 at 2:20 pm, Staff B RN, Director of Nursing, said, if items are reported missing, staff were to fill out a grievance form and they take it from there, trying to find the lost item, or replace it. Staff B was not aware of Resident 1's missing glasses. On 02/24/2026 at 3:20 pm, Staff G, RN, said via phone said, it sounds familiar when asked she if recalled anyone reporting Resident 1's glasses were missing. Staff G did not recall if they were found or a grievance form was filled out. Reference WAC 388-97-0460

Based on interview and record review the facility failed to promptly update and consistently implement care planned interventions for 1 of 3 residents (Resident 1) reviewed for care planning) to maintain the resident's ability and function in preparation for discharge home. This failure places residents at risk of unmet care needs, decreased quality of life, and decline in functional ability. Findings included . Resident 1 was admitted to the facility on [DATE], The admission Minimum data set (MDS), an assessment tool, dated 10/08/2025, showed the resident had moderate cognitive impairment, was dependent on staff for ADLs, medically complex, had no previous use of a mechanical lift ( a machine used to transfer/assist non weight bearing person from bed to chair or other surfaces), and no refusals of care. The resident discharged the facility on 12/29/2025. Review of Resident 1's Care plan, initiated 10/07/2026, included goals the resident would improve current level of function including transfers and included interventions of two-person dependent assist using a Hoyer mechanical lift, revised to a sit to stand lift on 12/19/2025. Review of the Social Services Meeting Care Conference Follow Up note, dated 10/29/2025 at 1:00pm showed resident one had progressed with transfers from the Hoyer lift to the sit to stand lift. Review of Resident 1's Physical Therapy Discharge note, dated 11/06/2025, showed the resident had reached max potential and had completed sit to stand training, and the resident required the assistance of two staff members and the sit to stand mechanical lift for transfers.On 02/11/2025 at 10:11am, CC1, resident's caregiver, said they had visited Resident 1 several times during the month of December and was concerned as they observed staff using a Hoyer lift with the resident despite being upgraded to the sit to stand lift. They never observed staff using the sit to stand lift with the resident. They were concerned because Resident 1 would be returning to the care home and would need to be able to use the sit to stand lift. CC1 said they reported their concerns to Staff C. On the day of discharge CC1 said they observed facility staff transfer the resident with a Hoyer. When the resident discharged to home the resident reportedly, had no idea how to use the sit to stand and he really struggled the first few days at home. CC1 said the facility did provide training on the sit to stand, but the resident was not included in the training.On 2/12/2026 at 1:45pm Staff E, Nursing Assistant (NA), said staff know how a resident transfers by what is on the care plan, they recalled Resident 1 was usually transferred via the Hoyer lift. Staff D said he wasn't assigned Resident 1 necessarily but was usually assigned their roommate and assisted with transfers. Staff D said, he may have gotten better and used a sit to stand, but I am pretty sure he was still a Hoyer lift' On 02/12/2026 at 1:51pm Staff C, Social Services Director, in a joint interview with Staff H, Social Services Assistant, said she did recall the reported concern, it was about two weeks prior to the resident's discharge, and she connected with therapy and nursing to see which lift was more appropriate; therapy worked with the resident prior to discharge and cleared him to use the sit to stand. Staff C said they communicated with staff and they were to use the sit to stand lift in preparation for discharge home but said they thought, possibly staff had been using the Hoyer lift because it was easier. Staff H said he recalled observing Resident 1 not want to get up with the sit to stand lift and the staff would have to use the Hoyer.On 02/12/2026 at 4:51pm CC2, Case Manager, said they visited Resident 1 multiple times and observed staff using a Hoyer lift to transfer the resident. CC2 was included in the care conference prior to discharge and questioned why staff were using Hoyer if they were supposed to be using the sit to stand, especially in preparation to discharge home. If he had to be transferred via a Hoyer lift, he would not be able to discharge to home. CC2 specifically recalled on December 16th, they requested staff to assist resident to get up for an appointment that was scheduled and observed staff transfer him out of bed using the Hoyer lift. On 02/24/2026 at 12:44pm Staff F, Physical Therapist (PT) said they worked with the residents to determine the appropriate lift necessary for transfer, when Resident 1 admitted they required a Hoyer lift and when therapy discharged services, he had made progress and was able to use a sit to stand for transfers. Their recommendations at the time of therapy discharge (11/06/2025) was the use of a sit to stand lift for transfers, her expectation would be for staff to use that lift. Staff F was not aware staff were still using a Hoyer or that the resident was refusing to get up. The resident was getting up six out of seven days when therapy was working with him and if there was a decline or reason for using the Hoyer, she would expect a referral for another PT evaluation to reassess. On 02/24/2026 at 1:47pm Staff D. Licenses Practical Nurse (LPN), said staff know how a resident transfers by what's in the care plan, she would expect the residents to be transferred out of bed at least once, preferably twice a day. Staff D said they recalled that Resident 1 was a Hoyer lift, he preferred to eat breakfast in bed and would frequently decline to get out of bed, agency staff would leave it at that but if the LN was informed, they could usually persuade the resident to get up. She would expect staff to document refusals and let her know. Staff D said they did not recall any specific lift required to be used prior to discharge, nor any reported concerns regarding the use of the Hoyer lift. Review of Resident 1's Task Record for 12/01/2025 through 12/28/2025 for mobility, including transfers, showed the resident was only transferred 16 times during the 28 days, only six of those times included the mobility item for sit to stand, meaning the resident may have possibly been transferred with the sit to stand as it documented the mobility action. On 02/24/2026 at 2:20pm, Staff B, Director of Nursing, Registered Nurse, said staff know how to transfer residents via the Kardex (bedside visual report derived from the care plan) in the electronic health record and they have run sheets that tell them about any changes in the residents' status. Staff B said they would expect staff to assist residents out of bed several times a day, but staff cannot make residents get up if they don't want to. Staff B said she believed staff were using the sit to stand on Resident 1 and that he was fairly unmotivated and did not like the lift or getting out of bed; and the days the resident was not transferred out of bed on the Task list were actual refusals. Staff B said they would expect refusals to be documented and followed up on. Staff B said they did not feel getting out of bed only 16 times in the last 28 days prior to discharge would have a negative impact on the resident's ability to use the sit to stand lift at home. On 02/24/2026 at 3:20pm Staff G, RN, Resident Care manager said, via phone call, Resident 1 transferred via a Hoyer lift, when he would let you transfer him, he did not like to get out of bed. Review of Resident 1's progress notes for 10/07/2025 through 12/31/2025 showed only one progress note related to refusals; on 10/12/2025 at 11:30am the resident declined a shower. Review of the Discharge MDS, dated [DATE], showed the resident was dependent on staff for transfers, and did not display rejection of care. Reference WAC 388-97-1020(1)(2)(a)(b)

Based on interviews and record review, the facility failed to ensure residents' records were complete, accurate, and/or accessible, for 1 of 1 sampled resident (Resident 1) reviewed for accurate and complete medical records. Failure to maintain complete and accurate medical records, that are accessible to staff, placed residents at risk for delayed resources, unmet needs, and a diminished quality of life. Findings included .An intake, dated 09/04/2025 at 2:31pm, showed that Resident 1 did not receive their Social Security benefits and that Resident 1 had reached out to the facility, to address the reason for cessation of Social Security payments (due to incorrectly being identified as still residing there) but had not received assistance from the facility to correct the issue.During an interview on 09/10/2025 at 1:48 pm, Resident 1 said they admitted to the facility on [DATE]th or 30th of 2024 and discharged on April 30th, 2025. Resident 1 said they had received a letter in August that said Resident 1 would not receive their Social Security pension for September. Resident 1 said when they reached out to the Social Security Administration (SSA), they were told it was because Resident 1 was still residing in a skilled nursing facility. Resident 1 said she then called the facility and spoke to Staff C, Business Office Manger, and also requested to speak to Staff A , Administrator, and Staff D, Social Services Director (SSD). She had not received a call back from either Staff A or Staff D.During an interview on 09/11/2025 at 9:05 am, Collateral Contact 1 (CC1), DSHS case manager, said they reached out to Staff D on 09/04/2025 to help facilitate the appropriate form that was believed to not have been filled out, in order to resume the resident's Social Security payments. CC1 requested the form be filled out and forwarded to the SSA right away.On 09/12/2025 at 1:34pm a Record Review for Resident 1 showed there was no record available in the electronic health records (EHR) system. During an interview on 09/12/2025 at 2:01pm, Staff B, Medical Records, said they could get copies of medical records, they just have to request them from the previous facility ownership. During an interview on 09/12/2025 at 2:17pm, medical records for Resident 1 were requested. During an interview on 09/12/2025 at 2:18pm, Staff D said that she recalled getting a call on 09/04/2025 from CC1 regarding Resident 1 stating, it had something to do with her Social Security. Staff D said CC1 emailed her a form to be filled out. Staff D provided the form. Record review of the form (SSA-186) titled, Temporary Institutionalization Statement to Maintain Household and Physician Certification, showed the facility address completed and the resident's name filled in. The rest of the form was blank. Staff D said she was unable to complete the form because the resident had discharged and she did not have access to the resident's record any longer so she did not know what to do with the form. During an interview on 09/12/2025 at 2:37pm, Staff A, Administrator said he would have expected the requested form to be filled out timely. On 09/15/2026 at 9:21am (two an a half days after they were requested), the medical record for Resident 1 was received. Record review of the EHR showed Resident 1 was admitted to the facility on [DATE] and discharged on 04/30/2029, 32 days later. Reference WAC 388-97-1720 (1)(a)(iii).

.Based on interview and record review, the facility failed to ensure at least eight consecutive hours of Registered Nurse (RN) coverage was provided daily, for 3 of 31 days reviewed (07/27/2025, 08/03/2025 & 08/17/2025) for RN coverage. This failure placed residents at risk for delay in resident assessments, identification of changes in condition, and provision of nursing care and services requiring a RN.Findings included . Review of the Staffing Pattern document completed by Staff B, Director of Nursing Services (DNS), for the 31-day period from 07/19/2025 - 08/18/2025, showed on 07/27/2025, 08/03/2025 and 08/17/2025 no RN coverage was provided. On 08/21/2025 at 2:50 PM, Staff B, DNS, confirmed no RN coverage was provided on the above-referenced dates and said the facility had difficulties finding RN coverage on some weekends, primarily for Sundays. Reference WAC 388-97-1080 (3)(a).

.Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were reviewed to ensure they accurately reflected residents' mental health diagnoses and/or selected the requirement for Level 2 PASRR referrals to be made, for 6 of 8 sampled residents (Residents 29, 1, 17, 58, 6, & 8) reviewed for PASRRs. This failure placed residents at risk for not receiving timely and necessary mental health services, and a diminished quality of life.Findings included.1) Resident 29 was admitted to the facility on [DATE], and had diagnoses of major depression disorder (persistent feeling of sadness and loss of interest) and bipolar disorder (mental health condition with severe high and low moods). Review of Resident 29's Level 1 PASRR, dated 10/18/2020, showed it did not have depression selected on the form and did not select that a Level 2 PASRR evaluation was required. No additional Level 1 PASRRs were completed. During an interview on 08/21/2025 at 1:05 PM, Staff C, Social Services Director (SSD), reviewed Resident 29's Level 1 PASRR, and said depression should have been listed on the form and the form should have been redone due to it not selecting that a Level 2 PASRR evaluation was required. 2) Resident 1 was admitted to the facility on [DATE], and had diagnoses of bipolar disorder, major depressive disorder, and anxiety disorder (intense, excessive and persistent worry and/or fear). Review of Resident 1's Level 1 PASRR, dated 08/07/2021, showed it did not have anxiety listed on the form and did not select that a Level 2 PASRR evaluation was required. No additional Level 1 PASRRs were completed. During an interview on 08/21/2025 at 1:05 PM, Staff C reviewed Resident 1's Level 1 PASRR, and said it should have been redone due to it saying Resident 1 did not need a Level 2 PASRR completed. After reviewing Resident 1's diagnosis of anxiety, Staff C said a Level 1 PASRR was not redone with the addition of this diagnosis and should have been. 3) Resident 17 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS, an assessment tool), dated 07/16/2025, documented Resident 17 was severely cognitively impaired. Resident 17's Level I PASRR, dated 07/23/2024, included a mood disorder (mental health condition that primarily affects a person's emotional state) diagnosis. Resident 17 was diagnosed with psychosis disorder (state of impaired reality) on 08/12/2025 and delusional disorder (a persona cannot tell what is real from what is imaginary, has delusions) on 11/30/2024. No new PASRR was submitted to include the new diagnoses. 4) Resident 6 was admitted to the facility on [DATE], and had diagnoses of major depressive disorder and anxiety. The Quarterly MDS, dated [DATE], documented Resident 6 was cognitively intact. Resident 6's Level I PASRR, dated 03/13/2024, documented the Level I PASRR was being resubmitted due to a significant change in condition. The Level I PASRR did not document the anxiety disorder diagnosis. 5) Resident 58 was admitted to the facility on [DATE], and had diagnoses of major depressive disorder, psychosis, and bipolar disorder. The Quarterly MDS, dated [DATE], documented Resident 58 was severely cognitively impaired. Resident 58's Level I PASRR, dated 01/18/2022, included major depressive disorder and bipolar disorder diagnosis and was resubmitted due to new behaviors. Resident 58's Level I PASRR failed to include psychosis. 6) Resident 8 was admitted to the facility on [DATE], with diagnoses of major depressive disorder and delusional disorder. The Quarterly MDS, dated [DATE], documented Resident 8 was severely cognitively impaired. Resident 8's Level I PASRR, dated 05/05/2025, documented no mental health diagnoses. On 08/21/2025 at 1:05 PM, Staff C said the correct diagnoses should have been included on the Level I PASRR's and they should have all been resubmitted. Reference WAC 388-97-1915 (1)(2)(a-c).

.Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice and their person-centered plan of care, for 5 of 8 residents (Resident 58, 8, 17, 15, &5) reviewed for bowel management, and 1 of 2 residents (Resident 5) reviewed for pressure ulcers. The failure to ensure the provision of bowel care was in accordance with physicians' orders and/or the facility bowel protocol, and that pressure redistribution devices functioned properly, placed residents at risk for delays in treatment, skin breakdown, unmet care needs and a decreased quality of life.Findings included .Bowel Management Review of facility's policy titled, Management of Constipation dated 11/2023, documented When a resident is identified with No/small Bowel Movement [BM] documented for 64hrs, the LN [Licensed Nurse] will assess the resident and determine if the bowel protocol will be initiated. Standard bowel protocol to relieve constipation (in the absence of a bowel obstruction) with a provider order may include the following: Milk of Magnesia 30 ml [milliliters] PO [by mouth] HS [at bedtime] after eight shifts of no BM Bisacodyl Suppository rectally if no results from the Milk of Magnesia Fleets Enema rectally if no results from the Bisacodyl Suppository 1) Resident 58 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool), dated 07/11/2025, documented Resident 58 was moderately cognitively impaired. Resident 58's bowel record documented Resident 58 had no BM from 08/11/2025-08/15/2025 (5 days). The electronic health record (EHR) showed no progress notes regarding bowel medication or bowel protocol. The August 2025 Medication Administration Record (MAR) showed the bowel protocol was never attempted. On 08/22/2025 at 9:03 AM, Staff D, Resident Care Manager (RCM), confirmed Resident 58 had no BM from 08/11/2025-08/15/2025. Staff D said the bowel protocol had never been started and should have been. 2) Resident 8 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 8 was moderately cognitively impaired. Resident 8's bowel record documented Resident 8 had no BM from 08/02/2025 - 08/06/2025 (5 days). The August 2025 MAR showed Milk of Magnesia was given on 08/06/2025. On 08/21/2025 at 10:25 AM, Staff I, Assistant Director of Nursing, said her expectation was that Resident 8 should have been assessed by day 3. 3) Resident 17 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], showed resident 17 was severely cognitively impaired. Resident 17 had a diagnosis of irritable bowel syndrome (IBS, an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation). On 08/18/2025 at 4:02 PM, Resident 17 said they had diarrhea a lot, and did not receive medication for it. Resident 17 said when their brief had been changed yesterday staff reported they had diarrhea. Review of Resident 17's orders, showed they had an active order, for Loperamide (anti diarrhea medication) to be given once every 3-4 days if resident had diarrhea. Review of Resident 17's MAR and bowel record from 08/01/2025 through 08/18/2025 showed no Loperamide had been administered during that time, and on the following days Resident 17 had loose/diarrhea consistency of bowel movements: 08/01/2025 08/03/2025 08/04/2025 08/05/2025 08/07/2025 08/08/2025 08/09/2025 08/10/2025 08/11/2025 08/12/2025 08/13/2025 08/14/2025 08/15/2025 08/16/2025 08/17/2025 08/18/2025 08/19/2025 On 08/21/2025 at 10:00 AM, Staff O, Certified Nursing Assistant (CNA) when asked what they would do if a resident had loose stools/diarrhea said they would clean the resident up, wash hands, report it to the nurse, then document the loose stool in the electronic health record. When asked if Resident 17 had loose stools, Staff O said yes, just the other day. When asked if they had informed the nurse, Staff O said, I did not tell the nurse. On 08/21/2025 at 10:10 AM, Staff D, RCM, when asked if a resident had loose stools/diarrhea what her expectations of staff were, said If there were loose stools staff could give Imodium (loperamide), that there was a standing order if a resident had diarrhea, and if the diarrhea did not resolve they should notify the provider for further interventions. When reviewing Resident 17's bowel record, Staff D confirmed Resident 17 had frequent loose stools, and that medication had not been administered for the month of August 2025. When told that Resident 17 reported they had diarrhea recently, and the CNA had confirmed this but reported they had not told the Nurse, Staff D said this did not meet her expectations, and staff needed education about communicating with the nurses so orders could be implemented. 4) Resident 15 was admitted to the facility on [DATE]. Review of Resident 15's alteration in bowel elimination related to constipation care plan, revised 05/06/2025, showed staff were directed to monitor for constipation and to follow the facility's bowel protocol. Record review of Resident 15's orders, dated 07/31/2025, showed the following bowel care orders:a) Milk of Magnesia (MOM)- administer at bedtime or residents preferred time, as needed, if no BM on the third day.b) Dulcolax suppository- administer per rectum (PR), as needed, if no BM 12 hours after MOM administration.c) Fleet Enema- administer PR, as needed, if no results from Dulcolax suppository in four to six hours. If there are no results, notify the provider. Review of Resident 15's bowel record showed they had no BM from 8/15/25 - 8/18/2025 (4 days). Review of the August 2025 MAR showed Resident 15 was not administered MOM on 08/18/2025 (after three days of no BM) as ordered. 5) Resident 5 was admitted to the facility on [DATE]. Review of Resident 5's alteration in elimination related to constipation care plan, revised 05/06/2025, showed staff were directed to monitor for constipation and to follow the facility's bowel protocol. Record review of Resident 5's orders, dated 05/24/2025, showed the following bowel care orders:a) MOM- administer at bedtime or residents preferred time, as needed, if no BM on the third day.b) Dulcolax suppository- administer PR, as needed, if no BM 12 hours after MOM administration.c) Fleet Enema- administer PR, as needed, if no results from Dulcolax suppository in four to six hours. If there are no results, notify the provider. Review of Resident 5's bowel record showed they had no BM from 08/13/2025 - 08/16/2025 (4 days). Review of Resident 5's August 2025 MAR, showed Resident 5 was not administered MOM 08/16/2025 (after three days of no BM) as ordered. During an interview on 08/21/2025 at 9:37 AM, when asked if Resident 15 and Resident 5 were administered MOM after three days without a BM as ordered, Staff B, Director Nursing Services (DNS), stated, No. <Pressure Redistribution Devices> Resident 5 had a 08/15/2025 order for an alternating low air loss mattress (LAL), with direction to verify every shift the mattress settings were set to a 10-minute alternating cycle and 170 pounds. On 08/18/2025 at 12:33 PM, 08/20/2025 at 1:57 PM and 08/22/2025 at 8:38 AM, observation of Resident 5's low air loss mattress display panel showed it was set to 340 pounds and had a flashing red light in the top left-hand corner that indicated low pressure. On 08/22/2025 at 8:50 AM, Staff P, Registered Nurse, confirmed Resident 5's alternating LAL mattress was set to 340 pounds and the low pressure alert light was flashing. On 08/22/2025 at 10:12 AM, Staff B, DNS, said Resident 5's LAL mattress should have been set to 170 pounds as ordered and staff should have identified the flashing alarm light that indicated low pressure and notified management or maintenance, but acknowledged that this did not occur. Reference WAC 388-97-1060 (1)

.Based on observation, interview, and record review, the facility failed to ensure services provided met professional standards for 6 of 22 sampled residents (Resident 15, 58, 8, 17, 6 & 5) reviewed unnecessary medication and for 2 of 2 nursing refrigerators (South Hall and North Hall) reviewed. The facility staff failed to label and date open vials and document, follow, or transcribe physician orders when indicated. These failures placed residents at risk for unmet care needs, medical complications, and a diminished quality of life.Findings included.Non-Pharmacological Interventions 1) Resident 15 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated [DATE], documented Resident 15 was severely cognitively impaired. A physician's order, dated [DATE], documented Resident 15 was to have 5 milligrams (mg) of oxycodone (an opioid) every 4 hours as needed (PRN) for pain. The order was discontinued on [DATE]. Review of the [DATE] Medication Administration Record (MAR), showed the PRN oxycodone was not given during this time frame. A physician's order, dated [DATE], documented Resident 15 was to have 5 milligrams (mg) of oxycodone (an opioid) every 4 hours PRN for pain. The order was discontinued [DATE]. Review of the [DATE] MAR, showed the PRN oxycodone was given 4 times during this time frame. A physician's order, dated [DATE], documented Resident 15 was to have 5 mg of oxycodone every 4 hours PRN for breakout pain. The order was discontinued [DATE]. Review of the [DATE] MAR, showed the PRN oxycodone was given 10 times during this time frame. A physician's order, dated [DATE], documented Resident 15 was to have 5 mg of oxycodone every 4 hours PRN for breakout pain. The order was discontinued [DATE]. Review of the [DATE] MAR, showed the PRN oxycodone was given once during this time frame. A physician's order, dated [DATE], documented for staff to provide non-pharmacological interventions (NPIs, non-medication interventions) to reduce pain, that included what interventions had been used and document the effectiveness of the interventions. Review of Resident 15's [DATE] Treatment Administration Record (TAR), showed no documentation that staff attempted any NPIs. 2) Resident 58 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 58 was severely cognitively impaired. A physician's order, dated [DATE], documented Resident 58 was to have 5 mg of oxycodone every 3 hours PRN for breakthrough pain. Review of the [DATE] MAR, showed the PRN oxycodone was given 11 times during this time frame. A physician's order, dated [DATE], documented for staff to provide NPIs to Resident 58 to reduce pain, that included what interventions had been used and document the effectiveness of the interventions. Review of Resident 58's [DATE] TAR, showed no documentation that staff attempted any NPIs. 3) Resident 8 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 8 was severely cognitively impaired. A physician's order, dated [DATE], documented Resident 8 was to have .25 milliliters (ml) morphine PRN for comfort care. The order was discontinued [DATE]. Review of Resident 8's [DATE] MAR, showed the PRN morphine was given 10 times during this time frame. A physician's order, dated [DATE], documented Resident 8 was to have .25 ml morphine PRN for comfort care and 0.5 ml morphine PRN for pain. Review of Resident 8's [DATE] MAR, showed the PRN morphine was given 9 times during this time frame. A physician's order, dated [DATE], documented for staff to provide Resident 8 with NPIs to reduce pain, that included what interventions had been used and document the effectiveness of the interventions. Review of Resident 8's [DATE] TAR, showed no documentation that staff attempted any NPIs. On [DATE] at 9:03 AM, Staff D, Resident Care Manager (RCM), confirmed all residents had orders for NPIs and said staff did not document any NPIs. Side Effect Monitoring 1) Resident 17 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], documented Resident 17 was severely cognitively impaired. Review of the electronic health record (EHR), showed Resident 17 was prescribed Olanzapine (an antipsychotic) for unspecified psychosis (the distortion of reality in which you have difficulty knowing what is real and what is not) and Sertraline (an antidepressant) for depression (a mood or emotional state that is marked by feelings of low self-worth or guilt and a reduced ability to enjoy life). A physician's order, dated [DATE], documented for staff to monitor Resident 17 for antidepressant side effects every shift and document with + if symptoms had been observed and – if symptoms had not been observed. A physician's order, dated [DATE], documented for staff to monitor Resident 17 for antipsychotic side effects every shift and document with + if symptoms had been observed and – if symptoms had not been observed. Review of Resident 17's [DATE] TAR, showed no documentation by staff if side effects had been or had not been observed for either medication. 2) Resident 6 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 6 was cognitively intact. Review of the EHR, showed Resident 6 was prescribed Buspirone (an antianxiety medication) for anxiety (a mental health condition characterized by excessive fear, worry, and anxiety that interfere with daily life). A physician's order, dated [DATE], documented for staff to monitor Resident 6 for antianxiety side effects every shift and document with + if symptoms had been observed and – if symptoms were had not been observed. A review of Resident 6's [DATE] TAR, showed no documentation by staff if side effects had or had not been observed for the antianxiety medication. 3) Resident 58 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 58 was severely cognitively impaired. Review of the EHR, showed Resident 58 was prescribed Venlafaxine (an antidepressant) for depression, Seroquel (an antipsychotic) for bipolar disorder (a mental health condition characterized by extreme mood swings that include emotional highs-mania or hypomania and lows-depression) and Lorazepam (an antianxiety) for anxiety. A physician's order, dated [DATE], documented for staff to monitor Resident 58 for antidepressant side effects every shift and document with + if symptoms had been observed and – if symptoms had not been observed. A physician's order, dated [DATE], documented for staff to monitor Resident 58 for antianxiety side effects every shift and document with + if symptoms had been observed and – if symptoms had not been observed. A physician's order, dated [DATE], documented for staff to monitor Resident 58 for antipsychotic side effects every shift and document with + if symptoms had been observed and – if symptoms had not been observed. Review of Resident 58's [DATE] TAR, showed no documentation by staff if side effects had or had not been observed for any of the psychotropic medications. 4) Resident 8 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 8 was severely cognitively impaired. Review of the EHR, showed Resident 8 was prescribed Risperdal (an antipsychotic) for delusional disorder (mental health condition in which a person cannot tell what is real from what is imagined) and Lorazepam for anxiety. A physician's order, dated [DATE], documented for staff to monitor Resident 8 for antipsychotic side effects every shift and document with + if symptoms had been observed and – if symptoms had not been observed. A physician's order, dated [DATE], documented for staff to monitor Resident 8 for antianxiety side effects every shift and document with + if symptoms had been observed and – if symptoms had not been observed. Review of Resident 8's [DATE] TAR, showed no documentation by staff if side effects had or had not been observed for either medication. On [DATE] at 9:03 AM, Staff D, RCM, said all residents had side effect monitoring in place for all medications. Upon review of each residents [DATE] MAR and TAR, Staff D confirmed staff had not documented if observations of side effects had been observed, saying the order did not provide space for staff to enter + or -. Nursing Refrigerators During an observation with Staff F, Registered Nurse (RN), on [DATE] at 12:02 PM, North Hall medication room had expired green top lab specimen test tubes, with an expiration date of [DATE], and expired blue top test tubes, with an expiration date of [DATE]. During an observation with Staff G, Licensed Practical Nurse, on [DATE] at 3:47 PM, South Hall medication room had expired green top lab specimen test tubes, with an expiration date of [DATE], and expired blue top test tubes, with an expiration date of [DATE]. During an observation with Staff H, RN, on [DATE] at 1:42 PM, South Hall medication room had expired green top lab specimen test tubes, with the expiration date of [DATE]. When asked if licensed nurses drew blood samples using the test tubes located in the medication room, Staff H said the facility's licensed nurses used the test tubes in the medication room for drawing labs, which were then picked up by the lab courier. On [DATE] at 2:20 PM, when asked about the expired test tubes, Staff I, Assistant Director of Nursing/RN, said it was her expectation for staff to assess the expiration date on the test tubes before using them. Pressure Ulcer Resident 5 was admitted to the facility on [DATE]. Record review showed a [DATE] order for Wound Healing Supplement - Thin Liquids, with instruction to mix in eight ounces of water and administer every morning for 14 days to promote wound healing. The order did not identify what the Wound Healing Supplement was or the dose that was to be administered. Review of Resident 5's [DATE] Medication Administration Record (MAR), showed facility nurses signed, from [DATE] - [DATE], they had administered the unidentified supplement daily as ordered. On [DATE] at 3:19 PM, Staff B, Director of Nursing Services (DNS), said the order was incomplete and needed to be clarified to include the supplement and dose to be administered. Staff B said they believed the order was for Arginaid or Juven (nutritional supplements containing the amino acid L-arginine, plus vitamins C and E, designed to support wound healing). When asked how a nurse would know to administer Arginaid from the current order Staff B said they would not. Resident 5 had a [DATE] order for an alternating low air loss mattress (LAL), with direction to verify the LAL mattress was set to a 10-minute alternating cycle and 170 pounds, every shift. On [DATE] at 12:33 PM, [DATE] at 1:57 PM and [DATE] at 8:38 AM, observation of Resident 5's LAL mattress display panel showed it was set to 340 pounds and had a flashing red light in the top left-hand corner that indicated low pressure. On [DATE] at 8:50 AM, Staff P, RN, confirmed Resident 5's alternating LAL mattress was set to 340 pounds and the low pressure alert light was flashing. Review of Resident 5's [DATE] MAR, showed facility nurses signed twice daily (12-hour shifts) from [DATE] - [DATE] that they verified Resident 5's LAL mattress settings were as ordered. On [DATE] at 10:12 AM, Staff B, DNS, said it was the expectation that facility nurses only sign for tasks they completed and acknowledged if nurses had checked Resident 5's LAL mattress setting each shift as ordered, they would have identified that it was set to 340 pounds, and the low-pressure alarm was flashing and taken corrective action. Reference WAC 388-97-1620(2)(b)(i)(ii),(6)(b)(i) .

.Based on observation, interview, and record review the facility failed to ensure residents received timely specialized rehabilitative services for 1 of 2 residents reviewed for therapy services (Resident 45). This failure to complete a Speech Therapy evaluation and provide services, placed residents at risk for unmet care needs and a diminished quality of life.Findings included .Resident 45 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 06/16/2025, documented the resident had a diagnosis of dysphagia (difficulty or inability to swallow) and was moderately cognitively impaired. The MDS documented Resident 45 required set up or clean-up assistance with eating and was on a mechanically altered diet. On 08/20/2025 at 7:46 AM Resident 45 was observed in the dining room eating breakfast and being assisted by staff.A review of Resident 45's electronic health record showed 2 orders dated 06/10/2025: -Speech Therapy to evaluate and treat-Regular diet easy to chew texture, mildly thick consistency, small dining for meals, scoop plate with all mealsOn 08/21/2025 at 9:59 AM, Staff L, Director of Rehabilitation, was asked if Resident 45 was seen by speech therapy, and he said they did not have a speech therapist in June 2025. Staff L said they had recently hired a speech therapist, and they were waiting for their license to be cleared with Washington State before they could start working. On 08/21/2025 at 1:05 PM, when asked if Resident 45 had been evaluated by speech therapy, Staff B, Director of Nursing, said we do not currently have a speech therapist. Staff B was asked if Resident 45 should have been evaluated and she said they were waiting for someone to fill the position. On 08/21/2025 at 1:23 PM, Staff B said she would look to see if there was any documentation that the speech therapy order was addressed and provided to Resident 45.On 08/22/2025 at 11:33 AM, Staff A, Administrator, said the Quality Assurance and Performance Improvement committee was aware the facility did not have speech therapy, and they put together a recruitment plan. Staff A said they had signed a contract with a speech therapist, and they were waiting for their [NAME] license to be approved.On 08/26/2025, no further documentation was provided regarding Resident 45's speech therapy order on 06/10/2025.Reference WAC 388-97-1280 (1)(a-b), (3)(a-b).

.Based on interview and record review the facility failed to assist with scheduling and/or coordinating notary public services (a public officer whose function it is to administer oaths; to attest and certify, by their hand and official seal, certain classes of documents, in order to give them credit and authenticity) for 2 of 2 residents (Residents 7 & 70) reviewed for advanced directives (written instruction for the provision of health care when the individual is incapacitated, such as a living will or durable power of attorney for health care) who required notarization. This failure placed residents at risk of not having their identified healthcare decisions and preferences honored.Findings included .1) Resident 7 was admitted to the facility on [DATE]. Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 08/12/2025, showed the resident was cognitively intact. A Social Services note, dated 08/30/2023, documented Resident 7 had completed an Advanced Directive form, and the Social Services Director was working on scheduling a notary public. Review of Resident 7's Durable Power of Attorney (DPOA) for Healthcare, dated 08/30/2023, showed it was required to be signed by two witnesses, not related by blood or marriage or mentioned in the declarer's will, and not the declarer's attending physician or an employee of a health care facility. In the absence of two qualifying witness signatures, the document had to be notarized by a notary public. Further review showed the document had not been witnessed or notarized. Review of Resident 7's electronic health record (EHR), showed no further documentation was present related to facility staff's attempts to coordinate/schedule a notary public. 2) Resident 70 was admitted to the facility on [DATE]. Review of the Quarterly MDS, dated [DATE], showed the resident was cognitively intact.A Social Services note, dated 08/30/2023, documented Resident 70 had completed an Advanced Directive form, and the next step was to schedule a notary public. Review of Resident 70's DPOA healthcare paperwork, dated 08/21/2023, showed it was required to be signed by two witnesses, not related by blood or marriage or mentioned in the declarer's will, and not the declarer's attending physician or an employee of a health care facility. In the absence of two qualifying witness signatures, the document had to be notarized by a notary public. Further review showed the document had not been witnessed or notarized. Review of Resident 70's EHR, showed no further documentation was present regarding facility staffs' attempts to coordinate/schedule a notary public. On 08/21/2025 at 2:50 PM, when asked if there was any documentation to show facility staff followed up on scheduling a notary public for Residents 7 and 70, Staff B, Director of Nursing Services, stated, No, not that I see.Reference WAC 388-97-0960 (1).

Based on observation, interview and record review the facility failed to develop and/or implement comprehensive resident centered care plans for 3 of 20 residents (Residents 45, 70, & 17) reviewed for care planning, and to ensure care conferences occurred for 1 of 2 residents reviewed (Resident 15) for care conferences. This failure placed residents at risk for unmet care needs. Findings included .Care Plans 1) Resident 45 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS, an assessment tool), dated 06/16/2025, documented the resident had a diagnosis of dysphagia (difficulty or inability to swallow) and was moderately cognitively impaired. The MDS documented Resident 45 required set up or clean-up assistance with eating and was on a mechanically altered diet. On 08/20/2025 at 7:46 AM, Resident 45 was observed in the dining room eating breakfast and being assisted by staff. A review of Resident 45's electronic health record (EHR), showed a diet order of: Regular diet Easy to Chew texture, mildly thick consistency, small dining for meals, scoop plate with all meals for diet. A review of Resident 45's care plan, dated 08/20/2025, did not show Resident 45 required feeding assistance. On 08/20/2025 at 2:11 PM, Staff K, Registered Dietitian, said Resident 45's feeding assistance was not in the care plan, and it should have been. 2) Resident 70 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 70 was cognitively intact and had a diagnosis of hemiplegia (the complete or severe loss of voluntary movement on one side of the body) of the left non dominant side. On 08/18/2025 at 11:37 AM, Resident 70 was observed lying in bed, with his left arm across his chest and his fist closed. On 08/21/2025 at 1:15 PM, Staff E, Licensed Vocational Nurse, was observed assessing Resident 70's left upper extremity. Resident 70 was unable to independently open his hand or stretch his arm. On 08/22/2025 at 10:31 AM, Staff B, Director of Nursing Services/Registered Nurse (DNS/RN), said it was the expectation that Resident 70's care plan (CP) would include a focus on his contractures. When asked to review Resident 70's care plan, Staff B confirmed there was no CP focus addressing Resident 70's left upper extremity contracture and said there should have been a contractures CP. 3) Resident 17 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], showed Resident 17 was severely cognitively impaired. Resident 17 had a diagnosis of irritable bowel syndrome (IBS, an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation). On 08/18/2025 at 4:02 PM, Resident 17 said they had a lot of diarrhea. Review of Resident 17's care plan, dated 08/19/2025, showed IBS was not on the care plan. On 08/21/2025 at 10:10 AM, Staff D, RN/Resident Care Manager, confirmed that IBS was not on Resident 17's care plan and said it should have been. Care Conference Review of the facility's Care Conferences policy, revised 05/2023, showed care conferences would be held upon admission, following the Baseline Care Plan policy and procedure, quarterly, with significant changes in condition, and as requested by resident/family or other team members. Review of the facility's Baseline Care Plan policy, revised 12/2024, showed a baseline care plan review meeting would be held with the resident/resident representative within 48-72 hours of admission. Resident 15 was admitted to the facility on [DATE]. On 08/18/2025 at 4:01 PM, Resident 15's guardian said they did not believe the resident had a care conference/ care planning meeting since admission. Review of Resident 15's EHR, showed no documentation that the facility had attempted to schedule or had an initial care conference. On 08/22/2025 at 12:17 PM, when asked for documentation of Resident 15's initial care conference or attempts to schedule one, Staff B, DNS, confirmed there was no documentation that showed Resident 15 or their representative, had been offered or participated in a care conference since admission. Reference WAC 388-97-1020(2)(c)(d)(f),(4)(b) .

Based on interview and record review, the facility failed to report to the state agency and/or log allegations of abuse/mistreatment by staff on the reporting log within five working days for 1 of 3 residents reviewed for abuse and neglect. This failure placed residents at risk for repeated incidents, unmet care needs and unidentified abuse and/or neglect. Findings included . Review of Nursing Home Guidelines, The Purple Book, dated October 2015 showed on page 7 that the facility should report via telephone and via the reporting log any act where there is reasonable cause to believe the act caused fear of imminent harm. Review of the undated facility policy titled, Prevention and Reporting: Resident mistreatment, Neglect, Abuse ., showed that facility staff were to report to the Director of Nursing or Executive Director any allegation of abuse, neglect or mistreatment, who would then immediately report to the state agency. All alleged violations involving abuse or mistreatment would be reported within 2 hours of when the allegation was made and no later than 24 hours if the allegation did not involve abuse or serious bodily injury. The investigation should include review of all allegations of abuse and be documented in the electronic accident and incident report form. Resident 1 was admitted to the facility on [DATE] with diagnosis of left hip fracture. A (struck out) Incident note dated 09/29/2024 at 12:47am, by Staff C, Licensed Practical Nurse (LPN), showed they received a call from Resident 1's family member (FM) who was concerned due receiving several calls from Resident 1 reporting being abused and assaulted by staff and feeling anxious. Staff C went to Resident 1's room , accompanied by staff, and found the resident awake and on the phone with the police department, the resident became increasingly anxious and verbalized an account of being assaulted at approximately 8:00pm and reported that three aids aggressively forced her to bed and tortured her when trying to remove her pants, Resident 1 reported being shoved and handled inappropriately and was expressing fear for her life and requested transport back to the hospital. Staff C reported the allegation to Staff B, Director of Nursing (DNS), Registered Nurse (RN), and followed up with Resident 1's FM and law enforcement. Resident 1 was transported to ER via non urgent ambulance. A late entry Incident note, dated 09/29/2024 at 12:10am by Staff C, showed they received a call from Resident 1 FM, concerned that the resident reported feeling unsafe. No signs of harm were observed, the resident was on the phone to police reporting she felt unsafe, the resident was anxious and agitated and requested transport back to hospital. The complaint intake, dated 09/30/2024 at 3:00pm, showed Resident 1 verbalized they felt attacked and reported staff pushed me into the bed from my chair, and ripped my pants and underwear off and hurt my hip. Review of the facility mandated reporting log for September 08, 2024, through October 08, 2024, showed no entry for Resident 1's allegation of abuse towards staff had been completed or reported to the state agency via the hotline or the facility mandated reporting log. On 10/08/2024 at 3:21pm, Staff B, said she had double checked the mandated reporting log with the risk management log and there was nothing missing from it. At 7:49pm Staff D, Certified Nursing Assistant (CNA), said they recalled Resident 1 and had assisted 2 other staff in the transfer, there was nothing out of the ordinary, but the resident was apprehensive of transferring and the staff explained the process to her. Staff D said she left after the transfer was completed and the other two staff assisted the resident with changing. Staff D was asked to fill out a witness statement the next day but reported no one had asked her for it and still had it in her possession. Staff D reported no one from facility management had spoken to her about the allegation. At 8:09pm Staff C, LPN, said signs and symptoms of abuse included if a resident reported abuse and the resident could be paranoid or anxious. If a resident reported abuse to him or he saw signs of abuse he would report it to Staff B. If the facility did not follow up, he would report to the state agency. Staff C said on 09/28/2024 Resident 1 was assisted by staff and was observed sleeping about 9:30pm, at 11:30pm she was observed awake, shouting, and anxious. Resident 1 reported to him she was put in bed against her will, assaulted an abused. Resident 1 reported she did not feel safe there and wanted to leave. Staff C said Resident 1 denied being injured, had no complaints of pain and declined to talk to him anymore. Staff C said he believed Resident 1 made an allegation of abuse and he reported it to his supervisor, Staff B. When asked why he struck the 09/29/2024 incident note out on 10/02/2024, he said he did not recall striking the note out but was asked by Staff B to put in a less detailed note. On 10/09/2024 at 10:51am, Staff B, DNS, RN said that a Resident being transferred against their will and staff being rough with care could be considered abuse. Staff B said she did ask Staff C to put in a less detailed note because she felt the note was more of a statement, verses what was factual and what Staff C observed. Regarding Resident 1's allegation of abuse, Staff B said they did an investigation and determine the allegation was unfounded and did not need to be reported or logged. At 11:13am Staff A, Administrator said he recalled Resident 1's name, but was not aware there was an allegation of abuse, he was under the impression she was calling out during care. When asked if a resident made an allegation of abuse would that be expected to be included on the facility mandatory reporting log, Staff A said he would have to look into that, he felt they had determined the allegation was unfounded. Reference: WAC 388-97-0640(5)(a) (6)(c)

Based on interview and record review, the facility failed to provide routine cleaning services to support a clean and homelike environment for 2 of 5 sampled residents (Resident 1 and 2) reviewed for clean, homelike environment. This failure placed residents at risk for a less than homelike environment, diminished quality of life and potential infection control issues. Findings included . Review of the undated facility policy titled, Healthcare Cleaning Policy, showed the purpose was to maintain cleanliness in the healthcare setting and included that floors, furniture, and bathrooms should be free from visible streaks or stains and that high touch surfaces would be cleaned and disinfected with hospital grade disinfectant. Resident 1 was admitted to the facility on [DATE]. The Admission Minimum Data Set, an assessment tool, dated 06/27/2024, documented Resident 1 was cognitively intact and required substantial to maximal assistance from staff for completion of activities of daily living (ADLs) On 08/28/2024 at 12:18 PM, when Resident 1 was asked if housekeeping had cleaned their room regularly during the previous 10 days, replied, No, not once. When asked if nursing staff provided cleaning services, they replied, well somewhat, but mostly my family cleaned my room. Resident 2 was admitted to the facility on [DATE]. The Admission MDS, dated [DATE], documented the resident was cognitively intact and required partial to moderate assistance from staff for completion of ADLs. Review of Facility Housekeeping Daily Assignment sheets for 08/18/2024 to 08/27/2024 (10 days) for the southwest hall, comprising of rooms 117 through 129 showed no housekeeping assignment/performed for cleaning Resident 1 and Resident 2's rooms. One additional room (123) on the same hall showed no housekeeping was performed during the 10 days reviewed. At 2:00 PM, Staff E, Housekeeping Staff, said they clean resident rooms daily by way of a list of assigned rooms, not necessarily that every room was cleaned daily. At 2:05 PM, Staff F, Housekeeping Staff, said resident rooms were cleaned according to the list he received and he cleaned the rooms on the list. At 2:11 PM, Staff D, Housekeeping Supervisor, when asked how frequently resident rooms were to be cleaned, they replied, I try to get to them once a week, if I can. When asked what would prevent the housekeeping staff from regularly cleaning resident rooms, Staff D said staffing and scheduling challenges were impacting the ability to complete all of the housekeeping tasks, that also included laundry and floor care. At 2:20 PM, Staff B, Assistant Director of Nursing, Infection Preventionist, said she would expect resident rooms to be cleaned once weekly. At 2:28 PM, Staff B, Director of Nursing, said she would expect resident rooms to be deep cleaned once weekly. At 2:44 PM, Resident 1's family member (FM) said they usually visited every other day, and they didn't think housekeeping ever mopped the floor or wiped anything down, it was gross, there would be white stuff smeared on the bedside table and nightstand and the bathroom was dirty. FM said they wiped everything down when they visited but had to use baby wipes as there was no disinfecting wipes. At 2:53 PM, Staff A, Administrator, said resident rooms were to be cleaned weekly and he would not expect resident family members to clean resident rooms. Reference WAC 388-97-0880

Based on observation, interview, and record review, the facility failed to ensure sufficient qualified nursing staff were available to provide care and services as evidenced by information provided in Resident/Surveyor interviews for 6 residents (Residents 67, 55, 11, 24, 65 and 2) interviewed, and 6 staff (Staff B, J, H, M, N & 1 anonymous staff) interviewed. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living and restorative services. These failures placed residents at risk for unmet care needs, decreased physical abilities and a diminished quality of life. Findings included . Resident 67 was admitted to the facility on [DATE]. The admission Minimum Data Set (MDS), an assessment tool, dated 06/13/2024, documented Resident 67 had severe cognitive impairment, was medically complex and dependent on staff for activities of daily living (ADLs). The care plan, initiated on 06/06/2024, showed Resident 67 required two person assist with mechanical lift for transfers. <Observation> On 08/06/2024 at 9:03 AM, Resident 67 was observed sitting in his wheelchair, in his room with spouse at his side and the call light on. The call light was answered by Staff D, Social Services director, who was not able to meet the residents need of being transferred to bed. Staff F was observed reporting to Staff J, Licensed Practical Nurse (LPN), Resident 67's request to transfer to bed. Resident 67's spouse said she was told that Staff K, Nursing Assistant (NA), would be there to help as soon as they could. Room and call light was continuously observed and at 9:50 AM, 47 minutes after the call light was initiated, Resident 67's call light was answered by Staff L, NA, who said they were on a lunch break and Staff K, NA, RA, was in charge of the hall. Staff asked Resident 67 what they needed and Resident 67 was not able to communicate their needs. The surveyor asked Staff L, if they would usually assist the resident back to bed after breakfast and they replied, they usually like to keep them up to participate in activities. Staff L was informed that Resident 67's spouse had placed the call light on, Staff L, said she would check with her to see what the resident needed. Staff L was observed entering another room that did not have a call light on. At 11:21 AM, Resident 67's spouse, also a resident at the facility, said Staff L had not inquired of her what Resident 67's need was and said she would have preferred Resident 67 to have been assisted back to bed. <Record Review> Review of the April 10, 2024 Resident Council Meeting minutes showed the nursing concern of call lights taking too long and being turned off before needs were met. Review of the May 8, 2024, Resident Council Meeting minutes showed the nursing concern of call lights being turned off before the need was met. Review of the June 5, 2024, Resident Council Meeting minutes showed the nursing concerns of call lights being turned off before needs are met and night shift does not have enough staff. <Resident Interviews> On 08/05/2024 at 1:53 PM, Resident 55 said call light times could be anywhere from 15 minutes to 2.5 hours and said the weekends were generally bad and holidays are atrocious. At 2:10 PM, Resident 11 said it took forever for staff to answer the call light. At 2:15 PM, Resident 24 said they don't have enough people around and when they do help, they are extremely rushed, they need more help. At 2:57 PM, Resident 2 said at night it took 4-5 hours waiting for someone to change their shorts. On 08/06/2024 at 9:55 AM, Resident 65 said, it sometimes took awhile for staff to get to us and they waited an hour during the day time. On 08/07/2024 at 1:31 PM, resident council members expressed concern regarding staffing, saying they just don't have enough people, call light times can be long, and weekend staffing is not enough. <Staff Interviews> 08/07/2024 at 10:45 AM, Staff J, LPN, said she is usually responsible for providing care for 24-26 residents on her shift. Staff J did not feel there was enough staff to meet resident needs. Staff J said providing showers and meeting the basic needs can be tough. On 08/08/2024 at 12:35 PM, Staff H, Nursing Assistant (NA) and Restorative Aide said he was frequently pulled to the floor. He said there was enough staff to meet the basic needs of residents. At 12:46 PM, Staff N, NA, said they usually have around 10 residents to care for, but sometimes it could be 15-20. Some days they do not have enough time to meet resident needs. At 1:12 PM Staff N said she usually has to stay two hours after the end of her shift to ensure residents have showers and to complete her charting. She stated, I have to do this all of the time. At 12:55 PM, Staff M, NA, said there was not enough staff to meet resident needs, they frequently are not able to complete showers and would substitute a bed bath or stay late. On 08/09/2024 at 10:05 AM, a staff member who wished to remain anonymous, said there was not enough staff to meet resident needs. They are not always able to complete all tasks assigned for their shift and sometimes vital signs are hard to obtain and wound care may not get completed. On 08/09/2024 at 2:24 PM, Staff B, RN, DNS, said they would have to say they do not have enough staff to meet the resident's needs, especially as it related to restorative services. Staff B said they try to staff with 8 NA's but some days they only have 6-7. Staff B said she would expect a call light to be answered, ideally within 5 minutes, but did not think it was unreasonable for the need to be met within 15-20 minutes. When asked if she would expect Resident 67 to wait as long as they did for their needs to be met, Staff B said she would rather they not have to wait that long. Refer to F688 Reference WAC 388-97-1080 (1)

Based on observation, interview, and record review, the facility failed to ensure consistent restorative services were provided for 4 of 6 sampled residents (Residents 17, 23, 28, and 65) reviewed for range of motion (ROM) and mobility. This failure placed residents at risk for avoidable decline and diminished quality of life. Findings included . <Resident 65> Resident 65 was admitted to the facility on [DATE] with diagnoses including cerebral infarction (disrupted blood flow to the brain cells depriving them of vital nutrients which can cause parts of the brain to die off) and hemiplegia (paralysis of one side of the body). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 08/01/2024, documented the resident was cognitively intact and was dependent to needing partial assistance with Activities of Daily Living (ADLs). The care plan, initiated 01/23/2024, included restorative program interventions initiated on 05/02/2024 for transfers related to self-care performance deficit and the care plan, initiated on 03/15/2024, included restorative program interventions for range of motion related to limited physical mobility. A review of Resident 65's Restorative Care flowsheets for 7/1/2024 through 7/31/2024 showed the resident received range of motion (ROM) with documented minutes of restorative services on 8 of 31 days and received transfers with documented minutes of restorative services on 17 of 31 days. On 08/08/2024 at 2:53 PM, Staff H, Restorative Aid (RA) said Resident 65 had a goal of restorative therapy daily. Staff H said he had worked with resident 65 a couple of days here and there with large gaps where Resident 65 did not get anything because Staff H was pulled from restorative to work the floor. On 08/09/2024 at 9:57 AM, Resident 65 said they received restorative therapy at least once a week. On 08/12/2024 at 10:45 AM, Staff S, Registered Nurse (RN) said she was sure Resident 65 was on Restorative Therapy, but would have to pull the RAs often to the floor. At 11:15 AM, Staff B, RN and Director of Nursing said the RAs were certified nursing assistants (CNA) too and the facility must prioritize by pulling the RAs to the floor when they needed CNAs. 45203 <Resident 17> Resident 17 was admitted to the facility on [DATE]. The quarterly MDS, an assessment tool, dated 06/22/2024, documented Resident 17 was cognitively intact, medically complex, and required substantial to maximal assistance for ADLs. The care plan, initiated 12/14/2023, included interventions, initiated on 03/25/2024, for restorative services for the focus of limited mobility related to weakness. Restorative interventions included TheraBand, omni cycle, and sit to stand with parallel bars. A therapy to nursing communication note, dated 08/02/2024 at 11:08 am, documented Resident 17 was observed during a restorative therapy session and was not appropriate for physical therapy services to resume and would need to progress further in transfers under his current restorative program. Review of Resident 17's Restorative Care flowsheets for 07/08/2024 to 08/08/2024 showed the resident received documented minutes of restorative services on 10 of 31 days. On 08/08/2024 at 2:26 PM, Resident 17 said he used to receive therapy services and now only receives restorative therapy about once a week, saying, the restorative aids are pulled to the floor, they were told, due to staff shortages. Resident 17 said the restorative aid got pulled to the floor a lot and said, I do the best I can on my own, all I know is I want to be able to stand up and go home. <Resident 23> Resident 23 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE] documented Resident 23 had moderate cognitive impairment, and required substantial to maximal assistance for ADLs. The care plan, initiated 12/21/2020, included interventions, initiated on 06/07/2022, for restorative services for the focus of limited physical mobility related to weakness. Restorative interventions included active range of motion and ambulation with parallel bars. Review of Resident 23's Restorative Care flowsheets for 07/08/2024 to 08/08/2024 showed the resident received documented minutes of restorative services on 20 of 31 days. On 08/06/2024 at 10:34 AM, Resident 23 said she supposedly gets restorative services, but they are pulled to the floor 90% of the time. When asked what impact that has on them, Resident 17 replied, well, you just slide downhill and don't get any better. On 08/08/2024 at 12:35 PM, Staff H, Nursing Assistant (NA), Restorative Aid, said they were pulled to the floor frequently. Staff H said this could have a negative impact on the residents and tried to prioritize those residents on a passive range of motion program to prevent contractures. <Resident 28> Resident 28 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 28 had moderate cognitive impairment and required substantial to maximal assistance for ADLs. The care plan, initiated on 12/20/2021, included interventions for restorative services related to the focus of limited physical mobility related to weakness. Restorative interventions included active and passive range of motion to left (affected) side to prevent formation of contracture (a permanent tightening of muscles, tendons, skin, and other tissues that can cause joints to shorten and become stiff, preventing normal movement of a body part or joint). Review of Resident 28's Restorative Care flowsheets for 07/08/2024 to 08/08/2024 showed the resident received documented minutes of restorative services on 9 of 31 days. On 08/09/2023 at 8:55 AM,, Resident 28 said he did not receive restorative therapy services. When asked specifically about passive range of motion to his affected side, Resident 28 replied, no, they don't do that. At 12:58 PM, Staff H, said Resident 28 was not receiving passive range of motion to the left upper extremity at the frequency he would prefer, unfortunately I am pulled to the floor a lot. At 2:15 PM, Staff B, Registered Nurse, Director of Nursing, said the facility had two restorative aids and when asked how often they were pulled to the floor, Staff B replied, it varies, at least once or twice a week. Staff B said they felt this did have a negative impact on providing restorative services to the residents. See F725 Reference WAC 388-97-1060 (3)(d) 37044

Based on observation, interview and record review, the facility failed to ensure Intravenous (IV) services were provided in accordance with professional standards of practice and facility policy for 2 of 2 residents (Resident 69 & 31) reviewed for IV therapy. The facility failed to provide Peripherally Inserted Central Catheter (PICC, a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart) care, maintenance and monitoring to include changing needleless injection caps, flushes, dressing changes, monitoring the external length to verify the line had not migrated, and monitoring insertion site for signs and symptoms of infection. These failures placed the resident at risk for loss of vascular access, infection, and other potential negative health outcomes. Findings included . <Facility Policy> Review of the facility's Central Vascular Access Device (CVAD) Dressing Change, Needleless Connector Change, and Flushing and Locking policies, all revised 06/ 01/2021, showed CVADs included PICCs, non-tunneled catheters (subclavian, jugular, femoral), Tunneled catheters, and Implanted venous ports. Staff were directed to: a) Perform CVAD dressing changes every seven days and as needed. b) Measure CVADs external length upon admission/during the initial assessment, weekly with dressing changes, upon suspicion of a change in length or if signs or symptoms of complications were present. c) Measure the upper arm circumference of residents with Peripherally inserted central catheters (PICCs) upon admission and/or with the initial assessment and then at least weekly. d) Assess the vascular access insertion site upon admission, during dressing changes, before and after administration of intermittent infusions, at least every 2 hours during continuous therapy, and at least once every shift when not in use. e) Change needleless connectors upon admission; at least every seven days; after blood draws; and any time the integrity of the needleless connector is in question. f) Specific flush/lock orders must be obtained, documented, and submitted to the pharmacy. 1) Resident 69 readmitted to the facility on [DATE]. On 08/06/2024 at 12:03 PM, Resident 69 was observed with a single lumen, valved PICC to their right upper arm. Review of Resident 69's physician's orders showed the following 07/17/2024 IV medication and PICC maintenance and monitoring orders: a) Ceftriaxone (an antibiotic) intravenously (IV) daily for a bone and bone marrow infection (osteomyelitis), b) Vancomycin (an antibiotic) IV daily for osteomyelitis. The orders did not include direction: to obtain initial and weekly external length or arm circumference measurements; to perform weekly PICC dressing changes; to monitor the IV insertion site for signs and symptoms of infection; to change the needleless connector caps at least weekly and after blood draws; when to flush the PICC, what solution should be used, or at what frequency. Additionally, the type and location of the IV access, and whether it was valved or non-valved was not identified. On 08/09/2024 at 2:57 PM, Staff C, Assistant Director of Nursing (ADON), said Resident 69s IV orders were incomplete. The PICC maintenance, monitoring, and flushing orders were never initiated. Staff C said facility nurses should have identified the PICC and IV orders were incomplete and should have clarified them but failed to do so. 2) Resident 31 readmitted to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS, an assessment tool), showed the resident was cognitively intact, had IV access and received IV medication during the assessment period. On 08/06/2024 at 10:35 AM, Resident 31 was observed a tunneled single lumen central catheter to their right upper chest. The central line dressing was dated, 07/26/2024. Review of Resident 31's physician's orders showed the following IV medication and central line maintenance, and monitoring orders were in place: a) Weekly IV dressing change. b) Measure external catheter length upon admission and with weekly dressing change. c) Flush with 10 ml NS before and after medication administration. d) Change primary administration set every 24-hours. The orders did not include direction to monitor the IV insertion site for signs and symptoms of infection; to change the needleless connector caps at least weekly; or identify the type and location of the IV access, and whether it was valved or non-valved. A 08/09/2024 order directed nursing to infuse one liter of IV normal saline (NS) at 75 milliliters (ml) per hour, continuous until completed. Review of the electronic health record (EHR) showed no documentation was present to show facility nurses assessed Resident 31's central line insertion site every two during the continuous infusion of NS. Additionally, no documentation was found to indicate what the external length of Resident 31's central line was upon admission, or what the weekly measurements were sense. The August 2024 MAR showed that staff were directed to measure the external length of the central catheter weekly with dressing changes, but no place was provided to record the external length. On 08/09/2024 at 3:13 PM, when asked if there was any documentation to show Resident 31's central line external length was measured upon admission/ after placement and then weekly thereafter, the needleless connector caps were changed weekly, or that staff were routinely assessing the IV insertion site, to include every two hours during the continuous infusion of NS Staff C, ADON, said, No, not that's documented. Reference WAC 388-97-1060 (3)(j)(ii)

Based on interview and record review, the facility failed to provide Care Conferences (a conference where staff and residents/families talk about life in the facility, review the progress of each patient and make adjustments, as needed, to their care), for 5 of 5 sampled residents (Residents 13, 17, 23, 28, and 44) reviewed for provision of care conferences, and failed to ensure care plans were reviewed, revised, and accurately reflected resident care needs for 3 of 31 sample residents (Residents 68, 69 and 31) reviewed for care plan timing and revision. These failures placed residents at risk of not feeling involved in the development of their plan of care, unmet needs, decreased quality of care and a diminished quality of life. Findings included . <Care Conferences> <Resident 13> Resident 13 was admitted to the facility on [DATE] with diagnoses including chronic kidney failure (damaged kidneys that cannot filter the blood the way it should) and hypertension (high blood pressure). The Quarterly Minimum Data Set (MDS), an assessment tool, dated 06/15/2024 documented the resident was cognitively intact and felt it was very important to have family involved in discussions about their care. On 08/06/2024 at 12:17 pm, Resident 13 said they had not had a care conference and thought the facility should have them. Review of the electronic health record (EHR) showed a care conference was conducted on 11/16/2023 and on 06/10/2024. On 08/09/2024 at 12:39 am, Staff D, Social Services Director (SSD) said Resident 13 had not had quarterly care conferences and said the facility recently identified the concern and had been working to get all the residents a quarterly care conference. On 08/12/2024 at 11:12 am, Staff B, Registered Nurse (RN) and Director of Nursing (DON), said Resident 13 should have had a care conference somewhere between the two identified in the EHR and her expectation was to have quarterly care conferences or documentation in the record if the resident had refused. 45203 <Resident 17> Resident 17 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE] documented Resident 17 was cognitively intact, medically complex, and expressed it was very important for family to be involved in discussion about their care. On 08/06/2024 at 2:53 pm, Resident 17 said the facility did not have care conferences and they had not had one since they had been off of Medicare services. Review of Resident 17's EHR from 12/14/2023 through 08/08/2024 showed a care conference was conducted on 01/16/2024. No other care conferences were documented. <Resident 23> Resident 23 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 23 had moderate cognitive impairment and felt it was important to have family involved in discussions about their care. On 08/06/2024 at 10:37am, Resident 23 said they thought they were supposed to have care conferences, they used to have them, but had not had any recently. Review of Resident 23's EHR showed the most recent care conference was documented on 03/06/2023. <Resident 28> Resident 28 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 28 had moderate cognitive impairment and felt it was very important to have family involved in discussion about their care. Review of Resident 28's EHR showed the most recent care conference was 04/19/2023. <Resident 44> Resident 44 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented Resident 44 was cognitively intact, medically complex, and felt it was very important for family to be involved in discussions about care. On 08/06/2024 at 10:19am, Resident 44 reported they had not had a care conference since admission. Review of Resident 44's EHR showed one care conference was conducted on 06/24/2024. On 08/08/2024 at 1:35 pm, Staff D said care conferences for long term care residents were held quarterly. Staff D said they reached out to the families and scheduled them. Staff D said she documented the offer in progress notes and completed a care conference note in the record. Staff D said it had been challenging to complete all of the care conferences. At 3:44pm, Staff D said she had just completed a care conference with Resident 28 and reached out to family of Residents 17 and 44. She attributed the lapse to not having enough time to complete everything; due to staffing challenges. Staff D reported answering more call lights, and 1:1 time for residents. On 08/09/2024 at 2:48pm, Staff B, RN, DON, said care conferences for long term care residents were expected to be offered quarterly and if there was a change in the resident. Staff B said the facility had identified, approximately two months ago, that care conferences were not being completed and they, did a ton of care conferences, and tried to catch up. Staff B attributed the care conferences not being completed to just overload. 37044 <Care Plans> <Resident 68> Resident 68 admitted to the facility on [DATE]. On 08/05/2025 at 11:43 AM, Resident 68 stated, I can't hear you. I had a pocket talker but last week in therapy it went dead. They took it to get new batteries and they haven't given it back yet. On 08/07/2024 at 1:34 PM, Resident 68 was observed sitting in their room utilizing a pocket talker (amplifies sound) to communicate with staff. When asked about hearing aids Resident 43 said they had them, but they did not work. An alteration in sensory/communication care plan related to being hard of hearing, initiated 06/25/2024, directed staff to assist with placing hearing aid in resident's ear, replace batteries in hearing aid as needed, and to turn off the TV/radio as needed to reduce environmental noise. The care plan did not identify that the resident's hearing aides were non-functional or identify that the resident was utilizing a pocket talker for communication. On 08/12/2024 at 3:31PM, Staff G, Unit Manager, said Resident 43's use of a pocket talker as their primary hearing assistive device should have been care planned, but acknowledged it was not. <Resident 69> Resident 69 readmitted to the facility on [DATE]. The resident's admission orders showed the resident had a Peripherally Inserted Central catheter (PICC) to their right upper arm, and orders for ceftriaxone (an antibiotic) intravenously (IV) daily for a bone and bone marrow infection (osteomyelitis), with direction to infuse via valved single lumen PICC, and an order for IV vancomycin (antibiotic) daily for osteomyelitis. Review of Resident 69's comprehensive care plan showed there was no mention of the resident's osteomyelitis, type and location of IV access, or need for ongoing IV antibiotics. On 08/09/2024 at 3:09 PM, Staff C, Assistant Director of Nursing (ADON), said the type and location of the resident's IV access, care instructions, ongoing IV antibiotic therapy and diagnosis of osteomyelitis should have been care planned, but were not. <Resident 31> Resident 31 admitted to the facility on [DATE]. Review of the 06/15/2024 Admission MDS showed the resident had IV access, received IV medications and antibiotics for a diagnosis of osteomyelitis. A 07/18/2024 central line insertion report showed the resident had a tunneled single lumen central catheter placed to their right chest for long term antibiotic therapy related to osteomyelitis. Review of Resident 31's comprehensive care plan showed no care plans had been developed/implemented to address resident's osteomyelitis, type and location of IV access, or need for ongoing IV antibiotic therapy. On 08/09/2024 at 3:09 PM, Staff C, ADON, said the type and location of the resident's IV access, care instructions, ongoing IV antibiotic therapy and diagnosis of osteomyelitis should have been care planned, but were not. Reference WAC 388-97-1020(2)(e)(f)

Based on observation, interview and record review, the facility failed to ensure the menu was followed for 4 of 4 residents (Residents 28, 50, 67 & 2) with mechanical soft or puree diets, whose meals were observed during tray line. Failure to provide accurate portion sizes, placed residents at risk of unmet nutritional needs, and potential negative outcomes. Findings included . Review of the facility's menu showed for lunch on 08/12/2024 smothered chicken, parslied rice, brussels sprouts and a dinner roll would be served. >Portion Sizes< Review of the menu showed residents on D1 pureed diets would receive: A #8 (4-5 ounces) scoop of pureed chicken. A #12 (2.5-3 ounces) scoop of pureed brussels sprouts. A # 16 (2-2.5 ounces) scoop of pureed dinner roll D2 mechanical soft diets would receive: A #12 (2.5-3 ounces) scoop of pureed brussels sprouts. Observation of the steam table on 08/12/2024 at 11:20 AM showed the pureed chicken, pureed brussels sprouts, and pureed dinner roll had a #8 scoops in them for serving. Observation of tray line from 10:49 AM - 11:20 AM, showed dietary staff served the following: Resident 2 (D1 pureed diet) - pureed brussels sprouts and dinner roll with a # 8 scoop. Resident 67 (D2 mechanical soft diet)- Pureed brussels sprouts with a #8 scoop. Resident 28 (D2 mechanical soft diet)- Pureed brussels sprouts with a #8 scoop. Resident 50 (D2 mechanical soft diet)- Pureed brussels sprouts with a #8 scoop. On 08/12/2024 at 11:29 AM, when asked about the appropriate scoop size to be used for D1 and D2 diets Staff F, Dietary Manager, stated, It was the wrong scoop size, those are all number 8 scoops. The puree brussels sprouts should be a number 12 and the puree dinner roll a number 16. Staff F then intervened and provided the dietary staff the proper scoop sizes before completing tray line. Reference WAC 388-97-1100(1).

Based on observation, interview and record review, the facility failed to: ensure their infection control and preventions practices were implemented to prevent the transmission of a highly transmissible disease Carbapenem-resistant Acinetobacter baumannii (CRAB, a bacteria resistant to nearly all antibiotics and difficult to remove from the environment, a multi-drug resistant organism [MDRO]); prevent the spread of CRAB within the facility for 6 of 6 sampled residents (61, 41, 42, 70, 37 & 39) reviewed for infection control prevention; utilize the proper types of disinfectant wipes against the Carbapenem-Resistant Organism (CRO); follow and implement Enhanced Barrier Precautions (EBP is a type of isolation for identified high risk residents to prevent the spread of disease from one person to another) for 15 of 65 facility residents (17, 5, 30, 53, 54, 35, 26, 16, 13, 102, 121, 108, 105, 110 & 124) reviewed for infection prevention and control; keep dispensers filled with alcohol rub or hand sanitizer in various locations throughout the facility (front entrance, Resident rooms [ROOM NUMBERS], two dirty utility rooms, a shower room and in various locations on the North Hall); ensure the laundry sanitizer was effective against CRAB; and use proper precautions while providing skin care to 2 of 3 sampled residents (4 & 53) reviewed for infection control related to wound care. This caused harm to Resident 37, Resident 39, Resident 42 and Resident 70 when they experienced a healthcare acquired infection (HAI) of CRO (CRAB). This failure placed all residents at risk of transmission of a highly transmissible disease and a diminished quality of life. On 07/25/2023 at 7:05 PM, the facility was notified of an immediate jeopardy (IJ) at CFR 483.80 (a)(1), F 880 Infection Prevention, related to the facility's failure to ensure infection control and prevention practices were implemented to prevent the transmission of CRAB. The facility removed the immediacy on 07/28/2023 at 2:07 PM with an on-site validation date of 07/28/2023 when a facility-wide sanitation of the building was completed, implemented EBP for all high risk residents, procured and made available to staff appropriate wipes to combat CRAB, and re-educated staff for infection control practices. Findings included . The facility policy entitled Infection Prevention and Control Program, revised 2018, documented, The infection prevention and control program is a facility-wide effort involving all disciplines and individuals . Elements of the infection prevention and control program consist of coordination/oversight . outbreak management, prevention of infection . Outbreak Management is a process that consists of . (2) managing the affected residents; (3) preventing the spread to other residents . (6) educating the staff and the public . Important facets of infection prevention include . (2) instituting measures to avoid complications or dissemination (spreading); (3) educating staff and ensuring that they adhere to proper techniques and procedures . (7) implementing appropriate isolation precautions when necessary; and (8) following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). The CDC web site https://www.cdc.gov/mmwr/volumes/69/wr/mm6948e1.htm documented, Carbapenem-resistant Acinetobacter baumannii (CRAB) causes health care-associated infections that are challenging to contain and often linked to infection prevention and control (IPC) breaches. Review of the facility's infection control binder showed the first identified case was on 02/20/2023 while the resident was at the local hospital. A second case was identified on 03/30/2023. Both residents were readmitted to the facility. Record review showed the facility participated in an Infection Control Assessment and Response (ICAR, a consulting inspection done by the state's Department of Health) on 03/14/2023. After the onsite visit, Department of Health (DOH) provided a printout of educational resources and facility specific guidance was provided. Included in the education were items the facility was doing well and areas where they could improve. The following was a list of infection control practices the facility was noted to be doing well during the 03/14/2023 ICAR but were identified as issues during the annual survey starting 07/23/2023: hand sanitizer dispensers located in and out of resident rooms, each resident had their own sling for Hoyer or Sit to Stand lift with a process in place to clean, appropriate personal protective equipment (PPE) storage bins (isolation carts) located out of the room for residents on precautions, the Infection Preventionist completed rounds to ensure PPE storage bins were well stocked and completed education with staff regarding infection control practices and the Director of Nursing Services or Infection Preventionist worked with central supply to ensure adequate levels of PPE were readily available. The areas identified on 03/14/2023 that the facility could improve on included fully implementing Enhanced Barrier Precautions, assessing the system for handling laundry especially for residents on isolation, staff education, and creating a system to identify who was responsible for cleaning items such as Hoyer lifts and shared resident equipment. <Positive CRAB Cases> 1) Resident 61 was admitted to the facility on [DATE] with a right thigh wound. The quarterly Minimum Data Set (MDS), an assessment tool, dated 05/19/2023, showed Resident 61 required extensive assistance with transfers and was dependent on helpers for safe mobility with moving from position to position. Review of facility Infection Control Binder showed on 02/14/2023 Resident 61 had a positive wound culture for CRAB. 2) Resident 41 was admitted to the facility on [DATE]. The discharge MDS, dated [DATE], showed Resident 41 required supervision with transfers and required moderate assistance from a helper for safe mobility with moving from position to position. Review of a hospital culture report showed on 02/15/2023 Resident 41 had a culture taken which was positive for CRAB. Review of the DOH culture report showed on 03/10/2023 a culture was taken during facility wide testing which was positive for CRAB. 3) Resident 42 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 42 required extensive assistance with transfers and required substantial assistance from a helper for safe mobility with moving from position to position. Review of facility Infection Control Binder showed on 03/15/2023, Resident 42 had a culture taken during facility wide testing, which was positive for CRAB. 4) Resident 70 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 70 required extensive assistance with transfers and was dependent on helpers for safe mobility with moving from position to position. Review of the infection control binder showed Resident 70 tested negative for CRAB in March 2023 during facility wide testing. Resident 70 was identified on 04/14/2023 as having a worsening of a wound infection with new or increased purulent drainage (pus) and tested positive for CRAB during the April 2023 facility wide testing. 5) Resident 37 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 37 required extensive assistance with transfers and required substantial assistance from a helper for safe mobility with moving from position to position. Review of facility infection control binder showed during the April 2023 facility wide testing, Resident 37 was negative for CRAB. During facility wide testing, on 05/16/2023, Resident 37 tested positive for CRAB. 6) Resident 39 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], showed Resident 39 required supervision with transfers and required supervision, cueing and steadying, from a helper for a safe mobility with moving from position to position. Review of the facility infection control binder showed on 05/16/2023, Resident 39 tested negative for CRAB during facility wide testing. Review of a DOH culture result showed on 05/22/2023 a culture was obtained and tested positive for CRAB for Resident 39. Review of the infection control binder, for the month of May 2023, showed an undated trend and analysis sheet that documented one resident tested positive for CRAB on 05/16/2023 and due to continued spread, the DOH had recommended positive residents be transitioned to contact precautions (contact precautions are a higher level of isolation than the required enhanced barrier precautions). On 07/26/2023 at 10:13 AM, Collateral Contact 1 (CC1), DOH staff, said during the outbreak, the facility did not have an onsite infection preventionist (IP) person. CC1 said Staff G, Regional Infection Preventionist, was traveling to other buildings and was only onsite a couple of days per month. CC1 said she was concerned for the lack of oversight with IP practices as things deteriorated when Staff G was not there. CC1 said the testing was too burdensome for the facility so the DOH sent two staff to help test residents and provide information/education to the facility. <Enhanced Barrier Precautions> On 07/25/2023 at 1:41 PM, room [ROOM NUMBER] was observed to be on EBP, used for high risk residents including identified but limited to open wounds, catheters, central lines, and respiratory issues. There were no disinfectant wipes in the isolation cart (cart that holds PPE and items necessary for infection control) or nearby for staff use. At 1:46 PM, room [ROOM NUMBER] was observed to be on EBP. There were no disinfectant wipes in the isolation cart or nearby for staff use. On 07/26/2023 at 8:32 AM, Staff J, Certified Nursing Assistant (CNA), was observed in Resident 39's room talking with the resident while Resident 39 was sitting in a wheelchair at the bedside. Staff J closed the door and transferred Resident 39 to bed without wearing a gown or gloves then left the room. When asked about precautions used when an EBP sign was posted, Staff J said the sign on Resident 39's room was new. When asked if gloves and a gown should have been worn, Staff J said he would have to ask about it. After looking over the sign, Staff J said he should have asked about the signs a few days ago. At 8:38 AM, the rooms of high-risk residents (17, 5, 30, 53, 54, 35, 26, 16, 13, 102, 121, 108, 105, 110 and 124) were observed without EBP available for use. The only EBP were for residents identified as being CRAB positive. <Disinfecting wipes> On 07/25/2023 at 1:43 PM, Staff J said he used bleach or purple top (hospital grade disinfectant wipes) on Hoyer lifts after use. Staff J said wipes were kept in the nurses' cart or the clean utility room. Staff J was observed looking for wipes then found a tub in a black file cabinet drawer. The wipes were a citric acid base wipe that was ineffective against CRAB. At 2:16 PM, Staff G, Infection Preventionist, said they had an ICAR with DOH regarding the CRAB outbreak. The biggest recommendation was to increase the amount of disinfectant wipes available to staff and they had to change the COVID (pandemic respiratory infection which can lead to serious health issues including death) wipes to an appropriate disinfectant to cover the new MDRO. Staff G said they got rid of the old and got all new. At 6:00 PM, Staff R, Licensed Practical Nurse (LPN), said Staff A, Administrator, came around at 2:00 PM that afternoon to lock up the wipes. Staff R said they were to only be locked in the nurse cart or in the medication room. The tub of citric acid based wipes were still observed in the file cabinet. On the North nurses station, there were yellow grocery store brand sanitizer wipes. On 07/26/2023 at 8:26 AM, room [ROOM NUMBER] was observed to be on EBP but did not have wipes on the isolation cart. At 8:27 AM, Staff W, LPN, said she had wipes in her cart but did not recall having staff come ask for them. Staff W said the staff used them but did not get them from her. Staff W said it was not their process to get wipes from the nurse cart. At 8:28 AM, there were no wipes observed on the South nurses station counters. The tub of citric acid based wipes was still in the file cabinet. room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] were on EBP but did not have wipes on the isolation carts. At 10:40 AM, Collateral Contact 2 (CC2), DOH staff, said when she was onsite in March 2023 for the ICAR, she noticed the facility had several different types of wipes. CC2 said she recommended the facility use just one type of wipe. CC2 said she made sure the facility staff understood how to read the disinfectant labels for effectiveness. CC2 said she recommended to have wipes in easily accessible places for equipment cleaning. When asked about the amount of wipes available, CC2 said they were not able to go into the supply room because Staff G was a regional staff who did not have access. CC2 said they did not get to see it. At 2:24 PM, Staff M, Central Supply Clerk, said if she did not get the items she requested or needed, she would go to Staff A. Staff M said the budget came from corporate and was based on the facility census. Staff M said the wipes could be found in utility closets. Staff M said a nurse came through and took them off the unit, and stated, I had them out last week. Staff M said the wipes were removed due to residents with dementia. Staff M said in stock at the time was four citric acid based wipes, one grocery store brand wipe, one purple top, and one orange top. Staff M said she was told by Staff G and Staff L, Maintenance Director, to not stock wipes on the isolation cart. The North Hall clean utility room was observed with Staff M and showed no wipes were stocked. At 2:40 PM, Staff X, Environmental Services, showed the housekeeping stock of disinfectant wipes and supplies. Observed were two purple top wipes that were almost empty, one small hydrogen peroxide wipe bottle and one citric acid based wipes tub (which was ineffective against CRAB). Staff X said the facility was getting away from foam hand sanitizer because it was too expensive and there were only three left. Staff X said the facility supply of hand soap was almost out because they needed the dispensers. They had soap but no way to use it. The facility had recently changed brands for soap and about two months prior had changed the main disinfectant cleaner away from Eco Labs. At 2:48 PM, Staff L, Maintenance Director, said she told her staff to not stock wipes on the isolation carts because she was a CNA and the residents could eat them. Staff L said the wipes should be kept locked in the nurses cart or at the nurses station. Staff L said if a CNA came out of a room, they need to ask a nurse or go to the nurses station to get the wipes. Staff L said if she saw the wipes out when she walked by, she took them away. Staff L said she thought they kept the wipes in the clean utility. On 07/27/2023 at 1:33 PM, Staff G said they put all the wipes out, and there were no more. Staff G said the DOH recommended to have wipes on every isolation cart. Staff G said when the supply came, they would add to the rest of the isolation carts. Staff G was observed seeing the grocery store brand wipes on the South Nurses station and tossed them away. Staff G said there should not be any other wipes, only purple top. At 2:09 PM, Staff M said there was a delivery of 12 boxes. When the delivery was observed, there was only 1 box and when opened, the box had 10 tubs of wipes instead of 12. Staff M said the box came from the corporate warehouse. A bottle of yellow grocery store wipes were on the table. On 07/28/2023 at 9:48 AM, CC1 said she told the facility to stop using mismatched wipes and use only one to prevent confusion among staff. CC1 said when she was onsite she looked up the Environmental Protection Agency (EPA) registration numbers and everything was good; and they had the purple top wipes. After being told the facility changed the disinfectant two months prior, CC1 said she was not aware and she informed the facility they needed to look up the EPA registration number for all disinfectants. <Disinfecting of Shared Resident Equipment> On 07/25/2023 at 1:09 PM, Staff V, Certified Nursing Assistant (CNA), and Staff U CNA were observed moving a Hoyer lift from the hallway into a resident room. Staff U and Staff V said they were supposed to wipe down the lifts after each use with the purple or gold top wipes (disinfecting wipes). Staff U said there should be a cage holder for the bottle on each lift. The North [NAME] Hall was observed to only have one cage holder on one of the two sit to stands and none on the Hoyer lift. Staff U went to get a bottle of wipes. Slings were observed hanging over each sit to stand. Staff V said they should use one sling per resident. When asked about the slings, Staff V stated, Yes. They are dirty. Staff U was observed looking around for wipes, and had to ask several staff to locate wipes. Staff U returned to the hall with a yellow bottle of grocery store brand wipes, not with the purple or gold top. At 1:17 PM, Staff F, Resident Care Manager (RCM), said staff should clean the lifts with wipes and the slings were to be washed. When asked about the dirty Sit to Stand slings on the North [NAME] Hall, Staff F said staff should take the slings to the laundry. Staff F said the lift had not been cleaned recently, and stated, We'll have to get those cleaned and do some education. At 1:21 PM, Staff B, Director of Nursing Services and Registered Nurse, said she expected the staff to clean the lifts with wipes. Staff B said if the sling portion was soiled, staff should send them to the laundry; and if not soiled, she would have to look up the facility policy. When asked if the slings could be used resident to resident, Staff B said she was not sure and would verify with the policy. Staff B said she expected the slings and lifts to be clean. At 1:41 PM, a Hoyer lift was observed in the South East Hall with a dirty cloth cover over the main handlebar. There were not any wipes or a cage holder for wipes on the lift. At 1:46 PM, a Sit to Stand lift was observed in the South [NAME] Hall with several layers of debris including white flakes that moved when blown on. There were not any wipes or a cage holder for wipes. At 1:53 PM, A Sit to Stand and Hoyer lift were observed outside the Resident Care Manager (RCM) office/TV room. The Sit to Stand was coated with debris and the Hoyer had an empty wipe cage holder. At 1:55 PM, Staff H, CNA, said she wiped down lifts with Antibacterial wipes, orange or purple top wipes (approved hospital grade disinfectant). Staff H said the wipes were normally on the lifts but she did not see them now. Staff H said she could find extra wipes in the clean utility. Staff H said the sling stayed in the residents' room and all residents had their own sling. When the lift came out of the room, it needed to be wiped down. Staff H said dirty slings would be sent to the laundry. At 1:59 PM, the North East Hall was observed with three Hoyers and two Sit to Stands (types of mechanical lifts). When asked if they were clean, Staff H stated, No. They were not clean. Staff I, CNA, said the purple wipes used to be there (in the holders), and stated, Yeah. Not there anymore. Staff I said the sit to stands were dirty. On 07/27/2023 at 1:07 PM, Staff J was observed pushing a Hoyer lift out of room into the South East Hall, parked the lift and walked off. Staff J did not wipe/sanitize the lift. Review of the electronic medical record (EMR) and infection control documentation, showed five of the six residents (Residents 61, 41, 42, 70 and 37), who had tested positive for CRAB, required the use of a mechanical lift for transfers. <Empty Alcohol-Based Sanitizer In and Out of Resident Rooms> On 07/24/2023 at 8:00 AM, the front entrance desk hand sanitizer, next to the visitor check in, was observed to be empty. On 07/25/2023 at 8:00 AM, on 07/26/2023 at 8:00 AM, and on 07/27/2023 at 8:00 AM, the hand sanitizer dispenser at the front entrance was checked daily at 8 AM. The dispenser remained empty until the afternoon of 07/27/2023. On 07/26/2023 at 9:56 AM, during wound treatment rounds with Staff K, LPN, the alcohol dispensers in room [ROOM NUMBER] and room [ROOM NUMBER] were observed to be empty in both the resident rooms. Staff K said maintenance was doing an audit and would fix it. The hand sanitizer dispensers were observed and were identified as being empty in both dirty utility rooms, the shower room, and several North Hall dispensers. <Laundry Services> On 07/28/2023 at 11:12 AM, when asked about retrieving soiled laundry process, Staff N, Laundry, said they picked the soiled laundry up from the soiled utility and shower rooms. Staff N said the staff were supposed to put isolation laundry in red bags but they had not done so in a long time. Staff N said the soiled laundry was all together. The laundry staff would not know if an item was from an isolation room. Staff N said a few weeks ago the ECO lab tech came out to fix the wash machine and reprogrammed the washers so they were not reaching the normal temps of 140-158. It was running in the 120s. Staff N said the sanitizer was automatically plumbed in, even during the week where they had low temps. Staff N said the ECO tech came back last week and increased the hot temperatures to back where they were used to seeing them. Staff N said the machine would not let the temperatures get too high, over 160 degrees, as a part of the programing. (Review of the EPA website for disinfectants showed the sanitizing solution used in the laundry was not effective against CRAB.). 48392 <Care to Skin Issues> 1) Resident 53 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS), an assessment tool, dated 06/19/2023, showed Resident 53 was moderately cognitively impaired, was able to answer yes/no questions and had a gastrostomy tube (g-tube, a tube surgically inserted through the abdomen that delivers nutrition, hydration, medication, etc. directly to the stomach). Resident 53's physician orders, dated 05/27/2023, documented to cleanse the gastrostomy tube site with soap and water and apply a T (tube) sponge (small dressing with a slit that is placed around a tube and used as barrier between and to absorb any discharge) daily and as needed. On 07/26/23 at 10:10 AM, Staff K, RCM and LPN, was observed providing wound care to Resident 53's g-tube site. Staff K utilized one pair of gloves for the entire procedure including removal of old dressing, cleaning of surgical site, and application of new dressing. Staff K placed all supplies on Resident 53's pillow. Strips of tape, to be used to secure the new dressing, were hung from Resident 53's wheelchair handle. Staff K disposed of the blood soiled dressing and cleaning supplies in Resident 53's garbage can which did not have a garbage can liner. On 07/28/2023 at 11:40 AM, Staff B said Resident 53's wound care supplies should have been placed on a clean barrier rather than on Resident 53's pillow. Staff B said the nurse should have changed their gloves after removing Resident 53's dressing, after cleaning their wound, and after putting on the new dressing. 2) Resident 4 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus I and right side below knee amputation. The quarterly MDS, dated [DATE], documented the resident was cognitively intact, required extensive assistance from 1-2 staff members for activities of daily living (toileting, transfers, mobility, dressing, etc.), and was at risk for development of a pressure injury. On 07/26/23 at 10:30 AM, Staff K was observed providing wound care to Resident 4's left ankle. Prior to beginning wound care, Staff K assisted a CNA providing care. The CNA pointed out a skin concern to Staff K, redness to Resident 4's coccyx. Staff K touched Resident 4's coccyx with a gloved hand and then assisted the CNA with straightening Resident 4's sheets and moving them up in bed. Wound care supplies were set on Resident 4's bed. Staff K did not change his gloves and utilized the same pair of gloves for all wound care provided. On 07/28/2023 at 10:08 AM Staff T, LPN, said during wound care gloves needed to be changed at least two to three times depending on the wound care being provided. Staff T said a clean barrier between wound care supplies and the surface they were setting on needed to be used to keep the wound care supplies clean. At 11:40 AM, Staff B said Resident 4's wound care supplies should have been placed on a clean barrier. Staff B said the nurse should have changed their gloves prior to starting wound care, after removing Resident 4's dressing, after cleaning their wound, and after putting on their new dressing. Reference WAC 388-97-1320 (1)(a)(c)(2)(a)(b)(3)(4)(5)(a)(c)(d)(e)

Based on observation, interview and record review, the facility failed to ensure identified weight loss acted upon and interventions developed for 1 of 1 sampled resident (Resident 53) reviewed for nutrition. This caused harm to Resident 53 when the resident experienced a significant weight loss of greater than 5% body weight within a 30-day period and the identified weight loss was not addressed. This failure placed residents at risk for weight loss, inadequate nutrition and a diminished quality of life. Findings included . Resident 53 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 06/19/2023, showed Resident 53 was severely cognitively impaired. Resident 53's Self-Care care plan, revised 09/20/2021 and 06/20/2023, showed Resident 53 had left sided hemiparesis (muscle weakness or paralysis to one side of the body) and the resident's needs would be anticipated by staff 100% of the time. The care plan documented the resident required nutrition through a feeding tube (medical device use to provide nutrition to people who cannot obtain nutrition by mouth) and received 100% of their nutrition through the feeding tube. Physicians orders, dated 12/10/2022 and 06/26/2023, showed, Enteral feed [tube feeding] '1.5 cal' (calorie dense tube feeding formula that contains fiber) 20 hours per day. The Electronic Health Record (EHR) showed the following weights: --06/27/2023 - 154.5 lbs --07/03/2023 - 147.0 lbs, 4.9% weight loss since 06/27/2023 --07/12/2023 - 145.6 lbs, 5.7% weight loss since 06/27/2023 --07/17/2023 - 144.2 lbs, 6.67% weight loss since 06/27/2023 Progress note, dated 07/09/2023, showed, Will review possibility of trying more concentrated 'TwoCal HN' formula (calorie and protein dense formula that supports volume intolerance) to allow for less volume infused and time on pump. Progress note, dated 07/16/2023, showed, Continue nutritional POC [plan of care] same for now. Will see if it is possible to order in TwoCal HN formula to try. Progress note, dated 07/20/2023, showed, Still looking at product availability for ordering in another formula option of TwoCal HN. For now continue with nutritional POC same. Record review of the EHR, dated 07/27/2023, did not show changes had been made to Resident 53's tube feeding, did not show any notes to the physician or dietician regarding Resident 53's weight loss, and did not show notes the resident had been placed on alert for the weight loss. On 07/27/2023 at 9:26 AM, Staff J, Certified Nursing Assistant, said if a resident was losing weight, they would document it and notify the nurse. On 07/28/2023 at 9:26 AM, Staff F, Resident Care Manager and Licensed Practical Nurse (LPN), said if a resident was losing weight they would notify the dietician, place the resident on alert, check their supplements and diet records and perform a resident assessment. At 10:08 AM, Staff T, LPN, said if they were alerted a resident was losing weight, they would re-weigh the resident, alert the dietician, notify the provider and start supplementing. At 11:40 AM, Staff B, Director of Nursing Services and Registered Nurse, said if a resident was losing weight they were referred to the dietician, the physician was notified, the residents family was updated and the resident was provided supplements. Staff B said with Resident 53 having lost 6.67% of his body weight in less than 30 days, the dietician should have made changes to increase his tube feeding or change his formula. Reference WAC 388-97-1060 (3)(h)

Based on observation, interview and record review, the facility failed to prevent pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development and promote wound healing by implementing and following care interventions for two of four sampled residents (4 & 6) reviewed for pressure wounds. This failure placed residents at risk for wound complications, infection, delayed healing, increased pain, and a decreased quality of life. This caused harm to Resident 6 when a low air loss mattress was physician ordered and not implemented, and the resident developed two Stage 3 pressure injuries. Findings included . 1) Resident 6 was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis affecting one side of the body). The admission MDS, dated [DATE], documented the resident was cognitively intact, had mild depression, required extensive assistance from 2 staff member for bed mobility transfers and bathing, and one-person extensive assistance for dressing, eating and personal hygiene. The MDS documented Resident 6 was at risk for development of pressure injury; and required pressure relieving devices for bed and wheelchair, and nutritional and hydration interventions to manage skin problems. Resident 6's care plan focus for has/potential pressure ulcer of bony prominences, initiated 08/20/2022, documented the resident's goal to have intact skin, remain free of redness, blisters or discoloration. The care plan included the focus, initiated 09/27/2022, for an air mattress with bolsters with the goal for resident to remain free of skin breakdown. A wound care provider note, dated 08/24/2022, documented: Wound 1: bilateral buttock had old scar tissue areas with moisture associated skin damage. Tissue type was 100% superficial. There was no documented size. A physician's order, dated, 08/24/2022, documented clean bilateral buttocks and right inner thigh with NA (normal saline) and apply EPC/barrier cream daily at bedtime. Resident 6's September 2022 MAR documented 7 omissions for wound care, indicating wound care was not provided. A wound care provider note, dated 09/21/2022, documented Wound 1: moisture associated skin disease, tissue type was 10% superficial and 90% epithelialized (wound covered). There was no documented size. A physician's order, dated 09/27/2022, documented LALM (Low air loss mattress) with bolster to bed for pressure relief. A physician's order, dated 09/28/2022, documented clean bilateral buttocks and right inner thigh with NS and apply EPC/barrier cream, apply bordered dressing every shift and when soiled. Resident 6's October 2022 MAR documented 3 omissions for wound care, indicating wound care was not provided. A wound care provider note, dated 10/19/2022, documented Wound 1: left sacral coccyx Stage 3, size was 2.0 x 1.1 x 0.3cm, tissue type was 30% granulation and 40% superficial and 30% epithelialized. Wound 2: right sacral coccyx Stage 3, was 0.5 x 1.1 x 0.2cm and tissue was 40% granulation, 30% superficial and 30% epithelialized. A wound care provider note, dated 11/02/2022, documented Wound 1: left sacral coccyx Stage 3 size was 5.7 x 2.4 x 0.1cm. Tissue type was 50% superficial, 30% epithelialized and 20% scab. Wound 2: right sacral coccyx was Stage 3 was 4.2 x 2.5 x 0.1cm, tissue type was 50% superficial, 30% epithelialized, and 20% scab. A wound care provider note, dated 11/16/2022, documented Wound 1: left sacral coccyx Stage 3 measured 5.2 x 0.7 x 0.2cm, tissue type was 30% granulation and 70% superficial. Wound 2: right sacral coccyx Stage 3 measured 4.5 x 1.1 x 0.2cm with 30% granulation and 70% superficial. A physician's order, dated 11/17/2022, documented to clean bilateral buttocks and right inner thigh with NS and apply EPC/Barrier Cream every shift and when soiled. Apply bordered dressing. Apply Medi honey to granulation tissue. A physician's order, dated 11/27/2022, documented Doxycycline 100mg by mouth every 12 hours for open area on buttocks related to bacterial infection for 10 days, no brief, open to air, side to side positioning per resident tolerance. Resident 6's November 2022 MAR documented 7 wound care omissions, indicating wound care was not provided. On 12/05/2022 at 11:10 AM, Resident 6 was observed resting in bed with a foam mattress in place and the head of bed elevated. An air mattress was not in place. Resident 6 said she had a wound on her bottom. The resident said staff changed the dressing about once a day, and said she had never had an air mattress. At 1:31 PM, Staff B said Resident 6 had a fixed leg position due to hip abduction and it made it difficult to reposition her, as the resident could not really be positioned side to side. Staff B said she felt implementing the LALM would have been helpful, and felt it was just lack of communication and follow though that it was not in place. At 2:26 PM, Staff I said she had not seen Resident 6 for a few weeks due to the facility not having enough available staff to assist with rounds. Staff I said she was not aware if the resident was supposed to be on an air mattress, but did recall the resident had impaired mobility in her hips. Staff I said she would have to review the notes, which were not available, to be able to answer anything else. On 12/06/2022 at 10:10 AM, Resident 6 was observed resting in bed laying on her back,with the head of the bed elevated. A LALM was not in place. At 10:45 AM, Resident 6's wound area was observed during a dressing change. The sacral/coccyx wound area was oval in shape measuring approximately 10cm and appeared reddened with scattered dark crusted areas. At 1:17 PM, Staff H said the wound nurse followed the residents with wounds weekly, and they utilized repositioning, pillows, air mattresses, and foam dressings to prevent pressure wounds from developing. Staff H said with Resident 6's wound, staff had been diligent about getting cream on her bottom and making sure the NAs assisted with repositioning. Staff H said she did not know why the resident did not have an air mattress, stating, Somehow that one went through the cracks. On 12/07/2022 at 11:48 AM, Resident 6 was observed in bed laying on their back. A LALM was not in place. At 12:25 PM, Staff B said the air mattress had been ordered for Resident 6. 2) Resident 4 was admitted to the facility on [DATE] with diagnoses including paralytic syndrome (loss or impairment of the ability to move a body part or parts, inability to move or function). The admission Minimum Data Set (MDS), an assessment tool, dated 08/19/2022, documented the resident had severe cognitive impairment, moderate depression, and required extensive assistance of two staff members for bed mobility, transfers, dressing, toileting, bathing, hygiene and eating. The MDS documented the resident was at risk for pressure injury, did not have a pressure injury upon admission to the facility and had moisture associated skin damage. A wound care provider note, dated 08/17/2022, documented the resident had identified as Wound 1: matted hair and flaking scalp, no measurements were included. Wound 2: moisture associated skin disease Peri area and sacral coccyx described as superficial erythema (reddening of the skin), maceration (skin exposed to moisture for a prolonged period of time) and discolored, no documented size. Wound 3: coccyx with moisture associated skin damage with measurements of 3.8 centimeters (cm) x 3.2cm x 0.2cm, the wound tissue was described as 80% granulation (pink tissue growing over the wound), 20% superficial (on the surface wound caused by friction). A wound care order, dated 08/17/2022, documented back of head to clean with dandruff shampoo and pat dry every shift until resolved. A wound care order, dated 08/17/2022, documented to cleanse coccyx with wound cleanser and apply honey, and cover with bordered dressing daily in the morning. A wound care provider note, dated 08/24/2022, documented Wound 1: posterior flaking scalp. No measurements were included. Wound 2: moisture associated skin disease to peri area and sacral coccyx. Tissue described as 20% granulation and 80% superficial. No documented size. Wound 3: coccyx with moisture associated skin disease, measurements were 3.6cm x 3.2cm x 0.2cm. Wound bed was described as 20% granulation, 20% slough (dead tissue) and 60% superficial. A wound care order, dated 08/24/2022, documented posterior scalp to be cleansed with dandruff shampoo and pat dry every Tuesday, Friday, and Sunday. A wound care order, dated 08/24/2022, documented to cleanse bilateral buttocks/peri area/coccyx with wound cleanser, pat dry, apply thin layer of Medi honey and cover with bordered dressing daily and as needed for soilage or missing. A wound care order, dated 08/31/2022, documented to cleanse bilateral buttocks/peri-area/coccyx site with wound cleanser, pat dry and apply EPC (Extra Protective Cream) and antifungal cream. Change daily and as needed for soilage or missing A daily skilled progress note, dated 09/05/2022 at 11:50 AM, documented, Sacral wound presenting as worsened from what this nurse observed last Friday. There are more/larger open areas, copious drainage, and a distinct odor. Discussed with Wound RCM [Resident Care Manager] as current ordered treatment obviously in need of a change. Wound RCM was not able to assess wound at that moment. Discussed with provider who ordered a wound culture. Order in for the morning when transportation to lab of said culture will be possible. Resident is already on Doxycycline [an antibiotic] BID [twice daily]. Treatment changed from EPC/Antifungal cream to medi honey followed by a foam dressing for both protection and the drainage. A wound care order, dated 09/05/2022, documented to cleanse bilateral buttocks/peri area/coccyx site with wound cleanser and apply Medi-honey and cover with large, bordered foam dressing. Change daily and as needed for soilage or if it came off. A physician's order, dated 09/05/2022, documented clean wound thoroughly before obtaining a wound culture of sacral wound. A physician's order, dated 09/10/2022, documented Ampicillin (broad-spectrum penicillin) 500 milligram (mg) give one capsule by mouth four times daily for wound infection. A wound culture report, dated 09/10/2022, documented growth of enterococcus faecalis (a bacteria commonly found in feces) and methicillin resistant staphylococcus aureus (MRSA) (a highly resistant bacteria which requires contact precautions) A physician's order, dated 09/11/2022, documented doxycycline (antibiotic) 100 mg by mouth two times daily for 10 days for MRSA infection. A wound care provider note, dated 09/14/2022, documented Wound 1: posterior scalp matted hair, flaking scalp. Wound 2: moisture associated skin disease to peri area and sacral coccyx, tissue described as 100% superficial with erythema. No documented size. Wound 3: coccyx moisture associated skin disease sloughing area measuring 3.0 x 2.0 x 0.2cm and wound bed described as 30% granulation, 40% slough, and 30% superficial. A wound care provider note, dated 09/21/2022, documented Wound 1: posterior scalp matted hair and flaking scalp measurements were 11.0 cm x 6.0 cm x 0.2cm, wound bed described as 60% granulation, 20% slough, and 20% superficial. Wound 2: moisture associated skin disease peri area and sacral coccyx tissue type was 100% superficial, no documented size. Wound 3: coccyx moisture associated skin disease 2.5cm x 2.1cm x 0.2cm, wound bed is described as 70% granulation and 30% superficial. A wound order, dated 09/21/2022, documented posterior scalp, cleanse with dandruff shampoo apply solosite wound gel (wound dressing with preservatives) and cover with bordered dressing once daily on Tuesday, Friday, and Sunday. A wound care provider note, dated 10/05/2022, documented Wound 1: posterior scalp measures 11.0 x 9.0 x 0.3 with 60% granulation, 30% slough and 10% superficial. Wound 2: coccyx moisture associated skin disease area measurements were 4.5 x 6.8 x UTD (unable to determine), wound bed described as 20% granulation, 50% slough, 30% superficial. Wound 3: No longer documented. A wound care order, dated 10/05/2021, documented cleanse posterior scalp with dandruff shampoo, apply solosite wound gel and cover with bordered dressing once daily. A wound care provider note, dated 10/12/2022, documented Wound 1: posterior scalp measured 5.4 x 9.4 x 0.3cm with 80% granulation and 20% superficial. Wound 2: reclassified as Stage 4 of the coccyx with measurements of 5.4 x 5.3 x 0.3cm, wound bed described as 20% granulation, 10% slough, 20% superficial and 50% tendon (holds muscle and bone together). A wound care order, dated 10/19/2021, documented to clean posterior scalp with dandruff shampoo and apply Medi honey and cover with bordered foam dressing in the morning. A wound provider note, dated 11/02/2022, documented Wound 1: posterior scalp measures 6.8 x 10.5 x 0.2cm, tissue type is 50% granulation and 50% superficial. Wound 2: coccyx Stage 4 pressure wound 7.2 x 3.5 x UTD with undermining at 4 o'clock to 5 o'clock to a depth of 1.4cm, tissue type was 20% granulation, 40% slough, 10% superficial and 30% tendon. Review of Resident 4's October 2022 Medication Administration Record (MAR) documented 7 omissions for coccyx wound care and 6 omissions for posterior scalp wound care, indicating wound care was not provided. Review of Resident 4's November 2022 MAR documented 4 omissions for coccyx wound care and 4 omissions for posterior scalp care between 11/1/2022 and 11/14/2022, indicating wound care was not provided. The medical record showed Resident 4 was admitted to the hospital on 11/14/2022 and required intravenous antibiotics for the treatment of the coccyx wound. A hospital provider note, dated 11/14/2022 at 2:45 AM, documented, a large wound to back of scalp, and sacral decub [decubitus pressure] bilateral worse on right . soiled with feces on initial inspection. On 11/18/2022 at 2:58 PM, Resident 4's Family Member (FM) 2 said they would visit the resident often and had concerns the wounds were not healing as they should. FM 2 said they felt staff were not assisting the resident to reposition frequently enough, and dressings were not changed as they should be. A hospital provider note, dated 11/20/2022 at 11:50 AM, documented Resident 4's Pressure sores are evidence of not being turned appropriately . the sacral wound culture grew MRSA and Proteus (a bacteria usually found in the intestinal tract) and a large palm sized wound on the posterior scalp. On 11/23/2022 at 11:45 AM, Staff E, Registered Nurse (RN), said when staff would reposition Resident 4, he would wiggle back to being on his back. Staff E said the coccyx wound was improving, but the wound on the scalp was more challenging. Staff E said Resident 4 did not refuse wound care; and if there were omissions on the wound treatment, it was more likely due to it just not being documented. On 11/23/2022 at 3:25 PM, Resident 4's FM 1 said there would be days that staff did not change the resident's dressings. FM 1 said they did not feel Resident 4 received the care he should have. FM 1 said Resident 4 was readmitted to the hospital and his wounds were infected. FM 1 said the wounds had previously been treated at the facility, but did not think the infection had resolved. On 11/28/2022 at 5:05 PM, Resident 4 said there were several occasions where he went 3 days without the dressings being changed . Staff would say they would come back and change it, but they never did. Resident 4 said they did wound rounds every Wednesday and they were always in a hurry. Resident 4 said he would be repositioned a couple of times each night, but there were occasions he was not repositioned at night. Resident 4 said the wound impacted his ability to be up in a wheelchair for extended periods of time and his ability to participate in therapy. On 12/05/2022 at 1:31 PM, Staff B, RN and Director of Nursing Services, said they had many interventions in place for pressure prevention including repositioning every 2 hours and not letting residents remain in soiled briefs for extended periods of time. Staff B said if a wound care was ordered daily, she would expect it to be done; and if it was not documented, then it wasn't done. Staff I, Wound Care Provider and Advanced Registered Nurse Practitioner, said if wound care was not performed 7 times in a month, it could have a negative impact on wound healing. At 2:26 PM, Staff I said she does rounds at the facility weekly, and Resident 4 had a wound on the coccyx and the back of the head. Staff I said the wounds initially got better, and then they worsened. Staff I said she did debridement when necessary, and said they were treated with antifungals and antibiotics. Staff I said the scalp area was originally crusty and then became an open granulating wound. Staff I said the wounds looked better the last time she saw them. Staff I said if the dressings were not changed for multiple days, it was possible to have a negative impact on healing. Staff I said she did not suspect staff were not repositioning appropriately, but she would not know because she only saw the resident for 15-20 minutes weekly. On 12/06/2022 at 11:30 AM, Staff F, Nursing Assistant (NA), said Resident 4 could not reposition himself and he needed to be assisted. At 1:17 PM, Staff H, RN and Resident Care Manager, said Resident 4's wounds were getting better and they were seen by the wound care provider weekly. Staff H said Resident 4 was non complaint with repositioning and staff did reposition him frequently. Reference WAC 388-97-1060 (3)(b)

Based on interview, observation and record review, the facility failed to ensure staff provided safe resident transfers using a hoyer (mechanical lift used to transfer residents) and were educated on hoyer use, and failed to implement fall risk interventions for four of five sampled residents (53, 3, 55 & 19) reviewed for accident hazards. This failure placed residents at risk for injury, falls and death. An Immediate Jeopardy was called on 05/03/2022 when the facility failed to ensure the safe use of mechanical lifts and slings when transferring three residents and failed to ensure facility staff had the competencies, skills and training needed for safe operation of Hoyer lifts and slings. The facility removed the immediacy on 05/05/2022 by training nurses and nursing assistants prior on proper use of the hoyer lift including sling placement, sling selection to support residents' head, resident positioning during transfer, stabilizing and locking the mechanical lift and/or wheelchair during transfers. Findings included . <Hoyer Lift Use> Review of Invacare Reliant 450 and 600 mechanical lift manual, undated, showed staff performing a transfer should be trained to perform the entire lift procedure several times with proper supervision. A resident's head should be supported by the sling and/or assistant. The lift legs should be always in the maximum open position, unless closing the legs to maneuver under a bed, then moved back into the maximum open position. Wheelchair brakes must be locked before lowering a resident into a wheelchair. Wheelchair brakes must be engaged to prevent movement of the chair. Divided leg slings should be removed once the resident is transferred into the wheelchair. 1) Resident 53 was admitted to the facility on [DATE] with diagnoses including a stroke with left side weakness, difficulty swallowing, and difficulty with verbal expression and communication. The quarterly Minimum Data Set, an assessment tool, dated 01/07/2022, showed the resident had moderate cognitive impairment and was able to make needs known. The care plan, dated 07/22/2021, showed Resident 53 required the use of a hoyer for transfers. On 05/03/2022 at 9:21 AM, Staff J, Certified Nursing Assistant (CNA), and Staff H, Registered Nurse (RN), were observed going to Resident 53 to transfer him from his wheelchair into his bed using a hoyer lift. The staff were not familiar with the type of sling under Resident 53, which was a divided leg sling. Staff J and Staff H made multiple attempts to adjust the sling under the resident although it was appropriately placed. At 9:28 AM, Staff J was observed returning to the resident's room with Staff K, CNA, who identified the cross-leg sling, and was able to pull the straps through Resident 53's legs as he was positioned. Staff K showed Staff J how to attach the straps to the hoyer lift multiple times as staff kept attaching the straps incorrectly. Resident 53 was lifted and lowered into the bed without the hoyer brakes locked. Staff J said she had a lot of residents who required hoyer transfers in her section. On 05/06/2022 at 1:22 PM, Staff T, CNA, was observed leaving a room with a Hoyer lift. Staff T said the hoyer lift was used on Resident 53. There were no other staff members observed in the room to assist with the transfer. Staff T said Staff M, Nursing Assistant Registered in training, was the second person but was unsure if she was allowed. Staff T said she did hoyer lift transfers by herself quite often because she could not find anyone to help. 2) Resident 3 was admitted on [DATE], had a moderate cognitive impairment and was able to make needs known. On 05/03/2022 at 1:59 PM, Staff N, CNA, and Staff K were observed assisting Resident 3 into her wheelchair with the use of a hoyer lift. The lift brakes were unlocked while under the bed during the process of hooking up the sling. Staff K moved the lift to adjust positioning while lifting up the resident. While the lift was lifting the resident, Staff K locked the brakes. Staff N positioned the wheelchair in front of the lift while the lift brakes remained unlocked. The back arm of the lift was positioned against another bed. The position of the lift locks, slightly under the bed, made it difficult to engage. Staff N did not make attempts to adjust the location of the lift or lock the brakes. Staff K was standing behind the wheelchair with his feet wedged behind each wheel. Staff K adjusted the resident as she was lowered into the wheelchair. During the lowering, Staff K reached down to ensure the right wheelchair brake was off. The wheelchair and the lift moved during the lower as Resident 3 was placed into her wheelchair. When asked if he locked the brakes, Staff K stated, Yeah, I keep my feet here so I can adjust. Staff K demonstrated how he wedged his feet behind the wheelchair wheels and said this was helpful to adjust the resident while being lowered into position. 3) Resident 55 was admitted on [DATE] and was alert and oriented. On 05/03/2022 at 2:14 PM, Staff S, CNA, and Staff Q, NAR, were using a hoyer lift to transfer Resident 55. While lifting the resident out of bed, the base legs of the Hoyer lift, were not spread out for stability. As Staff S and Staff Q began to lift the resident up, the resident's head was unsupported and was in an awkward position. On 05/03/2022 at 1:40 PM, Staff L, CNA, said her hoyer training was the [AGE] years of experience she had. Staff L said she completed a check-off list [AGE] years ago but had not completed any annual or on-line training. Staff M said she was a new hire and had been at the facility for about one week and did not work independently. Staff M said she did not have any formal hoyer training, no new hire training, and had only been shown by staff how to complete hoyer transfers. When asked what safety instructions Staff L had taught Staff M, Staff L said to always lock it and keep the legs wide when moving. On 05/03/2022 at 2:20 PM, Staff S, CNA, said she had worked here since September and been a CNA since January. Staff S said she felt like she did not get adequate hoyer training. Staff S said she had an average of three Hoyer lift residents on her load per shift. Staff S said it depended on who was working if it was difficult to find a second person to assist. Staff S said she never had a nurse help her with a hoyer lift transfer so she did not know if they know how to use a Hoyer lift. At 3:48 PM, Staff S said she did not know what kind of sling to use, and said she did not know there were different slings for different weight limits. On 05/04/2022 at 5:33 AM, Staff R, CNA, said she had trouble finding people to help with Hoyer lift transfers. Staff R said today we only had three aides on the floor right now and she had 30 residents to take care of. Staff R said if you would have been here on Sunday night you would have seen we had two aides for the entire building. Staff R said because she could not find help when she needed it, there had been several times when she had transferred a resident by herself. Staff R said it was not safe for the residents. At 5:44 AM, Staff O, LPN, said the care aids worked very hard. They just do not have enough help. There were times when there were only two aids for the entire building. Staff O said they must do Hoyer lift transfers by themselves. Staff O said it was not safe for the residents at all. At 8:02 AM, Staff N said wheelchair brakes should be locked before lowering a resident into a wheelchair. Staff N said her hoyer training was from her Certified Nursing Assistant (CNA) class. Staff N said slings were chosen based on the size of the resident, based on the amount of extra fabric around them. Staff N said if a resident required total care or could not move, they required a full body sling. Staff N said leg slings were not really used in the facility. They were for toileting and should only be used on residents that were smaller and had strong legs. Staff N said she knew which sling to choose because it was on the care plan. Staff N said physical therapy made the decision on what transfer and sling to use. On 05/05/2022 at 10:25 AM, Staff P, LPN and RCM, said she was not aware the aides were doing hoyer transfers by themselves. Staff P said her expectation was they follow the policy and use two certified staff members when doing a Hoyer lift transfer. At 11:07 AM, Staff B, Director of Nursing Services, said staff were trained by experienced CNAs for two days and then they were checked off to make sure they were doing the transfers correctly. The check off included a return demonstration. Staff B said if they needed help, they were to ask another aide, ask a nurse, or wait for someone to be available so they could do a safe transfer. Staff B said her expectation was that staff always did what was safe for the residents and followed policy. Staff B said if they were doing Hoyer lifts and transfers without another certified/licensed staff in the room, they should not have been doing it. <Fall Interventions> Resident 19 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], documented the resident was cognitively intact. Resident 19's fall risk care plan, initiated 12/14/2021 and revised on 03/02/2022, documented the intervention to ensure mat appropriately placed next to bed when resident [was] in bed. On 05/02/2022 at 1:00 PM, Resident 19 was observed in his room in bed. A fall mat was in the room, leaning on the wall across from the bed. It was not in position near the bed to prevent injury in the event of a fall. At 2:57 PM, Resident 19 was observed in his bed. The fall mat was observed across the room from the resident's bed, leaning on the wall. At 3:06 PM, Staff U, Certified Nursing Assistant (CNA), said Resident 19 was a fall risk. Staff U said Resident 19's fall risk interventions included the bed in low position, making sure the resident was comfortable, and a fall mat near his bed. On 05/03/2022, Staff B said a fall mat should be in Resident 19's fall risk interventions. When asked about the observations of the fall mat not in place, Staff B stated, That's not good. He should have a fall mat [in place]. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure pain medications were provided to adequately control pain for one of one sample resident (31) reviewed for pain management. This failure placed residents at risk for uncontrolled pain and a diminished quality of life. This caused harm to Resident 31 when she did not receive pain medication prior to movement. Findings included . Review of facility policy entitled Pain Management Program, undated, showed staff should notify the provider if pain management goals were not met. Staff should re-evaluate with a significant change in condition. Non-verbal expressions of pain included: yelling, moaning, grimacing, refusal to eat and resistive to care. Resident 31 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of electronic health records showed Resident 31 was sent to the hospital on 02/10/2022 for uncontrolled pain where she was diagnosed with a pelvic fracture. The care plan, dated 03/09/2022, showed Resident 31 would be free from non-verbal indicators of pain and staff were to administer pain medication as ordered. Anticipate need for pain relief and respond to any complaint of pain. Identify precipitating factors which may increase pain and or discomfort. Monitor/record/report to Nurse resident complaints of pain or requests for pain treatment. Notify Physician if interventions are unsuccessful or if current complaint was a significant change from resident's past experience of pain. Non-verbal indicators of pain were included. A pain assessment, dated 03/10/2022, showed Resident 31 was not able to be interviewed about her pain. On 05/02/2022 at 7:56 AM, Resident 31 said she was in pain, and that it was worse. Resident 31 was unable to provide additional information. Resident 31 was observed grimacing and whimpering. At 8:08 AM, Resident 31 could be heard moaning from the hallway. On 05/04/2022 at 9:07 AM, Resident 31 was observed moaning when the head of her bed was raised. At 9:31 AM, Resident 31 was observed to moan when the head of her bed was lowered. Staff K, Nursing Assistant (NA), lowered the bed in increments. Staff K said he did not like to move her because she was in so much pain. Staff K said pain was not a problem prior to comfort care. Resident 31 was observed to yell in pain when touched. Staff Y, Registered Nurse, entered the room at the request of Staff K, and left without providing pain relief or assessing Resident 31. Staff K said when Resident 31 yelled out like this, they would not get a response from nurses to get pain medication. Staff K said Resident 31 was not medicated prior to care being provided. Staff K said, She's in pain. The May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . No other as needed pain medications were given that morning. On 05/04/2022 at 11:06 AM, Staff B, Director of Nursing Services, was observed preparing to do a wound dressing change and said Resident 31 needed to be pre-medicated. At 11:39 AM, Resident 31 was observed moaning, grimacing and reaching out to staff with care and being moved. Staff B said Resident 31 was moaning in pain with care. Staff B said that was why they pre-medicated her. Resident 31 continued to moan with movement throughout the process. Staff B said she would expect a nurse to call the provider to increase the pain medication order. Staff B said she would expect the nurse to medicate for pain. On 05/05/2022 at 8:04 AM, Staff Y said when she was told about pain from care aides, she would assess the resident, call to get medication, and call the family. Staff Y said pain went first above other responsibilities. Review of physician note, dated 05/05/2022, showed the provider was notified by nursing staff that Resident 31's pain was out of control. Resident 31 was screaming uncontrollably with dressing change. Additional pain medication was ordered. Refer F686 Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to prevent pressure ulcer (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) development and promote wound healing by implementing and following care plans interventions for two of six sampled residents (31 & 53) reviewed for pressure wounds. This failure placed residents at risk for the development and worsening of pressure injuries and a diminished quality of care. This caused harm to Resident 31 when care the wound progressed from a Stage 2 to a Stage 3 and dressing changes were not completed when the dressing was soiled. Findings included . Review of facility policy titled, Pressure Injury Policy, undated, showed all residents would be assessed on admission and weekly for 4 weeks, quarterly, and with significant change in condition. Interventions included: manage moisture, manage nutrition, manage pressure: off load heels, use turning/repositioning. 1) Resident 31 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 31's pressure ulcer care plan, dated 02/08/2022, documented a stage 2 [the sore area of skin has broken through the top layer of skin and some of the layer below] pressure wound was present to [Resident 31's] buttock/coccyx [tailbone]. The facility implemented an air mattress and a goal the pressure wound would show signs of healing and remain free from infection. The intervention turn side to side except when eating was added on 02/18/2022. A change in condition MDS, dated [DATE], showed Resident 31 had one stage 2 pressure wound requiring a pressure reducing device for her bed and chair, and pressure wound care. Resident 31 was assessed to not need a turning/repositioning program. Resident 31's electronic health records showed Resident 31 was transferred to the hospital for pain management on 02/10/2022 and returned to the facility on [DATE]. Resident 31's admission skin assessment, dated 02/16/2022, showed there was a pressure wound when Resident 31 returned from the hospital. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound clinic note, dated 03/18/2022, showed Resident 31 was diagnosed with a new right heel wound. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A wound clinic note, dated 04/07/2022, showed Resident 31's pressure ulcer on her buttocks/coccyx was assessed as a Stage 3 pressure ulcer (broken completely through the top two layers of the skin and into the fatty tissue below). A wound clinic note, dated 04/20/2022, showed Resident 31's pressure ulcer on her buttocks/coccyx was assessed as an unstageable ulcer (full thickness tissue loss in which the base of the ulcer is covered by a thick black scab). The note documented mild odor under wound description. On 05/04/2022 at 5:18 AM to 9:31 AM, Resident 31 was observed to remain in the same position, unmoved. A strong, foul odor, coming from Resident 31's room, could be smelt in the hallway. At 9:31 AM, Staff K, Certified Nursing Assistant (CNA), said Resident 31 had a pressure wound with a dressing on her bottom and stated, It's really bad. Resident 31's legs were observed on a thin pillow which allowed her heels to press into the mattress. Staff K identified Resident 31 needed an incontinence change due to a bowel movement and said he would get the nurse for a wound dressing change. At 9:39 AM, Staff K said the nurse was too busy to come check the wound. When asked what he would do if the dressing was soiled, Staff K said he would get the nurse to immediately change it. Staff K said he was going to change Resident 31 without the dressing change by the nurse. Resident 31's right heel was observed with the skin lifted around the edges of a pressure wound measuring 2 centimeters. No dressings were observed on the heels. Staff K said the open skin on Resident 31's right heel was new to him and he would tell the nurse of the new skin finding. Resident 31's dressing on the coccyx was observed to be saturated with dark material, was undated, had a strong odor, and had the bottom side of dressing uplifted. Staff K stated, It smells so bad. Staff K asked Staff X, CNA, to get the nurse. Staff Y, Registered Nurse (RN), came in and said she was too busy and scheduled the dressing change for later in the day. Staff Y left without assessing the wound. Staff K completed care and left Resident 31 with the soiled sacral wound dressing. At 11:39 AM, Staff T, CNA, said Resident 31 was supposed to be turned every two hours and have her heels floated because of the ulcers. Staff T said Resident 31 had some breakdown on her heels about two weeks ago. At 11:40 AM, Staff B, Director of Nursing Services and RN, was observed during wound care. Staff B removed a soiled dressing on the resident's coccyx and pulled out packing (gauze inserted into a wound) from a golf ball size hole in the center of the wound. The entire wound was black with the surrounding tissue red. There was a dark purple area the size of a golf ball on the right upper side of the wound. There was a strong odor. Staff B said she knew the treatments were effective because the wound would get smaller. This was her expectation. Staff B said Staff F, Assistant Director of Nursing Services, monitored and tracked wounds for the facility. Staff B said there was no dressing on the right heel wound. Staff B did not place a dressing on the right heel wound. Staff B said she expected nurses to change a soiled dressing as soon as possible. On 05/05/2022 at 8:00 AM, Staff Y said if an aide came to her with concerns of a soiled dressing, she would do the dressing change immediately or as soon as possible. Staff Y said the nurses were responsible to ensure the care plan and pressure ulcer interventions were done. Staff Y said Staff F was responsible for wound care and infection control. On 05/07/22 at 10:04 AM, Staff F said she worked with an out of state, tele-health wound provider to create wound treatment interventions. Staff F said the off-loading and repositioning aids were the air mattress and pillows to off load heels and the body. Resident 31 did not have heel protectors or other specific aids. Staff F said if there was a soiled dressing, non-intact dressing, or missing dressing, she expected the nurse to change or replace the dressing immediately. 2) Resident 53 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly MDS, dated [DATE], showed Resident 53 was moderately cognitively impaired and able to answer yes/no questions. Resident 53's care plan, dated 04/20/2022, showed Resident 53 required two-person assistance for bed mobility, used a hoyer for transfers, and staff assistance for basic hygiene care. Resident 53's pressure ulcer care plan, dated 07/22/2021, documented interventions to frequent repositioning, Monitor/document/report to MD PRN [physician as needed] change in skin status . Notify Nurse immediately of any new areas of skin breakdown. On 05/01/2022 at 3:03 PM, Resident 53 was observed to be slouched in bed on his back. Resident 53 indicated he had pain in his bottom and pointed to his buttocks. On 05/03/2022 at 8:01 AM, Resident 53 was observed up in a tilt-in-space wheelchair. Resident 53 indicated he was in pain and pointed to his buttocks. When asked if staff were not changing his brief enough, Resident 53 nodded yes. The resident indicated staff did not move him side to side when he was in the wheelchair. At 8:24 AM, Staff H, RN, was observed going into Resident 53's room where the resident indicated he wanted to lay down. Staff H said he had to wait 10-15 minutes for an aide to be free, then they would put cream on his bottom for the pain. Staff H said Resident 53 had a rash from being wet. At 9:06 AM, Resident 53 was observed in his wheelchair in the same position. At 9:28 AM, Resident 53 was observed being assisted to bed. At 9:48 AM, Staff H was observed rolling Resident 53 to his side to apply the cream to his buttocks. Staff H stated, That's why it hurts. Staff H indicated there were three new open areas on Resident 53's coccyx. Staff H estimated the open areas to be approximately one to one and a half centimeters in length. Staff H said she was estimating the size because she did not have anything to measure the wounds with. Staff H said she would ask another staff member to look at the wounds and recommend a dressing. The gluteal cleft (groove between the buttocks) appeared open, approximately two to three centimeters long. Resident 53's medical record did not show documentation Resident 53's physician or the facility wound nurse were notified of the new skin finding on 05/03/2022. On 05/04/2022 at 5:45 AM, 9:25 AM, 11:35 AM, and 12:28 PM, Resident 53 was observed laying on his back in the same position. On 05/05/2022 at 7:44 AM, Resident 53 was observed laying on his back. At 8:02 AM, Staff AA, RN, said if a nurse was notified of a new skin wound, they should do an assessment of the wound, try to prevent it, call the doctor, and start the doctor orders. Staff AA said a nurse should call the family and notify the wound nurse. Staff AA said the wound nurse was usually there, but he could call. Staff AA said staff should reposition Resident 53 every two hours. At 3:10 PM, Resident 53 indicated staff did not turn him and did not put pillows under his bottom. Resident 53 was observed laying on his back. On 05/06/2022 at 8:15 AM, Resident 53 was observed laying on his back. At 9:41 AM, Staff T, CNA, said she was not aware of any open areas on Resident 53's skin. Staff T said Resident 53 had not been changed yet today. Staff T said the facility had not implemented a turning program. At 10:25 AM, Staff P, Residential Care Manager and Licensed Practical Nurse, said it was everyone's responsibility to implement the care plan. Staff P said if there was a new skin wound, there would be an incident report. Staff P said they would update the care plan to actual, not potential skin issues, then add the new issue. Then the wound nurse would do an assessment. If the wound nurse had new interventions, they would update the care plan. Staff P said the updates should be completed immediately. Staff P said if the wound nurse was not available; the nurses needed to do something immediately, like initiate basic skin care. On 05/07/2022 at 9:42 AM, Staff F said she expected nurses to immediately notify her of a new skin issue, then she would go right away to assess the skin issue. Staff F said she had her cell phone number posted for the staff. Staff F said she did not get any notifications this last week while she was gone. Staff F said the Resident Care Managers and Director of Nursing Services were responsible for skin issues when she was gone. Staff F said for residents with a history of skin wounds, the following interventions should be in place: educate staff, use skin prep or barrier cream, repositioning program, and reposition every two hours if not more frequently. At 11:10 AM, Staff F said staff should have notified me and took pictures of the new skin issues. Staff F said Resident 53 should have had a skin assessment completed. Staff F said Resident 53 was supposed to be turned/repositioned no matter what, even if they were on an air mattress. Staff F said Resident 53 should have been placed on a turning schedule and assessed by the nurses. Staff F said an incident report should have been done. Staff F said the nurses, not aides, should be applying the cream because the nurses needed to be putting eyes on the skin, and the aids cannot assess. Staff F was observed turning Resident 53 and said she observed a new pressure wound and it was quite red. Staff F said it was a stage 2 pressure wound and could have developed in hours. Staff F identified two of the three previously viewed skin wounds as a stage 1 and the other wound as a stage 2 pressure ulcer. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutrition when the facility failed to consistently monitor residents' weights, provide adequate assistance and/or set up with meal service and implement new interventions in a timely manner for one of six sampled residents (31) reviewed for nutrition. This failure placed residents at risk of weight loss, nutritional complications, and a diminished quality of life. This caused harm to Resident 31 when she experienced a severe weight loss of 24.79% in just over five months. Findings included . Resident 31 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The MDS did not identify a weight loss for this resident and no nutritional issues were noted including swallowing. Resident 31's weights record showed the following: On 10/30/2021, the resident weighed 238 pounds (lbs). On 12/09/2021, the resident weighed 210 lbs. On 03/30/2022, the resident weighed 191.6 lbs. On 04/08/2022, the resident weighed 179 lbs. The weight record showed a 24.79% weight loss from 10/30/2021 to 04/08/2022, five months and nine days. Provider order, dated 01/31/2021, showed Resident 31 was ordered to be weighed once per week to monitor for weight loss and [CONDITION(S)]. The January 2022 Medication Administration Record (MAR) showed Resident 31 was weighed zero of five opportunities. The February 2022 MAR showed Resident 31 was weighed zero of four opportunities. The March 2022 MAR showed Resident 31 was weighed once of five opportunities. The April 2022 MAR showed Resident 31 was weighed once of four opportunities. Weight monitoring summary, dated 01/31/2021 to 04/08/2022, showed Resident 31 was weighed a total of 15 times in 14 months. The summary showed Resident 31's first significant weight loss occurred on 12/09/2021 with an 11.8% weight loss. Nutritional risk assessment, dated 02/03/2022, showed Resident 31's intake was 51-75 percent for all three daily meals. Resident 31 was noted to be experiencing severe pain and refusing some meals. Staff reviewed the plan of care and documented it remained appropriate. Clinical summary note, dated 02/17/2022, showed Resident 31 was diagnosed with anorexia (lack of intake). Nutritional risk assessment, dated 03/07/2022, showed Resident 31's intake was poor for all three daily meals. Resident 31 was receiving Glucerna (nutritional supplement) three times a day and Juven (nutritional supplement) twice a day. The care plan, dated 03/09/2022, showed Resident 31 was able to feed herself and staff were to obtain a monthly weight. A nutritional risk intervention, revised 02/03/2022, showed staff were to monitor and record food intake at each meal. No additional interventions were included for weight loss or malnutrition (inadequate intake). On 05/03/2022 at 10:04 AM, an open Glucerna shake was observed on Resident 31's bedside tray, open with a straw. The May 2022 MAR showed on 05/02/2022, Resident 31 did not receive her evening Glucerna shake. On 05/03/2022, the resident only received her 2:00 PM Glucerna shake. On 05/04/2022, Resident 31 did not receive her morning Glucerna shake. On 05/04/2022 at 8:09 AM, Staff CC, Business Office Manager, was observed delivering a breakfast tray to Resident 31. Staff CC said she could not provide care and the care aides feed the residents. No assistance was provided for set up or meal assistance. Staff CC was not observed notifying a care aide that the resident's breakfast had been delivered. An opened Glucerna shake with a straw was on the bedside table. At 9:07 AM, Staff N, Certified Nursing Assistant, was observed going into Resident 31's room to provide feeding assistance. Staff N told Resident 31 it was time to eat and offered the opened Glucerna shake. Resident 31 moaned once when the head of bed was raised, and was not fully awakened. Staff N quickly ended the attempt without allowing time for the resident to wake up. The total time Staff N provided meal assistance was about one minute. Staff N said Resident 31 had not been responding lately. Staff N returned within a few minutes to remove Resident 31's untouched tray. No further attempts were made to offer nutrition to Resident 31. On 05/07/2022 at 8:54 AM, Staff DD, Licensed Practical Nurse, said prior to becoming non-responsive, Resident 31 required total assistance with meals beginning a month ago. Staff DD said Resident 31 had severe pain in her hip so they sent her to the hospital. In February 2022, when Resident 31 returned, she needed extensive eating assistance. Staff DD said meal intakes, supplements, and weights were documented on the MAR. Staff DD said Resident 31's weights were monthly but went to weekly. Staff DD said due to Resident 31 refusals, the staff did not monitor her weight regularly. Staff DD said a Hoyer lift was the only way to get Resident 31 up. Resident 31 yelled and screamed so staff did not weight her due to pain. Staff DD said the aids were supposed to chart Resident 31's intake every meal. Staff DD said if Resident 31 refused a meal, staff would come back to re-approach and give a supplement. Staff DD said Resident 31 lost weight because of not eating or drinking. The resident kept losing more and more weight. Staff DD said the dietitian said it was expected weight loss, but Staff DD did not agree. Staff DD said Resident 31 could have benefited from a magic cup (high protein, high calorie frozen supplement). Staff DD said the doctors knew about the weight loss; but did not do anything, just continue care. On 05/07/2022 at 9:42 AM, Staff F, Assistant Director of Nursing Services and Registered Nurse, said when there was a significant weight loss staff offered Juven, extra nutrition via supplements, and checked for food preferences. Staff F said staff would sit with Resident 31 and offer high calorie food as much as possible. Staff F said there was no other interventions. Staff F said prior to the recent decline, Resident 31 lost weight because she was struggling with heart issues. Staff F said the meal assistance provided to Resident 31 by Staff N on 05/04/2022 did not meet her expectations and that was not enough time. Staff F said she expected staff to re-attempt every 20 minutes and notify the nurse. Refer F686 Reference WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to ensure pain medications were provided in a timely manner for 1 of 5 sampled residents (#4) reviewed for pain management. This failure placed residents at risk for ongoing pain, medical complications [REDACTED]. This caused harm to Resident #4 when she did not receive pain medication for 24 hours. Findings included . Resident #4 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 11/27/19, documented the resident had moderate cognitive impairment, received hospice care and had almost constant pain. The MDS documented the pain made it hard for the resident to sleep at night and limited the resident's day to day activities. Resident #4's care plan Potential for acute pain related [MEDICAL CONDITION] of the lung, dated 07/18/19, documented, Administer [MEDICATION NAME] (pain interventions) as per orders . Anticipate need for pain relief and respond to any complaint of pain. Resident #4's January 2020 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Resident #4 did not receive another dose until 01/05/20 at 1:02 PM for a pain level of eight out of 10. Resident #4's January 2020 MAR, documentation for other medications were left blank for day shift on 01/05/20, including [MEDICATION NAME] Patch (for pain), [MEDICATION NAME] (for hypertension), and [MEDICATION NAME] (for pain). A progress note, dated 01/05/20 at 9:16 PM, entitled Alert Charting, documented, Resident not medicated for pain for a while, yelling out, crying at times, very unsettled/restless. Stated, 'Pain won't go away.' Given MS ([MEDICATION NAME]) and ABH cream (a medication given for anxiety) to assist with pain and calm her. Took several doses of [MEDICATION NAME] every 30 minutes or so to relieve pain. Resident tearful when nursing in room with her, inconsolable. Attempt to climb out of bed, throwing legs over edge of bed, fell at 6:30 PM, bed in lowest position. Assisted up with (mechanical lift) and 3 staff. 1 on 1 in room for approximately 2 hours until resident calmed and fell asleep. A facility incident report, dated 01/16/20, documented, Nursing was informed by the evening nurse that the day shift med pass had not been fully completed. On 02/11/20 at 12:24 PM, when asked if she was aware of a situation where residents did not get medications, Staff I, Licensed Practical Nurse and Cart Nurse, said she did hear about it and she was the Resident Care Manager at the time. Staff I said she had heard there was a nurse that was sick and a lot of meds weren't given. When asked about residents who did not receive pain medication, Staff I said, There is a resident on hospice who didn't get [MEDICATION NAME] . I'm not sure if any doses were given. When asked if she was referring to Resident #4, Staff I stated, Yes. At 12:27 PM, when asked about a situation regarding several residents not receiving medications, Staff C, Registered Nurse and Director of Nursing Services (DNS), stated, No, I'm not aware . Well, there was that one we turned in, a nurse that was sick. When asked if there were any outcomes to residents from not receiving medications, Staff C said there was not. When asked about Resident #4 not receiving pain medication for over 24 hours, Staff C indicated the resident should have received pain medication during that time period. Reference WAC 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to provide the necessary care, services, treatment, assessment and monitoring with wound care, treatments, and medical devices for two of four sampled residents (#1 & 2) reviewed for quality of care. This failure placed residents at risk for discomfort, health complications and a diminished quality of life. This caused harm for Resident #1 and Resident #2 when the residents developed infections. Findings included . 1) Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), an assessment tool, dated 01/17/20, showed Resident #1 was cognitively intact, required limited assistance with activities of daily living (ADLs), and had a surgical wound. admission orders [REDACTED]. Skin Assessment, dated 12/28/19, documented Resident #1 had a surgical incision with staples. The Skin Assessment did not describe the characteristics of the wound including the size, wound bed, surrounding tissue, or signs/symptoms of infection. Physician orders, dated 12/28/19, documented monitoring of RLE surgical site and staples three times daily. Admission Evaluation, dated 12/31/19, showed the assessment of Resident #1's skin integrity was blank. The evaluation documented Resident #1 had skin integrity concerns including a surgical incision. No description of the wound was noted. The plan of care, dated 12/31/19, documented Resident #1 had RLE incision with interventions included assessing, recording, and monitoring wound healing weekly; assessing and documenting status of wound perimeter, wound bed, and healing process; and monitor for signs of infection including redness, swelling, pain, and fever. Physician notes, dated 12/31/19, documented Resident #1's skin was warm, pink, and intact and continued to need wound care as ordered to the RLE laceration (incision). Progress notes, dated 01/02/20, documented when doing a dressing change, Resident #1 was found to have a 15 cm x 24 cm reddened area around the RLE staples. The incision had slight drainage and was tender and warm to touch. Resident #1 reported she had not been feeling well recently. The resident was sent to the emergency room . No additional documentation showed a description and status of the wound prior to 01/02/20. emergency room notes, dated 01/02/20, documented Resident #1's RLE was swollen, tender, and reddened with drainage and clearly has a wound infection/[MEDICAL CONDITION] (infection of the skin). A picture of wound shortly after Resident #1 arrived at the emergency room showed redness from Resident #1's knee down to her ankle. The leg was shiny due to swelling in the leg and had red streaks (a sign of infection) visible on her calf. Hospital History and Physical, dated 01/02/20, documented Resident #1 developed redness and infection of the RLE laceration while at the facility. Resident #1 required two intravenous (IV) antibiotics and progressive wound care. On 02/06/20 at 2:05 PM, Resident #1 said nursing staff did not respond to her concerns voiced about her RLE incision. Resident #1 said she asked several nurses to look at her wounds and they would either tell her she did not have an order for [REDACTED]. Resident #1 said she began asking nursing about her wound about 2-3 days prior to her hospitalization . The resident said she experienced pain and could fry an egg on her leg. The resident said when a nurse did look at the wound, the wound was burning and two times the size of normal. Resident #1 said she felt she could have possibly avoided the three procedures and hospitalization if the nursing staff had addressed her voiced concerns. Resident #1 said she felt she did not have her dressings changed or monitored upon request due lack of staffing. On 02/12/20 at 9:30 AM, Staff E, Licensed Practical Nurse (LPN), said she could not remember details about Resident #1's RLE incision. Staff E said staff should refer to the wound care nurses if there was a new wound so they could address any concerns. Staff E said wounds should have monitored and dressings changed when indicated. At 10:46 AM, Staff F, Registered Nurse (RN), Wound Care Nurse and MDS Nurse, said she was certified in wound care and was the contact at the facility for assisting with resident's wounds. Staff F said no staff notified her; or the other wound care nurse, Staff N, LPN, of the incision to Resident #1's RLE before it was infected. Staff F said the facility should have asked her to assess the wound. After reviewing the pictures of Resident #1's incision, Staff F said it looked like the infection had been going on for awhile. Staff F said these things (infections) don't just show up like that and it can go systemic and be very dangerous. It's very sad that happened. At 11:52 AM, Staff C, Director of Nursing Services (DNS) and RN, stated, I would have expected nursing to clarify and get wound care orders. Staff C said someone should have called the provider to get or clarify wound care orders. After reviewing the picture of the resident's RLE wound, Staff C said Resident #1's wound looked infected. 2) Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented the resident was cognitively intact and required extensive assistance with ADLs. Resident #2's Has amputation of right foot related to [MEDICAL CONDITION] care plan, dated 11/13/19, documented interventions including, Check and document on wound daily for signs and symptoms of infection, drainage, bleeding, any breakdown of skin and impaired circulation . Wound care daily as ordered by physician. Resident #2's Has right lower extremity and left lower extremity wounds and has potential for venous stasis ulcer related to [MEDICAL CONDITION] with right lower extremity skin grafting care plan, dated 11/13/19, documented interventions including document/measure wound weekly and prn (as needed) . evaluate wound for size, depth, margins, periwound skin . On 01/16/20 at 2:35 PM, Resident #2 said staff were regularly not completing dressing changes to his wounds due to lack of nursing staff. Resident #2 said he had to ask nursing to do dressing changes sometimes, and they still did not do it. Resident #2 said staff were inconsistent in how they applied the dressing. Resident #2 picked up a large dressing (used to cover the outside of a dressing) off of the floor and said this dressing was supposed to cover the outside of the dressing, but they didn't even wrap it up in the kerlix (a wrapping gauze used to hold a dressing into place). Resident #2 pointed to his bed and said look at all the drainage from my wounds. The resident's bed sheet were observed to be soiled with a brown-red stain. Resident #2 said the wound was draining so much because they were not changing the dressings timely. Resident #2 said he was concerned about his wounds healing. <Right Calf Venous Ulcer> Record review of Resident #2's medical record, on 02/07/20, showed a Skin Grid Weekly Evaluation, was completed for the right calf venous ulcer, to access and monitor the status of Resident #2's wound including measurements and description, on 12/04/19, 01/07/20 and 01/28/20; and showed the wound was worsening. No Skin Grid Weekly Evaluations were completed between 12/04/19 and 01/07/20, between 01/07/20 and 01/28/20, and between 01/28/20 and 02/07/20. <Right Tibia Venous Ulcer> Record review of Resident #2's medical record, on 02/07/20, showed a Skin Grid Weekly Evaluation, was completed for the right tibia venous ulcer, to access and monitor the status of Resident #2's wound including measurements and description, on 12/10/19 and 01/28/20; and showed the wound was worsening. No Skin Grid Weekly Evaluations were completed between 12/10/19 and 01/28/20 and between 01/28/20 and 02/07/20. <Left Calf Venous Ulcer Record review of Resident #2's medical record, on 02/07/20, showed a Skin Grid Weekly Evaluation, was completed for the left calf venous ulcer, to access and monitor the status of Resident #2's wound including measurements and description, on 12/04/19, 01/07/20 and 01/28/20; and showed the wound was worsening. No Skin Grid Weekly Evaluations were completed between 12/04/19 and 01/07/20, between 01/07/20 and 01/28/20, and between 01/28/20 and 02/07/20. Resident #2's January 2020 Treatment Administration Record (TAR) documented, Wound care for bilateral lower extremity (BLE) calf/tibial wounds . change (dressing) 3 times a week every day shift every Monday, Wednesday, and Friday for skin integrity. A documentation was blank on the TAR for 01/01/20, 01/06/20, 01/10/20, 01/13/20, 01/15/20, 01/17/20, and 01/20/20. Progress note for Resident #2, entitled Skin/Wound Note, dated 01/24/20, documented, This writer was asked by physician to assess wounds to legs Friday afternoon as foul wound odor was noted by staff. Right leg with copious amounts of drainage, increased maceration (softening of tissue) and redness to right lower extremity wounds. Increased pain and very foul wound odor. Culture taken per physician order [REDACTED]. Recommended to change to daily dressing changes due to increased drainage and probable infection. New orders received to start antibiotics . Progress note for Resident #2, entitled, Physician Documentation, dated 01/24/20, documented, Today he has very strong odor coming from leg wound on the left. We remove the dressing and it is grossly infected with green and yellow thick drainage . He is pretty miserable . Infected left leg wound, the wound is badly infected, the odor is overwhelming and the drainage is profuse. Culture the wound now . Dressing changes must be done daily. Progress note for Resident #2, entitled, Alert Note, dated 01/29/20, documented wound culture obtained 01/24/20, returned this AM (morning) positive. Resident #2's January 2020 TAR documented the order changed on 01/25/20 to, Wound care for BLE calf/tibial wounds . change (dressing) DAILY every day shift. The TAR documentation was blank on 01/27/20, 01/28/20, 01/29/20, 01/30/20, and 01/31/20. On 02/11/20 at 1:12 PM, Resident #2 was observed in bed with lower extremity dressings without drainage noted. When asked how things were going since January 2020, Resident #2 said not much had changed. When asked the last time his dressing had been changed, Resident #2 stated, Today, but only because I asked them to, because I was going to the hospital for a scheduled blood transfusion and the bandages were all bloody. It's embarrassing to go there and it's all bloody and falling apart. When asked when the dressing had been changed prior to today, Resident #2 stated, Friday (02/07/20) was the last time it had been done, that was at the doctor's and he was very upset with them (the facility). He said it's against the law to not do what he says. When asked if the resident knew how often his dressings were supposed to be changed, Resident #2 stated, Every day. Resident #2's February 2020 TAR, reviewed on 02/11/20 at 1:55 PM, documented an order for [REDACTED]. change (dressing) daily every day shift. The TAR documentation was blank on 02/01/20, 02/02/20, 02/05/20, 02/09/20, and 02/10/20. Resident #2's February 2020 Medication Administration Record (MAR), reviewed on 02/11/20 at 1:55 PM, documented an order for [REDACTED]. The MAR documentation was blank twice on 02/04/20, twice on 02/06/20, twice on 02/07/20, once on 02/08/20, and twice on 02/10/20. On 02/11/20 at 3:30 PM, Staff E said the floor nurses were struggling to get dressing changes and treatments done so management agreed they would come and help. Staff E said the floor nurse would not sign off the treatment because they did not complete them. On 02/12/20 at 10:46 PM, Staff F said the building was very busy. Staff F said the floor nurses were suppose to get help from the Resident Care Managers (RCM), but the RCM's have all left. Staff F said when she was entering MDS data she was seeing a lot of gaps in the MAR and TAR. Staff F said Resident #2 ended up with a really bad infection. Staff F said when she looked at the wound, the smell could have knocked you down. Resident #2 was put on three different antibiotics. Staff F said the wound looked scary. When asked if the lack of dressing changes and wound monitoring could have led to the infections, Staff F stated, I think so. That bacteria lays there. At 11:05 PM, Staff E said she was aware of an issue with treatments and dressings not getting done. Staff E said the day shift was staying until 8:00 PM or 9:00 PM just to get their work done, and they still could not get the treatments done. Staff E said nursing management was supposed to be helping out, but that was not consistently happening. At 11:52 AM, Staff C, Director of Nursing Services (DNS) and RN, said there was no excuse for not doing dressing or treatments changes. Staff C said he was not aware this was not being done. Staff C said the unit managers were supposed to be doing wound rounds one time a week; and if the unit managers were not doing that, they should be. Staff C said he was not made aware dressing changes were not being done. Reference WAC 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to identify and prevent avoidable pressure ulcers for 1 of 3 residents (#1) reviewed for pressure ulcers. The facility failed to comprehensively assess the resident's clinical condition and provide pressure ulcer care which was consistent with professional standards of care. These failures resulted in the development of four facility acquired pressure ulcers, in which one deteriorated to an unstageable wound. Findings include . Resident #1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Resident #1's Minimum data set (MDS), a comprehensive assessment tool, dated [DATE], documented Resident #1 required 2 persons physical assistance with bed mobility, transfers, and dressing. Resident #1 required extensive 1 person physical assistance with eating, toilet use, and personal hygiene. Resident #1 was identified as a risk for pressure ulcers and had no pressure, venous, or arterial ulcers present on admission. The MDS documented direct care staff believed resident was capable of increasing independence and had functional rehabilitation potential. On [DATE] at 9:12 AM, Resident #1 was in bed lying flat on his back. Multiple dark brown and red circular stains were present on Resident#1's fitted sheet. Resident #1 was wearing white cotton socks with dark brown and red circular stains covering both heels. At 10:30 AM, Resident #1 was in bed lying flat on his back. Multiple dark brown and red circular stains were present on residents bedding and socks. At 11:00 AM, Resident #1 was in bed lying flat on his back. Multiple dark brown and red circular stains were present on residents bedding and socks. At 11:30 AM, Resident #1 was in bed lying flat on his back. Multiple dark brown and red circular stains were present on residents bedding and socks. At 11:50 AM Resident #1's wife stated, she visits Resident #1 daily. She indicated he was started on medications that made him sedated and he was not able to eat or drink. Resident #1's wife reported she was concerned with the blood stains on the bed and several sores on Resident #1's back that had not been previously reported to her. Resident #1's wife said she noticed sores on residents back when care was being provided to resident. At 1:12 PM, Resident #1's skin was assesed by Staff D, a registered nurse, and was observed by surveyor. The following skin conditions were identified. 1) 5cm x 5cm Stage II Pressure Ulcer (Partial-thickness loss of skin with exposed dermis, presenting as a shallow open ulcer) on residents right heel. 2) 7cm x 7cm Unstageable pressure Ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) on residents left heel. 3) 1cm x 1cm Stage II Pressure Ulcer to the left lateral lower back at the bony prominence of the iliac crest. 4) 0.1cm x 0.2cm Stage II Pressure Ulcer to the right lateral lower back at the bony prominence of the iliac crest. 5) 0.3cm x 0.2cm Stage II Pressure Ulcer to the spine 5 cm superior to the tip of the coccyx. 6) A foam dressing dated [DATE] was present to resident's coccyx. Staff D, a registered nurse, removed the dressing. A 5cm x 8cm area of maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) was foul smelling and had exudate (fluid that has been forced out of the tissues or its capillaries because of inflammation or injury) present. At 1:15 PM Staff D stated, the dressing was applied the day after admission and had not been changed since (24 days prior). A review of Resident #1's care plan, dated [DATE], documented, Expected to stay short term at the center related to stroke. There were no care planned interventions related to the assessment, treatment or prevention of pressure ulcers. There were no active treatment orders for Resident #1. On [DATE] Staff C, a registered nurse and Resident #1's Resident Care Manager (RCM), stated the residents chart was not created correctly and a duplicate chart was created. When the charts were merged Resident #1's care plan did not activate. A review of Residnet #1's progress notes documnetd, on [DATE] Resident #1 died in the facility. On [DATE] at 10:00 AM, Staff B, The Director of Nursing, said, my expectation is every resident has a weekly skin assessment. When the aides are providing care they are to inspect the resident's skin and report any findings to the nurse. Staff B stated, dressings should be changed at a minimum weekly and sooner if saturated or soiled. Reference: WAC [DATE] (3)(b)

Based on interview and record review, the facility failed to ensure residents were free from physical abuse for 1 of 3 sampled residents (#1) reviewed for resident to resident altercations. This failure placed residents at risk for physical abuse and a diminished quality of life. This caused harm to Resident #1 when her upper right arm was bruised during a resident to resident altercation. Findings included . Resident #1 was admitted to the facility 01/06/17 with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 02/14/19, showed the resident had moderate cognitive impairment with no behaviors. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], documented Resident #2 had moderate cognitive impairment, experienced disorganized thinking and delusions and had verbal behaviors toward others 1 to 3 days of the assessment period. Resident #2's care plan for impaired cognitive function/dementia or impaired thought process, initiated 02/16/19, showed interventions including to provide consistent, simple, directive sentences . provide resident with necessary cues - stop and return if agitated. A Police report, dated 3/6/19, documented, on 03/03/19 at approximately 3:05 AM, local police responded to a call at the facility regarding Resident #2, who had struck a staff member and was continuing to strike other staff members. When the police arrived, Resident #2 was sleeping in his bed. Staff notified the police that Resident #2 made the statement that he liked beating the[***]out of other women. Staff notified the police that Resident #2 would wander into other resident rooms disturbing them, and other residents had become afraid of him. Staff were notified by the police to call back if the facility needed further assistance with Resident #2. At approximately 4:39 AM, the police received a second call that Resident #2 was assaulting Resident #1. Resident #1 told the police that she had been woken up by Resident #2 hitting Resident #1 in the arm. Resident #1's right upper arm was observed to be red with noticeable bruising. A facility incident report, dated 03/05/19, documented on 03/03/19 staff responded to Resident #1 calling for help with Resident #2 on top of and hitting Resident #1. Staff separated the residents. Staff B, Registered Nurse and Resident Care Manager, assessed the residents for new injuries and noted a golf ball sized swelling to Residents #1's right arm. On 04/04/19 at 12:30 AM, Staff B said Resident #2 had a history of [REDACTED]. Staff would attempt to redirect Resident #2 when he would do things like wander into resident rooms, but Resident #2 would become aggressive with staff when being redirected. Staff B said no particular staff member had been assigned to watch Resident #2 to make sure he did not continue to go into resident rooms after the initial police visit. Staff B stated, We were all working at the nurse's station and thought, between the three of us, we could just keep an eye on the hallway to see if (Resident #2) left his room. We didn't realize (Resident #2) had woken up until we heard (Resident #1) yelling. Reference WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to ensure residents were provided opportunities to be involved in advance in making decisions about care and treatment to attain and maintain the highest practicable physical, mental and psychosocial well being for 1 of 4 sampled residents (#16) reviewed for participation in care planning. This failure placed residents at risk of unidentified and unmet care needs, unwanted behaviors and a diminished quality of life. This caused harm to Resident #16. Findings include . Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 08/30/18, documented the resident was moderately cognitively impaired; experienced feeling down, depressed or hopeless; did not exhibit behavior issues; had a history of [REDACTED]. On 11/05/18 at 2:37 PM, Resident #16 said she recently had multiple medication changes, made by the provider, without first discussing them with her. Resident #16 said the nurse told her about the changes after the orders were changed. The resident said as a result she had increased side effects such as tremors and pain. Resident #16 said she reported to staff her concern about not being able to participate in her care and medication changes. Physician comprehensive review note, dated 06/05/18, documented Resident #16 was a delightful woman .originally admitted .due to unspecified ataxia. Resident #16 received klonopin (an anxiety medication) for foot tremors, [MEDICATION NAME] (an antidepressant medication) for depression with a dose increase for teariness, and [MEDICATION NAME] (a pain medication) for pain management. Pharmacist Recommendation Note, dated 09/20/18, recommended changing Resident #16 depression medication for [MEDICATION NAME] to duloxetine (an antidepressant) for complaints of burning pain. A pain assessment to determine contributing factors of the resident's pain was not located in the clinical record prior to or after the medication change recommendation. Pharmacist Recommendation Note showed the recommendations were accepted by the physician, Staff DD. A provider note was not located showing Staff DD spoke with the resident regarding the medication changes. Nursing progress note, dated 10/08/18, documented nursing staff notified Resident #16 of the medication changes, after the medication had been changed. Provider notes showed, on 10/09/18, 10/23/18, 10/29/18, and 11/05/18, the providers changed Resident #16's medication regimen. The notes did not indicate the resident was included in these medication changes. Nursing notes, dated 10/13/18, 10/15/18, 10/16/18 and 10/20/18, documented Resident #16 reported sleepiness, fatigue, burning pain, and was found to be more withdrawn. No assessments were located in the clinical record regarding the resident's change in condition during this time period. Progress notes documented the resident had two falls on 10/22/18 and one fall on 10/29/18. Medication use and the change in condition were not assessed in the post-fall assessment. Pharmacist notes, dated 10/29/18, documented Resident #16 had several falls and recommended dose reduction of klonopin and trazadone. Staff EE, Nurse Practitioner, accepted this recommendation. There was no documentation in the clinical record indicating Staff EE had spoken with the resident regarding the dose reduction of klonopin and trazadone. Nursing progress note, dated 11/01/18, documented Resident #16 was unhappy about the medication changes and did not agree with the provider making changing medication without consulting the resident. Resident #16 reported the side effect of [MEDICAL CONDITION]. Provider note, dated 11/05/18, Staff EE documented he doubted klonopin controlled tremors and recommended a further gradual dose reduction of the medication. There was no documentation Staff EE discussed this change with Resident #16. Nursing progress note, dated 11/05/18, documented Resident #16 was notified of another decrease in klonopin and became very upset. The resident wanted to speak with the provider because she was having more anxiety and tremors, not sleeping well, and her appetite increased since starting duloxetine. The resident felt she needed trazadone and klonopin. Provider note, dated 11/06/18, Staff EE noted Resident #16 showed no medical necessity to increase medication. The note did not indicate Staff EE discussed concerns with Resident #16. Nursing progress note, dated 11/07/18, documented Resident #16 reported shaking and was upset. Resident #16 said she was never informed there were going to be medication changes and has been on these medications a long time. Nursing progress note, dated 11/07/18, documented Resident #16 requested klonopin as she shakes without it. Nursing explained medication changes. Resident #16 requested to go to the hospital if she could not have her medication. Resident #16 reported to the ambulance crew she was feeling abused due to the medication changes and suicidal if she could not get klonopin. The administrator, Staff A, was notified of the abuse allegations and situation. emergency room record note, dated 11/07/18, documented Resident #16 reported [DIAGNOSES REDACTED]. Resident #16 said the medications had worked for the resident for the last nine (9) years. Resident #16 said she had voiced her complaints with the doctors, registered nurse, and facility social worker; and nothing had changed. On 11/08/18 at 2:25 PM, Staff BB, Nursing Assistant, said Resident #16 had medication changes which resulted in periods of [MEDICAL CONDITION] and drowsiness. Staff BB said the resident had a change in mood and general appearance. Staff BB said she had not heard Resident #16 make suicidal statements in the past. At 3:18 PM, Resident #16 said the recent medication changes caused her great distress to be excluded from changes to her medications. The resident said she was concerned she was not allowed input into her medication and choices of care. As a result, the resident did not want to get out of bed, was increasingly depressed, and no longer wanted to live. The resident said she had not been involved in discussing medication changes and was notified by nursing after they occurred. Resident #16 said there were so many medication changes in a short amount of time it was hard to determine what changes caused her to feel the way she did. The resident stated, They aren't in my body, but they assume they know what's best, yanking you off medications and screw(ing) everything up. The resident said she did not feel safe in the facility as long as the provider did not include her in the plan of care. During this time, the resident became physically upset and began crying. On 11/09/18 at 11:11 AM, Staff CC, License Practical Nurse, said the consultant pharmacist made recommendations regarding Resident #16's medication regimen. At that time, the provider approved the changes and the resident was notified by nursing staff. Then the provider made an additional reduction and the resident became very unhappy and requested to speak to the provider. Staff CC said the provider was notified three (3) times of Resident #16's concerns. Staff CC said the resident had been observed to be sleepier during the day, not sleeping as much during night, and reported weight gain. Staff CC said she was concerned about the resident and felt the resident was not at her baseline state. Staff CC said the provider was not going in to explain the changes to the resident and was not sure why. Staff CC said the resident was not known for making suicidal comments until the emergency room visit on 11/07/18. At 1:30 PM, Staff J, Social Worker, said Resident #16 ramped up when she found out about the medication changes and ended up going to the emergency room . Staff J said the emergency room gave her what she was seeking. Staff J said the facility had two documents, a P4 Suicidally Screener and a No-Suicide Contract to assess residents for suicidal ideation. Staff J said she did not complete these assessments on Resident #16. Staff J said the resident was drug seeking and the suicidal comments were not related to the medication changes. On 11/14/18 at 8:25 AM, Staff B, Director of Nursing Service, said she was aware of Resident #16's medication changes. Staff B said when the resident found out about the medication changes, the resident started to have behaviors. Staff B said every time a gradual dose reduction was attempted, the resident exhibited a change in behavior. Staff B said once Resident #16 was told of the medication changes she started ramping up. Staff B said the resident did have a number of medication changes, at one time, making it hard to determine what was effective and/or effecting the resident. Staff B said Resident #16 was not included in her plan of care. At 9:09 AM, Staff DD said Resident #16 throws a fit when there were medication changes. Staff EE said the resident was not showing any side effects from the medication changes. Staff EE said the resident's generalized anxiety disorder (GAD) and PHQ-9 (a depression assessment) were fine. When asked to provide the documented assessments, Staff EE said he remembered the question in his head so he did not document the results of the resident interview. Staff EE said the long-term goals and objectives for the resident's care were up in the air. Reference WAC 388-97-1020(1)(f)

Based on observation, interview and record review, the facility failed to ensure residents were free from abuse for 6 of 10 sampled residents (#17, 18, 42, 47, 60 & 238) reviewed for abuse when they failed to implement their abuse prohibition policy by immediately reporting abuse and allowed Nursing Assistant (NA) C to have continued access to residents. This failure placed residents at risk for physical harm, mental anguish, and a diminished quality of life. This caused harm to Resident #60, Resident #17, Resident #18 and Resident #238. Findings include . The facility's abuse prevention policy, dated December 2016, documented all alleged violations are to be immediately reported, thoroughly investigated and further abuse should be prevented while the investigation is in progress. 1) Resident #60 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool, dated 12/26/17, documented the resident was severely cognitively impaired and required extensive assistance with activities of daily living. On 01/18/18 at 9:12 AM, Resident #60 was observed with multiple bruised areas on both upper extremities. When asked how he had obtained the bruises, the resident stated, I don't know. They just show up. The Accident and Incident Log documented Resident #60 had sustained self-inflicted injuries on 01/12/18. Investigative documentation showed Resident #60 was observed by staff on the morning of 01/12/18 with significant bruising and skin tears that included a 27 x 8 centimeter (cm) forearm bruise, 3 x 3 cm inner left forearm bruise, a 1 x 2 cm crescent shaped skin tear on the left hand, a 12 x 12 cm bruise on the top of the right hand, a 1 x 2 cm skin tear on the back of the right hand and two scratches, 1 cm long, on the jaw line. A Witness Statement, dated 01/11/18, stated, This morning, when Nursing Assistant (NA) C gave me report, he told me he could not work with Resident #60. A Witness Statement, dated 01/12/18, and signed by NA C, documented, .On my last rounds, I went into (room of Resident #60) .he immediately started to scream and use foul language towards me and flail his arms around .I exited the room .resident was unscathed. The Nursing Home Guidelines, The Purple Book, Dated October 2015, documented an injury to an area, not generally vulnerable to trauma, such as the face, should be called in to the State Hotline. Resident #60's unwitnessed injuries of significant bruising and a scratch to the face was not reported to the State. The facility's abuse prevention policy documented injury of unknown source is an injury that was not observed by any person or the resident could not explain the source of the injury and the injury is suspicious because of the extent of the injury or location of the injury . 2) Resident #238 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Witness Statement/interview documentation note, dated 01/17/18, and signed by NA F, indicated Resident #238 told NA F that NA C had been rough with him, left him overly exposed and threw his blankets on him. When asked if he wanted to report it, Resident #238 said he did want to because it had been the same thing night after night and something needed to be done. Interview documentation showed the facility interviewed a large sample of staff and residents and the Interdisciplinary Team substantiated the allegation based on statements from Resident #238, residents and staff regarding NA C's actions. A Witness Statement/interview documentation note from Licensed Nurse (LN) E, Registered Nurse (RN), dated 01/19/18, stated NA C had no finesse, seemed rough, doesn't walk away and was antagonistic. On 01/24/18 at 6:00 AM, LN E said from her experience, she thought NA C needed counseling and/or additional training related to his approach with residents with dementia. LN E said she did not make a recommendation and/or inform the Director of Nursing Services (DNS) about this. LN E said she witnessed an incident with another resident, Resident #18, and reported it to LN B, RN. No documentation was found showing LN E and LN B had promptly reported the allegation. On 01/24/18 at 7:59 AM, NA F said NA C had been accused of being rough with Resident #238 and Resident #238 reported it to LN G, Licensed Practical Nurse (LPN), and LN F, LPN, on 01/15/18. NA F said she brought up calling the Administrator and DNS and State, and LN G told NA F she would not call that late. NA F said it was about 10:30 or 11:00 PM when she told the nurses. NA F said, I am not used to going over the nurse's heads. I wished I would have called myself. The facility's investigative documentation showed, LN G filled out a grievance form on behalf of Resident #238 and wrote on a sticky note that she would call the DNS in the morning. An investigation into the allegation of abuse was not started until the day after the resident told staff about it. 3) Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Investigative documentation showed an allegation that Resident #17 was locked in the bathroom and forced to use the facilities before being allowed out of the bathroom. The allegation was received on 01/17/18 during staff interviews related to a different allegation. The document showed it had been a night shift NA, and another NA had observed the resident after the supposed earlier incident, heard the allegation and noted the resident was sobbing and very upset, which was not her normal behavior. The investigative documentation noted, upon interview, the resident, who was confused at baseline, said she remembered being very upset in the bathroom the other night and did not remember other details. In a Witness Statement/interview document, dated 01/19/18, NA C said, I have never locked any resident in the bathroom. A witness statement by NA J, dated 01/16/18, documented NA J had observed NA C yelling at residents on a couple of occasions and when she intervened, residents told her they were afraid of NA C due to being scolded about wetting their briefs or beds. NA J documented a resident had told her she had been locked in the bathroom by NA C, and NA J reported it to the nurse on shift. There was no documentation actions to prevent abuse had been taken at the time of the incident, and that an investigation had been started promptly. On 01/24/18 at 5:58 AM, NA J said Resident #17 had told her she was afraid of NA C. NA J said she had reported it to LN B and thought he had reported it to the DNS. When asked if she had considered calling the State Hotline, NA J said, No, I really did what I thought I was supposed to do. When asked if she had ever heard NA C yell at a resident, NA J said, I heard him tell Resident #42 to relax in a non-comforting voice. 4) Resident #42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The residents MDS, dated [DATE], showed the resident had severe cognitive impairment and required extensive assistance with ADLs. On 01/18/18 at 02:18 PM, when asked if Resident #42 had ever been abused at the facility, the family member stated she had received a call that a Nursing Assistant had been rough with Resident #42's wrists. The facility's investigative documentation noted, On 1/17/18 an allegation of abuse was made against a noc (night) shift CNA. LN on duty states that noc shift CNA held down resident's wrists. LN on duty states she told him he cannot do that and he let go. It has also been reported by another CNA that he was overheard yelling at the resident. A witness statement, dated 01/17/18, by LN G, documented LN G had been assisting NA C with Resident #42's care and was holding the resident's wrist. LN G wrote she told NA C he couldn't do that and noted, That was after (Resident #60) had bruises on wrist. On 01/22/18 at 11:39 AM, the DNS said an allegation was made that a night shift NA held down Resident #42's wrists and a nurse, who said they witnessed the event, had reported it to the facility. The DNS stated the nurse retracted somewhat by saying the NA did not hold the wrist down hard. 5) Resident #47 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. A Witness Statement/ Interview documentation, dated 01/18/18 by NA K noted Resident #40 had told him that NA C had been mean to Resident #47 and he had reported it to LN D. The facility's Investigative documentation noted, the resident's roommate, Resident #40, who was assessed to be cognitively intact, reported a night shift NA had been rough with Resident #47, yelled at him and sounded mean. A Witness Statement/Interview documentation, dated 01/18/18, by LN D, RN, noted NA C had been too rough and had been yelling at Resident #47. No documentation was found indicating the incident was immediately reported. 6) Resident #18 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. The facility's investigative documentation noted Resident #18's personal caregiver informed facility staff the resident had repeatedly made comments about a man poking her eyes and beating her arms and hands and buttocks. On 01/18/18, the caregiver reported to LN K, RN, that Resident #18 said she was afraid of going to sleep and being woke up to by this person who would hit her in the bathroom. The caregiver documented she had initially discussed the resident's comments with LN F on 01/16/18. A Witness Statement/Interview documentation, dated 01/18/18, by LN F, documented, She did mention about hitting but I didn't think it was an official complaint. A Witness Statement/ Interview documentation, dated 01/18/18, by NA D, indicated there had been an incident that had taken place about a week and a half prior when Resident #18 put her foot on the bathroom door to avoid going into the bathroom with NA C and asked staff to not let him beat her. On 01/24/18 at 6:05 AM, NA D said, I was with Resident #18 when she put her foot against the bathroom door and didn't want to go to the bathroom with NA C. LN G had me take her. (Resident #18) asked me not to let NA C beat her. I asked LN G what I should do with that information and she said she would take care of it. The next day Resident #18 was really concerned about something. She was scared to go to sleep. She had never talked like that before. She was fearful and she didn't want to sleep until I told her she was safe. I know I should have gone further because LN G didn't say anything. Investigative documentation noted a verbal statement from NA L to the DNS which indicated NA L had been aware Resident #18 had been concerned about working with NA C. Documentation noted, Resident 18 is scared of him. Her demeanor changes when she has worked with him. The notes documented, Don't let that man touch me. The statement noted NA L brought the issues up to LN B when it first happened and he said he would keep an eye on it. Documentation showed staff had knowledge that Resident #49 was scared of NA C. Notes from a verbal statement from LN B documented LN G, NA L, NA D and NA J had told LN B they heard NA C yelling at residents. On 01/24/18 at 6:15 AM, NA E said, If I saw or heard about abuse I would inform the nurse on shift. If they didn't do anything, I would go to ADON (Assistant Director of Nursing), then the DNS (Director of Nursing Services), then the Administrator if it wasn't solved and then call the State. I would use the chain of command. NA E said they discussed the chain of command during their recent in-service. At 2:30 PM, the DNS said, It was identified that allegations were not being reported correctly. If it had been reported, half of these wouldn't have happened. If they had brought it to our attention earlier, we could have provided education or even firing. It could have at least prevented what happened to Resident #238. The DNS said she was disappointed the mandatory reporters were not reporting up the chain. The facility failed to immediately report allegations of abuse when multiple staff members were aware of concerns regarding NA C and the facility failed to protect residents from further incidents of abuse during their investigation when NA C continued to work in the facility and provide care to residents. Reference WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to conduct weekly weights to assist with identification and prevention of further weight loss for 2 of 6 sampled residents (#52 & 74) reviewed for nutrition. This failure placed residents at risk for unnecessary weight loss and a diminished quality of life. This caused harm to Resident #52. Findings include . On 01/24/18 at 10:00 AM, the Registered Dietician (RD) stated the weight monitoring policy required an admission weight, then weekly weights for 4 weeks, then weights would be done monthly if stable. If weight loss was identified during the first 4 weeks, weekly weights would continue until the weight was stable. The RD said residents with weight loss were followed by the weight loss committee weekly. The committee included the RD, unit managers, Director of Nursing Services (DNS), activities and social services. The facility's weight monitoring procedure included obtaining the weight of each resident within 24 hours of admit/readmit, weigh weekly for four weeks or until determined to be stable by the interdisciplinary team (IDT). The Nutrition Services Responsibilities included reviewing significant weight change alerts and weight alerts daily to assure all residents with significant weight change are reviewed and assessed for nutrition risk factors. 1) Resident #52 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS), an assessment tool, dated 11/27/17, documented the resident required extensive assistance with eating and was on a mechanically altered diet. Resident #52's Nutrition at Risk Care Plan, initiated 11/20/17 and updated 01/18/18, listed an intervention to monitor weights per policy weekly for four weeks then per RD recommendations. On 1/23/18 at 9:38 AM, 10:17 AM, 11:15 AM, 12:00 PM, and 12:25 PM the resident was observed asleep in his wheel chair in his room. At 12:35 PM, the resident was observed asleep in his wheelchair in the dining room. Staff attempted to wake him. He did not arouse and did not eat anything from his tray. At 1:15 PM, 2:02 PM, 2:30 PM and 3:02 PM, the resident was observed asleep in his wheelchair in his room. 01/25/18 at 12:16 PM, the resident was observed in bed sleeping very soundly. Lunch was sitting on the table in the assisted dining room with a lid covering the plate and shirt protector sitting on the lid. An admission weight for Resident #52, of 156 pounds, was documented by the RD on 11/21/17. On 11/26/17, the resident weighed 147 pounds, 9 pounds down from admission. On 12/11/17, the resident weighed 139 pounds, down 17 pounds from admission. On 01/08/18, the resident weighed 134 pounds, down 22 pounds, or 14% from admission. The RD assessed the resident on 11/21/17 at admission, and 9 days later on 11/30/17. The RD assessment, dated 12/12/17, the RD noted the resident had lost 18 pounds since his admission 3 weeks prior. The RD next assessment, dated 01/18/18, was on 01/18/18, 5 weeks after the 18 pounds weight loss had been identified. On 01/25/18 at 4:00 PM, the RD stated she did not have weights other than those provided and weekly weights were not completed on the resident as they should have been. Progress notes, from 11/20/17 through 01/21/18, did not show documentation the physician and family were notified of the severe weight loss, and that the weight loss committee and/or IDT had reviewed Resident #52. Care conferences notes, dated 01/17/18, documented the Social Service Director, resident, spouse and son were in attendance. There was no mention of the severe weight loss in the nursing section of the note. physician progress notes [REDACTED].#52 experienced. 2) Resident #74 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS, dated [DATE], showed the resident required extensive assistance with eating. Resident #74's Nutrition Risk Care Plan, initiated 12/15/17 and updated 01/09/18, listed an intervention to monitor weights per facility policy. Weights provided by the facility showed on 12/15/17 the resident weighed 223 pounds, on 12/19/17 she weighed 229 pounds and on 01/04/18 she weighed 210 pounds. On 01/24/18 at 10:00 AM, the RD reviewed the weight records for Resident #74 and stated there was not a more recent weight than 01/04/18 and there should have been. When asked if the resident's weight should be monitored more often, the RD said it needed to be continued weekly because it had not been stable. Reference WAC 388-97-1060 (3)(h)

Based on observation, interview and record review, the facility failed to ensure an order for [REDACTED].#52) reviewed for medication management. This failure placed residents at risk of [MEDICAL CONDITION], medication side effects and the inability to reach the highest practicable well being. This caused harm to Resident #52. Findings include . The 2016 Nursing Drug Handbook contains the following Black Box Warning for [MEDICATION NAME]: Respiratory depression, including fatal cases, may occur with [MEDICATION NAME], even when drug has been used as recommended and not misused or abused. Proper dosing and titration are essential and the drug should only be prescribed by health care professionals knowledgeable in the use of potent opioids for management of chronic pain. Monitor patient for respiratory depression, especially during initiation of drug or after a dosage increase. Drug Alert: Monitor circulatory, respiratory, bladder and bowel functions carefully. Drug may cause [MEDICAL CONDITION], urine retention, nausea, vomiting, constipation or altered level of consciousness. Resident #52 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set, an assessment tool, dated 01/21/18, documented the resident was severely cognitively impaired and required extensive assistance with activities of daily living. Resident #52's Physician order [REDACTED]. On 1/23/18 at 9:38 AM, 10:17 AM, 11:15 AM, 12:00 PM, and 12:25 PM the resident was observed asleep in his wheel chair in his room. At 12:35 PM, the resident was observed asleep in his wheelchair in dining room. Staff attempted to wake him. He did not arouse and did not eat anything from his tray. At 1:15 PM, 2:02 PM, 2:30 PM and 3:02 PM, the resident was observed asleep in his wheelchair in his room. The resident's January Medication Administration Record (MAR) documented the [MEDICATION NAME] order, which included a handwritten note, if not effective may give 2.50 ML in 4 hrs prn (as needed) 12/8/17. A nursing progress note, dated 12/08/17, documented, Continues to yell out in afternoon. Gave 1.25 ML of ms ([MEDICATION NAME] sulfate) at 1630 (4:30 PM) with little success. Order received to double [MEDICATION NAME] in 4 hours if yelling hasn't quieted. Settled down after dinner and went to sleep. Took meds without difficulty. No complaints of pain. Will continue to monitor. The resident's January MAR showed the resident was given 2.5 ML of [MEDICATION NAME] 37 times between 01/02/18 and 01/26/18. On 1/30/18 at 2:30 PM, the provider's off-site nurse said the resident's current order for [MEDICATION NAME] was 1.25 ML and a refill request had just been approved that morning with that dose. The provider's nurse said there was a telephone conversation with the facility's nurse on 12/08/17. Documentation showed, (Licensed Nurse (LN) D, Registered Nurse (RN)) calls back at 1650 (4:50 PM) to say 2.5 MG PO (by mouth) [MEDICATION NAME] given and pt (patient) is still yelling. Instructed nurse to give it some time and per (provider), she may increase PRN [MEDICATION NAME] to 5 MG PO with next dose due. If still ineffective, please notify on-call. LN D repeated V.O. (verbal order) back to this RN and voiced understanding. On 01/30/18 at 2:33 PM, the provider's nurse said, When we didn't hear back, we assumed it had been effective .The 12/08/17 order was a one-time order. At 3:20 PM, when asked how the facility ensured accuracy of telephone orders, the Director of Nursing Services (DNS) said the nurse will transcribe the order, then transcribe the order onto the MAR and the RCM will double check to make sure it was transcribed accurately. When asked whose handwriting was on the [MEDICATION NAME] order on the MAR, the DNS said, I don't know. The DNS reviewed the 12/08/17 telephone order and said it sounded like it was a one-time order and it should have been clarified. When asked if she considered the 2.5 ML [MEDICATION NAME] dose a medication error, she said, Yes, at this point, it is a medication error. Reference WAC 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to ensure 1 of 5 sampled residents (#1) was free from physical abuse. The failure to protect Resident #1 from physical abuse, caused Resident #1 to experience psychological harm and diminished quality of life, according to the reasonable person rule, when a caregiver forcefully applied pressure to Resident #1's genitalia during peri-care. Findings include: Washington state Nursing Home Guidelines AKA The Purple Book, Sixth Edition, October 2015, defines physical abuse: The willful action of inflicting bodily injury or physical mistreatment. The term willful does not mean that an individual intended to cause harm, pain, anguish or injury. Instead, willful means that the individual intended the action or inaction itself that he/she knew or should have known could cause one or more negative outcomes to nursing home resident(s), including harm, anguish, pain or injury. Review of the facilities Abuse and Neglect Policy stated every resident has the right to be free from abuse in all forms by anyone including employees, other resident, consults, volunteers, family members, friends or other individuals. Resident #1 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. Resident #1's Minimum Data Set, a comprehensive assessment tool, dated 5/16/17 documented she required staff assistance for toilet use, personal hygiene, dressing, transfers, and bed mobility. Resident #1 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 14. (a score of 13-15 indicates resident is intact cognitively) Resident #1's care plan dated 4/17/17 documented Resident #1 was on a scheduled toileting program and was toileted upon rising, before and after meals, at bedtime, and as needed. A Resident Grievance Report dated 6/7/17 documented, Resident #1 reported an incident with Nursing Assistant (NA) A. (NA A) was angry when (Resident #1) was not wet and then was immediately incontinent of urine due to being awake. (Resident #1) stated deliberate force on her genitals while being cleaned. (Resident #1) said ouch. When CNA returned patient states you hurt me. CNA refuted comment and blamed patient for not turning over properly. On 6/8/17 at 6:47 p.m., Resident #1 stated on 6/7/17 at approximately 3:00 a.m., NA A entered her room to check her brief for incontinence. Resident #1 woke as NA A was exiting her room. Resident #1 indicated immediately after waking she became incontinent and turned on the call light to request assistance. NA A returned and was rude and abrupt. Resident #1 stated, NA A put me on my back, spread my legs and attacked my genitals. I said ouch multiple times. When NA A returned 2 hours later I said you hurt me, NA A replied you did not turn over properly. Resident #1 indicated she was on her back, there was no turning involved. Resident #1 said (NA A) is angry if I'm wet and she is angry if I'm not. At 8:40 p.m., Resident #1 stated I'm really upset. I feel violated, she (NA A) had no right to dig in my vagina and attack me like that. Resident #1 started to cry and was initially inconsolable. At 9:44 p.m., NA A stated she cared for Resident #1 during the time of the allegation. NA A said that Resident #1 got really upset on 6/7/17. NA A said I told her I was just doing my job, I did not report the allegation because it's a nightly thing. I get that quite a bit from Residents. They all Ooch and Ouch. At 9:55 p.m., NA B indicated on the evening of 6/7/17 he was asked to provide care for Resident #1 due to an alligation involving NA A. NA B stated, I was not surprised.

Based on observation, interview and record review, it was determined the facility failed to ensure 1 of 4 sampled residents (#1) was free of physical restraints. This failure restricted Resident #1's freedom of movement, placed him at risk of not achieving and/or maintaining the highest level of physical function and impacted his psychosocial well being, and resulted in what a reasonable person would determine to be harm to Resident #1 when he was repeatedly restrained in his chair. Findings include: On 3/15/17, review of Resident #1's record indicated he was admitted to the facility from the hospital on [DATE] with multiple health conditions including history of falls, multiple fractures, and a left eye hematoma (localized blood swelling from a broken vessel). The Minimum Data Set (MDS), a comprehensive assessment tool dated 3/2/17, revealed the resident had dementia with a cognition score of 4 out of 15 (below 7 indicates significant cognitive loss). He required extensive assistance from 1 and/or 2 staff members for all daily living tasks including toileting and mobility. He had a wound infection, urinary tract infection, skin tears and was at risk for development of pressure related skin injures. He required frequent turning and toileting. The resident received physical and occupational therapies 5 days a week with the goal of returning to the community. Review of the assessments and documentation failed to show the assessed need for restraint use. During interview and observation of the resident on 3/15/17 at 1:30 p.m., he was on his way to play Bingo. Review of the progress notes dated 3/3/17, Nursing Assistant (NA) C documented: .called over to help because (Licensed Nurse (LN) A) tied him (Resident #1) up in with a blanket in front of her. She (LN A) tried to tell me to leave it alone and I told her it is a restraint .do not do it again, it is illegal. The resident asked if he was still tied up. The document continued: we kept walking him around the building because he did not want to be around (LN A). At 1:45 p.m., the Director of Nursing Services (DNS) reported finding out about the restraint use on 3/3/17 and implemented training. At 4:30 p.m., the administrator stated this issue (restraining the resident) was really upsetting and would be discussed at every staff meeting. According to the documentation dated 3/3/17, the resident was restrained on repeated occasions and resulted in harm to Resident #1 and placed all residents, especially those with limited cognition, at risk of being treated in the same manner. Refer to F 226

Based on observation, interview and record review, it was determined the facility failed to operationalize its policies and procedures for protection of residents and for the prevention, identification and investigation of abuse, neglect, and/or mistreatment. The failure of the facility to recognize and prevent initial and repeated occurrences of staff restraint use to 1 of 4 current sampled residents (#1), resulted in what a reasonable person would determine was physical and emotional harm to Resident #1 when staff members were aware and repeatedly restrained and/or allowed the resident to be restrained in his chair. Findings include: On 3/15/17 at 1:30 p.m., Resident #1 was observed walking to the activity room to play Bingo. Review of a facility investigation report, dated 3/3/17, indicated Licensed Nurse (LN) A used a blanket to restrain Resident #1 in his wheelchair, and Nursing Assistant (NA) C removed the blanket from the resident and notified the Director of Nursing (DNS). Review of a written statement by NA D dated 3/3/17 at 11:00 a.m., indicated about a month ago she saw LN A use a gait belt to keep Resident #1 from getting out of his wheelchair. The record failed to show NA D reported this incident to the administration or reported to the state hotline. On 3/15/17 at 1:45 p.m., the DNS said during her investigation of the event on 3/3/17, she found NA A and NA B had witnessed LN A use a gait belt to keep Resident #1 from getting out of his wheelchair. Nether NA A or NA B notified the DNS or called the state hotline. The resident's comprehensive care plan dated 1/31/17, indicated the resident needed the assistance of two people for ambulation and transfers with the use of a gait belt .general supervision. The revised care plan dated 3/4/17 indicated the same. There were no care planned interventions to indicate the resident required increased/close supervision or to be restrained in any way or for any reason. On 3/15/17 at 1:45 p.m., the Director of Nursing Services (DNS) reported finding out about the restraint use on 3/3/17. At 4:30 p.m., the administrator stated this issue (restraining the resident) was really upsetting and would be discussed at every staff meeting. It's a restraint, it's abuse. Review of a document sent to ALL STAFF MUST READ from the administrator dated 3/7/17 informed staff that Residents have a federally protected right to be free from restraints; tying a resident to a chair or bed by any means such as a blanket or gait belt .is abuse .and must be treated as such . The facility's policy and procedure for abuse and neglect prohibition included clear guidance as to whom staff should report abusive incidents such as with Resident #1. There was lack of documentation related to what management was doing to ensure staff correctly implemented the information especially when staff noted restraints used repeatedly on Resident #1 and should have been reported immediately rather than allowed to continue. According to the facility, the State's Nursing Home Guideline AKA 'The Purple Book' (Nursing Home Guidelines, 6th Edition, Partners in Protection, October 2015) is used for guidance on abuse prevention. Pages 6-7, direct facilities that Immediate telephone reporting is required when there is reasonable cause to believe abuse .has occurred, .Any act, when there is reasonable cause to believe the act caused a fear of imminent harm and .An incident of physical assault between residents always has to be reported via the log and/or the hotline to the Department. The facility's failure to implement its policies and procedures for abuse prevention allowed continued restraint use and harm to Resident #1 and placed all residents, especially those with limited cognition, of being treated in the same manner. .

Based on interview and record review it was determined that the facility failed to ensure that its policies and procedures that prohibit abuse were implemented; including training employees to deal with aggressive and/or catastrophic reactions of residents and the reporting of abuse to the required agencies. At least 3 licensed nurses (LN F, LN G, LN H) and 1 nursing assistant (NA J) had direct observation or knowledge of an abusive act to 1 of 4 residents including physical abuse of resident (#1) by 1 Licensed Nurse (LN H). These same 3 licensed nurses (LN F, LN G, LN H) and 1 nursing assistant (NA J) failed to immediately report observations or knowledge of LN H's abusive act to their immediate supervisor, the facility Administrator or the Director of nursing, the state abuse hot-line and local law enforcement per facility policy and procedure for abuse prevention. This failure by multiple staff to report abusive acts as required demonstrated the facility's Abuse Prevention Program was ineffective. The failure to ensure that a thorough Abuse Prevention Program was developed and implemented placed all residents in the facility at potential risk of abuse. Findings include: Policies and Procedures The facility's policy and procedure for abuse and neglect prohibition included clear description of who, staff should report abusive incidents to. However, their Abuse Prevention Program did not evidence what management was doing to ensure that staff were implementing correctly the information on which they were trained. There was no evidence that the facility's prevention program focused on management responsibility to prevent abuse to include such factors as ensuring supervision of staff providing care, particularly on evening and night shifts when there were lower numbers of personnel in the building. Licensed Nurse Observations of Abuse Once the facility was alerted to a physical abuse allegation by LN F on 9/16/16, they began an investigation concerning the physical abuse allegations that occurred 3 days prior. According to an investigation report provided by the facility and interviews with the Director of Nursing Services (DNS) and LN F on 9/28/16, LN F observed LN H commit physical abuse to Resident #1 on 9/13/16 by slapping Resident #1 across the face. LN F did not immediately report the observed abuse to her immediate supervisor, facility administration, or the State hotline for reporting abuse. LN F Stated that the reason she did not report the observation of abuse was that LN G was present and witnessed the abuse; LN G is a charge nurse in the facility and after observing LN H slap Resident #1 across the face she stated no one is going to get in trouble, nobody will say anything. LN F stated she felt intimidated and was afraid to come forward. The facility also identified NA #J as having been present along with LN F, LN G, and LN H at the time that LN H slapped Resident #1 across the left side of her face. Multiple Staff ' s Failure to Report Abuse LN F- did not report the physical abuse immediately when she observed it. LN G- did not report the physical abuse when she observed it. LN H- did not report the physical abuse after slapping a resident in the face that spit at her. NA J- did not report the physical abuse he heard/observed at the time it occurred. The failure of these 4 staff to report abusive acts demonstrated the facility's failure to insure that their abuse prevention procedures were implemented. During an interview on 9/28/16 the DON stated that all of the above staff are aware that they are mandatory reporters and responsible for immediately reporting abuse. LN G and LN H were both terminated from employment at the facility for their parts in the abuse of Resident #1 and attempting to cover it up. LN F was issued a last and final warning for not immediately reporting her observation of abuse. NA J was in-serviced on reporting abuse even when the abuse was witnessed by other staff who are LNs ' . During interviews conducted on 9/28/16, 4 different resident care managers (RCM), revealed that the facility administration is rarely present on nights, weekends or holidays. LN C and LN D indicated that they are unaware of their specific roles in the facilities abuse prohibition policy. LN D indicated that there is an RCM on call 24/7 and that they come in if they are called, but they do not routinely conduct off hour visits to monitor staff. The number of staff members who were witnesses to or had knowledge of abusive acts and failed to intervene or immediately report this knowledge, demonstrated that the facility failed to have an effective abuse prevention program, placing all residents at potential risk of continued abuse.

Based on interview and record review, it was determined the facility failed to ensure supervision to prevent repeated falls with injuries to 1 of 1 former Residents (#1) reviewed for accidents. This failure caused harm to Resident #1 when he became unresponsive after the first unwitnessed fall, incurred a head injury after the second unwitnessed fall and repeated falls and injuries. Findings include: Former Resident #1 was admitted to the facility from the hospital on [DATE] with a primary [DIAGNOSES REDACTED]. Previously he was independent and lived at home with family but was becoming more dependent. The admission note indicated the resident was alert and oriented. Able to make needs known. Pleasant and cooperative with care. Walks well without assistance. Continent of bowel and bladder .independent with activities of daily living. The Nursing Notes (NN) dated 8/6/15 indicated the resident fell at 1:30 a.m. with an injury, Resident with significant decline in condition .remained unresponsive until about 8:00 p.m. when the resident responded to his name and was tearful. The resident's comprehensive care plan dated 8/4/15 indicated after the resident fell while using his walker on 8/6/15. His walker was taken away and his wheelchair was locked and kept at the bedside. According to the Director of Nursing Services (DNS) this was to encourage the resident to use the wheelchair. On 8/7/15 at 11:00 p.m., the NN indicated: Found on floor in, blood around head .3.5 cm laceration to back of head. Walker was out of reach per care plan. On 8/8/15 (no time) days: Resident tried to get out of bed several times in early morning. Medicated for pain at 7:30 a.m. Resident educated to use call light for help and to stay in bed until the nursing assistants (NA) could come as soon as possible. The NN continued: about 7:40 a.m., Resident found sitting on floor with his back next to the bed when the NA arrived .Resident did not use his call light. The Resident has Back pain since last fall at night and increased anxiety .worked with speech therapy this morning . Despite the resident's condition, just being medicated for pain, lack of available walker and inability to use a call light, the nurse left the resident alone when he incurred the another fall. Review of the volunteer hospice (VH) note dated 8/8/15 indicated Nurse reported resident had another fall this morning, slid out of bed, no injury. There was no documentation to indicate interventions were in place to prevent repeated falls to keep the resident safe and that previous interventions were evaluated for effecitveness/changes. Review of the VH note dated 8/9/15 indicated: Per nurse, he fell again last night . There was no documentation to indicate the interventions in place to protect the resident from repeated falls were evaluated other than family with the resident at night. A NN dated 8/9/15 at 5:00 a.m., found bruises on left upper outer thigh measuring 11 x 6.5 cm; left outer shoulder 3.5 x 4 cm; right elbow 4 x 4 cm, faxed doctor. He has had multiple falls last 2 days, we're watching for them. There was no documentation to indicate the interventions in place were evaluated for effectiveness to keep the resident safe from repeated falls and injuries. On 8/11/15 due to the resident's poor safety awareness a safety care plan was created with interventions for bed against the wall, concave mattress and tilt wheelchair. On NN 8/13/15 6:00 a.m. the NN indicated, found large bruise on Right buttocks measuring 17 x 9.5 cm with a 3.5 x 2 cm open area in the center. The left buttock inside center area had a bruise 6.5 x 5 cm. Covered right open area with Alevyn dressing. There was no documentation to indicate the facility determined measures were in place to keep the resident from repeated injuries or the measures implemented on the previous days were effective. On 9/3/15 at 4:00 p.m., the DNS said the first fall could not be predicted because the resident was independent. She would review the other occurrences.

Based on interview and record review, it was determined the facility failed to ensure timely medical care was provided for 1 of 1 former Residents (#1) reviewed for necessary care and services. This failure caused harm to Resident #1 when there was a delay in treatment when he became unresponsive after the first fall and incurred a laceration to the back of his head after the second fall. Findings include: Former Resident #1 was admitted to the facility from the hospital on [DATE] with a primary [DIAGNOSES REDACTED]. Clinic transfer notes at 7:25 p.m. indicated: His mental status has improved with [MEDICATION NAME] (medication to remove toxins and increase alertness) and [MEDICAL CONDITION] reported to be resolved. Prior to admission, the resident was independent and lived at home with family. The admission assessment indicated he was alert and oriented. Able to make needs known, pleasant and cooperative with care, walks well without assistance. Nursing Notes (NN) by Licensed Practical Nurse (LPN) C dated 8/6/15 indicated the resident fell about 1:30 a.m., found on floor, back to cupboard, on knees sitting back on bottom .upper left back 15 x 5 centimeter (cm) abrasion .wound oozing not gaping. The NN at 4:15 a.m. indicated the resident was not responding and an order from the on-call physician monitor for now. Review of the clinic's message report indicated a message was left by LN A with the answering service on 8/6/15 at 5:17 a.m. for the on-call physician, almost 4 hours after the fall and 1 hour after becoming unresponsive. The message detailed the call as patient fall with priority (normal or urgent) of the call identified by the LN as normal. A fax message sent to the clinic by the facility dated 8/6/15 at 8:53 a.m. asked the provider to see the resident due to the 1:30 a.m. fall. According to clinic records at 9:38 a.m. a facility LN called the clinic asking a provider to see the resident today due to status change post fall; non-responsive. On 8/6/15 at 1:00 p.m., the ARNP wrote: Telephone call from facility reporting an acute deterioration of patient's mental status after a fall last night. Neurological Exam: He is unresponsive. Closed head injury post-fall .Goals of care--continue palliative care, when appropriate, may release body to funeral home without calling MD (doctor) on-call. Notify Healthy Aging by fax. The note continued: At 1:30 p.m., the ARNP spoke to resident's mother and agreed to palliative care only . Review of the volunteer hospice (VH) staff notes (not in the facility record) indicated a call from the facility nurse to the volunteer on 8/6/15 at 6:35 a.m. to report the 1:30 a.m. fall. On 9/11/15 at noon, during interview with VH staff, there was a question as to why the facility was informing the volunteer of falls because they have no medical authority over the care of the resident. On 8/7/15 at 11:00 p.m., the NN indicated the resident incurred a second fall in the bathroom and was found on the floor bleeding from a 3.5 cm laceration to the back of his head. The facility called the volunteer at this time. The NN indicated the facility contacted the volunteer group and received directions to put the resident to bed, clean the wound and medicate. There were no care orders from the primary physician. Review of the volunteer's note (not in the facility record) indicated s/he (volunteer) was called by the facility LN around 11:00 p.m. and was told the resident was still on the bathroom floor and blood around his head .Advised they attend to him right away and if needed call 911. The medics would be best able to assist with transfer and evaluate his condition. I recommended they do a thorough assessment before determining the need for transport to the hospital. The volunteer requested a call back from the facility with an update but did not receive a return call. The documentation was unclear why the facility was contacting and taking direction from a volunteer group with no medical authority for the resident. According to the physicians' clinic message detail reports, LN C left a message with the answering service on 8/8/15 at 12:50 a.m. for the on-call provider related to all with injuries with a normal priority. The clinic telephone encounter documentation from a second on-call physician was dated 8/8/15 at 7:03 a.m. and reported what had been said by facility staff: Resident complained of head pain and dizziness and has an area of swelling and bruising on his head .plan to increase pain medications and apply ice to the bruising. The note did not indicate awareness of a bleeding [MEDICAL CONDITION] or the increased pain medications already in place from a previous provider's order. <Medications> Review of physician orders [REDACTED]. According to Lippincott Drug Manual, 2014, [MEDICATION NAME] is metabolized in the liver and excreted in the urine and should be used with caution in the those with head injury, severe hepatic (liver) or renal (kidney) disease .monitor 30 minutes after administration for respiratory depression, slow pulse, low blood pressure and respiratory or [MEDICAL CONDITION]. Keep [MEDICATION NAME] ([MEDICATION NAME]-narcotic antagonist) and resuscitation equipment available. The clinical records failed to indicate consistent assessments and monitoring of the [MEDICATION NAME] were done. The Medication Narcotic Count Record (MNCR) indicated the resident received 40 mg of liquid [MEDICATION NAME] (narcotic [MEDICATION NAME] concentrate for pain management) and intermittent 8 mg tablets of [MEDICATION NAME] (narcotic [MEDICATION NAME]) by mouth prior to the fall on 8/6/15. After the fall, the [MEDICATION NAME] increased to 130 mg on 8/6/15 with additional doses of [MEDICATION NAME] and anti-anxiety medications by mouth. On 8/7/15 at 11:05 p.m., after the 2nd fall with [MEDICAL CONDITION] and increased restlessness, the MNCR indicated on 8/8/15, the resident received 260 mg of [MEDICATION NAME] with intermittent 8 mg tablets of [MEDICATION NAME] and anti-anxiety medications by mouth without documentation to indicate why the [MEDICATION NAME]/[MEDICATION NAME] was not given by alternate route if necessary to help remove the toxins that cause mental confusion ([MEDICAL CONDITION]). The Medication Administration Record [REDACTED]. The medications were consistently held from 8/6/15 through the day he passed away on 8/14/15, without documentation to indicate the physician and legal representative were involved in the decision to withhold medications or that timely discussion occurred related to alternate routes of medications or the amount of [MEDICATION NAME] that was being given. <Oxygen and Catheterization Trauma> A NN dated 8/9/15 at 10:40 p.m. indicated: Oxygen saturation at 62% (normal range 92-100%) on room air. Resident non-responsive. Breaths are shallow. No oxygen was provided at this time. The NN on the following day on 8/10/15 at 10:35 p.m. indicated: Oxygen saturation at 85% on room air. Placed on oxygen for comfort measures . after voiding in brief, urine (Foley) catheter inserted without return .non-responsive during evening, nothing by mouth, shallow breathing. At 2:00 a.m., Blood found at penis opening .no catheterization was performed due to prior trauma from catheterization. Failure to ensure the resident was assessed and evaluated by the provider in a timely manner after the first fall on 8/6/15 to ensure the resident's wishes were honored to receive timely medical care related to his rapid decline after his falls; received his ordered medications and/or orders for alternate routes for medications, was adequately assessed and monitored for pain management and received oxygen impacted his comfort and quality of life until his passing the early morning of 8/14/15.

Based on interview and record review, it was determined the facility failed to consult with the physician and to inform/consult with the legal representative in a timely manner when significant changes in condition; discontinuation of medications; increased narcotics/pain medication; need for oxygen and injury from a catheter insertion occurred for 1 of 1 former Residents (#1) reviewed for notification of changes. This failure resulted in harm to Resident #1 when the primary physician and his legal decision maker were not included in treatment decisions and when physician intervention was warranted. Findings include: Former Resident #1 was admitted to the facility from the hospital on [DATE] with a primary [DIAGNOSES REDACTED]. The admission note indicated the resident was alert and oriented, independent with daily living tasks, ambulatory and made his own care decisions. The facility's policy for Notification of Resident Change in Condition indicated:Notify the physician and family or legal representative immediately, if there is a significant change, regardless of the time .If an emergency, call area emergency number, 911 . Document in the Nurse Progress Notes the times notification was made and the names of the person(s) to whom you spoke. <Falls and Significant Change> A Nursing Note (NN) dated 8/6/15 indicated former Resident #1 had an unwitnessed fall around 1:30 a.m. He was found on floor with a 15 x 5 centimeter (cm) abrasion to his back .wound oozing blood, not gaping .unresponsive at 4:00 a.m. The NN indicated the resident remained unresponsive until around 8:00 p.m. that day. During interview with the legal decision maker on 9/4/15 at 4:00 p.m., she said: They didn't call me until about 6:30 in the morning .I was just getting up to come in to see him when they called to say he had a fall around 1:30 in the morning (8/6/15). They said they didn'tt call earlier because they didn't want me to worry needlessly. I didn't know he hurt himself. They said he was unconscious for a few minutes and that he was better by morning and responsive. After that fall, he got worse really fast . The record indicated the resident incurred a second unwitnessed fall and was found on the bathroom floor on 8/7/15 at 11:00 p.m. bleeding from a 3.5 centimeter (cm) laceration to the back of his head. When the legal decision maker was asked about not sending the resident to the hospital she said: That's not exactly right. I was really upset the first time (8/6/15) and I was told a doctor would see him that day. Then when I was told he had fallen again (8/7/15) and hit his head .it was so bad. I wanted him checked out but they said the doctor would come in to see him first. No doctor ever came in to see him and then after the second fall, he really never woke up. I felt it was not going to be helpful to send him (to the hospital) after so long of a time . <Medication> Review of the physician orders [REDACTED]. The Medication Administration Records (MAR) indicated medications were held after the 8/6/15 fall as the resident was non-responsive and they were consistently held from 8/6/15 through 8/14/15, prior to the resident's passing without documentation to indicate the physician and legal representative were notified. On 9/3/15 at 4:30 p.m., during review of the record with the Director of Nursing Services (DNS) she acknowledged there was no documentation the physician and legal decision maker were consulted about the medications because they were probably stopped because he couldn't swallow anymore. <Oxygen and Catheterization> A facility NN dated 8/9/15 at 10:40 p.m. indicated Oxygen saturation at 62% on room air (reference range 92-100%). Resident non-responsive. Breaths are shallow. No documentation was found to indicate the low oxygen level was reported to the physician or legal decision maker. The Physical Therapist's note dated 8/10/15 indicated the resident's oxygen saturation was 87% and (Resident) unable to follow commands. The NN at 10:35 p.m. indicated Oxygen saturation at 85% on room air. Placed on oxygen for comfort measures . The NN continued: after voiding in brief, urine (Foley) catheter inserted without return .non-responsive during evening, nothing by mouth, shallow breathing. At 2:00 a.m., Blood found at penis opening .no catheterization was performed due to prior trauma from catheterization. Documentation failed to show the physician was consulted or the legal decision maker was notified/consulted about the low oxygen saturation or the insertion of a urinary catheter and trauma that occurred. On 9/18/15 review of clinic records and interview with an associate revealed no documentation to indicate physicians were consulted regarding stopping the medications, low oxygen levels, increased amount of [MEDICATION NAME] administered or trauma from the catheter insertion. Failure to ensure the physician was consulted and the legal decision maker was notified/informed of care and treatment changes prevented them from being involved in the Resident's care and services and impacted the Resident's health status, pain, comfort and quality of life prior to his passing on 8/14/15. Refer to F 309.

Based on interview and record review, it was determined the facility failed to log, investigate and/or report unwitnessed falls and significant injuries to the facility administration and/or appropriate agencies for 1 of 1 former residents (#1) reviewed for possible neglect, abuse and/or mistreatment. This failure prevented opportunities to perform thorough investigations to ensure the resident was protected from repeated falls and injuries. Findings include: Former Resident #1 was admitted to the facility from the hospital on [DATE] with a primary [DIAGNOSES REDACTED]. During the resident's stay in the facility, the clinical record indicated he incurred an unwitnessed fall on 8/6/15 at 1:30 a.m. with injury to his upper left back 15 x 5 centimeter (cm) abrasion .wound oozing, not gaping. This was not found on the reporting log when reviewed on 8/26/15. Another unwitnessed fall occurred on 8/7/15 at 11:00 p.m., when he was found on his back on the bathroom floor with blood around head .3.5 cm laceration to back of head. This occurrence was not found on the reporting log when reviewed on 8/26/15. A third unwitnessed fall occurred on 8/8/15 around 7:40 a.m., when the resident was found sitting on floor with his back next to the bed .Back pain since last fall at night and increased anxiety. This occurrence was not found on the reporting log when reviewed on 8/26/15. A NN dated 8/9/15 at 5:00 a.m., indicated: found bruises on left upper outer thigh measuring 11 x 6.5 cm; left outer shoulder 3.5 x 4 cm; right elbow 4 x 4 cm, faxed doctor. He has had multiple falls last 2 days, we're watching for them. There was no documentation to indicate staff reported these injuries to administration for investigation. There was no investigation report and this was not found on the reporting log when reviewed on 8/26/15. On 8/26/15 at 4:30 p.m., during interview with the Director of Nursing Services (DNS), she said she was on vacation and the person covering for her must not have known or forgot what should be done and she would follow up. Refer to F 323 .

Based on interview and record review, the facility failed to conduct ongoing assessments, evaluate the resident's clinical conditions, pressure ulcer risk factors, define and implement interventions consistent with the resident needs and identified goals. The facility also failed to monitor and evaluate the impact of the interventions; and/or revise the interventions as appropriate for 1 of 9 residents (former resident #1) reviewed for pressure sore development. This failure caused harm to Resident #1 who was noted to have an unidentified pressure wound. Findings include: Interviews took place 6/18/2013 unless otherwise indicated. Resident #1 was re-admitted to the facility on [DATE] after having an episode of pneumonia. Documentation indicated, Resident had been a long term resident of the facility. Prior to having the pneumonia and going to the hospital on [DATE] she was reportedly able to get about the facility in her wheelchair/scooter and socialize with other residents. According to the documentation in the progress note written at 1830 (6:30p.m.) on 5/11/13, the resident was alert and oriented x 3 and she was having some problems swallowing. Resident required 2 staff assist with transfers and toileting. Resident was documented as being incontinent of urine. The skin assessment completed on 5/11/13 by two licensed staff indicated there were no skin issues on her buttocks. The Braden Risk Assessment Scale (tool used to determine risk for skin breakdown) completed on 5/11/13 was scored at 15 which indicated resident was at minimal risk for skin breakdown. Her care plan indicated she had a pressure reducing mattress. On 5/14/13 Resident #1 was seen by the physician. The physician documented, "patient more somnolent..." and she was far from her "baseline". According to documentation in the progress notes written 5/15/13 at 1015(1015a.m.) resident was no longer strong enough for sera lift and had been downgraded to a Hoyer lift for safety. Resident was more lethargic since admit. There was no evidence found in the medical record to suggest the staff re-evaluated her risk of skin breakdown, or changed her care plan to prevent skin breakdown even though she was more somnolent and unable to transfer without a mechanical lift. Resident had a Foley catheter (tube into the bladder to drain urine) placed 5/14/13 though there was no documentation as to why it was placed. Documentation on 5/18/13 at 2245 (1045p.m.) said, "Upon completing routine care my aid informed me of skin irritation. During my assessment I found that the x-large briefs were rubbing her skin to the point of causing red irritated areas all along the borders of the briefs on the resident ' s legs." An order was received for treatment to the excoriations be done twice a day. In review of the resident's treatment sheets, the treatment was completed on the evening shift of 5/20 and 5/21 only. In review of the treatment sheets which indicate the completion of weekly skin checks, there was no evidence of skin checks being done after her re-admit on 5/11/13. On 5/21/13 the physician again saw the resident and he documented, "...is actively declining." According to the physician documentation resident had end stage [MEDICAL CONDITION] [MEDICAL CONDITIONS] and increased pain. She had decreased intake and was given intravenous hydration on 5/21/13. Again, there was no noted change to the resident's plan of care. According to documentation in the EHSI - CNA Skin Detail Report (documentation tool for the aides to document their observations) there were no skin issues noted between 5/11 and 5/21. Even though on 5/18/13 the aide had reportedly informed the licensed nurse there was red irritated areas. On 5/22/13 there was noted skin issue made by the CNA which was reportedly reported to the nurse. Unable to determine from the documentation made by the nurse if or when the issue was brought to her attention. Documentation written in the progress notes on 5/22/13 at 0120 (120a.m.), "...Patient also with worsening of wound to buttocks; wound now on (B) buttocks (both buttocks) and coccyx area. Yellow dot initiated and allevyn gentle border dressing applied. MD (physician) faxed. Request made to central supply to order bariatric air mattress." In the fax sent to the physician 5/22/13 it was written, "Also patient noted to have worsening of pressure area to buttocks. Now on (B) buttocks. Measurements not obtained secondary to paramedics in room waiting to transport, but would estimate approximately 25cm x 15cm with some areas of shearing present. Allevyn gentle border dressing applied prior to sending out to the emergency room . How would you like to continue to treat? Could we have an air mattress order too? We will increase frequency of turning to every 1 to 2 hours and as needed." During a telephone interview on 6/22/13 S#A (staff) about her documentation of the worsening wound to the buttocks; she stated she was comparing the wound to what she remembered from the last time she had viewed the resident's buttocks which was on 4/24/13. She admitted she had not viewed the resident's buttocks since April and assumed the wounds were the same ones and not something new. She was unaware the resident had been re-admitted on [DATE] without any wounds on her buttocks. In a review of the report from the emergency department, it was documented the resident arrived with "well-circumscribed sacral decubitus ulcers without surrounding [DIAGNOSES REDACTED] (redness)."

Based on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 4 diabetic residents (#117) of 15 residents reviewed for medication administration. This failure occurred when the resident received too much diabetic medication and sustained a life threatening event requiring emergency medical intervention. This caused harm to the resident. Findings include: Resident #117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had orders to receive Humalog insulin (a rapid acting insulin) before each meal. He received [MEDICATION NAME] (a long acting insulin) once a day in the morning. Resident #117 had orders to self-inject the Humalog insulin that came in a pre-filled pen from the pharmacy. The order noted the nurse had to observe the self-injection process and document the resident received the insulin as ordered. The resident's Minimum Data Set (MDS), an assessment tool, dated 07/04/12, indicated the resident was cognitively intact and participated in his health care decisions. Resident #117's care plan, dated 6/28/12, documented the resident had a potential for alteration in blood glucose levels related to insulin dependent diabetes. The care plan documented the nurse was to "administer insulin per physician order [REDACTED]." On 7/13/12 at 10:00 a.m., Resident #117 was observed in his room with his wife (Resident #218). Resident #117 and Resident #218 recalled an incident when Resident #117 said he was overdosed with insulin. Resident #218 said she had been "so afraid" she was "still exhausted" from the event. On 7/13/12 at 10:00 a.m., Resident #117 said he usually had the nurse inject the insulin pen for him three times a day. Resident #117 said on 7/08/12, around 8:30 p.m., the nurse on duty (LN A) injected him with a "syringe of insulin." Resident #117 said this was after she gave him the Humalog pen injection just before he ate dinner. Resident #117 said he knew he should not have been gotten a second dose of insulin, but he did not question the nurse at the time because she must have known what she was doing. Resident #117 said he was "knocked out" by the overdose of insulin. He could not recall anything more about his condition until he woke up from his "coma" just before 11:00 p.m., while 911 medics (emergency medical team from the local fire department) were working on him in his room. On 7/17/12 at 10:12 a.m., Resident #117 stated, "I was very upset and fearful after the incident happened. I did not want the nurse back after she overdosed me with insulin. She came to my room (two days later) and we had to tell her she could not care for me again after the incident. I am not happy about this, but at least I survived. No one in management came to tell me there was an error. (LN B) told me the nurse (LN A) gave me a second dose of insulin. (LN A) was only to give me one evening dose. She did the pen and then gave me an injection of insulin. I should have just had the pen, but (LN A) gave me the injection, too. This is why I know I got overdosed with insulin." On 7/13/12 at 10:00 a.m., Resident #117's spouse (Resident #218) said, "On Sunday night (7/08/12) I woke up and (Resident #117's) light was on. He was sitting up in bed and (LN A) was in a chair. I asked what was going on and (LN A) said his blood sugar level was low. She then pushed a sandwich to my husband's mouth telling him to eat, eat, eat. (LN A) kept trying to get him to eat a peanut butter sandwich. By this time, he was in a coma. I said he would choke. (LN A) told me to pat his hand and then left and said she would return in 15 minutes. His eyes were closed and he was gurgling. (LN A) did not come back and (Resident #117) was getting worse. He was cold and sweating so much his blankets were wet. I called our doctor friend and she said to call 911. I called 911. He started jerking. I pushed the call light, but no one came. I went to the hall and started yelling for help. Then people started coming and stood at his bed. (LN C) was the night nurse. She had a needle and gave him some kind of shot. After 911 came, (Resident #117) finally opened his eyes. They gave him an IV and he came back." Resident #218 said she had been so afraid the evening of the incident when LN A never came back to help Resident #117 and he was unconscious from the overdose. Resident #218 said she did not want LN A to ever work with Resident #117 or herself again. Resident #218 said none of the managers came to ask her or her husband what had happened until the survey team came to the building on 7/12/12. Resident #218 thought her husband was going to die on 7/08/12. Record review of chart notes, dated 7/08/12 at 10:00 p.m., written by LN A, regarding Resident #117 documented, "...BG (blood sugar level) at 24 (which is considered a dangerously low level requiring instant intake of glucose-sugar)...gave one tube glucose gel and OJ...sugar rechecked BG = 24. Night nurse was called to room and saw resident with jerky movements, gave [MEDICATION NAME]. Resident's spouse called 911. EMTs responded and gave IV glucose, BG =227." The chart notes indicated the medics came to transport Resident #117 to a hospital, but he was responsive and stable by 10:50 p.m. The resident did not go to the hospital. Record review of chart notes, dated 7/09/12 at 3:10 a.m., written by LN C, documented, "At 10:20 p.m. (on 7/08/12) found nonresponsive resident with wife at bedside upset. BG = 24, administered [MEDICATION NAME] 1 mg IM (intramuscular injection) in left thigh. Wife called 911. At 10:30 BG = 27...At approximately 10:35 p.m. EMS arrived, placed IV (a tube inserted directly into a blood vessel)...administered IV [MEDICATION NAME] 10:45 p.m. resident becoming responsive. At 10:50 p.m. BG = 227 via EMS glucometer." On 7/12/12 at 4:30 p.m., the Administrator said he felt Resident #117 had self-injected too much insulin indicating the resident had caused the overdose. On 7/16/12 at 3:35 p.m., LN B said "(Resident #117) knows his insulin. If he said he got a double dose, he did. We keep the needles in the cart. He had his pen in his top drawer, but we always keep the needles. We take the needle, set it up and have to watch him do the injection. His order says to give the Humalog three times a day before each meal. There would be no reason for him to get a second dose of Humalog or any other insulin after dinner. That would make him crash with his blood sugars. He has no way to give himself an injection on his own without a nurse present. He got too much insulin that night and that is why he was unresponsive." On 7/17/12 at 9:00 a.m., LN D said Resident #117 could self-inject his insulin pen only after the licensed nurse placed a needle in the pen and dialed the correct dose for the resident. The nurse would then hand the pen to the resident for the self-injection. LN D said the nurse would document the resident had received his dose of insulin. LN D said Resident #117 had no access to insulin to self-inject on his own. LN D said, "The nurse has to supervise the dose and the injection at the time it is given." On 7/16/12 at 3:00 p.m., the Interim Director of Nursing Services (IDNS) said the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The facility determined LN A did not give the correct dose of insulin to the resident. The IDNS said, "She double dosed him." The IDNS acknowledged LN A gave a second dose of insulin to Resident #117 on 7/08/12 causing him to have dangerously low blood sugar levels requiring emergency medical intervention. The IDNS said she had no conversation with LN A to determine why Resident #117 sustained an overdose of medication. On 7/17/12 at 2:00 p.m., the Administrator said, "In the end, when we investigated we decided (LN A) did overdose him," but it was a transcription error and the facility did not ensure the MAR indicated [REDACTED]. The Administrator said it was unfortunate that LN A was an agency nurse that may have not known the resident or facility policies that well. When asked how the facility ensured agency staff was oriented to the residents and facility policies, the Administrator stated they had to sign a one page orientation sheet before they began working on the floor. The Administrator could not locate an orientation sheet signed by LN A. The Administrator said he did not file a written report with LN A's agency regarding the overdose. He only asked the agency to not have her return to work in the facility because the residents "did not want her back." On 7/08/12, from approximately 9:00 p.m. to 11:00 p.m., Resident #117 experienced a life threatening event when his blood sugar level dropped dangerously low and remained low for at least an hour. The resident was left unattended for at least 15 minutes, by LN A, while he was unresponsive after receiving too much insulin given by LN A. This event resulted in the 911 emergency medic team (notified by the resident's spouse) coming to the facility and placing an IV in the resident to give him a third dose of emergency glucose to revive him from an unresponsive state while under the care of the facility staff. Refer to F-333 .

Based on interview and record review, the facility failed to ensure 1 of 4 current diabetic residents (#117) of 15 residents reviewed for medication administration was free from medication errors. This failure caused harm to the resident when he received too much insulin. Findings include: According to nursing literature by Lippincott Williams and Wilkins (2003) entitled, Complete Guide to Documentation, page 257: "The MAR (Medication Administration Record) serves as the central record of medication orders and their execution." According to the Lippincott Fundamentals of Nursing 7th Edition 2011, page 738, "The five rights help to ensure accuracy in medication administration: right medication, right client, right dosage, right route and right time." Resident # 117 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had orders to receive 10 units of Humalog insulin (a rapid acting insulin) before each meal. He received 10 units of [MEDICATION NAME] (a long acting insulin) once a day in the morning. Resident #117 had orders to self-inject the Humalog insulin that came in a pre-filled pen from the pharmacy. The order noted the nurse had to observe the self-injection process and document the resident received the insulin as ordered. Medication Administration Records (MAR) for Resident #117, dated 6/27/12, documented the resident was to receive Humalog 100 units/ml vial (10 ml) Inject 10 units Sub-Q 3 x daily after meals. The MAR also documented, "Info Only-OK for resident to use insulin pen Humalog 75/25 for self- insulin admin with staff supervision." On 7/16/12 at 3:00 p.m., the Interim Director of Nursing Services (IDNS) said Resident #117 sustained a significant medication error on 7/08/12 when LN A administered a second dose of insulin that was not ordered for the resident. The IDNS said the MAR with Resident #117's insulin order was not correct. The MAR should have been written to give the Humalog before dinner not after. The IDNS said the physician order [REDACTED]. There was no order for the resident to receive a dose of Humalog or any other insulin after dinner. The IDNS said the facility determined that LN A read the incorrect MAR and gave a pen injection of Humalog before dinner, and then after dinner gave an additional 10 units of Humalog via a syringe on 7/08/12. The IDNS acknowledged this caused the resident to have dangerously low blood sugar levels requiring emergency medical treatment from the local 911 emergency response medic team. The IDNS said it was facility policy for each nurse to ensure the MAR was the correct order from the physician before placing it in the medication book to be followed by the nursing staff for medication administration. The IDNS said the facility had not determined why the MAR was allowed to be in the medication book when it was incorrect. The IDNS acknowledged the MAR had been incorrect from 6/27/12 through 7/09/12. The IDNS said the facility had not determined who had not followed procedure regarding the incorrect MAR. There had been no issues regarding the resident until LN A incorrectly gave an additional dose of Humalog insulin when she misread the incorrect MAR. The IDNS said the MAR was confusing but she had no conversation with LN A regarding professional standards of administering insulin. The facility did not question LN A as to why she would give a dose of insulin before and after dinner even in light of a "confusing" MAR. On 7/16/12 at 3:35 p.m., LN B said he knew Resident #117 was to receive his Humalog before meals. He acknowledged the MAR was not correct as written on 6/27/12. LN B said even though the MAR said "after dinner" he would never give an "additional" dose of insulin after dinner. LN B said he understood through his nursing knowledge the MAR did not direct you to give an additional dose of insulin even though it had been written incorrectly. The facility did not ensure they had correct medication administration records for Resident #117. The facility did not ensure that a contracted agency nurse did not give a double dose of insulin, placing the resident in a life threatening situation when he became unresponsive and required emergency medical intervention. Refer to F-309 .