Every finding on record at Shoreline Health and Rehabilitation

Based on observation, interview, and record review, the facility failed to ensure the water management program included an Infection Preventionist and an appropriate agency to report an outbreak. Additionally, the facility failed to follow infection control practices for disinfection of shared medical equipment and/or hand hygiene by 2 of 8 staff (Staff I and Staff S) and ensure hand hygiene products and supplies were readily available and accessible for 1 of 1 medication room (Second Floor Medication Room), reviewed for infection control. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications.Findings included. WATER MANAGEMENTReview of the undated facility's document titled, Water Management Program, showed, Contact the Snohomish County Health Department to report any outbreak or cases of Legionellosis [or Legionella - bacteria found in water that can cause pneumonia [a lung infection] or other water-borne illnesses [diseases caused by contaminated water] . Further review showed, Healthcare facilities water management team should include someone who understands accreditation of licensing requirements, someone with expertise in infection control, a clinician with expertise in infectious diseases, and risk/quality management staff. The document further showed that the Infection Preventionist was not part of the risk management team. A joint record review and interview on 03/23/2026 at 11:03 AM with Staff C, Maintenance Supervisor, showed the water management should include someone who understands accreditation of licensing requirements, someone with expertise in infection control, a clinician with expertise in infection diseases, and risk/quality management staff. Staff C stated that the risk water management team consisted of Staff A, Administrator, Staff B, Director of Nursing, Staff C, and a Regional Maintenance Director. When asked if an Infection Preventionist staff member was part of the water risk management team, Staff C stated that Staff B was part of the water risk management team. In an interview on 03/23/2026 at 2:56 PM, Staff N, Registered Nurse Practitioner, stated they previously worked at the facility as an Infection Preventionist. When asked if an Infection Preventionist staff member was part of the water risk management team, Staff N stated that Staff B was a member of the water management risk team. A joint record review and interview on 03/24/2026 at 12:53 PM with Staff A, the water management plan showed that legionella outbreaks would be reported to the Snohomish County Department of Health. Staff A stated that it should have been King County Department of Health. A joint record review of the water risk management team showed that the Infection Preventionist was not part of the water risk management team. Staff A stated that Staff B was part of the risk management team. When asked if Staff B was a certified infection preventionist, Staff A stated no. DISINFECTING MEDICAL EQUIPMENT Review of the facility's policy titled, Infection Prevention and Control Program, revised in October 2022, showed, The facility will provide areas, equipment. to implement its Infection Control Program with the goal of.effective cleaning and disinfecting equipment as needed. STAFF I An observation on 03/22/2026 at 12:51 PM showed Staff I, Certified Nurse Assistant, pushed a Hoyer Lift (a mechanical lift used for transfer) out of room [ROOM NUMBER]. Staff I continued to push the Hoyer lift down the unit hallway and parked it at a corner. Staff I then walked back to room [ROOM NUMBER]. No disinfecting or sanitizing of the Hoyer lift was observed. In an interview on 03/22/2026 at 12:55 PM, Staff I stated that they were expected to disinfect residents' equipment after use. When asked if they had disinfected the Hoyer lift used in room [ROOM NUMBER], Staff I stated, No. I should have sanitized it right away after using it. In an interview on 03/22/2026 at 1:12 PM, Staff J, Licensed Practical Nurse, stated that staff were expected to wipe down the machine [Hoyer lift] before and after use, using the sanitizing wipes. HAND HYGIENE Review of the facility's policy titled, Handwashing/Hand Hygiene, revised in October 2023, showed, Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc. [etcetera]) are readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Alcohol based hand-rub (ABHR) dispensers are placed in areas of high visibility and consistent with workflow throughout the facility. STAFF I An observation on 03/22/2026 at 12:54 PM showed Staff I went out of room [ROOM NUMBER] carrying a clear plastic bag with soiled linens and went to the soiled utility room. With the soiled utility door halfway opened, Staff I dropped the plastic bag in the bin then went towards the end of the hallway and walked back towards the nursing station and stood there. Staff I did not perform hand hygiene. Further observation showed a hand sanitizer attached to a wall about four feet away from the soiled utility room was not accessed by Staff I. In an interview on 03/22/2026 at 12:56 PM, when asked if they were expected to perform hand hygiene after handling soiled linens, Staff I stated, Yes. I should have done hand hygiene and I did not. In an interview on 03/22/2026 at 1:12 PM, Staff J stated that staff were expected to perform hand hygiene after handling soiled linens. In an interview on 03/22/2026 at 1:26 PM, Staff G, Resident Care Manager (RCM), was asked if a staff needed to wait before disinfecting or sanitizing an equipment used for a resident, Staff G stated, No, you have to sanitize it right away because somebody else might use it. Staff G further stated that they expected staff to sanitize before and after using the Hoyer lift and to perform hand hygiene after handling soiled linens. In an interview on 03/23/2026 at 2:30 PM, Staff N stated that they expected staff to disinfect resident's equipment after use and to perform hand hygiene after handling soiled linens. In an interview on 03/24/2026 at 10:12 AM, Staff B stated that they expected staff to disinfect the Hoyer lift before and after use and that they should use the sanitizing wipes with a purple top to wipe down the equipment. Staff B further stated that they expected staff to perform hand hygiene after handling soiled linens. STAFF SObservation on 03/21/2026 at 7:51 AM, showed Staff S, Registered Nurse, was opening the medication cart and started preparing Resident 30's morning medication. Staff S did not perform hand hygiene prior to preparing Resident 30's medication. After preparing the resident's medication, Staff S entered Resident 30's room, gave Resident 30 their medication, and touched and moved the resident's bedside table. After medication administration, Staff S left Resident 30's room without performing hand hygiene. Further observation showed Staff S started documenting medication administration and continued working on their medication cart without performing hand hygiene. Observation on 03/21/2026 at 8:04 AM, showed Staff S opened the medication cart started preparing Resident 11's morning medication. Staff S did not perform hand hygiene prior to preparing Resident 11's medication. After preparing the resident's medication, Staff S entered Resident 11's room and administered their medication without performing hand hygiene. In an interview on 03/21/2026 at 8:24 AM, Staff S stated that hand hygiene would be performed before and after each medication administration. Staff S stated that hand hygiene should have been performed before Resident 30's and Resident 11's medication preparation and after medication administration. HAND HYGIENE SUPPLIES-SECOND FLOOR MEDICATION ROOMDuring a joint observation and interview on 03/21/2026 at 2:49 PM, with Staff H, RCM, showed that the Second-Floor Medication room hand-washing station's soap dispenser was blocked by a small over-the-counter refrigerator, making it difficult to access. Additionally, the medication room lacked paper towels, a wastebasket, and/or an ABHR dispenser. Staff H stated that there should be paper towels and wastebasket available in the room and the soap dispenser should be accessible. In an interview on 03/23/2026 at 11:07 AM, Staff N stated that hand hygiene should be performed both before and after administering medications to residents. Staff N stated that hand hygiene supplies should have been readily available in the medication room. On 03/23/2026 at 11:47 AM, Staff B stated that staff were expected to perform hand hygiene before and after medication administration. Staff B stated that there should have been hand sanitizers available in the medication room. Reference: (WAC) 388-97-1320 (1)(a)(c)(2)(b)(5)(a)(c) .

Based on observation, interview, and record review, the facility failed to ensure food stored were handled appropriately in accordance with professional standards of food safety for 1 of 1 kitchen refrigerator (Kitchen Walk-in refrigerator) and 1 of 8 staff (Staff T), reviewed for food services. The failure to discard food items and perform hand hygiene when assisting residents with their meals, placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross-contamination, and a diminished quality of life.Findings included.Review of the facility's policy titled, Food Procurement, Storage and Distribution, updated on 07/08/2022, showed, The facility, store, prepare, distribute and serve food in accordance with professional standards for food service safety.Follows proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Safe food handling for the prevention of foodborne illnesses begins when food is received from the vendor and continues throughout the facility's food handling processes.KITCHEN'S WALK-IN REFRIGERATORIn a joint observation and interview on 03/18/2026 at 6:31 AM with Staff D, Dietary Supervisor, showed one clear bag of purple seedless grapes stored inside the kitchen walk-in refrigerator shelf with white hairy/fuzzy substance on the grapes. Staff D stated that the white fuzzy substance on the grapes looks like mold and that it should not have been there.In an interview on 03/24/2026 at 11:31 AM, Staff A, Administrator, stated that they expected staff to follow their policy for food storage and procurement of purple seedless grapes.HAND HYGIENE DURING ROOM TRAY DELIVERYAn observation on 03/18/2026 at 7:51 AM showed Staff T, Director of Rehabilitation, was pushing the meal cart from East 1 nurses' station to outside of room [ROOM NUMBER]. Staff T took out the meal tray and delivered it to room [ROOM NUMBER]. Staff T then exited room [ROOM NUMBER] with the plate warmer lid and placed it on top of the meal cart. Staff T did not perform hand hygiene. Further observation showed Staff T opened the meal cart and took out the meal tray and delivered it to room [ROOM NUMBER]. Staff T placed the meal tray on the bedside table, removed the lid, and exited room [ROOM NUMBER]. Staff T did not perform hand hygiene before and after they delivered meal trays to room [ROOM NUMBER] and room [ROOM NUMBER].In an interview on 03/18/2026 at 08:05 AM, Staff T stated that they would perform hand hygiene before they go into a resident's room and when they go out of resident's room. Staff T further stated that they should have performed hand hygiene between meal tray delivery to room [ROOM NUMBER] and room [ROOM NUMBER].In an interview on 03/24/2026 at 10:56 AM, Staff B, Director of Nursing, stated that they would expect staff to perform hand hygiene before and after delivering meal trays to residents.Reference: (WAC) 388-97-1100 (3).

Based on observation, interview, and record review, the facility failed to provide an ongoing program of activities for 3 of 4 residents (Residents 8, 55 & 71), reviewed for activities. This failure placed the residents at risk for dissatisfaction with their activity choices, poor psychosocial well-being, and boredom.Findings included . Review of the facility's policy titled, Activities Programming, revised in April 2025 showed, it is the policy of this facility to ensure that activities are available to meet resident needs and interests that support the physical, mental, and psychosocial well-being of the resident. The policy further showed that activities were intended to enhance [residents'] well-being and to promote or enhance physical, cognitive, and emotional health. RESIDENT 8Review of a face sheet printed on 03/23/2026 showed Resident 8 admitted to the facility on [DATE] with diagnoses that included walking difficulty and need for assistance with personal care. Review of the quarterly Minimum Data Set (MDS-an assessment tool) dated 02/20/2026 showed that Resident 8 was mildly impaired with cognition. The assessment showed it was somewhat important for Resident 8 to do things with groups of people and to do their favorite activities. Further review of the assessment showed that Resident 8 required substantial/maximal assistant (Helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort) with transfers and dressing. Review of Resident 8's comprehensive care plan printed on 03/23/2026 showed, Invite to and encourage activities with a low stimulation environment when available. [Resident 8] has an updated activity calendar in [their] room. On 03/18/2026 at 10:49 AM, Resident 8 was in bed and expressed a desire to participate in activities, stating they were not offered to them. Observation showed an activity program was concurrently in progress in the second-floor dining room. Observation on 03/19/2026 at 9:58 AM showed that Staff F, Activity Director, was inviting residents to the activity program scheduled at 10:00 AM. Further observation showed Resident 8 was in bed and stated they were not offered a chance to participate in the activity. Observation on 03/20/2026 at 10:11 AM, showed there was an exercise activity going on in the second-floor dining room. There were few residents participating but Resident 8 was not attending the exercise program. Observation on 03/20/2026 at 10:18 AM showed Resident 8 was resting in bed wearing their nightgown with their television off. Resident 8 stated that their TV remote was missing, requiring them to ask staff for assistance whenever they wanted to watch TV. Further observation of Resident 8's bedside table, nightstand and nightstand drawer showed there was no TV remote. Additionally, no activity calendar was posted in the resident's room. Review of the January 2026 documentation survey report showed one recorded activity for Resident 8, with no documentation of activity refusals during that month. Review of the February 2026 documentation survey report showed six recorded activities for Resident 8, with no documentation of activity refusals during that month. Review of the March 2026 documentation survey report showed six recorded activities for Resident 8, with no documentation of activity refusals during that month. RESIDENT 55Review of a face sheet printed on 03/20/2026 showed Resident 55 was admitted to the facility on [DATE] with diagnoses that included difficulty walking and need for assistance with personal care. Review of the quarterly MDS dated [DATE] showed that Resident 55 was mildly impaired with cognition. Further review of the assessment showed Resident 55 was dependent on staff with transfers and dressing. Review the quarterly activity evaluation dated 01/07/2026 showed, Activities will continue to meet with [Resident 55] on regular basis to ensure that [their] activity needs are being met. [Resident 55] has an updated activity calendar in [their] room. On 03/18/2026 at 12:30 PM, Resident 55 was in bed and expressed a desire to participate in activities, stating they were not offered to them. Observations on 03/19/2026 at 2:01 PM showed an activity program was underway in the second-floor dining room, however, Resident 55 was in bed with their nightgown on. Further observations on 03/20/2026 at 10:29 AM, on 03/21/2026 at 10:24 AM, and on 03/23/2026 at 9:12 AM showed Resident 55 was in bed with their nightgown on. Review of the January 2026 documentation survey report showed one recorded activity for Resident 55, with no documentation of activity refusals during that month. Review of the February 2026 documentation survey report showed no recorded activities for Resident 55, with no documentation of activity refusals during that month. Review of the March 2026 documentation survey report showed one recorded activity for Resident 55, with no documentation of activity refusals during that month. In an interview on 03/21/2026 at 12:44 PM, Staff R, Restorative Nurse Assistant, stated that Resident 8 and Resident 55 required one to two staff assistance for transfers and dressing. Staff R stated that the facility's activity calendar would be posted in each resident's room to offer and prepare them for upcoming activities. In an interview and joint observation on 03/21/2026 at 2:23 PM, Staff F stated that the facility's monthly calendars were posted in each resident's room. Staff F stated that certified nursing assistants would get ready residents for activities, and once a resident was dressed and ready, the activity personnel would transport them to the activity room. A joint observation of Resident 8's room showed no activity calendar was posted in the room. Staff F stated they would post the calendar. In an interview on 03/23/2026 at 9:42 AM, Staff F stated that any resident refusal of an activity would be documented in their medical record. In an interview on 03/23/2026 at 1:52 PM, Staff A, Administrator, stated that activity staff were expected to follow each resident's care plan, provide scheduled activities, and document participation. Staff A further stated that they expected activity staff to follow the facility's activity policies and regulatory requirements. RESIDENT 71 Review of a face sheet printed on 03/20/2026 showed Resident 71 was admitted to the facility on [DATE]. Review of the admission activity evaluation dated 02/04/2026 showed Resident 71 enjoys listening to classical music. Review of Resident 71's activity care plan dated 02/09/2026 showed, It is very/somewhat important to [Resident 71] to listen to music.Offer a personal stereo. In an interview on 03/19/2026 at 9:44 AM, Resident 71 stated that they did not remember if they were offered or provided activities by staff. Multiple observations on 03/20/2026 at 8:43 AM, at 2:50 PM and on 03/21/2026 at 8:21 AM, showed that Resident 71 was awake, lying in bed and did not have a personal stereo in their room. An observation and interview on 03/21/2026 at 8:29 AM showed Staff F was distributing reading materials to residents. When asked how they determine residents' activity preference, Staff F stated that they would complete an activity evaluation upon admission of the resident and that they offered/provided activities based on residents' interests. When asked about Resident 71's activity preference and their care plan, Staff F stated that Resident 71 liked music and that we should offer a portable [personal] stereo. Staff F stated that Resident 71 had no personal stereo in their room. A follow-up observation on 03/21/2026 at 8:51 AM showed Staff F brought a portable stereo to Resident 71. Resident 71 was heard asking Staff F, What is it for? Staff F stated that they brought the portable stereo so that Resident 71 could listen to music. Another observation and interview on 03/22/2026 at 8:35 AM showed a portable stereo on Resident 71's bedside table. Resident 71 stated, It was not plugged [in]. And last night it (portable stereo) was over there (pointed to where their wheelchair was located, about four feet away from Resident 71's bed). What's the use of it? I can't even reach it. Would love to listen to music. Further observation showed the portable stereo was not plugged into the electrical outlet. In an interview and a joint observation on 03/22/2026 at 8:51 AM, Staff Q, Activity Assistant, stated that they were made aware of Resident 71 having a portable stereo. A joint observation with Staff Q showed Resident 71's portable stereo was not plugged into the electrical outlet. Staff Q proceeded to plug the portable stereo into the wall outlet. Resident 71 was heard telling Staff Q that they have told maintenance that the radio may need an adapter to work. In an interview on 03/23/2026 at 3:07 PM, Staff A stated that they were overseeing implementation of activities for residents and that they expected staff to provide residents their preferred activities. Staff A further stated, I expect staff to meet their [residents'] needs related to their [interests] or activity. Reference: (WAC) 388-97-0940(1)(2) .

Based on interview and record review, the facility failed to ensure physician order was in place for continuous positive airway pressure (CPAP- a device used to treat sleep apnea [a condition where breathing repeatedly stops and starts during sleep]) settings and develop/implement care plan for CPAP for 1 of 1 (Resident 30), reviewed for respiratory care. This failure placed the resident at risk for respiratory related complications, respiratory infection, and a diminished quality of life.Findings included.Review of the facility's policy title, Comprehensive Person-Centered Care planning, revised in April 2025, stated that, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.Resident 30 was admitted to the facility on [DATE] with diagnoses that included sleep apnea.Review of Resident 30's physician orders printed on 03/19/2026 showed C1-Patient [Resident] wears C-PAP while sleeping with 2 [two] liters [a unit of measurement] of oxygen for sleep apnea. Further review showed no CPAP pressure settings were included in the order.Review of Resident 30's comprehensive care plan printed on 03/19/2026 showed no care plan for CPAP usage for sleep apnea.In an interview and joint record review on 03/20/2026 at 10:40 AM, Staff P, Licensed Practical Nurse, stated that for residents who use CPAP, they would check the physician's orders, assist residents with applying the CPAP mask, and fill the CPAP machine with distilled water if required. Staff P further stated that the physician's order would include the prescribed pressure settings for the CPAP. A joint record review of Resident 30's physician's orders showed, C1-Patient wears C-PAP while sleeping with 2 liters of oxygen for sleep apnea. Staff P stated they did not see CPAP pressure settings in the physician order. A joint record review of the comprehensive care plan showed no care plan for CPAP for sleep apnea. Staff P stated they do not see a care plan for CPAP.In an interview and joint record review on 03/22/2026 at 10:39 AM, Staff O, Resident Care Manager, stated that staff would know a resident's CPAP pressure settings and how to manage them from the physician's order. Staff O further stated that if the resident's CPAP were set to their home settings, it would be stated on the physician orders. A joint record review of Resident 30's physician's orders showed no order with CPAP pressure settings. Staff O stated there should have been an order with the CPAP pressure settings on admission. A joint record review of Resident 30's comprehensive care plan showed no care plan for CPAP usage for sleep apnea. Staff O stated they expected there to be a care plan for CPAP usage for sleep apnea.In an interview and joint record review on 03/24/2026 at 10:56 AM, Staff B, Director of Nursing, stated they expected there to be physician orders for CPAP pressure settings. A joint record review of Resident 30's physician's orders showed no order with CPAP pressure settings. Staff B stated the order should have been completed when the resident started CPAP on admission. A joint record review of Resident 30's comprehensive care plan showed no care plan for CPAP usage for sleep apnea. Staff B stated that the care plan should have been created when the resident started CPAP on admission.Reference: (WAC) 388-97-1060 (3)(j)(vi).

Based on observation, interview, and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised based on the resident's assessment for 1 of 13 residents (Resident 43), reviewed for care planning. This failure placed the resident at risk for unidentified and unmet care needs, and a diminished quality of life.Findings included.Review of the facility's policy titled, Comprehensive Person-Centered Care Planning, revised in April 2025, showed, The resident's comprehensive plan of care will be reviewed and/or revised by the IDT [Interdisciplinary Team] after each assessment, including both the comprehensive and quarterly review assessments.Review of a face sheet printed on 03/20/2026 showed Resident 43 was admitted to the facility on [DATE] and had a diagnosis of drug induced subacute dyskinesia (movement disorder characterized by involuntary, erratic, and uncontrollable muscle movements).Review of a quarterly AIMS (Abnormal Involuntary Movement Scale) assessment dated [DATE] showed Resident 43 scored 6 [six] indicating they had involuntary movement disorder.Review of the quarterly AIMS assessments dated 07/25/2025, 10/23/2025, and 01/23/2026 showed Resident 43 scored 11 (significantly increased compared to the 04/24/2025 assessment).Review of the March 2026 Medication Administration Record showed Resident 43 was on antipsychotic (medications to manage severe mental health symptoms and carry a risk of involuntary movement disorders).Review of the comprehensive care plan printed on 03/20/2026 showed Resident 43 had Positive AIMS 6.0 moderate to severe movement Disorder 4/24/25 [04/24/2025] Date Initiated: 01/24/2024 Revision on 04/24/2025.Observations on 03/18/2026 at 1:02 PM, on 03/21/2026 at 1:05 AM, and on 03/23/2026 at 9:03 AM showed Resident 43 had abnormal involuntary movements to their mouth and hands.In an interview and joint record review on 03/22/2026 at 2:13 PM, Staff H, Resident Care Manager (RCM), stated that residents AIMS assessment was completed by RCMs quarterly with Minimum Data Set (an assessment tool) and the resident's care plan would be updated based on the assessment. A joint record review of the AIMS assessments dated 07/25/2025, 10/23/2025, and 01/23/2026 showed Resident 43 scored 11. A joint record review of the comprehensive care plan printed on 03/20/2026 showed Resident 43's AIMS score was 6. Staff H stated that Resident 43's care plan should have been updated.In an interview on 03/23/2026 at 11:35 AM, Staff B, Director of Nursing, stated that the facility would review and revise resident care plans upon change in status, as well as on a quarterly and annual basis. Staff B further stated Resident 43's care plan should have been revised based on the resident's AIMS assessment.Reference: (WAC) 388-97-1020 (5)(b).

Based on interview and record review, the facility failed to ensure Level II Preadmission Screening and Resident Review (PASRR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or Related Conditions are not inappropriately placed in nursing homes for long-term care) referral was made for 1 of 7 residents (Resident 4), reviewed for PASRR screening. This failure placed the resident at risk of not receiving the care and services appropriate for their needs.Findings included.Review of the facility's policy titled, PASRR, revised in September 2018, showed, It is the policy of this facility to ensure that each resident is properly screened using the PASRR specified by the State. 1. A PASRR shall be completed on every resident upon admission. 2. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI [Mental Illness] . 3. Social Services shall contact the appropriate State Agency for referral of specialized care and services the resident may require.Resident 4 admitted to the facility on [DATE] with diagnoses that included depression (persistent, intense sadness or a loss of interest in activities).Review of Resident 4's PASRR level I form dated 12/24/2025, showed that they were marked yes for SMI for mood disorder depression and that the individual's attending physician certifies that the individual is likely to require fewer than 30 days of nursing facility services. The form further showed, No Level II evaluation indicated at this time due to exempted hospital discharge: Level II must be completed if scheduled discharge does not occur.In an interview and joint record review on 03/23/2026 at 1:46 PM, Staff E, Social Services Supervisor, stated that they were responsible for PASRR follow up and that they would follow up with the PASRR coordinator by phone, email, or fax depending on what was marked on the PASRR level I form. A joint record review of Resident 4's level I PASRR showed that they were marked yes for SMI and that no Level II evaluation was indicated at that time due to exempted hospital discharge and that Level II must be completed if scheduled discharge did not occur.In a follow up interview on 03/24/2026 at 8:31 AM, Staff E stated that they contacted the PASRR office yesterday [03/23/2026], and that there were no Level II PASRR referrals made for Resident 4. Staff E stated that a PASRR Level I with PASRR Level II evaluation indication should have been completed for Resident 4 no later than 30 days from admission.In an interview on 03/24/2026 at 11:31 AM, Staff A, Administrator, stated that they expected Resident 4's PASRR to be completed accurately and for staff to follow their PASRR policy.Reference: (WAC) 388-97-1975 (5).

Based on interview and record review, the facility failed to consistently maintain an established Antibiotic (medication to treat infection) Stewardship Program to promote the appropriate use of antibiotics for 2 of 6 residents (Residents 63 & 95) and failed to ensure standardized tools and criteria were utilized for Antibiotic Stewardship Program (such as Loeb Minimum Criteria [minimum set of signs symptoms used to determine whether to treat an infection with antibiotic]). These failures placed the residents at risk for potential adverse outcomes associated with the inappropriate and/or unnecessary use of antibiotics and an increased risk for multi-drug-resistant organisms (microscopic organisms that are resistant to many antibiotics).Findings included.Review of the facility's policy titled, Antibiotic Stewardship, revised in March 2023, showed, This policy is aligned with the CDC [Centers for Disease Control and Prevention] Core Elements of Antibiotic Stewardship for Nursing Homes. It is the policy of this facility to implement an Antibiotic Stewardship Program (ASP) that is incorporated in the overall Infection Prevention and Control Program which will promote appropriate use of antibiotics while optimizing the treatment of infections, at the same time reducing the possible adverse events associated with antibiotic use. This policy has the potential to limit antibiotic resistance in the post-acute care setting, while improving treatment efficacy and resident safety, and reducing treatment-related costs.Antibiotic Stewardship: refers to a set of commitments and actions designed to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. This can be accomplished through improving antibiotic prescribing, administration, and management practices thus reducing inappropriate use to ensure that residents receive the right antibiotic for the right indication, dose, and duration. The team will. Assess residents for any infection using McGeer's criteria.Review of the facility's policy titled, Infection Control, revised in September 2025, showed, The facility uses McGeer criteria as the nationally recognized surveillance criteria to define infections.Review of a Revised McGeer Criteria for Infection Surveillance Checklist, revised on 11/05/2024, showed that residents with Urinary Tract Infection (UTI - infection of the urinary system) without an indwelling catheter (tube left in the bladder that drains urine into a drainage bag) must meet criteria 1 and criteria 2 for symptomatic UTI infection. Criteria 1- At least one symptom - acute dysuria (burning sensation during urination); or acute pain, swelling, or testicular (testicles - organ that produce sperm in men) tenderness; or fever or leukocytosis (high white blood cell count) and at least one of the following localized urinary tract sub-criteria: acute back pain or tenderness, suprapubic (lower abdominal area) pain, gross hematuria (blood in urine), new or marked increased incontinence, urinary urgency or frequency; In the absence of fever or leukocytosis, then at least 2 or more localizing urinary symptoms need to be met. Criteria 2- culture identified no more than 2 species of microorganisms of more than 100,000 colony count (number of microorganisms grown) in a voided urine; or more than 100 colony count of any number of organisms in a specimen collected by in-and-out catheter.RESIDENT 63Review of the November 2025 Medication Administration Record (MAR) showed Resident 63 was administered Macrobid (an antibiotic) two times a day for five days from 11/06/2025 to 11/11/2025 for UTI. Review of an Infection Surveillance document for UTI dated 11/06/2025 showed Resident 63 had no indwelling catheter and started to have UTI symptoms on 11/05/2025. Further review of the document showed, Urinary Tract Infection for residents without an indwelling catheter-Both criteria 1 and 2 must be present. Additionally, the document showed Resident 63 had two symptoms (dysuria and increased urinary urgency) marked under criteria 1 and no qualified items were marked under criteria 2. Furthermore, the document showed, Surveillance criteria adopted from the Updated McGeer Criteria for Long Term Care Surveillance Definitions of Infections, 2012.Review of Resident 63's urine culture results collected on 11/04/2025 showed that the urine culture did not meet McGeer's criteria 2.A joint record review and interview on 03/23/2026 at 3:21 PM with Staff B, Director of Nursing, showed Resident 63's infection surveillance document indicated that criteria 1 had symptoms marked, and criteria 2 was blank. Staff B stated that McGeer's criteria were used for the initiation of antibiotics. A joint record review of the document showed Urinary Tract Infection for residents without an indwelling catheter-Both criteria 1 and 2 must be present. Staff B stated that for residents without an indwelling catheter, criteria 2 did not have to be met. Staff B stated that Resident 63 completed their antibiotic as ordered.RESIDENT 95Review of the February 2026 MAR showed Resident 95 was administered nitrofurantoin (an antibiotic) twice a day for five days from 02/17/2026 to 02/22/2026 for UTI.Review of an Infection Surveillance document for UTI dated 02/17/2026 showed Resident 95 had no indwelling catheter and started to have UTI symptoms on 02/13/2026. Further review of the document showed, Urinary Tract Infection (UTI) for residents without an Indwelling Catheter - Both criteria 1 and 2 must be present. Additionally, the document showed that Resident 95 had four symptoms (dysuria, suprapubic pain, increased urinary urgency, and increased urinary frequency) marked under criteria 1 and there were no qualified items marked under criteria 2. Furthermore, the document showed, Surveillance criteria adopted from the Updated McGeer Criteria for Long Term Care Surveillance Definitions of Infections, 2012.Review of Resident 95's urine culture and sensitivity (identifies bacteria in urine sample and determines which antibiotic medications are effective) laboratory results dated [DATE] showed the urine sample was collected via clean catch (voided urine sample) on 02/17/2026 and it grew Enterobacter cloacae complex [a type bacteria that causes infection] of 50,000 to 99,000 colony count. Further review of the laboratory results did not show that the McGeer's microbiologic (bacteria and their colony count indicating a true infection) criteria (of more than 100,000 colony count) was met.A joint record review and interview on 03/24/2026 at 12:26 PM with Staff B showed Resident 95's infection surveillance form dated 02/17/2026 was completed for UTI for a resident without an indwelling catheter. Staff B stated that Resident 95 had at least two symptoms of criteria 1 and that their urinalysis results showed a colony count of 50,000 to 99,000 for Enterobacter cloacae complex. Staff B s further stated that they did not use Situation Background Assessment Recommendation (SBAR, a structured communication tool for change of condition) or Loeb's criteria because McGeer's criteria has the same symptoms check. When asked what minimum criteria the facility used for starting antibiotics, Staff B stated, McGeer's criteria. When asked what criteria the facility used for infection surveillance, Staff B stated, McGeer's criteria.No Associated WAC.

Based on observation, interview, and record review, the facility failed to ensure medication was stored in accordance with professional standards and manufacturer specifications for 1 of 2 medication carts (East 2 Medication Cart), reviewed for medication storage and labeling. This failure placed the residents at risk for receiving compromised and ineffective medications.Findings included .Review of the Amneal Pharmaceutical (manufacturer) prescribing information titled, Lorazepam [a drug used to quickly calm severe anxiety] Oral Concentrate USP, 2 mg [milligram - a unit measurement] per mL, [milliliter - a unit measurement] revised in December 2015 showed, Store at Cold Temperature-Refrigerate 2 [two degrees] to 8 C [eight degrees Celsius- a unit measurement] (36 to 46 F [Fahrenheit - a unit measurement]) . Discard opened bottle after 90 days.During a joint observation and interview on 03/22/2026 at 8:39 AM with Staff M, Licensed Practical Nurse, showed the East 2 Medication Cart had one unopened bottle of Lorazepam 30 ml oral concentrate USP (2 mg/mL) for Resident 76 was found stored at room temperature inside the cart. Further observation showed the lorazepam was received on 02/13/2026. When questioned regarding storage protocols, Staff M stated that lorazepam would require refrigeration after opening. After review of the packaging, Staff M further stated that the instructions specified storage at a 'cold temperature' and stated, it [the instruction] did not show store it in fridge after opening. Staff M stated they would need to consult with their supervisor.On 03/22/2026 at 9:11 AM, Staff B, Director of Nursing, stated that unopened bottle of lorazepam liquid concentrate could be stored in room temperature for 90 days. Staff B further stated they would provide the manufacturer's instructions.On 03/22/2026 at 9:59 AM, Staff B stated that they confirmed with their pharmacist that the Lorazepam Oral Concentrate could be stored at room temperature and discarded within 42 days. Staff B provided a 9-page printout of Amneal Pharmaceutical prescribing information titled, Lorazepam Oral Concentrate USP, 2 per mL, revised in December 2015.Review of the facility provided instruction and the actual manufacturer's instructions for Lorazepam Oral Concentrate, revised in December 2015, revealed a discrepancy. Further review of the facility's version of the document included an added instruction stating, Once left at room temperature, discard within 42 days.In an interview and joint record review on 03/23/2026 at 11:52 AM, Staff B stated that they personally printed the manufacturer's instructions for lorazepam concentrate from the manufacturer's website on 03/22/2026 and provided to the surveyor. A joint record review of the facility's version of the document included an added instruction stating, Once left at room temperature, discard within 42 days which was not found on the actual manufacturer's document. Staff B could not explain how the document was altered before they provided it and further stated that staff were expected to follow the manufacturer's medication storage guidelines.Reference: (WAC) 388-97-1300 (2).

Based on observation, interview, and record review, the facility failed to ensure resident environment were maintained for 2 of 2 rooms (Rooms 218 & 223), reviewed for environment. The failure to ensure resident rooms were maintained in good repair placed the residents at risk for less than homelike environment and a diminished quality of life.Findings included.Review of the facility's undated policy titled, Preventative Maintenance Policy (Using TELS System [a digital maintenance management system], showed, This policy ensures that all building systems, equipment, and physical structures are maintained in safe working condition through a structured preventive maintenance program. The facility uses the TELS system to meet CMS [Centers for Medicare & Medicaid Services], Life Safety Code, and state regulatory requirements.room [ROOM NUMBER]Observations on 03/18/2026 at 7:58 AM, on 03/19/2026 at 2:20 PM, on 03/20/2026 at 8:07 AM, and on 03/23/2026 at 9:16 AM showed the room wall by the sink was painted reddish-brown. Further observation showed that multiple areas of the wall had multiple white patches from previous repairs that remained unpainted.In an interview on 03/20/2026 at 10:31 AM, Resident 79 in room [ROOM NUMBER] stated that the wall had been like that since they moved in and that someone forgot to finish the job after patching it. Resident 79 further stated they would try not to look at the wall and It would be nice if it was repaired.room [ROOM NUMBER]Observations on 03/18/2026 at 12:41 PM, on 03/19/2026 at 8:32 AM, on 03/19/2026 at 2:06 PM, and on 03/20/2026 at 8:05 AM showed the room's laminate flooring by the resident's bed was cracked and chipped, had missing pieces and part of the flooring was lifting off the subfloor. In an interview and joint observation on 03/22/2026 at 11:16 AM, Staff C, Maintenance Supervisor, and Staff K, Maintenance Staff, stated that most of the facility's repairs would be completed immediately. When asked if there were any pending maintenance needs for rooms [ROOM NUMBERS], Staff K stated that they were notified about room [ROOM NUMBER]'s flooring repair needs on yesterday [03/21/2025] and they repaired it. Staff C and Staff K stated that they were unaware of the necessary repair needs in room [ROOM NUMBER]. A joint observation of room [ROOM NUMBER] showed multiple areas of the wall had multiple white patches from previous repairs that remained unpainted. Staff C stated that they were waiting for another repair need the room had and the sanding of the patched wall and repainting job would be completed. A joint observation of room [ROOM NUMBER] showed that the sections of laminate flooring previously lifted from the subfloor had been glued down while the floor repair remained incomplete with sections of the floor still missing. Staff C stated that the missing section of the floor should have been repaired.In an interview on 03/23/2026 at 1:52 PM, Staff A, Administrator, stated that they expected all resident rooms to be maintained in good repair. Staff A further stated that they were unaware of the floor issues in room [ROOM NUMBER], and that the facility had a plan to replace the flooring.Reference: (WAC) 388-97-0880 (1)(2).

Based on interview and record review, the facility failed to ensure resident assessments were completed accurately for 1 of 13 residents (Resident 6), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessment was marked on the MDS regarding weights placed the resident at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included .According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. Further review of the RAI showed, The measurement of weight is one guide for determining nutritional status. check the medical record and enter the weight taken within 30 days of the Assessment Reference Date (ARD or assessment period) of this assessment. If a resident cannot be weighed, for example because of extreme pain, immobility, or risk of pathological fractures, use the standard no-information code (- [dash]) and document rationale on the resident's medical record.Review of an annual MDS dated [DATE] showed Resident 6's weight was recorded in Section K - Weight (K0200B) as 219 pounds (lbs. - unit of measurement).Review of a quarterly MDS dated [DATE] showed Resident 6's weight was recorded in K0200B as 219 lbs.Review of Resident 6's weight records from May 2025 to January 2026 showed the following weights:- 05/16/2025 - 219 lbs.- 01/09/2026 - 232 lbs.In an interview and joint record review on 03/22/2026 at 2:02 PM, Staff L, MDS Coordinator, stated they used the RAI manual to complete MDS assessments. Staff L stated they used the facility weight records to document weights in MDS and that they used a weight within 30 days prior to the ARD. A joint record review of Resident 6's MDSs dated 08/06/2025 and 11/05/2025 showed a weight of 219 lbs. Staff L stated that Resident 6's weight of 219 lbs. was recorded in both MDSs. A joint record review of Resident 6's weight records showed 219 lbs. for May 2025 and 232 lbs. for January 2026. Staff L stated that there were no other weights recorded between May 2025 to January 2026. Staff L stated that Resident 6's May 2025 weight of 219 lbs. was used for both MDSs dated 08/06/2025 and 11/05/2025 and that the weight recorded in both MDSs was not within 30 days from the ARD. Staff L further stated the MDSs weights section should have been dashed and that Resident 6's MDSs were not accurate.In an interview on 03/24/2026 at 10:29 AM, Staff B, Director of Nursing, stated they expected MDSs to be completed timely and accurately.Reference: (WAC) 388-97-1000 (1)(b).

Based on interview and record review, the facility failed to ensure a physician's order was followed when administering medication for 1 of 5 residents (Resident 6), reviewed for unnecessary medications. This failure placed the resident at risk for side effects related to the medications, medical complications, and a diminished quality of life.Findings included.Review of the facility's policy titled, Administering Medications, revised in March 2022, showed, Medications will be accurately prepared, administered, and documented per physician order .follow the special directions for administering such as blood pressures .Review of Resident 6's physician orders printed on 03/19/2026 showed an order for metoprolol (medication for high blood pressure [measurement that shows how hard the heart is pumping to move blood through the body]) once a day, with an instruction to hold it if their systolic blood pressure (the first or top number in a blood pressure reading, showing the pressure in the arteries [muscular and elastic tubes that carry blood from the heart to the tissues and organs of the body] when the heart beats) was less than 110.Review of the March 2025 to March 2026 Medication Administration Record (MAR) showed metoprolol were given when Resident 6's systolic blood pressure were below 110:- 03/19/2025: systolic blood pressure - 108- 09/01/2025: systolic blood pressure - 106- 10/03/2025: systolic blood pressure - 108- 10/14/2025: systolic blood pressure - 108- 10/15/2025: systolic blood pressure - 108- 01/01/2026: systolic blood pressure - 102- 01/09/2026: systolic blood pressure - 103In an interview and joint record review on 03/22/2026 at 1:49 PM, Staff M, Licensed Practical Nurse, stated that they would follow parameters for blood pressure medications. Staff M stated that if blood pressures were outside parameters, they would hold the medication. A joint record review of Resident 6's MAR for March 2025, September 2025, October 2025 and January 2026 showed that metoprolol was given to Resident 6 when their systolic blood pressure was below 110 on the above dates. Staff M stated that metoprolol was given and it should have been held when the systolic blood pressure was below 110, it [metoprolol] should not have been given.In an interview on 03/24/2026 at 11:56 AM, Staff B, Director of Nursing, stated they expected staff to follow physician orders. Staff B stated that if medications had parameters, they expected staff to follow [blood pressure] parameters, to recheck, and notify the provider [doctor]. Staff B stated that metoprolol should have been held on the above dates when Resident 6's systolic blood pressure was below 110.Reference: (WAC) 388-97-1060 (3)(k)(i).

Based on interview and record review, the facility failed to ensure the Preadmission Screen and Resident Review (PASRR or PASARR) Level II (refers to the evaluation process conducted after a Level I screening indicates a possible serious mental illness or intellectual disability to ensure that individuals receive appropriate care and support based on their specific needs and conditions) was obtained for 1 of 7 residents (Resident 6), reviewed for PASRR coordination. This failure placed the resident at risk of not receiving the necessary behavioral health services and a diminished quality of life.Findings included .Review of the facility's policy titled, PASRR, revised in September 2018, showed It is the policy of this facility to ensure that each resident is properly screened using PASRR specified by the State. 1. A PASRR shall be completed on every resident upon admission. 2. Based upon the assessment, the facility will ensure proper referral to appropriate state agencies for the provision of specialized services to residents with MI [Mental Illness] . 3. Social services shall contact the appropriate State Agency for referral of specialized care and services the resident may require.Review of a diagnosis list printed on 03/20/2026 showed Resident 6 had diagnosis that included bipolar disorder (mental health condition that causes extreme mood swings).Review of a document titled, PASRR Notice of Determination, dated 08/26/2025, showed that Resident 6 had a mental health diagnosis, met the requirements for nursing facility level of care due to current mental health needs, and that Resident 6 may benefit from specialized behavioral health services. Further review of the document showed, The full PASRR [Level II] report will be sent to the nursing facility where you are staying and will become part of your medical record within 30 days.Review of the Electronic Health Record (EHR - document tab and progress notes from 08/01/2025 to 03/18/2026) showed no documentation of Resident 6's Level II PASRR full report.In an interview and joint record review on 03/23/2026 at 1:46 PM, Staff E, Social Services Supervisor, stated if Level I PASARR was referred for Level II PASRR evaluation, they would send it to the PASRR coordinator, then they would follow up for the results of the evaluation. A joint record review of the PASRR Notice of Determination dated 08/26/2025 showed Resident 6 met requirements for nursing facility level of care and may benefit from specialized services. A joint record review of the progress notes and documents tab did not show Resident 6's Level II PASRR report. Staff E stated that there was no Level II PASRR for Resident 6 in their clinical record.In an interview on 03/24/2026 at 10:54 AM, Staff E stated that if residents had a Level II PASRR report, they would review the Level II PASRR recommendations, follow them up, and develop a care plan. Staff E further stated that they should have requested the Level II PASRR report after 30 days of receiving Resident 6's PASRR notice of determination.In an interview on 03/24/2026 at 1:10 PM, Staff A, Administrator, stated they expected staff to follow their PASRR policy and that they expected the facility to follow up/obtain the Level II PASRR reports to carry forward with the recommendations.Reference: (WAC) 388-97-1975(8)(10).

Based on observation, interview, and record review, the facility failed to ensure controlled drugs were accurately accounted for 1 of 2 medication carts (East 2 Medication Cart), reviewed for controlled drugs management. This failure placed the facility at risk for potential loss and/or drug diversion of the controlled medications.Findings included.Review of the facility's policy titled, Controlled Substances, revised in November 2022, showed, Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.During an interview and joint record review on 03/22/2026 at 8:39 AM, Staff M, Licensed Practical Nurse, stated that they had counted the controlled drugs in the East 2 Medication Cart at the start of their shift. A joint record review of the controlled drug logbook (page 49) indicated that Resident 56 had one 5 (five) mg (milligram-a unit measurement) oxycodone (prescription opioid painkiller) tablet remaining. A joint observation of the controlled drug box showed that one tablet of the 5 mg oxycodone was missing. When asked about the discrepancy between the controlled drug book and the controlled drug box, Staff M stated that they signed the shift-change log without verifying the drug book's balance against the physical stock in the box. Staff M stated that the night shift nurse may have administered the missing tablet without documenting it. Staff M further stated that they should have cross-referenced the physical inventory with the controlled drug book during the shift change count.On 03/22/2026 at 9:11 AM, Staff B, Director of Nursing, stated that they would investigate the missing oxycodone 5 mg tablet.In an interview on 03/23/2026 at 11:52 AM, Staff B stated that administered controlled drugs must be recorded in the logbook and validated during shift-change counts. Staff B further stated that their expectation was that all controlled medication records be accurate and regularly reconciled.Reference: (WAC) 388-97-1300 (3)(a).

Based on observation, interview, and record review, the facility failed to ensure foods were handled appropriately in accordance with professional standards of food safety for 1 of 1 dry storage room and 2 of 2 floors (First Floor & Second Floor), reviewed for food services. The failure to label food items and cover food items during meal tray delivery placed the residents at risk for food borne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life. Findings included . Review of the facility's policy titled, Food Procurement, Storage and Distribution, dated 07/08/2022, showed, Food safety requires consistent temperature control from the time food leaves the kitchen, to transport and distribution to prevent contamination (e.g. covering food items). FOOD LABELING IN THE DRY STORAGE ROOM Joint observation on 12/12/2024 at 8:32 AM with Staff C, Nutritional Services Manager, showed two unopened unlabeled bags of cereal. Staff C stated it was Cornflakes and that some brands of cereal did not have labels on them. Staff C stated that when they placed it in their bins, that they would be labeled. When asked if they labeled the cornflakes when they take it out of the box, Staff C stated, I don't put a label, just follow the expiration date. In an interview on 12/17/2024 at 2:33 PM, Staff K, Dietary Aide, stated that they expected food items in the dry storage room to be labeled and that they expected the Cornflakes to be labeled. In an interview on 12/18/2024 at 3:23 PM, Staff A, Administrator, stated that generally they take the food items out of the box, label, date it and if it was past the use by date, they would discard it. When asked if they would expect the unlabeled cornflakes to be labeled, Staff A stated, generally when it's opened, it was labeled and dated. Staff A further stated, It's not what they normally do. FOOD ITEMS UNCOVERED DURING MEAL TRAY DELIVERY Observations on 12/12/2024 at 11:48 AM, showed the meal cart was parked between room [ROOM NUMBER] and room [ROOM NUMBER]. Staff H, Certified Nursing Assistant (CNA), took a tray from the meal cart and delivered it to room [ROOM NUMBER] with a cup of blueberries uncovered. Staff H took another tray from the meal cart and walked down the hallway to room [ROOM NUMBER] with a cup of blueberries uncovered. Observations on 12/13/2024 at 11:13 AM, showed that the meal cart was parked by room [ROOM NUMBER]. Staff G, Human Resources, took a tray from the meal cart and delivered it to room [ROOM NUMBER] with a cup of peaches uncovered. Staff I, CNA, took a tray from the meal cart, walked down the hallway and delivered it to room [ROOM NUMBER] with a cup of strawberries uncovered. Staff J, CNA, took a tray from the meal cart, walked down the hallway and delivered it to room [ROOM NUMBER] with a cup of peaches uncovered. Observations and interview on 12/13/2024 at 11:18 AM, showed Staff I took another tray from the meal cart, walked down the hallway to room [ROOM NUMBER] and placed the meal tray on the bedside table with a cup of peaches uncovered. Joint observation of room [ROOM NUMBER]'s meal tray showed that a cup of peaches was uncovered. When asked if the cups of dessert came covered, Staff I stated, sometimes it does. In an interview with Staff K and Staff T, Registered Dietician, on 12/17/2024 at 2:33 PM, Staff K stated that they expected food to be covered. Staff K stated that staff were supposed to deliver meal trays room to room. Staff T stated that if staff were to deliver meal trays down the hallway, walking a distance, the food on the meal tray should be covered. In an interview on 12/18/2024 at 3:23 PM, Staff A stated that generally food items on the meal tray were covered in the kitchen, delivered to the resident, and set down before anything was removed. 46912 Observation on 12/13/2024 at 11:30 AM, showed an unidentified staff carrying uncovered salad and grapes down the hallway to room [ROOM NUMBER]. Observation on 12/13/2024 at 11:32 AM, showed Staff V, CNA, carrying an uncovered fruit cup down the hallway to room [ROOM NUMBER]. In an interview and joint observation on 12/13/2024 at 11:35 AM, Staff V stated that all food should be covered while being carried down the hallway. A joint observation of the meal tray in room [ROOM NUMBER] showed the fruit cup was uncovered. Staff V stated that usually these are covered and these were not covered. On 12/18/2024 at 12:49 PM, Staff K stated they expected staff to deliver trays room to room and when walking trays down the hall, food should be covered. On 12/18/2024 at 1:48 PM, Staff A stated that generally, they [food items] are covered until set down by the resident. Staff A further stated that staff, generally take [meal trays] from room to room and wouldn't [would not] expect [food items] uncovered down the hall. Reference: (WAC) 388-97-1100 (3)

Based on observation, interview and record review, the facility failed to provide a homelike environment when residents were served their meals on trays for 1 of 1 dining room (Second floor Dining Room), reviewed for dining services. This failure placed the residents at risk for a less than homelike environment and a diminished quality of life. Findings included . Review of the facility's policy titled, Homelike Environment, revised in May 2017, showed, Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Observation on 12/13/2024 at 11:39 AM, in the Second Floor Dining Room, showed Resident 60, Resident 25, Resident 21, Resident 42, Resident 50, and Resident 37 were eating their food on their lunch tray. Staff J, Restorative Nurse Assistant, assisted Resident 20 eat their lunch from their tray. Observation on 12/16/2024 at 11:38 AM, in the Second Floor Dining Room, showed Staff D, Resident Care Manager, delivered Resident 50, Resident 8 and Resident 20 their lunch tray. Staff D did not remove their tray from the tables. Staff J delivered Resident 60's lunch tray, assisted in opening their straw and took the cover off the plate. Staff J did not remove their tray from the table. In another observation at 11:56 AM, Staff D assisted Resident 17 and Staff J assisted Resident 20 eat their lunch from their tray. In an interview on 12/16/2024 at 12:26 PM, Staff J was asked if it was their process to leave the meal tray on the table, Staff J stated they delivered residents their meals on the tray. Staff J verified with Staff D about the meal trays which they both stated that they use the tray in the dining room. In an interview on 12/17/2024 at 2:28 PM, Staff D was asked if they expected staff to remove the tray in the dining room, Staff D stated, Not necessarily. Staff D stated they used to remove the trays but when COVID-19 (highly contagious respiratory infection) started and since then they have always been told to leave the tray on in the dining room. In interview on 12/19/2024 at 10:27 AM, Staff B, Director of Nursing, stated that their process right now was to serve residents with the meal trays in the dining room. Reference: (WAC) 388-97-0880 (1)

Based on observation, interview, and record review, the facility failed to appropriately store drugs and/or biologicals (diverse group of medicines made from natural sources) and medical supplies for 2 of 2 medication rooms (West 1 Medication Storage Room & Second Floor Medication Storage Room) and 1 of 3 medication carts (East 1 Medication Cart), reviewed for medication storage. This failure placed the residents at risk for receiving compromised and ineffective medications/medical supplies. Findings included . Review of the facility's policy titled, Storage of Medications, revised in March 2016, showed, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. WEST 1 MEDICATION STORAGE ROOM A joint observation and interview on 12/17/2024 at 9:13 AM with Staff Y, Licensed Practical Nurse (LPN), showed the [NAME] 1 Medication Storage Room had one Aquacel Advantage (brand name of an anti-microbial wound dressing) dressing 10 centimeter (cm-a unit of measurement) by 12 cm with an expiration date of 11/01/2024. Staff Y stated, Yes it expired on 11/01/2024. SECOND FLOOR MEDICATION ROOM A joint observation and interview on 12/17/2024 at 10:11 AM with Staff F, Registered Nurse (RN), showed the Second Floor Medication Room had the following expired medical supplies: - Two SafeDay (brand name) Intravenous (IV-refers to the administration of fluids, medications, other substances directly into the vein) administration set (flexible plastic tubing) with an expiration date of 02/24/2024. - Two SafeDay IV administration sets with an expiration date of 04/13/2024. - One SafeDay IV administration sets with an expiration date of 08/27/2024. - One SafeDay IV administration set with an expiration date of 09/08/2024. - Five SafeDay IV administration sets with an expiration date of 12/16/2024. Staff F stated that the IV administration sets were expired and that they would dispose of them. In an interview on 12/17/2024 at 1:44 PM, Staff D, Resident Care Manager, stated that they expected expired supplies and medications to get thrown out. In a follow-up interview on 12/18/2024 at 1:10 PM, Staff D stated, if they're [they are] expired, they're expired when asked about outdated medications and supplies. In an interview on 12/18/2024 at 2:05 PM, Staff B, Director of Nursing, stated that we shouldn't (should not) have expired medications and supplies. Staff B stated, we took out the expired IV administration sets and they should not be there. Staff B further stated that the Aquacel Advantage wound dressing was considered a medication and should be disposed of when it was expired. 51090 EAST 1 MEDICATION CART Review of the facility ' s policy and procedure titled Medication Storage Policy/Procedure, revised in March 2016, showed, The facility shall store all drugs and biologicals in a safe, secure and orderly manner .Drugs and biologicals shall be stored in the packaging, containers or other dispensing system in which they are received. A joint observation and interview on 12/17/2024 at 7:38 AM with Staff N, LPN, showed an unpackaged and unlabeled red capsule stored in the first top drawer of the East 1 medication cart during medication storage review. Staff N stated the unpackaged and unlabeled red capsule was a prescription antibiotic (used to treat and prevent bacterial infections) and That should not be there. Staff N showed a prescription blister package (a type of packaging that uses a plastic bubble to hold each individual dose of medication) from another drawer of the medication cart, of red capsules that were identical in shape, color and size to the unlabeled and unpackaged red capsule observed on the top drawer. When asked if the loose red capsule should be packaged and labeled, Staff N stated, Yes and that I will put it in the drug buster [product used to safely dispose of unwanted or expired medications] to waste it. In an interview on 12/18/2024 at 1:42 AM Staff M, RN, stated that prescription medications should be packaged and labeled. Staff M stated that they would not expect unpackaged and unlabeled prescribed medications to be stored in the medication cart. Staff M further stated that they expected prescription medications to be securely packaged and labeled when stored in the medication cart. In an interview on 12/19/2024 at 10:37 AM, Staff B stated they would not expect unpackaged and unlabeled prescription medication to be stored in the medication cart. When asked if they expected all medications are properly packaged and labeled when stored in the medication cart, Staff B stated, Yes. Reference: (WAC) 388-97-1300 (2)

Based on observation, interview, and record review, the facility failed to ensure Contact Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) practices were followed for 1 of 1 resident (Resident 35), reviewed for infection control. In addition, the facility failed to appropriately use Personal Protective Equipment (PPE -use of gown and gloves) and perform hand hygiene in the laundry room for 1 of 1 staff (Staff X), reviewed for infection control. These failures placed the residents, staff, and visitors at an increased risk for infection and related complications. Findings included . Review of the facility's policy titled, Transmission Based Precautions, revised in October 2022, showed that Contact Precautions are intended to prevent transmission of infectious agents .that are spread by direct or indirect contact with the resident or the resident's environment. It showed, Donning [putting on] PPE upon room entry and properly discarding before exiting the patient room is done to contain pathogens [agents that causes disease]. It further showed that All linen should be handled as if it were highly infectious. Review of the facility's policy titled, Hand Hygiene, revised on 02/21/2022, showed, Use an alcohol-based hand rub .or, alternatively, soap .and water after removing gloves. CONTACT PRECAUTIONS Review of the facility's document titled, Order Summary Report, printed on 12/12/2024, showed that Resident 35 had an active order for Contact Isolation for a dx [diagnosis] of MRSA [Methicillin-resistant Staphylococcus aureus- an infection caused by a type of bacteria that has become resistant to some antibiotics] right hip .for 14 days, with a start date of 12/09/2024 and end date of 12/23/2024. Observation on 12/12/2024 at 11:28 AM, showed Staff W, Activities Assistant, took a meal tray to Resident 35's room. Staff W entered Resident 35's room without putting on a gown or gloves. In an interview and joint observation on 12/12/2024 at 11:35 AM, Staff W stated that if a resident was on contact precautions, we should wear proper PPE. A joint observation of the Contact Precautions signage outside Resident 35's room showed to wear a gown and gloves when entering the room. Staff W stated that I didn't [did not] wear a gown and gloves when going into Resident 35's room. On 12/16/2024 at 2:04 PM, Staff U, Infection Preventionist, stated that they expected staff to wear a gown and gloves when entering the room of a resident who was on contact precautions, including when delivering meal trays to residents. On 12/18/2024 at 11:27 AM, Staff B, Director of Nursing, stated that they expected staff to follow what the sign says, what PPE they need to use before entering the room if a resident was on contact precautions. PPE USE/HAND HYGIENE Observation and interview on 12/18/2024 at 8:35 AM, showed Staff X, Housekeeping Staff, sorting soiled laundry while wearing a mask, gloves, and a gown that was not tied in the back. It showed the gown falling off Staff X, and Staff X was touching their clothing with their soiled gloves when trying to readjust their gown. Staff X stated that yes the gown was coming off because it was not tied in the back and that the gloves they were using were dirty. Staff X left the laundry sorting room, took off their PPE, including their gloves and did not perform hand hygiene. Staff X then went to the clean area of the laundry room and started touching clean linens. Staff X stated that they did not perform hand hygiene after removing their gloves. In an interview on 12/18/2024 at 10:14 AM, Staff D, Infection Preventionist, stated that staff should perform hand hygiene after removing gloves. Staff D further stated that staff should tie their gowns, so don't [do not] come off during care. In an interview on 12/18/2024 at 11:27 AM, Staff B stated they expected staff to perform hand hygiene right after [they] remove gloves. Staff B further stated that when staff used PPE, that their gowns should be tied. Reference: (WAC) 388-97-1320 (1)(a)(c)

Based on observation, interview, and record review, the facility failed to ensure bed hold (the opportunity to reserve a resident's current occupied bed while out of the facility to ensure their room was available when ready to return) notice was offered to 1 of 3 residents (Resident 65), reviewed for hospitalization . This failure placed the resident at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Review of the facility's policy titled Bed Hold, revised in December 2023, showed, It is the policy of this facility to inform the resident or resident's representative in writing of the right to exercise the bed hold provision upon admission and provide a second notice before transfer to a general acute care hospital .In the event of an emergency transfer, the second notice will be provided within 24 hours. Resident 65 admitted to the facility on [DATE]. Review of the nursing progress note dated 12/09/2024 showed Resident 65 was discharged to the hospital for medical evaluation on 12/09/2024. Further review of the nursing progress note dated 12/11/2024 showed Resident 65 returned to the facility on [DATE]. In an interview on 12/12/2024 at 9:34 AM, Resident 65 stated they had a private room before their hospital transfer on 12/09/2024 and that they returned to the facility in a shared room (room [ROOM NUMBER]). Resident 65 further stated, This really frustrates me; I need all my stuff from my old room. When asked if the facility offered them and/or their emergency contact, a bed hold notice for their hospital transfer on 12/09/2024, Resident 65 stated, No, I didn't know about a bed hold. I do not think my [emergency contact] was told about it; We [Resident 65 and their emergency contact] didn't know anything about it. Review of the electronic health record under the miscellaneous tab for December 2024 did not show documentation that Resident 65 was offered a written bed hold notice for their hospital transfer. Further review of the nursing progress notes dated 12/09/2024 through 12/15/2024 did not show documentation that a bed hold notice was offered or discussed with Resident 65. In an observation and interview on 12/16/2024 at 7:58 AM, showed that Resident 65 was no longer in room [ROOM NUMBER] with their roommate, Resident 41. Resident 41 stated that both Resident 65 and Resident 41 were put out of this room due to water leak last Thursday (12/12/2024) and that Resident 65 had been moved to another room while Resident 41 returned to room [ROOM NUMBER] when the water leak was fixed. Resident 41 further stated that they were informed that the water leak was due to something to do with upstairs and this room (room [ROOM NUMBER]); when somebody flushed the toilet, there was an overflow of clean water. Observation and interview on 12/16/2024 at 11:17 AM, showed Resident 65 was moved to room [ROOM NUMBER]. Resident 65 stated that they were moved to room [ROOM NUMBER] due to a water leak that affected their side of room [ROOM NUMBER]. When asked which room was their original room before their hospital transfer on 12/09/2024, Resident 65 stated they were in room [ROOM NUMBER]. When asked if they understood what a bed hold was, Resident 65 stated, [Staff] didn't ask me [regarding a bed hold], I went to the hospital and assumed I would keep my room; no one ever told me. When asked if they would have agreed to reserve their previously occupied bed, to include the associated costs for a bed hold, Resident 65 stated, I don't know what they would have charged me. Resident 65 stated they would have wanted to make an informed decision regarding a bed hold if it was offered to them. Resident 65 further stated that they were their own financial responsible party. In an interview and joint record review on 12/16/2024 at 11:50 AM, Staff L, Admissions, was asked if Resident 65 was offered a bed hold on their 12/09/2024 hospital transfer, Staff L stated, Yes and provided a document titled, Bed Hold Policy for Resident 65 that was completed by Staff L on 12/09/2024. Resident 65's Bed Hold Policy notice showed that their emergency contact was provided the bed hold information via in-person and that it did not show a signature from the recipient of the written notice. When asked if a copy of the written bed hold notice would be provided to the person signing it, Staff L stated Yes. When asked if a copy of the bed hold notice was provided to the recipient of the notice, Staff L stated, let me double check, I think I may have marked that wrong, I think it was by phone. When asked if they could provide a copy of the bed hold notice completed on 12/09/2024, which indicated Resident 65's emergency contact was provided the written bed hold notice in person, Staff L stated, let me get back to you on that. Staff L later provided a copy of the bed hold notice dated 12/09/2024 that showed that it was provided via phone and that the section for in-person notification was crossed out. Staff L stated they marked the document incorrectly and that the bed hold information was provided over the phone to the resident's emergency contact. Another joint record review and interview on 12/17/2024 at 7:30 AM with Staff L, showed Resident 65's face sheet listed them as their own financial responsible party and that their next of kin was listed as an emergency contact. Staff L stated that Resident 65's face sheet directed staff whom to contact for decision making and that Resident 65 was not informed about the bed hold. When asked if Resident 65 should have been informed of the bed hold, Staff L stated, I don't really know how to answer that, I just know that in my experience with [them], [they] deferred to their [emergency contact]. Staff L further stated that they did not know if Resident 65's emergency contact was able to make financial decisions on behalf of Resident 65. When asked again if Resident 65 should have been informed of the bed hold, Staff L stated, Can I get back to you on that; I need a minute if you don't mind. In a follow up interview on 12/17/2024 at 9:10 AM, Staff L stated that their process was to contact the financial responsible party when bed hold notice was discussed. Staff L further stated that for transfers to the hospital, they would try to reach the resident via phone. When asked if they attempted to contact Resident 65 about the option for a bed hold for their hospital transfer on 12/09/2024, Staff L stated, I don't remember if I tried to call at all at the hospital for Resident 65. In an interview and joint record review on 12/19/2024 at 9:57 AM, Staff A, Administrator, stated that Staff L was responsible for issuing bed hold notices and that they expected staff would first discuss the bed hold notice with the resident if they were their own responsibility party. Staff A stated that if the resident was unable to be contacted, then we call family and to ask them to check with the responsible party. Staff A further stated the resident's face sheet as well as advance directives directed staff on whom to contact for bed hold notifications. Joint record review of the document titled, Bed Hold Policy, completed on 12/09/2024, showed Resident 65's emergency contact was contacted to discuss the bed hold notice. When asked if Resident 65 should have been informed of the bed hold notice due to them being their own financial responsible party, Staff A stated that they expected an effort to inform [Resident 65] would be made first. Reference: (WAC) 388-97-0120 (4)

Based on interview and record review, the facility failed to accurately assess 1 of 20 residents (Resident 20), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessments regarding preferences to guide the development of a comprehensive activity care plan placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents when completing an MDS) Version 1.19.1, dated October 2024, showed, .The intent of items in this section (Section F- Preferences for Customary Routine and Activities) is to obtain information regarding the resident's preferences for their daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. The information obtained during this interview is just a portion of the assessment. Nursing homes should use this as a guide to create an individualized plan based on the resident's preferences .If a resident cannot communicate, then family or significant other who knows the resident well may be able to provide useful information about preferences .Providers are to attempt to conduct the interview with all conscious residents .If the resident is unable to complete the interview, attempt to conduct the interview with a family member or significant other .Preferences may change over time and extend beyond those included here. Therefore, the assessment of activity preferences is intended as a first step in an ongoing dialogue between the care provider and the resident .A dash (-) indicates No information. CMS [Centers for Medicare and Medicaid Services] expects dash use to be a rare occurrence. Resident 20 admitted to the facility on [DATE] with diagnosis that included dementia (memory loss). Review of Resident 20's Care Area Assessment worksheet dated 10/07/2024 showed that they discharged from hospice care services (type of care that focuses on comfort and support to people who are in the final stages of a serious illness) on 08/28/2024. Review of Resident 20's Significant Change in Status (SCSA) MDS dated [DATE], showed Section F0300, Should interview for daily and activity preferences be conducted? was coded 1 indicating that the interview was attempted with the resident and that Resident 20's responses were coded as 9 for all questions, which indicated no response or non-responsive. Section F0600, Daily and activity preferences primary respondent showed it was coded 9 indicating that an Interview could not be completed by resident or family/significant other. Section F0700, Should the staff assessment of daily and activity preferences be conducted? showed it was coded 1 which indicated Yes (because 3 or more items in interview for daily and activity preferences were not completed by resident or family/significant other). Further review showed Section F0800, Staff Assessment of Daily and Activity Preferences showed it was marked None of the above which indicated the resident had no preferences applicable within the choices from items A through Z that included choosing clothes to wear, caring for personal belongings, receiving tub bath, receiving shower, receiving bed bath, receiving sponge bath, snack between meals, staying up past 8:00 PM, family or significant other involvement in care discussions, use of phone in private, place to lock personal belongings, reading books, newspapers, or magazines, listening to music, being around animals such as pets, keeping up with the news, doings things with groups of people, participating in favorite activities, spending time away from the nursing home, spending time outdoors, and participating in religious activities or practices. Review of Resident 20's Quarterly MDS dated [DATE] showed Section F0300 was dashed (- ) indicating that the interview was not assessed or No information. Further review showed F0700 was dashed. A joint record review and interview on 12/18/2024 at 9:45 AM with Staff P, MDS Coordinator, showed that the facility's MDS electronic records included the RAI Manual that could be referenced by staff when MDS were being completed. Staff P stated the facility followed the RAI manual to guide coding accuracy of resident assessments. Continued joint record review with Staff P showed coded responses in Section F of Resident 20's SCSA MDS dated [DATE] and Quarterly MDS dated [DATE]. It further showed that Section F of Resident 20's SCSA MDS was signed and completed by Staff R, MDS part time. When asked if a family interview was completed or attempted for Section F of Resident 20's SCSA MDS, Staff P stated the SCSA MDS was completed by Staff R and that they would call to confirm with Staff R. Staff P further stated that they expected family to be interviewed for Resident 20 because they were not able to respond. When asked when it was appropriate to conduct staff interviews when completing an MDS, Staff P stated, We can interview staff after trying to interview the family. When asked if a resident, family, or staff interview was completed or attempted for Section F for Resident 20's Quarterly MDS, Staff P stated, No and that the coded responses by Staff O, Activities Supervisor, in Section F indicated interviews were not completed. Staff P further stated that they expected Section F of Resident 20's Quarterly MDS should have been completed and that they expected the completed MDS to have been accurate. A joint record review and interview on 12/18/2024 at 10:24 AM with Staff O, showed Resident 20's Section F of the Quarterly MDS dated [DATE] was dashed for all responses. Staff O stated they completed section F in Resident 20's Quarterly MDS and that they did not know why responses were dashed. When asked if they received training on how to complete the MDS Section F, Staff O stated, Yes. Staff O further stated that for residents who were non-verbal, they would interview family and if there were no family involved, they would interview staff. When asked if they interviewed family or significant other for Resident 20's Quarterly MDS dated [DATE], Staff O stated No, I know I did not interview the family. When asked if family interview should have been completed for Resident 20's Quarterly MDS, Staff O stated, Possibly, yes and that they always ask the [Certified Nursing Assistants]. In a follow up interview on 12/18/2024 at 3:04 PM, Staff P stated they contacted Staff R via phone on 12/18/2024 at 10:37 AM and that Staff R confirmed they completed Section F in Resident 20's SCSA MDS and that family interviews were not conducted. In an interview on 12/19/2024 at 10:37 AM, Staff B, Director of Nursing, stated that the facility followed the RAI manual to guide coding accuracy of resident assessments. When asked if family interview should have been completed for Resident 20's SCSA MDS dated [DATE] and Quarterly MDS dated [DATE], Staff B stated, Yes. Staff B further stated they expected MDS to be accurate and completed timely. Reference: (WAC) 388-97-1000 (1)(a)(b)(2)(m)

Based on observation, interview, and record review, the facility failed to implement activity care plan for 1 of 20 residents (Resident 20), reviewed for care planning. This failure placed the resident at risk for unmet care needs and a diminished quality of life. Findings included . Review of the facility's policy and procedure titled Comprehensive Person-Centered Care Planning, revised in August 2017, showed, It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychological needs that are identified in the comprehensive assessment .The comprehensive care plan will be developed by the IDT within seven days of completion of the Resident Minimum Data Set [MDS - an assessment tool] and will include resident's needs identified in the comprehensive assessment .The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment. Resident 20 admitted to the facility on [DATE] with diagnoses that included dementia (memory loss). Review of Resident 20's activity care plan revised on 10/02/2024 showed interventions included [staff to] offer in room story time and frequent 1:1 [one to one] visit. It showed, [Staff to] provide 1:1 program to support in-room activities with supplies, conversation, and comfort such as story time, room organization, and talking to [them]. It further showed that the care plan goal was that Resident 20 Will accept assistance with in-room activities to support end of life over the next 30 days as evidenced by activity documentation. Observations of Resident 20 in their room on 12/12/2024 at 11:06 AM, on 12/13/2024 at 10:39 AM, on 12/16/2024 at 8:27 AM, and on 12/16/2024 at 2:18 PM, did not show Resident 20 had one on one in-room activities. In an interview on 12/16/2024 at 2:24 PM, Staff O, Activities Supervisor, was requested to show activity documentation for Resident 20 from the last 30 days. Staff O stated they did not know how to generate the activity documentation report in Resident 20's electronic health record (EHR). Staff O further stated they would ask other staff members to assist with finding the activity documentation. When asked what other activities were provided for Resident 20, Staff O stated, We honestly just put on music for [them] and the roommate, not much .we also do friendly visits. When asked if activity documentation was available from sources other than Resident 20's EHR, Staff O stated, We document daily [on paper] and throw it away. A joint record review of Resident 20's EHR activity documentation on 12/16/2024 at 2:40 PM with Staff O and Staff U, Assistant Director of Nursing, did not show that Resident 20 had documentation in the last 30 days that included one on one activity participation in the following: nail care, library cart/letter writing/room art, auditory (hear) stimulation, olfactory (smell) stimulation, tactile (touch) stimulation, spiritual, music, reminisce, hair styling, and family video call. It showed that resident not available and resident refused was not documented in the last 30 days. Further review did not show Resident 20's EHR had activity documentation in social activity in the last 30 days and one day (12/05/2024) in the last 30 days, was documented for independent activity to indicate Resident 20 had their TV/Radio turned on for them in their room. Staff U stated Resident 20 had also received activity support from Hospice care services. When asked if Resident 20 was discharged from hospice services in August 2024, Staff U and Staff O stated Yes. When asked if it was the facility's process for staff to document activity participation when activities were provided, Staff O stated Yes. When asked if they expected there to be documentation for Resident 20 when activities were provided, Staff O stated Yes. A joint record review and interview on 12/18/2024 at 10:34 AM with Staff O, showed Resident 20's activity care plan revised on 10/02/2024. Staff O stated, I did not make this one. When asked who was responsible for developing Resident 20's activity care plan, Staff O stated For [Resident 20] I have not made a care plan and that Staff O worked closely with Staff D, Resident Care Manager, to assist with developing care plans. Staff O further stated, I think [Staff D] made one for us .[they] help us a lot with care plans especially for Resident 20. A joint record review and interview on 12/18/2024 at 11:02 AM with Staff D, showed Resident 20's activity care plan, revised on 10/02/2024. When asked if they were involved in care planning development and revision for Resident 20, Staff D stated, Yes, I am involved. Staff D stated they signed in the EHR that they reviewed Resident 20's care plan on 10/02/2024. When asked what was reviewed for Resident 20's activity care plan, Staff D stated, I am signing off that what's in the care plan is something that can be done for the resident. Joint record review of Resident 20's activity documentation in the EHR did not show that Resident 20 had activity documentation in the last 30 days that included one on one activity participation in the following: nail care, library cart/letter writing/room art, auditory stimulation, olfactory stimulation, tactile stimulation, spiritual, music, reminisce, hair styling, and family video call. It further showed that resident not available and resident refused was not documented in the last 30 days. Staff D stated there was no activity documentation for Resident 20 in the last 30 days and that there should have been. When asked if Resident 20's activity care plan goal of Will accept assistance with in-room activities to support end of life over the next 30 days as evidenced by activity documentation was met, Staff D stated No, it needs to be revised if there is no documentation. When asked if Resident 20's activity care plan interventions were implemented, Staff D stated No, because there's no documentation. A joint record review and interview on 12/19/2024 at 9:57 AM with Staff A, Administrator, did not show that Resident 20's activity documentation printed on 12/16/2024 had documentation that indicated one on one activity participation in the last 30 days. Staff A stated there was no activity documentation for Resident 20 and that all [staff] documentation was completed in the EHR. Joint record review of Resident 20's activity care plan showed the care plan goal was that Resident 20 Will accept assistance with in-room activities to support end of life over the next 30 days as evidenced by activity documentation. Staff A stated the activity department was responsible for providing an ongoing program of individualized activities for residents. Staff A further stated that the MDS and care plans should all be relatively supportive of each other. When asked if activity care plans were based on or in accordance with the comprehensive assessments. When asked if they expected activities offered and provided would be documented, Staff A stated, Yeah if it's an activity specialized for a resident in the care plan, yes. When asked if they expected staff to implement the resident individual care plan, Staff A stated, Yes, that's in our policy. Reference: (WAC) 388-97-1020 (1)(2)(a)(f)

Based on observation, interview, and record review, the facility failed to evaluate resident equipment for safety hazards and risks, failed to implement written policies and procedures for bed safety and use of side rails, and failed to comprehensively assess the risk for entrapment prior to the use of side rails for 5 of 6 residents (Residents 1, 2, 3, 4 and 5) reviewed for side rails. The facility's failure to assess the residents' risk of bed and side rails entrapment, lack of an effective system to monitor and evaluate the safety risk of side rails prior to use and the facility's failure to recognize the risk of entrapment, injury or death related to an incompatible side rails and wrong size bed/mattress constituted an Immediate Jeopardy (IJ) situation on 04/06/2022. Findings included . According to the United States Food and Drug Administration (FDA) article titled Safety Concerns about Bed Rails dated 07/09/2018 and Consumer Product Safety Commission (CPSC) report Adult Portable Bed Rail-Related Deaths, Injuries, and Potential Injuries, the agency received reports of 155 deaths and 5 injuries related to adult portable bed rails from January 2003 to September 2012. Of the deaths: 143 were related to rail entrapment, 11 were related to falls on the bed rail, and 1 victim hit his head on the rail. About half of the death reports indicated that the victim had a diagnosed medical condition. The most reported conditions included: mobility limitations and taking high risk medications. The FDA received medical device reports (also called MDRs) showing 901 incidents of patients caught, trapped, entangled, or strangled in hospital beds between January 1, 1985, and January 1, 2013. The reports included 531 deaths, 151 nonfatal injuries, and 220 cases where staff needed to intervene to prevent injuries, also called near misses. Most patients were frail, elderly or disoriented. A review of the facility policy titled Bedrail assessment dated [DATE], showed, It is the policy of this facility to attempt to use appropriate alternatives prior to installing a side or bedrail. If a bed or side rail is uses, the facility must ensure correct installation, use and maintenance of bedrails. The policy directed the facility staff to: 1. After the facility has attempted alternatives to bed rails and determined that these alternatives failed to meet the resident's assessed needs, the facility IDT (interdisciplinary team) will assess the resident for risks of entrapment and possible benefits of using bed rails. The risk and benefits of side rails will be considered for each resident. 2. Before Bed rails are installed, the facility should check with the manufacturer to make sure the bed rails, mattress, and bed frame are compatible since most bed rails and mattress are purchased separately from the bed frame. 3. When installing and using bed rails, the facility should ensure the bed dimensions are appropriate for the resident, confirm that the bed rails to be installed are appropriate for the size and weight of the resident using the bed, inspect and regularly check the mattress and bed rails for areas of possible entrapment and regardless of mattress width, length, and/or depth, the bed frame, bed rail and mattress should leave no gap wide enough to entrap a resident's head or body. RESIDENT 1 Resident 1 was a long-term care resident at the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the residents quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident had intact cognition and needed 1-person extensive assistance with bed mobility and 2-person extensive assistance with transfers. On 04/06/2022 at 10:00 AM, Resident 1 stated she was miserable and afraid because of her current bed, mattress, and side rails. The resident stated that she was worried of falling out of bed and getting trapped in between the bed and the rails because the size of her bed, mattress, and side rails were not compatible and appropriate for her size. According to the resident, the facility staff and management was aware of these safety concerns since last week (week of 03/22/2022 to 03/30/2022) but had taken no actions to keep her safe and address her concerns. The resident further stated that she was frustrated and at the same time fearful about her safety because even some of the facility staff had shared that they were afraid of her falling out of bed and getting trapped in between the mattress and the side rails. The resident was observed on a regular size bed and mattress with bilateral ¼ size side rails. The resident was positioned at the center of the bed with her right upper arm inserted/tucked in between the mattress and the side rail. The gap between the mattress and the side rails were measured at least 6 inches on the right side and at least 4-6 inches on the left side. On 04/06/2022 at 10:15 AM, Staff C, Nursing Assistant Certified (NAC) attended and helped the resident in bed. Staff C turned Resident 1 away from him to remove her brief and place a bedpan. The resident's lower body and extremities were hanging on the side of the bed with her right arm tucked under the gap between the mattress and the side rails. Staff C stated, he was concerned about Resident 1's safety and increase risk failing out of bed due to the wrong size of the bed, mattress, and the current size/position of the side rails. Staff C stated these safety concerns were already reported to the facility maintenance and administration (Operations Manager [OM] and Staff B, Director of Nursing [DNS]) and he was not sure why no actions were taken to correct them. On 04/06/2022 at 10:25 AM, another staff member, Staff D, NAC, attended and helped the resident get off the bed pan and provided perineal care. Staff D also turned Resident 1 away from her to clean and remove the bed pan. Similar findings were observed when the resident's lower body and extremities were hanging on the side of the bed with her right arm tucked under the gap between the mattress and the side rails. Staff D stated she was also concerned about Resident 1's safety and increase risk failing out of bed due to the wrong size of the bed, mattress, and the current size/position of the side rails. Staff D stated that the facility management, including the DNS and OM were aware of these concerns since last week (not able to recall specific date) and she was not sure why no actions were taken to address the resident's safety concerns. On 04/06/2022 at 11:30 AM, Staff E, Licensed Practical Nurse/Resident Care Manager (LPN/RCM) stated she was aware of the resident's concerns related to her bed and side rails. According to Staff E, the facility administration (Administrator and the DNS) was also aware of these safety concerns since last week (not able to recall specific date). However, Staff E was not able to provide an answer or explanation as to why the facility had taken no actions to address the resident's safety concerns related to the size of the bed, mattress and/or side rails. On 04/06/2022 at 11:45 AM, Staff F, Staff Development Coordinator/Registered Nurse (SDC/RN) stated he had observed the safety concerns and the gap between the side rails and the mattress, including the need for a bariatric/bigger size bed for Resident 1. Staff F stated he would immediately contact maintenance and the DNS to address the situation. The DNS, OM, and the Administrator were out of the facility and not available for an interview. A review of Resident 1's clinical records (Physician order sheets, Assessments and Evaluations, Care Plans/care directives, progress notes and physician visit notes, and therapy notes) showed the following: 1. There was no documented comprehensive assessment related to the use of bilateral side rails. The only documented evaluation was completed on 12/03/2021 (4 months ago) and showed that the facility had recommended the use of bilateral mobility bars. However, the evaluation was missing key information and was not comprehensive and detailed as directed by the facility policy. 2. There was no consistent documentation that showed that staff followed the written policies and procedures for Bedrail Assessment. A. There was no documented assessment to determine the resident's symptoms, risk of entrapment and reason for using side rails including the bed's dimensions are appropriate for the resident's size and weight. B. There was no care plan developed specific to the use of side rails including the type and/or size of side rails used. C. There was no documentation that showed evidence of an attempt(s) to use less restrictive interventions prior to the use of side rails or documentation that showed less restrictive approaches were not successful, prior to considering the use of side rails. 3. There was no documentation that showed a specific written physician order was in place prior to the use of side rails. 4. There was no documentation that showed an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative as directed by the facility policy. 5. There was no documentation that showed bed and bedrail inspection(s) had been completed by staff (and related equipment) to identify risks and problems including potential entrapment risks, and a review to ensure that gaps within the bed system are within the dimension established by the FDA. 6. The resident was taking [MEDICATION(S)] (an anti-[CONDITION(S)]/anti-epileptic drug) twice per day, a medication that could affect and alter her brain function increasing her risk of entrapment. On 04/06/2022 at 1:45 PM, during a phone interview, Staff B, DNS, stated she was not aware of the specific safety concerns regarding Resident 1's side rails, bed, and mattress. Staff B stated she could recall the need to replace Resident 1's side rails recently due to safety reasons but could not remember whether the new side rails were assessed to ensure it was compatible and appropriate for Resident 1. According to Staff B the resident should have a comprehensive and entrapment risk assessment prior to the installation and use of side rails to ensure the safety of the resident and to address/identify the risk for entrapment and other injuries/accidents associated with the use of side rails. On 04/06/2022 at 2:10 PM, Staff G, Maintenance Director, stated he installed Resident 1's bilateral siderails. However, Staff G stated he did not review or measure the compatibility of the side rails, the bed frame and/or the size of the mattress. Staff G further stated he did not measure the dimension including the gaps in between the mattress and the side rails when he installed the side rails. Similar findings were found for Resident 2, 3, 4 and 5. RESIDENT 2 Resident 2 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's quarterly MDS assessment dated [DATE] showed the resident had intact cognition and needed 1-person extensive assistance with bed mobility and 2-person extensive assistance with transfers. On 04/06/2022 at 11:50 AM, Resident 2 was observed in bed. The resident was on a bariatric size bed and mattress with bilateral ¼ side rails installed. The resident stated her side rails were loose most of the time and it would wiggle when she grabbed them. Both side rails were loose during this observation. A review of Resident 2's clinical records (Physician order sheets, Assessments and Evaluations, Care Plans/care directives, progress notes and physician visit notes, and therapy notes) showed the following: 1. There was no documented comprehensive assessment related to the use of bilateral side rails. The only documented evaluation was completed on 11/30/2021 (5 months ago) and showed that the facility had recommended the use of bilateral mobility bars. However, the evaluation was missing key information and was not comprehensive and detailed as directed by the facility policy. 2. There was no consistent documentation that showed that staff followed the written policies and procedures for Bedrail Assessment. A. There was no documented assessment to determine the resident's symptoms, risk of entrapment and reason for using side rails including the bed's dimensions are appropriate for the resident's size and weight. B. There was no care plan developed specific to the use of side rails including the type and/or size of side rails used. C. There was no documentation that showed evidence of an attempt(s) to use less restrictive interventions prior to the use of side rails or documentation that showed less restrictive approaches were not successful, prior to considering the use of side rails. D. There was no documentation that showed the risk and benefits of side rails were considered and reviewed with the resident. 3. There was no documentation that showed a specific written physician order was in place prior to the use of side rails. 4. There was no documentation that showed an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative as directed by the facility policy. 5. There was no documentation that showed bed and bedrail inspection(s) had been completed by staff (and related equipment) to identify risks and problems including potential entrapment risks, and a review to ensure that gaps within the bed system are within the dimension established by the FDA. 6. The resident was taking [MEDICATION(S)] (a narcotic pain medication) twice per day for pain management. A medication that could affect and alter her brain function increasing her risk of entrapment. RESIDENT 3 Resident 3 was a long-term care resident at the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's quarterly MDS assessment dated [DATE] showed the resident had intact cognition and needed 2-person extensive assistance with bed mobility and transfers. On 04/06/2022 at 12:05 PM, Resident 3 was observed in bed. The resident was on a bariatric size bed and mattress with bilateral ¼ side rails installed. The resident stated her side rails were recently replaced by the facility (within 1-2 weeks but could not recall specific date). The resident stated her side rails will come loose sometime and it would wiggle when she grabbed them. Both side rails were loose during this observation. A review of Resident 3's clinical records (Physician order sheets, Assessments and Evaluations, Care Plans/care directives, progress notes and physician visit notes, and therapy notes) showed the following: 1. There was no documented comprehensive assessment related to the use of bilateral side rails. The only documented evaluation was completed on 03/03/2022 and showed that the facility had recommended the use of bilateral mobility bars. However, the evaluation was missing key information and was not comprehensive and detailed as directed by the facility policy. 2. There was no consistent documentation that showed that staff followed the written policies and procedures for Bedrail Assessment. A. There was no documented assessment to determine the resident's symptoms, risk of entrapment and reason for using side rails including the bed's dimensions are appropriate for the resident's size and weight. B. There was no care plan developed specific to the use of side rails including the type and/or size of side rails used. C. There was no documentation that showed evidence of an attempt(s) to use less restrictive interventions prior to the use of side rails or documentation that showed less restrictive approaches were not successful, prior to considering the use of side rails. 3. There was no documentation that showed a specific written physician order was in place prior to the use of side rails. 4. There was no documentation that showed an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative as directed by the facility policy. 5. There was no documentation that showed bed and bedrail inspection(s) had been completed by staff (and related equipment) to identify risks and problems including potential entrapment risks, and a review to ensure that gaps within the bed system are within the dimension established by the FDA. 6. The resident was on [MEDICATION(S)] (a narcotic pain medication) every 3 hours as needed for pain. A medication that could affect and alter her brain function increasing her risk of entrapment. RESIDENT 4 Resident 4 was a long-term care resident at the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's quarterly MDS assessment dated [DATE] showed the resident had an intact cognition and needed 2-person extensive assistance with bed mobility and transfers. On 04/06/2022 at 12:10 PM, Resident 4 was observed in bed. The resident was on a bariatric size bed and mattress with bilateral ¼ side rails installed. The resident stated that her side rails were also recently replaced by the facility (within 1-2 weeks but could not recall specific date) because her previous side rails were loose and could not hold her weight. A review of Resident 4's clinical records (Physician order sheets, Assessments and Evaluations, Care Plans/care directives, progress notes and physician visit notes, and therapy notes) showed the following: 1. There was no documented comprehensive assessment related to the use of bilateral side rails. The only documented evaluation was completed on 06/02/2021 (10 months ago) and showed that the facility had recommended the use of bilateral mobility bars. However, the evaluation was missing key information and was not comprehensive and detailed as directed by the facility policy. 2. There was no consistent documentation that showed that staff followed the written policies and procedures for Bedrail Assessment. A. There was no documented assessment to determine the resident's symptoms, risk of entrapment and reason for using side rails including the bed's dimensions are appropriate for the resident's size and weight. B. There was no care plan developed specific to the use of side rails including the type and/or size of side rails used. C. There was no documentation that showed evidence of an attempt(s) to use less restrictive interventions prior to the use of side rails or documentation that showed less restrictive approaches were not successful, prior to considering the use of side rails. D. There was no documentation that showed the risk and benefits of side rails were considered and reviewed with the resident. 3. There was no documentation that showed a specific written physician order was in place prior to the use of side rails. 4. There was no documentation that showed an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative as directed by the facility policy. 5. There was no documentation that showed bed and bedrail inspection(s) had been completed by staff (and related equipment) to identify risks and problems including potential entrapment risks, and a review to ensure that gaps within the bed system are within the dimension established by the FDA. 6. The resident was on [MEDICATION(S)] (an anti-depressant medication), [MEDICATION(S)] (an anti-depressant medication), [MEDICATION(S)] (a narcotic pain medication) as needed for pain, and [MEDICATION(S)] (an anti-[CONDITION(S)]/anti-epileptic drug) daily. These medications could affect and alter the resident's brain function increasing her risk of entrapment. RESIDENT 5 Resident 5 was long term-care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's quarterly MDS assessment dated [DATE] showed the resident had impaired cognition and needed 1-2-person assistance with bed mobility and transfers. On 04/06/2022 at 12:25 PM, Resident 5 was observed in bed. The resident was not able to follow verbal commands and was immobile (not able to move or turn independently). The resident was on a regular size bed with bilateral quarter side rails installed. A review of Resident 5's clinical records (Physician order sheets, Assessments and Evaluations, Care Plans/care directives, progress notes and physician visit notes, and therapy notes) showed the following: 1. There was no documented comprehensive assessment related to the use of bilateral side rails. The only documented evaluation was completed on 03/02/2022 and showed that the facility had recommended the use of bilateral mobility bars. However, the evaluation was missing key information and was not comprehensive and detailed as directed by the facility policy. 2. There was no consistent documentation that showed that staff followed the written policies and procedures for Bedrail Assessment. A. There was no documented assessment to determine the resident's symptoms, risk of entrapment and reason for using side rails including the bed's dimensions are appropriate for the resident's size and weight. B. There was no care plan developed specific to the use of side rails including the type and/or size of side rails used. C. There was no documentation that showed evidence of an attempt(s) to use less restrictive interventions prior to the use of side rails or documentation that showed less restrictive approaches were not successful, prior to considering the use of side rails. 3. There was no documentation that showed a specific written physician order was in place prior to the use of side rails. 4. There was no documentation that showed an interdisciplinary assessment of the resident, consultation with the attending physician, and input from the resident and/or legal representative as directed by the facility policy. 5. There was no documentation that showed bed and bedrail inspection(s) had been completed by staff (and related equipment) to identify risks and problems including potential entrapment risks, and a review to ensure that gaps within the bed system are within the dimension established by the FDA. 6. The resident was on [MEDICATION(S)] daily and [MEDICATION(S)] (an anti-psychotic medication). Both medications could affect and alter the resident's brain function increasing her risk of entrapment. On 04/06/2022 at 2:15 PM, during a phone interview, Staff B, DNS, stated the facility had a system problem related to the use of side rails. The DNS stated the facility was currently working on process improvement and will immediately reassess residents on side rails to ensure residents safety and eliminate risk of entrapment related to the use of side rails. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure two of two residents sampled (Resident #1 and #2) remained free of significant medication errors. This failure led to wrong medications being administered to Resident #1 which contributed to blood pressure/mental status changes that required emergency room intervention and an unplanned hospital stay. This failure also led to Resident #2, who had repeated falls, receive narcotics that had been discontinued, and placed the resident at risk for more confusion/falls. Findings included . RESIDENT #1 The facility Policy and Procedure for Medication Administration showed the facility expected the following: Medication must be administered in accordance with the orders, including any required time frame. The individual administering medications must verify the resident's identity before giving the resident his/her medications. Methods of identifying the resident include: a. Checking identification band; b. Checking photograph attached to medical record; and c. If necessary, verifying resident identification with other facility personnel. The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. Review of facility medical records showed Resident #1 was admitted to the facility in July 2020 for rehabilitation. Records on admission to the facility showed Resident #1's blood pressure was 116/84 and pulse rate 76, and was cognitively alert and oriented times three. Resident #1 ambulated with a walker and had previously lived alone at home. Review of the facility record showed vital signs for Resident #1 had blood pressure readings ranging from 130/70 to 140/90 from admission on 07/24/20 until a medication error on 07/26/20. Review of the admission physician orders [REDACTED]. Review of a facility progress note, dated 07/27/2020, showed the nurse on duty, Staff A, administered wrong medications to Resident #1 after allegedly attending to another resident with a potential emergency. The physician was notified and an order to monitor Resident #1 every 30 minutes was started, check for confusion, and an order to notify the physician if blood pressure systolic (top number) was less than 100 and diastolic (bottom number) was less than 55 or pulse less than 65. The progress note by Staff A also showed Resident #1's initial blood pressure reading (taken after the wrong medication administration) was 128/68 with a pulse= 86. The resident's blood pressure then dropped to 118/70, and dropped again to 88/58 with dizziness. Resident #1 was sent to the hospital emergency room for change in condition. Review of the facility investigation showed Resident #1 had been given 5 medications by Staff A, a licensed nurse, on 07/26/2020 at around 9:00 pm: [MEDICATION NAME] 12.5 mg (for high blood pressure), [MEDICATION NAME] 0.1 mg (for high blood pressure), [MEDICATION NAME] 300 mg (an anticonvulsant), [MEDICATION NAME] 100 mg (treats high blood pressure), [MEDICATION NAME] 10mg (antidepressant). The investigation showed that Staff A, LN, had interrupted her medication pass to tend to a coughing resident, returned to the medication cart, and then mistakenly gave the medications to Resident #1. Staff A immediately realized the error. Resident #1 was transferred to the emergency room and treated for [REDACTED]. The LN was reeducated for medication administration and had subsequent medication administration reviewed. Review of the 07/24/2020 admission physician orders [REDACTED]. Review of the physician progress notes [REDACTED].#1 was hospitalized for [REDACTED]. The physician note also showed, Resident #1 had been given wrong medications at the facility, resulting in a hospitalization for four nights 07/26/20 to 07/30/20. Resident #1 arrived in the emergency room with a blood pressure of 90/60 that changed with the 90 down to the 70's, which had to be corrected with intravenous fluids for the abnormally low blood pressure which was medication-induced. Resident #1 also had medication-induced changes in mental status with somnolence (drowsiness) which was also resolved when the blood pressure was corrected. Other symptoms induced by the medication error were dizziness and fast heart rate, also corrected at the hospital. During an interview on 08/28/2020 at 6:00 p.m., Staff A, a licensed nurse, stated that she had administered the wrong medications to Resident #1 during a busy time when she got distracted with a possible emergency with another resident. Staff A stated that she would review the five rights of medication administration again if she poured medications and became interrupted in the future. The facility failed to ensure Resident #1 was free of significant medication errors when the facility staff administered five medications that were not ordered by the physician to Resident #1. This significant medication error of wrong medications and wrong resident resulted in significant low blood pressure and mental status changes, that led to an emergency room transfer for treatment and a four night stay in the hospital. RESIDENT #2 Review of facility records showed, Resident #2 admitted to the facility in July 2020 for rehabilitation after a fall and fractures at home. Review of the facility progress note dated 07/29/2020, shortly after admission to the facility, showed Resident #2 was alert and oriented x 2-3, and able to make her needs known. Resident #2 had some back pain with movement during cares or positioning. Routine Tylenol was administered as ordered with good relief per patient. Offered prn [MEDICATION NAME] or [MEDICATION NAME] but resident declined those medications. Review of the physician's orders [REDACTED]. Review of a facility progress note by Staff C, licensed nurse, dated 08/05/2020, showed Resident #2 was alert and confused per baseline and able to make her needs known. Resident #2 expressed back pain with movement. Offered pain medication, but the resident declined and stated, I don't want to take any narcotic. Routine Tylenol was administered as ordered with good relief per patient. Review of the physician note, dated 08/06/2020, showed [MEDICAL CONDITION], Plan - stop narcotics for now. The physician note also showed Resident #2's POA (Power of attorney) stated he wanted the narcotics stopped because Resident #2 had increased confusion when she took narcotics in the hospital. Resident #2 had some confusion and [MEDICAL CONDITION] since admit to facility, but today appears to be more exacerbated. In discussing with POA, he feels strongly about having the resident on narcotics. He tells me resident had similar presentation in the hospital with narcotic use requiring at least four days before she began to clear. Her [MEDICATION NAME] had been stopped a while ago, but she continues on [MEDICATION NAME] for back pain. He asked for this to be stopped as well. Review of facility progress note by Staff E, a licensed nurse, 08/07/2020 showed Staff E spoke to the legal representative for Resident #2 who was more adamant about telling me that his Mom can't have narcotics. He said this is from his Mom taking them, and then going goofy. I (Staff E) told him the [MEDICATION NAME] had been discontinued. The [MEDICATION NAME] had been discontinued. I said she was confused again. I assured him no narcotics had been given. During an interview on 08/26/2020 at 2:20 p.m., the legal representative for Resident #2 stated he told the facility not to give narcotics to Resident #2 for pain because it caused her to be confused in the hospital. Review of a facility progress note, dated 08/08/2020 by Staff C, a licensed nurse on day shift, showed Resident #2 was alert and confused, able to make her needs known, had back pain and noted to have frequent episodes of moaning. Staff C offered [MEDICATION NAME], a narcotic, multiple times during the shift but Resident #2 declined to take any and she stated I don't want to take any [MEDICATION NAME] Tylenol was administered as ordered with some relief. (Staff C offered [MEDICATION NAME], a narcotic that was discontinued 07/31/20). Review of the facility progress note, dated 08/08/2020 by Staff B, a licensed nurse on night shift, showed Resident #2 complained of pain, [MEDICATION NAME] and [MEDICATION NAME] given with relief (both discontinued medications). Review of the facility investigation, dated 08/14/2020, showed Staff B, a licensed nurse, administered both [MEDICATION NAME] and [MEDICATION NAME] to Resident #2 on 08/08/2020, even though the narcotic medication orders had been discontinued. The investigation showed Staff B obtained the medications out of the medication cart without checking the medication administration record. During an interview on 08/25/2020 at 4:20 p.m., the Director of Nursing (DNS) stated that the narcotics were still in the medication cart after being discontinued and had not been disposed of yet by the nurses when the medication error happened. The DNS stated that Staff B had not checked the Medication Administration Record [REDACTED]. During an interview on 08/26/2020 at 11:00 a.m., Staff B, a licensed nurse, stated that Resident #2 was yelling with foot pain and he told her he would give her some medication for the pain, but did not discuss what he would give. Staff B stated he went to the medication cart narcotic book and got two pain pills for Resident #2, one [MEDICATION NAME] and one [MEDICATION NAME] and gave them to her. Staff B stated he did not check the Medication Administration Record [REDACTED]. Staff B stated he was in a hurry to treat the pain and had not checked the current medication orders in the Medication Administration Record [REDACTED]. Review of a facility progress note dated 08/09/2020 by Staff C, a licensed nurse, showed Resident #2 was alert and confused, responds to yes and no questions. Moans and grimaces with movement or positioning. Offered [MEDICATION NAME] but Resident #2 adamantly declined. Routine Tylenol administered with some relief. (Again, Staff C offered Resident #2 a narcotic pain medication that had been discontinued.) The facility staff failed to follow physician's orders [REDACTED].#2 after the medications had been discontinued per physician orders. Reference (WAC) 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to prevent the development and worsening of an avoidable pressure ulcer for one of two residents sampled (Resident #2). This failure led to an open pressure wound for Resident #2 that worsened to an unstageable wound under a medical brace and caused pain. Findings included . Review of the facility pressure ulcer prevention policy showed the following interventions for skin pressure ulcer prevention: 1. Review the resident's care plan and identify the risk factors as well as the interventions designed to reduce or eliminate those considered modifiable. 2. Review and select medical devices with consideration to the ability to minimize tissue damage, including size, shape, its application and ability to secure the device. 3. Monitor regularly for comfort and signs of pressure-related injury. Evaluate, report and document potential changes in the skin. 4. Review the interventions and strategies for effectiveness on an ongoing basis. The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 1 Pressure Injury: Non-blanchable [DIAGNOSES REDACTED] of intact skin. Intact skin with a localized area of non-blanchable [DIAGNOSES REDACTED], which may appear differently in darkly pigmented skin. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 Pressure Injury: Full-thickness skin loss Full-thickness loss of skin, in which adipose (fat) is visible in the ulcer and granulation tissue and epibole (rolled wound edges) are often present. Slough and/or eschar may be visible. The depth of tissue damage varies by anatomical location; areas of significant adiposity can develop deep wounds. Undermining and tunneling may occur. Fascia, muscle, tendon, ligament, cartilage and/or bone are not exposed. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. Review of facility records showed Resident #2 admitted to the facility in July 2020 for rehabilitation after a fall with fractures at home. Resident #2 needed extensive assistance from two people for all activities of daily living. Review of the facility admission skin assessment for Resident #2, dated 07/09/2020, showed no abnormalities or no open pressure wounds were identified for Resident #2 on admission to the facility. Review of the facility skin risk assessment, dated 07/10/2020, on admission to the facility showed Resident #2 was at risk for an alteration in skin integrity mainly due to immobility. On 07/10/2020, an abduction hip brace was placed for dislocation of hip in the emergency room after Resident #2 fell in the facility. (An abduction brace holds the femur/thighbone in the hip socket, and is used to prevent excessive motion in the hip to promote healing.) Review of a facility physician note, dated 07/13/20, showed the abduction hip brace was to be on Resident #2 at all times except for hygiene. Review of progress notes, dated 07/16/2020, six days after the brace was applied for Resident #2 showed Staff F, a licensed nurse, had noted two open skin areas on Resident #2's lower back, 6 cm (centimeters) by 5 cm total, caused by the hip brace rubbing. The wound areas were red, and a treatment order, dated 07/16/2020, for cleansing and a dressing was obtained. The progress note also showed: open areas to lower back x 2, areas appeared to have been caused from left hip brace rubbing area; area as a whole is red and indurated (hard) measuring 6 cm x 5 cm, there are 2 open areas within the indurated area, the upper open area measuring 2.5 cm x 3 cm and the lowermost open area measures 1 cm x 1 cm; no drainage noted to either area, resident denies pain upon palpation to area; received new order to cleanse areas and apply foam dressing daily. Review of the facility care plan, dated 07/09/2020, 07/22/2020, 07/28/2020, and 07/29/2020, for Resident #2 showed the following interventions for Impaired Skin Integrity: consult wound nurse, monitor for symptoms of infection, monitor for redness of skin especially over bony prominences, air mattress on bed, reposition in wheelchair, weekly skin checks. The resident's care plan did not mention the medical device (hip brace) or the increased need for monitoring of the device for pressure or rubbing on the skin. The care plan did not mention any other interventions to prevent pressure ulcers from the device that was applied to Resident #2 on her front and back hip and up the abdomen and back above the waist. During an interview on 08/31/20 at 9:00 a.m., Staff E, a licensed nurse, stated that Resident #2's hip brace was made of hard plastic, was secured with straps, and the brace extended above the waist. Staff E stated that there was no skin irritation at first, but then the skin became irritated so the staff put clothing under the brace. Staff E stated the skin still got irritated, especially when Resident #2 was up in the wheelchair so they put a pillow behind her in the chair, The wound then needed a treatment and dressing. It got irritated in bed too. I checked it daily. Therapy staff pointed out the wound was open. Size of nickel, red no slough (dead skin tissue) at first. The brace was big for her. A treatment was added for debridement (removal of dead tissue). There was no evaluation of the size of the brace for Resident #2, it seemed it was too big for her. Review of the facility July 2020 medication and treatment records for Resident #2 showed the following orders: -An order to Monitor skin under brace every day was started on 07/18/2020 (8 days after the brace was applied and 2 days after the wound was discovered); -Weekly skin check documentation: Skin check. Yes = skin issue No = No skin issues, one time a day every Fri Y = Yes, N=No: On 07/10/2020 was marked as no (no skin issues); 07/17/2020 not charted; 07/24/2020 marked N (although there was an open wound), 08/07/2020 marked N (although there was an open wound); -Pressure mattress started on 07/27/2020 (11 days after wound found); -Turn every two hours started on 07/30/2020 (14 days after wound found); August 2020: monitor skin under the brace was still only daily (not every shift). During an interview on 09/01/20 at 1:00 p.m., the Director of Nursing (DNS) stated that she expected skin care with a brace device to prevent pressure ulcer should include skin inspected at least every shift, The facility is working on a new skin care system. And you should see a progress note every time the staff do a wound treatment. Review of the physician note, dated 07/16/2020 for Resident #2 showed: Pressure ulcer of unspecified part of back, stage 2, Plan: covered with foam dressing to protect from rubbing against hip brace. Wound on lumbar spine noted by nurse approximately 2.5 x 3 cm and 1 x 1 with [DIAGNOSES REDACTED] in surrounding tissues. No pain to touch. Wound bed is dry. It appears to may have been caused by hip brace rubbing on skin. [DIAGNOSES REDACTED]. There was no further wound description in the facility record for Resident #2 until 07/24/2020, eight days later. when documentation by Staff E showed: wound open and tender with no further description of the wound or further interventions implemented to prevent worsening of the pressure ulcer. Review of facility medicare meeting notes, dated 07/23/2020 and 08/06/2020 showed Resident #2 had a pressure wound from the medical brace rubbing. There was no further description of the wound or updated plan to prevent worsening of the pressure wound on the back of Resident #2. Review of a facility progress note, dated 07/25/2020, nine days after discovery of the wound, showed Resident #2 was alert and confused per baseline, able to make her needs known. Complained of mild pain on lower back with movement. Tylenol given. Lower back wound dressing changed as ordered. Wound bed with 100% slough (dead tissue), peri-wound skin red, scant drainage on old dressing, no foul odor. Affected area is painful to touch during treatment. Further review of the facility progress notes showed a note dated 07/26/2020, Alert and able to make her needs known. Complained of back pain mostly at wound site. Stated that it is usually pain with movement during cares or touch. Routine pain regimen administered with good relief. Lower back wound measured-4.5 cm x 2 cm, wound bed with 100% slough, mild redness noted at peri-wound, small amount of yellowish drainage noted on old dressing, wound is tender to touch. On call physician notified about current condition of the wound. New treatment order received and started. New order received to remove abductor brace while in bed due to pressure and friction on the wound. On 07/27/2020, eleven days after the discovery of the pressure wound, a physician order [REDACTED]. A physician note, dated 07/27/2020, showed Pressure injury of left lower back, unstageable .Offload pressure. Review of the following facility wound monitoring progress notes between 07/27/2020 and 08/10/2020 showed inconsistent measurements, limited changes in interventions, and that the pressure wound was worsening: 07/27/2020- wound on back measured 4.5 cm by 1.5. It has yellow slough on it. It is also painful to her. She has order for air mattress and she was put on it. She is to off load throughout the day and night. The wound is now getting a debridement treatment to the wound base. Doing labs and looking for possible infection to the wound on the spine from the brace to the left leg that she had been wearing. 07/28/2020- wound bed is covered with slough (dead tissue), redness noted surrounding wound; brace in place to left hip. 07/29/2020- Wound measured 4.5 x 2 cm, wound bed with 100% slough (dead tissue), redness on peri-wound skin, scant drainage on old dressing. 07/30/2020- wound healing consult note-[MEDICATION NAME] Spine Wound Medical Device Related Pressure Injury Pressure Ulcer 4.5 cm x 2 cm total 9 square cm 76-100 percent slough-unstageable-treatment for [REDACTED]. 07/31/2020- wound bed continues to be slough covered with redness and warmth noted to peri-wound; resident has complaints of pain with wound care. 08/01/2020- the wound is still yellow in color. 08/02/2020 wound on mid low back spine region. There is yellow slough in the wound bed. There is some redness around the perimeter of the wound. It is tender to the touch. 08/03/2020 wound to spine continues with slough (dead issue) to wound bed and redness around wound. 08/04/2020 wound care done to pressure area on mid back, wound bed continues to be slough covered, continues with noted redness and warmth surrounding wound; brace is in place to left hip. 08/05/2020- Lower back wound dressing changed as ordered. Wound bed is still covered with 100% slough, tender to touch. 08/06/2020-physician note: Pressure ulcer on lower back -wound is slowly improving but still with 100% slough, does not want back brace-uncomfortable due to scoliosis. 08/06/2020- wound-slough remains-unstageable pressure ulcer-not healed-4.1 cm x 2.8 cm scant drainage, periwound red. 08/08/2020- Wound is tender to touch, 100% slough on wound base, mild redness on peri-wound(surrounding) skin. Scant drainage noted on old dressing. 08/09/2020- lower back wound dressing changed as ordered. Wound still has 100% slough at wound base with mild peri-wound [DIAGNOSES REDACTED]. Wound area is very tender to touch. 08/10/2020- wound on back hurting. During an interview on 08/26/2020 at 11:00 a.m., Staff B, a licensed nurse who worked on the evening/night shift while Resident #2 had the open wound, stated he knew nothing about any skin wound for Resident #2. During an interview on 08/28/2020 at 1:00 p.m., Staff F, a licensed nurse who was the first to document the wound on 07/16/2020, stated that the hip brace for Resident #2 extended up mid-back, was made of plastic and had Velcro to tighten and to keep it on which took two people to do. The brace was supposed to be off only for hygiene. Staff F also stated that Resident #2 had pain from an open wound on her back from the brace rubbing on the skin. Staff F also stated that the first time she saw the wound, it was about 5 cm by 4 cm and had hard yellow slough on the wound with redness around the outside and that the wound was unstageable from the first time it was identified, When you touched the wound you could see the pain on her face, it hurt. There was padding inside the brace, but no other pressure relief interventions at that time. During an interview on 08/28/20 at 1;20 p.m., Staff C, licensed nurse, stated that the open pressure wound on Resident #2's back was related to the hip brace, and staff checked the skin daily, The wound was definitely painful. Especially during treatment. During an interview on 08/25/20 at 12:20 p.m., a family member/emergency contact for Resident #2 stated that she received many complaints from Resident #2 about pain caused by the brace and the open wound on her spine. Review of emergency room records, dated 08/10/2020, showed Resident #2 was sent to the emergency room (ER) after a fall and arrived in the ER with an unstageable pressure ulceration on her back. The facility failed to timely implement, evaluate and monitor interventions to relieve and prevent pressure ulcers on the skin under the medical device/hip brace for Resident #2 that resulted in an avoidable unstageable pressure wound on the back spine area and pain. Reference (WAC) 388-97-1060(3)(b)

Based on interview and record review, the facility failed to notify the physician immediately of laboratory results that fell outside of clinical reference ranges for one of one residents sampled for critical blood test results (Resident #2). This failure led to delayed treatment for [REDACTED].#2 was then subsequently hospitalized for [REDACTED]. Findings included . According to Lippincott, Williams, and Wilkins 2013, [MEDICAL CONDITION] is an abnormally low hemoglobin and level of circulating red blood cells decreases the blood's oxygen carrying capacity. [MEDICAL CONDITION] is most often due to excess bleeding or inadequate red blood cell production. The lab test helps determine the severity and cause of the [MEDICAL CONDITION]. Red blood cell transfusion is indicated for signs and symptoms of [MEDICAL CONDITION] such as a critical oxygen carrying deficit. Review of facility records showed Resident #2 admitted to the facility in July 2020 for rehabilitation. Resident #2 needed extensive assistance from two people for all activities of daily living and had a [DIAGNOSES REDACTED]. Review of facility physician notes by Staff D, a nurse practitioner, showed Resident #2 had lab blood test results on 07/21/2020- hemoglobin 8.8 started iron for [MEDICAL CONDITION]; and again on 07/29/2020- hemoglobin 8.2 stable [MEDICAL CONDITION]. Review of a facility physician note, dated 08/07/2020, showed Resident #2 more confused today and refusing her am medications. During my exam, patient is alert and interactive, but very confused when it comes to details about her care. When I asked her if she declined her AM meds, patient denies declining her am meds. She then agreed to take her meds. She appears to have difficulty following commands and has word salad. She had assisted fall from her bed overnight. She was found attempting to get out of bed, then assisted to the floor by staff. No reported injury from fall. Patient has no recollection of the fall. Review of a facility progress note by Staff E, a licensed nurse, dated 08/07/2020, showed Staff D, a nurse practitioner, had ordered a STAT (immediate as soon as possible) blood count (CBC) for that evening and the laboratory was notified. Review of the facility physician orders for Resident #2 showed a STAT CBC blood test ordered on [DATE] for lethargy and confusion. During an interview on 08/31/2020 at 9:00 a.m., Staff E, a licensed nurse, stated the nurse practitioner ordered a STAT blood test for Resident #2 on Friday 08/07/2020. Staff E stated that she notified the lab who drew the blood around 8:50 pm that evening and STAT blood tests usually took about 4 hours then we report to physician, I put Resident #2 on nursing alert and told the nurse on the next shift about the STAT blood test. I did not hear anything else about it until Monday morning 08/10/2020 after she fell again and was found lying next to her bed confused and restless and we sent to her to the emergency room . That is when the nurse practitioner found the critical lab result in the computer from Friday. Review of the facility policy for laboratory tests, provided by the facility Director of Nursing(DNS), showed the Attending Physician will be notified of the results of diagnostic tests. During an interview on 09/01/2020 at 1:00 p.m., the DNS stated the staff should notify the physician immediately for any critical or abnormal lab result, The nurse did not communicate about the lab test. We are working on a system that each shift should report when labs are pending. During an interview on 09/01/2020 at 12:40 pm, Staff B, the licensed nurse on duty at night when the STAT lab was drawn, stated he did not know a lab was pending or ordered to be STAT the night of 08/07/2020 for Resident #2. During an interview on 08/28/2020 at 1:20 p.m., Staff C, a licensed nurse who also worked on that floor at the time of the STAT lab for Resident #2 stated that he did not have knowledge that a STAT blood test was ordered. Staff C stated, We now have system in place for tracking labs. During an interview on 08/31/2020 at 9:00 a.m., Staff E, a licensed nurse who was present when the STAT lab was ordered, stated that three days later on Monday 08/10/2020, Staff E sent Resident #2 out to the emergency roiagnom on [DATE] when she was confused and restless and had another fall. When speaking to the nurse practitioner at that time on 08/10/2020, the practitioner found the STAT lab results from Friday 08/07/2020 with a critical value. Review of the laboratory report for Resident #2 showed a STAT blood test was drawn at the facility on 08/07/2020 at 9:53 p.m. with Critical Low results: Hemoglobin 3.1 (normal 11.3 to 15.5); Hematocrit 10 (normal 34 - 46); Red Blood cells 0.94 (normal 3.7 to 5.10). The lab report showed the critical results were called to the facility at 10:19 p.m. on 08/07/2020 and the report printed at 10:21 p.m. The lab report had a fax date at the top of 08/07/2020 at 10:25 p.m. According to The Lippincott Manual of Nursing Practice 2014, the most common cause of [MEDICAL CONDITION] in adults is chronic stomach/intestinal tract bleeding and symptoms of [MEDICAL CONDITION] generally develop when the hemoglobin falls below 11.0. These symptoms can include dizziness and fatigue. During an interview on 08/31/2020 at 10:30 a.m., Staff D, a nurse practitioner, stated that she was concerned about Resident #2 on Friday 08/07/2020 because of her increased confusion and back pain after a fall she had at the facility that day. Staff D stated that she ordered a STAT (immediate) blood count to be done by the facility at that time. In addition, Staff D stated Resident #2 had stable [MEDICAL CONDITION] and some low blood values during her stay at the facility. Staff D further stated she did not receive the critical lab blood work results done on 08/07/2020 until Monday 08/10/2020, almost 72 hours after the STAT was ordered. Staff D found it on a computer after being called about Resident #2's fall on 08/10/2020. The lab value for Resident #2's was critically low and Resident #2 was sent to the emergency room . Review of emergency room and hospital records, dated 08/10/2020 to 08/20/2020, showed Resident #2 had a hemoglobin of 3.4 (normal is 11.5-15.5) and RBC of 1.10 (normal 3.8-5.0) upon arrival to the emergency room (critical) and was found to have stomach/intestinal tract bleeding from ulcers that led to acute blood loss [MEDICAL CONDITION]. The resident's blood pressure was 99/43 and 97/51 per the ER report. Resident #2 received three units of blood for significant [MEDICAL CONDITION] at the hospital to bring the hemoglobin up to 7.9. Resident #2 also had blood in the feces at the emergency room . Resident #2 also received intravenous iron at the hospital for the critical [MEDICAL CONDITION]. Resident #2 also had acute heart failure from the [MEDICAL CONDITION] and low blood cell count that resolved after the blood [MEDICAL CONDITION] in the hospital. The resident was admitted to the special care unit in serious condition at 4:30 pm on 8/10/2020 according to the hospital record. The facility failed to report the critical lab result of low blood cells/hemoglobin after a STAT blood test on 08/07/2020 which led to delayed treatment and hospitalization needed for bleeding and critical interventions to correct heart failure. Resident #2 experienced a ten day hospitalization due to delayed treatment. Reference (WAC) 388-97-0320(1)(b)

Based on observation, interview and record review, the facility failed to comprehensively assess, monitor and evaluate pain, and ensure pain management was provided consistent with professional standards of practice and facility policy for six of six residents (#76, #280, #7, #35, #64, #67) reviewed for pain. These failures caused harm to Resident #76 who experienced uncontrolled pain and placed the other residents at risk for serious harm and diminished quality of life. Findings included . Review of the facility's Pain Assessment and Management policy, dated (MONTH) (YEAR), showed the purpose of the policy/procedure was to help the staff identify pain in the resident, and to develop interventions that were consistent with the resident's goal and needs and that address the underlying causes of pain. The policy directed facility staff to: [NAME] a. Assessing the potential for pain, b. Effectively recognizing the presence of pain; c. Identifying the characteristics of pain, d. Addressing the underlying causes of pain, e. Developing and implementing approaches to pain management, f. Identifying and using specific strategies for different levels and sources of pain, g. Monitoring for the effectiveness of interventions; and h. Modifying approaches as necessary. B. 1. During the comprehensive pain assessment father the following information as indicated from the resident (or legal representative): a. History of pain and it's treatment including pharmacological and non-pharmacological interventions; b. characteristics of pain: (1) Intensity of pain (as measured on a standardized pain scale); (2) Descriptors of pain; (3) Pattern of pain (e.g., constant or intermittent); (4) Location and [MEDICAL CONDITION] of pain; and (5) Frequency, timing and duration of pain; c. Impact of pain on quality of life; d. factors that precipitate or exacerbate pain; e. Factors and strategies that reduce pain; and f. symptoms that accompany pain (e.g., nausea, anxiety). C. 2. Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. D. 3. Discuss with the resident (or legal representative) his or her goals for pain management and satisfaction with the current level of pain control. Resident #76 Resident #76 was admitted on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's admission Minimum Data Set (MDS) assessment, dated 11/07/19, showed the resident had intact cognition and needed two person assistance with bed mobility and transfers. During an interview on 11/18/19 at 10:53 AM, the resident stated, I have bilateral knee pain. The left one particularly. It started 3 days ago. The resident also stated that she had reported her pain concerns to the nurses and they offered her Tylenol (an over the counter pain reliever) but it upsets my stomach. The resident stated, During the day it bothers me and the pain felt like I dislocated my knee. That's how painful it was. The resident stated her pain level was 7 out of 10 (7/10) in which 0 meant no pain to 10 being the worst pain. The resident further stated that the pain bothered her mostly in the morning and, I can't' enjoy my day. I get cranky and easily mad or angry. It does affect my breathing, makes it harder to breath. During the interview, the resident was grimacing and massaging her knees. The resident also stated that the staff gave her [MEDICATION NAME] (a narcotic pain medication) before rehabilitation, but they won't give it to me if she asked for that medication at a different time, They told me take Tylenol, but Tylenol doesn't help. During a record review and interview on 11/19/19 at 9:33 AM, Staff B, Licensed Practical Nurse (LPN) stated that the resident complained of pain on a regular basis and was receiving routine Tylenol. However, Staff B stated that the resident's clinical records showed no evidence of a comprehensive assessment for pain and the resident had no pain care plan. A review of the resident's clinical records (both electronic and paper) showed no evidence of a comprehensive pain assessment or care plan for pain as directed by the facility policy. A review of the vital signs and pain record from 11/01/19 to 11/22/19 showed the resident had an onset of moderate to severe pain on 11/12/19 to 11/22/19. The pain records showed that a pain rating of 1 to 3 = mild pain, 4 to 6 = moderate pain, 7 to 10 = severe pain, and documented the resident reported her pain level(s) as follows: 11/12/19 at 1:31 PM: 8/10. 11/12/19 at 5:58 PM: 4/10. 11/12/19 at 7:58 PM: 6/10. 11/13/19 at 12:34 PM: 7/10. 11/14/19 at 12:22 PM: 7/10. 11/15/19 at 12:43 PM: 7/10. 11/16/19 at 10:21 AM: 2/10. 11/16/19 at 1:04 PM: 3/10. 11/17/19 at 1:01 PM: 1/10. 11/17/19 at 2:02 PM: 7/10. 11/18/19 at 1:46 PM: 6/10. 11/19/19 at 1:34 PM: 6/10. 11/21/19 at 10:17 AM: 6/10. 11/21/19 at 1:27 PM: 6/10. 11/21/19 at 1:53 PM: 7/10. 11/22/19 at 1:00 PM: 4/10. A review of the resident's Physician order [REDACTED]. [NAME] [MEDICATION NAME] every 24 hours as needed for back pain. B. [MEDICATION NAME] every 2 hours as needed for shortness of breath and moderate to severe pain. C. Tylenol every 8 hours routine for pain management. D. Non-pharmacological interventions to be offered prior to giving as needed medications. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. The MAR indicated [REDACTED]. However, the record did not show evidence of documentation that the facility had consistently evaluated the effectiveness of the regularly scheduled pain medication. Additionally, the record showed the resident did not receive the routine Tylenol on 11/07/19 at 10:00 PM, 11/14/19 at 6:00 AM and 11/15/19 at 10:00 PM. During an interview on 11/22/19 at 3:08 PM with the resident and her spouse, Resident #76 stated that she had a long-standing history of abdominal pain and it is sore and it hurts sometimes. The resident stated, This pain is not something new. I had this before coming here. According to the resident, My leg and knee pain are new. Especially my right knee. The resident stated that she had reported this pain concern to the nurse for almost a week now. The resident stated her current pain level was 7/10 to her knees. The resident also reiterated how her pain had affected her mood in the morning, and her breathing patterns and participation with day to day activity. I wanted to get out of bed and get strong, but my breathing and the pain were just too much. During an interview on 11/22/19 at 3:13 PM, Staff E, LPN stated that the resident had reported right knee pain today and she was not familiar with the resident's care. Staff [NAME] reviewed the clinical records for Resident #76 and stated that there was no pain information, no pain assessment and no pain care plan for Resident #76. During an interview on 11/22/19 at 3:14 PM, Staff GG, Nursing Assistant Certified (NAC) stated that the resident complained of pain every time they were working with the resident and when providing care in bed. Staff GG stated that they reported the pain to the nurse. Staff GG reviewed the Kardex (care directives) for Resident #76 and stated that there was no pain information or pain care plan for Resident #76. During an interview and record review on 11/22/19 at 3:18 PM, Staff A, Resident Care Manager (RCM)/LPN, Staff A stated that the resident's clinical records (both electronic and paper) showed no evidence of a comprehensive pain assessment or care plan for pain for Resident #76. Staff A also stated that he was not aware of any pain concerns for Resident #76. During a meeting on 11/22/19 at 3:27 PM with the resident, the resident's spouse and Staff A, RCM/LPN, the resident reported her chronic abdominal pain and the new onset of severe pain on her knees. The resident reported a pain level of 7/10 on her knees on a daily basis which was not relieved by her routine Tylenol. The resident also told Staff A that staff would only give her Tylenol and refused to give her [MEDICATION NAME] when she reported moderate to severe pain. During an interview and record review on 11/22/19 at 3:38 PM, the Director of Nursing (DNS) stated that the resident's clinical records (both electronic and paper) showed no evidence of a comprehensive pain assessment or care plan for pain for Resident #76 to accurately and effectively assess, monitor, treat and evaluate the resident's pain. During an interview on 11/25/19 at 1:57 PM, the resident's Nurse Practitioner (NP) stated that the resident had a history of [REDACTED]. The NP stated that the resident reported knee pain during her visits, and she had addressed this pain and updated the resident's pain management orders as needed. RESIDENT #280 Resident #280 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's hospital discharge summary and discharge orders, dated 11/01/19, showed the resident was discharged from the hospital with a Stage 2 pressure ulcer on the left buttock area and a DTI on the left heel. During a joint skin observation on 11/19/19 at 9:52 AM with Staff B, LPN, the resident stated that his left leg and heel had caused so much pain and the facility did an x-ray yesterday to find out if there was a more serious problem, but the x-ray was negative. The observation showed the resident had macerated open skin with traces of blood to his bilateral inner buttock (Peri-anal) area and Deep Tissue Injuries on his bilateral heels. (Refer to F684 - Quality of Care, F686 - Treatment/Services to Prevent/Heal Pressure Ulcers for more information.) During a joint record review and interview on 11/20/19 at 2:06 PM, Staff A, RCM/LPN, Staff A stated that the resident's clinical records (both electronic and paper) showed no evidence of a comprehensive pain assessment or care plan for pain for Resident #280 as directed by the facility policy. During an interview and record review on 11/21/19 at 1:59 AM, the DNS stated that the resident's clinical records showed no evidence of a comprehensive pain assessment and no baseline and/or person-centered care plan to address the resident's increase risk for pain as directed by the facility policy. RESIDENT #67 Resident #67 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The initial MDS assessment, dated 07/31/19, showed the resident needed extensive assistance with the activities of daily living(ADLs), did not walk, could not feed herself, was on hospice, and received multiple routine [MEDICAL CONDITION] medications and pain medications. The MDS showed the resident had severe cognitive impairment. The MDS assessment showed the resident rarely had pain and described the pain as mild, had pain medications ordered on an as needed basis (PRN), and had no non-pharmacological pain interventions in place. Two additional assessments Pain in Advanced Dementia were completed 07/24/19 and 10/31/19. The one dated 07/24/19, showed the resident had sad, frightened facial expressions described as a frown and charaterizied the pain as mild. The other dated 10/31/19, documented the was on a scheduled pain medication because the resident was not able to verbalize. The physician admission orders [REDACTED]. In addition, there were orders for two other pain medications that were to be administered PRN (as needed) for breakthrough pain: Tylenol 325 mg, 2 tablets every 4 hours; and [MEDICATION NAME] Solution 20 mg/ml, which could be administered at 0.5 ml(milliliters) every 30 minutes for pain or shortness of breath. (A narcotic medication often ordered for hospice patients to ease pain.) Review of the (MONTH) 2019 MAR indicated [REDACTED]. The plan of care/MAR did not provide clear direction to staff as to when to administer the narcotic medication versus the Tylenol. The MAR indicated [REDACTED]. Review of the MAR's for (MONTH) and (MONTH) 2019 showed that the PRN pain medications were sporadically administered, and there was no evidence that non-pharmacological interventions were attempted prior to the administration of the pain medications. Nor was there any evidence the staff administered Tylenol prior to administering the [MEDICATION NAME]. During an interview on 12/02/19 at 3:35 PM, Staff HH, a Licensed Practical Nurse was asked how staff determined which PRN pain medication should be used ([MEDICATION NAME] or Tylenol). Staff HH stated that the Tylenol should be administered first, and if it was not effective, then staff would administer [MEDICATION NAME]. When asked what (pain-related) behaviors the resident displayed, Staff HH stated that if the resident was tearful, they should try and console her first, and then administer medications. During an interview on 12/03/19 at 10:15 AM, Staff C, a Registered Nurse, stated that the Tylenol should be administered first and if not effective, the [MEDICATION NAME] could be administered. When asked about behaviors, he stated that when the resident cried, staff should first attempt some non-pharmacological interventions before administering the PRN pain medication. The MAR's for (MONTH) showed [MEDICATION NAME] was administered on 11/08, and 11/12/19 and tylenol was administered on 11/13/19. There was no evidence that non-pharmacological interventions were attempted prior to the administration of the pain medication nor was there any evidence the staff administered Tylenol prior to administering the [MEDICATION NAME]. RESIDENT #35 Resident #35 was admitted to the facility on [DATE], with multiple [DIAGNOSES REDACTED]. The initial MDS assessment, dated 10/09/19, showed the resident needed extensive assistance with most ADLs and was able to communicate her needs. The MDS pain assessment interview showed the resident did not have pain (at the time of the interview), had pain medications in which could be administered PRN, and showed that no non-pharmacological interventions were in place. The MDS also showed an opioid medication was administered 1 time during the 7 day assessment period. No additional in-depth assessment of the resident's pain was completed at the time of admission. Observation throughout the survey showed Resident 35 was independent with ADLs. During an interview on 11/19/19 at 10:25 AM, Resident 35 stated that her pain was due to [MEDICAL CONDITION] arthritis and displayed her hands. The knuckles on both hands were swollen and enlarged (a common symptom of [MEDICAL CONDITION] arthritis). Review of the care plan for pain showed it was initiated 05/14/19, during a previous admission. The care plan showed that the source of pain was hip and back, and listed a number of interventions, also dated 05/14/19. The only care plan revision, dated 10/23/19, showed the Goal as optimal pain management. The (MONTH) 2019 Medication Administration Record [REDACTED]. There was no documentation that showed the non-medication interventions were attempted prior to administering the PRN medication(s). On 11/22/19 at 3:00 PM, Staff DD completed a joint review of Resident 35's narcotic log for (MONTH) 2019. The log showed that medication was removed from locked storage at times, but was not documented as administered on the MAR. (See citation under F 842 for inaccurate and/or incomplete clinical records for additonal details.) On 11/26/19 at 10:00 AM, Staff DD, Resident Care Manager, Licensed Practical Nurse, stated a pain assessment should have been completed but was not able to locate one in the clinical record. Staff DD reported non-pharmacologic interventions should have been implemented prior to administering PRN medications. Staff DD, stated that since admission to the facility the resident's condition had improved and was now independent with all ADLs, except showers. The facility failed to conduct an accurate assessment, that identified the source, intensity, duration and frequency of the resident's pain, failed to develop an accuarate care plan with individualized interventions, and failed to implement non-pharmacological interventions. RESIDENT #64 Resident #64 was admitted to the facility in (YEAR) with multiple chronic medical diagnoses, including chronic pain. The most recent MDS assessment, dated 10/24/19 identified the resident had pain medications ordered on a PRN basis, and had non-pharmacological interventions in place. The MDS showed the resident reported occasional mild pain and that the pain had no effect on sleep or functional abilities. During an interview on 11/19/19 at 12:53 PM, Resident #64 stated that he had pain related to [MEDICAL CONDITION] and arthritis. He stated he had pain medication that could be administered PRN, which had been prescribed prior to his admission to the facility. The resident stated that pain interfered with his ability to participate in ADLs. The resident stated he was currently satisfied with his pain management program, but stated that in the past, he had an argument with staff who refused to administer the medication when he requested it. (See F 610 for Failure to report and investigate potential exploitation and or neglect.) Observations on 11/18, 11/19, 11/20/19 showed the resident was not dressed and did not get out of bed. On 11/21/19 at 1:30 PM, the resident was out of bed, dressed, and in his wheelchair. The care plan, dated 05/29/19, showed the last care plan review was completed 11/06/19. Although the [DIAGNOSES REDACTED]. The current physician orders [REDACTED].#64 had an 08/24/19 order for [MEDICATION NAME] 5-325 mg, 1 - 2 tablets every 6 hours PRN. The MAR indicated [REDACTED]. Review of the clinical record showed two completed Pain Evaluations: a re-admission evaluation, dated 12/12/18, and a quarterly assessment, dated 09/01/19, which noted the resident had pain related to a sacral pressure ulcer. Review of the MDS data base showed the pressure ulcer was healed by 07/27/19. There was no evidence that any other Pain Evaluations were completed annually, quarterly, or when new issues related to pain developed. During an interview on 11/20/19, the DNS stated that the resident should have a care plan in place for pain management and in regards to any non-pharmacological interventions in place, the DNS stated, the resident does go to the gym a lot and that really helps. During an interview on 11/25/19 at 10:00 AM, Staff DD, RCM, and LPN, stated that residents were routinely assessed for pain, should have a care plan in place, and non-pharmacological interventions should be attempted prior to the administration of PRN medications. Resident #7 Resident #7 was admitted to the facility on [DATE], from a hospital after being treated for [REDACTED]. The initial MDS, dated [DATE], noted the resident was alert and oriented, and had experienced a fracture. The pain section of the MDS showed the resident rarely had pain, which was mild, had PRN medications in place, and non-pharmacological interventions in place to assist with pain management. During an interview on 11/20/19 at 9:00 AM, Resident #7 stated that she was hospitalized after she fractured an ankle. Resident #7 stated that at the time of admission a cast was place which was removed, a boot was ordered and applied which caused more pain, and therefore the boot was removed and another cast was applied. Resident #7 stated that it was her desire to return to her apartment. Resident #7 stated that the frequency of her pain medication was reduced to two times a day and stated that she was just out of luck until the next morning if she needed any additional pain medications. The resident stated, If I was at home, I could take them when I needed to. She stated that had narcotics prescriptions prior to her admission to the facility due to chronic pain. The care plan for pain, dated 06/12/19, did not show the resident had a fracture. The care plan, initiated 01/04/17 (during a previous admission), showed the source of pain was [MEDICAL CONDITIONS], and chronic pain. The interventions, initiated on 01/04/17, had not been updated, except for a revision on 11/18/19, which showed optimal pain control and pain resolved within an hour of intervention. Review of the the clinical record for Pain Evaluation forms showed no evidence that a Pain Evaluation was completed at the time of the 6/12/19 admission. A Pain Evaluation, dated 09/12/16, showed the resident described pain as moderate, and walking, standing and bending made the pain worse and that pain interfered with sleep, mobility and physical activity. The (MONTH) 2019 MAR indicated [REDACTED]. In addition, the staff were administering [MEDICATION NAME], three times a day for [MEDICAL CONDITION], which was initiated at the time of admission on 06/12/19. The facility did not ensure an accurate assessment of the resident's pain was completed which left staff without sufficient information to develop an effective care plan with individualized interventions to assist the resident with optimal pain managment. Reference WAC: 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to ensure two of five residents (#14, #5) who experienced weight loss, were assessed and provided interventions to assist in maintaining a healthy body weight. Failure to conduct timely nutritional assessments and implement interventions for residents who experienced significant weight loss resulted in one resident losing 22% of their body weight, and may have contributed to the other resident developing a wound. Findings included . The facility policy titled, Weight Assessment and Intervention showed nursing staff were to monitor weights either weekly or monthly. If a 5% weight change was noted, the policy directed the staff to retake the weight the following day. If the change is verified, nursing must notify the RD in writing. Any verbal notification needed verification in writing, and directed the Registered Dietitian (RD) to respond within 24 hours. The following criteria noted the threshold for significant weight loss 5% within 30 days, 7.5% within 3 months (weight loss greater than 7.5% was categorized severe weight loss), and 10% within 6 months was significant (greater than 10% was severe weight loss.) The policy indicated weight loss would be analyzed by the Interdisciplinary Team (IDT) and identified conclusions should be made to determine target weight, protein, calorie needs and current intake. Any clinical factors or current conditions related to weight fluctuations, and to what extent weight stabilization or improvement can be anticipated. The policy also indicated individualized care plans for weight loss should, to the extent possible; indicate the cause of weight loss, goals and bench marks for improvement, time frames and parameters for monitoring and assessment. The policy also showed interventions for undesirable weight loss shall be based on careful consideration of a resident's choice and preferences. During an interview on 11/25/19, at 12:15 PM, Staff P, the RD, was asked about the process for notification when a resident was losing weight. Staff P stated that she did not receive any written notifications/referrals from nursing for residents with weight loss, and that weight records were reviewed weekly to identify residents with weight loss. The RD also stated an IDT meeting was held once a week with the nursing staff to discuss nutritional issues, however the only documentation of those meeting was sent to the team members through email. RESIDENT #14 Resident #14 was admitted to the facility on [DATE] with multiple complex medical conditions, including [MEDICAL CONDITION] and diabetes. The initial Minimum Data Set (MDS) assessment, dated 03/02/19, showed the resident needed supervision and physical assistance with eating. The last quarterly MDS assessment, dated 08/22/19, showed an improvement, and that the resident required meal set-up and supervision for eating. In addition, both MDS assessments, dated 05/29/19 and 08/22/19, showed a significant weight loss of 5% or greater. During the initial tour on11/18/19 at 9:40 AM, Resident #14 was asked about meals served and stated the Food is awful. During an interview on 11/19/19 at 10:55 AM, Resident #14 stated, I lost a lot of weight. Resident #14 stated her weight was currently 112 pounds(lbs), and that her weight was about 140 lbs at the time of admission. When asked if the RD had discussed the weight loss with her, Resident #14 stated, No. When asked about food quality, Resident 14 stated that the facility did not have a good cook, and that for the most part I don't like it. Resident 14 stated the food was cold, and that if she did not eat the meal served, a substitute was not offered. When asked if snacks were available, Resident #14 stated it depends on what time of day or evening. When asked if she received a select menu (to select her meal choices), she stated No. During an follow up interview on 11/22/19 at 11:34 AM, the resident was seated on the edge of the bed with her lunch meal on the overbed table. Resident 14 stated everything was cold. The only thing that appeared consumed on her meal tray was a cup of soup; an uneaten sandwich was present on the tray. The weight recorded at the time of admission was 141 pounds and during the first month of the resident's admission varied by 2 - 3 lbs. A weight of 140 pounds was documented on 3/05/19 and 120 pounds (lbs) on 08/27/19, showing a loss of 14 % of body weight in six months. Over the next three months, the weight loss continued and on 11/28/19, the documented weight was 108 lbs ( an additional loss of 11% of body weight during the last three months). According to the facility policy and guidelines, this was categorized as severe weight loss. During an interview on 12/04/19 at 1:45 PM , Staff P, RD, was asked about Resident 14's weight loss. The RD stated that the resident's weight was reviewed at a weekly IDT meeting. When asked if the resident weight loss had been assessed, Staff P stated that the resident had a [MEDICAL CONDITION] disorder that was contributing to weight loss. The RD stated that nutritional assessments for Resident 14 could be found in the progress notes. The nutritional assessments in progress notes showed the following: On 04/09/19, a weight change note by the RD recommended a liberalized diet and discontinued the restriction for no concentrated sweets (NCS, a diet commonly prescribed for diabetics); a restriction for No Added Salt (NAS) remained. The note showed the resident was eating 25% to 50 % of the meals as served. On 06/03/19, a RD note showed Resident #14 continued to lose weight. The entry showed that the resident weighed 127 lbs on 05/28/19, and that a lab indicator of adequate protein stores, [MEDICATION NAME], was within normal limits. On 07/22/19, a weight change note by the RD showed the resident's weight was 118 lbs. It also noted the [MEDICATION NAME] was now 3.4 (at the low end of normal limits), that the resident's potassium was low (K+), and that the physician added a K+ supplement. On 07/24/19, a note by the Resident Care Manager, Staff H, LPN, documented the physician was notified of the weight loss and requested lab tests to check the [MEDICAL CONDITION] Stimulating Hormone (TSH) level. On 07/29/19, the resident was placed on a liquid nutritional supplement, Med Pass 2.0 two times a day. On 07/30/19, a note showed the physician had assessed the weight loss, abnormal weight loss due to unknown cause, and ordered labs to assess the TSH. On 08/06/19, a physician note showed the abnormal TSH levels were not the reason for weight loss and made changes in the medications to normalize the TSH values. On 08/30/19, a Dietitian Note showed the resident now weighed 120 pounds. The RD note showed that a dietary supplement had been started on 07/29/19, and the resident's weight had been stable. On 11/19/19, an RD note showed the resident's weight had declined another 8 lbs, and recommended increasing the supplement from two times a day (120 cc of Med Pass 2.0) to three times a day. Review of the care plan, initiated 02/27/19, showed the goals Dry stable weight +/- 5%, no signs and symptoms of dehydration, and note prompt identification and interventions if a nutritional deficit should occur. The liquid supplements and snacks were not identified on the care plan, and it lacked any resident specific interventions. The (MONTH) 2019 Medication Administration Record (MAR) showed the nurses offered a 120 cc of a supplement (Med Pass 2.0) two times a day, however the resident sometimes refused it and did not always consume 120 cc's of the liquid supplement. The MAR showed the supplement was increased to three times a day on 11/19/19. The MAR also directed staff to offer a evening snack and document +/- if consumed (initiated 02/21/19). However, a check mark was entered on the MAR and the +/- was not documented to indicate whether the evening snack was consumed. Although snacks and supplements were added to the MAR, the did not document whether the resident consumed the snacks. In addition when provided 120 cc's of nutrition supplements two times a day, the supplement was not consistently accepted or consumed by the resident, the RD increased it to three times a day. During an interview on 11/22/19 at 1:00 pm, Staff II, the Dietary Manager (DM), was asked about an activity Help with Menus scheduled weekly at 2:00 PM. The staff stated she held a weekly meeting to get feed back on the menus, and assist residents who needed help with filling out a weekly menu . When asked how many resident attend the group, Staff II stated between 12 to 16 resident attended the meeting. During a follow up interview on 11/27/19 at 1:43 PM, Staff II was asked if there was a staff person who was responsible for retuning choice menus to the kitchen. Staff II stated no. Although the resident was confused at times and appeared to have short term memory loss, she was not provided or assisted with filling out a choice menu. Even though the RD assessed the weight loss, there was no evidence she approached the resident to discuss her weight change, her complaints about the food served, preferences and or dislikes. RESIDENT #5 Resident #5 was admitted to the facility in (MONTH) (YEAR) with multiple [DIAGNOSES REDACTED]. A comprehensive MDS assessment, dated 02/18/19, for a significant change in condition, showed the resident had a stroke and required extensive assist of one person to eat and was no longer able to communicate verbally. Review of the MDS assessments, completed 12/30/19, 02/18/19, 05/14/19, and 08/08/19, showed Resident #5 had a significant weight loss which was not planned by the physician. The next quarterly MDS, dated [DATE], showed the resident had developed a [MEDICAL CONDITION]. During an interview on 12/05/19 at 10:15 AM, Staff R, MDS coordinator, was asked about Resident #5's significant change in condition. Staff R stated that the resident had a stroke and was sent to the emergency room for an evaluation, but was never admitted to the hospital. Staff R stated that prior to 02/18/19, the resident did have [DIAGNOSES REDACTED] of the right side that became more pronounced after the stroke, and the Resident's [DIAGNOSES REDACTED]. The weight history showed the following weights: 12/23/18: 190 lbs. 02/11/19: 186 lbs. 05/07/19: 158 lbs. 08/13/19: 151 lbs. 11/05/19: 143 lbs. Review of progress notes showed the following: On 01/08/19, the RD completed an assessment which showed the resident's weight was stable. The plan was to monitor the resident quarterly and as needed. There was no evidence the Registered Dietitian assessed the resident at the time the significant change in condition MDS, dated [DATE], was completed. On 05/27/19, the RD assessment showed the resident was offered snacks three times a day between meals and that the previous year the weight had increased the previous year due to excessive snacking. The MAR, dated 11/01/19, documented a snack was given bedtime (initiated 07/25/17) and three times a day (initiated on 03/11/19), however they did not document if the snack was accepted and consumed. No new dietary recommendations were made. On 05/28/29, the RD note showed Med pass 120 ml three times a day would be added due to a decreased oral intake and weight loss, and recommended updating the [MEDICATION NAME] lab test to assess protein status. Although the supplement was added to the MAR on 05/28/19, the staff did not document if the resident consumed the supplement. On 05/30/19, the RD note showed the [MEDICATION NAME] was 4.4 mg/dl result was within normal limits. The plan was to monitor weekly weights and review with the IDT team until stable. On 08/27/19, the RD note showed the resident food intake declined compared to 8 months ago. The RD assessment showed Resident 5's Body Mass Index (BMI) was 25 and weight loss was slowed and no recommendations for changes were made. The goal was to maintain a BMI at 22 or above, and that the resident was monitored weekly, quarterly, and as needed. On 10/21/19, a note showed the facility notified the ARNP that the resident had developed an infected wound on the right lateral ankle (a bony prominence). The wound was assessed by the ARNP and an order for [REDACTED]. On 11/17/19, the RD assessed the resident and no changes were made. This entry noted the resident [MEDICATION NAME] had dropped to 3.8 mg/dl, which was on the low end of normal, and recommended no further dietary changes. The entry indicated the resident's BMI was 24 and any further decline was undesirable. Review of the care plan, initiated 08/1/17, showed the goals were for Dry stable weight +/- 5% or weight loss of 1-2 pounds a week to IBW (ideal body weight) with adequate PO (oral) intake were updated 03/04/19, estimated fluid goal greater than 1700 ml (revised 11/20/19), and that prompt identification and interventions if a nutritional deficit should occur. The interventions identified on the care plan were initiated 08/01/17, and identified generic interventions (i.e monitor weight per policy, refer to RD PRN, check labs as needed .). The interventions to provide snacks and supplements were not identified on the care plan. Even though these interventions were in place, the resident continued to lose weight. Even though the interventions did not assist with maintaining weight, the RD failed to assess why weight loss continued, or revise the interventions. The facility policy concerning Weight Assessment and Intervention was not followed. The facility failed to implement a system for written referrals to the RD, they failed to complete timely assessments, evaluate the effectiveness of care plan interventions and develop individualized interventions to deter weight loss for each resident. Reference (WAC) 388-97-1060 (3)(h)

Based on observation, interview, and record review, the facility failed to comprehensively assess the increased risk for skin breakdown and follow written policy and procedures, and failed to develop and implement timely interventions necessary to prevent the development of avoidable pressure ulcers for two of four residents (#280, #1), reviewed for pressure ulcers(PU). These failures caused harm to Resident #280 who developed an avoidable facility acquired pressure ulcer and placed Resident #1 at risk for serious harm and diminished quality of life. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. Stage 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture-associated skin damage (MASD), including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Deep Tissue Pressure Injury (DTI): Persistent non-blanchable deep red, maroon or purple discoloration Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or [MEDICATION NAME] separation revealing a dark wound bed or blood filled blister. Pain and temperature change often precede skin color changes. Discoloration may appear differently in darkly pigmented skin. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury, or may resolve without tissue loss. If necrotic tissue, subcutaneous tissue, granulation tissue, fascia, muscle or other underlying structures are visible, this indicates a full thickness pressure injury (Unstageable). A review of the facility policy titled, Pressure Ulcer/Injury Risk Assessment and Protocol dated (MONTH) (YEAR), showed The purpose of this procedure is to provide guidelines for the structure assessment/evaluation and identification of residents at risk of developing pressure ulcers/injuries. The policy directed facility staff to: [NAME] 3. Once the assessment/evaluation is conducted and risk factors are identified and characterized, a resident centered care plan can be created to address the modifiable risk for pressure ulcers/injuries. B. 6. The Wound Observation Evaluation should be completed upon the findings of the skin issue. It is to be completed weekly by the wound nurse or designee. C. 7. All residents with skin issues or wounds will be reviewed weekly in the Skin at Risk Meeting with changes made as applicable to orders and the care plan. D. 8. Refer all residents with wounds to (a consultant wound service). After they are referred and seen the weekly wound observation evaluation can be discontinued for the wounds being seen by (consultant wound service) . E. Develop the resident-centered care plan and interventions based on the risk factors identified in the assessment/evaluations, the condition of the skin, the resident's overall clinical condition, and the resident's stated wishes and goals. A review of the facility policy titled, Pressure Ulcer/Skin Breakdown - Clinical Protocol dated (MONTH) 2014, showed that The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores. The policy directed facility staff to: 1. The nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissues; b. Pain assessment; c. Resident mobility status; d. Current treatment, including support surfaces; and e. All active diagnoses. 2. During resident visits, the physician will evaluate and document the progress of wound healing-especially for those with complicated, extensive or non-healing wounds. RESIDENT #280 Resident #280 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's [DIAGNOSES REDACTED]. A review of the resident's hospital discharge summary and discharge orders, dated 11/01/19, showed the resident was discharged from the hospital with a Stage 2 pressure ulcer on the left buttock area and a DTI on the left heel. A review of the facility's admission Skin Evaluation, dated 11/01/19, showed the resident was admitted to the facility with a Stage 2 pressure ulcer on the coccyx (tailbone) area. There were no other skin issues identified and/or documented at the time of admission to the facility. Additionally, there was no Wound Observation Evaluation completed for the identified pressure ulcer as directed by the facility policy. A review of the resident's admission Minimum Data Set (MDS) assessment, dated 11/08/19, showed the resident had intact cognition and needed two person extensive assistance with bed mobility and transfers. The MDS also showed the resident was at risk for pressure ulcer development and was admitted to the facility with one Stage 2 pressure ulcer. A review of the resident's care plan, dated 11/14/19, showed no evidence the facility had developed a baseline care plan and/or a comprehensive care plan to meet the needs of the resident, specifically on how to care for the identified pressure ulcer on admission, and how to minimize the risk of developing an avoidable pressure ulcer. (Refer to F655 - Baseline Care Plan and F656 - Develop/Implement Comprehensive Care Plan for more information.) During an observation on 11/18/19 at 12:02 PM, the resident was observed in lying flat on his back. The resident was lying on a regular mattress and his bilateral heels were in direct contact with the mattress/bed. During an interview and observation on 11/19/19 at 9:06 AM, the resident stated that he admitted to the facility with bed sores, I came with a rash too. The resident was again observed in bed with his bilateral heels in direct contact with the mattress/bed. A joint skin inspection/observation on 11/19/19 at 9:52 AM with Staff B, Licensed Practical Nurse (LPN) showed the resident had macerated open skin with traces of blood to his bilateral inner buttock (Peri-anal) area. The resident stated, It hurt sometimes. It burns. The resident also stated that he had the skin breakdown since admission to the facility and the caregivers (nursing assistants) had been putting a cream on it. Staff B concurred and stated that the Nursing Assistants (NAC) were the ones who would usually apply the cream, and not the nurses. Staff B further stated that he was aware of the skin breakdown and only put the cream on himself today but usually it was Staff J, NAC or other NACs that would put the cream. (Refer to F684- Quality of Care for more information.) Staff B also inspected the resident's bilateral heels. The resident's left heel showed a non-blanchable purple discoloration with surrounding skin tender to touch per Staff B and the resident complained of pain upon palpation of the area by Staff B. Per Staff B, the wound measured 1.5 centimeters (cm) in length, 1cm wide, and depth not able to assess. Staff B stated that he was not aware of and had not seen the left heel skin breakdown until today. Staff B inspected the resident's right heel. The right heel showed a non-blanchable dark purple discoloration with surrounding skin tender to touch per Staff B. According to Staff B, the wound measured at 1.5cm in length and 1.5cm wide and the depth not able to be assess. Staff B further stated that he was not sure where the pressure ulcer came from and he was not aware of the pressure ulcers and excoriation, and he had been working with the resident for a while. During the skin inspection/observation, the resident stated that his, left leg and heel had caused so much pain and the facility had to do an x-ray yesterday to find out if there's more serious problem, but the x-ray was negative. During an interview on 11/19/19 at 10:00 AM, Staff Q, NAC, stated that she was not aware of the resident's bilateral heel skin breakdown. During an interview and joint record review on 11/19/19 at 10:13 AM, Staff B, LPN stated that there was documentation that the NACs were floating the resident's heels. However, there was no current treatment, no comprehensive skin assessment or care plan to manage and treat the resident's bilateral DTIs. Staff B also stated that there was no evidence of a comprehensive pain assessment and/or pain care plan in the clinical record. (Refer to F697 - Pain Management for more information.) During an interview on 11/19/19 at 10:21 AM, Staff J, NAC, stated that she was not aware of the resident's bilateral heel skin breakdown. During an interview on 11/20/19 at 12:50 PM, the Nurse Practitioner (NP) stated that she was aware of the resident's left heel DTI. The NP also stated that she was aware of a Stage 2 pressure ulcer on the resident's coccyx on admission that was now healed. According to the NP, both the Stage 2 PU on coccyx and left heel DTI were present on admission, but she was not aware of the right heel DTI and any excoriation to the buttocks area. A review of the Physician/NP note, dated 11/04/19, showed the resident's coccyx Stage 2 and left heel DTI were addressed. However, the buttock excoriation and the right heel DTI were not addressed or documented. A joint skin inspection/observation on 11/20/19 at 1:13 PM with the NP and Staff A, Resident Care Manager (RCM)/LPN, showed the resident had the following skin conditions: [NAME] Inner buttocks (Peri-anal) area with maceration/excoriation, per the NP. B. Left outer heel - DTI, per the NP. The area had a dark black skin at the center where was unable to visualize the wound bed, with surrounding skin tender and blanchable. C. Right outer heel - DTI per the NP. The area had a dark black skin at the center and was unable to visualize the wound bed, with surrounding skin tender and blanchable. The NP stated that she was not aware of the right heel DTI until this day. During a joint record review and interview on 11/20/19 at 2:06 PM, Staff A, RCM/LPN stated that the resident's pressure ulcers were all present on admission. When asked about the PU, and a joint review of the hospital discharge orders, facility's admission skin assessments and the NP comprehensive notes, dated 11/04/19 (4 days after admission), Staff A stated that he was not sure why there were discrepancies with the assessment and why the resident's right heel DTI was not documented or addressed in the clinical records. According to Staff A, he also completed an admission skin assessment on 11/13/19 (13 days after admission) to add the resident's bilateral heels DTI. However, Staff A was not able to provide an answer on why he would complete an assessment 13 days after admission that differed from the original admission assessment with no supporting documents. Additionally, Staff A stated that he completed a late entry progress note on 11/19/19 that the resident was admitted with a Stage 2 pressure ulcer, but it resolved on 11/15/19. However, Staff A showed no evidence of any supporting documents of treatment records, skin/wound evaluation or plan of care for the resident's pressure ulcer. Staff A stated that the resident's clinical records did not show a comprehensive skin assessment/evaluation, no comprehensive pain assessment and no baseline and/or person-centered care plan to address the resident's increase risk for skin breakdown as directed by the facility policies and procedures. Staff A also stated that the resident was not referred to wound consultation service to assess, monitor and treat the resident's pressure ulcer. Staff A further stated that he would immediately address these concerns and further review the resident's clinical records. During a joint interview on 11/21/19 at 9:30 AM with the resident and his spouse, the resident stated that his buttock area sometimes hurt and sometimes bled. The resident stated it was a Burning type of pain or discomfort. The resident also stated that his heels sometimes hurt and bothered him, especially when walking and when he put pressure on his heels during standing and when working with therapy. During a phone interview on 11/21/19 at 10:03 AM, the resident's daughter stated that she was aware of the coccyx and left heel pressure ulcer that were present on admission to the facility but not on the right heel. The resident's daughter further stated that she came regularly to visit and apply lotion to the resident's lower extremities and she just noticed the right heel DTI about 3-4 days ago. During an interview and record review on 11/21/19 at 1:59 AM, the DNS stated that she was not aware of the resident's excoriation and right heel DTI. The DNS also stated that the resident's clinical records showed no evidence of a comprehensive skin assessment/evaluation, comprehensive pain assessment or baseline and/or person-centered care plan to address the resident's increase risk for skin breakdown as per the facility policies and procedures. The DNS further stated that the resident should have been referred to wound consultation service to better assess the resident's wound(s) and the physician or NP should have been notified of any new skin breakdown/pressure ulcer. See also the following FTAG's for more information: F641 - Accuracy of Assessment F655 - Baseline Care Plan F656 - Develop/Implement Comprehensive Care Plan RESIDENT #1 Resident #1 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of the admission nursing progress note, dated 11/09/19, showed the resident was admitted to the facility with a Stage II pressure ulcer on the coccyx that measured 0.7 centimeters (cm) in length, 0.2 cm in width and 0.1 cm in depth. The documentation also showed the surrounding skin was within normal limits and without drainage and/or odor. The resident was also identified as at risk for pressure ulcer development. Record review of the admission MDS assessment, dated 11/16/19, showed the resident required extensive assist of two persons for positioning in bed or transfers in and/or out of bed. The assessment also showed the resident was always incontinent of bladder and bowel without a toileting plan. Review of the Treatment Administration Record (TAR), dated (MONTH) 2019. showed, Weekly and prn (as needed) skin check document - = intact, + = open area. There was a (+) documented on 11/16/19 which indicated an open area on the skin. There was no further documentation in the clinical record that described the open area. Further review of the TAR dated (MONTH) 2019 showed physician's orders for the coccyx wound started 11/09/19 and was discontinued on 11/18/19. An observation on 11/19/19 at 1:58 PM showed the resident was in bed lying on her back with the head of the bed (HOB) elevated to approximately 45 degrees. Another observation on 11/20/19 at 1:07 PM showed the resident was in bed lying on her back with the HOB elevated to approximately 30 degrees. An observation on 11/21/19 at 9:15 AM showed the resident was in bed lying on her back; the HOB was elevated to approximately 30 degrees. A joint observation on 11/21/19 at 11:25 AM with Staff BB, NAC, showed the resident had two Stage II pressure ulcers: One PU was on the upper coccyx (tailbone) and the other PU was on the lower coccyx. Both buttocks had MASD spread throughout the skin on the buttocks. In an interview at this time with Staff BB NAC said, open areas and skin problems found on the resident's were supposed to be reported to the nurse when found. A joint observation and interview on 11/21/19 at 1:28 PM with Staff H, LPN/RCM, showed there were two Stage II pressure ulcers, one on the upper coccyx (tailbone) and one on the lower coccyx, and both buttocks had MASD spread throughout. Staff H LPN/RCM stated, I had no reports of it reopening or that there was a new pressure ulcer. I asked them this morning and they told me it was closed. They never said anything about a new pressure ulcer. During an interview on 11/21/19 at 2:29 PM, Staff L, RN, stated that the aides were required to report any skin problems to the nurse, If something was reported to me, I would go and take a look, call the doctor and get a treatment order. Routine skin checks are done weekly, if we did a weekly skin check and there was a problem, a plus would be documented for that skin check and a nursing progress note would be completed to describe the problem, and measurements if needed. Pressure ulcers would be measured and described in the nursing progress notes every week until healed. The resident would also be placed on alert charting for monitoring. Yes, I worked with her yesterday, and no one reported a skin problem to me about her. During an interview on 11/21/19 at 2:36 PM, Staff CC, LPN, stated that the the aides reported skin problems to the nurses when found during care or at any time. Staff CC stated that the nurse would go and check the skin, call the doctor for a treatment if a treatment was needed, and place the resident on alert charting. The routine skin checks were done weekly by the nurse, if a skin problem was found, a plus sign+ would be documented on the TAR and a nursing progress note would be competed to describe and measure the wound or the pressure ulcer. During an interview on 11/22/19 at 10:24 AM, Staff H LPN/RCM stated, We are getting a mattress overlay for her today. When residents are identified at risk for pressure ulcers or for skin break down, we put them on a turn schedule and tell the aides to tell us everything about their skin, everything. Anything different. We also get them on a overlay mattress. Resident #1 just came to us recently with a stage II pressure ulcer. We got it healed, discontinued the treatments and now it is open again, with a new Stage II in that same area. During an interview on 11/26/19 at 2:36 PM, the DNS stated that for residents identified at risk of pressure ulcers, We turn them and make sure they have pressure relieved. That could have been avoided, I did not know she reopened until Staff H, LN/RCM came and told me. She would be considered at risk. During an interview on 11/27/19 at 11:11 AM, Staff H, LPN/ RCM, stated, It was healed on 11/13/19, the treatment was discontinued on 11/18/19 a few days later. No there is no documentation of the pressure wounds, the new one or the one that reopened. No descriptions or measurements documented about the healing of the pressure wound she admitted with since admit. When they first find a wound, they should measure and describe it and report to the MD and everybody else who needs to know. When they do the weekly assessments and if a plus sign is charted, that means a problem was found. The nurses should measure and describe the wounds or the problems weekly until healed. If it is new, they should call the doctor to get a treatment and let the family know. Then place them(resident) on alert charting for further monitoring. Reference WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to ensure a resident received adequate supervision to prevent accidents for one of 3 sample residents (1). Failure to provide consistent & sufficient supervision for a resident with a known decline in condition of weakness, confusion and recent falls resulted in Resident 1 sustaining a shoulder fracture. Findings included: Resident 1 was admitted in (MONTH) (YEAR) with [DIAGNOSES REDACTED]. The record showed the resident had several non-injury falls in (MONTH) of (YEAR). The written plan of care (P[NAME]) for falls was revised at that time to include interventions such as non-skid socks or shoes when out of bed. Visual checks every hour to ensure safety and directions were placed on the Medication Administration Record [REDACTED]. Review of Resident 1's Minimum Data Set Assessments from admitted d 1/23/18, showed a decline in Resident 1's transfer, toileting and standing/walking balance abilities from needing a 1 person assist (PA) to 2 PA. Review of (MONTH) (YEAR) progress notes: On 1/2/18, Therapy told nursing that the resident now needed more help with transfers of 2 person assist (PA). Nursing noted it as a decline in condition. Between 1/3/18 - 1/9/18, Resident 1 was not walking as well with her walker and had increased weakness and confusion. Resident 1 was also started on antibiotics for a suspected urinary infection. On 1/9/18, Resident 1 had an unwitnessed non-injury fall in her room. Between 1/9/18 - 1/21/18, it was noted, Resident 1 had significant changes such as trying to get up from a wheelchair (w/c) without staff assist. Resident 1 had confusion, was unable to use the call light and was spoon fed by staff at times and required maximum assist with activities of daily living. Her Fall Plan of Care was briefly revised to include an (unsuccessful) trial use of a tilt in space wheelchair, was then switched back to the use of a manual w/c. On 1/17/18, a note indicated the resident was on 30-minute visual checks related to her fall risk. This intervention was not documented again anywhere else, i.e. the Plan of Care, medication record or treatment record or other progress notes. On 1/21/18, the resident required maximum assistance for activities of daily living was oriented to name only, was a pivot 2 PA transfer and used a w/c for all transport. The resident did ask to use a walker, but did not meet the requirements at that time. The resident would become angry when not getting her way regarding the use of the walker and redirection usually worked. On 1/22/18 at 12:30 pm, Resident 1 had another unwitnessed non-injury fall. She was found on floor in her room next to bed. The note indicated Resident 1 denied she fell as she was just getting her shoes. The P[NAME] was revised to include environmental checks to ensure the resident could reach items she needed. On 1/23/18, Occupational therapy noted the resident required 2 PA for transfers due to diminished standing balance. On 1/24/18 at 9:35 am, the resident had another unwitnessed, non-injury fall. Staff found her on floor next to the bed. Range of motion (ROM) was within normal limits (WNL). There were no complaints of pain, the resident was assisted up by 2 people. The note indicated the resident was then taken to dining room to be observed by staff & placed on 72 hour alert charting. On 1/24/18 at 1:32 pm, noted no visible injuries, ROM WNL. She complained of her right (R) shoulder being sore. There was no swelling or bruising and the resident was sitting by nurse's station to be observed. On 1/24/18 at 3:32 pm, the resident used the w/c for all transport. Was able to propel self. The resident believes she's capable to ambulate by self and fell twice this shift related to this belief. During an interview on 2/26/17 at 10 am, Staff A, Licensed Nurse stated regarding the resident's multiple (4) falls in January. Staff A said, The resident kept thinking she could get up, and was very impulsive, wouldn't wait for help. She was feeling better, but still needed assist. I can't remember if I was there when she fell resulting in the shoulder injury. I think I was. She didn't immediately have pain or obvious problem with her shoulder that came on a few days later. Review of facility incident report document dated 1/24/18 at 9:35 am, showed the resident had a fall in her room. The resident told staff she had been trying to walk to bathroom just prior to the fall. The immediate action taken was a physical assessment of the resident, but the report did not indicate whether there was an immediate P[NAME] revision(s) put in place in response to the resident's having another unwitnessed fall, such as increased visual checks/supervision of Resident 1 or one to one supervision. Resident 1 had a 2nd unwitnessed fall that same day at 10:25 am, 1 hour after the first unwitnessed fall. The associated incident documentation indicated the resident said she was trying to get ice and tripped over the w/c legs. No visible injuries were noted at time of incident, but the resident did complain of soreness to her right (R) shoulder without swelling/bruising and her range of motion (ROM) was within normal limits (WNL). A nursing assistant's (NA) statement regarding the care provided around the time of the 1/24/18 falls indicated the resident's brief was changed at 9:15 am. The NA returned from a break and was informed by a partner NA that the resident had fallen. Then at 10:05 am, I helped her (Resident 1) to sit on the chair and I leave her in the hallway. The NA's statement did not indicate whether she received any immediately revised care instructions for Resident 1 after the 1st fall, such as increased visual checks or increased supervision. On 3/5/18 at 2 pm, the Director of Nursing and facility administrator were asked whether the Karedex (individual resident's specific daily care information for nursing assistants) that were in place at the time of the fall(s) could be obtained. Only the formal written plan of care was provided by the facility. The facility did provide additional written information about the resident's fall from an activities staff, dated 3/5/18, which revealed the following: On the morning of 1/24/18, the activities person recalled walking by and seeing Resident 1 standing up in her room. She went into the room, asked the resident to sit down, wheeled the resident to the nurse's station, and told the nurse about the resident standing up unassisted. The activities person wrote the nurse told her that she had been trying to keep the resident near the station to keep an eye on her, but that the resident refused to stay there. The staff then offered an activity to the resident to which Resident 1 refused and wheeled herself away down the hall. Later 'around mid-morning', the activities person said she was sitting in her office and heard the resident yelling for help from the dining room. She went to the dining room, found Resident 1 lying on the floor, and then nursing came in to assess the situation. Further review of progress notes from 1/25/18 - 1/26/18 indicated the resident was complaining of R shoulder pain, but that her ROM was good/WNL. Review of the medical record showed the resident routinely received a narcotic medication patch for chronic back pain. Resident 1 also had an oral narcotic ([MEDICATION NAME]) order to be given as needed (prn) for pain: According to the (MONTH) (YEAR) MAR, the resident received only 2 prn narcotic doses between 1/11/18- 1/22/18. However between 1/23/18 -1/26/18, the resident received 1-2 doses of prn [MEDICATION NAME] per day for pain levels averaging 7.5 out of 10 (severe pain). A physical therapy note on 1/26/18 indicated the resident was a fall risk and had pain 7/10 at R shoulder 'from fall other day' which limited the resident's functional activities. A medical provider ordered a STAT shoulder x-ray on 1/26/18. The x-ray revealed the resident had an acute R humeral fracture, and the resident was sent to the emergency room . An interview with Resident 1 on 2/26/18 at 10:20 am, the resident said she fell in the main dining room (on 1/24/18). She said she got up to get some water, slipped, and fell into the wall/ice machine. The resident said she had shoulder pain for 3 days before being sent to the emergency room . The facility did not recognize or implement increased supervision for a resident who had a history of [REDACTED]. Reference: (WAC)388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure staff were competent and knowledgeable, properly supervised, and able to provide safe nursing care for 2 of 2 residents (189 &148) reviewed who required tube-feeding nutrition and had indicators they had aspirated (a condition in which food, liquids, saliva, or vomit is breathed into the airways/lungs and can result in aspiration pneumonia). Failure to: ensure the resident's upper body was safely elevated per the plan of care, to respond timely and appropriately when a resident on aspiration precautions (interventions to reduce the risk of aspiration) had slid down in bed while receiving tube feedings, and to ensure 5 of 8 nursing assistants (M, EE, GG, CC, P) interviewed were knowledgeable about aspiration risk/precautions and providing safe nursing care for special needs/tube-feeding residents. These failures resulted in an Immediate Jeopardy (IJ) on 10/06/17 after observing staff failing to respond timely and appropriately when Resident 189 had slid down in the bed while receiving tube-feedings, and after interviewing staff regarding how to safely care for residents that received tube feedings. Additionally, the facility failed to adequately assess, monitor and care plan for 1 of 3 residents (85) assessed for a non-pressure-related skin condition and swelling and to follow a physician's orders [REDACTED]. These failures placed the residents at risk for medical complications [REDACTED]. Findings include: RESIDENT 189 The resident was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was discharged to the hospital on [DATE]. Review of hospital records reveal the resident was admitted to the hospital from 09/17/17 - 09/21/17 with a primary [DIAGNOSES REDACTED]. The history and physical indicated Today, medics were called because the patient was having shortness of breath, vomiting, fevers and oxygen saturation of 85% on room air. When EMS (Emergency Medical Services) arrived, he had dried emesis (vomit) in his mouth and on the bed. The resident was admitted to critical care due to a high probability of imminent deterioration which could result in an immediate life or limb threat . The resident was admitted back to the facility from the hospital on [DATE]. Review of the Minimum Data Set (MDS) assessment and care area assessments, dated 09/28/17, revealed: he was rarely able to make his needs and wants known and was rarely able to follow instructions, had total dependence on staff for bed mobility and positioning, had difficulty maintaining a sitting balance, was unable to swallow or eat food, and had a peg tube (tube inserted into the stomach through the abdomen for feeding) due to his severe dysphagia. Review of the resident's Medication Administration Records (MARs) (print date 10/05/17) revealed orders that he received tube-feeding continuously and to keep the head of bed elevated 45 degrees during tube-feeding. Review of Speech Therapy treatment notes, dated 10/03/17, revealed the resident was on Aspiration Precautions. Review of the KARDEX (care directive for nursing assistants), print date 10/05/17, revealed no information regarding the aspiration precautions. The KARDEX revealed an entry .head of bed 45 degree while tube feeding .). Review of the care plan, print date 10/05/17, revealed no information the resident was on Aspiration Precautions. The care plan did indicate Turn and re-position every 2-3 hours. In multiple observations from 10/03/17 - until the morning of 10/06/17, the resident's head was never observed to be higher than 30 degrees. There was a sign hanging on the wall that read Keep HOB: Min 30 degrees at all times. Review of his MAR's/Treatment Administration Records (TAR) revealed an order to keep HOB (head of bed) elevated 45 degrees during tube feeding every shift. Staff had signed it off as being done every shift from 10/01/17 through day shift on 10/05/17, as being followed. In an observation on 10/03/17 at approximately 9:40 AM, Resident 189 was lying in bed. The head of the bed was raised approximately 30 degrees, however the resident's head was not positioned with his head at the head of the bed. Due to his positioning lower in the bed, only his head was raised; the bend in the bed was approximately at his neck. The foot of the bed was not raised. In an observation on 10/05/17 at 8:45 AM, the resident appeared to have slid down in bed, the head of the bed was at 30 degrees, but the resident's upper body was flat and 1 of his feet was extending down beyond the foot of the bed. Staff M, Nursing Assistant (NA), was asked if the resident was positioned properly. Staff M repositioned the resident's pillow and asked How is that? Staff M was asked what it meant to keep the head of bed at 30 degrees, Staff M pointed to the resident's shoulders and said from there on up needs to be 30 degrees. In an interview at 9:34 AM, Staff L, Licensed Practical Nurse (LPN)/Resident Care Manager, stated 45 degrees, when asked what the resident's head of bed was supposed to be. When informed about Staff M's response when asked how to properly position a resident with an order to have the head of bed elevated, Staff L stated It sounds like he needs some training. In an observation on 10/06/17 at 7:16 AM, the resident appeared to have slid down in bed, he was flat except for his head which was up slightly due to the head of the bed still being elevated approximately 30 degrees. In an interview at 7:16 AM, Staff EE, NA, was asked how high the resident's head of bed was supposed to be, she pointed to the sign on the wall that indicated 30 degrees. Staff EE stated No when asked if the resident was positioned with his head of bed at 30 degrees, she said she needed to get help to move him up in bed and she was observed to leave the room. In an observation at 7:43 AM, the resident was observed to still be lying flat in bed with his head up slightly on a pillow. In an interview at 7:43 AM, Staff E, LPN, stated No, when asked if Staff EE had notified him the resident had been lying flat in bed since 7:16 AM with tube-feeding infusing. In an interview at 8:28 AM, Staff EE stated I couldn't find anybody, when asked why she did not return to reposition the resident when she had left the room earlier at 7:16 AM, over an hour earlier. In an interview at 12:31 PM with Staff CC, NA, said: I have never taken care of a resident who had a PEG tube before. Staff CC stated I don't know about it when asked about positioning and how to safely care for a resident receiving tube-feeding. In an interview at 12:41 PM with Staff P, NA, was asked how she positioned and safely cared for a resident with a PEG tube. Staff P stated the resident received nothing by mouth. I turn them every 2 hours, if they are incontinent I change them and clean them. That is what I do. Staff P did not state anything regarding how she would position a resident while receiving tube-feeding. In an interview at 12:47 PM, Staff E stated a minimum of 30 degrees when asked how high the residents head of bed was supposed to be considering that he had continuous tube-feeding infusing. Staff E stated Immediately when asked how soon he would expect to be notified by a nursing assistant if they were unable to properly position a resident with tube-feeding infusing. In an interview at 12:54 PM, Staff FF, NA, was asked what it meant to her when a resident's head of bed was supposed to be 30 degrees. She stated the resident's upper body, not just the head should be up to 30 degrees. Staff FF was asked what she would do if she walked into a resident's room where the head of bed was supposed to be at 30 degrees and the resident was flat in bed while tube-feeding was infusing, she stated she would get help to raise them back up in bed, and if no help was available, she would go to the DNS (Director of Nursing Services) office to ask for help. In an interview at 1:21 PM, Staff GG, NA, was asked what it meant to her when a resident's head of bed was supposed to be at 30 degrees, she stated From the top of the shoulders on up should be at 30 degrees because I don't want them to choke. When asked what she would do if a resident with tube-feeding infusing had slid down in bed and their head of bed was supposed to be above 30 degrees, she stated most of them (residents) are a 2 person assist, so she would get help, and they would pull the resident up in bed, and if no help was available, she would put the call light on and stay with them because I don't want to get in trouble because they could choke. In an interview 3:08 PM, the DNS stated Resident 189 was very wiggly and the scooting down was concerning. She stated she had become concerned about his scooting down yesterday. When asked if there had been a change in the residents' plan of care since yesterday when she became concerned, she looked in the computer and then denied any changes to the plan of care. The DNS stated it is the upper body with the esophagus and stomach up above the body, when asked what head of bed at 30 degrees meant. The DNS was unable to provide any specific information when asked whether Resident 189's head of bed was supposed to be 30 or 45 degrees when tube-feeding was infusing, she stated she thought it was the admission nurse probably trying to put in standard orders and monitoring and that it wasn't something she saw as coming from the hospital. The DNS was asked about the resident's recent hospitalization and whether the facility had analyzed what happened to try to prevent an aspiration reoccurrence, to which she stated We attributed it (the aspiration) to the increased rate (of the tube-feed infusion) to give him some time off at the time. The DNS did not provide documentation of any analysis the facility may have conducted. RESIDENT 148 The resident admitted to the facility in July 2017 with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE], revealed she had total dependence on staff for bed mobility and positioning and was receiving tube-feeding. Review of a complaint intake allegation, dated 09/27/17, revealed the reporter alleged staff not getting Resident 148 to the correct position to receive the food through her PEG tube (30 degree positioning). This had resulted in the resident aspirating. In an interview on 10/02/17 at 3:07 PM, the resident's daughter stated her mother had aspirated tube-feeding while a resident at the facility and had been treated at the hospital. The resident's daughter was concerned there was not enough staff at the facility because recently a NA had laid her mother flat to change her and was waiting for another NA to assist her, but the other NA did not show up, so she felt her mother was laying flat for an excessive amount of time. Review of the resident's clinical record revealed 2 hospital visits that were concerning for aspiration: 1. Hospital records dated 07/27/17 revealed Patient was transferred to a skilled nursing facility, where she was noted to have high residuals on her tube feeds. Today, daughter noticed her to be coughing, and seemed to be struggling to breathe. This was shortly after receiving her tube feeds and receiving a dose of [MEDICATION NAME] . Patient was recently hypoxic with a oxygen saturation reading in the 70's, then stabilizing in the 80's without intervention. The report indicated on the chest x-ray likely atelectasis (collapse or closure of a lung resulting in decreased gas exchange) but cannot exclude aspiration or pneumonia. The listed differential [DIAGNOSES REDACTED]. The listed impression/[DIAGNOSES REDACTED]. 2. Hospital records dated 09/24/17 revealed a Chest x-ray with possible consolidation in right upper lobe concerning for aspiration. The impression list included the [DIAGNOSES REDACTED]. Upon comprehensive review of the facility's tube-feeding care and services practices, as well as the associated risks, it was concluded facility skilled nursing staff were not properly trained/supervised and/or responsive to the high aspiration risks associated with caring for a resident receiving tube-feedings. See also F328 - Treatment/Care for Special Needs (Tube-feeding practices) See also F497 - Nurse Aide Perform Review - 12-hr/yr Inservice See also F498 - Nurse Aide Demonstrate Competency/care Needs RESIDENT 185 Resident 185 was readmitted to the facility September 2017 with [DIAGNOSES REDACTED]. Review of the history and physical revealed the resident had a [DEVICE] placed when hosptalized on [DATE]. The resident currently received all of her nutrition intravenously (IV) and the [DEVICE] was not to be used for nutrition but flushed every shift. Review of a physician order [REDACTED]. Review of the September 29th through October 9th revealed the LN had not flushed the abdominal tube per the physician order. In an interview and record review on 10/10/17 at 9:15 AM, Staff J, LPN, viewed the resident's physician orders. Staff J was not aware the resident's abdominal tube was to be flushed every shift. Staff J stated she would look into why this physician order [REDACTED]. RESIDENT 85 Resident 85 admitted to the facility August 2017 with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE], revealed the resident had cognitive impairment and required extensive assistance of 2 staff for mobility and hygiene needs. Review of the Nursing Admission Assessment showed the resident had a skin tear to her right forearm and no swelling in her extremities. Review of the medical record revealed a nursing progress note dated 09/26/17, which documented right hand swelling a left forefinger discoloration was noted. Review of subsequent progress notes showed no further documentation of the right hand swelling or forefinger. Review of the care plan, with a last review date of 09/15/17, revealed the care plan was not updated to include the new right hand swelling or treatment for [REDACTED]. Review of the MARs and TAR's for August-October 2017 showed no monitoring or treatment for [REDACTED]. TED hose (compression stockings) where placed on during the day and removed at night. Review of the medical record showed a fax cover sheet sent to they physician on 10/02/17. The LN documented the resident's daughter's request for [MEDICATION NAME] (water pill) and potassium be started for her mother as soon as possible due to the increased swelling of the right hand. In an observation made on 10/02/17 at 12:19 PM the resident was noted to have 3 to 4 plus right arm swelling up to her elbow with some discoloration appearing like bruising on forearm where the skin tear had been documented on admission. At 2:40 PM, the resident was observed sitting in the common area in her wheelchair. The right arm remained swollen to elbow. In an interview on 10/05/17 at 9:12 AM, Staff Z, LN, stated I worked with the resident a few days ago and she had some slight swelling in her right hand but not as bad as it got on Monday (10/02/17). I haven't worked with her this week but I heard her nurse say it had gotten worse. In an interview on 10/06/17 at 10:39 AM, Staff A, Resident Care Manager, stated the resident had the swelling in her legs and hand for a couple of weeks. The hand swelling seemed to increase as the day goes on because she slouched down in her wheelchair and her right hand hanged down. Staff A stated therapy was working with the resident on wheelchair positioning. In a subsequent interview on 10/09/17 at 1:00 PM, Staff A stated they were .trying to figure out what was going on with her hand on 10/03/17. The hand swelling was first noted on 09/26/17 and the daughter was notified. The resident saw her private physician on 09/29/17. The daughter had made the appointment evidently for the hand swelling but didn't tell us she was taking her to the doctor. Staff A stated she sent an e-mail to notify the physician who oversees her care here but not sure what day the e-mail was sent. Staff A stated she would follow up on when this e-mail was sent. Staff A stated Her private doctor ordered [MEDICATION NAME] and potassium for the swelling but called it in to the pharmacy and did not let the facility know about the order. I saw the [MEDICATION NAME] here on 10/02/17 but we couldn't give it to her until we had an order. I started working on it on 10/02/17 and she got her first dose on 10/03/17. She was then sent to the hospital per the daughter's request to have the swelling evaluated. The resident's physician's office visit note documented right arm swelling with forefinger bruise and bilateral leg [MEDICAL CONDITION]. The resident had no known injury, fall, or fracture. In an interview on 10/09/17 at 3:15 PM, the DNS stated care plans are updated quarterly and should be updated when there is a change in a resident's condition. At 4:22 PM, the DNS stated the facility did not know the daughter had taken the resident to her primary physician on 09/29/17. The DNS stated the doctor faxed the order for [MEDICATION NAME] directly to the pharmacy and not to the facility. Therefore the facility did not know about the order until 10/02/17. The DNS stated the right arm swelling was from the arm being dependent, .we tried to get her to change position. I don't know why the care plan and KARDEX wasn't updated to reflect that . In a subsequent interview on 10/10/17 at 9:42 AM, the DNS stated she could not find documentation the facility's physician had been notified on 09/29/17. Review of the copies of the e-mails sent by Staff A revealed the facility's physician had been contacted on 10/02/17 and the swelling was discussed. The facility physician was to contact the private doctor for more history on the resident's [MEDICAL CONDITION] and treatment. The facility had also contacted the resident's private physician on 10/02/17 to request orders for the [MEDICATION NAME] which was then obtained on 10/03/17. The facility failed to assess, document, monitor and care plan the resident's right arm swelling and leg [MEDICAL CONDITION]. Additionally, the facility delayed in notifying the facility's physician of the change in her condition in a timely manner so she could be assessed and interventions implemented. Reference: WAC 388-97-1060(1)

Based on observation, interview and record review, the facility's administration failed to effectively and/or efficiently use its resources to maintain the highest practicable well-being for 17 of 34 residents reviewed. Failure of the Administrator to ensure quality of care was provided for 2 of 2 residents (189, 148) reviewed who required tube feeding nutrition, failure to ensure the facility had an effective pressure ulcer prevention program for 3 of 4 residents (119, 190 and 185), failure to ensure 1 of 2 residents (88) urinary status was maintained at their highest practicable level of well-being, and failed to have sufficient qualified staffing to provide and supervise care for residents with complex health care conditions for 15 of 30 residents (185, 37, 35, 53, 148, 175, 29, 20, 17, 178, 191, 87,an anonymous family member, 189 and 88). This failure caused an immediate jeopardy to Resident 189 as provide in F 309, caused harm to Resident 119 and 190 as provided in F 314, and caused harm to Resident 88 as provided in F 315. Additionally, the Administrator failed to ensure sufficient nurse staffing was available as identified in F 353. Findings include: 1. The Administration failed to ensure staff were competent and knowledgeable, properly supervised, and able to provide safe nursing care for residents who required tube feeding nutrition and had indicators they had aspirated. Refer to CFR 483.24, F- 309 - Provide Quality Care/Services for Highest Well-being 2. The Administration failed to ensure residents who were admitted to the facility without pressure ulcers did not develop pressure ulcers. Refer to CFR 483.25 (b)(1)(i)(ii) , F-314 - Treatment/services to Prevent/heal Pressure Sores 3. The Administration failed to ensure a resident's urinary status was properly assessed and reassessed to prevent a decline in the resident's urinary status and to maintain the resident at their highest level of well-being. Refer to CFR 483.25 (e )(1)(2)(iii), F - 315 - No Catheter, Prevent UTI, Restore Bladder 4. The Administration failed to ensure the facility had adequate staff to provide basic care and services. Refer to CFR 483.30(a), F 353 - Sufficient 24-hour nursing staff per care plans 5. The Administration failed to have in place an annual performance review program for certified nursing assistants which was then used to establish needed individualized training for the nurse aides. Refer to CFR 483.75(e)(8), F-497 - Nurse Aide Perform Review - 12 Hr/Yr In-service 6. The administration failed to have in place a regular in-service education program for nurse aides which provided 12 hours of training and failed to ensure continuing education curriculum addressed the needs of residents. Refer to CFR 483.35(c) and 483.95(g)(1)2)(4), F 498 - Nurse aides demonstrate competency Reference: WAC 388-91-1620 (1)

Based on observation, interview and record review, the facility failed to ensure 1 of 2 residents' (88) reviewed for urinary continence was accurately assessed and/or reassessed, and also failed to utilize sufficient skilled nursing staffing to implement continence programs to improve or restore the resident's urinary continence. This failed practice resulted in harm to Resident 88 when the facility had assessed her on the bowel and bladder program screener as being continent on admit, but then did nothing when it should have been immediately obvious by review of nursing assistant toileting documentation that she had many shifts where she was incontinent. Then, approximately 90 days after admission, the facility erroneously reassessed her as being continent, even though facility documentation reflected a 3 month pattern of incontinence. This pattern of failed practice continued for approximately 6 months after admission without skilled nursing staff performing an accurate comprehensive urinary assessment or implementing any urinary continence programs. Findings include: RESIDENT 88 The resident admitted to the facility 04/14/17 with [DIAGNOSES REDACTED]. Review of her Minimum Data Set (MDS) assessment, dated 04/21/17, revealed she had no cognitive impairment, required extensive assist of 2 staff for toileting, and was coded as frequently incontinent of urine (7 or more episodes of urinary incontinence, but at least 1 episode of continent voiding). The MDS also indicated a trial of a toileting program (e.g. scheduled toileting, prompted voiding, or bladder training) had not been attempted on admission/entry or reentry or since urinary incontinence was noted in this facility). Review of her MDS assessment, dated 07/22/17, revealed she was coded as always incontinent of urine. The MDS also indicated no trial of a urinary toileting program had yet been attempted since entry to the facility. Review of a Nursing Admission Assessment, dated 04/14/17, revealed no information under [MEDICAL CONDITION]: Associated Diagnosis, except for color of urine - yellow. The bottom of the form indicated a bowel and bladder assessment would be completed in PCC (Point Click Care (electronic health record)). In an interview on 10/09/17 at 1:24 PM, the Director of Nursing Services confirmed this assessment referenced on the Nursing Admission Assessment was titled the Bowel and Bladder Program Screener form. Review of a Bowel and Bladder Program Screener, dated 04/14/17, revealed she was documented as: always voids appropriately without incontinence, required 1 person assist to toilet, and was always mentally aware of the need to toilet. The form indicated she was a Good candidate for retraining. This form was prepared by Staff Y, Licensed Practical Nurse (LPN). Review of a Documentation Survey Report for toileting revealed she was continent of urine on the evening shift of 04/20/17 and the night shift of 04/21/17. The report also indicated she was incontinent of urine 17 shifts from 04/14/17 - 04/21/17. The form also indicated she was continent of urine on the day and evening shifts of 04/23/17. Review of progress notes revealed a urinary catheter was inserted on 04/21/17 at 9:30 AM for a 24-hour urine collection (lab test). Review of the corresponding Care Area Assessment Worksheet, dated 04/21/17, revealed she had an actual problem of being frequently incontinent of urine and was at risk for decline in elimination status related to impaired mobility secondary to [MEDICAL CONDITION], generalized weakness and malnutrition. The worksheet indicated she had a modifiable factor of restricted mobility that contributed to her transitory urinary incontinence. The form also indicated other factors that contributed to her incontinence included urinary urgency and need for assistance with toileting. The form did not indicate the facility had assessed the type of incontinence she experienced (i.e. stress, mixed, transient, urge, overflow, or functional). The form also indicated the resident managed her toileting regimen independently at home prior to admission. Additionally, the form indicated the facility would Continue to monitor for decline in elimination status. Proceed to care plan. Review of a progress note dated 04/28/17 at 11:04 PM, revealed Continent of bowel and bladder. Review of the care plan, print date 10/09/17, revealed no documentation of any interventions for staff to attempt any toileting programs. Review of the KARDEX (care directive for nursing assistants), print date 10/09/17, revealed Bladder Continence - Incontinent of Bladder, and Toileting - Extensive x 1 person. Review of a quarterly Bowel and Bladder Program Screener, dated 07/15/17, revealed she was documented as always voids appropriately without incontinence and was always mentally aware of the need to toilet. The form indicated she was a Good candidate for retraining. This form was prepared by Staff Y, LPN. Review of Documentation Survey Reports detailing urinary continence by shift revealed: April (14th - 30th) - 4 shifts she was continent of urine. May - 2 shifts she was continent of urine. June - 0 shifts she was continent of urine. July - 0 shifts she was continent of urine. August - 1 shift she was continent of urine. September - 0 shifts she was continent of urine. October (1st - 10th) - 0 shifts she was continent of urine Review of a progress note dated 09/17/17 at 8:30 AM, revealed a social services progress note detailing efforts to assist the resident back to work. The note indicated The other issue per resident, is assuring she can get to the toilet at the job site independently. The note also indicated she was planning on doing a trial run at the job while accompanied by her job coach. The resident indicated she didn't want to be overwhelmed so she would like to start out with 1 hour per week. In an interview on 10/09/17 at 11:01 AM, the resident stated before admission when she was at home she was able to urinate on her own. She stated she did wear pull-ups at home because sometimes she had to go too fast and was not able to make it to the bathroom on time. She said since admit to the facility, she used briefs instead of pull-ups because when she has to go to the bathroom she has to go real fast. She stated The real problem is my safety, when I have to go and I call for help, it takes too long for them to get in here to help me. I don't want to fall down and then get hurt. She stated once she tried to go pee by herself and she didn't have shoes and she fell down. In an interview at 11:15, Staff A, LPN/Resident Care Manager, stated the resident had not been on a urinary toileting program since admit, then added It would probably be a good idea to put her on a program to see if it helps her because she is planning to go back to work. I think her case manager is going to try to work with her to get her back to work. Staff A was asked if the facility had assessed the urinary decline the facility coded between the admission MDS and the 1st quarterly MDS, she did not provide any information. In an interview at 11:20 AM, Staff C, LPN/MDS Nurse, was unable to provide any information when asked if the facility had attempted any urinary training programs for the resident. She was also unable to provide any information whether the facility had assessed the urinary decline the facility had coded between the admission MDS and the 1st quarterly MDS, she stated she would look in to it. In an interview at 1:24 PM, the Director of Nursing Services (DNS) was asked about the Bowel and Bladder Program Screener dated 04/14/17. The DNS stated that was based upon what the resident told us when she was admitted . I don't think this is an accurate assessment of what she was actually doing at the time, it was based on her perception. That was about all we had at that time. The DNS was asked about the Bowel and Bladder Program Screener dated 07/15/17, she stated that was also based on the resident's perception. The DNS then added I have not had an opportunity to assess her or her needs yet. The DNS was unable to provide any information how the facility utilized the Bowel and Bladder Program Screeners in the facility. The DNS stated I will get her started on a toileting program right away. The DNS was notified the resident had indicated that her incontinence was a barrier of her returning to work, to which the DNS stated She used to work, but how much did she really work? In an interview at 2:12 PM, Staff P, Nursing Assistant (NA), stated the resident was on a 2-hour check and change program. She did not know of any facility efforts to attempt to restore the resident's bladder function. Staff P stated the resident got her briefs changed in bed and she does not ever use the toilet or commode. In an interview on 10/10/17 at 8:38 AM, the DNS stated there was a 2-hour toileting schedule posted next to the resident's bed and the resident had been refusing to toilet per the schedule. The DNS was asked for the dates and documentation related to implementation of the toileting schedule and the resident refusals, she stated she was still looking into it. The DNS was asked about the Bowel and Bladder Program Screener dated 07/15/17, that was prepared by Staff Y, LPN, she stated That was all wrong. In an interview at 9:17 AM, the DNS provided a copy of the undated Toileting Schedule sign from above the resident's bed. The DNS was asked why the toileting schedule and resident refusals to participate were not documented and/or considered in the toileting assessment, she stated We are looking into that. The DNS was asked if the resident was on a toileting schedule, would it be her expectation as the DNS that the information would be included on the KARDEX and care plan, she stated Yes, if therapy had communicated it to nursing staff. She then stated they were still looking into it. In an interview on 10/11/17 at 1:07 PM, the resident stated her urination issues were a Medium problem, and I need help standing up, pulling my pants down, and getting on the commode, and then put the pants up and then getting back to the chair. Why is this a problem? Because I cannot stand maybe for a minute. I can get from the chair to the bed with no problem and from the bed to the chair, the toilet gonna be hard, and the social worker and my caseworker like for me to go back to work, and because of my bathroom problem, I think I should just drop it and not go back to work. Since you've been here have you got help going to the bathroom? When I was in room [ROOM NUMBER] staff did not give me help to go to the bathroom, when I was in room [ROOM NUMBER], staff helped me 1 or 2 times to go to the bathroom. How did you go to the bathroom all the other times? I peed in my briefs, then they helped me to change them. Also, I really need to be careful, sometimes when I'm sitting in a chair wearing briefs, I get the back wet because the pee is coming out and then the pee goes on the floor, that happens once in awhile, the last time was Monday. I see there is a sign on the wall? That sign has been there since I was in room [ROOM NUMBER]. They started me yesterday (to go to the bathroom). I need help standing up, pulling pants and briefs down and then standing again. Were they doing that before yesterday? They were not, I can't wait 2 hours, if I have to go, I have to go. How often do you go? About every 20 minutes. Do you feel if staff offered you help more often, do you feel you could maybe control your urine? No, because it goes fast, I just don't know, maybe too much time has passed. Can you tell me about how things worked going to the bathroom at home before you went to the hospital? I wore pull-ups, and I was able to go to the bathroom fine, except at nighttime. At nighttime, I put pads on my bed and I still wore pull-ups. During the day I wore pull-ups and I could mostly go to the bathroom ok, I used a walker and I could go to the bathroom. If my legs were not the way they are, I would be able to go to the bathroom. Before I was able to go to the bathroom, not now though. They (the nursing assistants) think they can't help me, because they have to help me stand up, pull my pants down, put me on the toilet, help me stand back up and then put me in a chair. That's too much for them? They think so. Did they tell you that? Yes. Do you know their names? No, but I know what they look like. She stated Yesterday I told the head nurse I can't wait 2 hours to go to the bathroom, she told me I can go to the bathroom anytime I want, I just started that. Are you sitting in wet briefs all day? She stated Not often. Asked for more information regarding this, she provided no additional information except to state she urinated about every 20 minutes. How long after you tell staff you need to be changed do they change you? Well, before you guys came to talk to me, I went pee in the bathroom, I said something to them and they took me to the bathroom, Thank You. In an interview on 10/11/17 at 2:21 PM, Staff OO, Director of Therapy, stated Resident 88 was able to care for herself at home and she wore depends. So every time the therapist went in her room, she was already incontinent and wet, and she declined to use the bathroom on certain therapy days. She refused to have the OT's (Occupational Therapists) to help her to change her wet depends, so the therapist put the sign on the wall to remind her to go to the bathroom every 2 hours. It wasn't intended for nursing, it was simply a reminder for Resident 88 to go to the bathroom every 2 hours so she is not sitting in a wet diaper. The therapists didn't involve nursing in this, they might have reminded nursing she was supposed to go to the bathroom, but it wasn't formal . Pt (patient) agreed on toileting program. This specific time nursing was not involved. The CNAs (certified nursing assistants) were to remind the resident every 2 hours to go to the bathroom. Is that pretty common not to involve nursing in the toileting care plan? No, that's not common. Normally nursing initiates a continence program, but that's not what happened here .Maybe she might have been refusing .I don't know why nursing didn't do that this time. Has there been any collaboration at all between nursing and therapy related to the resident's incontinence? Not that I know of, I'm not sure, maybe nursing tried and she refused, I'm not sure. How long did therapy work with the resident to improve continence? 1 ½ weeks after admit. Then we stopped it after a week because she was refusing to participate. She said she could do it on her own. She needed help pulling her pants up, but she wasn't doing it herself. She declined a BSC (bedside commode). She said her urgency reduced continence. Staff OO did not provide any information why the resident had refused. Review of therapy treatment encounter notes revealed: 05/05/17 - Educated pt (patient) on importance of assessing toileting using pull ups if that is Pt PLOF (prior level of functioning). Pt states that she will soak through them and requests a brief. 05/11/17 - Noted pts brief wet but unaware. 05/17/17 - Pt incontinent. Already soiled. 05/26/17 - Toileting = Other (Pt was incontinent upon therapist arrival .) Review of a progress note, dated 10/09/17 at 11:55, revealed On admit resident had a foley cath (catheter) which indicated that she was occ. (occasionally) incontinent of bladder. Since the cath is no longer in place she freq. (frequently) incontinent. I have asked her if she would like to be on a program to assist her to the bathroom routinely and she said yes but not when she is asleep. In an observation/interview on 10/12/17 at 8:03 AM, during a resident interview, a nursing assistant knocked on the door and asked the resident if she wanted to go to the bathroom and she did. The staff member took her into the bathroom at 8:06 AM, after getting the resident into the bathroom, the staff member left the room and got another nursing assistant to help bring her out of the bathroom. At 8:18 AM, the resident came back out of the bathroom, 12 minutes had elapsed. The resident stated maybe a little bit, I don't want to sit wet all day when asked if she was wet when staff took her to the bathroom. She then stated On your job time, you have to have time to go to the bathroom, and to get back to work, for me, I need help to go to the bathroom. For me now, I'm retired because of my problem going to the bathroom. In an interview on 10/12/17 at 8:40 AM, Staff Y, LPN, was asked about the accuracy of the 07/15/17 Bowel and Bladder Program Screener, he stated he basically just copied the information over from the previous Bowel and Bladder Program Screener on 04/14/17. When asked what the form should have stated, he stated that sometimes she was able to void and sometimes not. The DNS was also in the interview, she was asked if the facility had yet performed an accurate urinary assessment for this resident, she stated We are doing bladder patterning now as part of the assessment, what we are finding right now is when we take her to the bathroom, she is already wet. When asked again if the facility had ever performed an accurate urinary assessment on this resident during this admission, the DNS stated No. Upon comprehensive review of the facility's urinary care and services practices for this resident, it was concluded the facility skilled nursing staff were not responsive to the specific urinary needs of Resident 88. The resident informed nursing staff on admit that she had previously been continent of urine. Staff assessed her on the admission MDS as frequently incontinent of urine, yet when it was apparent, or should have been apparent she was mostly or always incontinent, staff failed to implement any urinary continence training programs thus allowing her urinary function to decline to always incontinent. Reference: (WAC) 388-97-1060(3)(c)

Based on observation, interview and record review the facility failed to ensure necessary care and services were provided to prevent the development of new and the worsening of existing pressure ulcers on 3 of 4 residents (119, 190 and 185) reviewed for pressure ulcers (PU). Failure to timely identify and assess skin changes, develop and update plans of care, and implement interventions to prevent skin breakdown caused harm to the residents who develop new and had worsening pressure ulcers. Findings include: According to the National Pressure Ulcer Advisory Panel defined the following: - A pressure ulcer was a localized injury to the skin and/or underlying tissue usually over a bony prominence as a result of pressure, or pressure in combination with shear. - A stage II PU: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed. May also present as an intact or open/ruptured serum-filled blister. - an unstageable PU: Full thickness tissue loss in which the base of the ulcer was covered by slough (yellow, tan, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. RESIDENT 119 Resident 119 admitted to the facility June 2017 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was cognitively intact, was an extensive 2 person physical assist for bed mobility, transfers, dressing, toileting, and personal hygiene. The MDS also documented the resident had no PU on admit, but was at risk for developing a PU. Review of the MDS assessment dated [DATE], revealed the resident had 2 unstageable PU's. Review of the Nursing Admission assessment dated [DATE], showed the resident was alert and oriented and her skin was intact with no open areas. Review of the nursing progress note dated 08/15/17, documented blisters on right heel and toe noted. Informed RCM (resident care manager) and pillow placed under her foot. Review of the 08/17/17 Weekly Pressure/Non-Pressure Assessment (WP/NPA) form indicated the right outer heel blister was documented as unstageable and measured 3 centimeter (cm) x 3 cm by 0 cm in depth. The overall impression of wound stated resolving blister on outer edge, non blanch red, light brown skin blister. The right toe wound was not addressed. Review of the 08/24/17 WP/NPA form indicated the right heel blister measured 3 x 3 x 0 cm and the overall impression stated flat brown skin. The right toe wound was added and documented as not pressure related. Review of the 09/07/17 WP/NPA form indicated the right heel blister measured 2 x 1.5 x 0 cm, brown skin, no sign of infection. Review of the 10/03/17 WP/NPA form indicated the heel blister was documents as 3 x 2 x 0.1 cm; the dried blister skin fell off, pink wound bed. The right toe wound measured 1.5 x 1 x 0 cm with pinkish color and some brown skin area. Review of the physician's orders [REDACTED]. A stat x-ray was ordered on [DATE]. This x-ray showed a healing right ankle fracture. an order for [REDACTED]. Review of the care plan with the last care plan review dated 07/11/17, revealed the Focus Problem of Self Care Deficit related to impaired mobility with the interventions to include extensive 2 person assist with bed mobility; Special Considerations: N/A. The Focus Problem of High Risk for skin breakdown (Pressure) initiated on 07/02/17 had a goal to minimize risk for skin breakdown with the interventions to apply protective cream or ointment after care, pressure reducing surface to bed and wheelchair (no specific type of mattress identified other than the standard mattress); reposition in bed as tolerated; and weekly skin checks. Review of the care plan, with the last review date of 10/03/17, revealed the Focus Problem of Self Care Deficit due to impaired mobility with the Special Considerations now documented resident to wear blue boots on both feet at all times. This revision to the care plan was dated on 09/19/17, after the right heel ulcer had already developed. The Focus Problem of [MEDICAL CONDITION] was added 08/30/17 with an intervention to elevate heels in bed. The Focus Problem of impaired skin integrity: Pressure sore on left heel and lateral metatarsal (incorrect documentation as blister was on the right heel and lateral metatarsal) was not added to the care plan until 10/03/17, 6 weeks after the ulcers developed. There were no specific wound care interventions or pressure relieving devices identified in the interventions. The right lower extremity splint was not added to the care plan with interventions to remove and assess the skin every shift. Review of the KARDEX (care directive for the nursing assistants) showed the only interventions related to skin care or position was to use blue boots on both feet at all times. Review of the electronic medical record revealed the Nursing Assistant (NA) documented the resident's heels were elevated by using a check mark. The right lower extremity splint was not added to the KARDEX, nor was the blue boot instructions updated when the the right lower extremity splint was added. Review of the Medication Administration Records/Treatment Administration Records (MARS/TARS) for June 2017 to October 2017 revealed wound care to right heel ulcer was started on 08/16/17; the wound care was changed and blue boots to be worn at all times was ordered on [DATE]; wound care was changed and right lateral metatarsal wound care was added on 09/01/17; remove right foot splint every shift to assess skin for breakdown was added on 09/11/17. There was no discontinuation of the blue boot for the right foot when the splint was initiated. There were 16 missing splint removal and skin assessments for the night shift in September and 8 missing skin assessments for the night shift from 10/01/17-10/10/17. In an interview on 10/04/17 at 9:53 AM, Staff Z stated Yes, she had the heel blister and toe wound before the splint was place. She developed them here after she admitted . I'm not sure what pressure relieving devices were put in place before she developed them. At 12:10 PM, the resident was observed in bed. No specialty pressure reducing mattress was observed on the bed. The resident had a splint on the lower right extremity (RLE). The left heel was under the covers and was not observable. The resident stated I'm not sure when I got the blister on my heel, it is tender sometimes. I'm not sure if they were using the any boots on my feet before I got this splint. Didn't do anything special that I can remember. On 10/05/17 at 8:55 AM, wound care to the right heel and metatarsal area was observed being performed by Staff Z, LN. The right heel blister had 3 small dried areas of dry brownish colored, peeling skin remaining from the previous blister. There was no drainage or surrounding redness. The discolored skin on the right lateral metatarsal remained unchanged from the skin assessment flow sheet documentation. The resident was observed to be on an air mattress but she did not like it and requested it be removed from her bed. At 9:28 AM Staff CC, Nursing Assistant (NA), stated she had worked with the resident for a little while. She was able to move herself a little around the bed when she got here. We didn't use pillows for her heels that I know of. In an interview on 10/09/17 at 9:50 AM Staff P, NA, stated I don't remember if she had a special mattress on her bed before her ulcer. We used the blue boots at all times but I don't remember when we started to use them. We didn't have her on a turn schedule because she was alert and oriented and could move a little bit herself. At 10:07 AM, Staff Z stated the resident didn't have a special mattress prior to the ulcer developing. Staff Z stated the moon (blue) boots were initiated when the blister developed but it didn't work too well because it rubbed on the blister so we went to elevating the heels and now we have the splint which elevates the right heel at all times. Now it is healing really well. At 12:56 PM, Staff A, Resident Care Manager (RCM), stated we had no pressure relieving devices in place prior to the heel blister, just placed pillow to elevate the heels then started using the boots after she got the blister. The splint she has now works really well keeping the are pressure free. In an interview on 10/12/17 at 8:07 AM, Staff A stated it was her expectation that the staff remove the splint and assess the skin every shift as ordered. If the resident refused then it should be documented and not just left blank. The resident was observed multiple times throughout the survey. The resident remained in bed at all times per her request. The right lower extremity splint was in place correctly which kept the right heel and metatarsal area pressure free. No blue boots were observed in the resident room. The left heel was floated on a pillow. There was no other pressure relieving devices used. RESIDENT 190 Resident 190 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], the resident required extensive assist of two for bed mobility and transfers, had occasional bladder incontinence, and was cognitively intact. Review of the nursing admission skin assessment, indicated the resident admitted to the facility with a stage II pu to the left inner buttock. Resident 190 went to [MEDICAL TREATMENT] three times a week. Review of the Braden risk assessment tool dated 09/22/17, identified the resident at moderate risk for skin breakdown. Review of a physician order [REDACTED]. Review of the WP/NPA form dated 09/23/17 identified a 1 cm by 0.7 cm by 0.1 cm stage II PU on the left inner buttock. On 09/27/17, there was no change in the left inner buttock stage II PU. Review of a nursing progress note dated 09/29/17 at 3:56 PM, Staff J, LN, documented the resident's daughter stated the resident's .bottom has been sore. I checked and there was 4 new open areas . Review of the WP/NPA form dated 09/29/17, the left inner buttock stage II PU measured 3 cm by 1 cm by 0.1 cm. The PU had increased. There were two new stage II PU's identified as: on the upper coccyx measured 1 cm by 0.5 cm by 0.1 cm and one on the middle coccyx region measured 0.5 cm by 0.25 cm by 0.1 cm. Protective ointment was applied. On 10/02/17 a 0.5 cm by 0.2 cm by 0.1 cm stage II PU was identified right inner buttock. Review of the TAR from 09/22/17 to 09/30/17 revealed the LN never applied a dressing to the resident's left inner buttock per the physician order. A new order was obtained to treat the new PU's on 09/29/17. Review of the TAR from 09/29/17 through 10/08/17 revealed the LN did not provide the treatment to the multiple PU's on the day shift of October 1st, 2nd and 3rd. The TAR was blank on those shifts, indicating the treatment was not done. Review of the nursing progress notes and NA documentation identified the resident occasionally refused care from staff which included repositioning or treatment to skin concerns. Additionally, there was no documentation the LN had alerted the [MEDICAL TREATMENT] center that Resident 190 had current PU's or risk factors for skin breakdown. The resident's skin care plan was not initiated until 10/03/17. The care plan was not individualized to reflect the resident's occasional refusing care or preventative measure for skin breakdown. In an observation and interview on 10/09/17 at 8:56 AM, Staff L, LN, stated Staff Y, LN, did weekly wound rounds. This information was documented in the medical record. Staff L was aware the resident had PU's, and was not able to provide any additional information why interventions were not implemented on the care plan until 10/03/17. At 9:31 AM, the resident was lying in bed. The resident declined for his wounds to be observed with care. At 1:50 PM, Staff Y stated the care plan was located in the electronic medical record. Staff Y stated he was responsible to update/implement the care plan for the resident's wounds. Staff Y was not able to state why the care plan was not implanted until 10/03/17. At 2:14 PM, the DNS stated the expectation was an interim care plan should have been implemented for Resident 190's skin when he admitted to the facility. The DNS stated the LN should document on the TAR when a treatment was done. The DNS stated Resident 190 developed additional PU's because he refused care at times. The DNS was not able to state why the care plan was not updated to reflect his refusing care and direct staff on how to care for the resident when this occurred. In an interview on 10/10/17 at 7:00 AM, the DNS stated the resident's PU's had resolved. There was no information documented in the resident's progress notes prior to 09/29/17 of interventions the facility implemented prior to the development of three new stage II PU's. The facility failed to communicate with the [MEDICAL TREATMENT] center to coordinate the resident's care regarding the PU's and risk factors. The facility failed to implement a skin care plan until 12 days after the resident admitted and developed three new PU's. The resident had been identified as refusing care, and the care plan lacked any interventions to direct staff on how to appropriately care for Resident 190 when he exhibited behaviors. RESIDENT 185 Resident 185 was readmitted to the facility 09/29/17 with [DIAGNOSES REDACTED]. According to the MDS assessment dated [DATE], indicated the resident required extensive assistance of two for bed mobility, was dependent for transfers with a mechanical lift, was always incontinent of bowel and bladder and had no cognitive impairment. Review of a Braden assessment, dated 09/29/17, identified the resident was at moderate risk for pressure ulcer development. Review of the impaired skin integrity care plan, initiated on 09/29/17, was not individualized with interventions to prevent/improve the resident's current stage II pressure ulcer. Review of the KARDEX directed the NA to turn and reposition the resident frequently due to the stage II coccyx ulcer. Review of the nursing admission skin assessment dated [DATE] identified Resident 185 had a 2.5 cm by 2 cm by 0.1 cm stage II coccyx pressure ulcer. Review of a physician order [REDACTED]. Review of the WP/NPA form dated 10/04/17, identified the stage II sacral ulcer measured 1.5 cm by 1 cm by 0.1 cm. The LN documented the current treatment was a foam dressing to cover the wound and bony area. In an observation on 10/04/17 at 1:50 PM, Staff UU and Staff M, NA's, provided personal care to Resident 185. Staff UU was observed to remove the resident's brief, there was no dressing observed on the resident's coccyx or in the resident brief. There was an approximate quarter size open area on the resident's coccyx. There was pink ointment in the wound bed. Staff UU cleaned the pressure ulcer with disposable wipes and then applied a pink ointment to the pressure ulcer and surrounding tissue. In an interview on 10/05/17 at 1:03 PM, the resident was sitting in a wheelchair in her room. The resident was asked if she had a dressing on her PU and replied no. In an interview on 10/09/17 at 9:05 AM, Staff Y, LN, stated Resident 185's wounds were assessed weekly. Staff Y stated he assisted with wound rounds. Staff Y was not able to state why the resident's care plan was not individualized to reflect her current skin interventions. In an interview on 10/10/17 at 9:30 AM, the DNS stated PU's were assessed weekly and documented on the WP/NPA form. The DNS stated NA's should not apply ointment on a PU. The DNS was made aware of Staff UU putting ointment on the resident's PU. The DNS was not able to state why the resident's stage II PU dressing change was not done per the physician order [REDACTED]. Reference: WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to ensure 1 of 3 residents reviewed for medication administration remained free of significant medication errors (Resident #1) when the facility failed to administer a medication for diabetes, and administered three other medications incorrectly. This failure placed Resident #1 at risk for significant physical harm and contributed to elevated blood sugars. Findings include: --also see F225 and F281-- Review of the facility medical records revealed, Resident #1 admitted to the facility in July 24, 2017 for rehabilitation with [DIAGNOSES REDACTED]. According to the facility Minimum Data Set (MDS) assessment dated [DATE], Resident #1 could not complete the BIMS test, had severe cognitive impairment, and was totally dependent on staff for all activities of daily living. Review of the hospital records in facility medical record for Resident #1, dated 07/24/17, the day of transfer to the facility, revealed, Resident #1 left the hospital at 3:00 p.m. with records for the facility that included a hospital discharge summary, discharge orders, and discharge prescriptions. Discharge Packets reviewed and sent with patient, were signed by an RN at the hospital and dated 07/24/17 at 2:00 p.m. Review of the hospital discharge summary, which was also in the facility medical record, dated 07/24/17 (the day of admission) and had a fax stamp of 07/24/17 at 1:10 p.m. The documented revealed, Resident #1 was on insulin during her hospital stay to keep blood sugars at goal, the plan was to start her on an oral diabetic medication upon discharge ([MEDICATION NAME] 500 mg every day). In addition the hospital summary noted to continue the high blood pressure medication ([MEDICATION NAME] 25mg twice per day). The discharge summary noted a plan for titration up of [MEDICATION NAME] (a drug for muscle spasms) post discharge from the hospital from 2.5 mg at bedtime and increase gradually to 5 mg at bedtime. Review of the hospital Discharge Orders (11 pages) dated 07/24/17 at 2:27 p.m., which was in the facility medical record revealed, Resident #1 had diabetes, high blood pressure, and stroke; and included orders for these medications: [REDACTED] [MEDICATION NAME] (diabetes medication) 500 mg daily; [MEDICATION NAME] (high blood pressure medication) 25mg every 12 hours; [MEDICATION NAME] (nerve pain medication) 250mg twice a day and 400 mg at bedtime; [MEDICATION NAME] (muscle spasm medication) with a titration for every 7 days. In addition, there were prescriptions in the facility record dated 07/24/17 at 2:10 p.m., day of admission to the facility, which matched the above MEDICATION ORDERS FOR [REDACTED] Record review of the skilled nursing facility transcribed physician's orders [REDACTED].#1 arrived at the facility) and entered into the computer by the facility revealed, the facility did not include the diabetes medication ([MEDICATION NAME]) ordered by the hospital at discharge, the blood pressure medication dosage was incorrect at 5mg twice a day instead of 25mg twice a day, the muscle relaxant [MEDICATION NAME] was entered in 6 different lines and did not reflect the titration ordered by the hospital. Review of the hospital emergency room report dated 07/26/17, 2 days after admission to the skilled nursing facility, revealed Resident #1 went to the ER at the request of the family member who was concerned about her increased lethargy. The ER report showed Resident #1 had a list of medications reviewed discharge medications that matched the hospital discharge medication orders dated 07/24/17 and included: the diabetes medication, the high blood pressure medication, the titration of [MEDICATION NAME] and nerve pain medication. This report presented another opportunity for the facility to identify and correct the medication orders/errors for Resident #1. Record review of facility Progress Notes revealed, a note by Staff D, a nursing supervisor, dated 08/09/17, 16 days after admission to the facility, noting the family member for Resident #1 told Staff D that Resident #1 needs blood sugar checks for diabetes and she received insulin in the hospital, also had a question about the blood pressure medication. Staff D noted she went through the chart and found several discharge orders from the hospital with orders including a diabetes medication and blood medication dosage not administered or noted by the skilled nursing facility since admission on 07/24/17. Record review of facility Progress Notes revealed, a note by Staff D, a nursing supervisor, dated 08/09/17, 16 days after admission to the facility, revealed the family member for Resident #1 told Staff D that Resident #1 needs blood sugar checks for diabetes and she received insulin in the hospital, also had a question about the blood pressure medication. Staff D noted she went through the chart and found several discharge orders from the hospital with orders including a diabetes medication and blood medication dosage not administered or noted by the skilled nursing facility since admission on 07/24/17. In an interview on 08/17/17 at 1:30 p.m., Staff D, a nursing supervisor, stated the family member for Resident #1 told her several times there were medication concerns of dosages and medications not being given as ordered by the hospital doctor. Staff D stated she found that the medications were not transcribed into the computer on admission so she fixed it and notified the DNS. Staff D also stated she later found the correct admission medication orders in the back of the physician's orders [REDACTED].#1. MEDICATION ERRORS: Four incorrect medications for Resident #1 Review of the facility Medication Administration Records (MAR) dated July and August 2017 revealed the following significant medication errors for Resident #1: [MEDICATION NAME] 500 mg per day for diabetes was not started until 08/12/17, 19 days after admission to the facility. Total 18 significant medication omission errors. [MEDICATION NAME] for high blood pressure the following dosages were administered instead of 25mg twice per day for high blood pressure: 5mg were administered for 3 days after admission, then 6.25 mg was administered for 1 day, then 6.25 mg was administered twice a day for 15 days; the correct dose of 25 mg twice per day started 08/11/17, 18 days after admission. Total 38 significant medication errors for high blood pressure medication. [MEDICATION NAME] 250 mg for nerve pain was given at bedtime on 07/24/17 but not the 400 mg dose that was ordered. Then the dose of 250 mg was given the day after admission on 07/25/17, as follows: 250 mg at am and bedtime, the 400 mg at bedtime as ordered. Total 2 medication errors for pain medication. [MEDICATION NAME] for muscle spasms: the dosage given was more than what was ordered for the first 7 days after admission: from 07/25/17 through 07/31/17 a noon dose of 2.5 mg was given in addition to the 2.5mg morning and 5 mg bedtime doses when the order was for 2.5 mg am and 5 mg pm until 08/04/17. In addition, 3 more days of wrong dosages (under dose ordered) given on 08/01 and 08/02/17: 2.5 mg given in the am and at noon, then 2.5 mg given am only on 08/02/17 and 08/03/17. Total 10 medication errors for the muscle spasm medication. The facility administered a total of 68 medication errors for Resident #1. OUTCOME Review of the facility laboratory report for Resident #1 dated 08/09/17 revealed, Resident #1's blood glucose level was high at 217 on 08/08/17. Normal is 75-110. A facility Progress Note dated 08/10/17 noted the blood sugar for Resident #1 was 220 (high) at noon and the nursing supervisor planned to start the diabetes medication. Review of the facility Blood Sugar Summary dated 08/10/17 revealed, Resident #1 had a blood sugar of 256 on 08/10/17. A Progress Note by Staff D, the nursing supervisor dated for 08/10/17 noted, blood pressure and blood sugar was high (did not specify blood pressure numbers) and the correct medications and dosages were being started by the facility for diabetes and blood pressure ([MEDICATION NAME] 500 mg per day and [MEDICATION NAME] 25 mg twice a day). And check blood sugar twice a day. Review of an emergency room visit report in the facility medical record for Resident #1 dated 08/11/17 revealed, Resident #1 had a blood glucose of 224 high on 08/11/17. Review of the facility MAR indicated [REDACTED]. After the [MEDICATION NAME] was started on 08/12/17, blood sugars on 08/13/17 were 133, 157, 180, 120. Review of facility physician orders [REDACTED]. Reference (WAC) 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to report, recognize or thoroughly investigate allegations of possible neglect for 1 of 2 residents sampled for allegations, (Resident #1) when it was reported to the facility that staff may have been omitting medication and incorrectly administering medications for Resident #1. This failure led to undetected medication administration errors, failure to investigate facility neglect and placed Resident #1 at significant risk of physical harm/neglect. Findings include: --also see F281 and F333- Review of the facility Abuse and Neglect Policy received from the facility revealed, the facility defined neglect as failing to properly care for a resident in a manner conductive to professional care standards and failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. In addition the facility abuse and neglect policy states, the facility management staff is required to handle any and all allegations of abuse and will conduct a complete investigation including reporting to proper authorities, all reports whether from family, resident or staff will be reported immediately to the administrator or DNS. It is the policy of this facility to fully investigate and report all alleged and actual incidents of neglect all incidents will be thoroughly thoroughly investigated and documented, preventative actions will be instituted immediately. The mandated reporter includes an employee who hears about an incident from a family member. Neglect is the failure to provide the goods and services that are necessary to maintain the health and safety of an elder. Review of the facility medical records revealed, Resident #1 admitted to the facility in July 2017 for rehabilitation with [DIAGNOSES REDACTED]. According to the facility Minimum Data Set (MDS) assessment dated [DATE], Resident #1 could not complete the BIMS test, had severe cognitive impairment, was dependent on staff for all activities of daily living, and had a family representative. In an interview on 08/17/17 at 2:10 p.m., the family member for Resident #1 stated she told the facility staff several times over several weeks, about her concerns of wrong medications being given to Resident #1 since admission, and they did not correct it in a timely manner. Review of a facility Medication Error Reporting Form dated 08/03/17 revealed, Staff D, a nursing supervisor, noted [MEDICATION NAME] (for Diabetes) had not been ordered since admit on 07/24/17 and the DNS was notified. In addition, another error form dated 08/03/17 noted the blood pressure medication for Resident #1 should have been 25 mg twice a day ([MEDICATION NAME]) since admit on 07/24/17 and the DNS was notified. Further review revealed, a third medication error form dated 08/03/17 by Staff D, noted a facility transcription error for the nerve pain medication ([MEDICATION NAME]) due to a transcription error and the DNS was notified. On all three of the error reports, the top part of the form were signed off by the DNS and the nursing supervisor. The bottom of the three medication error forms were blank, which included: for investigation of factors contributing to error, type of error, level of error, plan to prevent reoccurrence, person responsible for the error, and DNS signature were all blank on the medication error forms. Record review of facility Progress Notes revealed, a note by Staff D, a nursing supervisor, dated 08/09/17, 16 days after admission to the facility, revealed the family member for Resident #1 told Staff D that Resident #1 needed blood sugar checks for diabetes and she received insulin in the hospital. The family member also had a question about the blood pressure medication. Staff D noted she went through the chart and found several discharge orders from the hospital which included orders for a diabetes medication and blood pressure medication dosage not administered or noted by the facility since admission on 07/24/17. The facility had no report of this allegation of possible neglect on the state reporting log, or in the state hotline for medications being missed or wrong medication dosages given to Resident #1. The facility had did not have thorough investigation to rule out neglect for the concerns about multiple medication errors including the omission of the diabetic medication although Staff D noted errors on 08/03/17 and 08/09/17. Review of the physician office visit report for Resident #1 dated 08/11/17 in the facility medical record revealed, the family member with Resident #1 was concerned about medication administration and less attention from nursing at the skilled nursing facility, and concerns about her nursing home care. Review of facility Progress Note dated 08/16/17 by the Director of Nursing noted detailed care conference with the daughter (of Resident #1) expressed concerns about medication discrepancies from time of admit, daughter expressed concern over nursing staff attentiveness .and medications not administered. There was no report in the state hotline, incident required reporting log or any facility investigation to rule out neglect (for failure to provide care and services i.e. administer medications per assessment and plan of care as possible neglect) as noted by the DNS at the care conference 08/16/17. In an interview with the Director of Nursing (DNS) on 08/17/17 at 11:10 a.m., the DNS stated the hospital sent 2 sets of medication orders on admission. The DNS stated the error was on the part of the hospital. I transcribed the first set of orders that were faxed from the hospital, that night when Resident #1 came in she had different orders with her and the nurse did not notice. Staff D handled the medication errors. In an interview on 08/22/17 at 11:30 a.m., the DNS stated the family member for Resident #1 reported in a care conference in August 2017 that she was concerned that the facility was not giving medications correctly for diabetes, high blood pressure and nerve pain and asked me to review the concern for errors. The DNS stated she did not do an investigation to rule out abuse and neglect, she just did a medication review. The DNS also confirmed she did not report any allegation of neglect about the medication concerns from the daughter to the hotline or enter the allegation into the reporting log. Review of a facility document Medication Review received from the DNS on 08/17/17 and dated 08/17/17 revealed, the DNS concluded the facility [MEDICATION NAME] was correct with no med error; no med error for the blood pressure medication per discharge orders received before resident arrived at facility per fax; not able to validate med order for diabetes medication ([MEDICATION NAME]) because it was not on the discharge orders (received prior to admission); muscle relaxant ([MEDICATION NAME]) orders input into computer incorrectly on admission, no error. The med review did not include any investigation to rule out neglect, and did not include a review of the discharge orders in the chart that came to the facility on admission 07/24/17. Review of the facility incident reporting log and hotline intakes revealed, the facility did not report the allegation of missed medications to the state agency as required to rule out abuse and neglect. The failure of the facility to thoroughly investigate the allegations of possible neglect from incorrect and omitted medications, although concerns from the legal representative for Resident #1 were noted on 08/03/17, 08/09/17, on an MD note dated 08/11/17 and to the DNS in a care conference on 08/16/17. The facility failure to identify the reason for the possible neglect in regards to the incorrect medications, rule out any facility staff or facility systems responsible for the missed medications, led to extended medication errors for Resident #1 over 18 days after admission to the facility, and an incorrect conclusion that there were no errors or minimal errors as stated in the medication review above completed by the DNS. These failures placed Resident #1 and other residents at significant risk for harm, and contributed to high blood sugar readings for Resident #1. Reference (WAC) 388-97-0640(6)(a)(b)(c)

Based on interview and record review, the facility failed to provide care and services to 1 of 3 residents reviewed for medication administration/physician's orders [REDACTED].#1) according to professional standards of care, when the facility did not correctly transcribe or administer four medications correctly to Resident #1 upon admission to the facility, and for 18 days after admission. This failure placed Resident #1 at significant risk for physical harm and contributed to elevated blood sugar levels. Findings include: --also see F225 and F333- According to Fundamentals of Nursing, 7th Edition, 2011 (Taylor, Lillis, LeMone & Lynn), page 125, Nurses are legally responsible for carrying out the orders of the physician in charge of a patient . Review of the facility medical records revealed, Resident #1 admitted to the facility in July 2017 for rehabilitation with [DIAGNOSES REDACTED]. According to the facility Minimum Data Set (MDS) assessment dated [DATE], Resident #1 could not complete the BIMS test, had severe cognitive impairment, was totally dependent on staff for all activities of daily living and had a family representative involved in her care. According to the facility Progress Note by Staff E, a charge nurse, dated 07/24/17, Resident #1 was admitted to the facility via ambulance at 4:15 p.m. with the family member present. In an interview on 08/14/17 at 1:15 p.m., the family member/decision maker for Resident #1 stated the facility did not administer medications to Resident #1 as prescribed by the doctor when Resident #1 was admitted to the facility. The family member stated for the first three weeks at the facility, Resident #1 did not receive her diabetic medication, and received incorrect dosages of her blood pressure medication [MEDICATION NAME], nerve pain medications [MEDICATION NAME], and medication for muscle spasms [MEDICATION NAME]. The family member also stated she reported this to the facility several times however the facility did not correct the errors completely until almost 3 weeks after admission to the facility. In an interview on 08/22/17 at 10:10 a.m., the family member for Resident #1 stated she was with the resident on admission on 07/24/17 and saw the packet of hospital paperwork given to the facility nurse from the ambulance staff. She stated she assumed the facility noted all of the medication orders correctly, until she found out weeks later they did not administer the medications correctly. The family member stated the facility did not review the medications with her on at admission to the facility, but she had her own copy of the physician orders [REDACTED]. In an interview on 08/22/17 at 1:50 p.m., Staff D, RCM (resident care manager) stated, it was the policy and procedure of the facility to have the admission medication orders faxed from the hospital before the resident arrives to the skilled nursing facility and those orders are transcribed by the DNS or the MDS nurse. When the resident arrives, the admitting nurse, either Staff D or Staff E, or on the weekends the floor nurse, completes the assessments and other paperwork. Staff D stated a packet of paperwork and physician's orders [REDACTED]. Staff D stated she did not review the packet of orders for Resident #1 after her admission to the facility on [DATE] because she does not work on Mondays. Staff D stated she was upset to find the medication omission errors and incorrect dosages weeks later when reported again by the daughter, at that time Staff D found the medication orders at the bottom of the physician's orders [REDACTED]. In an interview with the Director of Nursing (DNS) of the facility on 08/17/17 at 11:10 a.m., the DNS stated the hospital sent 2 sets of medication orders on admission. The DNS stated the error was on the part of the hospital. I transcribed the first set of orders that were faxed from the hospital, that night when Resident #1 came in she had different orders with her and the nurse did not notice. In an interview on 08/22/17 at 11:30 a.m., the DNS also stated she transcribed the orders before the Resident #1 arrived to the facility on [DATE], and she did not know who did the admission on the unit or who reviewed the packet that arrived with the resident with the additional medication discharge orders from the hospital. In an interview on 08/22/17 at 12:00 p.m., Staff E, the charge nurse, on duty when Resident #1 was admitted to the facility, stated he recalled Resident #1 had a paperwork/orders packet on admission but he did not recall if he reviewed it or not. Review of the hospital records transferred with the patient to the facility, and dated 07/24/17, the day of transfer. Resident #1 left the hospital at 3:00 p.m. with records for the facility that included a hospital discharge summary, discharge orders, and discharge prescriptions. Hospital staff signed that the Discharge Packets reviewed and sent with patient, dated 07/24/17 at 2:00 p.m. In an interview on 08/17/17 at 1:30 p.m., Staff D, a nursing supervisor, stated the family member for Resident #1 told her several times there were medication concerns of dosages and medications not being given as ordered by the hospital doctor. Staff D found that the medications were not transcribed into the computer on admission so I fixed it and notified the DNS. I also later found the admission medication orders in the back of the physician's orders [REDACTED].#1. Record review of the facility transcribed physician's orders [REDACTED].#1 arrived at the facility). These were entered into the computer by the DNS and revealed, the facility did not include the diabetes medication ([MEDICATION NAME]) ordered by the hospital at discharge, blood pressure medication dosage was incorrect at 5mg twice a day instead of 25mg twice a day, the muscle relaxant [MEDICATION NAME] was entered in 6 different lines and did not reflect the titration ordered by the hospital. In an interview on 9/1/17 at aproximately 1:00 pm, the Administrator acknowledged there was not a policy or procedure directing staff, on how to complete an admit, or verify medications prior the medications being administered. The facility failed to review the physician's orders [REDACTED].#1. Reference (WAC) 388-97-1620(2)(b)(ii)

Based on observation, interview and record review the facility failed to provide enough supervision or ensured equipment was fully functioning prior to transferring 1 of 4 residents (2) reviewed for injuries. This failure resulted in a mechanical lift collapsing while Resident 2 was suspended in the air. Resident 2 fell to the ground, landed on her back and hit her head which caused an injury and psychological harm. Findings include: Resident 2 was admitted to the facility in 2015 with [DIAGNOSES REDACTED]. Resident 2 was alert and oriented and able to make her needs known. The resident was unable to move her arms or legs. The Director of Nursing (DNS) documented on an Occurrence Report dated 4/7/17, the Nursing Assistant (NA) was using a hoyer lift without a partner. The resident complained that her leg was uncomfortable while being suspended. The NA came around to the front of the machine to adjust the sling that was under the resident's legs, this caused the machine to tip. The resident fell to the floor striking her head and her back. Upon rising she complained of a headache so she was sent to the emergency room . Per the NA's statement, he was aware that it was the facility policy for 2 staff to be present while using a mechanical lift. The DNS also documented that there was damage to the base of the hoyer lift causing the legs of the lift to adduct further destabilizing it, the machine tipped over causing the resident to fall to the floor striking her head and her back. A review of the equipment maintenance logs showed for January, February and March of 2017. There were tick marks under each machine except one. Below that area was writing that the machines were looked at on 1/10/17, 2/7/17 and 3/8/17. One month prior to the mechanical lift not functioning. There were also a number 1, 2 and 3. 1. Tightened all bolts and clean wheels. 2. 3. Indicating that they completed the same procedure for the other two months. There was no other information about the condition of the mechanical lifts i.e. if they were tested and worked appropriately etc. On 04/18/17 at 9:07 AM, Resident 2 stated on 04/03/17 she was being transferred from her bed to a wheelchair by Staff A by use of a mechanical lift (Hoyer lift). She said there were supposed to be two staff but Staff A said it was difficult for him to find someone to help with the transfer. Resident 2 said during the middle of the transfer, Staff A tried to adjust me while I was in the air and the lift came out from under me. I fell and hit the hardwood floor and the Hoyer fell on top of me. Part of the lift hit me on the hairline on my forehead and gave me quite a bump. The back of my skull hit the floor and I got a horrendous knot back there. I was very shaky, nervous and scared. It triggered a panic attack. Often there has been one aide transferring me with the Hoyer but I know there should be two aides. Resident 2 was sent to a hospital for evaluation and was diagnosed with [REDACTED]. She returned to the facility the same day. At 1:45 PM, the Director of Nursing Services (DNS) said all residents who are transferred with a mechanical lift are to have 2 staff assist with the transfer. It was facility policy. Resident 2 should have been transferred with 2 staff. She said We don't know if it could have been prevented because part of the lift was found to be not working properly. The DNS went on to say the mechanical lifts have been checked by maintenance monthly and would now be checked weekly. In an interview on 4/24/17 the DNS stated the resident fell because the mechanical lift failed and she did not feel as if there were 2 nursing assistants it would have prevented the fall. On 4/28/17 at 3:15 PM, the Administrator stated the reason the mechanical lift failed was because there was to much pressure placed on one side of the lift caused it to collapse. In addition, the mechanical lift was now repaired, which included the whole handle. He stated that even though the maintenance man did his routine checks on the equipment the Nursing Assistants are also responsible to ensure the equipment is safe and they do report that. Staff A was unavailable for interview due to his termination. See also F 279 for additional information. Reference WAC: 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure 1 of 4 residents reviewed for falls, (Resident #1) had adequate devices to prevent accidents, when the facility placed Resident #1 in the hall to eat with a rolling unlocked overbed table, without an individualized assessment of safety risk for the resident. This failure led to Resident #1's fall with substantial injuries and pain, and treatment at the hospital emergency room . Findings include: Record review of facility medical records on 10/21/15 revealed, Resident #1 admitted to the facility for rehabilitation at the end of August 2015. According to the facility Minimum Data Set (MDS) assessment dated [DATE], Resident #1 had a BIMS score of 13, and needed extensive assistance for activities of daily living. The facility medical record [DIAGNOSES REDACTED].#1 was legally blind. Additional record review revealed, the discharge summary from the hospital dated 08/25/15 noted Resident #1 had a history of [REDACTED]. According to the facility physician's note dated 08/27/15, Resident #1 had a flaccid tone on the left side of her body, poor eye contact, and weakness, as well as poor judgement, decreased attention span and decreased concentration. Further record review revealed, the facility Physical Therapy Evaluation dated 08/26/15 noted, Resident #1 had kyphotic posture, i.e. she leaned head forward, and was at risk for falls. In an interview on 10/22/15 at 10:30 a.m., Staff G, a physical therapist, stated Resident #1 had an extreme kyphosis, lean forward of the head/neck at least 30 degrees which was why we put her in a tilted chair. Staff G also stated the facility does not include rolling overbed table devices in their assessments. According to the facility incident report dated 08/30/15, Resident #1 fell out of her wheelchair and hit her head/face on the floor, while eating breakfast on a wheeled rolling overbed table in the hallway of the facility. The facility investigation also revealed Resident #1 had bleeding of the forehead after the fall, 911 was called, and she went to the hospital for treatment. Further review of the facility fall investigation revealed, Staff A witnessed the fall while walking in the hall. The witness statement by Staff A noted, Staff A saw Resident #1 reach for her breakfast on the rolling tray table, and as the table moved away from her, Resident #1 continued to move forward to eat and fell forward and hit her head on the floor. In an interview on 10/21/15 at 11:20 a.m., Staff A, witness to the fall, stated the overbed rolling tray table moved forward as Resident #1 reached for her breakfast which was on top of the rolling table in front of her wheelchair, and the rolling table on unlocked wheels moved as Resident #1 also fell forward on her face onto the floor. In an interview on 10/21/15 at 11:35 a.m., Staff C, the nurse on duty when Resident #1 fell stated, Resident #1 was eating breakfast in the hallway where staff could watch her. Staff C stated Resident #1 was touching the rolling table while she was eating and she fell forward, and the table rolled away. Staff C stated he did not think the rolling tables had any brakes on them. In an interview on 10/21/15 at 11:30 a.m., Staff B, the caregiver on duty that day stated, she was not in the area when Resident #1 fell . Staff B stated the nurse on duty told her to put Resident #1 in the hallway to eat breakfast because she was at risk for falls. Staff B further stated, she placed the rolling overbed tray table in the hallway in front of Resident #1 to eat from, and the table did not lock, it moved on wheels. Observation on 10/21/15 throughout the morning revealed 26 overbed tray tables on wheels in resident rooms throughout the facility. There was no overbed tray table in the facility observed with any wheel locks on them, and the tables rolled very easily when tested . In an interview on 10/22/15 at 10:25 a.m., Staff F, the facility equipment maintenance director, confirmed none of the overbed rolling tables in the facility had any locks on them for the wheels. In an interview on 10/21/15 at 8:40 a.m., Staff D, a facility caregiver for the past two months stated, the facility staff bring residents to the hallway with a rolling overbed table to eat if they are a high fall risk instead of leaving them in their rooms. Staff D stated they bring the rolling tables from the residents' rooms and the tables do not lock or have brakes on the wheels. In an interview on 10/21/15 at 9:25 a.m., Staff E, a licensed nurse, also stated the facility staff place residents in the hall to eat with a rolling overbed table if they cannot eat in the dining room for some reason. Observation on 10/21/15 and 10/22/15, of the main dining room for residents receiving rehabilitation services, as well as 2 dining rooms on the second floor revealed, the facility had dining tables that remained stationary for residents to eat on. In an interview on 10/22/15 at 10:40 a.m., the Director of Nursing stated when the facility had residents who need assistance or supervision on the rehabilitation hall, they eat in the hallway with overbed tables instead of having the residents eat in the dining room because of the utilization of staff time to go to the dining room for just a few people who need assistance. Review of the hospital emergency room report dated 08/30/15 after Resident #1 transferred to the emergency room for treatment from the fall in the facility revealed, Resident #1 sustained pain, laceration on forehead, sprain to thoracic spine, and a contusion to head that were treated in the emergency room . There was no assessment or safety evaluation on record in the facility for the use of an unlocked rolling overbed table device for Resident #1 to eat on, in relation to the resident's documented lean forward or other physical functioning limits and risks as documented in the resident's medical record. The facility failed to ensure the device used for Resident #1 to eat in the hallway did not present an accident hazard, which contributed to Resident #1's substantial injuries, pain and need for hospital emergency room treatment.

Based on observation, interview and record review, the facility failed to ensure 1 of 4 residents sampled (Resident #1), received adequate supervision and assistance to prevent an accidental fall. This failure contributed to a hospital visit for a fractured hip, pain and a decreased level of functioning when Resident #1 was not able to participate in Restorative Programs after the fall with substantial injury. Findings include: According to record review of facility medical records for Resident #1 on 06/11/2014, Resident #1 resided in the facility for long term care since 2012. Review of the facility Minimum Darta Set (MDS) assessment dated [DATE] for Resident #1 revealed, Resident #1 had cognitive impairment (BIMS score 2/15) and needed extensive assistance from facility staff for all mobility and transfers, as well as hygiene. Further record review revealed the facility Care Plan dated 03/12/2014 listed Resident #1 at High Risk for Falls due to confusion, deconditioning, impulsive behavior, a history of self transferring, and previous falls, including one from a wheelchair that resulted in a left fractured hip in 2012. According to record review on 06/11/2014, the facility Nurses Notes dated 04/03/2014 noted, Resident #1 tried to get out of the wheelchair and was found sitting out of the chair on the footrests. Review of the facility investigation dated 04/03/2014 revealed, on 04/03/2014 Resident #1 was in the facility hallway when the staff found her sitting out of the wheelchair. Further review revealed Resident #1 said "I want to go see my mother" at the time of the incident. Additional record review of the facility investigation report of the fall on 04/03/2014 revealed, the facility conclusion: Resident #1 had cognitive deficits, restlessness, attempted independent ambulation, slid out of the wheelchair and "care plan followed as resident was in common area while up in wheelchair". In an interview on 06/11/2014 at 11:45 a.m., Staff B , an administrative employee, stated the facility updated the care plan after the April 2014 fall from the wheelchair by adding "ambulation with FWW (front wheeled walker)" to the Restorative Nursing program for Resident #1. In an interview on 06/11/2014 at 1:00 p.m., Staff A stated Resident #1 tries to get up out of the wheelchair, the staff is not encouraged to leave the resident in the room alone due to safety risk of falling out of the chair, which she did recently in the hallway (April 3, 2014 fall). In an interview on 06/11/2014, Staff C, a facility caregiver, also stated Resident #1 sometimes tried to get out of ther wheelchair and her behavior changes unexpectedly from time to time. In an interview on 06/11/2014 at 1:40 p.m., Staff D stated, the facility staff keeps Resident #1 in visual sight in the hall in the wheelchair for safety because she tries to get up by herself, and the staff never leave her alone in her room because of the unpredictable behavior. In an interview on 06/11/2014 at 1:45 p.m., Staff E also stated the facility staff keep an eye on Resident #1 in her wheelchair by the nurses station in the hall, and they were advised not to leave her in her room alone because she tries to get up herself. In an interview on 05/11/2014 at 2:00 p.m., Staff F stated he always tilted the wheelchair when Resident #1 was in it, and would sit her in the hall because sometimes she tried to get out of the wheelchair. In a facility Monthly Progress Note dated 04/27/2014, Staff I, a nurse manager, noted Resident #1 needed tab alarms in bed and wheelchair due to her impulsive behavior of trying to self transfer. In an interview on 06/11/2014 at 2:30 p.m., Staff I, a nurse supervisor, stated staff were trained to always keep Resident #1 in the common area for safety in the wheelchair because she can get restless and unsafely try to get out of the chair without assistance. Record review of the facility investigation dated May 14, 2014 revealed, Resident #1 was found on the floor in her room alone by her wheelchair on 05/14/2014 at 2:00 p.m. and Resident #1 stated she tried to get out of her wheelchair, and complained of right hip pain after the fall. Review of the facility xray record dated 05/14/2014 revealed, Resident #1 had an acute right hip fracture with mild displacement. According to Hospital records dated 05/14/2014, Resident #1 was transferred to the hospital after the fall in her room on 05/14/2014 for a right fractured hip. The hospital notes further revealed surgery was not chosen, and Resident #1 was placed on hospice care. Review of the facility Nursing Rehab notes for April and May 2014 revealed, Resident #1 had a Restorative nursing program that included ambulation in the hall with a walker, seated lower extremity stretches, marching, and grabbed the hallway handrail to sit and stand. The rehab nursing notes also revealed Resident #1 began to refuse these Restorative programs more frequently, after the fall on 05/14/2014, and the ambulation program was discontinued after the hip fracture. In an interview on 06/12/2014 at 12:55 p.m., Staff G, a Rehab Nursing staff member who worked with Resident #1 stated Resident #1 did not appear to want to do the sit and stand program after the May 14, 2014 fall and fracture, and the ambulation program was discontinued. In an interview on 06/12/2014 at 1:02 p.m., Staff E also stated Resident #1 complained of pain with standing after the fall and fracture in May of 2014 and she said she "fell and got a fracture" on the right side and she says "stop" to range of motion and stretches to the leg because the right leg "hurts": she wants to stand and walk but she cannot. Review of the facility Restorative Note dated 06/04/2014 by Staff B revealed, Resident #1 was "agreeable to the arm bike, does not want any activity to lower extremity status [REDACTED]. In an interview on 06/12/2014 at 2:00 p.m., Staff H stated Resident #1 complained of pain and said she "hurt" when he got got up this morning. In an interview on 06/12/2014 at 2:05 p.m., Resident #1 stated she had pain in her right leg that morning, and hip, but was okay in the afternoon lying in bed. The facility failed to prevent an accident with substantial injury for Resident #1 by failing to provide adequate supervision for safety for Resident #1 with known high risk for falls out of the wheelchair. This failure contributed to the fall qwith substantial injury, fractured right hip, causing pain and the discontinued ability to participate in ambulation, sit and stand, and leg stretch exercise programs previously in place for Resident #1 prior to the fall with fracture.

Based on observation, interview and record review, the facility failed to ensure that an assistive device was used according to the manufacturers' instructions, to prevent accident and injury for 1 of 4 residents (Resident #1) sampled who were at risk for falling. This failure led to a fall that resulted in a painful substantial injury to Resident #1's head. Findings include: According to record review of facility records for Resident #1 on 09/12/12, the Minimum Data Set (MDS) for Resident #1 dated 08/17/12, noted Resident #1 was totally dependent on staff for transfer from wheelchair to bed, and bed to wheelchair, and needed the assistance of 2 people. Record review of the facility Care Plan dated 07/12/12 for Resident #,1 revealed an intervention for Fall Risk: "resident needs mechanical lift with assist of 2 persons for transfers" and "Vander hoyer lift for transfers". According to the facility "Nurses Notes" dated 08/29/12 at 8:00 p.m., Resident #1 had a fall to the ground when staff was transferring the resident to bed after dinner. According to the licensed nurse note, Resident #1 sustained an injury and had pain, was given first aide, and was transferred to the hospital emergency room for further treatment for [REDACTED]. Observation on 09/12/12 at 10:15 a.m., revealed Resident #1 had a large green and purple bruise on the side of the head, neck and face, and a swollen area on the side of the head. In an interview on 09/12/12 at 10:15 a.m., Resident #1 stated, "I still have a bump on my head and a lot of pain, headaches and discomfort when trying to sleep at night. They used a different lift that is for larger residents and not me. I said something did not feel right when they were putting me in the sling and getting ready to lift me up but they proceeded anyhow and I fell on the floor. After the fall, they told me the sling I had on at the time did not match the lift they used on me when I fell ". In an interview on 09/12/12 at 11:15 a.m., Staff C stated, Resident #1 had a sling on that said "Vancare" for the transfer at the time of the fall. According to the manufacture's reccomendation that was not the correct sling that was to be used with this mechanical lift. Record review on 09/12/12, of the manual provided by the facility adminstrative staff entitled, "Operating Manual for the Vancare Lift 2007", the manual for the mechanical lift sling used for the transfer of Resident #1 during the fall, noted the manufacturer WARNING that slings may be used with that lift only and using other slings with that lift is prohibited. This is the sling used for resident 31 during the fall. Record review on 09/12/12, of the "Joerns Healthcare User-Service Manual", for the lift used for Resident #1 during the fall, noted the lift's slings are specifically designed for that lift, and slings designed by any other manufacturer is prohibited and will void the warranty; use only slings for that manufacturer to maintain user safety . Staff C confirmed the lift used for the transfer for Resident #1 at the time of the fall, was not the lift that matched the sling that was placed on Resident #1. Staff C also stated the facility did not have a procedure in place to assure the correct slings are used on the correct mechanical lifts for transferring residents in the facility. In an interview of Staff D on 09/12/12 at 2:45 p.m., Staff D confirmed the facility did not have training in place or procedures in place at the time of the fall, to assure the staff used the slings for mechanical lifts that match the appropriate equipment as recommended by the manufacturer. Staff D also confirmed the incorrect sling was used for the lift for Resident #1 at the time of the fall leading to the sling coming off the lift and the resident fall to the ground, which resulted in a substantial injury. In an interview on 09/12/12 at 2:50 p.m., Staff A, a caregiver who performed the transfer at the time of the fall, confirmed the sling fell off the lift, and the lift usually used for Resident #1 was not available, and there was no training in the facility regarding what slings to use with each mechanical lift. In an interview of Staff B on 09/12/12 at 3:10 p.m., Staff B confirmed the sling came off of Resident #1 during the transfer and there was no training in the facility regarding what sling to use with each mechanical lift. In an interview with Staff E on 09/12/12 at 10:50 a.m., an employee who maintains the lift machines,Staff E confirmed the facility did not have training or procedures for matching slings to mechanical lifts, and Staff E did not know about the use of the slings. Failure of the facility to have systems in place to ensure the proper use of lift devices according to the manufacturers recommendations, and failure to prevent accidents with the use of a mechanical lift device, led to a substantial injury and pain for Resident #1 from a fall from the lift during a transfer.