Every finding on record at Snohomish Health and Rehabilitation of Cascadia

Based on observation, interview and record review the facility failed to ensure residents who engaged in smoking had adequate supervision to protect residents and/or staff from potential fire hazards for 2 of 3 residents (Resident 51 and 32) reviewed for smoking. This failure placed all residents at serious risk for injury related to unsafe smoking practices and constituted an Immediate Jeopardy (IJ).The failed practice resulted in an IJ on 04/26/2026 when the facility failed to ensure the residents' environment was safe from burns and fire. The IJ was removed on 04/28/2026 after the facility provided a safe receptacle for properly disposing of cigarette butts, reassessed and educated staff and residents of the facility's no smoking policy and confiscated residents smoking paraphernalia. Findings included.Review of a facility policy, titled Non-Smoking Campus- Smoke Free, with revised date 09/12/2025 documented:The resident or representative sign an acknowledgement that the facility is a smoke-free environment upon admission.The facility staff are responsible for enforcing the Smoke-Free Policy.Employees, contractors and visitors are expected to comply with the smoke-free policy while on facility property. Employees who choose to smoke may do so off property or within their personal vehicles. Review of a grievance, dated 3/19/2026, showed a resident had a concern about residents smoking as they did not like the smell was reported to the administrator. The action taken showed that all smoking residents were told that smoking on property was not allowed. <RESIDENT 51>Resident 51 was admitted to the facility on [DATE].Review of Resident 51's Smoking/Nicotine use evaluation, dated 01/15/2026, documented the resident did not demonstrate an understanding that smoking was not permitted while using any form of oxygen (O2) and that smoking materials were to be used in designated smoking areas. The form designated the resident as dependent/assisted for smoking. The form documented not to proceed with a care plan.Review of Resident 51's care plan, print date 04/26/2026, showed no information about smoking.Review of Resident 51's Order Summary Report for 04/26/2026 showed an order for O2 at 1-2 liters/per minute (L/PM) continuously per nasal cannula (tubing that delivers O2 into the nose).In an observation and interview on 04/26/2026 at 9:00 AM, Resident 51 was observed sitting in their wheelchair, outside on the driveway near a group of trees. (Driveway from the road comes to a T in the road due to a group of trees. Route to the left goes to the facility entrance and the route to the right is the exit from the facility parking lot.) Resident 51 was observed to be holding a cigarette. There was a portable O2 tank hanging on the back of their wheelchair, running at 2 L/PM. There were ashes observed on the ground and on Resident 51's shoes, and there was an odor of smoke. Resident 51 told the surveyor that they smoked cigarettes.On 04/26/2026 at 9:15 AM there was an odor of cigarette smoke outside Resident 51's room. At 9:21 AM, another surveyor noted an odor of cigarette smoke outside Resident 51's room.In an interview on 04/26/2026 at 9:23 AM, Staff AA, Certified Nursing Aide (CNA), reported they were not aware of any current residents that smoke, but some of the staff smoked. Staff AA stated there was a smoking area on the property, back by the shed where there was a sign posted.In an interview on 04/26/2026 at 9:25 AM, Staff W, Culinary Cook, stated there was a picnic table outside out back that staff and residents used as a smoking area. Staff W stated they believed that there were a few residents who smoked but did not know any names.During an observation on 04/26/2026 at 10:04 AM, on the back corner of the facility grounds, there was a grassy hill with a picnic table and a sign that read Designated smoking area.In an interview on 04/26/2026 at 9:56 AM, Staff H, Licensed Practical Nurse, stated residents that smoke kept their cigarettes and lighters with them, the nurses did not keep any of their paraphernalia in their carts.In an interview on 04/26/2026 at 10:20 AM, Staff T, CNA, stated they were aware that Resident 51 and Resident 38 smoked. Staff T stated residents go to the smoking area or smoke outside by the circle by the trees.In an interview on 04/26/2026 at 12:44 PM, Staff B, Chief Nursing Officer, stated that the facility was aware that Resident 51 was a current smoker. Staff B replied they did not know how the resident extinguished their cigarettes and since they were a non-smoking facility, they did not provide any ashtrays. Staff B replied that Resident 51 had their smoking paraphernalia with them as the facility had not searched them or their room. <RESIDENT 32>Resident 32 was admitted to the facility on [DATE].Review of the hospital orthopedic consult, dated 03/23/2026, showed Resident 32 smoked cigars and cigarettes.Review of the hospital cardiology consult, dated 03/23/2026, showed resident smoked cigars.Review of Resident 32's Smoking/Nicotine use evaluation, dated 03/31/2026, documented the resident could not safely light the cigarette and they were not able to demonstrate safe technique for disposing of ashes. The form designated the resident as dependent/assisted for smoking. The form documented not to proceed with a care plan.Review of Resident 32's care plan showed no information on smoking was documented until 04/27/2026.Review of a provider note, dated 04/01/2026, documented that Resident 32 was a current smoker.Review of Resident 32's Smoke Free Campus Acknowledgement revealed it was signed on 04/08/2026, nine days after admission to the facility.In an observation and interview on 04/26/2026 at 10:05 AM, Resident 32 was observed sitting in their wheelchair outside the facility entrance with their spouse. Resident 32 was observed smoking a cigar. Resident 32's spouse stated that other residents smoke down by the trees, but they could not get down there. Resident 32's spouse stated they were 25 feet from the front door. Resident 32 and their spouse were on the sidewalk to the left of the facility entrance but were sitting within 25 feet of the office front windows. Staff V, maintenance director, walked in the front door from the parking lot while Resident 32 was smoking the cigar. Staff V greeted Resident 32 and their spouse while walking inside but did not say anything to them about smoking on facility property.During an observation on 04/26/2026 at 11:29 AM, three cigar butts were found on the ground in the parking stalls just outside the facility's office windows. There were no cigarette receptacles observed near the facility entrance nor at the group of trees in the parking lot.During an interview on 04/26/2026 at 11:51 AM, Resident 32 reported putting out their cigar by rubbing it on the concrete in the parking lot and throwing the butt in the garbage can on their way back into the facility.During a joint observation and interview on 04/26/2026 at 12:52 PM, Staff B observed the parking spaces just outside the facility windows. Staff B observed the cigar butts on the ground and stated they did not know who smoked cigars. Staff B observed the garbage cans at the entrance to the facility. Both garbage cans were made of plastic and one of the garbage cans had 2 paper bags inside. Staff B acknowledged that a cigarette butt could potentially light the paper bags on fire. Staff B reported there were no cigarette disposal containers as they were a non-smoking facility. Refer to WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure food items were stored under sanitary conditions in two of two nourishment refrigerators. Failure to ensure refrigerator temperatures were monitored and maintained placed residents at risk for food borne illness. Findings included . According to the Food and Drug Administration food code, refrigerator temperatures must be maintained below 41 degrees Fahrenheit (f). In an interview and observation on unit 2 on 04/28/2026 at 9:48 AM with Staff E, Resident Care Manager, the unit 2 nourishment refrigerator temperature read 47 degrees (f). There was no temperature log observed. The refrigerator was observed to contain individual yogurts, applesauce, one carton of thickened lemon drink, one carton of fortified shake, and half sandwiches wrapped in plastic. Staff E stated the kitchen staff stocked the fridge and monitored the temperatures. In an interview and observation on unit 1 on 04/28/2026 at 10:03 AM with Staff Z, Certified Nursing Assistant stated the kitchen took care of the refrigerators. The unit 1 refrigerator temperature was observed to read 46 degrees (f). The unit 1 refrigerator was observed to include yogurts, sandwiches, applesauce and cartons of juices and shakes. There was no temperature log observed. In an interview on 04/28/2026 at 10:40 AM, Staff X, Dietary Services Manager, stated the nursing staff were responsible for monitoring of the nourishment refrigerators on the units. Staff X was made aware of the observations and interviews on the units and stated they would go check those refrigerators, remove food items and ensure there were temperature logs. Staff X stated the kitchen would resume the monitoring. Refer to WAC 388-97-1100(3)

Based on observation, interview and record review, the facility failed to ensure the facility assessment addressed the physical environment, equipment, services, and other physical plant considerations that are necessary to care for its identified resident smoking population. Failure to thoroughly assess all factors associated with resident smoking placed residents at risk for adverse events related to smoking safety.Findings included.Review of a facility policy, titled Non-Smoking Campus- Smoke Free, with revised date 09/12/2025 documented:The resident or representative sign an acknowledgement that the facility is a smoke-free environment upon admission.The facility staff are responsible for enforcing the Smoke-Free Policy.Employees, contractors and visitors are expected to comply with the smoke-free policy while on facility property. Employees who choose to smoke may do so off property or within their personal vehicles.In an observation and interview on 04/26/2026 at 9:00 AM, Resident 51 was observed sitting in their wheelchair, outside on the driveway near a group of trees. Resident 51 was observed to be holding a cigarette. There was a portable O2 tank hanging on the back of their wheelchair, running at 2 L/PM. There were ashes observed on the ground and on Resident 51's shoes, and there was an odor of smoke. Resident 51 told the surveyor that they smoked cigarettes and kept their smoking supplies in their room or on their person.In an observation and interview on 04/26/2026 at 10:05 AM, Resident 32 was observed sitting in their wheelchair outside the facility entrance with their spouse. Resident 32 was observed smoking a cigar. Resident 32's spouse stated that other residents smoke down by the trees, but they could not get down there. Resident 32's spouse stated they were 25 feet from the front door. Resident 32 and their spouse were on the sidewalk to the left of the facility entrance but were sitting within 25 feet of the office front windows. Staff V, maintenance director, walked in the front door from the parking lot while Resident 32 was smoking the cigar. Staff V greeted Resident 32 and their spouse while walking inside but did not say anything to them about smoking on facility property.On 04/26/2026 at 11:29 AM three cigar butts were observed on the ground in the parking stalls just outside the facility's office windows. There was no cigarette receptacles observed near the facility entrance nor at the group of trees in the parking lot.In an interview on 04/26/2026 at 12:44 PM, Staff B, Chief Nursing Officer, stated that the facility was aware that Resident 51 was a current smoker. Staff B replied they did not know how the resident extinguished their cigarettes and since they were a non-smoking facility, they did not provide any ashtrays. Staff B replied that Resident 51 had their smoking paraphernalia with them as the facility had not searched them or their room.Review of the Facility assessment dated [DATE] documented the resident population included 9 residents identified with tobacco use. Further review of the Facility Assessment revealed no further documentation regarding physical environment, equipment or services necessary related to the identified resident smoking population. In an interview on 05/01/2026 Staff B stated they assisted in filling out portions of the facility assessment and was reviewed annually. Staff B stated were aware of issues regarding residents following the facility smoking policy and it was addressed on different levels such as all staff. Staff B stated they were unaware of specifics related to residents who smoked in the facility assessment.No associated WAC reference

Based on interview and record review, the facility failed to provide a response to concerns voiced by 1 of 1 resident groups (Resident Council) that had concerns. The failure to respond to Resident Council about their concerns left the issues unresolved and resulted in the Resident Council process being ineffective at improving resident quality of life.Findings included.Review of Resident Council Minutes for December 2025 documented there were concerns for beverages arriving early before meals, nursing assistants not providing care properly and not getting residents up when they preferred, nursing assistants complaining about their employment, televisions not working properly with no service in some rooms, and medications not given on time by nurses. The section, on the Resident Council Minutes, titled, Recommendations/Follow-up was blank.Review of the Grievance Resolution Log for December 2025 showed no documentation or resolution to the noted concerns from Resident Council from December 2025.Review of the Resident Council Minutes for January 2026 documented there were concerns about nursing assistants choosing bedtimes for the residents and staff not answering the doorbell after 6 pm to allow visitors to come into the facility. The section, on the Resident Council Minutes, titled, Recommendations/Follow-up was blank.Review of the Grievance Resolution Log for January 2026 showed no documentation or resolution to the noted concerns from Resident Council from January 2026. There were two logged entries titled Resident Council dated 01/02/2026 for flies and snack rotation.Review of the Resident Council Minutes for February 2026 documented concerns of call light wait times were too long, more variety in the food was needed, availability of snacks, and the laundry detergent smelled funny. The section, on the Resident Council Minutes, titled, Recommendations/Follow-up was blank.Review of the Grievance Resolution Log for February 2026 showed no documentation or resolution to the noted concerns from Resident Council of February 2026.Review of the Resident Council Minutes for March 2026 documented their concerns included they did not believe their grievances were taken seriously and felt ignored, call lights wait times were too long, and cold food was being placed on the warm plates leaving the intended cold food warm. The section, on the Resident Council Minutes, titled, Recommendations/Follow-up was blank.Review of the Grievance Resolution Log for March 2026 showed no documentation or resolution to the noted concerns from Resident Council of March 2026.Review of the Resident Council Minutes dated 04/03/2026 documented concerns of mislabeled and watered down juice, missing activities due to showers, therapy visits, and vitals, smoking remained a problem and there was smoke smell in the facility and rules not being followed, and the language barrier between staff and residents had grown.Review of the Grievance Resolution Log for April 2026 showed no documentation or resolution to the noted concerns from Resident Council from April 2026.In an interview on 04/27/2026 at 1:06 PM Resident 49, Resident Council President, stated smoking in the facility had been an issue and the facility was starting to smell like smoke. Resident 49 stated call light wait times varied and it could take up to an hour for a call light to be answered and care received. They stated the juice was less watered down and the televisions worked at times and other times not; there were not enough boxes for all the rooms. They stated sometimes Staff A, Administrator, will come and talk with them about concerns, but they feel they should speak with Staff KK, Activities Director, too because their memory was not always reliable.In an interview on 04/27/2026 at 2:17 PM Staff KK, stated if residents had a grievance and they were able to complete it themselves they would, but more times than not they ask them to write it out for them. Staff KK stated when they complete a grievance, they take a copy and provide the original to Staff A. When asked about the resident council concerns, they stated they were the go between the residents and staff, the form used to document the minutes were provided by corporate, and during the resident council meetings they asked if the concern required documentation on the grievance form.In an interview on 04/30/2026 at 3:17 PM Staff A, Administrator stated grievance forms are located throughout the building, and anyone can pick them up and fill them out. Staff A stated they review the resident council minutes and talk to the resident council president about the concerns. Staff A stated that sometimes the concern is placed on a grievance and other times it is not as it is hard to tell whether they need to be on a grievance.Reference WAC 388-97-0920

Based on interview and record review, the facility failed to periodically inform residents of their rights after residents were admitted to the facility for 7 of 7 sampled residents (Residents 7, 20, 35, 40, 49, 67 and 75) when reviewed for resident rights. This failure placed residents at risk of not being informed of their rights and a diminished quality of life.Findings included .Findings included .On 04/28/2026 at 2:07 PM during resident council, Residents 7, 20, 35, 40, 49, 67, and 75 all stated they the staff did not talk about or review the rights of the residents in the facility. When asked if resident rights were reviewed at resident council meetings, they all stated they were not.Review of the resident council meeting minutes for November 2025 through April 2026 showed no documentation/confirmation that resident rights were reviewed.In an interview on 04/30/2026 at 3:17 PM Staff A, Administrator, stated they did not know if resident rights were routinely reviewed with residents in resident council or otherwise.Reference: WAC 388-97-0300(1)(a)

Based on interview and record review, the facility failed to ensure complete and updated Notification of Medicare Non-Coverage (NOMNC - a document informing Medicare beneficiaries that their covered services will be terminated and providing information on their appeal rights) for 4 of 4 sampled residents (Resident 15, 91, 90 and 63) reviewed for liability notice. The facility failed to provide the Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN-a form to inform their responsibilities for the services cost when Medicare discontinues) for 2 of 4 sampled residents (Resident 15 and 63) reviewed for Beneficiary Notices. The facility failed to utilize the current CMS-approved forms and failed to ensure proper complete the forms as the facility staff signed in the place of the resident and/or representatives; the facility failed to document an explanation of appeal rights and provide copies to residents and/or representatives. This failure placed residents and/or their representatives at risk for not fully understanding their Medicare benefits, appeal rights and financial liability. Findings included .Review of Center for Medicare and Medicaid Services (CMS) electronic web site (CMS.gov), shows the NOMNC form (CMS-10123) was last updated January 2025, and the ABN form was last updated in 2024. <RESIDENT 15>Resident 15 admitted to the facility on [DATE]. Resident 15's Medicare service was discontinued on 02/16/2026, and the resident remained in the facility.Review of the NOMNC form dated 02/13/2026, documented that Resident 15 could not sign due to dementia (progressive disease affecting memory and ability to make decisions) and the form was served to the son via a phone call. In the area labeled Signature of Patient or Representative was signed by facility Staff C, Social Services. There was no signature from the resident's representative.Review of Resident 15's electronic health record (EHR), showed there was no documentation that Resident 15's representative was provided an explanation of the NOMNC, including appeal process, phone number, or deadline, or if the representative understood the process. There was no documentation verifying the representative received a copy of the NOMNC. The form utilized was a version approved by CMS in 2011, which was not the current version.Review of Resident 15's ABN form dated 02/13/2026, showed the Signature of Patient or Authorized Representative was signed by Staff C. The EHR contained no documentation that an explanation of the ABN was provided or that a copy was sent to the representative. The ABN utilized was a 2018 version, which was not the current version. <RESIDENT 63>Resident 63 was admitted to the facility on [DATE]. Resident 63's Medicare was discontinued on 04/13/2026 and the resident remained in the facility.Review of the NOMNC dated 04/10/2026 showed the resident signed the form.Review of Resident 63's EHR showed no documentation that an explanation of appeal rights was provided or that a copy was given to the resident. The form utilized was the outdated 2011 version.Review of Resident 63's ABN dated 04/10/2026 showed the resident signed the form.Review of Resident 63's EHR, showed no documentation of an explanation of the ABN form or confirmation that a copy was received. The form utilized was the outdated 2018 version. <RESIDENT 91>Resident 91 was admitted on [DATE] and discharged on 02/19/2026.Review of the NOMNC form dated 02/16/2026 documented the notice was served to the resident's daughter. The Signature of Patient or Representative section was signed by Staff C, rather than the representative.Review of Resident 91's EHR showed no documentation that an explanation of the NOMNC or the appeal process was provided, nor was there confirmation that the daughter received a copy of the form. The form utilized was the outdated 2011 version. <RESIDENT 90>Resident 90 was admitted to the facility on [DATE] and discharged on 02/25/2026. According to the discharge Minimum Data Set (MDS-an assessment tool) assessment, dated 02/25/2026, the resident had severe cognitive impairment.Review of the NOMNC form, dated 02/20/2026, documented the NOMNC signed by the resident. Review of Resident 90's EHR showed no documentation that an explanation of the appeal process was provided to the resident or their representative, nor was there confirmation that a copy was provided. The form utilized was the outdated 2011 version. In an interview on 04/29/2026 at 10:09 AM, Staff C stated they were responsible for the issueance and explain the NOMNC and ABN forms. Staff C stated they served the forms via phone to the representatives if the residents were cognitively impaired. Staff C confirmed they signed under Signature of Patient or Representative line because they were the representative of the facility serving the form. Staff C confirmed there was no documentation in the medical record or the EHR that explanations were provided. Staff C stated they were not aware of the current CMS versions of the forms.In a phone interview on 04/29/2026 at 1:59 PM, Staff PP, Assistant Business Office Manager, stated they were responsible for providing the NOMNC and ABN forms to the social services. Staff PP stated they were unaware that the form was outdated and acknowledged that the outdated forms were still being utilized in the facility currently.In an interview on 04/30/2026 at 3:54 PM, Staff C stated they would give the representative a physical copy or email them an electronic copy, but there was no documentation if they gave or emailed copies to Resident 15 and Resident 91's representatives.In a joint interview and record review on 04/30/2026 at 2:49 PM with Staff QQ, Director of clinical service, and Staff A, Administrator, Staff A confirmed the outdated forms were the incorrect version and should not have been used. Staff A stated the expectation was for the facility to utilize the most current CMS-approved forms to ensure residents and/or representatives were properly notified of their financial rights and liabilities. Staff A and Staff QQ stated the facility staff was not the Patient or Representative and was not supposed to sign for residents or representatives.In an interview on 05/01/2026 at 10:14 AM, Staff B, Chief Nursing Officer, stated they expected staff to document the explanation of appeal process in the EHR. Reference WAC 388-97-0300(1)(e)

Based on interview and record review, the facility failed to ensure 3 of 5 residents (4,6 and 34) selected for medication review were free from unnecessary medications. This failure placed residents at risk for adverse side effects and decreased quality of life.Findings included.Review of the facility policy Psychotropic Drugs dated 04/22/2025 stated Psychotropic medications and those used to manage behavioral symptoms must be clinically justified, individualized, and aligned with the resident's assessed needs, goals of care, and accepted standards of practice. The facility prohibits the unnecessary use of psychotropic drugs including any medication prescribed in excessive dose, excessive duration, without clear indication, or without adequate monitoring. <RESIDENT 4> Resident 4 admitted [DATE]. Review of Resident 4's physician's orders with a print date 04/27/2026 showed an order for an antianxiety medication ordered on 04/16/2026 and available every four hours as needed for anxiety. Review of Resident 4's Medication Administration Record (MAR) print date 04/27/2026 documented the antianxiety medication had been administered six doses since it was ordered. The MAR did not document target behaviors for the antianxiety medication, or document what behaviors consistent with anxiety had occurred prior to administration. The MAR included non-pharmacological interventions to attempt prior to administration; however, none were documented as attempted. In an interview on 04/27/2026 at 1:42 PM, Staff E, Resident Care Manager (RCM), stated medication orders were reviewed when they were ordered to check for consents and diagnosis. There should be target behaviors and non-pharmacological interventions on the MAR. Staff E stated there was a psychotropic meeting every month and they did a double check at that meeting. Staff E stated Resident 4 had orders for as needed medication for anxiety but was not aware that the orders did not include target behaviors or documentation of non-pharmacological interventions attempted. <RESIDENT 34> Resident 34 admitted to the facility on [DATE]. Review of Resident 34's Order Summary with a print date of 04/26/2026 documented an order for an antidepressant medication and an antipsychotic medication. (medication to manage delusions, hallucinations and paranoia). Review of Resident 34's MAR/ Treatment Administration Record (TAR) for 03/23/2026 through 04/26/2026 showed no adverse side effects (ASE) monitors in place. In an interview on 05/01/2026 at 8:54 AM, Staff B, Chief Nursing Officer, stated ASE monitors should be initiated as medications were prescribed and at admission. <RESIDENT 6> Resident 6 was re-admitted to the facility on [DATE]. Record review of Resident 6's Order Summary with a print date of 04/27/2026 documented three antidepressants were ordered. Record review of Resident 6's MAR and TAR for March and April 2026 did not show documentation of ASE monitoring. In an interview on 04/29/2026 at 12:06 PM Staff DD, Licensed Practical Nurse stated that residents taking antidepressants were monitored for possible ASE and they document the monitoring every shift. Staff DD reviewed current MAR/TAR and was not able to show any documentation of ASE monitoring. In an interview on 04/29/2026 at 2:51 PM, Staff BB, RCM stated residents who were taking antidepressants were monitored for possible ASE. Documentation for the monitoring should be in the MAR and progress notes if they observed any ASE. Staff BB was unable to provide any documentation showing Resident 6 was being monitored for ASE. They stated that Resident 6 was recently readmitted and most likely it was not added when they returned to the facility. Refer to WAC 388-97-1060(3)(k)(i), 0620(1)(a)

Based on interview and record review, the facility failed to ensure 6 of 8 residents (Residents 4, 6, 9, 34, 42, and 51), reviewed for pre-admission screening and resident review (PASRR - a federal requirement which identifies individual with Serious Mental Illness (SMI) or intellectual or developmental disabilities to provide appropriate services), received the required screening for necessary services. This failure placed the resident at risk for unidentified mental health needs.Findings included .Review of a facility policy, titled, Pre-admission Screening & Resident Review (PASRR) Process, revised date 08/29/2025, documented a positive Level 1 screen necessitated an in-depth evaluation of the individual by the state designated authority, known as PASRR Level 2. If a resident was admitted with an exemption and the stay was going to last more than 30 days, then the state designated authority must conduct a Level 2 review within 40 calendar days. <RESIDENT 9> Resident 9 admitted to the facility with diagnoses to include schizoaffective disorder (mental health condition where a person has symptoms of a mood disorder and psychosis) and mild cognitive impairment. Review of Resident 9's PASRR dated 06/16/2025 documented they were exempted from a level two evaluation as their stay in the facility was anticipated to be less than 30 days. Review of Resident 9'sElectronic Health Record (EHR) showed no documentation related to the 30-day exempted PASRR or that a level two evaluation was sought after the 30 days. In an interview on 04/29/2026 Staff C, Social Services, stated they have tried to keep up on the PASRR accuracy by reviewing them quarterly, keeping a list and they were not up to date. <RESIDENT 34> Resident 34 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (progressive disease characterized by cognitive decline, memory loss and behavioral changes), dementia with other behavioral disturbance and history of stroke. Review of Resident 34's PASRR dated 03/20/2026 documented they were exempted from a level two evaluation as their stay in the facility was anticipated to be less than 30 days. Review of Resident 34's EHR showed no documentation related to the 30-day exempted PASRR or that a level two evaluation was sought after the 30 days. <RESIDENT 42> Resident 42 was admitted on [DATE] with diagnoses to include depression and anxiety. In a record review on 04/29/2026, Resident 42 had a PASRR dated 02/12/2026 documented they were exempted from a level two evaluation as their stay in the facility was anticipated to be less than 30 days. Review of Resident 42's EHR showed no documentation related to the 30-day exempted PASRR or that a level two evaluation was sought after the 30 days. In an interview on 04/29/2026 10:30 AM Staff C, stated the PASRR was not faxed to the PASRR evaluator after 30 days and should have been. In an interview on 05/01/2026 at 8:54 AM Staff B, Chief Nursing Officer, stated they had reviewed and audited PASRR's several times and had forwarded the results to social services to review and follow up. <RESIDENT 6> Resident 6 was admitted to the facility on [DATE] with depression and anxiety. In a record review of Resident 6's PASRR dated 01/01/2026 documented a level two referral was required on admission. There was no Level 2 evaluation or invalidation found in Resident 6's EHR. In an interview on 04/29/2026 at 10:08 AM, Staff C stated they reviewed PASRR's prior to resident's admission to check for accuracy. If a resident was admitted and the level two was not provided, they followed up with the PASRR Coordinator via email. Any communication with the PASRR Coordinator should be in the resident's progress note. Staff C could not provide any documentation regarding the level two evaluation for Resident 6. <RESIDENT 4> Resident 4 admitted [DATE] and had diagnoses which included dementia, anxiety and developmental delay. Review of Resident 4's level one PASSR dated 12/15/2025, documented level two evaluation was indicated based on indicators of SMI. Review of the Resident Record on 04/28/2026 showed no evidence of referral for level two evaluation and no level two evaluation or invalidation was found. In an interview on 4/29/2026 at 10:09 AM, Staff C, stated PASSRs were reviewed on admission and daily at the facility standup meeting. Staff C stated PASSR statuses were tracked and reviewed quarterly. Staff C stated Resident 4's level two PASSR was required on admission and should have been followed up on. Staff C confirmed there was no documentation that there had been a referral for Resident 4 for level two evaluation since their admission on [DATE]. <RESIDENT 51> Resident 51 was admitted to the facility on [DATE]. Review of Resident 51's PASRR level one form dated 01/13/2026, revealed a level two evaluation was required prior to admission as resident showed indicators of a SMI. Review of Resident 51's EHR, no PASRR level two evaluation was found. During a phone interview on 04/28/2026 at 10:33 AM, Staff R, admissions, stated if a resident had a positive level one PASRR form, then there would need to be a notice of determination or an invalidation prior to the resident admitting to the facility. During an interview and record review on 04/28/2026 at 10:39 AM, Staff S, Medical records, stated they did not see a notice of determination or invalidation for Resident 51. On 04/28/2026 at 11:43 AM, Staff S provided a level two PASRR invalidation that was dated 04/28/2026. The comment section of the level two invalidation documented that Resident 51 was admitted to the facility without the level two determination being done. Refer to WAC 388-97-1915 (2)

Based on observation, interview and record review, the facility failed to ensure food services met the dietary needs and preferences for residents on 2 of 2 resident units, 1 of 1 resident group and 1 of 2 residents (Resident 77) reviewed for food. Failure to ensure snacks were available, preferences were honored and alternates of similar nutritional value were provided during meals placed residents at risk for decreased quality of life. Findings included .<RESIDENT COUNCIL/SNACK AVAILABILITY> Review of Resident Council Minutes dated 02/06/2026, documented snacks were never available, and the nursing assistants didn't know where they were located. Review of Resident Council Minutes dated 03/06/2026, documented food that was meant to be cold was placed on warm plates during meals. In an interview 04/27/2026 at 1:06 PM, Residents 44 and 49 stated snacks were not available, at times they might not have any, or only peanut butter and jelly sandwiches were offered. In an interview on 04/28/2026 at 2:12 PM, Resident 20 stated the only snacks available yesterday were teddy graham cookies. Resident 20 stated the chips went fast and thought they should limit how many bags someone could have. In an interview and observation of unit 2's pantry on 04/28/2026 at 9:48 AM with Staff E, Resident Care Manager, the unit 2 pantry refrigerator was observed to contain five individual yogurts, four applesauce cups, one carton of thickened lemon drink, one carton of fortified shake, and five and a half sandwiches wrapped in plastic. The cupboards and drawers contained only one partial box of six dried oatmeal packages and condiments. Staff E stated, it is very empty. Staff E stated the pantries were only stocked once a day in the evening. In an interview and observation of unit 1's clean utility room on 04/28/2026 at 10:03 AM with Staff Z, Certified Nursing Assistant, the cupboards and shelves contained resident care supplies and no food items. The refrigerator contained three yogurts, four sandwiches dated 04/26/2026, eight applesauce cups, one carton of thickened juice and one carton of nutrition shake. There was a small tray on the counter with condiments and one silver bin with some packages of Teddy [NAME] graham cracker snacks. Staff Z stated this utility room was the only place they kept snacks on unit 1. In an interview on 04/28/2026 at 10:36 AM, Staff CC, Culinary Cook, stated day shift kitchen staff did not stock snacks on the units, the night shift re-stocked. They were supposed to stock enough to last until the next night when they came back. There was supposed to be a certain amount on the units, and they tried not to stock too much so they didn't have to throw things out. Staff CC stated there should be a variety of items like fruit snacks, chips, crackers and cheeses, puddings, etc. In an interview on 04/28/2026 at 10:40 AM, Staff X stated the kitchen was responsible for re-stocking the snacks. Staff X stated they used to stock snacks before dinner, but when they did that, all the snacks would be gone by dinner, so now they did it later. Staff X was not aware that snacks did not last throughout the day until the next restock or of any resident complaints about lack of snacks available. Staff X stated they had not been to a Resident Council meeting in a long time. In a follow-up interview and observation on 04/29/2026 at 11:14 AM, Staff X stated there had been a lack of snacks the last couple of days because they were out. It was observed that a delivery had just arrived and the back shelf of the dry storage area now included boxes of chips, cookies, pretzels, cheese 'n' crackers etc. that were not observed on prior visits to the kitchen. <ALTERNATE MEAL ITEMS> Review of a grievance dated 04/24/2026, written by Resident 44, documented oat milk was not available on 04/17/2026 through 04/22/2026 and they had not received extra protein with their meals, especially at breakfast. In an interview on 04/27/2026 at 10:43, AM Resident 44 stated they were gluten free, dairy free, and on a diabetic diet. Resident 44 stated they were only able to select a minimal number of meals from the menu due to their diet restrictions. Resident 44 stated there was limited number of snacks provided by the facility that met their diet restrictions and as a result they had to purchase their own snacks to meet their diet needs. In an interview and observation on 04/27/2026 at 8:54 AM, Resident 77 stated they disliked white bread, but would like brown bread. Resident 77 stated this had never been corrected and they never get any type of bread. An observation of the resident's meal ticket stated they disliked bread. In an interview on 04/28/2026 at 10:48 AM, Staff X, Dietary Manager, stated the menu showed five alternates per day, and residents could choose the main meal or choose one of the five alternates. They could also choose which specific items they wanted or didn't want and could mix and match items from the alternate choices. The meal tickets included allergies, special diets, and likes/dislikes. In an observation of lunch meal service on 04/29/2026 at 11:52 AM, the meal listed on the menu was creamy herbed chicken, wild rice, and broccoli. Staff Y, Culinary Cook, explained the items on the tray line which included the main meal items as well as other items such as mashed potato, soup, mechanically altered items and gravies. There were five alternate meal choices listed as everyday options on the menu which included: Chicken Caesar salad/dinner roll, Chef's choice deli sandwich/side salad, Hotdog/chips, Cottage cheese and fruit plate/dinner roll, French toast sticks/sausage/fruit. Staff Y was observed reading resident meal tickets and adding food items to residents' plates. A meal ticket was observed to include the words no rice at the top of the ticket. Staff Y was observed to read the ticket and then plate only chicken and broccoli and pass the plate to the dietary aid, who placed the plate on the tray and into the meal cart. Staff Y was asked why there had been no alternate starch or similar item such as the mashed potato added to the resident's plate, and Staff Y stated, we don't do that. Staff Y stated that if the ticket showed a resident did not like something, or to avoid something, they just didn't add that item to the plate, but generally don't add something else. In a continued observation, a meal ticket was observed to read that a resident disliked broccoli. Staff Y was observed to omit the broccoli and plate only chicken and rice, not adding a similar alternate vegetable or other item to the plate. Staff Y was asked again why there wouldn't be a substitute vegetable item to replace the broccoli, and Staff Y stated, I don't think anyone complains, we could, but we generally don't do that. In an interview on 04/29/2026 at 12:30 PM, Staff X was not aware that some food items or disliked items were not being replaced with similar items during meal service and stated they would review that process. <RESIDENT 77> Resident 77 was admitted to the facility on [DATE]. In an interview on 04/27/2026 at 8:54 AM, Resident 77 stated that the facility did not follow what was listed on their dietary slip. Resident 77 stated that there was a list of food that they could not eat because it caused them stomach upset or constipation. The resident's diet slip documented that they disliked bread, Mexican food and beef. In an observation and interview on 04/27/2026 at 1:16 PM, Resident 77 was eating lunch. The meal tray was observed to include two meatballs. The meatballs were untouched. Resident 77 stated that the meatball was made of beef and they did not eat beef. In an interview on 04/27/2026 at 1:27 PM, Staff X stated that the meatballs were made of beef. Staff X stated that the cook and the dietary aid reviewed the diet slip prior to putting the food tray together would read and review to ensure residents preferences and allergies were followed. Staff X reviewed Resident 77's diet slip with beef listed as a dislike. Staff X stated Resident 77 occasionally ate beef but could not provide documentation that the resident had requested meat balls and stated the resident did not fill out the menu for the week. Refer to WAC 388-97-1100(1),1120(3)(a),1140(6)

Based on interview and record review, the facility failed to ensure a system in which resident's records were accurate, complete and readily accessible for 1 of 4 residents (Resident 2) reviewed for closed record, 1 of 2 residents (Resident 9) reviewed for Advance Directive, and 1 of 1 residents (Resident 4) reviewed for Hospice Services. This failure placed the residents at risk of a delay in care or services after discharge, unmet care needs, and diminished quality of life. Findings included .Review of the facility policy titled, Resident Medical Record, revised dated [DATE], documented medical records were maintained on each resident were to be complete, accurately documented, readily accessible and systematically organized. <RESIDENT 9> Resident 9 was admitted to the facility on [DATE] with a guardian in place. Resident 9's electronic medical record showed letters of guardianship with expiration dates of [DATE]. In an interview on [DATE] at 11:00 AM, Staff C, Social Services stated they were unaware that Resident 9's letters of guardianship had expired. In an interview on [DATE] at 11:15 AM, Staff S, medical records, stated there was no process that they were aware of to ensure letters of guardianship were updated after expiration. Staff S stated when they were given documents and they uploaded it into the medical record of the resident. <RESIDENT 4> Resident 4 admitted [DATE] on Hospice services. Review of Resident 4's record on [DATE], the Hospice Certification and plan of care start date was the day of admit ([DATE]), and the certification period ended [DATE]. The Hospice plan of care planned for Licensed Nursing (LN) visits weekly, Home Health Aide (HHA) visits twice a week, Social Worker visits monthly, Chaplain visits monthly, and a onetime Occupational Therapist (OT) visit. Further review of the record showed no updated Hospice Certification beyond [DATE]. Review of Resident 4's progress notes and scanned documents on [DATE] revealed only four notes since admission from the Social Worker and Hospice Chaplain. There were no LN, HHA or OT visit notes or summaries found in the record since admission. In an interview on [DATE] at 1:42 PM, Staff E, Resident Care Manager (RCM), stated Hospice faxed visit notes over, the nurses reviewed them and they got scanned by medical records. Staff E stated they did not know that Resident 4 did not have a current Hospice Certification and Plan of Care in the chart or what the process was to ensure visit notes were received. In an interview on [DATE] at 2:00 PM, Staff S stated they did not have any documentation pending to scan for Resident 4. In a follow-up interview on [DATE] at 10:52 AM, Staff S stated there was no standard process for full chart audits. Staff S stated when visit notes or after visit summaries were received, they were scanned and uploaded within two days. Staff S stated they did not know if it should be medical records or nursing to audit for missing notes or visit summaries from outside providers. Staff S stated they did not know they should be looking for those. <RESIDENT 2> Resident 2 was admitted to the facility on [DATE] and discharged on [DATE]. Review of the discharge Minimum Data Set (MDS-an assessment tool) assessment, dated [DATE], showed the resident had an unplanned discharge to a hospital. Review of a progress note dated [DATE] at 10:04 PM, documented Resident 2 was transferred to the Emergency Department (ED). Review of a Discharge-Anticipated/Planned evaluation, dated [DATE] at 1:54 PM, documented the date of discharge/transfer was [DATE], and Resident 2 was discharged to an Adult Family Home (AFH) with home health services. The evaluation was signed by Staff II, RCM. Review of a Nursing Home Transfer or Discharge Notice form indicated Discharge, and Resident 2 was discharged to AFH. The form was signed by Staff C, Social Services, dated [DATE]. Review of a second Nursing Home Transfer or Discharge Notice form indicated Transfer, and Resident 2 was transferred to the hospital. The form was signed by Staff II, dated [DATE]. In an interview on [DATE] at 10:09 AM, Staff C stated they were not sure where Resident 2 was discharged . Staff C stated it was very confusing since there was documentation showing Resident 2 was discharged to both the hospital and an AFH. In an interview on [DATE] at 10:45 AM, Staff II stated Resident 2 was transferred to the hospital on [DATE]. Staff II stated the Discharge-Anticipated/Planned evaluation dated [DATE] was incomplete and the resident did not discharge to AFH. Staff II stated the Nursing Home Transfer or Discharge Notice form which indicated Discharge should be removed from Resident 2's medical record. In an interview on [DATE] at 2:27 PM, Staff B, Chief Nursing Officer, stated Resident 2 was transferred to the hospital on [DATE]; the discharge notice on [DATE] indicated Resident 2 went to AFH was predated and not supposed to be a part of Resident 2's medical record. Staff B stated the expectation was for the medical record to be accurate, complete, and not predated. Reference WAC 388-97-1720 (1)(a)(i-iv)

Based on interview and record review, the facility failed to allow residents to make choices about daily routines for 1 of 3 residents (Resident 51) reviewed for choices. The facility's failure to accommodate resident choice placed residents at risk for a diminished quality of life.Findings included.Resident 51 was admitted to the facility on [DATE]. According to the quarterly minimum data set assessment (an assessment of care needs), dated 04/22/2026, the resident was cognitively intact.During an interview on 04/26/2026 at 10:05 AM, Resident 51 reported they were awakened at least three times a night for medications and to have their blood pressure and heart rate checked. Resident 51 reported that they had a difficult time getting back to sleep after they had been awakened. Resident 51 stated they had spoken with the medication nurse about not wanting to be awakened at night, but the staff did not adjust their schedule.Review of Resident 51's Medication Administration sheets from 04/01/2026- 04/28/2026 showed an order for albuterol (medication for breathing difficulty) scheduled at 6AM, 12 PM, 6PM and 12 AM (midnight). There was also an order for Resident 51 to have their vital signs (blood pressure, heart rate, amount of oxygen percentage in the blood, and temperature) every shift, scheduled on day shift, evening shift and on the night shift.During an interview on 04/29/2026 at 9:48 AM, Staff P, Licensed Practical Nurse, stated that Resident 51 had mentioned on several occasions that they did not like to be awakened at night. Staff P reported they had not adjusted Resident 51's schedule nor had they reported the residents' concern to the Resident Care Manager (RCM).On 04/29/2026 at 9:54 AM, Staff D, RCM, reported if a resident's preference was not to be awakened at night, they would look at the care needs and try to rearrange the schedule for the resident. Staff D stated they were not aware that Resident 51 did not want to be awakened at night.On 04/29/2026 at 9:58 AM, Staff B, Chief Nursing Officer, reported they expected the care staff to report to the RCM when a resident did not want to be awakened at night so the RCM could adjust the schedule.Reference WAC 388-97-0900 (1)

Based on interview and record review, the facility failed to notify the State PASRR (Pre-admission Screening and Resident Review-an assessment used to identify people [resident] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities [ID], or related conditions are not inappropriately placed in nursing facility for long term care) Coordinator after a significant change in mental condition for 1 of 5 residents (Resident 37), reviewed for PASRR. This failure placed the resident at risk for unmet mental health services necessary to obtain the resident's highest level of psychosocial well-being and diminished quality of life.Finding included .Resident 37 admitted to the facility 01/04/2024 with diagnoses to include Parkinson's disease (progressive movement disorder of the nervous system), major depressive disorder, and anxiety.Review of Resident 37's PASRR dated 01/04/2024 documented they had indicators of serious mental illness but did not require a level two evaluation due to their stability on medications of venlafaxine (an antidepressant medication) and busbar (an antianxiety medication).Review of Resident 37's psychiatric provider note dated 04/29/2025 documented venlafaxine may be contributing to their anxiety and recommended to change of antidepressant.Review of Resident 37's progress notes dated 05/05/2025 documented they were given a one-time dose of hydroxyzine (an antianxiety medication) for an acute episode of anxiety.Review of Resident 37's provider progress note dated 06/25/2025 documented they were prescribed hydroxyzine on 06/16/2026 as needed for 14 days related to increased anxiety.Review of Resident 37's progress note dated 07/05/2025 documented they came to the nurse's station with complaints of anxiety and panic. An order for Hydroxyzine was provided to Resident 37 for three days.Review of Resident 37's provider progress note dated 07/23/2025 documented an order to cross [NAME] Venlafaxine with Zoloft and discontinue Venlafaxine on 07/30/2025.Review of Resident 37's progress notes from 05/01/2025 through 04/26/2026 showed no documentation that a new PASRR was completed and a level two requested for significant changes in their mental status.In an interview on 04/29/2026 at 10:30 AM Staff C, Social Services, stated they were reviewing residents PASRR's quarterly for accuracy. Staff C stated they would not complete a new PASRR or seek a level two evaluation for a resident who had changes in their psychotropic medications, only if a new diagnosis was added.Reference WAC 388-97-1975

Based on observation, interview, and record review, the facility failed to ensure professional standards were met for 2 of 5 residents (Resident 6 and Resident 52) reviewed for unnecessary medication review; 1 of 2 residents (Resident 29) for blood glucose monitoring; and 1 of 2 residents (Resident 6) for skin observation and treatment. The facility failed to ensure physician-ordered parameters were followed for blood pressure medication administration, failed to perform blood glucose (test to check sugar level in the blood) checks prior to meals, and failed to provide treatments for a wound. These failures placed the residents at risk for adverse outcomes, medication errors, infections, clinical complications, and unmet needs.Findings included .According to the facility policy titled Skin Integrity & Wound Prevention with revision date of 09/14/2025, new areas of concern identified are documented in the medical record, provider notified with treatment orders obtained and care plan updated. <WOUND> <RESIDENT 6> Resident 6 was re-admitted to the facility on [DATE]. According to the admission Minimum Data Set (MDS – an assessment tool) dated 03/14/2026, the resident had cognitive impairment and had no pressure ulcers but was at risk for pressure ulcers/injuries. In an interview on 04/27/2026 at 8:23 AM, Resident 6 stated that they had an open area on their buttocks. Review of Resident 6's skin inspection evaluation dated 04/22/2026 documented a small open area to the left of their buttock. Review of Resident 6's April 2026's Treatment Administration Record (TAR) did not show any treatments or documentation regarding the small open area on their buttock. There were no orders in Resident 6's electronic chart for the treatment of the open area on their buttocks. In an interview on 04/30/2026 at 8:09 AM, Staff DD, Licensed Practical Nurse (LPN) stated that Resident 6 did not have any open areas on their buttocks. In an interview on 04/30/2026 at 9:30 AM, Staff BB, Resident Care Manager (RCM) stated that Resident 6 did not have any open areas on their buttocks. In an observation and interview on 04/30/2026 at 9:41 AM, with Staff EE, Certified Nursing Assistant (CNA) there was a small open area consistent with a Stage 2 (a shallow, painful open wound caused by prolonged pressure, resulting in top layer of skin is broken) observed on Resident 6's left buttock. There was no bandage or ointment applied to the wound. Staff EE stated the nurse was aware of the open area and that they would let them know that the bandage was off. In an interview on 04/30/2026 at 9:56 AM, Staff DD, LPN observe the open area and stated that it was the first time they had seen it. Staff DD added that it was just red and blanchable previously. In an interview on 04/30/2026 at 10:13 AM, Resident 6 stated that they knew about their open area on their buttocks when they went to their doctor's appointment about four-five days ago. They stated that it was painful when they sat on their wheelchair. Resident 6 stated that some staff knew about their open area but were not aware of their names. In a record review of Resident 6's progress note showed that the doctor's appointment was on 04/22/2026, which was the same day that a nurse documented the small open area on the resident's buttocks. <MEDICATION PARAMETERS> <RESIDENT 6> Review of Resident 6's order summary dated 04/27/2026 documented a blood pressure medication to be given two times a day with a parameter to hold if the systolic blood pressure (SBP – the top number that measures the pressure in the arteries when the heart beats) less than 100 or heart rate (HR) less than 60. Record review of March 2026 Medication Administration Record (MAR) documented that on March 1, 26 and 30, the blood pressure medication was given outside the ordered parameters. Record review of April 2026 MAR documented that on April 8, 25, 27 and 28, blood pressure medication was given outside the ordered parameters. In an interview and record review on 04/29/2026 at 3:30 PM, Staff BB, confirmed that the check marks in the MAR meant the medications were given. Staff BB reviewed Resident 6's MAR and confirmed that that the nurses gave the medication outside the ordered parameters and that the nurses should have held the medication. <RESIDENT 52> Resident 52 was admitted to the facility on [DATE] with diagnoses to include high blood pressure. Review of Resident 52's 04/01/2026 - 04/28/2026 MAR, showed an order for a blood pressure medication to be given twice a day. The order directed nurses to hold the medication for a heart rate below 60 beats per minute (bpm). However, the medication was administered when the resident's heart rate was below 60 bpm on the mornings of 04/03/2026,04/09/2026, and 04/21/2026, and the evening of 04/09/2026. In a record review and interview on 04/29/2026 at 3:23 PM, Staff H, LPN, stated nurses needed to check the parameter if the order had specific instructions and follow the provider's order to hold the medication if the parameter was out of range. Staff H stated the medication was supposed to be held and it was very upsetting that the nurses gave the medication when the resident's heart rate was out of parameter. In a record review and interview on 04/29/2026 at 3:56 PM, Staff BB, stated all nurses needed to follow the order and check the parameter prior to administering blood pressure medications. Staff BB stated the blood pressure medications should have been held on those days with out-of-range parameters. In an interview on 04/30/2026 at 2:27 PM, Staff B, Chief Nursing Officer, stated the expectation was to follow the provider's order, to read the parameter, and to hold the medication if the parameter was out of range. <BLOOD SUGAR> During an observation on 04/27/2026 at 7:52 AM, a staff member was observed removing the breakfast tray from Resident 29's bedside. Staff O, LPN, then proceeded to check Resident 29's blood sugar. Staff O reported they did not have time to check all blood sugars before breakfast. During an interview on 05/01/2026 at 8:45 AM, Staff B, reported that blood sugars needed to be checked before the meal and that they expected the staff to check the blood sugar before the resident had eaten. Refer to WAC 388-97-1620 (2)(b)(i-ii)

Based on interviews and record reviews, the facility failed to ensure that 1 of 1 resident (Resident 34) who had been continent of bladder prior to admission to the facility, received appropriate treatment and services to restore continence to the extent possible. This failure placed residents at an increased risk of urinary tract infections, discomfort, loss of dignity, and decreased quality of life.Findings included . In a review of the facility policy titled Urinary Assessment & Toileting Program revised 09/15/2025 documented the facility would ensure residents were evaluated for bladder function and continence upon admission and as needed. Residents who were incontinent of bladder would receive appropriate care and services to prevent infection and restore bladder function as possible.Resident 34 admitted to the facility on [DATE] with diagnoses to include falls with concussion, Alzheimer's disease (progressive disease characterized by cognitive decline, memory loss and behavioral changes) and history of stroke.In an interview on 04/26/2026 at 2:55 PM Collateral Contact 1 (CC 1) stated Resident 34 had been continent when residing at home, did not utilize a brief and now they were wearing a brief at the facility. CC 1 stated Resident 34 was independent prior to their fall and hospitalization, and the facility was more cautious with them, utilizing a brief, because of their fall risk. CC 1 stated Resident 34 should be allowed to utilize the bathroom with supervision.Review of Resident 34's hospital Discharge summary dated [DATE] documented they had an order for Flomax (medication used to treat difficulty in urinating). There was no notation regarding Resident 34's continence status.Review of Resident 34's clinical evaluation summary note dated 03/23/2026 documented resident was incontinent with bowel and bladder.Review of Resident 34's bladder status evaluation dated 03/31/2026 documented they were incontinent prior to admission to the facility, no voiding pattern had been completed, and they were not able to communicate their toileting needs or follow direction to participate in a training program.Review of Resident 34's admission Minimum Data Set (MDS-an assessment tool) dated 03/26/2026 documented they were frequently incontinent and a toileting program had not been attempted.Review of Resident 34's Care Area Assessment (CAA-care planning worksheet) dated 03/28/2026 documented no input from the resident or family. The CAA documented Resident 34 was dependent on staff for toileting hygiene and transfers, they were frequently incontinent of bladder, and staff were to continue to assist them with toileting needs and report to the nurse if any issues arose. The CAA lacked details of Resident 34 bladder incontinence, use of briefs, and overall goal related to their toileting needs.Review of Resident 34's care plan dated 03/23/2023 documented that they were at risk for urinary complications related to impaired mobility and cognition. The goal was for Resident 34 to remain free from skin breakdown due to incontinence and brief use. Interventions included prompted voiding (asking them if they were wet or dry and prompt to use the toilet) and routine toileting (toilet with AM and PM care, before meals and as needed).Review of Resident 34's occupational therapy (OT) evaluation dated 03/24/2026 documented their prior level of function for self-care was independent, they required substantial/maximal assistance for toileting with a goal of performing toileting tasks with max cues to return to prior level of function. Review of Resident 34's subsequent OT notes documented the following:-04/21/2026 education was provided to their spouse regarding toileting routine, with no specific details.-04/15/2026 facilitated resident participation in toileting schedule after lunch to increase opportunities to use the bathroom, with no specific details of the schedule.-04/09/2026 toileting tasks were focused on cues to facilitate performance.Review of Resident 34's task response, dated 03/31/2026 through 04/29/2026 for urinary continence documented they were continent 14 times out of 87 documented opportunities. The task did not capture whether Resident 34's instances of continence/incontinence was during a time of prompted/scheduled toileting.In an observation on 04/28/2026 at 9:33 AM Staff LL, Registered Nurse (RN), asked Resident 34 if they were in pain, the location of their pain, and level of their pain. Staff LL provided Resident 34 with medication for their pain and then asked if they needed to use the bathroom. Resident 34 indicated they needed to use the bathroom and Staff LL assisted them to their room.In a continuous observation on 04/29/2026 starting at 1:49 PM and ending at 3:57 PM Resident 34 was outside the nurse's station. At 2:35 PM Staff OO, Nursing Assistant Certified (NAC), pushed Resident 34 around the facility and played music for them on a speaker and returned them to the nurse's station at 2:58 PM. Resident 34 remained at the nurse's station until they started to self-propel down the hall at 3:32 PM and engaged in conversation with Staff GG, Assistant Director of Nursing, at 3:34 PM. At 3:44 PM Staff MM, NAC, pushed Resident 34 outside and returned to the nurse's station at 3:57 PM. During the observation Resident 34 was not toileted.In an interview on 04/29/2026 at 2:38 PM Staff NN, NAC, stated they were assigned to care for Resident 34 for the day. Staff NN stated Resident 34 was incontinent at night and during the day they toilet them. Staff NN stated they get Resident 34 up for the day which includes changing their brief, getting dressed, and up in their wheelchair. Staff NN stated Resident 34 then hangs out at the nurse's station. Staff NN stated they changed Resident 34 around 10-10:30 AM and they were incontinent. Staff NN stated Resident 34 had their lunch in the dining room and then they were changed again between 12:30-1:00 PM and was incontinent. Staff NN stated Resident 34 was a one person assist with a walker and they toileted them on the toilet.In an interview on 04/29/2026 at 3:58 PM Staff E, Resident Care Manager (RCM), when asked what prompted toileting consisted of, stated nursing assistants helped residents for toileting as possible. Staff E stated they assisted with toileting too, for residents who required one person assistance, and answered call lights as well. Staff E stated Resident 34's was a fall risk, and care was over seen by Staff BB, RCM.In an interview on 04/29/2026 at 4:00 PM Staff DD, Licensed Practical Nurse, stated Resident 34 showed indicators of needing to use the toilet and they would say things such as I need to powder my nose, become fidgety, or tried to get up. Staff DD stated Resident 34 was prompted to use the toilet when they showed indicators. Staff DD stated scheduled toileting included toileting before and after meals.In an interview on 04/30/2026 at 1:50 PM Staff BB, RCM, stated Resident 34's incontinence was identified in the hospital and when they arrived at the facility their brief was full of urine. Staff BB stated a bladder evaluation was completed. When asked about whether a voiding pattern was conducted after admission for Resident 34, Staff BB stated one was not completed as they had cognitive challenges and it was determined they were not at a level where they could understand and follow directions, contradictory to the observation on 04/28/2026. Staff BB stated Resident 34's spouse had provided information about their incontinence stating they were more continent when at home.In an interview on 05/01/2026 at 8:54 AM Staff B, Director of Nursing Services, stated the process for determining bladder incontinence and interventions was gathering information from the hospital, completing an initial assessment with the resident/family to determine needed supplies and bowel and bladder evaluation within 24 hours of admission. Reference WAC 388-97-1060(3)(c)

Based on observation, interview and record review, the facility failed to ensure 2 of 4 residents (Residents 37 and 42) reviewed for respiratory care and services were provided care consistent with professional standards of practice. The facility failed to ensure the oxygen concentrator (a medical device that filters air to deliver concentrated medical-grade oxygen) was set to the ordered rate and failed to ensure oxygen supplies were appropriately maintained, changed regularly and dated. This failure placed residents at risk for receiving care and services that were not physician ordered, unmet care needs and potential for complications of the respiratory system.Findings included .Review of a facility policy titled, Oxygen Administration, Safety, Storage and Maintenance with revised date 08/04/2023 documented:monitor oxygen parameters as needed and/or as ordered,change oxygen supplies weekly,equipment should be dated when set up or changed out,Humidifier (container of sterile water to add moisture to oxygen) should be dated and replaced every seven days regardless of water level.<RESIDENT 42> Resident 42 was admitted to the facility on [DATE] with diagnoses to include Chronic Obstructive Pulmonary Disease (COPD- a group of lung diseases that make it hard to breathe and get worse over time). In an observation on 04/26/2026 at 11:34 AM, Resident 42 was in bed with an oxygen concentrator set to three liters per minute (lpm), there was an empty oxygen humidifier container attached to the concentrator with no date. The nasal cannula (a flexible tube, with two prongs placed in the nostril to deliver oxygen) connected to the concentrator was not dated. Review of Resident 42's order summary documented oxygen at 1-3 lpm per nasal cannula via oxygen concentrator every four hours as needed for oxygen desaturation (decreased oxygen level in blood) or resident distress. There was also an order to monitor oxygen saturation to keep oxygen saturation greater than 88% and to titrate oxygen per protocol. Both orders were dated 02/13/2026. There were no orders for oxygen humidifier, the oxygen order for as needed and not for continuous use of oxygen, and the monitoring of saturation did not include if the oxygen saturation was on room air or with oxygen. In an observation and interview on 04/29/2026 at 7:53 AM, Resident 42 was using oxygen set at three and a half lpm. The humidifier was empty. The oxygen tubing was not dated. Resident 42 stated they were on oxygen all the time. Observed a nebulizer machine (a medical device that turns liquid medicine into mist to breathe in) with tubing and face mask attached that were not dated and was laying directly on the resident's bedside table. In an interview and observation on 04/29/2026 at 12:15 PM, Staff DD, Licensed Practical Nurse, stated Resident 42 was on continuous oxygen at two lpm. Staff DD stated that if a resident required a humidifier with oxygen, there must be a doctor's order. Staff DD reviewed Resident 42's orders and they stated that the oxygen order was only PRN (as needed) and it should be changed to continuously since the resident was using oxygen all the time. Staff DD also confirmed that Resident 42 did not have a humidifier ordered. Staff DD confirmed that the humidifier was empty and the oxygen was at three and a half lpm. Staff DD reported the oxygen tubing was to be changed once a month or if dirty. In an interview on 04/29/2026 at 3:30 PM, Staff BB, Resident Care Manager, stated that for residents requiring oxygen, they must have a doctor's order and an order for the maintenance of the concentrator and the tubing. Staff BB stated that the staff should be dating their tubing and storing them in a plastic bag if not being used. Staff BB stated they were to change the tubing once a week or as needed if they were dirty. For residents on PRN oxygen, the nurses should be checking the residents' oxygen saturations and administering oxygen as ordered. Staff BB stated that the nurses should be documenting oxygen saturations and amount of oxygen in the Medication Administration Record (MAR). Staff BB stated that Resident 42 was on oxygen continuously and not PRN and the order was incorrect. Staff BB stated that humidifiers were only applied for residents needing four or more lpm of oxygen and they must have a doctor's order. Staff BB was not sure why Resident 42 had an empty humidifier attached to their oxygen concentrator. <RESIDENT 37> Resident 37 admitted to the facility on [DATE] with diagnoses to include COPD. Review of Resident 37's April 2026 MAR documented an order for oxygen at two lpm. In an interview on 04/26/2026 at 11:23 AM Resident 37 stated they used their oxygen continuously. Resident 37 stated their settings were at two and half lpm. In an observation on 04/26/2026 at 11:32 AM Resident 37's oxygen concentrator was set to three lpm. In an observation on 04/27/2026 at 2:13 PM Resident 37's oxygen concentrator was set to three lpm. In an interview on 04/30/2026 at 2:26 PM Staff U, Registered Nurse, stated they knew the settings for residents on oxygen by reviewing the MAR/orders. Staff U stated the settings were checked on the concentrator at the beginning of the shift. Staff U stated Resident 37's order was for two lpm. Staff U checked Resident 37's oxygen concentrator and provided education to Resident 37 about their physician orders. Staff U stated they should have checked Resident 37's oxygen setting on the concentrator. Refer to WAC 388-97-1060(3)(j)(vi)

Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 3 of 5 residents reviewed for unnecessary medications (Residents 4,6 and 52) and 1 of 3 residents reviewed for pain management (Resident 20). Failure to follow providers orders for pain medication parameters and provide non-pharmacological interventions for pain placed residents at risk for adverse effects of unnecessary medication and decreased quality of life. Findings included . <RESIDENT 4> Resident 4 admitted [DATE] and had diagnoses to include dementia and chronic pain. Review of Resident 4's physician's orders with a print date 04/27/2026 documented an order for pain medications: Acetaminophen (non-narcotic pain medication) every four hours as needed for pain rating between 1-5, Oxycodone (narcotic pain medication) every four hours as needed for pain. Review of Resident 4's routine pain monitor from April 1-27, 2026, documented their pain rating as 0 on 24 days, 2 on one day, and 1 on two days. Review of the Medication Administration Record (MAR) from April 1-27, 2026, documented Resident 4 received zero doses of Acetaminophen but was documented as having received three doses of oxycodone. The oxycodone was given on 04/09/2026, when the resident's pain was documented as 0, 04/14/2026, when the resident's pain was documented as 5, and on 04/16/2026, when the resident's pain was documented as 3. Resident 4 had non-pharmacological interventions (treatments not involving drugs, such as repositioning or heat/cold packs) listed to attempt prior to administering pain medications, and none were documented as having been attempted. The side effect monitors directed staff to monitor for adverse side effects of narcotic pain medication such as lethargy and constipation. The side effect monitor documented no side effects. Review of the MAR from April 1-27, 2026, documented the resident required four doses of medications that stimulates bowel movement related to constipation. In an interview on 04/28/2026 at 2:16 PM, Staff E, Resident Care Manager (RCM), stated the pain medication orders were given by Hospice and Hospice wanted Resident 4 to have more of the oxycodone. Staff E stated the resident got mad and could be hard to get up or give medications to and staff equated that to non-verbal signs of pain. Staff E acknowledged the documentation did not capture the resident's pain and the documentation of their pain level at 0-5 would indicate that the Acetaminophen would be attempted per the orders prior to the oxycodone. Staff E stated the orders needed to be clarified and documentation improved. <RESIDENT 20> According to the National Institutes of Health (nih.gov) the maximum standard dose of Acetaminophen for healthy adults is 4,000 milligrams (mg) from all sources in a 24-hour period, and 2-3,000mg for those in high-risk groups such those with liver problems, due to risk of liver toxicity. Resident 20 admitted on [DATE] with diagnoses which included a history of stroke, history of fractures and chronic pain. Review of Resident 20's physician's orders for pain medications on 04/27/2026 documented the resident had orders for: Acetaminophen 650 mg two per day routinely. This order began 06/16/2024 and was discontinued on 04/20/2026. The order gave the resident 1100 mg of Acetaminophen in a 24-hour period. Resident 20 had an additional order for a 7-day period 04/14/2026 through 04/20/2026 for Acetaminophen 1000 mg every 8 hours routinely and gave the resident an additional 3000mg of Acetaminophen in a 24-hour period (total 4100 mg.) The order did not address the Acetaminophen maximum allowable dosage guidelines. Following the discontinuation of the 7-day order, a new order was entered on 04/20/2026 for Acetaminophen 650 mg every four hours as needed. This order allowed for 3900 mg of Acetaminophen in a 24-hour period if the resident used all available doses. In addition to the routine Acetaminophen, the resident now had orders which amounted to a potential of 5,000 mg of Acetaminophen in 24 hours. The orders did not address the Acetaminophen maximum allowable dosage guidelines. In an interview on 04/30/2026 at 1:58 PM, Staff B, Chief Nursing Officer (CNO) stated normally the pharmacist would review orders and would catch if a parameter, duplication or other instruction were missing, Staff B stated the April pharmacy reviews were in progress but stated there should have been follow-up. The nurses that were entering in orders and the nurse managers that reviewed orders should be looking for that. <RESIDENT 6> Resident 6 was re-admitted to the facility on [DATE] with diagnoses to include repair of a right hip fracture, non-displaced proximal humerus fracture on the left (a break near the shoulder where the bone pieces remain in anatomical position, typically treated without surgery using sling) and type 2 Diabetes Mellitus (a chronic disease in which the body does not use insulin properly which results in consistently high blood sugar) . According to the admission Minimum Data Set (MDS – an assessment tool) dated 03/14/2026, the resident had moderate cognitive impairment, received routine and as needed (PRN) pain medications and received non-pharmacological intervention for pain. Review of Resident 6's order summary documented oxycodone oral tablet 5 mg be given every 6 hours PRN for moderate right hip pain (pain level 4 to 6 out of 10) and 10 mg be given every 6 hours PRN for severe right hip pain (pain level 7 to 10 out of 10). The orders were dated 03/31/2026. There were no non-pharmacological interventions ordered prior to giving the PRN pain medications. Review of Resident 6's care plan with a print date of 04/27/2026 documented interventions for pain included providing reassurance to the resident that pain was time limited and to encourage attempts at different non-pharmacological pain-relieving methods. The care plan did not list what specific non-pharmacological interventions should be offered to the resident. Review of Resident 6's March 2026 MAR documented oxycodone 10 mg were given on March 14, 17, 18, 22 and 30 with pain level of 6 which was outside the ordered parameters. Oxycodone 5 mg was given on March 12, 14 and 17 with pain level of 7 which was outside the ordered parameters. Review of Resident 6's April 2026 MAR, dated 1-27th, documented oxycodone was given daily. On April 17, oxycodone 10 mg was given with a pain level of 6 which was outside the ordered parameter. On April 10 and 14, oxycodone 5 mg was given with a pain level of 8 and 7 respectively which were outside the ordered parameters. Review of Resident 6's MAR and Treatment Administration Record (TAR) for March and April 2026 did not have any non-pharmacological interventions for pain listed. Review of Resident 6's progress notes from 03/11/2026 to 04/28/2026 did not have any documentation that staff offered any non-pharmacological interventions prior to giving PRN oxycodone. In an interview on 04/29/2026 at 12:06 PM, Staff DD, Licensed Practical Nurse, stated Resident 6 had pain in their right hip and left shoulder. Staff DD stated prior to giving PRN pain medications, they offer non-pharmacological interventions, and they document that in the MAR and assess if it's effective or not and if the non-pharmacological interventions were not effective, then they give the PRN pain medications. Staff DD stated the non-pharmacological interventions they provided to Resident 6, were icing, repositioning, ensuring the sling was on properly and monitoring the resident's wound. Staff DD could not show where they documented non-pharmacological interventions for Resident 6. In an interview on 04/29/2026 at 3:30 PM, Staff BB, RCM stated prior to giving PRN pain medications, non-pharmacological interventions should be offered to the residents. When asked where the nurses would document the non-pharmacological interventions Staff BB stated, in the MAR. Staff BB stated Resident 6's non-pharmacological interventions were repositioning, distractions, and offering snacks (contradictory to Staff DD's descriptions of non-pharmacological interventions). Staff BB stated they would review Resident 6's care plan for pain management and update it. Staff BB reviewed Resident 6's medical record and stated there were no documentation of non-pharmacological interventions for pain offered. <RESIDENT 52> Resident 52 was admitted to the facility on [DATE]. Review of Resident 52's MAR from 04/01/2026 to 04/28/2026, showed an order with a start date of 05/25/2025 that instructed to encourage nonpharmacological interventions prior to administering pain medications, if the resident reported pain or had sign and symptoms of pain. The MAR documented Resident 52 experienced verbal and non-verbal pain on multiple days; however, there were no documentation that non-pharmacological interventions were provided. Further review of the MAR showed Resident 52 had an order with a start date of 05/24/2025 for acetaminophen, two tablets every six hours as needed for pain. Documentation showed Resident 52 received acetaminophen on 04/13/2026 and 04/22/2026; however, no nonpharmacological interventions were documented as having been provided prior to the administration of the medication. Review of Resident 52's progress notes from 04/01/2026 to 04/28/2026, showed no documentation of non-pharmacological interventions were attempted or provided. In a record review and interview on 04/29/2026 at 3:56 PM, Staff BB stated the nurses were supposed to offer, provide, and document nonpharmacological interventions prior to giving PRN pain medication. Staff BB reviewed Resident 52's record and stated there was no documentation of nonpharmacological interventions provided on 04/13/2026 and 04/22/2026, but they should have been documented. In an interview on 04/30/2026 at 2:27 PM, Staff B stated the expectation was the nurses provide nonpharmacological interventions before giving PRN pain medications and document the interventions in the MAR. Refer to WAC 388-97-1060(3)(k)(i)

Based on observation and interview, the facility failed to store medications securely for 2 of 2 residents (Resident 37 and 49) reviewed for medications stored in their room and failed to ensure 1 of 4 medication carts and 1 of 2 treatment carts were locked when left unsupervised by staff. These failures placed residents at risk for receiving compromised or ineffective medications and for having unintended access to drugs that should have been securely stored.Findings included . On 04/26/2026 at 9:39 AM observed the treatment cart located outside of nursing station two, unlocked. The treatment cart contained scissors, zinc oxide ointment (medicated ointment), hydrocortisone cream (medicated cream), Vaseline, iodine antiseptic pads (medicated pads), silicone cream, and medicated wound dressings.In an interview on 04/26/2026 at 9:39 AM Staff B, Director of Nursing Services, stated treatment carts were expected to be locked when not in use and secured by staff.In an observation on 04/26/2026 at 12:15 PM observed the medication cart on the second hall unlocked outside of nursing station two. Observed Staff DD, Licensed Practical Nurse, the assigned nurse to the medication cart, sitting behind the nurse's station. When asked Staff DD about the medication cart being unlocked, the came to the cart and immediately locked it and stated the cart should always be locked when unattended.In an observation on 04/28/2026 at 4:05 PM observed Resident 49 to have a can of topical pain relief, in an aerosol can, sitting on the windowsill.In an observation on 04/28/2028 at 4:05 PM observed Resident 37's overbed table to have a red inhaler sitting on top of it. In a brief interview Resident 37 stated the inhaler was their rescue inhaler and they needed it in case of a sudden attack.In an interview on 04/29/2026 at 3:50 PM Staff E, Resident Care Manager, stated residents required to have an order for medication to be kept in their room, lockbox for any medication in their room, and an evaluation to ensure they could administer the medication safely. Staff E stated Resident 37 had been educated regarding maintaining medication in their room and would follow up with them. Staff E stated some other residents had ordered other items, such as topical pain medication, shipped to them without the facility's knowledge.In an interview on 05/01/2026 at 8:54 AM Staff B, stated medications were not allowed at a resident's bedside without an evaluation to ensure the medications could be used safely.Reference WAC 388-97-1300 (2)

Based on observation, interview, and record review, the facility failed to ensure staff were compliant with Infection Prevention and Control Guidelines and standards of practice for 2 of 4 residents (Resident's 11 and 79) reviewed for Enhanced Barrier Precaution (EBP- personal protective equipment (PPE) required for staff during high contact care activities), 1 of 1 observation of pericare (washing of the genitalia and buttocks), 1 random observation of medical equipment sanitation and 1 of 4 nurses (Staff U) reviewed for medication administration. The facility failed to ensure the staff to wear appropriate PPE in accordance with recommended national standards; failed to ensure staff were compliant with hand hygiene during pericare; failed to ensure appropriately disinfecting reusable medical equipment; and failed to ensure proper barriers were used for medication items. These failures placed all residents and staff at risk of potential infection. Findings included .According to the facility policy titled, Enhanced Barrier Precaution dated 09/20/2025, documented examples of high-contact resident care activities requiring gown and glove use included transferring and toileting.According to the facility policy titled, Environmental Cleaning and Disinfecting revised date 10/08/2025, documented reusable resident care items were cleaned and disinfected between each use. <ENHANCED BARRIER PRECAUTION> <RESIDENT 11> Resident 11 was admitted to the facility on [DATE]. In an observation and record review on 04/26/2026 at 10:35 AM, EBP signage was posted at the entrance of Resident 11's room. The signage documented that gloves and gowns were required for high-contact resident care activities, which included transferring. Review of a physician's order, with a start date of 02/26/2026, documented Resident 11 was to be on Enhanced Barrier Precautions. Review of the care plan, initiated on 11/26/2025, documented Resident 11 required EBP. The care plan specified that gowns and gloves were required for high-contact resident care, which included toileting. In an observation and interview on 04/28/2026 at 3:02 PM, Staff Z, Certified Nursing Assistant (CNA), was observed pushing Resident 11 in a wheelchair to the resident's in-room toilet without wearing a gown. Staff Z stated they were assisting Resident 11 with toileting. Staff Z confirmed Resident 11 was on EBP and required a gown for toileting care and transferring. Staff Z stated they forgot and should have put on a gown prior to the activity. In a joint interview on 04/30/2026 at 10:55 AM, Staff GG, Infection Control Nurse and Staff B, Chief Nursing Officer, stated they expected staff to follow the instructions from the precaution signage posted by the resident's room door and the interventions in the care plan. Staff B stated the expectation was for staff to apply PPE for high-contact activities, which included transferring and assisting with toileting. <RESIDENT 79> Resident 79 was admitted to the facility on [DATE]. Review of Resident 79's orders showed an order for EBP dated 04/03/2026. Review of Resident 79's care plan with a print date of 04/27/2026 showed EBP to be used. In an observation on 04/26/2026 at 9:40 AM, Staff EE, CNA and Staff FF, CNA transferred Resident 79 from their wheelchair to their bed. Both staff were wearing gloves, but they were not wearing gowns. In a joint interview on 04/26/2026 at 9:48 AM with Staff EE and Staff FF, Staff FF stated that the EBP was a sign to wear gloves and gown when changing resident's briefs. Staff EE stated that we were supposed to wear gowns and gloves when they were touching bodily fluids for example, during brief change but if the resident was dressed then they don't need to wear gowns during care. After reviewing the EBP sign, Staff EE stated that they should have worn gowns before they transferred the resident to their bed. In an interview on 04/30/2026 at 10:55 AM, Staff GG, stated that it was an expectation for staff to follow the precaution signs that were posted by the residents' doors. The staff were expected to know who was on precaution by checking the residents' care plan. <HAND HYGIENE> Resident 6 was readmitted to the facility on [DATE]. In an observation on 04/30/2026 at 9:41 AM, Staff HH, CNA cleansed Resident 6's groin and genitalia and then cleansed resident's buttocks area. With the same gloves, Staff HH placed the clean sheets and brief under the resident, removed the dirty sheets and fastened the brief. In an interview on 04/30/2026 at 10:09 AM, Staff HH stated they did not perform hand hygiene and did not change their gloves after they performed peri care to Resident 6. Staff HH stated that after doing peri care they were supposed to take their dirty gloves off and wash their hands and put on new gloves before touching the clean sheets and brief. <MEDICAL EQUIPMENT SANITATION> In an observation on 04/30/2026 at 9:41 AM, Staff EE, took a resident's weight using a mechanical lift. Staff EE was observed pushing the mechanical lift into the hallway and left it there without sanitizing it. In an interview on 04/30/2026 at 10:14 AM, Staff EE stated that after using the mechanical lift, they placed it in the hallway for the next staff to use. When asked the process for cleaning the mechanical lift after use, Staff EE stated, we don't do that. In an interview on 04/30/2026 at 10:55 AM, Staff B stated that it was an expectation that staff were to clean the mechanical lift using the disinfectant wipes after each use. <MEDICATION PASS> During an observation on 04/27/2026 at 7:42 AM, Staff U, Registered Nurse, brought an inhaler (device to deliver medication when a person takes a breath) and bottle of eye drops into the room for Resident 39. Staff U placed the items on the resident's meal tray without a barrier. When Staff U was finished with administering medications, they picked up the eye drop bottle and the inhaler and brought them out of the room and placed them on top of the medication cart without using a barrier. During an interview on 04/27/2026 at 7:46 AM, Staff U stated they were not aware they should have used a barrier when bringing resident medication devices in and out of the resident's room. Staff U stated they were aware that items brought into a room are considered contaminated but had not thought of that for resident specific medication devices that were kept in the medication cart. Refer to WAC 388-97-1320(1)(a,c)(5)(c) <MEDICATION PASS> During an observation on 04/27/2026 at 7:42 AM, Staff U, Registered Nurse, brought an inhaler (device to deliver medication when person takes a breath) and bottle of eye drops into the room for Resident 39. Staff U placed the items on the resident's meal tray without a barrier. When Staff U was finished with administering medications, they picked up the eye drop bottle and the inhaler and brought them out of the room and placed them on top of the medication cart without using a barrier. During an interview on 04/27/2026 at 7:46 AM, Staff U stated they were not aware they should have used a barrier when bringing resident medication devices in and out of the resident's room. Staff U stated they were aware that items brought into a room are considered contaminated but had not thought of that for resident specific medication devices that were kept in the medication cart. Refer to WAC 388-97-1320(1)(a,c)(5)(c)

Based on interview and record review, the facility failed to implement policies and procedures for screening of potential staff to ensure the protection of residents against abuse, neglect, exploitation, or misappropriation by requesting reference checks and/or reviewing information from former employers for 4 of 4 staff (Staff F,G,H, and I ) reviewed for hiring practices. Failure to obtain references or obtain information from former employers placed residents at risk of potential abuse.Findings included.Review of a facility policy titled, Preventing Abuse, revised date 08/01/2023, documented the facility would complete at least two reference checks to obtain information from previous/current employers upon hire as part of the screening process.On 04/27/2026 at 5:56 AM, the facility was sent an email requesting documentation of screening prior to hire which included evidence of reference checks for Staff F, G, H, and I.On 04/27/2026 at 9:37 AM, surveyor received an email with the requested documents, but no reference checks were received for the four staff members.On 04/27/2026 at 2:15 PM, Staff Q, Human Resources/payroll coordinator, reported that the identified staff did not have reference checks in their files. Staff Q stated the facility no longer did reference checks as previous facilities would not give any information when they were called. On 04/28/2026 at 10:22 AM, Staff B, Chief Nursing Officer, stated Staff Q oversaw the hiring process. Staff B reported Staff Q would be the person in charge of obtaining reference checks and if they did not have them, there would not be anyone else to speak with.On 04/29/2026 at 1:36 PM - Staff A, Chief Executive Officer, reported they were not aware of the facility policy that staff should have two reference checks prior to being hired. Reference WAC 388-97-0640 (2)(a)

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 4 sampled residents (Residents 1, 2, 3, and 4) reviewed for care planning. The failure to ensure the comprehensive care plan was person-centered to maintain and or attain the resident's highest practicable well-being placed the residents at risk of not receiving services and monitoring that would meet their needs, adverse health effects and a decreased quality of life. Findings included .Review of a facility policy titled, Comprehensive Care Plans and Conferences, revised date 09/03/2025, documented the facility will ensure that each resident has a timely, person-centered comprehensive care plan developed and maintained in accordance with professional standards of practice. The care plan will reflect the individual conditions, risks, needs, behaviors, cultural values, and preferences, and will include measurable goals, appropriate interventions, and realistic timeframes. The plan will be created, reviewed, and revised by an interdisciplinary team familiar with the status and care needs, with active involvement from the residents and their representative, when applicable. Updates to the care plan will occur as needed based on the response to interventions or changes in condition.<RESIDENT 1>Resident 1 re-admitted to the facility on [DATE] with diagnoses including falls and left femur fracture. According to the admission Minimum Data Set (MDS - an assessment tool) assessment, dated 03/14/2026, showed the resident had moderate cognitive impairment. Resident 1 was independent with walking with a front wheeled walker(FWW), bed mobility, and transfers.Review of the facilities reporting log dated March 2026 showed the resident had a fall with fracture on 03/31/2026 at 5:15 PM.Review of an incident investigation, dated 03/31/2026 documented Resident 1 rolled out of bed and sustained a non-displaced humeral neck fracture (a broken upper arm bone just below the shoulder joint not requiring surgery) to their left arm.Review of a progress note titled Skilled Daily Progress Note dated 04/01/2026 at 4PM, Staff D, Licensed Practical Nurse (LPN), documented Resident 1 returned from the hospital with a sling to their left arm and instructions not to move their left arm until further notice. Review of Resident 1's electronic medical record (EMR) showed documentation from an orthopedic appointment dated 04/09/2026 that Reisdent1 was to wear a sling to their left arm, and was non-weight bearing to their left arm. Review of Resident 1's comprehensive care plan showed there was no care plan developed for the fracture to their left arm , did not show use of sling to their left arm, the increased need for assistance for activities of daily living (ADLs). The care plan did not show the resident was non weightbearing to the resident's left arm until 04/13/2026. Review of Resident 1's Kardex (a tool used to provide directions on how to care for a resident), dated 04/09/2026, showed no documentation that Resident 1 was to wear a sling and was non-weight bearing to their left arm. The Kardex showed the resident was independent with transfers, bed mobility, and ambulation with a walker.In an interview on 04/13/2026 at 3:37 PM, Staff C, Certified Nursing assistant stated information about a resident's care and preferences would be found on the Kardex.In an interview on 04/14/2026 at 11:48 AM, Staff E, LPN, stated nurse managers updated care plans and that a fracture should be care planned especially if they have restrictions. Staff F stated slings, braces and skin issues should be care planned so that everyone monitoring. In an interview and record review on 04/14/2026 at 1PM, with Staff G, Registered Nurse (RN), Nurse Manager, stated the Resident 1 sustained a left arm fracture from a fall on 03/31/2026 and the care plan was not updated to show left arm fracture, use of sling to their left arm, and changes to the assistance the resident would need. Staff G stated the resident is no longer using a walker and is not getting out of bed, the care plan has not been updated.In an interview on 04/14/2026 at 2:22PM, Staff B, RN, Director of Nursing, staff B stated if there is a change to a resident's mobility the care plan should be updated. When the care plan is updated the Kardex is also updated. <RESIDENT 2>Resident 2 admitted to the facility on [DATE] with diagnoses including fall, muscle weakness, unsteadiness on feet, and need for assistance with personal care. Review of the admission MDS, dated [DATE], showed the resident had severe cognitive impairment. Resident 2 was independent with bed mobility, dressing, transfers and toileting with FWW.Review of the facilities reporting log dated March 2026 showed the resident had a fall with fracture on 03/05/2026 at 11:20 AM. Review of Resident 2's physician orders dated 03/02/2026 showed an order for an Xray to the residents left shoulder.Review of Resident 2's left shoulder Xray results dated 03/03/2026 at 5:55 PM, showed the resident had a possible non-displaced humeral neck fracture to their left arm.Review of a progress note titled Health Status Note dated 03/04/2026 at 6:11 AM, Staff H documented the provider ordered use of a sling to Resident 2's left arm.Review of the resident 2's care plan showed there was no care plan developed for the fracture to their left arm, use of sling and non-weight bearing to left arm. The care plan for a Focus titled Physical Mobility Impaired related to, dated 3/5/2026, was incomplete for bed mobility and transfers.Review of Resident 2's Kardex showed the resident was independent with bed mobility, dressing, transfers and toileting with FWW. The Kardex did not show use of sling or non-weight bearing to the resident's left arm.In an interview and record review on 04/14/2026 at 1PM, Staff F, RN, Nurse manager reviewed Resident 2's care plan and confirmed the care plan did not show the fracture to the left arm, sling to left arm, and non-weight bearing to left arm. Staff F stated they did not complete the care plan for a focus titled status/post (s/p) fall-physical mobility. <RESIDENT 3>Resident 3 admitted to the facility on [DATE], with diagnoses including dementia, need for assistance with personal care, muscle weakness, and unsteadiness on feet. Review of the Quarterly MDS, dated [DATE], showed the resident had severe cognitive impairment. Review of the facilities reporting log dated March 2026 showed the resident had a fall with fracture on 04/2/2026 at 12:30 AM. Review of a hospital document titled After Visit Summary, dated 04/02/2026 at 3:56 AM, showed Resident 3 had a broken nose, abrasion to the face, and laceration with sutures to their forehead. Review of the resident 3's care plan showed there was no care plan developed for the fracture to their nose, laceration to forehead or abrasion and bruising to their face. In an interview and record review on 04/14/2026 at 1PM, Staff F, RN, Nurse Manager, reviewed Resident 3's care plan and confirmed that the fractured nose, laceration to forehead, abrasion and bruising to face were not on the care plan. <RESIDENT 4>Resident 4 admitted to the facility on [DATE] with diagnoses including stroke, falls, hemiplegia (paralysis) and hemiparesis (partial weakness) of right side, muscle weakness, and anxiety. Review of the Quarterly MDS, dated [DATE], showed the resident had severe cognitive impairment.Review of the facilities reporting log dated March 2026 showed the resident had a fall with fracture on 03/07/2026 at 6:20 PM.Review of Resident 4's hospital document titled After Visit Summary dated 03/07/2026 at 11:16 PM showed a fracture to the fifth left finger and to keep the left hand in the splint and a laceration to the forehead with sutures.Review of Resident 4's Kardex, dated 04/09/2026, showed the resident was non-weight bearing to their right wrist (resident to wear ulnar brace).Review of the resident 4's comprehensive care plan showed there was no care plan developed for the fracture to their left fifth finger, laceration to left side of face, or bruising to the face. The care plan entry dated 03/18/2026,showed the resident was non-weight bearing and had a brace to their right wrist.In an interview and record review on 04/14/2026 at 1PM, Staff G, reviewed Resident 4's care plan and confirmed the fracture the left fifth finger, brace to the left wrist, laceration to left side of face, and bruising to face were not on the care plan. Staff G acknowledged the care plan showing non-weight bearing and brace to right wrist was documented as the wrong hand and was not initiated until 03/18/2026.In an interview and record review on 04/14/2026 at 3:19 PM Staff B stated resident care plans should be updated to show fractures, braces, slings, and weight bearing status. Staff B stated resident care plans should be updated if there is a change in the ability to mobilize or complete ADLs and injuries would be included in the care plan.Reference WAC 388-97-1020 (1)(2)(a)(3)

Based on observation, interview, and record review, the facility failed to comprehensively assess the increased risk for skin breakdown, follow written policy and procedures, develop, and implement timely interventions necessary to prevent the development of avoidable pressure ulcers (PUs)for 4 of 6 sampled residents (Resident 1, 2, 3 and 4), reviewed for PUs. These failures caused harm to Resident 1 who admitted to the facility with a Stage 2 PU which deteriorated into an unstageable PU with osteomyelitis (bone infection), debridement (removal of dead [necrotic] or infected skin tissue to try to help wound heal), and a hospital treatment. developed a facility acquired unstageable PU with osteomyelitis (bone infection) and Residents 2, 3, and 4 experienced harm when they developed facility acquired PU's with partial and full thickness skin loss, and pain. This failed practice placed other residents at risk for the development of PUs, serious harm, and diminished quality of life. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (PI- also known as a PU) definition and stages of PU's include: -A PI (PU) 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 the 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 (the skin temperature, humidity, and airflow next to the skin's surface), nutrition, perfusion (measures how well the circulatory system is working), co-morbidities, and condition of the soft tissue. -Stage 2 PI (PU) is a partial-thickness skin loss with exposed dermis (the middle layer of the skin). The wound bed is viable, pink, or red, moist, and may also present as an intact or ruptured serum-filled blister. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. Stage 3 PI (PU) is a 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 (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) and tunneling (when a wound progresses to form passageways underneath the surface) may occur. Stage 4 PI (PU) is a full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough (dead tissue that may appear yellow, tan, gray, green or brown in the wound bed) and/or eschar (dead tissue may be visible. Epibole (rolled edges), undermining occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface), and/or tunneling (when a wound progresses to form passageways underneath the surface) often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable PI. Unstageable PI is an obscured 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 PI's will be revealed. Stable eschar (i.e. dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Unstageable PI (PU) is an obscured 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 erythema or fluctuance) on the heel or ischemic limb should not be softened or removed. Deep Tissue Pressure Injury (DTPI) is a 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 epidermal separation revealing a dark wound bed or blood-filled blister. Pain and temperature change often precede skin color changes. 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 PI. Review of the facility policy titled, Prevention and Treatment of Pressure Ulcer & Other Skin alterations, revision date of 07/13/2018, stated the facility has a system in place to promote skin integrity, prevent PU development/other skin alterations, promote healing of existing wounds consistent with professional standards of practice and prevent further development of additional skin alterations unless the individual's clinical condition demonstrates they were unavoidable to ensure that a resident who has a PU receives necessary treatment and services to promote healing, prevent infection and prevent new ulcers from developing. The policy stated with each dressing change or at least weekly (and more often when indicated by wound complications or changes in wound characteristics), an evaluation of the PU/PI or non-pressure skin alteration should be documented. At a minimum, documentation should include the date observed and location, staging if applicable; size; drainage description if present; pain if present; and wound bed description including evidence of healing or necrosis (tissue death). The interdisciplinary team, resident/family collaborate to establish goals and interventions to address resident specific risk factors for the prevention of skin alteration, promote the healing of wounds, and/or prevent further breakdown. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses that included left femur fracture, anemia, and failure to thrive (when a resident has a loss of appetite, eats and drinks less than usual, loses weight, and is less active than normal). Review of the admission skin inspection form, completed by nursing dated 12/20/2023, showed Resident 1 has a PI on (did not state location) buttock measuring 2 centimeters (cm) by 1 cm. Will continue to monitor pressure injury [PU], have the wound nurse follow and attempt to alleviate pressure as resident allows. The body diagram on this form (Section B: Skin Impairments) that allowed for further description/location/measurements of the wound/s was left blank. Review of Resident 1's care plan, dated/created 12/22/2023, showed the resident has an actual Stage 2 PU to their coccyx (tailbone), was present on admission, and measured 1.08 cm x 0.48 cm. Interventions included to assess, record, and monitor the status of the wound, and to notify the physician for any improvements or decline of the PU. Review of form titled, Wound Evaluation, dated 12/25/2023, Staff I, Licensed Practical Nurse (LPN)/Wound Nurse, documented Resident 1 had a Stage 2 PU on the sacrococcygeal (a joint form between the oval surface at the lower part of the spine and the tailbone) area measured 1.08 centimeter (cm) long by 0.48 cm wide 1.08 cm long by 0.48 cm wide. A review of Resident 1's Admission Minimum Data Set (MDS- an assessment tool) assessment, dated 12/26/2023, showed Resident 1 was cognitively intact and they required maximum assistance with toileting and bed mobility. The MDS assessment identified the resident admitted with a Stage 2 PU and was at a high risk for developing a PU. Review of Resident 1's wound evaluation form, dated 01/02/2024, Staff I documented Resident 1 had a Stage 2 PU on the sacrococcygeal area measured 8.96 cm long by 0.87 cm wide, a deterioration in their PU. Review of Resident 1's weekly skin inspection, dated 01/10/2024 completed by nursing, documented Right buttock PI [PU] measuring 2 cm by 1 cm. The body diagram on this form (Section B: Skin Impairments) was blank. The comment section documented to continue to monitor, continue with current treatment, and wound nurse following PU to the resident's coccyx and right buttocks. The skin inspection stated the resident now had two PU's (the coccyx PU was not measured). Review of Resident 1's wound evaluation form, dated 01/15/2024, Staff I documented the resident had a Stage 2 PU on the sacrococcygeal area measured 1.97 cm long by 0.68 cm wide. There was no assessment of the right buttock PU. Review of weekly skin inspection form, dated 01/17/2024 completed by nursing, documented Has pressure injury on buttock, measuring 2 cm by 1 cm. The body diagram on this form (Section B: Skin Impairments) was blank. The comment section documented to continue to monitor, continue with current treatment, and wound nurse following PU to the resident's coccyx and right buttocks, no new skin issues. Review of a progress note, dated 01/22/2024 at 8:43 PM (five days after the licensed nurse assessed the PU), Collateral Contact (CC) 1, contracted wound company's Physician Assistant Certified (PAC), documented Initial Visit, Resident 1 admitted to facility with a possible Stage 2 on sacrum, staff were concerned because the wound had deteriorated. Physical exam of wound showed DTPI on the sacrum measured 8.98 cm x 4.67 cm x 0.1. CC1 recommended a new treatment orders and air mattress for the resident's bed. Review of a progress note, dated 02/05/2024 at 7:47 PM, CC1 documented follow up assessment of a new wound that is deteriorating. CC1 documented Resident 1 had dementia, morbid obesity with impaired bed ability. Resident 1's wound was unstageable due to slough in lower left sacrum and coccyx that measured 8.98 cm by 4.67 cm by 0.02 cm. Treatment changes recommended included a low air loss mattress (the second time this was recommended by CC1) for pressure reduction. Review of Resident 1's wound evaluation form, dated 02/12/2024, Staff I documented the resident had an unstageable PU, present on admission, on the sacrococcygeal -middle measured 6.96 cm long by 3.06 cm wide (review of the picture taken there appears to be two separate PU's located on the resident's left buttock and coccyx). The PU was documented as a Stage 2 on admission and in fact had deteriorated to an unstageable PU. Review of the care plan, revised on 02/13/2024, to indicate the resident now has an actual unstageable PI (PU) to the coccyx that was present on admission and measured 1.08 cm by .48 cm (on 12/22/2023 the resident had a Stage 2 with the same exact measurements. The interventions were not updated, and the air mattress was not implemented on the care plan per CC1's recommendations on 01/22/2024 and 02/25/2024 (the resident was admitted with a Stage 2 PU on their coccyx not an unstageable PU). Review of the Significant Change in Status MDS Assessment 02/24/2024, showed Resident 1 had moderate cognitive impairment (a decline from their admission MDS), and they required maximum assistance with toileting and bed mobility. Review of the Care Area Assessment (CAA, a systematic process to interpret the triggered information from the MDS assessment to assess the potential problem and determine if the area should be care planned) 02/24/2024, showed Pressure Ulcer/Injury CAA was triggered related to Resident 1 needing increased assistance with activities of daily living including bed mobility, transfers, toileting, hygiene and having current skin issue and noted incontinence episodes- all increase the risk for pressure injury or exacerbation of current injury. CAA documented that Resident 1 needed a special mattress or seat cushion to reduce or relieve pressure and required regular schedule of turning, neither intervention was documented as implemented on the care plan. Review of a progress note dated 03/04/2024 at 4:36 PM, CC1 documented Resident 1 was seen for sacrum/coccyx PU. CC1 documented the resident had impaired bed mobility and was totally dependent for repositioning and offloading. Resident 1's wound was unstageable with most of the wound be covered in slough, measuring 6.67 cm by 2.44 cm by 0.0 cm. Further documentation showed that the resident needs a low air loss pressure reducing mattress (the third time the air mattress was recommended), as they were immobile and had poor bed mobility. In a late entry progress noted, dated 03/04/2024 at 2:36 PM, Staff I documented that Resident 1 was seen by CC1 today for an unstageable PU to their sacrum. Staff I documented the resident would be turned/repositioned while in bed with assistance from nursing staff and a low air loss mattress was started due to wound treatment. Review of Resident 1's wound evaluation form, dated 03/18/2024, Staff I documented the resident had an unstageable PU, present on admission, on the sacrococcygeal -middle measured 6.96 cm long by 3.06 cm wide (review of the picture taken by the facility show that the wound is one large wound now, with muscle and possible bone exposed). Review of a progress note dated 03/18/2024 at 8:21 PM, CC1 documented Resident 1 was seen for sacrum PU. Resident 1's wound was unstageable with most of the wound be covered in slough and eschar, measuring 8.4 cm by 4.7 cm by 5.4 cm. Further documentation showed that the resident required clinical debridement. Following debridement, the wound was staged as a Stage 4 on the sacrum with bone exposed. Review of a nursing progress note, dated 03/20/2024, showed Resident 1 was sent to the emergency room by facility after wound x-ray results indicated possible osteomyelitis. The resident did not return to the facility. Resident 1's diagnosis list was updated, dated 03/20/2024, to include a Stage 4 PU and osteomyelitis (infection of the bone) of the sacral region. In an interview on 04/30/2024 at 1:30 PM, Staff H, Maintenance Director, stated if residents need specialty equipment such as a lipped mattress (perimeter mattress), transfer pole, low air loss mattress etc., the maintenance department would be responsible to install those devices. Staff H stated they would not install anything unless directed by the proper person, such as an air mattress, nursing would need to assess the resident first and ensure that it was appropriate then maintenance would install it. Staff H stated there was a log maintained that tracked which residents have air mattresses. Staff H provided a copy of the log titled Equipment Rental, that showed an air mattress was placed for Resident 1 on 03/05/2024, 43 days after it was recommended by CC1. In an interview on 05/01/2024 at 1:30 PM, Staff C, Registered Nurse (RN)/Regional Nurse, stated they were familiar with Resident 1 and had reviewed their record recently. Staff C reviewed the progress notes of CC1 where they recommended an air mattress be placed on multiple occasions and stated they had recently spoke to the owner of the contracted wound company and were told by the owner that a low air loss mattress should not have been recommended for this resident but that the facility doctor should have been notified of the recommendation and given the opportunity to make a decision. Staff C then reviewed the log provided by maintenance showing that the air mattress for Resident 1 was not placed until 03/05/2024 and Staff C stated they had been asking for this log for a few days now and no one was able to give it to them. Resident 1 no longer resided in the facility and was not able to be interviewed. <RESIDENT 2> Resident 2 admitted to the facility on [DATE] with diagnoses including anemia, right femur fracture, dysphagia (difficulty swallowing), protein- calorie malnutrition (the body lacks enough protein and energy to function properly), and cognitive impairment. A review of Resident 2's Admission MDS assessment, dated 02/18/2024, showed Resident 2 had severe cognitive impairment, required extensive assistance from two staff with transfers, toileting, and bed mobility. The MDS assessment showed the resident admitted to the facility without PU/PI's. Review of the admission skin inspection form dated 02/12/2024, Staff J, LPN/Nurse Manager documented Resident 2 had a surgical incision on the right hip with a bruise from above the knee to the hip. The section with the body diagram was left blank. The form did not indicate that Resident 2 had any PU's present on admission. Review of Resident 2's care plan printed on 04/10/2024, showed a potential for alteration in skin/tissue integrity related to incontinence, created/initiated on 02/12/2024. On 03/14/2024 the care plan was revised to show Resident 2 had an actual skin alteration DTPI to the right heel. Interventions included to offload their heels or use Prevalon boots (a boot that provided continuous pressure relief) when in bed, created/initiated on 02/12/2024. Skin inspection done during CNA care opportunities, and to report changes to the Licensed Nurse (LN) created/initiated on 02/12/2024. The LN to perform weekly skin inspections to include review/check for footwear and report alterations as needed to the resident's provider, created/initiated on 02/12/2024. Right heel wound treatment orders (not specified), created/initiated on 03/14/2024 and Med pass (wound management/weight loss liquid supplement, created/initiated on 04/05/20204. Review of Resident 2's Skin Inspection Eval form, dated 03/11/2024, Staff J, LPN/Nurse Manager documented no new skin issues this week. The section with the body diagram was left blank. The form did not show that Resident 2 had any current PU's. Review Resident 2's Skin Inspection Eval form, dated 03/14/2024, Staff J, LPN/Nurse Manager documented Right heel worsening now deep purple in color. Family notified. Treatment in place. Off load heels while in bed. The section with the body diagram was left blank. The were no measurements of the PU on the form. During an observation on 04/08/2024 at 10:00 AM, Resident 2 was observed lying in bed on their back. The resident was noted to be on a standard mattress, heels resting directly on the mattress. The resident was not wearing foam boots. Attempted to interview this resident but they were unarousable at this time. Observation on 04/08/2024 at 1:40 PM, Resident 2 was in the same position as early in the day. There were no pressure relieving devices in place. Review of a Skin/Wound Eval form, dated 04/08/2024, documented Resident 2 had a DTPI on the right heel and was documented present on admission. The PU measured 4.2 cm long by 3.6 cm wide. The form had a section where the resident's physician and family were to be notified of the new skin alteration, this section was left blank. During an observation on 04/10/2024 at 9:40 AM, Resident 2 was observed lying in bed in the supine (on back) position, asleep unable to arouse. There were no pressure relieving devices in place at the time of this interview. At 11:45 AM, Resident 2 remained lying in bed, with the head of bed slightly elevated. The residents' feet/legs were positioned directly on the mattress with no pressure relieving devices in place. At 3:10 PM, returned to room for follow up observation and the resident remained in bed, asleep and was observed to be wearing light blue heel protector boots on bilateral feet. Review of Resident 2's clinical record on 04/11/2024, showed that on 04/10/2024 at 12:48 PM, during the facility skin sweep of all residents, Resident 2 was found to have additional wounds not identified during the skin inspection completed on 04/08/2024. Staff I identified a DTPI on the lateral (to the side of, or away from, the middle of the body) right foot, measuring 7.64 cm x 2.18 cm (in-house acquired) and a DTPI on the left heel, measuring 3.16 cm x 2.32 cm (in-house acquired). <RESIDENT 3> Resident 3 admitted to the facility on [DATE] with diagnoses including bipolar disorder, diabetes mellitus, polyneuropathy (the simultaneous malfunction of many peripheral nerves throughout the body), and anemia. A review of Resident 3's' Quarterly MDS assessment, dated 02/27/2024, showed Resident 3 was cognitively intact, required partial/moderate assistance from staff for bed mobility and had no PU/PI's present. Review of Resident 3's weekly skin inspection form, dated 03/25/2024, Staff K, RN, documented the resident had no skin issues/injuries noted on their arms/legs or feet. Review of the Skin & Wound evaluation, dated 04/01/2024, Staff I, documented Resident 3 had a DTPI on the right heel, was present on admission, and measured 2.4 cm x 1.3 cm, with 100% black eschar covering the wound. The evaluation form did not indicate if the resident physician and family had been notified. Review of weekly skin inspection form, dated 04/02/2024, showed Resident 3 had no skin issues present, arms/legs/feet were clear (this form was completed a day after the DTPI was noted on the resident's right heel). In an interview on 04/08/2024 at 8:32 AM, CC2, Resident 3's family member, stated they were at the facility on 03/31/2024 to visit with the resident for Easter. CC2 stated they went a little early to the facility to help the resident get ready before other family members showed up. CC2 stated when they were helping Resident 3 put their socks on and asked for Neosporin (an ointment). CC2 asked what they needed that for, and the resident stated, For my foot and showed CC2 their right heel. CC2 stated there was a huge black sore on their heel that they had never seen before, stating What the h*ll is that? CC2 went out to the nurse on duty and told the nurse they needed a bandage on Resident 3's foot, and the nurse tried to hand them a Band-Aid. CC2 stated that they laughed and asked, What is that going to cover, [Resident 3] has a huge wound on her foot, you need to come look at it. CC2 was very upset at finding the sore stating These people get paid a lot of money to care for people, they get one shower a week and then they don't even know she has this huge sore on her foot, it's just not right. I don't want them to just sit in this place, keep getting sores because they aren't getting care, then die there, I am trying to get her moved out of there to an adult family home. During an interview/observation on 04/08/2024 at 9:35 AM, Resident 3 was lying in bed in a supine position. The resident was not observed to have any pressure relieving devices in place. The resident's feet were noted to be bare, with a gauze type dressing wrapped around the right foot. The resident stated they have a sore on their right foot and was unsure for how long they had the sore, stating it really hurts sometimes and thought the nurse changed the dressing three times a week. Resident 3 stated they do not have any kind of boots they wear on their feet, usually they wore just socks. Observation on 04/09/2024 at 1:50 PM, Resident 3 was observed self-propelling their wheelchair and wearing socks. The resident returned to their room, got into their bed, and there no pressure relieving devices present on their bed or in the room. Review of the current care plan, printed on 04/10/2024, showed a focus area of potential for alteration in skin/tissue integrity related to a scabbed area right knee, and history of moisture associated dermatitis. Interventions in place as of 11/21/2023 included: - Needs assistance to apply protective garments (specify: geri-sleeves, a protects sensitive thin skin on the resident's arms, Tubigrip (fabric that provides continuous support) legs, Prevalon boots, etc.). - Offload heels or use Prevalon boots when in bed. - Skin inspection during NAC care opportunities, report changes to LN. - Weekly LN skin inspections to include review/check footwear. Report alterations as indicated. On 04/10/2024, Resident 3's alteration in skin/tissue care plan was updated to include an actual alteration in skin integrity regarding a PU to the right heel. Interventions included to off load the resident's heels when in bed, Registered Dietitian would monitor and evaluate the resident's nutritional intake and condition of their wound and make recommendations as indicated. On 4/11/2024, an intervention was added to encourage Resident 3 to float their heels when in bed, assist the resident when they need help, and the resident required consistent reminding to continue to float their heels. Observation on 04/10/2024 at 9:15 AM, Resident 3 was observed lying in bed, sleeping in the fetal position. The resident was observed with a dressing in place on the right foot, and there was no pressure reliving devices observed on their feet or in their room. During an interview and observation on 04/10/2024 at 9:30 AM, Staff K, RN, stated they were the nurse for Resident 3 today. Staff K stated the resident currently had a PU on their right heel and the interventions in place included dressing changes and offloading their heels. Staff K stated they thought they had tried to have the resident wear pressure relieving boots at one point but stated Theres no way they would wear those. Staff K stated the resident did not have Prevalon boots in the room and doesn't remember ever seeing those type of boots in this facility. At 9:40 AM, Staff K was observed to change the resident's dressing to their right heel. Resident 3 complained of pain in the right foot during the dressing change, that went unaddressed by Staff K. Staff K stated the facility had a wound nurse and that was how wounds were assessed to determine progression or deterioration of the wound, stating we just change the dressings, do the treatments, and were not responsible to measure anything. The wound appeared to be the approximate size of a golf ball and was solid black/brown in color. The edges around the wound were noted to be red in color and appeared irritated. Staff K stated that the wound looked the same the last time they saw it. In an interview on 04/10/2024 at 12:25 PM, Staff B, RN/Director of Nursing (DNS), stated that the expectation for staff who find new skin alterations is to complete a Skin alteration incident investigation (Risk Management). Staff B was asked to provide the investigations for Resident's 2, and 3's in house skin issues and they stated that they had not been completed. Staff B stated that they would be completing investigations now for both residents and would get them to me tomorrow. Staff B was asked if a resident admitted with a skin issue that deteriorated while in the facility would they expect an investigation and they stated Yes. Staff B reviewed the completed skin inspections from 04/01/2024 and 04/02/2024 and was unable to provide any information regarding the skin check on 04/02/2024, completed by Staff L, documented the resident did not have any skin issues/PI on their feet, stating, They [Staff L] are going to be upset that they missed that, referring to Staff L completing a skin check and not documenting that Resident 3 had a PU on the right heel. Review of the facility's skin investigation dated 04/10/2024 at 12:39 PM, Staff B documented the report was completed due to worsening of Resident 3's right heel wound, initially not completed on 04/01/2024 when staff noted a deterioration in wound status. < RESIDENT 4> Resident 4 admitted to the facility on [DATE] with diagnoses including protein-calorie malnutrition, dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) without behaviors, Alzheimer's disease, and dysphagia. Review of the Admission MDS assessment, dated 02/23/2024, showed Resident 4 had severe cognitive impairment and had no PU/PIs on admission. Review of Resident 4's weekly skin inspection forms showed the following: -On 02/18/2024 (admission to the facility), both of the resident's feet were purple, blanchable, and were that the resident's baseline. - On 03/21/2024 and 03/28/2024, there were no skin issues noted. - On 04/05/2024 and 04/11/2024, showed a right heel wound was identified, there was a treatment in place, and there were no measurements of the wound (the section with the body diagram was left blank). Review of Skin & Wound Evaluation, dated 04/08/2024, showed Resident 4 had a Stage 3 right heel PU. The evaluation showed the PU was present on admission (per the weekly skin inspections the PU developed on 04/05/2024 after the resident admitted to the facility) to facility and measured 2.3 cm x 2.3 cm x 1.3 cm. Observation on 04/16/2024 at 12:50 PM, Resident 4 was observed sitting up in their wheelchair, wearing only non-skid socks on their feet. Observation on 04/16/2024 at 3:10 PM, Resident 4 was noted to be lying in bed with their heels lying directly on the mattress. There was a blue boot and two pillows on the chair in their room, but no pressure relieving devices were observed in place. Observation on 04/19/2024 at 2:14 PM, Resident 4 was lying in bed watching TV. The resident's heels were lying directly on the mattress, and no pressure relieving devices were in place. Observation on 04/22/2024 at 7:44 AM, Resident 4 sitting in their bed, with their legs extended out directly on the mattress, wearing non-skid socks on both feet, no pressure relieving devices were observed in place. Observation on 04/22/20204 at 9:30 AM, Resident 4 was sitting up in their wheelchair in their room, there were no protective heel boots observed on the resident feet or in the room. During an observation/interview on 04/22/2024 at 11:25 AM, CC1 stated Resident 4 currently had a PU on their right heel but was unsure if they admitted with it or if it was acquired in the facility. CC1 removed an undated dressing on the right heel. The wound appeared as red tissue, no yellow tissue noted. At the time of the observation the measurements were 2.4 cm long by 1.7 cm wide and 0.2 cm deep. CC1 stated interventions in place currently for Resident 4 included heel prep to the right heel and foam boots on both of their feet when up in a chair or in bed. CC1 asked Staff M, RN/Nurse Manager, if the resident had protective boots available and Staff M opened the residents closet and stated, there are some in the closet and closed the door. Staff M was asked if Resident 4 refused to wear the boots and they stated, not that I have seen. After CC1 and Staff M completed the residents wound treatment, they exited the room and did not attempt to place the protective boots on the resident. During a joint record review/interview on 04/22/2024 at 12:43 PM, Staff B reviewed the current care plan for Resident 4 and stated interventions in place currently included to check the resident's footwear and complete weekly skin inspections. Staff B reviewed the physician orders and stated an intervention in place included to elevate the resident's heels when in bed, started on 03/17/2024. Staff B stated their expectation for Resident 4's protective boots were that Staff M should have removed them from the closet and placed them on the resident before leaving the room. Refer to WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to consistently implement care plan interventions related to bed height and mattress type to prevent accidents/falls for 1 of 1 sample resident (Resident 7) reviewed for falls and accident hazards. Resident 7 experienced harm when they fell out of bed and sustained a left hip fracture (broken bone), pain, and required hospitalization . These failures placed residents at risk for potential falls, injuries, and a decreased quality of life. Findings included . Review of the facility's policy titled, Fall Response & Management, revised on 05/17/2021, showed for a fall with injury, staff should avoid moving the resident their status is fully evaluated to prevent further injury if an injury occurred as a result of the fall. Staff were to evaluate the resident's limb strength and motion. Don't perform range of motion (ROM) exercises if a fracture is suspected or if the resident complains of any odd sensations or limited movement. Review of the facility policy titled, Accidents and Supervision to prevent accidents, revised on 10/15/2022, showed the facility provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents. The facility monitors to verify interventions are in place and effective and is to ensure that interventions are implemented correctly and consistently. Resident 7 was admitted to the facility on [DATE] with diagnoses to include vascular dementia (a general term for problems with reasoning, planning, memory, and other thought processes cause by brain damage from impaired blood flow to the brain) with behavioral disturbance, history of stroke, atrial fibrillation (a fast irregular heart rate) with long term use of blood thinners and history of falls. The resident was readmitted to the facility on [DATE] with a diagnosis of a left femur fracture. A review of Resident 7's activity of daily living (ADL - includes activities such as dressing, transfers, bed mobility, walking/locomotion, bathing personal hygiene, toileting and eating) care plan, dated 06/20/2022, showed Resident 7 was a two-person extensive assist for bed mobility, transfers, dressing, and toileting. Review of Resident 7's care plan, printed on 04/10/2024, showed a focus of impaired mobility with risk for falls, and actual fall with fracture on 03/17/2024. Interventions included to keep the bed in a position (care plan did not specify the position) for safe transfers and lock bed brakes, initiated on 06/20/2022. A perimeter mattress (a type of mattress to create a raised edge and defines the perimeter for enhanced fall prevention without using restraints) to assist resident in clearly identifying the edge of their bed, initiated on 11/18/2023. The care plan did not show updates/changes being done after Resident 7 sustained a fall with fracture on 03/17/2024. Review of the facility incident reporting log, dated 03/17/2024 at 12:05 AM, showed Resident 7 sustained an unwitnessed fall in their room. The facility documented in the reporting log the fall resulted in a fracture. Review of the facility's investigation for Resident 7's fall on 03/17/2024, showed Staff D, Registered Nurse (RN), documented the resident was found lying on the floor on their left side and the bed was in the high position. Staff D documented Resident 7 stated I fell out of bed. Staff D documented Resident 7 was unable to move their left leg, complained of left groin pain, and had a skin tear to their left elbow. Staff D documented Resident 7 was assisted into bed with a Hoyer (a type of mechanical lift device) lift, the provider was contacted, and gave orders to send the resident to the emergency room to rule out a possible fracture. Staff D documented that 911 was called and Resident 7 was sent to the hospital. Review of Resident 7's clinical record showed a form titled Acknowledgement of Physical Restraint Use, a consent for the use of a scoop (perimeter) mattress dated 11/21/2023. Review of a nursing progress note, dated 03/18/2024 at 10:04 AM, showed the Interdisciplinary Team (IDT)) met to review Resident 7's recent fall with injury that occurred on 03/17/2024. The progress note showed Resident 7 reported they were self-transferring when they fell . Observation on 4/10/2024 at 11:40 AM, Resident 7 was observed sitting in their wheelchair next to the bed. A standard mattress was observed on the bed. There was a blue fall mat (a safety feature that is placed on the floor along the side of the bed) on the floor next to the left side of the resident's bed. In a joint observation/interview on 04/10/2024 at 1:56 PM, Staff F, Certified Nursing Assistant (CNA), stated they found specific resident information on the Kardex (care plan for nursing assistants). Staff F entered Resident 7's room and observed the mattress in place stating, This is the mattress that has always been on their bed. Staff F stated the mattress in place was a standard mattress not a perimeter mattress. Staff F stated they thought Resident 7's fall interventions in place included a fall mat at the bedside and low bed (a bed that was able to go to the floor) because that's what was in their room currently. Review of Resident 7's Kardex, dated 03/22/2024, showed under the section Safety/Falls to keep the adjustable bed in position for safe transfers, and lock the brakes. The Kardex did not indicate that a perimeter mattress was on the bed, the bed should be kept in the low position, or fall mat was in use. In an interview on 04/10/2024 at 2:25 PM, Staff E, RN, stated they were aware that Resident 7 had fell and sustained a left hip fracture. Staff E stated they were unsure where to find resident's fall intervention information but I would just use common sense. Staff E observed the resident's mattress and stated, That is a regular mattress, not a perimeter mattress. In an observation on 04/22/2024 at 7:35 AM and on 04/24/2024 at 9:39 AM, Resident 7 was observed lying in bed, with a standard mattress in place, a blue fall mat on the left side of the bed and the bed was in the low position. In an observation on 04/30/2024 at 1:26 PM, Resident 7 was observed in lying in bed with no perimeter mattress in place. A blue fall mat was folded up by the door, the bed was positioned approximately three to four feet off the ground, and not in a low position. In an interview on 04/30/2024 at 1:35 PM, Staff H, Maintenance Director, stated the facility owns their own perimeter mattresses, but they do not maintain a log for them. Staff H was unable to state if Resident 7 had a perimeter mattress in place but did not think they did. Staff H stated the maintenance department was notified verbally by nursing when a perimeter mattress needed to be placed for a resident. In an interview on 05/01/2024 at 11:57 AM, Staff E stated if a resident had a fall, complained of pain, and unable to move during assessment, they would not move the resident, and would call 911. Staff E stated that Resident 7 was physically unable to operate their bed controller, staff assist them with raising and lowering their bed. In an interview on 05/01/2024 at 12:11 PM, Staff G, CNA, stated the resident was not physically able to independently adjust their bed using the bed controller, stating I do it for them. Staff G stated resident specific fall interventions would be listed on the Kardex. In an interview on 05/01/2024 at 1:30 PM, Staff C, RN/Regional Nurse Consultant, stated if a resident complained of pain in the left lower extremity and groin during an assessment after a fall, the resident should not have been moved and 911 should have been called. This is a repeat citation from survey dated 05/24/2023. Refer to WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to consistently recognize and respond to complaints of pain and failed to consistently implement wound care recommendations related to pain management in accordance with professional standards for 1 of 3 sampled residents (Resident 55) reviewed for pain management. Resident 55 experienced harm when nursing staff failed to recognize and respond to complaints of pain and failed to implement wound care recommendations related to pain management. This failed practice placed residents at risk for unmanaged pain and a diminished quality of life. Findings included . Resident 55 admitted to the facility 06/30/2023 with diagnoses which included diabetes, history of bleeding in the brain, and throat cancer. The resident required extensive assistance for activities of daily living and was alert with some memory impairment but was able to communicate and respond appropriately to questions such as describing their pain level and location. Review of Resident 55's electronic medical record, dated 10/21/2023, showed the resident developed a pressure wound (pressure ulcer is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device.) to the left ankle in a previously healed area. Review of Resident 55's Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 01/06/2024, showed the resident pain interview and assessment were not completed as required. The resident's interview was marked not assessed, and there was no update related to pain management in the resident care plan. Review of Resident 55's weekly wound consultant notes, dated 10/21/2023 to 02/05/2024, showed the resident was referred to a wound consultant group who provided onsite weekly visits for wound management. The wound consultant notes showed the resident's complaints of pain were not consistent some visits the resident had no pain observed, and other visits the resident reported mild or moderate pain during assessment and treatment. The orders for wound care for the resident's left ankle wound were three times per week and as needed. Each visit note included the recommendation to administer pain medication 30 minutes prior to wound treatment; to please administer as needed (PRN) pain medication and/or topical anesthetic. Review of the current February 2024 physician orders, showed Resident 55 had an existing order for gabapentin (used to treat nerve pain), start date 06/30/23, scheduled to be given routinely three times per day at 8:00 AM, 2:00 PM and 8:00 PM, for nerve related pain and had orders for additional pain medication for breakthrough pain. An order for Tylenol (non-narcotic medication) PRN for mild breakthrough pain, and tramadol (a narcotic pain medication), with a start date of 07/11/2023, PRN for moderate to severe breakthrough pain. Review of Resident 55's Medication Administration Record (MAR), dated 02/01/2024 to 02/07/2024, showed the resident received no doses of PRN medication. The MAR did not include the wound recommendations to premedicate the resident prior to wound care. In an interview and observation on 02/04/2024 at 10:15 AM, Resident 55 pointed to their left foot and said their ankle hurt. They said they thought they could take something for pain but didn't know what it was. The resident replied I don't know to any further questions asked. In an observation on 02/05/2024 at 3:02 PM, Resident 55 was heard from the nurse's station calling out from their room stating hey, hey, my foot hurts .bad. In an observation and interview on 02/06/2024 at 1:16 PM, Resident 55 was calling out hey, hey, Staff M, Licensed Practical Nurse, went to the resident's room with their 2:00 PM gabapentin. The resident was observed to point to their left foot with a furrowed brow and say to Staff M, this d*** foot. Staff M stated, I know it is hurting and I am waiting to see if the wound nurse can come, otherwise I will do it (the dressing change) .I have until 10:00 PM to do it. Staff M did not ask further questions or further assess the resident's statement about their foot, did not offer the resident any breakthrough pain medication and left the room. Staff M stated the resident was just given their pain medication and stated the resident had nerve pain. Observation on 02/06/2024 at 1:26 PM, Staff H, Nursing Assistant Certified (NAC), and Staff Q, NAC, responded to Resident 55 calling out Hey, Hey, I need some help now. The resident was heard to state to the staff, this damn foot hurts, and Staff H and Q both stated (while standing in the hall outside of the room), the resident called out like this when they want to be moved. When asked if the resident ever stated they were having pain, Staff H stated the resident, doesn't usually . they will just say they want to be moved and stated they would tell the nurse if the resident was complaining about pain. Review of the Treatment Administration Record (TAR) for 02/06/2024 day shift (6:00 AM through 2:00 PM), showed Staff M documented Resident 55's pain level as a zero and the resident received no PRN pain medication on 02/06/2024. In an interview on 02/07/2024 at 12:37 PM, Staff N, NAC, stated Resident 55 sometimes complained about their foot hurting, I think it hurts a lot sometimes, but they don't really ask, they don't use the call light, but they will just call out and want to be moved, they will say their foot hurts or their bum hurts. We tell the nurse, and the nurse can give them medicine but [the resident] won't ask will just say they want help. In an interview on 02/07/2024 at12:43 PM, Staff O, Registered Nurse (RN), stated Resident 55 does best with yes or no questions, and stated when they asked the resident about their pain, they usually just shook their head no. I have not given them anything, nobody reported to me that they were having pain. Staff O stated the resident called out rather than using their call light. In an observation of wound care on 02/07/2024 at 2:30 PM, with Staff P, LPN/facility wound nurse, Resident 55 stated they were having pain to their left foot. Staff P asked the resident to rate their pain on a scale of zero to 10 (zero being no pain and 10 being severe), and the resident said 10. Staff P stated, that is a lot, and stated they had checked with Staff O and Staff O had given the resident their PRN pain medication. Staff P stated sometimes the resident complained of pain and sometimes not, but they were not always aware whether the resident had been pre-medicated unless they went to ask the nurse. Staff P stated they were present when the wound consultant rounds were done weekly and reviewed the notes. Resident 55 was observed to wince during cleansing of the ankle wound which was observed to be a small open area, about the size of a pea, over the bony prominence of the ankle and the surrounding tissue was pink. The resident stated, it hurts when you touch it like that. Record review showed Resident 55 had received PRN Tramadol at 2:00 PM on 02/07/2024. In an interview and observation on 02/08/2024 at 10:22 AM, Staff E, LPN/Resident Care Manager, stated Staff P was responsible for reviewing and implementing the orders and recommendations from the wound consultant visits and was not aware there were recommendations to premedicate Resident 55 had not been implemented. Staff E was not aware the resident was having complaints of pain which were not being recognized or assessed by the nursing staff. Staff E stated the residents PRN used to be routine, but they were not having complaints of pain and did not want it anymore, so it was changed to as needed, maybe something is changed. Staff E walked to the Resident 55's room where Staff E asked the resident how they were doing and if they had any pain. The resident stated, not really .except for that ankle and pointed to their left foot. Staff E was observed to ask the resident further probing questions about their pain and touched the resident's lower leg, foot and around the ankle where the bandage was in place and the resident stated, it hurts under there, it throbs all the time. Staff E asked if it was better after they had received a pain pill, and the resident stated they thought so. Staff E stated they would notify the provider the resident was having increased complaints of pain and would update the resident record with the wound recommendations and to increase the frequency the staff was monitoring the resident's pain to every four hours. Review of Resident 55's current pain monitor, dated 02/01/2024 to 02/07/2024, showed the monitor was set up for twice per day in the day and evening. Each of the day shift entries for the month of February were 0, except 02/04/2024, which was documented as a 2. The evening entries showed 02/01/2024, a 1, and 02/02/2024, a 2, and the remaining entries were 0. In an interview on 02/08/2024 at 11:53 AM, Staff C, RN/Director of Nursing Services, stated there should be coordination between the floor nurses and the wound nurse if staff were to premedicate 30 minutes before a resident's treatment, so they needed to know when the wound nurse was coming. The wound notes were in the progress notes section of the medical record and there was no way to acknowledge it, but the wound care nurse would stop in, we would talk, and Staff P lets me know directly after the wound rounds if there were new orders or recommendations but stated they did not personally double check that the record was updated. Staff C was informed of the concern related to lack of recognition, further assessment, and intervention of Resident 55's complaints of pain and Staff C stated they would provide education right away. This is a repeat citation from survey dated 03/24/2023. Refer to WAC 388-97-1060 (1)

Based on interview, and record review the facility failed to protect a cognitively impaired resident from unwanted touch for 1 of 1 resident (Resident 2) reviewed for sexual abuse. Resident 2 experienced psychosocial harm, based on a reasonable person concept, when they received a non-consensual sexual touch from Resident 1, who had been identified in the past of inappropriate behaviors and sexually suggestive statements with female staff and a history of wandering into Resident 2's room on multiple occasions. The facility failed to identify an incident of sexual abuse, report it timely to the state agency, and potentially placed cognitively impaired residents at risk for unwanted sexual touch and psychosocial harm. Findings included . Review of the facility policy titled, Abuse, revised on 08/01/2023, showed the facility respects the resident right to be free from abuse and neglect. The facility identifies residents most at risk of neglect and abuse. The policy also showed that allegations of sexual abuse are reported to the state agency within two hours if there was alleged abuse or serious bodily injury as a result of an event. Review of the online incident report submitted by the facility to the state agency, dated 10/16/2023 at 9:43 AM, showed After review of documentation from the event on 10/14/2023 the interdisciplinary team decided this even was a reportable situation. The report showed the date and time of this incident occurred on 10/16/2023 at 9:30 AM, almost 48 hours after the allegation of sexual abuse had occurred. Review of a facility incident investigation, dated 10/14/2023, showed Staff D, Nursing Assistant Certified (NAC), observed Resident 1 with their hand up Resident 2's shirt. Staff D removed Resident 1 from the room and notified the nurse. The summary of the investigation showed the interventions implemented after the incident included a room move was completed for Resident 1 (which occurred on 10/16/2023, two days after the incident), both residents were placed on alert charting (not completed until 10/18/2023). Review of each resident's medical record showed no documentation indicating these interventions were implemented timely. <RESIDENT 1> Resident 1 was a long-term care resident of the facility with diagnoses to include major depressive disorder, cognitive communication deficit, cerebral ischemia (brain injury) and mild cognitive impairment. According to the Quarterly Minimum Data Set (MDS - assessment tool) assessment, dated 09/05/2023, the resident had moderate cognitive impairment and required supervision with mobility in their wheelchair (w/c). Review of Resident 1's behavior progress notes showed: - On 09/24/2022, the resident made a statement about another female resident being their spouse. No other inappropriate behavior noted at this time. - On 12/31/2022 at 2:10 PM, the resident was redirected out of another resident's room twice this shift. Resident found sitting next to female resident and making statements that they believe the female resident was their wife. - On 01/07/2023 at 11:07 AM, the resident had increased agitation with staff when trying to redirect them from another resident's doorway (Resident 2). Resident 1 believed Resident 2 was their spouse. Resident 1 was noted sitting outside of Resident 2's room and trying to enter when staff were not around. Documentation showed, when Resident 1 seen a male staff member enter Resident 2's room they made threatening comments to the staff stating they would kill them. - On 01/27/2023 at 8:21 AM, review of a physician note, Resident 1 touched them inappropriately during their meeting and the facility had reported the resident pulled a staff member into their bed. - On 10/14/2023 at approximately 10:15 AM, Resident 1 went into Resident 2's room and the aide witnessed Resident 1 putting their hand up Resident 2's shirt. Review of Resident 1's care plan showed: - Focus problem, created on 01/27/2023, of the potential to demonstrate verbally and physically inappropriate sexualized behaviors towards staff related to poor impulse control. Interventions included analyze key times, places, circumstances, triggers and what de-escalates Resident 1's behavior and document; if the resident becomes agitated and begins inappropriate conversation, intervene before agitation escalates, if response was aggressive, staff should walk calmly away and approach later. - Focus problem impaired cognitive function or impaired thought processes, created 10/18/2023 (four days after the inappropriate touching incident on 10/14/2023), related to difficulty making decisions, impaired decision making, long and short-term memory loss. Interventions included room move completed to assist in deterring Resident 1 from entering the female resident's room they mistake as their wife; Resident 1 has history of mistaking another female resident for a member of their family, during these events redirect resident away from the female resident, ensure both residents are safe and attempt to re-orient to current situation. - Focus problem elopement risk/wanderer, created on 11/03/2023 (20 days after the wandering and sexual abuse incident on 10/14/2023), as evidenced by decreased cognition, decreased safety awareness, and history of wandering. Interventions included address wandering behavior by walking with or attempt to redirect from inappropriate area; engage in diversional activity; distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book. Observation on 12/12/2023 at 12:30 PM, Resident 1 was sitting in their w/c in their room. Resident 1 was not able to answer questions that were asked. <RESIDENT 2> Resident 2 was a long-term resident of the facility with diagnoses to include cerebral palsy (disorder resulting in impaired muscle coordination), quadriplegia (paralysis affecting all limbs of the body), and cognitive communication deficit. According to the Quarterly MDS assessment, dated 11/02/2023, Resident 2 had severe cognitive impairment and required extensive assistance from staff for all activities of daily living. Review of Resident 2's progress notes, dated 10/14/2023 through 10/18/2023, showed no psychosocial monitoring had been documented by facility staff for the resident following the allegation of sexual abuse on 10/14/2023. On 10/18/2023 at 12:16 PM, four days after the incident, Staff B, Registered Nurse (RN)/Chief Nursing Officer (CNO), documented they completed a visual observation of Resident 2 related to the incident with a male resident on 10/14/2023, no signs or symptoms of psychosocial distress noted. Observation on 11/28/2023 at 11:10 AM, Resident 2 was observed in their room in their w/c and was unable to be interviewed. During an interview on 12/12/2023 at 1:30 PM, Staff C, RN, stated they were the nurse on duty at the time of the incident between Resident 1 and Resident 2 on 10/14/2023. Staff C stated Staff D had notified them Resident 1 was in Resident 2's room and had their hand up Resident 2's shirt. Staff C stated they separated the two residents immediately and kept Resident 1 near the nurse's station for the remainder of their shift but was unsure as to when Resident 1's room was changed but that they did not handle the room change at the time of the incident. Staff C stated they notified facility management and the families but did not report it to the state hotline and had not realized at the time it needed to be reported. Staff C stated they thought they had put both Resident 1 and Resident 2 on alert charting and was unable to state why neither resident had been placed on psychosocial monitoring following the incident of non-consensual touching on 10/14/2023. On 12/12/2023 at 2:00 PM, Resident 2 was observed in bed making loud noises and unable to be interviewed. During a joint interview/record review on 12/12/2023 at 3:00 PM, Staff B stated when there was an incident that involved non-consensual touch between two residents their expectation was to protect the residents first and then the incident should be reported to the state immediately. Staff B stated Staff C was a fairly new nurse and was unsure about the reporting process of this specific incident. Staff B stated after this incident they had became aware there was a history of inappropriate behaviors with Resident 1 and that this was not the first time they had been found in Resident 2's room, but it was before they worked at the facility. After review of both Resident 1 and Resident 2's clinical records, Staff B was unable to show documentation that either resident had been monitored by facility staff after this incident, stating I had the Nurse Practitioner (non-employee of facility) see both residents on 10/16/2023. Staff B was unable to provide additional information about the delay in reporting to the state agency, the delay in moving Resident 1's room until 10/16/2023, or the delay in updating/revising the care plans of either resident until 10/18/2023. Refer to WAC 388-97-0640(1)(5)

Based on interview and record review, the facility failed to permit a resident to return (re-admit) to the facility for 1 of 1 sampled resident (Resident 2), reviewed for transfer to the hospital when the resident was ready to return to the facility after a hospital stay. Resident 2 experienced harm and a decreased quality of life when they expressed unnecessary psychosocial distress when the resident was not permitted to return to the facility where she had lived since June 2023, and felt they had nowhere to safely discharge. Findings included . Review of the facility's policy, Transfer and Discharge, revision date 10/15/2022, showed residents who are sent emergently to the hospital are considered facility-initiated transfers because the residents return is generally expected. The facility allows residents whose hospitalization exceeds the bed-hold period under the State plan to return to the facility immediately upon first availability of a bed in a semi-private room even if the resident has an outstanding Medicaid balance, if the resident requires the services provided by the facility, and is eligible for Medicaid nursing facility services. Resident 2 was admitted to the facility on [DATE] with diagnoses including colon cancer, chronic pain syndrome, anxiety disorder, major depressive disorder, and sepsis (infection in the bloodstream). Review of a facility form titled, Brief Interview of mental status, dated 09/20/2023, showed Resident 2 was cognitively intact. Review of Resident 2's progress note, dated 09/23/2023, showed the resident was sent to the emergency room (ER) for complaints of uncontrolled pain. The resident stated they wanted to go and make sure everything was ok as they were supposed to start chemotherapy (chems - a drug treatment that uses powerful chemicals to kill fast-growing cells in the body) the following day. Review of a progress note, dated 09/24/2023, Staff C, Admission Coordinator, documented Received a call from resident they will remain in the hospital for several days, offered a bed hold and Resident 2 stated they could not afford to pay the bed hold fee but would like to return to the same bed. Review of the hospital discharge planner communication documentation between the hospital and the facility, dated 09/25/2023 at 9:39 AM, showed the hospital declined Resident 2 to return to the facility. The facility's reason was Per nursing we cannot accept patients on Chemotherapy. Review of a progress note, dated 09/26/2023, showed Staff D, the prior Social Services Director (SSD), documented they had spoken with Resident 2 and the resident reported being told they could not return to the facility if they were receiving chemo (chemo) due to infection control and safety issues. Staff D stated they informed Resident 2 they would not be able to receive chemo while a resident in any skilled nursing facility (SNF) and suggested the resident look for placement at an adult family home (AFH). Staff D documented the resident verbalized understanding of this and felt they would be returning to the facility in a few days. Review of hospital progress note, dated 10/11/2023, showed Collateral Contact 1 (CC1), hospital discharge planner, documented speaking with Staff C about Resident 2 returning to the facility. Staff C reported they were unable to accept the resident back due to neutropenic (a condition that lowers white blood cells in the body making the person more prone to infections and bacteria) precautions and the cost of chemo. CC1 explained the resident would only need chemo once a month and would be receiving that at the cancer clinic and transportation would also be arranged. Staff C reported the facility was still unable to accept the resident back after receiving this information. During a telephone interview on 10/24/2023 at 10:15 AM, CC1 stated Resident 2 was currently inpatient at the hospital as the facility refused to re-admit the resident after sending them to theER on [DATE]. CC1 stated the hospital communicated with the facility on 09/24/2023 to discuss them re-admitting the resident once able, but they were told that the facility would not be able to take the resident back due to them receiving chemo, and the facility would not want to pay for the chemo treatments. CC1 stated they explained to the admission coordinator the resident would be receiving their chemo treatments at an outside facility, and it would not cost the facility anything and they had even scheduled transportation to and from the appointments. CC1 stated the admission coordinator said they did not have a neutropenic room for the resident to stay in, and CC1 then explained that was not a requirement for this resident, but the facility continued to refuse admission after receiving this information. CC1 stated after this facility refused to take the resident back, they began looking for another facility and the resident was currently on a waitlist for another local SNF. Review of a hospital discharge planner note, dated 10/30/2023, showed Resident 2 cannot return to the facility due to refusing to accept pt [patient] back. Resident 2 was currently on a wait list for another SNF, and currently had an option of discharge to a trailer on a friends property. At 4:03 PM, showed an updated note that the friend, who was at the resident's bedside, could offer the trailer, expressed concerns the resident would be alone in the trailer, could not provide any medical or activities of daily living care needs (dressing, toileting, bathing, etc.), and would like a back-up plan for Resident 2's discharge. During an interview on 11/03/2023 at 12:30 PM, Staff C stated they were familiar with Resident 2, and they had accepted the resident back to the facility, but the hospital never sent additional requested information over. Staff C was unable to provide any documentation in the resident's clinical record to confirm these interactions/conversations with the hospital, stating I do not document all communications with the social workers at the hospitals, that's impossible. Staff C stated the last thing they remember seeing in EPIC (hospital health information site) was Resident 2 was waiting for an available bed at another facility and was unable to access the resident's record through EPIC at the time of this interview. During an interview on 11/08/2023 at 11:47 AM, CC2, Resident 2's family member, stated the resident really wanted to return to the facility since they had been there since June 2023, they really liked being there. CC2 stated Resident 2 was very upset about not being allowed to return and felt it was because they would be starting chemo. CC2 stated this whole situation caused a lot of stress to Resident 2 as they felt they had nowhere to go, and they felt the only option they were going to have would be to discharge to a trailer on a friend's property with no assistance and that was not a safe option. CC2 stated that Resident 2 was still in the hospital is actively passing away at the time of this interview. CC2 the facility never notified them regarding Resident 2 being sent to the hospital, it wasn't until the hospital called them that they knew Resident 2 had been admitted . During an interview on 11/08/2023 at 3:30 PM, Staff A, Executive Director, stated to their knowledge the facility can admit residents to the facility that received chemo outside of the facility. Staff A stated they were new to the facility, and it was discovered shortly after they started the previous admission coordinator was denying a lot of admissions. Staff A stated, We do not deny people, we are here to work with the hospitals and should be able to care for most residents, obviously there are a few conditions we are not equipped to handle like ventilators or in house chemotherapy. Staff A was unable to provide any further information as to why Resident 2 was denied re-admission to the facility but agreed they should have been able to re-admit even with receiving chemotherapy at an outside facility. Refer to CFR 483.15(c )(3)(i)-(iii), (c )(4)(i)(ii), (c )(5)(i)-(v), F-623 Notice before transfer. Refer to CFR 483.15(d), (d)(1)(i) - (iv), (d)(2), F -625 Notice of bed-hold policy and return. Refer to WAC 388-97-0120 (4)(b)

Based on interview and record review, the facility staff failed to conduct a thorough investigation for potential neglect for 1 of 3 residents (Resident 1) who experienced a fall, was on the floor and staff was reported to not come to their assistance or communicate the fall timely to licensed staff. This caused harm to Resident 1 when they did not receive timely assistance after falling and experienced a hospitalization for a fractured (broken) left elbow and left hip. The facility failed to thoroughly investigate the fall to rule out abuse/neglect which placed residents at risk for inappropriate corrective actions, ineffective care planning, repeat incidents, injury, and the potential for unidentified abuse or neglect. Findings included . According to the [NAME] State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, A thorough investigation is a systematic collection and review of evidence/information that describes and explains an event or a series of events. It includes guidelines for prevention and protection, incident identification, investigation and reporting for nursing homes, the facility investigation should end with the identification of who was involved in the incident, and what, when, where, why, and how the incident happened including the probable or reasonable cause. Review of facility policy titled, Accidents and Supervision to prevent Accidents, dated 11/28/2017 and revised 10/15/2022, showed: - Identification: Post incident, the facility is to identify additional medical, environmental, staff issues/training, and/or other items that may impact additional falls/residents. - Supervision (Falls): If a fall occurs, manage the fall, then conduct a root-cause analysis to assist with updates to the fall prevention plan. When reviewing the incident for root-cause, evaluate the casual factors leading to the resident fall as that may also assist in developing and implementing relevant, consistent, and person-centered interventions to prevent future occurrences. Resident 1 admitted to the facility on [DATE] with diagnoses that included repeated falls, impaired mobility, right side rib fractures, stroke (when the blood supply to part of the brain was interrupted or reduced), and dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). The discharge Minimum Data Set (MDS - an assessment tool) assessment, dated 06/24/2023, showed Resident 1 required two-person extensive assistance with bed mobility, transfers, dressing and toileting. The resident's cognitive section was not completed and left blank. Review of the facility's State incident reporting log on 06/30/2023, showed Resident 1 had an incident on 06/26/2023 that resulted in a fracture. Review of the facility's investigation, dated 06/26/2023, showed the facility initiated an investigation, after receiving communication from a local hospital informing the facility that Resident 1 had been admitted to the hospital on 06/24/2023 after the resident sustained a fall in the facility. The investigation stated the hospital determined Resident 1 had acute fractures to their left hip and left elbow. The facility's investigation found that Resident 1 sustained a fall during the evening of 06/23/2023 which had not been investigated at the time of the fall, Nursing Assistants (NAs) assisted Resident 1 up from the floor, and the resident did not have a nurse assess them after the fall occurred. Review of a witness statement, dated 06/24/2023, and included in the facility's investigation conducted on 06/26/2023, showed Staff H, NA, documented they observed Resident 1 on the floor on 06/23/2023 at 3:30 PM and Staff G, NA, was standing next to the resident. Staff H documented they observed the resident 15 minutes prior to the fall sitting in their wheelchair attempting to stand. Review of a witness statement, dated 06/24/2023, and included in the facility investigation conducted on 06/26/2023 showed Staff G documented they observed Resident 1 half lying and half sitting on the floor attempting to get up. Staff G documented staff members walked by the resident without offering assistance. Staff G stated immediately [Staff G] and my co-worker had talked to the nurse, and they seemed very busy, and we waited for them [the nurse]. Staff G documented Resident 1 was attempting to get up, asked their partner (Staff H) to assist them to get the resident up off the floor and back into their wheelchair. Review of an undated witness statement, included in the facility investigation, Staff C, Licensed Practical Nurse (LPN), showed they were approached by Collateral Contact 1 (CC 1), Resident 1's family member, asking if Resident 1 had a fall in the facility. Staff C replied to CC 1 that no staff member had reported to them that Resident 1 had fallen in the facility. Review of a progress note, dated 06/24/2023 at 2:18 AM, showed Staff C documented Resident 1 was found to have an abrasion to the left lateral (side) elbow, measuring approximately 1.5 centimeters (cm) by 2 cm in size, the area was bleeding and swollen. Staff C documented the area was cleansed and a dressing was applied. Further review of the clinical record showed there was no documentation that indicated Resident 1 fell while in the facility. In an interview on 06/29/2023 at 3:30 PM, Staff C stated while working on 06/23/2023, a NA requested the licensed nurse to come to the dining room to assess Resident 1, who had an area on their elbow that was bleeding. Staff C went to the dining room, assessed the residents left arm and noted there was a skin tear that was bleeding, swollen and required treatment. Staff C stated this injury had not been observed earlier in their shift and initiated a skin injury incident investigation. On 06/23/2023, CC 1 approached Staff C and asked if Resident 1 had fallen because another staff member had reported to CC 1 that the resident did have a fall. Staff C stated, No, I am not aware they fell . Staff C stated on 06/24/2023 at 12:00 PM, they received a text from Staff D, LPN/weekend supervisor, who asked if Resident 1 fell on [DATE] and Staff C replied they were not aware the resident had a fall. In a telephone interview on 06/30/2023 at 11:10 AM, Staff F, LPN/Staff Development, stated while they were walking down the hallway on 06/23/2023 around 4:00 PM, they heard someone yell that someone was on the floor and that's when they observed Resident 1 on the floor with Staff G sitting next to the resident. Staff F stated they did a quick visual check of Resident 1 and did not notice anything significant. Staff F instructed Staff G not to move the resident, and they would find Resident 1's nurse. Staff F stated they walked through the facility and upon returning to where Resident 1 fell , they observed Resident 1's nurse, Staff C, where the resident was found on the floor and did not see the resident on the floor. Staff F assumed Resident 1's fall was being managed by Staff C and left the facility and went home. Staff F stated they did not complete a witness statement or speak to Staff C directly, and stated this was a mistake on their behalf. Staff F further stated that they received a text message from Staff B, Director of Nursing Service (DNS), on 06/24/2023 at approximately 12:00 PM, to ask if they were aware that Resident 1 fell yesterday evening. Staff F replied to Staff B, No, any injuries? Staff B replied Yes, the CNA [NA] is trying to feed us a line, likely to cover up cuz [because] they had picked the resident up off the floor, after a recent in-service saying not to. Staff F asked Staff B who the NA was, and Staff B stated that the NA was Staff G. In a telephone interview on 06/30/2023 at 12:22 PM, CC 1 stated they were informed by an unnamed staff member that Resident 1 fell on [DATE]. CC 1 stated they returned to the facility the morning of 06/24/2023, asked about the fall, and facility staff were unable to confirm if Resident 1 fell on [DATE], but CC 1 was informed an x-ray had been ordered of the resident's left elbow for an injury of unknown cause. CC 1 stated Resident 1 had increased pain and CC 1 was tired of waiting for the x-ray technician to come to the facility and notified staff they were signing Resident 1 out of the facility and took the resident to the emergency room (ER). CC 1 stated the hospital determined Resident 1 had sustained a left elbow and left hip fracture and would probably require surgery. In a telephone interview on 06/30/2023 at 12:55 PM, Staff E, LPN, stated they worked a double shift (the day and evening day shift) on 06/24/2023 and were responsible for Resident 1. Staff E stated that Staff J, LPN, said they heard Resident 1 had a fall but there was no paperwork filled out to indicate the resident fell the previous day, 06/23/2023. Staff E asked Staff G if Resident 1 fell Staff G replied yes, they had. Staff E asked Staff G if they assisted the resident up off the floor without the nurse. Staff G stated they had because no one would help them. On 06/24/2023 at 10:07 AM, Staff E assessed Resident 1's left elbow and noted that it was black/blue/purple in color and swollen and requested an x-ray be ordered to rule out injury and or infection. In a telephone interview on 06/30/2023 at 2:41 PM, Staff H stated while working on 06/23/2023 they were walking down the hallway when they observed Staff G standing next to Resident 1, who was sitting on the floor and leaning to their left. Staff G asked Staff H if they could stay with Resident 1 while they went to tell the nurse about the fall, and they did. Staff H reported that they, along with Staff G, waited with Resident 1 for approximately 30 minutes and the nurse never came to assess the resident. Staff H stated Resident 1 was reaching up, grabbing Staff H and Staff G saying, Get me up, get me up, so after no one came to help them, Staff G asked Staff H's help to assist Resident 1 up from the floor. Staff H stated they knew this was against facility protocol and they should not have gotten the resident up without a nurse. During a telephone interview on 07/12/2023 around 2:15 PM, Staff B stated they communicated with Staff E on 06/24/2023, to obtain an x-ray for Resident 1's elbow. Staff B stated that they (Staff B) along with Staff E tried to talk with other staff to determine if there had been a fall involving Resident 1 the day before. Staff B confirmed messaging with Staff F on 06/24/2023 to see if anyone had reported to them that Resident 1 fell on [DATE], and stated the NA was trying to feed them a line, because they assisted the resident up from the floor without the nurse's knowledge. Staff B stated the facility initiated a fall investigation on 06/26/2023, after confirming with the hospital documentation and facility staff statements that Resident 1 had a fall on 06/23/2023. During an interview on 07/12/2023 at 4:30 PM, Staff A, Administrator, stated on the morning of 06/24/2023, unsure of the time, Staff D, the weekend supervisor, called to notify them an x-ray was ordered for Resident 1's elbow and that staff were upset as the family took the resident out of the facility. Staff A explained to Staff D that families had the right to take residents out as long as they signed them out of the facility. Staff A stated later that day they verified via the local hospital secured information site (EPIC) that Resident 1 was in the ER without any further information related to why the resident was in the ER Staff A stated they checked the site again the following day (06/25/2023) and it continued to show that Resident 1 was in the ER. On 06/26/2023, upon arriving at facility, Staff A, checked EPIC, which showed Resident 1 was admitted to the hospital on 06/24/2023 after a fall in the facility that resulted in a left elbow and left hip fracture. Staff A stated after reviewing that information, they immediately initiated an investigation for a potential fall but felt the resident had possibly fell while out of the facility with their family on 06/24/2023. During the facility investigation, Staff A stated three staff members failed to follow proper protocol for a fall in the facility and, as a result, their employment was terminated. Staff A stated the staff members failed to report and investigate an unwitnessed fall. This is a repeat citation from 2567 SOD dated April 5, 2022 Reference WAC 388-97-0640 (6)(a-c)

Based on interview and record review, the facility failed to provide two-person staff assistance with bed mobility while providing care, have ambulatory devices within reach for resident use, and consistently implement the care plan to prevent accidents/falls for 2 of 4 residents (Resident 2 and 1) reviewed for accidents. This failure caused harm to Resident 2 who fell out of bed and experienced a bump, bruises on their head, and a head injury and harm to Resident 1 who had a fall resulting in a left femur fracture (a broken bone). Findings included . <RESIDENT 2> Resident 2 was a long-term resident admitted to the facility on [DATE], with diagnoses to include developmental delay, unspecified disorder of the brain, obesity, and quadriplegia (paralysis of all four limbs). On re-admission to the facility on [DATE], additional diagnoses included disorientation, delirium (disturbance in mental abilities, confused thinking), unspecified psychosis (mental disorder), tremors and unspecified injury of head. A review of Resident 2's quarterly Minimum Data Set (MDS) assessment, dated 04/27/2023, showed the resident required extensive assistance of two staff for bed mobility, transfers, and dressing and was totally dependent on two staff for toileting. Review of the facility incident reporting log showed on 04/24/2023 at 7:00 PM Resident 2 sustained a fall in their room. The facility documented this resulted in injury (S30) which indicates surface layer of the skin. Actions taken by the facility following the resident's fall included staff training, care plan revisions, neuro checks, and therapy. Review of the facility's completed investigation for Resident 2's 04/24/2023 fall, showed that one Certified Nursing Assistant (CNA) was providing care to the resident in their bed, rolled the resident towards them, the resident was too close to edge of the bed, and rolled out. The investigation documented that Resident 2 hit their head on the bed during the fall, an ice pack was applied to bump/bruise to the left forehead for swelling and pain, they complained of a headache and had 2 episodes of vomiting. Lastly the investigation stated, NAC did not follow care plan, 1on 1 additional training provided. Review of Resident 2's current care plan, dated 05/16/2023, showed a focused area that the resident's had an activity of daily living (ADL) self-care performance deficit due to the resident's lack of expected normal physiological development in childhood, and was dependent upon staff for all ADL cares/needs. Interventions were in place for bed mobility however, the facility failed to include directive on how many staff were required to assist the resident with care, it only showed Dependent. Review of a progress note dated 04/30/2023 at 3:56 PM, Staff G, Licensed Practical Nurse (LPN), documented Resident 2 complained of dizziness while lying in bed. Resident has hematoma to left side of head related to prior fall on 04/24/2023. Observed swelling to left side of face, left side of jaw and under the left ear. Complained of tenderness to touch. On call provider notified and order received to obtain a 2-view x-ray to the left side of head related to hematoma expansion. Review of Resident 2's x-ray results dated 05/01/2023 showed it was negative for fracture and overall unremarkable. Review of Resident 2's provider progress note, dated 05/02/2023, showed Skilled Nursing Facility Monthly Follow up was completed by Staff H, Nurse Practitioner. This monthly follow up by the provider was a full head to toe assessment that did not mention the fall on 04/24/2023, or review of the x-ray results received on 05/01/2023. Review of a physician progress note, dated 05/16/2023 (3 weeks after the fall), showed Staff I, Medical Doctor (MD), had been alerted by nursing staff of Resident 2's fall that occurred 3 weeks prior that resulted in bump on the front of their head. Staff also reported progressive increase in confusion and reports of sadness since the fall. Staff I ordered a Computed Tomography Scan (CT which was a medical imaging technique used to obtain detailed internal images of for body) of the head to rule out a subdural hematoma (caused by head injury). Review of an Emergency Department note, dated 05/16/2023, showed Resident 2's CT scan showed no acute intracranial process identified and it could not exclude acute infarct (tissue death or necrosis due to inadequate blood supply to affected area). Further review of hospital records showed Active Hospital Problems, included delirium (confusion) and a head injury. During an interview in the facility on 05/23/2023 at 2:10 PM, CC 2, Resident 2's Representative/Power of Attorney, stated they were notified on 04/24/2023 their sister had fallen out of bed, and stated, I questioned the nurse on how that happened because my sister requires two people to move in bed and the nurse told them the NAC provided care to Resident 2 by themselves. CC2 also stated that they didn't believe that a doctor ever assessed Resident 2 after the fall out of bed on 04/24/2023, until they were sent out on 05/16/2023 for changes in behavior. On 05/23/2023 at 2:20 PM, Resident 2 was observed in bed, recently being readmitted to the facility. Resident 2 was unable to answer questions related to the incident that occurred on 04/24/2023, where they fell out of bed, due to severely impaired cognition. During an interview on 05/23/2023 at 3:15 PM, Staff D, NAC, stated they were assisting Resident 2 in bed by themselves, when they rolled the resident towards them, they lost their balance and the resident fell off the bed. Staff D stated they assisted the resident to the floor and the resident hit their head on the bed. Staff D also acknowledged that it was not until after the fall they realized Resident 2 required two staff members assistance with bed mobility, stating I don't think I checked their Kardex that day, I usually only review it if I have a new resident. During an interview on 05/23/2023 at 3:35 PM, Staff E, Registered Nurse (RN), stated CNAs used a Kardex to get resident specific information for their care needs. Staff E stated that the resident had hit their head during fall, resulting in a bump and bruises to their forehead. Staff E stated that an ice pack was applied to bump on forehead, and pain medication was given for a headache and that Resident 2 also had two episodes of vomiting immediately after the fall. Staff E stated that Resident 2 required two-person assist with care in bed and transfers, stating They have always been a two person assist, and when the NAC told them Resident 2 had fallen out of bed and they were providing care alone, I educated the NAC immediately that [Resident 2] requires two-person assistance at all times. Staff E further stated, I think what happened was the resident was too close to edge of bed and when the aide rolled the resident towards them, they couldn't keep them in bed by themselves, and the resident rolled out, hitting their head on the nightstand next to the bed. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses to include history of falls, infection/inflammation of internal orthopedic prosthetic device after a left ankle fracture, dementia with behavioral disturbances (a global term to describe agitation including verbal and physical aggression, wandering, and hoarding), anxiety disorder and major depressive disorder. Review of Resident 1's MDS assessment, dated 03/05/2023, showed the resident had severe cognitive impairment (a resident who had a very hard time remembering things, making decisions, concentrating, or learning) and required extensive assistance of two staff for bed mobility, and dressing, extensive assistance of one staff for toileting and supervision of two staff for transfers. Review of facility incident reporting log, dated 03/05/2023, showed Resident 1 had a fall in their room that resulted in a left femur fracture. Review of Resident 1's baseline care plan, dated 03/02/2023, showed a focus area of impaired mobility, was at risk for falls due to pain, had a recent surgical removal of orthopedic hardware, and a history of falls. Interventions directed staff to keep personal items and assistive devices in reach, ensure the bed brakes were locked, and keep the bed adjusted in a safe position when transferred. Review of the facility's completed investigation for Resident 1's unwitnessed fall with a substantial injury on 03/05/2023, showed Staff B, prior Director of Nursing Services (DNS), documented in the incident summary a care plan was initiated and at the time of the fall all care planned interventions were in place. Ambulation devices were not within reach in order to discourage use. Further review of the investigation information showed Staff J, RN, previous employee documented on a Post Fall Investigation form Floor was dry, walker and wheelchair not within reach. Review of a communication by Collateral Contact 1 (CC 1), a family member, on 05/08/2023, showed they were notified by the facility on 03/05/2023 at 7:00 AM that Resident 1 had experienced a fall, that had occurred earlier that morning, and had been told by the facility everything was OK. CC 1 arrived at the facility around 11:00 AM on 03/05/2023 and found Resident 1 in extreme pain. CC 1 said the family had directed the facility to send the resident to the emergency room immediately. CC 1 stated that Resident 1 required a total hip replacement following the fall. In an interview on 05/24/2023 at 1:50 PM, Staff C, Certified Nursing Assistant (CNA), confirmed nursing assistants (NAs also referred to as CNA's) used a Kardex (care plans for nursing assistant's) to find resident specific information such as how the resident transferred, toileted, bed mobility status/requirements, assistive devices they may use/require, etc. Staff B stated, I make sure I check my residents Kardex's before I start my shift, everyday no matter what, you never know when things can change. Staff C stated they would never remove assistive devices that were on the Kardex out of a residents reach to prevent resident use. Resident 1 no longer resided in the facility and was unable to be interviewed. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to provide necessary treatment and services to prevent a pressure ulcer (PU) for one of two residents (#60) reviewed for pressure ulcers. The facility caused harm to Resident #60 when they failed to care plan and implement interventions necessary to prevent an avoidable Stage 3 right heel PU in a resident that admitted without a PU. Findings included . Review of the facility policy titled, Skin Integrity, updated (MONTH) 2019, revealed the nurse established a Plan of Care (P[NAME]) based on risk factors in an effort to limit their potential effects. Review of the facility Matrix for Providers (form that listed pertinent care categories), dated 12/09/19, revealed the resident was listed as having a facility-acquired Stage 3 PU. Review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.17.1, dated (MONTH) 2019, revealed a Stage 3 PU was an ulcer with full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle was not exposed. Slough (non-viable yellow, tan, gray, green or brown tissue that may be adherent to the base of the wound) may be present but does not obscure the depth of tissue loss, and may include undermining or tunneling. Resident #60 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Admission Minimum Data Set (MDS) assessment dated [DATE], showed he had moderate cognitive impairment, and was total dependent on two staff for bed mobility, transfers and toilet use. The MDS also indicated he had functional limitation/impairment of range of motion of both an upper extremity and a lower extremity, and he was at risk for developing PUs. The MDS assessment showed he did not have any current PUs. Review of the Care Directive Form (directives for Nursing Assistants), reviewed date 11/11/19, revealed in the Skin at Risk section there were blanks in the areas for pressure reducing mattress, specialty mattress, turn/reposition routinely and for elevating heels. Review of a Braden Scale for Predicting Pressure Sore (ulcer) Risk dated 11/17/19, revealed a score of 12, which identified the resident as a high risk for developing a PU. Review of an incident investigation report dated 11/22/19, revealed staff discovered the right heel injury (also identified as a pressure ulcer) when they noticed his sheets were stained with blood. Staff removed the resident's socks and discovered the skin injury (pressure ulcer). Immediate actions taken were to cleanse the wound, apply a dressing, and offload the heels. The incident investigation findings did not indicate what pressure redistribution interventions were in place prior to him developing the pressure injury (ulcer). The report indicated after the injury was discovered an alternating pressure relieving mattress was obtained and boots (pressure relieving) were applied. The investigative report indicated the resident was dependent on staff for most cares and he preferred to be on his back. Review of the care plan, print date 12/10/19, revealed no care planning regarding PU prevention/pressure redistribution prior to the resident developing a right heel PU. In an observation on 12/11/19 at 11:37 AM, a right heel dressing change was observed. The resident had a right heel wound that was 1 centimeter (cm) by 1.4 cm, with no appreciable depth, and there was a scab on the wound. In an interview on 12/13/19 10:00 AM, the Director of Nursing Services (DNS) stated to be honest the resident did not have a PU care plan in place until after her developed the right heel PU. The DNS stated when she (the DNS) did the investigation she realized he didn't have one, so that's when the DNS developed a PU care plan. In summary, the resident had multiple risk factors that placed him at high risk for developing a PU, to include poor nutritional intake, impaired mobility, decreased range of motion, cognitive deficits, [MEDICAL CONDITION], pain, dependence on staff for bed mobility, and he was bedfast (confined to bed). The facility failed to develop an individualized care plan to prevent a PU, and he developed a right heel PU on the twelfth day after he admitted to the facility. Reference: (WAC) 388-97-1060 (3)(b)

Based on observation, interview and record review the facility failed to ensure residents who engaged in smoking were adequately supervised, had ongoing comprehensive assessments, were protected from the weather and assessments were followed by staff. In addition, the facility failed to put a plan in place ensuring Resident 39 was supervised and not smoking in areas of high risk of fire. Failure to ensure all smoking residents were consistently supervised, comprehensively assessed and staff followed facility policy placed sample residents (39, 51, 63 and 119) who engaged in smoking and all residents at risk for injury from burns and/or fire. This failed practice resulted in an Immediate Jeopardy (IJ) on 08/10/17 at 4:35 PM when the facility failed to ensure the residents and the resident environment were as safe as practicable from injury from burns and fire. After the IJ was implemented, the facility initiated reassessment of all residents who smoked, as well as increased supervision of Resident 39, revised the smoking policy/procedure and provided in-service to all staff. The IJ was removed on 08/11/17 at 1:10 PM. Additionally, the facility failed to supervise 1 of 1 resident (51) reviewed for accidents. The failed practice contributed to an incident in which the resident had a motor vehicular accident resulting in injury. Findings include: SMOKING On 08/09/17 at 4:20 PM, Resident 39 was observed with a cigarette, sitting in a wheelchair in the front parking lot of the facility by herself. She was located on the asphalt drive, in an empty parking spot, adjacent to a dry grassy area with a picnic table. The Resident Smoking Safety Policy, updated March 2017, stated, The Center completes the Smoking Safety Evaluation for residents desiring to smoke tobacco products (cigarettes, cigars, or pipes, including electronic e-cigarettes). Residents store tobacco products and fire materials at the nurses' station or other Center designated location. Residents only smoke with supervision. The procedure included the following but not limited to: 1. The Licensed Nurse (LN) completes the Smoking Safety Evaluation, if the resident smokes (including e-cigarettes) on admission, quarterly, and with change in condition, and places it in the medical record. 5. Appropriate interventions are care planned and implemented based on the results of the Smoking Safety Evaluation. 6. A copy of Center Smoking Regulations (e.g. designated smoking times, locations, and Center-specific rules) is provided to the resident/resident's authorized representative and verbally explained as indicated. 7. A copy of the Center Smoking Regulations, this policy, and the Acknowledgement of Smoking Risks, is provided to the resident/resident's authorized representative and verbally explained as indicated. Residents choosing to smoke sign the Acknowledgement of Smoking Risks. 9. Residents are supervised when smoking, whether it is actual cigarettes, cigars, pipes, or electronic e-cigarettes. 10. If a resident wants to smoke independently off grounds, the Center does not knowingly allow this to occur without supervision. a. If a resident requests to go on LOA (leave of absence) and request smoking materials, the Center does not give the materials, as the Center is unable to supervise the resident. The resident, if able, may purchase their own smoking materials while off grounds but must relinquish them when they return. Environmental Factors included in the policy were but not limited to: 2. The Center provides a suitable number of noncombustible ashtrays in designated smoking areas. a. Smoking materials are not left unattended in ashtrays. b. Staff and visitors use the same noncombustible receptacles in designated smoking areas. 4. A portable Fire Extinguisher, rated Class A, is stored in the designated smoking area. 5. A fire blanket is stored in the designated smoking area. 6. Residents who smoke (including e-cigarettes) are required to utilize NFPA 701 Compliant Smoking Aprons when they smoke. 7. The designated smoking area is kept free of dry vegetation and refuse. 8. Staff are educated on smoking policy annually. Notice of Center Smoking Policy, posted in the facility, also included the following: The resident and the resident group agree that smoking is dangerous and can cause fires, explosions, or both. The resident and resident group expressly assume all risk, damage, or both that may result from the resident smoking on Center property. On 08/10/17, 9:25 - 9:40 AM, the first scheduled smoke break of the day was observed. The designated smoking area was located out in the back of the facility. There was a pole with a fire extinguisher along with a pouch containing a folded blanket. The blanket was labeled All purpose thermal blanket. It was a red nylon on one side and bright reflective silver on the other. There was no indication it was non-flammable. Beside the pole was a large open bucket, which had cigarette butts in the bottom, and a metal smoker's receptacle (MSR). It had a wide bottom and long thin neck, designed to safety discard cigarette butts. The grassy area along the back of the facility was yellow and very dry. Resident 63 and Resident 119 were present, sitting in their wheelchairs along the grass edge, on the driveway. Neither was within reach of the bucket or the MSR. They each smoked cigarettes and were supervised by Staff C, Certified Nursing Assistant (CNA). Staff C placed the appropriate smoking aprons on each resident and their cigarettes were lit for them. Neither resident had an ashtray and as they smoked, their ashes were being flicked on the ground around them. When Resident 119 had smoked his cigarette he snuffed it between his fingers on the soul of his tennis shoe (as he had his lower leg propped on his knee). He then handed it to Staff C who discarded it in the MSR. Resident 63 smoked her cigarette down about 2/3 of the way, then handed it to Staff C who discarded it in the MSR. On 08/10/17 at 1:40 PM another smoke break was observed. Resident 51 who was present along with the two residents observed during the morning break described above. None of the residents were within reach of the bucket or MSR and none had an ashtray for their use. The fire extinguisher was not within immediate reach of staff. The residents were situated on the opposite side of the driveway near a 6 foot wooden fence. The wooden fence was set back about 2 feet from the driveway. The 2 foot area was covered with dry twigs, dead leaves, pine needles and other debris. On 08/10/17 at 3:55 PM a third smoke break was observed. It was 85 degrees and the area where the residents had their smoke break had no shade or weather protection. Resident 119 was already in the area with a family member (FM) had wheeled him outside. Resident 119 did not have a smoking apron on. The FM who had placed the thermal blanket, taken from the pouch, over his lap. The FM stated staff told her she could take him out to smoke as long as she stayed with him while he smoked. The FM stated she was unaware the blanket was not acceptable to use and was unaware of the smoking aprons. Resident 63 was wheeled out by Staff D, CNA. When Staff D became aware Resident 119 did not have a smoking apron on she went back inside, obtained one and placed it on the resident. Staff D stated the aprons were kept with the resident's smoking supplies and brought out each time for smoke breaks. On neither observation the resident did not use any assistive device while holding his smoking products. Resident 119 was positioned about 10 feet down the driveway, away from the bucket and MSR, with his back to shrubs. Resident 63 was positioned across the driveway with her back to the wooden fence. When Resident 63 had smoked 2/3 of the cigarette she leaned way forward in the wheelchair and snuffed out her cigarette on the driveway and handed it to Staff D. Staff D assisted her to light a second cigarette. When Resident 119 had smoked his cigarette almost down to the end he handed it to the FM and she disposed of it. Resident 119 declined a second cigarette, and stated it was too hot to stay out any longer. RESIDENT 39 Resident 39 was admitted to the facility in October 2016. According to the quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident was independent with set-up for activities of daily living and was cognitively intact. On 08/10/17 a Smoking Safety Evaluation (SSE) was completed and indicated the resident was independent for decision-making. She used a wheelchair for locomotion, she was on a medication with side effects of drowsiness and had no history of smoking related incidents. The care plan for alteration in safety-smoking dated 06/01/17 listed a problem of history of non-compliance with the facility smoking policy. Interventions included standard (pre-printed) approaches including smoking apron, assist with lighting tobacco products, keeping cigarettes and lighting material at the nurses station or other designated area, providing smoking materials only when in designated area, and education on center smoking regulations. Additionally, there was a handwritten approach to offer smoking cessation materials as needed. Review of social service notes and nurse's notes revealed Resident 39 did have a history of smoking related incidents: Review of the social service note dated 11/16/16 revealed Resident 39 was smoking unsupervised, in a non-designated area, including by a propane tank, and had cigarettes and a lighter in her room. Documentation on nurses' progress notes dated 03/29/17 and 04/01/17 revealed Resident 39 was observed smoking without supervision in non-designated smoking areas and she was not wearing a smoking apron. The nurse's note dated 06/07/17 revealed the resident was observed smoking without supervision or use of a smoking apron. On 08/10/17 at approximately 1:30 PM, Resident 39 told the surveyor she smoked in the smoking area, and also smoked in the front of the facility because she did not want to wear a smoking apron or propel her wheelchair uphill to the smoking area. At 2:30 PM, Resident 39 was informed that due to the risk of injury to herself and others, the facility administrator was going to be informed of her violation of the facility smoking policy. She stated the administrator was going to have to come and talk to her again and would insist she had a lighter in her room. She stated he could not frisk her. She then stated someone had picked up her cigarette butts in the front of the building the prior day and offered to take her to the smoking area. She was unable to identify the person, however inferred the individual was responsible for getting her in trouble again. On 08/15/17 at 2:30 PM, during an unrelated interview, Staff T, Dietary Manager (DM) stated she had observed Resident 39 on Sunday, 08/13/17 smoking unsupervised in front of the facility. She stated she approached her and stayed with her until she was done and came back in the building with her. Review of nurse's notes from 08/10/17 through 08/15/17 revealed Resident 39 was informed to not go outdoors unless escorted by staff. She was observed several times on 08/11/17 and 08/12/17 to be outside by herself and was re-educated. She was not observed smoking on these occasions. Resident 39 was not observed to be part of the smoker observed during any of the 3 observed smoking breaks. On 08/16/17 at 8:00 AM, the Administrator stated he spoke with Resident 39 and she admitted to smoking in front of the facility on 08/13/17. With her permission, he searched her room and found her supply of loose tobacco and placed it with the smoking materials that were kept locked up. He stated he had assigned staff to monitor Resident 39, 24 hours a day and informed the resident of this. RESIDENT 119 Resident 119 was admitted [DATE]. According to the admission MDS assessment the resident required extensive assistance of 1 staff member for activities of daily living and had moderately impaired cognitive status. A SSE was completed 8/4/17 and indicated Resident 119's cognitive skills for decision making was independent. He was able to self-propel a wheelchair, was on a medication with a side effect of drowsiness and had no history of smoking related incidents. The observation portion of the evaluation indicated he could safely hold, light and smoke a cigarette, could use a lighter safely and use an ashtray to extinguish a cigarette. The care plan for alteration in safety - smoking, developed 08/04/17 included the following interventions (pre-printed approaches with a check box in front of each approach): apply smoking apron, assist with lighting tobacco products only, assist devices to hold smoking products, keep cigarettes and lighting material at Nurses Station or other designated area, provided resident smoking materials only when in designated area and educate on center smoking regulations. During each of the observations of Resident 119 there was no device utilized to hold the smoking product. Additionally, the resident's FM was not informed about use of smoking aprons and the resident was never provided an ashtray to utilize. RESIDENT 63 Resident 63 was admitted on [DATE] after a fall with fracture. According to the admission MDS assessment the resident required limited to extensive assistance of 1 staff member with activities of daily living and had moderately impaired cognitive status. A SSE was completed 07/08/17 and indicated Resident 63's cognitive skills for decision making was modified independence. She was on a medication with a side effect of drowsiness and had no history of smoking related incidents. There was no assessment of her ability to self-propel the wheelchair or what kind of assistance was needed to move to the smoking area. The observation portion of the evaluation indicated only that she had the ability to safely hold, light and smoke a cigarette. Her care plan for alteration in safety - smoking, developed 07/06/17, included the interventions as for Resident 119 except, assist devices to hold smoking products, was not an indicated intervention. RESIDENT 51 Resident 51 was admitted [DATE]. According to the most recent MDS assessment, dated 08/14/17, the resident was independent in his activities of living and had no cognitive impairment. A SSE was completed 06/28/17, indicated he was taking a medication with drowsiness as a side effect. The observation portion of the evaluation indicated he had the ability to safely hold, light and smoke a cigarette and could use a lighter safely. His care plan for alteration in safety - smoking, developed 06/28/17, included all the interventions, including need for an assist device to hold smoking products. During observation there was no assist device used to hold his smoking product. ACCIDENTS Review of the Resident Sign Out Policy revealed the following: 1. All residents must sign out when leaving the facility. 2. All residents must have an order from the attending provider to leave the facility for any reason other than medical appointments. 3. Sign out sheet must be complete and must include: who is driving them, Licensed nurse initials, check in time on return. 4. Always verify resident is not planning to drive. Resident 51 was admitted to the facility in June 2017. According to the most resent MDS assessment, dated 07/21/17, Resident 51 had [DIAGNOSES REDACTED]. Review of the sign out sheet for Resident 51, revealed incomplete documentation by staff and no dates listed when resident signed out or back into the facility. On 08/03/17, Resident 51 was involved in a motor vehicular accident (MVA) that resulted in hospitalization . In an interview on 08/09/17 at 11:30 AM, Resident 51 stated he was going to see his sister when the accident occurred. He also stated that the facility staff knew he had his car in the parking lot. They knew I was driving and they never told me I could not drive. Review of the hospital discharge information dated 08/7/17, revealed Resident 51 had received a fracture to his leg from the MVA. In an interview on 08/15/17 at 1:14 PM, the Director of Nursing Services stated, administration was unaware the resident had the car at the facility. She also stated that during the investigation, it revealed Staff N, Registered Nurse and Staff O, Nursing Assistant were aware of the car at the facility but the staff did not inform administration. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to follow the standards of professional practice regarding medication administration for 3 of 3 Residents (1, 2 and 3). Failure to administer medications without a physician's orders [REDACTED]. Failure to correctly transcribe orders resulted the omission of medications for Resident 2 and placed the resident at risk of additional medication errors. Findings included: Nursing 2016 Drug Handbook 36th edition, describes the eight rights of medication administration as: 1. The Right drug 2. The Right patient 3. The Right dose 4. The Right time 5. The Right route In addition to the traditional five rights of individual practice, best-practice researchers have added three additional rights. 6. The Right reason 7. The Right response 8. The Right documentation The facility's Medication Administration policy directed Licensed Nurses (LNs) to review each resident's Medication Administration Records (MARs) for ordered medications and when new medication orders are received, the LNs will write the medication order completely on the MAR, the Right route, dose, time frequency, diagnosis, and date the medication was ordered. For Medication Order changes, the LNs are NOT to write over or cross out the old medication order but are to re-write the new medication order. The LN will highlight the old medication order, and write DC and the date for the discontinued medication order. VERIFICATION OF medication orders [REDACTED] Resident 1 The facility investigative report for a medication error for Resident 1 dated 7/7/17 documented the Licensed Nurse (LN A) had administered the wrong mediation ([MEDICATION NAME] an anti-anxiety medication) to Resident 1 and LN B had pulled the [MEDICATION NAME] from the E-kit without reviewing Resident 1's physician's medication orders. The Medication Error/Adverse Drug Reaction Report dated 7/7/17 revealed Resident 1 was administered [MEDICATION NAME] without an order which resulted in Resident 1 having mild hallucination During an interview on 7/19/17 at 11:40 am. LN B stated she had signed out the [MEDICATION NAME] from the emergency kit/supply (E-kit) for LN A even though LN A was the nurse administering medications to Resident 1. The facility report revealed LN's are not to pull medications from the E-kit for another LN and that prior to pulling a medication from the E-kit, LNs need to verify the order, verify the MAR prior to administrating any medication from the E-kit. Resident 3 Another medication error report documented that LN D had flushed Resident 3's PICC (peripheral inserted central catheter) with [MEDICATION NAME] without a physician's orders [REDACTED]. The manufacturer booklet for Resident 3's PICC instructed LNs to only use normal saline (NS) to flush the catheter lines to maintain patency. MEDICATION CHANGES PER PHYSICIAN ORDER [REDACTED].>Resident 2 Review of Resident 2's Medication Administration Record [REDACTED]. The narcotic log was also reviewed on 7/19/17 and revealed Resident 2 received a narcotic pain medication by LN C and LN E, even though the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Documentation in the narcotic log showed that LN C documented that he administered two doses of pain medication to Resident 2 at 12:30 am and 5:30 am on 6/21/17 even though the MAR indicated [REDACTED]. The facility's medication error reports for Resident 2 revealed narcotic orders were administered beyond the stop date as LN C and LN E administered pain medications even though discontinued on the MAR but did receive the prescribed routine medication due to LN A not following standards of practice and DC both the routine and prn (as needed) pain medication. During an interview on 7/27/17, the Director of Nursing stated LN A had discontinued Resident 2's routine narcotic pain medication instead of the prn medication per physician's orders [REDACTED]. The DNS stated LN E had documented the medication administration on the routine order instead of where the prn administration should be recorded and LN C only documented administration in the narcotic log and nursing notes and not on the MAR. By not following the facility policy and standards of practice resulted in Resident 2 not receiving two routine doses of narcotics on 6/21/17 at 3:00 pm and 6:00 pm doses per facility medication error reports. Another medication transcription error was on 6/17/17 when LN A did not follow facility practice. Resident 2's routine narcotic was changed from 5 times a day to 4 times a day and the physician ordered to decrease the antidepressant dose from 60 mg to 40 mg. Review of the MAR for 6/27/17 revealed LN A did not rewrite the two new orders to reflect the new date, times and/or dose change. The MAR for 6/27/17 revealed LN A crossed out the 6:00 pm administration time for the narcotic medication and wrote over the prior order times and crossed out the prior dose instead of rewriting the new orders (4 x a day routine narcotic and the dose decrease for antidepressant) in accordance to facility policy. The facility's three medication error reports for Resident 2 revealed narcotic orders were administered beyond stop date as LN C and E administered pain medications even though discontinued on MAR, Resident 2 did not received the prescribed routine medication, 3:00 pm and 6:00 pm dose on 6/21/16 due to LN A not following standards of practice. The facility's investigative report for 6/27/17 documented LN A altered the current orders by marking through the dosing schedule and dose. Refer to F tag 333 REFERENCE: WAC 388-97-1620

Based on interview and record review, the facility failed to ensure residents were free of significant medication errors for 3 of 3 resident (1, 2 and 3). Failure to review physician's orders and Medication Administration Records (MARs) resulted in harm for Resident 1 who experienced hallucination and was transferred to the hospital and resulted in the omission of Resident 2's pain medication and placed Resident 3 at risk for complications. Findings included: The facility's Medication Administration policy directed Licensed Nurses (LNs) to review each resident's Medication Administration Records (MARs) for ordered medications and when new medication orders are received, the LN will write the medication the order completely on the MAR, the Right route, dose, time frequency, diagnosis, and date the medication was ordered. For Medication Order changes, the LNs are NOT to write over or cross out the old medication order. The LNs are to re-write the new medication order. The LN will then highlights the old medication order, and write DC (discontinue) and the date for the discontinued medication order. The policy instructed LNs to follow the 5 Right of Medication Administration: a) Right Person b) Right Medication c) Right Dose's d) Right time e) Right Route The policy directed LNs to verify the five rights of medication administration when removing a medication from the E-kit (emergency medication supply) and administer medications per physician's order. NO PHYSICIAN ORDER: RESIDENT 1 Resident 1 was admitted to the facility on [DATE] and had an order for [REDACTED]. The admit physician's orders and Medication Administration Record [REDACTED]. The facility investigative report dated 7/7/17 documented LN A had administered a wrong medication ([MEDICATION NAME]) to Resident 1. The report revealed another LN B had signed out the [MEDICATION NAME] instead of LN A who administered the wrong medication ([MEDICATION NAME]). The facility's investigative report documented that Resident 1's spouse had informed LN A prior to administrating the [MEDICATION NAME] (antianxiety) that [MEDICATION NAME] gives him (Resident 1) hallucinations, but LN A still administered the wrong medication. Resident 1's spouse had notified LN B that LN A had administrated [MEDICATION NAME] even though she informed LN A that the [MEDICATION NAME] could cause him to have hallucinations. Resident 1's spouse requested him to be transferred to the hospital. A facility Medication Error/Adverse Drug Reaction Report dated 7/7/17 revealed Resident 1 was administered [MEDICATION NAME] without an order which resulted in Resident 1 having mild hallucination Review of the E-Kit transaction report for 7/7/17 revealed Licensed Nurse (LN B) had signed for the [MEDICATION NAME] medication that LN A administered to Resident 1. During an interview on 7/19/17 at 11:40 a.m., with LN B, she stated when she had the E-kit open, LN A requested a narcotic medication ([MEDICATION NAME]) for Resident 1 and was holding his MAR. LN B stated when she was getting ready to close the Cubex, LN A stated she needed a [MEDICATION NAME], so I pulled a [MEDICATION NAME] and gave one [MEDICATION NAME] (0.5 mg) to LN A. LN B stated she thought the [MEDICATION NAME] was for Resident 1 when LN A requested the [MEDICATION NAME]. LN B stated she had signed for the [MEDICATION NAME] without checking Resident 1's MAR indicated [REDACTED]. An urgent pharmacy report faxed to the facility on [DATE] titled urgent e-kit pull error indicated a dose of [MEDICATION NAME] was removed from the E kit for Resident 1 in error and there was no orders on file for the [MEDICATION NAME]. The hospital's emergency room note dated 7/7/17 documented Resident 1 had received [MEDICATION NAME] at the facility for anxiety and subsequently developed hallucinations. RESIDENT 3 The MAR for June 2017 revealed Resident 3 had a physician's order to flush his PICC (peripheral inserted central catheter) for patency every shift with 3 cc of normal saline (NS) for patency every shift. The PICC manufacturer literature revealed Resident 3's PICC was to be flushed with NS using a 10 cc syringe. Review of the facility's medication error report dated 6/4/17 revealed LN D had administered a flush of [MEDICATION NAME] instead of NS. The report revealed LN D administered a [MEDICATION NAME] (blood thinner) flush without an order by the physician. During an interview on 7/19/17, the Administrator verified that per the facility investigation, medication errors were the result of LNs not following facility policy. FACILITY POLICY FOR MEDICATION NOT FOLLOWED RESIDENT 2 Resident 2's initial physician's order dated 6/19/17 indicated he was to receive a narcotic pain ([MEDICATION NAME]) (2 mg) routinely five times a day and a prn (as needed) dose as needed. The MAR for June 2017 revealed the routine medication was to be administered at 6:00 am, 9:00 am, 12:00 pm, 3:00 pm and 6:00 pm. On 6/20/17, the physician wrote an order to discontinue only the prn pain medication. Review of Resident 2's Medication Administration Record [REDACTED]. The June MAR indicated [REDACTED]. Even though a DC was written and dated 6/20/17, the MAR indicated [REDACTED]. The narcotic log also revealed LN C also administered two doses of pain medication at 12:30 am and 5:30 am on 6/21/17 without documentation on the MAR indicated [REDACTED] The discontinuing (DC) of Resident 2's routine pain medication on 6/20/17 resulted in two missed doses of routine narcotic pain medication (1500 & 1800) on 6/21/17. During a interview with the Director of Nursing on 7/27/17, she stated LN A had discontinued Resident 2's routine medication on 6/21/17 instead of the prn dose, LN E had documented prn administration on the routine space instead even though a DC notice was written by LN A (6/20/17) and LN C only documented administration on the narcotic log instead of the MAR. Refer to F tag 281 REFERENCE: WAC 388-97-1060

Based on interview and record review, the facility failed to develop a comprehensive care plan for 1 of 2 sampled residents (1) relating to post-operative care. Failure to develop a comprehensive care plan regarding transfers and precautions related to newly inserted pacemaker and risks due to anticoagulant (blood thinning agents) resulted in Resident 1 experiencing increased pain, bruising and transfer to hospital. Findings include: RESIDENT 1 Resident 1 was admitted to the facility on [DATE] following a pacemaker insertion and had a history of [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed he required 2 person assist with transfers and toileting and required surgical wound care. The Care Directive Form dated 12/23/16 directed staff to transfer resident using a mechanical (hoyer) lift. The hospital emergency (ER) note dated 12/25/16 documented that Resident 1 had been assisted in the bathroom and instead of using a lift the patient was held under his arms. He noted pain and developed a hematoma at device (pacer) site. The hospital note revealed he required pain (narcotic) medication and an antibiotic medication as hematoma increases risk of device infection. There was no documented evidence that a care plan was developed in regarding to post-op assessment or the need for safe handling due to anticoagulant therapy. During an interview on 03/20/17 with Resident Care Manager (RCM A) stated no Care Plan had been developed regarding interventions for Resident 1. During a telephone interview with Resident 1 on 03/22/17, he stated the staff had not transferred him correctly and there were no instructions regarding care needs after having my pacemaker inserted. He stated I experienced pain and developed a large hematoma. Refer to F 323

Based on observation, interview, and record review, the facility failed to ensure sufficient supervision during the care for 4 of 5 Residents (1, 2, 3 & 4). Failure to have adequate staff present during a mechanical lift (hoyer) for Resident 2 and adequate supervision for Resident 4 resulted in falls. Failure to provide care according to facility policy and care directive resulted in in harm for Resident 1 and 3 who both experienced pain and resulted in Resident 1's transport to hospital. Finding include: The facility's policy for gait belt indicated the purpose of using a gait belt was to provide safe, comfortable method of transferring resident and to reduce the risk of injury to residents and employees. The use of gait belt for transfers and ambulation is mandatory. Failure to comply with this policy will result in disciplinary action. RESIDENT 1 Resident 1 was admitted to the facility on [DATE] following a pacemaker insertion and had a history of [REDACTED]. The Minimum Data Set (MDS) assessment dated [DATE] revealed he required 2 person assist with transfers and toileting and required surgical wound care. The Care Directive Form dated 12/23/16 directed staff to transfer resident using a mechanical (hoyer) lift . During interviews with Resident Care Manager (RCM B) and the Director of Nursing (DNS), RCM B stated on admit residents are transferred per mechanical lift until assessed by skilled therapy. On 03/21/17 at 3:30 p.m., the DNS stated staff had not transferred Resident 1 correctly and that even though the nursing assistants (NACs) were interviewed there was no documented evidence that when assisting the resident off the toilet that a gait belt was used according to facility policy. The nursing admit assessment form dated 12/23/16 documented under the skin section that he had a surgical incision-pacemaker. The nursing progress note dated 12/23/16 revealed bruising was noted to the right groin incision and that the pacemaker placement was noted on his left chest area with steri-strips and the area had no drainage or signs of infection. A nursing note entry for 12/24/16 documented the physician was notified regarding scattered bruising on upper body and current medications that effect blood clotting (aspirin, liquids). The following day (12/25/16), the Licensed Nurse (LN) documented both upper arm had bruising related to the blood thinner medications and indicated gently handling during care. On 12/25/16, Resident 1 complained of pain on pacemaker incision area which he rated as being 10 on a 1 to 10 scaled (1 being less amount of pain, 10 being severe pain). The nursing note revealed the resident was sent to the hospital for pacemaker incision area swelling and pain. The hospital emergency (ER) note dated 12/25/16, documented that Resident 1 had been assisted in the bathroom and instead of using a lift the patient was held under his arms. He noted pain and developed a hematoma at device (pacer) site. The hospital note revealed he required pain (narcotic) medication and an antibiotic medication as hematoma increases risk of device infection. A facility investigative report dated 12/24/16, documented that the resident reported that he was transferred by grabbing under armpits. The NAC's statement, documented the resident was unable to stand up on his own so another NAC bear hugged him around the waist and I helped support him from the back of the waist. Even though the resident was a mechanical lift, the NACs did not follow Care Guide Directive, which directed staff to use a hoyer lift and Resident 1 experienced pain and required ER evaluation due to the development of a hematoma. On 03/22/17 at 12:59 p.m., Resident 1 stated he had informed staff that due to his recent pacemaker insertion, staff were not to grab or pull on his arms when assisting him with transfers. He stated staff grabbed under arms. RESIDENT 2 Resident 2's Minimum Data Set (MDS) assessment dated [DATE] revealed he required 2 person assist for transfers. The plan of care for mobility directed staff to transfer with a mechanical lift with two staff members due to poor safety awareness, his inability to position self and hypertonicity ([DIAGNOSES REDACTED]). The care plan also revealed a seatbelt was to be applied across his hips when positioned in his wheelchair due to retropulsion. The physician's notes for 01/18/17 and 02/22/17 documented Resident 2 was dependent of staff, had rigidity of upper and lower extremities and the plan was to try to prevent falls. On 03/21/17 during a group activity, Resident 2 was observed in his tilted wheelchair with his upper body leaned over the side of the wheelchair. The Care Guide Directive used by the nursing assistants (NACs) indicated Resident 2 was dependent on staff and required 2 person assist with transfers using a mechanical lift. A facility investigative report dated 03/13/17 document revealed Resident 2 became restless, moving his body intensely and slid down as the NAC attempted to find the buckle him in his wheelchair (WC). The report indicated only one staff was present during the transfer when using a mechanical lift. During an interview with the DNS on 03/21/17 at approximately 2:30 p.m., she stated the NAC had transferred Resident 1 by herself and had not followed the plan of care and/or followed the facility policy that required 2 person assist with all mechanical lifts. The resident did not receive any injuries. RESIDENT 3 Resident 3 was admitted to the facility on [DATE]. The nursing assessment dated [DATE] indicated she was a 2 person assist for transfers and the admit pain assessment documented she had back pain which was treated with APAP (Tylenol). Review of the nursing notes from from 03/04/17 to 03/17/17 documented Resident 3 had back pain and a headache which was relieved by Tylenol. An entry for 03/18/17 revealed the resident complained of breast pain being a 6 out of 10 (0 - no pain, 10 severe pain scale) due to being held too tightly during a transfer on 03/17/17. Resident 3 stated her breast was tender and painful. The facility investigative report dated 03/17/17 documented a NAC had transferred Resident 3 without using a gait belt and gave resident a bear hug instead of a proper transfer. During an interview on 03/28/17 with the DNS, she stated the NAC did not transfer Resident 3 according to facility policy. The DNS stated the NAC did not use a gait belt when transferring Resident 3 and transferred with a bear hug. RESIDENT 4 Resident 4 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessments for 9/14/16 and 11/30/16 revealed he required 2 person maximum assist with bed mobility, transfers and toileting. The MDSs indicated he had severe cognitive impairment, and was always incontinent of bladder and bowel. On 2/1/17 at 4:25 p.m., Resident 4 was observed asleep in his recliner next to his bed. The call light was observed on his bed and on 3/21/17 at 11:00 a.m. was observed in hall in a tilt back wheelchair. No staff were engaged with resident. During an interview with RCM B on 3/20/17, he stated Resident 4 walks with a shuffled gait, requires two person assistant with transfers, has had one room moved since admission and his wife had brought in a recliner for him in October 2016. Review of the clinical record revealed Resident 4 had a fall when attempting to go to the bathroom by himself. The Plan of Care was do to promoted toileting. The resident second fall occurred on 11/10/16 in the dining room. The investigative report indicated the resident was impulsive and had poor safety awareness. Resident 4's third fall that was unwitnessed which occurred in his room. The investigative report indicated he slipped out of his wheelchair at 11:30 a.m. The report documented he slipped out of his wheelchair. Even though the facility had identified Resident 4 as being at high risk for falls, there was no documented evidence whether adequate supervision or staff were present in dining room at the time of fall. There was no doucmented evidence as to what safety precautions were necessary to prevent further falls for a resident who was identified as being impulsive, poor trunk control and severe cognition. On 3/21/17 at 10:58 a.m., the Director of Nursing (DNS) stated if a resident has cognitive impairment and a fall risk, staff are not to leave at bedside area in their wheelchairs. The DNS stated if a resident is impulsive or agitated staff need to provide eye supervision. On 3/21/17 at approximately 11:00 a.m., the Licensed Nurse (LN C) stated Resident 4 is able to use the call light, requires cueing in the dining room and needs assistance to transfer to the chair or bed.

Based on observation, interview, and record review, the facility failed to ensure sufficient supervision during the care for 1 of 2 Residents (1). Failure to have adequate staff present during repositioning and personnel care caused harm of when a resident fell out of bed and received a fracture and a head contusion requiring hospitalization . Findings include: Resident 1's Minimum Data Set (MDS) assessment, dated 5/24/16, indicated she required extensive assistance of 2 staff for bed mobility, transfers and toilet use. She had no cognitive impairments and was 71 inches in height and weighed 202 pounds. The Care Directive Form, dated 4/21/16, directed nursing staff to have two person assist for bed mobility and the care plan for alterations in mobility indicated she was maximum assist for bed mobility. Review of the nursing notes documented Resident 1 received a new air mattress for pressure reduction on 6/17/16 and confirmed that she required 2 person assist for repositioning in bed. During an interview on 7/18/16 at 1:25 p.m., the nursing assistant (NAC A) stated that Resident 1 required two persons to assist for repositioning and/or peri care when in bed. The hospital transfer history for 7/3/16 to 7/8/16 documented Resident 1 sustained a fracture of her toe and contusion of her head. Review of the facility's investigative report, dated 7/3/16, indicated Resident 1 slipped off her bed while being changed. The report revealed that one NAC was providing care and she attempted to pull the draw sheet, which got stuck under the resident. NAC B went to the other side of the bed in order to pull the draw sheet from under the resident. NAC B documented the brief time it took to quickly walk to the other side of the bed, I noticed that it looked like she was starting to roll off the bed, so I tried to grab her, but was not strong enough to prevent the fall. The investigative report indicated the resident landed her head on the soiled linen bag. The LN documented Resident 1 was face down, was left immobilized on the floor and 911 was activated. The NAC was counseled after the incident. Review of hospital documtation, revealed the resident received a toe fracture and a head contusion. In an interview on 7/18/16 at 11:13 a.m., Resident 1 stated when she had her old mattress she was able to grab the bed frame and felt secure when being repositioned and changed in bed. She stated the new mattress sits on top of the frame and with the regular mattress I was able to feel where I was in the bed. I can no longer feel the frame, I have nothing to grab onto now. She stated only one NAC was assisting her when she fall out of bed. Resident 1 also stated that the bed was elevated at the time of the fall. During an interview on 7/18/16 at 1:50 p.m., with the Director of Nursing stated Resident 1's care directive instructed staff to have 2 persons to assist with bed mobility.

Based on observation, interview and record review, the facility failed to adequately assess or implement the resident's physician orders [REDACTED]. Failure to adequately assess the resident's pain, notify the attending physician and implement interventions resulted in harm due to inadequate pain relief as evidenced by the resident's verbal and non-verbal complaints of pain. Findings include: Review of the facility's Pain Management Policy dated July 2014, indicated, the following sections that applied were: 1. Residents are evaluated by a licensed nurse (LN) at admission using the Pain Evaluation, as needed (PRN) medication review and record review. 3. When there is a change in pain level, or if there is newly identified pain, the licensed nurse contacts the physician for appropriate treatment orders. Resident 172 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The initial pain assessment dated [DATE], was incomplete and had 4 blank areas where questions were not answered. Review of the hospital discharge instructions directed staff: to report to the physician right away if after pain medication, the resident's pain is not reduced to less than a 3 out of 10 or if the resident's pain reaches or exceeds tolerable or acceptable levels. (The pain scale is 10 is the most severe pain and 0 being no pain) Per the facility pain evaluation form dated 07/2014, it directed staff, if a resident reports severe pain (7 to 9) then requires escalated interventions. If the resident reports Worst Possible (10) then use aggressive pain management measures. Per the hospital documentation dated 06/07/16, the resident was on Intravenous pain medications during her hospital stay. Review of the nursing home admission orders [REDACTED] 1. [MEDICATION NAME] 2 tablets every 8 hours routinely. 2. [MEDICATION NAME] sustained release every 12 hours routinely. 3. [MEDICATION NAME] immediate release 1-2 tablets every 4 hours as needed. 4. [MEDICATION NAME] ½ to 1 tablet every 8 hours as needed. 5. Tylenol 325 mg every 4 hours as needed. 6. [MEDICATION NAME] 650 mg every 4 hours as needed. Review of the resident's Medication Administration Record [REDACTED]. Day shift documented the resident's pain rating of 8 out of 10 (severe pain) and evening shift documented her pain was 10 out of 10 (worst possible) and 06/08/16 night shift documented 10 out of 10 (worst possible). The MAR indicated [REDACTED]. In a written statement by the nurse who worked on 06/07/16 from 2:30 pm to 10:30 pm she documented the resident was very upset about her pain control. Review of the resident's progress notes dated 06/07/16 at 10:30 PM, revealed the resident did not have any shortness of breath, but complained of her back pain being 10 out of 10 (worst possible). The note also indicated that she had been given pain relief medications. There was no indication that the medications had helped or that the physician had been contacted. The progress notes dated 06/08/16 at 12:00 AM (midnight), documented the resident was crying with rapid breathing at 11:00 PM. She reported her pain as 10/10. The resident was asking about a [MEDICATION NAME] pump and was demanding a dose of as needed [MEDICATION NAME]. The resident was informed the next dose of pain medication was not due until 1:30 AM. The note also indicated that at 1:30 am, (2 ½ hours later, the MAR indicated [REDACTED].) The resident was given routine [MEDICATION NAME] (which was ordered to be given at midnight) with Tylenol at 1:30 am along with the as needed dose of [MEDICATION NAME]. There was no documentation that the physician was notified of the resident's elevated pain levels or that aggressive action was taken to relieve the resident's pain. It was unclear why the [MEDICATION NAME] was not given at midnight as ordered and there was no documentation the resident was checked on again until 5:00 am. Observation and interview on 06/08/16 at 6:40 AM, revealed Resident 172 lying in her bed crying. The resident stated she was in severe pain and had been in severe pain through the night. The resident stated she had the call light on during the night and no one answered the call light. The resident stated, The pain was so severe, I had to yell out for someone to come in to answer my call light. The resident stated half an hour later the staff responded and the resident was told she would have to wait two hours to get her pain medication. The resident stated she felt she did not receive her medications the night before and she felt the staff ignored her purposefully. The MAR indicated [REDACTED]. An incident report was written, and an in-service was provided to 11 nurses indicating: Pain management is a nursing skill. We need to notify the physician of new pain, changes in pain or failure to obtain relief from pain. In an interview with the facility nurse consultant, Staff J, a Licensed Nurse on 06/08/16 at 9:43 AM, Staff J was informed of Resident 172's pain. Staff J stated she would follow up on the reported resident's complaints. In a follow up interview with the resident on 06/09/16 at 10:33 AM, the resident reported the night of 06/07/16 the nursing staff's attitude toward her while she was calling out in pain was why are you calling. Resident 172 stated she felt scared and helpless. In an interview on 06/10/16 at 1:30 PM, Staff K, Staff Development, was asked what the facility's usual practice after hours for residents that are in pain. Staff K stated the physician would be called if the resident's pain was not controlled after administering the resident's as needed pain medication.

Based on interview and record review the facility failed to ensure a resident was allowed to exercise his rights as a resident of the facility and a citizen of the United States for 1 of 11 sample residents (2). Failure of the facility to evaluate or recognize how the use a door alarm, in conjunction with one on one (1:1) supervision and establishing a daily schedule for the resident, could pose as a violation of the resident's right of autonomy and choice which resulted in psychological harm as evidenced by the resident's stating that his rights were being violated, and as a reasonable person left him feeling powerless and/or with minimized self-esteem. Findings include: Resident 2 was admitted in December 2015 with [DIAGNOSES REDACTED]. The initial Minimum Data Set (MDS) assessment, dated 12/17/15 revealed the resident was involved in his assessment and he had no documented behaviors. Review of the nursing notes from 12/10/15 to 1/20/16 revealed Resident 2 was cooperative, was able to make decisions about his care, self-propelled his wheelchair around the facility, and would use his walker to ambulate to the dining room for meals. Review of the record on 1/27/16 revealed the following physician orders [REDACTED]. 1) Licensed Nurse (LN) to sign and ensure resident is escorted when out of his room at all times, 2) Evening LN will ensure that door alarm is working, 3) Door alarm for safety. An undated/unnamed handwritten behavior care plan indicated a daily schedule was to be followed with understanding it may be vary related to day to day issues/concerns that may arise. This daily schedule started with morning care at 7:30 a.m., and listed out a specific timeframe for meals, toileting, activities, and rest until 7:30 p.m. bedtime. A care directive form (daily care plan information for nursing assistants) indicated under the Behavior and Interventions Section Please make sure to follow schedule provided in care plan. LN(nurse) to ensure the resident was escorted when out of his room. Another entry regarding .evening nurse will ensure door alarm is working . was marked 'discontinued.' A behavior care plan dated 1/20/16 indicated the daily schedule was to be established to provide supervision. There was no documented evidence the daily schedule plan had been discussed with the resident and/or his family. A nursing note entry, dated 1/21/16, documented the family was called to obtain a consent for use of a door alarm for the resident's room. In addition, the note documented that the licensed nurses (LNs) were to have Resident 2 escorted when he was out of his room at all times. The note indicated the door alarm was for safety. During an interview with Staff A on 2/2/16 at approximately 2:30 p.m., Staff A stated Resident 2 had a door alarm chime placed on his doorway for a short time, but it was no longer in use. She stated Resident 2 was on strict one on one (1:1) supervision by staff when not in his room. Staff A also indicated alarm devices for individual residents were not generally used at the facility. In an interview on 2/2/16 at 11:15 a.m., Resident 3 stated there had been an alarm placed on the entry door to his room, It was for my roommate(Resident 2) so he didn't go wandering off. It's not up there anymore, it was on top of the doorsill. It went off (alarmed) when anyone went out the room door. During an interview with Staff B on 2/2/16 at approximately 3:50 p.m., Staff B said a door alarm had been placed on Resident 2's door for several days, but that it had been removed. She said the resident's door was to be closed when the contact alarm was turned on, so that the alarm would ring whenever the door was opened. Then if the alarm sounded, staff would check to see if Resident 2 was coming out of his room, and they would monitor his whereabouts and accompany him while he was outside his room. She said she had obtained verbal consent from the resident's family member for use of the alarm device whenever the resident was in his room. On 2/2/16 at approximately 3 p.m., the Director of Nursing (DNS) was interviewed regarding the use of the door alarm. The DNS said that a few weeks after the resident's admission to the facility, they were made aware of a series of behaviors by Resident 2 that happened approximately [AGE] years ago. Therefore on 1/8/16, the facility started to monitor Resident 2 for behaviors. A review of the behavior monitor for January 2016 with the DNS did not reveal any documented behaviors. The DNS stated a physician order [REDACTED]. She stated the order was obtained in response to a comment made by the resident's family regarding Resident 2's past behavior of approximately [AGE] years ago. The DNS stated she discussed the placement of the door alarm with Resident 2, but said she did not document the discussion(s) in his medical record. The door alarm was turned on at bedtime, with the room door closed, so that staff would be alerted whenever the room door opened, and then staff would escort the resident while he was out of his room. The alarm was turned off during the day while the resident continued to be on 1:1 staff supervision. The door alarm was removed from the resident's door after a care conference. The DNS verified there were no residents currently with any type of alarm device. During an interview with the facility administrator on 2/2/16 at 3:45 p.m., she stated she was made aware of past behaviors (approximately [AGE] years ago) after Resident 2 was admitted to the facility. She stated they researched the information regarding the alleged behaviors, and then met with the resident's family to discuss possible transfer of Resident 2 to an adult family home. There was no documentation in his medical record regarding the discussion. The administrator stated while trying to move forward on the possible transfer, they were told the family wanted Resident 2 to stay at the facility. So the facility decided to implement the use of a door alarm and 1:1 staff supervision of Resident 2 for safety. Less than a week after implementation, a care conference was held wherein the resident stated the door alarm violated his rights and Resident 2 told the facility that he did not want the alarm on his door. The administrator said the door alarm was subsequently removed from the resident's door. Review of the clinical record revealed a care conference was held on 1/26/16 with Resident 2 and his family to discuss his current living situation. The documentation revealed Resident 2 was told he would remain on 1:1 supervision to ensure the safety of other residents and visitors while he resided at the facility. It also documented Resident 2 stated at the conference that he did not like the alarm on his door and felt it was a violation of his rights.

Based on observation, interview and record review, the facility failed to recognize or consider the impact of placing a door alarm device and/or 1:1 supervision as a restraint without medical justification which restricted the mobility of one of one sample resident (2). Failure to thoroughly evaluate how the device and supervision impacted Resident 2's mobility and psychological well being resulted in him feeling restricted to his room, disciplined and singled out. Findings include: The facility's Quick Reference Guide: Devices vs Restraint, dated 2014, read: Devices need to be evaluated individually for the EFFECT they have on the residents. The policy on devices stated in the event a resident's medical condition or symptom(s) warrants the use of a physical device, the least restrictive device is used after a comprehensive evaluation is completed. The facility's procedure directed staff to completed the Device Evaluation, Care Plan Use of Device and devices are implemented only after consent is obtained; addressing the risks and benefits with the resident and/or resident's authorized representative. Review of the nursing notes from 12/10/15 to 1/20/16 revealed Resident 2 was cooperative, was able to make decisions about his care, self propelled his wheelchair around the facility and would use his walker to ambulate to the dining room for meals. On 2/2/16 at 4:05 p.m., the Administrator stated when Resident 2 was first admitted to the facility (12/15) he needed help but his physician (MD) told him he needed to walk. A nursing note entry, dated 1/21/16, documented the family was called to obtain a consent for use of a door alarm on the resident's room. In addition, the note documented that the Licensed Nurses (LNs) were to have Resident 2 escorted when he was out of his room at all times. During initial rounds of the facility on 1/20/16, Resident 2 was observed seated in his wheelchair in the door way of his room. He was able to have a conversation about sports. On 1/27/16 from 9:30 a.m. to 11:00 a.m., he was observed seated in his wheelchair at the foot of his bed and would not engage in conversation. During an interview with Staff B on 2/2/16 at approximately 3:50 p.m., Staff B said a door alarm had been placed on Resident 2's door for several days, but that it had been removed. She said the resident's door was to be closed when the contact alarm was turned on, so that the alarm would ring whenever the door was opened. Then if the alarm sounded, staff would check to see if Resident 2 was coming out of his room, and they would monitor his whereabouts and accompany him while he was outside his room. She said she had obtained verbal consent from the resident's family member for use of the alarm device whenever the resident was in his room. During an interview with the Director of Nursing on 2/2/16 at 2;18 p.m., she stated Resident 2 was able to make his own decisions and had no history of wandering. She stated Resident 2's door was closed at night with a alarm device. She indicated the alarm was used to alert staff if he was getting out of bed and 1:1 supervision was implemented as we did not want him to walk freely. During an interview on 2/9/16 with the family member who was involved with Resident 2's care stated he did not care for the alarm, it was noisy and his door was kept shut all day. The family member stated the alarm limited his mobility and made him feel depressed. She stated with the door closed and alarm on, he was unable to open his door. She stated she was informed the benefit to using the alarm was so Resident 2 would not leave his room without staff knowing. The family member stated that Resident 2 felt he could not say anything about the use of the alarm as he did not want to jeopardize his freedom. The family member stated the use of the alarm was disciplinary and singled him out. The family member stated when she visited the resident, the one to one supervision limited her privacy with him and was uncomfortable, someone sitting there during the day, no privacy. S/he stated Resident 2 now felt that the facility is not his home since the use of the door being closed with the alarm. A undated document Device Informed Consent was reviewed on 1/27/16. The form indicated the door alarm was the least restrictive device and the medical reason for its use was safety. Another undated form reviewed on 1/27/16, Device Evaluation for a recommended door alarm indicated safety as the medical condition/symptom for its use. There was no indication documented what other measures had been attempted prior to the door alarm. The form did not document what the benefits/reasons for the device (door alarm). There was no documented evidence found in the resident's record between 1/8/15 to 1/26/16 that Resident 2 had ever been appropriately assessed for the use of the alarm on the door, one to one supervision as related to his behaviors from [AGE] years ago or how these measures would affect his psychological well-being. In addition, documentation revealed there was no discussion with Resident 2 in regard to the reason or effect these measures would have on him due to his past history. Additionally, there was no medical condition which warranted the use of the alarm device for Resident 2. Use of the alarm with the door closed limited him to freely enter and exit his room. The one on one supervision by staff imposed on his privacy when family visited.

Based on interview and record review, the facility failed to consistently provide the necessary care and services related to wound management for 1 of 1 sampled residents(1). Failure to perform consistent and thorough skin evaluations, treatments, ongoing monitoring, and timely physician notification of lower extremity wound changes resulted in harm to Resident 1. Findings include: Resident 1 was admitted to the facility on [DATE] with multiple medical [DIAGNOSES REDACTED]. An initial 4/14/15 admission nursing note indicated the resident was admitted with skin ulcers. The associated Nursing Admission Evaluation form showed multiple skin ulcers & skin concerns with the locations marked on a body diagram. There were wounds noted on both lower extremities (LE), an outer L (left) foot ulcer noted as black in color, a L heel area noted as dark in color, an open sore on the coccyx/buttock area, and an undescribed skin issue on bilateral toes. On 4/15/15 evening note revealed the following initial wound measurements: 3 wounds on the outer Right lower extremity (RLE): Top= 3 x 3 cm (centimeter), Middle= 2.5 x 2.5 cm, Bottom= 1.5 x 1.5 cm 1 wound on inside RLE 4.5 x 3 cm. 1 wound on the outside of L foot 1.5 x 1.25 cm. 1 wound on L front shin 1.75 x 1cm. The 4/15/15 note indicated the above wounds were present on admit and indicated the resident had since developed 2 more wounds on front R shin measuring 3 x 1.5 cm and 3 x 2 cm. The wounds were cleaned, treated, dressings applied, and gauze placed between necrotic toes. There was no documentation that the physician was notified of the new wounds or a request made for treatment orders. Review of 4/14/15 admission physician orders and all physician telephone orders did not reveal any specific treatment/dressing orders related to wound care. Weekly Skin Evaluation forms were initiated on 4/15/15. Separate forms documented the wound descriptions & measurements for each R & L LE wound and the L outer foot. The L LE shin wound form did not note a description of the wound bed, such as color and skin tissue (necrotic or healing), and the L outer foot wound was described as having 80% slough (dead skin tissue) with purulent drainage. There were no Weekly Skin Evaluation forms documenting assessment & measurement of the dark L heel area, open sore on the buttock, or necrotic toes. On 4/16/15, an evening shift nurse noted the resident had a few more knicks on the L leg that were bleeding, and 2 open areas on his bottom (both 1.5 x 1cm) which were cleaned and dressed. There was no documentation that the physician was notified of the new L leg wounds or a request made for treatment orders. On 4/21/15 evening shift, a nurse noted dressing changes were done for both lower extremities. The note indicated, Wound on outside R leg outside (lowest of 3) is slightly necrotic. Antimicrobial dressing applied to this wound and wound on the L outside foot. Meta honey to all other open wounds .Iodine swabs applied between toes. There was no documented evidence that a medical provider was notified of the R LE changes in condition (necrotic) and/or a request made for treatment/dressing orders. April 2015 Treatment record revealed the following nursing treatments: 1)Weekly skin assessment, head to toe, was initialed as completed on 4/21/15 and 4/28/15. The 4/21/15 entry was marked (-) indicting no skin impairment, and 4/28/15 indicated no new areas. There were no corresponding or updated wound evaluations documented on Weekly Skin Assessment forms for 4/21/15 or 4/28/15 for any of Resident 1 ' s skin issues. 2)Change dressings to Leg wounds daily each evening. There was no corresponding written physician order for [REDACTED]. In addition, there were no physician orders for any nursing treatments, dressings or ongoing monitoring of the other previously identified skin areas, such as the buttocks, L heel, L foot or toes. There were no other specific nursing progress notes related to Resident 1's skin issues until a final nursing note on 4/28/15: Resident left for wound clinic appointment at 1445 .Wound clinic called and informed resident will be going to hospital for admission to get amputation. A review of medical provider visit notes on 4/15/15 and 4/23/15 did not mention the presence of any lower extremity wounds: The 4/15/15 MD progress note (Admit evaluation) indicated the reasons for admission was to treat a decubitus ulcer, chronic kidney failure, and a bowel infection. The MD's physical exam of the skin noted, Some contusions, Decubs(decubitus pressure ulcers) not examined. Multiple stage II buttock ulcers reported, left 2nd, 3rd, 4th toes black and mummified . The MD assessment & plan indicated .3. Decubs, present on admission, the product of prolonged pressure sustained at home prior to admission. Rx(treat) with pressure sparing and [MEDICATION NAME](skin cream) 4. Ischemic necrosis left toes 5. Most of this is not really reversible. The 4/23/15 nurse practitioner progress note indicated the visit for follow-up and evaluation of a bowel infection and low blood potassium level. The physical exam of skin noted, Some contusions, Decubs not examined. Multiple stage II buttock ulcers reported, left 2nd, 3rd, 4th toes black and mummified. The assessment/plan indicated, .4. Pressure Ulcer buttocks-continue wound care, diarrhea is contributory 5. [MEDICAL CONDITION]/ischemic toes- no further treatment of [REDACTED]. The last medical provider visit note on 4/28/15 revealed the resident was being evaluated for confusion/hallucinations after [MEDICAL TREATMENT] with no new medical changes in condition. It noted the resident continued with multiple wounds which were being treated topically, but the wounds have slightly worsened and so the resident was going to be seen at a wound clinic for further evaluation. The physical exam noted BLE (bilateral lower extremities) with [MEDICAL CONDITION],tight with vascular changes visible .and BLE with dressing in place without strikethrough drainage, and decubitus ulcer on buttocks not seen today (going out). The assessment/plan included, .4. Pressure Ulcer buttocks-Evaluate per wound center 5. [MEDICAL CONDITION]/Ischemic toes- no further treatment of [REDACTED]. An outside state agency provided the following information on 8/26/15: Resident 1 was admitted to the hospital emergency room in 4/28/15 for L foot had gangrene of his left foot and toes . foul-smelling drainage and odor with multiple areas of combined dry and wet gangrene of the left forefoot and heel . left foot and lower leg were not viable and resident required an emergent left above-knee amputation for control of gangrene and septic foot. During an interview with the Director of Nursing (DNS) on 4/18/15 at approximately 4 pm, the DNS stated there were new nursing staff working at the facility while the resident resided at the facility. The DNS was unable to provide additional information or documentation related to wound treatment orders, monitoring, and/or physician notification of LE wound changes.

Based on observation, interview and record review the facility failed to provide adequate supervision and protection after an avoidable accident for 1 of 6 sampled residents (44). This failure resulted in physical and mental harm for Resident 44, who stated he was "rolled out of bed" by staff and he did "not feel safe in the facility". Findings Include: Resident 44 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set Assessment (MDS), dated [DATE], showed that Resident 44 was cognitively intact and had not shown any symptoms of delusions or hallucinations, and had no changes in behavior since his last review. According to the MDS the resident used a wheelchair, a transfer pole, and required the assistance of one staff person to assist him with transfers and bed mobility. At approximately 10:15 a.m. on 9/22/11 in an interview, the resident stated he was not doing well. He continued, " I was asleep and was rolled out of bed about two days ago. He continued "The world just spun around and I landed on the floor. I landed beside my bed here (Resident 44 pointed to an approximately two foot or less space between his bed and the transfer bar). I landed on my hands and knees and got all banged up. My knees are all bruised and I got this deep gash on my arm. (The resident pointed to his left arm which had two steri strips, located just below his elbow, with purple bruising to mid upper arm." When asked if he felt safe at the facility, the resident stated, "No, but what choice do I have?" He said he had planned to call the Ombudsman but hadn't. He stated he felt safe talking to the new social service person here at the facility and that he had discussed this issue with her. On 9/22/11 at 10:50 a.m., the Director of Nursing Services (DNS) was notified of the resident's concerns including not feeling safe at the facility. According to the facility's investigation documentation recieved on 9/28/11, the nursing assistant providing care at the time of the accident stated she was changing the resident's brief. She continued that she had begun the care with the resident lying on his right side. When she pullied the brief over to the other side the resident rolled out of bed." In a later interview with the DNS, the NA was noted as stating she had turned the resident to the other side, made sure he was secure then the resident fell before she had gotten to the other side. The picture she had drawn of how she was providing care was consistent with her statement. According to the LN's, statement the NA reported to her that while providing care to the resident she assisted the resident to turn away from her and the resident slid to the floor. It was also documented by the NA responding to the first NA's request for assistance, that when she entered the room, she observed the resident on the floor on his knees yelling, "My knees, my knees." She documented that she had placed a gait belt on him, then the LN came into the room and the resident was assisted back to bed. Preventative measures for recurrence of the incident included, "Have aides roll residents toward them instead of away from them so the aides have more control of the resident. " The resident's documented injuries from the incident incuded a skin tear that measured 2.5 cm (centimeter) to his left forearm (LFA), a bruise that measured 2 cm x 4 cm distal to the skin tear on the LFA , a skin tear that measured 0.6 cm to left elbow, and a bruise that measured 5 cm x 5 cm to left elbow. There were two bruises to left bicep, one that measured 3 cm x 1 cm and the other one measured 5 cm X 8 cm. He had two bruises to his right knee, one measured 1.1 cm X 1 cm the other measured 2.5cm X 3.5 cm: dusty and red. An abrasion was found on his left knee which measured 1 cm X 1 cm, and an abrasion was found on his left 2nd toe, which measured 1.1 cm X 1 cm. A skin tear, "slit like over end of toe", that measured 1.5cm was found on his right great toe. Per an untitled form, dated 9/22/11, the Social Service Director (SSD) wrote that during her interview with the resident regarding the incident, he had reported that he had safety concerns about " rolled off his bed". He did not feel safe in the building at night. SSD further documented that the resident would not provide her with anything specific the facility could do to make him feel safe. On 9/26/11 the resident was seen by a mental health professional (MHP) as requested by the facility, related to the 9/21/11 incident. On 9/28/11 at 11:15 a.m. the Administrator stated she had not heard the resident was fearful for his safety. She described the policy the facility followed when a resident expressed fear. She said staff would first attempt to identify who or what they were fearful of and why. If it was a staff member, that person would be immediately removed from duty until an investigation was complete. Other residents that person cared for would be interviewed and depending on the outcome of the investigation staff training would be done or the person terminated.

Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as body weight and protein levels, for 1 of 5 residents (Resident 15) reviewed for nutritional status. The failure to consistently provide Resident 15 with the nutritional supplements recommended by the facility Dietician, and the failure to comprehensively monitor her food intake, resulted in Resident 15 losing 15.3% of her body weight, or 19.4 pounds, in 6 months. Findings include: Resident 15 was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident 15 had memory problems, no recall, at times physically resisted care, was rarely understood and had periods of inattention and disorganized thinking. Resident 15 had a poor appetite and used a wheelchair for mobility. Resident 15's was weighed weekly between 3/13/11 and 9/26/11. During the six month period of time, Resident 15 lost 19.4 pounds. The facility "Meal Monitor Care Plan Flow Sheets" instructed staff to "Give 4 oz. of instant breakfast, eggnog or equivalent as a replacement if 1) Resident left all of meat or entree item; 2)Resident left more than 50% of the entire meal." Resident 15 had an order for [REDACTED]. On 9/28/11 at 2:30 p.m., Licensed Nurse (LN) 1 reported it was a facility expectation for the staff to offer the replacement when a resident eats poorly and the replacement at meals was in addition to the prescribed nutritional supplement (Med Pass 2.0) given with medications. Resident 15 received Med Pass 2.0 three times per day. Resident 15 was receiving those nutritional supplements and documentation in her clinical record indicated she consumed 100% every time it was offered. Resident 15 was observed at lunch 5 times 9/19/11 to 9/23/11. Resident 15 did not ever appear to be resistant to eating during those observations and required full assistance to eat. Resident 15 was not offered the additional meal supplement of eggnog, instant breakfast or the equivalent during the lunch observations. The nutritional supplements of ice cream and peanut butter were not offered to Resident 15 with the exception of two bites of ice cream on 9/22/11. On 9/23/11 the Registered Dietician observed Resident 15 at lunch. Resident 15 was offered her ice cream and her peanut butter of which she consumed 100%. LN 5 reported Resident 15 "loved" ice cream and peanut butter and that she usually eats it all. LN 5 stated the facility got her a "Peanut Butter shake once and she would not stop drinking it until it was gone." Resident 15 ate 75% of her lunch. The "Meal Monitor" for 09/2011 indicated Resident 15 received the supplement of eggnog or instant breakfast 4 times from 9/01/11 to 9/23/11 and ate less that 50% at 64 meals. The "Meal Monitor" for 08/2011 indicated Resident 15 received the supplement of eggnog/instant breakfast 5 times for the month of August and ate less than 50% at 87 meals. The "Meal Monitor" for 07/2011 indicated Resident 15 received the supplement of eggnog/instant breakfast 4 times for the month of July and ate less that 50% at 83 meals. Resident 15 was to be offered a snack every night at bed time. The "Care Plan Flow Sheet" for snacks indicated Resident 15 was offered and refused a snack 21 times in July 2011, 14 times in August 2011 and 5 times from 9/01/11 to 9/23/11. The "Alteration in Nutrition, Weight Loss Care Plan", dated 7/26/11, for Resident 15 read: "Problems: Weight loss, advanced age, no teeth, pureed texture. Goals: Consume enough fluid for comfort. Anticipate weight loss. Approach: Guardian and MD notified. Registered Dietician referral. Multivitamin everyday. Offer replacement if eats less than 50%. Weekly weights. POLST:(advanced directives) review with guardian. 5/02/11 Supplement between meals." Resident 15's "Annual Nutritional Review", dated 7/26/11, read: "Resident had an increase in dementia behaviors with a decrease in oral intake this quarter which contributes to residents weight loss...has has a 11% significant weight loss this past 6 months.. Current weight (116 pounds) within ideal body weight range. Current interventions include Med Pass 2.0 and supplements in place for weight maintenance...Resident remains at increased nutritional risk secondary to advanced age..dementia and poor oral intake. Guardian aware of progressive dementia and that further weight loss may be expected and unavoidable." Another Dietician referral, dated 8/17/11, read: "Referral received from nursing secondary to constipation..resident may benefit from increased encouragement of fluids to help...resident consumes increased amounts of peanut butter throughout the day which can be a constipating however this is her favorite food and thoroughly enjoys.." On 09/23/11 at 12:47 p.m., The Registered Dietician reported she was not aware of the supplements (ice cream, peanut butter, eggnog, instant breakfast or equivalent) not being offered to Resident 15. The Registered Dietician reported Resident 15 was not on comfort care or end-of-life restrictions. A fax to Resident 15's physician, written on 8/25/11, included: "...Multiple dietary interventions in place, intake fluctuates but is poor most of the time." No documentation in Resident 15's clinical record indicated Resident 15 was receiving end-of-life or comfort care. There were no physician orders for comfort or end-of-life care or a [DIAGNOSES REDACTED]. The facility failed to consistently offer the nutritional supplements that had been ordered for Resident 15, or to comprehensively assess and monitor her oral intake, and this failure led to a significant weight loss.

Based on interview and record review, the facility failed to provide timely care services to maintain physical well being for residents. Affected were two of two sampled residents (1 and 2) reviewed for bowel status and treatment. Failure to consistently implement facility policy and provide treatment for [REDACTED]. Findings include: 1. Resident 2 was admitted in July 2011 for rehabilitation after a fall at home that resulted in a fractured spine and right pelvic area. Her MDS assessment, dated 07/27/2011 identifed her recall and memory as intact. Her bowel status indicated no constipation. On 08/08/11 at 4:30 p.m., Resident 2 reported she was very constipated when she arrived at the facility in July. Sometimes at home she used milk of magnesia when she felt constipated. She stated there was a hardened stool and she could not expel it. The nursing staff told her to lie in the bed on her left side. The LN "dug it out with her fingers." She had never had the procedure before. "Boy did it hurt, I won't forget that - and I don't want that done again, it was painful," she said. On 08/08/11 at 1:25 p.m., Licensed Nurse (LN) 3 reported the facility policy "Bowel Monitoring and documentation", dated July 2008, read nurses were to administer oral agents identified in the policy in the sequence listed if a resident failed to have a BM in 2 days. After 3 days, nurses were to assess for bowel obstruction. If there were no obstruction, they should administer a [MEDICATION NAME] or [MEDICATION NAME] suppository rectally. At 1:35 p.m., LN 2 reported that because digital removal of stool was an invasive procedure, the nurse should notify the resident's physician if the plan was to digitally remove hardened stool. Review of the nursing clinical notes revealed no documentation of manual removal of BM for Resident 2. Resident 2's admission orders [REDACTED]. Her "BM Monitor" record for July 2011 noted she had no BM for 4 days, 07/13/2011 to 07/16/2011. On 07/17/2011 she had a medium BM. Her Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. [MEDICATION NAME], an anti-diarrheic, was listed on the MAR indicated [REDACTED]. There was documentation of administration of [MEDICATION NAME] on 07/14/11, 07/15/11 and 07/17/11. Additional doses were documented on 07/18/11 through 07/21/11. All doses for July 2011 were documented by the same LN, who was no longer employed at the facility. Only two doses, 07/20/11 and 07/21/11, documented reasons for administration. Both of the doses were administered "for constipation." 2. Resident 1 was admitted in March 2011. Her [DIAGNOSES REDACTED]. Review of her clinical record for BM revealed Resident 1 had small amounts of BM daily from 07/12/2011 through 07/17/2011. The record noted on 07/18/2011 Resident 1 had a large BM. Nursing documented digital (manual) removal of hard stool on 07/18/11. At 1:42 p.m., Resident 1 reported nurses had manually removed stool "several times". She did not recall the last time they had done so. At 1:35 p.m., after reviewed Resident 1's clinical record, LN 2 stated there was no evidence any nurse notified the physician and obtained permission for digital removal of hardened stool. 3. At 5:55 p.m., the Director of Nursing Services (DNS) reported if a resident was unable to have a BM or had not responded to the facility bowel protocol, the staff LN should notify the resident's physician as the facility may have to send the resident to the hospital for XRAY of possible obstruction. Staff should follow any new orders from the physician.

Based on observation, interview and record review, the facility failed to provide social services to address discharge needs for 1 of 3 residents reviewed for assistance with discharge (Resident 1). Failure to advocate for the resident with his insurance company in a timely manner caused the resident much distress over his discharge timeline. This caused Resident 1 to feel like he had to discharge from the facility immediately without any discharge plans being finalized. Findings include: 1. Resident 1 was admitted in June 2011 for recovery after renal surgery. His most recent Minimum Data Set (MDS) assessment, dated 07/11/11, identified his recall both short-term and long-term memory ability were intact. On 07/29/11 at 10:20 a.m., Resident 1 reported he was informed on 07/28/11 his insurance coverage ended 07/29/11. Prior to that time, he had asked the facility staff to telephone the insurance company and request he stay until the following week when his surgeon returned to town as he did not know what the future plan was for his renal issues including the capped nephrostomy tubes on his back. No one from the facility staff had responded and advocated to call the insurance company when he asked. Additionally, observation found a peripherally inserted central catheter (PICC) line in the resident's right upper arm. Resident 1 stated the insurance company had granted the stay as long as he had the PICC line. Staff told him it would be removed later in the day (07/29/11), but no one had approached him about the removal. Resident 1 reported he did not have a place to live when discharged . The facility Social Services Director (SSD) told him he could remain in the facility and pay the total cost, over $200/day, at his personal expense. He reported he had $400 in a personal trust fund account in the facility, which staff told him would be used towards the personal payment of the daily charges. Resident 1 wanted to keep the funds as they were the only money he currently possessed. The other options he recalled the SSD presented to him - staying at the local gospel mission (not available until at least 08/02/11) or requesting housing via Everett Housing Authority (not available for at least 2 months) Because none of the proposed options met his needs or preference, and no staff advocated for an appropriate discharge location, he thought his only and best option was to live in his car. When he told the SSD that was his plan, she told him he could make his own choice. On 7/29/11 at 11:46 a.m., Resident 1 reported he signed the "Notice of Medicare Provider Non-Coverage" form on 07/28/11. It read his insurance coverage terminated on 07/29/11. No staff had discussed, reviewed or asked him to sign a discharge notice. However, he was under the impression that he would have to discharge immediately from the facility as he did not have funds to cover his care. At 3:50 p.m., the Administrator reported the facility contacted Resident 1's insurance company and they granted authorization for coverage through 08/01/11. She did not know why the facility staff had waited to contact the insurance company. At 4:35 p.m., Resident 1 reported he felt "not as much stress" as staff had finally called the insurance company and the company had extended his coverage for stay. He wondered why they had not called sooner as he had asked. On 08/01/11 at 7:55 a.m., Resident 1 reported he felt "better." His surgeon was due back in town that day and he needed to know what the surgeon wanted done with the nephrostomy tubes. Resident 1 had no place to discharge that was appropriate due to his medical needs. Social services failed to clarify for the resident that he did not have to leave the facility immediately even with his insurance ending. Social service did not proactively contact the resident's insurance carrier with the resident's continued medical needs when the resident was notified of the end of coverage. The facility instead had him sign an acknowledgement of non coverage by his insurance carrier. They did not assist the resident to ask for further authorization from his medical insurance until this was brought to the attention of the facility by the investigator. Social service failed to discuss with the resident that living in his car was not a good option for him especially with his current medical challenges. This resulted in harm for Resident 1.

Based on interview, observation and record review, the facility failed to ensure 2 of 4 residents (Resident 1 and Resident 2) reviewed for accidents received adequate supervision and assistive devices to prevent those accidents. The failure to assess the resident's environment for potential hazards related to falling, to implement appropriate interventions (including consistent supervision), and to evaluate and revise the interventions after repeated falls with injuries, resulted in harm for Resident 1 and Resident 2. Findings include: 1. Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 5/06/11, indicated Resident 1 had some memory problems, moderate recall and had periods of inattention and disorganized thinking. At times, Resident 1 resisted care, wandered and had delusions. Resident 1 required extensive assistance with all of her daily care needs and used a walker for mobility and ambulated independently. From 8/20/10 to 5/01/11, Resident 1 had 16 falls in the facility. Preventative safety measures in place prior to 8/20/10 included non-skid socks at all times and a low bed. On 8/20/10 at 12:40 a.m., Resident 1 was found on the floor in her bathroom. She had fallen and hit her head which resulted in a laceration. The Incident Report (IR) indicated the preventative actions taken after the fall were to remain with the resident when toileting and to offer the toilet every 2 hours. On 8/24/10 at 3:45 p.m., Resident 1 was found on the floor in her room. Resident stated she had hit her head and had skin tears on her right elbow and left wrist. Resident 1 reported she was pushing her bedside table across the room. The IR indicated the preventative actions were to remove the bedside table in her room and to keep her walker next to her bed. On 9/14/10 at 8:00 p.m., Resident 1 was observed to fall at her door, stating she had forgotten her walker. The witness account reported "I believe she hit her head and her cheek on the way down" and she had abrasions on her right elbow and left hand. The IR indicated the preventative actions were to "Remind over and over to use her walker and to give her medications at night when she is in bed and ready to sleep." On 11/1/10 at 12:00 p.m., Resident 1 reported she was in her room and lost her balance falling against the window sill. Resident 1 reported "I did not hit the ground". Resident 1 had a bruise on her left forearm and her right wrist. The preventative actions on the IR included monitor Resident while ambulating and "if further incident will have therapies assess transfer safety". On 11/5/10 at 6:45 a.m., Resident 1 was found in bed with some blood on her pillow. Resident 1 had a lump and a "large bruise" on her right forearm, her ear was "bleeding and 75% bruised", a bruise on her right wrist and a laceration on her back. The IR indicated Resident 1 had "gotten up some time during the night and had lost her balance and had fallen." The IR had no preventative actions listed and no care plan changes were noted. No transfer safety assessment from "therapies" could be found in Resident 1's clinical record. On 11/28/10 at 10:40 a.m., Resident 1 was found on the floor in her room. Resident 1 had a 3 centimeter laceration above her right eye which continued to bleed and she was sent to the emergency room at 12:25 p.m.. The IR indicated to preventative actions were "Have therapies evaluate for safety plan of care and proper assistive devices." An order requesting therapy for an assessment was present in Resident 1's clinical record but no assessment was found. On 12/23/10 at 12:50 p.m., Resident 1 was found kneeling on her knees by her bed. She had reddened knees. No preventative actions were listed in the IR. On 12/26/10 at 2:00 a.m., Resident 1 was found on the floor in her room. No injuries were noted. The IR listed the preventative actions to be "Resident is already care planned for toileting every 2 hours. Continue with all current safety measures as per care plan. Resident remains independent with ambulating and transfer. Resident has dementia and anxiety. Doesn't always use her call light to ask for assistance from staff at night to toilet every two hours." On 1/07/11 at 8:15 p.m., Resident 1 was found on the floor in her room. Resident 1 stated she hit her head and her right hip. Resident 1 reported she had "gotten up and was walking to her walker and felt light-headed, turned and walked back to bed and fell ." The IR listed the preventative actions as "Walker to be at bedside when resident is in bed." On 2/13/11 at 7:30 p.m., Resident 1 was observed to fall in the hallway while ambulating with her walker. No injuries were noted. The IR listed the preventative actions to be "I told the resident how to use her walker properly. Witness report indicated resident looked like she was almost walking sideways." On 3/08/11 at 10:05 a.m., Resident 1 was found on the floor in her room. No injuries were noted. The IR listed the preventative actions to be "Staff to ensure personal items in proper place like the closet." The care plan was revised to include: 1. Distant supervision when ambulating. 2. Needs frequent reminder for walker use. 3. Keep personal items stored in her room. 4. Safety check every 2 hours. 5. Monitor for behaviors per protocol. No documentation indicating a safety check every 2 hours had occurred was present in Resident 1's clinical record. On 4/23/11 at 9:00 a.m., Resident 1 reported that she had fallen. Resident 1 had an "extensive..deep purple contusion to her left forearm" which spread to her hand on 4/25/11. Resident 1 went to the hospital on [DATE] for stitches after the contusion ruptured. The fall summary read "Potential contributing factors to fall: dementia with impaired safety awareness and cognition. Delusions of looking for items i.e. car, sewing machine and her son and mother. Anxiety disorder. High risk medications..no side effects noted...fall risk score: high." The IR had no preventative actions noted and no care plan changes were noted in relation to falls. There was no evidence in Resident 1's clinical record that the intervention of every 2 hour safety checks had been completed or revised after another fall. On 04/28/11 at 7:35 a.m., Resident 1 was observed to be holding herself up by her left arm against the heater in the dining room. Resident did not hit the ground and no injuries were noted. The facility initiated a wheelchair due to "confusion and unsteadiness on feet. Referral to rehab therapy for Physical Therapy evaluation and plan of care." No assessment related to the safety of a wheelchair for this resident could be found. On 4/28/11 at 4:10 p.m., Resident 1 was found sitting on the floor with her wheelchair behind her. No injuries were noted. No changes in the interventions were noted. The IR summary of the fall, dated 5/02/11, indicated Resident 1 should be on safety checks every 1 hour. The care plan was updated with that intervention on 5/02/11. On 4/30/11 at 11:25 a.m., Resident 1 was found on the floor between the bed and the wheelchair. No injury was noted. The IR fall summary indicated the safety plan was to place Resident 1 in a high traffic area to enable staff to meet her needs quickly. On 4/30/11 at 12:00 a.m., Resident 1 was found on the floor in her room with no injuries noted. The IR fall summary, dated 5/03/11, indicated Resident 1 should be on every 30 minute safety checks. The care plan was updated with that intervention on 5/03/11. The 30 minute safety checks took effect on 5/03/11 and Resident 1 had not had a fall between 5/03/11 and 6/17/11. There was documented evidence the 30 minute checks were ongoing and completed. The facility failed to place the intervention of increased supervision in effect in a timely manner. Resident 1 was observed on 6/15/11 and 6/16/11 using her walker in the hallways of the facility. On 6/16/11 at 10:15 a.m. and at 3:15 p.m., a Licensed Nurse was observed to remind Resident 1 to get her walker while the resident was leaving her room. On 6/15/11 at 10:00 p.m., Residential Care Manager (RCM) for Resident 1 reported the resident was "returning to her baseline and was falling much less" The RCM reported increased supervision was usually used in the facility when a resident was a danger to others or themselves. The RCM did not know why increased supervision was not started with Resident 1 before 5/03/11. The facility "Fall" policy, undated, did not address interventions or specifically increased supervision. 2. Resident 2 was admitted into the facility on [DATE] after a hospitalization with [DIAGNOSES REDACTED]. The MDS assessment, dated 5/02/11, indicated Resident 2 had unclear speech, some memory problems with poor recall and periods of inattention with disorganized thinking. Resident 2 required extensive assistance with all of his daily care needs and used a wheelchair for mobility. From 3/31/11 to 5/31/11 Resident 2 had 12 falls in the facility. Resident 2 was admitted with a large bruise on his hip from a recent fall in the hospital. Preventative safety measures in place prior to 3/31/11 included the bed in the lowest position and a mat on the floor. On 3/31/11 at 7:00 a.m., Resident 2 was found sitting on the floor in his room. No injuries were noted. Resident 2 stated "I crawled out of bed to the corner because the window curtain is going to fall on me." The IR listed the preventative actions as "keep the bed in lowest position, a mat on the floor and move the bed away from the window." On 4/4/11 at 12:15 p.m., Resident 2 was seen to be walking from his bed to his wheelchair and falling. No injury was noted. The IR listed the preventative actions as "keep wheelchair at the side of the bed with the wheels locked." On 4/05/11 at 12:00 p.m., Resident 2 was found sitting on the floor in his room. No injuries were noted. The care plan was updated to include the intervention of "high-low bed in lowest position." On 4/13/11 at 1:25 a.m., Resident 2 was found on the floor in his room. Resident 2 reported "I guess I got over there, sat down and bumped my head." The IR listed the preventative actions as "Hip protectors on while in bed." On 4/18/11 at 7:30 p.m., Resident 2 was found sitting on the floor in front of his bed. Resident 2 reported "I fell and hit my head." The IR indicated Resident 2 had "Lost his balance when he tried to transfer from his wheelchair to bed without help." The IR listed the preventative actions as "When he is not in bed, his bed is supposed to be up." On 5/11/11 the Resident 2's care plan was updated to include the interventions including non-skid socks on while in bed, toilet every 2 hours and a Physical Therapy evaluation and plan of care. The Physical Therapy plan of care or safety assessment could not be found in Resident 2's clinical record. On 5/20/11 at 1:00 a.m., Resident 2 was being assisted by facility staff when he fell and hit his head. No non-skid socks were on Resident 2. Resident 2 received a 7 centimeter by 3 centimeter abrasion on his head and was sent to the emergency room for evaluation. The IR listed the preventative actions as "Place mats on both sides of the bed." On 5/20/11 at 3:45 p.m., Resident 2 was found on the floor mat in his room. No injuries were noted but Resident 2 reported "His head hurt." Resident 2 was in bare feet and the IR summary indicated "He is able to remove non skid socks and shoes." No additional preventative actions were initiated. On 5/21/11 at 3:45 a.m., Resident 2 was found on the floor in his room. Resident 2 was complaining of shoulder pain and was sent to the emergency room for evaluation. The emergency room X-Ray report, dated 5/21/11, read "Linear, non-displaced fracture..right sinus.. and a linear fracture of the right temporal (forehead) bone is not completely excluded." The IR summary listed "In Physical Therapy for gait training" as the preventative action. On 5/26/11 at 2:50 p.m., Resident 2 was found in his room on the floor having a seizure lying in a "large pool of blood under his head." Resident 2 was sent to the emergency room and received sutures for his head wound. The IR summary indicated preventative actions included "Low bed, non-skid socks, mats to both sides of the bed and hip protectors." On 5/28/11 at 6:00 a.m., Resident 2 was found on the floor in the dining room with his oxygen tubing around his feet. No injuries were noted. The IR listed the preventative actions as "Supervise oxygen tubing placement each shift." On 5/31/11 at 4:30 p.m., Resident 2 was found on the floor in his room. No injuries were noted. The IR listed the preventative actions a "current safety plan appropriate. Add to care plan to place his wheelchair at bedside to assist with transfers." Resident 2 was discharged [DATE]. On 6/15/11 at 10:00 p.m., Residential Care Manager (RCM) for Resident 2 reported the facility had not implemented increased supervision for Resident 2 because he was "independent in mobility." The facility failed to implement the intervention of increased supervision to prevent further falls or injuries to Resident 2.

Based on observation, interview and record review the facility failed to ensure all incidents of injury were reported and thoroughly investigated to prevent further injuries for one of four sampled residents (1). Failure to report and thoroughly investigate injury to Resident 1 prevented the facility from putting intervention in place and resulted in further incidents of injury. Findings include: The facility's "Standing Policy for Skin Care" for bruising instructed staff to measure and documented location of bruises on the skin observation sheet and the chart in the progress notes. It also directed staff to "complete an incident report." Included in the policy were "guidelines to estimate the age of a bruise." The guidelines indicated: 0 - 2 days, swelling, tender 0 - 5 days, red/blue/ purple 5 - 7 days, green 7 - 10 days, yellow Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The assessment also indicated she was totally dependent on staff for all of her activities of daily living. Resident 1's record indicated the resident was not on any anti-coagulant medications(blood thinning medications that increase bruising) and had she did not have any [DIAGNOSES REDACTED]. The facility documented multiple incidents of injury to Resident 1. 1. On 8/7/10 an LN documented in the progress notes the resident was injured during a transfer. The resident's left toe was bumped on the bed and the skin rolled back causing it to bleed. There was no incident report completed and no investigation to determine if the nursing assistant (NA) was neglectful with the transfer. Failure to investigate left the facility without a plan to prevent future occurrences. In addition, there was no evidence the facility looked at other residents transferred by the NA involved for injury. 2. On 8/18/10 an LN documented on the treatment sheets for staff to monitor bruises located on the resident's left outer elbow and right hand. There was no documentation in the progress notes, no incident report was completed, and there was no investigation to determine how the resident received the bruises and thus no plan to prevent further injury to the resident. 3. On 9/8/10, documentation on an incident report indicated the resident had a 9 centimeter (cm) by 3 cm bruise under her right arm pit. No description of the color of the bruise was found. Preventative actions to prevent reoccurrence included a therapy evaluation of transfer techniques. The facility concluded the origin was unknown but it was "reasonably related to the condition." There was no supporting documentation to indicate how staff made this determination and the specific [DIAGNOSES REDACTED]. The investigation of the bruises was incomplete and lacked statements by staff who had contact with the resident prior to discovery of the bruise. There was no documentation from the therapist who evaluated the transfer. 4. On 10/20/10 the resident had a bruise on her right thumb and on 11/19/10 the resident had a skin tear on her left elbow.. There was no documentation in the progress notes, no incident report was completed, and there was no investigation to determine how the resident received the injuries or a plan to prevent further injury to the resident. 5. On 11/20/10, an LN documented on a incident report the resident developed a bruise under her right eye. The LN documented the bruise was caused by the resident leaning downward and hitting her drinking cup during a meal. There were no witness statements supporting the conclusion. There was one witness statement from a NA who documented "maybe a cup from drinking at dinner" caused the injury. The witness statement did not identify the NA as being the person who fed the resident. The resident was observed to be total assistance with feeding and staff sat with her during meals. 6. On 11/30/10, an LN documented on a incident report an NA reported the resident had 11 new bruises ranging in color from green to dark purple. The LN measured and assessed the bruises. Three of the bruises were old and documented to be green in color (5-7 days old). The green bruises were one bruise to the center of the chest (7cm by 8cm), and 2 on the resident's left upper arm measuring (12 cm by 5 cm and 3 cm by 3 cm). The 11/24/10 skin check indicated there were skin problems. The documentation instructed staff to refer to the skin observation record (SOR). At that time the only current issues on the SOR were a skin tear and the bruise under the resident's eye. The investigation was incomplete and lacked witness statements from all of the assigned NAs and LNs to determine how long the bruises had been there. Even though the injuries were substantial the facility did not report to them to the department. 8. On 12/11/10, an LN documented on an incident report at 7:30 am the resident had an "abnormally swollen left shoulder." The LN assessed the resident and documented the "resident was guarding left side - which was bulged swollen. Old bruising and new bruising present at the site, underarm and under left breast - black bruising. The resident was sensitive to touch." The resident was sent to the emergency room and the LN documented, "The bulge had already increased considerable in size." The investigation was incomplete and lacked witness statements from all staff member that came in contact with the resident prior to the discovery of the injury. On 12/13/10, the Director of Nursing (DNS) documented the conclusion of the resident's bruising and injury was either caused spontaneously during a mechanical lift transfer or by her cough or potentially by staff. There was no supporting documentation from the physician or documentation to support spontaneous bruising. On 12/14/10, the Resident Care Manager (RCM) and the DNS stated they thought the bruising came from the way the resident was being transferred. They both stated that they do not log injuries vulnerable for bruising susceptible to trauma like arms and legs, even though the resident was dependent on staff for all of her care needs.