Every finding on record at Spokane Falls Care

Based on interview and record review, the facility failed to transcribe provider orders correctly and administer medication as intended by the provider for 1 of 3 sampled residents (Resident 1), reviewed for unnecessary medications. This failure placed residents at risk of adverse side effects and unnecessary medications. Findings included .According to the 06/01/2026 admission assessment, Resident 1 was admitted with diagnoses to include heart and lung disease. The resident had memory impairments and difficulty verbalizing their needs. Review of the 05/26/2026 admission orders showed the Resident 1 had been taking Prednisone (a steroid that reduces swelling in order to treat a condition) 60 milligrams (mg) daily. The orders instructed the facility to taper (slowly lowering a medication dose over time instead of stopping it all at once) the Prednisone by 10 mg a week and then discontinue. Resident 1's Medication Administration Record (MAR) for May 2026, June 2026, and July 1 st - 7th, 2026 showed an order was entered on 05/26/2026 for Prednisone 60 mg per day. The resident remained on the 60 mg daily and had not been tapered by 10 mg weekly as ordered. Review of notes from a 07/08/2026 visit with a Pulmonologist (a medical doctor who diagnoses and treats problems in the lungs) showed the resident had not been tapered off the Prednisone, as ordered, and noted it was imperative the resident be tapered off as safely and quickly as possible. An order was written to decrease the Prednisone by 10 mg a week for 6 weeks. In an interview on 08/13/2026 at 12:32 PM, Staff A, Resident Care Manager, stated when a resident was admitted to the facility, medical records staff would input the orders into the electronic system, and the admitting nurse would then verify the orders were accurate. In an interview on 08/18/2026 at 11:45 AM, Staff B, Medical Records, stated when a resident was admitted to the facility the orders would be sent to them. Staff A would then transcribe the orders into the electronic system. A nurse would then review the orders to check for accuracy. On 08/18/2026 at 2:05 PM, Staff C, Administrator, stated when a resident was admitted to the facility medical records would transcribe the orders into the electronic system. Staff C stated two nurses reviewed the orders for accuracy; one nurse would read the orders and the other would verify accuracy.Staff C confirmed a significant medication error had occurred with Resident 1. Reference: WAC 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to ensure a resident remained free from sexual abuse for 1 of 3 sampled residents (Resident 1), reviewed for abuse. This placed residents at risk for sexual abuse and psychosocial harm. Findings included . Review of the admission assessment, dated 04/06/2026, showed Resident 1 was admitted with diagnoses to include neurological and seizure disorders. Resident 1 was cognitively intact, able to make their needs known and was dependent for most Activities of Daily Living. Review of the facility investigation, dated 06/01/2026, showed Resident 1 approached Staff B, Registered Nurse and stated Staff A, Certified Nursing Assistant, was a sexual predator and the facility needed to get rid of them. Staff B asked Resident 1 what they meant and Resident 1 stated Staff A made sexual statements about their body and what they would do sexually to them. Resident 1 said what kind of perverse person says those things to somebody that can't take care of themselves. Resident 1 told Staff B they were concerned about themselves, along with other female residents in the facility. Staff B reported the allegation to Staff D, Interim Director of Nursing, Staff A was immediately suspended, and an investigation was started. Staff A was later terminated after the facility substantiated abuse. During an interview on 06/03/2026 at 1:25 PM, Resident 1 was sitting up in their wheelchair. Resident 1 stated Staff A said sexual things to them over the period of 3 weeks. Resident 1 stated they thought Staff A was joking, but realized they weren't jokes, and they reported the concern to Staff B. Resident 1 stated Staff A had never touched them and only made sexual comments towards them. When asked if they felt safe, Resident 1 stated now that Staff A was no longer at the facility, they did feel safe. On 06/18/2026 at 1:10 PM, Staff C, Social Services Director, stated they interviewed Resident 1 after the allegation was reported. Resident 1 reported they were sorry they hadn't reported Staff A sooner, but thought Staff A was joking. Resident 1 did not feel fearful since Staff A was no longer at the facility. Staff C checked on Resident 1 for multiple days after the incident and they did not show any signs of psychosocial harm. On 06/18/2026 at 2:25 PM, Staff D stated they were made aware of Staff A's sexual statements from Staff B. The investigation was started immediately and Staff B was suspended during the investigation. The investigation substantiated abuse and Staff A's employment was terminated. Reference: WAC 388-97-0640(1)

Based on interview and record review the facility failed to identify multiple incidents of resident-to-resident verbal and physical altercations as potential abuse and ensure the allegations and investigation results were reported to the state agency, as required for 13 of 20 sampled residents (Resident 4, 15, 34, 72, 90, 99, 100, 102, 103, 104, 105, 106, and 107), reviewed for abuse. Additionally, the facility failed to report a resident accident/injury and the investigation results for 1 of 20 sampled residents (Resident 8). These failures placed residents at risk for potential continued abuse, possible safety concerns due to inadequate follow-up, and diminished quality of life. Findings included. Review of the facility policy titled, Abuse Prevention and Reporting revised August 2025 showed, when allegations that met the definition of abuse were received the facility would 1) report the allegations to the State Survey Agency no later than two hours if the event caused or resulted in serious bodily injury or not later than 24 hours if the event did not result in serious bodily injury, 2) complete a thorough investigation and retain documents to show the allegation was thoroughly investigated, 3) prevent further abuse, neglect or mistreatment while the investigation was in process, 4) report investigation results to the State Survey Agency within five working days, and 5) take all necessary corrective action if the alleged violation was verified. The policy defined verbal and mental abuse as oral, written, or gestured language that included disparaging and derogatory terms to the resident, their families or within their hearing distance regardless of age, ability to comprehend, that would demean or humiliate. Mental abuse could be verbal or non-verbal and could include humiliation, harassment, or threats of punishment or deprivation. Neglect was defined as indifference or disregard for resident care, comfort or safety that resulted in or could have resulted in physical harm, pain, mental anguish, or emotional distress. <Resident 8> According to the 03/08/2026 annual assessment, Resident 8 had diagnoses that included arthritis and paraplegia (complete paralysis of the lower half of the body). The assessment further showed Resident 8 utilized a motorized wheelchair (WC) independently. Resident 8 was cognitively intact and able to clearly verbalize their needs. Review of the 06/06/2025 mobility care plan showed Resident 8 utilized a wheelchair for mobility. No documentation was found that identified Resident 8 utilized a motorized WC or to show goals and interventions for safe motorized WC mobility were developed or implemented. Review of the facility incident and accident log from 10/01/2025 through 04/01/2026 showed an entry on 01/25/2026 Resident 8 was stuck by a vehicle when out of the facility. There was no documentation of the alleged incidents or investigation findings were reported to the state agency, as required. Review of the 01/25/2026 facility incident report showed Resident 8 returned to the facility from a community outing at approximately 10 PM and reported their motorized WC had been struck by a car and it caused them to fall out of their WC. Resident 8 had abrasions to their right leg. Resident 8's motorized WC was assessed by a WC technician due to it not functioning properly after the accident and required a wheel adjustment. In an interview on 04/08/2026 at 1:20 PM, Resident 8 sat in their room in their motorized WC. Resident 8 stated they were hit by a car when they were returning to the facility from a community outing at night. Resident 8 explained the impact caused their motorized WC to tip over, they flew out of it, sustained road rash and the impact dented their WC wheel. In an interview on 04/08/2026 at 2:07 PM, Staff D, Physical Therapist, stated if staff observed safety concerns with motorized WC use then it would be brought up to the team for follow-up. Staff D stated Resident 8 was involved in an accident recently where there was damage to the motorized WC. Staff D acknowledged Resident 8 tends to drive on the road. In an interview on 04/08/2026 at 2:40 PM, Staff C, Resident Care Manger, stated Resident 8 was involved in a car accident while they drove their motorized WC in the community. <Resident 4 and Resident 72> Review of the facility incident log from 10/01/2025 through 04/01/2026, showed that Resident 4 was involved in a physical altercation with Resident 72 on 10/24/2025 and another altercation with Resident 15 on 12/07/2025. There was no documentation that the alleged incident or investigation findings were reported to the state agency, as required. According to a comprehensive assessment dated [DATE], Resident 4 was fully alert, oriented and made their needs known. They had diagnoses that included anxiety, depression and arthritis of their hip. Resident 4 used a wheelchair independently to get around in the facility. Review of the 11/20/2025 care plan, showed Resident 4 had a impulsive behaviors and made accusations against staff. Staff were to approach in a calm manner, provide opportunities for positive interactions by stopping and talking with them, and document behaviors and resident response to interventions attempted. According to the 01/07/2026 quarterly assessment, Resident 72 had diagnoses that included anxiety. Resident 72 was cognitively intact and able to verbalize their needs. Review of the facility investigation regarding the incident on 10/23/2025 between Resident 4 and Resident 72, included Resident 4's face sheet, care plan and two reports. One report, written by the former Director of Nursing (DNS), documented that Resident 4 and Resident 72 got into a disagreement in the smoking area. The report summarized the interview with Resident 4, who reported that Resident 72 raised their fist (as if to punch), so they grabbed Resident 72 and they hit each other. The former DNS told Resident 4 that the altercation could be considered abuse. Resident 4 told the former DNS they would not threaten or hit anyone again. The document concluded that abuse was not suspected in this incident. The note from Staff DD, Social Services Director, showed the same conclusion. The investigation contained no documentation the allegation was reported to the state agency, as required. <Resident 4 and Resident 15> Review of the facility investigation dated 12/07/2025, showed a nursing assistant (NA) had reported that Resident 4 told Resident 15 to get the f**k out of my way and then backhanded Resident 15 on the shoulder as they passed. The two residents were separated and assessed. The investigation folder included a physical aggression-initiated form about Resident 4, which showed that the resident denied the situation and did not remember the interaction. A physical aggression received report about Resident 15 showed that they were unable to give a description of the incident. Both reports documented the resident was observed as they smacked Resident 15 on the shoulder while passing. The investigation contained no documentation the alleged incident or investigation results were reported to the state agency, as required. During an interview on 04/13/2026 at 11:38 AM, Staff L, NA, stated that if one resident hit another resident, that would be considered abuse, and the facility would need to report it to the state and investigate it. During an interview on 04/13/2026 at 11:53 AM, Staff H, NA, stated that if a resident was observed or admitted to hitting another resident, that needed to be reported to the state by calling the hotline. They further stated if in doubt, report it. During an interview on 04/13/2026 at 12:05 PM, Staff GG, Licensed Practical Nurse (LPN), stated that physical abuse could be hitting or pushing. If a resident hit another resident, that would definitely be abuse and should be reported to the DNS and administration immediately because there is a certain amount of time that it must be reported to the state. <Resident 34 and Resident 107> Review of the facility 10/01/2025 through 04/01/2026 incident log showed Resident 34 and 107 were involved in a resident-to-resident altercation on 11/09/2025. There was no documentation that the alleged incident or investigation findings were reported to the state agency, as required. According to the 12/04/2025 discharge assessment, Resident 107 had diagnoses that included depression. Resident 107 was cognitively intact and could clearly verbalize their needs. Review of the 02/08/2025 care plan, showed Resident 107 demonstrated verbally aggressive behaviors related to ineffective coping skills. Staff were to assess and anticipate the residents' needs and understanding of the situation, provide time to express self, intervene before agitation escalated, and guide away from the source of the distress. According to the 01/21/2026 annual assessment, Resident 34 had diagnoses that included dementia with behavioral disturbance. The assessment further showed Resident 34 was able to ambulate independently without an assistive device, had moderate cognitive impairment and could clearly verbalize their needs. Review of the 02/12/2025 care plan, showed Resident 34 received mood stabilizing medication related to exhibiting verbally aggressive outbursts. Staff were to approach in a calm manner, provide the resident opportunities for a positive interactions by stopping and talking with them, and monitor effectiveness of interventions attempted. Review of the 11/09/2025 facility investigation showed Resident 107 received verbal aggression from Resident 34. Resident 107 explained they were sitting at the nurses' station, with residents and staff present, visiting with a peer when Resident 34 approached them, grabbed an item from them and threw it in the trash. When Resident 107 stated they did not request the item be thrown out Resident 34 became very upset and replied, I should just beat the s**t out of you. The investigation contained no documentation the alleged incident or investigation results were reported to the state agency, as required. <Resident 105 and Resident 106> Review of the facility 10/01/2025 through 04/01/2026 incident log showed Resident 105 and 106 were involved in a resident-to-resident altercation on 12/05/2025. There was no documentation that the alleged incident or investigation findings were reported to the state agency, as required. According to the 12/13/2025 discharge assessment, Resident 105 had diagnoses that included bipolar disorder (chronic mental health disorder characterized by intense, extreme mood swings that interfere with daily life). Resident 105 was cognitively intact. Review of the care plan initiated on 12/09/2025, showed Resident 105 had a history of making accusations towards care givers and roommates frequently. Staff were to approach in a calm manner, provide the resident opportunities for positive interactions by stopping and talking with them, monitor effectiveness of interventions attempted, and provide cares in pairs (with two staff). According to the 03/05/2026 discharge assessment, Resident 106 had diagnoses that included anxiety. Resident 106 was cognitively intact. Review of the 02/24/2026 care plan showed Resident 106 had depression. Review of the 12/05/2025 facility investigation showed Resident 105 initiated verbal aggression towards their roommate, Resident 106, regarding cleanliness of the room but contained no incident details. The investigation contained no documentation of resident or staff witness statements or interviews. A summary showed staff completed a room move, both residents remained at baseline with no psychosocial harm observed so abuse/neglect was ruled out. There was no documentation that the alleged incident or investigation results were reported to the state agency, as required. <Resident 103 and Resident 104> Review of the facility 10/01/2025 through 04/01/2026 incident log showed Resident 103 and 104 were involved in a resident-to-resident altercation on 12/09/2025. There was no documentation that the alleged incident or investigation results were reported to the state agency, as required. According to the 01/02/2026 discharge assessment, Resident 103 had diagnoses that included stroke with paralysis on one side of the body. Resident 103 was cognitively intact. Review of the 12/05/2025 self-care deficit care plan showed Resident 103 required extensive assistance from staff to perform most activities of daily living. According to the 12/14/2025 discharge assessment, Resident 104 had diagnoses that included intracranial abscess (pus-filled pocket of infection in the brain) and granuloma (solid tumor-like lump). Resident 104 was cognitively intact and able to ambulate independently. Review of the 12/09/2025 facility investigation showed Resident 103 received verbal aggression from their roommate, Resident 104. Resident 103 explained that their roommate made threatening statements about putting their hands on them and they were concerned for their safety. The investigation contained no documentation of resident or staff witness statements or interviews. A summary showed staff completed a room move, both residents remained at baseline with no psychosocial harm observed so abuse/neglect was ruled out. There was no documentation that the alleged incident or investigation results were reported to the state agency, as required. <Resident 90 and Resident 102> Review of the facility 10/01/2025 through 04/01/2026 incident log showed Resident 90 and 102 were involved in a resident-to-resident altercation on 12/11/2025. There was no documentation that the alleged incident or investigation results were reported to the state agency, as required. According to the 02/11/2026 annual assessment, Resident 90 had diagnoses that included non-traumatic brain dysfunction (brain damage caused by internal forces such as illness or infection). Resident 90 had moderate cognitive impairment. Review of the care plan initiated on 12/07/2022 showed Resident 90 had the potential to demonstrate verbally aggressive behaviors towards staff and peers. Staff were to assess the residents' needs and understanding of situation, document behaviors observed, and to intervene before agitation escalated. According to the 01/23/2026 discharge assessment, Resident 102 had diagnoses that included surgical site infection. Resident 102 was cognitively intact. Review of the 10/28/2025 baseline care plan showed Resident 102's goal was to maintain quality of life. Review of the 12/11/2025 facility investigation showed Resident 90 initiated verbal aggression towards Resident 102 regarding telephone use and volume but contained no incident details. Resident 90 could not recall the incident events. The investigation contained no documentation of resident or staff witness statements or interviews. A summary showed both residents remained at baseline with no psychosocial harm observed so abuse/neglect was ruled out. There was no documentation that the alleged incident or investigation results were reported to the state agency, as required. <Resident 99 and Resident 100> Review of the facility 10/01/2025 through 04/01/2026 incident log showed Resident 99 and 100 were involved in a resident-to-resident altercation on 02/05/2026. There was no documentation that the alleged incident or investigation results were reported to the state agency, as required. According to the 02/20/2026 discharge assessment, Resident 99 had diagnoses that included dementia. Review of the 01/23/2026 care plan showed Resident 99 was resistive to cares and instructed staff to educate the resident/family of the possible outcomes of non-compliance, allow choices, and reapproach if care was refused. According to the 02/10/2026 discharge assessment, Resident 100 had diagnoses that included arm and leg skin infection. Resident 100 was cognitively intact. Review of the 01/29/2026 care plan showed Resident 100 had anxiety and instructed staff to educate the resident/family on the potential risks versus benefits of medication use and monitor for medication effectiveness and side effects. Review of the 02/05/2026 facility investigation showed Resident 99 initiated physical aggression towards their roommate, Resident 100, after a verbal altercation became physical. Resident 99 hit Resident 100 in the forehead. The investigation contained no documentation of resident or staff witness statements or interviews. A summary showed staff completed a room move, both residents remained at baseline with no psychosocial harm observed so abuse/neglect was ruled out. There was no documentation that the alleged incident or investigation results were reported to the state agency, as required. In an interview on 04/08/2026 at 1:39 PM, Staff F, Nursing Assistant, stated when an allegation of abuse or neglect was received it was immediately reported to the nurse, social services, Director of Nursing (DNS), administrator and the State Survey Agency. Staff F explained that residents involved in verbal or physical resident-to-resident altercations were also potential allegations of abuse that needed to be reported and thoroughly investigated because it placed residents at risk for continued abuse if not. Staff F acknowledged staff should definitely take allegations of abuse seriously. In an interview on 04/08/2026 at 1:47 PM, Staff E, Licensed Practical Nurse, stated when there was an allegation of abuse to include verbal and physical resident-to-resident altercations, it was reported to the supervisor on duty and the administrator and if needed the administrator would report to the State Survey Agency. In an interview on 04/08/2026 at 2:46 PM, Staff C, Resident Care Manager, stated when there was an allegation of abuse the DNS, administrator, and State Survey Agency was notified. Staff C stated resident-to-resident altercations could be allegations of abuse. Staff C further stated residents were at risk for continued abuse and harm if abuse was not properly identified and reported. Staff C acknowledged staff were mandatory reporters. In an interview on 04/08/2026 at 2:51 PM, Staff CC, Social Service Director, stated resident to resident altercations could be potential allegations of abuse that needed to be reported to the State Survey Agency. Staff CC acknowledged staff were expected to appropriately identify and report allegations of abuse to keep residents out of harms way. In an interview on 04/08/2026 at 3:46 PM, Staff B, DNS, allegations of abuse varied and depended on what and how something was reported. Staff B further stated staff were expected to identify and report allegations of abuse to ensure resident safety. In an interview on 04/08/2026 at 4:07 PM, Staff O, Regional Director, acknowledged the resident to resident altercations mentioned above were not reported to the state agency, as required. In an interview on 04/13/2026 at 11:39 AM, Staff A, Administrator, stated they expected staff to appropriately identify and report allegations of abuse, as required. Reference WAC 388-97-0640(5)(a)

Based on interview and record review, the facility failed to ensure monthly medication reviews were completed in December 2025, as required, and pharmacist recommendations were not addressed as indicated, for 4 of 5 sampled residents (Resident 3, 69, 6, and 11), reviewed for unnecessary medications. This failure placed residents at risk of inadequately monitored medications, potentially unidentified adverse consequences, and a diminished quality of life.Findings included.<Resident 11> The 02/06/2026 significant change assessment documented Resident 11 had diagnoses that included heart failure, diabetes and depression. A review of Resident 11's medical record showed no pharmacy recommendation had been completed for December 2025. The monthly medication review binder showed Resident 11 was not on the no irregularities list. The pharmacy recommendations for December 2025 did not include Resident 11. The January 2026 pharmacy recommendation was to obtain blood work related to a medication Resident 11 was taking. A review of Resident 11's medical record showed the labs were not obtained. In an interview on 04/09/2026 at 3:35 PM, Staff N, Resident Care Manager, stated pharmacy recommendations were completed by the Resident Care Managers (RCMs) and given back to the Director of Nursing. Staff N stated it was important to follow up on the recommendations and Resident 11 should have had their blood work drawn. In an interview on 04/09/2026 at 3:39 PM, Staff B, Director of Nursing, stated pharmacy recommendations were given to the physician after they were received and then distributed to the RCMs to process. Staff B stated it was important to follow up on the recommendations to ensure blood work was drawn when needed, residents had the appropriate diagnoses, and medications were titrated when needed. <Resident 3> According to a quarterly assessment dated [DATE], Resident 3 was cognitively intact and had diagnoses which included Chronic Obstructive Pulmonary Disease (COPD, a lung condition that made it progressively harder to breathe) and Gastroesophageal reflux disease (GERD, a condition when stomach acid flows back up the esophagus and causes heartburn) Review of the pharmacy binder showed an October 2025 recommendation from the pharmacist to change medications to treat their GERD. The order was agreed to and signed by the provider on 11/03/2025. Review of the resident orders and Medication Administration Records (MARs) showed the order was not changed, and the resident was currently still on the original medication. The monthly medication review binder showed Resident 3 was not on the no irregularities list. The pharmacy recommendations for December 2025 did not include Resident 3. No pharmacist recommendations were found in the pharmacy binder or the resident's medical record. <Resident 69> According to a recent quarterly assessment dated [DATE], Resident 69 had moderately impaired cognition with hallucinations, disorganized thinking and inattention. The resident had diagnoses which included dementia, history of a stroke that affected one side of the body and weakness. The monthly medication review binder showed Resident 69 was not on the no irregularities list. The pharmacy recommendations for December 2025 did not include Resident 69. During a telephone interview on 04/09/2026 at 2:13 PM, the consulting pharmacist stated that the facility had changed pharmacies in December 2025, and there were told the previous pharmacy would complete all of the December monthly medication reviews. During a telephone interview on 04/09/2026 at 3:06 PM, the previous consulting pharmacist stated that they did not do the monthly medication reviews for December 2025, and they notified the facility's medical director and Staff O, Regional Director that the new pharmacy consultants needed to complete them. During an interview on 04/13/2026 at 1:39 PM, Staff B, Director of Nursing, acknowledged that pharmacy medication reviews were required to be completed monthly and any recommendations followed up on timely. <Resident 6> The 02/04/2026 quarterly assessment documented Resident 6 had diagnoses that included heart failure, diabetes and depression. A review of Resident 6's medical record showed no pharmacy recommendation had been completed for December 2025. The monthly medication review binder contained a sheet that listed residents with no medication irregularities, Resident 6 was not on the list. The pharmacy recommendations for December 2025 did not include Resident 6. Reference: WAC 388-97-1300(1)(c)(iii, iv), (4)(c)

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure received and opened dates were placed on food items in the refrigerator and freezer, and in 1 of 1 dry storage areas. Additionally, the tile floor in the kitchen was broken, dirty, and not a cleanable surface and there was an active water leak that had not been addressed. The facility failed to wear facial hair coverings appropriately and maintain a clean cooking environment. These failures placed residents at risk for food-borne illnesses.Findings included .<Undated food>During an initial tour of the kitchen on 04/01/2026 at 8:49 AM, the dry storage area revealed three bags of chicken and herb stuffing, a bag of opened vanilla wafers, a bag of 10 opened miniature graham cracker pie crusts, 11 large graham cracker pie crusts and a muffin in a bag that had no received or expiration dates. The main refrigerator in the kitchen had a pan that contained cheese slices, tomatoes, and lettuce that had no date. There was zucchini in a box, some were cut in half and wilted. The freezer contained a chocolate cream pie and a bag of opened waffles with no received or expiration dates. <Sanitary Environment>During an observation on 04/01/2026 at 9:41 AM, the small freezer had food debris on the bottom shelf. The juice machine was unclean with dirt debris covering the filter, the ovens were unclean with food debris on the bottom rack, the convection ovens had thick dirt debris on the outside with brown splatter down the front, the plate warmer was unclean with brown splatter on all sides and the shelf that held the mixer was unclean with food debris. There was a stool in the back near the dishwasher that had dirty rags sitting on it, the toaster had crumbs and brown splatter on the front and all sides, the counters were unclean with food on them. In the back of the kitchen near the toaster, the floors were unclean with food debris, gloves and garbage, a sheet pan that held their vegetable oils and vinegars under the steamer was unclean with spilled oils and dirt debris. As you entered the kitchen there was an area approximately 3 feet long where the tiles were broken along the wall and on the floor with thick dirt debris. There was a bucket on the floor that was catching water from a leak. On 04/07/2026 at 12:18 PM, the cook opened the oven, and it had crusted food debris on the bottom and on the oven door. The convection oven was covered with a brown/black substance on the bottom rack and food debris on the outside. The March and April 2026 cleaning schedules had multiple omissions. In an observation on 04/07/2026 at 1:49 PM, the ice machine had dust debris on the left filter slats and there was dirt built up on the right side of the machine. In an interview on 04/07/2026 at 1:54 PM, Staff T, Dietary Manager, stated it was important to keep the ice machine free of dust debris because it could get into the machine. Staff T stated it was important to keep the ovens clean to prevent bacteria and it could be a fire hazard. Staff T stated it was important to keep the juice machine, freezer, plate warmer, toaster, and shelving clean to prevent bacteria. Staff T stated the broken tiles needed repaired to maintain a clean and safe environment. In an interview on 04/10/2026 at 2:00 PM, Staff V, Maintenance Director, stated they had water damage in the kitchen, and the broken tiles were not a cleanable surface.<Beard coverings>In an observation on 04/10/2026 at 11:29 AM, Staff II, Cook, was wearing a beard cover that did not cover their long, thick mustache or all their beard. Staff II was pulling different shelves out of a cart that had food on them. In an observation on 04/10/2026 at 11:44 AM, Staff T was plating food, and their beard covering did not cover their mustache and part of their beard. Staff T had a thick mustache and beard. In an observation on 04/10/2026 at 11:45 AM, Staff II, stood over the food and read the meal tickets to the dietary manager. Their long, thick mustache and part of their beard was uncovered. In an interview on 04/10/2026 at 1:02 PM, Resident 79 stated they had hair in their food last evening. <Timeliness of meals>In an observation on 04/07/2026 at 12:00 PM, the meal trays went out to the dining room an hour after the meal service was to begin. In an observation on 04/10/2026 at 11:33 AM, the plating of the food had not begun. Staff JJ, Registered Dietician, stated the meals were normally served within about five minutes of their listed times but over the last couple of weeks it had been late. On 04/10/2026 the meal cart went out to the dining room at 12:02 PM, one hour and two minutes after the meal was to be served. In an interview on 04/10/2026 at 12:44 PM, Resident 112 stated with a raised voice they discussed new timelines of when the food would be served in resident council, and the meal was over an hour late. Resident 112 stated they would probably have 10 minutes to finish their meal before their activity and that was unacceptable. In an interview on 04/10/2026 at 2:01 PM, Resident 96 stated lunch was late and they were upset. Resident 96 stated it happened frequently for lunch and dinner. In an interview on 04/13/2026 at 10:04 AM, Staff JJ and Staff T, stated it was important to label food, so they knew when it expired and to prevent bacteria. Staff T stated it was important to start the meal service on time for diabetics who received insulin and for residents who had outings. Staff T and JJ stated beard coverings were worn anytime someone had facial hair and they needed to cover all facial hair for sanitary reasons as it was a physical contaminant. In an interview on 04/13/2026 at 1:34 PM, Staff JJ stated it was important to keep the kitchen clean to prevent the spread of dirt or anything in the environment that may contaminate the food and cause foodborne illness. Reference: WAC 388-97-1100 (3), 2980

Based on observation, interview and record review, the facility failed to prevent and monitor residents after accidents occurred for 4 of 9 sampled residents (Resident 7, 8, 44, and 69), reviewed for accidents. These failures resulted in Resident 7 sustained an injury and placed residents at risk of potentially avoidable accidents, increased falls and defective devices. Findings included. Record review of the facility policy titled, Accidents and Incidents revised February 2023 showed, the facility was to provide an environment that was free from hazards over which the facility had control over and provided supervision and assistance devices to each resident to prevent avoidable accidents. The policy defined an avoidable accident as an incident that occurred when the center failed to: identify environmental hazards, evaluate hazards and risks, implement interventions, monitor and modify interventions as necessary. An incident report was to be completed to investigate unusual incidents. The administrator was to be notified if a medical device caused or contributed to an injury. Residents were to be monitored for a minimum of 72 hours after an incident occurred. Record review of a 2024 Neurological Assessment Flowsheet (neuro sheet) showed the form should be completed after a fall if the head was struck or if the fall was not witnessed. The form further documented that neurological checks (neuro checks, pupil reaction and hand grasps) and vital signs (VS, temperature, pulse, respiratory rate and blood pressure) should be done every hour- 4 times, then every 4 hours- 6 times. <Resident 8> According to the 03/08/2026 annual assessment, Resident 8 had diagnoses that included arthritis and paraplegia (complete paralysis of the lower half of the body). The assessment further showed Resident 8 utilized a motorized wheelchair (WC) independently. Resident 8 was cognitively intact and able to clearly verbalize their needs. Review of the 06/06/2025 mobility care plan showed Resident 8 utilized a wheelchair for mobility. The care plan did not address any identified risk, assessed hazards or ability to safely operate, safety interventions or monitoring for safety and risk regarding the WC for Resident 8. Review of the facility incident and accident log from 10/01/2025 through 04/01/2026 showed an entry that Resident 8 was struck by a vehicle when out of the facility on 01/25/2026. Review of the 01/25/2026 facility incident report which was received on 04/02/2026, showed Resident 8 returned to the facility from a community outing at approximately 10:00 PM and reported their motorized WC had been struck by a car and it caused them to fall out of their WC. Resident 8 had abrasions to their right leg. The provider was notified of the event and ordered a left shoulder x-ray. Resident 8's motorized WC was assessed by a WC technician due to it not functioning properly after the accident and required a wheel adjustment. The motorized WC was noted to have several reflectors in place for safety, staff offered additional reflectors, a safety jacket, and a light. Review of physical therapy progress notes from 01/26/2026 through 04/03/2026 showed the following: -01/26/2026 Resident 8's motorized WC was inspected and found to have a right bent wheel. Resident 8 was educated on avoiding long community trips and uneven terrain until the WC could be further assessed by a motorized WC technician. -1/28/2026 a motorized WC mechanic assessed Resident 8's chair and uncovered further damage and repairs would be needed. -02/03/2026 a motorized WC assessment and evaluation was completed to determine all parts required for the needed repairs. As of 04/02/2026 there was no motorized WC driving assessment or updated mobility care plan to include interventions or preventative measures. -04/03/2026 (the day after the car accident incident report was requested and 68 days after Resident 8 was hit by a car) Resident 8 was given a motorized WC driving assessment indoors with various standard tasks such as reversing, doorways, maneuvering in congested areas, out in the courtyard, and out in the community over sidewalks and crosswalks. Resident 8 was identified as independent with motorized WC use. In an interview on 04/08/2026 at 1:20 PM, Resident 8 sat in their room in their motorized WC. Resident 8 stated they were hit by a car when they were returning to the facility from a community outing at night. Resident 8 stated they were crossing the street, was halfway through the intersection, when a car failed to stop at a stop sign and hit them. Resident 8 explained the impact caused their motorized WC to tip over, they flew out of it, sustained road rash and the impact dented their WC wheel. In an interview on 04/08/2026 at 1:38 PM, Staff F, Nursing Assistant, stated residents who utilized a motorized WC needed to be evaluated by therapy for safety prior to allowing use. Staff F further stated motorized WC use should be care planned. In an interview on 04/08/2026 at 1:45 PM, Staff E, Licensed Practical Nurse, stated therapy needed to evaluate residents for motorized WC safety prior to use and motorized WC use would be care planned. In an interview on 04/08/2026 at 2:07 PM, Staff D, Physical Therapist, stated if a resident wanted to utilize a motorized WC, therapy would do an assessment. Staff D explained that the therapist would review the resident's motorized WC use history, if a resident was questionable then they would only be allowed to utilize the motorized WC during therapy sessions and required three consecutive days of error-free driving prior to clearing them for independent use and requesting the care plan be updated accordingly. Staff D further stated if staff observed safety concerns with motorized WC use then it would be brought up to the team for follow-up. Staff D stated Resident 8 was involved in an accident recently where there was damage to the motorized WC but it remained drivable while needed parts were on order. Staff D acknowledged Resident 8 tends to drive on the road. In an interview on 04/08/2026 at 2:40 PM, Staff C, Resident Care Manager, stated Resident 8 was involved in a car accident while they drove their motorized WC in the community. Staff C acknowledged Resident 8 should have been reassessed by therapy for motorized WC safety after the accident to make sure it was not an error on Resident 8's part. In an interview on 04/08/2026 at 3:42 PM, Staff B, Director of Nursing, acknowledged Resident 8 should have been reevaluated by therapy for motorized WC safety after they were hit by a car during a community outing. <Resident 7> The 02/23/2026 annual assessment, documented Resident 7 had diagnosis that included amputations (removal below the knee) of both lower legs. Resident 7 was cognitively intact, required set up assistance to moderate assistance with activities of daily living. The 03/10/2025 fall care plan, documented Resident 7 was at risk for falls related to poor balance and deconditioning. The fall care plan instructed nursing staff to monitor the resident for 72 hours post falls for pain, bruises, and changes in mental status and to complete neurological assessments per protocol. The facility incident log showed Resident 7 had a fall on 03/29/2026 in the bathroom. A 03/29/2026 progress note at 8:56 PM, documented Resident 7 fell off of the shower room bench due to the bench tipping forward. The bench was missing the rubber caps on the bottom of the legs which caused it to move. A 03/29/2026 progress note at 9:10 PM, documented Resident 7 fell when they attempted to get dressed in the shower room while sitting on the shower bench. Resident 7 stated the shower bench was moving and not seated correctly on the floor. Resident 7 stated they pulled up on their brief and the bench tilted forward and caused them to fall. Resident 7 received a skin tear to their right stump. A 04/02/2026 progress note by the provider stated Resident 7 reported they had a fall during the weekend due to faulty equipment in the shower. The post fall packet that was included in the facility investigation completed on 03/29/2026 documented the shower chair was missing the rubber caps that went on the bottom of the legs of the shower bench. The neurological checks were not completed on 03/29/2026 at 8:15 PM, 03/30/2026 at 2:15 AM, 2:15 PM, and 6:15 PM. In an observation on 04/07/2026 at 3:35 PM, the shower bench in the Southeast Hall was missing two of the four rubber stoppers on the bottom of the chair. In an observation on 04/08/2026 at 1:09 PM, the shower bench in the Northwest Hall was missing one of the rubber stoppers on the bottom of the chair. In an interview on 04/09/2026 at 8:55 AM, Staff M, Nursing Assistant, stated when equipment had missing parts or needed repair, they put it in the electronic maintenance system and informed the nurse. In an interview on 04/09/2026 at 9:34 AM, Staff N, Resident Care Manager, stated it was important to have the rubber stoppers on the shower benches to prevent the shower chair from slipping and falls. Staff N stated neurological assessments were required to be completed for unwitnessed falls and when someone hit their head. Staff N stated it was important to monitor neurological assessments to rule out trauma. In an interview on 04/10/2026 at 2:00 PM, Staff V, Maintenance Director, stated they were notified when things were missing parts or needed repaired through the electronic maintenance system. Staff V stated they replaced the rubber stoppers on the shower bench but did not check the other benches in the rest of shower rooms. Staff V stated it was their expectation staff notified them when things were broken or missing parts. In an interview on 04/13/2026 at 11:24 AM, Staff B, Director of Nursing, stated it was their expectation that the shower benches had all their rubber stoppers on them for stability. <Resident 44> According to the 02/08/2026 admission assessment, Resident 44 admitted to the facility on [DATE] with diagnoses that included stroke and absence of right upper limb. The assessment further showed Resident 44 did not sustain any falls in the last six months prior to facility admission but sustained falls since facility admission. Resident 44 was severely cognitively impaired and required use of a wheelchair. Review of the 02/03/2026 care plan, showed Resident 44 had limited physical mobility, was at risk for falls, and was dependent on staff for cares. Staff were instructed to remind Resident 44 to use call light when needing assistance, wear proper footwear, and involve Resident 44 in activities that minimize the potential for falls while providing diversion and distraction. Review of the facility incident and accident log from 02/01/2026 through 04/01/2026 showed Resident 44 sustained 7 falls in two months: on 02/05/2026, 02/15/2026, 02/20/2026, 02/24/2026, 03/17/2026, 03/20/2026, and 03/22/2026. Review of the Resident 44's facility fall investigations showed the following: There was no documentation of vital signs and neuro checks being completed as required, per the flowsheet timeline for falls on 02/05/2026, 02/20/2026, 03/17/2026, and 03/22/2026. There was no documentation that the resident was monitored after incidents that occurred on 02/05/2026, 02/20/2026, 03/17/2026, and 03/22/2026. In an interview on 04/08/2026 at 1:14 PM Staff U, Registered Nurse, stated when a resident fell, they were to make sure the environment was safe and obtain vital signs. Staff U stated there was a paper fall packet that needed to be completed. The packet included nursing actions to be taken, such as a complete body assessment, obtain vital signs, and complete neuro checks every hour for four hours then every four hours after. Staff U also stated the fall packets should be completely filled out without omissions. In an interview on 04/09/2024 at 10:47 AM Staff C, Resident Care Manager, stated a fall packet was to be completed after a resident fell, the resident placed on alert charting to assess and monitor for latent injuries, and complete neuro checks for 72 hours. Staff C stated it was important to complete the fall packet to appropriately assess for any signs or symptoms of potential latent injury. In an interview on 04/09/2026 at 02:24 PM Staff B, Director of Nursing, acknowledged Resident 44 was not consistently monitored for injury as required after their falls. <Resident 69> According to a recent quarterly assessment dated [DATE], Resident 69 had moderately impaired cognition with hallucinations, disorganized thinking and inattention. The resident had diagnoses which included dementia, history of a stroke that affected one side of the body and weakness. Resident 69 required staff assistance with bed mobility, transferring, toileting and using their wheelchair. Review of the facility incident log showed that Resident 69 had 12 falls in six months, from 10/01/2025 through 03/30/2026. Review of the fall investigations referenced in the incident log and Resident 69's medical record showed the following: There was no documentation of vital and neuro checks being completed as required, per the flowsheet timeline for falls on 10/12/2025, 02/05/2026 and 03/30/2026. There was no documentation that Resident 69 was monitored for 72 hours after the incidents, for the falls that occurred on 12/19/2025, 12/23/2025, 01/01/2026 and 02/05/2026. During an interview on 04/08/2026 at 1:21 PM, Staff M, Nursing Assistant (NA), stated that when a resident fell, they would be assessed by a nurse and then vital and neuro checks would be done. They were not sure of the frequency but did them according to the schedule on the paper neuro flowsheet. During an interview on 04/09/2026 at 12:33 PM, Staff N, Residential Care Manager (RCM), stated that after a fall where a resident may have hit their head, staff completed vital and neuro checks, according to the timeline on the neuro flowsheet. They further stated that the resident should be put on alert charting, and charted on every shift for at least 72 hours, to monitor for injury. During an interview on 04/13/2026 at 1:39 PM, Staff B, Director of Nursing, acknowledged that Resident 69 had not been monitored completely for injury, following some of their falls. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review the facility failed to implement care planned interventions for 2 of 4 sampled residents (Resident 28 and 62), reviewed for quality of care. Specifically, Resident 28 did not have bed rails in place and Resident 62 was not provided large print reading material as care planned. This failure placed residents at risk of unmet care needs and diminished quality of life.Findings included.Review of the facility policy titled, Care Planning revised May 2023 showed, the care plan was an interdisciplinary communication tool that must contain measurable objectives with time frames and describe services to be provided to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. <Resident 28>According to the 02/18/2026 quarterly assessment, Resident 28 had diagnoses that included a left leg above the knee amputation. The assessment showed Resident 28 required substantial assistance from staff for bed mobility. Resident 28 was cognitively intact and able to clearly verbalize their needs.Review of the 08/12/2025 care plan showed Resident 28 had a self-care deficit and required extensive staff assistance of two staff for bed mobility. The 08/15/2025 care plan showed Resident 28 was to utilize bed rails to assist with bed mobility related to their left leg amputation.Review of 03/30/2026 and 04/03/2026 therapy to nursing communication notes indicated Resident 28 could benefit from bed rails to participate better with cares, repositioning, and bed mobility with reduced assistance.During observation and interview on 04/02/2026 at 9:42 AM, Resident 28 was observed laying in bed and the bed did not have bed rails or mobility bars attached. They stated their bed used to have bed rails/mobility assist bars on it, but they were removed when they changed rooms. Resident 28 explained they had significant trouble with bed mobility and was practically dependent on staff assistance. They stated if there were bed rails in place, it allowed for them to but with the bed rails in place it allowed for them to help a little with their bed mobility. Resident 28 stated I need them. I want them back. Similar observations of the resident laying in bed were made on 04/02/2026 at 3:53 PM, on 04/03/2026 at 8:28 AM, 10:22 AM, and 2:31 PM, on 04/06/2026 at 9:13 AM, 11:40 AM, 1:08 PM, and 2:23 PM, on 04/07/2026 at 8:36 AM, 10:48 AM, and 1:03 PM, on 04/08/2026 at 1:31 PM, and on 04/09/2026 at 10:27 AM.During observation and interview on 04/09/2026 at 10:46 AM, Staff G, Nursing Assistant (NA), stated they could find how much assistance and what assistive devices a resident needed by reviewing the Kardex (quick reference guide with information from the care plan). Staff G stated staff were expected to implement interventions because each resident's needs were different and the Kardex was tailored to their specific needs and could potentially have adverse effects if not followed. Staff G observed Resident 28's bed without bed rails. Staff G acknowledged Resident 28 used to have rails on their bed to assist with bed mobility.During observation and interview on 04/09/2026 at 10:59 AM, Staff E, Licensed Practical Nurse (LPN), stated a resident's care plan would identify a resident's needs. Staff E observed Resident 28's bed without bed rails. Staff E stated Resident 28 used to have bed rails on their bed. Staff E reviewed Resident 28's medical record. Staff E acknowledged Resident 28 should have bed rails on their bed to assist with bed mobility related to their left leg amputation.During observation and interview on 04/09/2026 at 11:08 AM, Staff C, Resident Care Manager (RCM), stated staff could find a resident needs in the care plan and were expected to follow it. Staff C observed Resident 28's bed without bed rails. Staff C acknowledged Resident 28's bed should have bed rails on it.In an interview on 04/09/2026 at 11:55 PM, Staff B, Director of Nursing (DNS), stated staff were expected to implement care planned interventions, the resident's ability to function could be negatively impacted if not followed. Staff B reviewed Resident 28's medical record. Staff B acknowledged Resident 28 could benefit from bed rails, they were care planned and should be on their bed.<Resident 62>According to the 03/12/2026 admission assessment, Resident 62 had diagnoses that included fractures. The assessment further showed Resident 62 had impaired vision and could see large print but not regular print in newspapers or books with glasses but did not use glasses. Resident 62 was cognitively intact.Review of the 03/10/2026 life enrichment evaluation showed Resident 62 read on occasion and did not wear glasses or use special reading devices such as magnifying equipment.Review of the 03/18/2026 care plan showed Resident 62 had impaired vision and instructed staff to approach from the front, keep walkways free of clutter, provide adequate lighting and large print books or books on tape as desired.During observation on 04/02/2026 at 3:42 PM, Resident 62 had an activities calendar with extremely small print on regular sized paper posted across the room from their bed, on the wall under the television. Similar observations were made on 04/03/2026 at 10:30 AM, 11:37 AM, and 2:30 PM, on 04/06/2026 at 8:52 AM, 11:38 AM, and 1:07 PM.During observation and interview on 04/06/2026 at 2:20 PM, Resident 62 laid in bed and was asked if they could read the activity calendar (which was located across the room from their bed on the wall under the television), Resident 62 stated they could not read it if they put it up close to their face and moved their hand within four inches of their eyes.During observation and interview on 04/09/2029 at 10:49 AM, Staff G, NA, stated the facility cared for residents with visual impairments and the Kardex would show what a resident's needs were. Staff G looked at the activities calendar and acknowledged the print was extremely small and a person with visual impairment could not read it. Staff G further stated, I need glasses to read it myself.During observation and interview on 04/09/2026 at 10:56 AM, Staff E, LPN, stated the facility cared for residents with visual impairments and staff could find their particular needs in the care plan. Staff E observed the activity calendar with extremely small print. Staff E acknowledged a person with visual impairment could not read the activity calendar.During observation and interview on 04/09/2026 at 11:11 AM, Staff C, RCM, stated the facility cared for residents with visual impairments and the care plan would show a resident's needs that staff were expected to implement. Staff C observed the activity calendar with extremely small print. Staff C acknowledged the print was really tiny and someone with visual impairment might not be able to read it.During observation and interview on 04/09/2026 at 11:19 AM, Staff EE, Activities Director, stated the facility cared for residents with visual impairments and the care plan would show a resident's needs that staff were expected to implement. Staff EE observed the activity calendar with extremely small print. Staff EE acknowledged the activities calendar print was tiny. Staff EE reviewed Resident 62's medical record. Staff EE acknowledged Resident 62 had visual impairment, required large print books and most likely also needed larger print for other reading materials.During observation and interview on 04/09/2026 at 11:51 AM, Staff B, DNS, stated the facility cared for residents with visual impairments and staff were expected to implement care planned interventions. Staff B observed the activity calendar and acknowledged the activities calendar font was small and was even difficult for them to read with glasses.In an interview on 04/13/2026 at 11:39 AM, Staff A, Administrator, stated they expected staff to implement care planned interventions.Reference WAC 388-97-1020 (1)(2)(a)(b)

Based on observation, interview, and record review, the facility failed to maintain a safe, clean, and homelike environment for 3 of 7 sampled residents (Resident 7, 35, and 69), reviewed for environment. Additionally, the toilet seats in 2 of 4 shower rooms (Shower room [ROOM NUMBER] - Southeast and Shower room [ROOM NUMBER] - Southwest) were broken and the South unit therapy room tile floor had significant large black and rust stains. These failures placed residents at risk of potentially avoidable accidents and diminished quality of life.Findings included.<Resident 7> The 02/23/2026 annual assessment documented Resident 7 had diagnoses that included heart failure, kidney failure and diabetes. Resident 7 was cognitively intact. In an observation on 04/01/2026 at 10:19 AM, Resident 7's closet had 2 large areas where part of the wood was missing. The first area was approximately 1 foot long by 3 inches (in) wide and the second area was approximately 6 in long by 5 in wide. The shelf above the sink was a piece of wood that was not a cleanable surface. The caulking around the sink had come loose and there was missing paint above the caulking. Resident 7's wall near the bathroom had multiple dents and pieces of missing drywall. The transition strip between the room and bathroom was missing and there was dirt built up. Observations of Resident 7's room on 04/02/2026 at 9:08 AM and 3:54 PM, 04/03/2026 at 8:28 AM, 04/07/2026 at 8:18 AM and 3:09 PM, 04/08/2026 at 1:17 PM and 04/09/2026 at 8:42 AM, showed the room was unchanged from the initial observation and required repairs. In an interview on 04/02/2026 at 8:43 AM, Resident 7 stated if this was their home the walls and holes would not look that way. Resident 7 stated it sort of bothered them. In an interview on 04/09/2026 at 8:55 AM, Staff M, Nursing Assistant, stated when something needed repaired, they placed it into the electronic notification system for maintenance. In an interview on 04/10/2026 at 2:00 PM, Staff V, Maintenance Director, stated the staff put needed repairs into the electronic notification system for maintenance. Staff V observed Resident 7's room and stated the shelf was not a cleanable surface and the room was not a homelike environment. Staff V stated the missing transition strip in the bathroom was a safety hazard and they were unaware of it. Staff V stated it was important to have Resident 7's room in good, safe repair so the resident felt like they were at home. <Resident 35> According to the 03/16/2026 admission assessment, Resident 35 had diagnoses that included fractures. Resident 35 was cognitively intact and clearly able to verbalize their needs. Review of the 03/10/2026 care plan showed Resident 35 was at risk for infection related to recent hip surgery with a healing surgical incision. During an interview on 04/02/2026 at 12:11 PM, Resident 35 stated the toilet seat in the shower room was broken and voiced concern that a resident could get injured using it. Resident 35 stated the shower room toilet seat had been broken for at least one week. During observation on 04/02/2026 at 12:38 PM and 3:43 PM, the Shower room [ROOM NUMBER] - Southeast room toilet seat had approximately six in broken completely off the left front edge. Similar observations were made on 04/03/2026 at 8:29 AM, 10:21 AM, and 2:31 PM, on 04/06/2026 at 9:08 AM, 11:39 AM, and 2:23 PM, on 04/07/2026 at 8:31 AM and 1:03 PM. During observation on 04/02/2026 at 12:40 PM and 3:41 PM, the Shower room [ROOM NUMBER] - Southwest room toilet seat had approximately six inches broken completely off of the right front edge. Similar observations were made on 04/03/2026 at 8:26 AM, 10:18 AM, and 2:29 PM, on 04/06/2026 at 8:51 AM, 11:37 AM, and 2:18 PM, on 04/07/2026 at 8:27 AM and 1:01 PM. On 04/07/2026 at 1:14 PM during observation and interview in Shower room [ROOM NUMBER] - Southeast, Staff FF, Housekeeping, stated staff utilized the shower rooms daily. TStaff FF stated they were unsure of the facility process when something was broken. Staff FF acknowledged the toilet seat had been broken for approximately one month. During observation and interview on 04/07/2026 at 1:28 PM, Staff F, Nursing Assistant, stated staff utilized the shower rooms twice daily, on day shift and evening shift. Staff F stated if something was broken it needed to be reported to maintenance via an electronic notification system. Staff F observed the broken toilet seat in Shower room [ROOM NUMBER] - Southeast room. Staff F stated they were unsure how long the toilet seat had been broken but it should have been reported to maintenance for repair or replacement. In an interview on 04/07/2026 at 1:52 PM, Staff V, stated the shower rooms were utilized daily and if staff observed something broken or in disrepair it had to be entered into the electronic maintenance system so it could be followed up on. Staff V acknowledged they just received a notification about the broken toilet seats in the shower rooms. <South Unit Therapy Room Tile Floor> During interview on 04/02/2026 at 12:11 PM, Resident 35 stated they were at risk for infection and had a serious concern about the facility cleanliness. Resident 35 explained the South unit therapy gym appeared as if it had not been cleaned in ten years, it was unsanitary and needed to be cleaned and shined professionally. During observation on 04/02/2026 at 12:37 PM and 3:42 PM, the therapy room tile floor had a linear rust stain the length of a file cabinet and significantly large areas of dark black stains in numerous areas. Similar observations were made on 04/03/2026 at 8:27 AM, 10:19 AM, and 2:30 PM, on 04/06/2026 at 8:51 AM, 11:42 AM, and 2:18 PM, on 04/07/2026 at 8:29 AM, 11:38 AM, and 1:01 PM. During observation and interview on 04/08/2026 at 2:13 PM, Staff D, Physical Therapist, observed the South unit therapy room tile floor. Staff D acknowledged the therapy room tile floor had black and rust stains for over a year. Staff D explained when the facility recently remodeled the facility, the therapy room was supposed to be redone as well but it was put on hold. During observation and interview on 04/10/2026 at 12:12 PM, Staff V, observed the South unit therapy room tile floor. Staff V stated the facility had a staff member who was trained on floor maintenance and that was a task that could be addressed right away. In an interview on 04/13/2026 at 11:39 AM, Staff A, Administrator, stated they expected staff to maintain equipment and resident care areas in a safe and sanitary manner. <Resident 69> According to a recent quarterly assessment dated [DATE], Resident 69 had moderately impaired cognition, disorganized thinking and inattention. The resident had diagnoses which included dementia and frequent falls. Resident 69 required staff assistance with bed mobility, transferring, toileting and using their wheelchair. A 01/23/2026 provider order documented to have the resident's bed against the wall for safety. On 04/01/2026 at 11:32 AM, Resident 69 was observed resting in their bed, which was against the wall. The dark brown paint on the wall had deep gouges/scrapes, which exposed the white drywall plaster next to the resident's bed. The wall was observed on 04/03/2026 at 8:57 AM, 04/06/2026 at 9:11 AM, 04/07/2026 at 9:40 AM, 04/09/2026 at 12:06 PM and 04/13/2026 at 10:36 AM in the same condition. During an interview on 04/13/2026 at 10:35 AM, Staff V, stated they were trying to create a system that they would go through each room regularly, to determine if there were any maintenance issues. They were also considering making panels to put up against the beds to protect the walls. They stated they already had Resident 69's room on their list to repair the drywall because housekeeping had told them the exposed drywall made it a non-cleanable surface, but they had not gotten around to it yet. Staff V was unsure when the housekeeper had informed them, but it was a while ago. Reference WAC 388-97-0880, WAC 388-97-2024

Based on observation, interview and record review, the facility failed to coordinate with the State designated authority to ensure residents with a mental disorder received integrated care based on their needs for 1 of 5 sampled residents (Resident 11), reviewed for Pre-admission Screening and Resident Review (PASRR, a mental disorder and intellectual disabilities screening). Specifically, Resident 11's Level I screening was not completed correctly prior to admission. This failure placed the resident at risk of decline in their psycho-social needs or inability to benefit from all services they were entitled to.Findings included.The 02/06/2026 significant change assessment documented Resident 11 was admitted to the facility on [DATE] and had diagnoses that included depression, anxiety and post-traumatic stress disorder (PTSD, a mental health condition triggered by experienced or witnessed terrifying, life threatening or abusive events).The history and physical from the emergency room on [DATE] documented Resident 11 had a diagnosis of anxiety.On 12/03/2025, a Level I PASRR screening (which determined the presence of a severe mental illness or developmental disability) was completed. It was documented Resident 11 had no serious mental illness and that a Level II PASRR screening (an evaluation to determine if nursing home placement was the appropriate level of care and what behavioral health or other community services were recommended once a resident is admitted to the facility) was not indicated.In an interview on 04/09/2026 at 3:19 PM, Staff DD, Social Service Director, stated PASRRs were completed in the hospital prior to admission. Staff DD stated they reviewed PASRRs for accuracy, and if they were incorrect, they were not supposed to admit the residents. Staff DD stated if a resident had a diagnosis of anxiety from the hospital and were staying in the facility greater than 30 days a Level II was required. Staff DD stated it was important the [NAME] II be completed in the hospital prior to admission to ensure the facility had the resources needed to care for the resident. Staff DD stated Resident 11's PASRR was incorrect because they had diagnoses including depression, PTSD, and substance use disorder and a Level II should have been completed. In an interview on 04/09/2026 at 3:39 PM, Staff B, Director of Nursing, stated PASRRs were completed at the hospital and evaluated by Social Services. Staff B stated most PASRRs were not completed prior to admission. Reference: WAC 388-97-1915(1)(2)(a-c)

Based on observation, interview, and record review, the facility failed to consistently provide bathing for 1 of 3 sampled residents (Resident 6) reviewed for activities of daily living (ADLS). This failure placed residents at risk for poor personal hygiene, diminished quality of life and unmet care needs. Findings included .The 02/04/2026 quarterly assessment documented Resident 6 had diagnoses that included heart failure, dementia and diabetes. Resident 6 required set up and clean up assistance from nursing staff for bathing. The 09/12/2023 ADL care plan instructed nursing staff to provide assistance with bathing. Review of the bathing task record from 02/01/2026 through 04/11/2026 showed Resident 6's scheduled shower days were on Tuesdays and Fridays. Resident 6 had one shower from 02/01/2026 through 02/07/2026, 02/22/2026 through 02/28/2026, 03/08/2026 through 03/14/2026, and 03/29/2026 through 04/04/2026. The showers were not given twice weekly as scheduled and no shower refusal forms were provided for these dates.In an observation on 04/02/2026 at 1:14 PM, Resident 6 was sitting in their wheelchair, and their hair was greasy in appearance.In an observation on 04/08/2026 at 1:32 PM, Resident 6 was lying in bed, wearing the same shirt as the previous day. Resident 6's hair was greasy in appearance. Resident 6 stated they did not receive their shower the previous day. In an interview on 04/10/2026 at 9:14 AM, Resident 6 stated they refused showers when they were not feeling well and that did not happen very often. Resident 6 stated they were told by staff they were unable to wake them and that is why they did not get their shower and that this upset them. In an interview on 04/09/2026 at 9:44 AM, Staff W, Nursing Assistant (NA), stated showers were given twice weekly and if they did not have an extra staff available, modified bed baths were completed. Staff W stated when a resident refused their showers a refusal form was filled out and the refusal was documented in the shower book. In an interview on 04/13/2026 at 8:58 AM, Staff X, NA, stated the shower refusal forms were filled out and signed by the residents and the nurse. Staff X stated Resident 6 wanted to take their showers later and they wrote in the shower book for evenings to offer the shower. Staff X stated the expectation was for nursing staff to offer the shower the next day if the resident refused. In an interview on 04/13/2026 at 9:02 AM, Staff Y, Licensed Practical Nurse, stated showers were provided twice weekly. Staff Y stated Resident 6 chose different days to shower other than their scheduled shower days. In an interview on 04/13/2026 at 11:30 AM, Staff B, Director of Nursing, stated it was important for the residents to have showers twice weekly to prevent skin issues. Reference (WAC): 388-97-1060 (2)(c)

Based on observation, interview and record review, the facility failed to ensure residents received an ongoing program of activities that met their interests for 1 of 2 sampled residents (Resident 6), reviewed for activities. This failure placed the resident at risk for sadness, feeling alone and diminished quality of life. Findings included The 02/04/2026 quarterly assessment documented Resident 6 had diagnoses that included anxiety and depression. Resident 6 was cognitively intact and able to make their needs known. The 06/06/2024 activities care plan documented Resident 6 structured their leisure time independently and was highly involved in group activities and/or independent activities. The care plan did not address spending 1:1 time with the resident as they desired. In an observation and interview on 04/02/2026 at 3:49 PM, Resident 6 was lying in bed in a dark room watching television. Resident 6 stated they had a counselor they used to talk to and it was helpful and they enjoyed it. Resident 6 stated they liked visiting and talking to people.Observations made on 04/03/2026 at 12:43 PM, 04/06/2026 at 12:16 PM and 1:42 AM, 04/08/2026 at 1:32 PM, 04/10/2026 at 9:14 AM showed Resident 6 was sitting in their dark room. In an interview on 04/10/2026 at 9:14 AM, Resident 6 stated they liked it when people came to their room and visited with them, but staff did not do that. Resident 6 stated activities did not come to their room, and they had requested them to do so. Review of the planned activity record from 02/01/2026 through 04/05/2026 showed Resident 6 had five 1:1 visits in their room for the month of February, three 1:1 visits in March, and two 1:1 visits from 04/01/2026 through 04/05/2026. In an interview on 04/09/2026 at 9:44 AM, Staff W, Nursing Assistant, stated activities provided for residents who liked to stay in their rooms consisted of coloring materials and if there were things like ice cream socials the activity staff went door to door and offered it to all residents. In an interview on 04/09/2026 at 10:44 AM, Staff EE, Activities Director, stated 1:1 visits were provided for residents who did not like to leave their room. Staff EE stated they have not had an assistant in the last couple of months, and they relied on their assistant to do the 1:1 visits. Staff EE stated Resident 6 did not do much, enjoyed having their nails done on the weekends and bought snacks from the snack shop. Staff EE stated they should have provided more 1:1 visits with Resident 6. Staff EE stated it was important to do 1:1 visits for socialization. In an interview on 04/13/2026 at 11:30 AM, Staff B, Director of Nursing, stated it was important for the residents who did not leave their room to have 1:1 visits for socialization and to be involved and not feel depressed.Reference (WAC) 388-97-0940(1)(2)

Based on observation, interview and record review, the facility failed to provide foot care and seek podiatry services (a physician that specialized in care and treatment of the feet) for 1 of 3 sampled residents (Resident 74) reviewed for skin conditions. This failure placed the resident at risk for skin breakdown and unintended health consequences.Findings included.The 12/04/2025 quarterly assessment documented Resident 74 had diagnoses that included diabetes (high blood sugar) and high blood pressure. Resident 74 was cognitively intact and required partial to moderate assistance with personal hygiene. The 08/08/2025 activities of daily living care plan documented Resident 74 required total assistance with personal hygiene. The 10/14/2025 diabetic care plan instructed nursing staff to inspect Resident 74's feet daily for open areas, sores, pressure areas, blisters, swelling or redness and report it to the physician. The 02/10/2026 chronic ulcer to left foot care plan instructed nursing staff to avoid dry skin.The March 2026 medication administration record (MAR) documented nail care and foot checks were completed on 03/04/2026. Resident 74 was hospitalized on [DATE] and the rest of the month was blank. There was nothing on the MAR for April 2026 regarding diabetic nail care or foot checks. In an observation on 04/02/2026 at 11:50 AM, Resident 74 was lying in bed and their feet were uncovered. Resident 74's toenails were very long and thick and the bottom of their feet were very dry with thick scales of dead skin. Resident 74 stated they had asked to have their toenails cut but staff presented like they did not know who to contact. At 3:41 PM that same day, Resident 74 stated nursing staff had not applied lotion on their feet since their admission to the facility. Observations made on 04/06/2026 at 8:44 AM, 12:14 PM, and 1:35 PM, on 04/08/2026 at 1:21 PM, and on 04/09/2026 at 8:37 AM showed Resident 74's toenails were thick and long, and the bottom of their feet were dry with thick scales of dead skin. On 04/06/2026 at 12:14 PM, Resident 74 stated they were unable to leave the facility for a podiatrist appointment and would have to be seen at the facility. In an interview on 04/10/2026 at 2:33 PM, Staff M, Nursing Assistant (NA), stated the nurses or the podiatrist were responsible for nail care for diabetic residents. Staff M stated a podiatrist came to the facility but were unsure how often. Staff HH, NA, who was also present, stated the nursing assistants applied lotion after showers and when the residents asked for it. In an interview on 04/10/2026 at 2:34 PM, Staff R, Licensed Practical Nurse, stated diabetic nail care was completed weekly by the nurses. Staff R stated if the nurse was unable to do the nail care, the resident was placed on a list for the podiatrist to see them. At 2:39 PM, Staff R observed Resident 74's feet and stated they needed to be seen by the podiatrist and that their feet were very dry. Resident 74 stated they needed lotion on their feet. Staff R touched the bottom of Resident 74's feet and flakes of skin came off. Staff R stated it was important to keep the resident's skin moisturized to prevent skin breakdown and infections. In an interview on 04/10/2026 at 2:52 PM, Staff B, Director of Nursing, stated nail care was completed on shower days by the nursing assistants and if the resident was diabetic it was completed by the nurses. Staff B stated if the staff were unable to cut toenails the residents were placed on a list and seen by the podiatrist that came into the facility. Staff B stated it was important to maintain toenails because it was a dignity issue and if the skin was dry, it could cause skin breakdown. Reference: WAC-388-97-1060(3)(j)(viii)

Based on observation and interview, the facility failed to maintain oxygen equipment in a clean and sanitary manner for 2 of 3 sampled residents (Residents 62 and 74) and failed to administer oxygen per provider orders for 1 of 3 sampled residents (Resident 74), reviewed for respiratory care. This failure placed residents at risk of potential medical complications, potential respiratory infections, and diminished quality of life.Findings included. <Resident 74> The 12/04/2025 quarterly assessment documented Resident 74 had diagnoses that included chronic obstructive pulmonary disease (COPD, a progressive lung disease that blocked airflow and made it difficult to breathe), and respiratory failure. Resident 74 was cognitively intact and dependent on oxygen. The 08/28/2025 oxygen care plan instructed nursing staff to administer medications as ordered by the physician. An 08/28/2025 provider order instructed nursing staff to wash the concentrator filter weekly. A 03/21/2026 provider order instructed nursing staff to administer oxygen at 2L continuously for COPD. The March 2026 Medication Administrator Record (MAR) showed Resident 74 received 3L (liters) of oxygen on 16 occasions. The April 2026 MAR showed Resident 74 received 3L of oxygen on six occasions. In an observation on 04/01/2026 at 10:51 AM, Resident 74 was lying in bed wearing oxygen at 3L via a nasal cannula, not 2L as ordered. The oxygen filter was covered in thick dust debris. Observations of Resident 74's oxygen concentrator on 04/02/2026 at 3:41 PM, 04/03/2026 at 2:29 PM, 04/06/2026 at 8:44 AM and 1:35 PM, 04/07/2026 at 3:17 PM, 04/08/2026 at 1:21 PM and 04/09/2026 at 8:37 AM showed they received 3L of oxygen. Observations of Resident 74's oxygen filter on 04/02/2026 at 11:50 AM, 04/02/2026 at 3:41 PM, 04/03/2026 at 8:37 AM and 2:29 PM, 04/06/2026 at 8:44 AM, 12:14 PM and 1:35 PM, 04/07/2026 at 8:21 AM and 3:17 PM, 04/08/2026 at 1:21 PM, and 04/09/2026 at 8:37 AM showed it was covered in thick dust debris. In an interview on 04/10/2026 at 2:34 PM, Staff R, Licensed Practical Nurse, stated oxygen filters were cleaned weekly on Sundays by the nurses. Staff R stated it was important to maintain the filters in a clean manner, so the flow of oxygen was not blocked, and the residents received the proper amount of oxygen. Staff R stated it was important to administer oxygen as ordered to prevent residents with COPD from retaining carbon dioxide. Staff R stated Resident 74 was prescribed 2L of oxygen. At 2:39 PM, Staff R observed Resident 74's oxygen and turned it down from 3L to 2L and removed the oxygen filter. When Staff R touched the filter dust fell off, and they stated it was very dusty. In an interview on 04/10/2026 at 2:52 PM, Staff B, Director of Nursing, stated it was important to administer oxygen as ordered to maintain the resident's oxygen saturations and to avoid the residents from retaining carbon dioxide. Staff B stated it was important to keep the filters clean, so the residents did not breathe dust into their lungs. <Resident 62> According to the 03/12/2026 admission assessment, Resident 8 had diagnoses that included COPD, interstitial pulmonary disease (group of conditions that caused inflammation and scar tissue to lungs which made the lungs stiff and caused difficulty breathing), and chronic respiratory failure. The assessment further showed Resident 8 utilized a non-invasive mechanical ventilator (machine that helped a person breathe by pushing air into the lungs through a tight-fitting mask). Resident 8 was cognitively intact and able to clearly verbalize their needs. Review of the 03/17/2026 care plan showed Resident 62 had obstructive sleep apnea (common sleep disorder where the airway collapsed or becomes blocked during sleep that caused breathing to repeatedly stop and start) and utilized a Bilevel Positive Airway Pressure (BiPAP, non-invasive ventilator that delivered pressurized air through a mask). An intervention instructed staff to monitor the resident for signs and/or symptoms of respiratory distress and report to the provider. No documentation was found to show how the BiPAP was to be maintained. Review of provider orders showed a 03/10/2026 order that Resident 62 was to utilize a BiPAP nightly. No documentation was found to show how the BiPAP equipment was to be maintained. In an interview on 04/01/2026 at 2:30 PM, Resident 62 laid in bed with a BiPAP machine sitting on the nightstand. Resident 62 stated they brought their BiPAP machine in from home and wore it nightly. Resident 62 further stated staff did not clean their BiPAP mask or tubing. In an interview on 04/09/2026 at 10:51 AM, Staff G, Nursing Assistant, stated BiPAP equipment needed to be cleaned after each use to prevent bacteria build up which could cause a respiratory infection. In an interview on 04/09/2026 at 10:55 AM, Staff E, Licensed Practical Nurse, stated the nurse was responsible for cleaning the BiPAP mask and tubing daily, it would be documented in the resident's treatment administration record. Staff E further stated residents were at risk for infections if this was not completed. In an interview on 04/09/2026 at 11:13 AM, Staff C, Resident Care Manager, stated if a resident utilized a BiPAP machine, provider orders would be entered for daily cleaning of the mask and tubing with soap and water. Staff C reviewed Resident 62's medical record. Staff C acknowledged they were unable to find provider orders for routine cleaning of Resident 62's BiPAP equipment. Staff C stated residents were at risk for respiratory infections if their BiPAP equipment was not cleaned routinely. In an interview on 04/09/2026 at 11:52 AM, Staff B, Director of Nursing, stated that when a resident utilized a BiPAP orders were implemented to clean the mask and tubing daily to prevent potential infection. Staff B further stated they expected staff to maintain BiPAP equipment in a clean and sanitary manner. In an interview on 04/13/2026 at 11:39 AM, Staff A, Administrator, stated they expected staff to maintain BiPAP and oxygen equipment in a sanitary manner. Reference WAC 388-97-1060 (3)(j)(iv)-(vi)

Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent. Specifically, two medication errors were identified during 26 medication administration opportunities. This resulted in an error rate of 7.69 %. This failure placed residents at risk of receiving subtherapeutic (a dosage or concentration that is too low to produce the intended medical effect or treat a disease) effects of their medications, possible adverse side effects, and diminished quality of life.Findings included.During observation on 04/10/2026 at 9:20 AM, Staff Q, Registered Nurse, prepared and administered ten medications for Resident 76.Included in the medications given were the following:Calcium (a supplement) 500 milligrams (mg, a unit of measurement) with Vitamin D 10 micrograms (mcg, a unit of measurement), one tablet by mouth.Colestipol (a cholesterol medication) 1 Gram (Gm, a unit of measurement), one tablet by mouth.A review of Resident 76's orders and April 2026 Medication Administration Record (MAR) showed the following morning medication orders:Calcium 500 mg daily by mouthColestipol 1 Gm, one hour before or three hours after other medications.During an interview with Staff Q on 04/10/2026 at 10:31 AM, Resident 76s morning medication orders were reviewed. Staff Q reviewed the orders on the computer and the stock medication for Calcium, and stated that they should have noticed they gave Calcium with Vitamin D, rather than just calcium. Additionally, when Staff Q looked at the screen for the Colestipol, the directions to give the medication one hour before or three hours after other meds was not fully visible, until the staff clicked on more to see the full directions. Staff Q stated they should have looked closer, and both were medication errors.During an interview on 04/13/2026 at 1:39 PM, Staff B, Director of Nursing, acknowledged both the medication errors. Reference: WAC 388-97-1060(3)(k)(ii)

Based on observation, interview and record review, the facility failed to ensure refrigerator temperatures were maintained in an acceptable range and expired medications were removed from inventory in 1 of 2 medication rooms (Medication room [ROOM NUMBER] - South Unit) observed. This failure placed residents at risk of receiving potentially compromised or expired medications. Findings included.<Glucometer Quality Control Testing Solutions>On 04/10/2026 at 9:15 AM the Southeast Medication Cart was observed with Staff E, Licensed Practical Nurse. The cart had two small bottles of control testing solutions in the box of Assure Dose Quality Controls (solutions placed on a test strip that verified the accuracy of glucometer blood sugar test results). The solutions had a manufacturer expiration date of 08/17/2025. Staff E stated the glucometer checks were completed on the nightshift. Staff E stated they did not work nights, so they were unaware of the process. The solutions were removed from the cart's inventory. During an interview on 04/10/2026 at 10:10 AM, Staff B, Director of Nursing (DNS), stated the staff on nightshift performed the glucometer quality control checks each night and documented their results in a logbook kept at the nurse's station. Results in the logbook were reviewed, and it was confirmed that the quality control checks were not completed with the expired control solutions. <Medication room [ROOM NUMBER] - South Unit Medication Room>On 04/10/2026 at 9:35 AM, Medication room [ROOM NUMBER] - South Unit was observed with Staff E and the following findings:Three bottles of Gericare brand Aspirin 325 milligram tablets were expired. One bottle had a manufacturer's expiration date of June 2025, and two bottles had expiration dates of August 2025. Staff E removed the bottles from inventory. The refrigerator was observed. The temperature was 34 degrees Fahrenheit (F), and the freezer compartment contained large quantities of frost. Contents of the refrigerator included the following:Lantus Solostar insulin pensTwo vials of Retacrit (used to treat anemia caused by kidney disease)Humalog 50/50 insulin pensTwo Lorazepam vials (used to treat anxiety)Lispro insulin pensSemglee insulin pensNovolog insulin pensOne Basaglar insulin penTubersol protein derivative (used to test for the presence of Tuberculosis, a bacterial infection found mainly in the lungs)All were reviewed by manufacturer brands and appropriate temperature range for storage was 36 to 46 degrees F.On 04/10/2026 at 10:15 AM, the April 2026 Medication Room and Refrigerator Temperature Log Sheet was reviewed with Staff B, DNS. The log instructed staff to check the temperature both inside and outside of the refrigerator and report out of range temperatures immediately to the Director of Nursing for alternate storage. The log documented refrigerator temperature parameters were 36 to 46 degrees F. The last column on the log asked, if temp is outside of specification, what was done about it? The column had no entries. The following dates had readings outside the documented parameters:04/01/2026 AM 35 degrees F04/02/2026 PM 35 degrees F04/03/2026 AM 35 degrees F04/04/2026 AM 35 degrees F04/05/2026 AM and PM, both 34 degrees F04/06/2026 AM 33 degrees F, PM 35 degrees F,04/08/2026 AM 35 degrees F, PM 34 degrees F04/09/2026 AM 35 degrees [NAME] 04/10/2026 at 10:19 AM, Staff B stated when refrigerator temperatures were too cold, maintenance checked the refrigerators. Staff B notified maintenance at this time. During an interview on 04/13/2026 at 9:52 AM, Staff P, Stock Room Nursing Assistant, stated they checked the medication rooms on Thursdays and Fridays and refilled or replaced expired medications. Staff P stated they missed removing the expired Aspirin found in Medication room [ROOM NUMBER] - South Unit. At this time, the North Medication Room was observed, and there were no additional bottles of expired Aspirin in the inventory. During an interview on 04/13/2026 at 10:31 AM, Staff A, Administrator, stated expired medications were to be removed from the medication rooms. Staff A stated they would check with the Pharmacy regarding the medications stored in the Medication room [ROOM NUMBER] - South Unit to ensure they were acceptable to use. Reference: WAC 388-97-1300(2)

Based on observation, interview, and record review, the facility failed to follow the ordered diet for 1 of 10 residents (Resident 23), reviewed for food preferences. This failure placed residents at risk for inadequate nutrition, possible weight loss and diminished quality of life.Findings included.According to the 03/05/2026 admission assessment, Resident 23 admitted to the facility on [DATE] with diagnoses including sepsis (a life-threatening medical emergency caused by the body's extreme, overactive response to an infection, which damages its own tissues and organs) and a wound infection. Resident 23 was cognitively intact. The assessment further showed Resident 23 did not receive a therapeutic diet while at the facility. Review of the 03/05/2026 nutrition care plan showed Resident 23 was at risk for significant weight changes related to alteration to skin integrity and food allergies. Staff was instructed to serve diet as ordered, allow choices at mealtime and menu selection, monitor and record food and fluid intake, and offer alternative food choices when items were refused.Review of 03/03/2026 provider order showed Resident 23 was to have a vegetarian (no meat, poultry, or seafood) diet, regular texture, thin liquid consistency, high protein, and extra sauces/gravy on the side.Review of the 03/05/2026 nutrition evaluation showed Resident 23 was to receive a vegetarian therapeutic diet. A summary showed Resident 23 was ordered to have a high protein diet to help wound healing. The dietician was to discuss the extent of Resident 23's vegetarian diet to determine whether they consumed eggs, dairy, or any products made from animals.In an interview on 04/06/2026 at 12:21 PM Resident 23 stated that they were given meat for both lunch and dinner.During interview and record review on 04/07/2026 at 8:53 AM, Resident 43 stated dinner last night was beef and something with rice. Resident 43 sent the tray back to the kitchen and was sent a meat sandwich as an alternative. Resident 43 then sent back the meat sandwich and received a chef salad as an alternative, but the chef salad also had meat on it. Resident 43 stated they then took the salad to the nurse's station and then they finally received a toasted cheese sandwich.Resident 23 provided their meal ticket. Review of the meal ticket showed they were vegetarian and lacto-ovo (vegetarian diet that included dairy products and eggs) and it was highlighted in yellow. In an interview on 04/07/2026 at 9:01 AM Staff S, Nursing Assistant, acknowledged Resident 23 had many issues during meals, they had been getting meat at meals since they admitted .In an interview on 04/10/2026 at 2:29 PM Staff T, Dietary Manager, stated food preferences were determined upon admission and meal tickets were expected to be followed to ensure correct resident food preferences were met. Staff T also stated that they expected a vegetarian to get a vegetarian meal, and it was important to follow resident preferences to avoid potential malnutrition and weight loss.In an interview on 04/13/2026 at 11:53 AM Staff A, Administrator, stated they expect a vegetarian meal order to be followed.Reference WAC 388-97-1160 (1)(a)(b), -1120 (3)(c )(4)

Based on observation, record review and interview, the facility failed to provide food in the correct consistency for 1 of 6 sampled residents (Resident 11), reviewed for nutrition. This failure placed the resident at risk for choking, aspiration pneumonia (an infection caused by inhaling foreign material-such as food, liquid, or vomit into the lungs) and a diminished quality of life.Findings included.The 02/06/2026 significant change assessment documented Resident 11 had diagnoses that included dysphagia (difficulty swallowing). Resident 11 had severe cognitive impairments and was on a mechanically altered texture diet. The 01/20/2026 nutritional care plan showed Resident 11 was at risk for malnutrition from decreased food intake secondary to chewing/swallowing difficulties. The goal was for Resident 11 not to have any choking episodes. The care plan instructed nursing assistants to report signs of coughing and choking to the nurses. The 01/20/2026 dysphagia care plan documented Resident 11 would not have complications related to aspiration and choking. The care plan instructed nursing staff to serve Resident 11's diet as prescribed.A 02/03/2026 provider order showed Resident 11 was on a pureed texture diet (smooth, pudding-like, and moist foods that required no chewing designed for people with swallowing difficulties).In an observation on 04/02/2026 at 3:40 PM, Resident 11 was sitting in their wheelchair near the nurse's station. Resident 11 had a pack of Oreo cookies in their lap. In an observation on 04/03/2026 at 8:33 AM, Resident 11 was sitting alone in their room in their wheelchair eating a banana. In an observation on 04/03/2026 at 3:07 PM, Resident 11 was playing bingo in the dining room. Resident 11 was consuming popcorn out of a bag in front of them. In an observation on 04/07/2026 at 8:10 AM, Resident 11 was sitting in their wheelchair across from the nurse's station. Resident 11 had a container of mandarin oranges.In an interview on 04/13/2026 at 9:06 AM, Staff X, Nursing Assistant, stated they knew what diet the residents were on by looking at the Kardex (part of the care plan). Staff X stated Resident 11 liked oatmeal, bananas, applesauce and pudding. Staff X stated Resident 11 was on a puree diet for swallowing difficulties. Staff X stated it was important to provide them with pureed food, so they did not choke or aspirate.In an interview on 04/13/2026 at 9:11 AM, Staff Y, Licensed Practical Nurse, stated they knew what diet the residents were on by their medication administration record. Staff Y stated whole bananas, popcorn, cereal and Oreos were not included in a puree diet. Staff Y stated it was important to provide Resident 11 with pureed food to prevent aspiration and choking.In an observation on 04/13/2026 at 9:48 AM, Resident 11 was sitting in their wheelchair in their room. Resident 11 had a Snickers candy bar, Reeses peanut butter cups, and chocolate rolls on their nightstand. Resident 11 stated she ate and liked them all. Staff X entered the room and stated Resident 11 had cereal in their room before and they reported it to the nurse. Resident 11 also had a jar of peanut butter on their nightstand and Staff X stated they had also reported that to the nurse. In an interview on 04/13/2026 at 11:39 AM, Staff B, Director of Nursing, stated it was important to follow Resident 11's diet orders to prevent choking, aspiration and adverse outcomes. Staff B stated Resident 11 should have received pureed food. Reference: WAC 388-97-1100(1)

Based on interview and record review, the facility failed to ensure arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreements were explained in a form and manner understood by the resident and/or their representative for 2 of 3 residents (Resident 11 and 28) reviewed for arbitration. This failure placed residents at risk of losing legal protection, forfeiture (loss or giving up of something) of the right to a jury or court, lack of understanding of the legal document signed, and a diminished quality of life.Findings included.<Resident 11>According to the 12/09/2025 admission assessment, Resident 11 admitted to the facility on [DATE] with diagnoses that included borderline personality disorder and severe cognitive impairment. According to the admission agreement dated 12/08/2025, Resident 11 did not have a Power of Attorney (a legal document enabling a person to designate another to manage their financial, legal, or health affairs).Record review of the arbitration agreement showed Resident 11 electronically signed it on 12/08/2025.In an interview on 04/10/2026 at 9:03 AM, Resident 11 stated they did not remember signing any documents at admission, specifically an arbitration agreement. When asked, Resident 11 stated an arbitration was an agreement to not go to court.In an interview on 04/13/2026 at 9:24 AM Staff Z, Business Office Manager, stated upon admission they explained the arbitration agreement to residents or their representative and allow for questions. Staff Z stated the resident Brief Interview for Mental Status (a 0-15 point assessment tool used to measure cognitive function, specifically focusing on short-term memory, orientation, and ability to recall information) score was reviewed prior to having the arbitration agreement signed to ensure the resident would understand what they were signing. Staff Z acknowledged Resident 11 was not cognitive enough to understand and sign the arbitration agreement and the agreement should have been rescinded. <Resident 28>According to the 02/18/2026 quarterly assessment, Resident 28 had diagnoses that included a left leg above the knee amputation. Resident 28 was cognitively intact and able to clearly verbalize their needs.Record review showed Resident 28 electronically signed an arbitration agreement on 08/19/2025.In an interview on 04/02/2026 at 9:17 AM, Resident 23 stated staff did not review or explain an arbitration agreement with them and did not recall signing an arbitration agreement. Resident 28 further stated they did not agree to arbitration and was told by a family member to not sign anything in that regard. In an interview on 04/13/2026 at 11:53 AM Staff A, Administrator, stated they expect an arbitration agreement to be reviewed, understood and signed with a cognitively aware resident or the resident representative. No associated WAC

Based on interview and record review the facility failed to routinely complete annual staff performance reviews yearly as required and provide education based on the outcome of these reviews for 2 of 5 sampled staff (Staff AA and BB), reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life.Findings included.<Staff AA>Review of Staff AA's, Nursing Assistant (NA), personnel file showed they were hired on 10/30/2023. No documentation of a yearly performance evaluation was on file.<Staff BB>Review of Staff BB's, NA, personnel file showed they were hired on 07/23/2019. No documentation of a yearly performance evaluation was found on file.In an interview on 04/07/2026 at 1:53 PM, Staff O, Regional Director, stated they did not have performance evaluations for Staff AA and Staff BB.In an interview on 04/10/2026 at 1:53 PM, Staff B, Director of Nursing, stated performance evaluations were to be completed yearly and conducted by Staff B or the Resident Care Manager.In an interview on 04/13/2026 at 11:53 AM, Staff A, Administrator, stated performance evaluations were expected to be completed yearly, as required.Reference WAC 388-97-1680 (1), (2)(a-c)

Based on observation, interview and record review the facility failed to maintain a urinary catheter (flexible tube inserted into the bladder) in a dignified manner for 1 of 7 sampled residents (Resident 95), reviewed for resident rights. Additionally, the facility obtained psychotropic (medications that affected the brain, mood, thoughts, behaviors, and perception) medication consent from a severely cognitively impaired resident for 1 of 5 sampled residents (Resident 11), reviewed for unnecessary medications. This failure placed residents at risk of not being fully informed of the potential risks versus benefits associated with treatment, embarrassment and a diminished quality of life.Findings included. <Resident 95> According to the 03/29/2026 admission assessment, Resident 95 had diagnoses that included encephalopathy (disease, damage, or malfunction that altered brain function). The assessment showed Resident 95 had an indwelling urinary catheter and was dependent on staff assistance for toileting. Review of the 03/23/2026 care plan showed Resident 95 had an indwelling urinary catheter and instructed staff to change the catheter per provider orders, empty the urine collection bag every shift, keep the catheter anchored to prevent tension or trauma, ensure catheter tubing and collection bag were below bladder level, and report changes in urine to the nurse. No documentation was found to show how Resident 95's dignity was to be maintained. During observations on 04/01/2026 at 11:09 AM and 11:41 AM, Resident 95 laid in bed with a urine collection bag hanging on the bedframe, without a dignity privacy cover, and yellow urine was observed in the collection bag from the hallway. Similar observations were made on 04/02/2026 at 8:29 AM, 11:30 AM, 12:10 PM and 3:47 PM, on 04/03/2026 at 8:31 AM, 10:26 AM and 2:33 PM, on 04/06/2026 at 1:10 PM and 2:24 PM, on 04/07/2026 at 8:43 AM, 10:49 AM, 11:41 AM, 1:04 PM, on 04/08/2026 at 1:32 PM, and on 04/09/2026 at 10:34 AM. In an interview on 04/09/2026 at 1:29 PM, Resident 95 was observed laying in bed with the urine collection bag, not in a dignity privacy cover with yellow urine visible from the hallway. Resident 95 was asked if it bothered them to have their urine collection bag exposed and visible for others to see. Resident 95 just stared at the surveyor and did not provide a response. During observation and interview on 04/09/2026 at 1:32 PM, Staff G, Nursing Assistant, observed Resident 95's urine collection bag, not in a privacy cover, visible from the hallway. Staff G explained that staff typically placed urine collection bags in a dignity privacy cover when residents were out of their room. Staff G further stated Resident 95 only spoke when they wanted to. During observation and interview on 04/09/2029 at 1:35 PM, Staff E, Licensed Practical Nurse, stated that when a resident had an indwelling urinary catheter the urine collection bag was placed in a dignity privacy cover. Staff E observed Resident 95's urine collection bag, not in a privacy cover, visible from the hallway. Staff E explained the dignity cover was only utilized when a resident was out of their room, not when in their room. Staff E further stated Resident 95 had good days and bad days and could not verbalize if it bothered them to have the urine collection bag visible to others so it should be placed in a privacy cover for their dignity. In an interview on 04/09/2026 at 1:40 PM, Staff C, Resident Care Manager, stated the facility typically utilized urine collection bags that came with an attached dignity privacy cover. Staff C acknowledged Resident 95's urine collection bag should be in a dignity privacy cover to maintain their dignity. In an interview on 04/09/2026 at 3:20 PM, Staff B, Director of Nursing, explained the facility typically utilized a urine collection bag that came with an attached dignity cover and staff were to place urine collection bags in a dignity privacy cover so it was not visible and maintain the resident's dignity. Staff B stated the facility ran out of dignity covers and acknowledged Resident 95's urine collection bag should have been placed in a dignity privacy cover. In an interview on 04/13/2026 at 11:39 AM, Staff A, Administrator, stated they expected staff to maintain a resident's catheter in a dignified manner. <Resident 11> The 12/09/2025 admission assessment documented Resident 11 admitted to the facility on [DATE] with diagnoses that included alcoholic cirrhosis of liver (advanced irreversible scarring of the liver caused by long-term, heavy alcohol use), borderline personality disorder (a mental health condition characterized by intense, unstable emotions, moods, and relationships, alongside a self-distorted image) and diabetes. The Brief Interview for Mental Status (BIMS, a screening tool used in long-term care that assessed cognitive impairment and identified potential dementia) showed Resident 11 had severe cognitive impairment. Review of the medical record showed Resident 11 admitted with orders for the following psychotropic medications: Cymbalta (antidepressant), Trazodone (antidepressant) and Seroquel (antipsychotic). The Seroquel had possible adverse effects that included increased mortality rate in the elderly. The 12/03/2025 psychotropic medication consents showed Resident 11 consented to the use of the medications. The record also showed Resident 11 signed the admission paperwork on 12/08/2025 which included monetary charges, financial obligations, and denial of Medicare and Medicaid. The 01/20/2026 care plan did not address Resident 11's impaired cognition, goals or interventions. In an interview on 04/09/2026 at 1:51 PM, Staff I, Therapy Director, stated Resident 11's St. Louis University Mental Status test (a screening tool used to detect early signs of dementia and mild cognitive impairment) was 1 out of 30, which indicated severe cognitive impairments. In an interview on 04/09/2026 at 1:55 PM, Staff J, Licensed Practical Nurse, stated they were responsible for the admission paperwork. Staff J stated they looked at the resident's face sheet to see if they were their own responsible party and if so, they had them sign the paperwork. Staff J stated Resident 11 was probably unable to understand the admission paperwork. Staff J stated it was important the residents understood what they were signing. In an interview on 04/09/2026 at 3:39 PM, Staff B, Director of Nursing, stated residents were able to sign admission paperwork and medication consents if they were able to answer questions appropriately and by their BIMS score. Staff B stated it was important the residents were cognizant to sign so they understood the side effects of the medication and what they were signing. Reference: WAC 388-97-0180(1)-(4)

Based on observation, interview, and record review, the facility failed to provide necessary pain management for 2 of 3 sampled residents (Resident 1 and 3), reviewed for pain. Resident 1 and 3 each experienced harm when the facility did not treat their pain timely, after the residents rated their pain as a 10 (0 is no pain and 10 is the most intense pain) on admission to the facility. This failure placed residents at risk of uncontrolled pain and diminished quality of life. Findings included . <Resident 1> Review of a facility assessment, dated 04/16/2025, showed Resident 1 was admitted on [DATE] and had diagnoses which included a below the knee amputation (BKA). The resident was able to make their needs known. Review of the admission assessment, dated 04/09/2025 at 2:30 PM, showed Resident 1 answered yes to being fatigued and it was noted the resident complained they were tired and had pain. The pain assessment showed the resident was currently in pain and their pain was described as throbbing, stabbing, burning, which occurred with movement and at rest. The resident was asked to rate their pain over the last five days and they responded 10. Review of the Medication Administration Record (MAR) for April 2025 showed Resident 1 had an order for Tylenol 500 milligrams (mg) to be given every four hours, as needed for pain, and Oxycodone (a narcotic pain medication) one tablet if they rated their pain 1 - 5, and two tablets if they rated their pain 6 - 10, every four hours as needed for pain. The MAR showed the resident had received Tylenol 500 mg at 8:05 PM and Oxycodone 2 tablets at 9:02 PM which was around six hours after admission. During an observation and concurrent interview on 04/25/2025 at 10:15 AM, Resident 1 was sitting in their wheel chair in their room. The resident had a compression bandage on the end of their left BKA stump. Resident 1 stated they were admitted after surgery for rehabilitation. The resident stated on admit, their pain was a 10. The resident asked for pain medication and it was not administered until several hours later. They stated it was awful and it took a long time to get their pain controlled. During an interview on 05/13/2025 at 1:50 PM, Staff D, Licensed Practical Nurse (LPN), stated they had admitted Resident 1 at the end of their shift. Staff D could not remember if the resident had significant pain and stated they had not given the resident any pain medication. Staff D was asked the process if medications for a new admit had not arrived to the facility. Staff D stated they would call pharmacy to confirm the order and the pharmacy could give the nurses a code to get the medication out of their Cubex (a medication dispensing machine). <Resident 3> Review of a facility assessment, dated 04/29/2025, showed Resident 3 was admitted to the facility on [DATE] with diagnoses which included spine surgery. The resident was able to make their needs known. Review of the vitals and pain only form, dated 04/23/2025 at 3:00 PM, Resident 3's current pain was rated at a 10. The resident described their pain in their lower back and down their right leg. The admission assessment showed the resident had two surgical wounds, one on the lower back and one on their left side. Review of the resident's MAR for April 2025 showed Resident 3 had an order for Morphine Extended Release (ER) tablet to be given every 12 hours, as needed for pain, a muscle relaxant every eight hours, as needed for pain, and Oxycodone every four hours as needed for pain and they were to receive one tablet if they rated their pain 1 - 5, and two tablets if they rated their pain 6 - 10. On 4/23/2025 at 6:30 PM, the resident received Morphine ER and Oxycodone two tablets for their pain which was over three hours after admission. On 04/24/2025, a grievance was filed for Resident 3 after concern of care were expressed during a care conference. Staff A, Administrator, went to talk to Resident 3 about the care concerns and during the conversation, the resident reported it took several hours for their medications to come to the facility after they were admitted and they were not happy. During an observation and concurrent interview on 05/13/2025 at 12:55 PM, the Resident 3 was lying in bed. They stated when they were admitted after spine surgery, they had to wait several hours for pain medication. The resident said their pain level was a 10 out of 10. Resident 3 stated they were told the facility ran out of their pain medication. Resident 3 was asked if any other type of pain medication had been offered or any non-medication interventions, such as repositioning, and the resident stated no. During an interview on 05/13/2025 at 1:50 PM, Staff D, Licensed Practical Nurse (LPN), was asked the process if medications for a new admit had not arrived to the facility. Staff D stated they would call pharmacy to confirm the order and the pharmacy could give the nurses a code to get the medication out of their Cubex. During an interview on 05/13/2025 at 2:50 PM, Staff E, Resident Care Manager (RCM), stated the floor nurses did the admission assessments, which included the pain assessment. If a resident rated their pain a 10 and their medication wasn't available from pharmacy, the staff could call the pharmacy and get a code to pull the medication from the Cubex. When asked what should be done if a resident rated their pain a 10 on admit, Staff E stated they would have offered the resident pain medication. During an interview on 05/13/2025 at 3:20 PM, Staff A, Regional Direction of Operations, confirmed if a resident had a pain rated at a 10 they should have been offered pain medication. On 05/20/2025 at 3:25 PM, Staff B, Director of Clinical Education, stated if a resident had rated their pain at a 10, medication should be offered to the resident. Reference: WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to ensure 2 of 4 sampled residents (Residents 4, and 5), reviewed for accidents, was free from injury. Resident 4, who had a history of seizure-like activity (spasms/involuntary jerking movements), experienced harm when they were left unsupervised in their wheelchair after a seizure-like episodes earlier that morning, fell out of their wheelchair onto the floor and sustained a neck fracture. Resident 5 experienced harm when their wheelchair was not properly secured in the facility transport van; when the van stopped to avoid an accident, the resident ' s wheelchair flipped backwards which resulted in the resident hitting their head on the back door. Resident 5 was transported back to the facility where it was determined the resident needed hospital evaluation and was transferred to the hospital via emergency transportation where they were diagnosed with a neck fracture. These accidents constituted Past Non-Compliance (the facility was not in compliance at the time the situations occurred; however, there was sufficient evidence that the facility corrected the non-compliance after they were identified) at harm level. For Resident 4, the facility immediately implemented and completed a plan of correction which included all? staff education which was verified by surveyors, measures to prevent recurrence, and monitors to ensure solutions were sustained. For Resident 5, the van was immediately removed from service for a full inspection. Van transporters, front-line staff and Human Resource (HR) manager had been educated on the policy for Comprehensive Vehicle Safety. Van drivers received additional education on how to properly secure wheelchairs for transport. Staff F, Maintenance Director, ensured each day the van was used, the transporter had completed all requirements to conduct transports. Findings included . <Resident 4> According to the facility assessment, dated 02/26/2024, Resident 4 was admitted with diagnoses to include an intellectual disability and anxiety. The resident required extensive assistance with all activities of daily living (ADL's). Resident 4 was severely impaired in decision making. On 02/27/2024 at 11:05 AM, Resident 4 was observed in bed with a neck brace on. The resident was asleep. Review of a nursing progress note, dated 02/17/2024, showed Staff G, Licensed Practical Nurse (LPN), documented the resident had seizure-like activity, described as involuntary jerking movements to both upper arms The resident was lethargic (decrease in consciousness), awake but unresponsive to physical stimulus. The resident was sent to the hospital for an evaluation. Review of the facility investigation, dated 02/19/2024, showed written statements by staff who cared for Resident 4 at the time of the incident. Staff H, NAC, reported they gave the resident a shower about 7:30 AM. During the shower, Resident 4 had a slight spasm and leaned forward in the chair. Staff H had to place their arm in front of the resident to prevent them from falling or sliding out of the chair. Staff H stated prior to the shower, Resident 4 didn't seem like their usual self. Staff H described Resident 4 staring blankly, not moving much, and didn't seem all there. Staff I, Hospitality Aide, had assisted the resident after the shower. Staff I reported after the resident was done eating, the resident had one of their spasms. Staff I waited until the resident no longer had the spasm and got the nurse, Staff J, LPN. After Staff J left the room, Staff I went to the sink and heard a thud. Resident 4 was on the floor. Staff I reported they had seen the spasm like activity multiple different times with Resident 4. Staff I described the resident would have a blank stare, their shoulders would twitch, the resident's head would go to the side, and they would stare straight ahead. This would last about a minute or two. During an interview on 03/08/2024 at 10:46 AM, Staff H , NAC, explained they had taken the resident to the shower the morning of the fall. The resident had a spasm. After the spasm, the resident leaned forward and Staff H had to put their hand in front of them to not fall. Staff H stated they had witnessed the spasms since December and had reported to nursing after each incident. Staff H stated they had witnessed a more intense spasm prior. The resident stared off, wasn't talkative like their usual, said the water was cold but it wasn't. The resident then let out a yelp, drooped over and stared for about 15-20 seconds before they answered Staff H. The incident was reported to the nurse on shift. During an interview on 03/08/2024 at 12:35 PM, Staff J, LPN, stated they were at the resident's door when the resident had the spasm the day of the fall. Staff J described it more as a weird shimmy. Staff J remained in the room about five minutes, nothing further happened, so left the room. Staff J stated Staff I reported to them later to report the resident had fallen. Staff J entered the room, the resident was on the floor, and complained of head pain. The resident was transported to the hospital. Staff J stated they had not seen the resident spasm before but heard a couple days prior, the resident had been sent to the hospital for seizure-like activity. During an interview on 03/08/2024 at 12:45 PM, a Collateral Contact (CC) was interviewed. The CC stated they were with Resident 4 on 01/16/2024 to help the resident eat. The CC stated the resident's body shot up in the wheelchair and then their head slammed on the table. The resident then started to jerk and did not respond to their named being called. The CC reported the incident to a nurse, asked the provider to be informed and document the incident in the resident's chart. The CC went on to say they came to visit the resident the following day and was told the resident was visited by a provider and the provider felt the resident looked fine and it was a spasm not a seizure. Per record review, there was no documentation related to the 01/16/2024 incident or the provider had been contacted. During an interview on 03/08/2024 at 2:03 PM, Staff C, Director of Nursing (DNS) stated they were unaware the resident had seizures. Staff C stated nursing assistants had described it as more of a movement. Staff C stated family had told them they reported a seizure the month prior but no staff witnessed it and they were not able to identify who the family told. <Resident 5> According to the facility assessment, dated 01/24/2024, Resident 5 had diagnoses to include seizures and heart disease. Resident 5 was able to make their needs known. On 02/27/2024 at 11:50 AM, Resident 5 was observed lying in bed with a neck brace on. Resident 5 stated they were in the van headed back to the facility when Staff E slammed on the brakes because a car was coming. Resident 5 stated they fell back in the wheelchair and their feet went up into the air. Resident 5's head hit the back door and they got punctures on their scalp which caused their head to bleed. Resident 5 stated Staff E had them get up, climb over the wheelchair and sit it back in the wheelchair. Staff I then cleaned off some of the blood on the resident's head. The resident recalled telling Staff E to take them to the hospital but they were taken back to the facility instead. Resident 5 stated they arrived at the facility and an ambulance was called. They had a fractured neck. Review of the facility investigation, dated 02/13/2024, showed Staff I was interviewed about the incident. Staff I explained they suddenly had to stop to avoid a collision from another car. Staff I stated Resident 5's wheelchair flipped over backwards, with the resident still strapped in the wheelchair, and the resident hit their head and started to bleed. Staff I assisted the resident up, had the resident get back into the wheelchair, and headed to the facility. Staff I did not call an ambulance immediately after the accident. During an interview on 02/27/2024 at 11:00 AM, Staff C stated Staff I no longer was employed at the facility. Staff C stated Resident 5 should have been taken to the hospital but Staff I brought them back to the facility. As soon as the resident arrived, the ambulance was called and they were transported to the hospital. During an interview on 02/27/2024 at 11:43 AM, Staff F stated after the incident the van was pulled from service until the investigation was completed. Staff F checked the van to ensure there wasn't any equipment failure that may have contributed to the incident. Staff F had Staff E go to the van and asked how the wheelchair had been secured. Staff E stated they couldn't remember if all straps had been placed. Staff F then demonstrated to Staff E on how to properly secure wheelchairs. Staff were educated on the policy Comprehensive Vehicle Safety. Staff F stated Staff E was no longer the transporter and going forward, all perspective drivers would have comprehensive training. Staff F would have the staff load them into the van in a wheelchair, secure the straps, take them around the block, and then unload them to ensure it was done correctly. The staff also had to take a distracted and defensive driving course on line, be certified in the restrain system being used, have drug screens done, and background checks. Staff F stated they had the only keys to the van so they could be aware of who was transporting the residents. This was Past Non-Compliance at harm level and is no longer outstanding. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to provide adequate pain management for 2 of 4 sampled residents (Resident 1 and 2), reviewed for pain. Resident 2 experienced harm when their pain was not assessed on admission and failed to receive their scheduled narcotic pain medication as ordered until the following day, and was sent to the hospital for intractable (severe, constant, relentless, and debilitating) pain. This failure placed residents at risk of uncontrolled pain and diminished quality of life. Findings included . < Resident 2 > According to the facility assessment, dated 10/17/2023, Resident 2 was admitted with diagnoses which included recent abdominal surgery. The resident was able to make their needs known. Resident 2 was admitted to the facility on [DATE] at about 6:30 PM. The resident had orders for a narcotic pain medication to be given every 4 hours as needed, a muscle relaxer every six hours as needed (PRN), and Tylenol every 6 hours PRN. Resident 2's pain level was to be assessed every shift. Review of the October 2023 Medication Record Administration (MAR), showed Resident 2's pain level was not assessed until the morning of 10/18/2023 and they rated it a 10 (pain scale is 0 no pain to 10 worst pain). The resident received a medication for anxiety and medication for muscle spasms at 5:30 AM and effectiveness of the medications was undetermined. The MAR documented an entry at 12:21 PM on 10/18/2023 as receiving the narcotic pain medication. The effectiveness was marked as undetermined. Review of progress notes showed there was no admission documentation to support a pain assessment was completed, and no documentation why the resident had not received pain medication until the morning of 10/18/2023. Review of the first progress note, dated 10/18/2023 at 1:00 PM documented by Staff D, Resident Care Manager (RCM). Staff D documented Resident 2 had intractable pain despite receiving pain medication. The Director of Nursing (DNS) was consulted and Resident 2 was transferred to the hospital for an evaluation. On 10/18/2023 at 1:29 PM, Staff B, documented the resident was crying in pain and stated they could not take a full breath related to abdominal pain that radiated down the right side. Resident 2 stated the pain was beyond a 10/10. Review of the facility investigation, dated 10/18/2023. showed the staff member who was on during the night shift, Staff F, Registered Nurse (RN), was interviewed. Staff F stated a code was received from pharmacy but they were unable to get into the medication distribution machine to get the narcotic pain medication for Resident 2. Staff F stated they did not ask the other nurse on shift for help and did not call the provider or DNS when they were unable to get the medication. In the morning of 10/18/2023, the on-coming nurse helped Staff F pull the medication at 06:30 AM. Staff F stated they did not administer the medication at that time because a narcotic count had already been done. Staff F stated they gave the medication to Staff G, RN, and told Staff G to give the medication to Resident 2 as soon as possible. Staff G was interviewed and explained Staff F had pulled the narcotic medication and was instructed to give it to Resident 2. The medication was not given to Resident 2 until 9:45 AM on 10/18/2023 and a 2nd dose was given at 12:00 PM. The investigation concluded the pain was uncontrolled as a result of Resident 2 not receiving the narcotic medication that was available to them. Once the prescription was available at 9:30 PM on 10/17/2023, after receiving the pharmacy code, the medication would have been available to be pulled from the machine every four hours until the medications arrived at the facility. On 11/02/2023 at 09:12 AM Staff B stated the process with a new resident or a resident with a new prescription was to call the pharmacy, get an authorization code, and pull the medication from the dispensing machine. Staff could call the pharmacy every four hours, if needed, and get a new code to get the pain medication for a resident until it arrived at the facility. Staff B stated they spoke to Staff F who stated they did not ask the nurse on the other unit to help, did not call Staff B, and waited until 06:30 AM to get help from an oncoming nurse. Staff B spoke to Staff G who stated they did not give the pain medication to Resident 2 until 09:45 AM because they had forgotten. After the second dose of pain medication the resident continued to be out of control with pain so was sent to the hospital. In an interview on 11/09/2023 at 10:45 AM, Staff F, stated the Resident 2 was admitted on [DATE] at about 6:15 PM. Staff F stated the day shift nurse spent an hour to an hour and a half getting a prescription sent to pharmacy for the pain medication and received an authorization code to get the medication out of the dispensing machine. Staff F stated the code came through about 10:44 PM, and when Staff F went into the room, Resident 2 was sleeping so Staff F did not try to get the pain medication out of the machine. At around 5:00 AM, Resident 2 started complaining of pain and when Staff F tried to enter the authorization code into the medication dispenser, it didn't work. Staff F stated the oncoming nurse assisted them in getting the medication which she gave to another nurse at 6:00 AM to administer. < Resident 1> According to the facility assessment, dated 09/11/2023, Resident 1 was admitted with heart and lung disease. The resident was able to make their needs known. On 10/26/2023 at 11:16 AM, Resident 1 was observed lying in bed. In an interview at that time the resident stated they had a vaccination when they first arrived at the facility and their right arm started to become painful and swell afterwards. Resident 1 stated they reported this to the staff and staff kept telling them they would notify the provider. Resident 1 stated the provider came in to see them about a week later to assess their right arm. Resident 1 went on to say they also started to have intermittent pain on the left side of their abdomen. Resident 1 explained this had occurred at times prior to coming to the facility but the pain started to get worse. Resident 1 stated they notified staff they were having pain and wanted something to be done. Resident 1 stated they finally had a scan that showed they had a large kidney stone. Review of nursing progress notes showed no documented of Resident 1's right arm pain or swelling and no documentation of the pain in the resident's lower abdomen. Review of provider progress notes, dated 10/09/2023, by Staff C, Physician Assistant, showed the resident was lying in bed in mild distress rating their pain an eight out of 10 (a scale used to rate pain, 0 is no pain, 10 is worst pain). Resident 1 stated they had intermittent left lower abdominal pain in the past but the pain had worsened over the last two days. Resident 1 stated they were nauseated and was requesting pain medication and anti-nausea medication. A Computed Tomography (CT) scan was ordered to be done immediately on the abdomen. Staff C documented to wait on pain medication, other than Tylenol, until the results were obtained. Electronic Medical Records (EMR) showed the CT scan was ordered 10/09/2023 and was done on 10/11/2023. Review of the October 2023 Medication Administration Record (MAR), showed the Resident 1 had an order for non-pharmacological pain interventions such as repositioning, relaxation, or diversion activities. There was no documentation to show any of the non-pharmacological interventions were attempted. There was no order for pain medication until 10/12/2023, after the scan showed a kidney stone. On 10/27/2023 at 10:15 AM, Staff E, RCM, stated if a resident had a change in condition, such as new complaints of pain, then the nurse should either find the provider, if they were in the building, or call the provider. Staff E was not familiar with Resident 1 and their pain. During an interview on 11/02/2023 at 10:36 AM, Staff C stated Resident 1 had abdominal pain and Staff C ordered a STAT CT scan to rule out a potential issue with Resident 1's bowels. Staff C stated the CT scan showed a kidney stone. Staff C ordered pain medication after the scan and an urinary medication to help in passing the stone. Staff C stated they were not aware STAT orders were not done the same day, unless it was an x-ray. Staff C found out after ordering STAT studies for Resident 1 that they had to be sent to the hospital for same day appointments. Reference: WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to provide thorough assessments and evaluate for changes in condition, for 1 of 3 residents (Resident 1), reviewed for change in condition. Failure to monitor Resident 1's right arm after complaints of pain and increased edema (swelling caused by too much fluid in the tissues)resulted in harm to Resident 1, who was sent to the hospital and diagnosed with blood clots in their right arm and lungs. Findings included . Review of a facility assessment, dated 09/11/2023, showed Resident 1 was admitted with diagnoses which included lung and heart disease. The resident was able to make their needs known. In an interview on 10/24/2023 at 9:20 AM, with collateral contact (CC). The CC stated Resident 1 had started to have swelling in the right arm and hand which doubled in size over a week. CC stated they let the staff know, who told them the facility provider would look into it. Resident 1 tried to elevate the arm themselves and asked for ice to reduce the swelling. The CC stated they told the staff numerous times and nothing was done. Resident 1 finally had a test done which showed blood clots in the right arm and their lungs. On 10/26/2023 at 11:17 AM, Resident 1 was lying in bed. The resident had slight swelling in the right arm. The resident stated swelling started happening after they had received a vaccine in the arm, along with pain. The resident reported it everyday to the staff and explained to them the swelling was worsening. Resident 1 stated the right arm was much better now but it had been twice the size and extremely tight. Resident 1 explained they finally had a scan that showed two blood clots in their right arm. Resident 1 was sent to the hospital and they found a clot in the lungs as well. Review of Staff C's, Physician Assistant, progress notes dated 10/03/2023, showed Staff C was informed by nursing the resident had right arm pain and swelling. Resident 1 was examined by Staff C and the resident reported they received a vaccination about a week prior and since then they have had ongoing pain and swelling to the right arm. The resident had tried ice to reduce the swelling which only mildly helped. Staff C's plan was to notify the Infection Preventionist, Director of Nursing, and Resident Care Manager for protocol on vaccination reactions. A right upper arm Doppler (an ultrasound to view blood flow) was ordered to be done immediately as well as blood work. Staff were to monitor the resident's arm. Review of orders showed the immediate Doppler ultrasound was ordered on 10/03/2023, the study was done on 10/05/2023. Review of nursing progress notes showed no documentation about the resident's pain and swelling in the right arm until 10/04/2023 by Staff A, Infection Preventionist. Staff A documented the resident reported they had swelling and pain in their right arm after receiving a pneumonia vaccine on 09/22/2023. Staff A assessed the resident's right arm and noted the resident's right arm/hand/fingers had 1-2 non-pitting edema (swelling that ranges from 2 millimeters(mm) - 4 mm when pressing on the swollen area and no indentation remains). Staff A documented there was no sign of a systemic reaction to the vaccine (a systemic reaction would include fever, body aches, headache). Staff A spoke with Staff C and an ultrasound was ordered. In an interview on 10/27/2023 at 2:05 PM, Staff D, Resident Care Manager (RCM), stated if a resident had a change in condition the nurses would be expected to contact the provider and then a supervisor. Staff D stated they were not familiar with Resident 1 because they had recently started the position. Staff D stated if a resident had a vaccination and started having pain and swelling, the nurses should have called the provider. The facility had providers that were new to the building and they made it clear they wanted to be called at all times of the day/night if needed. Staff D stated if an order was put in to be done immediately, it was often one to two days until it was done, unless it was an x-ray. Staff D stated if a study was needing to be done the same day, the resident would need to go to the hospital to have it done. On 10/27/2023 at 2:18 PM, Staff A was interviewed. Staff A went to assess Resident 1's right arm which was swollen from their fingers to the upper arm. Staff A stated the resident had noticed the swelling after a vaccination so the provider was concerned about a possible reaction. Staff A stated there was no redness or warmth at the injection site and the resident didn't appear to have a systemic reaction to the vaccine. Staff A consulted with Staff C and an ultrasound was ordered. The resident ended up having blood clots in their arm. On 10/27/2023 at 10:15 AM, Staff E, RCM, stated if a resident had a change in condition then the nurse should either find the provider, if they were in the building, or call the provider. The only time the communication book should be used was if it was a non-urgent situation. When a study such as a Doppler was ordered to be done immediately, it would not be done the same day unless the resident was sent to the hospital. On 11/02/2023 at 10:36 AM, Staff C was interviewed and stated they were made aware of Resident 1's pain and swelling in the right arm after reviewing their communication book. The nurse who made the entry had not called Staff C or any provider on call with the change in condition. When Staff C assessed Resident 1's arm, it was pretty swollen from their upper arm to fingers. The resident had mentioned it started after receiving a pneumonia vaccine, which was a week prior. Staff C stated they were not aware if an ultrasound was ordered to be done immediately, it would not be done the same day. Staff C stated it was very frustrating after the order was put in for an immediate ultrasound and it wasn't done for a couple of days. Staff C stated this was the first they were made aware of immediate orders for a study would only be done same day if the resident was sent to the hospital. Resident 1 ended up having two blood clots in their arm. Repeat deficiency from 04/20/2023 and 09/15/2023 Reference: WAC 388-97-1060(1)

Based on interview and record review, the facility failed to ensure 1 of 3 sampled residents (Resident 1), reviewed for insulin administration (a hormone that controls the amount of sugar in the blood), was free from a significant medication error. Resident 1 received a long-acting and an additional dose of short-acting insulin without a blood sugar reading and did not receive nutrition as ordered when the insulin was administered. Resident 1 was found unresponsive, had an unreadable blood sugar (too low to register a reading), and had to be hospitalized . This constituted a Past Non-Compliance (the facility was not in compliance at the time the situation occurred; however, there was sufficient evidence that the facility corrected the non-compliance after it was identified) at harm. The facility immediately educated the licensed nurses involved as well as all facility licensed nurses, audited residents to identify those on enteral nutrition and insulin and immediately reviewed their records and moved central supply to a more readily available location which included at least a week supply of nutrition and equipment it required. The facility was notified on 05/05/2023. Findings included . An assessment dated [DATE] showed Resident 1 had diagnoses to include diabetes, kidney disease, and malnutrition. The resident was alert, oriented and able to make their needs known. Per the assessment, Resident 1 had a gastric tube to receive enteral nutrition (a tube inserted through the stomach that brings nutrition directly to the stomach by a liquid). In addition, the resident had orders for a regular, thin consistency, diet. Review of physician orders showed Resident 1 was on long-acting insulin twice a day, with orders to not give the medication if blood sugars were less than 100, and a regular insulin based on a sliding scale (meaning the insulin dose depended on the blood sugar level) every 6 hours. The orders also showed the resident's liquid nutrition was to be infusing from 7:00 PM until 10:00 AM each day. Review of 04/21/2023 progress notes at 9:00 AM showed Staff B, Licensed Practical Nurse (LPN), documented Resident 1 was found unresponsive by staff. The resident was sent to the hospital. Review of the facility investigation, dated 04/21/2023, showed Resident 1 was given both long-acting insulin and short-acting insulin in the morning by Staff B, LPN, who used the blood sugar reading from the previous shift. Staff C, Licensed Practical Nurse (LPN), had taken the resident's blood sugar at 6:00 AM (which was 209 - normal levels before meals is between 70 and 130), and had already administered the short-acting insulin according to the sliding scale. In addition, Resident 1 did not have their enteral nutrition connected, as ordered, and did not receive a breakfast tray, which contributed to the resident's blood sugar levels not being maintained after receiving the insulin. Per the investigation, Staff C had not hung a new bag of tube feeding and told Staff B there was no enteral nutrition for the resident in the facility, however, according to the investigation, there was plenty of formula available at the time. In addition to the resident not receiving their tube feeding, they also were not served a breakfast tray. It was not on the food delivery cart, and staff did not go and ask the kitchen to make one. During an interview on 05/05/2023 at 12:47 PM, Staff A, Licensed Practical Nurse (LPN), stated prior to administering insulin they would obtain a blood sugar. If a resident had sliding scale insulin ordered, they would administer the insulin according to the scale. Staff A stated they would never administer insulin based on another nurse's blood sugar reading and they always checked on their diabetic residents to ensure they had received their meal after insulin had been administered. On 05/05/2023 at 1:30 PM, Staff B, LPN, stated they sent Resident 1 to the hospital on 04/21/2023, due to unresponsiveness. Staff B stated when they came on shift, they were told by Staff C the resident ran out of enteral nutrition. Staff B went in and checked on Resident 1, who had no signs or symptoms of low blood sugar and administered the scheduled insulins. Staff B stated it was facility practice to have the nurses on night shift take the blood sugars and then the nurses on day shift would give the insulin. Staff B gave the short-acting insulin based on the previous shift blood sugar reading at 6:00 AM. Staff B stated they were not aware Staff C gave the insulin after taking the blood sugar reading on the previous shift. At around 8:30 AM, an aide reported to Staff B that Resident 1 was sleeping. At 9:00 AM the same day, staff went in to get the resident ready for an outside appointment and found them unresponsive. Staff B went to the room, and was unable to get the resident to respond, so they called the ambulance. Staff B stated when the ambulance arrived, the blood sugar readings were so low they didn't register, the resident was given glucose, and continued to be unresponsive. Staff B stated as far as the enteral nutrition, they didn't think to connect it because Resident 1 was going to an outside appointment. During an interview on 05/05/2023 at 2:20 PM, Staff D, Administrator, and Staff E, Director of Nursing were interviewed. Staff E was made aware of the practice of the night shift nurses taking the blood sugars and the day shift nurses giving the insulin after the incident and confirmed that was not to be done. This was a Past Non-Compliance citation at harm and is no longer outstanding. Reference: WAC 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to timely determine the cause of a resident's increasing pain for 1 of 3 sampled residents (Resident 3), who slid out of a wheelchair at the facility. This failure resulted in harm to Resident 3, who had a decline in activities of daily living, refused care related to a significant increase in pain, and was found to have a leg fracture 15 days after the accident. Findings included . Review of a 01/02/2023 assessment showed Resident 3 had diagnoses to include heart and respiratory disease, anxiety, and chronic pain. The assessment also showed the resident was alert, oriented, and able to make their needs known, and was independent with most activities of daily living. Review of the April 2023 physician orders showed the following medications were ordered to control the resident's chronic pain: A muscle relaxant (pill) was ordered once a day and every eight hours as needed, a narcotic pain medication (pill) was ordered to be given every four hours, and the resident had a pain patch applied every three days. Resident 3's most recent care plan, dated 02/27/2023, showed the resident was at risk for acute and chronic pain. The staff were to encourage different positions, relaxation, and distraction. The staff were to monitor/record/report to nursing staff if the resident complained of pain, and to provide alternate comfort measures. A 03/13/2023 facility investigation showed Resident 3 was found sitting in front of their wheelchair on the floor on 03/12/2023 at 5:45 PM. The resident stated they had fallen asleep and slid out of the wheelchair, onto the floor. There were no complaints of pain at the time of the initial assessment. On 03/13/2023 at 6:12 AM, Staff K, Licensed Practical Nurse (LPN), documented Resident 3 complained of breakthrough pain and muscle spasms in the left thigh. Staff G, Nurse Practitioner, was notified and an x-ray was ordered for the left leg. No fracture was seen at that time. On 03/14/2023 at 3:04 AM Staff J, Registered Nurse (RN), documented a change in condition since Resident 3's fall. Per the note, the resident's mouth was open, their speech a little slurred, and skin color pale. The note showed the resident was much weaker and needed two staff to assist them to the bathroom; the resident previously transferred independently. On 03/14/2023, when Staff G visited Resident 3, staff reported the resident continued to complain of pain in the left leg. A pain gel and heat therapy were ordered, which physical therapy was to provide. On 03/17/2023, Staff G documented the resident had continued pain and Resident 3 stated they had not received heat therapy. Staff G contacted therapy to inform them of the order for heat therapy from 03/14/2023. Review of progress notes showed the following: On 03/14/2023, 03/15/2023, and 03/16/2023, Staff I, Licensed Practical Nurse (LPN), documented Resident 3 continued to complain of pain and the medications administered had ineffective results. The resident was requesting a higher dose of their pain medication. Various methods of pain relief including repositioning and use of pillows for comfort were tried (as per the care plan current in February 2023). The provider had been made aware. A progress note dated 03/21/2023 by Staff A, Resident Care Manager (RCM), showed Resident 3 continued to complain of pain to the left thigh/hip region. The note showed the resident was unable to stand or transfer on their own, as they had previously been able to do, and the resident was refusing cares. The note also showed Resident 3 did not have a bed in their room due to refusing to use it in the past, but that day requested it from the nurse so they could try and be more comfortable and make it easier to be changed. On 03/21/2023, 03/22/2023, and 03/23/2023, Staff I documented Resident 3's routine medication continued to be ineffective, and interventions were tried to keep the resident comfortable. On 03/24/2023, Staff G's progress note showed Resident 3 continued to have severe muscle spasms and pain in their left thigh since the fall. The resident stated they wanted more pain medication, which was increased. Per review of all above progress notes, there was no re-evaluation found to determine why Resident 3 had a continuation of pain and a decline in their activities of daily living, 11 days after the fall On 03/28/2023 Staff G documented the left leg was causing so much pain and discomfort the resident refused personal cares, and that Resident 3 screams out in pain. Another x-ray was ordered (15 days after the initial x-ray) which showed a fracture of the left leg. During an interview on 04/20/2023 at 1:15 PM Staff I stated Resident 3 had fallen, and their pain escalated each day. Staff I stated the resident liked to sleep in their recliner before the fall but requested a hospital bed afterwards, to try to get better pain relief. Staff I went on to say Resident 3 started to have pain relief after the fracture was found, when they received a leg immoblizer and a different pain medication was ordered. On 04/20/2023 at 1:25 PM, during an interview with Staff H, Nursing Assistant (NA), they stated Resident 3 fell and didn't initially have pain. After a few days, the resident started to complain of pain. Per Staff H, the pain continued to get worse, and Resident 3 would often refuse care, such as a brief change or showers, because any movement would cause them pain. In an interview on 04/20/2023 at 2:40 PM Staff A, RCM, stated Resident 3 had an x-ray on the day of their fall because they had complaints of pain. Staff A stated Resident 3 then went a couple of days without pain, but started to complain of continuous pain. Staff A stated the pain continued to get worse, even with additional pain medication, the resident had trouble standing, and the resident usually slept in a recliner but requested a bed, so they could try and be more comfortable. The provider ordered another x-ray which found the fracture in the left leg. Staff A stated Resident 3 then received a leg immobilizer and different pain medications. Resident 3 did not want to go to the hospital, but just wanted to be comfortable. Reference WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to implement interventions necessary to prevent the development of a pressure ulcer for one of three sample residents (3), reviewed for pressure ulcers. This failure caused actual harm to Resident 3, who developed an avoidable left heel pressure ulcer. Findings included . The facility's undated Wound Prevention and Management policy stated weekly skin assessments would be completed, and any wounds would be monitored weekly to include: documentation of size, color, odor, healing progression, and notifications. Per the policy, other pertinent information related to skin conditions would be documented in the medical record, and physician and resident/responsible party notification would be completed as needed. Per the 01/26/2022 admission assessment, Resident 3 was admitted [DATE] and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission skin assessment showed Resident 3 had some redness to the buttocks, the top and sides of both feet, two small blisters on the third and fifth toes of the right foot, and some small bruises to the back of both hands. Review of the January 2022 and February 2022 electronic Treatment Administration Record (eTAR) showed an ongoing order for a weekly skin assessment, and instructed the nursing staff to notify the physician of any new areas of skin impairment and document in the progress notes. Documentation showed the assessments had been completed. A therapy to nursing progress note dated 02/01/2022 showed physical therapy provided a soft boot for the resident to be used on the left foot while in bed, and requested staff to float the resident's heels with pillows if they refused to wear the boot. Prior to 02/01/2022, there was no other documentation of any skin impairment to the left foot. On 02/03/2022 at 1:35 PM, a nursing progress note from Staff F, Nurse Manager, showed the resident had a suspected deep tissue injury (an injury to the underlying tissue below the skin's surface, as a result of prolonged pressure), to the left heel. The Order Summary Report showed on 02/04/2022, the physician ordered skin prep (a liquid film-forming dressing) to be applied to the left heel every evening. No other orders prior to that date were found, nor were there any orders for the soft boot. Review of the February 2022 eTAR showed the treatment was done as ordered. Review of the Skin Grid Weekly Skin Evaluations in the resident's electronic record showed ongoing assessments were completed and on 02/03/2020, Resident 3 was found to have a suspected deep tissue injury to the left heel that was 0.5 centimeters long by 0.8 centimeters wide. In addition, an assessment was completed the same day by an outside wound management/treatment provider that described the wound, provided measurements, and treatment recommendations. The 01/20/2022 admission care plan showed interventions implemented to prevent pressure ulcers were not implemented until 01/28/2022 and included: educating the resident about the causes of skin breakdown, frequent repositioning, and to notify the nurse of any new areas of skin breakdown. On 01/31/2022, the care plan was updated to inform staff Resident 3 had a pressure injury to the left heel, however, interventions were not added until 02/07/2022 (six days later), and instructed staff to avoid pressure to the left heel, and to assess and monitor the wound weekly. On 02/04/2022 at 11:30 AM Staff A, Administrator, stated that facility utilized an outside service provider for wound management/treatment and when a new skin issue was identified, the resident was added to their list to be seen for weekly evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] On 02/04/2022 at 12:15 PM Staff G, Licensed Practical Nurse, stated skin assessments were done weekly by the nurses, and the physician was informed of any concerns. In addition, Staff G stated care plans should include interventions specific to the resident's care needs, and were to be updated when care needs changed. In an interview on 02/04/2022 at 12:20 PM Staff H, Nursing Assistant, stated resident skin was checked for any issues each time care was provided, and the nurse was informed of any concerns. Staff H further stated the individual resident care plans directed their care, and instructed them of the specific care needs for each resident. On 02/10/2022 (10 days after the pressure injury was found, and nine days after the request was made from physical therapy), the care plan was revised again to instruct nursing staff to float the heels while in bed. Additional revisions to the care plan occurred on 02/21/2022, and instructed nursing staff to inspect the resident's feet daily for open areas, sore, pressure areas, blisters, [CONDITION(S)], or redness, and to report any findings to the physician. Further review of Resident 3's record did not show any documentation that the resident's feet were being inspected daily, as directed in the care plan. On 03/01/2022 at 2:45 PM, Resident 3 was sitting in a wheelchair in their room with non-skid socks on both feet. The resident stated they had no concerns about their care, and denied having any foot pain. The resident refused to allow an observation of their foot, but review of the skin assessment sheets, notes from the outside wound management provider, and the eTAR showed the wound was still present, but healing. During an interview on 03/01/2022 at 3:00 PM, concerns about the facility's failure to implement interventions to prevent pressure ulcers for Resident 3 was discussed with Staff A, Administrator. After review of Resident 3's record, Staff A acknowledged interventions were not implemented timely (prior to the development of a pressure wound). Reference: WAC 388-97-1060(3)(b).

Based on observation, interview, and record review, the facility failed to identify, thoroughly monitor, assess, and take timely action regarding changes in a skin condition for 1 of 3 sample residents (1), reviewed for skin alterations. Failure to provide necessary care resulted in actual harm to Resident 1, who was hospitalized for [CONDITION(S)] (a severe, systemic infection), due to necrotizing skin (skin that had died ), and a soft tissue infection of the left lower extremity which required surgical intervention, and resulted in the resident having a left below the knee amputation (LBKA). Findings included: Resident 1 admitted to the facility in May of 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident required 2-person extensive assistance with activities of daily living. Per the record, the resident had some refusals of care and smoked tobacco. Evaluations for predicting pressure ulcer risk showed the resident was at risk for pressure-related skin issues. Resident 1's admission skin assessment showed no skin integrity concerns. According to the facility's undated Wound Prevention and Management policy, any wounds would be monitored weekly to include: documentation of size, color, odor, healing progression, and notifications. Per the policy, other pertinent information related to skin conditions would be documented in the medical record, and physician and resident/responsible party notification would be completed as needed. Review of the [DATE] and [DATE] electronic Treatment Administration Record (eTAR) showed an ongoing order for a weekly skin assessment (checking for any skin alterations/problems) for all residents, with nursing staff to document a negative (-) for no new area of impairment, or a positive (+) for any area of impairment - whether new or old. If a new area of impairment was identified, the nursing staff was to complete an accident and injury (A and I) document, document the impairment in the progress notes, and notify the MD (medical doctor). During interview on [DATE] at 11:30 AM Staff A, Administrator, stated that facility policy was to notify United Wound Healing (UWH - a contracted outside service) when a new skin issue was identified, and the resident was added to their list to be seen for weekly evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview on [DATE] at 12:15 PM Staff G, Licensed Practical Nurse, stated that weekly skin checks were done by the nurses. Staff G also stated nursing assistants would note any skin issues during cares and report them to the nurse. They further stated that the eTAR would show a positive (+) if it was a new issue, and a progress note should be completed; the skin assessment would also show positive (+) whether the issue was new or ongoing, and negative (-) meant no new skin issue. During interview on [DATE] at 12:20 PM Staff H, Nursing Assistant, stated that skin issues were checked for during resident care and showers, and any new concern was reported to the nurse. During interview on [DATE] at 1:00 PM, Resident 1 stated they were told the area on the left foot was a callous. The resident further stated they complained multiple times of a burning pain in the left foot, and were told by the nurses it was a callous. Resident 1 was not able to see the foot because of [CONDITION(S)], and stated they thought the nurses were doing dressing changes to that foot. The resident was observed at the time of the interview to have an amputation below the left knee. Review of skin assessment records from [DATE] through [DATE] showed Resident 1 had skin alterations to the right lower extremity, related to psoriasis plaques (raised red patches covered with a whitish buildup of dead skin cells called scales or referred to as scaly). Review of the [DATE] through [DATE] eTAR revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 1:09 AM Staff C, Licensed Practical Nurse, wrote a progress note showing Resident has an old callus to her left arch foot. It is starting to pull away from the foot and there is an odor from it. No drainage seen. No pain reported. Area moisturized. Both feet are dry and scaly. On [DATE] at 2:35 PM Staff B, Advanced Registered Nurse Practitioner (ARNP) wrote, staff report scab to lt (left) foot loosening with wound beneath with no dng (drainage), streaking redness or warmth-UWH to follow. The same note showed Staff B wrote may be from psoriasis with multiple layered scabs, very thin fragile skin, high risk for infection/worsening .discussed with nursing/RCM (Resident Care Manager) with UWH for evaluation/tx (treatment) with new wound noted with no presence of infection to be evaluated tomorrow. Per the record, on [DATE] and [DATE], notes written by Staff B had similar documentation as the note written on [DATE]. In addition, there was no evidence of further review and revision made to Resident 1's care plan regarding actual skin impairment, no evidence of UWH having evaluated the resident for a wound on the left foot, and no new skin assessment completed by nursing staff. On [DATE] the eTAR weekly skin assessment showed an NA (not applicable) - with a reference to a progress note. The progress note dated [DATE] at 2:12 AM, completed by Staff C showed, she (the resident) would not get into bed when I was not taking care other people. She was asleep after this. On [DATE] Staff B wrote in a note lt foot wound with dressing in place with no dng, streaking redness or warmth-UWH to follow. The same note showed Staff B wrote wound report reviewed with mult (multiple) wounds BLE (bilateral lower extremity) with escar (eschar - a collection of dry, dead tissue within a wound) -need to evaluate lt foot wound-discussed with RCM. Per record review, there was no evidence of treatment/dressing orders for the left foot, or notes from United Wound Healing, related to the left foot or left lower extremity wound. On [DATE], [DATE] and [DATE], Staff B wrote notes with the same statement as in the note from [DATE]. A UWH note from [DATE] did not show knowledge of, or treatment to the left foot or left lower extremity wound. On [DATE] Staff B wrote, Patient with BLE wounds with wound report review. Discussed with RCM with no notation to bottom of foot with pt (patient) with wound to this as well. On [DATE] Staff B wrote, Nursing with wound care to bottom of lt foot with wound extending-plan for wound care to evaluate and treat. Not bothering her unless messed with. Discussed with nurse/RCM. Staff B also wrote, need to evaluate lt foot wound-discussed with RCM/nursing-with evaluation with extensive area with escar/thin fragile skin, SS (serosanguinous - clear drainage with tinge of red) dng no report of infection-high risk to worsen. Per record review, no dressing or treatment orders were found for that time period, and no nursing assessment of the wound was found. On [DATE] at 12:40 PM Staff F, Nurse Manager, completed a skin assessment of the left plantar (bottom of foot) wound. It showed a description of the wound as 14 centimeters (cm.) long, 8.0 cm. wide, 0.0 cm. deep, with serosanguinous drainage, yellow color and mild odor. The same day United Wound Healing wrote their first evaluation of the left foot wound, and gave treatment orders. The note showed Resident 1 .had a new plaque and blister form on her left foot last week. Additional documentation showed the left plantar (bottom/sole) of the foot wound to measure 14 cm. x 8.0 cm. x 0.0 cm., with 70% eschar (dead tissue), moderate serosangenous and tan drainage, with a mild odor. On [DATE] the treatment record showed an as needed (PRN) order for a left foot dressing. There was no indication on the record that order was administered by nursing staff. On [DATE], there was a scheduled dressing order for the left foot. On [DATE] Resident 1 had [CONDITION(S)] treatment outside the facility, during which time Staff E, Registered Nurse wrote, wound to left foot. Dressing to wound saturated. Malodourous (bad smell). Pt instructed to notify RN at facility to change dressing on entry back. On [DATE] Staff E wrote a progress note with a summary of a phone conversation with Resident 1's daughter with a description of visualization of the dressing and podus boot (a protective boot used to prevent pressure to areas of the foot), a saturated bandage with drainage at the top of the foot, and from between the toes, with a malodourous smell on [DATE] and a malodourous smell from the left foot on [DATE], through a sock and podus boot covering a dressing. During a phone interview on [DATE] Staff E stated that it was obvious from the smell of the left foot there was something very wrong. Staff E stated she called the resident's daughter on [DATE], and explained their concerns, as well as notifying the [CONDITION(S)] center provider physician and social worker. On [DATE] Staff B, ARNP, wrote, scattered scabs BLE with mult (multiple) wounds/scabs BLE, lt foot wound-dressing in place/boot in place. On [DATE] Staff B wrote RLE mult wounds with LLE wound-lt foot wound likely from psoriasis with multiple layered scabs with maceration and escar UWH following. On [DATE] Staff E wrote Resident 1 had increased pain in the left foot, not controlled with a [MEDICATION(S)] patch (a strong narcotic pain medication). When assessed by the provider/MD, a new dark discoloration of the left great toe was found, with nursing having reported overwhelming foul odor during a dressing change the previous day. At that time, an x-ray was ordered and performed, and communication with the resident's daughter and resident was done. The resident was sent to the hospital for evaluation. Review of hospital records dated [DATE] showed the emergency department noted a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Evaluation by the orthopedic surgery physician showed a recommendation for a left below the knee amputation, which was done on [DATE]. The facility staff did not identify, thoroughly monitor and assess, and/or take timely action on changes in the resident's skin condition during the time period referenced above. The United Wound Healing orders for involvement to assess and determine treatment were not completed in a timely manner. Assessment documentation of the left foot skin alterations was incomplete. Staff did not follow up on changes in Resident 1's skin alterations. Staff did not consult with the resident's physician regarding the changes, nor were timely revisions made to the plan of care. Reference: (WAC) [DATE](1)

Based on interview and record review, the facility failed to maintain an infection control program that included adequate, timely surveillance, oversight, and follow up of staff COVID-19 testing. Failure to ensure all staff completed the required testing during an active COVID-19 outbreak at the facility put all residents at risk for COVID infection, when staff continued to work with unknown COVID status. On 01/08/2021 at 3:30 PM, the facility's Executive Director was notified of an Immediate Jeopardy at F880, related to lack of adequate surveillance of staff COVID-19 testing. The facility removed the immediacy on 01/11/2021 at 1:07 PM, by ensuring a surveillance system was in place and appropriate education completed, to ensure all staff were being tested appropriately. Findings included . During an entrance conference on 01/04/2021 at 10:24 AM, Staff B, Director of Nursing, informed the surveyor the facility had an active COVID-19 outbreak. Per Staff B, eight residents and four staff tested positive for COVID-19. Staff B also stated staff were completing their own COVID tests at a station that had been set up in the dining room, near the front entrance to the facility In an interview on 01/08/2021 at 11:02 AM, Staff K, Nursing Assistant, stated staff did COVID testing every Monday and Thursday. During a phone interview on 01/05/2021 at 10:01 AM, Staff B confirmed she also acted as the facility's Infection Control Preventionist, and stated facility staff was tested every Monday and Thursday (secondary to the current county positivity rate). Review of the facility's COVID-19 test tracking log for 12/16/2020 through 01/04/2021 showed the following: Staff C, Dietary Staff, tested negative on 12/17/2020, and was not tested again until 12/24/2020 (one week later), when he was negative. Staff D, Nursing Assistant, tested negative on 12/21/2020, and was not tested again until 12/28/2020 (one week later), when he tested positive. Staff E, Nursing Assistant, tested negative on 12/21/2020, and was not tested again until 12/28/2020 (one week later), when she tested negative. Staff F, Nursing Assistant, tested negative on 12/21/2020. Tests for 12/24/2020 and 12/28/2020 were not found. Staff G, Licensed Practical Nurse, tested negative on 12/22/2020, and was not tested again until 12/31/2020 (9 days later), when she tested negative. Staff H, Nursing Assistant, tested negative on 12/21/2020, and was not tested again until 12/28/2020 (one week later), when she tested negative. No documentation of a test for Staff I, Nursing Assistant, who was to be tested on [DATE], was found. Staff J, Registered Nurse, was not listed as being tested on [DATE], 12/21/2020, 12/24/2020, and 12/28/2020. Staff J was documented as testing negative on 12/31/2020. In a phone interview on 01/07/2021 at 12:37 PM, Staff B, Director of Nursing, confirmed Staff D worked on 12/24/2020, but did not get tested (see above). During a follow-up phone interview at 2:10 PM the same day, Staff B stated the process had been for her, or a Unit Manager, to be in the dining room to monitor and check names off as staff came in to complete their COVID tests. She would then make sure any staff who missed their test were given rapid tests. Staff B added recent staffing issues had made it difficult to keep up with the follow through to ensure that was being done, and ensure all staff were being tested . In an phone interview on 01/08/2021 at 11:31 AM, Staff A, Executive Director, confirmed the missing tests for Staff C, E, F, G, H, as well as the fact that each of the employees continued to work despite not having been tested , and therefore were potentially working while COVID positive. In a follow-up interview by phone at 11:40 AM the same day, Staff A confirmed Staff I was not tested on [DATE] and worked 12/21/2020 through 12/23/2020. During an on-site interview on 01/08/2021 at 3:30 PM, Staff A stated that a breakdown with the facility's staff COVID testing program occurred after a change was made to allow staff to perform self-testing, just before the holidays in December 2020. At 4:16 PM, Staff A confirmed Staff F and Staff J worked for two weeks with unknown COVID status, due to their missed tests. Refer to F886 for additional information Reference: WAC 388-97-1320 (1)(2)

Based on interview and record review, the facility failed to ensure staff COVID-19 testing was performed as required for eight of nine staff members (Staff C, D, E, F, G, H, I, J), reviewed for testing. This failure placed all residents at risk of COVID-19 infection, due to staff working with unknown COVID status during a COVID outbreak at the facility. On 01/08/2021 at 3:30 PM, the facility's Executive Director was notified that an Immediate Jeopardy was identified at F886, related to lack of adequate staff COVID-19 testing. The facility removed the immediacy on 01/11/2021 at 1:07 PM, by ensuring a surveillance system was in place and appropriate education completed, to ensure all staff were being tested appropriately. Per the undated Cornerstone Policy for Long-Term Care (LTC) Facility Testing Requirements for Staff and Residents, in Accordance with CMS-3401-IFC, routine COVID-19 testing of staff would be triggered by the county positivity rate during the prior week, and documented via a tracking log. Review of the COVID-19 Positivity Rate posted at Data.CMS.gov showed the facility was to test staff twice weekly during the time period of 12/11/2020 through 01/04/2021. Review of the facility's COVID-19 testing tracking log for 12/16/2020 - 01/04/2021 showed the following: Staff C, Dietary Staff, tested negative on 12/17/2020, and was not tested again until 12/24/2020 (one week later), when he was negative. Staff D, Nursing Assistant, tested negative on 12/21/2020, and was not tested again until 12/28/2020 (one week later), when he tested positive for COVID-19. Staff E, Nursing Assistant, tested negative on 12/21/2020, and was not tested again until 12/28/2020 (one week later), when she tested negative. Staff F, Nursing Assistant, tested negative on 12/21/2020. Tests for 12/24/2020 and 12/28/2020 were not found. Staff G, Licensed Practical Nurse, tested negative on 12/22/2020, and then was not tested again until 12/31/2020 (9 days later), when she tested negative. Staff H, Nursing Assistant, tested negative on 12/21/2020, and then was not tested again until 12/28/2020 (one week later), when she tested negative. No documentation of a test being completed on 12/21/2020 for Staff I, Nursing Assistant, was found. Staff J, Registered Nurse, was not listed as being tested on [DATE], 12/21/2020, 12/24/2020, and 12/28/2020. Staff J was documented as testing negative on 12/31/2020. In a telephone interview on 01/07/2021 at 12:37 PM, Staff B, Director of Nursing, confirmed Staff D worked on 12/24/2020, but did not get tested . In a telephone interview on 01/08/2021 at 11:31 AM, Staff A, Executive Director, confirmed the following: - Staff C was not tested on [DATE], as he should have been. - Staff E was not tested on [DATE] as she should have been, and continued to work each day until tested on [DATE]. - Staff F was not tested on [DATE] and 12/28/2020 as required, and worked 12/25/2020, 12/27/2020, and 12/28/2020. - Staff G did not get tested on [DATE] as she should have, and worked 12/25/2020 through 12/28/2020, before getting tested on [DATE]. - Staff H was not tested on [DATE], and worked 12/25/2020 through 12/28/2020. In a follow-up interview by telephone at 11:40 AM the same day, Staff A confirmed Staff I was not tested on [DATE] as required, and worked 12/21/2020 through 12/23/2020. During an on-site interview on 01/08/2021 at 3:30 PM, Staff A stated that a breakdown with the facility's staff testing program occurred after a change was made to the testing procedure, just before the holidays in December 2020. At 4:16 PM the same day, Staff A confirmed Staff F did not get tested until 01/04/2021, which showed Staff F had worked without being tested for a two week period. Staff A also confirmed Staff J missed at least two weeks of tests (a total of 4 tests), despite the fact that she was working at the facility during that time period. Reference WAC 388-97-1780(1)(2)(c)(d).

Based on observation, interview, and record review, the facility failed to implement an effective infection control program related to COVID-19 (a highly [MEDICAL CONDITION]) monitoring, and failed to prevent further transmission to residents without COVID-19 infections. These failures placed all 56 residents of the facility in the likelihood of serious harm and potentially death, related to COVID-19 infection, and placed Resident #1 at a potential risk for psychological harm related to fear of contracting a respiratory infection subsequent to COVID-19 virus transmission. Findings included . The facility's failure to enact appropriate surveillance (data used to measure the success of infection prevention and control programs, to identify areas for improvement) of resident and staff COVID-19 infections, to place residents in appropriate rooms/units, ensure staff appropriately used personal protective equipment (PPE), and accurately communicate resident COVID-19 statuses, constituted a situation of an immediate jeopardy (IJ). On 07/31/2020 at 4:30 PM, the facility was notified of the IJ related to CFR 483.80 F880, Infection Prevention and Control. SURVEILLANCE Per the facility policy titled, Infection Prevention and Control Program, dated October 2018, surveillance data was used to identify facility trends, and potential issues related to infection control, including whether management of infections was optimal, and included appropriate follow up. Review of the Centers for Disease Control (CDC) July 17, 2020 document titled, Criteria for Return to Work for Healthcare Personnel with [DIAGNOSES REDACTED]-CoV-2 Infection (i.e., COVID-19) (Interim Guidance), showed there were different recommendations for when healthcare personnel should return to work if they had a mild to moderate illness, versus a severe to critical illness. Observation of the northwest unit on 07/30/2020 from 5:15 PM to 5:50 PM showed Resident #5 was in bed in her room receiving oxygen through a nasal cannula (a thin plastic device that delivers oxygen via the nose), and fluids through a tube under her skin. During the observation, Staff I, Registered Nurse, stated all but one of the 19 residents on that unit had tested positive for COVID-19, and many were fatigued and required extra assistance due to their current illness. Per Staff I, Resident #5 did not use oxygen or additional fluids prior to illness with COVID-19. Review of an undated electronic document titled COVID 2020 FH, provided by facility staff via electronic mail (e-mail) on 07/30/2020 at 10:32 PM, showed a line listing of residents and staff who were tested for COVID-19 in July 2020, with a positive or negative result. Though the document had spaces to include symptoms and comments, both the resident and staff lists did not include any symptoms for those with positive results, or when symptoms started/ended. In an interview on 07/31/2020 at 12:10 PM, Staff E, Director of Nursing, stated she started working in the facility on 07/13/2020, when Staff C, Interim Director of Nursing, was managing the infection control program, including surveillance. Per Staff E, she and Staff D, Interim Director of Nursing, took over monitoring after Staff C was no longer able to work due to illness, after Staff E's arrival at the facility. Staff E reviewed the provided electronic document, and confirmed symptoms were not listed for residents or staff, and stated most residents and staff did not have any symptoms. When asked how residents with symptoms were monitored for severity of illness, Staff E stated staff would directly notify the physician if a resident was experiencing severe symptoms. Staff E stated she did not believe any residents currently residing in the facility were experiencing severe symptoms, but was unable to provide additional information. When asked about staff symptoms and return to work criteria, Staff E stated the facility followed CDC guidance, and COVID-19 positive staff would speak to a member of the administrative team before returning to work, but was unable to provide further information or documentation. In a follow-up interview on 08/04/2020 at 1:25 PM, Staff E stated Staff G, Regional Clinical Nurse, who was present in the facility only intermittently, had also been creating surveillance lists for the facility during the past two weeks. Per Staff E, those lists included resident symptoms as documented in nursing progress notes, but were subject to communication errors due to Staff G's offsite reviews, were not consolidated with multiple other lists of resident and staff COVID-19 tracking, and staff present in the building responsible for infection surveillance were not previously aware of them. On 08/04/2020 at 2:00 PM, Staff D, Interim Director of Nursing, stated he started working at the facility on 07/16/2020 to assist in training Staff E, but he was frequently working on a medication cart providing direct patient care. Staff D stated he was still attempting to get clarification from Staff A, Administrator, and Staff B, Assistant Administrator, as to who was responsible for coverage of the infection control program, including surveillance, after Staff C was no longer available. COHORTING Per the CDC document titled Responding to Coronavirus (COVID-19) in Nursing Homes dated April 30, 2020, nursing homes should ensure physical separation of confirmed positive COVID-19 residents from negative residents (separate floor, wing or cluster of rooms). The document also showed if the facility was unable to provide positive residents with their own rooms, they could cohort (share a room) with other confirmed positive residents, thus minimizing the risk of [MEDICAL CONDITION] spreading to non-infected residents. Review of the 07/30/2020 facility census sheet showed the facility had a total of 15 unoccupied rooms on the south unit. Further review showed three of the occupied rooms were shared rooms, with one COVID-19 negative resident (Residents' #1, 12, 14), and one COVID-19 positive resident (Residents' #9, 13, 15) sharing rooms. Observation of the northeast unit on 07/30/2020 from 5:10 PM to 6:20 PM showed Resident #1 was in his wheelchair, in a secure facility-designated outdoor area. Resident #1 stated he did not want to go into the building because he was worried about the possibility of COVID-19 transmission, and was hoping to be discharged from the facility. The resident stated he stayed outside as much as possible, and staff checked on him frequently. In interviews during the observation of the northeast unit, Staff M and N, Nursing Assistants, confirmed Resident #1 stayed outside most of the time, including during the nighttime. Both staff stated Resident #1 was the only COVID-19 negative resident residing on that unit, and his roommate was COVID-19 positive. Review of the nursing progress notes for Resident #1, from 07/12/2020 to 07/31/2020 showed all residents in the facility were tested for COVID-19; Resident #1 tested negative on 07/11/2020 and 07/28/2020, and his roommate tested positive on 07/21/2020. There was no documentation showing the resident was offered a move to a private room, was offered to cohort on a unit with only other residents who tested negative, or was provided education on strategies to help him feel safe in the facility, while awaiting a safe discharge plan. In an interview on 07/30/2020 at 7:00 PM, Staff E, Director of Nursing, stated the facility had a COVID-19 positive unit, a unit for close observation and monitoring of residents with COVID-19 exposures or high risk factors, as well as COVID-19 negative units when she originally arrived in the facility (on 07/13/2020), but the units were reorganized once a large portion of the facility population were COVID-19 positive. Staff E confirmed COVID-19 negative residents resided on all open units, and stated there had already been too many room moves, and stated it was not in the residents' best interest to continue moving rooms. Per Staff E, the only other intervention in place to separate COVID-19 positive and negative residents was to close the room doors, however several residents required their doors open for safety monitoring. In an interview on 07/31/2020 between 11:25 AM and 12:15 PM, Staff P, Nursing Assistant, stated staff were to wear clean PPE for COVID-19 negative residents, but in two rooms on the northwest unit, there was a COVID-19 positive and negative resident in the same room. Per Staff P, staff had to walk through the COVID-19 positive resident's area to reach the COVID-19 negative resident, potentially having to touch the positive resident and/or items in their area, contaminating the clean PPE. PPE USE Review of the CDC July 15, 2020 document titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease (COVID-19) Pandemic, showed nursing home staff should wear eye protection during patient care and a face mask (covering that prevents the spread of droplets from/to the nose and mouth) at all times. Additionally, if working with a person suspected or positive for COVID-19, staff should wear eye protection, gown, gloves, and a respirator (a device worn over the nose and mouth, designed to protect the wearer from inhaling hazardous atmospheres, providing a higher level of protection than a facemask) instead of a facemask, if a respirator was available. Per the CDC, healthcare personnel must receive training on, and demonstrate understanding of when to use PPE, what PPE was necessary, and the limitations of PPE. In an interview on 07/30/2020 at 12:20 PM, Staff H, Registered Nurse, stated there had been many changes in the expectations for staff use of PPE, and staff did not receive adequate notification of what the expectation for PPE use was, despite the availability of a message system that could be accessed by all staff. Per Staff H, the facility had a COVID-19 positive unit two weeks prior, which had special requirements for PPE use, but once additional residents outside the unit showed potential signs of COVID-19, staff were not directed to use respirators instead of face masks for those residents, despite an adequate supply of respirators in the facility. Staff H stated she educated the nursing assistants working with her to wear a respirator, gown, gloves and eye protection when assisting a resident suspected of or positive for COVID-19, but she was concerned about the lack of training for staff on other units and shifts. Observation on 07/30/2020 at 5:15 PM showed the fire doors to both the northeast and northwest unit were closed, with several occupied rooms near the nurses station, outside of the fire doors. An empty PPE cart was outside one room near the station. On the inside of the fire doors on both units was a STOP sign, that instructed staff to remove their PPE before leaving the units. Additional observations from 5:15 PM to 6:20 PM showed Staff I, Registered Nurse, and Staff L, M, and N, Nursing Assistants, all entered and exited through the fire doors on both units without changing and/or removing their PPE, while delivering meal trays to residents in their rooms. Staff L, M, and N wore gowns, respirators, eye protection, and applied and removed gloves with hand hygiene (handwashing or hand sanitizer) between glove uses. The following interviews with Staff I, L, and N took place during the 5:15 PM to 6:20 PM observation period: Staff I stated all residents in rooms near the nurses station were COVID-19 positive, and staff did not have to change PPE between providing care to positive residents (see communication section for further information). Per Staff I, staff were remove PPE before exiting the fire doors at the end of their shift, but could go through the doors while wearing PPE during their shift (contaminating the doors). Staff N stated the expectations for PPE changed all the time. Staff L stated staff only needed to change gowns between COVID-19 positive and negative residents. Per Staff L, staff were to apply gloves before working with residents in their rooms, but gloves were not required in the hallway between working with COVID-19 positive residents, as long as staff performed hand hygiene. At the end of the interview, Staff L asked the surveyor if he was wearing his PPE correctly. When asked what the facility's expectation for PPE use was, Staff L stated he wasn't sure. In an interview on 07/30/2020 between 6:00 PM and 6:40 PM, Staff R, Nursing Assistant, stated staff only needed to change gowns (not eye protection and respirators) between COVID-19 positive and negative residents, and staff were to change gloves and perform hand hygiene between all residents. On 07/31/2020 at 11:05 AM, Staff S, Nursing Assistant, stated staff were to wear respirators and eye protection at all times, and change gowns between COVID-19 negative and positive residents. On 07/31/2020 at 12:10 PM, Staff E, Director of Nursing, stated eye protection could be used for COVID-19 positive and negative residents, only if it was cleaned between uses, and all other PPE including respirators, gowns, and gloves should be changed between positive and negative residents. When asked how staff knew the expectations for PPE, Staff E stated signs were posted in the units, and the previous Interim Director of Nursing, Staff C, had provided some education to staff members, but there was no documentation of who received education, or what was included. She stated there were currently no audits of staff to determine their understanding of use of PPE, but per Staff E, management staff were helping out with patient care, and corrected any observed errors at the time they occurred. COMMUNICATION Observation of the northeast unit on 07/30/2020 from 5:10 PM to 6:20 PM showed signs were posted on resident room doors with notification of transmission-based precautions (additional precautions including PPE required to minimize risk of transmission of infections) needed to enter the room. Some occupied rooms did not have any signs on the door. In shared rooms the signs had additional writing in marker either in red, showing positive (for COVID-19), or green, showing negative (for bed 1 and bed 2). Two rooms had a sign indicating one resident was positive and one was negative: Resident #1 and #8's shared room, and Resident #10 and #11's shared room. Staff M, Nursing Assistant, was asked about the sign on the doors. Staff M stated Resident #1 was the only COVID-19 negative resident on the unit, and asked Staff N, Nursing Assistant, who confirmed the sign on Resident #10 and #11's door was incorrect. Review of the 07/30/2020 facility census sheet showed Resident #1 was the only COVID-19 negative resident on the unit. Observation of the northwest unit on 07/30/2020 from 5:15 PM to 5:50 PM showed 13 resident rooms were occupied, with either one or two residents. Laminated signs were present on some, but not all, of the doors or surrounding walls of the occupied rooms, with COVID-19 positive or negative written in erasable marker. Staff L, Nursing Assistant, entered multiple rooms without changing PPE between resident contacts, including Resident #12. In an interview on 07/30/2020 at 5:15 PM, Staff I, Registered Nurse, stated she was the usual nurse assigned to the northwest unit, and all residents on the unit were COVID-19 positive, except for Resident #16. Per Staff I, staff were to change their PPE between caring for COVID-19 positive and negative residents. Review of the 07/30/2020 facility census sheet showed five residents on the northwest unit were negative for COVID-19, including Resident #12. Observation of the south unit on 07/30/2020 from 6:00 PM to 6:40 PM showed 10 resident rooms were occupied. Signs were posted on some, but not all, of the resident rooms, with notations of COVID-19 positive or negative status, handwritten on the top. In an interview during the observation of the south unit, Staff Q, Nursing Assistant, stated three residents on the south unit did not have COVID-19, which she knew from report from the previous shift. Staff Q pointed to three different closed doors, and stated all three residents were in private rooms, and staff would use separate, COVID-19 negative PPE to enter those three rooms. Two of the doors Staff Q indicated to did not have signs posted. Review of the 07/30/2020 facility census sheet showed only one resident residing on the south unit had tested negative for COVID-19 (all others were positive). In an interview on 07/30/2020 at 7:15 PM, Staff E, Director of Nursing, was asked about the discrepancies between the facility census sheet and staff reports of resident COVID-19 positive or negative status. Staff E stated she was unsure of the specific number of COVID-19 residents without checking the surveillance sheets, which she would provide. In an interview on 07/31/2020 at 11:00 AM, Staff B, Assistant Administrator, stated the facility census sheet, listing resident's COVID-19 status as either positive or negative, was accurate. On 07/31/2020 between 11:25 AM and 12:15 PM, Staff O, Housekeeping, stated she knew which residents were COVID-19 positive or negative by the signs posted on or near the door. In an interview on 07/31/2020 between 11:25 AM and 12:15 PM, Staff P, Nursing Assistant, stated staff did not always receive timely and adequate communication of residents' COVID-19 status. In a follow-up interview on 07/31/2020 at 4:30 PM, Staff A, Administrator, Staff B, and Staff E, Director of Nursing, were notified of multiple staff members' inability to accurately identify COVID-19 positive/negative residents. Staff E stated staff should be able to identify the resident status by the signs posted on or near the doors, if they did not have access to the daily census sheet. Reference: (WAC) 388-97-1320 (1)(a)(2)(a)(b)

Based on observation, interview, and record review, the facility failed to implement effective interventions to prevent falls, for one of five sample residents (#45), reviewed for accidents. This failure resulted in actual harm to the resident, who suffered an arm fracture and dislocation, as a result of a preventable fall. Findings included. Per the quarterly assessment, dated 01/28/2020, Resident #45 required extensive assistance of two staff for activities of daily living, rejected care daily, and had a [DIAGNOSES REDACTED]. (See F 641 for additional information.) Review of the 06/11/19 fall prevention care plan, showed staff were to anticipate the resident's needs, and encourage the resident to change positions slowly. Additionally, the resident was to have the bed against the wall, with a concave mattress (a specialty mattress with foam raised sides). Per a 10/16/19 facility investigation, the resident had an unwitnessed non-injury fall from her bed to the floor. The root cause evaluation listed the resident seems unable to tell when she is sitting too close to edge of bed.putting herself at risk for a fall. The care plan was updated to include keeping the bed in the lowest position, when the resident was in bed without staff present. Review of a 12/04/19 progress note showed the resident moved from a room on one unit to a room on another unit that day. Review of two facility investigations, dated 12/05/19 and 12/09/19, showed the resident had two additional falls that occurred while sitting at the edge of the bed. The root cause evaluation listed the mattress was too large for the frame of the bed, resulting in decreased support at the edge of the mattress. Per the investigations, the mattress was replaced with a standard mattress. In an interview on 02/27/2020 at 4:23 PM, Staff B, Director of Nursing stated when the resident moved rooms on 12/04/19, the bed was placed into transport mode, and was not put back into an extended position once it was in the new room, resulting in a lack of support for the edges of the mattress, where the resident sat. Per a 12/11/19 physical therapy note, the resident was evaluated, and was found to be at her mobility baseline. The root cause of the December 2019 falls (mattress size) was addressed, however, there was no indication the October 2019 fall root cause (poor safety awareness) was addressed. Per the therapy note, the bed was to be placed at a height to keep the resident's hips and knees at 90 degrees or less, when sitting at the edge of the bed. Review of an 0[DATE]20 facility investigation showed the resident was found on the floor in her room, next to her bed, with complaints of pain to her right shoulder. An attached x-ray report showed the resident had a fracture and dislocation to her right arm/shoulder, as well as osteopenia (weakness of the bone, less severe than [MEDICAL CONDITION]). Per the investigation, the resident had last been seen sitting at the edge of the bed, with her bedside table in front of her. There was no evidence the resident was encouraged to sit in a different position, despite staff initially identifying the resident was not safe to sit at the edge of the bed in October 2019. The care plan was updated to assist the resident to lie down, if observed at the edge of the bed on 01/28/2020 (after the fall with fracture). Observation on 0[DATE] at 11:31 AM showed Resident #45 was lying in bed in a room near the end of the hallway, moaning. The bed was in a low position, but not against the wall. Yellow and dark blue bruises were seen to the resident's right arm from shoulder to elbow, and to the right side of her chest. The resident responded when spoken to, but was not able to answer questions related to the injury or her fall. In an interview on 02/26/2020 at 9:58 AM, Staff J, Nursing Assistant, stated prior to the most recent fall, the resident was forgetful and had poor safety awareness, requiring frequent checks of every two hours. Per Staff J, no additional interventions were in place prior to the January 2020 fall, and no new interventions had been put in place after the fall. Staff J additionally stated the resident would sometimes refuse care or safety interventions, which staff would report to the nurse, but she generally was agreeable when staff re-approached her. In an interview on 02/27/2020 at 10:54 AM, Staff S, Licensed Practical Nurse, stated Resident #45 was confused and required frequent checks, at least hourly while awake. Per Staff S, the resident had a history of [REDACTED]. On 02/27/2020 at 4:23 PM, Staff B, Director of Nursing, stated in an interview no trends had been identified with the resident's falls. Staff B stated the interventions of a concave mattress and bed against the wall were discontinued after the December 2019 falls, and a physical therapy evaluation done, due to the resident's preference to sit at the edge of the bed. No alternative interventions were put in place at that time. In an interview on 02/27/2020 at 4:48 PM, Staff Y, Physical Therapist, stated Resident #45 was not followed by physical therapy, and had a limited evaluation in December 2019, related to the two falls that month. Per Staff Y, nursing staff reported the root cause of the December 2019 falls (i.e., the mattress size) had been addressed, and he was not informed of the safety concern related to sitting on the edge of the bed, initially identified by staff in October 2019. Additionally, Staff Y stated if residents self-transferred, he recommended more frequent checks. Reference: (WAC) 3[AGE]-[AGE]-10[AGE] (3)(g)

Based on observation, interview, and record review, the facility failed to ensure seven of 12 sample residents (#1,2,3,4,5,6,7), reviewed for smoking, did so safely. Failure to have comprehensive/accurate smoking assessments, the necessary staff to ensure supervision/monitoring of supervised smokers, and the development of care plans related to smoking safety, placed residents at risk for injury. In addition, the facility failed to ensure Resident #1, who was dependent on oxygen (which is flammable) and had a history of [REDACTED]. This placed Resident #1 at risk for fire damage/burns to himself and others. As a result, an Immediate Jeopardy was called on 04/10/19 at 5:15 PM, and was removed on 04/11/19 at 4:15 PM. Findings included . The facility smoking policy, entitled Smoking Safety, dated (MONTH) (YEAR), was reviewed. The policy documented a resident who smoked were to have an assessment of the resident's abilities, in order to determine whether supervision was required. The facility prohibited smoking by residents when oxygen was in use. Precautions include, but are not limited to: Smoking only in designated area, supervising residents who need supervision, limiting the accessibility of matches and lighters by the resident who needs supervision. The facility had posted times the supervised smokers would be taken out to smoke. The times posted were 7:00 AM, 11:00 AM, 1:00 PM, 3:00 PM, and 7:00 PM. Residents met outside the Director of Nursing office, and staff took them out to the smoking area. 1. An assessment dated [DATE] showed Resident #1 had [DIAGNOSES REDACTED]. The resident required continuous use of oxygen, had no memory impairments, and was able to make his needs known. Per the assessment, the resident was independent with ambulating. Per interview on 04/10/19 at 3:05 PM, the resident was observed lying in bed, wearing oxygen per a nasal cannula (a lightweight tube, with two prongs placed in the nostrils, to deliver oxygen). The resident stated he usually smoked one time a day, and was able to go outside by himself. He stated he kept his cigarettes and lighter in his room. The oxygen tubing was noted to have an extension, so the resident could walk around the room while continuing to receive oxygen. When the resident was out of his room, he used a portable oxygen tank. The resident's room was the last room before the door out to the smoking area. The resident's care plan, dated 05/28/18, related to smoking, identified the resident was independent with smoking, wore oxygen, and needed to store his smoking materials at the nurse's station. Per review of progress notes dated 07/11/18 at 2:15 PM, Resident #1 was observed exiting the building, out the smoking door. A staff member was unable to see him through the window in the smoking area, so went outside to look for him. The resident was found smoking about 15 feet from the door, and the oxygen could be heard from about 10 feet away. The staff member told the resident to put the cigarette out, and resident stated it was perfectly safe, and did not see the danger in it. The staff member explained to the resident he could not smoke with oxygen on, and the resident replied he was aware of the rule. Staff did not ask for the resident's cigarettes or lighter. Review of Resident #2's recent smoking assessment, dated 07/11/18, showed the resident required supervision with smoking, related to being found smoking while having his oxygen on. The resident's care plan had not been reviewed and/or revised, after the change in the resident's smoking status (it showed he was an independent smoker). The resident's smoking materials were not at the nurse's station, as per the care plan in (MONTH) (YEAR). During an interview with Staff A, Licensed Practical Nurse (LPN), at 11:15 AM, he stated Resident #1 was an independent smoker, so was able to keep his cigarettes and lighter in his room. Staff A was further interviewed at 4:25 PM, and was asked how staff ensured Resident #1 did not go out to smoke with his oxygen on, or smoke in his room with oxygen on. Staff A stated Resident #1 had to be reminded when going out to smoke, to remove his oxygen, and to be reminded that oxygen was combustible. Staff A stated Resident #1 would try to get away with it, and had tried to hide the oxygen under his coat before (the resident has a portable oxygen tank when going out of the building). We let him know over, and over. He is non-compliant if you let him. On 04/10/19 at 11:45 AM, Staff B, Registered Nurse (RN), stated The smoking thing is frustrating, every one is sharing .no one will follow the rules. No one is enforcing (the rules) from above. Staff B went on to say there was not enough staff to monitor all the smokers, especially at night. 2. Per review of an assessment, dated 02/08/19, Resident #2 had [DIAGNOSES REDACTED]. He had some memory impairments, but was able to make his needs known. Per the assessment, Resident #2 was independent with locomotion with his walker. Per review of the most recent smoking assessment, dated 04/10/19, the resident was a dependent smoker, due to being caught smoking in his bathroom. The resident's care plan for smoking, dated 04/10/19, identified him at risk with smoking, and his smoking materials were to be locked in the nurse's cart. A progress note on 03/08/19 showed the resident was smoking marijuana in his room. The resident was not seen actually smoking, however, there was a strong odor in his room. The resident had a lighter and a marijuana cigarette in the storage box of his walker, and the resident did not deny smoking in his room. The resident was reminded it was prohibited to smoke in the building. He was allowed to keep the lighter and cigarette. On 04/08/19, the resident was found smoking cigarettes in his bathroom. Staff smelled cigarette smoke, and went to check on the resident. Ashes were found on the toilet seat. The administrator and director of nursing were made aware, and placed the resident's cigarettes and lighter in the medication room. A new assessment was completed, the resident was deemed a supervised smoker, and was to be taken out by staff during designated times. Review of a 04/09/19 facility investigation showed the resident was found outside, sitting on the ground in the smoking area on 04/09/19 at 6:30 PM. The staff had been notified by other residents that Resident #2 had fallen. The resident was sent to the hospital for an evaluation, and sustained a broken leg. Resident #2 told staff he was out smoking, and another smoker had given him a cigarette. The resident was not supervised, as per the care plan. Per interview on 04/10/19 at 11:15 AM, Staff A (LPN), stated awhile back, it was suspected Resident #2 had smoked in his room, however, it wasn't actually observed. Per Staff A, the resident was told he was not allowed to smoke in his room. Staff A was unaware of the resident's most recent incident of smoking in his bathroom on 04/08/19, stating the resident was currently at the hospital. On 04/10/19 at 11:45 AM, Staff B (RN) stated Resident #2 was smoking in his bathroom, and the director of nursing and administrator had the resident lock up his cigarettes and lighter in the nurse's cart. Staff B stated after he had to lock up his smoking supplies, the resident was asking staff every 5 minutes for his cigarettes. In addition, the resident would bum cigarettes from other residents. Staff B stated, the smoking thing is frustrating, every one is sharing .no one will follow the rules. No one is enforcing (the rules) from above. Staff B went on to say there was not enough staff to monitor all the smokers, especially at night. During an interview on 04/11/19 at 2:40 PM, Staff C, Nursing Assistant, stated she was working the night Resident #2 fell . Staff C stated the resident was recently made a dependent smoker, and didn't have any cigarettes with him. After the fall, Resident #2 told Staff C he got a cigarette from another resident, and snuck out to smoke. Staff C went on to say smokers go out all the time, they give cigarettes to each other, even though we tell them not to. Staff C stated she felt the facility was not enforcing the rules. 3. An assessment dated [DATE] revealed Resident #3 had [DIAGNOSES REDACTED]. The resident had moderate impairment with decision-making. Per the assessment, the resident required supervision with locomotion in his wheel chair. A smoking assessment, dated 03/04/19, identified the resident had poor safety awareness, was unable to use the ashtray, and was unable to let go or retrieve a cigarette if dropped. The resident was determined to be a dependent smoker. On 03/25/19, another smoking assessment was done, indicating the resident had no dexterity issues, and was safe to smoke independently in the day, however, required supervision at night to smoke. Review of Resident #3's care plan had nothing related to smoking. The kardex (information on a document for direct care staff) instructed staff to supervise the resident at night to smoke. On 04/10/19 at 11:45 AM, Staff B (RN), stated Resident #3 was supposed to be watched at night, however, he goes out all the time by himself. Staff B stated there was not enough staff to monitor the smokers at night. During an interview on 04/10/19 at 12:30 PM, Staff A (LPN) stated Resident #3 was independent in the day, and needed supervision at night. Per Staff A, the resident was dependent at night because of his fall risk, and now that the snow was gone, he was fine to go out independently during the day. Staff A stated Resident #3's smoking materials were not locked up. Staff A went on to say the nurses were in conflict, as the resident needed supervised at night, but gets upset when told someone had to go with him. On 04/10/19 at 2:30 PM, Staff D, Social Services, stated Resident #3 was one of the residents that goes in and out to the smoking area all night, even though he was supposed to be supervised at night. 4. Per an assessment, dated 01/07/19, Resident #4 was admitted to the facility on [DATE]. She had [DIAGNOSES REDACTED]. The resident was alert, oriented, and able to make her needs known. Per the assessment, the resident required supervision for locomotion in her wheel chair. On 04/10/19 at 2:20 PM, Resident #4 was sitting on the side of her bed. The resident stated she was an independent smoker. Resident #4 couldn't recall if she was told about the smoking policy on admission, but was initially going out to the front of the building on the sidewalk to smoke. She stated staff told her she couldn't go out there, so she no longer did. Per record review, the resident had no smoking assessment to determine her ability to safely smoke and manage smoking materials. Per review of the resident's care plan, dated 01/07/19, the resident was identified as a smoker. Staff were directed to assist the resident in following the smoking policy. There were no other interventions and no additional information, related to smoking. 5. Resident #5 was admitted on [DATE]. Per review of an assessment, dated 02/18/19, the resident had [DIAGNOSES REDACTED]. She was able to make her needs known. Per the assessment, Resident #5 required supervision with locomotion in the facility in her wheel chair, and needed limited assistance with locomotion out of the facility. Per an interview on 04/10/19 at 2:10 PM, Resident #5 stated she was a smoker, and was able to smoke independently. She stated she was initially going to the sidewalk in front of the building to smoke, stating it was public grounds. Then she stated that a staff member yelled at her, stating she wasn't to smoke out there. Resident #5 stated no one had told her where the smoking area was, so she thought it was okay. Per record review, the resident did not have a smoking assessment, to determine her ability to safely smoke and manage smoking materials, and did not have a care plan related to smoking. 6. A 03/08/19 assessment showed Resident #6 had [DIAGNOSES REDACTED]. The resident was able to make her needs known. Per the assessment, the resident needed supervision with locomotion. On 04/10/19 at 3:20 PM, Resident #6 was observed using a walker to enter through the door of the smoking area. Resident #6 stated she was an independent smoker, and kept her cigarettes and lighter in the storage area in her walker. I always have been independent. Per record review, the resident had a smoking assessment, dated 08/28/18. The resident was identified as a dependent smoker, related to being found outside going through the receptacle, trying to find cigarettes to smoke. The resident's care plan, revised on 02/28/18, identified the resident as a supervised smoker, showing her smoking materials were to be locked up at the nurses station. The assessment and care plan were not followed. 7. An assessment dated [DATE] showed Resident #7 was admitted for a history of a stroke. The resident was able to make her needs known. Per the assessment, the resident was to have supervision with locomotion in her wheel chair. On 04/10/19 at 3:25 PM, Resident #7 was lying in bed. She stated she was independent, and could smoke on her own. Per record review, Resident #7 had a smoking assessment dated [DATE]. The resident was unable to safely transport herself to the smoking area, and required supervised smoking. The resident's kardex (information for direct care staff) instructed staff to assist the resident in following the smoking policy. During an interview on 04/10/19 at 11:15 AM, Staff A (LPN), stated independent residents were able to keep their smoking material in their room. Supervised smokers had their materials locked in the nurse's cart. Resident #7's smoking materials were kept in her room. On 04/10/19 at 2:30 PM, Staff D stated she spoke to the smokers when they weren't going to the designated smoking area, or were staying too close to the smoking door. Staff D stated the administrator was going to write a form for residents to sign, to get a handle on the night time smoking. They just go in and out all night long. On 04/12/19 at 10:55 AM, Staff E, Administrator, stated he had recently met with smokers in small groups and discussed the policy, and reiterated no sharing of cigarettes was allowed. Staff E stated he did not know the staff had frustrations with the smokers at night. Reference: (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure one of three sample residents (#1), was served and consumed the appropriate diet texture, as prescribed by the physician. This failure resulted in actual harm to Resident #1, who aspirated (inhaled a foreign object into the lungs, such as food), after receiving the wrong diet. Findings included . Per a 09/04/18 assessment, Resident #1 had [DIAGNOSES REDACTED]. The resident had moderately impaired decision-making, and required supervision while eating. Resident #1 was on a dysphagia diet (i.e., moist foods in bite-size pieces, which are easier to chew and swallow). Per review of a progress note on 10/18/18 at dinner, the resident began coughing. It was documented the resident aspirated, did not tolerate regular diet well. Per the progress notes, the resident had to be monitored closely, and coughed most of the shift. On 10/19/18, a progress note showed the resident was thought to have aspirated, and had a constant cough. On 10/20/18, a progress note showed the resident's breathing was labored, the skin warm and clammy, and the resident was coughing violently. At that time, the resident was started on antibiotics, due to pneumonia (inflammation of one or both lungs, with dense areas of lung inflammation). During an interview on 02/28/19 at 9:55 AM, Staff C, Dietary Manager, stated staff had received written discipline, related to Resident #1 receiving the incorrect diet, in the fall of (YEAR). Per Staff C, Resident #1's diet card had been mixed up, and the resident received the wrong textured food. Staff C stated after the incident, kitchen staff were educated on diet textures, and a new system was implemented. He stated the system which was put in place, to prevent another incident of that nature, was for residents on dysphagia diets to have an X on their diet cards. Staff C stated this was so the altered diet stood out, and so staff would check to ensure it was the correct diet for the resident. On 02/28/19 at 12:55 PM, Staff A, Administrator, confirmed Resident #1 had aspirated due to receiving the wrong diet. Staff A was not sure why the incident had not been called into the State Survey Agency or investigated. Staff A stated immediately after the incident occurred, a kitchen-wide inservice was done, to re-educate staff on diet textures, and a new system was implemented. Per Staff A, the plan included using placemats with each resident name in the dining room; those on a specialized diet had a X by their name, to alert staff the resident was on an altered diet. Staff A stated that in addition, the residents on specialized diets had a X on their meal cards. A follow-up interview was done with Staff C at 1:20 PM. Staff C stated the placemats on the dining room tables were for seating assignments, and not to identify resident diets. When interviewed on 02/28/19 at 2:10 PM, Staff L, Corporate Nurse, stated from what she remembered, there had been a discussion as to whether an incorrect diet had been served. Staff L understood the resident was served the wrong diet, however, had not consumed any of it. Per Staff L, there was training done with staff, and audits were conducted to ensure it didn't happen again. Staff L was asked by the surveyor to provide records of the training and audits. During an interview on 02/28/19 at 2:35 PM, Staff B, a former facility Resident Care Manager, stated he was walking by the dining room on 10/18/18, and heard Resident #1 coughing. Staff B stated he entered the dining room, saw Resident #1 had the wrong meal in front of him, so he removed the tray immediately. Staff B stated Resident #1 had eaten food from the tray, and Staff B encouraged the resident to spit out the food from his mouth. During an observation on 03/07/19 at 11:30 AM, food trays were being delivered to residents eating in their rooms. Staff D, Hospitality Aide, was serving the trays, and was asked how he ensured the correct diet was being served to the residents. Staff D stated the trays all had diet slips on them, which had their likes, dislikes and allergies [REDACTED]. On 03/07/19 at 11:45 PM, Staff E, Nursing Assistant, was asked how to ensure the correct diet was being served to the residents. She stated each tray had diet slips on them, indicating the type of diet the resident was on. Staff E stated she would then lift the lid off the plate, and make sure it matched the diet slip. During a follow-up interview at 12:25 PM, Staff E was assisting with meal delivery in the dining room, was shown the X on the diet slip; she did not know what the symbol was for. When asked about the placemats, she stated they were in place to identify who sat where. On 03/07/19 at 11:50 PM, Staff F, Hospitality Aide, was asked how to ensure the correct diets were provided to residents. Staff F stated the proper diet was on the tray card, and she made sure the card matched what was being served. Staff F was not aware there was anything on the diet slips, to make the different textured diets stand out. During observation in the main dining room on 03/07/19 at 11:55 PM, a resident was seated at a table where a laminated placemat was in the middle of the table. The name on the placemat had an X near it, but a different resident was seated at the table (i.e., the resident sitting in that place was not the resident listed on the card). On 03/07/19 at 12:20 PM, Staff G, Hospitality Aide, was delivering lunch trays to residents in their rooms. Staff G stated the paper on the tray had the resident room numbers and names. Staff G stated she verified the resident's name when entering the room, and would serve them their tray. When asked about different food textures, and how to make sure the resident got the correct diet, Staff G stated the slip should say what it was. Staff G commented it was her first day serving meal trays. At 12:35 PM on 03/07/19, Staff H, Nursing Assistant, stated she looked at the meal card on the tray, to make sure it matched what the resident was being served. Staff H stated the meal cards would show if a resident was on a different texture diet. When asked what the X was for on the dietary card, she stated she did not know. On 03/07/19 at 1:00 PM, Staff I, Licensed Practical Nurse, stated she did not have time to do anything but pass medication. She stated theoretically, the nurse should oversee passing of trays, but there was no time. At 1:05 PM on 03/07/19, Staff J, Registered Nurse, stated the slips on the tray listed which diet the resident was on, and she made sure the diet matched the slip. Staff J was asked what an X meant on the dietary slip, and she stated she didn't know. On 03/07/19 at 2:00 PM, Staff K, Director of Nursing, stated in (MONTH) (YEAR) a new system with symbols was implemented (as a result of the incident with Resident #1). She stated on 02/21/19, an all-staff inservice was done, which included the new system, as well as pictures of different diet textures. Staff K stated the inservices were mandatory, but not all staff attended. At 2:05 PM on 03/07/19, Staff L, Corporate Nurse, stated she only knew of education done for the kitchen staff. When asked if nursing staff should have been educated since they helped in passing trays, Staff L agreed. Staff L stated she would look in the education binders that were at each nurses station, and provided an educational form that was directed at nursing and dietary staff. Per the document, effective (MONTH) 5, (YEAR), a new system was implemented to identify residents on dysphagia diets. Staff were instructed an X would now be in the corner of the tray cards, to indicate the resident was on a dysphagia diet. Per the form, It is the responsibility of nursing staff as well as dietary to ensure the safety our residents. When you see an X on a resident's tray card, please be sure to slow down and verify that they are receiving the correct meal. The document also showed that in the dining room, a corresponding symbol would be on the resident's place setting, stating, Be sure to check a resident's name on their place setting and look for this symbol. Staff were to sign and date to indicate they acknowledged and understood the process. There were four signatures on the North hallway, and one signature on South hallway, out of approximately 14 nurses and 32 nursing assistants, employed at the facility. Staff L was asked how the facility ensured all staff were educated about the new system, or other important information. Staff L stated all staff received education on diets during new orientation, the director of nursing and unit managers were to ensure staff read and signed the education binders, and stated one on one education was also provided. The facility failed to ensure a resident was provided the correct dietary texture during a meal, resulting in aspiration pneumonia, and did not ensure all staff had been educated, related to the new system put in place to prevent such an incident did not reoccur. Reference: WAC: 388-97-1060(3)(h)

Based on observation, interview, and record review, the facility failed to ensure two of four sample residents (#28, 36), reviewed for rehabilitation and restorative services (services that assist a resident to maintain/improve their ability to participate in activities of daily living), received appropriate care to meet their needs. This failure resulted in actual harm for Resident #36, who experienced a potentially avoidable decline in her range of motion, and placed Resident #28 at risk for decreased mobility, and diminished quality of life. Findings included: 1. Per record review, Resident #36 was initially admitted to the facility on [DATE], and had been in/out of the facility for hospitalization s several times, during her time in the facility. The most recent assessment, dated 10/08/18, showed the resident had [DIAGNOSES REDACTED]. The assessment showed the resident required assistance of one staff for all activities of daily living. Review of the occupational therapy notes, from 01/09/18 to 03/06/18, showed the resident started therapy with a baseline of chronic contracture with minimal hygiene to the left hand, and pain to her fingers with movement. Per the notes, the resident had a hand splint (medical device used to prevent or slow the development of a contracture) that included finger separators, which she was able to tolerate wearing daily by the completion of therapy, in addition to range of motion exercises and hand hygiene. Further review showed the resident was noted to still have significant impairments to her joint integrity at the completion of therapy, but documentation of the actual limitation to the resident's range of motion was not found. Per a 06/06/18 nursing to therapy communication, the resident was no longer able to wear her splint or have range of motion performed, due to pain. The resident's restorative program was changed to once daily warm water soaks of the left hand, and range of motion as tolerated after the soak. The communication form documented the resident's program would be re-evaluated after physical therapy assessed the resident, and as needed. Review of a therapy note, dated 06/12/18, showed the resident was assessed by occupational and physical therapy, and was referred to the physician for abnormally high muscle tone. Per the note, therapy was not indicated at that time, due to the resident's high muscle tone, but the resident was at risk for skin breakdown, if additional treatment was not provided. Review of a physician's note, dated 06/15/18, showed the resident was prescribed a muscle relaxer three times daily, due to the contracture. No additional recommendations or orders, related to treatment of [REDACTED]. In an interview on 12/10/18 at 11:23 AM, Staff JJ, Occupational Therapist, stated the resident had a decline in the contracture to her left hand, and had recently begun therapy to loosen her hand enough to place a therapeutic device, to prevent further skin breakdown. Per Staff JJ, the resident had very poor hygiene in her hand, and her nails were not able to be clipped, due to the contracture. In an interview on 12/10/18 at 2:20 PM, Staff II, Nursing Assistant, stated she was responsible for range of motion exercises and splints for residents on the restorative program. She stated Resident #36 was on a restorative program, which included putting a washcloth in her hand. Per Staff II, no other interventions had been in place for the resident, since her splint was discontinued several months previously. Staff II showed the surveyor the restorative plan details listed on the computer where the restorative program was documented for Resident #36; the only intervention listed was to place a washcloth in the resident's hand. Observation on 12/10/18 at 3:12 PM, with Staff JJ, showed the resident was not able to open her fingers enough to see the palm of her hand, though the spaces between each finger were reddened and had a strong yeast-like odor. The resident's fingers had deformities at the joints, causing the fingers to overlap, and she had thick, dark yellow-brown nails. Per Staff JJ, it took approximately 15 minutes of therapy to loosen the resident's hand enough to allow staff access to the palm for skin care, and was sometimes painful for the resident. In an interview on 12/10/18 at 3:47 PM, Staff B, Director of Nursing, stated she did not know why there were no new interventions to prevent the resident's contracture from continuing to decline, after she started a muscle relaxer in (MONTH) (YEAR). Per Staff B, either the physician should have followed up, or nursing staff should have reported, if the medication was effective, so the resident's restorative program or therapy needs could be reassessed. Additionally, Staff B stated the resident should have been receiving warm water soaks and range of motion as part of her restorative program. See F-657 for additional information. 2. Per the 09/28/18 assessment, Resident #28 was receiving physical therapy services, and had impaired range of motion in both legs. Review of the restorative care plan, updated 10/22/18, showed the resident was to receive assistance with range of motion to both legs, and was to stand in a standing frame to build up her strength. The care plan did not indicate how frequently the resident's restorative program was to occur. In an interview on 11/30/18 at 2:39 PM, the resident stated she was not able to move her legs on her own, since the time of her admission, and she was no longer receiving physical therapy. She stated she was in a restorative program, but she did not believe it was helpful, as she was not standing in her standing frame, and did not consistently receive assistance with her range of motion exercises. Review of the restorative program documentation, from 10/22/18 to 12/10/18 (50 days), showed the resident received assistance with range of motion 11 days, with only one refusal listed. 12 days showed no documentation, and 26 days were marked as no or not applicable. No documentation related to the use of a standing frame was available. In an interview on 12/10/18 at 2:20 PM, Staff II, Nursing Assistant, stated she was the only restorative aide in the facility since the middle of (MONTH) (YEAR), and noted no residents had received their restorative program that day, due to short staffing which required her to work on the floor. She added that she was not able to complete restorative programs for residents residing on both halls every day, so she alternated between which halls she worked on. Per Staff II, Resident #28 was on a current program for daily range of motion to her legs, which she was compliant with. When asked about the standing frame, Staff II stated she had received verbal instruction to stop that intervention. In an interview on 12/11/18 at 10:10 AM, Staff B, Director of Nursing, confirmed there was only one restorative aide in the facility, though she stated it had only been a few weeks since the second restorative aide position had been open. Per Staff B, the resident was usually compliant with her program, which should still have included use of the standing frame. She acknowledged the resident's restorative program was not consistently documented, and stated the facility was aware of an ongoing issue with documentation. Reference: WAC 388-97-1060 (3)(d)

Based on observation, interview, and record review, the facility failed to ensure nurses consistently assessed and/or evaluated pressure ulcers, and consistently provided treatments as ordered, for three of three sample residents (#2,3,4), reviewed for pressure ulcers. This failure resulted in harm to Resident #2, who developed a worsening pressure ulcer (unstageable - a full thickness tissue loss, in which the base of the ulcer is covered by dead tissue), and a second pressure ulcer, and placed other residents at risk to have worsening of their wounds. Findings included: 1. According to an assessment dated [DATE], Resident #2 had [DIAGNOSES REDACTED]. She required extensive assistance with most activities of daily living, including bed mobility. The resident was identified as having two stage II pressure ulcers (partial-thickness loss of skin, presenting as a shallow open ulcer), at the time of the assessment. Per observation on 11/19/18 at 1:00 p.m., Resident #2 was in bed, on her back, sleeping. An air mattress overlay (cushioning that can be added to the top of a mattress) was on the bed. The resident did not arouse to her name. At 3:00 p.m., the resident remained in the same position, on her back, sleeping. Review of the Treatment Administration Record (TAR) for (MONTH) (YEAR) showed on 09/16/18, a skin assessment was done, and a (+) mark was documented, which according to the record, indicated an area of impairment. On 09/17/18, a treatment had been ordered, for a wound on the resident's coccyx (tail bone). The wound was to be cleansed, and a dressing placed, every 3 days. A review of the progress notes, TAR, and skin sheets during that time period showed no detailed assessment of the area (i.e. description, drainage, size), at the time it was initially identified. A 09/13/18 care plan identified the resident at risk for skin breakdown, and showed she was on a turning and repositioning program. There was no documentation in the record to show whether or not the program was consistently implemented. Per review of the (MONTH) (YEAR) TAR, there was no order for a treatment or dressing change to the resident's wound on her coccyx, and no assessment of the area, to indicate it's status. The nurse's notes during that time period did not address the coccyx wound. On 10/30/18, the record showed a wound care team from an outside agency evaluated the resident's pressure ulcer on her coccyx. It showed the resident acquired the pressure ulcer on 09/30/18, the wound measured 2.6 centimeters (cm.) x 6.0 cm., and was unstageable. Orders for wound treatment were written, and the document showed encourage repositioning every 2-3 hours - turn side to side limiting time on back when in bed. Use pillows to assist with offloading (relieving pressure on the coccyx). Lay down after meals. A wheelchair cushion, as well as repositioning when up in the wheelchair, were recommended. A review of the TAR showed the treatment orders for the wound were not transcribed, and not done. Documentation of whether or not the turning schedule was consistently implemented was not found. The next wound care team visit was on 11/06/18, which showed the wound had increased in size, to 3.4 cm. x 7.0 cm. On that day, the wound was debrided (dead tissue removed), and a slight modification was made to the treatment order. The recommendation was again made for frequent repositioning. Per review of the (MONTH) (YEAR) treatment record, the treatment was not added to the TAR, and was not done. On 11/13/18, the wound care team again saw Resident #2. Per the documentation, in addition to the pressure ulcer on the coccyx, the resident had a wound in the left gluteal fold (the fold in the buttocks). The coccxy wound was still classified as unstageable, and the other wound was shown as deep tissue pressure injury/persistent non-blanchable deep red, maroon or purple discoloration. An updated treatment was ordered for the coccyx wound, and skin prep (creates a barrier film on skin) was to be applied to the pressure wound in the gluteal fold, twice daily. Per review of the (MONTH) (YEAR) treatment record, the wound care orders for the coccyx pressure area were transcribed on 11/13/18, but as of the date of the surveyor's on-site visit (11/19/18), had not been documented as done. The application of skin prep to the gluteal fold pressure wound had only been done once a day, rather than twice, as ordered. The 11/20/18 wound care team documentation showed the gluteal fold wound was closed. The note related to the coccyx pressure ulcer showed a recommendation for a general sugery consult, indicating, Coccyx wound needs assessment and surgical debridement. Strong odor, eschar (i.e. dead tissue), purulent (pus) drainage. In an interview on 11/20/18 at 1:10 p.m., Staff A, Licensed Practical Nurse, stated Resident #2 had declined over the last few weeks. Staff A stated the wound the resident had on her bottom was worsening, and was now starting to tunnel (a channel in the wound that extends from the wound into and through tissue or muscle). On 11/20/18 at 1:45 p.m., Staff B, Director of Nursing, stated staff should be measuring wounds weekly, or more often, if there was a change in the wound. Staff B stated the facility had identified there was an issue with the documentation of wounds. At 2:25 p.m. on 11/20/18, Staff C, Resident Care Manager, stated the resident's pressure ulcer on her bottom was chronic, and would heal and then return. Staff C stated the resident would often refuse to offload (relieve the pressure to her bottom). He stated the ulcer returned about 4 to 6 weeks ago, and the provider at the facility ordered wound care. Per Staff C, no improvement was seen, so an evaluation by an outside wound care agency was ordered. Staff C was unable to provide any further information about the condition of the resident's coccyx pressure ulcer, prior to the evaluation on 10/30/18. In addition, no other information was provided, to show why nursing staff had not done the treatments to the pressure ulcers consistently, or as ordered, or whether frequent pressure relief was provided, or refusals had been documented. 2. According to an assessment dated [DATE], Resident #3 had [DIAGNOSES REDACTED]. The resident required extensive assistance with most activities of daily living, including bed mobility. The resident was identified as high risk for pressure ulcers, but had none during the assessment period. On 11/16/18 at 3:02 p.m., Resident #3 was in bed, on her back. She stated she had sores on her bottom, and staff were dealing with it. The resident's most recent care plan identified the resident at risk for pressure ulcers, and showed she was to have her heels kept off the bed, and turned and respostitioned every 2 hours. Review of a skin assessment and Treatment Administration Record (TAR) for (MONTH) (YEAR), showed the resident was identified with an open area on her left thigh, measuring 0.5 cm. x 0.5 cm., on 09/01/18. The TAR had an order to cleanse the wound, and cover it with a dressing; there were no documented dressing changes for the month of September. Per review of the nursing notes for (MONTH) (YEAR), no documentation was found describing the wound, and there were no further assessments, after its initial identification on 09/01/18. The record contained no information to show the type of wound (pressure or non-pressure), or if the wound was better, worse, or the same. Per review of the (MONTH) (YEAR) TAR, wound care for the resident's thigh was to be completed by nursing staff daily. Wound care was provided, however, there was no assessment of the wound, to show its condition, in order to determine if additional/alternate treatment was required. A skin assessment, dated 11/10/18, identified open wound left buttocks, which was a new area of skin impairment. The (MONTH) (YEAR) TAR showed wound care was being done to the posterior thigh, and a new order was written to cleanse the left buttock wound, apply skin prep, and cover with a dressing. There was no assessment or description of the continuing thigh wound, or the newly developed left buttock wound, found in the record. In an interview on 11/20/18 at 1:35 p.m., Staff D, Resident Care Manager, stated staff were expected to fill out skin assessments weekly, and document wounds on a specific form, if there was an issue found. Staff D stated Resident #3 currently did not have any open areas, only rashes. Further information was requested to show when the wounds had healed; none was provided. 3. Resident #4 was admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. He was totally dependent on staff for all cares. On 11/20/18 at 9:25 a.m., Resident #4 was in bed on his back. The resident was on an air mattress, with a pillow under each of his sides. The resident stated the pillows were to take pressure off of his backside. He was not sure when he had developed the pressure sores. The resident's care plan, dated 11/14/18, identified the resident as currently having a pressure ulcer on his sacrum/coccyx. The resident was on an air mattress, and was to avoid being positioned on his back. Per review of admission orders [REDACTED]. Review of Nurse Practitioner progress notes, dated 11/14/18, showed the resident had a small Stage 2 (partial thickness skin loss, usually superficial) open area on right buttocks. On 11/19/18, the Nurse Practitioner documented Stage 2 right and left buttock pressure ulcers. During an interview on 11/20/18 at 11:10 a.m., Staff E, Nurse Practitioner, stated the resident admitted with the pressure ulcer. Staff E stated she looked at Resident #4's wound on the day of admission, and again yesterday (11/19/18). Per Staff E, the wound had worsened since admission; the resident initally had an area on the right side of his buttocks, but now he had areas on both sides. Staff E stated she had informed the resident care manager, and changed the treatment to be done. Per review of the resident's record, there was no documentation found, related to the resident's wound - there was no description or measurements on admission, and no additional assessment, at the time the wound was identified as worsening, by Staff E. On 11/20/18 at 2:00 p.m., Staff D, Resident Care Manager, stated she had evaluated the resident's wound on admission, and measured it at that time, however, could not find the documentation. Staff D stated the wound was superficial, and was on one side of the buttocks on admission. Staff D stated Resident #4 now had wounds on both sides. No further documentation was provided. Reference: (WAC) 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to assess, monitor, and document non-pressure related skin conditions, for two of five sample residents (#2, 3), reviewed for skin integrity. This failure resulted in harm to Resident #2, who had open sores that had not been identified or treated, and placed other residents at risk of not receiving timely treatment and services, to prevent potential worsening skin conditions. Findings included: 1. An assessment dated [DATE] showed Resident #2 had [DIAGNOSES REDACTED]. The assessment also showed the resident was able to make his needs known, and required extensive assistance with most activities of daily living. The most recent care plan, dated 07/05/18, showed the resident was at risk for infection, related to having open areas and/or scaly sloughed areas (dead skin that falls off), on his right calf. Staff were to monitor for signs of infection which included: redness, swelling, drainage or odor. Open areas were to be cleansed with normal saline (a salt solution), an antibiotic ointment was to be applied, and the sores were to be covered with a dressing. Additionally, the resident was identified as having dry, scaly skin on his lower legs. Lac-hydrin lotion (a lotion to treat dry, scaly, itchy skin) was to be applied twice a day, and the skin was to be monitored for increased spread of the dry, scaly skin, or for signs of infection. During an interview on 08/28/18 at 1:20 PM, Resident #2 was sitting in a wheelchair beside his bed. The resident stated he didn't think he had any open sores on his legs, and when asked if lotion was being applied to them he stated, staff don't do anything with my legs. The resident had sweatpants on, with his ankles exposed. A wanderguard device (which would alarm if he tried to exit the facility) was around his right ankle; no dressings were visible. On 08/28/18 at 3:25 PM, Resident #2's legs were observed with Staff C, Resident Care Manager. The right leg had reddened, scaly, dry skin. There were several scabs on the right outer leg. The resident's left leg was red and swollen. Staff C touched the resident's leg, and stated it was firm and warm to touch. There were five open areas on the outside of the left leg. No dressings or [MEDICATION NAME] (an elastic bandage to help with swelling) were on either leg. Review of the physician orders [REDACTED]. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) also showed an order for [REDACTED]. The facility skin book (where skin alterations were documented) was reviewed; no skin sheets were found for Resident #2. During an interview with Staff C on 08/28/18 at 3:25 PM, she stated ideally there should be a skin sheet on all residents with skin alterations. Staff C stated Resident #2 did not have a skin sheet, but his skin issues should be documented in the progres notes. Staff C stated Resident #2 had chronic problems with his legs, and the sores would come and go. She confirmed the TAR lacked documentation on skin assessments and treatments for the resident. Progress notes were reviewed for (MONTH) (YEAR); there was no documentation found related to the skin issues on Resident #2's lower legs, including the redness, warmth, and open sores on the left leg. On 08/28/18 at 4:00 PM, Staff B, Director of Nursing, stated if a skin check was positive (which indicated there was an issue), then the nurse and Resident Care Manager would address it. Per Staff B, an order would be obtained for treatment, and there would possibly be a referral to the skin team. The issue would then be monitored until resolved. Staff B confirmed the skin checks and treatments for Resident #2 were not documented as they should have been. Review of the skin assessment, dated 08/28/18 (after the legs were observed with the surveyor), identified five open areas on the resident's left outer leg. The five open areas had the following measurements: 1. 4.0 centimeters (cm.) x 1.5 cm./0.2 cm deep; 2. 3.0 cm. x 1.0 cm./0.2 cm deep; 3. 2.0 cm. x 2.5 cm./0.2 cm. deep; 4. 0.5 cm. x 0.5 cm./0.2 cm deep; 5. 1.0 cm. x 1.0 cm/0.2 cm deep. 2. An assessment dated [DATE] showed Resident #3 had [DIAGNOSES REDACTED]. The asessment also showed the resident had severe impairments with decision-making, and required extensive assistance with most activities of daily living. Review of provider progress notes, dated 07/26/18, documented the resident had a red rash under her breasts. An order was written for an antifungal cream to be applied to the rash between and under the breasts, twice a day. Review of the resident's care plan, dated 07/20/18, showed no care plan related to non-pressure skin issues. Review of the (MONTH) (YEAR) Treatment Administration Record (TAR) showed an order for [REDACTED]. size, appearance, drainage). In addition, the 07/26/18 order for antifungal cream was not on the (MONTH) (YEAR) TAR. Review of (MONTH) (YEAR) TAR showed no skin assessments had been documented for the month. The order for the anitfungal cream was written on the TAR, however, the first date it was signed as given was 08/02/18 (7 days after it had been ordered). Additionally, the cream was signed as applied 22 out of a possible 45 times. Per interview on 08/28/18 at 3:25 PM, Staff C, Resident Care Manager, stated there had been problems with nurses not transcribing the orders onto treatment sheets. Upon review, Staff C confirmed Resident #3's TAR lacked documentation, stated the resident's rash had resolved, and she currently had no redness under the breasts. When interviewed on 08/28/18 at 4:00 PM, Staff B, Director of Nursing, stated skin assessments should be documented on the TAR. If there was a positive finding (meaning a skin alteration), the nursing staff were to get a treatment order, and it would be monitored until resolved. A progress note, dated 08/29/18, documented a skin assessment had been completed. The assessment showed Resident #3 had increased redness/yeast (the area between the breast and the chest cavity collects moisture that isn't able to dry, and becomes inflamed) under the breasts. Reference: WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to re-assess a resident's smoking capability, after a change in condition, for one of three sample residents (#5), reviewed for smoking. This resulted in harm to Resident #5, who sustained a cigarette burn to his leg. In addition, the facility failed to provide adequate supervision for one of three sample residents (#7), reviewed for accidents. Findings included: Smoking: Resident #5, per record review, had [DIAGNOSES REDACTED]. A 03/08/18 facility assessment showed the resident was alert, oriented, and able to make his needs known. The resident required extensive assistance with most activities of daily living. Per interview on 04/20/18 at 10:45 a.m., Resident #5 stated he dropped a cigarette on his leg awhile ago. He stated he had burned his leg, and thought it was now healed. During an observation at 10:50 a.m. with Staff C, Registered Nurse (RN), the resident had a dime- sized red, shiny area, on his right inner leg. There was a small scab in the center of the wound. Per review of a smoking assessment, dated 12/28/17, the resident was a dependent smoker, becaused he required assistance with wheelchair locomotion. A progress note on 03/18/18 showed a nursing communication to the therapy department, which indicated the resident was showing a possible change in condition related to resident's ability to walk, increased falls, and other changes. The note further showed the resident was also now having trouble lifting his arms. Progress notes on 03/22/18 documented the resident had continued weakness. On 03/26/18, the resident was noted to have continued left sided weakness, and staff were concerned he may no longer be able to paticipate in supervised smoking, because of his inability to hold his own cigarette. Per review of the resident record, no new smoking assessment was done during the noted changes of condition. On 04/03/18 a progress note identified the resident had a small 1.0 centimeter (cm.) x 0.5 cm. oval dried blister appearing area, on the right inner thigh, with no discharge, swelling, or increase redness noted. The note showed the resident was unsure of how or when the injury occurred. On 04/04/18 , a smoking assessment was completed - after finding the blister on the resident's inner thigh. It identified the resident was an unsafe smoker, and was unable to smoke without supervision. The assessment showed that during the time period the resident was being evaluated, he had dropped cigarettes twice, was required to wear a smoking apron, required supervision, and 1:1 assistance while smoking. Per review of a facility investigation dated 04/04/18, nursing staff were alerted the resident had a right inner thigh injury, possible related to a smoking incident. When the resident was interviewed, he stated over a week and a half prior, a nursing assistant told him he had a burn on his thigh, after he had returned from a supervised smoking session. A right inner thigh partial thickness injury was then observed, measuring 1.3 cm. x 0.6 cm., with 100% slough (dead tissue). The conclusion of the investigation, dated 04/08/18, showed nursing assistants had reported the burn to the licensed nurse on 03/28/18, but no additional interventions were implemented at that time. Additionally, the investigation showed because of inaction on the part of nursing staff after having knowledge of the resident acquiring a burn when smoking, the investigator could not completely rule out abuse and/or neglect. During an interview on 04/27/18 at 2:35 p.m., Staff A, Director of Nursing, confirmed nursing staff had done nothing about the burn to the resident's right leg. Elopement: Resident #7, per record review, had [DIAGNOSES REDACTED]. A facility assessment, dated 01/25/18, showed the resident was able to make his needs known, but had confusion at times. He required supervision with most activities of daily living. Per review of a 04/10/18 facility investigation, the resident was discovered missing at dinnertime on 04/10/18. The resident had not signed out on the sign-out log, so the facility implemented their missing resident action plan. After multiple attempts to contact the resident by cell phone, he finally answered the call, and was located about 2.6 miles away. Staff picked the resident up, and returned him to the facility. No injury was noted to the resident. An elopement risk assessment was completed on 04/11/18. The resident was identified at risk for elopement, related to memory issues, and the desire to go out of the facility to shop. Per record review, prior to the elopement risk assessment completed on 04/11/18, the resident's last assessment was dated 11/07/16. The 11/07/16 assessment showed the resident had confusion that varied, had no exit-seeking behaviors, and understood and demonstrated the ability to use the sign-out log, when leaving the facility. Review of the most recent care plan, revised on 04/11/18, identified the resident at risk for elopement, related to dementia with confusion. Staff were instructed to make sure the resident checked out, and the resident was to leave the facility with a responsible person. It was noted the resident had a Wanderguard on (a device which alarmed when the person wearing it approached an exit door), and a photograph of the resident was placed in a book which identified at-risk residents. Per record review, the elopement book on the south hall did not have any information regarding Resident #7. The elopement book on the north hall had a paper with the resident's name, but no photograph, or additional information with regard to the resident's change in elopement risk. Per interview on 04/26/18 at 9:45 a.m., Resident #7 stated he got lost when he got on the bus, because he wasn't let out at the right stop, and had to walk a couple of miles to find the store. At 1:00 p.m. on 04/26/18, the resident stated he had an ankle bracelet on. The resident stated he was told by a staff member he could still leave the building, but had to sign out first. Per observation, the resident's left ankle had a Wanderguard attached. During an interview on 04/27/18 at 9:30 a.m., Resident #7 stated he left the facility the afternoon prior (04/26/18). He stated the alarm sounded, so he got the nurse, and she fixed it for me. Now it (Wanderguard) was to ensure I sign out before leaving. He stated he went to the store by himself saying, I can get there blindfolded. On 04/27/18 at 2:25 p.m., Staff C, Registered Nurse, was interviewed. She stated Resident #7 had gotten lost awhile back, because he got disoriented and confused. Staff C stated Resident #7 now had a Wanderguard on, to make sure he signed himself out, and told staff where he was going. She went on to say the resident did go out yesterday afternoon, he signed out, left his cell phone number, and went to a local store. The resident returned without any issues. During an interview on 04/27/18 at 2:35 p.m., Staff A, Director of Nursing, stated since Resident #7's previous elopement, a Wanderguard was placed on his ankle, because he would sometimes forget where he was at, when he went outside. Staff A also stated Resident #7 needed to have someone with him, and couldn't go out by himself. At 3:05 p.m., Staff A reviewed the elopement book, and confirmed the resident's information was not present. Staff A immediately placed the resident's information in the elopement book, and reminded staff the resident required a second person when leaving the facility, to provide supervision, and ensure he didn't get lost. Reference: (WAC) 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure 1 of 1 residents (#1), in a sample of 4, was free from abuse. The resident was given a non-working call light, and was unable to alert staff of her need for assistance. This resulted in harm to Resident #1, who experienced distress when she became ill, and was unable to call for help. Findings included: Per the record, Resident #1 had [DIAGNOSES REDACTED]. According to an assessment dated [DATE], the resident was alert, and oriented, and able to make her needs known. She required extensive assistance with most activities of daily living. Per review of the resident's most recent care plan, the resident was identified as having behaviors of being verbally abusive, accusatory towards staff, and pushing her call light repeatedly when anxious. Review of progress notes, dated 11/12/17 at 9:37 a.m., documented the resident had low oxygen levels, and was unresponsive. The physician was aware, and the resident was on comfort care. At 10:11 p.m., it was noted the resident's oxygen levels remained low, and the resident was vomiting everything she ate or drank. Per review of a facility investigation, dated 11/16/17, on the morning of 11/13/17, Staff A, Charge Nurse (CN), received a report Resident #1 had been given a fake call light. Staff A immediately went to Resident #1's room, and found her with the call light in hand, pushing it repeatedly. The call light was not plugged into the wall. The functioning call light was at the head of the bed, out of reach and sight. The resident was found confused and gagging. Per interview on 11/30/17 at 10:55 a.m., Staff A stated she went into the room and saw the resident pushing a non-working call light. Staff A stated she had to turn the resident on her side because she was gagging. The resident had thrown up and had vomit on herself and the bed, requiring a full bed change. The investigation concluded the fake call light had been in place for 3 shifts, with other staff being aware. Staff B, Certified Nursing Assistant (CNA), had given the resident the fake call light as an intervention for repeatedly using the call light. Abuse was substantiated, and Staff B's employment was terminated. During an interview on 11/30/17 at 11:10 a.m., Staff C, Assistant Director of Nursing, stated she had conducted the investigation and confirmed abuse was substantiated. She stated Staff B had been terminated, and the other staff involved received additional abuse education.

Based on observation, interview, and record review, the facility failed to identify weight loss in a timely manner for two of three residents reviewed for weight loss (13, 49), and failed to put additional care plan interventions in place to prevent additional weight loss. This failure resulted in actual harm to Resident #13, who had a significant weight loss in a month, and placed Resident #49 at risk for unrecognized and unplanned weight loss. Findings included: 1. Review of the resident's record showed Resident #13 was readmitted to the facility in August 2013 with multiple medical diagnoses, including left side weakness, dementia, pressure ulcers, and [MEDICAL CONDITION]. The July 2017 facility assessment identified the resident had cognitive impairments that made it difficult to communicate her needs, and required meal assistance (set up) for eating. The October 2017 physician orders [REDACTED]. The current care plan identified the resident was at potential nutritional risk. Care plan interventions included: staff were to monitor and record food intake, offer protein based snacks three times daily, and offer an additional snack before bedtime. Staff were to document acceptance or refusal of snacks, and record the amount consumed at each meal. The nutritional care plan goal (which was to be reviewed on 10/11/17) was for the resident to consume at least 50% of meals and snacks. Review of the resident's record showed the resident weighed 251 pounds on 04/07/16. On 07/11/17, the resident weighed 236 pounds (a weight loss of 15 pounds in 90 days). On 09/06/17, the resident weighed 238.2. An October 2017 weight was not available in the record, but was found recorded on a weight log (attached to a clipboard). The most recent weight recorded was on 10/06/17, and showed the resident weighed 190 pounds (a total loss of 48.2 pounds in one month). The record did not reflect the physician and/or dietician were notified. In an interview on 10/09/17 at 2:00 p.m., Staff C, Licensed Practical Nurse, confirmed the resident currently weighed 190 pounds, and stated that weight would be taken from the clipboard and entered into the electronic record at some point. In reviewing the resident's electronic weight record, no weekly weights had been recorded from 09/06/17 through 10/06/17. In addition, review of the October 2017 medication administration records (MAR) showed the resident refused all offers of bedtime snacks and protein snacks, once documentation was initiated on 10/09/17. The MARs for August and September 2017 showed the resident refused all protein based and bedtime snacks. Per record review of meal monitors (where staff record food intake), from 09/17/17 through 10/15/17, Resident #13's intake for 51 of 77 meals was recorded. The meal monitors showed the resident refused 5 meals, and consumed less than 50% of 16 recorded meals. A quarterly nutritional review, completed by Staff O, Registered Dietician (RD) on 10/09/17, identified the resident's current weight was 238.2. The RD documented awareness of the resident's meal intake of 51-75%, and that Resident #13 normally rejected the therapeutic snacks. Staff O was not aware of the 10/06/17 weight of 190, and the nearly 50 pound weight loss in a month. Because of this, the RD documented the resident was meeting her goals, was stable, and wrote no further review needed. The RD identified nursing staff had not documented snack intake on the most recent MAR, so she reordered snacks; no other changes were made in the plan of care. The resident was observed on 10/16/17 at 9:00 a.m. sitting upright in bed, with a tray table in front of her, and a breakfast tray, uncovered. The resident was holding a cup with a lid, and appeared to be asleep. The resident was again observed on 10/16/17 at 12:30 p.m.; the breakfast tray was placed on the dresser, and her lunch remained uneaten on the tray table. The resident appeared asleep. In an interview on 10/16/17 at 2:00 p.m., Staff I, Residential Care Manager, (RCM) said if a resident is on weekly weights, nursing assistants weigh them, and give the results to the RCM's. They give the weights to the Dietary Manager, who then enters the weights into the computer. If there is a weight loss, it will trigger in the electronic system, so staff will be alerted to follow up. Staff I stated since the 10/06/17 weight was not yet entered into the electronic system, nothing triggered for Resident #13. In an interview on 10/16/17 at 2:10 p.m. with Staff D, Dietary Manager, she stated if a weight gain or loss is noted when she reviewed weights, she would request the resident be re-weighed. Staff D stated she requested a re-weigh for Resident #13 on 10/15/17 (9 days after a 48.2 pound loss was recorded). In an interview on 10/16/17 Staff C, Licensed Practical Nurse, was asked if there had been a request to re-weigh Resident #13; she stated no. Staff C stated resident weights should be reviewed in weekly weight meetings, but they haven't had time to hold any meetings lately. Per record review on 10/16/17 at 3:00 p.m., the facility weighed Resident #13, and recorded she now weighed 186 pounds (an additional 4 pound weight loss, since the 10/06/17 recorded weight). In an interview on 10/17/17 at 8:50 a.m. Staff O, RD, said she did not know which residents were on weekly weights, and relied on the electronic system triggers to inform her of nutrition/weight concerns. Staff O stated to her knowledge, Resident #13's weight had been stable, and there had been no concern with weight loss. In an interview on 10/17/17 at 9:31 a.m. Staff B, Director of Nursing, confirmed the process for resident weight monitoring was not working, and when brought to their attention by the surveyor, they identified the root cause as a system failure. Staff B stated because of this, Resident #13's significant weight loss had not been identified in a timely manner. 2. According to the 09/04/17 admission assessment, Resident #49 had [DIAGNOSES REDACTED]. She had been re-admitted to the facility on [DATE], after a hospital stay for a [MEDICAL CONDITION]. Resident #49's current care plan identified she was at risk for nutritional problems. A review of Resident #49's weights revealed her weight on 09/06/17 was 126 pounds. The 10/09/17 weight was documented at 117.8 pounds, which represented a 6.5% weight loss in 30 days. A dietician note, dated 10/09/17 at 1:25 p.m., indicated the resident's food intake was 0-50%, which was not adequate to meet her estimated daily nutritional needs. She ordered a fortified juice drink twice daily, to be given between meals, as a supplement. Staff were also to monitor and document if she accepted the juice drink, and how much was consumed. Per observation on 10/10/17 at 2:38 p.m., the resident was asleep in bed, with a lunch tray on the bedside table, untouched. No fortified juice container was observed on the table. On 10/11/17 at 1:07 p.m., the resident's lunch tray was on the bedside table, untouched. The resident was in bed asleep, however, awakened easily when her name was called. She was asked if was going to eat her lunch today. The resident stated she was not hungry and did not feel good. She also said she was not feeling well the previous day, stating she did not eat her lunch, and had slept most of the day. She was asked if she had recieved a juice drink during the day from the staff, and stated not that she remembered. A review of the Medication Administration Record [REDACTED]. In addition, there was no documentation of the amount of juice the resident had consumed. In an interview on 10/13/17 at 1:48 p.m., Staff C, Assistant Director of Nursing, was asked what was the process was, when orders were written by the dietician. She stated the nurse would process the order, then sign that it was done. After finishing the order, the charge nurse was to double check, to ensure the order was implemented. Staff C stated in this instance, the order was initially missed. Reference: (WAC) 388-97-1060 (3)(h)

Based on observation, interview, and record review, the facility failed to ensure three of 21 residents reviewed for smoking (#1, 3, 4) did so safely. Failure to complete timely assessments, and develop care plans related to smoking safety, put them at risk for injury, related to unsafe smoking. In addition, the facility failed to provide a safe environment for all smokers. This failure placed residents at risk for a potential fire and related injury, due to having no receptacles available to extinguish their cigarettes. As a result, an immediate jeopardy was called on 07/11/17 at 2:45 p.m., and was removed on 07/12/17 at 9:45 a.m. Findings included: Per observation on 07/11/17 at 10:15 a.m., three residents were observed in the driveway of the facility smoking, and one resident was observed half way on the driveway and sidewalk smoking. There were numerous cigarette butts scattered on the facility lawn, facility driveway, and in the street. There were no smoking receptacles seen anywhere in the area. Per interview on 07/11/17 at 10:40 a.m., Staff A, interim Administrator, stated residents that had been identified as independent smokers were directed to go out to the front sidewalk to smoke. He stated there had been issues with residents not following the smoking policy. When asked about receptacles for residents to place their cigarettes, he stated he thought there were some in the smoking area. Staff A and the surveyor went out to the front smoking area. Resident #1 was observed in the driveway smoking. Staff A told her she needed to be on the sidewalk. Staff A then confirmed there were no receptacles in the smoking area, and acknowledged the cigarette butts on the lawn and driveway. The facility smoking policy, entitled Safety Plan regarding smoking, dated 06/22/17, was reviewed. Staff A was asked if an incident with a smoker(s) had occurred on 06/22/17 and he stated no; rather that was the new policy which was going to be implemented. 1. Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Per an assessment dated [DATE], she required supervision with locomotion in her wheelchair. The assessment showed she had some confusion, and was moderately impaired for daily decision-making. A smoking assessment, dated 06/17/17, identified Resident #1 as an independent smoker. The resident's current care plan, related to smoking, identified her as non-compliant with smoking rules. Interventions directed staff to educate the resident on the risks of non-compliance, encourage her to follow the smoking rules, and monitor for compliance. On 07/11/17 at 11:15 a.m., Resident #1 stated the facility didn't provide anything for residents to put their cigarettes in after they were done smoking them. She stated she puts the cigarette butts in the street. Staff #1 stated residents had spoken to administration about providing receptacles several weeks ago, but nothing had been done about it. During an interview on 07/11/17 at 11:35 a.m., Staff A, interim Administrator, stated Resident #1 had recently been identified as needing a re-assessment on her safety and independent smoking status. When the surveyor exited the facility, a new assessment still had not been completed. 2. Resident #3 was admitted with [DIAGNOSES REDACTED]. Per review of an admission assessment dated [DATE], Resident #3 required supervision with most activities of daily living (ADL's). The assessment showed the resident had memory impairments, and difficulty making her needs known. Per record review, there was no smoking assessment found for Resident #3. The facility completed one on 07/11/17, after the Immediate Jeopardy had been called, and identified her as an independent smoker. The resident's care plan related to smoking, dated 07/07/17, identified she was non-compliant with smoking rules. Staff were to educate her on the risk of non-compliance, encourage her to follow smoking rules, and monitor compliance of smoking policies. During an interview on 07/11/17 at 11:55 a.m., Resident #3 stated she goes out to smoke in the front of the facility. She stated there was not a receptacle provided for the cigarettes, so she puts them out and places them in a bag. She mentioned she sees other smokers toss their cigarette butts in the street and stated, we have been wanting a receptacle .no one wants to throw their butts on the ground. 3. Resident #4 was admitted with [DIAGNOSES REDACTED]. Per an admission assessment dated [DATE], the resident was alert and oriented, and independent with most ADL's. Per record review, Resident #4 had a smoking assessment dated [DATE]. He was identified as an independent smoker, however the assessment showed the resident would benefit from an appropriate location for smoking, that he needed to pick up the cigarette butts, and to keep smoking material off his clothes (i.e., loose tobacco). The most recent care plan related to smoking, dated 02/02/17, identified the resident was non-compliant with smoking rules, related to appropriate locations to smoke. Interventions directed staff to educate the resident about the risks related to non-compliance, and encourage him to follow smoking rules. On 07/11/17 at 12:05 p.m., Resident #4 stated he goes out front to smoke, and there were no receptacles provided to dispose of cigarette butts. Resident #4 stated he puts the butts in the street. 2 packs of cigarettes were observed on the resident's bedside table in his room. The following interviews were conducted on 07/11/17: At 11:30 a.m., Resident #2 stated he was allowed to smoke off facility grounds. He stated nothing was provided for cigarettes to be placed in. When asked what he did with his cigarette butts, he did not answer. At 12:10 p.m., Resident #5 stated there was no receptacle outside for cigarettes. He stated a meeting was held with all the smokers, and they were told a courtyard was going to be opened for the smokers, which had ash trays, however, it had not been opened. Resident #5 went on to say the facility refused to put a receptacle in the front of the facility for the cigarette butts, and he was worried about safety. At 1:10 p.m., Resident #6 was observed in the front of the facility, on the lawn, sitting on her front-wheeled walker. She stated there had not been receptacles for the smokers, and she had a hard time bending over, so she put the cigarettes out on the lawn, and then picked them up when she was going back into the facility. Resident #6 stated she wished the facility would pick up all the cigarette butts on the grass and sidewalks. Resident council minutes were reviewed for 06/15/17. The minutes showed residents expressed a concern related to a few smokers not following the smoking policy, and flipping their cigarette butts on the ground. Staff explained to the residents that maintenance staff would pick up all the butts on the grounds. During an interview on 07/11/17 at 4:30 p.m., Staff B, Director of Operations, stated that a mock survey was done on 06/22/17, which identified an Immediate Jeopardy related to smoking safety. He stated that smoking receptacles were identified as not being outside in the smoking area, and smokers were non-compliant with the smoking policy. When asked if any interventions or corrective actions had been implemented at that time, he responded no. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facilty failed to provide necessary care and services for 1 of 6 residents (#1), reviewed for a change in condition, and 1 of 4 residents (#2), reviewed for skin conditions. This failure resulted in actual harm to Resident #1, who required hospitalization , and Resident #2, who experienced an alteration in skin integrity, with resulting pain and discomfort. Findings include: 1. Per the record, Resident #1 had [DIAGNOSES REDACTED]. Per review of an assessment dated [DATE], the resident had no memory impairments, and was able to make her needs known. She required extensive assistance with most activities of daily living. A review of the 12/13/16 care plan documented the resident was identified at risk for having changes in her respiratory condition, related to the [DIAGNOSES REDACTED]. The care plan directed staff to: administer and monitor the effectiveness of medications ordered to improve breathing, and to monitor for signs and symptoms of respiratory distress, which included increased respirations (i.e., shortness of breath), increased heart rate, restlessness, and cough. Per review of a physician progress notes [REDACTED]. A chest x-ray was ordered to rule out pneumonia, a swab was done to test for the flu, medications to help with breathing and congestion were ordered, and vital signs were to be assessed every 4 hours, for 24 hours. Per review of the nursing progress notes, from 01/18/17 (the date the nurse practioner saw the resident and wrote orders), to 01/20/17, there were no licensed nurse assessments of the resident's lung sounds, vital signs (which included temperature), or how the resident was responding to the medication. There was no evidence to indicate nursing staff were monitoring the resident's condition, to determine if it was better, worse, or the same. On 01/20/17, the physician wrote orders for Resident #1 to receive a [MEDICATION NAME] dose pack (a steroid medication, used to reduce inflammation). Per review of the Resident #1's Medication Administration Record [REDACTED]. The record was again reviewed, from 01/20/17 through 01/23/17. There was no documentation by the licensed nursing staff, related to monitoring the resident's general respiratory status, vital signs, or response to medications. On 01/23/17, the resident was seen by the nurse practitioner, as a follow-up related to the cough and upper respiratory symptoms. It was documented in the physician progress notes [REDACTED]. The NP further indicated the resident probably had [MEDICAL CONDITION] with an upper respiratory infection. The resident was started on antibiotics. In reviewing the nursing progress notes from 01/23/17 to 01/26/17, there was no evidence licensed nursing staff were monitoring the resident's condition, in particular her respiratory status, to determine if it was better, worse, or the same. On 01/26/17, the nurse practitioner saw the resident, due to staff reporting the resident was shaking. Per review of the physician progress notes [REDACTED]. Per the record, the resident was non-responsive initially, and then slightly awake, but was not speaking and not following commands. The paramedics were called. No documentation was found in the nursing progress notes, prior to the nurse practioner's documentation, with regard to the resident's shaking, or severe respiratory distress, which necessitated an emergent trip to the hospital. Hospital notes were obtained and reviewed. The resident was admitted on [DATE] to the hospital, for evaluation of shortness of breath. It was noted the resident had increasing shortness of breath over the past few days, was weak, and fatigued. The resident was intubated (a tube is inserted into the trachea, to assist with breathing), and was in the intensive care unit for 9 days. During an interview on 03/13/17 at 2:45 p.m., Staff A, resident care manager, stated if a resident had a change in condition she would expect to see the resident placed on the 24-hour report, and the condition of the resident monitored and documented by licensed nursing staff. Staff A confirmed there didn't appear to be any documentation from the facility nurses, related to the resident's condition in the days prior to her being sent to the hospital. On 03/13/17 at 3:30 p.m., Staff B, director of nursing, also confirmed he was unable to find any documentation from licensed nursing staff, with regard to the resident's worsening medical condition. 2. The record documented Resident #2 had [DIAGNOSES REDACTED]. Per an assessment dated [DATE], the resident was alert, oriented, and able to make her needs know. She required supervision/oversight with most activities of daily living. During an interview on 03/10/17 at 11:10 a.m., Resident #2 stated she hadn't been receiving the care she was supposed to. She stated she had irritated skin, and open sores under her skin folds. Things get missed and I pay for it, by having skin that is bloody and raw. Per review of the resident's most recent plan of care, she was identified as having moisture associated skin damage, related to excessive perspiration. The resident was to be observed for indications of fungus, signs and symptoms of inflammation, erosion of skin folds, and treated per physician orders. Review of the Treatment Administration Record (TAR) for February and March 2017 revealed the resident had an order for [REDACTED]. During an interview on 03/13/17 at 2:30 p.m, Staff C, resident care manager, stated if a resident had a skin condition with physician ordered treatment, she would expect to see documentation by the facility nursing staff on the TAR, to indicate the treatment was being done as ordered. Staff C reviewed the documents for February and March 2017, and confirmed it did not appear the anti-fungal treatment was being provided as ordered. On 03/13/17 at 3:15 p.m., an observation of the resident's skin was done with Staff D, licensed nurse. She lifted up the skin under the resident's left breast and the left side of her abdomen; the skin was red and inflamed, with small, closed sores. The areas under her right breast and the right side of the abdomen had areas that appeared dry and flaky. During an interview on 03/13/17 at 3:20 p.m., Staff D, the nurse, stated the resident's skin had been an issue for a prolonged period of time. She verified the resident had an order for [REDACTED].

Based on observation, interview, and record review, the facility failed to provide necessary care and services for 1 of 3 residents (#1), related to pain management. This failure resulted in harm to Resident #1, who experienced inadequate pain relief. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The resident was alert and oriented, and able to make her needs known. Per review of an assessment dated [DATE], the resident required extensive assistance with most activities of daily living and was totally dependent on staff for transfers. During an interview on 11/17/16 at 2:00 p.m., Resident #1 stated she was in pain. She said she had as needed pain medication, and if she remembered, she asked for it. The resident was teary during the interview, explaining the pain was in her broken leg, and from the pressure sores on her buttocks. Resident #1 said, If I lay real still it doesn't hurt. On 11/18/16 at 9:30 a.m., Resident #1 was observed receiving personal care, which required her to be turned from side to side. When she was turned, the resident moaned, as staff instructed her to take deep breaths. When the staff needed to move the resident's leg, they spoke to the resident, telling her they knew it was painful, reassured her they would be careful, and asked if it was alright. The resident agreed, and grimaced and moaned as the leg was being moved. A pain assessment of 10/25/16 documented the resident had a fractured leg, pressure ulcers, and an infection. The resident had narcotic medication ordered every 6 hours as needed, and the non-medication intervention listed was repositioning. Per the assessment, the resident described her pain as throbbing, and said she had increased pain when being repositioned. Her goal was to not hurt. Per review of the Pain Flow Sheet for October and November 2016, the resident received as needed narcotic pain medication on multiple occasions. The resident's pain was documented as either generalized, left leg, and/or buttock pain (from the pressure ulcers). The resident's pain rating, prior to medication, ranged from 6-9 (on a scale of 0-10, 0 being no pain, 10 being the most intense pain imaginable). The non-medication interventions documented as attempted were: positioning, environment control (not defined), and distraction. The response to the narcotic pain medication was inconsistently documented and/or unclear, and only listed a pain scale rating on 2 occasions. Per interview on 11/18/16 at 9:35 a.m., Staff A, a nursing assistant, said the resident had pain all the time. She said the resident's pain seemed to be constant, and she didn't like to be moved. Staff A stated, she is in a lot of pain, explaining the resident has had pain for a long time, but it seemed to be increasing. During an interview on 11/18/16 at 9:40 a.m., Staff B, a nurse, stated the resident's pain pills never really helped alleviate her pain. Staff B said the resident frequently asked early for her pain medication, because she was hurting. On 11/18/16 at 1:35 p.m., Staff C, Resident Care Manager, stated the resident's pain was not well controlled. Staff C said the resident broke her leg in September 2016, and was on narcotic medication as needed, every 6 hours. She felt that helped her leg pain, but the resident now had sores on her bottom, which were painful. She was unaware if any other type of medication had been tried. Per interview on 11/18/16 at 2:25 p.m., Staff D, a nursing assistant, said the resident had pain when she was turned. She stated the resident's left leg hurt so bad they use 2 staff members with cares, to help the resident with her leg.

Based on observation, interview, and record review, the facility failed to ensure 1 of 4 sample residents (#1), received necessary care and services related to pain management. This resulted in harm to the resident, who experienced unrelieved pain. Findings include: Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was alert and oriented, and able to make his needs known. According to a pain assessment dated [DATE], the resident reported he had incisional pain almost constantly. He had an order for [REDACTED]. During an interview on 02/18/16, Resident #1 was in bed, with his right leg in a brace, and elevated on pillows. The resident stated he was admitted to the facility a couple days after he had surgery on his leg. He said on the evening of admission, 02/01/16, he asked the nurse for pain medication, and the nurse told him the pharmacy had not delivered it yet. I explained that I was in a tremendous amount of pain. He stated when he finally received the pain medication my pain was a 9 out of 10. I was almost crying it hurt so bad. The resident stated a nurse came to talk to him the morning of 02/02/16, and told him he should have gotten the back up medication, and shouldn't have had to wait until the pharmacy delivered his medication. Per review of a Medication Administration Record [REDACTED]. The resident's first documented dose of pain medication was on 02/01/16 at 9:30 p.m.; the next documented dose was not until 02/02/16 at 7:30 a.m. In addition, the record contained a pain flow sheet for February 2016 . The flow sheet was used to document the location of pain, a pain rating (from 0-10, with 10 being severe pain), the medication dose, any non-medication interventions attempted, and pain relief ratings (0-10). There was nothing documented on the flow sheet indicating Resident #1's pain location had been identified, the severity of the pain rated (before or after pain medication administration), or that any non-medication interventions had been attempted on the day of his admission to the facility (02/01/16). The first documented assessment of the resident's pain was the morning of 02/02/16. During an interview on 02/19/16 at 10:40 a.m., Staff A said if a resident was admitted with an order for [REDACTED]. Per interview on 02/19/16 at 12:45 p.m., Staff B stated the resident had received pain medication when he arrived to the facility around 3:30 p.m. on 02/01/16. She stated the medication hadn't been delivered yet from pharmacy but the nurse got a dose out of the emergency medication kit. She went on to say the resident did not receive another dose of pain medication until 10:00 p.m., after the pharmacy delivered the resident's medications. Staff B stated that after the resident received the pain medication at 10:00 p.m., the nurse on duty at that time told the resident he needed to use the pain pills sparingly so he wouldn't run out of medication. Staff B said, The pharmacy delivered 22 pain pills; he wasn't going to run out. She verified the resident had not received pain medication for the rest of the night, until she came on duty the morning of 02/02/16 and gave him a dose. Staff B explained Resident #1 had to be medicated every 3 hours after that, and received a potentiator (a medication that intensifies the effects of the pain medication), in order to get his pain under control. On 02/19/16 at 1:30 p.m., Staff C confirmed the resident had received a dose of pain medication at 3:30 p.m., and then had to wait until 10:00 p.m. for another dose. She stated the nurse had told the resident he had to wait until the medication was delivered by the pharmacy, when he should have gotten a dose of pain medication available from the facility emergency kit.

Based on interview and record review, the facility failed to provide the necessary care and services to maintain the highest practicable level for 1 of 5 residents (#5) related to pain management in a sample of 32 residents. This resulted in harm for Resident #5. Findings include: Resident #5, per record review, had [MEDICAL CONDITIONS], and chronic back pain. The resident was alert and oriented and had no memory problems or difficulty with making daily decisions. He required assistance with wound care and diabetic management. Per record review, the care plan directed staff to assess for signs/symptoms of pain, give as needed pain medications, and monitor the effectiveness of the medications. His doctor ordered [MEDICATION NAME] 10/325 milligram (mg) 1-2 tablets every 4 hours as needed for pain. He took the medications usually every 4-6 hours regularly. Per record review, on 10/1/13 the resident was medicated for pain at 4:00 p.m. and used the last 2 tablets in his supply and the the facility ran out of the medications in the back up Emergency kit (E-kit) of the strength of the pain medication he used. On 10/2/13 in the morning, the nurse contacted the doctor on 10/2/13 in the morning and got a 1 time order to give [MEDICATION NAME] 5/325 mg 2 tablets, because they had that strength in the E-kit. The resident went thru the night without having his pain medication available when he reported being in pain. Per record review, on 10/5/13, three days later, the resident was medicated at 10:00 a.m. and the last 2 [MEDICATION NAME] tablets were used. Later that day the resident complained of pain, but the E-kit was out of the medication. The nurse contacted the pharmacy and was told the medications would be delivered at around 9:00 p.m. The resident was medicated at 10:00 p.m. and rated his pain "8" out of 10. The resident went for an additional 8 hours after his pain medication could have been given before receiving any pain medication. On 10/9/13 at 10:40 a.m., the resident reported he always had pain and his goal would be "4" out of 10. He said the facility ran out of his pain medications twice. He said one time he had to wait for 9 hours and another time 12.5 hours. He said the last time it occurred the nurse told him at 10:00 a.m. that the pills she was giving were the last 2 and she would contact the pharmacy. He said at around 2:00 p.m. he requested pain medications, but never got any until 10:00 p.m. that night. On 10/10/13 at 3:40 p.m., Staff #A and B reported they had an issue with the pharmacy only sending 30 tablets. They increased it to 60 tablets, and then to 120 tablets to be sent. They reported the nurse could have let the doctor know and request an order for [REDACTED]. During an interview with the resident on 11/1/13, he reported they ran out of his pain medications again on 10/12/13. He said he got pain medications at 10:00 a.m. and was told that was the last 2 tablets, He then requested more pain medications at 2:00 p.m. He said the nurse told him she would get them ordered from the pharmacy. At 6:00 p.m. he told the nurse that he would call the pharmacy himself and she told him she was unable to get in touch with the pharmacy. He said at 2:00 p.m. his pain was "6" out of 10, by 5:00 p.m. his pain was "7-8" out of 10, but by 10:00 p.m. he reported his pain was "10" out of 10. On 11/1/13 at 9:10 a.m., Staff #C reported they should order and refill when they are down to 10 pills on a card. She said "mistakes happen" when questioned about pulling the stickers timely. The facility failed to ensure that on three occasions a resident's pain was managed at his highest practicable level and resulted in Resident #5 having to wait for treatment to control his pain level.

Based on interview and record review, the facility failed to ensure pain medications were available to be administered timely for 1 of 5 residents (#5) in a sample of 32. This resulted in poor pain management for resident #5. Findings include: Resident #5, per record review, had chronic back pain, neuropathy and foot ulcers. He required extensive assistance with wound care and diabetic management. Per record review, he admitted to the facility on [DATE] at 5:00 p.m. The doctor ordered a pain medication to be given every 4 hours as needed for pain. He was unable to get pain medications until 10:00 p.m. and his pain was "10" out of 10. His pain medications needed to be ordered and delivered to the facility. Staff C stated for new admissions the orders are faxed to the pharmacy and they should get the medications in 2 hours. This residents waited 5 hours after he got to the facility. Per record review, the facility ran out of his pain medications on 10/1/13 at 4:00 p.m. He had been taking the pain medications every 4 hours, but didn't get another dose until 10/2/13 at 12:15 p.m. the next day. Per record review, the facility ran out of pain medications on 10/5/13 at 10:00 a.m. The resident did not recieve any pain medications until 10:00 p.m. and rated his pain "8" out of 10. According to the nursing notes that the medications were also not available in the Emergency-kit. On 11/1/13 at 9:05 a.m., the resident reported they ran out of pain medications again on 10/12/13. He said he got pain medications at 10:00 a.m. and then requested more pain medications at 2:00 p.m. but they were not available. He said the nurse told him she gave the last 2 pain medications and she would get them ordered from the pharmacy. At 6:00 p.m. he told the nurse that he would call the pharmacy himself and she told him she was unable to get in touch with them. He said at 2:00 p.m. his pain was "6" out of 10, by 5:00 p.m. his pain was "7-8" out of 10, but by 10:00 p.m. he reported his pain was "10" out of 10. On 10/10/13 at 3:40 p.m., Staff #B and C reported the pharmacy makes 2 runs per day and medications must be ordered by 11:59 a.m. to come on the 4:00 p.m. delivery. Other medications needed come on the second run at 10:00 p.m. She reported the Emergency-kit was not stocked with the pain medication that was ordered for the resident. She reported the nurse could have let the doctor know and to request a different pain medication they had in stock. On 11/1/13 at 9:10 a.m., Staff #C reported they should order and refill when they are down to 10 pills on a card. She said "mistakes happen" when questioned about reordering medications timely. The facility failed to have a system in place to ensure that a resident had pain medications available.

Based on observation, interview, and record review, the facility failed to evaluate, monitor, and take appropriate action in a timely manner when 1 of 7 sampled residents (#6) experienced a change in condition. The lack of nursing assessment and appropriate action resulted in Resident #6 not receiving the necessary care and services to meet his needs, which placed residents at risk of significant harm and was determined to be immediate jeopardy. Findings include: Resident #6 had [DIAGNOSES REDACTED]. Per record review, the resident, who was alert and oriented, was admitted to the facility for strengthening and rehabilitation after experiencing repeated falls. Per record review, on 6/3/11 during the day shift, the resident was noted to have a low blood pressure of 90/60. Per the vital sign flow sheet, the resident's blood pressure was usually between 100/60 and 128/68. During an interview on 6/15/11 at 12:30 p.m., Staff A (an administrative nurse), stated Staff B (the licensed nurse caring for the resident), asked her to look at the resident because his blood pressure was low and he looked "bad." Staff A and Staff C (nurse manager) checked the resident and thought he looked, "puny and pale." Both Staff A and Staff C suspected the resident was dehydrated and told Staff B to get a blood test to see if the resident needed fluids. (Staff C was present during the interview and verified the information). Although both Staff A and Staff C identified a change in the resident's condition, neither nurse conducted a thorough assessment/evaluation of the resident or documented anything in the medical record. Staff A stated she passed the information on to Staff B to follow up. According to the record, Staff B recorded the resident's vital signs, but failed to further evaluate the resident's condition or to contact the physician and request lab work. All three licensed nurses failed to act and/or follow up on the resident's change of condition resulting in a delay in treatment. Per the record, on 6/4/11 a nursing assistant reported to Staff B the resident had not voided during the night or that day. Staff B inserted a catheter into the resident's bladder but no urine was returned. The physician was consulted and ordered immediate lab work and IV (Intravenous) fluids to be administered at a rate of 100 mls (milliliters) per hour to treat dehydration. Staff B documented the IV start on 6/4/11 at 1:35 p.m. in the progress notes, but failed to initiate an IV flow sheet to monitor the amount of fluid delivered, or to record the new order on the MAR (Medication Administration Sheet), as per facility policy. Aside from the note indicating the IV was started, no further documentation regarding the IV infusion was found anywhere in the record. Staff B also failed to initiate the facility's "Alert Charting" system in order to ensure the resident's condition was monitored and charted on each shift. As a result, a period of almost 17 hours elapsed without any documented resident assessment. At 5:45 a.m. on 6/5/11 the resident was found with a decreased level of consciousness, vomiting, and respiratory distress. The facility called 911. Per the Pre-Hospital Care Report utilized by emergency medical personnel, facility staff stated they did not know how long the resident had been in respiratory distress, as he had not been checked on since 7:00 p.m. the previous night. During an interview on 6/15/11 at 6:35 p.m. Staff D (licensed nurse who worked the evening shift) stated he was aware the resident had an IV and that the resident "looked fine" at 8 p.m. when he gave the resident his medication. Staff D did not know what rate the IV was set for or where the IV site was located on the resident. Staff D also stated he did not check the resident's vital signs, listen to lung sounds, or otherwise assess/evaluate the resident, and did not document anything in the record except the medications he administered. Staff D further stated he did not change the IV bag because it was over half full, and did not check on the resident again during his shift. During an interview on 6/15/11 at 4:30 p.m., Staff E (licensed nurse who worked the night shift), stated she heard in report that the resident was dehydrated and had an IV running. Staff E stated she visually checked the resident at 11:00 p.m. and, "he was fine " Staff E stated she did not do vital signs, lung sounds, or any assessment, "just looked at him." Staff E did not know what rate the IV was set at, but indicated there was 300 mls at the beginning of her shift and she did not change the bag. The IV was discontinued when the ambulance arrived and there was about 100 mls left in the bag. Staff E stated that after her initial check of the resident at 11:00 p.m., she did not enter the room again until 5:45 a.m. when the resident was found to be in respiratory distress. On 6/6/11 at 11:15 a.m. a state surveyor observed a 1000 mls bag of IV fluid with the tubing still attached hanging in the resident's room. Both the bag and tubing were labeled with a start time of 6/4/11 at 1335 (1:35 p.m.). There was approximately 100 mls of fluid remaining in the bag indicating the resident received 900 mls in 17 hours at an approximate rate of 54 ml per hour. Per the physician order [REDACTED]. Had the physician orders [REDACTED]. A second bag of IV fluid would have been hung and labeled with a new time. Staffs' failure to thoroughly assess/evaluate the resident's condition and take action on 6/3/11, failure to perform a complete assessment when his condition deteriorated on 6/4/11, and failure to assess the resident's condition and monitor his IV for a period of 17 hours afterwards, resulted in actual harm to the resident who was hosptalized on [DATE] and diagnosed with [REDACTED].

Based on interview and record review, the facility failed to notify the family when 1 of 7 sample residents (#6) had a change in condition and a change in treatment. Findings include: Resident #6 had [DIAGNOSES REDACTED]. The resident was alert and oriented. The resident was admitted to the facility for rehabilitation after having multiple falls. Per record review, the resident had an identified family member that was notified of changes in the resident's condition, falls, and medications. On 6/3/11, the nursing staff noticed a change in the resident's condition (see F309 Care/Services for additional details). The facility did not notify the resident's family member of the change. On 6/4/11 the resident had no urine out put and had signs of dehydration. The physician was contacted and orders for lab work and IV (intravenous) fluids were received. Although there was a significant change in the resident's condition and treatment, there was no documentation to indicate the resident's family was notified. During an interview on 6/10/11 at 10:45 a.m., the resident's family member stated the facility had not notified her that the resident was sick or that he had received IV fluids. The family was not notified regarding the resident's condition until 911 was called and he was transferred to the hospital. The family member further stated she did not find out about the IV until 6/7/11 when she returned to the facility to collect the resident ' s belongings and a nursing assistant told her.

Based on interview and record review, the facility failed to notify the legal representative and consult with the physician for 1 of 6 sample residents (#1) when the resident experienced a significant change in condition related to a worsening pressure ulcer. Failure to notify the legal representative & consult with the physician in a timely manner resulted in harm to the resident. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review, the resident had memory problems, difficulty understanding and making herself understood, and required extensive to total assistance of 2 staff with activities of daily living. The resident had a left above the knee amputation related to poor circulation and skin breakdown. At the time of the investigation, the resident no longer resided in the facility. Per record review, the resident was admitted to the facility on [DATE] with diabetic ulcers on the right foot. The facility noted no other open areas. Per record review, on 1/31/11, the resident developed 3 new open areas on the sacrum/coccyx. The facility evaluated the open areas as Kennedy pressure ulcers (begin as superficial ulcers and worsen rapidly in size and depth). The facility notified the physician and legal representative of the presence of the ulcers and initiated wound treatments. The resident's physician visited the facility on 2/1/11 and noted the presence of the ulcers and noted "wound care per skin team". Review of the Skin Grid dated 2/2/11 revealed the largest of the sacrum/coccyx pressure ulcers had increased in size from a 5.2 centimeters (cm) x 3.2 cm. Stage II depth (partial loss of skin thickness) to a 10.5x7.5 cm Stage III depth (full loss of skin thickness). Per record review, on 2/2/11 the facility did not immediately consult with the resident's physician regarding the dramatic change in the wound and did not notify the legal representative of the wounds significant change in status. The only notification to the legal representative on 2/2/11 was regarding the facility adding oral supplements to the resident's plan of care. However, the facility did not discuss the risks/benefits or options of the resident being evaluated for more intensive treatment than the facility could offer. Per hospital record review, the resident was admitted to a local hospital on [DATE] with symptoms [MEDICAL CONDITION] (infection that has spread throughout the blood and tissues). The largest of the sacral/coccyx pressure ulcers had worsened to a Stage IV depth (tissue loss to the bone) and had developed an infection in the bone. On 3/8/11 at 10:30 a.m., Staff #B stated in January 2011 the resident's legal representative was offered out-patient wound treatment for [REDACTED]. The legal representative declined out-patient treatment at that time due to the resident's medical condition. Staff #B stated the facility thought the legal representative would not want out-patient treatment for [REDACTED].

Based on interview and record review, the facility failed to evaluate, develop, and implement new interventions to monitor a rapidly worsening pressure ulcer for 1 of 4 residents reviewed for pressure ulcers (#1) in a sample of 6. The resident suffered harm as a result of the facility's failed practice. Findings include: Resident #1 had [DIAGNOSES REDACTED]. Per record review, the resident had memory problems, difficulty understanding and making herself understood, and required extensive to total assistance of 2 staff with activities of daily living. The resident had a left above the knee amputation related to poor circulation and skin breakdown. The resident no longer resided in the facility at the time of the investigation. Per record review, the resident was admitted on [DATE] with blisters on the right foot that the facility evaluated as diabetic ulcers. The resident's care plan for treatment of [REDACTED]. Per record review, on 1/31/11 the resident developed 3 new open areas on the sacrum/coccyx. The largest open area was 5.2 centimeters (cm) x 3.2 cm. Stage II pressure ulcer (partial loss of skin thickness). The facility identified the ulcer type as a Kennedy pressure ulcer (begins as a superficial ulcer and worsens rapidly in size and depth.) Besides measurements, there was no description of the ulcer wound bed and surrounding tissues. Per record review, on 1/31/11 the facility notified the resident's physician and legal representative of the development of the new pressure ulcers and initiated wound treatment. On 2/2/11, the facility evaluated the sacral/coccyx pressure ulcer as a Stage III depth (loss of full skin thickness) with measurements of 10.5 cm x 7.5 cm., approximately double in size compared to 1/31/11. There was no measurement of the depth of the pressure ulcer, no description of the ulcer wound bed, drainage, signs of infection, or appearance of surrounding tissues. There was no information to indicate the facility re-evaluated the resident and developed new interventions to monitor the resident more frequently than weekly for possible complications of the rapidly worsening pressure ulcer, including signs of infection. There was no further consultation with the resident's physician despite the wound treatment being initiated on 1/31/11 and the wound deteriorating rapidly in 2 days. Per record review, between 2/2/11 and 2/7/11 the facility records documented they provided daily wound treatment to the sacral/coccyx pressure ulcer but did not evaluate the ulcer for change in status or signs/symptoms of complications or infection. The resident was sent to a previously scheduled appointment with a neurologist on 2/7/11. The neurologist arranged for the resident to be transferred to the hospital emergency room for evaluation. The resident's hospital records revealed the resident was admitted to the emergency room with symptoms [MEDICAL CONDITION] (infection that has spread throughout the blood and tissues). During physical examination, the resident's pressure ulcer was described as a Stage IV (tissue loss to the depth of the bone) sacrococcygeal ulcer with "foul-smelling purulent" drainage. Additional hospital record review revealed the resident was admitted for treatment and further evaluation of the pressure ulcer confirmed the resident had developed osteo[DIAGNOSES REDACTED] (bone infection) as a complication of the Stage IV pressure ulcer. The resident's clinical record was reviewed with Staff #A on 3/8/11 at 10:30 a.m. Staff #A confirmed there was no evaluation of the resident's wound to indicate when the depth of the pressure ulcer increased from Stage III to Stage IV and developed "foul-smelling purulent" drainage. The facility failed to evaluate, develop, and implement new interventions related to the rapid worsening of a pressure ulcer.

Based on observation, interview, and record review, the facility failed to ensure catheter care was properly managed for 2 of 4 residents with urinary catheters (#2, 3) in a sample of 6. Resident #2 was left with a non-functioning Foley catheter for 2 hours, experienced catheter-related pain and placed the resident at risk for a urinary tract infection [MEDICAL CONDITION]. Findings include: 1. Resident #2 had [DIAGNOSES REDACTED]. Per record review, the resident had short-term memory problems and required extensive to total assistance of 1-2 staff for most activities of daily living. Per record review, the resident had a urinary problem related to the neurological condition and had a Foley (indwelling) catheter. The resident had a history of [REDACTED]. Per facility record review, on 2/25/11 at 4:30 a.m., Staff #C reported to Staff #D the resident had a large amount of urine leaking around the catheter tubing and was uncomfortable related to her bladder. Staff #D attempted to flush the urinary catheter to determine the catheter patency and was unable to, indicating the catheter might be plugged and needed to be changed. Staff #D stated she was unable to perform the catheter change procedure because of "a sore arm". Between 4:30 a.m.-5:00 a.m., she told Staff #E, the licensed nurse working on the other section, that the resident's catheter needed changing but her arm was bothering her so she didn't think she could complete the procedure. There was no information to indicate Staff #D asked for assistance, explained the resident's catheter was plugged and not draining, or took further action related to the resident's catheter. During shift report at 6:30 a.m., Staff #D reported to Staff #F (on-coming nurse) that the resident's catheter was not flushing. Staff #F changed the resident's catheter immediately. The resident was again leaking urine around the catheter, had a return of 500 milliliters (ml) immediately and another 2000 ml within 10 minutes of the catheter change (normal bladder capacity is approximately 1000 ml). The resident stated her pain was relieved after the catheter was changed. Per record review, on 2/28/11 the resident showed symptoms of a UTI and was treated with oral antibiotics. During observation of care with Staff #G on 3/7/11 at 2:20 p.m., the resident's Foley catheter was patent and the resident reported no further discomfort. In an interview on 3/8/11 at 2:40 p.m., Staff #A confirmed the resident was left for at least 2 hours unable to empty her bladder without further licensed nurse intervention or action taken. 2. Resident #3 had [DIAGNOSES REDACTED]. Per record review, the resident had a urinary problem related to chronic disease and had a suprapubic urinary catheter (inserted into the bladder through the abdominal wall). The resident had a history of [REDACTED]. Per record review, a physician's orders [REDACTED]. Review of the resident's February 2011 treatment record revealed the resident refused the catheter flush at least daily from 2/1-18/11. The facility did not monitor the resident for increased risk of infection, notify the physician, evaluate the reason for the resident's refusals, or implement new interventions to promote the resident's acceptance of the procedure; including offering treatments at a different time. Per review of hospital records, the resident developed "acute alteration of consciousness" on the morning of 2/18/11. The facility transferred the resident to the local hospital emergency room where it was determined that his suprapubic catheter was not draining. A new catheter was placed and was "excessively" draining. The resident was admitted to the hospital and remained there until 2/22/11 for treatment of [REDACTED]. In an interview on 3/7/11 at 2:00 p.m., the resident stated he currently had no discomfort and the catheter was patent. During interviews on 3/8/11 at 2:40 p.m. and 3/14/11 at 10:00 a.m., Staff #A stated she was not aware of the information in the resident's hospital record indicating the suprapubic catheter was non-functioning. She stated the resident's refusals of care were more frequent in February 2011 and had no additional information to show the facility's efforts to appropriately manage the catheter care. The resident was placed at risk for repeated UTI's [MEDICAL CONDITION].