Every finding on record at Spokane Health & Rehabilitation

Based on interview and record review, the facility failed to assess, evaluate and monitor non-pressure skin conditions for 1 of 3 sampled residents (Resident 1). Resident 1 developed an inflammatory skin rash while in the facility between the folds of skin under their stomach and in the groin area. In addition, the resident was sent to the hospital on [DATE] where it was discovered their staples remained in place from a 12/18/2025 surgery. These failures placed residents at risk of not receiving timely treatment and services to prevent worsening skin conditions. Findings included . The undated facility policy Non-Pressure injury/Ulcer management documented the nursing facility would ensure systems and processes were in place to assist in the identification, investigation, treatment and care of residents with non-pressure injury related wounds. Staff would report any observation of a change in the resident's skin integrity, which would include surgical wounds. Weekly skin observations would be conducted by a licensed nurse and findings documented in the resident's medical record. Documentation may include location of ulcer/injury, date ulcer/injury acquired, description to include measurements, type of tissue, presence/absence of drainage, surrounding tissue description, and presence/absence of pain with the wound.The 01/09/2026 facility admission assessment documented Resident 1 was admitted on [DATE] with diagnoses to include a hip fracture with a surgical wound on the right hip. Resident 1 was able to make their needs known. The 01/02/2026 hospital transfer orders documented the resident had a wound to their right hip with staples. Wound care was to include the surgical dressing be changed daily or as needed. The orthopedic (specialty in medicine dealing with conditions that affect bones) discharge instructions documented the resident had surgery on 12/18/2025 and a follow-up appointment with the surgeon was to be made 12-14 days after surgery for an incision check and x-rays. The documentation did not show a follow up appointment had been made at the time the resident was discharged from the hospital. The resident's care plan, dated 01/02/2026, documented the resident had skin impairment to the right hip related to a surgical incision. The interventions included to not apply any heat, ointments, or lotions to the incision, do weekly skin observations, notify the wound physician when needed, and treatments were as ordered. The 01/02/2026 admission nursing skin assessment documented the resident had bruises and a surgical incision. The 01/23/2026 nursing skin assessment documented the resident had staples to the right hip and thigh. The facility shower sheets for the resident were reviewed. The shower sheets instructed staff who give showers to notify the nurse of any skin conditions and the nurse was to open a risk management for any new areas, complete a skin assessment and notify the provider for wound care orders. The document was to be signed by the staff giving the shower and the nurse. The 01/06/2026 shower sheet showed the area between the resident's buttocks was circled and the groin was marked redness and chapped. There was no signature from a nurse.The 01/13/2026 shower sheet showed the area of the resident's groin circled and documented redness. There was no signature from a nurse. The 01/18/2026 shower sheet showed circled areas on both arms, the groin, and both lower legs that documented redness. A nurse had signed the shower sheet. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) for January 2026 had no documentation related to the resident's incision with staples and no documentation for the resident's reddened areas which had been identified on 01/06/2026, 01/13/2026, and 01/18/2026. From 01/02/2026 to 02/07/2026 the nursing skin assessment sheets and progress notes were reviewed and there was no documentation or assessment of the resident's reddened areas in the groin or the rest of the identified reddened areas on the body.The hospital records, dated 02/07/2026, showed the resident was sent to the hospital with altered mental status. It was documented the resident had surgical staples in place since surgery on 12/18/2025, and the skin had redness with tissue that begun to overgrow on the staples. The staples were removed, 51 days after surgery, and the resident's incision was noted to have mild irritation. The document also showed the resident had intertrigo (a common inflammatory skin rash occurring in body folds caused by skin-on-skin friction, moisture, heat, and lack of ventilation). Staff cleansed the area and the skin was noted to be inflamed and irritated with maceration (the softening and breakdown of the skin as a result of prolonged exposure to moisture).In an interview on 03/05/2026 at 12:26 PM, Staff F, Licensed Practical Nurse (LPN), stated residents had weekly skin assessments. If a resident had a new skin issue, the nurse would assess the area and it would be documented in the resident's record. In an interview on 03/05/2026 at 12:30 PM, Staff A, Certified Nursing Assistant (CNA), stated if a new skin issue was identified they would immediately tell the nurse. Staff A stated during the resident's shower there was a skin check done which would be documented on a shower sheet. Staff A stated when a skin issue was found, the CNA and nurse would both sign the form. In an interview on 03/05/2026 at 1:00 PM, Staff B, Resident Care Manager (RCM), stated when a resident was admitted from the hospital, the RCM's would review the orders, put the medications and/or treatments in the electronic record and a second nurse would review to ensure they were transferred accurately. For non-pressure skin issues, the nurse was to complete risk management and then the facility's treatment nurse would be notified. Orders for wound care would be placed in the TAR's if needed. Staff B stated they did not work at the facility when Resident 1 resided in the facility.In an interview on 03/05/2026 at 2:30 PM, Staff C, Director of Nursing (DNS) stated if a resident had an order for a follow up appointment on admission, the DNS or Assistant Director of Nursing would make the appointments. For a resident with a non-pressure skin issue, the facility had risk management packets for skin the nurses would refer to. The provider would be notified if needed, and the area would be placed on the TAR and assessed weekly until resolved. After review of documentation, Staff C confirmed a follow-up had not been scheduled with orthopedics for an incision check and x-rays. Reference: WAC 388-97-1080(1)-(3)

Based on observation, interview, and record review, the facility failed to provide pressure reducing measures to prevent the development or worsening of a pressure ulcer/injury for 3 of 3 Residents (Residents 1, 2, and 3) reviewed for pressure ulcer/injury (areas of damaged skin and tissue caused by sustained pressure). Resident 1 experienced harm when they developed Stage 3 (a full thickness skin loss potentially extending into the subcutaneous tissue layer) pressure ulcer to their left heel and that required debridement. This placed other residents at risk for developing/worsening pressure ulcers, pain, and a diminished quality of life.<Resident 1>Resident 1 was admitted to the facility on [DATE] with diagnoses including a repaired hip fracture and diabetes (a chronic metabolic disease characterized by elevated levels of blood sugar, which can lead to serious damage to various organs, nerves and tissues), and were cognitively intact.Review of Resident 1's care plan showed a focus, dated 07/15/2025, that the resident was at risk for development of pressure ulcers.Review of Resident 1's admission Minimum Data Set (MDS--a standardized assessment tool that measures health status in nursing home residents) dated 07/21/2025, indicated the resident required assistance from staff for activities of daily living including bed mobility, transfers, and positioning. The MDS documented that the resident was at risk of developing a pressure ulcer/injury (PU/PI) and did not have either at the time of admission.Review of Resident 1's medical record showed that on 07/27/2025 at 9:36 AM, Staff C, Licensed Practical Nurse documented in a progress note that the resident was noted to have a pressure ulcer/injury. Lt (left) heel.Review of Resident 1's medical record showed a note written by Staff B, Medical Doctor, on 07/28/2025 at 11:33 AM, patient has new open area left heel. Wound care added and unloading of heels (refers to the process of redistributing pressure away from the heels to promote healing and prevent complications, particularly in individuals at risk for pressure ulcers/injuries).Review of Resident 1's medical record showed a progress note from an outside wound care provider, dated 07/31/2025 at 3:08 PM, with a statement that this was their first observation of a left heel wound that was noted over the last week. The left heel wound was described as Stage 3 (a full thickness skin loss potentially extending into the subcutaneous tissue layer), with a size of 1.3 cm by 1.1 cm by 0.1 cm (about the size of a dime) with subcutaneous tissue exposed (innermost layer of skin composed primarily of fat and connective tissue). The wound was then surgically debrided (use of a sharp tool to remove nonviable tissue) by the wound care provider, with a measurement afterwards of 1.4 cm by 1.2 cm by 0.2 cm.On 08/08/2025 at 11:20 AM, Resident 1 was observed lying on their bed with the head of the bed elevated about 45 degrees, a pillow was observed turned length wise under both feet, with both heels resting on the pillow and against the footboard of the bed. Both feet had clean, non-slip socks on and during an interview with the resident at the same time, they stated that the nursing staff had just changed the dressing on their left heel, that there was an open area about the size of a dime, that it was painful, and they did not want anyone to mess with it. They further reported that when they were first admitted their right hip was very painful and they did not think they were moving around enough, that they had laid in bed quite a bit and thought that was how they developed the heel wound.<Resident 2>Resident 2 was admitted to the facility on [DATE] with diagnoses including an existing pressure ulcer on their sacral area (just above the buttocks at the base of the spine), multiple fractures in their spine (T11-T12 burst fractures) and dementia (loss of cognitive functions that interferes with daily life and activities).Review of Resident 1's care plan showed a focus, dated 07/09/2025, that the resident had an area of impaired skin integrity to their coccyx (tailbone area), left heel and right heel. The interventions included the application of heel protectors and floating their heels (use of a pillow or another device to keep heels from contacting mattress or other surfaces).Review of Resident 1's admission MDS, dated [DATE], indicated the resident required assistance from staff for activities of daily living including bed mobility, transfers, and positioning. The MDS also documented that the resident was at risk of developing a PU/PI and had one unstageable pressure ulcer (a pressure injury that cannot be formally staged because the depth and extent of the wound is obscured by dead tissue that covers the wound) on admission.Review of Resident 1's medical record showed that on 07/09/2025 at 2:56 PM, Staff D, Registered Nurse wrote in a progress note that the resident was noted to have a pressure ulcer/injury. Boggy heels (a heel that feels soft, spongy, and mushy to the touch, indicating a potential issue with the underlying tissues. This sensation is often a sign of deep tissue injury (DTI), which can be a precursor to a PU/PI).Review of Resident 1's medical record showed on 07/09/2025 an order for moon boot (also known as a walking boot, a device used to protect the foot and ankle) to bilateral heels while in bed. Document all refusals.Review of Resident 1's Medication Administration Record (MAR) for August of 2025, showed an order dated 07/09/2025 at 2:15 PM, for moon boot to bilateral (both sides) heels, with a box for day, evening and night shift nurses to document if the resident was wearing the boots. Of the 22 opportunities to document the boots, four were marked as the resident refusing to wear the boots, one was blank, and the other 17 were marked as the resident wearing the boots, including day shift of 08/08/2025 (6:30 AM to 2:00 PM).Observation of Resident 1, on 08/08/2025 at 1:55 PM, showed them lying on a typical mattress, with both feet bare, heels resting on the mattress, no boots were visible anywhere in the room.During an interview on 08/08/2025 at 2:05 PM, Staff E, Nursing Assistant, stated that they had worked with Resident 2 that day and they were not aware of the resident having an order to wear boots to protect their heels, they had not seen any boots in the room and that the resident had not worn the boots that day. They further stated that this was the second time they had worked with the resident, and they had not seen boots in the room or on the resident.<Resident 3>Resident 3 was admitted to the facility on [DATE] with diagnoses including a pressure ulcer of unspecified heel, acute and chronic respiratory failure with dependence on oxygen (short term worsening of a long term condition characterized by difficulty of the lungs in exchanging oxygen and carbon dioxide, leading to low levels of oxygen in the blood, with dependence on oxygen from a machine to keep oxygen levels in the blood high enough to live) and polyneuropathy (a type of nerve disorder leading to symptoms such as numbness, tingling and pain in multiple areas of the body).Review of Resident 3's Braden Scale (an assessment tool that measures risk for pressure injury), dated 08/06/2025, scored the resident as 16, at risk for PU/PI development.Reviews of Resident 3's admission skin assessment, dated 08/07/2025 at 8:24 AM, showed an open area to right heel. No measurements of the open area were found in the resident's records.Review of Resident 3's medical orders showed on 08/06/2025 Staff B, Medical Doctor wrote to use heel boot when in bed to offload right heel. Document refusals every shift.Review of Resident 3's August MAR did not show an order, or a place to document any type of offloading of the resident's heels.Review of the Resident's care plan did not show a focus, or interventions related to impaired skin and or treatment/prevention of PU/PI. The Kardex (summary of the care plan often used by direct care staff) also did not contain information related to the resident's right heel PU/PI.On 08/08/2025 at 2:08 PM Resident 3 was observed sitting in their room in a wheelchair, wearing sandals on both feet, with their right heel visible and covered by a 4 in by 4 in bordered foam type dressing (a type of wound dressing designed to provide a moist environment conducive to wound healing, with adhesive at the edges to seal the dressing against the skin) that was peeling at the edges. During an interview with their family member, Collateral Contact 1, at the same time as the observation, they stated that the resident had a pressure ulcer on their right heel. They further stated that they had a soft boot at the hospital but had not had one while they had been at the facility. They looked through the resident's belongings and confirmed that there was not a soft boot. They further stated that the resident needed some way to float [their] heels and then spoke to the resident who stated that they had not been doing that since admission.During an exit interview on 08/08/2025 at 2:15 PM, Staff A, Administrator, stated that the facility had hired a full time wound care nurse that would help to correct the current situation. Reference WAC 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure available staff provided the necessary care and services in a timely manner for 8 of 10 sampled residents (Resident 1, 2, 3, 4, 5, 6, 7, and 8), reviewed for call light response. This failure placed the residents at risk for unmet care needs and a diminished quality of life.Findings included. <Resident 1>A facility assessment, dated 06/16/2025, showed Resident 1 was admitted with diagnoses to include both arms fractured. The resident was able to make their needs known and was dependent on most Activities of Daily Living (ADL's).During an interview on 07/22/2025 at 1:18 PM, Resident 1 stated the call light response time was not good at the facility. Resident 1 said sometimes staff came in, told them they had to get help, and took a long time to return. On 07/22/2025 at 3:30 PM, Resident 1's call light was on and sounded at the nurses' station. Staff seen in the nurses' station and several staff walked past the resident's room. The call light system at the nurses' station read the call light had been on 45 minutes. At 3:32 PM, the surveyor went into Resident 1's room and Resident 1 stated they needed to have their brief changed. At 3:35 PM, a staff member entered Resident 1's room to assist them. The call light had been on for 50 minutes before Resident 1 received help. <Resident 2>A facility assessment, dated 06/19/2025, showed Resident 2 was admitted with diagnoses of a prior stroke. The resident had difficulty making their needs known and was dependent with toileting. On 07/22/2025 at 1:13 PM, Resident 2's call light was on. The call light system at the nurses' station showed it had been on 26 minutes before being answered. On 07/25/2025 at 10:00 AM, Resident 2 was lying in bed with their call light within reach. The resident was asked about what the response was when they used the call light, the resident lifted up their call light and did not answer the question. <Resident 3>A facility assessment, dated 07/01/2025, showed Resident 3 was admitted with diagnoses to include a narrowing of their spine in the neck. The resident was able to make their needs known and required partial/moderate assistance with most ADL's.On 07/11/2025 at 1:07 PM, Resident 3's call light was turned on. It lit outside of the resident's room and sounded at the nurses' station. At 1:29 PM, Resident 3's call light remained on. Several staff walked past the resident's room and a nurse was at their cart just outside the resident's room. The call light had been on for 22 minutes. The resident's call light was answered at 1:34 PM, 27 minutes after the call light had been pushed.On 07/18/2025 at 11:25 AM, Resident 3 was in their wheelchair in their room. The resident had a collar on their neck. When asked about call light response times, the resident stated somedays it took a long time to be answered. The surveyor told the resident the prior day their call light had been on for 27 minutes and Resident 3 stated that was not as bad as other times. Resident 3 stated they felt their call light was ignored because someone had told them they were a difficult patient. <Resident 4>A facility assessment, dated 06/21/2025, showed Resident 4 was admitted with diagnoses to include a stroke. The resident was able to make their needs known, required substantial/moderate assistance with most ADL's and dependent with toileting.On 07/22/2025 at 2:03 PM, Resident 4's call light came on in the hall. At 2:22 PM Resident 4 was laying in their bed. When asked what they had their call light on for, the resident stated they didn't know it was on. Resident 4 stated the facility was very slow on everything, which included the call lights.At 2:43 PM, the call light remained on. The call light system sounded in the nurses' station and showed the resident's call light had been on for 40 minutes. Staff were seen at the nurses' station and walked by the resident's room. At 2:55 PM, the call light was answered after being on for 52 minutes.<Resident 5>A facility assessment, dated 06/27/2025, showed Resident 5 was admitted with diagnoses to include a fractured leg. The resident was able to make their needs known, required substantial/maximum assistance with most ADL's, and partial/moderate assistance with toileting.On 07/22/2025 at 3:33 PM, Resident 5's call light was on. The call light system at the nurses station showed it had been on for 29 minutes. The light was answered at 3:34 PM, after 30 minutes on.On 07/25/2025 at 10:13 AM, Resident 5 was sitting in their wheelchair in their room. The resident stated the care at the facility was slow and they needed more help. The resident stated when they pushed their call light it would take a long time for someone to answer it.At 12:55 PM, Resident 7, Resident 5's roommate, stated they had to wait for an hour at times to get help. Resident 7 stated they couldn't stand or walk by themselves and required a sit to stand lift to get to the commode.<Resident 6>A facility assessment, dated 07/25/2025, showed Resident 6 was admitted with diagnoses to include a fractured arm and pelvic bone. The resident had some difficulty making their needs known and required substantial/maximum assistance for ADL's which included toileting. On 07/25/2025 at 9:06 AM Resident 6's call light was on. Several staff walked by the resident's room and did not answer the call light. At 9:34 AM, 28 minutes later, a staff member went into the resident's room to answer the call light. The staff was heard telling the resident since they had already started to go in their brief they could finish and would then be cleaned up. At 10:05 AM, Resident 6 was lying in bed. The resident stated they didn't think it took long for staff to respond to the call light. The resident said they had to use the call light often to be changed out of their dirty briefs.At 10:09 AM, Resident 8, Resident 6's roommate, stated they tried not to use the call light when they saw staff running around in the hall. Resident 8 for the most part staff responded quickly to their call light. The resident did say one shift they had to wait about 40 minutes before they received help. During an interview on 07/25/2025 at 10:10 AM, Staff A, Nursing Assistant, (NAC), stated the staffing was usually good unless staff called off and couldn't be replaced. Staff A stated the problem was more that some staff didn't work as a team to help answer the call lights. Staff A stated at times Administration would come to the floor but would pick up meal trays and not answer call lights.On 07/25/2025 at 10:21 AM, Staff B, NAC, stated there seemed to be enough staff and most days they would be with a partner that worked as a team. There were times, however, their partner didn't work as a team and wouldn't answer a call light if it was not their assigned room.On 07/25/2025 at 10:25 AM, Staff C, NAC, stated it depended on who they were paired with as a partner. Some would work as a team and answer call lights and some wouldn't. On 07/25/2025 at 12:20 PM, Staff D, Director of Nursing (DNS) and Staff E, Administrator, were interviewed. Staff D stated ideally, they would like to see call lights be answered in 5 - 10 minutes but sometimes things happened on the floor that could delay that. Staff E said they would like to see the call lights answered within 15 minutes. Staff E stated they had only started in the building a few days prior and would like to see staff work more as a team which was something Staff E would work on moving forward. Reference: WAC: 388-97-1080(1),1090(1)

Based on observation, interview, and record review the facility failed to consistently and accurately assess residents smoking abilities and implement safety interventions to prevent smoking related injuries for 3 of 3 sampled residents (Resident 73, 86 and 461), reviewed for smoking. The failure to accurately assess residents' smoking abilities and implement safety interventions to prevent smoking related injuries represented an immediate jeopardy (IJ). On 04/15/2025 at 5:21 PM, the facility was notified of the identified IJ related to F689 CFR S483.25 Accidents and Supervision. Onsite verification by surveyors on 04/17/2025 showed, the facility removed the immediacy by placing Resident 73 on one-to-one surveillance, secured the resident's smoking paraphernalia, re-assessed the resident's ability to smoke, and revised the care plan to show the level of assistance and supervision the resident required to smoke safely. The facility closed access to unsupervised patio areas. The facility added a fire blanket and an outdoor ashtray to the designated smoking area. The facility interviewed other residents and staff to identify other residents who smoked and completed smoking safety evaluations of all the residents in the facility and for any residents identified as a smoker/tobacco user, to include development or revision of their care plans to show individualized interventions and supervision levels related to smoking preference. The facility completed a facility-wide sweep to remove unauthorized smoking materials. The facility notified the residents of the smoking policy. The facility educated the staff on the smoking policy, and identifying, managing, and reporting unsafe smoking behaviors. Immediacy was removed 04/16/2025. Findings included . Review of a facility admission agreement showed smoking or vaping was prohibited within and on the grounds of the facility. The agreement informed the residents that possessing smoking related items, like cigarettes and lighters, was strictly prohibited. Residents were informed that the facility would provide information and assistance with exploring smoking cessation interventions and products if they had a history of smoking or tobacco use prior to admission to the facility and if so desired. Violation of the Smoke-Free Facility policy endangered the health and safety of the residents in the facility and was ground for discharge. Review of the facility policy titled, Smoking Prohibited for Residents But Allowed For Staff dated October 2021, showed if staff found a resident with smoking materials, they were to be given to the nurse who secured them. The policy further showed staff would notify the provider for each incident of policy violation, document incident in the medical record, and investigated by the facility leadership team to evaluate the scope and potential endangerment to other residents and staff. The results of the investigation determined the course of action to protect other residents and staff from endangerment, to include re-education of the resident, removal of smoking materials, discussion about smoking cessation support, evaluation of the resident's ability to smoke safely without staff assistance or supervision in a location out of the facility and off the facility grounds, and/or discharge from the facility. During the entrance conference on 04/14/2025 at 8:42 AM, Staff A, Administrator, stated the facility was a non-smoking facility and there were no residents that smoked. <Resident 73> Review of a 01/24/2025 hospital document showed Resident 73 fell asleep easily during the interview but awakens easily again. The document showed the resident smoked cigarettes on some days. Review of a 02/03/2025 facility provider note showed Resident 73 was, Current smoker some days. Review of a 02/07/2025 facility admission assessment showed Resident 73 admitted to the facility from the hospital on 02/01/2025 with medically complex conditions, including Parkinson's disease (a neurological disorder) and diabetes. The assessment showed Resident 73's speech was unclear, was cognitively intact, experienced fluctuating altered levels of consciousness and required staff assistance during transfers and walking. The assessment showed Resident 73 did not use tobacco. Review of progress notes showed on 02/17/2025, the staff observed Resident 73, smoking outside in the parking lot. Social worker went out to speak to resident and remind [them] that we are a non-smoking facility. [The resident] was agreeable and put out [their] cigarette. Review of a 02/17/2025 Smoking - Resident Safety Evaluation, signed off as completed on 03/05/2025 (16 days later), showed the staff identified Resident 73 used tobacco products, allowed the resident to smoke, and used Cigarettes / Cigars. The staff assessed Resident 73 was unable to hold or extinguish a cigarette safely or use an ashtray to extinguish the cigarette. The staff concluded, Resident is not a safe smoker at this time. [They] agreed to Nicotine patches and to not smoke at this time. Family notified and nicotine patch order placed. Review of a 03/03/2025 progress note showed, the facility informed the resident, that this is a non-smoking facility as was noted to be smoking at one point. Smoking materials obtained until safety can be established. Review of a 03/04/2025 Tobacco Use care plan showed, Resident 73 preferred to smoke cigarettes. The goal was for the resident to follow non-smoking policy. The interventions included, Instruct the resident about smoking risks and hazards and about smoking cessation aids that are available, Notify social services or nurse manager if patient is found to be smoking, and smoking assessment as needed. The interventions were dated 03/04/2025 and 03/05/2025. The care plan showed no documentation the facility developed interventions to keep the resident safe from smoking related injuries or that compensated for their inability to manage smoking supplies. The care plan showed no documentation where smoking supplies were kept. Review of 03/03/2025, 03/06/2025 and 03/14/2025 facility provider notes showed once more Resident 73 was, Current smoker some days. Review of March and April 2025 Medications Administration Records (MAR) showed no documentation the provider prescribed nicotine patches for Resident 73 prior to 04/15/2025, as indicated in the 02/17/2025 resident smoking safety evaluation. An observation on 04/15/2025 at 2:23 PM, by the entire survey team, showed Resident 73 self-propelling in their wheelchair in the patio area with a lit cigarette in their hand. The resident attempted to enter the conference room where surveyors were with the lit cigarette, but was unable to open the door. Resident 73 then wheeled over to the barbecue area under the [NAME] and sat next to a propane tank with the lit cigarette. At 2:34 PM, a surveyor entered the patio area, and it smelled of cigarette smoke. No fire blanket or ashtrays were observed. Resident 73 stated that they liked to smoke three times a day, and when asked if there was an ashtray outside, they said, No. Observation of a white plastic fold-up table showed black streaks on its surface resembling the stubbing of a cigarette (to put out a cigarette by pressing the lit end against a surface, often done using a surface like an ashtray or the ground). Resident 73 again attempted to get into the conference room but was unable to do so. The resident then self-propelled across to the other side of the patio to enter another side of the building. A staff member was observed to escort Resident 73 back in the building. In an interview on 04/15/2025 at 3:23 PM, Staff Q, Registered Nurse (RN), stated that the facility was a non-smoking establishment, and smoking was allowed out on the street or off the premises. Staff Q became aware if a resident actively smoked and the assistance required by checking the resident's roster (a basic information sheet used by the staff). Staff Q stated that they did not have any resident smoking materials secured. Staff Q stated that they were unaware of any residents who smoked in the facility but that if they did see a resident smoke, they would stop the resident and notify the Unit Manager. In an interview on 04/15/2025 at 3:29 PM, Staff R, Nursing Assistant (NA), stated that they became aware of resident information by review of the Kardex (a summary of the care plan). Staff R stated, We are non-smoking so I am unsure if there are smokers [in the facility] but if they did smoke, they would have to go off property. Staff R stated that there was no designated place for a resident to smoke on facility premises. Staff R stated if they saw a resident violate the facility smoking policy they would, stop it from happening and let the nurse supervisor know and report it up above. Go through the chain [of command] not just the nurse. Staff R stated that smoking materials would be kept in a lock box with the Social Services department. In a confidential interview on 04/15/2025 at 3:36 PM, an Anonymous Staff stated, Not a lot of residents here smoke and As long as [the resident] is on the sidewalk, that's considered off property. The staff stated if they saw a resident violate the facility smoking policy they would, Ask them if they can go to the sidewalk and educate them on the policy. I'd let my Unit Managers know or the ADON [Assistant Director of Nursing]. The staff identified Resident 73 was the only resident they were aware of that currently smoked and stated the resident kept their smoking materials in their jacket and never has it out in the open. The Anonymous Staff was unaware how long Resident 73 smoked since admission to the facility. An observation and interview on 04/15/2025 between 3:36 PM and 4:00 PM showed, Resident 73 lying in bed. Resident 73 stated that they kept their cigarettes in their pocket along with the lighter and smoked more than twice a day and off the property. Additionally, Resident 73 stated that when the front doors to the facility were locked after 7:00 PM or 8:00 PM, I have to wait until someone sees me to let me in because the doors are locked. Resident 73 stated that their preferred smoking time began at noon or after lunch. The above findings were shared with Staff A, Administrator, in an interview on 04/15/2025 at 5:21 PM. Staff A confirmed the patio was not a smoking area and that, North [Hall] staff said they were not aware of [any] smoker [in the facility]. Staff A stated that when staff escorted Resident 73 back to the facility, the resident had a faint smell of smoke. Staff A stated the resident was known to have paraphernalia on [them] which was relinquished to the facility and the resident, will not tell us how [they] got the smokes and lighter [afterwards and] we are assuming the family brought it in or visitors. Staff A stated that since Resident 73 refused to relinquish the cigarettes and lighter they were placed on a one-to-one surveillance after the 04/15/2025 observations in the patio. In an interview on 04/24/2025 at 9:45 AM, Staff C, ADON, described the process on how the facility identified residents who smoked and ensured their safety. Staff C stated that hospital paperwork was reviewed, and part of the facility's admission assessment completed by the nurse asked about smoking preferences. Once a resident was identified as currently smoking, We care plan if they are an active smoker and let them know we are a non-smoking facility and if they prefer to smoke, come up with a smoking plan and establish locations to smoke and smoking times. Staff C stated the facility identified concerns related to smoking, At initial assessment if admitting, observations of the resident, communication at Stand Up [a daily Inter-disciplinary meeting], and review of the 24-hour report [progress notes]. Staff C stated that when a resident was identified as unsafe to smoke or noncompliant with the smoking policy, the facility should ensure the resident, does not have smoking paraphernalia in their room, provide a smoking apron and supervision, and re-do their smoking assessment. On 04/28/2025 at 8:13 AM in a follow up telephone conversation, the facility provided additional information. Staff C stated the facility should have added instructions to the care plan to direct the staff on the level of supervision and amount of assistance Resident 73 required during smoking after completion of the 02/17/2025 Smoking Safety Evaluation, to include staying with the resident while they smoked. Staff C stated that the additional safety interventions did not show in the care plan because the evaluation concluded a smoking cessation program (nicotine patches) would be started. Staff C acknowledged upon review of the medical record that the nicotine patches never started as mentioned in the 02/17/2025 smoking evaluation. 47328 <Resident 461> According to the 01/03/2025 quarterly assessment, Resident 461 admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD, progressive lung disease that makes it difficult to breathe). The assessment further showed Resident 461 was cognitively intact, did not exhibit behaviors and was able to clearly verbalize their needs. Review of the 07/04/2024 hospital history and physical provided to the facility during the admisson process showed Resident 461 smoked tobacco and had a tobacco abuse diagnosis. Review of the 07/11/2024 resident safety assessment showed Resident 461 used tobacco products including cigarettes/cigars and the facility did not allow smoking. A nicotine patch was listed as a smoking cessation intervention. Resident 461 was identified as safe to smoke with supervision. Review of provider orders showed a 07/12/2024 order for Resident 461 to use a nicotine patch daily for nicotine dependence. Review of the July 2024 through September 2024 MAR showed Resident 461 began to refuse the nicotine patch on 08/10/2024. The nicotine patch was discontinued on 09/11/2024. Review of the 08/21/2024 care plan showed Resident 461 smoked and was agreeable to smoke off premises. Interventions instructed staff to educate the resident about smoking risks and hazards, smoking cessation aids available, educate the resident about the facility smoking policy to include smoking off premises only, notify the charge nurse immediately if the resident was suspected of violating the facility smoking policy, and monitor clothing and skin for signs of cigarette burns. Review of the 08/22/2024 resident safety assessment showed Resident 461 used tobacco products including cigarettes/cigars and the facility allowed resident smoking. The assessment further showed Resident 461 was offered a nicotine patch but refused it and requested to smoke. Resident 461 was educated on not smoking in their room and to store cigarettes and lighter in a safe location. Resident 461 was identified as safe to smoke without supervision. Review of the 10/11/2024 resident safety assessment showed Resident 461 used tobacco products including cigarettes/cigars, resident declined smoking cessation interventions, and the facility allowed resident smoking. Resident 461 was identified as safe to smoke without supervision. No documentation was found that showed Resident 461's smoking materials were stored securely for safety after additional record review. Review of August 2024 through December 2024 nursing progress notes showed the following: - 08/21/2024, Resident 461 stated they had five packs of cigarettes, knew how to wean themselves off, and did not need a nicotine patch. - 08/22/2024 the facility non-smoking policy was reviewed with Resident 461, they were no longer wearing the nicotine patch and continued to smoke on the facility property, no additional smoking safety interventions were implemented at that time. - 12/27/2024 Resident 461 continued to demonstrate unsafe behavior of smoking on the facility property. When Resident 461 was reminded smoking was not permitted on the premises, Resident 461 stated they were not leaving the premises and would continue to smoke on the property. A 30-day notice was discussed with Resident 461 related to their health had improved sufficiently so they no longer needed services provided by the facility and their continued smoking on the property endangered other facility residents. No additional smoking safety interventions were implemented at that time. - 12/29/2024 the fire alarm was set off at approximately 2:30 AM, staff smelled smoke in Resident 461's bathroom, Resident 461 denied smoking indoors and refused to hand over their cigarettes or lighter, frequent checks for safety were implemented. At noon, Resident 461 was placed on 1:1 monitoring due to safety concerns. Resident 461 again refused to give staff their lighter and stated, I'm going to smoke no matter what. - 12/30/2024 Resident 461 was provided a discharge notice. Review of the 12/29/2024 fire alarm detailed activity report showed at 2:18 AM the fire alarm was activated, the fire department was dispatched, facility staff were contacted by the fire alarm monitoring company, the fire alarm was cleared and restored. Review of the 12/30/2024 nursing home transfer or discharge notice showed Resident 461's health improved sufficiently so that they no longer needed services provided by the facility and the safety of other individuals in the facility was endangered due to the status of the resident. A brief explanation showed Resident 461 was independent with all activities of daily living and left the facility daily in their car or motorcycle. Resident 461 continues to smoke on property and has been found smoking in [their] room. In an interview on 04/21/2025 at 9:29 AM, Staff G, Maintenance Director, acknowledged the fire alarm went off on 12/29/2024 because Resident 461 smoked in their bathroom. Staff G further stated Resident 461 was placed on 1:1 monitoring after that incident and did not smoke indoors after that. Staff G explained Resident 461 was a challenging resident and would ignore staff when asked to do things. In an interview on 04/21/2025 at 9:36 AM, Staff C, ADON, stated Resident 461 smoked, they were offered a nicotine patch but refused it and chose to smoke. Staff C explained on 12/29/2024, Resident 461 exercised their right to smoke in their bathroom and was placed on 1:1 monitoring after that incident. Staff C stated Resident 461 was not safe to smoke independently, they were self directed and did what they wanted to do. In an interview on 04/23/2025 at 2:44 PM, Staff A stated Resident 461 would smoke in the facility parking lot and refused to quit smoking. Staff A explained on 12/29/2024 the fire alarm went off, staff thought Resident 461 had smoked in their room, but Resident 461 denied it and refused to give staff their smoking paraphernalia. Staff A stated Resident 461 was placed on 1:1 monitoring after the 12/29/2024 fire alarm incident and was given a 30-day notice. <Resident 86> According to the 03/31/2025 quarterly assessment, Resident 86 admitted to the facility on [DATE] with diagnoses including weakness. Resident 86 had severe cognitive impairment and was able to verbalize their needs. Review of the 11/06/2024 hospital history and physical that was provided to the facility during the admission process showed Resident 86 smoked cigarettes every day. Review of the 11/12/2024 safety assessment showed Resident 86 did not use tobacco products and the facility did not allow resident smoking. Review of the 11/19/2024 tobacco use care plan showed Resident 86 preferred to smoke cigarettes daily. Interventions instructed staff to educate the resident about smoking risks and hazards, smoking cessation aids available, remind the resident the facility was non-smoking, there was no smoking on the facility property, and to complete a smoking assessment as needed. In an interview on 04/16/2025 at 9:24 AM, Resident 86 stated they used to smoke but had not smoked in a while. Resident 86 further stated staff had not spoken to them about smoking and they were unaware the facility was a non-smoking building. In a follow-up interview on 04/24/2025 at 9:55 AM, Staff A stated they expected staff to accurately assess residents for tobacco use and safe smoking abilities when a resident chose to smoke. Staff A further stated they also expected staff to implement smoking safety interventions as needed for resident safety. Reference: WAC 388-97-1060 (3)(g) Refer to F572, F620, and F657 and F867 for additional information 42802 46115

Based on interview and record review, the facility failed to repeatedly notify the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, adult family homes, and assisted living facilities who protect and promote the resident rights under federal and state law and regulations) of residents who discharged the facility or transferred to the hospital for 3 of 3 months (January, February, and March 2025), reviewed for hospitalization and discharge. This failure detracted from all facility residents' rights being protected, the opportunity to explore other options, or provide them with support and advocacy during a potentially stressful and confusing time. Findings included . Review of the facility policy titled, Facility Initiated Transfer and Discharge dated October 2021, showed when a resident was transferred or discharged from the facility, the facility would send a copy of the Notice of Discharge to a representative of the State LTC Ombudsman. A copy of the notice would be sent at the same time as it was provided to the resident or their representative, but for emergency transfers when practicable, such as in a list of residents monthly. <Resident 19> Review of Resident 19's medical record showed they experienced a change in condition on 02/23/2025 and required a transfer to the hospital. On 04/17/2025 at 12:23 PM, the Survey team requested documentation from the facility that showed they notified the Office of the LTC Ombudsman of discharges that occurred between January 2025 through March 2025. No records were provided. Review of a Discharge Report showed that between 03/20/2025 and 04/17/2025, seven residents were discharged to the hospital. <Resident 90> A review of the medical record documented that Resident 90 was admitted to the nursing facility on 12/30/2024. A progress note dated 03/09/2025 at 12:21 PM documented the resident developed difficulty breathing and a fever. The resident's family member requested they be sent to the emergency room for evaluation and treatment. A progress note on 03/09/2025 at 12:37 PM documented the resident was transported by ambulance and admitted to the hospital. <Resident 41> According to the 02/10/2025 admission assessment, Resident 41 admitted to the facility on [DATE] with diagnoses including spinal cord compression (pressure on the spinal cord). Resident 41 was cognitively intact and able to clearly verbalize their needs. Review of 04/08/2025 provider progress notes showed Resident 41 had significant spinal stenosis (narrowing of spinal canal) of the neck with spinal cord compression. Resident 41 was scheduled to undergo spinal neck surgery on 04/18/2025. Review of April 2025 nursing progress notes showed no progress notes documented on 04/18/2025. During observation on 04/18/2025 at 8:50 AM, Resident 41 was not in their room and their bed was stripped of linens. Similar observations were made at 10:47 AM and on 04/21/2025 at 6:16 AM. During interview on 04/18/2025 at 12:25 PM, Staff Z, LPN, stated Resident 41 was out of the facility at a surgery appointment today. <Resident 16> According to the 03/11/2025 assessment, Resident 16 had diagnoses including heart failure (heart unable to pump sufficient blood) and muscle weakness. Resident 16 was cognately intact and able to clearly verbalize their needs. Review of February 2025 nursing progress notes showed on 02/04/2025 Resident 16 was ashy in color, unresponsive, had an increased temperature, decreased oxygen levels, and they were transported to the hospital for evaluation. In an interview on 04/22/2025 at 1:54 PM, Staff A, Administrator, stated they believed social services notified the Ombudsman of hospital transfers and discharges at the end of each month. In an interview on 04/22/2025 at 2:07 PM, Staff V, Social Service Director, stated they were unsure who was responsible for notifying the Ombudsman of hospital transfers or discharges. In an interview 04/22/2025 at 3:11 PM, the Regional LTC Ombudsman stated, [The facility] did not send [notifications] to us. I went back as far as May 2024 to current. We found one notice from the facility dated 12/30/2024. Reference WAC 388-97-0120 (2)(a-d), -1040 (1)(a)(b)(c )(i-iii) Refer to F622 and F625 for additional information.

Based on interview and record review, the facility failed to establish and maintain a written transfer agreement with at least one area hospital approved for participation with Medicare/Medicaid programs. This failure placed all residents at risk for delayed hospital transfers, lack of access to hospital level of care and diminished quality of life. Findings included . On 04/23/2025 at 11:17 AM, Staff A, Administrator, and Staff E, Regional Director of Clinical Operations, were asked to provide the facility-hospital transfer agreements. In an interview on 04/23/2025 at 1:11 PM, Staff E acknowledged the facility did not have a transfer agreement with any local hospital. Reference: WAC 388-97-1620(6)(a) Refer to F622, F623, and F625 for additional information.

Based on interview and record review the facility failed to not request or require residents to waive potential facility liability for losses of personal property upon admission to the facility for 3 of 8 sampled residents (Resident 85, 463, and 41), reviewed for resident rights. This failure placed all residents at risk of inability to exercise their resident rights, unmet needs, and a diminished quality of life. Findings included . <Resident 41> According to the 02/10/2025 admission assessment, Resident 41 admitted to the facility on [DATE] with a diagnosis of spinal cord compression (pressure on the spinal cord). Resident 41 was cognitively intact and able to clearly verbalize their needs. Review of the 02/04/2025 facility admission agreement showed the facility will not be responsible for any of your valuables or personal effects stored in your room and/or kept on your person beyond the exercise of reasonable care. You may bring small items for your personal use, but you must label all items with your full name. The facility maintains a secure area available to use to secure small personal items, upon request. Residents and their legal representatives may request a bedside drawer or cabinet with a lock. The admission agreement was electronically signed by Resident 41. Review of the 02/11/2025 inventory list included the statement We urge you not to keep cash/valuables or irreplaceable items at the facility. We encourage you to take these items home or allow staff to lock them in the facility safe. The facility is not responsible for items of value that you elect to keep unlocked the form was signed by Resident 41. <Resident 463> According to the 03/15/2025 assessment, Resident 463 admitted to the facility on [DATE] with diagnoses which included weakness and need for assistance with personal care. Resident 463 was cognitively intact. Review of the 03/04/2025 facility admission agreement showed the facility will not be responsible for any of your valuables or personal effects stored in your room and/or kept on your person beyond the exercise of reasonable care. You may bring small items for your personal use, but you must label all items with your full name. The facility maintains a secure area available to use to secure small personal items, upon request. Residents and their legal representatives may request a bedside drawer or cabinet with a lock. The admission agreement was electronically signed by Resident 463. Review of the 03/04/2025 inventory list included the statement We urge you not to keep cash/valuables or irreplaceable items at the facility. We encourage you to take these items home or allow staff to lock them in the facility safe. The facility is not responsible for items of value that you elect to keep unlocked the form was signed and dated by Resident 463. <Resident 85> According to the 03/30/2025 quarterly assessment, Resident 85 admitted to the facility on [DATE] with diagnoses which included weakness and need for assistance with personal care. The assessment further showed Resident 85 was cognitively intact and clearly able to verbalize their needs. Review of the 10/18/2024 facility admission agreement showed the facility will not be responsible for any of your valuables or personal effects stored in your room and/or kept on your person beyond the exercise of reasonable care. You may bring small items for your personal use, but you must label all items with your full name. The facility maintains a secure area available to use to secure small personal items, upon request. Residents and their legal representatives may request a bedside drawer or cabinet with a lock. The admission agreement was electronically signed by Resident 85. Review of Resident 85's undated and unsigned inventory of personal effects sheet showed they brought a cell phone into the facility. The bottom of the form included the statement I agree that the above is a correct listing of the personal belongings that I have chosen to keep in my possession while I am a resident/patient at this facility/community/center. I take full responsibility for these items and any other personal effects brought to me. Review of December 2024 through March 2025 nursing progress notes showed on 01/11/2025 around noon a nursing assistant (NA) entered Resident 85's room. Resident 85 asked them to complete a task, the nurse heard something fall, the NA stated Resident 85's phone had fallen, the phone was picked up and handed back to the resident. Resident 85 reported their phone had a cracked screen. No other documentation was found related to Resident 85's broken cell phone screen. Review of the facility January 2025 through February 2025 grievance log showed one entry for Resident 85, on 01/29/2025 related to a care issue concern. Review of Resident 85's 01/29/2025 grievance showed it was not related to their broken cell phone screen. In an interview on 04/14/2025 at 2:00 PM, Resident 85 stated staff broke their cell phone three months ago and they had spoken to Social Services about the issue, but the facility did not replace or reimburse them for the broken phone. In an interview on 04/22/2025 at 9:06 AM, Staff Y, NA, stated the facility completed a resident inventory sheet upon admission. Staff Y further stated they would notify Social Services, if a resident reported missing or broken personal items, so follow up could be completed. In an interview on 04/22/2025 at 9:14 AM, Staff X, Licensed Practical Nurse, stated the facility completed a resident inventory sheet upon admission. Staff X further stated a concern form was to be completed if a resident reported a missing or broken personal item. Staff X was unsure if the facility reimbursed residents for missing or broken personal items. In an interview on 04/21/2025 at 11:11 AM, Staff U, Director of Business Development, reviewed the facility admission agreement. Staff U stated the admission agreement was to be reviewed and signed with every new admission 72 hours after their admission. Staff U read the verbiage on the admission agreement related to valuables and personal effects. Staff U acknowledged the verbiage sounded like it waived potential facility liability for losses of personal property. In an interview on 04/22/2025 at 9:40 AM, Staff F, Resident Care Manager, stated the facility completed a resident inventory sheet upon admission, the inventory sheet was recently revised. Staff F further stated a grievance form was to be filled out if/when a resident reported a missing or broken personal item and given to Social Services to track/resolve the issue. Staff F was unsure if residents were reimbursed for missing or broken items. A copy of the facility inventory sheet used was requested. In an interview and record review on 04/22/2025 at 9:49 AM, Staff C, Assistant Director of Nursing, provided a copy of the recently updated inventory sheet that was to be completed upon admission. Review of the inventory sheet provided included the statement We urge you not to keep cash/valuables or irreplaceable items at the facility. We encourage you to take these items home or allow staff to lock them in the facility safe. The facility is not responsible for items of value that you elect to keep unlocked. Staff C was asked if the inventory sheet statement waived potential facility liability for losses of personal property. Staff C referred the surveyor to Staff A, Administrator. In an interview and record review on 04/22/2025 at 10:05 AM, Staff V, Social Service Director, explained when a resident reported a missing or broken item, the inventory sheet would be checked, and a grievance filled out so the facility could follow up as needed. Staff V was shown the admission agreement and inventory sheet. Staff V acknowledged every resident should have that admission agreement and inventory sheet completed upon admission. Staff V reviewed verbiage on the inventory sheet and admission agreement related to valuables and personal effects. and acknowledged the verbiage sounded like it waived potential facility liability for losses of personal property. Staff V acknowledged there was no grievance for Resident 85's reported broken cell phone screen. In an interview and record review on 04/22/2025 at 10:22 AM, Staff A stated the facility would provide residents with the following options to secure their valuables, 1) take items home, 2) use of the facility safe, and 3) a lock box. The verbiage on the inventory sheet and admission agreement related to valuables and personal effects was reviewed with Staff A. Staff A stated verbiage referred to resident clothing. Staff A was asked if the verbiage waived potential facility liability for losses of personal property. Staff A stated the facility provided reasonable care for resident's property. Staff A was asked about Resident 85's broken cell phone screen. Staff A stated they thought there was a grievance about Resident 85's broken cell phone. A copy of the grievance was requested at that time, no documentation was provided. Reference WAC 388-97-0040 (2)(a)(b),-0180 (4)(i)(ii) Refer to F552, F578, F572, F579, F582, and F625 for additional information.

Based on interview and record review, the facility failed to implement an effective Quality Assessment and Assurance (QA&A) program that ensured corrective actions for identified problem areas [activities of daily living, falls/monitoring, care planning conferences and admission procedures] were monitored and sustained. This failure precluded facility staff the opportunity to analyze potential and actual system deficiencies and modify corrective actions for deficiencies placing all residents at risk for a diminished quality of life and care. Findings included . The undated facility Quality Assessment Performance Improvement (QAPI) Plan documented the QAPI Committee was to analyze data gathered through a variety of sources, including recertification surveys, to look for trends and negative outcomes. The committee would then establish benchmarks or targets to achieve through the implementation of performance improvement plans (PIPs). The plans were to be monitored for effectiveness. During the unannounced Recertification Survey conducted from 04/14/2025 to 04/24/2025, the following areas of repeated deficiency were identified by the survey team: -Activities of Daily Living Similar deficiencies were cited during a complaint survey dated 01/23/2025. <Resident 3> The 03/08/2025 annual assessment documented Resident 3 had diagnoses including chronic obstructive pulmonary disease (COPD, a lung disease that makes it difficult to breathe), seizures and chronic pain. Resident 3 was cognitively intact and able to make their needs known. In an interview on 04/14/2025 at 11:20 AM, Resident 3 stated they were supposed to get two showers per week and a lot of times they only received one. The 03/10/2025 care plan stated Resident 3 needed assistance with activities of daily living (ADLs) related to chronic health conditions and weakness. The care plan instructed nursing staff to assist the resident with showers. A shower binder documented Resident 3's showers were to be given on Tuesdays and Fridays. A review of Resident 3's record revealed they did not receive two showers per week on 03/09/2025, 03/16/2025, 03/23/2025 and 04/06/2025. <Resident 15> The 01/01/2025 quarterly assessment documented Resident 15 had diagnoses including COPD, high blood pressure and depression. Resident 15 was cognitively intact and able to make their needs known. In an interview on 04/14/2025 at 1:59 PM, Resident 15 stated they had not consistently received two showers per week. The 03/24/2023 care plan stated Resident 15 needed assistance with activities of daily living (ADLs) related to their disease processes and physical limitations. The care plan instructed nursing staff to assist the resident with bathing on Tuesday and Friday evenings. A review of Resident 15's record revealed they did not receive two showers per week on 03/09/2025, 03/16/2025 and 04/06/2025. In an interview on 04/22/2025 at 9:30 AM, Staff W, Nursing Assistant, stated showers were given every three to four days and documented in the plan of care or the shower binder. In an interview on 04/23/2025 at 11:05 AM, Staff C, Assistant Director of Nursing (ADON), stated showers were supposed to be given twice a week. Staff C stated it was important for the residents to have their showers for overall health and skin integrity. <Resident 264> The 04/04/2025 quarterly assessment documented Resident 264 had diagnoses which included stroke and muscle weakness. In addition, the assessment documented Resident 264 was dependent on nursing staff to complete activities of daily living for oral care and personal hygiene such as nail care. On 04/14/2025 at 1:56 PM, Resident 264 was observed lying in bed wearing a hospital gown. When the resident opened their mouth to respond after being greeted, their breath smelled very foul and their teeth were observed to be broken and unclean. Resident 264's fingernails were observed to have dark brown matter underneath them. Similar observations of Resident 264 with foul-smelling breath and dark matter under the fingernails were made on 04/15/2025 at 9:10 AM and 04/16/2025 at 12:11 PM. On 04/17/2025 at 11:15 AM, Resident 264 was observed lying in bed watching television. When asked if the staff assisted them with brushing their teeth or cleaning/trimming their nails, Resident 264 shook their head side to side, indicating no, then verbally stated No. Resident 264's breath was still foul-smelling, and the dark brown matter was observed to still be present under the fingernails. In an interview on 04/18/2025 from 10:21 AM to 10:27 AM, Staff P, Nursing Assistant (NA), stated the care plans informed them what the resident's type of assistance and specific care needs were. When asked when oral and nail care were done, Staff P stated oral care was part of morning care that was supposed to be provided daily, and nail care was done on shower days and when needed. In an interview on 04/21/2025 at 6:55 AM, Staff C was informed of the multiple observations of Resident 264 with foul smelling breath and dirty fingernails Staff C stated nail care was to be done when the resident was bathed, and as needed, and oral care was to be done daily during morning cares. In an interview on 04/24/2025 at 1:17 PM, Staff A, Administrator, stated they had concerns with showers and were not sure if they were back in substantial compliance. The facility alleged a back in compliance date of 02/21/2025. Staff A stated they did a plan of correction and audits were completed and they still had some holes. -Falls/Monitoring See F658 for additional information. Similar deficiencies were cited during the annual recertification survey dated 01/19/2024 and during a complaint investigation on 05/29/2024. In an interview on 04/24/2025 at 1:17 PM, Staff A stated they were not aware there were concerns with monitoring after falls occurred. Staff A stated the previous Director of Nursing (DNS) completed a PIP in December 2024 in which they performed audits and educated the staff. Staff A stated the DNS felt the PIP was successful as they reduced their number of falls from 28 to 23 and they no longer needed to do a full QAPI on falls. -Care Conferences See F657 for additional information. In an interview on 04/24/2025 at 1:17 PM, Staff A stated they were unaware there were issues with care conferences not being offered or held. Staff A asked how they were out of compliance, and it was explained that 12 residents were reviewed and only one resident had a care conference for those that were scheduled in February 2025. Staff A stated the PIP included looking at the scheduled care conferences daily and asking if they had been completed and the staff said they were. Staff A did not check to see that the care conferences had been completed. -Admission Processes See F552, F572, F579, F582, and F625 for additional information. In an interview on 04/24/2025 at 1:17 PM, Staff A stated they were aware they were out of compliance with completing admission documents with the residents. Staff A stated they monitored the progress of the PIP through a report from the admissions staff on who was still outstanding. Staff A stated the PIP was not sustained. Reference: WAC 388-97-1760 (1)(2)

Based on interview and record review the facility failed to designate a Registered Nurse (RN) to serve as the Director of Nursing (DNS) on a full-time basis, as required. This failure placed all residents at risk of lack of RN oversight for care provided, unmet care needs, and a diminished quality of life. Findings included . In an interview on 04/14/2025 at 8:34 AM, Staff A, Administrator, identified Staff B as the interim Director of Nursing. Staff A stated the facility had no nurse staffing waivers in place. Review of the facility staff list provided on 04/15/2025 showed Staff B was the MDS (Minimum Data Set, standardized resident assessment tool) RN/DNS. Staff C was identified as Licensed Practical Nurse (LPN)/Assistant Director of Nursing (ADON). In an interview on 04/18/2025 at 11:29 AM, Staff C, explained they reviewed the facility incident reports after they were completed by floor staff, they tried to implement other interventions, but did not always have a chance to complete reviews. In an interview on 04/23/2025 at 11:16 AM, Staff B, Interim Director of Nursing, stated they were the MDS Coordinator. Staff B explained they became the interim DNS in February 2025 but Staff C, LPN/ADON, handled most of the DNS duties. Staff B further stated they worked a 40-hour work week and focused on MDS duties. Staff B stated they were not on-call after hours, staff contacted Staff C in case of emergencies and/or if there were allegations of abuse/neglect made but they were kept in the loop. In a follow-up interview on 04/23/2025 at 12:01 PM, Staff A, again stated Staff B was the interim DNS since 02/22/2025 and worked 40-ish hours a week. Staff A was asked if they expected Staff B to perform DNS duties 40 hours a week. Staff A stated Staff B was available to work 40 hours a week as a DNS if needed. Staff A further stated Staff B reviewed incident reports and was notified if/when allegations of abuse were made. Payroll data was requested at that time for Staff B from February 2025 until current. No documentation was provided. Reference WAC 388-97-1080 (2)(b) Refer to F552, F554, F622, F625, F655, F656, F657, F658, F689, F695, F698, F725, F730, F757, F761, F880, F881, F883, F887, WAC 1380 and 1480 for additional information.

Based on observation, interview and record review, the facility failed to repeatedly ensure the facility had enough staff to provide care according to the facility acuity (the level of severity of residents' illnesses, physical, mental, and cognitive limitations, and conditions) and/or care plans for 9 of 17 sampled residents (Resident 16, 46, 61, 64, 65, 15, 22, 63 and 85), reviewed for sufficient staffing. This failure placed all residents at risk for potentially avoidable accidents, unmet care needs, and diminished quality of life. Findings included . Review of the facility assessment reviewed 09/01/2023 showed the assessment was conducted annually to determine and update the capacity to meet the needs of and competently care for the residents during day-to-day operations. The assessment further showed the facility was licensed for 125 beds, had an average daily census of 84 which included 55 long-term care residents and 29 short term skilled (received higher level of medical care and/or rehabilitation services) residents. The facility had between two to five admissions during the week and two to three admissions on weekends. The facility provided care to residents who required specialized care, had mobility impairments, required assistance completing activities of daily living (ADLS) such as toileting, and were incontinent (unintentional leakage of urine or stool). The assessment showed on average the facility cared for 78 residents with urinary incontinence, 44 residents with bowel incontinence, and 15 residents that required a toileting program. The assessment further showed the facility had adequate staffing, staffing was reviewed daily to ensure that adequate staff was available to meet the needs of facility residents, the facility employed a full-time staffing coordinator (during weekdays) and used contracted/agency staff when facility staff was unable to meet the needs of [facility] residents. <Resident 65> According to the 02/11/2025 significant change assessment, Resident 65 admitted to the facility on [DATE] with diagnoses including syncope (to faint) and collapse. The assessment further showed Resident 65 required substantial staff assistance for toileting hygiene, was frequently incontinent of urine and always incontinent of bowel. Resident 65 had severe cognitive impairment. Review of the 02/06/2025 rehabilitation care plan showed Resident 65 required maximum assistance from two staff for transfers and was dependent for toileting. The 02/06/2025 risk for falls care plan instructed staff to anticipate Resident 65's needs, ensure appropriate footwear, place common items within reach, keep the bed against the wall, and ensure Resident 65 was in areas of high visibility when up in their wheelchair. Review of the 02/15/2025 allegation of neglect incident investigation showed at 6:54 PM it was reported Resident 65 was not changed. Review of the February 2025 through March 2025 facility incident log showed Resident 65 sustained falls on 02/05/2025 (1 hours and 50 minutes after admission), 02/13/2025, 02/28/2025, 03/12/2025, and 03/14/2025. <Resident 46> According to the 03/29/2025 significant change assessment, Resident 46 required moderate staff assistance to complete most of their ADLS which included toileting hygiene. The assessment further showed Resident 46 had severe cognitive impairment and was frequently incontinent of bowel and bladder. Review of the 01/08/2025 continence care plan showed Resident 46 was frequently incontinent of bowel and bladder and instructed staff to assist with toileting, apply barrier cream, provide toileting hygiene, monitor for signs of a bladder infection, and check and change incontinence brief every two hours. The 01/08/2025 risk for fall care plan instructed staff to keep items within reach, do not leave in the bathroom unattended, ensure proper footwear, and encourage Resident 46 to stay in areas of high visibility when up in their chair. Review of the 03/25/2025 allegation of neglect incident investigation showed at 7:00 AM it was reported Resident 46 had not been checked and/or changed during the night shift. The investigation included a 03/25/2025 staff statement that showed Resident 46 had not been changed by night shift and was soiled through brief when checked on day shift. In an interview on 04/15/2025 at 9:31 AM, Resident 46's family member stated the facility needed more staff, Resident 46 did not get help needed, and had a few falls. Review of the November 2024 through March 2025 facility incident log showed Resident 46 sustained falls on 11/06/2024, 12/12/2024, 01/08/2025, 02/06/2025, 02/24/2025, 03/07/2025, 03/09/2025, and on 03/17/2025. <Resident 64> According to the 03/25/2025 annual assessment, Resident 64 was frequently incontinent of urine and was dependent on staff assistance for toileting. Resident 64 was cognitively intact. Review of the 01/07/2025 continence care plan showed Resident 64 was frequently incontinent of bowel and bladder and instructed staff to provide maximal assistance with toileting, apply barrier cream, and check and change their incontinence brief frequently as needed. Review of the 02/13/2025 Resident Council (group of facility residents that met normally to discuss care and/or concerns) Meeting Minutes showed the Council voiced concerns related to excessively long call light wait times. Review of the 03/26/2025 allegation of neglect incident investigation showed it was reported Resident 64 had not been changed. The investigation included a 03/26/2025 staff statement that showed Resident 64 was unhappy and yelling because staff had not checked or changed them. Resident 64 did not have their call light, their bed and brief was completely soaked with a wet brown ring of urine. In an interview on 04/14/2025 at 11:14 AM, Resident 64 stated there were excessively long call light wait times, sometimes up to an hour. <Resident 63> According to the 02/12/2025 quarterly assessment, Resident 63 was always incontinent of bowel and bladder, and dependent on staff assistance for toileting hygiene and bed mobility. Resident 63 had moderate cognitive impairment and was able to clearly verbalize their needs. Review of the 01/03/2025 respiratory care plan showed Resident 63 utilized supplemental oxygen and instructed staff to administer oxygen as ordered, obtain vital signs as needed, and monitor for signs and/or symptoms of respiratory complications. The 02/11/2025 continence care plan showed Resident 63 was frequently incontinent of bowel and bladder and instructed staff to apply barrier cream, provide maximal assistance with toileting, provide the bed pan as requested, and check/change Resident 63's incontinence brief as needed. In an interview on 04/14/2025 at 1:22 PM, Resident 63 stated the facility did not have enough staff because they experienced excessively long call light wait times and seldom got changed on time. Resident 63 further stated they were unable to get up or walk, they wore oxygen but sometimes was unable to get to their call light or oxygen. <Resident 16> According to the 03/11/2025 significant change assessment, Resident 16 required substantial staff assistance for toileting hygiene and was always incontinent of bowel and bladder. The assessment further showed Resident 16 was cognitively intact and able to clearly verbalize their needs. Review of the 03/17/2025 rehabilitation care plan showed Resident 16 required substantial/maximal assistance with bed mobility and toileting. The 03/17/2025 continence care plan showed Resident 16 was usually continent of bladder and instructed staff to apply barrier creams and observe for signs and/or symptoms of a bladder infection. The 04/10/2025 interventions instructed staff to provide assistance with toileting, provide the bed pan upon request, provide toileting hygiene as needed, record bowel movements, and check and change the incontinence brief while in bed. Review of the 04/01/2025 allegation of neglect incident investigation showed at 2:15 PM Resident 16 reported they had not been changed since that morning and their bed was found to be wet with odor. The investigation included a 04/01/2025 2:18 PM staff statement that showed Resident 16's bed was found to be saturated when [Resident 16] got up. [Resident 16's] brief found to be completely soaked through and heavy. In an interview on 04/14/2025 at 11:08 AM, Resident 16 stated they were incontinent, did not know how much or when they urinated, and needed to be routinely checked and changed. Resident 16 stated the facility had been short staffed for a while. Resident 16 explained they could tell the facility was short staffed because they did not receive care when needed and have had to wait up to an hour for assistance, which occurred three weeks ago. Resident 16 further stated, I wish they could do something to level out this staffing issue, it is not the resident's fault they don't have enough staff, they got to be able to hire some more people. Review of the 04/07/2025 unwitnessed fall investigation showed Resident 16 attempted to self-transfer but their legs gave out and they sustained a fall with a left-hand skin tear. In a follow-up interview on 04/14/2025 at 11:18 AM Resident 16 stated they recently fell and sustained a skin tear to their left hand. Resident 16 explained I did not want to keep waiting for [staff] to help me, I wanted to get in bed, so I did it myself. <Resident 61> According to the 02/26/2025 quarterly assessment, Resident 61 was dependent on staff assistance for toileting hygiene, was frequently incontinent of urine and always incontinent of bowel. Resident 61 was cognitively intact and able to clearly verbalize their needs. Review of the 06/12/2024 self-care deficit care plan showed Resident 61 required extensive staff assistance for bed mobility and personal hygiene. The 09/20/2024 care plan showed Resident 61 required long-term care and instructed staff to render appropriate nursing care. The care plan showed no documentation Resident 61 was incontinent of bowel and bladder. Review of the 04/01/2025 allegation of neglect incident investigation showed at 2:15 PM Resident 61 reported they had not been changed all day. The investigation included an undated handwritten staff statement that showed Resident 61 stated they had not been changed since 7:30 AM and their bed was soaked. In an interview on 04/14/2025 at 9:47 AM, Resident 61 stated the facility absolutely did not have enough staff, day shift was extremely short staffed, and weekends were worse than other days. Resident 61 explained they had excessive long call light wait times and has had to wait up to 45 minutes to be changed, which happened a few weeks ago on day shift. Review of the October 2024 through April 2025 facility incident log showed the following: - October: 10/01/2024 allegation of abuse, 10/06/2024 four different allegations of neglect, 10/09/2024 allegation of neglect, and 10/15/2024 injury of unknown origin. - November: 11/02/2024 allegation of neglect, 11/05/2024 allegation of abuse, and 11/29/2024 allegation of abuse. - December: 12/09/2024 allegation of abuse, 12/17/2024 allegation of misappropriation, 12/23/2024 three different allegations of neglect, 12/25/2024 allegation of abuse, and 12/31/2024 allegation of abuse. - January: 01/01/2024 allegation of neglect, 01/02/2024 one allegation of abuse and one allegation of neglect, 01/10/2025 two different allegations of neglect, 01/21/2025 allegation of abuse, 01/23/2025 allegation of neglect, 01/24/2025 allegation of neglect, 01/29/2025 allegation of neglect, 01/30/2025 allegation of misappropriation, and 01/31/2025 allegation of neglect. - February: 02/12/2025 allegation of abuse and two residents were involved in resident-to-resident altercation, 02/15/2025 five different allegations of neglect, 02/21/2025 allegation of neglect, 02/22/2025 allegation of abuse, 02/26/2025 two residents were involved in a resident-to-resident altercation, and 02/27/2025 allegation of neglect - March: 03/06/2025 allegation of neglect, 03/09/2025 three different allegations of neglect, 03/20/2025 two residents were involved in a resident-to-resident altercation, 03/22/2025 allegation of neglect, and 03/25/2025 two different allegations of neglect. - April: 04/01/2025 two different allegations of neglect and one allegation of misappropriation, 04/07/2025 allegation of neglect, 04/13/2025 allegation of abuse, and 04/17/2025 two different allegations of neglect. In a follow-up interview on 04/18/2025 at 10:52 AM, Resident 61 again stated, the facility is so short staffed, but that does not even begin to describe it. <Resident 22> According to the 04/01/2025 significant change assessment, Resident 22 had diagnoses which included diabetes. Resident 22 had moderate cognitive impairment and was able to clearly verbalize their needs. Review of provider orders showed an active 11/09/2023 order for staff to monitor for signs and/or symptoms of low blood sugar and implement the facility low blood sugar protocol as needed. Review of the 01/20/2025 diabetes care plan showed Resident 22 was at risk for blood sugar fluctuations and instructed staff to administer medications as ordered, provide diabetic foot care, and observe for signs and/or symptoms of high or low blood sugars. In an interview on 04/14/2025 at 1:33 PM, Resident 22 stated they had excessively long call light wait times and has had to wait an hour or longer for their call light to be answered. Resident 22 explained they were diabetic, they had a low blood sugar during the night and it took staff 45 minutes to get them a glass of juice. Resident 22 voiced concern because they did not want staff to take forever if and/or when their blood sugar dropped again. <Resident 15> According to the 03/20/2025 quarterly assessment, Resident 15 was frequently incontinent of bowel and bladder and was dependent on staff assistance for toileting hygiene and bed mobility. Resident 15 was cognitively intact and able to clearly verbalize their needs. Review of the 03/24/2023 self-care deficit care plan showed Resident 15 was dependent on Hoyer (full body mechanical lift) for transfers and required moderate staff assistance for toileting. The 03/24/2023 elimination care plan showed Resident 15 was usually continent of bowel and bladder and instructed staff to encourage Resident 15 to get out of bed daily, monitor bowel movements, and implement the bowel protocol as needed. In an interview on 04/14/2025 at 1:59 PM, Resident 15 stated they were not impressed with resident care because the facility was totally understaffed especially when residents required a lot of care. Resident 15 explained they can never find [staff] if we need help and had waited up to three hours to have their brief changed, which happened at least once a week. Resident 15 further stated when they talked to staff about their excessive long call light times, Resident 15 was told they are shorthanded. <Resident 85> According to the 03/30/2025 quarterly assessment, Resident 85 was dependent on staff assistance for toileting hygiene and bed mobility. The assessment further showed Resident 85 was always continent of bowel and occasionally incontinent of bladder. Resident 85 was cognitively intact and able to clearly verbalize their needs. Review of the 10/31/2024 care plan showed Resident 85 was administered diuretics (medication used to help rid the body of excess fluid). The 01/14/2025 rehabilitation care plan showed Resident 85 required extensive assistance for bed mobility and was dependent for transfers and toilet use. During observation on 04/14/2025 at 11:47 AM, Resident 85 was wheeled into their room by an unidentified female staff and then walked out of the room. With an upset and loud tone of voice, Resident 85 began to yell out, that girl took off! you need to find her! I need to go pee! At 11:48 AM Resident 85's roommate walked out into the hall in search of staff to assist Resident 85. At 11:50 AM, as an unidentified male staff walked past Resident 85's room, Resident 85 again yelled out, I am going to pee my pants! The lady that brought me in here disappeared! In an interview on 04/14/2025 at 1:44 PM, Resident 85 stated they had been out of the facility from 6:45 AM until 11:30 AM at a doctor appointment in Idaho and really needed to urinate. Resident 85 stated they did not like to be incontinent of urine. Resident 85 further stated the facility was short staffed and they were stuck in bed when there was not enough staff to get them up, because two staff were required to use the Hoyer, even though their record showed they needed to be up daily. Resident 85 preferred to be up in their wheelchair by 10 AM. Resident 85 stated they had excessively long call light wait times, waiting up to 50 minutes to be toileted. Review of provider orders showed an active 03/17/2024 order for Resident 85 to be out of bed and in their wheelchair twice daily for at least an hour. Review of the Medication Administration Record from 03/17/2025 through 03/31/2025 showed Resident 85 was not gotten out of bed and into their wheelchair 10 out of 29 times, only three refusals were documented. Review of 04/01/2025 through 04/15/2025 showed Resident 85 was not gotten out of bed and into their wheelchair 19 out 30 times, only three refusals were documented. During observation on 04/16/2025 at 11:54 AM 38 out of 60 residents on the North (100 hall, long-term care) were observed eating lunch in bed. Review of the 04/17/2025 allegation of neglect incident investigation showed Resident 85 was upset because they were not gotten out of bed. The investigation included a 04/17/2025 staff statement that showed Resident 85 reported they were very upset because they requested to get out of bed but was told most of the Hoyers were not working, only one Hoyer was in working order, but other residents needed to get up and Resident 85 was not gotten out of bed as requested. During observation and interview on 04/17/2025 at 1:37 PM, Resident 85 was observed lying in bed. Resident 85 stated staff did not get them out of bed today because staff told them there was only one functioning Hoyer lift and all staff were fighting to use it. Resident 85 stated I am stuck in bed for the day. I am not happy. I do not like to be in bed all day long. My preference is to be up in my chair for a while. In an interview on 04/17/2025 at 2:33 PM, the Resident Council stated the facility did not have enough staff, they experienced excessively long call light waiting times, up to an hour. The Resident Council explained sometimes staff were also unable to find a second staff to assist with cares, when cares required two staff. In a follow-up interview on 04/22/2025 at 9:34 AM, Resident 85 again stated they were stuck in bed all day yesterday because staff told them they were shorthanded, I was pissed. During a confidential interview on 04/18/2025 at 10:25 AM, Confidential Staff A, stated the facility did not have enough staff, the North (100 hall, long-term care) unit was heavy care, and normally staffed with only four nursing assistants but that was not enough staff, it was hard to get things done. Review of the 04/19/2025 facility census showed Residents 15, 16, 22, 46, 61, 63, 64, 65, and 85 all resided on the North 100 long-term care hall. In an interview on 04/22/2025 at 9:30 AM, Staff W, Nursing Assistant (NA), stated the facility was short staffed most of the time and they typically cared for about 15 residents. During observation on 04/22/2025 at 9:32 AM, Staff KK, NA, was observed asking several NAs for assistance to change the resident in room [ROOM NUMBER] but was unable to get help. Staff W told Staff KK to ask a manager for help because they needed to help a resident who asked for help. At 9:47 AM Staff KK was observed asking Staff LL, Registered Nurse, for help but Staff LL stated, I am sorry, I can't help you, I am running way behind and asked Staff KK to let them know when they changed the resident in room [ROOM NUMBER] because they needed to apply cream to them. Staff KK replied, that is what I have been trying to do, I have been trying to get help. At 9:49 AM Staff KK told the resident they would change them alone, since they were unable to find staff to help. In an interview on 04/23/2025 at 12:07 PM, Staff N, Staffing Coordinator, stated they used a HPD (hours per resident day, minimum staffing requirements) spreadsheet that was based on census, not based on acuity as a guide to see how many staff were needed. A copy of the spreadsheet was requested at that time. Staff N explained if the facility needed to provide 1:1 monitoring for a resident they would make an exception to the budget and cover the 1:1 needs. Staff N stated if the facility acuity increased they would have to pull staff from the other units and adjust section assignments to better staff the more acute unit. Staff N explained the North 100 hall was the easier unit, it was more consistent because the residents were long-term care and the South hall was the more acute unit because that was where residents admitted to and were typically more ill. Staff N was asked what would happen with staffing if the census increased. Staff N stated if the census increased they would have to schedule more agency staffing because the facility did not have enough facility staff. Staff N further stated the facility used agency staffing seven days a week, for both NAs and nurses. Staff N further stated the facility had a high staff turnover rate and needed more staff. Staff N acknowledged staff voiced staffing concerns related to the need for more staff, residents with excessively long call light wait times, and residents not changed timely. In an interview on 04/23/2025 at 12:43 PM, Staff A, Administrator, had a copy of the HPD spreadsheet used by Staff N as a guide for staffing. Staff A stated the form was just a quick and fast tool used to see if the facility had enough staff, based on census. Staff A did not provide a copy of the spreadsheet as requested. In a follow-up interview on 04/24/2025 at 8:34 AM, Staff A, explained the facility reassessed staffing every shift and attempted to balance staffing, census, and acuity. Staff A stated they used agency staffing daily and staff would bring staffing concerns to them, if there were any. Staff A stated if/when residents reported excessively long call light wait times, it was reported as an allegation of neglect. Staff A acknowledged the facility had an increased number of allegations of abuse and/or neglect. Staff A stated, I am not short staffed. Reference WAC 388-97-1080 (1), 1090 (1) Refer to F658 and F919 for additional information.

Based on observation, interview, and record review the facility failed to ensure services provided consistently and routinely met professional standards of practice for 12 of 13 sampled residents (Resident 6, 262, 69, 16, 41, 83, 312, 63, 65, 311, 79, and 85), reviewed for skin conditions, constipation and accidents. Failure of staff to monitor wounds, follow and/or clarify physician orders when indicated, develop and implement an effective fall prevention policy and consistently monitor residents for injury after falls, placed residents at risk for a delay in treatment, injury, hospitalization , and a diminished quality of life. Findings included . The American Nurses Association (ANA) is a national professional organization that represents the interests of registered nurses in the United States and sets and promotes high standards of nursing practice to ensure quality and ethical care for patients. The ANA developed the document, Nursing: Scope and Standards of Practice, with its fourth edition released in 2021. The resource informs and guides nurses in providing safe, quality, and competent patient care. The resource outlined and described 18 standards of practice for nursing professionals to follow. Review of the Nursing: Scope and Standards of Practice resource showed the first six standards included: 1. Assessment: effectively collect data and resident information that is relative to their condition or situation. 2. Diagnosis: analyze the data gathered during the assessment phrase, to determine potential or actual diagnoses. 3. Outcomes Identification: effectively predict outcomes for the resident. 4. Planning: After identifying a diagnosis and outcomes, develop a plan or strategy to attain the best possible outcome for the resident in need. 5. Implementation: Implement the identified plan. This may be done by coordinating care for the residents, such as administering treatment, or implementing/following provider orders. 6. Evaluation: After implementation, a nurse must monitor and evaluate the patient's progress towards the expected outcome or health goals. FAILURE TO ASSESS AND IMPLEMENT TREATMENT FOR NON-PRESSURE SKIN CONDITIONS Review of an undated facility policy titled, Skin Tears, Abrasions, and Bruises Management showed, the nurses completed weekly skin observations and documented their findings in the medical record. The documentation included the location of the skin condition and its description, to include the size, along with treatment orders and interventions to promote healing. The policy instructed the nurses to evaluate the effectiveness of the treatment weekly. <Resident 6> Review of a 02/23/2025 significant change in condition assessment showed Resident 6 admitted to the facility on [DATE] with medically complex conditions, to include Sjogren's syndrome (a chronic autoimmune disease that can cause dry skin). The assessment showed the resident had moderately impaired cognition and had no lesions, skin tears, or abrasions. An observation on 04/14/2025 at 11:28 AM showed Resident 6 sitting in a wheelchair in a resident lounge area. An undated dressing was observed towards the top of the resident's head, partially lifted on the right side and exposed an open area of an undetermined size. The exposed area was not actively draining and seemed to have a dry, red wound bed, like an abrasion. Resident 6 stated the staff, Change the dressing if I need it every day. Observations on 04/16/2025 at 09:25 AM and 04/17/2025 at 8:39 AM showed Resident 6 up in a wheelchair and out of their room, with no dressing present. Observed was a dry abrasion, approximately 1.5 centimeters (cm, a unit of measurement) by 2 cm. No active drainage or signs of infection were observed. Review of the April 2025 Treatment Administration Records (TAR) showed no instructions to monitor or care for the abrasion to Resident 6's head. A 03/06/2025 progress note documented Resident 6 had opened several scabbed wounds by scratching on [their] forehead and right leg resulting in bleeding. Antibiotic antibiotic ointment and skin prep was applied to the wounds and dressed with bordered dressings. Another 03/06/2025 progress note showed the staff identified abrasions to the right lower leg and to the right side of the scalp. Review of the March 2025 Treatment Administration Records (TAR) showed no orders for the application of the antibiotic ointment and bordered dressings to the wounds on the forehead or right leg. Review of a 03/13/2025 Wound Consultant note showed, the staff assessed Resident 6 had, bruises and abrasions from falls and scratching [themselves]. The consultant instructed the staff to apply one or more ounces of emollient [moisturizing] cream to all the skin at least two times a day. Subsequent notes by the Wound Consultant on 03/20/2025, 03/27/2025, 04/03/2025, and 04/10/2025 showed the same instructions. Review of the March and April 2025 TAR or care plan showed no documentation the nurses implemented the Wound Consultant's specific instruction. Review of the progress notes from 03/21/2025 to 04/12/2025 showed the staff identified various skin conditions as follows: - On 03/21/2025, an abrasion to the forehead - On 03/24/2025, skin tears and abrasions - On 03/26/2025, abrasions to knees - On 03/28/2025, skin abrasions - On 04/12/2025, a skin tear that is not covered; skin found to be open, size is about 8cm in length with moderate amount of blood; Per the documentation, the resident was sent to the hospital, returned to the facility at 8:15 PM, and had obtained 9 stitches and 5 steri-strips [adhesive strips]. Review of provider notes showed they also identified the following various skin conditions: - On 02/19/2025 and 03/17/2025 - abrasions to both knees and scalp -On 03/06/2025, 03/11/2025, 03/14/2025, 3/27/2025, 03/28/2025, 4/17/2025 - Wound on scalp or Scabbed wound on scalp. Review of the medical record showed the nurses completed weekly Skin Observation assessments on 02/17/2025, 02/24/2025, 03/03/2025, 03/06/2025, 03/11/2025, 03/13/2025, 04/10/2025, and 04/17/2025. The medical record showed no documentation that showed the nurses assessed or evaluated the status or progress of the multiple identified non-pressure skin conditions, to include the substantial skin tear of unknown location, or developed and implemented measures to ensure adequate healing and/or prevent complications associated with the non-pressure skin conditions. Review of the physician orders showed no instructions to care for the substantial skin tear of unknown location that required the resident's transfer to the hospital for invasive treatment on 04/12/2025. The above findings were shared with Staff C, Assistant Director of Nursing (ADON), on 04/18/2025 at 11:21 AM. Staff C acknowledged the nurses should have, but did not procure or implement provider orders for the management of non-pressure skin conditions, assessed or evaluated the status or progress of non-pressure skin conditions, or developed and implemented measures to ensure adequate healing and prevent complications associated with the non-pressure skin conditions. <Resident 63> According to the 02/12/2025 quarterly assessment, Resident 63 was dependent on staff assistance to perform personal hygiene which included washing/drying their face. Resident 63 had moderate cognitive impairment and was able to clearly verbalize their needs. Review of the 02/04/2025 weekly skin assessment observation showed Resident 63 had dry skin. Review of the 02/11/2025 weekly skin assessment observation showed Resident 63 had extremely dry skin. Review of Resident 63's care plan showed no documentation or interventions to address Resident 63's extremely dry skin. During observation and interview on 04/14/2025 at 9:00 AM, Resident 63 had thick white dry skin flakes covering their entire forehead, down both sides of their face, inside both ear crevices, down both sides of their neck, and behind both ears. Resident 63 stated they had Psoriatic [skin condition that resulted in red patches covered with silvery scales] Arthritis [joint pain, stiffness, and swelling]. Resident 63 stated they were experiencing a bad flare up and explained their skin itched and was irritated. Resident 63 stated they had a cream to help but they had to request it and I never seem to get it. Resident 63 further stated it took their skin a while to calm back down after a flare up. Similar observations were made at 11:31 AM, 1:20 PM, on 04/15/2025 at 8:58 AM and 12:03 PM, on 04/16/2025 at 12:14 PM, and on 04/18/2025 at 8:43 AM. In an interview on 04/22/2025 at 1:18 PM, Staff C reviewed Resident 63's medical record. Staff C acknowledged Resident 63 had extremely dry skin and no treatment for psoriasis. Staff C stated they expected staff to follow up on skin issues as needed. <Resident 16> According to the 03/11/2025 assessment, Resident 16 was cognitively intact and able to clearly verbalize their needs. Review of the 04/07/2025 facility unwitnessed fall report showed Resident 16 attempted to self-transfer but their legs gave out and fell . Resident 16 sustained a skin tear to the back of their left hand that was closed with steri-strips (thin strips of tape used to close small cuts). Review of April 2025 nursing progress notes showed on 04/07/2025 Resident 16 fell and sustained a skin tear to the back of their left hand that was closed with steri-strips. On 04/08/2025 the left hand steri-strips were getting a little dirty and were covered with gauze. No documentation of skin tear monitoring or assessment for signs and/or symptoms of infection was found until 04/15/2025. On 04/15/2025 the left-hand dressing was dislodged, the wound was cleansed, assessed, and redressed. Resident 16 informed the staff the skin tear was an injury from their recent fall. Review of provider orders as of 04/14/2025, seven days after Resident 16 sustained a fall, showed no provider orders to monitor the left-hand skin tear for signs and/or symptoms of infection or to change the bandage. During observation and interview on 04/14/2025 at 11:18 AM, Resident 16 stated they sustained a skin tear to their left hand when they attempted to self-transfer recently and fell . Resident 16 pointed to a white undated bandage on the back of their left hand with a dark blood drainage stain spot observed through the bandage. Resident 16 stated the bandage had not been changed for a week and thought the skin tear was worsening because it was becoming painful, warm, and continued to bleed. Similar observation was made on 04/15/2025 at 8:52 AM. In an interview on 04/22/2025 at 12:02 PM, Staff H, Licensed Practical Nurse (LPN), explained if a resident fell and sustained a skin tear the provider would be notified and orders to monitor and/or skin treatment orders implemented. Staff H stated skin issues could worsen or get infected if they were not monitored. Staff H reviewed Resident 16's medical record. Staff H acknowledged Resident 16 experienced a fall on 04/07/2025, sustained a skin tear to the back of their left hand, and staff should have implemented orders to monitor the skin tear. In an interview on 04/22/2025 at 12:19 PM, Staff C, ADON, stated skin issues could worsen or get infected if they were not consistently monitored. Staff C reviewed Resident 16's medical record. Staff C acknowledged Resident 16 sustained a skin tear from a fall on 04/07/2025, but treatment orders were not implemented until 04/16/2025, nine days later. Staff C stated they expected staff to follow-up on skin issues. In an interview on 04/22/2025 at 2:01 PM, Staff A, Administrator, stated they expected staff to follow up on skin issues. FAILURE TO ASSESS AND IMPLEMENT ORDERS FOR CONSTIPATION Review of provider standing orders showed directions to address constipation before and after 48 hours of not experiencing a bowel movement (BM). The protocol was time-specific regarding administration of the different laxatives. The standing orders showed that after 48 hours of no BM, the nurses were instructed to administer Lactulose every two hours as needed and if the resident did not have a BM after six hours, then Milk of Magnesia (MOM). If the resident did not have a BM after six hours of receiving the MOM, the nurses were to administer a Bisacodyl suppository. If the suppository proved ineffective after six hours, the nurses were ordered to administer a Fleets enema once and to notify the provider if they wished to repeat it. The orders instructed the nurses to notify the provider if a resident did not have a BM greater than 3 days and to let them know of all medications that were already attempted. <Resident 262> Review of a 04/03/2025 admission assessment showed Resident 262 admitted to the facility on [DATE] with medically complex conditions, which included Parkinsonism (a neurological disorder) and chronic pain syndrome. The assessment showed the resident was cognitively intact and presented with a bowel pattern of constipation. An observation and interview on 04/18/2025 at 1:04 PM showed Resident 262 sitting up in a chair in their room. Resident 262 said they independently walked to the bathroom. The resident said they had a BM one every 4 or 5 days here [in the facility] which was a change from home where they had a BM, almost every day. The resident shared that at home they took a a big gulp of Milk of Magnesia about once a week and, Apparently [staff] don't know about Milk of Magnesia here. The resident referred to being offered a liquid twice a day that they thought was for the management of constipation but, I wonder about it because I'm still not pooping. Maybe I should mention it to [the staff]. That would make me go poop. I'd like that. When asked if the staff inquired if they had a bowel movement, Resident 262 stated, No, I don't think anybody has asked that. Review of the April 2025 Medication Administration Records (MAR) showed physician orders for routine or scheduled administration of medications that had the side effect of constipation, to include amiodarone (a cardiac agent), bupropion (an antianxiety agent), iron tablets, semaglitude (for diabetes), and carbidopa-levidopa (for Parkinsons). The MAR showed that both scheduled senna tablets and gavilax (both over the counter [OTC] medications used to treat constipation) were discontinued on 04/07/2025. The MAR showed no as needed orders for medications to treat episodes of constipation. Review of a 03/29/2025 care plan showed the staff assessed and determined the resident was at risk for constipation related to medications. The care plan showed, if the resident experiences constipation it will be resolved thru the review period. The interventions directed the nurses to administer medications as ordered, implement bowel protocol when indicated, observe for signs and symptoms of constipation or extended abdomen that may indicate constipation, and track and record bowel movements. Review of a Bowel Elimination Record from 03/28/2025 to 04/18/2025 showed Resident 262 did not have a BM recorded for three days from 03/28/2025 to 03/30/2025, for six days from 04/04/2025 to 04/09/2025, and for three days from 04/11/2025 to 04/13/2025 and from 04/15/2025 to 04/17/2025. The above findings were shared with Staff C on 04/18/2025 at 1:30 PM. Staff C clarified that the bowel protocol the care plan referred to was the provider's standing orders and the nurses had to manually input those orders into the electronic medical record for their use. Staff C acknowledged the medical record showed no documentation the nurses assessed Resident 262 or implemented the standing orders for constipation, as per professional standards of practice, to include notifying the provider when Resident 262 did not have a BM greater than 3 days. 46115 <Resident 69> The 03/07/2025 significant change in condition assessment documented Resident 69 had diagnoses which included constipation and high blood pressure. The resident was cognitively intact and able to make their needs known. In an interview on 04/14/2025 at 10:04 AM, Resident 69 stated they had constipation and MOM helped. The 12/09/2025 care plan instructed nursing to monitor for signs and symptoms of constipation, implement bowel protocol when indicated, administer medications as ordered, and track and record bowel movements. The care plan documented if the resident experienced constipation it would be resolved through the review period. The bowel record from 03/01/2025 to 04/18/2025 documented Resident 69 did not have a BM on the following dates: 03/05/2025 to 03/12/2025, eight days 03/21/2025 to 03/24/2025, four days 04/14/2025 to 04/19/2025, six days Review of the March and April 2025 MARs showed Resident 69 had as needed Bisacodyl to treat episodes of constipation and none was administered. <Resident 38> The 02/01/2025 quarterly assessment documented Resident 38 had diagnoses which included diabetes and heart failure. The resident was cognitively intact and able to make their needs known. The 10/30/2024 care plan instructed nursing to monitor signs and/or symptoms of constipation, implement bowel protocol when indicated, administer medications as ordered, and track and record bowel movements. The care plan documented if the resident experienced constipation it would be resolved through review period. The bowel record from 03/01/2025 to 04/18/2025 documented Resident 38 did not have a BM on the following dates: 03/18/2025 to 03/27/2025, ten days 04/01/2025 to 04/04/2025, four days 04/06/2025 to 04/12/2025, seven days Review of the March and April 2025 MARs showed Resident 38 had no as needed medications to treat episodes of constipation. In an interview on 04/22/2025 at 9:00 AM, Staff X, Licensed Practical Nurse, stated the bowel protocol was started on day three of no BM and they were to administer DOSS (a stool softener), Senna (a laxative) and Miralax (a stimulant). Staff X stated small bowel movements did not count. Staff X stated it was important to follow the protocol, so blockage and pain did not occur. In an interview on 04/22/2025 at 1:30 PM, Staff C stated they had standing orders for the bowel protocol from a group of their providers, and they had a provider that ordered MOM on day three of no BM, if no results a suppository was given, and if no results the next day an enema was given. Staff C stated the bowel protocol should have been followed for the above residents or a progress note made stating they spoke to the residents and inquired if they had a BM. Staff C stated it was important to follow the bowel protocol to prevent pain and blockage. <Resident 16> According to the 03/11/2025 assessment, Resident 16 was always incontinent of bowel and their bowel patterns showed constipation was present. Resident 16 was cognitively intact and able to clearly verbalize their needs. Review of the 02/21/2025 care plan showed Resident 16 was at risk for constipation and instructed staff to administer medications as ordered, track BMs, observe for signs of constipation, and implement the bowel protocol when indicated. Review of provider orders showed a 02/11/2025 order for Resident 16 to be administered MOM every 24 hours as needed for constipation, MiraLAX to be administered every 24 hours as needed for constipation, and a Bisacodyl suppository daily as needed for bowel care. Review of the bowel elimination record from 03/19/2025 to 04/17/2025 showed Resident 16 did not have a BM for three days from 03/27/2025 to 03/29/2025, for four days from 04/01/2025 to 04/03/2025, for four days from 04/05/2025 to 04/08/2025, and for four days from 04/11/2025 to 04/14/2025. Review of the March 2025 through April 2025 MAR showed Resident 16 was not administered any as needed bowel medication from 03/24/2025 through 04/16/2025. <Resident 41> According to the 02/13/2025 admission assessment, Resident 41 was continent of bowel, was cognitively intact and able to clearly verbalize their needs. Review of the 02/05/2025 continence care plan showed Resident 41 was usually continent of bowel and instructed staff to record BMs, provide staff assistance with toileting, and provide toileting/incontinence supplies as needed. Review of provider orders showed a 02/04/2025 order for Resident 41 to be administered MiraLAX every 24 hours as needed for constipation. Review of the bowel elimination record from 03/20/2025 to 04/18/2025 showed Resident 41 did not have a BM for five days from 03/30/2025 to 04/03/2025 and for four days from 04/06/2025 to 04/09/2025. Review of the April 2025 MAR record showed Resident 41 was not administered MiraLAX for constipation as needed. <Resident 85> According to the 03/30/2025 quarterly assessment, Resident 85 was always incontinent of bowel and their bowel patterns showed constipation was present. Resident 85 was cognitively intact and able to clearly verbalize their needs. Review of the 01/14/2025 opioid (class of drugs used to reduce moderate to severe pain) use care plan showed Resident 85 was at risk for complications and instructed staff to administer medications as ordered, record/track bowel movements, and implement the bowel regimen protocol. Review of provider orders showed a 12/30/2024 order for Resident 85 to be administered a bisacodyl suppository every 24 hours as needed for constipation, and a 02/17/2025 order for Resident 85 to be administered MOM every 24 hours for constipation lasting more than 48 hours. Review of 12/18/2024, 12/30/2024, 02/06/2025, 03/01/2025, and 03/17/2025 provider progress notes showed Resident 85 struggled with recurrent constipation going up to several days before having a hard BM. Review of February 2025 nursing progress notes showed on 02/23/2025 Resident 85 had an incident of hard impacted stool. Several large hard stools were passed after Resident 85 was administered a Bisacodyl suppository. Resident 85 will require education on bowel maintenance when taking scheduled [opioid] medication. Review of the bowel elimination record from 03/18/2025 to 04/16/2025 showed Resident 85 did not have a BM for 10 days 03/20/2025 to 03/29/2025, for four days from 04/04/2025 to 04/07/2025, and for five days from 04/12/2025 to 04/16/2025. Review of the March 2025 through April 2025 MAR showed Resident 85 was not administered MiraLAX or a Bisacodyl suppository for constipation as needed. In an interview on 04/22/2025 at 9:23 AM, Resident 85 stated the facility did not monitor or track BMS and often went 9-10 days without a BM. Resident 85 further stated it was painful to have a BM after 10 days, staff did not offer bowel interventions and often had to request a suppository or enema. In an interview on 04/22/2025 at 9:43 AM, Staff F, Resident Care Manager, stated residents were at risk for bowel blockages if the bowel protocol was not implemented when indicated and staff should document bowel interventions attempted and/or refused. Staff F reviewed Resident 85's medical record. Staff F acknowledged Resident 85 went 9-10 days without a BM and staff should have implemented the bowel protocol. In an interview on 04/22/2025 at 10:34 AM, Staff A, Administrator, stated they expected staff to implement the bowel protocol when indicated. 47328 FAILURE TO IMPLEMENT FALL PRECAUTIONS Review of the facility policy titled, Fall Safety- Everyone is at Risk of Falling dated October 2022, showed anyone could fall regardless of age, gender, or illness. The policy instructed staff to be alert to situations that could lead to falls and included some potential situations to avoid and interventions to implement. The Falling Leaves program consisted of a leaf sticker placed next to a high fall risk resident's door name tag. The sticker was to notify staff the identified resident required frequent rounding to help reduce falls. The policy did not instruct staff how to assess fall risk, what steps to take when a fall occurred, or how to monitor residents when falls were sustained. Review of an undated facility incident report form instructed staff to use the format as a guide on what steps were required after a resident sustained a fall. Staff were to place the resident on alert charting: every shift for 72 hours, or longer if not resolved. The form additionally instructed staff to complete a neurological evaluation (neuro and/or neuro checks, a series of tests that assess mental status, reflexes, movement, and pupil reaction to evaluate brain and nervous system function) if a resident hit their head or the fall was unwitnessed by staff. Review of the Neurological Evaluation Flow Sheet used by the facility to assess for any changes instructed staff to complete a neuro evaluation with vital signs every 30 minutes for two hours, then every hour for four hours, then every 8 hours for nine hours (72 hours), compare vital signs over time and pay close attention to respiratory patterns. The form included a graph to document the required information on. <Resident 65> According to the 02/11/2025 admission assessment, Resident 65 admitted to the facility on [DATE] with diagnoses including Dementia, syncope (to faint) and collapse. The assessment further showed Resident 65 sustained a fall in the month prior to admission and a non-injury fall since their admission. Resident 65 had severe cognitive impairment, disorganized thinking and inattention. Review of the 01/30/2025 hospital history and physical showed Resident 65 experienced a fall at home and was down for approximately an hour. The notes further showed Resident 65 had a history of falls, needed assistance with walking, had a soft-spoken voice, and spoke minimally per their baseline. Review of the 02/05/2025 admission assessment showed Resident 65 arrived to the facility at 3:00 PM, had cognitive impairment, was confused, oriented to self only, and unable to make their needs known. The assessment further showed Resident 65 had post fall injuries including significant bruising, four lacerations, and an eyebrow abrasion. Review of the 02/06/2025 care plan showed Resident 65 was at risk for falls related to cognitive and functional impairments, weakness, recent hospitalization , unsteady gait, and incontinence. The care plan instructed staff to anticipate Resident 65's needs, have the bed against the wall in the lowest position, non-skid strips at bedside, educate resident on safe transfers, provide and use non-skid socks while out of bed. An intervention implemented on 02/13/2025 showed Resident 65 was added to the Falling Leaves program. Revisions on 03/03/2025 instructed staff that resident was to be in high visibility areas when up in the wheelchair (WC), and on 03/13/2025 a fall mat was to be placed to the left side of the bed. Review of the February 2025 through March 2025 facility incident reporting log showed fall entries related to Resident 65 were made on 02/05/2024, 02/13/2025, 02/28/2025, 03/12/2025, and 03/14/2025. Review of Resident 65's fall reports showed: - Unwitnessed fall on 02/05/2025 at 4:50 PM (1 hour and 50 minutes after their admission), staff entered Resident 65's room to answer their call light and found them lying on the floor. Resident 65 was restless, continued to attempt to self-transfer out of bed. Resident 65 had aphasia (disorder that made it hard to understand and speak) and could not explain the situation. Interventions implemented were to place the bed against the wall in the lowest position and provide the resident with non-skid socks. No documentation of neuro checks was found. - Unwitnessed fall on 02/13/2025, Resident 65 was found on the floor next to their roommate's bed. The mattress on the floor next to [Resident 65's] bed had been moved away from the bed about 4-5 inches and appeared the resident self-transferred. Intervention implemented was to add Resident 65 to the Falling Leaves program. The attached neurological evaluation flow sheet vital signs section showed only five of 12 sets of vital signs were documented. - Unwitnessed fall on 02/28/2025, Resident 65 slid out of their WC, was confused, unable to state what happened and neuro checks were started, however, no documentation of neuro checks were found. - Unwitnessed fall on 03/12/2025, Resident 65 was found sitting on the floor next to their bed with the fall mat again pushed away from the bed, neuro checks were initiated. The incident summary showed Resident 65's care plan remained appropriate. No documentation of intervention implemented, or neuro checks was found. - Unwitnessed fall on 03/14/2025, Resident 65 was found lying on the floor next to their WC near the nurses' station, and neuro checks were initiated. Intervention implemented was a therapy referral for WC evaluation. The attached neuro sheet showed omissions in documentation for four of 12 neuro assessments and eight of 12 sets of vital signs. Review of February 2025 through March 2025 nursing progress notes showed Resident 65 was inconsistently monitored for latent injuries after falls occurred. In an interview on 04/24/2025 at 10:34 AM, Staff H, Licensed Practical Nurse (LPN), stated residents were assessed for fall risk upon admission. Staff H explained when a fall occurred, an incident report was completed, the resident assessed for injuries, placed on alert to monitor for potential latent injuries, provider notified, and interventions implemented. Staff H further stated all unwitnessed falls and falls with head injury needed to have neuro checks completed and documented on the paper form. A fall intervention needed to be implemented when a fall occurred to prevent further falls and/or injury. Staff H acknowledged a resident's health and safety was in jeopardy if a resident was not consistently monitored after a fall occurred. In an interview on 04/24/2025 at 10:40 AM, Staff C, ADON, explained neuro checks were to be completed for unwitnessed falls or falls with head injury. Staff C stated staff were to document neuro checks on the paper neurological evaluation flow sheet when implemented. Staff C further stated residents were monitored for latent injuries via the neuro check flow sheet and nursing progress notes, if a resident was not monitored then staff would not know if or when a resident had a worsening injury, pain, or change of condition. Staff C reviewed Resident 65's fall reports and acknowledged there were omissions in Resident 65's neuro check monitoring, and staff should have monitored neuros consistently. <Resident 69> The 03/07/2025 significant change assessment documented Resident 69 had diagnoses including high blood pressure, anxiety and repeated falls. Resident 69 was cognitively intact and was able to make their needs known. The 12/10/2024 risk for falls care plan documented Resident 69 was at risk for falls related to weakness, poor vision, incontinence and functional impairments. The care plan had multiple fall interventions in place. Review of the September 2024 through March 2025 facility incident log showed Resident 69 sustained a fall on 09/19/2025. A 09/19/2024 progress note documented Resident 69 reported they fell in their room and had gotten themselves up off the floor. The resident stated they landed on their right side. The nurse stated they initiated neuros. The neuro monitoring sheet revealed 10 omissions and documented the resident was asleep. Review of Resident 69's record revealed there were no further progress notes regarding the fall. <Resident 311> The 04/04/2025 admission assessment documented Resident 311 had diagnoses including cancer, high blood pressure and diabetes. Resident 311 had moderate cognitive impairments and was able to make their needs known. The 12/10/2024 risk for falls care plan documented Resident 311 was at risk for falls related to deconditioning, pain and medications. The care plan had multiple fall interventions in place.<br[TRUNCATED]

Based on interview and record review, the facility failed to fully inform residents and/or their representatives on admission to the facility of the care to be provided and/or the professional who would furnish that care for 4 of 5 sampled residents (Residents 12, 262, 263 and 313), reviewed for admission. Additionally, the facility failed to provide information of potential risks and/or benefits of psychotropic medications (medications that treat disorders of the mind and emotions) prior to their use for 3 of 5 sampled residents (Residents 79, 313 and 38), reviewed for unecessary medications. These failures placed residents and/or their representatives at risk of not being fully informed of the risks, benefits or alternative treatment options available before decisions were made regarding medications and/or medical care. Findings included . ADMISSION CONSENT TO TREAT <Resident 12> The 03/09/2025 admission assessment documented Resident 12 was admitted to the facility on [DATE] with diagnoses that included muscle weakness and bacterial blood infection. Resident 12 was cognitively intact and able to clearly verbalize their needs. A review of Resident 12's record found no documentation the Admission Agreement and/or supporting documents had been reviewed or discussed with Resident 12 at the time of admission as required. Review of the 03/03/2025 floor nurse Admission Process check list and March 2025 nursing progress notes did not include documentation that Resident 12 signed a consent for routine nursing care, or other care and services to be provided by the facility or providers. <Resident 313> The 03/31/2025 admission assessment documented Resident 313 was admitted to the facility on [DATE] with diagnoses that included dementia and failure to thrive. The assessment further showed Resident 313 had severe cognitive impairment. A review of Resident 313's record found no documentation that the Admission Agreement and/or supporting documents had been reviewed or discussed with Resident 313 at the time of admission as required. Review of the 03/25/2025 floor nurse Admission Process check list and March through April 2025 nursing progress notes did not include documentation that Resident 313 or their representative signed a consent for routine nursing care, or other care and services to be provided by the facility or providers. During an interview on 04/18/2025 at 2:47 PM, Resident 313 stated they did not recall if staff informed them of the type of care they were to receive or who was to provide their care when they were admitted to the facility. Resident 313 was unable to recall if they signed a consent for care and treatment when admitted . <Resident 262> The 04/03/2025 admission assessment documented Resident 262 was admitted to the facility on [DATE] with diagnoses that included weakness and wound infection. Resident 262 was cognitively intact and able to clearly verbalize their needs. A review of Resident 262's record found no documentation that the Admission Agreement and/or supporting documents had been reviewed or discussed with Resident 262 at the time of admission as required. Review of the 03/28/2025 floor nurse Admission Process check list and March through April 2025 nursing progress notes did not include documentation that Resident 262 signed a consent for routine nursing care, or other care and services to be provided by the facility or providers. During an interview on 04/18/2025 at 2:49 PM, Resident 262 stated they were not informed of the type of care they were to receive or who was to provide their care when admitted to the facility. Resident 262 further stated they did not recall signing a consent for care and treatment when admitted . <Resident 263> The 04/06/2025 admission assessment documented Resident 263 was admitted to the facility on [DATE] with diagnoses that included hip fracture. Resident 263 was cognitively intact and able to clearly verbalize their needs. A review of Resident 263's record found no documentation that the Admission Agreement and/or supporting documents had been reviewed or discussed with Resident 263 at the time of admission as required. Review of the 03/31/2025 floor nurse Admission Process check list and March through April 2025 nursing progress notes did not include documentation that Resident 263 signed a consent for routine nursing care, or other care and services to be provided by the facility or providers. During an interview on 04/18/2025 at 2:53 PM, Resident 263 stated they were not informed of the type of care they were to receive or who was to provide their care when admitted to the facility. Resident 263 further stated they did not recall signing a consent for care and treatment when admitted . On 04/17/2025 at 10:37 AM, a list of admissions in the past 30 days with full admission packets were requested from Staff A, Administrator. Review of the provided 30-day admissions report documented that from 03/20/2025 through 04/17/2025, the facility had 36 admissions. Only two of the 36 admission packets that contained a consent for routine nursing care, or other care and services to be provided by the facility or providers, were provided. During an interview on 04/21/2025 at 9:45 AM, Staff T, Social Service Assistant, stated they were unsure if admission consents were required to be completed within a certain timeframe. Staff T acknowledged that residents or their representatives would not be fully informed of care and/or services to be provided if admission documents were not reviewed with them timely during the admission process. During an interview on 04/21/2025 at 11:11 AM, Staff U, Director of Business Development, stated admission documents that included consents for routine nursing care, or other care and services to be provided by the facility or providers were completed electronically. Staff U acknowledged they were able to locate only two admission packets for admissions that occurred in the past 30 days. Staff U stated the facility struggled to complete admission documents timely since January of 2025; the Admissions Director/Coordinator position had been vacant. Staff U acknowledged that a lack of reviewing admission documents with residents prevented residents from being informed of and making decisions regarding their care. During an interview on 04/22/2025 at 10:22 AM, Staff A, Administrator, acknowledged the facility had identified admission documents and consents were not completed timely but had been unable to implement corrective action due to staffing vacancies. Staff A stated they expected admission agreements to be reviewed and signed by residents or their representatives within 72 hours of admission. PSYCHOTOPIC MEDICATION CONSENTS <Resident 79> The 02/27/2025 admission assessment documented Resident 79 had diagnoses that included debility (physical weakness, especially from illness) and dementia (a long-term mental decline that involved problems with memory, behavior and muscle control.) Resident 79 had severely impaired cognition and required maximum assistance to stand and transfer between the bed or wheelchair. Resident 79's adult child was the resident's primary decision maker. During a telephone interview on 04/15/25 at 10:28 AM, Resident 79's representative stated they had been notified four or five times since the resident's admission that Resident 79 had fallen. They stated they were then called and told Resident 79 was being started on an antipsychotic medication, quetiapine, because Resident 79 tried to get up unassisted frequently. Resident 79's representative stated they agreed to have the resident started on a medication to stimulate their appetite but was unsure if the quetiapine had been started or not. Review of the facility Accident and Incident log documented Resident 79 had fallen frequently since their admission. A 04/12/2025 at 10:29 PM nursing progress note documented Resident 79 had been very impulsive, insistent on standing and attempts to maintain the resident's attention had little effect to maintain the resident's safety. The physician was notified and ordered quetiapine to be given every 12 hours as needed to stabilize the resident's mood. There was no mention of attempts to contact Resident 79's representative for consent and no consent was present in Resident 79's medical record. The April 2025 Medication Administration Record (MAR) documented that quetiapine was administered that evening, on 04/12/2025 at 8:18 PM. A 04/13/2025 at 8:48 AM nursing progress note documented that Resident 79's representative was called and informed about the physician recommendation for quetiapine and because the resident became agitated when staff asked them to not try to stand up without staff assistance. The family member declined the medication because it was indicated for bipolar and schizophrenia and because of possible side effects. The note documented the resident's representative was then asked what they would like staff to do then, to keep the resident safe when the resident was agitated and did not follow instructions. The medication was discontinued. During an interview on 04/24/2025 at 10:20 AM, Staff DD, Medical Records, confirmed there was no consent for quetiapine for Resident 79. <Resident 313> The 03/31/2025 admission assessment documented Resident 313 had diagnoses that included dementia (a disease that caused a decline in memory, thinking and reasoning skills and affected daily life). In addition, Resident 313 received hospice services for end-of-life care. The Order Summary Report dated 03/25/2025 through 04/16/2025 documented Lorazepam and Haloperidol, psychotropic medications, were prescribed on 03/25/2025 and were to be administered on an as needed basis to treat symptoms of anxiety and agitation commonly experienced at the end of one's life. The March 2025 and April 2025 Medication Administration Records (MARs) documented Resident 313 received their first dose of Lorazepam on 03/26/2025, and the first dose of Haloperidol on 03/27/2025. An informed consent regarding risks and benefits of Lorazepam was completed on 03/25/2025, prior to the resident's first dose of the medication. An informed consent regarding the risks and benefits of Haloperidol was completed on 04/06/2025, after the medication had already been administered to Resident 313. During an interview on 04/21/2025 at 9:35 AM, Staff H, Licensed Practice Nurse (LPN), stated informed consents for psychotropic medications needed to be obtained when the medication was ordered by the physician and prior to giving the first dose of the medication to the resident. During an interview on 04/21/2025 at 10:44 AM, Staff C, Assistant Director of Nursing, confirmed Resident 313's consent had not been completed. <Resident 38> The 02/01/2025 quarterly assessment, documented Resident 38 had diagnoses that included anxiety, depression, schizophrenia (disturbances in thoughts that affected a person's ability to think, feel and behave) and post-traumatic stress disorder (PTSD, a mental health disorder that was caused by an extremely stressful or terrifying event). Resident 38 was cognitively intact and received psychotropic medication daily. A review of the provider orders documented venlafaxine was ordered on 10/29/2024 to treat depression, and quetiapine was ordered on 10/30/2024 to treat schizophrenia. The November and December 2024 MARs documented the medications were administered to the resident daily. Further review of Resident 38's record showed the consents, and risks and benefits of the medications were obtained 49 days after the resident had received the medication. The psychotropic consents had not listed the more serious side effects/black box warnings (serious or life-threatening risks) of the medications. During an interview on 04/22/2025 at 9:00 AM, Staff X, LPN, stated informed consents were obtained prior to the first dose of the medication. Staff X added it was the resident's choice to take the medication, and they needed to be aware of the risks. In an interview on 04/22/2025 at 12:07 PM, Staff C, Assistant Director of Nursing, stated informed consents were obtained prior to the first dose of the medication. Staff C stated it was important so the residents could make a decision and acknowledge the side effects. Reference: WAC 388-97-0300 (3)(a) Refer to F572, F578, F579, F582, F620, and F625 for additional information 37544 42802 46115

Based on interview and record review the facility failed to routinely inform cognitively intact residents and/or the legal representatives of cognitively impaired residents of the facility rules, regulations governing resident conduct, resident rights including notice of Medicaid rights and responsibilities for 4 of 5 sampled residents (Resident 12, 313, 262, and 263), reviewed for admission. This failure placed residents at risk of not being fully informed of their rights, facility rules, and resident conduct expectations. Findings included . <Resident 12> According to the 03/09/2025 admission assessment, Resident 12 admitted to the facility on [DATE] with diagnoses including muscle weakness and bacterial blood infection. Resident 12 was cognitively intact and able to clearly verbalize their needs. Review of March 2025 nursing progress notes showed no documentation the admission agreement that included information on all resident rights and services, facility rules governing resident conduct, State-developed notice of Medicaid rights and obligations, and written acknowledgement of understanding was reviewed and/or discussed with Resident 12 upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 12 upon admission, as required. <Resident 313> According to the 03/31/2025 admission assessment, Resident 313 admitted to the facility on [DATE] with diagnoses including dementia and failure to thrive. The assessment further showed Resident 313 had severe cognitive impairment. Review of March 2025 nursing progress notes showed no documentation the admission agreement that included information on all resident rights and services, facility rules governing resident conduct, State-developed notice of Medicaid rights and obligations, and written acknowledgement of understanding was reviewed and/or discussed with Resident 313 and/or their representative upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 313 and/or their representative upon admission, as required. In an interview on 04/18/2025 at 2:47 PM, Resident 313 stated they did not recall if staff reviewed the facility rules, resident rights including Medicare/Medicaid rights, resident conduct expectations and responsibilities with them, upon admission to the facility. <Resident 262> According to the 04/03/2025 admission assessment, Resident 262 admitted to the facility on [DATE] with diagnoses including weakness and wound infection. The assessment further showed Resident 262 was cognitively intact and able to clearly verbalize their needs. Review of March 2025 through April 2025 nursing progress notes showed no documentation the admission agreement that included information on all resident rights and services, facility rules governing resident conduct, State-developed notice of Medicaid rights and obligations, and written acknowledgement of understanding was reviewed and/or discussed with Resident 262 upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 262 upon admission, as required. In an interview on 04/18/2025 at 2:49 PM, Resident 262 stated they did not recall if staff reviewed the facility rules, resident rights including Medicare/Medicaid rights, resident conduct expectations and responsibilities with them, upon admission to the facility. <Resident 263> According to the 04/06/2025 admission assessment, Resident 263 admitted to the facility on [DATE] with diagnoses including hip fracture. The assessment further showed Resident 263 was cognitively intact and able to clearly verbalize their needs. Review of March 2025 through April 2025 nursing progress notes showed no documentation the admission agreement that included information on all resident rights and services, facility rules governing resident conduct, State-developed notice of Medicaid rights and obligations, and written acknowledgement of understanding was reviewed and/or discussed with Resident 263 upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 263 upon admission, as required. In an interview on 04/17/2025 at 10:37 AM, a list of admissions in the past 30 days with full admission packets were requested from Staff A, Administrator. Review of the admissions report from 03/20/2025 through 04/17/2025 showed the facility had 36 admissions. Only two out of 36 admission packets that contained information on the facility rules, resident rights including Medicare/Medicaid rights, resident conduct and responsibilities were received. In an interview on 04/18/2025 at 2:53 PM, Resident 263 stated staff did not review or inform them of the facility rules, resident rights including Medicare/Medicaid rights, resident conduct expectations and responsibilities, upon admission to the facility. In an interview on 04/21/2025 at 9:45 AM, Staff T, Social Service Assistant, stated they were unsure of the time frame the admission packets and the asssociated paperwork were to be completed by. Staff T acknowledged residents and/or their representatives would not be fully informed of facility rules, rights, and responsibilities if admission paperwork and the associated paperwork was not reviewed with them timely. Staff T stated admission related paperwork should be reviewed and filled out timely upon admission. In an interview on 04/21/2025 at 11:11 AM, Staff U, Director of Business Development, explained admission packets and the associated admission paperwork were completed electronically. Staff U was informed the survey team requested admission packets for all admits in the past 30 days but only received two packets. Staff U acknowledged that was correct, they were only able to locate two admission packets for admits in the past 30 days. Staff U explained the facility had been struggling since January 2025 to complete admission packets timely because of the admissions director/coordinator position vacancy. Staff U acknowledged residents and/or their representatives would not be fully informed of facility rules, rights, resident conduct and responsibilities, if admission paperwork was not reviewed with them timely. In an interview on 04/22/2025 at 10:22 AM, Staff A, Administrator, stated the admissions director/coordinator and/or Staff U reviewed and completed the admission agreement packets and the associated paperwork with residents and/or their representatives. Staff A acknowledged the facility had identified admission packets were not being completed timely but were unable to implement corrective action due to staffing. Staff A stated they expected admission agreements to be reviewed and signed within 72 hours of an admission. Reference WAC 388-97-0300 (1)(a), (7)(b) Refer to F552, F578, F579, F582, F620, and F625 for additional information.

Based on record review and interview, the facility failed to routinely inform and provide written information regarding the right to formulate an advance directive (legal document that oulined wishes for medical care if a person was unable to make decisions for themselves) for 4 of 19 sampled residents (Resident 3, 15, 69, and 263), reviewed for advanced directives. This failure placed residents at risk of not being able to exercise their rights, not having their wishes honored, and a diminished quality of life. Findings included . Review of the facility policy titled Advance Directives dated March 2023, showed residents would be provided with written information concerning the right to formulate an advanced directive if they chose to do so. If the resident was incapacitated and unable to receive information about their right to formulate an advanced directive, the information may be provided to the resident's legal representative. Upon admission, the Social Service Director or designee would inquire of the resident, their family, and/or legal representative about the existence of any written advanced directives. <Resident 3> A review of the record showed Resident 3 had diagnoses which included chronic obstructive pulmonary disease (COPD, inflammation in the lungs that made it difficult to breathe) and chronic pain. The record did not contain documentation that Resident 3 had been informed of their right to form an advance directive or if they had accepted assistance in forming one. <Resident 15> A review of the record showed Resident 15 had diagnoses which included COPD and high blood pressure. The record did not contain documentation that Resident 15 had been informed of their right to form an advanced directive or if they had accepted assistance in forming one. <Resident 69> A review of the record showed Resident 69 had diagnoses which included high blood pressure and anxiety. The record did not contain documentation that Resident 69 had been informed of their right to form an advance directive or if they had accepted assistance in forming one. In an interview on 04/22/2025 at 9:55 AM, Staff C, Assistant Director of Nursing, stated advance directives were completed upon admission and it was important so they would know how to care for the residents. Staff C stated they believed Social Services were responsible for completing the advance directives. In an interview on 04/22/2025 at 9:59 AM, Staff V, Social Service Director, stated advance directives were discussed in the care conferences which were held within 48 to 72 hours of admission. Staff V stated the discussion about advanced directives were placed in the progress notes. Staff V was unable to provide information that advanced directives were offered to the residents listed above. <Resident 263> According to the 04/06/2025 admission assessment, Resident 263 admitted to the facility on [DATE] with diagnoses which included a hip fracture. The assessment further showed Resident 263 was cognitively intact and able to clearly verbalize their needs. Review of March 2025 nursing progress notes showed no documentation the admission agreement that included information on the right to formulate advanced directives was reviewed and/or discussed with Resident 263 upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 263 upon admission, as required. In an interview on 04/17/2025 at 10:37 AM, a list of admissions in the past 30 days with full admission packets that included information on the right to formulate advanced directives was requested from Staff A, Administrator. Review of the admissions report from 03/20/2025 through 04/17/2025 showed the facility had 36 admissions. Only two out of 36 admission packets were received. In an interview on 04/18/2025 at 2:53 PM, Resident 263 stated staff did not review and/or discuss the right to formulate advanced directives with them when they admitted to the facility. In an interview on 04/21/2025 at 9:45 AM, Staff T, Social Service Assistant, stated they were unsure of the time frame the admission packets that contained information on the right to formulate advanced directives, were to be completed by. Staff T acknowledged residents and/or their representatives would not be fully informed of the right to formulate advanced directives if admission paperwork was not reviewed with them timely. Staff T stated admission paperwork should be reviewed and filled out timely upon admission. In an interview on 04/21/2025 at 11:11 AM, Staff U, Director of Business Development, explained admission packets and the information on the right to formulate advanced directives, were completed electronically. Staff U was informed the survey team requested admission packets for all admits in the past 30 days but only received two packets. Staff U acknowledged that was correct, they were only able to locate two admission packets for admits in the past 30 days. Staff U explained the facility had been struggling since January 2025 to complete admission packets timely because of the admissions director/coordinator position vacancy. Staff U acknowledged residents and/or their representatives would not be fully informed of the right to formulate advanced directives if admission paperwork was not reviewed with them timely. In a follow-up interview on 04/22/2025 at 10:11 AM, Staff V explained they asked residents if they had advanced directives when their care conferences were held and requested copies of paperwork if they had advanced directives. Staff V further stated they did not offer or provide information on the right to formulate advanced directives if and/or when a resident stated they did not have any. In an interview on 04/22/2025 at 10:22 AM, Staff A stated admission agreement packets that contained information on the right to formulate advanced directives was to be reviewed and completed with residents and/or their representatives by the admissions director/coordinator or Staff U but information on advanced directives was also reviewed during care conferences. Staff A acknowledged the facility had identified admission packets were not being completed timely but were unable to implement corrective action due to staffing. Staff A stated they expected admission agreements to be reviewed and signed within 72 hours of admission. Reference: WAC 388-97-0300(1)(b), (3)(a-c) Refer to F552, F579, F572, F582, F620, and F625 for additional information.

Based on interview and record review, the facility failed to routinely provide residents and/or their representatives oral and written information on how to apply for and use Medicare and/or Medicaid benefits for 4 of 5 sampled residents (Resident 12, 313, 262, and 263), reviewed for admission. This failure placed residents and/or their representatives at risk of not being fully informed of their Medicare/Medicaid rights, unmet care needs, and a diminished quality of life. Findings included . <Resident 12> According to the 03/09/2025 admission assessment, Resident 12 admitted to the facility on [DATE] with diagnoses which included muscle weakness and bacterial blood infection. Resident 12 was cognitively intact and able to clearly verbalize their needs. Review of the March 2025 nursing progress notes showed no documentation the admission agreement that included information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare was reviewed and/or discussed with Resident 12 upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 12 upon admission, as required. <Resident 313> According to the 03/31/2025 admission assessment, Resident 313 admitted to the facility on [DATE] with diagnoses which included dementia and failure to thrive. The assessment further showed Resident 313 had severe cognitive impairment. Review of March 2025 nursing progress notes showed no documentation the admission agreement that included information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare was reviewed and/or discussed with Resident 313 and/or their representative upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 313 and/or their representative upon admission, as required. In an interview on 04/18/2025 at 2:47 PM, Resident 313 stated they did not recall if staff orally reviewed or provided them written information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare, when they admitted to the facility. <Resident 262> According to the 04/03/2025 admission assessment, Resident 262 admitted to the facility on [DATE] with diagnoses which included weakness and wound infection. The assessment further showed Resident 262 was cognitively intact and able to clearly verbalize their needs. Review of March 2025 nursing progress notes showed no documentation the admission agreement that included information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare was reviewed and/or discussed with Resident 262 upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 262 upon admission, as required. In an interview on 04/18/2025 at 2:49 PM, Resident 262 stated staff did not orally review or provided them written information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare when they admitted to the facility. <Resident 263> According to the 04/06/2025 admission assessment, Resident 263 admitted to the facility on [DATE] with diagnoses which included a hip fracture. The assessment further showed Resident 263 was cognitively intact and able to clearly verbalize their needs. Review of March 2025 through April 2025 nursing progress notes showed no documentation the admission agreement that included information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare was reviewed and/or discussed with Resident 263 upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 263 upon admission, as required. In an interview on 04/17/2025 at 10:37 AM, a list of admissions in the past 30 days and full admission packets were requested from Staff A, Administrator. Review of the Admissions Report from 03/20/2025 through 04/17/2025 showed the facility had 36 admissions. Only two out of 36 admission packets that included information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare were received. In an interview on 04/18/2025 at 2:53 PM, Resident 263 stated staff did not orally review or provided them written information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare when they admitted to the facility. In an interview on 04/21/2025 at 9:45 AM, Staff T, Social Service Assistant, stated they were unsure of the time frame the admission packets that included information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare were to be completed by. Staff T acknowledged residents and/or their representatives would not be fully informed on how to apply or use Medicare and/or Medicaid benefits if admission paperwork was not reviewed with them timely. Staff T stated admission paperwork should be reviewed and filled out timely upon admission. In an interview on 04/21/2025 at 11:11 AM, Staff U, Director of Business Development, explained admission packets that included information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare were completed electronically. Staff U was informed the survey team requested admission packets for all admits in the past 30 days but only received two packets. Staff U acknowledged that was correct, they were only able to locate two admission packets for admits in the past 30 days. Staff U explained the facility had been struggling since January 2025 to complete admission packets timely because of the admissions director/coordinator position vacancy. Staff U acknowledged residents and/or their representatives on would not be fully informed on how to apply for and use Medicare and/or Medicaid benefits if admission paperwork was not reviewed with them timely. In an interview on 04/22/2025 at 10:22 AM, Staff A, Administrator, stated admission agreement packets that contained included information on how to apply for and use Medicare and/or Medicaid benefits, Denial of Medicare and Medicaid, discontinuation of Medicaid or Medicare were reviewed and completed with residents and/or their representatives by the admissions director/coordinator or Staff U. Staff A acknowledged the facility had identified admission packets were not being completed timely but were unable to implement corrective action due to staffing. Staff A stated they expected admission agreements to be reviewed and signed within 72 hours of an admission. Reference WAC 388-97-0300 (9) Refer to F552, F578, F572, F582, F620, and F625 for additional information.

Based on interview and record review, the facility failed to routinely inform cognitively intact residents and/or their legal representatives, of items and services included in nursing services which the resident may and may not be charged for and amount of potential costs for services not covered under Medicare and/or Medicaid or by the facility's per diem rate for 4 of 5 sampled residents (Resident 12, 313, 262, and 263), reviewed for admission. Additionally, the facility failed to provide the required beneficiary notices for 2 of 3 sampled residents (Residents 19 and 85), reviewed for required notices and associated choices related to Medicare services ending. These failures placed residents at risk of not being fully informed of their rights and/or financial responsibilities, unmet care needs, and diminished quality of life. Findings included . Review of the Skilled Nursing Facility (SNF) Advanced Beneficiary Notice (ABN) form showed it provided information to Medicare beneficiaries so that they could decide if they wished to continue receiving the skilled services that might not be paid for by Medicare and assume financial responsibility. The form was required when a resident had skilled benefit days remaining, was being discharged from Medicare Part A services, and continued living in the facility. ADMISSION INFORMATION <Resident 12> According to the 03/09/2025 admission assessment, Resident 12 admitted to the facility on [DATE] with diagnoses which included muscle weakness and bacterial blood infection. Resident 12 was cognitively intact and able to clearly verbalize their needs. Review of March 2025 nursing progress notes showed no documentation the admission agreement which included information on basic charges, payments, interest on late payments, and the facility discharge check out time of 11:00 AM. No documentation was found that showed the facility policy of charging a fee of 660 dollars, the private daily room rate, for going past the 11:00 AM discharge time was provided to the resident and/or their representative. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 12 upon admission, as required. <Resident 313> According to the 03/31/2025 admission assessment, Resident 313 admitted to the facility on [DATE] with diagnoses which included dementia and failure to thrive. The assessment further showed Resident 313 had severe cognitive impairment. Review of March 2025 nursing progress notes showed no documentation the admission agreement which included information on basic charges, payments, interest on late payments, and the facility discharge check out time of 11:00 AM. No documentation was found that showed the facility policy of charging a fee of 660 dollars, the private daily room rate, for going past the 11:00 AM discharge time was provided to the resident and/or their representative. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 313 upon admission, as required. In an interview on 04/18/2025 at 2:47 PM, Resident 313 stated they did not recall if staff reviewed items and services included in nursing services which the resident may and may not be charged for and costs of potential charges for services not covered under Medicare and/or Medicaid or by the facility's per diem rate with them, upon admission to the facility. <Resident 262> According to the 04/03/2025 admission assessment, Resident 262 admitted to the facility on [DATE] with diagnoses which included weakness and wound infection. The assessment further showed Resident 262 was cognitively intact and able to clearly verbalize their needs. Review of March and April 2025 nursing progress notes showed no documentation the admission agreement which included information on basic charges, payments, interest on late payments, and the facility discharge check out time of 11:00 AM. No documentation was found that showed the facility policy of charging a fee of 660 dollars, the private daily room rate, for going past the 11:00 AM discharge time was provided to the resident and/or their representative. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 262 upon admission, as required. In an interview on 04/18/2025 at 2:49 PM, Resident 262 stated they did not recall if staff reviewed items and services included in nursing services which the resident may and may not be charged for and costs of potential charges for services not covered under Medicare and/or Medicaid or by the facility's per diem rate with them, upon admission to the facility. <Resident 263> According to the 04/06/2025 admission assessment, Resident 263 admitted to the facility on [DATE] with diagnoses which included a hip fracture. The assessment further showed Resident 263 was cognitively intact and able to clearly verbalize their needs. Review of March 2025 nursing progress notes showed no documentation the admission agreement which included information on basic charges, payments, interest on late payments, and the facility discharge check out time of 11:00 AM. No documentation was found that showed the facility policy of charging a fee of 660 dollars, the private daily room rate, for going past the 11:00 AM discharge time was provided to the resident and/or their representative. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 263 upon admission, as required. In an interview on 04/17/2025 at 10:37 AM, a list of admissions in the past 30 days and full admission packets that included the above information was requested from Staff A, Administrator. Review of the Admissions Report from 03/20/2025 through 04/17/2025 showed the facility had 36 admissions. Only two out of 36 admission packets were received. In an interview on 04/18/2025 at 2:53 PM, Resident 263 stated staff did not review items and services included in nursing services which the resident may and may not be charged for and costs of potential charges for services not covered under Medicare and/or Medicaid or by the facility's per diem rate with them, upon admission to the facility. In an interview on 04/21/2025 at 9:45 AM, Staff T, Social Service Assistant, stated they were unsure of the time frame the admission packets that contained information on basic charges, payments, nursing services which the resident may and may not be charged for and amount of potential costs for services not covered under Medicare and/or Medicaid or by the facility's per diem rate such as the facility $660 late discharge fee NOT payable by insurance for late discharges without prior arrangements made, and interest on late payments, were to be completed by. Staff T acknowledged residents and/or their representatives would not be fully informed of facility rules, rights, and responsibilities if admission paperwork was not reviewed with them timely. Staff T stated admission paperwork should be reviewed and filled out timely upon admission. In an interview on 04/21/2025 at 11:11 AM, Staff U, Director of Business Development, explained admission packets that contained information on basic charges, payments, nursing services which the resident may and may not be charged for and amount of potential costs for services not covered under Medicare and/or Medicaid or by the facility's per diem rate such as the facility $660 late discharge fee NOT payable by insurance for late discharges without prior arrangements made, and interest on late payments, were completed electronically. Staff U was informed the survey team requested admission packets for all admits in the past 30 days but only received two packets. Staff U acknowledged that was correct, they were only able to locate two admission packets for admits in the past 30 days. Staff U explained the facility had been struggling since January 2025 to complete admission packets timely because of the admissions director/coordinator position vacancy. Staff U acknowledged residents and/or their representatives would not be fully informed of potential charges, fees, interest and/or financial responsibility if admission paperwork was not reviewed with them timely. In an interview on 04/22/2025 at 10:22 AM, Staff A, Administrator, stated admission agreement packets that contained information on basic charges, payments, nursing services which the resident may and may not be charged for and amount of potential costs for services not covered under Medicare and/or Medicaid or by the facility's per diem rate such as the facility $660 late discharge fee NOT payable by insurance for late discharges without prior arrangements made, and interest on late payments were reviewed and completed with residents and/or their representatives by the admissions director/coordinator or Staff U. Staff A acknowledged the facility had identified admission packets were not being completed timely but were unable to implement corrective action due to staffing. Staff A stated they expected admission agreements to be reviewed and signed within 72 hours of an admission. MEDICARE COVERAGE NOTICES <Resident 19> Review of a Notice of Medicare Non-Coverage (NOMNC) form showed Resident 19's last day of Medicare Part A services ended on 01/30/2025. Record review found no documentation that showed the facility provided a SNF ABN to Resident 19 as required. Resident 19 currently resided at the facility. <Resident 85> Review of a NOMNC form showed Resident 85's last day of Medicare Part A services ended on 11/25/2024. Record review found no documentation that showed the facility provided a SNF ABN to Resident 85 as required. Resident 85 currently resided in the facility. On 04/23/2025 at 1:46 PM, the SNF Beneficiary Notification Review forms were reviewed with Staff A, Administrator. Staff A stated that the SNF ABN forms were not given to Residents 19 and 85 because, there was no BOM in the facility since the beginning of February [2025]. Staff A stated the BOM's duties were absorbed between them and Corporate oversight. Reference WAC 388-97-0300 (1)( e) (5), (6) Refer to F552, F578, F572, F579, F620, and F625 for additional information. 40297

<Resident 90> According to the 01/05/2025 admission assessment, Resident 90 had diagnoses which included septicemia (a serious infection caused when bacteria entered the bloodstream and spread throughout the body) and respiratory failure (a condition where the lungs cannot exchange oxygen and carbon dioxide correctly.) The resident had severe cognitive impairment. A 03/09/2025 progress note at 12:21 PM documented the resident developed difficulty breathing and a fever. The resident's family member requested they be sent to the emergency room for evaluation and treatment. A progress note on 03/09/2025 at 12:37 PM documented that the resident was transported by ambulance and admitted to the hospital. A review of Resident 90's record showed no documentation that any records were sent to the hospital, including recent vital signs, current medication list, care plan, code status and current provider, as required. There was no documentation that the resident's condition was reported to the hospital. During an interview on 04/23/2025 at 9:55 AM, Staff BB, LPN, stated the nurse would send the face sheet (that has name, birth date, insurance/provider/family contact information), medication list and recent vital signs with the resident to the hospital. When asked if there was a form or check list, where they could document what was sent with the resident, they responded they didn't think so, but a progress note should be made. During an interview on 04/24/2025 at 10:42 AM, Staff CC, LPN stated when a resident went to the hospital, the nurse sent them with copies of current provider orders, their med list, code status, vital signs and face sheet. Staff CC further stated the facility did not have a checklist, but the nurse needed to make a progress note and fill out the Transfer Form. Staff CC searched for the form in Resident 90's electronic medical record and was unable to find the transfer form. During an interview on 04/24/2025 at 11:17 AM, Staff F, RCM, stated copies of the resident face sheet, POLST, current med list and any chart notes were sent to the hospital. Staff F stated they just found out about the transfer form in the electronic documentation system, they had not been aware of it before. They further stated they hoped staff put in a progress note. Staff CC acknowleged this information should have been sent to the hospital, and documented in the resident's record. Reference WAC 388-97-0120 (1) Refer to F623 and F625 for additional information. Based on interview and record review the facility failed to repeatedly ensure resident hospital transfer documentation was completed as required to include the basis for hospital transfer, specific resident needs unable to be met by the facility, facility attempts to meet the needs, services available at the receiving facility to meet needs, and what information was conveyed to the receiving provider for 3 of 4 sampled residents (Resident 16, 41, and 90), reviewed for hospitalization. This failure placed residents at risk of potential delays in emergent hospital treatment, unmet care needs, and diminished quality of life. Findings included . <Resident 41> According to the 02/10/2025 admission assessment, Resident 41 admitted to the facility on [DATE] with diagnoses including spinal cord compression (pressure on the spinal cord). Resident 41 was cognitively intact and able to clearly verbalize their needs. Review of the 03/19/2025 neurosurgeons (doctor that specialized in nerve, brain, and spinal cord surgery) progress note showed Resident 41 had worsening spinal cord compression of the neck with worsening weakness and functional abilities. The neurosurgeon's plan was for Resident 41 to [NAME] surgery in the near future. Review of the 03/28/2025 neurosurgeon's pre-operative (before surgery) instructions showed Resident 41 was scheduled to undergo surgery on 04/18/2025. Review of the 04/08/2025 provider progress note showed Resident 41 had significant spinal stenosis (narrowing of spinal canal) of the neck with spinal cord compression. Resident 41 was scheduled to undergo spinal neck surgery on 04/18/2025. Review of the April 2025 nursing progress notes showed no progress notes documented on 04/18/2025. No documentation was found in the resident's record to show the basis for hospital transfer, what condition Resident 41 was in at the time of hospital transfer, what information was provided to the receiving hospital, what specific needs were unable to be met by the facility, and what services were available at the receiving facility. During an observation on 04/18/2025 at 8:50 AM, Resident 41 was not in their room and their bed was stripped of linens. Similar observations were made at 10:47 AM that same day and on 04/21/2025 at 6:16 AM. During an interview on 04/18/2025 at 12:25 PM, Staff Z, Licensed Practical Nurse (LPN), stated Resident 41 was out of the facility at a surgery appointment today. During an interview on 04/23/2025 at 9:30 AM, Staff C, Assistant Director of Nursing (ADON), stated Resident 41 went to the hospital for a planned spinal cord surgery. Staff C reviewed Resident 41's medical record. Staff C acknowledged there were no progress notes in Resident 41's record to show where they were at or what condition they were in at time of transfer and there should have been. <Resident 16> According to the 03/11/2025 significant change in condition assessment, Resident 16 had diagnoses including heart failure (heart unable to pump sufficient blood) and muscle weakness. Resident 16 was cognitively intact and able to clearly verbalize their needs. Review of the February 2025 nursing progress notes showed on 02/02/2025 Resident 16 had a harsh cough with chest congestion. On 02/03/2025 Resident 16 was flushed, hot to touch, had a barky cough, and increased confusion and tremors. On 02/04/2025 Resident 16 was ashy in color, unresponsive, had an increased temperature, decreased oxygen levels, and they were transported to the hospital for evaluation. No documentation was found in the resident's record to show what information was provided to the receiving hospital, what specific needs were unable to be met by the facility, and what services were available at the receiving facility. In an interview on 04/22/2025 at 12:06 PM, Staff H, LPN, stated the facility did not utilize the eINTERACT (form that would electronically transmit entered information to the hospital) hospital transfer forms at the facility when a resident was transferred to the hospital. Staff H explained they documented in the progress notes, sent relevant information to the hospital, and called and gave the hospital a report on the resident's condition. In an interview on 04/22/2025 at 12:24 PM, Staff C, ADON, explained they would send a resident's physician order for life sustaining treatment (POLST), medication list, progress notes, and face sheet when a resident was transferred to the hospital. Staff C reviewed Resident 16's medical record. Staff C acknowledged they were unable to find what information was provided to the receiving hospital, what specific needs were unable to be met by the facility, and what services were available at the receiving facility for Resident 16's 02/04/2025 hospital transfer. In an interview on 04/22/2025 at 1:54 PM, Staff E, Regional Director of Clinical Operations, explained the facility utilized two different eINTERACT forms for hospital transfers that included detailed resident information including the reason for the hospital transfer. Staff E reviewed Resident 16's medical record. Staff E stated they were unable to find what information was provided to the receiving hospital, what specific needs were unable to be met by the facility, and what services were available at the receiving facility for Resident 16's 02/04/2025 hospital transfer. Staff E acknowledged staff should have completed the eINTERACT forms for Resident 16's hospital transfer.

Based on interview and record review the facility failed to routinely review and provide written information regarding bed holds (the right to pay the facility to hold their room or bed while hospitalized or on therapeutic leave) upon admission for 4 of 5 sampled residents (Resident 12, 313, 262, and 263), reviewed for admission and upon transfer to the hospital for 4 of 4 sampled residents (Resident 19, 16, 41, and 90), review for hospitalizations. This failure placed residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized or on therapeutic leave. Findings included . An undated facility policy titled Bed Hold showed that the facility would inform the residents or their representatives in writing of the bed hold return policy at the time of admission. A second written notice was provided at the time of transfer, or in cases of emergency transfer, within 24 hours. The policy also showed the facility would document multiple attempts to reach the resident's representative in cases where the facility was unable to notify them. BED HOLD UPON admission <Resident 12> According to the 03/09/2025 admission assessment, Resident 12 admitted to the facility on [DATE] with diagnoses including muscle weakness and bacterial blood infection. Resident 12 was cognitively intact and able to clearly verbalize their needs. Review of the March 2025 nursing progress notes showed no documentation the admission agreement that included information on the facility bed hold policy was reviewed and/discussed with Resident 12 upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 12 upon admission, as required. <Resident 313> According to the 03/31/2025 admission assessment, Resident 313 admitted to the facility on [DATE] with diagnoses including dementia and failure to thrive. The assessment further showed Resident 313 had severe cognitive impairment. Review of the March 2025 nursing progress notes showed no documentation the admission agreement that included information on facility bed hold policy was reviewed and/or discussed with Resident 313 and/or their representative upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 313 and/or their representative upon admission, as required. In an interview on 04/18/2025 at 2:47 PM, Resident 313 stated they did not recall if staff reviewed the facility bed hold policy with them, upon admission to the facility. <Resident 262> According to the 04/03/2025 admission assessment, Resident 262 admitted to the facility on [DATE] with diagnoses including weakness and wound infection. The assessment further showed Resident 262 was cognitively intact and able to clearly verbalize their needs. Review of the March 2025 through April 2025 nursing progress notes showed no documentation the admission agreement that included information on the facility bed hold policy was reviewed and/or discussed with Resident 262 upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 262 upon admission, as required. In an interview on 04/18/2025 at 2:49 PM, Resident 262 stated they did not recall if staff reviewed the facility bed hold policy with them, upon admission to the facility. <Resident 263> According to the 04/06/2025 admission assessment, Resident 263 admitted to the facility on [DATE] with diagnoses including hip fracture. The assessment further showed Resident 263 was cognitively intact and able to clearly verbalize their needs. Review of the March 2025 nursing progress notes showed no documentation the admission agreement that included information on the facility bed hold policy was reviewed and/or discussed with Resident 263 upon admission, as required. Additional review of the resident's record found no documentation the admission agreement and/or included paperwork had been reviewed or discussed with Resident 263 upon admission, as required. In an interview on 04/17/2025 at 10:37 AM, a list of admissions in the past 30 days with full admission packets that included information on the facility bed hold policy were requested from Staff A, Administrator. Review of the admissions report from 03/20/2025 through 04/17/2025 showed the facility had 36 admissions. Only two out of 36 admission packets were received. In an interview on 04/18/2025 at 2:53 PM, Resident 263 stated staff had not reviewed and/or discussed the facility bed hold policy with them, upon admission to the facility. In an interview on 04/21/2025 at 9:45 AM, Staff T, Social Service Assistant, stated they were unsure of the time frame the admission packets that contained information on the facility bed hold policy, were to be completed by. Staff T acknowledged residents and/or their representatives would not be fully informed of the facility bed hold policy if admission paperwork was not reviewed with them timely. Staff T stated admission paperwork should be reviewed and filled out timely upon admission. In an interview on 04/21/2025 at 11:11 AM, Staff U, Director of Business Development, explained admission packet that contained information on the facility bed hold policy, were completed electronically. Staff U was informed the survey team requested admission packets for all admits in the past 30 days but only received two packets. Staff U acknowledged that was correct, they were only able to locate two admission packets for admits in the past 30 days. Staff U explained the facility had been struggling since January 2025 to complete admission packets timely because of the admissions director/coordinator position vacancy. Staff U acknowledged residents and/or their representatives would not be fully informed of the facility bed hold policy if admission paperwork was not reviewed with them timely. In an interview on 04/22/2025 at 10:22 AM, Staff A, Administrator, stated the admission agreement packet that contained information on the facility bed hold policy was to be reviewed and completed with residents and/or their representatives by the admissions director/coordinator or Staff U. Staff A acknowledged the facility had identified admission packets were not being completed timely but were unable to implement corrective action due to staffing. Staff A stated they expected admission agreements to be reviewed and signed within 72 hours of admission. BED HOLD UPON TRANSFER <Resident 19> Review of Resident 19's medical record showed they were admitted to the facility on [DATE], assessed to have moderately impaired cognition, and had a Power of Attorney (an agent who can act on their behalf in certain matters). The progress notes showed the resident experienced a change in condition on 10/16/2024 and 02/23/2025 and required a transfer to the hospital from the facility. Review of the medical record showed no documentation the facility provided a bed hold notice to the resident or their representative when the hospital transfers occurred. The above findings were shared with Staff C, Assistant Director of Nursing, on 04/23/2025 at 8:49 AM. Staff C confirmed the medical record showed no bed hold was provided to the resident or their representative and expected to see documentation that showed it was provided at the time of transfer or shortly thereafter. <Resident 41> According to the 02/10/2025 admission assessment, Resident 41 admitted to the facility on [DATE] with diagnoses including spinal cord compression (pressure on the spinal cord). Resident 41 was cognitively intact and able to clearly verbalize their needs. Review of the 04/08/2025 provider progress note showed Resident 41 had significant spinal stenosis (narrowing of spinal canal) of the neck with spinal cord compression. Resident 41 was scheduled to undergo spinal neck surgery on 04/18/2025. Review of the April 2025 nursing progress notes showed no progress notes documented on 04/18/2025. No documentation was found to show Resident 41 was offered a bed hold at the time of hospital transfer, as required. <Resident 16> According to the 03/11/2025 assessment, Resident 16 had diagnoses including heart failure (heart unable to pump sufficient blood) and muscle weakness. Resident 16 was cognitively intact and able to clearly verbalize their needs. Review of the February 2025 nursing progress notes showed on 02/04/2025 Resident 16 was ashy in color, unresponsive, had an increased temperature, decreased oxygen levels, and they were transported to the hospital for evaluation. No documentation was found to show Resident 41 was offered a bed hold at the time of hospital transfer, as required. <Resident 90> According to an admission assessment dated [DATE], Resident 90 had diagnoses which included septicemia (a serious infection caused when bacteria entered the bloodstream and spread throughout the body) and respiratory failure (a condition where the lungs cannot exchange oxygen and carbon dioxide correctly.) The resident had severe cognitive impairment. A 03/09/2025 progress at 12:21 PM documented the resident developed difficulty breathing and a fever. The resident's family member requested they be sent to the emergency room for evaluation and treatment. A 03/09/2025 progress note at 12:37 PM documented the resident was transported by ambulance and admitted to the hospital. A review of the medical record found no documentation a bed hold had been offered to the resident's representative, after the hospital transfer. In an interview on 04/22/2025 at 12:06 PM, Staff H, Licensed Practical Nurse, stated the nurse that transferred a resident to the hospital did not offer and/or provide information on bed holds, upon hospital transfer. Staff H explained bed holds were offered by nurse management if/when a resident was out of the facility after midnight. In an interview on 04/22/2025 at 12:24 PM, Staff C, Assistant Director of Nursing, stated residents were offered a bed hold at time of hospital transfer, if not offered at that time, then staff followed up the next day. Staff C acknowledged the facility was inconsistent about offering bed holds and completing the bed hold form. In an interview on 04/22/2025 at 1:54 PM, Staff A, Administrator, stated they expected staff to offer residents a bed hold at time of hospital transfer. Reference WAC 388-97-0120 (4) Refer to F622 and F623 for additional information.

Based on interview and record review, the facility failed to ensure a baseline care plan was developed that contained resident-specific goals and interventions which included the minimum healthcare information necessary to properly care for each resident immediately upon their admission for 4 of 6 sampled residents (Resident 313, 312, 33, and 263) reviewed for baseline care plans. Failure to develop a baseline care plan for Resident 313 related to hospice and nutrition, failiure to develop a baseline care plan for Resident 263 for nutrition, and failure to develop baseline care plans for both Residents 312 and 33 related to Multiple Sclerosis (MS), a disease where the immune system attacks the nerves which resulted in various symptoms such as fatigue, difficult coordination, muscle weakness, and vision changes, placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 313> The 03/31/2025 admission assessment documented Resident 313 admitted to the facility on [DATE] and had diagnoses which included malnutrition, adult failure to thrive, and dementia. In addition, the assessment documented Resident 313 received hospice services. Review of Resident 313's care plan showed interventions were developed to address the resident's care needs related to hospice on 03/28/2025, and nutrition on 03/30/2025, however, no documentation was found that showed a baseline care plan had been developed for hospice and nutrition within the 48 hours of admission as required. <Resident 312> The 12/18/2024 admission assessment documented Resident 312 admitted to the facility on [DATE], was cognitively intact to make decisions regarding their care and had diagnoses which included weakness and MS. Review of Resident 312's record found no documentation that showed a baseline care plan had been developed to instruct nursing staff of Resident 312's immediate care needs related to MS. <Resident 33> The 02/03/2025 significant change assessment documented Resident 33 admitted to the facility on [DATE], was cognitively intact to make decisions regarding their care, and had diagnoses which included weakness and MS. Review of Resident 33's record found no documentation that showed a baseline care plan had been developed to instruct nursing staff of Resident 33's immediate care needs related to MS. In an interview on 04/21/2025 at 6:48 AM, Staff C, Assistant Director of Nursing, stated baseline care plans were developed within the first 24 hours of the resident's admission to the facility. After discussion and review of Resident 313, 312, and 33's records, Staff C acknowledged the baseline care plans had not been completed. 42802 <Resident 263> According to an admission assessment dated [DATE], Resident 263 was admitted with diagnoses which included surgical aftercare following a hip fracture, Cirrhosis (a chronic condition which scar tissue replaced healthy liver tissue) and Ascites (an abnormal buildup of fluid in the abdomen, often caused by late-stage cirrhosis of the liver.) The resident was alert and able to make their needs known. A physician note, dated 04/02/2025, documented that the resident had required weekly paracentesis (a medical procedure in which a tube is inserted into the abdomen, to drain excess fluid) and was taking a diuretic (medication to decrease fluid retention) twice daily. The resident had admission orders for weekly weights for three weeks, then monthly for four weeks. The resident's weight dropped from 142.7 pounds on 03/31/2025 to 116.2 pounds on 04/15/2025, a loss of 26.5 pounds in 15 days. A review of the resident's care plan documented a focus of Nutrition/Hydration status: The resident was at risk for dehydration, weight loss or malnutrition related to chronic disease. The care plan goal was to have optimal nutrition and hydration status, and interventions included ice water at the bedside, record meal intake, dietician consult as needed, review dietary preferences and diet and weights as ordered. This care plan focus was initiated on 04/02/2025. Another care plan focus, dated 04/03/2025, documented the resident had a history of alcoholism with alcoholic cirrhosis with ascites. The care plan goal was for the resident to not have any adverse reaction related to alcoholism, and interventions included administer ordered medications, vital signs as needed and to observe for any signs of intoxication or alcohol withdrawal, and notify the physician as indicated. There was not any documentation in the resident's care plan that they required weekly paracentesis and daily diuretics, which would significantly impact their fluid retention and weight. A review of the medical record showed the resident was transferred to the hospital on 04/21/2025, three weeks after admitted . During an interview on 04/23/2025 at 3:47 PM, Staff HH, Registered Dietician (RD) stated that they were aware of her liver disease, ascites and paracentesis and expected weight fluctuation for that reason. They concurred that should be on the care plan, and the nutrition care plan was not resident specific. During an interview on 0424/2025 at 11:17 AM, Staff F, Residential Care Manager (RCM) stated that it was important for the care plan to show the resident got regular paracentesis, as it would impact their care, and they would add it to the care plan when the resident returned from the hospital. Reference: WAC 388-97-1020(3)

Based on observation, interview and record review, the facility failed to repeatedly ensure care plans were developed that included resident specific goals and interventions related to their specific care needs for 3 of 60 sampled residents (Residents 264, 60, and 311), reviewed for care planning. Failure to develop care plans for Residents 264 for nail care, Resident 60 for shaving preferences, and for Resident 311 related to hospice placed the residents at risk for unmet care needs and a diminished quality of life. Findings included . <Resident 264> The 04/04/2025 quarterly assessment documented Resident 264 was admitted to the facility on [DATE] and had diagnoses which included stroke, traumatic brain injury, muscle weakness, and was dependent on nursing staff to complete activities of daily living for personal hygiene such as nail care. On 04/14/2025 at 1:56 PM, Resident 264 was observed lying in bed wearing a hospital gown. Resident 264's fingernails were observed to have dark brown matter underneath them. Review of Resident 264's care plan found no interventions had been developed that instructed nursing staff what Resident 264's care needs were related to nail care. In an interview on 04/18/2025 from 10:21 AM to 10:27 AM, Staff P, Nursing Assistant (NA), stated the care plans informed them what the resident's type of assistance and specific care needs were. In an interview on 04/21/2025 at 6:55 AM, Staff C, Director of Nursing (ADON), stated care plans should be resident centered with interventions specific to the resident's care needs. After discussion and review of Resident 264's care plan, Staff C acknowledged the care plan did not include interventions or instructions related to nail care. 40297 <Resident 60> Review of a 03/16/2025 admission assessment showed Resident 60 admitted to the facility on [DATE] with medically complex conditions. The assessment showed the resident was cognitively intact and required supervision or touching assistance for personal hygiene (like combing hair, shaving, applying makeup, washing/drying face and hands). The assessment showed there was no rejection of care. Observations on 04/15/2025 at 10:40 AM, 04/16/2025 at 9:27 AM, and 04/18/2025 at 1:16 PM showed Resident 60 in bed under the linens. Resident 60 presented with a hospital gown and facial hair to the moustache area, the chin and below jaw area. In an interview on 04/16/2025 at 12:04 PM, Resident 60 said that they did not like the facial hair, preferred their spouse to shave them and the spouse decided when it was time for shaving. The resident stated the spouse shaved them in the facility and the staff did not offer to shave them. Review of the care plan or Kardex (a quick-reference guide that provides a concise overview of resident information) showed no instruction to the staff regarding the resident's preference to have their spouse shave them as needed or to offer them assistance with shaving when the spouse was unavailable. In an interview on 04/21/2025 at 7:10 AM, Staff Y, NA, stated they shaved residents, Only if requested. Sometimes we don't have time to do all that. If we see a lot of hair we will do it. We do offer. They will usually let us know or will have their own razors in the room. Staff Y said they would offer to shave a female resident because of, personal hygiene and I wouldn't want to have facial hair. Staff Y said Resident 60, refuses a lot of care. In an interview on 04/24/2025 at 10:20 AM, Staff V, Social Services Director, said there was no involvement of Resident' 60's spouse with their care at this time, and hasn't been in the facility since a month ago. In an interview on 04/18/2025 at 1:25 PM, Staff F, Unit Manager, said that preferences and inclusion of non-staff persons to provide cares was documented in the care plan, in the Tasks area of the electronic medical record, or under orders if clinically related, and flows into the Kardex. Staff F stated Resident 60's, spouse has taken a step back recently regarding coming in and if they were aware of the resident's preference to have their spouse shave them, they would, make that note in the care plan. Our staff should be offering to do it for [them] or assisting [the resident] if the spouse does not come in. Staff F acknowledged the resident's preference for shaving was not and should have been included in the care plan. 46115 <Resident 311> The 04/04/2025 admission assessment documented Resident 311 had diagnoses which included cancer. The resident had moderate cognitive impairments and was on hospice (a specialized type of care focused on comfort and quality of life for individuals with a serious illness and a life expectancy of six months or less). A review of the 04/05/2025 comprehensive care plan showed there were no interventions developed to delineate what care the nursing staff would provide versus what care hospice provided. The care plan had no contact information for the hospice facility. In an interview on 04/18/2025, Staff W, NA, stated they knew what care to provide the residents with by looking at their care plan. In an interview on 04/18/2025 at 2:10 PM, Staff AA, Licensed Practical Nurse, stated the care provided by the facility versus what care hospice provided needed to be included in the care plan. Staff AA stated this was important because if they had staff work that were unfamiliar with the residents they would need that information. In an interview on 04/18/2025 at 2:14 PM, Staff C stated hospice provided bathing and normally that was placed in the care plan. Staff C acknowledged the information was not a part of Resident 311's care plan and stated the care plan was basic and needed to be updated. Reference: WAC 388-97-1020(1), (2)(a)(b) Refer to F867 for additional information.

Based on interview and record review, the facility failed to order labs on admission, to act timely in accordance with professional standards for critical lab results and medical provider orders for 1 of 3 residents (Resident 1) reviewed for quality of care. Resident 1 experienced harm when they had the change in condition that required transfer to the hospital for treatment and were diagnoised with acute kidney failure. These failures placed residents at risk for unintended health consequences and decreased quality of life. Findings included . Record review showed that on [DATE] Resident 1 admitted from the hospital to the facility. Review of their hospital discharge documentation showed that the resident had been at the hospital for treatment of heart failure (the heart cannot pump enough blood to meet the body's needs) with pulmonary hypertension (high blood pressure in the arteries in the lungs) and fluid overload (occurs when the body cannot get rid of excess fluid). They were discharged to the facility with normal kidney function (glomerular filtration rate (eGFR) of 91 (above 90 is considered normal) on [DATE])) on oral diuretic medication (torsemide) with an order to monitor the resident's kidney function twice weekly. The same record indicated the resident was a full code (wanted all treatment possible to sustain life). Record review showed that on [DATE], Staff D, Medical Doctor, saw the resident and ordered labs to be completed on [DATE]. They further reviewed the resident's history and most recent labs and wrote that the resident was medically stable. Record review of progress notes for Resident 1 found that on [DATE] at 6:52 AM, Staff B, Licensed Practical Nurse (LPN) wrote, Resident was worried last night about [their] fluid overload. [They] feel as if [they] [are] filling up again. [They] [have] not had any urination since [their] dose of torsemide evening shift .[their]diuretic was given early .per [their] request. Day shift nurse to monitor for results. Placed in provider book so [they] can speak to them about the issue. Lung sounds are diminished in the bases with upper field wheezing (indicates possible fluid in the lungs). Record review found that Resident 1 was not seen by a medical provider on [DATE] and no nursing progress notes were written for the resident. Further review of the Resident's Medication Administration Record (MAR) showed the lab scheduled for that day was signed off by the nurse, indicating it was completed. Record review of Resident 1's resulted labs showed that on [DATE] at 8:11 PM the ordered labs were collected, and the labs resulted the same day at 10:15 PM. The lab results showed an eGFR of 12 (indicated kidney failure-kidneys can no longer filter fluids and waste products and they build up in the body), a creatinine (a measure of how well the kidneys are filtering waste products from the blood) of 4.74 mg/dL (normal is between 0.7 to 1.5, with higher levels indicating waste is not being filtered) and a Blood Urea Nitrogen (levels above normal indicate kidney damage) of 71 mg/dL (normal is between ,d+[DATE]). Record review of the Resident 1's facility medical record did not documentations that the resident was refusing hospital care. During an interview on [DATE] at 10:03 AM, Resident 1's spouse stated that they woke on the morning of [DATE] to find a voicemail from Resident 1 asking them if they thought they should go to the hospital. They further stated that they didn't know what [Resident 1] was thinking, of course [they] should have gone to the hospital, I did not get the voicemail until morning because I were so exhausted. They further stated that Resident 1 had possibly not been thinking clearly as they had a medical background and should have understood what the lab values meant. They stated that if they had spoken to their spouse, they would have told [them] [they] had to go to the hospital and that no one else from the facility called. Resident 1's spouse further stated that they had met Resident 1 at the hospital on [DATE] and there had been an attempt to try dialysis (a medical procedure that removes waste products from the bloodstream when the kidneys are unable to function) but that it had not worked, and Resident 1 had died of kidney failure on [DATE]. During an interview on [DATE] at 1:40 PM, Staff F, Advanced Registered Nurse Practitioner (ARNP), stated that they saw Resident 1 on [DATE] and during the visit the resident expressed concern that they were filling up with fluid, also that labs had not been done. They stated that they then ordered STAT (to be completed as soon as possible) labs. At that time, Staff F stated that the resident did not want to go to the hospital, that they wanted to see their labs and decide after that if they needed to go to the hospital. During an interview on [DATE] at 11:53 AM, Staff B, stated they worked with Resident 1 on the night shift of [DATE] into [DATE] and again on [DATE] into [DATE]. They stated that the resident was concerned they were filling up with fluid on both nights. They indicated that on the night of [DATE] into [DATE] they had written the resident's concerns in the doctor book so that the resident could be seen by the medical provider that day. They further stated that on the night of [DATE] they had received the resulted labs for Resident 1 after 10:00 PM, showing that the resident was in kidney failure. They stated that they then gave a copy of the labs to the resident per their request and told them they were going to call the on-call medical provider. They stated that they called the on-call medical provider, Staff E, ARNP, with the critical lab values between ,d+[DATE] AM. They stated that the ARNP they spoke to did not give any orders but stated that the facility medical provider would see the resident on [DATE]. They stated that they could not remember if they went back and talked to the resident after speaking to Staff E, I had 55 patients that night, I can't remember if I went back or not. During an interview on [DATE] at 11:56 AM, Staff C, Registered Nurse, stated that they were told by the night shift nurse that during the night of [DATE] into [DATE] Resident 1 had complained of decreased urine output and trouble breathing. Staff C then worked for 16 hours on [DATE], during which time the Resident had one wet incontinence brief, had diminished lung sounds and was short of breath when they got up to have their weight taken. Staff C further stated that they thought that the labs scheduled to be completed that day had already been completed. Record review of the medical provider on-call log showed that at 1:00 AM on [DATE], Staff E, ARNP, took a call related to Resident 1. The note stated that STAT labs had been completed with an elevated creatinine. The note further stated alert and oriented at baseline, no complaints reported. Nurse reports resident is very anxious about condition. The recommendations section of the note state, in house to follow up to discuss results and goal of care and notify provider of any change in condition. Record review showed a note from Staff F, on [DATE], that indicated Resident 1 needed hospital treatment related to the lab values that had resulted the night before. Record review showed Staff G, LPN, wrote a progress note on [DATE] at 10:22 AM that stated the staff F ordered Resident 1 to go to the hospital for evaluation and an ambulance was called. Staff G wrote another note at 10:56 AM that the resident had left in the ambulance, about 12 hours after the critical lab results had been available and about three days since Resident 1 had started complaining of decreased urination and feeling like they were filling up with fluid. During an interview with Staff A, Resident Care Manager, on [DATE] at 12:33 PM, they stated that the lab orders for Resident 1, that came from the hospital, should have been entered upon admit and were not. They further stated that the labs ordered to be completed on [DATE] had also not been completed. They further stated that if a resident is having trouble breathing or had concerns for filling up with fluid, that the nurse working with the resident should not write in the medical provider book, the book is for non-urgent needs, but should have called the medical provider. They further stated that when the critical labs for Resident 1 had resulted that the nurse could have called the on-call nurse manager for consult. They stated that if they had received a call with the lab values reported they would have told the resident they needed to go to the hospital, that there was nothing that could be done for them at the facility. Reference (WAC) [DATE](1)

Based on observation, interview and record review, the facility failed to evaluate the effectiveness of interventions implemented to prevent accidents to determine if supervision or other interventions were needed to prevent accidents for 2 of 5 sampled residents (Resident 1 and 65), reviewed for accidents. Specifically, Resident 65 was not evaluated for the need for additional supervision after an unwitnessed fall occurred while using the bathroom, then harm w when they fell under similar circumstances four days later which resulted in a broken left femur. In addition, Resident 1 was at risk for harm when they sustained a second degree (blister) to their thigh from a potentially uncontrolled hot coffee temperature and experienced skin tears with repeated falls out of bed when fall interventions were not implemented. These failures placed residents at risk for more accidents, diminished quality of life, and additional harm. Findings included . Review of the facility's undated policy titled, Fall Protocols, showed the interdisciplinary team would identify and document resident risk factors for falls and establish a resident-centered fall prevention plan based on relevant assessment information. A fall risk assessment would be completed on admit, re-admission, quarterly and when the resident's risk for falls changed. The policy further showed a fall investigation would be conducted by the interdisciplinary team to identify reason, contributing factors and/or root cause of a fall to implement a change in care to minimize recurrence. The policy instructed staff to implement additional or different interventions until falls reduced or stopped. The policy gave examples of potential interventions. <Resident 65> According to the 09/19/2023 re-admission assessment, Resident 65 had diagnoses of ulcerative colitis (inflammation in the digestive tract) and malnutrition. Resident 65 was cognitively intact, always continent of both bowel and bladder, and had not fallen in the month prior to their admission. Resident 65 required moderate assistance (the resident performed less than half the work) for toilet transfers and walking less than 50 feet distances. Review of a care plan initiated on 08/09/2023 documented Resident 65 was at risk for falls related to gait and balance problems. Interventions listed included: to ensure the resident's call light was within reach, encourage the resident use call light for assistance as needed, staff to respond promptly to all requests for assistance, follow the facility fall protocol, and physical therapy to evaluate and treat as ordered or as needed. Review of a 09/23/2023 change in condition evaluation showed the provider was called to report Resident 65 had fallen, which had not occurred before that afternoon. There were no changes in the resident's mental status or injuries listed. A recommendation was included to have the resident use non-skid socks. Review of a 09/23/2023 Morse Fall Scale (a tool used to assess one's risk for falling) post fall assessment identified Resident 65 as moderate risk for falls. Review of a 09/23/2023 Post Fall assessment documented Resident 65 ambulated without assistance and fell in the bathroom. There was no apparent bruising or changes in their range of motion. A review of the 09/2023 accident and incident log showed on 09/23/2023 at 5:30 AM, Resident 65 fell in their room, there were no injuries, and the care plan was updated. An entry on 09/27/2023 ( four days later) at 12:30 AM showed Resident 65 sustained another fall, sustained a fracture, and required medical care. Review of the 09/23/2023 facility fall investigation showed Resident 65 fell in their bathroom, and the resident stated they felt dizzy and lost their balance while they ambulated without assistance. Staff were instructed to make sure the resident had their call light in reach, encourage call light use to request help prior to attempting to transfer. It was documented that the care plan had been updated. Further review of the care plan showed there had been no additional interventions added. The use of non-skid socks recommended in the 09/23/2023 change of condition evaluation was not added to the care plan. Review of the 09/27/2023 facility fall investigation showed Resident 65 had an unwitnessed fall while they ambulated out of bed without assistance after an incontinence episode, did not use their call light for assistance, and was not wearing non-skid socks. Resident 65 stated they were looking for another incontinence brief. The investigation documented Resident 65 had intermittent periods of confusion. The investigation noted that on 09/28/2023 an x-ray was ordered, a potential fracture of the left greater trochanter (the top outside edge of the thigh bone) was in question and Resident 65 was sent to the hospital for further evaluation. Imaging at the hospital diagnosed a fracture and Resident 65 was admitted to the hospital. The investigation did not state whether abuse or neglect were ruled out, or that the fall with major injury was reported to the State Survey Agency. Review of the 10/05/2023 hospital discharge summary showed Resident 65 did not require surgery for their fracture and was discharged back to the facility. Upon readmission, Resident 65's care plan was not updated to include additional interventions to prevent falls, even after they had fallen and broken their femur. Review of the Nursing Assistant KARDEX (Nursing Assistant care instructions card) effective date 01/10/2024, listed under the Safety category the same interventions to be sure the resident's call light was within reach, encourage the resident to use the call light for assistance as needed, and prompt response to all requests for assistance. In an observation on 01/09/2024 at 3:25 PM, Resident 65's room showed a sign posted at the entrance that instructed staff that Resident 65 was on isolation precautions related to infectious stool, and that a gown and gloves were required to be put on prior to entering the room. There were two residents in the room, Resident 65's bed was by the window, and the other resident had the bed by the door. A privacy curtain was pulled between the two residents such that Resident 65 was unable to be observed from the hall. Upon entrance to the room, Resident 65 was observed lying in bed on a specialty air mattress, napping with their call light across their lap, the floor was linoleum. Resident 65's sheets had worked their way off the resident and their legs were visible. Resident 65 was not wearing non-skid socks. Similar observations were made upon entrance to the Resident 65's room on 01/10/2024 at 11:37 AM, 01/11/2024 at 12:42 PM, 01/12/2024 at 11:35 PM, and 01/16/2024 at 12:05 PM. During an interview on 01/18/2024 at 1:45 PM, Staff E, Nursing Assistant (NAC), stated they had been employed by the facility for just over a year and provided care for Resident 65 often. Staff E stated residents that were at risk for falling were brought to the nurse's station for closer observation at times, or their doors was left open so they could be seen from the hall. Staff E stated they knew what care a resident required by looking at the KARDEX or from receiving the information in shift report from the previous shift. They stated Resident 65 was not as active as they used to be and rarely got out of bed. Staff E further stated they were not aware if there was anything to do for Resident 65 to prevent falls other than make sure their bed was in low position. During an interview on 01/19/24 at 8:58 AM, Staff Q, NAC, stated they had been employed by the facility since September of 2023. Staff Q stated if a resident fell , an alert popped up on their computer screen when they logged in or resident the information was on the KARDEX. Staff Q stated Resident 65 had never gotten out of bed for them and they were unaware Resident 65 had fallen. During an interview on 01/19/2024 at 5:28 PM, Staff B, Director of Nursing, stated at the time Resident 65 fell , they sent the resident to the hospital, but it was not until much later they learned the resident's femur was broken. Staff B acknowledged Resident 65's plan of care had not been updated after they broke their femur and should have been. 47328 <Resident 1> According to the 12/06/2023 quarterly assessment, Resident 1 had diagnoses of stroke with hemiplegia (paralysis that affects one side of the body) affecting left dominant side, dementia (loss of thinking, remembering, and reasoning that interferes with daily life activities), and left-hand contracture (fixed tightening of muscle, tendons, ligaments, or skin that prevents normal movement). Resident 1 had severe cognitive impairment and was able to make their needs known. The assessment showed Resident 1 sustained falls while in the facility. <Burn> The website medlineplus.gov showed first-degree burns affect only the outer layer of skin. They cause pain, redness, and swelling. Second-degree (partial thickness) burns affect both the outer and underlying layer of skin. They cause pain, redness, swelling, and blistering. Third-degree (full thickness) burns affect the deep layers of skin. They cause white or blackened, burned skin. Review of the 11/28/2023 facility investigation showed Resident 1 spilled their coffee onto their right thigh and a blister was noted two days later. A skin assessment dated [DATE] was included in the investigation which showed Resident 1 had a 6-centimeter (cm) x 3cm blister (pocket of fluid under the skin in response to pressure or injury) on their right middle thigh. The incident report showed no documentation of implemented intervention. Review of the July 2023 through [DATE] facility incident log showed Resident 1 sustained a self-inflicted injury on 11/28/2023 at 1200 with the injury listed as a burn. Review of wound specialist progress notes showed Resident 1 was assessed on 11/30/2023 related to a hot coffee spill to their right inner thigh that caused a 3cm x 4.5cm burn. A 12/07/2023 note classified the burn as partial thickness wound that healed. Review of Resident 1's care plan initiated 01/09/2024 (42 days after the coffee burn) showed they were at risk for burns and/or injuries related to hot liquid spills and needed a lid on all hot beverages. Per observation on 01/08/2024 at 9:38 AM, Resident 1 dropped a cup of cocoa with a lid on the floor. Per observation on 01/10/2024 at 9:10 AM, Resident 1 drank fluid out of a cup with lid placed in a cup holder attached to the right side of their wheelchair. In an interview on 01/18/2023 at 3:52 PM, Staff M, Licensed Practical Nurse (LPN), acknowledged at the end of November 2023 Resident 1 spilled coffee on themselves and it caused a second-degree burn because a blister formed. Staff M further stated Resident 1's coffee cup was changed because their previous cup would get hot, and Resident 1 now obtained their coffee from the kitchen which placed ice in the coffee to cool it down. In an interview on 01/18/2024 at 4:24PM, Staff L, LPN, stated Resident 1 had spilled coffee on themselves and the coffee machines were removed from the nutrition rooms. Staff L furhter stated the kitchen now provided the coffee in pots after the temperature was verified, and facility residents were assessed for the need for lids on their coffee based on their risk for potential burns as interventions related to Resident 1's burn from spilled coffee. In an interview on 01/18/2024 at 4:40 PM, Staff N, Maintenance Director, stated coffee machines were removed from the nutrition rooms as one of the interventions related to Resident 1 sustaining a burn from spilled coffee. In an interview on 01/19/2024 at 3:49 PM, Staff B, Director of Nursing, acknowledged Resident 1 sustained a burn from spilled coffee and the facility removed the coffee machines from the nutrition rooms because the temperature could not be adjusted on them. Staff B further stated they attempted to cool Resident 1's coffee to the coolest temperature they would accept. In an interview on 01/19/2024 at 4:55PM, Staff A, Administrator, acknowledged Resident 1 spilled coffee on themselves and the facility completed safety assessments on all the residents to see who needed lids on coffee and the coffee machines were removed from nutrition rooms. Staff A further stated the kitchen now checked coffee and soup temperatures prior to leaving the kitchen, kitchen staff were trained on acceptable temperature ranges, and the facility conducted audits to ensure compliance. Staff A further stated Resident 1's care plan was updated to include the need for a lid on their coffee. Review of safety assessments completed and provided by the facility as part of their plan to prevent other residents from potentially sustaining burns from hot liquid spills showed seven residents were identified as high risk for hot liquid spills. Five of seven safety assessments, including Resident 1, were not completed until 01/09/2023 (42 days after Resident 1 sustained the coffee burn). <Falls> Review of the July 2023 through [DATE] facility incident log showed Resident 1 had falls on 09/20/2023, 10/24/2023, 11/20/2023, and 12/19/2023. Review of the fall reports showed: -09/20/2023: Resident 1 had an unwitnessed fall attempting to self-transfer out of bed and sustained two small skin tears to their right shin. Memory impairment, confusion, and unsafe or absent footwear were listed as predisposing factors. Resident 1 had frequent falls related to noncompliance and not locking their wheelchair, needed frequent reminders to lock their wheelchair and request assistance during transfers. Intervention listed was repeat resident education on call light use and locking wheelchair prior to transfers. -10/24/2023: Resident 1 had an unwitnessed non-injury fall attempting to self-transfer out of bed. Memory impairment, confusion, and incontinence were listed as predisposing factors. Resident 1 frequently self-transferred and refused to call for assistance. Intervention listed was repeat resident education on call light use and locking wheelchair prior to transfers. -11/20/2023: Resident 1 had an unwitnessed fall attempting to self-transfer out of bed and sustained a small skin tear to their right shin. Memory impairment, weakness, and incontinence were listed as predisposing factors. Resident continued to self-transfer despite staff encouragement to use call light and wait for assistance. -12/19/2023: Resident 1 had an unwitnessed fall attempting to self-transfer out of bed and sustained a 15cm x 8cm abrasion to their back. Memory impairment, confusion, and incontinence were listed as predisposing factors. Resident cognitively at baseline and already care planned for noncompliance with transfers. Review of the fall care plan initiated 02/17/2021 showed no evaluation for the effectiveness of fall prevention interventions was completed when the resident continued to fall. On 01/11/2024 (the day fall incident reports were requested from the facility) interventions for safety checks and a therapy evaluation were added to the care plan. In an interview on 01/18/2024 at 3:52PM, Staff M, LPN, acknowledged Resident 1 had frequent monthly falls out of bed and the unit managers were usually responsible for initiation of interventions. Staff M further stated that Resident 1 did not use their call light because they did not remember to use it, but it did not matter because Resident 1 was getting weaker and now had a harder time self-transferring. In an interview on 01/18/2024 at 4:24 PM, Staff L, Infection Preventionist, stated fall interventions should be put into place and care planned immediately. Staff L further stated resident education depended on the level of cognitive impairment. Staff L reviewed Resident 1's care plan and acknowledged there were not many fall interventions listed. In an interview on 01/19/2024 at 9:09 AM, Staff O, Director of Rehab, stated therapy recently started working on transfer training with Resident 1because they continued to self-transfer. In an interview on 01/19/2024 at 12:55 PM, Staff P, Nursing Assistant, stated they had not witnessed Resident 1 have any falls, but they were informed Resident 1 would attempt to self-transfer out of bed, so the bed was always placed in the low position. In an interview on 01/19/2024 at 3:49 PM, Staff B, DNS, acknowledged most of Resident 1's falls occurred when they attempted to self-transfer out of bed, staff had attempted to remind Resident 1 to call for assistance, but Resident 1 did not remember. Staff B further stated they had a care conference recently and recommended discharge to an adult family home related to increased falls at the facility. Staff B acknowledged no new fall interventions had been attempted for the 09/20/2023, 10/24/2023, 11/20/2023, or 12/19/2023 falls out of bed. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure weights were consistently obtained and acceptable parameters of nutrition were maintained for 3 of 10 sampled residents (Residents 9, 65 and 429) reviewed for nutrition. Resident 65 experienced harm when they experienced a significant weight loss, over 25% of their weight from 11/21/2023 to 01/12/2024, when their weight was not consistently and accurately obtained, staff did not provide consistent assistance and cueing with eating, and weight loss was not reported timely to the provider. This failure placed the resident at risk for further decline in their weight, unintended consequences of poor nutrition, and decreased quality of life. Findings included . Review of the facility policy titled Nutritional assessment dated [DATE] showed the dietician is to conduct a nutritional assessment for each resident upon admission and as indicated by a change in condition that placed the resident at risk for impaired nutrition. The interdisciplinary team may consider additional situations that place a resident at increased risk for impaired nutrition-cognitive or functional decline, chewing or swallowing abnormalities, increased need for calories or protein, poor digestion or absorption or inadequate availability of food or fluid. Once analyzed, individual care plans will be developed to minimize the resident risks for nutritional complications where possible. Review of the facility policy titled Weight Assessment and Intervention dated 10/01/2021 showed the interdisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss. Significant and undesired weight change was defined as: 1 month- 5% weight change is significant, greater than 5% is severe. 3 months-7.5% weight change is significant, greater than greater than 7.5% is severe. 6months-10% weight change is significant, greater than 10% is severe. Weights will be measured on admission as ordered by the practitioner. If no weight concerns are noted, weights will be measured monthly and recorded in the resident's medical record. If any inaccurate weight is suspected, the resident will be reweighed and if found to be accurate, will be reported to the practitioner immediately. The dietary team will review the weight records to follow weight trends over time. <Resident 65, significant weight loss with harm> A review of the record showed Resident 65 had diagnoses including ulcerative colitis (long-term inflammation in the digestive tract) recurrent Clostridium difficile (C-diff, a bacterium that causes inflammation and diarrhea) and protein calorie malnutrition (reduced availability of nutrients that leads to changes in the body composition and function.) The 08/13/2023 Minimum Data Set (MDS) assessment (a comprehensive clinical assessment of a resident's functional capabilities) documented Resident 65 was cognitively intact, did not reject care, was able to eat independently, weighed 119 pounds (lbs.), and had lost 5% of their weight in one month or 10% in 6 months, not on a prescribed diet. A 10/10/2023 significant change MDS assessment documented Resident 65 was cognitively intact, weighed 120 lbs., and had no or unknown weight loss. A 01/10/2024 quarterly MDS assessment documented Resident 65 was severely cognitively impaired, required set-up or clean-up assistance for eating, their weight was not listed, and had no or unknown weight loss. Resident 65's 08/09/2023 comprehensive care plan had the following care areas implemented: -Activities of daily living (ADL) self-care deficit related to their disease process and fatigue; the resident is independent for eating with set-up assistance. This was updated on 11/30/23 to 1:1 assist of one caregiver for eating. -Risk for alteration in nutritional status related to poor oral intake, unplanned weight loss and ulcerative colitis (UC); interventions included to give diet as ordered-updated on 11/30/23 to include regular, soft and bite-sized textures, regular/thin consistency of fluids, identify and honor preferences, medications/labs as ordered, weights per protocol, encourage fluids, supplements as ordered and document consumption, Speech/occupational therapy evaluate and treat as ordered. A 08/09/2023 Nutrition at Risk admission assessment by the Registered Dietitian (RD) documented Resident 65 was 63 inches tall and weighed 118.6 lbs.; their usual body weight 150 lbs., and their ideal bodyweight was 120 lbs. Resident 65 had dentures but did not wear them to eat, had constant diarrhea, and required additional calories due to their medical condition. Resident 65 had a moderate decrease in food intake and altered nutrient absorption. They required 1908 calories, 1908 milliliters (ml) of fluids and 71 grams of protein daily. Ensure (a liquid drink containing extra calories and nutrients) three times a day with meals (TID) was to be ordered for additional energy needs. On 11/21/2023, the hospital provider Skilled Nursing Facility Transfer Orders documented Resident 65's weight readings from the last 3 hospitalization s: 08/21/2023 127 lbs. 6.8 ounces 09/28/2023 121 lbs. 14.6 ounces and 11/20/2023 137 lbs., 9.6 ounces. The orders included Resident 65 to have a general diet, dental soft texture, thin fluids, vegetarian. Boost plus (a liquid nutritional shake-like drink) supplement was also ordered, but the order did not include how many the resident was to receive daily. The following provider orders were given for Resident 65: -11/21/2023 regular diet, soft and bite-size texture, thin liquids, vegetarian. -11/22/2023 Boost once a day for supplement. -An order for Ensure TID with meals had been entered on 10/09/2023 and was discontinued on 11/04/2023. On 01/10/2024, Resident 65's facility obtained weights were reviewed and showed the following: -08/09/2023 118.6 lbs. -09/14/2023 124.6 lbs. -09/19/2023 122.4 lbs. -10/05/2023 120.0 lbs. -11/21/2023 120.3 lbs. There were no other weights For Resident 65 documented in the electronic medical record (EMR). The 11/29/2023 provider readmission History and Physical documented Resident 65 had been hospitalized for sepsis and diverticulitis (inflammation or infection in the colon). Resident 65 weighed 120.2 lbs. and ate less than 50% of their meals. Staff were to monitor closely, monitor the resident's labs and replace electrolytes when warranted. Additional provider notes reviewed through 01/18/2024 did not mention the providers had been notified of Resident 65's weight or that there had been a significant weight loss. A review of nursing progress notes from 11/21/2023 to 01/11/2023 documented that Resident 65 began to refuse the Boost supplement drinks in November 2023. In December 2023, Resident 65 declined to get out of bed, refused care, had periods of confusion, and preferred to sleep during the day. In January 2024, Resident 65 began refusing medications they had ordered to treat their ulcerative colitis, declined to get out of bed, slept most of the time, had poor appetite, was incontinent of both bowel and bladder, and required total assistance with most of their care. On 01/05/2024, a quarterly nutrition assessment was completed by Staff CC, RD. The assessment documented Resident 65 weighed 120.3 lbs., obtained 11/21/2023. Resident 65's ideal body weight was 115 lbs. and their weight was stable the past quarter with some fluctuations of +/- 4 lbs. The resident received a soft diet with bite sized foods and Boost daily. Resident 65's meal intake was highly variable, likely contributing to the weight variance. The current interventions were maintained. On 01/09/2024 at 3:21 PM, Resident 65 was observed lying in bed. They leaned to the right and their bed was in disarray. The resident's hair was uncombed and sticking up. The resident looked cachectic (frail, loss of weight and muscle mass), their collar bones protruded. and their skin had a grey undertone to it. Resident 65's cheeks were sunk in, and their mouth and skin were dry. The resident answered simple yes or no questions but closed their eyes when interviewed and reported feeling tired. On 01/10/2024 at 11:50 AM, Staff E, Nursing Assistant (NAC) brought Resident 65 their lunch tray and positioned it in front of the resident, who was lying in bed. From 11:52 AM to 12:53 PM, no staff entered Resident 65's room, aided or encouraged the resident to eat or offered the resident an alternative. At 12:53 PM, Staff S, Nursing Assistant Registered, entered Resident 65's room and asked Resident 65 if they were hungry or wanted a nutrition shake. Staff S removed their uneaten lunch and went to retrieve a shake. Staff E stated Resident 65 did not eat their breakfast either. Staff S stated they would notify the nurse. At 2:52 PM, Staff S stated Resident 65 did not drink the shake they were given at lunch and they would notify the nurse. On 01/11/2024 at 9:00 AM, Resident 65 was observed in bed. Staff Q, NAC, stated Resident 65 ate 50% of breakfast, drank a milk, and a nutritional shake. At 12:32 PM, Staff Q and the surveyor entered Resident 65's room. Resident 65 was in bed, the head of the bed was elevated, but Resident 65 had slid down and was leaning over to the right in an awkward position. Resident 65's lunch was untouched, lids were still on the salad and peaches, and the drink cups of punch and coffee were full. There was no nutritional shake on the tray. Resident 65 drank all the milk. Resident 65 stated they were not hungry, and Staff Q removed their lunch without offering a substitute or encouraging the resident to eat. On 01/12/2024, a weight of 89.4 lbs had been entered in Resident's 65's EMR, a loss of 30.9 lbs. or 25.7% since last recorded weight of 120.3 on 11/21/2023. On 01/12/2024 at 11:43 AM, Staff FF, Registered Nurse (RN) stated Staff E had weighed Resident 65 that morning. Staff FF stated every resident was weighed once a week on a certain day, which they thought was Tuesdays. When asked if Resident 65's weight looked low, Staff FF stated, No, Resident 65 is tiny. Staff FF then reviewed Resident 65's weights and stated they would have the NAC get a reweight. There was no reweight documented in the resident's EMR. On 01/13/2024, the Staff C, Assistant Director of Nursing, nursing progress note documented that Resident 65's weight was not documented correctly-the wheelchair weight was not deducted. Staff were educated to deduct the weight of the resident's wheelchair. The progress note did not document that the provider or the RD had been notified of the resident's weights. A Care Conference Assessment completed on 01/15/2024 documented a care conference was held that day with Resident 65, the Social Worker, Therapy, Nursing and a family representative related to limited care participation and weight loss. Goals were to add nutritional interventions and encourage out of bed activity, and chocolate shakes were being added. A review of Resident 65's weights completed on 01/16/2023, revealed Resident 65's weights documented in the EMR had been changed to reflect the following: -08/09/2023 118.6 lbs. -08/15/2023 87.4 lbs., a loss of 31.2 lbs. -09/05/2023 89.6 lbs. -09/14/2023 89.6 lbs. -09/19/2023 89.6 lbs. -10/05/2023 120.0 lbs., a gain of 30.4 lbs. -11/21/2023 106.0 lbs., a loss of 14 lbs. from 10/05/2023. -11/28/2023 106.6 lbs. -12/05/2023 93.4 lbs., an additional loss of 13.2 lbs. from 11/28/2023. -12/26/2023 88.2 lbs., an additional loss of 5.2lbs. from 12/05/2023. -01/12/2024 89.4lbs. The weights did not correlate with the weights documented in the 11/21/2023 hospital Skilled Nursing Transfer Orders. On 01/16/2024 at 12:05 PM, Resident 65 was observed lying in bed, with their lunch in front of them. Resident 65 had taken a few bites of the fish and nothing else. Heir meal ticket documented Resident 65 was to have a chocolate nutritional shake, but it was not on their tray. Resident 65 stated they were not hungry. There were no staff are in the room to cue or encourage Resident 65 to eat. During an interview on 01/18/2024 at 1:45 PM, Staff E stated Resident 65 hardly ate. If Resident 65 sat upright and was awake they were able to feed themselves, but the resident was rarely awake. If Resident 65 was supposed to get Boost, it would come on their meal tray from the kitchen. Staff E stated that after the resident returned from the hospital in November, they did less and got out of bed less. During an interview on 01/18/2024 at 2:54 PM, Staff DD, Food Services Manager stated if a resident was ordered a supplement, nurses notified Staff DD using a requisition form. Staff DD stated they served a generic house shake they ordered from their distributor. They had difficulty obtaining Boost and other brand-named shakes. Staff DD reviewed their orders and stated they showed Resident 65 was to receive their house shake three times a day, not the Boost. During an interview on 01/19/2024 at 8:58 AM, Staff Q stated they would have Resident 65 sit up for their meals but Resident 65 usually only drank their milk and did not drink their shakes. Staff Q notified the nurse if the resident did not drink the shake. Staff Q thought Resident 65 was required to be weighed once a month. They stated Resident 65 did look thin and it was concerning. Staff Q stated at times, they mixed ice cream with the resident's nutritional shake, but if Resident 65 refused twice Staff Q didn't push it. On 01/19/2024 at 11:51 AM, Resident 65 was observed lying in bed. The head of the bed was elevated, and the resident had slid down and was leaning to the left in an awkward position. Resident 65 had a baked potato covered in a cheese sauce and sour cream and was picking up pieces of the potato with their fingers. The resident's fork had fallen behind their plate, and their spoon was resting on the plate in the potato. The milk and half of a chocolate nutritional shake had been drunk. There were no staff in the room to cue or aid the resident with their meal. During an interview on 01/19/2024 at 12:33 PM, Staff CC stated they had just completed their first full week of employment at the facility. They had seen Resident 65 prior to their official employment on a consult basis. Staff CC stated Resident 65 did not seem interested in talking and was covered in blankets so their body was not able to be observed. Resident 65 declined further interview so Staff CC obtained much of the information for their assessment from the EMR. Staff CC stated when they begin to document an assessment in the EMR, the most current weight and vital signs auto-populated in the assessment screen so it auto-populated the weight from 11/21/2023 of 120.3 lbs. Staff CC stated they had not been notified after the resident's weight was obtained on 01/12/2024, and that this was a time when they should have been notified to come and reassess Resident 65. During an interview on 01/19/2024 at 1:40 PM, Staff C stated weights on Resident 65's unit were to be obtained weekly and they had audited Resident 65's weights on 01/13/2024. Staff C had requested Resident 65 be reweighed, and a weight the same as the one obtained on 01/12/2024 of 89.4 lbs. was obtained. It was determined through interviews that the NACs had not subtracted the weight of the wheelchair when they weighed Resident 65. Staff C stated they changed the weights recorded in the EMR but had not compared those weights with the ones from the hospitalization s. Staff C stated they had identified that weights were not obtained consistently, and they were having a difficult time getting staff to obtain them. Staff C stated they had not notified the RD of the weight of 89.4 lbs. but thought the RD would have seen it. During an interview on 01/19/2024 at 5:35 PM, Staff B, Director of Nursing, stated they had been updated that Resident 65's weights were off, and that staff had not subtracted the weight of the resident's wheelchair. After reviewing Resident 65's weights with the surveyor, Staff B agreed that the weights that had been revised in the EMR on 01/13/2024 did not correlate with previous weights recorded for the resident. Staff B agreed that Resident 65 had had a significant amount of weight loss at some point after their return from the hospital in November 2023. Staff B stated they had not had consistent RD coverage in the past and Staff CC had just started. Staff B stated that Resident 65 had always had some confusion, but in their opinion was more withdrawn and Staff B stated they did not see Resident 65 getting better. <Resident 9> A 12/22/2023 admission assessment documented Resident 9 had diagnoses including end-stage renal disease (ESRD, kidney failure) and was dependent on dialysis, a way of removing waste from the body using a machine when the kidneys no longer function. Resident 9 was cognitively intact, was able to eat independently, weighed 180 lbs., and had no or unknown weight loss. The 12/17/2023 care plan revealed Resident 9 was at risk for alteration in nutrition. Staff were instructed to provide a consistent carbohydrate diet that included 2 grams (gm) of potassium and no more than 1200 milligrams (mg) of phosphorous daily. Resident 9 had dialysis session at the local provider every Tuesday, Thursday and Saturday from 10:00 AM to 2:00 PM. Resident 9 had the following provider orders: 12/18/2023 Novasource Renal supplement drink once daily, document amount consumed. 12/17/2023 liberal renal diet, regular texture, thin consistency fluids, consistent carbohydrates, 2 gm potassium, 1200 mg phosphorous restricted. The 12/22/2023 dietary profile documented Resident 9 was on a 1200 milliliter (ml) fluid restriction, but this was not reflected in the provider orders. A further review of the electronic medical record (EMR) showed one weight only of 180.0 lbs. was recorded for Resident 9 on 12/17/2023. There were no assessments or progress notes completed by the RD, and no areas in the medication administration record (MAR) or NAC tasks where fluid intake was documented. The 12/17/2023 nursing admission progress documented Resident 9 was to be restricted to 1200 ml of fluid daily. On 12/26/2023, Resident 9 did not feel well, and declined to go to dialysis. On 12/29/2023, the nurse practitioner (NP) noted Resident 9 had been nauseated, the nurse reported to them Resident 9 had not been taking in enough fluids, but they had advised Resident 9 not to take in more fluid than was recommended by the dialysis center. On 01/08/2024 at 9:17 AM, Resident 9 was observed in their room in seated in a chair. They stated they had been ill in the hospital, had lost weight and was severely dehydrated from their illness. They had met with the RD at the dialysis center many times but had not met the RD from the facility. Resident 9 stated they were supposed to watch how much fluid they drank. A large mug with a blue lid on it provided by the facility was observed to be full of water. The resident also had their own water bottle on their overbed table. They pointed to their water bottle and stated if they thought they were drinking too much, they cut back on what they drank from their water. On 01/12/2024 at 8:36 AM, Resident 9 was observed after breakfast. They stated they had a small glass of orange juice at breakfast. The large mug was on the overbed table and was full of water. The resident's water bottle also contained water and was 2/3 full. The resident's meal ticket was on their breakfast tray and showed Resident 9 was on a 1200 ml fluid restriction. Resident 9 stated they were being discharged home later that day and had not met the facility RD. During a telephone interview on 01/18/2024 at 11:28 AM, the technician at the local dialysis center stated Resident 9 was to have a fluid restriction. Resident 9 had been nauseated at their sessions, and this was new for Resident 9 in the last two weeks. The dialysis center RD stated after Resident 9's hospitalization , their protein levels were low but that was to be anticipated and they had not changed Resident 9's interventions. <Resident 429> A 12/27/2023 admission assessment documented Resident 429 had diagnoses including ESRD dependent on dialysis, severe protein-calorie malnutrition, and esophageal cancer. Resident 429 was cognitively intact, ate independently, weighed 185.0 lbs. and had no or unknown weight loss. The 12/22/23 care plan documented Resident 429 was at risk for potential nutritional problems. Staff were to provide the ordered diet, obtain weights as indicated and notify the provider as needed. The resident received dialysis on Mondays, Wednesdays, and Fridays. The provider orders documented Resident 429 was to have a high protein, high calorie consistent carbohydrate diet, and nutritional drinks to supplement three times a day with their meals. An initial review of Resident 429's record revealed there were no assessments or progress notes by the RD, and no weights had been recorded for the resident after the admission assessment dated [DATE]. On 01/16/2024 a weight was entered in the EMR that documented Resident 429 weighed 159.2 lbs. This represented a significant weight loss of 14%, 25.8 lbs. During an interview on 01/09/2024 at 3:01 PM, Resident 429 stated they left for their dialysis sessions at 6:30 AM and so missed breakfast. A snack was not sent with them to dialysis, so they waited until they returned and had their lunch. On 01/10/2024 at 2:45 PM, Resident 429 was in bed and had an emesis bucket resting on their abdomen. They stated they ate lunch when they got back from dialysis but had not eaten breakfast. They were given medications at dialysis when their stomach was empty, but Resident 429 was unsure if that was what caused their stomach upset. They stated the nausea was new for them. During an interview on 01/18/2024 at 1:45 PM, Staff E, Nursing Assistant, stated whoever took a resident to the lobby for their ride to dialysis was supposed to stop by the scale and weigh them. Staff E stated a piece of paper was taped to the ice machine in the unit kitchen and it showed which residents were supposed to have their fluids restricted. They were unsure if Resident 9 was supposed to be on a fluid restriction, but stated any resident with a fluid restriction would not have a mug with the blue lid on their overbed table; nurses or the kitchen provided their fluids. During an interview on 01/19/24 at 9:41 AM, Staff EE, Registered Nurse (RN), stated in the past, when the facility had a consistent RD, residents were usually assessed by the RD in their first week following their admission. Resident 9 refused to be weighed often so did not want weighed again at the facility. Staff EE was unaware Resident 9 was supposed to have a fluid restriction. Staff EE stated they used to send paperwork with the residents to their dialysis treatments so those things could be documented, but that was not always done, and communication with the dialysis centers was lacking. During an interview on 01/19/2024 at 12:33 PM, Staff CC, RD, stated they had just completed their first week of employment with the facility. They had not assessed Resident 9 and 429 as they were not employed when the residents were admitted . Staff EE stated it was their practice prior to starting their employment with the facility to assess new admissions within the first 3-7 days. Reference: WAC 388-97-1060(3)(h)

Based on interview and record review, the facility failed to provide pain management that met the individuals acceptable level of pain, for a resident who experienced uncontrolled pain during movement and daily wound care treatments, for 1 of 3 sampled residents (Resident 1). This failed practice resulted in harm related to inadequate pain control and a diminished quality of life for the resident, and placed other residents at risk for unmanaged pain. Findings included . Review of hospital discharge records, dated 04/18/2023, showed Resident 1 had an unstageable pressure ulcer (localized damage to the skin and underlying soft tissue usually over a bony prominence) on their sacral (base of the spine) region, and a deep tissue injury (pressure injury that begins in the muscle closest to the bone) to their left buttock. Review of Resident 1's admission assessment, dated 04/25/2023, showed the resident had moderate cognitive impairment and an unstageable sacral pressure ulcer and fractures of the sacrum (the large triangular bone at the base of the spine). The Revised National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer (Injury) Stages, dated November 14, 2016, definitions included: Stage 4: full thickness skin loss, with exposed muscle, tendon, cartilage and or bone. Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Review of Resident 1's pain assessment, dated 06/13/2023, showed their acceptable level of pain as two out of 10 (2/10) on a pain scale (zero on the scale represented no pain, one to three represented mild pain, four to six represented moderate pain and seven and above represented severe pain, with 10 on the scale being the worst possible pain). Interventions identified in Resident 1's assessment to manage pain were pain medication and rest. Review of Resident 1's care plan related to pain, initiated on 04/20/2023, included interventions to manage pain related to a Stage 4 pressure ulcer. Goals for their care included direction to notify the facility physician if interventions to manage Resident 1's pain were unsuccessful and to give the resident pain medication prior to treatment/turning to ensure their comfort. Review of a comprehensive physician orders recap for 06/01/2023 through 07/03/2023 showed Resident 1 had active physician orders for acetaminophen to be given every four hours, as needed, for pain. The medication was held from 07/03/2023 at 11:45 AM until 07/07/2023 at 11:44 AM. The medication was not restarted until 07/07/2023 at 11:45 AM, with the same direction as prior to the hold order. Review of Resident 1's allergy list recorded on admission included three medications used to treat pain - aspirin, hydrocodone (narcotic) and tramadol (narcotic)). The allergy list did not indicate what were the allergic effects to the resident when they had taken the medications. Resident 1's June 2023 Medication Administration Record (MAR) showed acetaminophen (ordered to manage the resident's pain) was administered 13 times. Each time the medication was administered, the nurse noted Resident 1's pain level. The pain level was documented at above their acceptable level of pain (2/10 on the pain scale) nine of the 13 times the medication was administered. A pain evaluation completed by a nurse at 6:15 AM, 2:15 PM, and 10:15 PM daily was recorded as above the resident's acceptable level of pain during seven shifts. No indication was found that the medical provider had been notified by the nurses completing the evaluations that Resident 1's pain had not been successfully controlled to their acceptable level (2/10). Resident 1's July 2023 Medication Administration Record (MAR) showed acetaminophen was administered five times from 07/01/2023 until 07/12/2023. Each time the medication was administered the nurse noted Resident 1's pain level. The pain level was documented above their acceptable level of pain (2/10 on the pain scale) four of the five administration times. A pain evaluation done on each shift, at 6:15 AM, 2:15 PM, and 10:15 PM was recorded as above the resident's acceptable level of pain 14 times. From 07/03/2023 through 07/07/2023, an order to hold the resident's only pain control medication was made, due to Resident 1's family member (Collateral Contact 1 - CC 1's) concern that the medication had caused a rash. On 07/03/2023 at 11:46 PM Staff G, Licensed Practical Nurse, wrote they notified the provider of Resident 1's possible rash in a facility communication book. From 07/03/2023 until 07/07/2023 there was no evidence of follow up by nursing staff to obtain alternate pain control medication. On 07/07/2023 at 11:45 AM Resident 1's order for acetaminophen was restarted. Review of the undated facility policy titled, Pain Management, showed pain management will be a collaborative effort between the resident, physician, and representatives of the interdisciplinary team including but not limited to pharmacy, nursing, .social services, activities, etc. The policy showed the process of pain management for residents included developing and implementing approaches to pain management, identifying, and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of interventions, and modifying approaches as needed. In addition, the policy showed, if pain had not been adequately controlled, the multidisciplinary team, including the physician, may reconsider approaches and make adjustments as indicated. Review of Resident 1's electronic medical record showed on 06/23/2023 at 2:02 PM Staff B, Social Services Director, wrote a progress note showing CC 1 had asked for the facility medical director to review Resident 1's medications to see if anything would work for them to manage pain, as the resident was allergic to multiple medications and had taken pediatric doses in the past. Record review showed that on 07/02/2023 at 10:23 PM Staff C, Licensed Practical Nurse, wrote a progress note showing Resident 1 exhibits a lot of pain when doing wound care, repositioning or brief care. Resident 1's MAR for the same day showed no pain medication was administered. Record review showed that on 07/02/2023 at 10:38 PM Staff A, Director of Nursing, wrote a progress note showing, Per caregiver: Right hip, buttocks and upper thigh are red and warm to the touch. Pt. exhibits a great deal of pain when turning, dsg (dressing) changes or brief change. [CC 1] is requesting a call back from MD (medical director). Record review showed that on 07/03/2023 at 11:46 PM Staff G, Licensed Practical Nurse, wrote a progress note showed CC 1 wanted Resident 1's pain-relieving medication held because they were concerned the resident had a rash. The same staff wrote that the red area seen on Resident 1's right leg and buttock did not seem to cause them pain or discomfort. Record review showed that on 07/06/2023 at 3:43 PM Staff D, Resident Care Manager, wrote a progress note describing Resident 1's wound to their sacral area as about the size of a [NAME], with muscle and bone exposed and heavy purulent drainage (foul smelling, thick fluid indicating infection). The note showed that comfort was the goal for the resident, as the wound was increasing in size and severity, and the possibility of infection being present was discussed with the facility's medical provider. CC 1 was involved in this discussion per the note. There was no documentation to address alternative comfort/pain control for Resident 1 while the acetaminophen was on hold. Review of Staff E's, Wound Care Provider, progress note, dated 07/07/2023 at 11:26 AM, showed they provided care to Resident 1 on 07/06/2023. Staff E noted that Resident 1's pressure wound was continuing to deteriorate, and there was purulent drainage as well as exposed bone that was starting to splinter (break apart). Staff E documented the resident was uncomfortable during wound care and cleaning, and that the resident's only pain-relieving medication had been discontinued (held 07/03/2023 at 11:45 AM until 07/07/2023 at 11:44 AM). The note further stated that given the severity of the resident's wound as well as the deterioration of the wound and the obvious discomfort with cleaning and care of the wound, I would recommend the patient be premedicated with an oral pain medication. Given the extent of [their] wound, I would also recommend that [they] have pain medication available throughout the day as needed for pain. Staff E's note showed a surgical debridement (removal of dead skin) down to the bone was performed with only a topical (medication absorbed through the skin to treat pain) pain reliever on that day. During an interview on 07/20/2023 at 2:06 PM, Staff F, Nursing Assistant, stated that Resident 1 was in pain when the staff moved the bed or repositioned them in bed. They further stated that during daily dressing changes to care for the wound on the resident's back the resident would open their mouth and wail. Staff F stated they would hold the resident's hand and squeeze it and they thought that helped a little. During an interview on 07/20/2023 at 1:44 PM, Staff C, Licensed Practical Nurse, stated that Resident 1's wound was terrible, and they felt awful about how much pain the resident was in. They stated that during daily wound care the resident would call out, grab at staff and grab at the sheets on their bed. Staff C stated that they spoke with Staff A, with Staff D present, on 07/02/2023, and expressed their concern over the lack of pain control for Resident 1, especially during daily wound care. Staff C stated they had spoken with CC 1 prior to this date, and CC 1 had stated that they had conversations with the medical staff about the need for pain control for Resident 1, especially during wound care, and that they had wanted to find a pain medication that worked better for Resident 1, other than acetaminophen, since May 2023. CC1 had further stated that they but did not feel like the medical staff had offered options other than a narcotic pain medication they thought Resident 1 might be allergic to. Staff C stated that they tried to educate CC 1 on pain control but were not sure if they understood. In an interview on 07/20/2023 at 1:25 PM Staff B, Social Services Director, stated that their understanding was that Resident 1 was in pain and when they looked at Resident 1, they appeared to be in pain. Staff B said that they had several meetings with CC 1, who was concerned about what pain medications the resident could take because of a history of having rashes. Staff B stated that the medical provider was not at these meetings, and they were not sure if the medical provider had followed up on CC 1's request to discuss pain control for Resident 1 on 06/23/2023. Staff B stated that they had passed on the information from CC 1 verbally to the medical provider and Staff B thought that a conversation about pain control for Resident 1 would then take place. In an interview on 07/20/2023 at 2:43 PM, Staff A, Director of Nursing, stated that Resident 1 had experienced pain during wound care and movement. They stated they had multiple conversations with CC 1, and CC 1 would not commit to a specific course for pain control. Staff A stated that they thought the medical provider talked to CC 1 on 06/23/2023 but no changes were made to the resident's pain control plan. Staff A stated that the medical provider did not follow-up with the CC 1 on 07/02/2023, when a follow-up had been requested after the acetaminophen was held because CC 1 was concerned it was causing a rash, and after Staff C had expressed concerns for the Resident 1's level of pain and lack of pain control. Staff A further stated that on 07/06/2023, the wound care provider, Staff E, verbally told them they would not continue to provide wound care if Resident 1 did not have pain medication available. Staff A stated they had tried to contact the medical provider on that day and did not receive a response. On 07/07/2023, a new medical provider assumed care of Resident 1. On 07/12/2023, a care conference with the new medical provider, CC 1, Staff B and Staff A occurred. After the team discussed pain management, CC 1 was accepting of a narcotic pain medication to treat Resident 1's pain during movement and daily wound care. Staff A stated that Resident 1's pain control was important to them, and they did not feel it had been addressed by the former medical director. They further stated that adequate pain control for Resident 1 was one of the first things they wanted the new medical provider group to address when they took over from the previous medical director on 07/07/2023. Staff A could not provide an explanation of why a care conference meeting with all concerned medical staff and CC 1 to discuss pain control/comfort was not then held until five days later. Staff A stated that the pain medication ordered after the care conference on 07/12/2023 was effective in treating Resident 1's pain during movement and wound care treatments until they passed away on 07/15/2023. This is a repeat deficiency from 05/01/2023. Reference: WAC 388-97-1060(1)

Based on record review and interview, the facility failed to ensure 2 of 5 sampled residents (Residents 3 and 4), reviewed for medication administration, were free from significant medication errors. This failure resulted in actual harm for Resident 3 who experienced an adverse medication side effect requiring emergency hospitalization , and placed Resident 4 at risk for worsening of their medical condition. Findings included . <Resident 3> Review of Resident 3's facility medical record showed they were first admitted with diagnoses of respiratory failure with hypoxia (a condition where there is not enough oxygen in the tissues of the body), pulmonary hypertension (a type of high blood pressure that affects the lungs and the right side of the heart) and atrial fibrillation (a condition of the heart characterized by irregular and often faster heartbeat). The resident was first admitted on [DATE] from the hospital, returned to the hospital on 02/13/2023, and was readmitted on [DATE]. Review of the February and March 2023 Medication Administration Record (MAR) for Resident 3 showed they were admitted on [DATE] with orders for digoxin 0.25 milligrams (mg) to treat atrial fibrillation, and diltiazem ER (extended release) 180 mg, to treat high blood pressure. On 02/22/2023, when the resident was readmitted from the hospital, they returned with the same dose of digoxin and a lower dose of diltiazem ER (120 mg). On 02/24/2023, another order for 180 mg diltiazem ER was entered. According to the February and March 2023 MAR, Resident 3 received, in error, a combined dosage of diltiazem ER 120 mg and 180 mg, for a combined dose of 300 mg daily, from 02/24/2023 until 03/14/2023. Review of Resident 3's nursing progress note, written by Staff F, Licensed Practical Nurse, dated 03/14/2023 at 12:20 PM, showed the resident reported being dizzy, short of breath, became hard to arouse, lethargic, and had decreased oxygen levels. The resident was transferred to the hospital for emergency care at 11:50 AM that day. Review of hospital records, dated 03/14/2023, showed Resident 3 arrived with a very low heart rate and a high level of digoxin in their blood. The records showed the resident had a temporary pacemaker (an emergency procedure meant to stabilize a slow or irregular heart rate) placed, and was transferred to another local hospital for intensive care treatment, where the resident was placed on a ventilator (a machine that is used to support or replace the breathing of a person) later the same day. Per the hospital records, the physicians treating the resident were not aware of the increased dose of diltiazem. In an interview with Resident 3's family member on 04/25/2023 at 11:40 AM, they stated that Resident 3 was taken to the hospital because they could not breathe, and the hospital told them that their digoxin level was at a toxic level. They further stated that the experience was very scary, and the resident thought they were going to die. In an interview on 04/21/2023 at 12:26 PM, Staff B, Licensed Practical Nurse, stated that when a resident was admitted to the facility a double check was done by the nurses to assure medication orders were correct. Staff B stated that after the orders were double checked, a nurse could still enter an order, and there was no procedure in place to catch an error. Staff B showed the surveyor how the medication error happened with Resident 3 - the correct medication order was entered on 02/22/2023, double checked by another nurse, and then a third nurse entered the incorrect dosage on 02/24/2023 without discontinuing the 02/22/2023 dosage (which led to the resident receiving 300 mg of diltiazem ER daily at 8:00 AM instead of 120 mg.). In an interview on 05/01/2023 at 8:16 AM, Staff D, Pharmacist, confirmed that there was a medication interaction between digoxin and diltiazem that could lead to elevated blood levels of digoxin. When both medications were entered into the facility system when Resident 3 was readmitted , the nurse had to confirm the order was correct, and the facility doctor was aware of the possible interaction. Per Staff D, it looked like the resident had started on 180 mg of diltiazem, it was decreased to 120 mg, and then increased back to 180 mg. They further stated that an elevated dose of diltiazem given in error, especially for 18 days, could lead to digoxin toxicity as well as leading to a low heart rate, trouble breathing, low oxygen levels and a decreased level of consciousness. In an interview on 05/01/2023 at 1:07 PM, Staff E, Resident Care Manager, stated they do not review new medication orders to try and catch errors. Staff E thought the director of nursing probably did. In an interview on 05/01/2023 at 1:34 PM, Staff A, Director of Nursing (DNS), stated the elevated dose of diltiazem was given due to an error. They further stated that they were aware an elevated dose of diltiazem could lead to digoxin toxicity, as well as causing other side effects such as a low heart rate and trouble breathing. Staff A stated that there had not been a process in place for checking newly entered medication orders for errors, but that a new process was hopefully starting that week. <Resident 4> Resident 4 was admitted to the facility on [DATE] with a diagnosis of necrotizing fasciitis (a soft tissue infection that is severe and spreads rapidly) in their right lower arm. Admission orders included intravenous (IV) antibiotics to be administered four times per day to treat the infection. Review of Resident 4's MAR showed missed doses of the IV antibiotic on 03/27/2023 at 8:00 PM, and again on 03/28/2023 at 2:00 PM. The order for the dose of antibiotic was charted as given on 03/28/2023 at 6:00 AM. Review of Resident 4's nursing progress note, dated 03/28/2023 at 7:32 AM, showed missed IV antibiotic doses from last night and this morning. The same note detailed the resident's orders being faxed to the pharmacy that morning, and the antibiotic dose was to arrive in two to three hours. In an interview with Staff A, Director of Nursing, on 05/01/2023 at 1:34 PM, they stated they tried not to admit residents late in the day, but Resident 4 came in about 6:00 PM, and because of that, it was hard to get some medications the same day. Staff A stated that the situation occurred prior to them taking over the DNS role but that they had been present when the doctor was notified, the doctor was very angry, and had threatened to call the state about the missed antibiotic doses. Reference: (WAC) 388-97-1060(3)(k)(iii)

Based on interview and record review, the facility failed to follow standards of care related to wound management for 1 of 3 sampled residents (1), reviewed for skin and wound care. This failure resulted in actual harm to Resident 1, who had pain and a skin infection requiring topical antibiotics. Findings included . Per the Procedure Manual for High Acuity, Progressive, and Critical Care, 7th edition (pages 1156-1161), the timing of removal of sutures/staples depended upon the location they were placed, and ranged from 3 to 21 days. Unexpected outcomes included embedded sutures/staples and wound infection. Review of the 12/14/2022 admission assessment showed Resident 1 required extensive assistance of one or two staff for activities of daily living. Per the hospital discharge orders, dated 12/06/2022, the facility was to schedule a televisit appointment as soon as possible with the resident's orthopedic surgeon for three weeks after their admission to the facility. There were no orders regarding care of staples. Review of a 12/07/2022 admission body audit tool showed the resident had 22 staples covering a surgical incision to the hip, and an additional eight staples covering a laceration to the head. Review of the December 2022 and January 2023 Treatment Administration Records (TAR) showed nursing staff changed a dressing to the resident's hip daily. Per review of the TAR and nursing notes, there was no monitoring of the staples to the head, or treatment orders regarding when to remove the resident's staples. There was no documentation the physician who placed the staples was contacted to determine when they were to be removed. On 01/08/2023 at 12:34 PM, a collateral contact (healthcare provider) stated Resident 1 discharged from the facility more than four weeks after their admission, with both head and hip staples in place. The contact stated the staples were ingrown (embedded), red, infected, and the resident required substantial amounts of pain medication during the procedure to remove the embedded staples. In an interview on 01/23/2023 at 2:00 PM Staff C, Licensed Practical Nurse (LPN), stated Resident 1 had a daily dressing change to their hip, and staff were aware of the placement of staples to the incision. Per Staff C, residents typically had their staples removed when they went to see their surgeon for a follow-up visit, or had them removed by facility staff if there were physician orders for them to do so. When asked who followed up on staple removal when there was no physician order, Staff C stated a Resident Care Manager (RCM) would call the resident's physician to obtain an order for removal. In an interview on 01/23/2023 at 2:40 PM Staff F, Admissions Coordinator, stated they were in charge of scheduling resident appointments at the time Resident 1 was admitted to the facility. Per Staff F, nurses responsible for admitting the resident would notify Staff F of the need to schedule an appointment, and they would set up transportation. Staff F stated they were not notified of the need to set up any appointments for Resident 1 during their stay. Staff F consulted with Staff E Medical Records, and both staff reviewed the hospital discharge orders and verified the order for the facility to set up a follow-up appointment. Both staff reviewed the facility appointment calendar and stated no outpatient appointment for Resident 1 had been made during their stay, but they were unable to provide any details regarding a televisit appointment for the resident. At 3:05 PM the same day, Staff G, LPN/RCM, stated resident care managers were responsible for setting up resident appointments, and notifying transportation staff of the need for transport. Staff G confirmed that sutures/staples would be removed by facility staff based upon physician orders, and RCMs would follow-up with the physician if there were no orders. Staff G was unable to provide any information regarding Resident 1's follow-up appointment and/or staple removal orders. On 01/26/2023 at 1:45 PM Staff A, Administrator, and Staff B, Director of Nursing, were asked to provide evidence of a televisit appointment for Resident 1 as ordered. An electronic communication received at 4:38 PM that day showed a note that facility staff attempted to contact the physician's office to schedule an appointment on 01/10/2023 (after the resident had discharged from the facility, and more than the three weeks listed in the physician orders). In an interview on 01/27/2022 at 1:40 PM, a representative of the resident confirmed that the resident endured significant pain during the procedure to remove the staples due to overgrown skin, and required topical antibiotic treatment to the sites afterwards due to skin infection. The representative stated the resident required staff assistance with care during their stay at the facility, and would not have been able to schedule their own follow-up appointments due to confusion. Reference: (WAC) 388-97-1060 (1)

Based on interview and record review, the facility failed to investigate a source of pain and perform identified necessary diagnostics, prior to discharge from the facility, for one of six sample residents (1), reviewed for quality of life. This failure caused actual harm to Resident 1, who experienced pain, hospital re-admission, and a diminished quality of life, related to an unrecognized worsened health condition. Findings included . Per the admission assessment dated [DATE], Resident 1 had been admitted to the facility on e week prior with pelvic fractures, and received physical and occupational therapy. Review of the physical and occupational therapy notes, dated 05/12/2021 through 05/26/2021, showed the goal of therapy was pain management and increased function with bed mobility, transfers, and walking, related to pelvic fractures identified on 04/27/2021 (two weeks prior to admission to the facility). The therapy notes showed the resident frequently refused to participate with scheduled therapy sessions due to severe pain, which continued through to the time of discharge from therapy. Additionally, the therapy notes showed the resident was discharged with little to no functional progress made, and needed a full body lift for transfers at the time of discharge. In an interview on 06/25/2021 at 4:09 PM, Staff C, Physical Therapist, stated the resident admitted to the facility approximately two weeks past the initial injury which caused the fractures, and should have been in a healing phase. Per Staff C, the resident's severe pain level was not consistent with the injuries, and diagnostic studies were requested from the nursing staff, to determine if further injury existed. Staff C stated a Doppler study (a test that can be used to estimate blood flow through blood vessels) of one of the lower extremities was done, and was negative; however, a requested follow-up x-ray (a test which produces images of structures in the body, especially bones) of the hip and/or pelvis was not done. At 5:05 PM the same day, Staff B, Advanced Practice Registered Nurse, confirmed Resident 1 was in constant pain, and their pain level appeared to be out of context with their known injury. Staff B stated she believed a follow-up x-ray to determine the resident's injury level had been done during the resident's stay at the facility. At 5:13 PM on 06/25/2021, Staff E, Medical Records, stated no x-ray had been completed for Resident 1, while at the facility. In an interview on 06/10/2021 at 4:17 PM, the resident's representative stated the resident was discharged from the facility on 05/29/2021 and was unable to walk, although they had been able to walk when initially admitted . The representative stated they did not feel as though they were prepared for the extent of the resident's needs at discharge, and the resident was readmitted to the hospital less than 24 hours after discharge, due to extreme pain and loss of function. Review of the hospital records dated 05/30/2021, showed the resident was found to have new pelvic fractures, as well as extension of the previously identified pelvic fractures. The resident was admitted for treatment and appropriate planning for further treatment, upon discharge from the hospital. Reference: (WAC) 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to prevent the development of a pressure ulcer/injury (areas of skin injury from prolonged pressure), and failed to monitor/evaluate pressure ulcers after developing, for one of three sample residents (#3), reviewed for pressure ulcers. This failure resulted in harm to Resident #3, who developed a Stage III (full thickness skin and tissue loss) on his right heel, and a unstageable pressure ulcer (full thickness skin and tissue loss in which the wound bed is covered by slough (non-viable yellow, tan, brown tissue, usually moist) or eschar (dead tissue that is usually black) on his left heel. Findings included . Per the 12/02/2020 admission assessment, Resident #3 was admitted on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment showed the resident was able to make his needs known, required extensive assistance with bed mobility, was at risk for developing pressure ulcers, and had no pressure ulcers on admission. On 03/29/2021 at 10:00 AM, Resident #3 was sitting in his wheelchair at the side of his bed. The resident stated he had sores on his heels, which had been there for a few months, and stated they seemed to be getting better. Resident #3 stated when he was first admitted , he was in bed a lot, because he had a broken leg and foot, and wore a boot cast. At 11:05 AM, staff assisted the resident to remove his socks in order to observe the resident's heels. The right heel had approximately a dime sized area that was yellow in color. The left heel had a small, black, scabbed area. A 03/21/2021 care plan showed the resident was at risk for skin breakdown due to impaired mobility, diabetes, and recent surgery. Interventions were in place to prevent pressure ulcers, however, the care plan was developed approximately four months after admission, at which time he was identified as being at risk for developing pressure ulcers. Review of facility progress notes on 01/11/2021 showed the resident complained of right heel pain when his foot touched down. There was no documentation to show the heel had been evaluated by the facility at that time. Review of notes written by an outside specialist, dated 01/21/2021, showed a friction blister was identified on the resident's right heel, related to the resident's heel rubbing on the boot cast. The boot was discontinued, and wound care was ordered for the facility to follow. No documentation was found to show the right heel had been evaluated or monitored by the facility after the appointment identifying skin impairment on the right heel in January 2021. On 02/18/2021, the resident returned to the specialist, who documented the right ulcer had healed. On 03/11/2021, a progress note documented the resident complained of both heels being sore. There was no documentation found to show the heels were evaluated by the facility. On 03/15/2021, a contracted wound specialist evaluated the resident's heels. The right heel was assessed as having a Stage III pressure ulcer, with a small amount of drainage, measuring 0.5 x 0.4 x 0.1 centimeters (cm). The left heel had an unstageable pressure ulcer which measured 0.9 x 0.9 cm. On 03/29/2021 at 10:50 AM, Staff B, Unit Manager, stated when a resident was admitted , interventions would be placed to prevent pressure ulcers, such as a pressure relieving mattress or floating the resident's heels, especially if a resident was unable to move in bed. Per Staff B, once a pressure ulcer developed a treatment would be started, and the skin would be monitored. If needed, an outside wound team could be consulted. Staff B was asked for information on Resident #3's pressure ulcers on his heels as to when they developed, and evaluation/monitoring of the ulcers. There was no documentation provided prior to the evaluation on 03/15/2021. During an interview on 03/29/2021 at 11:45 AM, Staff C, Director of Nursing, stated interventions to prevent pressure ulcers depended on the resident. They could implement a pressure reducing mattress or reposition the resident. If a resident developed a pressure ulcer then the skin would be monitored daily, or monitoring could depend on how often treatment was ordered. Additional documentation of the skin condition was requested for Resident #3, prior to the assessment on 03/15/2021; none was provided. In a follow-up interview on 04/05/2021 at 8:15 AM, Staff C confirmed there was no additional documentation for Resident #3, showing the facility had evaluated or monitored the resident's heels, prior to the development of pressure ulcers. Reference: WAC 388-97-1060(3)(b).

Based on observation, interview, and record review, the facility failed to monitor the effectiveness of a heart medication, and to timely intervene when it appeared to be ineffective, for one of five sample residents (#54), reviewed for medication management. This failure caused actual harm to Resident #54, who was hospitalized for [REDACTED]. Per the 07/01/19 admission assessment, Resident #54 had [DIAGNOSES REDACTED]. The assessment showed the resident did not have shortness of breath, and received a diuretic (a medication that reduces fluid in the body by increasing urine production), for seven out of seven days of the assessment period. Review of the care plan, revised 07/01/19, showed the resident had the potential for weight fluctuations related to fluid shifts (inside the body), and staff were to review weights and notify the physician of changes. Review of the progress notes showed an entry dated 06/24/19, which documented the resident admitted with [MEDICAL CONDITION] (excess fluid collected in the tissues of the body) to both legs. The [MEDICAL CONDITION] was measured at 1-2 in the right leg, and 2-3 in the left leg. [MEDICAL CONDITION] is generally measured using a scale from 1-4+, with 1 being slight, and 4 being severe. There were no further entries from 06/25/19 to 07/01/19, which showed whether the [MEDICAL CONDITION] continued, increased, or decreased. Further review of the progress notes showed an entry dated 07/02/19, which documented the resident had a 6.6 pound weight gain since the previous weight (six days earlier). Per the note, the resident took a diuretic and had swelling in the legs, so weight fluctuations were anticipated. The documentation did not include how much swelling was in the legs, changes since the swelling was last measured, or whether the physician was notified of the weight gain. Per the electronic weight summary on 07/07/19, the resident had gained an additional 3.2 pounds in five days. On 07/14/19, the resident's weight remained unchanged. Review of the progress notes from 07/07/19 to 07/19/19 did not show an associated assessment of the weight gain, assessment of [MEDICAL CONDITION], or communication of the results to the physician. The notes did show the resident's blood oxygen level was assessed as the facility attempted to wean her off of oxygen, prior to hospitalization on [DATE] for chest pain. Per the hospital records, dated 07/26/19, the resident was hospitalized for [REDACTED]. The hospital records showed the resident had an increased oxygen need, shortness of breath, and increased swelling in her legs, prior to hospitalization . On 08/02/19 at 10:30 AM, Resident #54 stated she lost 18 to 20 pounds of fluid from my heart while in the hospital, and her breathing and laboratory test results were better. The resident stated her legs had increased swelling in the days prior to her hospitalization , but staff were not checking for that. The resident was seated in a wheelchair in her room with her legs elevated, and oxygen on. The resident appeared comfortable, without shortness of breath. In an interview on 08/02/19 at 11:49 AM, Staff O, Licensed Practical Nurse, stated residents taking diuretics should be monitored for the presence of [MEDICAL CONDITION], and weight changes greater than three pounds in one to two days should be reported to the physician. Staff O was unable to recall if Resident #54 was monitored for [MEDICAL CONDITION], or if her weight changes were reported, prior to hospitalization . In an interview on 08/05/19 at 10:32 AM, Staff CC, Advanced Registered Nurse Practitioner, stated the resident was taking a low dose diuretic which she was less familiar with ([MEDICATION NAME]), prior to hospitalization . Per Staff CC, the facility primarily monitored diuretics with weekly weights, and some weight changes for Resident #54 were reported to her, though she was unable to recall when, or what was done to address the weight gain. Staff CC stated the resident returned to the facility on a different diuretic at a high dose, and her weight would be monitored daily, due to the high dose. In an interview on 08/05/19 at 1:42 PM, Staff G, Resident Care Manager, stated if a resident admitted with [MEDICAL CONDITION], it should be monitored for changes. Staff G reviewed the resident's record, and stated that was not done. Staff G stated he believed the changes to the resident's weight had been reported, though he was not able to find documentation of that, or recall what had been done to address the change. Reference: (WAC) 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review, the facility failed to ensure complete skin assessments, ongoing monitoring, and timely interventions were in place, to prevent the development of a facility-acquired pressure ulcer, for one of two sample residents (#46), reviewed for pressure ulcers. The facility failed to adequately assess, monitor, and promptly intervene, when an unstageable heel wound (full thickness tissue loss in which the base of the ulcer is covered by dead tissue) was discovered, resulting in actual harm to Resident #46. Findings included . According to a 05/12/19 quarterly assessment, Resident #46 admitted to the facility with [DIAGNOSES REDACTED]. In addition, the assessment showed the resident was moderately impaired in cognition, required limited to extensive assistance with activities of daily living, and had no pressure ulcers. An alteration in skin integrity care plan was initiated on 06/20/17, and revised on 01/03/19. Risk factors identified included: impaired mobility, incontinence, refusal of showers, refusal to get out of bed or reposition, and refusal to change soiled clothing at times. The goal was for her skin to remain free of breakdown within the limits of her disease process (by the target date of 09/26/19). Interventions included: Barrier cream to the peri area/buttocks as needed, change dressing to heels (added on 07/30/19), diet and supplements per physician order, encourage fluids, fingernail care to prevent scratching, observe skin condition with activities of daily living care daily, and report abnormalities. Review of the (MONTH) 2019 Treatment Administration Record (TAR) showed that staff were to perform a body audit (a full skin assessment by a licensed nurse, to determine if any new skin issues had developed), every seven days on Wednesdays, during the day shift. According to the (MONTH) 2019 TAR, on 05/22/19 and 05/29/19, documentation showed the body audits were not completed, as the resident had refused. A review of the nursing progress notes did not show any attempts at follow-up skin assessments, or identify if any new skin issues had developed during that time. The (MONTH) 2019 TAR showed a new order, dated 06/13/19, to cleanse the right medial heel with normal saline and cover with a dressing, every three days for a blister. Per record review, there were no measurements of the blister, and no skin assessment in the progress notes. There was no assessment to determine how the blister had developed. In addition, the (MONTH) 2019 TAR showed the body audit had been marked as completed on 06/05/19 and 06/12/19, however, nursing progress notes for that same time period did not show that new skin issues or heel pressure ulcers had developed. The (MONTH) TAR also showed that on 06/13/19, the treatment was not completed, as the resident was sleeping. On 06/16/19, the treatment was not initialed as having been completed, as the resident refused. Per review of the record, no other refusals were documented. There were no progress notes indicating any follow-up assessment, or documentation of the heel wound. On 06/19/19 (seven days after the order) the treatment to the right heel blister was marked as completed by the licensed nurse. Per review of the record during that time, there was no documentation of an assessment of the left heel. On 06/15/19, the resident was placed into hospice care for declining health. The initial hospice note and physician plan of care indicated that the resident had bilateral heel wounds. On 06/17/19 a new specialty mattress was supplied by hospice for the bilateral heel wounds, and care was coordinated with the facility staff. A 06/18/19 significant change assessment showed the resident was assessed to be severely impaired in memory, required extensive assistance of one to two staff for activities of daily living, was on hospice care, and had one stage two pressure ulcer (a partial-thickness skin loss). A skin alteration record, dated 06/20/19 (five days after being placed on hospice), showed the first facility documentation of skin breakdown to the left heel. The wound measured 4.5 centimeters (cm.) x 3.0 cm., had black necrotic (dead) tissue, clear drainage, and the surrounding skin was red. There was no treatment documented on the TAR for the left heel, and no progress note regarding the left heel wound prior to that time. An observation of the heel wound on 07/30/19 at 1:08 PM with Staff C, Hospice Nurse, was made. Prior to entering the resident's room, Staff C asked Staff D, Licensed Practical Nurse, if she wanted to visualize the heel wounds with her. Staff D declined, and asked only for the measurements. Upon entering the room, the resident was observed in bed, on her back. A pillow was located under her knees, and both heels were flat on the bed. Staff C removed the dressing to the right heel. The wound intact without any open areas; Staff C stated the covering was just there for protection. The left heel dressing was removed; the wound was located on the medial aspect of the left foot. The wound measured 4.0 cm x 3.5 cm. The entire wound bed contained black necrotic (dead) tissue. Staff C cleansed the wound with normal saline, and applied a clean dressing. The resident did not verbalize pain, or show any signs or symptoms of pain during the treatment. After the treatment was completed, Staff C was asked when the left heel wound was first observed. She stated she had taken over the resident's care shortly after she was admitted to hospice, and stated the left heel wound was big and thick with eschar (dead tissue). Per Staff C, the right heel wound had never been more than a blister, and both wounds were present at the time she was admitted to hospice care. In an interview on 08/01/19 with Staff A, Administrator, and Staff B, Director of Nursing, both confirmed that hospice and the facility had coordinated care on 06/17/19, and a specialized mattress was ordered by hospice for the identified bilateral heel wounds. Staff B then verified that there was no facility documentation of any assessment, monitoring, or interventions, including treatment orders, related to the left heel wound (prior to the resident being placed on hospice). Reference: (WAC) 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to ensure two of six sample residents (#66, 59), reviewed for nutrition, received adequate weight monitoring, to determine whether their nutritional status was stable. This failure led to unintended weight loss for Resident #66 which was not discovered timely, resulting in harm to the resident, in the form of severe weight loss. Findings included: Facility Policy: According to the facility's Weight Management Guidelines, dated (MONTH) (YEAR), The key for effective weight management is to appropriately identify weight variances and initiate nutrition strategies when indicated in time to reduce nutrition related complications. The Guidelines instructed staff to weigh newly admitted residents upon admission, and weekly, for a total of four consecutive weeks. After that time, they were to be weighed monthly, if there were no nutritional concerns identified by the interdisciplinary team, which would warrant more frequent weights. 1. According to his admission assessment dated [DATE], Resident #66 was cognitively intact, and required extensive assistance with most activities of daily living, including transferring and bed mobility. The assessment showed he required only supervision for eating, and had no difficulties with swallowing. Review of Resident #66's hospital discharge records showed he weighed approximately 166 pounds on 05/09/18, before leaving the hospital. Review of the facility weight record for Resident #66 showed he weighed 160.2 pounds on 05/12/18, the day after he admitted . No further weights were documented until 05/31/18, 19 days later. On that date, the weight was recorded as 138.4 pounds, demonstrating a severe weight loss of 21.8 pounds, or 13.6%. An additional weight on 06/02/18 was consistent with the weight loss, at 137 pounds. In an interview on 06/07/18 at 11:11 a.m., Staff O, Nurse Practitioner, stated when Resident #66's weight loss was identified, they performed a medical rule out to determine any medical cause, and none was found. In an interview on 06/06/18 at 3:07 p.m., Staff J, Dietitian, stated Resident #66 admitted to the facility with the understanding that his family would bring in all of his meals, due to severe allergies [REDACTED]. She said the facility only provided fresh fruits from the kitchen. Staff J stated the resident did have a weight loss, so staff were now recording how much of each specific food the resident ate for each meal, and she was encouraging the family to bring in high calorie foods, with larger portions. Staff J stated when Resident #66 first admitted , he was facilitating his own elimination diet, eating only very few, specific foods. She stated when the weight was documented the prior week, and the weight loss was identified, the facility staff addressed the possibility of artificial nutrition with the resident, who declined that intervention. Staff J reviewed the weight record with the surveyor, and then confirmed Resident #66 was not weighed weekly, as he should have been. She stated she put out her weight list for a weekly weight on him, and couldn't provide a good reason for why he went so long between weights. When the surveyor's concerns for how long the resident went between weights, in light of how much weight he lost, was discussed with Staff J she stated, I agree. In an observation and interview on 06/06/18 at 3:24 p.m., Resident #66 was seated in his bed, and a family member (resident appointed representative) was also present. When asked what his typical weight was, Resident #66 stated it was 165 pounds. His representative added, if he fluctuated from that weight in the past, it was only a couple of pounds higher or lower. Resident #66 stated his appetite was better on the date of the interview, but had been low, due to not feeling well earlier in his stay at the facility. When asked about the frequency of the weights being checked, the resident's representative stated they had problems getting information about the weights, and confirmed the resident had lost a lot of weight in a short amount of time. She stated she was now requesting weekly updates on his weight, as well as other information. The resident's severe weight loss occurred during a period in which his weight was not being monitored as often as indicated. 2. Review of the record for Resident #59 showed he weighed 271.8 pounds, upon admission on 05/11/18. Per the weight record, he was next weighed on 05/31/18 (20 days later), and weighed 262.8 pounds, demonstrating a weight loss of nine pounds. Per the record, two weekly weights were missed between these dates. When asked about contributing factors for Resident #59's weight loss, Staff J noted he had [MEDICAL CONDITION] (an accumulation of fluids in the tissues) when he first admitted , and the weight loss was not unexpected. The surveyor stated the concern for Resident #59 was that the resident was not weighed for almost three weeks, as a new admission. In an interview on 06/07/18 at 2:32 p.m., when asked about the weights being missed for Resident #66 and Resident #59, Staff C, Unit Manager, stated unit managers got a form from the dietitian, listing residents who needed to be weighed, but stated as he was not the unit manager during the time of the missed weekly weights, he did not know why the residents were not weighed. Reference: (WAC) 388-97-1060(3)(h)

Based on interview and record review, the facility failed to develop and implement a discharge plan that addressed all of the needs for three of five residents (#1, 2, 3), reviewed for discharge to home. Failure to address Resident #2's need for home health therapy services, and the availability of two persons for all transfers, resulted in harm, as two persons were not available at home, the resident remained in a recliner chair for two days, and home health therapy services could not be provided. Failure to evaluate Resident #1's worsening venous stasis ulcers, in preparation for discharge to a community setting, resulted in harm, as the resident required hospital evaluation and treatment the day after discharge for [MEDICAL CONDITION] (infection) in both lower legs, requiring wound care and intravenous antibiotics. Findings included: 1. According to the [DATE] facility assessment, Resident #2 had a right leg amputation, a new left [MEDICAL CONDITION], mild cognitive impairment, no mood or behavior problems, frequent urinary incontinence, bowel incontinence, and required the extensive assistance of two staff for transfers, bed mobility, and toileting. Review of the discharge care plan, initiated [DATE], showed the resident planned to discharge home with a family member. Interventions included arranging transportation, investigating the need for home health services, and resident /resident representative education related to self-care techniques, medications, diet, and activities. Additional record review showed the facility issued written notice to the resident/resident representative on [DATE], informing them Medicare services would end on [DATE], because Resident #2 was self-limiting her therapy participation, and was no longer progressing toward the goal of requiring less assistance with transfers. Staff offered the family member information about resources for hiring help at home, which the resident representative refused at that time. No other preparations for discharge were provided, as indicated in the discharge care plan. According to the record, the resident was discharged to home [DATE]. The facility referred the resident for home health services, to start [DATE]. There was no information or evidence of planning, related to the family member's abiity to provide two-person assistance with transfers. In a telephone interview on [DATE] at 1:40 p.m., the family member stated she felt the facility kicked the resident out, once she had problems in therapy. According to the family member, on [DATE], the facility sent Resident #2 home in their recreational van, and the driver helped her transfer the resident into a recliner chair. The family member stated she tried to transfer the resident, but was physically unable to do so, without a second person. She rolled the resident over in the recliner chair, and changed her briefs, which she stated was very difficult for both herself and the resident. The family member stated on [DATE], home health agency therapists came out, and refused to provide therapy services (because of the resident's need for two-person assistance). They provided information about hiring help at home. The family member stated caregivers started coming two hours per day, beginning [DATE]. She and the caregiver transferred the resident to bed, and the resident was now transferring out of bed every day. In addition, she was arranging for a transfer to another skilled nursing facility, because of the resident's extensive need for assistance with activities of daily living. During an interview on [DATE] at 11:00 a.m., Staff C, Social Services, stated the family member was informed, and refused assistance with hiring help at home. Staff C confirmed that Staff D, Activity Director, drove the resident home in the recreational van, and assisted the family member to transfer the resident into a recliner chair. In addition, Staff C stated she did not know there were conditions under which home health agencies could not accept a resident. Refer to F661 for additional findings. 2. According to the [DATE] facility assessment, Resident #1 had chronic kidney problems requiring out-patient treatment three times weekly, poor circulation to both lower legs, no cognitive impairment, no behavior problems, and required extensive assistance with bed mobility and transfers. Review of the discharge plan, initiated [DATE], showed the resident planned to discharge home with a family member, when her clinical and rehabilitation goals were met. Additional record review showed the resident's family member died in June, 2017. The discharge care plan was not updated after that date, but record review showed the facility and another family member identified a plan for discharge to a community setting. Additional record review showed the resident was admitted with intact skin, developed lower extremity wounds on [DATE], and continued to require daily treatment until discharge on [DATE]. Review of evaluations by a wound consultant, who assessed the resident's skin condition weekly between [DATE] and [DATE], showed the resident had problems with lower leg [MEDICAL CONDITION], and variable improvement and/or worsening of her open wounds, week by week. According to the wound consultant note dated [DATE], the resident's [MEDICAL CONDITION] was improved, there were two wounds that were smaller, but more painful, with no signs of infection. The wound consultant documented the resident was too weak for a community setting, and needed support to help remind her to manage her wound care and [MEDICAL CONDITION]. According to the wound consultant note dated [DATE], the resident had increased [MEDICAL CONDITION], and breaking down of the skin on both lower legs. The wound consultant documented the resident would benefit from wound debridement (removal of dead tissue in the wounds), but the legs were painful just to clean them with gauze. The note indicated there was no sign of infection. The wound consultant also documented lower leg healing was not likely, with a goal to slow the development of significant infection. Record review showed no additional evaluation of discharge goals, based on the wound consultant's evaluation of the resident's needs, including risk for development of lower leg infection. According to the record, on [DATE], the resident's family member informed the facility that discharge to a community setting had been arranged for that same day. There was no notification to the family member regarding the resident's current skin condition. The resident was discharged from the facility to out-patient treatment on [DATE], and from out-patient treatment to the community setting, with a referral for home health services. Review of hospital records showed on the morning of [DATE], the resident was admitted to the hospital, after having been confused and combative overnight at the new facility. On [DATE], the hospital record showed the resident had bilateral lower leg skin infections, described as bright red [MEDICAL CONDITION] to both lower legs with warmth, and [MEDICAL CONDITION] from chronic circulation problems. The resident's confusion cleared, with ongoing treatment for [REDACTED]. During interview on [DATE] at 3:00 p.m., Staff H, Licensed Practical Nurse, confirmed she was the assigned nurse on [DATE], when the resident was discharged . When asked, Staff H stated she had just started working at the facility, and wouldn't have known if the resident's wounds were worse. During interview on [DATE] at 11:00 a.m., Staff E, Director of Nursing, had no additional information related to the resident's skin condition and discharge plan. 3. According to the [DATE] facility assessment, Resident #3 had a right [MEDICAL CONDITION], severe cognitive impairment, required extensive assistance of two staff for mobility and transfers, and had a right hip surgical wound. Review of the transfer orders from the hospital showed no physician orders for removal of the surgical wound staples. Additional record review showed on [DATE], the resident developed a suspected deep tissue injury (pressure-related injury to subcutaneous tissues under intact skin) to the upper right heel. According to the facility discharge plan, the resident was discharged to a community setting on [DATE], with a referral for home health services. Review of the facility discharge plan showed no information about the surgical wound staples that were still in place, including who was responsible to remove them, and no information about the upper right heel suspected deep tissue injury. According to the facility investigation dated [DATE], after the resident was discharged , the home health agency had to contact the physician for an order to remove the staples. During interview on [DATE] at 11:00 a.m., Staff E, Director of Nursing, had no additional information to offer. Reference (WAC) [DATE] (3)(a).

Based on interview and record review, the facility failed to ensure that two of three residents reviewed for medication errors (#283, #54), were free from significant errors. Failure to administer an anticoagulant (blood thinning) medication as ordered by the physician caused actual harm to Resident #283, who developed blood clots requiring hospitalization , after having been discharged from the facility on a lower dose of medication than ordered. Additionally, failure to administer a [MEDICAL CONDITION] medication as ordered by the physician placed resident #54 at risk for increased [MEDICAL CONDITION] and adverse side effects. Findings included: 1. Per the record, Resident #283 was admitted to the facility for short-term rehabilitation following a motor vehicle accident, on 05/31/17. The resident had fractures of the left leg and hip, and had a history of [REDACTED]. The admission assessment, dated 06/08/17, indicated Resident #283 was cognitively intact for daily decision-making, required extensive assistance with activities of daily living, and had been on an anticoagulant medication since admission to the facility. A review of the May and June 2017 medication administration records (MAR) indicated the resident was admitted on two blood thinning medications. One of the medications, [MEDICATION NAME], was given by mouth, and the other medication, [MEDICATION NAME], was given by injection daily. A pharmacy consultant report, dated 06/09/17, documented a request to the physician, to increase the dose of [MEDICATION NAME] to twice daily, to ensure that a consistent therapeutic drug concentration was maintained throughout the day. The physician agreed with the recommendation, and the order was signed. The resident was seen by his orthopedic physician on 06/19/17 and an order to discontinue the [MEDICATION NAME] injections was received. According to the MAR, the [MEDICATION NAME] was discontinued on 06/19/17, however, the documentation showed the resident continued on once daily [MEDICATION NAME], rather than twice daily, as ordered by the physician on 06/09/17. Resident #283 discharged from the facility on 06/30/17. Per the discharge medication instruction sheet, the [MEDICATION NAME] was to be given once daily. The correct dose had never been transcribed and/or given. Hospital records were obtained. The resident was readmitted to the hospital on [DATE], with blood clots to the lungs, and right-sided heart strain. A pacemaker was inserted, due to a significant heart rhythm problem during his hospital stay. The physician's progress note, dated 07/19/17, indicated that the [MEDICATION NAME] (one tablet per day) was not enough to thin the resident's blood, to prevent further blood clot development. In an interview on 08/29/17 at 11:14 a.m., Staff A, Director of Nursing, was asked what the process was, to ensure pharmacy recommendations and physician's orders [REDACTED]. If there is a signed physician order, the unit managers are to initiate the order as written. Staff A was asked if the order to increase the [MEDICATION NAME] was followed. She stated it appeared the physician's orders [REDACTED]. 2. According to the 06/04/17 quarterly assessment, Resident #54 was admitted to the facility in June 2014, with [DIAGNOSES REDACTED]. The assessment indicated the resident was moderately impaired in cognition for daily decision-making, and required limited to extensive assistance with activities of daily living. A review of the record also showed the resident was on several medications to treat [MEDICAL CONDITION], including a routine and as needed antianxiety medication. A review of the facility accident/incident log indicated a medication error occurred on 06/05/17, involving Resident #54. A review of the facility investigation indicated on 05/03/17, the physician had ordered [MEDICATION NAME] 0.5 milligrams (mg.) - a medication for anxiety and [MEDICAL CONDITION]), to be given twice daily for [MEDICAL CONDITION] precautions. On 05/30/17, Staff F, Registered Nurse, wrote an order to discontinue the [MEDICATION NAME]. There was no documentation as to why the [MEDICATION NAME] was discontinued. A review of the medication record sheet, from 05/23/17 to 06/06/17, indicated on 05/30/17, Resident #54 received the scheduled morning dose of [MEDICATION NAME]. The record further showed the resident received two doses of [MEDICATION NAME] on 05/31/17, and one dose on 06/03/17, 06/04/17, and 06/06/17, despite the fact the medication had been discontinued on 05/30/17. A physician's telephone order, dated 06/06/17 documented a new order for [MEDICATION NAME] 0.5mg., twice daily for [MEDICAL CONDITION] precautions. In a written statement dated 06/14/17, Staff F, Registered Nurse, indicated he had received orders on to change the as needed [MEDICATION NAME] dose. Per the statement, Staff F accidentally deleted the scheduled 0.5mg [MEDICATION NAME] order, and replaced it with the as needed order. In an interview on 08/30/17 at 1:22 p.m., Staff A, Director of Nursing, stated she had reviewed the medication record from 05/23/17 to 06/06/17, and acknowledged the [MEDICATION NAME] had been given without an order. She further stated the error was discovered on 06/09/17, Resident #54 did not have any [MEDICAL CONDITION] during that time, and the resident was assessed by the nurse practitioner and had no adverse effects from the medication error. WAC 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to provide timely care and services, for 1 of 2 sample residents (#2), reviewed for pressure ulcers. Failure of the facility to follow an order for [REDACTED]. Per the 02/08/17 quarterly assessment, Resident #2 was admitted to the facility with [DIAGNOSES REDACTED]. The assessment indicated the resident was cognitively intact for daily decision-making, required extensive assistance to total dependence on staff for all activites of daily living, and was at risk for pressure ulcers. A review of the care plan, intiated on 02/20/17 and revised on 04/05/17, indicated the resident had developed a skin condition, resulting in pimple-like eruptions that developed into blisters which opened up, and merged together on the left buttock, developing into an ulcer. Care plan goals, related to the ulcer, included the wound would not show signs of infection, and the area would heal without complication. Interventions included pain management, wound treatment, lab monitoring, repositioning, and providing incontinent care. The resident was identified as non-compliant at times with repositioning and incontinent care, placing him at increased risk for worsening of the wound. A skin assessment progress note, dated 02/21/17 at 10:03 a.m., documented the resident had three small blisters on the left posterior thigh, which had merged into an open area, measuring 0.5 centimeters (cm.) x 1.2 cm. According to the progress note, the wound had measured 1.0 cm x 2.5 cm. with 100% slough (dead tissue) on 02/16/17; surrounding skin was normal in appearance. Per the record, the open area was treated with [MEDICATION NAME] cream daily. A skin assessment progress note on 02/28/17 documented the left posterior thigh wound measured 0.5 cm x 1.2 cm., was scabbed over, and had flaky, fragile skin surrounding it. A skin assessment progress note, dated 03/07/17 at 8:30 a.m., indicated the left thigh wound was caused by moisture associated skin damage, and had increased in size, now measuring 1.25cm x 2.5cm. The assessment indicated the wound center was 50% brown eschar (a dry, dark scab of dead skin), and the surrounding skin was red. The progress note further indicated the treatment was changed. A nurse practioner progress note, dated 03/17/17 at 2:32 p.m., indicated the resident now had a wound infection from the ulcer, located on the back of his left lower extremity. An antibiotic was ordered for 10 days. A progress note, dated 03/21/17, documented the left upper thigh wound now measured 2.0 cm x 2.5 cm., with the wound bed containing 100% dead tissue, and the surrounding skin was red. The treatment had been changed from every three days to daily. A nurse practioner progress note, dated 03/22/17 at 12:03 p.m., indicated the wound on the resident's leg, near his buttocks, was not getting better, despite treatment. She recommended a consultation with the wound clinic, and wrote an order. A 03/28/17 progress note (6 days later) documented the wound now measured 6.0 cm x 4.0 cm., extending to the buttocks. The note further documented the registered nurse would discuss treatment options with the therapy director at the faclity. There was no indication the wound clinic had been notified of the deteriorating wound, or a referral sent. A progress note on 04/04/17 indicated the wound measured 5.0 cm. x 3.5 cm., and the center of the wound contained 100% dead tissue, with reddened surrounding skin. There was no documentation of a referral to the wound clinic, despite the fact the wound was worsening. Per observation on 04/05/17 at 11:00 a.m., with Staff A, director of nursing, the wound was approximately 5.0 cm in diameter, with the entire center portion of the wound covered in black, scabbed, dead tissue. The surrounding skin was red, raw, and bleeding. The top portion of the wound (at approximately the 11:00-12:00 o'clock position) was hard and swollen. Staff A was asked when the appointment was scheduled, for Resident #2 to go to the wound clinic. She stated they were working on it, but had not heard if there was an appointment at that time. Staff A further stated she had spoken to the therapy manager and the physical therapist, who was wound certified, who would be able to debride the wound at the facility, possibly on 04/06/17. Staff A was then asked if Staff B, resident care manager, had kept her up-to-date on the status of getting the resident into the wound clinic, as it had been more than two weeks since the order was written, and the wound was worsening. Staff A said she was not given any wound clinic updates from Staff B. In an interview on 04/05/17 at 12:40 p.m., Staff C, nurse practioner, was asked if she had been kept up-to-date on the status of the wound clinic appointment. She stated as far as she was aware, all the information had been sent, and they were waiting to hear back from the clinic. Staff C also said the resident really needs to be seen soon. In an interview on 04/05/17 at 1:03 p.m., Staff B, resident care manager, was asked about the referral to the wound clinic (per the order on 03/22/17). She stated the resident had not yet been given an appointment at the wound clinic. Staff B said she had sent progress notes, labs, and treatment orders to them. Staff B was asked if she had followed-up with the clinic, due to the worsening of the wound; she said she had not. On 04/05/17 at 2:03 p.m., Staff A told the surveyor she had called the wound clinic, and the next available appointment for the resident was on 04/14/17. Staff A further stated they had scheduled the wound debridement for 04/06/17, with the physical therapist at the facility. On 04/06/17 at 1:00 p.m., Staff A stated the pharmacy had sent the wrong pain medication, to give the resident prior to the debridement, so the procedure was cancelled. At 3:30 p.m. the same day, Staff A said she had called and spoken to the wound clinic physician. He was updated regarding the wound condition, size, and current treatment. He recommended the resident be taken to the hospital for observation and debridement of the wound. Per review of the hospital records, dated 04/06/17, the resident had a 10 cm. x 10 cm. reddened area to the left sacral/buttocks area. The record identified the wound initially as a stage IV pressure sore (full thickness tissue loss with exposed bone, tendon or muscle) with eschar (dead tissue) in the center, which measured approximately 5.0 cm x 4.0 cm., with no drainage. The resident was admitted to the hospital for further treatment. A hospitalist progress note, on 04/08/17, documented the pressure sore was surgically debrided (the dead tissue was removed). The resident was discharged back to the facility on [DATE] with orders for bedrest, wound treatments, and a wound clinic appointment on 04/14/17. A wound clinic progress note, dated 04/14/17, indicated the pressure sore was a stage III (full thickness tissue loss). The resident was to remain on bedrest, with specific wound treatments. The facility failed to ensure a consultation and appointment with the wound clinic, to treat a resident's worsening pressure sore, was done timely. Reference: (WAC) 388-97-1060 (3) (b)

Based on observation, interview, and record review, the facility failed to consistently provide adequate supervision to prevent falls with injuries, for 1 of 3 residents reviewed for falls (#5), in a sample of 12. This failure resulted in harm for Resident #5, who sustained a fracture and a head injury. Findings include: Resident #5 was admitted to the facility 11/15/15 for rehabilitation and monitoring, after hospitalization for a systemic infection. Per record review, the resident had [DIAGNOSES REDACTED]. Review of the resident's therapy evaluations on 11/16/15 revealed the resident was legally blind, had a history of [REDACTED]. According to the comprehensive care plan dated 11/15/15, the resident was at risk for falls due to impaired balance, poor coordination, and a tendency to be impulsive with transfers. Interventions included: encouraging placement in high traffic areas for increased visibility, when up in the wheelchair. Record review revealed the resident had 5 falls during her stay at the facility. -11/25/15 at 7:37 p.m. The resident became confused about the placement of the wheelchair during a transfer with Staff I. She slipped to the floor without injury. The care plan was modified to keep commonly used articles within easy reach. -12/03/15 at 9:00 a.m. The resident again became confused about the location of her wheelchair during a transfer with Staff I, and fell , without injury. -12/11/15 at 11:30 p.m. Staff N answered the resident's call light. The resident was sitting on the edge of her bed. Staff N placed the resident's walker in front of her. Before she could assist further, the resident stood up on her own, and fell to the left, hitting her head. The resident was transferred to the Hospital emergency room , where serious injuries were ruled out. The care plan was modified to ensure proper footwear was in place, then position the walker in front of the resident, and provide step-by-step verbal cues. -12/16/15 at 10:45 p.m., Staff J was assisting the resident to transfer, and the resident fell face first onto her mattress, without injury. On 12/17/15, the care plan was modified to move the resident to a room closer to the nurse's station for increased supervision. There were no additional care plan modifications to address the resident's impulsiveness and poor balance during transfers, including consideration of 2 staff assistance with transfers. -12/22/15 at 7:15 p.m. Staff M answered the resident's call light, and was preparing the resident's bed, when the resident stood up on her own, and fell forward, landing on the floor next to the wall and dresser, hitting her head. The resident was transferred to the hospital emergency room . X-rays confirmed the resident had a fractured cervical spine that did not require surgery, and a head injury. The care plan was modified for one-to-one supervision, upon redmission to the facility; however, the resident was not readmitted . During interview on 02/09/16 at 04:40 p.m., Staff L, a therapist, stated the resident did not have the same impulsive behavior during transfers with therapy staff. He stated nursing staff did not specifically ask him about care plan modifications, to reduce the risk fo falls, because they knew the resident was working on balance in therapy. When asked what care plan modifications would decrease the risk of falls while the resident was working on balance, he stated a high degree of supervision (possibly including 2 staff for assistance). Staff M was interviewed on 02/11/16 at 8:20 p.m. Staff M stated she thought the resident had a perceptual problem. When possible, Staff M stated she tried to keep a hand on the resident, to guide her. When asked if the resident was ever care-planned for 2 staff during transfers, Staff M responded no. During interview on 02/19/16 at 2:15 p.m., Staff B stated the resident was reviewed in interdisciplinary team meetings. The facility's failure to provide sufficient supervision for a resident with frequent falls resulted in harm to the resident, who suffered serious injury to her cervical spine and head as a result of a fall.

Based on interview and record review, the facility failed to prevent accidents by re-evaluating and implementing new interventions for 1 of 6 residents (#2) related to falls in a sample of 9 residents. This failure resulted in harm to Resident #2. Findings include: Resident #2, per record review, had chronic respiratory/cardiac issues with a recent history of loss of consciousness, falls, dizziness, and unsteady gait. The resident had memory problems and difficulty with making daily decisions. He required extensive assistance with bed mobility and toileting, but required limited assistance with other activities of daily living (ADL's). The resident's balance was not steady and he was not able to stabilize without physical assistance safely. Per record review, the facility assessed the resident as high risk for falls and initiated care plan interventions which included appropriate non slip footwear, encouraged the resident to call for assist, and to lock the wheel chair brakes. Per record review, the resident fell on [DATE] at 3:55 p.m. from his wheel chair and hit his head sustaining a 3.1 centimeter (cm) laceration. He required sutures at a local hospital. The hospital performed x-rays and determined the resident had no fractures. He returned that evening to the facility at the start of the night shift with orders for an antibiotic for a urinary tract infection (UTI) and an order for [REDACTED]. Per review of the facility investigation dated 11/25/11, the facility did not update the care plan following the fall. The licensed staff observed the resident through the night and placed the bed in the low position, but never updated the safety plan. Per review of the facility investigation dated 11/26/11, prior to the fall the resident was sitting at the edge of his bed eating lunch and was later found on the floor next to his bed. He sustained a 5 cm x 5 cm abrasion to his right forehead, 2 cm x 2.8 cm laceration to his right index finger, and a 1 cm x 0.8 cm bruise to his right middle finger. The resident complained of headache after the fall and the family requested that he be sent to the hospital for evaluation. Per review of the hospital record following the 11/26/11 fall, the resident sustained [REDACTED]. On 12/14/11 at 3:35 p.m., Staff #A reported the facility had a fall program and said they add new interventions after each resident fall. He reported the system included the therapist evaluating the residents transfer status following a fall, but said in this case Resident #2 was discharged from physical therapy services on the morning of 11/25/11. The physical therapist updated the resident's status to stand by assistance with transfers and walking. He said the nurses monitored Resident #2 closely through the night, but did not update the care plan. On 1/4/12 at 4:20 p.m., Staff #B reported if she had a resident that was high risk for falls she would add a mat on the floor to prevent injury. On 1/4/12 at 4:21 p.m., Staff #A reported the facility did put the bed in low position during the night. He confirmed the resident was not re-evaluated by physical therapy staff on for balance after the fall. On 1/5/12 at 1:45 p.m., Staff #C reported she would not have left the resident sitting at the edge of the bed. On 1/5/12 at 1:53 p.m., Staff #D reported prior to the resident's fall he got dizzy from sitting to standing and she had him sit in the hall so she could watch him closer. She said she did not let him sit at the edge of his bed. On 1/9/12 at 10:00 a.m., Staff #F reported the resident was discharged from case load prior to the falls and was not re-evaluated after the fall. On 1/30/12 at 1:15 p.m., Staff #A confirmed the resident was not re-evaluated after his fall on 11/25/11. The facility failed to put measures in place to protect a high risk resident for falls or re-evaluate the resident's ability after a fall. This caused harm to Resident #2.