Every finding on record at Summitview Rehab and Health Center

Based on observation, interview and record review, the facility failed to provide dignified care in a manner and in an environment that enhanced dignity and quality of life for 4 of 6 residents (Residents 2, 5, 7 and 28) reviewed for dignity. This failure placed residents at risk for unmet needs and a poor quality of life. Findings included. Record review of a facility policy titled, Dignity, dated 02/2021 showed .Residents are always treated with respect and dignity.Residents are provided with a dignified dining experience.Staff protect confidential clinical information, and verbal communication is kept outside the hearing of other residents or the public. Resident 2 Review of the resident's medical record showed they were admitted to the facility with diagnoses which included a history of stroke (blood flow to the brain is blocked causing lack of oxygen to brain tissue), dementia (a decline in mental ability that interferes with daily life) and depression. The comprehensive assessment dated [DATE] showed the resident had moderate cognitive impairment, required substantial assistance from staff for dressing and grooming and was dependent on staff for transfers and mobility. During an observation on 05/18/2026 at 11:54 AM, Resident 2 was in the dining room sitting at a table with two other residents waiting for their lunch meal. The dining room had 19 total residents seated at various tables also waiting for their meals. Additionally, there was a family member sitting with their mother. A visitor entered the dining room with an open computer and approached Resident 2 while they were seated at their table. The visitor identified themselves as a Hospice nurse and the reason for their visit was because Resident 2 had a telehealth appointment with the Hospice physician. The visitor stated to the resident they were scheduled to have a meeting with the physician. The visitor placed their computer monitor in front of Resident 2 and proceeded to discuss the resident's Hospice status with the resident and the physician via computer monitor. The confidential conversation could be overheard by other residents, staff and the family member of another resident who were present in the dining room. Resident 5 Review of the resident's medical record showed they were admitted with diagnoses which included a left hip fracture and a urinary tract infection. The comprehensive assessment dated [DATE] showed they were cognitively intact, required only set up assistance for grooming and were independent with transfers and ambulation for short distances. In an observation on 05/18/2026 at 12:35 PM, Resident 5 was seated at a table with three other residents who had been served their lunch meal and had begun eating. Resident 5 had a cup of tea and was fiddling with the tea bag looking down while the other residents ate. At 12:46 PM Resident 5 was served their meal tray, 11 minutes after the other residents had been served. Resident 7 Review of the resident's medical records showed they were admitted with diagnoses which included Alzheimer's disease (a progressive brain disorder that destroys memory and thinking skills) and epilepsy (a brain condition that causes repeated seizures). The comprehensive assessment dated [DATE] showed Resident 7 was severely cognitively impaired and required total assistance from staff for dressing, grooming, eating, mobility and transfers. During an observation on 05/20/2026 at 12:03 PM, Resident 7 was seated at a table with two other residents who had received their lunch meal trays and were being assisted with eating by staff. Resident 7 did not get their meal tray until 12:17 PM, 14 minutes after the other residents had been served and were eating. During an observation on 05/20/2026 at 12:04 PM, Resident 5 was sitting at their table waiting for their meal tray as their two tablemates had already been served and were eating. At 12:16 PM Resident 5 received their meal tray, 12 minutes after the other residents had been served and began eating. During an interview on 05/22/2026 at 8:33 AM, Resident 5 stated their meal trays were usually late, they were not sure why, but kept themselves busy while the others were eating. During an interview on 05/21/2026 at 9:02 AM, Staff B, Director of Nursing Services stated they expected staff to serve residents one table at a time so other residents did not have to watch their tablemates eat in front of them as this was not dignified. Additionally, Staff B expressed concern for Resident 2's confidential health information being discussed in the dining room in a telehealth meeting in front of other residents, staff and family members as this is not allowed in the dining room. Resident 28 Review of the medical record showed the resident was admitted to the facility on [DATE], with diagnoses including a stroke with right side weakness, dementia, blindness, falls and hearing impairment. The 03/03/2026 quarterly assessment showed the resident was alert, oriented and able to make their needs known. Resident 28 required set up with their meals and information where the utensils, plate, cups and food location in front of them, but were able to eat by themselves. The resident required assistance to ambulate and transfer. Resident 28s preference was to stay in their room for all activities. During an observation on 05/21/2026 at 9:35 AM, showed a nurse take a report from a nursing student that Resident 28 told them a Nursing Assistant (NA) was rude to them. During an interview on 05/21/2026 at 10:30 AM, Resident 28 stated that they could not identify the staff, but the staff was rude and should not work with the elderly. Resident 28 asked the staff member if they could assist them with eating, but the staff stated they had been busy and if the resident needed help, they could take them to the dining room. Resident 28 stated the staff repeated that they could take them to the dining room and this upset the resident further. Resident 28 stated they preferred not to leave their room due to being self-conscious of their inability to see and felt safe in their room. During an interview on 05/22/2026 at 9:50 AM, Staff I, NA, stated Resident 28 did not like to get up before 9:00 AM and the resident could feed themselves after setup. Staff I stated on the morning of 05/21/2026, they brought Resident 28's meal tray into the room. Staff I then told the resident what the meal was and location of the food. Resident 28 began eating their oatmeal and Staff I left the room. Staff I stated the resident used their call light after they had left the room. Staff I stated when they answered the resident's call light they requested assistance with eating Staff I informed the resident if they needed more assistance they could take them to the dining room. Review of the 05/22/2026 investigation by the facility showed that Staff I had acted undignified to Resident 28 by suggesting taking the resident to the dining room. Reference: WAC 388-97-0180(1)-(4)

Based on interview and record review, the facility failed to ensure a resident's Power of Attorney (POA), was fully informed of the admission agreement to include payment for services and co-payment requirements for 1 of 3 residents (Resident 43) reviewed for admission to the facility. This failure placed the resident/POA at risk for the inability to make informed decisions regarding the resident's health care, alternative treatments and the right to refuse care/services. Findings included. Resident 43Review of the medical record showed the resident was admitted to the facility on [DATE] with a post-operative diagnosis of a fractured left shoulder with a shoulder joint replacement. Other diagnoses included depression and delirium (a state of confusion, memory issues related to a medical or psychological condition). The 05/05/2026 nursing admission assessment showed the resident had cognitive impairment and required assistance with Activities of Daily Living (ADL) for transfers. Review of the 05/04/2026 Social Service History and Initial Assessment showed that under section B, the advanced care planning, Resident 43 stated they had a POA for Health and Financial authority and would ask someone to bring a copy. During an interview on 05/18/2026 at 11:00 AM, Collateral Contact 1 (CC1), POA stated they had not received any paperwork on Resident 43's admission process or any information regarding what the resident's insurance covered. During an interview on 05/18/2026 at 11:30 AM with Staff E, [NAME] Coordinator and Staff H a second [NAME] Coordinator, it was stated that Staff H had reviewed the admission paperwork with Resident 43. Staff H stated that they asked Resident 43's visitor (a family member visiting with Resident 43, not their POA) about going over paperwork and if the resident could fill it out. The visitor asked Staff H to come back later. Staff H came back later and had the resident sign paperwork. Staff H was unaware that the resident had a POA who was responsible for their finance and healthcare. Staff H had not contacted or asked for their POA document. Record review of Resident 43's paperwork showed they were admitted to the facility on [DATE] and had a co-pay that would start on the 20th day, 05/20/2026, at $217 a day. Currently, Resident 43 was on the 19th day of their stay at the facility. During an interview on 05/18/2026 at 12:15 PM, CC1, POA stated they were unaware of the upcoming $ 217 a day charge starting on 05/20/2026 for Resident 43's stay on the 21st day. Additionally, CC1stated they were not asked to bring the durable power of attorney paperwork. During the interview with the POA and Resident 43, the resident stated they did not recall reviewing or signing the admission paperwork. During an interview on 05/18/2026 at 2:00 PM, Staff D, Social Services Director, stated a social service admission review was completed on 05/04/2026 with Resident 43. Staff D stated there was no follow up on obtaining a copy of the POA. Reference: WAC 388-97-0260 and WAC 388-97-0240

Based on interview and record review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR, a process to determine if a potential nursing home resident had a serious mental illness [SMI] or intellectual disability needs which required further assessment/treatment) had the required Level 2 PASARR referral sent when a resident had a positive Level 1 PASARR and was in the facility more than 30 days for 1 of 7 residents (Resident 10) reviewed for PASARR. This failure placed the residents at risk for inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.Findings included.Review of the medical record showed Resident 10 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease (a progressive brain disorder that affects movement and balance), syncopal episodes (fainting or a loss of blood flow to the brain leading to loss of consciousness) and depression. The 04/09/2026 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. Review of Resident 10's PASARR Level 1 form completed on 04/07/2026, showed Resident 10 had a positive SMI indicator of depression but did not have a Level 2 referral sent. The document showed that Resident 10 was expected to be discharged from the facility within 30 days and met the requirements for an exempt hospital discharge (a process that required a Level 2 be sent if a resident was not going to be discharged from a facility within 30 days).During an interview on 05/20/2026 at 2:50 PM an additional PASARR for Resident 10 was requested from the facility since no other PASARR document was noted in the resident's chart. Staff D, Social Services Director, stated they would look for another PASARR for Resident 10. Review of an additional PASARR Level 1 form completed by Staff D on 05/11/2026, showed the resident was positive for a SMI and a Level 2 referral would need to be sent (completed four days after the required 30-day mark). During an interview on 05/21/2026 at 10:30 AM, Staff D stated the process for ensuring PASARR's were completed/accurate included screening the resident on admission and if the Level 1 PASARR was positive, a referral for a Level 2 evaluation (an in-depth, person-centered evaluation triggered by a positive Level 1 screen to determine if an individual required specialized services) was sent. If the resident had a SMI diagnosis, a Level 2 referral would be required prior to the residents admission, but if a resident was approved for an exempted hospital discharge, the facility would then need to screen the resident and send a referral if they were going to be admitted to the facility longer than the 30 days. Staff D stated that Resident 10 had an exempted hospital discharge and their PASARR Level 1 screening should have been completed the week before the resident's 30-day mark. Staff D stated the Level 1 PASARR form was completed on 05/11/2026 but the Level 2 referral was not sent until 05/20/2026 (13 days after the required date). Staff D stated the correct process was not followed for Resident 10's PASARR referral. During an interview on 05/21/2026 at 10:58 AM, Staff A, Administrator, stated they would have expected Resident 10's Level 1 PASARR screening and referral to have been completed/sent with the required 30 days of an exempt hospital discharge. Staff A stated the correct process was not followed. Reference: WAC 388-97-1915(1)(2)(a)(b)(c)

Based on observation, interview and record review, the facility failed to implement documentation/monitoring of depression symptoms per the comprehensive resident centered care plan and honor resident preferences with nighttime routines for 1 of 6 residents (Resident 38) reviewed for care plan implementation. This failure placed residents at risk for unidentified mental health symptoms and unmet care needs.Findings included .Review of the medical record showed Resident 38 was originally admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of a fracture to the left leg, respiratory failure (occurs when the lungs fail to provide adequate oxygen to the rest of the body), lung infection and protein calorie malnutrition (a form of undernutrition, caused by not eating enough protein/calories, leading to muscle/fat loss and impaired bodily functions). The 04/23/2026 comprehensive evaluation showed the resident was cognitively intact, able to make their needs known and required assistance from one to two staff with activities of daily living (the basic self-care tasks needed to maintain your health and well-being). Additionally, within the comprehensive evaluation Resident 38's mental health screening assessment showed they met criteria of moderately severe depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in things and actives you once enjoyed). A concurrent observation and interview on 05/18/2026 at 2:13 PM, showed Resident 38 sitting up in bed with downward turned lips and watery/glossy eyes and on the verge of crying when conversing with the surveyor. Resident 38 proceeded to convey a list of unfortunate and sorrowful (full of or feeling sad) events they were going through, from the loss of a family member to losing their home, lots of bad things that are happening. Additionally, the resident stated that a Nursing Assistant (NA) had come into the resident's room during the night shift on 05/16/2026 and woke them up to turn and change the resident's brief, they know not to wake me up in the middle of the night.Review of Resident 38's care plan showed that on 04/28/2026 the resident was very tearful and a focus had been developed related to the resident's depression on admission due to their realization of knowing they would have to sell their home and the loss of their independence. The developed intervention was to monitor/document in the resident record signs/symptoms of depression, including sadness, anxiety, negative statements, and tearfulness. Additionally, the care plan showed the resident needed assistance from staff on repositioning in bed and was on a turning schedule to be turned every two hours while the resident was awake. The 05/07/2026 intervention specified the resident did not want to be woken up during the night shift for turning. During an interview on 05/20/2026 at 12:09 PM, Staff K, NA, stated they had known about some of Resident 38's unfortunate sorrowful events like the recent loss of the resident's family member. Staff K stated the resident's mood had been different since that had happened. During an interview on 05/21/2026 at 8:28 AM, Staff L, Licensed Practical Nurse (LPN), stated the resident had been tearful, but thought it might have been due to the resident's pain. Staff L stated that Resident 38 had conveyed some of the unfortunate/sorrowful events to the staff member before. During an interview on 05/21/2026 at 12:25 PM, Staff G, Registered Nurse/Resident Care Manager, stated they were familiar with Resident 38, and the resident had a list of unfortunate/sorrowful events with a family member passing away to cancer, a friend requiring brain surgery and the residents dog getting sick. Staff G stated that Resident 38 had depressive symptoms/statements since they were admitted and nursing staff should be monitoring/documenting them in the resident's record for the provider to see. When Staff G was reviewing Resident 38's records with the surveyor, Staff G stated they did not see documentation on the resident's depressive symptom monitoring after being developed in the care plan until 05/20/2026. Staff G stated the correct process was not being followed and the documentation of depressive symptom monitoring should have begun immediately after Resident 38's care plan was developed.During an interview on 05/21/2026 at 1:49 PM, Staff M, NA, stated they were familiar with Resident 38 and had taken care of them before. Staff M stated the resident was cognitively intact, utilized the call light to notify staff of needs and would inform nursing staff if the resident needed to have a brief change. Staff M stated it was known that the resident was not to be woken up at night for cares.Review of the facility's call light audits for 05/16/2026 and 05/17/2026 showed Resident 38 did not put on their call light for staff assistance during the nighttime. During an interview on 05/21/2026 at 3:27 PM, Staff C, Assistant Director of Nursing Services, stated they had investigated the NA coming into the resident's room during the night shift and performed a brief change with Resident 38. Staff C stated they were unsure why the NA was turning/changing the resident's brief when the resident was care planned to not be woken up at night. During an interview on 05/22/2026 at 7:21 AM, Staff A, Administrator, stated that Resident 38 should have been monitored for depressive symptoms/statements after it was identified and developed in the resident's care plan on 04/27/2026. Staff A stated they were not sure the night shift NA staff member knew Resident 38 did not want to be woken at night to be turned/changed. Staff A stated that Resident 38 was able to utilize the call light to notify nighttime staff if they needed assistance with a brief change. Staff A stated the correct process with implementing Resident 38's care plan was not being followed. Reference: WAC 388-97-1020(2)(a)(3)

Based on interview and record review the facility failed to ensure the nature/terms of entering into a binding arbitration agreement (an alternative means of settling disputes through a third party arbitrator, instead of traditional court/judicial systems) were explained to residents in a form and manner in which they could understand for 2 of 5 residents (Resident 11 and 5) reviewed for arbitration. This failure placed the residents at risk for a lack of understanding concerning the legal contract that had been signed/entered into and being fully informed regarding their choice in the event of a dispute with the facility.Findings included.Resident 11Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnosis including multiple respiratory complications, stroke (a complication when blood supply to the brain is blocked or reduced which can lead to brain damage), altered mental status (a change in mental function from various illnesses, disorders, or injures affecting the brain), and dementia (the loss of cognitive functioning, thinking, remembering, and reasoning, to such an extent that it interferes with a person's daily life and activities). The 04/07/2026 comprehensive assessment showed the resident had severely impaired cognition, had difficulty communicating but was able to make their needs known.Record review of Resident 11's arbitration agreement showed the resident had signed the legal document themselves on 04/09/2026 consenting to the arbitration agreement. Staff H, [NAME] Coordinator, signed the arbitration agreement as the facility's representative on 04/09/2026.During an interview on 05/21/2026 at 9:01 AM, Resident 11 stated they were unaware of what arbitration was and did not remember signing the arbitration agreement, I signed a lot of things that day. After explaining arbitration, Resident 11 stated they did not want or consent to the arbitration agreement and they were not aware that it was voluntary nor that they could rescind the document within 30 days of signing it.Resident 5Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnosis including heart complications, and a bone fracture of the left leg/lower back. The 04/03/2026 comprehensive assessment showed the resident was cognitively intact and able to make their needs known.Record review of Resident 5's arbitration agreement showed the resident had signed the legal document themselves on 04/09/2026 consenting to the arbitration agreement. Staff H signed the arbitration agreement as the facility's representative on 04/09/2026.During an interview on 05/20/2026 at 11:27AM, Resident 5 and their family were visiting in the resident's room. Resident 5 stated they were unaware of what arbitration was or that they had signed/consented to the arbitration agreement, I do not like that. The resident stated their family was not present for the admission paperwork signing and the facility staff did not explain the arbitration agreement form or what it entailed. Resident 5 stated they did not know of the agreement being voluntary and not a requirement to sign, I just signed it (as in signing all the admission forms).During an interview on 05/21/2026 at 9:14 AM, Staff E, [NAME] Coordinator, stated they and Staff H both were charged with going over admission paperwork and arbitration agreements with residents and/or their representatives. Staff E stated they had recently implemented the arbitration agreements in the facility and it was the last thing that was reviewed in the admission paperwork. Staff E stated they do not go into great detail with the arbitration form explanation and that residents have the option to consent to the document or not. Staff E stated that they usually went over the arbitration agreement forms with the family and had not completed it with many residents. Staff E stated that Staff H was often the one to go through the admission and arbitration documents with facility residents.During an interview on 05/21/2026 at 9:56 AM, Staff H stated they were new to the position and had just started going through the admissions/arbitration documents with residents. Staff H stated they inform the residents of the document being a standard arbitration, voluntary to sign and that the resident can rescind the document within 30 days. Staff H stated, I do not read through it verbatim (going through the arbitration document, word for word) and the admissions paperwork was already confusing to residents. When asked how the staff member ascertains the resident cognitive status, Staff H stated their process was to talk with the residents upon admission and ask them if they were comfortable filling out their own paperwork or if the resident needed a representative to be present, sometimes I ask the Certified Nursing Assistant (if the resident would understand the admission paperwork). During a continued interview on 05/21/2026 at 9:56 AM, when conveying Resident 5 and Resident 11's understanding of the arbitration document they had signed, Staff H stated (Resident 5) just kind of signed it, and did not have a RR present when going over arbitration. Staff H stated they were unable to recall if Resident 5 nor Resident 11 understood the arbitration document or what they were consenting to when signing the document, do not recall what happened that day. Staff H stated they did not ensure that both residents understood what arbitration was but informed the residents the document was voluntary, they did not have to sign and had 30 days to rescind the agreement. Staff H stated the correct process was not followed for either resident and the staff member reviewing the form should ensure that residents understand what their consent to the arbitrations agreement means. During an interview on 05/21/2026 at 10:58 AM, Staff A, Administrator, stated the arbitration agreement document had a lot of legal jargon (referring to the specific vocabulary and phrases used by legal professionals) and the facility staff reviewing arbitration with the residents should be explaining the nature and terms of what the document entails. Staff A stated they expected facility staff to assess if the residents understood the arbitration agreement and what they would be consenting to. Staff A stated the correct process for explaining the arbitration agreement in a form and manner the residents could understand was not followed.Reference: WAC 388-97-1620(2)(b)(i)

Based on observation, interview, and record review, the facility failed to ensure infection control interventions intended to mitigate the risk for transmission of infections were consistently implemented in the areas of hand hygiene (HH) for 1 of 2 dining rooms (DR 1 and Transmission Based Precautions ([TBP] specialized infection control measures used in health care settings alongside basic standard precautions) for 1 of 2 residents (Resident 12) reviewed for infection control practices. This failure placed the residents at risk for transmission of communicable diseases, and illness. Findings included. Hand Hygiene During an observation on 05/18/2026 at 11:36 AM, Staff P, Dietary, was in DR 1 with gloves on. Staff P touched resident wheelchairs to assist them to their tables, repositioned them, placed shirt protectors on the residents and touched multiple surfaces. Staff P, without performing HH or changing their gloves, proceeded to make drinks and serve them to the residents who were seated in the dining room. During an observation on 05/18/2026 at 11:46 AM, Staff P, still wearing the same contaminated gloves, assisted the meal server by obtaining food items and placing them on resident meal trays as they were prepared to be served to the residents. Transmission Based Precautions Resident 12Review of the resident's medical record showed they were admitted with diagnoses which included pneumonia (an infection in the lungs), chronic respiratory failure (the respiratory system struggles to adequately exchange oxygen) and atrial fibrillation (an irregular heart rate). The 04/03/2026 comprehensive assessment showed the resident was cognitively intact and required substantial assistance from staff for dressing, toileting and bed mobility. Observations on 05/18/2026 at 10:21 AM, showed Resident 12's room with a sign posted outside that identified the room as Contact Precautions (a type of TBP with infection control measures that are used to prevent the spread of disease that are transmitted by direct or indirect contact with the residents or items in their environment). The sign had instructions to perform HH or use hand gel, wear a gown and gloves prior to entering the room and use only equipment dedicated to the room or disposable equipment. Observations on 05/19/2026 at 9:13 AM showed Staff Q, Physical Therapist, had entered Resident 12's room. They did not perform HH or put on a gown or gloves as directed by the contact precautions sign Staff Q brought Resident 12 into the hallway to ambulate with their contaminated walker and with no gown or gloves on them which had the potential to spread infection outside of their room. During a concurrent observation and interview on 05/19/2026 at 10:38 AM, Staff N, Licensed Practical Nurse, stated that there were no residents who were currently on contact precautions in the facility. Staff N, who was standing in the hall outside of Resident 12's room observed the contact precautions sign posted and stated they had been unaware that Resident 12 was on contact precautions and had been going in and out of the room without wearing a gown or gloves. During an interview on 05/22/2026 at 11:04 AM, Staff O, Infection Preventionist, stated Resident 12 had been placed on contact precautions related to a positive wound culture, however had not been placed on an antibiotic (a powerful medication used to trat bacterial infections) and had no acute infection symptoms. Staff O stated Resident 12 should not have been on contact precautions as it had not been necessary. Staff O further stated staff still should have followed the directions for contact precautions as posted on Resident 12's door. During an interview on 05/22/2026 at 11:16 AM, Staff B, Director of Nursing Services, stated they would have expected all staff to follow any TBP signs posted outside of resident rooms and would be ensuring some additional training on TBP, specifically contact precautions, was completed. Reference: WAC 388-97-1620(2)(b)(i)(ii)

Based on interview and record review the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for falls with injury, was provided adequate supervision to prevent accident hazards. Resident 1 experienced harm when they were left alone on the toilet and found on the bathroom floor after an unknown amount of time. The fall resulted in a forehead hematoma (a pooling of blood in the surrounding tissues after an injury to the blood vessels) with bleeding, and transfer to the hospital where they were diagnosed with a brain bleed. Failure to identify residents that need supervision while on the toilet put residents at risk for injuries and diminished quality of health. Findings included .Review of Resident 1's medical record showed that they were admitted on [DATE] after a stroke (a medical emergency occurring when blood flow to part of the brain is blocked or a blood vessel bursts). Review of the 01/20/2026 comprehensive assessment showed that they had severe cognitive impairment and required assistance from staff for bed mobility, transfers and toileting. Review of Resident 1's 01/16/2026 care plan showed they were at risk for falls due to intermittent confusion and from taking medications for anxiety and high blood pressure that can affect balance and cause dizziness. Fall prevention interventions included sensor alarms and hourly rounding (There were no directives/interventions to stay with the resident while toileting). Record review of a 02/10/2026 bedside care plan for Resident 1 showed they required the assistance of one staff for toileting and had sensor alarms in place and hourly rounding for injury protection (There were no directives to stand by while using the toilet). During a telephone interview on 03/12/2026 at 11:08 AM, Resident 1's Representative (RR1) stated staff notified them on 02/28/2026 that Resident 1 was found on the bathroom floor at 6:20 PM after being toileted. RR1 stated that Resident 1 had many falls at the facility, and the staff should have known not to leave Resident 1 while toileting. RR1 stated the hospital emergency room reported [Resident 1] had two subdural (outermost membrane that protects the brain) brain bleeds and a huge bump at least an inch and a half. [Resident 1] was in a lot of pain while in the hospital. Record review of Resident 1's progress notes showed they had five falls prior to 02/28/2026:- 01/24/2026 resident found on the floor outside bathroom door at 9:57 PM. There were no injuries.-01/27/2026 resident found next to the bed, on the floor at 3:00 AM. There were no injuries.-02/05/2026 bed alarm sounding at 5:05 AM, resident sitting on floor mat next to the bed and stated they needed to use the bathroom. There were no injuries.-02/07/2026 at 12:05 AM, resident found on the floor mat, stated they needed to use the bathroom. There were no injuries.-02/10/2026 resident found on the floor at 10:10 AM, they stated they needed to go to the bathroom. There were no injuries. Record review of a 03/04/2026 Staff D, Nursing Assistant (NA), statement showed on 02/28/2026 Staff D responded to Resident 1 yelling they needed to use the bathroom and saw the resident standing next to their bed beginning to lower their pants. Staff D helped Resident 1 to sit on the toilet where Resident 1 said it was going to take a minute. Staff D stepped out due to another alarm going off down the hall. They helped another resident to and from the toilet and then returned to Resident 1's bathroom about five minutes later and found them on the bathroom floor. During an interview on 03/12/2026 at 4:54 PM, Staff C, Registered Nurse (RN), stated they were the Charge Nurse on 02/28/2026 when Resident 1 was found on the bathroom floor. Staff C stated that Staff D took the resident to the bathroom that evening and stepped out of the to take care of a couple of things. Staff C stated that after their initial assessment, Staff E, Nurse Tech, and Staff D started the neuro checks and vital signs while they prepared for their change of shift. Record review of the 02/28/2026 incident report written by Staff C showed Resident 1 was found lying on their left side. There was a hematoma on the right side of the forehead with a three-millimeter open area where it was losing blood, 90 cubic centimeter (cc, a metric unit of volume) was observed on the floor under and around Resident 1's head. Pressure was applied to slow bleeding. The predisposing factors to the fall included an impaired memory and was toileting. Notifications to the provider and family were not documented on the incident report form. During an interview on 03/12/2026 at 5:20 PM, Staff F, NA, stated that Resident 1 did not use the call light very well and needed their walker with one staff to go to the bathroom. Staff F stated, One time [Resident 1] said they needed a minute, so I waited by the bathroom door until they were done. On 03/23/2026 at 1:33 PM, Staff H, RN and Case Manager (CM) stated they were currently Resident 1's CM and their office was right next to the resident's room. Staff H stated that Resident 1 was very impulsive, they were not safe to stand alone and needed one staff to assist them in the bathroom. Resident 1 had many falls, and various interventions were tried like a mat beside the bed and position alarms. Staying with the resident during toileting was not an intervention but I would have stayed outside the door and in hindsight, the staff should have stayed with [Resident 1]. During a telephone interview on 03/24/2026 at 9:50 AM, Staff I, NA, stated that they helped Resident 1 to the bathroom several times the morning of 02/28/2026. Staff I stated they would stay by the bathroom with the door cracked for the resident's safety. They stated Resident 1 seemed more confused that morning and was very impulsive. During a telephone interview on 03/24/2026 at 10:18 AM, RR 1 stated they visited Resident 1 every day between 9:00 AM and 6:00 PM and would assist them to the bathroom while they were visiting. RR1 stated that Resident 1 was confused, impulsive and needed someone to stay by the bathroom, the staff knew this. RR1 stated that [Resident 1]'s bedside care plan required one staff assist and to stand by while toileting. RR1 stated [Resident 1] should not have been left alone, this could have been avoided. Record review of 02/28/2026 emergency department documents showed Resident 1 arrived at 9:24 PM and had two CT scans (a special kind of X-ray that can show more details than regular X-rays) that showed subdural hematomas on both the right and left side of their brain. A decision was made with family for Resident 1 to be admitted to the hospital, monitor and medicate for their pain. During an interview on 03/24/2026 at 12:15 PM, Staff A, Administrator, stated they could not find fall interventions to stay near the bathroom when toileting Resident 1. During an interview on 03/24/2026 at 12:18 PM, Staff B, Director of Nursing, acknowledged Resident 1's care plan did not include a directive for staff to stand by during toileting. Staff B stated that they believed Resident 1 wanted privacy. The surveyor pointed out that staff interviewed stated they would stay by and monitor through the crack in the door because the resident was impulsive. Staff B stated there should have been a stand by in the care plan and that might have prevented the fall. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to provide food at the proper temperatures, appetizing and palatable to taste for 4 of 7 residents (Resident 20, 25, 42, and 43) reviewed for nutrition. This failure placed residents at risk for foodborne illnesses, a decreased nutritional intake, and potential for weight loss. Findings included . Review of the facility's undated policy, titled Food Safety, showed food would be served in such a way as to prevent bacterial growth and served immediately. Additionally, to provide food that is fresh at the proper temperature to keep food safe, wholesome and appetizing. <Resident 20> During an interview on 04/16/2025 at 11:07 AM Resident 20 stated that they were served eggs daily in their room for breakfast, which were cold, and they are unable to eat them. <Resident 25> During an interview on 04/16/2025 at 11:10 AM Resident 25 stated that the food served was sometimes cold and reported this to the staff. <Resident 42> During an interview on 04/16/2025 at 11:15 AM Resident 42 stated that the meal service was too long, and depending on whether they eat in the dining room or in their room, the food was cold on the hallway trays. <Resident 43> During an interview on 04/16/2025 at 11:22 AM Resident 43 stated that the food is cold by the time it arrived to their room, and they were one of the last ones served. During an observation on 04/16/2025 at 1:09 PM, Staff V, Dietary Manager (DM), served two test trays (1 puree tray and 1 regular texture tray), per request of the survey team, and measured the temperatures of various items on the tray. The following temperatures [in Fahrenheit (F)] were obtained from the two test trays: Tray 1 Mashed potatoes - 153.0 F (normal range-180.0 F) Puree cheese pizza - 136.0 F (normal range-155.0 F) Mixed vegetables -113.0 F (normal range-135.0 F) Tray 2 Cheese pizza - 124.0 F (normal range-155.0 F) Cold slaw - 42.9 F (normal range-40.0 F or below) Ambrosia salad - 44.0 F (normal range-41.0 F or below) During an interview on 04/16/2025 at 1:22 PM, Staff V, DM agreed the temperatures of the food were not at the required temperatures to be served. Reference: WAC 388-97-1100 (1), (2) 46722

Based on observation, interview, and record review, the facility failed to ensure infection prevention and control practices were maintained by not performing hand hygiene and glove changes between dirty and clean tasks for 3 of 4 staff (Staff R, T and Q) reviewed during resident cares and dining. This failed practice placed residents at an increased risk for exposure to cross contamination (harmful spread of infections) and the development of communicable diseases. Findings included . Review of the facility's policy dated August 2019, titled Handwashing/Hand Hygiene showed the facility considered hand hygiene the primary means (define or source/action/infection preventions) for preventing the spread of infections. <Dining> An observation on 04/14/2025 at 11:58 AM, showed Staff R, Nursing Assistant, grabbed Resident 35's spoon and assisted the resident with a bite of food without performing hand hygiene. Staff R then grabbed an unidentified resident's napkin, wiped the unidentified resident's face and then placed the napkin in their hand. Staff R then proceeded to assist Resident 35 with their drink without performing hand hygiene. A dining observation on 04/14/2025 at 12:09 PM, showed Staff T, Nurse Technician (NT), rubbed the shoulder of Resident 30. Staff T then grabbed Resident 12's spoon and fed Resident 12 without performing hand hygiene. Staff T then assisted Resident 15 with a spoon full of food into their mouth, without performing hand hygiene in between the residents. <Personal Care> An observation on 04/16/2025 at 9:17 AM, showed Staff P Licensed Practical Nurse (LPN), and Staff Q, NT, assisted Resident 208 with a urinary retention catheter (a type of catheter designed to remain in the bladder for an extended period to drain urine) replacement. Staff Q explained the procedure to Resident 208 and began to remove their pants. Staff Q explained they would have to clean their groin area before the nurse began. Staff Q grabbed a cleansing wipe and began to wipe the resident's groin. Staff Q did not change gloves or perform hand hygiene and held onto the resident's hand while Staff P placed the retention catheter. After the procedure, Staff Q, with the same dirty gloves on, explained to Resident 208, they had to clean their groin again and secure a leg strap (an elasticized thigh strap to securely anchor Foley catheters in place) for their retention catheter. During an interview on 04/16/2025 at 9:55 AM, Staff Q, NT, stated they did not realize they had not changed their gloves or performed hand hygiene and acknowledged they should have. During an interview on 04/18/2025 at 9:10 AM, Staff H, Infection Preventionist Nurse, stated they acknowledged the lack of hand hygiene. Staff H mentioned that we constantly reviewed hand hygiene and conducted in-services to discuss the importance of hand hygiene. Reference: WAC 388-97-1320 (1)(c) 46722

Based on interview and record review, the facility failed to ensure each resident's right to choose important aspects of their life including frequency and type of bathing preferences for 2 of 3 residents (Residents19 and 29) reviewed for choices. This failure to honor resident choices placed the residents at risk for impaired hygiene and feelings of embarrassment. Findings included . Review of the policy titled, Resident Rights, revised on 02/2021, showed the resident has the right to self-determination and be supported by the facility when exercising their rights. <Resident 19> Review of the medical record showed Resident 19 was admitted to the facility on [DATE] with diagnosis including Alzheimer's (a progressive disease that destroys memory and other important mental functions), pressure ulcer (a wound that develops when constant pressure on the skin restricts blood flow to the area, leading to tissue damage), and chronic pain. The 01/31/2025 comprehensive assessment showed Resident 19 was dependent on one to two staff members for activities of daily living (ADLs) and had severely impaired cognition. Additionally, the assessment showed it was very important for Resident 19 to choose between a tub bath or a shower. During an interview on 04/14/2025 at 11:12 AM, Resident 19 stated they preferred tub baths and did not like showers. Resident 19 stated the tub bath was more comfortable and they did not like how the shower water sprayed their head and body and made them feel perturbed (a feeling of being anxious or unsettled). Review of Resident 19's nursing assistant (NA) shower record for April 2025 showed the resident's preference for a bath, but showers were provided on 04/03/2025, 04/11/2025, and 04/18/2025. <Resident 29> Review of the medical record showed Resident 29 was admitted to the facility on [DATE] with diagnoses including stroke (happens when the blood supply to part of the brain is suddenly cut off, causing brain cells to die) with left-sided weakness, diabetes (a condition that results in too much sugar in the blood), and dementia (a progressive disease that destroys memory and other important mental functions). The 03/17/2025 comprehensive assessment, showed Resident 29 required substantial/dependent assistance of one to two staff members for ADLs and moderately impaired cognition. Additionally, the assessment showed it was very important for Resident 29 to choose their bathing preference. During an interview on 04/14/2025 at 1:15 PM, Resident 29 stated they had waited over a week for a shower, and it was embarrassing for them to have to ask for one. Review of Resident 29's NA shower record for March 2025 showed they were provided a shower on 03/18/2025 and the next shower was provided on 03/26/2025, eight days later. During an interview on 04/16/2025 at 9:34 AM, Staff R, NA, stated they worked as a shower aide with one more shower aide Monday through Friday. Staff R stated the second shower aide would often have to work elsewhere and would decrease the number of showers and/or baths that could be provided each day. During an interview on 04/18/2025 at 9:09 AM, Staff S, NA, stated residents were provided with one shower or bath per week. Staff S stated usually residents did not request another shower or bath, however when they did, they would be offered a bed bath as it was hard to squeeze residents into the bathing schedule. During an interview on 04/18/2025 at 10:29 AM, Staff A, Administrator, stated the residents should have the choice and be offered what they want for bathing. Reference WAC: 388-97-0180(1)(2)(3)

Based on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission that included the minimum requirements of resident specific goals, physician orders, dietary orders, treatment plans and social service needs for 3 of 5 residents (Residents 29, 208, and 258) reviewed for baseline care plan. This failure placed residents at risk of not receiving necessary care and services, and a continuity of care. Findings included . Review of the facility's policy titled Care Plans-Baseline, revised March 2022, showed a baseline plan of care would be developed within 48 hours of admission to meet the resident's immediate health and safety needs. The baseline care plan would include effective, person-centered care of the residents and contain the minimum healthcare to include initial goals based on admission orders, discussion with residents/representatives, physician orders, dietary orders, therapy services, and social services. <Resident 29> Review of the medical record showed Resident 29 was admitted to the facility on [DATE] with diagnoses including stroke (happens when the blood supply to part of the brain is suddenly cut off, causing brain cells to die) with left-sided weakness, diabetes (a condition that results in too much sugar in the blood), and dementia (a progressive disease that destroys memory and other important mental functions). The 03/17/2025, comprehensive assessment, showed Resident 29 required substantial/dependent assistance of one to two staff for activities of daily living (ADLs) and moderately impaired cognition. Review of Resident 29's baseline care plan dated 03/14/2025, showed no resident specific goals or interventions for Resident 29's specific care needs related to physician orders, treatments or social services. <Resident 208> Review of the medical record showed Resident 208 was admitted to the facility on [DATE] with diagnoses including lumbar osteomyelitis (an infection of the lower spine bones), sepsis (a life-threatening condition caused by the body's response to an infection that can cause organ failure), and urine retention (the inability to completely empty the bladder). A nursing admission note dated 04/10/2025, showed Resident 208 had a peripherally inserted central catheter (PICC, a long thin flexible tube inserted through a vein in the arm and passed through larger veins near the heart to deliver medications and fluids) and a urine catheter (a flexible tube inserted into the bladder to drain urine). The admission notes further showed Resident 208 was alert and oriented and able to make their needs known. Review of Resident 208's baseline care plan dated 04/11/2025, showed no focus areas, initial goals or interventions for Resident 208's specific care needs related to physician orders, treatments, dietary orders or social services. <Resident 258> Review of the medical record showed Resident 258 was admitted to the facility on [DATE] with diagnoses including respiratory failure, embolism (blood clot) of the left leg vein, alcohol withdrawal, chronic pain, and edema (excess fluid buildup in the body's tissues). The 04/07/2025 comprehensive assessment, showed Resident 258 required supervision/partial assistance of one staff member for ADLs and had intact cognition. Review of Resident 258's baseline care plan dated 04/06/2025, showed no resident specific goals or interventions for Resident 258's specific care needs related to their medical conditions or social services. During an interview on 04/16/2025 at 1:45 PM, Staff C, Resident Case Manager (RCM), stated the RCM's completed the baseline care plans when a resident was admitted to the facility and were to be fully completed within 48 hours. Staff C stated the baseline care plans were to include the resident's admission diagnoses, immediate goals, medications, types of therapy, specialty orders, and plans for discharge. During an interview on 04/18/2025 at 12:12 PM, Staff B, Director of Nursing, stated the baseline care plan process needed to be improved. Reference WAC: 388-97-1020(3) 45642

Based on observation, interview, and record review, the facility failed to ensure resident care plans were developed with appropriate interventions for 2 of 2 residents (Resident 18 and 208) reviewed for care planning. This failure to develop care plans with appropriate interventions placed the residents at risk for inadequate or unsafe care. Findings included . Review of the facility's policy dated March 2022, titled Care Plans, Comprehensive Person Centered, showed assessments of residents were ongoing, and care plans were to be revised as information about the residents and/or their condition changed. <Resident 18> Review of Resident 18's medical records showed they were admitted to the facility on [DATE] with diagnoses to include muscle weakness, right shoulder pain, osteoporosis (a bone disease that weakens and makes bones brittle, increasing the risk of fractures), and dementia (the loss of thinking, remembering, and reasoning to the extent that interferes with Activities of Daily Living [ADLs]). Review of the comprehensive assessment dated [DATE] showed Resident 18 was dependent on staff for care needs and their cognition was severely impaired. An observation on 04/15/2025 at 9:22 AM, showed Resident 18 sitting in their wheelchair with the position of their right arm/hand lying down alongside their right leg. Their fingers were curled under, and their hand was red and swollen. During an observation and concurrent interview on 04/15/2025 at 12:07 PM, the Resident Representative (RR), stated they were waiting for a nurse to check Resident 18's right hand as their hand was very swollen. Resident 18's hand was red, swollen, and hanging down by their right side. The RR stated the resident had an arm rest on their wheelchair at one time to help with the position of their arm/hand. Resident 18 ' s wheelchair did not have an arm through/rest. Review of Resident 18's care plan dated 02/19/2025, showed Resident 18 had an ADL self-care performance deficit related to right-sided weakness. The care plan showed no person-centered interventions for Resident 18's right arm/hand positioning. Review of Resident 18's Kardex (care task assignments for nursing assistants) dated 05/28/2024, posted in the resident's closet, showed no positioning task for the nursing assistants to guide them on positioning of the resident's right arm/hand. During an interview on 04/16/2025 at 10:03 AM, Staff J, Nursing Assistant (NA), stated when providing care for a resident they referred to a care plan that was posted in the resident's closet. Staff J stated the care plan had information such as whether a resident required one or two people for care and transfers, positioning of a resident, and any medical equipment the resident may need to use. An observation on 04/17/2025 at 11:40 AM, showed Resident 18 in therapy, with their right hand down to their right-side next to their knee. Resident 18's right hand was red and swollen. During an observation and interview on 04/17/2025 at 11:43 AM, Staff I, Resident Case Manager (RCM)/Restorative Coordinator (RC), stated Resident 18 had a right arm trough (an arm rest for a wheelchair) that was broken, and parts had been ordered. Staff I stated the arm trough had been broken and removed in November 2024 (five months ago). Staff I stated they (staff), used a teddy bear to help keep their right hand in an upright position. Resident 18's right hand was red and swollen while doing their therapy. Staff I lifted Resident 18's hand, and the resident voiced to Staff I their right arm was painful with the movement. Staff O, Restorative Assistant (RA), stated the resident needed something to elevate their right hand and arm while doing their therapy. Observation of a small brown, flat teddy bear was lying in Resident 18's lap. Staff I stated the NAs were to be placing a pillow under the resident's right arm for positioning. During an interview on 04/17/2025 at 3:13 PM, Staff I, RCM/RC, acknowledged that Resident 18's care plan did not reflect the residents' use of a right arm through/rest, a pillow, or the teddy bear for positioning of the resident's right arm/hand. <Resident 208> Review of Resident 208's medical records showed they were admitted to the facility on [DATE], with diagnoses to include heart disease, osteomyelitis (bone infection) of the low back, and urine retention (the inability to completely empty the bladder). Review of the comprehensive assessment dated [DATE] showed the resident was cognitively intact and dependent on staff for their care needs. An observation on 04/15/2025 at 3:29 PM, showed Resident 208 lying in bed with an indwelling urinary retention catheter (a tube that is inserted into your bladder, allowing your urine to drain freely) hanging on the bed rail of their bed. Review of the care plan dated 04/10/2025, showed Resident 208 did not have an indwelling urinary retention catheter. The care plan showed no goals or interventions for the care of Resident 208's indwelling urinary retention catheter. During an observation and concurrent interview on 04/16/2025 at 8:10 AM, Staff P Licensed Practical Nurse, and Staff Q, Nurse Technician, assisted Resident 208 with a transfer to bed. Staff P stated Resident 208 had orders to change their indwelling urinary retention catheter. Staff Q stated the resident had an upcoming appointment with urology (a part of health care that deals with diseases of the male and female urinary tract system) and wanted the catheter changed. Staff Q stated the NAs had information on how to care for a resident in the resident's closets, via the Kardex. The Kardex dated 04/10/2024 showed no task for Resident 208's indwelling urinary retention catheter. During an interview on 04/18/2025 at 9:10 AM, Staff B, Director of Nursing, stated they agreed that resident care plans and revisions should have reflected any changes and care needs of each resident. Reference: WAC 388-97-1020 (1), (2)(a)(b)

Based on observation, interview and record review, the facility failed to ensure the provision of bathing, nail care, and oral care for 3 of 10 dependent residents (Residents 26, 41 and 15) reviewed for activities of daily living (ADLs). This failure placed residents at risk for poor hygiene, body odor, dental caries (cavities or tooth decay), decreased self-worth and diminished quality of life. Findings included . Review of the facility's policy dated March 2018, titled Activities of Daily Living (ADL's), Supporting, showed appropriate care and services would be provided for residents who are unable to carry out ADLs independently and receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. <Resident 26> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with multiple sclerosis (MS-a disease that causes breakdown of the protective covering nerves causing trouble walking, vision changes and numbness). A stroke (happens when the blood supply to part of the brain is suddenly cut off, causing brain cells to die) with right side paralysis (loss of ability to move a body part due to nerve damage), difficulty swallowing, and inability to speak. Review of the 03/05/2025 comprehensive assessment showed Resident 26 was cognitively impaired, rarely spoke, but vision was adequate. The 03/05/2025 assessment showed the resident was impaired on both sides of their body and dependent on staff for all ADLs and could not brush their teeth, dress themselves, or bathe without staff assistance. During an observation on 04/14/2025 at 12:25 PM, Resident 26 was lying in bed with the head of the bed up. When asked if they were doing okay, Resident 26 smiled and nodded their head indicating yes but was unable to verbalize or speak. Resident 26 had food particles in their teeth that were white and brown in between the front upper and bottom teeth. The resident's fingernails were long with a dark brown substance under the fingernails, and their toenails were long. During an observation on 04/15/2025 at 1:00 PM, Resident 26 was sitting up in bed and when asked if they had pain, they shook their head (indicating no). Resident 26's mouth had dark, colored food packed in their upper back teeth. There was a broken tooth on the top left with visible food particles that were white and gray along the gum line. The resident's fingernails were long with dark brown substances. During an interview on 04/15/2025 at 11:00 AM, Staff M, Licensed Practical Nurse (LPN), stated the resident was to have their nails trimmed weekly, and the person who did them before was no longer at the facility, so the task was not being completed. Staff M stated that brushing the resident's teeth after meals was important to maintain clean and healthy teeth and gums. During an observation and concurrent interview on 04/16/2025 at 12:00 PM, Resident 26 was observed at the assisted dining table with Staff R, Nursing Assistant (NA), who reminded the residents to eat and to take a bite of food. Staff R stated the resident had to be reminded to eat their meal. Staff R stated the only concerns for Resident 26 during meals was to watch if they were not eating and/or prevent them from choking. During an observation on 04/17/2025 at 10:40 AM, Resident 26 was up in wheelchair in front of the television. Resident 26 had food located in their lower back teeth and food particles white in color between their front teeth and side of bottom teeth. Review of the 02/24/2024 care plan showed the resident was to be monitored during meals for holding food in their mouth, pocketing food, choking and refusing to eat. Additionally, the resident was to be cued several times to swallow their food during the meal. Resident 26 was on a mechanical soft diet with nectar thickened fluids (for people with difficulty swallowing and to help them less likely to aspirate while swallowing). Review of the 12/18/2024 Dental Evaluation showed the dentist had to brush and clean out food of Resident 26's mouth to visualize the resident's teeth that were broken and had cavities. There was no follow up for further care. <Resident 41> Review of the medical record showed the resident was readmitted to the facility with diagnoses to include a stroke with right side paralysis and difficulty with swallowing and speaking. The 04/05/2025 quarterly assessment also showed Resident 41 was alert with impaired cognition and spoke limited English. Resident 41 was dependent on staff for all ADLs. During an observation and concurrent interview on 04/14/2025 at 9:50 AM, Resident 41's fingernails were long with a brown substance under the nails. Resident 41 was scratching their neck and left side with their left hand. During observation of the resident back, brown scratch marks to their left side of their back, neck and chest area were noted. The scratch marks were red on the chest and neck with scratches to the left back side with slightly small, scabbed areas. Resident 41 stated they were itchy and could not stand it (the itching of their skin). Resident 26 stated they needed a bath and continued to state a preference for a bath. The resident had opened their mouth, their teeth were observed to be yellow in color and black and white food particles were between their teeth. Resident 41's breath was odorous with a stale sour smell. During an observation and concurrent interview 04/15/2025 at 3:15 PM, Resident 41's fingernails were dirty with brown substances under the fingernails. The residents' skin on their chest and back was dry. Staff M, LPN, stated Resident 41 could answer questions about their care. Staff M stated the residents recieve one bath a week, and resident's oral care should be done between meals and before bed. Review of the Bath Team Schedules for 04/01/2025 through 04/15/2025 showed Resident 41's last shower was 04/01/2025 with a resident refusal of a bed bath on 04/11/2025. During an observation and concurrent interview on 04/16/2025 at 8:40 AM, Resident 41's fingernails to left and right hands continued to be long with a brown colored substance under the nails. The resident's mouth was with food particles that were white, dark brown and black particle substances between the teeth. Resident 41 had not eaten breakfast yet and continued to scratch their chest and neck with their left hand. During an interview on 04/16/2025 at 9:00 AM, Staff M stated the resident was supposed to have a bath on the evening of 04/15/2025 but was charted as a resident refusal. Staff M stated that the licensed nurses were to clip the resident's finger and toenails but was not documented in the resident's record as completed for two months. During an observation and concurrent interview on 04/17/2025 at 12:19 PM, Staff B, Director of Nursing Services (DNS), observed Resident 41's unclean teeth and stated the oral care and bathing on Resident 41 had not been completed. 45642 <Resident 15> Review of the medical record showed the resident was admitted on [DATE], with diagnoses including dementia (the loss of thinking, remembering, and reasoning- to the extent that interferes with ADL's), dysphagia (difficulty swallowing), weakness, and need for assistance with personal care. Review of the comprehensive assessment dated [DATE], showed Resident 15's cognition was severely impaired and was dependent on staff for personal hygiene. During an interview on 04/16/2025 at 2:51 PM, Resident Representative, (RR) stated Resident 15 had been disheveled when they come in to visit. The RR stated the resident's fingernails and toenails were horrible the last time they visited. Review of the Physician orders dated 06/01/2024, showed .provide fingernail and toenail care.Trim nails, remove debris (grime, substances), and clean the resident's hands. Document refusals. Notify MD if any issues are present. During an observation on 04/15/2025 at 11:20 AM, Resident 15 was fully dressed in bed, resting and covered with a blue blanket. The resident's left hand exposed, their fingernails long, dry, flakey and had a brown substance underneath the nails. During an observation and concurrent interview on 04/16/2025 at 2:32 PM, Resident 15 was lying in bed, awake, visiting with their RR. The RR removed the resident's slipper, stated look at their toenails the toenails were raised, long, dry, and flakey. During the same observation Resident 15 had food stuck in their dentures. The RR stated that the resident's dentures do not get brushed regularly. During an interview on 04/16/2025 at 2:46 PM, Staff U, Nursing Assistant (NA), stated they were responsible for the resident's personal care. Staff U stated that the personal care tasks were brief changes, putting on clothing, and setting up or doing the resident's oral care. During an interview on 04/17/2025 at 9:39 AM, Staff S, NA, stated staff used a binder that gives a list for weekly showers. Staff S, stated that they did nail care, skin checks, apply lotion, shaving and sometimes haircuts when bathing/showering a resident. Staff S stated they had no documentation for nail care, skin checks, lotion application, shaving or haircuts. During an interview on 04/18/2025 at 10:13 AM, Staff B, DNS, stated they were aware of Resident 15's lack of nail care. Staff B stated that they had a process in place and that the residents had been receiving nail care services weekly. Staff B stated they had trouble with nail care recently related to losing staff and had to pull the nurse assigned to that task to work on the floor. Staff B stated they were having some issues with getting the residents' nails done. Reference: WAC 388-97-1060 (2)(c)

Based on observation, interview and record review the facility failed to ensure 2 of 3 sampled residents (Residents 41and 18) reviewed for positioning and range of motion received services to prevent further decrease in range of motion and hand contracture (a permanent tightening of the muscles, tendons, skin and nearby tissues that causes the joints to shorten and become very stiff) through use of assistive devices. This failure increased the resident's risk of being unable to maintain their current level of functioning, increased risk of pain and breaks in skin integrity related to a contracture. Findings included . <Resident 41> Review of the medical record showed the resident was readmitted to the facility on [DATE] with diagnoses to include a stroke (happens when the blood supply to part of the brain is suddenly cut off, causing brain cells to die) with right side paralysis (loss of ability to move a body part due to nerve damage), and difficulty with swallowing and speaking. The 04/05/2025 comprehensive showed Resident 41 had cognitive impairment with behaviors to include hallucinations. Resident 41 was dependent on staff for all Activities of Daily Living (ADLs). During an observation and interview on 04/14/2025 at 9:48 AM, Resident 41 was observed lying in bed positioned on their right side. The paralyzed right hand was located under the resident's right side. Resident 41 had stated they were in pain and their right shoulder was painful. During an observation and interview on 04/15/2025 at 3:11 PM, showed Resident 41 lying in bed postioned on their right (affected) side, lying on their right upper arm and hand without any support. Staff M, Licensed Practical Nurse, (LPN) stated Resident 41 had a right-hand brace but it had been removed by nursing staff. Staff M stated the resident sustained a right thumb injury due to the splint. Staff M stated Resident 41's arm should have been on a pillow and positioned correctly. During an observation and concurrent interview on 04/16/2025 at 8:20 AM, Resident 41 was in bed lying on their right shoulder, and their lower right arm was underneath their right side. Staff K, Nursing Assistant (NA), stated they were getting Resident 41 up for breakfast. Staff K repositioned Resident 41 to their left side and the resident complained of pain in their right side, right lower wrist and hand. Resident 41's skin to the right lower arm and hand appeared red and swollen. Staff K stated Resident 41 was wearing a soft hand brace, but it had been removed due to a laceration between the thumb and index finger of the right hand. There was no other support or positioning device in place for Resident 41's right arm and hand. During an observation and concurrent interview on 04/17/2025 at 9:24 AM, Staff N, Occupational Therapist (OT), stated they had applied a soft wrist/ hand brace to maintain the position of Resident 41's wrist and hand. Staff N stated they were unaware the resident was not wearing their soft hand restraint on their right wrist and hand. Staff N stated had they known the hand brace had been removed, they would have suggested a wrist positioning device to maintain Resident 41's wrist and arm position. Review of Resident 41's 11/15/2025 care plan showed the resident was dependent on staff for turning in bed, transfers with assistance of two to and from wheelchair, positioning of body and right arm /shoulder, assistance with eating, oral care, and bathing. The care plan showed no documentation for the use of the right-hand soft brace application or any intervention for the positioning of the right hand. Review of the 01/17/2025 Bedside Care Plan showed the resident's right arm was painful, but no documentation was found regarding interventions for right arm positioning or devices for Resident 41's right arm or hand. During an interview on 04/17/2025 at 9:50 AM, Staff C, Resident Case Manager (RCM), stated the right hand/ wrist soft brace had been removed to allow healing of the wound between the right thumb and index finger. Staff C stated they did not believe that Resident 41's right arm positioning was an issue and were unaware Resident 41 had not been being positioned correctly. 45642 <Resident 18> Review of Resident 18's medical records showed they were admitted to the facility on [DATE] diagnosis to include muscle weakness, lymphedema (a condition causing swelling, typically in the arms or legs, due to a buildup of protein-rich fluid within the tissues), right shoulder pain, osteoporosis (a bone disease that weakens and makes bones brittle, increasing the risk of fractures) and dementia (the loss of thinking, remembering, and reasoning- to the extent that interferes with ADL's). Review of the comprehensive assessment dated [DATE] showed Resident 18's was dependent on staff for care needs and that their cognition was severely impaired. An observation on 04/15/202525 at 9:22 AM, showed Resident 18 was sitting in their wheelchair, their right arm /hand was lying down next to their leg. Their fingers were curled under, their hand appeared red and swollen. During an observation and concurrent interview on 04/15/25 12:07 PM, Resident Representative, (RR), stated Resident 18 had a right arm postioning device on their wheelchair to support their right arm and hand but it was no longer attached to the right arm of the wheelchair. During the 04/15/2025 observation, Resident 18 was seated in their wheelchair their right arm and hand was swollen without a positioning support device to their right arm/hand. Review of Resident 18's Kardex (care task assignment for NAs) dated 5/28/24, posted in the resident's closet, did not show a positioning task for the nursing assistants to guide them on positioning of the resident's right arm/hand. During an interview on 04/16/2025 at 10:03 AM, Staff J, NA, stated to care for a resident they refer to a care plan that is posted in the resident's closet. Staff J stated the care plan has information such as whether a resident requires one or two people for care and transfers, positioning of a resident and any medical equipment the resident may need to use. An observation on 04/17/2025 at 11:40 AM, showed Resident 18 in therapy, Their right hand was red and swollen hanging down to their right-side next to their knee. During an observation and interview on 04/17/2025 at 11:43 AM, Staff I, Resident Case Manager (RCM)/Restorative Coordinator (RC), stated Resident 18 had a right arm trough (an arm rest for a wheelchair) that was broken and had been removed in November 2024 (5 months ago). Staff I stated they use a teddy bear to help keep the resident's r hand up. During an observation of Resident 18's right hand (red and swollen) while in therapy. Staff I lifted Resident 18's hand, and the resident expressed pain with the movement. Staff O, Restorative Assistant (RA), stated that the resident needed something to elevate her hand and arm during their therapy. Observation of a small brown, flat teddy bear in Resident 18's lap. Staff I stated the NAs were to be placing a pillow under the resident's arm. During an observation and concurrent interview on 04/17/2025 at 11:44 AM, Staff I, RCM / RC, stated Resident 18 had a teddy bear to help keep their right arm/ hand elevated. Observation of the resident's right hand showed it was red and swollen. Staff I lifted the resident's hand, and the resident complained of discomfort with the movement. Staff I stated the nursing assistants were to place a pillow under the resident's arm to assist in the elevation of the resident's right arm/hand. During an interview on 04/17/2025 at 3:13 PM, Staff I, acknowledged Resident 18 did not have any interventions in place for the nursing assistants to follow regarding the positioning of Resident 18's right arm/ hand. Reference: WAC 388-97-1060 (3)(d),(j)(ix)

Based on observation, interview and record review, the facility failed to honor food preferences for 2 of 4 residents (Resident 29 and 32) reviewed for dietary preferences. This failure placed the residents at risk for dissatisfaction with their dining experience and weight loss. Findings included . <Resident 29> Review of the medical record showed Resident 29 was admitted to the facility on [DATE] with diagnoses including a stroke (happens when the blood supply to part of the brain is suddenly cut off, causing brain cells to die) with left-sided weakness, diabetes (a condition that results in too much sugar in the blood), and dementia (a progressive disease that destroys memory and other important mental functions). The 03/17/2025 comprehensive assessment showed Resident 29 required substantial/dependent assistance of one to two staff for activities of daily living (ADLs) and had moderately impaired cognition. Record review of a document titled, Nutrition Food Preference form, dated 03/28/2025, showed no selections had been identified for likes and/or dislikes, preferences, goals, comments or mealtime, menu and if alternates had been explained to the resident. An observation and interview on 04/14/2025 at 1:04 PM, showed a lunch tray on Resident 29's bedside table. The lunch tray contained a chicken salad sandwich on white bread, cooked broccoli, soup, cola and a cupcake. Resident 29 stated the food was salty all the time. Resident 29 further stated they had not been asked about their food preferences. During an interview on 04/16/2025 at 1:45 PM, Staff C, Resident Case Manager, (RCM), stated they were responsible for performing the resident food preferences when residents were admitted to the facility. Staff C stated they did not always document the resident preferences as they would be too busy to complete. Staff C stated they did not ask Resident 29 if they had any cultural food preferences. During an interview on 04/17/2025 at 9:42 AM, Resident 29 stated their preference for breakfast would be eggs, potatoes and refried beans, lunch would be salad, tomatoes, Mexican rice, refried beans and tortillas and dinner would be Mexican chili and tortillas. Resident 29 stated they preferred fish and salmon for meat options, and fresh fruits and vegetables. Resident 29 further stated the food they were provided did not come hot when served and was usually cold. <Resident 32> Review of the medical record showed Resident 32 was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), malnutrition, and arthritis. The 03/21/2025 comprehensive assessment showed Resident 32 required supervision/partial assistance of one to two staff for ADLs and their cognition was intact. Record review of a document titled, Nutrition Food Preference form, dated 03/24/2025, showed no selections had been identified for likes and/or dislikes, preferences, goals, comments or mealtime, menu and if alternates had been explained to the resident. During an interview on 04/14/2025 at 3:00 PM, Resident 32 stated the facility food needed more variety and was bland and repetitive. Resident 32 stated they had asked staff for a banana a few times and it would take a week or two before they would be provided a banana. Resident 32 further stated they asked daily for condiments that included salt, pepper and sugar for their hot tea, as the items had not been provided with their meals even after they had asked for them. During an observation and concurrent interview on 04/16/2025 at 9:50 AM, showed a breakfast tray on Resident 32's bedside table. The breakfast tray contained French toast, oatmeal and mandarin oranges. Resident 32 stated they were not provided with any butter or sugar for their breakfast, and they had told staff they did not like oatmeal but the facility continued to serve oatmeal for breakfast. During an interview on 04/16/2025 at 2:15 PM, Staff V, Dietary Manager, stated they did not discuss food preferences with residents. Staff V stated they would be notified by e-mail by staff when a resident wanted a change to their order or did not like a certain food. Staff V further stated they did not follow up with residents to ensure their change and/or preference was completed. During an interview on 04/16/2025 at 3:39 PM, Staff B, Director of Nursing Services, stated the dietician would speak with residents about their individual food preferences and the dietary aides would speak to each resident daily about what they wanted to eat the following day based off the menu options. During an interview on 04/17/2025 at 10:15 AM, Staff W, Dietary Aide, stated they reviewed with residents daily for the following days meal for any changes they may want to make from the menu. Staff W stated condiments were not always included with meals and should be available in each unit or other staff may obtain from the dining room. During an interview on 04/18/2025 at 10:29 AM, Staff A, Administrator, stated condiments should be on the residents' meal tray when they were served. Reference WAC: 388-97-1120(3)(a)(c)

Based on observation, interview, and record review, the facility failed to ensure the nutritional refrigerator was kept in a sanitary manner and undated /expired foods were discarded, for 1 of 2 nutritional refrigerators (recreational room refrigerator), reviewed for food safety. This failure placed residents at risk of consuming contaminated, expired foods and obtaining a food-borne (a disease transmitted to people by food) illness. Findings included . An observation on [DATE] at 4:01 PM, of the nutritional refrigerator located in the resident recreation room, showed within the freezer there was a large container of ice cream without a resident's name or a date to show a open or use by date. The freezer contained three chocolate ice cream bars with resident names and had no date of when they were placed in the freezer, or a date of expiration. During the same observation of the nutritional refrigerator, showed a strong foul, sour odor of spoiled food. The shelves were filled with trays of food sitting on top of other plates or boxes of food. The refrigerator had five Jello cups in the refrigerator door with a resident's name and no date, a large birthday cake without a name or date, and a large paper bag with a name and no date, and two zip lock bags with fruit inside. During an interview on [DATE] at 12:19 PM, Staff V, Dietary Manager, stated the kitchen staff did not clean the residents' nutritional refrigerator. Staff V stated the nursing staff had the responsibility for cleaning the nutritional refrigerator. During an interview on [DATE] at 9:28 AM, Staff Y, [NAME] Clerk, stated they were responsible for monitoring the daily temperatures and had not been told that the cleaning of the nutritional refrigerator was their responsibility. During an interview on [DATE] at 11:59 AM, Staff Z, Housekeeper, stated they were unsure who had the responsibility of cleaning the nutritional refrigerator. During an interview on [DATE] at 12:09 PM, Staff H, Infection Preventionist Nurse, stated they were aware of the condition of the residents' nutritional refrigerator and noticed the refrigerator had food with no dates or names on items and that it was a mess. Reference: WAC [DATE] (3)

Based on interview and record review, the facility failed to implement interventions to prevent injuries or falls, during resident transfers (helping residents move safely from one place to another) for 2 of 5 residents (Resident 1 and Resident 4) reviewed for falls or injuries acquired during transfers by staff. Resident 1 experienced harm when the facility failed to use a two-person transfer, as determined necessary by the comprehensive care plan, during a transfer from the resident's bed to wheelchair, resulting in pain and ankle fractures and put residents that require transfer assistance at risk for injury. Findings included Record review of the facility's policy titled, Safe Lifting and Movement of Residents, dated 07/2017, showed that a resident's safety will be incorporated into the goals and decisions regarding the safe moving of residents; Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' need for transfer assistance. Staff will document resident transferring and lifting needs in the care plan. Record review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, dated 03/2022, showed that care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. <Resident 1> Record review showed Resident 1 was admitted on [DATE] with multiple diagnoses including heart failure, orthostatic hypotension (a condition in which the blood pressure quickly drops when a person stands up after sitting or lying down), and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living, ADLs). Review of the 09/16/2024 comprehensive assessment showed Resident 1 was dependent on staff for their ADLs, including transfers to and from their bed/chair and had moderate cognitive impairment. Review of Resident 1's Bedside Care Plan dated 09/19/2024 showed that the resident was dependent on two staff for transfers. Review of a physical therapy note dated 10/18/2024 showed that Resident 1 was referred for assessment and treatment due to functionally declining in their ability to participate with transfers going from one-person assistance to two-person maximum assistance. Review of an incident investigation dated 11/20/2024 showed that Staff C, Nursing Assistant (NA) heard a pop sound when they pivot transferred (the resident bears at least some weight on one or both legs and spins to move their bottom from one surface to another) Resident 1 from their bed to their wheelchair. Resident 1 reported there was pain in their left ankle immediately after. Review of a 11/20/2024 written statement from Staff C showed they transferred Resident 1 from their bed to the wheelchair and heard the pop sound as the resident sat down and noticed the resident's left foot was caught under the wheelchair. Staff C reported the incident immediately to Staff D, Registered Nurse (RN). Review of the statement showed Staff C reported they were not following the resident's care plan. Review of a 12/16/2024 investigation summary by Staff B, Director of Nursing Services, showed Resident 1 had x-rays of their left foot/ankle that were negative for fractures on 11/20/2024 and 11/21/2024. The resident was changed to a mechanical lift and continued to have pain in their ankle. A MRI (magnetic resonance imaging, a scan that produces very clear images of the organs and structures inside the body) of the resident's left leg on 12/13/2024 showed left medial and lateral malleolar fractures (a bone fracture on the inside part of the tibia (inner and larger of the two bones between knee and ankle) and a bone fracture at the end of the fibula (outer and smaller of the two bones between the knee and ankle). During an interview on 01/23/2025 at 11:45 AM, Staff C stated they thought Resident 1's transfer assist care plan was for one to two staff depending on the resident's strength at the time and did not know Resident 1 had required two staff assistance for transfers. <Resident 4> A record review showed Resident 4 was admitted on [DATE] with rib fractures. Review of their 12/02/2024 comprehensive assessment showed the resident was dependent of staff for transfers between surfaces and was cognitively intact. Review of Resident 4's care plan dated 10/24/2024 showed that the resident required to assistance from two staff for transfers. Review of a 12/02/2024 fall investigation showed that Staff E, NA, attempted to transfer Resident 4 from the wheelchair to the toilet alone and the resident ended up on the floor. A statement given by Resident 4 at the time showed before I knew it, I was on the floor. Review of a 12/10/2024 note added to the incident investigation by Staff F, RN, showed Staff E was not familiar with Resident 4's transfer care plan and did not follow the care plan. Resident 4 was monitored for three days for injuries. During an interview on 01/24/2025 at 2:25 PM, Staff F stated that resident transfer status was included on all the Bedside Care Plans that were maintained inside the resident's closet door. Staff should always review to ensure resident safety. Staff F stated that when there were changes to a resident's transfer status, they would make the changes on the Bedside Care Plan and tell the unit nurse the change so they could inform the NAs. Staff E stated there was no system to inform the NAs who were not working on the day of the change. During the exit interview on 01/24/2025 at 3:30 PM, Staff A, Administrator, stated staff should be aware of changes and follow the resident care plan. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review the facility failed to notify the local health jurisdiction (LHJ) and the State of a communicable disease outbreak within required time frames for 20 of 20 residents (1,2,3,4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19, and 20) reviewed for symptoms of a highly contagious gastro-intestinal (GI) illness starting on 11/18/2024. Additionally, 19 staff reported symptoms with the last symptom onset on 12/09/2024. These failures placed residents at risk for a diminished quality of life, unmet care needs and placed residents at risk for the spread of infection. Findings included . Record review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Rev 02/03/2023, F880, showed the definition of an infectious disease outbreak was the occurrence of more cases of disease than expected in a given area over a particular period of time. Record review of [NAME] Administrative Code 246-101-101 Notifiable Conditions, showed that health care facilities were required to report immediately to the LHJ of outbreaks and suspected outbreaks. Record review of Nursing Home Guidelines, AKA The Purple Book, dated October 2015, Appendix D, showed nursing homes were required to report communicable disease outbreaks to the State hotline, logged on State reporting log within 5 days and reported to the local health department. During an interview on 12/10/2024 at 10:50 AM, Staff C, Registered Nurse / Infection Preventionist (IP) stated the facility had a norovirus (an infection that can cause severe vomiting and diarrhea, starts suddenly and was highly contagious) outbreak that involved 20 residents and 19 staff beginning 11/18/2024. The IP stated they had been in communication with the LHJ but had not reported to the State because they were not aware that was required. Record review of the State reporting log on 12/10/2024 showed no entry that the norovirus outbreak was reported to the State as required. Review of a 12/06/2024 e-mail communication between the facility and the LHJ showed the first notification of the norovirus outbreak. During an interview on 12/18/2024 at 12:25 PM, Staff C stated they received a telephone call in the evening on 11/23/2024, from the facility charge nurse, who reported Resident 1, Resident 2 and Resident 3 on hall 5 had nausea, vomiting and diarrhea. Staff C stated they advised the residents be placed in contact precautions (measures in health care designed minimize spread of infection where gloves, gowns and masks are worn to avoid direct with resident's body fluids), in addition to notifying the physician and family. <Resident 1> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include ulcerative colitis (a type of inflammatory bowel disease) and dementia (a loss of mental ability severe enough to interfere with normal activities of daily living.) Review of the 11/18/2024 comprehensive assessment showed Resident 1 was continent of bowel and bladder and had moderate cognitive impairment. Review of the facility outbreak line list (a table that contains key information about each case in an outbreak) showed after record review, Resident 1 had GI distress since admit on 11/09/2024, vomiting that started on 11/15/2024, and diarrhea on 11/21/2024 with their symptoms resolved by 11/30/2024. Resident 1 received therapy services until 11/22/2024. During an interview on 12/18/2024 at 12:30 PM, Staff C stated Resident 1's symptoms were initially thought to be related to their chronic GI distress diagnosis. During an interview on 12/18/2024 at 3:19 PM, Resident 1 stated they recalled having more GI symptoms last month than they usually had. Resident 1 stated GI issues had been an ongoing problem, and they feel much better now. <Resident 2> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include malnutrition (a condition that results from nutrient deficiency or overconsumption) and depression. Review of the 11/22/2024 comprehensive assessment showed the resident required moderate staff assistance for activities of daily living (ADL) and had moderate cognitive impairment. Review of the facility outbreak line list showed Resident 2 had nausea, vomiting and diarrhea beginning on 11/23/2024 that lasted 24 hours and nausea last reported on 12/04/2024. Resident 2 received therapy services until 11/23/2024. During an interview on 12/18/2024 at 3:25 PM, Resident 2 stated they could not recall being sick last month. <Resident 3> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include inflammatory bowel disease and malnutrition. Review of the 11/04/2024 comprehensive assessment showed the resident was independent with ADLs and was cognitively intact. Review of the facility outbreak line list showed Resident 3 had nausea and vomiting on 11/23/2024 and diarrhea on 11/26/2024. Resident 3 received therapy services until 11/23/2024. During an interview on 12/18/2024 at 3:30 PM, Resident 3 stated they were sick about a week, and they were glad it was over. <Resident 4> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include malnutrition. Review of the 10/03/2024 comprehensive assessment showed the resident was dependent on staff for ADLs and had severe cognitive impairment. Review of the facility outbreak line list showed Resident 4 had nausea, vomiting and diarrhea on 11/24/2024 that lasted 24 hours. <Resident 5> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include malnutrition. Review of the 11/15/2024 comprehensive assessment showed the resident was dependent on staff for ADLs and had moderate cognitive impairment. Review of the facility outbreak line list showed Resident 5 had diarrhea that began on 11/25/2024 with symptoms resolved by 11/30/2024. <Resident 6> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include heart failure (a severe failure of the heart to function properly) and malnutrition. Review of the 11/14/2024 comprehensive assessment showed the resident was extensive staff assistance for ADLs and was cognitively intact. Review of the facility outbreak line list showed Resident 6 had nausea that began on 11/23/2024 and diarrhea on 11/25/2024. Resident 6 received therapy services until 11/25/2024. A stool specimen was collected on 11/25/2024 with a laboratory result reported on 12/02/2024 that norovirus was detected. During an interview on 12/18/2024 at 12:35 PM, Staff C, stated they did not realize they should call the LHJ when they realized there was a GI illness outbreak in the facility. Staff C stated they notified the LHJ on 12/06/2024 when they realized Resident 6's stool sample came back positive for norovirus. <Resident 7> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include dementia and malnutrition. Review of the 11/20/2024 comprehensive assessment showed the resident was dependent on staff for ADLs and had severe cognitive impairment. Review of the facility outbreak line list showed Resident 7 had nausea, vomiting and diarrhea on 11/25/2024 that lasted 72 hours. <Resident 8> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include malnutrition. Review of the 11/19/2024 comprehensive assessment showed the resident was dependent on staff for ADLs and had moderate cognitive impairment. Review of the facility outbreak line list showed Resident 8 had diarrhea on 11/26/2024 and had a stool sample collected, sent to the laboratory with negative norovirus result reported on 12/02/2024. Resident 8 received therapy services until 11/16/2024. <Resident 9> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include cancer, dementia and malnutrition. Review of the 09/17/2024 comprehensive assessment showed the resident was cognitively intact and on hospice services. Review of the facility outbreak line list showed Resident 9 had nausea on 11/28/2024 as their only symptom and probably not related to the outbreak. <Resident 10> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include dementia and malnutrition. Review of the 11/01/2024 comprehensive assessment showed the resident was dependent on staff for ADLs and had severe cognitive impairment. Review of the facility outbreak line list showed Resident 10 had nausea and vomiting on 11/30/2024 and diarrhea on 12/01/2024. The resident was symptom free after 48 hours. <Resident 11> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include cancer, dementia and malnutrition. Review of the 11/06/2024 comprehensive assessment showed the resident had severe cognitive impairment and on end-of-life care. Review of the facility outbreak line list showed Resident 11 had nausea and vomiting on 12/01/2024. Symptoms resolved after 48 hours. <Resident 12> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include cancer and malnutrition. Review of the 10/28/2024 comprehensive assessment showed the resident was dependent on staff for ADLs and had moderate cognitive impairment. Review of the facility outbreak line list showed Resident 12 had nausea and diarrhea beginning 12/01/2024 that lasted 24 hours. <Resident 13> Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include septicemia (an infection that occurs when germs get into the bloodstream and spread) and malnutrition. Review of the 12/02/2024 comprehensive assessment showed the resident was dependent on staff for ADLs and had severe cognitive impairment. Review of the facility outbreak line list showed Resident 13 had vomiting and diarrhea beginning 12/01/2024 that lasted 24 hours. <Resident 14> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include malnutrition. Review of the 10/02/2024 comprehensive assessment showed the resident had intact cognition. Review of the facility outbreak line list showed Resident 14 had nausea and vomiting beginning 12/01/2024 that lasted 24 hours. <Resident 15> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include dementia and malnutrition. Review of the 11/07/2024 comprehensive assessment showed the resident was dependent on staff for ADLs and had severe cognitive impairment. Review of the facility outbreak line list showed Resident 15 had vomiting and diarrhea beginning 11/27/2024 with symptoms resolved by 12/02/2024. <Resident 16> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include dementia and malnutrition. Review of the 12/02/2024 comprehensive assessment showed the resident was dependent on staff for ADLs and had severe cognitive impairment. Review of the facility outbreak line list showed Resident 16 had nausea, vomiting and diarrhea beginning on 12/02/2024 that were resolved by 12/06/2024. <Resident 17> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include malnutrition and end stage renal disease (ESRD, when kidneys permanently fail to filter dangerous levels of fluid, electrolytes and waste from the blood). Review of the 09/13/2024 comprehensive assessment showed the resident had intact cognition. Review of the facility outbreak line list showed Resident 17 had nausea and vomiting on 12/03/2024 that lasted 24 hours. <Resident 18> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include dementia and malnutrition. Review of the 12/05/2024 comprehensive assessment showed the resident was dependent on staff for ADLs and had severe cognitive impairment. Review of the facility outbreak line list showed Resident 18 had nausea and a fever on 12/05/2024 and was admitted to the hospital with a diagnosis of urosepsis (a type of sepsis [a bacterial infection in the bloodstream or body tissues] that begins in the urinary tract). <Resident 19> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include dementia and ESRD. Review of the 10/10/2024 comprehensive assessment showed the resident was dependent on staff for ADLs and had severe cognitive impairment. Review of the facility outbreak line list showed Resident 19 had vomiting and diarrhea on 12/08/2024 that lasted 24 hours. <Resident 20> Review of the resident's medical record showed they were admitted to the facility with diagnoses to include malnutrition and heart failure. Review of the 10/01/2024 comprehensive assessment showed the resident had intact cognition. Review of the facility outbreak line list showed Resident 20 had vomiting and diarrhea on 12/09/2024 that lasted 24 hours. During an interview on 12/18/2024 at 3:38 PM, Staff B, Director of Nursing, stated they were also not aware they were required to notify the State of an infectious disease outbreak and stated they were not clear when they would have known there was an outbreak since Resident 1 had ongoing GI issues prior to other residents having symptoms. Looking at the outbreak line list, they stated they probably should have notified the LHJ on 11/24/2024 when there were three residents with symptoms in addition to Resident 1. Reference: WAC 388-97-1320(1)(a); 1640(7) This is a repeat citation from the Statement of Deficiencies dated 06/12/2024.

Based on observation, interview, and record review, the facility failed to ensure residents received timely treatment and care in accordance with professional standards of practice to prevent facility acquired pressure injury (PI) and worsening of PIs for 2 of 3 residents (Residents 49, and 18) reviewed for PIs. Resident 49 experienced harm when they developed a stage 4 medical device-related PI (MDRPI) to their right lower leg from an immobilization brace (a rigid medical device that holds a joint or bone in place to aid in restricting movement of the injured area to assist with healing) that became infected and resulted in extreme pain. Resident 18 experienced harm when they developed a right buttock PI that worsened, became infected, and required antibiotic treatment. These failures placed residents at risk for medical complications, and unmet care needs. Findings included . Review of the National Pressure Injury Advisory Panel's (NPIAP, the leading expert in PIs/wounds) guidelines and definitions, dated September 2016, defined pressure injury stages as follows: Stage 1 PI has intact skin with a localized area of non-blanchable erythema (redness). Stage 2 PI is a partial thickness skin loss with exposed dermis (the top inner layers of skin). Stage 3 PI is a full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may include with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which may be shallow or deep and impairs wound closure). Stage 4 PI is a full thickness loss of skin and tissue with exposed or directly palpable fascia (a layer of connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. Epibole undermining and tunneling often occur. Unstageable PI is a full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen. Further review of the NPIAP, Best Practices for Prevention of Medical Device-Related Pressure Injuries in Long Term Care, dated January 2020, showed the medical device should be assessed for the correct size, and fit regarding the individual. Also, the skin under and around the device should be inspected daily and repositioned. <Resident 49> Review of the medical record showed the Resident 49 was admitted on [DATE] with diagnoses including a fracture of their right lower leg bone, that did not require surgery but had a compression bandage (a stretchable cloth that applies pressure when wrapped around a limb to help reduce/prevent swelling) wrapped around a hard immobilization brace and an open non pressure related left foot wound. The 05/13/2024 comprehensive assessment showed the resident was cognitively intact and was able to make their needs known. Additionally, the resident was at risk for pressure injuries, but did not have any PIs during the assessment timeframe. Review of Resident 49's hospital wound care and discharge notes, dated 05/08/2024 showed they had an abrasion (a type of wound) to the left foot and a right lower leg fracture that required immobilization (no other open wound/injuries were noted in the resident's hospital records). Resident 49 was to follow up with their orthopedic provider (a doctor that specializes in injuries to the bone, muscles, joints, and soft tissues) due to their fractured right leg and showed no documented directives on whether the right leg's hard immobilization brace could be removed or had to stay in place. Review of Resident 49's physician's orders showed: On 05/09/2024 resident's right leg fracture was to be assessed once a day and to ensure that the hard immobilization brace was on at all times. On 05/16/2024 wound care provider was consulted for resident's left foot injury. Review of Resident 49's facility provider note dated 05/10/2024 at 2:05 PM, showed the facility staff needed to clarify the removal of the resident's right leg immobilization brace with the orthopedic provider (two days after the resident was admitted ). Review of a nursing progress note on 05/13/2024 at 2:46 PM showed, Staff G, Licensed Practical Nurse/Treatment Nurse (LPN/TN), stated that a call had been placed to the orthopedic provider for clarification of orders to Resident 49's right leg brace (five days after the resident was admitted ). Review of the wound care provider notes dated 05/16/2024 (eight days after the resident was admitted ) showed, Ace-wrapped (a type of compression bandage) immobilization brace on right upper leg has been in place since admission and has not been assessed .strong foul odor emanating (the source or what is producing something) from (Resident 49's) wounds . The wound care providers initial assessment, after removing the compression bandages/hard immobilization brace showed the resident had an infected Stage 4 MDRPI to the right/front lower leg from the immobilizing brace. Additionally, .culture was then obtained for concerns of wound infection ., and urgent follow-up with the orthopedic provider was recommended. During an interview on 06/12/2024 at 7:57 AM, when asked about the hard immobilization brace on their right leg, Resident 49 stated their pain when they first admitted was very minimal and then increased as the brace was kept in place around their leg. Resident 49 stated that it had gotten to the point that they were a 10 out of 10 on the zero to 10 pain scale (a method to measure an individual pain intensity, zero equals no pain and 10 is severe pain) and the immobilization brace was .cutting off circulation (how blood moves throughout the human body) . Resident 49 stated they were informing the nursing staff of the increasing pain in their right leg everyday but was told they could not take off the immobilization brace, even though it was hurting. Resident 49 stated that nursing staff told them their right leg would come out of the brace when they saw the orthopedic provider in two weeks. During an interview on 06/12/2024 at 9:52 AM, Staff N, Registered Nurse (RN), stated they had completed the admission assessment on Resident 49. Staff N stated they performed a full skin assessment but did not take off the compression wrap/immobilization brace to assess Resident 49's right leg because the resident did not have orders, when they came from the hospital, clarifying if the immobilization brace could be removed or not. Staff N stated the resident informed them that the compression bandage had recently been changed that day in the hospital. Staff N stated they called the hospital but were told they needed to clarify the orders with the orthopedic provider. Staff N stated that since they were not able to assess Resident 49's right leg skin, the process would be for the treatment nurse to complete the assessment. During an interview on 06/12/2024 at 10:36 AM, Staff H, LPN/TN, stated they were one of the TN that had briefly worked with Resident 49 after they were first admitted to the facility. Staff H stated that Staff G, LPN/TN, worked with the resident the most but they did remember Resident 49 complaining about the right leg immobilization brace and that it was rubbing on the resident's right leg. During an interview on 06/12/2024 at 10:44 AM, Staff G, stated there was some confusion after Resident 49 had arrived in the facility on if the resident's right leg immobilization brace should have been removed or left in place and that they were requesting confirmation from the orthopedic provider. Staff G stated they had not assessed the resident's right leg skin, under the compression bandage, until 05/16/2024 when the wound care provider came in and took it off (eight days after the resident had admitted ). Staff G stated the resident did have a lot of pain in their right leg from the fracture but did not know of any wounds on the resident's right leg until the brace was taken off. Staff G stated that after the hard immobilization brace was removed the resident had immediate pain relief and it seemed like the positioning of the brace was malformed (not having the expected shape) and not fitting correctly, with obvious pressure from the device on the resident's right/front lower leg.getting (Resident 49) out of the brace was significant (regarding the resident pain). During an interview on 06/12/2024 at 12:35 PM, Staff B, Director of Nursing Services (DNS), stated the correct process was not followed for Resident 49 and that nursing staff should have assessed the resident's skin under the compression bandage/hard immobilization brace and confirmed orders for the right leg brace. Staff B stated they had made some attempts to contact the orthopedic provider but were unsuccessful and at that point they should have communicated with the facility provider and or the medical director to clarify what intervention/orders they would have wanted to implement. Staff B stated that Resident 49 should not had to wait eight days to have their orders clarified and skin check completed on the resident's right leg. Staff B stated that the brace could have been too tight and that it was most likely to have caused the resident's right/front lower leg MDRPI that was assessed by the wound care provider. During an interview on 06/12/2024 at 2:55 PM, Wound Care Provider, stated they had been consulted to evaluate Resident 49's left foot injury but was informed of a foul odor and drainage that was coming from the resident right leg hard immobilization brace. The wound care provider stated the hard immobilization brace needed to come off on their 05/16/2024 visit and when they assessed Resident 49's right leg skin, they noted the resident acquired a stage four MDRPI. The wound care provider stated it was clear where the hard immobilization brace was applying pressure and made an indentation over the same place that Resident 49 developed the PI. 44922 <Resident 18> Review of the resident's medical records showed they admitted to the facility on [DATE] with diagnoses to include a stroke (when the supply of blood to the brain is reduced or blocked completely, which prevents brain tissue from getting oxygen and nutrients) with right sided weakness and diabetes (a condition that affects your blood sugar levels and can cause serious complications, including delayed wound healing). The 05/30/2024 comprehensive assessment showed the resident's cognition was severely impaired and was dependent on the assistance of two or more staff for activities of daily living. The assessment further showed the resident was incontinent of their bowel and bladder, was at risk for developing PIs, and had an unhealed stage four PI. The 08/21/2023 comprehensive admission assessment showed the resident's skin was intact and was at risk for developing PIs. During a concurrent observation and interview on 06/04/2024 at 8:41 AM, Resident 18 was observed lying in bed, with the head of their bed elevated and had an alternating air mattress (APM, a therapeutic bed designed to prevent pressure sores and injuries by inflating and deflating air cells within the mattress in a rhythmic pattern). The resident had a blank stare, did not respond when spoken to, but followed movement with their eyes. Staff K, Nursing Assistant (NA), entered to assist the resident with their breakfast and stated the resident had declined in their health and had not been speaking for about a month. Review of Resident 18's medical record from 11/2023 through 06/12/2024 showed the resident's ongoing PIs as follows: 11/11/2023, skin breakdown to the crease of the buttocks that was three centimeters (cm, a type of measurement) by 0.2 cm. Cleanse the wound and cover with an appropriate dressing and change per manufacturer's recommendations and PRN (as needed). (nursing progress notes showed this was a partial thickness opened wound, Stage 2 per NPIAP guidelines). 02/07/2024, partial thickness, opened area to the right buttock, two cm by one cm. Cleanse, apply barrier cream, and place non-adhering dressing if resident is willing. Resident is allergic to adhesives. One time a day ensure written documentation had been completed. 02/15/2024, full thickness, unstageable opened area to the right buttock, four and a half cm by four cm. Cleanse, skin prep to edges, cover with dressing, assess daily, and change per manufacturer's recommendations. 02/15/2024, open area to the coccyx (tailbone), five cm by 0.2 cm. Cleanse, apply calmoseptine (a brand of skin barrier cream), apply non-adhering dressing, assess daily. One time a day ensure written documentation had been completed. 03/05/2024, initiated an APM, to be monitored every shift (115 days after skin integrity began to deteriorate). Review of the 03/22/2024 through 06/06/2024 wound care provider notes and recommendations showed: 03/22/2024, initial wound assessment, right buttock, 3.3 cm by 7.2 cm by two cm depth, 6.8 cm undermining, and the wound had visible muscle, tendon/ligament, and tissues exposed. The wound had 90 percent debridement (the process of removing dead skin and foreign material from a wound to reduce the risk of infection and promote healing), had heavy drainage, was macerated (when skin is in contact with moisture for too long and looks lighter, wrinkly, and wet) and had a strong odor. Treatment orders were to place a non-bordered adhesive foam over the wound and change the dressing daily and PRN for accidental removal, saturation, and/or soiling (order was inaccurately transcribed into the electronic health record and did not include to cover the wound with a foam dressing and change daily and PRN). Recommendations: 03/22/2024, consider a temporary foley catheter (a tube placed into the bladder and carries the urine outside of the body into a bag connected to the tube) for moisture management due to incontinence (was not ordered or followed up on). 03/22/2024, obtain labs, comprehensive metabolic panel ([CMP] measures 14 different substances in your blood), complete blood count ([CBC] provides information about the cells in your blood), high-sensitivity C-reactive protein (CRP-H, measures inflammation in the body. Normal range is zero to five milligrams per Liter [mg/L, a unit of measure]), showed an elevated level at 38.3 mg/L, and the erythrocyte sedimentation rate (ESR, helps detect inflammation and infection. Normal range is zero to 20 millimeters per hour, [mm/hr, a unit of measure]) was elevated at 56 mm/hr. (Labs were obtained on 03/28/2024, six days after ordered and there was no documentation of the facility provider notification or wound care provider regarding abnormal lab results. 03/22/2024, obtain an electromagnetic radiation ([X-ray] of the sacrum (a large triangular bone at the base of the spine), a quick, painless test that captures images of the structures inside the body, especially the bones) imaging to rule out osteomyelitis (an infection in the bone) (imaging obtained on 03/22/2024 but not addressed with the wound care provider until 04/18/2024). 04/12/2024, referral for infectious disease specialist (this was not ordered or followed up on). 04/18/2024, vascular study referral to be completed at the hospital due to discoloration to both lower extremities and treatment guidance. (Notes showed this referral was not followed up on until 05/30/2024, 42 days later). 04/18/2024, obtain a re-culture of the wound or polymerase chain reaction quantitative analysis (a test that can detect the presence of specific bacteria) of right buttock tunneling (culture not obtained until 04/22/2024 (four days after ordered, positive for infection on 04/25/2024 and started antibiotic treatment on 04/26/2024 (eight days after ordered). o04/18/2024, wound vac (negative wound pressure therapy, a technique using a suction pump, tubing, and a dressing to remove excess exudate and promote healing in acute or chronic wounds) recommended (was not ordered or followed up on). 04/18/2024, magnetic resonance imaging ([MRI, a painless test that produces very clear images of the organs and structures inside your body) to assess bone level involvement in the wound (was not ordered or followed up on). 04/25/2024, once antibiotic treatment is in place for 72 hours, initiate the wound vac (was not ordered or followed up on). 05/02/2024, please provide update on lab order recommendations and repeat imaging to the sacrum. Please start wound vac if available. 05/23/2024, wound care provider inquiring about the initiation of the wound vac for the right buttock wound, since it had not been started and Unable to locate updated labs/imaging, or updates on vascular study to the legs. Despite the wound care provider's recommendations above, there was no follow-up on the foley catheter, wound vac, or the infectious disease referral from 03/22/2024 through 06/06/2024. Review of Resident 18's lab results, obtained on 05/06/2024, showed an abnormal CRP-H level at 34.1 mg/L and no ESR had been obtained per the wound consultant's recommendations. Review of Resident 18's 02/06/2024 Braden skin assessment (a tool used to assess a person's risk for PIs using a scoring system) showed the resident had a score of 11 which placed them at high risk (score of 10-12 was high risk) for pressure injuries. A concurrent observation and interview on 06/07/2024 at 10:48 AM, during Resident 18's right buttock wound dressing change, showed a dressing, saturated with brownish exudate being removed. The wound was unmeasured (nursing staff stated they measured once a week) and observation showed an opened wound, with depth, undermining, tunneling, and visible bone in the wound bed. The wound was cleansed, barrier cream applied to the edges of the wound, packed with three sheets of calcium alginate (a biodegradable dressing made from seaweed that absorbs exudate and forms a gel), and covered with a foam dressing. Staff K stated they recalled going on vacation in October 2023 and when they returned the wound to the right buttock was present. Staff K stated the wound was dime size when they first observed it and the wound had never resolved, it only got bigger. During an interview on 06/11/2024 at 10:31 AM, Staff G, LPN/TN, stated when Resident 18's initial PI started they should have had an APM put into place to prevent further skin breakdown and a weekly head to toe skin assessment. Staff G recalled the foley catheter had been discussed, but did not know why one was not initiated, it would have helped with the moisture. Staff G stated they understood Resident 18 was treated with antibiotics for the infection to their right buttock PI in order to prepare them for use of the wound vac but did not know if the facility provider agreed. Staff G could not recall having a provider observe/assess the right buttock PI when they worked prior to the wound care provider's first visit. Staff G stated they had protocols for wounds, and they would enter orders that were not specific like change per manufacturer's recommendations, so they could have the freedom to change it as needed. Staff G stated they did not contact the facility provider prior to changing the type of dressing used or the duration of the days it needed to be changed prior to the wound care provider's recommendations on 03/22/2024. Staff G was unaware the order for daily dressing changes given by the wound care provider were entered incorrectly and Staff G did not complete daily documentation with Resident 18's PI dressing changes as ordered. During an interview on 06/11/2024 at 11:34 AM, Staff B, DNS, stated the charge nurse was responsible for reviewing the wound care provider notes and communicating with the facility providers on cultures, labs or imaging that was recommended, and all communication with the providers should have been documented. At times the facility provider did not agree with what the wound care provider ordered so they would have to wait for them to answer which trying to get clarification from the providers (Medical Director and other attending physicians/providers) had caused some delays in the management of Resident 18's PI. Staff B further stated they would have expected an APM be placed when Resident 18 started with skin issues in November 2023 and that was not done. During an interview on 06/11/2024 at 1:16 PM, Resident 18's Representative (RR), stated they were not asked or informed about a wound vac being used to heal the resident's pressure injury. The RR stated that if the wound vac could heal the wound and Resident 18 could be kept comfortable at the same time, that is what they would want. During an interview on 06/11/2024 at 2:08 PM, Staff D, Attending Physician, stated they had observed the right buttock wound once but did not document on it and did not give orders at that time for wound management. Staff D stated they would expect the wound care provider's recommendations be communicated with the facility provider or a call made to the on-call attending physician so that treatment could be started as soon as possible. Staff D stated they were not aware of the recommendation for the wound vac. During an interview on 06/12/2024 at 10:10 AM, Staff H, LPN/TN, stated when the order was not specific to a certain dressing and showed per manufacturer's recommendations they did not get clarification from any provider and would use the same type of dressing they removed from the previous dressing change. Staff H stated they would assess skin weekly for residents with a high Braden score and did not know why Resident 18 did not have an APM applied until 03/05/2024. Staff H stated they were not aware the wound care provider's order was incorrect but understood that if there was not as much drainage as before they were okay to not change the PI dressing daily. Staff H further stated they understood the wound vac was ordered but never came and did not know why (the wound vac was never ordered). Staff H stated Resident 18 did not have an allergy to adhesive dressings they just did not like them and thought they were uncomfortable. During an interview on 06/12/2024 at 12:34 PM, Staff I, Charge Nurse, stated they were responsible for reviewing the wound care provider's notes and processed dressing changes, cultures, imaging, and labs when they received them and was not aware of, nor had they communicated with the facility provider regarding Resident 18's recommendations for NWPT, MRI, or the foley catheter. Staff I stated they were not aware the order for the right buttock PI was incorrect and did not update the order after each visit if it remained the same. During an interview on 06/12/2024 at 12:44 PM, Staff C, Resident Care Manager, stated their normal process would be to initiate an APM when the resident was a higher risk for skin issues or started to develop skin issues and could not recall why this was not done for Resident 18. Staff C stated they were unaware the wound care provider requested a foley catheter be used to manage Resident 18's moisture and did not know why the order had not been completed. During an interview on 06/12/2024 at 2:35 PM, Wound Care Provider, stated the DNS communicated that there were stipulations in place and would need permission from the facility providers for labs, cultures, antibiotics, and imaging. The wound care provider stated they would ask the nursing staff about their recommendations and preventative measures and was told by the staff they were being held up by the facility providers. The wound care provider stated they would have expected the staff to follow their dressing recommendations as they were written and to have communicated any recommended changes. The wound care provider further stated they felt the preventative measures could have been used during palliative care (aimed at optimizing quality of life and mitigating suffering among people with serious, complex, and often terminal illnesses) and would continue to make wound care recommendations and it would be up to the facility to implement them. Reference: WAC 388-97-1060(3)(b)

Based on interview and record review, the facility failed to address required documentation for Advanced Directives (AD), a legal document in which a person specifies what actions should be taken for their health if they are no longer are able to make decisions for themselves because of illness or incapacity) including incorporating ADs into the care planning process for 1 of 5 residents (Resident 10) reviewed for ADs. These failures placed the residents at risk of losing their right of having their preferences and/or decisions followed regarding their end-of-life care. Findings included . Review of a policy titled Advanced Directives, dated September 2022, showed when a resident admitted , the facility would inquire about any existing written ADs and if not, would provide the resident or the resident's legal representative assistance and written information with the resident's right to refuse, accept, or formulate an AD. The facility would then document in the resident's medical record the resident's decision. <Resident 10> Review of the resident's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include Rheumatoid Arthritis (a chronic inflammatory disorder that damages the joints and other body systems) and chronic kidney disease. The 04/24/2024 comprehensive assessment showed the resident was cognitively intact and could make their own decisions. During an interview on 06/04/2024 at 10:17 AM, Resident 10 stated they did not have an AD in place but felt they needed to have one. Resident 10 stated they had not been asked about an AD or assisted by the facility regarding formulating an AD since they admitted . During an interview on 06/06/2024 at 3:06 PM, Staff Z, Social Worker, stated they were responsible for addressing ADs with Residents. Staff Z stated they addressed ADs with residents on admission and then quarterly (every 3 months) during their Interdisciplinary Team (IDT) care conferences and they documented the outcome in the box provided on the IDT document. Review of the 02/08/2024 and 04/24/2024 IDT care conference documents showed ADs were not discussed or documented. The documents showed boxes regarding AD's, but they were blank, and the notes did not show ADs were discussed, offered, formulated, or refused. Reference: WAC 388-97-0280(3)(c)(i-ii)

Based on observation, interview and record review, the facility failed to ensure that 1 of 1 resident (Resident 1) was not left unattended on the side of the bed to administer their own breathing treatment prior to assessing the resident's condition/respiratory status, when they experienced an acute change of condtion with significant changes in breathing, had expressed anxiety and signs of respiratory distress. This failure caused actual harm and a potential life-threatening situation for Resident 1 due to being left alone during their respiratory distress and was later found on the floor, unresponsive, with bruising to the face and a hematoma to the right side of their head (a pool of mostly clotted blood that forms in the tissue due to a broken blood vessel caused by injury). On 05/05/2023 at 4:40 PM, the facility was notified of an immediate jeopardy (IJ) at Code of Federal Regulation 483.25 (g)(i), F 684 - Quality of Care, related to the facility's failure to thoroughly assess Resident 1's acute change in respiratory status. The facility removed the immediacy on 05/08/2023 with implementing the IJ removal plan which included the re-educating of all nursing staff (prior to working their next scheduled shift). The education of the nursing staff included a review of signs and symptoms of respiratory distress, change of condition policies and procedures, treatment and management, monitoring, and a respiratory assessment tool guide to ensure an effective system was in place. The facility adopted the tool to guide the nursing staff in determination of further assessment for all residents, including those who experienced a significant change in their respiratory condition. Findings included . Review of the 2019 Lippincott Nursing Procedures, 8th edition, standard of practice for nebulizer therapy showed for implementation, .Obtain the patient's vital signs, perform a respiratory assessment .to establish a baseline .Remain with the patient and continue the treatment until the nebulizer begins to sputter .Monitor heart rate and respiratory status during the procedure to detect any adverse reactions to the medication . Resident 1. Review of the medical record showed the resident initially admitted to the facility on [DATE], then was transferred/admitted to the hospital on 03/23/2023 after an acute decline in their respiratory status. Resident 1 returned to the facility on [DATE]. Diagnoses included significant heart and lung disease and diabetes (when the body does not make enough insulin or cannot use it as well). Additionally, the resident experienced a significant change in respiratory status with a fall and was transferred and/admitted to the hospital on 04/07/2023 with diagnoses of acute hypoxia (a state where oxygen is not available in sufficient amounts to the body due to low blood supply or oxygen in the blood), atrial fibrillation (irregular heartbeat, racing heart rate which can cause shortness of breath, light-headedness and chest pain), and congestive heart failure (the heart's capacity to pump blood cannot keep up with the body's need), and returned to the facility on [DATE]. Review of the 04/17/2023 comprehensive assessment showed the resident was alert and oriented and able to make their needs known. During an observation and concurrent interview on 05/03/2023 at 10:10 AM, Resident 1 was in bed with the head of the bed at a 90-degree angle. The resident was wearing a nasal canula (a two-pronged device that is placed in the nostrils and used to deliver supplemental oxygen) and was on continuous oxygen at three liters (volume of oxygen measurement). Resident 1 had multiple bruises, blueish-green in color, to the right side of their face, their right upper forehead, and multiple small, scattered bruises under the right eye, above the right jaw line, and face. The resident stated the bruises occurred three weeks prior. During a 05/03/2023 interview at 10:16 AM, Resident 1 stated that early in the morning on 04/07/2023 they experienced increased shortness of breath, difficulty breathing, and anxiety. Resident 1 asked the nurse (Staff H, Agency Licensed Practical Nurse [LPN]), for a breathing treatment and Staff H told Resident 1 they had to lie down and not sit up with their legs over the side of the bed. Resident 1 told Staff H that they could not lie down because they [Resident 1] couldn't breathe. Staff H set up the nebulizer treatment and asked the resident to lie down again, then Staff H left the room without performing a respiratory assessment. During a continuation of the 05/03/2023 interview at 10:16 AM, Resident 1 stated they must have fainted and fell face down on the floor. The next thing Resident 1 remembered was that they were in the ambulance and then admitted to the hospital. Resident 1 stated they knew that their oxygen level had decreased, and their heart rate was pumping fast. Resident 1 stated that their oxygen level was too low for them. The resident stated their oxygen level was 78% and 80%. (Oxygen level for diagnosis of lung disease may be lower than the normal level of 95%-100%). Resident 1's oxygen level order was to measure at 90% and above. Review of the 04/07/2023 investigative report showed that staff were not in attendance during the fall (there was no documented time of the unwitness fall). Staff H returned to Resident 1's room, the resident was found on the floor unresponsive. There was no assessment before the resident was left alone with their nebulizer treatment. The resident was found later unconscious due to the fall and respiratory/breathing issues. The resident's oxygen level was at 78% (normal 90% and above). The 04/07/2023 investigation showed Staff H started the nebulizer treatment but did not stay in the room during the treatment for Resident 1. The investigation for the incident showed .while this is the policy to be in attendance, it is not the practice . Additionally, the investigation showed the policy/system was for the nurses .to obtain vital signs before treatment, mid-treatment, and after treatment and the resident must be in constant visual contact . Review of Resident 1's 04/05/2023 care plan showed their oxygen level was to be maintained at 90% or above for safe oxygen levels, and the facility was to report to the physician any signs and symptoms of respiratory distress, increased heart rate, and other symptoms with problems breathing. Review of the 04/12/2023 hospital inpatient discharge documentation showed Resident 1 was admitted for acute hypoxia and atrial fibrillation. The resident was in the hospital from 04/07/2023 and was discharged back to the facility on [DATE]. During an interview on 05/03/2023 at 1:20 PM, Staff B, Director of Nursing Services (DNS), stated Resident 1's fall on 04/07/2023 could have been avoided if Staff H would have stayed in the room during Resident 1's breathing treatment. Staff B felt the hospitalization would have still occurred due to Resident 1's significant breathing issue. During a telephone interview on 05/08/2023 at 11:15 AM, Staff H stated that around 4:00 AM the resident wanted their oxygen level checked and was very anxious about something. Staff H stated Resident 1 began to hyperventilate (breathe at an abnormally rapid rate) around 4:30 AM and requested a nebulizer treatment. Staff H stated they set-up the treatment and asked the resident not to sit on the side of the bed because it was not safe. The resident refused Staff H's request. Staff H stated they left the room to take care of other residents and returned about five minutes later to find Resident 1 on the floor unresponsive with a hematoma on the right side of their forehead, heart rate was 135 (normal range between 60 to 100 beats a minute) and oxygen saturation level was 78% (normal 90% and above). During an interview on 05/11/2023 at 1:00 PM, Resident 1 stated they had a nebulizer treatment on 05/10/2023 and that was the first time a nurse took their vital signs and lung sounds and checked them during the nebulizer treatment without leaving them in the room with the nebulizer. Reference WAC 388-97-1060(1)

Based on observation, interview, and record review, the facility failed to ensure accident prevention by identifying and evaluating potential accident hazards for 1 of 1 resident (Resident 4), reviewed for falls. Resident 4 had a mechanical lift recliner with a handheld remote, placed in their room without an evaluation to determine if they were safe to use it. This failure caused actual harm to Resident 4, who used the handheld remote to raise the lift recliner to its highest upright position, fell , and sustained a fracture to the right knee and tibia (the shinbone) from the remote lift chair. Findings included . Resident 4. Review of Resident 4's medical record showed the resident was readmitted to the facility on [DATE] with diagnoses including significant history of falls with fractures, lung issues, and high blood pressure. Review of the 02/14/2023 comprehensive assessment showed Resident 4 was at moderate risk for falls, had issues with balance and walking, and required extensive assistance of two staff for transfers, toileting, and positioning. Resident 4 was alert with impaired cognition, but able to make their needs known. During an interview on 05/05/2023 at 10:15 AM, Staff F, Licensed Practical Nurse (LPN), stated Resident 4 was in pain and was on their way to administer a narcotic pain reliever. Upon entry to Resident 4's room with Staff F, Resident 4 was observed lying in their bed and had a long, velcro immobilizer on their right leg from the right thigh to the right lower leg. Resident 4 was on oxygen per a nasal cannula (plastic tubing used to give person oxygen). When asked how the right leg injury happened, Resident 4 stated they used the lift recliner remote to stand so they could go to the bathroom, fell , and vomited. Resident 4 refused the narcotic pain medication from Staff F who readjusted the resident for comfort. Staff F then stated they heard about a lift recliner being placed in Resident 4's room, but had no other information on how the process worked for placement and/or safety for furniture/devices. Review of the 05/04/2023 investigation report showed Resident 4 had an unwitnessed fall out of a lift recliner. Resident 4 was found on the floor, seated on their buttock, with the lift recliner in the highest upright position. Resident 4 was in quarantine for COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise (general feeling of discomfort/uneasiness), headache, dizziness, nausea, vomiting, diarrhea, loss of taste and smell, and in severe cases difficulty breathing that could result in severe impairment or death) at the time of the incident and on airborne precautions; the door was closed to Resident 4's room. Staff were instructed to check on Resident 4 every hours. On 05/04/2023 at 3:15 PM the pressure alarm that was placed in the lift recliner sounded and alerted staff to the resident's room. Resident 4 was found on the floor and had vomited. There was a bulge to the lateral side of the right knee and shortening of the right leg. Resident 4 was sent by ambulance to the local emergency room and sustained a closed fracture to the right knee and upper tibia of the right leg. The 05/04/2023 investigation report showed Resident 4's mechanical lift recliner had not gone through proper safety inspection process. The recliner arrived at the facility on 04/14/2023 and was checked for cleanliness and bugs. On 04/21/2023 the facility completed their mechanical check to ensure the lift recliner was operational and placed it in Resident 4's room. During an interview on 05/05/2023 at 11:40 AM, Staff O, Maintenance Director, stated they checked Resident 4's lift recliner to ensure it worked when they plugged it in and the remote worked. Staff O further explained they did not have anyhthing to do with making determination of the resident's safe use of the lift recliner, only the electrical functioning of the lift recliner. During an interview on 05/05/2023 at 11:00 AM, Staff B, Director of Nursing Services, stated the staff did not follow proper process for the use of the of the mechanical lift recliner. During an interview on 05/05/2023 at 1:50 PM, Staff Q, Social Services, stated there was no communication about the lift recliner being in the facility and the recliner would have needed to be evaluated by the therapy department before placed in the resident's room for their safety. Staff Q then stated the case manager would be notified before the lift recliner was placed in the resident's room. During an interview on 05/05/2023 at 2:00 PM, Staff C, RN Case Manager, stated they had noted the recliner was new to the room but did not question it. Staff C stated they were surprised Resident 4 used the remote of the lift recliner to an upright position because Resident 4 had never used the remote on their bed to reposition their bed. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to provide adequate supervision for each resident to prevent avoidable accidents for 2 of 5 residents (1, 2) reviewed for falls with injuries. Failure to implement adequate supervision, consistent with residents' assessments and care plans placed residents at risk for falls, injury and a diminished quality of life. The failure caused harm for Resident 1 when they were left standing, unsupervised, at the grooming sink and fell hitting their head on the sink causing a scalp laceration requiring staples to close the wound at the hospital. Findings included . Record review of the facility's policy titled, Falls and Fall Risk, dated March 2018, showed that based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Medical factors that contribute to the risk of falls included heart failure, arthritis and balance/gait disorders. A possible resident centered approach included position-change alarms used to assist the staff identify patterns and routines of the resident to assist in fall prevention. Resident 1. Medical record review showed the resident was admitted to the facility on [DATE] with diagnoses to include respiratory failure, arthritis (the swelling and tenderness of one or more joints) and frequent falls. Review of the 11/03/2022 comprehensive assessment showed Resident 1 was cognitively intact and had heart failure. The resident required the extensive assistance from two staff for transfers and ambulation with a walker. Review of the fall care area assessment showed that the resident's balance was not steady and only able to stabilize with staff assistance when moving from a seated to standing position. Review of Resident 1's fall care plan dated 06/18/2020 showed the following fall precautions were: - Anticipate and meet the resident's needs, - Be sure resident's call light was within reach and encourage the resident to use it for assistance, - Follow facility fall protocol, - Resident was not to be left unattended at any time (updated on 12/28/2022), - Resident seems to understand their limitations and had not attempted to self-transfer since admit. Review of a 12/11/2022 at 8:16 AM nursing progress note showed that Resident 1 fell while standing at the grooming sink that caused a substantial injury. They had bruising to their left hand extending up the left forearm approximately 15 centimeters (cm). There was bruising to the left upper arm approximately 20 cm in diameter. Blood was flowing from a laceration on the left temple that required compression. The resident was sent to the hospital for evaluation and treatment. Review of a 12/11/2022 at 11:24 AM nursing progress note showed the resident sustained a 2 cm laceration to the left temple requiring 2 sutures to close the wound. During a telephone interview on 01/27/2023 at 4:10 PM, Resident 1's Representative (RR 1) stated they were upset about the fall on 12/11/2022 and that It should not have happened, they all should know that [Resident 1] cannot be left standing alone. RR 1 stated the fall caused Resident 1 a head injury requiring an emergency room visit, stitches on the head, bilateral black eyes, extensive bruising on their left arm, edema, and pain in their hand. On 01/30/2023 at 10:34 AM, Resident 1 was observed in their wheelchair in their bedroom. They were dressed and well groomed. The bruising from the fall had faded to faint yellow. The resident stated they were not in pain, that they had a bad fall and went to the hospital; but they could not recall how it happened. During an interview on 01/30/2023 at 12:30 PM, Staff C, Nursing Assistant (NA) stated Resident 1's morning routine included standing at the grooming sink with their walker in front of them and the wheelchair locked behind them. Resident 1 liked to stand at the sink to brush their teeth and wash their face. One staff would stand next to them and hold the resident's gait belt (a safety device wore around a resident's waist, used by staff to provide stability during transfers or ambulation). Staff C stated they would not leave Resident 1's side because they were not steady on their feet. During a telephone interview on 01/30/2023 at 1:00 PM, Staff D, NA, stated that they were assisting with Resident 1's grooming the morning they fell . The NA stated while standing at the sink with Resident 1, their roommate needed to use toilet and tried to get up. The NA stated they left Resident 1 standing at the sink to assist the roommate to the toilet. When in the toilet with the roommate, they heard a crash and Resident 1 was on the floor bleeding. Staff D stated that they knew Resident 1 needed assistance with the gait belt to sit down safely. Staff D stated they should not have left Resident 1's side that morning. During an interview on 02/07/2023 at 12:45 PM, Staff E, NA, stated they would assist Resident 1 with morning care at the grooming sink. Staff E stated the resident would stand with the walker at the sink and the wheelchair would be locked behind them. Staff E stated they knew not to leave Resident 1's side because they did not have steady balance and would take their hands off of the walker to wash their face. Resident 2. Medical record review showed the resident was admitted to the facility on [DATE] from the hospital after a fall at home fracturing their pelvis (basin-shaped complex of bones that connects the trunk and the legs, supports and balances the trunk) and sacrum (a single bone located at the base the spine) and diagnoses to include history of stroke with left side hemiparesis (weakness on one side of the body) and an overactive bladder. Review of the 12/30/2022 facility Restraint Assessment and Consent Form showed Resident 2 consented to their bed against the wall as a fall precaution. Review of a 01/01/2023 at 3:58 PM progress note showed the resident self-transferred to the bed once and the nurse encouraged the resident to turn on the call light and wait for assistance. Review of the 01/03/2023 comprehensive assessment showed Resident 2 was cognitively intact, required the extensive assistance from two staff for transfers and was at risk for falls due to weakness and impaired balance. The resident had a urinary catheter (a hollow, partially flexible tube that collects urine from the bladder and leads to a drainage bag) in place. Review of the Mobility Assessment completed on 01/04/2023 at 1:52 PM by Staff F, Registered Nurse (RN), showed Resident 2 was considered high risk for falls due to their fall with fractures prior to admission and their left side hemiparesis related to a stroke. No recommendation for fall alarms. The resident was alert, oriented and able to demonstrate use of the call light. Review of a 01/04/2023 at 2:04 PM progress note showed the resident was forgetful at times and self-transferred to their bed once. The resident was reminded to use their call light. Review of a 01/05/2023 at 2:50 PM progress note showed Resident 2 self-transferred during day shift. Review of a 01/06/2023 at 8:52 AM progress note showed Resident 2 tested positive for COVID-19 (an infectious disease - causing respiratory illness with symptoms including cough, fever, shortness of breath, new or worsening fatigue, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell.) Review of a 01/07/2023 at 2:48 AM Incident Investigation showed Resident 2 was found lying on the floor near their bed with no injuries found. The resident stated, I was having a party and reported they were getting up to get a drink of water and spilled the water pitcher. The resident was returned to their bed in the lowest position. Review of the 01/07/2023 fall care plan showed the resident's fall precautions were: - To anticipate and meet needs, - Be sure resident's call light was in reach and encourage them to use it for assistance, - Follow facility fall protocol, - Review past falls. Review of a 01/07/2023 at 12:54 PM progress note showed Resident 2's urinary catheter became separated from the collection bag and the catheter was discontinued at that time. Review of a 01/08/2023 at 1:21 PM progress note showed Resident 2's Representative (RR 2) stated that Resident 2 was not acting like themselves and requested an assessment for a urinary tract infection (UTI). An assessment was completed, and the resident denied the sensation of burning with urination. The plan was to monitor the resident for symptoms of UTI (a strong urge to urinate, burning feeling when urinating, urinating often and strong-smelling urine) and encourage fluids. Review of a 01/08/2023 at 2:34 PM Incident Investigation showed Resident 2 was found on the bathroom floor with their pants around their ankles and their walker nearby. No call light had been activated. The resident had a significant amount of blood from a deep laceration, exposing the skull beneath, on the left side of the forehead near the hairline that required compression. The resident stated they needed to go to the bathroom and lost their balance. Resident 2 was transported to the hospital for evaluation and treatment. Review of a 01/08/2023 at 5:35 PM progress note showed Resident 2 returned from the emergency department with 5 staples to their head laceration. Review of a 01/09/2023 at 9:02 AM progress note showed the Interdisciplinary Team met to review Resident 2's fall with injury and added sensor alarms to the resident's wheelchair and bed with the resident's and RR 2's consent. Resident 2's care plan was updated with this fall intervention at that time. Observation and interview on 01/30/2023 at 10:45 AM showed Resident 2 lying on their bed well-groomed and wearing make-up. Sensor alarms were noted on their bed and wheelchair. The left side of the bed was against the wall. Resident 2 stated they knew they needed to ask for assistance from staff to transfer or use the bathroom. While touching the healing laceration on their forehead they stated that it did not hurt much at all. During an interview on 01/30/2023 at 10:50 AM, RR 2 stated they had just been visiting prior to the resident's fall in the bathroom. They stated Resident 2 hit their head on the bathroom door and had to go to the hospital for staples. I kept reminding [Resident 2] they needed to call for assistance and not try to transfer alone. During an interview on 02/07/2023 at 1:30 PM, Staff F, RN/Therapy Coordinator, stated that fall interventions initiated on admission depended on the resident's assessment. Whether they fell prior to admission, if they were trying to self-transfer, or were impulsive. Staff F stated that after Resident 2's assessment the standard interventions were initiated like having the call light in reach and frequent used items in reach. The Resident's self-transfer progress notes and fall on 01/07/2023 were reviewed with Staff F and they stated that the fall on 01/08/2023 could have been prevented had the alarms been implemented sooner. On 02/07/2023 at 1:50 PM, Staff G, RN/Resident Care Manager, was asked for a copy of the Facility Fall Protocol that was listed as an intervention in both Resident 1 and 2's fall care plans. Staff G stated they could not find a copy. During an interview on 02/07/2023 at 2:30 PM, Staff H, RN, stated they were the previous Therapy Coordinator. When asked when the fall intervention of sensor alarms would be considered for a resident, Staff H stated that if the resident were attempting self-transfers, not calling for assistance and after a fall, they would implement sensor alarms with the consent of the resident and their representative. During an interview on 02/07/2023 at 5:00 PM, Staff B, RN/Director of Nursing, agreed that both Resident 1 and Resident 2's falls could have been prevented had the staff not left Resident 1's side at the sink and Resident 2's sensor alarms had been implemented when they started self-transferring. Reference: WAC 388-97-1060(3)(g) This is a repeat citation from the Statement of Deficiencies dated 11/29/2021 and 03/30/2022.

Based on observation, interview and record review, the facility failed to ensure a resident's transfer device/gait belt was used to prevent injury during a transfer which resulted in a [CONDITION(S)] and a rib fracture for 1 of 3 residents (Resident 1) reviewed for accidents. This failure caused harm to the resident requiring medical treatment and pain. Findings included . Resident 1. Review of the resident's 09/08/2021 quarterly assessment showed they were cognitively intact and required one staff assistance to transfer, toilet and walk with a walker. The resident did not have steady balance and required staff assistance for stability with standing and walking. Review of Resident 1's 06/09/2021 bedside care plan showed the resident required one staff assistance with a gait belt (a safety device that is used by caregivers to help a resident move) to aid in steadiness for transfers, toileting and walking with the walker. Review of a 11/05/2021 investigation report showed the resident had a fall and sustained two 3.5 centimeter (cm) by 3.0 cm skin tears on the back of each hand, a 4.5 cm laceration to the right temple, and a 3.5 cm laceration to the right side of the forehead. The resident was evaluated at the emergency department, received sutures to the head lacerations, and found on x-ray to have a fracture to the second rib on the right side. Review of a 11/05/2021 witness statement written by Staff D, Nursing Assistant (NA), showed We were walking back from the bathroom. I was holding [their] pants from behind. Then when we got back from where [the] wheelchair was parked, I tried to pull the chair closer while telling [them] to turn around and sit. As [they] tried to turn around, [they] lost [their] balance. I tried helping [them] to the ground, but [they] kept sliding down. [They] fell against me, but I could not support [them], so [they] landed on [their] right side. Review of a 11/08/2021 physician progress note showed the resident had a fall on 11/05/2021 after losing their balance. The exam showed the resident appeared uncomfortable with a swollen, bruised right eye and right side of their face. There was bruising on the right arm and thigh. There were dry lacerations to the right forehead with stitches in place. There was marked pain to the resident's right lower rib area during the examination. On 11/15/2021 at 2:10 PM, Staff C, Registered Nurse and Resident Care Manager, stated that when Resident 1 fell , the Nursing Assistant (NA) assisting them was not using a gait belt and held on to the resident by the waist of their pants. On 11/15/2021 at 2:40 PM, Resident 1 was observed in their bedroom, sitting in their recliner with oxygen being delivered by a nasal cannula (a small, flexible tube that contains two open prongs intended to sit just inside the nostrils). The bruising to the right side of the face was dark purple and there were steri-strips (thin adhesive strips used to close small wounds) to the forehead lacerations as the sutures had been removed. The resident stated the pain in their ribs had improved a little but it hurt to take a deep breath and move. They stated they had not needed oxygen before they fell . On 11/18/2021 at 11:00 AM, during a telephone interview, Staff D stated that she was familiar with Resident 1 and had assisted them to the toilet many times. On 11/05/2021, the resident used their walker to and from the toilet that evening. Staff D stated she held onto the back of the resident's waist band while walking. She stated she knew a gait belt was required; however, did not look for one that evening. On 11/29/2021 at 10:20 AM, during a telephone interview, Resident 1's Representative (RR) stated the resident continued to have pain when moving around The RR stated the fall was an accident that should not have happened. A telephone exit was held on 11/29/2021 at 10:50 AM. The facility Administrator and Director of Nursing were informed of the failed practice where the NA ambulated Resident 1 without a gait belt before their fall. No further information was offered. Reference: WAC 388-97-1060 (3)(d)

Based on observation, interview, and record review, the facility failed to ensure care was consistent with professional standards of practice, to prevent the development of an avoidable pressure ulcer (PU), for one of four sample residents (#35), reviewed for pressure ulcers. Resident #35 did not receive a thorough and ongoing skin assessment that included pressure points, and evaluating effectiveness of interventions. This failure resulted in actual harm to Resident #35, who developed an unstageable pressure ulcer on his left heel, within two weeks of admission, and had a wound infection that progressed to a Stage III pressure ulcer (see definition below). Findings included: The National Pressure Ulcer Advisory Panel (NPUAP) document, dated (MONTH) (YEAR), defines Pressure Ulcer Stages as follows: -Stage I: Intact skin with non-blanchable redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. -Stage II: Partial thickness loss of dermis (the thick layer of living tissue below the epidermis) presenting as a shallow open ulcer with a red pink wound bed, without slough (a layer of dead tissue separated from surrounding living tissue). (MONTH) also present as an intact or open/ruptured fluid filled blister. -Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining and tunneling. -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 (a dry tan, brown or black scab) in the wound bed. Resident #35. Per the record was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the 07/04/18 admission assessment showed the resident had no cognitive impairment, required extensive assistance from two staff to change position in bed, and was at risk for pressure ulcer development. A 06/26/18 progress note identified a partial thickness open area (Stage II pressure ulcer) to the left of the coccyx, which was present on admission. A physician order [REDACTED]. Review of the resident's care plan, dated 06/30/18, did not include assisting the resident to turn on a schedule, or a plan for licensed nurses to monitor the resident's other pressure points. Review of the following electronic medication administration nursing progress notes revealed: On 07/10/18 at approximately 1:00 AM the resident complained of 10/10 (on a pain scale measuring from 0-10, with 10 being the most severe pain) left leg and foot pain, and received Tylenol. There was no assessment by the nurse of the site of the residents pain. On 07/10/18 at approximately 9:00 PM the resident complained of left heel pain, rates pain of 8 out of 10, and received Tylenol. There was no assessment of the left heel by the nurse. On 07/11/18 at approximately 5:00 AM the resident received Tylenol 650 mg (milligrams) given for c/o (complaints of) foot pain 7-8 (out of 10). There was no assessment of the resident's foot, to determine the cause of the pain. Review of an Occurrence Note dated 07/11/18 at 12:43 PM showed, Res(ident) found by nac (nursing assistant certified) to have an open/blister (Stage II) to the left heel. The initial measurements were 7.0 centimeters (cm.) long by 6.0 cm. wide. Resident #35 was placed on an air mattress, heel elevators, and had a heel pad placed, for when when he was up in the chair. Review of a 07/18/18 physician visit note showed the physician diagnosed the left heel ulcer as unstageable (see definition above), and ordered a culture of the foul smelling wound drainage. A nursing progress note dated 07/22/18 revealed the left heel wound had a Methacillin Resistant Staph Aureus infection (MRSA) - a bacterium that is resistant to commonly used antibiotics), and the resident was started on an oral antibiotic. A physician visit note dated 07/23/18 revealed the left heel was now a stage 3 pressure ulcer. On 08/13/18 at 9:15 AM the resident was observed in his wheelchair, with a dressing and heel pad to his left foot. The resident stated he was in a lot of pain yesterday, and had a bad day because of his (left) foot (wound). Review of a 08/13/18 Staff I, Licensed Practical Nurse/Treatment Nurse progress note showed the heel dressing had been changed that: Dressing saturated with odorous drainage. Area resembles a bulls eye with dark black eschar (i.e. dead tissue) to the center with macerated skin edges (when the skin is exposed to fluid for an extended period of time, like when a wound is covered with a bandage). The total wound measured 2.8 cm. by 4.3 cm., including the macerated edges. On 08/14/18 at 10:30 AM Staff D, Registered Nurse/Resident Care Manager stated Resident #35 admitted with a small pressure ulcer to his coccyx. Per Staff D, the interventions in place at the time of admission were the standard facility mattress with pressure reduction properties, and also stated the interventions did not change until the heel ulcer developed. Staff D stated the pressure ulcer to the coccyx had healed as of 07/03/18. The same day at 11:00 AM an observation of the left heel wound was made with Staff I, Licensed Practical Nurse/Treatment Nurse. The wound appeared as described by her on 08/13/18, and was foul smelling. Staff I stated the resident's heel wound was diagnosed by the physician as an unstageable pressure ulcer. She stated the air mattress and blue heel pad were not implemented until after the heel wound developed. When asked if the resident was on a schedule for her to monitor his pressure points, she stated he was not on weekly assessment checks, the NACs check the skin during (weekly) showers and daily cares, and let me know if there are any areas (on the skin). On 08/15/18 at 9:30 AM Staff B, Registered Nurse/Resident Care Manager stated the nurses rely on the nursing assistants to inform them of changes in the resident's skin. They see the residents skin daily when being changed and dressed. The nursing assistants also do a thorough skin assessment, no I mean skin check, at the weekly shower. We have a very good system. She stated if a resident currently had a pressure ulcer, the nurse would be checking that wound daily, and should see all of the resident's skin at that time; however, there was no policy or practice for licensed nurses to check resident's skin after the initial skin check on admission and quarterly, even residents at high risk for pressure ulcers. On 08/15/18 at 10:00 AM Staff A, Director of Nursing Services, stated that nurses do a skin assessment as part of admission. After that, the standard of care was for the nursing assistants to do the skin checks. Per Staff A, the nursing assistants are our go to, because they dress and change the residents. When alerted to the documentation that reflected three different nurses administered pain medication for foot pain the day prior to the pressure ulcer discovery by a nursing assistant, she stated they should have checked. I would have checked, it's standard nursing to look at where the pain was coming from. Reference: WAC 388-97-1060(3)(b)