Every finding on record at Three Creeks Post Acute

Based on observation, interview and record review, the facility failed to coordinate with the State designated authority to ensure a resident with a developmental disability received integrated care based on their needs for 1 of 3 residents (Resident 1) reviewed for Pre-admission Screening and Resident Review (PASARR, a two part screening; Level I determined presence of a Developmental Disability and if present required a Level II evaluation by a specialized evaluator to determine if nursing home placement was the appropriate level of care, and what behavioral health or other community services were recommended. A Level II was required to be completed prior to nursing home admission.) Specifically, the facility failed to ensure Resident 1's PASARR Level II was coordinated with the specialized evaluator which resulted in an incomplete report. These failures placed the residents at risk of decline in their psycho-social needs and the inability to benefit from all services they were entitled to.Findings included.Resident 1's electronic medical record (EMR) was reviewed on 08/18/2026 at 11:50 AM with diagnosis of mild intellectual disability (involves limitations in both intellectual function and adaptive behavior), Prader-Willi syndrome (a rare congenital condition characterized by excessive appetite, as well as a variety of other signs including intellectual disability and short stature) and a fracture of their right upper leg.A review of their EMR documented Resident 1 transferred to the facility on [DATE] to be closer to family after they broke their upper leg. A PASARR Level II, started on 06/24/2026, and completed on 07/24/2026, documented Resident 1 had a developmental disability and was eligible for services. Resident 1s physical health, as well as what was needed to attain/maintain their highest level of health could not be determined due to the facility not responding to requests for necessary documentation that included their care plan, Medication Administration Records (MAR), and other necessary resident specific information.During an interview with Collateral Contact (CC1), State Agency PASARR Evaluator, on 09/17/2026 at 12:42 PM, they stated they had called the facility on five different occasions to request documents specific to Resident 1 that were necessary to complete the Resident's PASARR Level II evaluation. They stated they had never been able to speak with the Social Services Director (SSD) and had not received any of the requested and necessary documents to complete the assessment. CC1 stated they had to sign off on the evaluation without all the details necessary to help determine Resident 1's specific needs.On 08/19/2026 at 10:00 AM, during an Interview with Staff B, Director of Nursing, they stated they had been unaware of the request for documents to complete Resident 1's Level II PASARR. Staff B stated the facility SSD would have normally handled those requests but had left their position around the time frame of the requests.On 08/19/2026 at 10:10 AM, during an interview with Staff A, Administrator, they stated they had started working at the facility in July of 2026 and became aware the facility SSD was not completing portions of their assigned duties. Staff A stated the SSD had left their position without notice and they had been trying to figure out what had or had not been completed. Staff A further stated they were aware of the requirements for the facility to coordinate with the PASARR evaluators and would make sure this was happening moving forward.Reference: WAC 388-97-1915(4)

Based on interview and record review, the facility failed to ensure a high-risk medication, a tricyclic antidepressant (TCA - a class of antidepressant medication used to treat low mood), had a documented diagnosis attached to the same medication, was consented to by the resident, and had a side effect monitor in place for 1 of 3 residents (Resident 1). This failure placed residents at risk of not being informed of health risks associated with potential adverse side effects and medical complications.Findings included . On 08/18/2026 at 11:50 AM Resident 1's electronic medical record (EMR) was reviewed and showed they were admitted to the facility on [DATE] and at that time were taking a TCA medication twice daily (AM and PM) for obsessive compulsive disorder (OCD -a chronic mental health condition defined by a cycle of unwanted, intrusive thoughts and repetitive behaviors).Further review of Resident 1's EMR showed no documentation of a reviewed and/or signed consent by the resident for the high-risk TCA drug.Review of Resident 1's diagnosis list did not show a diagnosis of OCD.Review of Resident 1's August 2026 medication administration record (MAR) showed an order, beginning on admission, for the TCA medication to be given twice daily. The same August MAR showed the medication was not being monitored by staff for possible side effects of this medication. In an interview on 08/19/2026 at 11:10 AM Staff B, Director of Nursing, stated consent for high-risk medications was required to be reviewed and signed by residents prior to the medication being administered so they knew the risks of taking the medication. Staff B stated they had noticed Resident 1 did not have a diagnosis of OCD in their medical record, but the diagnosis had been associated with the TCA drug on the resident's admission orders and was transcribed the same way it had been written on those orders. They stated monitors for adverse side effects of antidepressant drugs, including TCA drugs, were a standard of care and should be on the MAR for every resident taking those medications and should be documented every shift. They further stated that these monitors were important to determine if a medication was working, but also to determine if the medication was causing unwanted or dangerous side effects. Reference (WAC): 388-97-1060 (3)(k)(i)

Based on interviews and record reviews, the facility failed to ensure pharmacy services were provided to meet the needs of 1 of 3 residents (Resident 1). The failure to ensure a medication was acquired and administered as ordered placed the resident at risk for adverse events related to missed medications.Findings included . On 08/18/2026 at 11:50 AM Resident 1's electronic medical record was reviewed with an admission date of 06/26/2026 and diagnosis of mild intellectual disability (involves limitations in both intellectual function and adaptive behavior), Prader-Willi syndrome (a rare congenital condition characterized by excessive appetite, as well as a variety of other signs including intellectual disability and short stature) and a fracture of their right upper leg.Review of Resident 1's Medication Administration Record (MAR) for August 2026 showed an order for clomipramine (a tricyclic antidepressant drug) to be administered twice daily (AM and PM). The same MAR showed codes indicating the medication was not given on 08/12/2026 (AM and PM), 08/13/2026 (AM and PM), 08/14/2026 (AM and PM), 08/15/2026 (AM and PM), 08/16/2026 (AM and PM), 08/17/2026 (AM and PM), 08/18/2026 (AM and PM) and 08/19/2026 (AM).In an interview on 08/19/2026 at 11:00 AM, Staff C, Resident Care Manager, stated a new prescription for Resident 1's clomipramine had been needed on 08/12/2026. The new prescription was sent to the pharmacy, but the medication did not arrive. On 08/14/2026 they called the pharmacy to find out where the medication was and were told it would be sent. On 08/17/2026 the medication had still not arrived, and Staff C called the pharmacy again and was told the medical provider on the prescription was not correct and had to be changed. The prescription was sent back to the pharmacy the same day. On 08/19/2026 the medication had still not arrived, and Staff C called the pharmacy again and was told the medical provider change had just been processed and the medication would be sent the next day.In an interview with Staff B, Director of Nursing, on 08/19/2026 at 11:10 AM, they stated there had been several occasions lately where resident medications had not arrived from the facility pharmacy when they were expected to arrive. They further stated it was their expectation that if the medication did not arrive timely the nursing staff would call the pharmacy daily, and continue to do so, until the medication arrived. Staff B stated Resident 1 was prescribed the clomipramine for obsessive compulsive type maladaptive behaviors and had been taking the medication twice daily since they had admitted . Staff B stated that abruptly stopping that type of medication could result in physical and psychological withdrawal effects. Reference: (WAC) 388-97-1300 (1)(a)(b)(i)(ii)

Based on observation, interview, and record review, the facility failed to ensure safety risk preventative measures were assessed and implemented for 2 of 3 sampled residents (Residents 18 and 19), reviewed for smoking. In addition, the facility failed to monitor 1 of 1 sampled residents (Resident 4) reviewed for falls. This failure resulted in Resident 4 not being monitored for 72 hours after a multiple unwitnessed falls. These failures placed the residents at risk of fires, injury, health complications and a diminished quality of life.Findings included.<Smoking>The undated No smoking policy documented the facility was smoke-free. Smoking was not allowed at any time, inside or outside the building or on the property by residents, staff or visitors. Smoking supplies were to be kept in a locked container.<Resident 19>The 11/14/2025 Smoking Safety Evaluation documented Resident 19 used tobacco and the only concern checked on the form was balance problems while sitting or standing. The boxes that stated they were unable to light tobacco safely, unable to hold tobacco products safely, unable to extinguish tobacco safely and unable to use ashtray to extinguish tobacco were not checked. Resident 19 originally admitted to the facility on [DATE] and discharged on 12/05/2025. The resident readmitted to the facility on [DATE] and there was no updated Smoking Safety Evaluation completed.The 01/08/2026 comprehensive care plan did not address smoking.The 01/13/2026 admission assessment documented Resident 19 had diagnoses including substance abuse disorder and diabetes. Resident 19 was cognitively intact and made their needs known.In an observation and interview on 02/25/2026 at 10:50 AM, Resident 19 was lying in bed and there was a smoke odor in the room. Resident 19 stated they smoked and went off the premises to do so. Resident 19 stated it was a non-smoking facility so they put their cigarette out and then placed it in their pocket and threw it away in the garbage can.In an observation on 02/26/2026 at 9:21 AM, Resident 19 was lying asleep in bed and had a pack of cigarettes lying on their nightstand.In an observation on 02/28/2026 at 3:09 PM, Resident 19 went outside to smoke. Resident 19 put their cigarette on the wheel of their wheelchair and placed it in their pocket, wheeled themselves to their room and threw the unlit remains of the cigarette away in their garbage can. Resident 19 was observed smoking again on 03/01/2026 at 9:05 AM and the same process was followed.<Resident 18>The 02/11/2026 Smoking Safety Evaluation documented Resident 18 used tobacco and was safe to do so when wearing their glasses.The 02/12/2026 admission assessment documented Resident 18 had diagnoses including emphysema (a progressive lung disease that made it hard to breathe), anxiety and chronic pain.In an interview on 02/25/2026 at 1:57 PM, Resident 18 stated they had quit smoking today. Resident 18 stated when they smoked, they went off the property, put their cigarette out and threw it in the trash can by the front door of the facility or in their personal trashcan in their room. Resident 18 stated they put the cigarette butts in a bottle so they did not stink.In an observation on 02/28/2026 at 3:09 PM, Resident 18 went outside to smoke. It was unknown where Resident 18 discarded their cigarette because a staff member approached them outside and they hid the cigarette between their legs and quickly put it out.In an interview on 03/01/2026 at 1:00 PM, Resident 19 stated they put their cigarettes out on their wheelchair or on the ground and put them in their pocket. Resident 19 stated they pinched the end of their cigarette and made sure it was not hot. Resident 19 stated they knew the cigarette was out because it stayed in their pocket and it took them about five minutes to get back into the facility before they threw it away. Resident 19 stated it was just a cigarette butt (cigarette that has been put out) and that there was no tobacco left in the cigarette. Resident 18 was present in the room for the interview and stated an ashtray or container was not provided to dispose of their cigarettes.During an interview on 03/01/2026 at 2:11 PM, Staff P, Registered Nurse (RN), stated the residents who smoked had to go off the property and disposed of their cigarettes somewhere off the property. Staff P stated it was not appropriate for the residents to bring their cigarettes back into the facility to throw them away because it was against their protocol.In an interview on 03/01/2026 at 2:16 PM, Staff A, Interim Administrator, stated residents who smoked signed a smoking agreement stating the facility was non-smoking. Staff A stated the residents were given a lock box to keep their smoking supplies in and they smoked off the property. Staff A acknowledged there was no receptacle for the residents to dispose of their cigarettes in and no smoking blanket to put out a fire. Staff A stated they were unaware of where the residents were disposing of their cigarettes and stated they should not have put their cigarettes in the garbage can in their rooms and this was important to prevent fires. In an interview on 03/01/2026 at 2:51 PM, Staff N, RN, stated the facility was non-smoking. Staff N stated Resident 19 should have been reassessed for their smoking ability upon their second admission to the facility as they may have had a decline. Staff N acknowledged there were no smoking care plans for the above residents and stated it was important to have a care plan to monitor for possible injury and health complications.<Falls>The 01/12/2026 fall care plan documented Resident 4 was at risk for falls related to poor balance, history of falls and impaired cognition. The fall care plan instructed nursing staff to monitor the resident for 72 hours post falls for pain, bruises, and changes in mental status.The 01/26/2026 annual assessment documented Resident 4 had diagnoses including dementia, anxiety and a stroke. Resident 4 had severe cognitive impairments, required moderate to substantial assistance with activities of daily living and had two or more falls. The facility incident log showed Resident 4 had unwitnessed falls on 08/29/2025, 09/14/2025, 09/26/2025, 12/06/2025, 01/09/2026, and 02/05/2026. An initial neurological assessment was completed after the falls. The neurological assessments sheets showed omissions on 08/29/2025, 09/14/2025, 09/26/2025, 12/06/2025, 01/09/2026 and 02/05/2026. A review of the medical record showed no documentation that Resident 4 had neurological monitoring after the unwitnessed falls occurred. In an interview on 03/02/2026 at 2:39 PM, Staff P, Registered Nurse, stated after an unwitnessed fall occurred, they completed neurological assessments for 72 hours. Staff P stated it was important to do neurological assessments to monitor for a head injury and decrease in level of consciousness.In an interview on 03/03/2026 at 9:22 AM, Staff B, Director of Nursing, stated neurological monitoring was completed after unwitnessed falls and it was important to assess the residents for cognitive changes and potential bleeding in the brain. Staff B acknowledged Resident 4 did not have neurological assessments completed as required. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure medications were given as ordered for 3 of 11 sampled residents (Residents 4, 30, and 48) reviewed for medication administration. This failure resulted in Resident 4 not having their blood pressure medication held when indicated by ordered parameters, and Residents 4, 30, and 48 had doses of medications omitted when medications were unavailable. This failure placed the residents at risk of decline in their medical conditions and decreased quality of life.Findings included. <Resident 30> On 11/26/2025, an order was written for Resident 30 to be given aprimilast, a medication used to treat plaque psoriasis, twice daily. The 12/01/2025 comprehensive admission assessment documented Resident 30 had diagnoses that included paraplegia (paralysis of the lower body) and psoriasis (a rapid build-up of skin cells that caused thick itchy scaly patches on elbows, knees or the trunk). Resident 30 was cognitively intact and was dependent on staff for activities of daily living. The 12/04/2025 skin evaluation documented Resident 30 had two wounds on their right shoulder blade. The type of wound was not documented. The 12/26/2025 skin evaluation documented the resident had a wound on their right upper back that was related to psoriasis. The 01/10/2026 skin evaluation documented the right upper wound was present, and the entire body was flaky and dry. A review of the January 2026 Medication Administration Record (MAR) showed that beginning 01/07/2026 until 01/27/2026, the aprimilast was not administered and a code 6 was entered on the MAR. A key on the MAR identified code 6 to mean the medication was unavailable. On 01/27/2026, and the medication had resumed and Resident 30 began to receive it regularly again as ordered. On 03/02/2026 at 1:19 PM, Resident 30's wound care was observed with Staff D, Infection Prevention Registered Nurse, Staff M, Nursing Assistant (NAC), and Staff F, NAC. When Resident 30 was turned on their left side, they were very vocal regarding how bad their back itched. Their entire back was red and had patches of flaky dried skin throughout. The area was cleansed and towel-dried and small pieces of dead skin came off on the repositioning pads under the resident. Staff D used the towel to gently relieve the itching then applied a protective ointment. On the residents upper mid-back, an old dressing that was saturated with bloody drainage was removed. An irregular shaped wound approximately three finger widths in size began to ooze bloody drainage. Staff D stated the wound was caused by Resident 30's psoriasis and had vastly improved in the amount of bleeding and size. An area of bloody drainage similar in size to a grapefruit had saturated the repositioning pads. The wound required application of a powder to the wound bed to decrease the amount of bleeding. During an interview on 03/03/2026 at 2:44 PM, Staff D stated they were aware the resident had been unable to get aprimilast for a period of time. When medications were unavailable, they called the provider, but Staff D stated there should have been follow up on the medication sooner. Staff D stated it was important for Resident 30 to get the aprimilast because it helped treat their psoriasis. <Resident 4> The 01/26/2026 annual assessment documented Resident 4 had diagnoses that included high blood pressure, delusional disorder (false beliefs) and depression. Resident 4 had severe cognitive impairments and required supervision to maximal assistance with activities of daily living. Resident 4 had the following medication orders: -Amlodipine 10mg (milligram) one tablet daily for high blood pressure, hold for systolic blood pressure (SBP, the top number of the blood pressure that measured the maximum pressure in the arteries when the heart contracted and pumped blood) less than 120 -Carvedilol 25mg twice daily for high blood pressure, hold for SBP less than 120 and apical pulse (a pulse obtained by listening to the heartbeat with a stethoscope) less than 60 -Cetirizine 10mg one tablet daily for allergies -Buspirone 15mg twice daily for anxiety -Lactobacillus one capsule twice daily for supplement -Risperdal 1mg three times a day for delusional disorder -Sucralfate 1gm (gram) three times a day for stomach pain Review of the January 2026 and February 2026 MAR showed Resident 4 received the Amlodipine on 01/07/2026, 01/12/2026, 01/17/2026, 02/14/2026 and 02/15/2026 when the SBP was less than 120. Resident 4 received the Carvedilol on 01/06/2026, 01/07/2026, 01/12/2026, 01/14/2026, 01/17/2026, 01/22/2026, 01/23/2026, 01/25/2026, 01/29/2026, 02/04/2026, 02/06/2026, 02/12/2026, 02/13/2026, 02/14/2026 and 02/15/2026 when the SBP was less than 120. The MAR was blank for the Risperdal and Sucralfate on 01/25/2026 and 02/06/2026, Cetirizine on 02/06/2026, and Buspirone and Lactobacillus on the evening of 02/13/2026. <Resident 48> The 02/17/2026 admission assessment documented Resident 48 had diagnoses that included pain, benign prostatic hyperplasia (BPH, enlargement of the prostate that caused urinary frequency or urgency) and chronic obstructive pulmonary disease (COPD, a group of lung diseases that made it difficult to breathe). The resident was cognitively intact, able to make their needs known and required continuous oxygen. Resident 48 had the following medication orders: -Diclofenac Sodium 2% topical gel apply to affected joints four times a day for pain -Gabapentin 800mg three times a day for nerve pain -Lidoderm patch apply to affected area topically in the morning for pain and remove the affected area topically one time a day, off for 12 hours -Tamsulosin 0.4mg twice daily for BPH -Oxygen 1-4 liters continuously for COPD Review of the February 2026 MAR showed Resident 48 had blanks for oxygen administration during the evening shift on 02/17/2026 and 02/18/2026 and on 02/22/2026 for the day shift. The Lidoderm patch for 02/18/2026 had a code 9 which meant see progress notes. The progress notes stated there was no patch to remove. There was a code 9 for the Lidoderm patch on 02/22/2026 without a progress note. The Gabapentin and Tamsulosin had a code 6 on 02/22/2026 which meant the medication was not available. In an interview on 03/02/2026 at 2:39 PM, Staff P, Registered Nurse, stated when a medication was not available, they would check the electronic emergency medication dispensing machine, if the medication was not in there, they would call the pharmacy and order the medication, and it came on the next delivery. Staff P stated it was important to administer medications as ordered for the residents' health. In an interview on 03/02/2026 at 3:02 PM, Staff B, Director of Nursing, stated their expectation was for the residents to receive their medications as ordered. Staff B stated there were times when they were waiting for the medications to be delivered from pharmacy and nursing staff needed to write a progress note. Staff B stated to re-order medications the nurses went to the resident's MAR and clicked the medication, and it was sent directly to the pharmacy. Staff B stated the medications needed to be ordered timely, so they did not run out. Staff B stated they had a lot of medications available in the electronic emergency medication dispensing machine and were also able to order medications and have them satellited (sent the same day) from the pharmacy. Staff B stated it was important to give the residents their medications as ordered to treat their acute and chronic conditions. In an interview on 03/03/2026 at 9:22 AM, Staff B acknowledged the above medications were not given as ordered and should have been and stated the blood pressure medications should have been held per the parameters. Reference: WAC 388-97-1060(3)(k)(iii)

Based on observation and interview, the facility failed to perform hand hygiene during the meal service for 2 of 2 staff (Staff S and T) and to maintain the cleanliness of 1 of 1 ice machines (ice machine). These failures placed residents at risk for foodborne illnesses.Findings included . <Hand Hygiene>In an observation on 02/28/2026 at 11:53 AM, Staff S, Cook, had a pair of gloves on, plated food and touched the biscuits once on the plate to keep them from falling off. At 11:55 AM Staff S, while wearing the same gloves, moved a cart that other staff had touched and continued to plate food. In an observation on 02/28/2026 at 11:58 AM, Staff S, wearing the same gloves, pushed two other carts and continued to plate food. At 12:10 PM, Staff S used the same gloved hands to open the microwave, cut up chicken strips and touched them with their gloved hands. At 12:14 PM, Staff S, wearing the same gloves touched the blender, placed a plate in the dirty dish area and then added gravy to the blender. At 12:15 AM, Staff S opened a drawer with the same gloved hands and continued plating food without changing their gloves or performing hand hygiene. At 12:17 PM, Staff S, while wearing the same gloves, placed more dishes in the dirty dish area, picked up a meal card and continued plating food. At 12:21 PM, Staff S, wearing the same gloves, moved a cart, opened drawers, and continued plating food without hand hygiene performed throughout the meal service. In an observation on 02/28/2026 at 12:33 PM, Staff T, Dietary Manager, removed their gloves and put a plate of chicken in the microwave without performing hand hygiene. Staff T then removed other chicken from the oven and checked the temperature. Staff T put on a pair of gloves, did not perform hand hygiene, opened the microwave and rechecked the temperature of the chicken. Staff T then closed the microwave, cleaned the thermometer off with a wipe and touched the counter with their gloved hands. At 12:40 PM, Staff T gave the plate to Staff S, wiped the thermometer again with the same gloved hands, touched the counter with gloved hands, then used the tongs to flip the pork in the pan. At 12:44 PM, Staff T continued to wear the same gloves, opened the microwave, heated pork, and touched the pork with their gloved hands while checking the temperature. At 12:49 PM, Staff T removed their gloves, did not perform hand hygiene, and used tongs to turn over the pork in the pan. <Sanitary Environment>In an observation of the kitchen on 02/28/2026 at 1:43 PM, the right side of the ice machine was pushed up against a metal stand where dishes were washed. The filter on that side was unable to be observed.In an interview on 02/28/2026 at 2:18 PM, Staff E, Maintenance Director, stated the ice machine was cleaned monthly and filters were changed every six months. Staff E lifted the top off the ice machine and the filter slats on the right side were covered in dust debris. They stated that dust debris may enter the ice machine and it was important to keep the filteer clean in order to keep the machine cool and for sanitation reasons. Reference: WAC 388-97-1100 (3), 2980

Based on interview and record review, the facility failed to ensure Preadmission Screenings and Resident Reviews (PASRR, a mental disorder and intellectual disabilities screening) were completed prior to admission as required for 3 of 9 sampled residents (Residents 26, 34 and 36) reviewed. Additionally, 1 of 9 sampled residents (Resident 30) reviewed were not referred for an evaluation after a 30-day hospital exemption (when the resident was expected to be at the facility less than 30 days) expired and the resident remained at the facility. These failures placed the residents at risk of not having their behavioral health needs met and possible decline in their mental health.Findings included.<Resident 26>A review of the record showed Resident 26 was admitted on [DATE] and had diagnoses that included depression and anxiety.A PASRR Level I screen (which screens for possible serious mental disorders or intellectual disabilities) dated [DATE], documented Resident 26 had indicators of serious mental illness. A Level II evaluation (an evaluation that is conducted by a state designated authority to determine if the resident meets nursing facility criteria and/or specialized behavioral health or rehabilitative services) was required and was not completed.<Resident 34>A review of the record showed Resident 34 was admitted on [DATE] and had diagnoses that included major depressive disorder.A PASRR Level I Screen dated [DATE] documented Resident 34 had indicators of serious mental illness. A Level II evaluation was required and was not completed.<Resident 36>A review of the record showed Resident 36 was admitted on [DATE] and had diagnoses that included depression and anxiety.Further review of the record showed a PASRR Level I screening was not completed until [DATE], after Resident 36 had been at the facility several weeks.<Resident 30>A review of the record showed Resident 30 was admitted on [DATE] and had a diagnosis of depression.A PASRR Level I screen dated [DATE] showed Resident 30 had indicators of serious mental illness. A Level II evaluation was not indicated. Resident 30 had a 30-day hospital exemption and was expected to be at the facility less than 30 days. Resident 30 remained a resident of the facility as of [DATE], but a new PASRR screening and Level II evaluation had not been completed.During an interview on [DATE] at 1:00 PM, Staff H, Social Services Director, stated they began their employment at the facility in July of 2025. Staff H stated they were not aware the PASRR screens and Level II evaluations were required to be completed before the residents were admitted . Staff H stated it would be important for any recommendations made by the evaluator to be added to a resident's plan of care, and it was important to provide behavioral health services to the residents.Reference: WAC 388-97-1915(1)(2)(a-c)

Based on observation and interview the facility failed to maintain a safe and sanitary environment for staff and residents. 1 of 1 Laundry Rooms (Laundry Room) had significantly large holes from water damage and a majority of the cement floor contained large cracks, chips and had large sections missing. This failure placed staff at risk for potentially avoidable accidents and residents at risk of receiving unsanitary laundry services.Findings included.<Laundry Room>During observation and interview on 03/02/2026 at 12:03 PM, the laundry room was observed with Staff E, Maintenance Director. The designated area in the laundry room where the soiled linens and clothing were placed before being washed, showed a section of the drywall that had a large hole at knee level that was approximately 3 feet long by 2 inch wide. Staff E explained the drywall damage was caused by a water leak that occurred at the beginning of this winter and they had not gotten around to fixing the damaged area. The laundry room cement floor was observed to be significantly damaged, and a majority of the cement had large cracks, chips, and large chunks were missing. The damage to the cement floor created an uneven walking surface and made it difficult for it to be thoroughly sanitized. Staff E explained the laundry room cement had been in disrepair for over a year.During observation and interview on 03/02/2026 at 2:02 PM, the laundry room's damaged cement floor was observed with Staff D, Infection Preventionist. Staff D acknowledged the damaged cement floor was not the best cleanable surface and should be repaired timely.During observation and interview on 03/03/2026 at 12:35 PM, the laundry room's damaged drywall and cement floor was observed with Staff A, Interim Administrator. Staff A acknowledged the area was not safe or sanitary.Reference WAC 388-97-3220 (1)

Based on interview and record review the facility failed to routinely maintain documentation of staff's COVID-19 (a highly contagious viral illness that caused fever, breathing difficulty and potential hospitalization) vaccination status, provide education regarding the risks versus (vs) benefits and offer the COVID-19 vaccine if desired to 4 of 6 sampled staff (Staff I, J, K, and L), reviewed for immunizations. In addition, the facility failed to develop and implement 1 of 1 policies (COVID-19 immunization policy) to educate and offer each staff the COVID-19 vaccine. This failure placed residents and staff at risk of exposure to and illness from COVID-19.Findings included .Review of the facility policy titled, COVID-19 Immunization revised January 2026 showed, each resident was offered the COVID-19 vaccine unless medically contraindicated. Education on the potential risks vs benefits was to be provided and documented in the resident's medical record. The resident was to sign a consent prior to receiving the vaccine, if desired. The policy included no documentation related to the staff COVID-19 vaccination process.According to The Centers for Disease Control and Prevention website, www.cdc.org, Recommended Adult Immunization Schedule 2026 for ages 19 years or older adults age [AGE]-64 years, or adults age [AGE] or older who were unvaccinated for COVID-19, were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of the COVID-19 vaccine unless contraindicated. Those previously vaccinated before the 2024-2025 were recommended to receive 1 or 2 doses (dependent on the vaccine brand) of 2025-2026 COVID-19 vaccine unless contraindicated.<Staff I>In an interview on 03/03/2026 at 9:59 AM, Staff I, Registered Nurse, stated they were unable to recall if the facility offered them the COVID-19 vaccine for the 2025-2026 season.Staff I's COVID-19 vaccination documentation was requested from Staff B, Director of Nursing, on 03/03/2026 at 10:07 AM.Review of Staff I's COVID-19 records included a mobile phone screen shot that showed a timestamp of 10:47 AM that documented Staff I received the COVID-19 vaccine on 01/06/2021. The screen shot was signed and dated 03/03/2026, the same day Staff I's COVID-19 vaccination documentation was requested. Additional review showed a COVID-19 vaccine declination, dated 03/03/2026 containing no documentation Staff I was provided education on the potential risks vs benefits.During an interview on 03/03/2026 at 11:36 AM, Staff A, Interim Administrator, stated they were unsure of the facility process for tracking staff's COVID vaccination status or how education was provided regarding the seasonal COVID-19 vaccine. COVID-19 vaccination documentation for Staff J, K, and L was requested at that time.<Staff J>Review of Staff J's, Nursing Assistant, COVID-19 records showed no documentation of their COVID-19 vaccination status or that they were provided education on the potential risks vs benefits or offered the seasonal COVID-19 vaccination.<Staff K>Review of Staff K's, Registered Nurse, COVID-19 records showed no documentation of their COVID-19 vaccination status or that they were provided education on the potential risks vs benefits or offered the seasonal COVID-19 vaccination.<Staff L> Review of Staff L's, Nursing Assistant, COVID-19 records showed no documentation of their COVID-19 vaccination status or that they were provided education on the potential risks vs benefits or offered the seasonal COVID-19 vaccination.In an interview on 03/03/2026 at 2:00 PM, Staff D, Infection Preventionist, stated they assumed the role in January 2026 and were still developing a process to track, educate, and offer the COVID-19 vaccine to staff. Staff D further stated the facility was able to obtain the COVID-19 vaccine. Staff D acknowledged they offered Staff I the COVID-19 vaccine today, but they declined.In an interview on 03/03/2026 at 2:27 PM, Staff A, Interim Administrator, stated they expected staff COVID-19 vaccine status to be tracked, staff provided education on potential risks vs benefits and offered the seasonal COVID-19 vaccine.The facility policy related to staff COVID-19 vaccines was requested from Staff A and Staff C, Facility Manager, on 03/03/2026 at 2:52 PM, no documentation was provided. Reference WAC 388-97-1620 (2)(b)(i)(ii)

Based on observation, interview and record review, the facility failed to ensure nutritional requirements and assessments were completed timely by the Registered Dietician for 2 of 4 sampled residents (Residents 22 and 30) reviewed for nutritional services. This failure placed the residents at risk of nutritional decline, and unintended health consequences.Findings included .<Resident 22>The 10/28/2025 admission comprehensive assessment documented Resident 22 was admitted on [DATE] and had diagnoses that included obesity, diabetes with foot ulcers, and heart failure. The resident was cognitively intact, was dependent on staff for bed mobility and toileting, and had no pressure ulcers.A review of 10/10/2025 admission orders documented Resident 22 was to have a consistent carbohydrate diet with large protein portions. Staff were to follow the Registered Dietician (RD) recommendations for diet changes and supplements and to give the provider notice of the changes.Further review of the provider orders showed the resident was to take a multi-vitamin, Vitamins C & D as supplements, and required injections of long-acting insulin with additional short-acting insulin injections based on blood sugar readings. The 10/10/2025 Care Plan showed, Resident 22 had a diabetic foot ulcer of the heel, was dependent on staff for mobility, but refused to be repositioned except when toileted. The care plan was updated on 10/13/2025 to show Resident 22 was at nutritional risk related to excessive carbohydrate intake, food and nutrition knowledge deficit, undesirable food choices and obesity. Staff were to administer medications as ordered, reinforce the importance of maintaining the diet ordered, explain and document consequences of poor choices, and monitor the resident's weight weekly. The 11/07/2025 Provider History and Physical showed Resident 22 weighed 455 pounds (lbs) as of 10/30/2025 and had 90 lbs of fluid removed through medication while at the hospital. The plan was to continue weight loss measures, but noted Resident 22 was non-compliant with wound care, dietary measures and their blood sugar was poorly controlled. The initial Dietary Profile, a general recording of cultural or personal likes or dislikes of foods or dietary concerns, was completed on 12/26/2025, which was more than two months after Resident 22 was admitted . The profile documented Resident 22 had no concerns regarding the consistencies of their food and fried eggs were the only food the resident did not like. The 01/21/2026 provider progress note showed staff reported Resident 22 had a 25 lb weight gain since 10/2025, and the provider considered an increase in medication to rid the resident of extra fluid accumulation. The note documented the resident became combative and refused the medication increase.On 02/02/2026 a Registered Dietician Nutrition Assessment documented Resident 22 was reviewed in a Nutrition at Risk (NAR) meeting related to non-pressure related wounds. The form had no entries related to the following: medications, pertinent lab data, estimated caloric, protein, fluid needs, what percentage of meals the resident consumed, if the resident's nutritional needs were met with the current diet and intake, nutritional goals, interventions and the nutritional plan.There were no RD assessments or entries in Resident 22's record prior to 02/02/2026. On 02/26/2026 at 10:47 AM, Resident 22 was observed lying in a bariatric bed (a heavy-duty bed with a reinforced frame that supported higher weight capacity). Resident 22 stated they had spent large amounts of money on food since they had been at the facility because they did not like many of the meals. They stated they had not been seen by the RD. < Resident 30>The 12/01/2025 admission assessment documented Resident 30 was admitted on [DATE] and had diagnoses that included paraplegia (loss of function in the lower half of the body), obesity, and diabetes. Resident 30 was cognitively intact, was dependent on staff for activities of daily living, and had a history of pressure ulcers. The 11/27/2025 Care Plan documented Resident 30 had wounds on their back related to psoriasis and pressure, was at nutritional risk and at risk for dehydration related to obesity, diabetes and paraplegia. Staff were to monitor the resident's weight and notify the provider of significant gain or loss, explain the importance of maintaining the prescribed diet and adequate nutritional intake, and were to provide supplemental protein, vitamins and minerals as ordered to promote wound healing. A review of the 11/26/2025 admission orders showed Resident 30 was to receive a regular diet. Staff were to follow RD recommendations for diet changes and supplements and give the provider notice of the changes. The resident took oral medications to manage their diabetes and psoriasis, and a multi-vitamin and iron supplement. On 01/12/2026, an order was added for the resident to take Prosource (a concentrated protein supplement that aided wound healing) daily.The 12/01/2025 initial Interdisciplinary Team (IDT) meeting note documented only Resident 30 and the Social Services Director were in attendance. The Nutrition Summary sections of the document were left blank. The 12/02/2025 provider History & Physical documented the resident received wound care to the buttocks and sacrum area and the resident's blood sugar was well controlled. The plan for treatment did not mention the resident's nutrition status or make recommendations regarding the resident's obesity.The RD admission Assessment was completed on 01/12/2026, over 6 weeks after the resident was admitted . The assessment documented Resident 30 weighed 309 lbs, averaged 60% intake for most of their meals, and their needs were met with the current diet and intake. The RD recommended Prosource be added daily and the order was added.Review of the February 2026 Medication Administration Record showed that Resident 30 refused the Prosource and received only 4 doses for the month.During an interview on 03/03/2026 at 10:30 AM with Staff B, Director of Nursing, and Staff N, Assistant Director of Nursing, Staff N stated they completed the initial nutrition section in the admission comprehensive assessment. Staff N stated the initial assessment was required to be completed within 14 days of admission. Staff N stated new admissions were to be seen by the RD within the first 14 days. Staff B stated the RD and nursing department conducted NAR meetings each Monday but acknowledged progress notes for NAR were not a substitute for a comprehensive nutrition assessment when a resident was admitted .During an interview on 03/03/2026 at 11:33 AM, Staff U, RD, stated if there was something pressing, they saw a new admission right away; if not, the admission assessment was to be completed within 14 days and was reassessed quarterly, annually or if needed. Staff U stated residents with diabetes, obesity and wounds were complex, and they had missed completing the admission assessments for Residents 22 and 30. Staff U stated they were not aware Resident 30 had been refusing the Prosource and would have made a recommendation to change the Prosource to a different supplement. Staff U acknowledged they were responsible for calculating the caloric, protein and fluid needs for the residents. Reference: WAC 388-97-1160(1)

Based on observation, interview and record review, the facility failed to accurately reconcile all controlled medications in 2 of 2 medication carts (North and South Carts), reviewed for medication storage. In addition, the facility failed to discard expired medication in 1 of 1 medication rooms. This failure placed residents at risk for misappropriation of their controlled medications, placed the facility at increased risk for controlled substance drug diversion and residents receiving medications that may not be effective. Findings included.In an observation of the medication room on 03/01/2026 at 3:31 PM with Staff D, Infection Preventionist, there was a bottle of Lansoprazole (medication used to treat heartburn) in the refrigerator for Resident 49. The medication expired on 02/23/2026. A review of the medication administration records for February 2026 and March 2026 showed Resident 49 received their Lansoprazole. The medication room refrigerator only contained one bottle of Lansoprazole, and it was almost empty.In an interview on 03/01/2026 at 3:42 PM, Staff R, Licensed Practical Nurse, stated they gave Resident 49 the Lansoprazole that morning. Staff R stated expired medication needed to be discarded as the efficacy of the medication may be affected.In an interview on 03/01/2026 at 3:43 PM, Staff D stated they had checked the refrigerator and missed that medication because it was in the side of the door. In an observation on 03/01/2026 at 3:55 PM, the narcotic book on the North Cart showed a discharged resident's Hydrocodone (narcotic medication used to treat pain) was destroyed by Staff I, Registered Nurse, with no documentation a second staff member was present. Staff R stated two staff members were required to destroy narcotics. The South cart narcotic book was observed, and a discharged resident's Pregabalin (analgesic medication used to treat pain) was destroyed by Staff I without a second staff member present. In an interview on 03/02/2026 at 9:59 AM, Staff I stated two nurses had to sign the narcotic book verifying the number of narcotics destroyed. Staff I stated narcotics were destroyed by placing them in Drug Buster (a chemical mixture that broke down and destroyed medication). Staff I stated it was important for two nurses to destroy narcotics to prevent drug diversion. In an interview on 03/02/2026 at 10:02 AM, Staff B, Director of Nursing, stated it was important to discard expired medications as they may lose their effectiveness. Staff B added narcotics were destroyed using Drug Buster by two nurses and it was important to prevent drug diversion. Staff B acknowledged Staff I signed the narcotic sheets by themselves and stated their expectations were to have two nurses present. Reference: WAC 388-97-1300(1)(b)(ii)(c)(ii)-(iv), (a)(4)(e)

Based on observation, interview and record review, the facility failed to ensure nutritional requirements and assessments were completed timely by the Registered Dietician for 2 of 4 sampled residents (Residents 22 and 30) reviewed for nutritional services. This failure placed the residents at risk of nutritional decline and unintended health consequences.Findings included .According to the website www.mayoclinic.org, referenced on 3/10/2026, Post Traumatic Stress Disorder (PTSD) was a mental health condition that could develop after witnessing or being part of an extremely stressful or terrifying event. Symptoms could include flashbacks (feelings that the traumatic event was occurring again), nightmares (repeated disturbing dreams), intrusive thoughts, severe anxiety, avoidance (not wanting to think or talk about a traumatic event), changes in mood or thinking and physical and emotional reactions. These symptoms last more than one month can cause major problems in social or work situations and affect how well a person gets along with others.Review of the undated facility policy titled, Trauma-Informed and Culturally Competent Care documented a resident's experiences were accounted for in the development of a plan to eliminate or mitigate triggers that may cause re-traumatization. The policy listed examples of potential trauma which included experiencing or witnessing physical abuse or domestic violence. The policy documented all residents would be screened for trauma to determine if additional referrals and services were needed. Review of medical record documented Resident 46 admitted to the facility on [DATE] with diagnoses including PTSD, depression and insomnia. Resident 46 was cognitively intact and able to make their needs known. In an observation and interview on 02/25/2026 at 11:02 AM, Resident 46 was lying in bed. Resident 46 stated they had PTSD related to a lifetime of torture, guns and sexual abuse. Resident 46 stated they told staff they could not speak to them in a fast manner because it caused them to have seizures. The resident stated loud noises triggered their seizures that were psychologically induced. Resident 46 stated staff came into their room without making a noise and they could not visualize them out of their right eye and they turned and saw a man standing in their room and it was terrifying. Resident 46 stated they tried to tell a therapist they could not speak fast to them and needed time to respond before being asked the next question.The 02/21/2026, Resident 46's baseline care plan showed the social service section was incomplete. The areas that showed social services provided mental health needs, behavioral concerns, social service goals and depression screening were blank. The 02/23/2026 social service trauma evaluation documented Resident 46 experienced physical and sexual assault, life threatening injury or illness, sudden or violent death, unexpected death by someone close to them, bullying and discrimination. Resident 46 experienced repeated disturbing thoughts, images, dreams, physical reactions, heart pounding, trouble breathing, avoidance of certain situations due to reminders of past events, loss of interest in activities they once enjoyed, felt distant or emotionally numb from other people, felt angry/had angry outbursts, had difficulty concentrating, and felt jumpy, watchful or was easily startled.The 02/26/2026 care plan addressed depression but did not address PTSD, triggers or interventions to prevent re-traumatization. Review of a social service progress note on 02/26/2026 at 10:57 AM, documented the trauma assessment was not completed due to Resident 46 having a migraine and once it was finished their care plan would be updated to include trauma care if needed. In an interview on 03/02/2026 at 12:35 PM, Resident 46 stated the facility had not asked them what their triggers were or what caused them fear or re-traumatization and interventions that helped until today. The resident stated their counselor had moved a year ago and they had been without counseling and their PTSD was extreme. Resident 46 stated they suffered multiple events over a span of 20 years.On 03/02/2026 at 12:41 PM, Staff F, Nursing Assistant, stated they knew what care to provide the residents by looking at their Kardex (part of the plan of care that is generated from information on the care plan) and if a resident had PTSD the information would be there. Staff F pulled up Resident 46's Kardex on the computer and stated there was nothing specific regarding triggers or interventions. Staff F stated there was a sign on Resident 46's door to knock but was unsure why and knocked because of the sign.In an interview on 03/02/2026 at 1:06 PM, Staff P, Registered Nurse, stated they knew what care to provide the resident by looking at the care plan. Staff P stated baseline care plans and comprehensive care plans were formed based off the residents' diagnoses and orders. Staff P stated behaviors and mood were placed on the baseline care plan. Staff P stated it was important to include resident specific needs on the care plans to enable person-centered care. Staff P stated they knew if a resident had PTSD if it was in their care plan and followed the interventions when providing care. Staff P pulled up Resident 46's comprehensive care plan on the computer and stated PTSD was not on their care plan. Staff P stated it was important for PTSD to be on their care plan so they had guidelines on how to properly care for the residents and be aware of ways to handle their triggers and not trigger them. Staff P stated residents with PTSD were offered mental health services upon admission or when exhibiting behaviors.In an interview on 03/02/2026 at 2:16 PM, Staff H, Social Service Director, stated residents were interviewed for mood upon admission and then quarterly. Staff H stated they were working on trauma informed evaluations because they did not create a trauma plan unless there was something severe marked on the evaluation. Staff H stated they were now making a plan if there were any questions answered yes. Staff H stated the trauma evaluations were completed within three days of admission and trauma informed care was placed on the care plan within 24 hours of admission. Staff H stated resident specific triggers needed to be put on the care plan for nursing staff to follow, and it was important that triggers and interventions were put in their care plan to ensure the residents were not triggered and had a PTSD episode. Staff H stated if a resident experienced sexual abuse they would care plan for the resident not to have cares provided by the opposite sex. Staff H stated Resident 46 was startled by unexpected noises, people coming up behind them and their care plan was going to ensure that same sex staff provided cares. Staff H stated Resident 46 should have had interventions placed on their care plan sooner and that they should have completed their plan after Resident 46's migraine to finished the trauma evaluation. In an interview on 03/02/2026 at 2:26 PM, Staff B, Director of Nursing stated it was important to care plan PTSD to prevent the residents from being triggered and to monitor their symptoms. Staff B stated it was their expectation that care plans are completed in a timely manner for residents who have PTSD. Staff B stated they were currently working on this as they were not identifying residents with PTSD and offering them therapy.Reference: WAC 388-97-1620(2)(b)(i)(ii)

Based on observation, interview, and record review, the facility failed to implement preventative measures to prevent avoidable pressure ulcer/pressure injuries (PU/PI) for 1 of 3 sampled residents (Resident 36) reviewed for PU/PI prevention. This failure caused Resident 36 to develop an avoidable deep tissue injury (DTPI, a pressure injury to deep layers of the skin that may resolve without opening or that may open to reveal a serious injury that involved muscle or even bone) on their left heel and created a risk for further skin compromise and decreased quality of life. Findings included.Findings included.The National Pressure Injury Advisory Panel Prevention and Treatment of Pressure Ulcers/Injuries: Quick Reference Guide Fourth Edition. [NAME] Haesler (Ed.). 2026. [cited: 03/09/2026], available from: https://internationalguideline.com, defined a DTPI as a non-blanchable deep red, maroon or purple discoloration of intact or non-intact skin that resulted from intense and/or prolonged pressure and shear forces at the bone-muscle interface. The wound may evolve rapidly to reveal the actual extent of tissue injury or may be resolved without tissue loss. Recommendations for prevention included:- Develop and implement a risk-based prevention plan for individuals identified as being at risk of developing pressure injuries and to consider factors that decrease blood flow to the skin such as diabetes (high blood sugar) or peripheral arterial disease.-Evaluate the skin regularly and develop a structured skin care regimen.-Frequently reposition and elevate the heels of individuals at risk of pressure injuries so the heels are not in contact with support surfaces.<Resident 36>The 01/30/2026 admission Clinical Assessment documented Resident 36 had skin tears on both elbows, an open wound on their left lower extremity, and an open venous ulcer and cellulitis on the right lower extremity. There were no wounds documented regarding the resident's heels.The 01/30/2026 care plan documented Resident 36 had actual impairments on their skin and was at risk for pressure injuries. Staff were instructed to avoid scratching the skin, keep the skin free from excess moisture, encourage good nutrition and hydration, use lotion on dry skin, check skin when assisting with cares, report abnormalities and document the location, size, type of tissue, any drainage and treatment of skin injuries weekly. The resident required the assistance of one staff member to turn and reposition in bed every 2 hours and as necessary.There were no care-planned interventions developed regarding the use of assistive devices or positioning to offload pressure when Resident 36 was in bed.The 02/05/2026 admission assessment documented Resident 36 had diagnoses that included diabetes (high blood sugar) and cellulitis (common infection of the skin) of the left lower leg. Resident 36 was mildly cognitively impaired, required partial assistance from staff for bed mobility, and was at risk for pressure ulcers and used a pressure relieving mattress for their bed. Additionally, a Braden Scale Assessment (a tool used to assess one's risk for developing PU/PI) completed as part of the admission Clinical Assessment on 01/30/2026, documented Resident 36's risk for pressure ulcer development was moderate related to limited sensory perception, occasional moist skin, severely limited ability to walk and change body positions, and probable inadequate food intake.Weekly skin evaluations completed on 02/06/2026, 02/16/2026 and 02/23/2026, documented Resident 36 had warm skin with good elasticity that was normal in color and condition and there were no skin concerns. The area of the evaluations where one could document the location and description of any skin concerns were blank.On 02/27/2026 at 11:32 AM, Resident 36 was observed lying in bed on a pressure reducing mattress positioned on their back. The resident had a sheet over their abdomen and their lower legs and feet were uncovered and visible. The resident's heels were resting on the mattress. The calves and tops of the feet were edematous (tissue that is abnormally swollen with excess fluid) and discolored shades of pink. The calves had large scales of dry skin and small scabbed areas present. The resident's toenails were thick, yellow, and deformed. Some of the toes had scabbed areas at the cuticles or on the tops of the toes, and several nailbeds contained dried dark brown bloody appearing discoloration. The soles and sides of the feet were covered in thick yellow calloused skin that was cracked and peeling and large pieces were on the bed sheet. Resident 36 stated staff were not doing any special treatments for their legs and feet. Additional observations of Resident 36 lying on their back with their heels resting on their mattress were made on 03/01/2026 at 11:57 AM, and 03/02/2026 at12:24 PM. On 03/03/2026 at 12:48 PM, Resident 36 was observed in bed eating their meal. Their heels were resting on their mattress. They stated no one had observed their feet. On 03/03/2026 at 1:40 PM, Resident 36's lower legs and feet were observed with Staff O, Licensed Practical Nurse. The legs and feet remained discolored with large dry skin scales and thick cracked skin. There remained small, scabbed areas on the toes and at the cuticles. Resident 36's feet were lifted off the mattress and were observed. The left heel had a purple discolored area similar in size to a quarter that did not blanch when pressed. The area was not open or draining. Staff O notified Staff N, Assistant Director of Nursing, Registered Nurse. Staff N cleaned the resident's left heel and assessed their heel. They determined the purple area was similar in size to a quarter and was a deep tissue pressure injury. The area was coated with skin prep, a substance that when dried provided a layer of protection to the skin. Staff O retrieved a foam pressure relieving boot (an assistive device that kept the heel suspended off the mattress) and placed it on Resident 36's left foot. The right heel was left resting on the mattress.During an interview on 03/03/2026 at 2:17 PM, Staff N stated they added orders for Resident 36 regarding the pressure injury. Staff N stated they expected staff to check each resident's skin daily when they provided cares. They stated interventions for the resident's heels had been missed. Reference: WAC 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to seek podiatry services (a physician that specialized in care and treatment of the feet) and implement provider orders for a skin ointment for 1 of 3 sampled residents (Resident 36) reviewed for skin conditions. This failure placed the resident at risk for further skin breakdown and unintended health consequences.Findings included.Provider orders on admission, dated 01/29/2026, showed Resident 36 required dressings and wraps to open wounds on both lower legs from their ankles to their knees related to cellulitis and those treatments were completed. Staff were to monitor both lower legs for edema (increased swelling) and notify the provider if a change in the edema was noted. Additionally, there was an order for the resident to be seen by the Podiatrist as needed for mycotic/hypertrophied (thickened, discolored yellow/brown brittle nails caused by fungal infection) toenails. The Podiatrist order was discontinued on 02/06/2026. The 01/30/2026 care plan documented Resident 36 had actual impairments of their skin and was at risk for pressure injuries. Staff were instructed to avoid scratching the skin, keep the skin free from excess moisture, encourage good nutrition and hydration, use lotion on dry skin, check skin when assisting with cares, report abnormalities and document the location, size and treatment of skin injuries weekly.The 01/30/2026 admission Clinical Assessment documented Resident 36 had skin tears on both elbows, an open wound that measured 4.0x5.0x0.1 centimeters (cm) on the front of the left lower leg that looked like rug burn, and an open venous ulcer that measured 5.0x3.0x0.1cm, and cellulitis on the rear of the right lower leg. There was no description of the condition of the skin on the resident's feet.The 02/05/2026 admission assessment documented Resident 36 had diagnoses that included diabetes (high blood sugar) and cellulitis (common infection of the skin) of the left lower leg. Resident 36 was mildly cognitively impaired and required partial assistance from staff for bed mobility.Weekly skin evaluations completed on 02/06/2026, 02/16/2026 and 02/23/2026, documented Resident 36 had warm skin with good elasticity that was normal in color and condition and there were no skin concerns. There were no further measurements of the lower leg wounds identified on the admission assessment and no descriptions of the skin on the resident's feet.The 02/19/2026 physician admission History and Physical documented Resident 36 was pleasant, frail, and was concerned about their legs. The skin on both lower extremities below the knees was dry and irritated. The plan was to continue antibiotics for cellulitis, complete wound care, monitor for improvement, and apply A&D ointment (moisturizer containing lanolin and petrolatum that soothed chapped or cracked skin) for dry skin on the legs. Review of a provider order, dated 02/20/2026, showed staff were to apply two A&D ointment packets to both legs daily for routine dry skin care for four weeks.A review of the February 2026 and March 2026 Medication and Treatment Administration records (MAR/TAR) had no entries or documentation of A&D ointment applications to the resident's legs. A review of the Certified Nursing Assistant (NAC) skin monitor task forms from 01/29/2026 to 02/27/2026 showed three entries dated 01/29/2026, 02/14/2026 and 02/20/2026 that documented Resident 36's toenails needed clipped. All other entries documented the resident's toenails were clean. On 02/27/2026 at 11:32 AM, Resident 36 was observed lying in bed. The resident had a sheet over their abdomen and their lower legs and feet were uncovered and visible. The resident's heels were resting on the mattress. The calves and tops of the feet were edematous (tissue that is abnormally swollen with excess fluid) and discolored shades of pink. The calves had large scales of dry skin and small scabbed areas present. The resident's toenails were thick, yellow, and deformed. Some of the toes had scabbed areas at the cuticles or on the tops of the toes, and several nailbeds contained dried dark brown bloody appearing discoloration. The soles, and sides of the feet were covered in thick yellow calloused skin that was cracked and peeling and large pieces were on the bed sheet. Resident 36 stated they thought the Podiatrist was going to see them but had not visited when they were at the facility the day prior. Resident 36 stated staff were not doing any special treatments or applying any lotion to their legs and feet. On 03/01/2026 at 11:57 AM, Resident 36 was observed lying in bed. They lifted the blanket off their legs. The lower legs and feet continued to be discolored and edematous. The lower legs had large scales of dead skin on them, and the feet had thick calloused cracked skin. The toenails were unchanged from the 02/27/2026 observation. Resident 36 inquired about a visit by the Podiatrist and stated regular lotion had been applied to their legs twice but not A&D ointment. During an interview and observation on 03/02/2026 at 12:24 PM, Staff M, NAC, stated a nursing assistant was able to apply lotion to a resident, but anything medicated was to be applied by the licensed nurse. The supply room was entered, and there were no containers or packets of A&D ointment present. Resident 36's room was entered, and their nightstand contained no A&D ointment, only an anti-fungal cream and a barrier cream. Staff M stated they had never applied any creams or ointments to Resident 36's legs. Resident 36's legs and feet were observed and were in the same condition as observed on 03/01/2026.On 03/03/2026 at 12:48 PM, Resident 36 was observed in bed eating their meal. They stated no one had observed their feet.During an interview on 03/03/2026 at 12:49 PM, Staff H, Social Services Director, stated they were responsible for making Podiatry appointments, but were not aware that Resident 36 requested a podiatrist appointment. Staff H stated the Podiatrist visited the facility quarterly and had just been to the facility but had only seen residents already established. They were unsure why the 02/06/2026 Podiatrist order for Resident 36 had been discontinued. During an interview on 03/03/2026 at 1:17 PM, Staff O, Licensed Practical Nurse, stated they were passing medications that day, and did not remember seeing an order for A&D ointment for Resident 36. The orders were reviewed and confirmed that the A&D ointment was not on the MAR/TAR. The A&D order was corrected at that time. Staff D, Infection Prevention Registered Nurse (RN), was present and stated they saw Resident 36's legs and feet when they first admitted and at that time the resident's legs required dressing changes and had been scabbed and crusty. Staff D stated the resident no longer needed those treatments. Staff O and Staff D stated it was important for Resident 36 to have their feet examined because they had a history of diabetes and were at risk of complications. Staff O added an order for Resident 36 to have diabetic foot checks weekly by a licensed nurse at that time.During an interview on 03/03/2026 at 2:17 PM, Staff N, Assistant Director of Nursing, RN, stated they expected staff to check each resident's skin daily when they provided cares. They stated that after Resident 36's leg dressings were done, other interventions for their feet got missed. They acknowledged that the order for A&D ointment had been missed.Reference: WAC-388-97-1060(1-3)

Based on observation, interview and record review, the facility failed to ensure residents or representatives were provided the opportunity to participate in care planning conferences for 1 of 1 sampled residents (Resident 4) reviewed for care planning. This failure placed the residents at risk for unmet needs and a diminished quality of life. Findings included . An undated facility policy titled Resident Participation - Assessment/Care Plans documented the facility invited residents and their representatives to participate in the development of the resident assessment and care planning conference. The policy instructed the Social Services Director (SSD) or designee to maintain records that showed their efforts to invite the residents and representatives to the care planning conference, including refusal of participation.The 01/26/2026 annual assessment documented Resident 4 had diagnoses including dementia, anxiety and a stroke. Resident 4 had severe cognitive impairments. In an interview on 02/26/2026 at 10:13 AM, Resident 4's guardian (a person appointed by the courts to make decisions for the residents unable to make their own decisions) stated they had never been invited to a care planning conference and had brought it to the facility's attention numerous times.Review of Resident 4's medical record showed the last care conference was held on 01/23/2025, over a year ago. The above findings were shared with Staff H, Social Services Director, on 03/03/2026 at 9:15 AM. Staff H stated care conferences were held quarterly, and Resident 4 did not have a care conference because their cognition was impaired and had no family involved in their care. Staff H stated Resident 4's guardian was not invited to the care conference and stated they should have had a care conference but did not. Staff H stated it was important to have care conferences to discuss possible changes and to have someone advocate for the residents. Staff H acknowledged the last care conference was held on 01/23/2025.In an interview on 03/03/2026 at 9:22 AM, Staff B, Director of Nursing, stated care conferences were important to assess and monitor changes in the residents, discuss any needs the residents may have and discharge plans. Staff B stated family and guardians needed to be invited to the care conferences to be aware of what was happening with the residents and acknowledged Resident 4 had not had a care conference. Reference: WAC 388-97-1020(2)(e)(f)(4)(b)(d)-(f)

Based on observation and interview, the facility failed to provide a clean, comfortable, and homelike environment for 1 of 3 sampled residents (Resident 41), reviewed for environment. This failure placed residents at risk for possible illness from unclean equipment, a lack of dignity, and a decreased quality of life. Findings included .A 02/02/2026 annual assessment documented Resident 41 had diagnoses including heart failure, depression, and hemiplegia (paralysis on one side of the body). Resident 41 had moderate cognitive impairments, required partial to substantial assistance for activities of daily living and used a wheelchair for mobility.In an observation on 02/05/2026 at 10:27 AM, Resident 41 was lying in bed. Resident 41 had a right arm trough (device used to hold the resident's arm in place) on their wheelchair and had an ace wrap like material wrapped around the outer edges and on the brake extender (an addition to the wheelchair brake that made it easier for the resident to use) and a large piece of foam in the center. The ace wrap material was hanging off the edges, was unraveled and was not kept in a manner which allowed it to be cleaned. Similar observations of Resident 41's wheelchair were made on 02/26/2026 at 9:05 AM, 02/27/2026 at 9:47 AM, 02/28/2026 at 9:11 AM, and 03/01/2026 at 9:21 AM.In an interview on 03/02/2026 at 11:20 AM, Staff F, Nursing Assistant, stated they notified maintenance when a resident's equipment was in disrepair. Staff F stated it was important to keep resident equipment clean and in good condition for sanitary reasons. In an interview on 03/02/2026 at 11:28 AM, Staff G, Therapy Director, stated they were notified by staff when there was an issue with a resident's equipment. Staff G stated resident equipment needed to be in good repair and able to be kept clean for infection control. At 11:30 AM that same day, Staff G observed Resident 41's wheelchair and stated a reassessment needed to be completed as it was not a cleanable surface. Staff G stated it looked like the ace wrap like material was added to Resident 41's wheelchair and was not sure if the foam came with the wheelchair. Staff G stated they thought the resident's foam piece had a cover that was able to be cleaned. In an interview on 03/03/2026 at 1:47 PM, Staff A, Interim Administrator, stated their expectation was for resident equipment to be maintained in a sanitary manner and in good repair. Staff A stated it was important for infection control and to prevent hazards. Reference: WAC 388-97-0880

Based on interview and record review, the facility failed to issue notices of potential insurance non-coverage of services for 2 of 3 sampled residents (Residents 30 and 31) reviewed for beneficiary notices. This failure placed the residents at risk of not being informed of their insurance coverage changes and paying for services they no longer wanted. Findings included .<Resident 30>A review of the record showed that Medicare Part A Skilled Services for Resident 30 began on 11/26/2025. The last day of covered services was 01/14/2026. Further record review showed Resident 30 had remained at the facility but was not issued a notice in advance that informed them of any services that may no longer be covered once their insurance coverage ended as required. <Resident 31>A review of the record showed that Medicare Part A Skilled Services for Resident 31 began on 01/02/2026. The last day of covered services was 02/28/2026. Further record review showed Resident 31 remained at the facility but was not issued a notice in advance that informed them of any services that may no longer be covered once their insurance ended as required. When interviewed on 02/28/2026 at 3:00 PM, Staff C, Facility Manager, confirmed Residents 30 and 31 were not provided notice of their benefits when their insurance coverage changed. Staff C stated it was important that the residents received advanced notice of insurance changes so they could be informed of the potential costs associated with the change and make decisions based on that information. Reference: WAC 388-97-0300(1)(e)(5)(6)

Based on interview and record review, the facility failed to ensure 1 of 4 sampled residents (Resident 1) received mental health services. This failure placed residents at risk for worsening mental health status, and diminished quality of life. Findings included: Record review of Resident 1's admission Minimum Data Set (MDS-a tool for implementing standardized assessment and for facilitating care management in nursing homes) showed the resident admitted to the facility on [DATE] with diagnoses of a fractured right hip and schizophrenia (a chronic, severe brain disorder characterized by a loss of contact with reality, involving persistent psychotic symptoms like hallucinations, delusions, and disorganized thinking. Diagnosed typically in late teens to early 30s, it involves significant functional impairment, including negative symptoms (reduced emotion/motivation) and cognitive issues). The same assessment showed the resident had a depression screening completed on [DATE], with a score indicating they experienced moderate depression. Review of Resident 1's care plan, dated [DATE], revised on [DATE], and active through the date of the investigation, showed a focus for paranoid schizophrenia with the resident experiencing delusions, hallucinations and/or paranoia, with interventions to include psych consult as needed. Further record review found a progress note dated [DATE], [Resident 1] expressed [they feel] depressed and scored moderately depressed on PHQ-9 (depression screening tool) assessment. [Resident 1] has made three prior suicide attempts; the last one in 2019 after [their] mother died unexpectedly. [Resident1] denied any suicidal feelings since 2019. Further record review of the resident's progress notes found that the nurses who worked with Resident 1, noted on [DATE] at 1:30 PM that they were anxious and restless, noted on [DATE] at 2:46 PM that they were anxious and restless, noted on [DATE] at 2:24 PM that they were anxious, noted on [DATE] at 11:41 AM that they were anxious, noted on [DATE] that they were anxious, noted on [DATE] at 1:28 PM that they were anxious, noted on [DATE] at 1:54 PM that they were anxious and very restless., noted on [DATE] at 1:09 PM that they were anxious. Review of Resident 1's electronic medical record showed the resident had not been seen by any mental health services during their stay at the facility. During an interview with Resident 1, on [DATE] at 1:10 PM, they stated that they had struggled with schizophrenia since they were in their teen years and had been in and out of facilities and hospitals most of their life. They further stated that they were worried about what was going to happen when they discharged from the facility, had had some traumatic life experiences and thought they would benefit from mental health services, and that none had been offered to them during their stay at the facility. Resident 1 further stated that this was unusual as they had always been offered and participated in mental health services during their stays at various medical institutions. During an interview on [DATE] at 1:50 PM PM, Staff C, Social Services Director, stated that Resident 1 had expressed interest in having mental health services and they thought they would benefit from such services, but that the facility was not contracted with any mental health provider and there were no mental health services in the building. They further stated that they had brought this to the attention of the facility administration on multiple occasions but that nothing had changed. During an interview on [DATE] at 2:10 PM with Staff B, Director of Nursing, they stated that they had recently taken the position and that there were no mental health services at the facility. During an interview on [DATE] at 2:20 PM with Staff A, Administrator, they stated that they were aware that there were no mental health services at the facility. They further stated that they had been looking for a provider who would work with the facility but, had so far, been unable to establish a mental health provider to work with the facilities residents when needed. No Associated WAC

Based on observation, interview, and record review the facility failed to keep Potentially Hazardous Foods (PHFs) within safe temperature guidelines during an extended power outage during which the facility backup generator did not power kitchen appliances, PHFs that were above safe temperatures were not discarded and served above safe temperature PHFs (specifically milk) to residents during two subsequent meal services for 33 of 33 residents. These failures placed residents at risk of serious food borne illness and constituted immediate jeopardy (IJ).The facility failed to consistently monitor refrigerator and food temperatures during a power outage on 12/17/2025 from 5:10 AM until 3:30 PM, with kitchen staff identifying one refrigerator temperature above 45 degrees Fahrenheit (F) after lunch service on 12/17/2025 and then failed to discard PHFs and then served PHFs to residents during dinner service 12/17/2025, and again on 12/18/2025 for breakfast. The Department intervened to prevent service of PHFs to residents for lunch service on 12/18/2025. An IJ was identified on 12/18/2025. The facility was notified of the noncompliance on 12/18/2025 at 2:28 PM, regarding, F812, Food Storage, when the complaint investigator interviewed kitchen staff who reported elevated refrigerator temperatures during an extended power outage (greater than four hours) affecting refrigerators containing PHFs. The IJ was determined to begin on 12/17/2025. The immediate jeopardy was removed on 12/18/2025 at 4:30 PM, as confirmed by an onsite verification by the complaint investigator on 12/22/2025. The Facility removed the IJ by discarding affected PHFs, education to food service staff, implementing safety protocols for food temperature monitoring, and updating policies and procedures.Findings included.Review of the facility policy titled Food receiving and storage revised November 2022, documented PHFs, like milk, are to be stored at or below 41 F, further review showed no documentation for when and how to discard the PHFs, like milk, when out of acceptable storage temperatures.Review of Department of Health Food Safety guidelines, https://www.foodsafety.gov/food-safety-charts/food-safety-during-power-outage, showed that milk held at or above 40 degrees F for more than two hours should be discarded after a power outage. Review of Department of Health power outage guidance for food establishments, https://doh.wa.gov/emergencies/be-prepared-be-safe/power-outages/food-establishment-poweroutage, showed that upon power restoration, cold PHFs should have an internal temperature taken prior to use, with the zone of safety being at or below 45 degrees F as long as the foods were below 41 degrees F when the power went out. Further direction from the same source showed that during a power outage of more than four hours, cold PHFs that were found to be above 46 degrees F should be discarded.In an interview with Staff D, Cook, on 12/18/2025 at 11:20 AM, they stated that they were the primary cook on 12/17/2025 and started work at 5:00 AM that morning and were just beginning daily work when there was a power outage beginning at 5:10 AM during which time the backup generator did not power the kitchen appliances. They stated that they notified their boss, Staff C, Dietary Manager, about the power outage and were told to try and keep the appliance doors closed to keep food cold. They further stated that during breakfast and lunch the kitchen staff had to open the door for one refrigerator which contained milk and juices and that after lunch Staff D noticed the inside thermometer of the refrigerator with the milk and juice was above 45 degrees F. They stated that they then texted Staff C for directions. Document review showed a text sent from Staff D to Staff C on 12/17/2025 that stated the refrigerator temperature was 50 degrees F. They further stated that they ended their shift at 2:00 PM that day and did not take, document or notice any further temperature readings for the kitchen appliances. They further stated that no food was discarded from the refrigerator during or after the outage and that on 12/18/2025 for breakfast the milk that was in the refrigerator during the power outage was served to resident's and was still in the refrigerator during the interview. During an interview with Staff F, Dietary Aide, on 12/18/2025 at 11:35 AM, they stated that they and Staff D worked together on the day shift on 12/17/2025, starting at 5:00 AM. They stated that shortly after they started work there was a power outage. They stated that during the power outage they were told to keep the kitchen appliance doors closed as the backup generator did not power the refrigerators or freezer. They stated that they did not take any temperatures of foods inside the refrigerators or freezer during the power outage and was not sure if temperatures in the refrigerator and freezer stayed within acceptable limits. In an observation of the refrigerator identified by Staff D as being above acceptable temperature limits for PHFs, on 12/18/2025 at 11:22 AM, there was milk present with dates written on the containers showing prior to 12/16/2025. Record Review of the Refrigerator/Freezer Temperature logs for December 2025 showed the refrigerator temperature for the identified refrigerator as 40 degrees F on the morning (identified as Temp AM freezer/fridge). The line for recording temperatures for 12/17/2025 was lined out with red marker and a comment was written, OO service, under the section titled If temperature is outside of specification, what was done about it? For the second refrigerator a line was drawn through 12/17/2025 and a comment was written in, OO service. The freezer temperature log for 12/17/2025 for AM was recorded as -10. The line for recording temperatures for 12/17/2025 was lined out with red marker and a comment was written, OO service. In an interview with Staff C, Dietary Manager, on 12/18/2025 at 11:40 AM, they stated that they were aware of the power outage on 12/17/2025 that started at 5:10 AM and ended at 3:30 PM. They further stated that they came to work that day at 2:00 PM and they did not check the temperatures in the refrigerators or freezer during their shift or when the power came back on. They stated that Staff D had texted them that the temperature in the one refrigerator was 50 degrees F and there was milk in that refrigerator. They stated that they served the milk for dinner that night and for breakfast on 12/18/2025. They stated that they knew what items were in the refrigerators because they dated them when they came into the building. They further stated that no food was thrown away after the power outage, that they did notice that the freezer items were frozen solid after the power outage, and they thought the other refrigerator was in the safe zone because the door was not opened. In an interview with Staff A, Administrator In Training, on 12/18/2025 at 10:45 AM, they stated that the generator in the building was old and did not provide power for the kitchen or heat during the power outage on 12/17/2025. They stated that a new generator was on the list of things to purchase after a change in ownership in June of 2025. At 1:00 PM on 12/18/2025, Staff A, stated that they were not aware that temperatures in the one refrigerator were above 45 degrees F on 12/17/2025 and that no food was discarded. In an Interview with Staff B, Director of Nursing, on 12/18/2025 at 2:25PM, they stated that they would monitor residents in the building for signs or symptoms of food borne illness. During an interview on 12/22/2025 at 12:10 PM they stated that all residents in the building on 12/17/2025 were monitored for signs and symptoms of food borne illness and no concerns were identified. Reference: WAC 388-97-1100 (3)

Based on observation, interview and record review the facility failed to ensure Preadmission Screening and Resident Reviews (PASRR, a two-part screening assessment; Level I was determined by the presence of a Severe Mental Illness [SMI] or Developmental Disability. If present, a Level II evaluation by a specialized evaluator would then occur where it would be determined if nursing home placement was the appropriate level of care, and if behavioral health or other community services were recommended for the given resident. A Level I, and if indicated, a Level II PASRR was required to be completed prior to nursing home admission) were completed correctly and PASSR Level II were referred for evaluation prior to admission as required for 1of 6 sample residents (Resident 1). This failure placed residents at risk of behavioral health needs not being met and diminished quality of life.Findings included . A record review showed Resident 1 was admitted to the facility on [DATE] and had diagnoses that included major depressive disorder (a serious mental health condition characterized by persistent sadness, loss of interest in activities, changes in sleep/appetite, fatigue and difficulty concentrating, significantly impacting daily life) and vascular dementia (a decline in memory thinking and judgement due to reduced blood flow to the brain). Further record review for Resident 1 found A PASRR Level I, dated 06/12/2025, that documented Resident 1 had a mental health diagnosis, did not have a diagnosis of dementia, and indicated the resident needed a Level II evaluation referral required for SMI. A PASRR Level II Initial Psychiatric Evaluation Summary, the detailed findings of the Level II evaluation, was not included in Resident 1's record. Further record review found a SLUMS examination (St. Louis University Mental Status - A set of questions used to assess adults for orientation, memory, attention and executive function), completed after Resident 1 admitted to the facility on [DATE], indicating the resident had severely impaired cognition. No behavioral health provider notes were found in Resident 1's record. During an interview on 12/16/2025 at 12:45 PM, Resident 1 was in their room finishing their lunch. They stated that they believed the year was 1974 and they had just been discharged from the military to the current facility. They further stated that they did take medication for depression daily. During an interview on 12/22/2025 at 1:20 PM, Staff J, Admissions Director, stated that Resident 1 had not been admitted to the facility through the standard process. They stated that the resident had transferred from a sister facility after the directors of the current facility and the former facility had discussed the transfer. They further stated that prior to a resident being admitted they, or social services, would review the resident record to see if a PASRR Level I had been completed and if a Level II was needed. They stated that if a Level II was needed it should occur prior to the resident having admitted to the facility. Staff J further stated that they did not review this resident's records prior to admission and were not aware that the resident had a need for a Level II to be completed, nor that the Level I was filled out incorrectly. During an interview on 12/22/2025 at 2:05 PM, Staff A, Administrator In Training, stated that they had accepted the transfer of Resident 1 from their sister facility. They further stated that they were not aware that prior to their admission to the facility, Resident 1 had a Level I PASRR which indicated they needed a PASRR Level II completed, and they had not reviewed the resident's PASRR prior to admission. Reference: WAC 388-97-1915(4)

Based on observation, interviews and record review, the facility failed to perform a thorough and timely assessment of a lower leg injury at the time a fall occurred, and evaluate for changes in condition for 1 of 3 residents (Resident 1) reviewed for assessments. Resident 1 experienced harm when they developed a necrotic (death of cells or tissue), contagious (spreads from one person to another), wound infection which extended their stay in the facility, and a delay in treatment. Findings included . <Resident 1> Review of the medical record showed Resident 1 was admitted to the facility on [DATE] from the hospital with diagnoses which included right hip fracture with surgical repair and dementia. Review of Resident 1's comprehensive assessment, dated 04/24/2024, showed they were rarely/never understood and had short and long term memory issues. Review of Resident 1's plan of care, revised on 04/23/2024, showed they required extensive staff assistance with turning in bed, personal hygiene, dressing, transfers; and was totally dependent on staff for eating and toilet use. In addition, the plan of care showed Resident 1 was at risk for falls. Nursing Progress Note (NPN), dated 05/06/2024, showed Staff F, Director of Nursing, was first made aware on 05/06/2024 (five days later) that Resident 1 had a fall on 05/01/2024 after getting out of their wheelchair (w/c) hitting the outside of their left lower leg on the footrest of the w/c potentially causing a skin tear. Review of PNs showed there was no documentation Resident 1 fell in the facility with injury prior to 05/06/2024. The skin tear on 05/06/2024 measured 1.0 by 0.5 by 0.2 inches with the deepest open area on the top, then proceeded to get shallower on the bottom of the skin tear. Review of a NPN, dated 05/10/2024 at 4:27 PM, showed the resident's representative was notified Resident 1 would be discharging back to their Adult Family Home (AFH) on 05/13/2024. An assessment of the wound that day (05/10/2024 at 5:57 PM) showed the left lower leg skin tear had increased redness, pain, swelling with slough (dead cells that accumulated in the wound which contributed to a delay in wound healing and prevented an accurate assessment) in 100% of the wound bed. The wound had increased in size to 2.0 by 1.0 by 0.5 inches. The on-call provider was notified (four days after the NPN documenting the injury) and gave orders to culture the wound, antibiotic therapy every eight hours for five days, and begin treatment using Aquacel (wound dressing). Later at 6:23 PM on 05/10/2024 showed there was wound drainage. Review of a NPN, dated 05/13/2024 at 10:37 AM, showed staff called Resident 1's AFH stating the culture obtained from the resident's wound showed a contagious, bacterial infection resistant to many antibiotics. The decision was made for Resident 1 to continue residing in the facility until the infection resolved as they shared a room with their spouse at the AFH to avoid spreading the bacteria. Review of a NPN, dated 05/17/2024 at 5:38 PM, showed Resident 1's left leg wound appeared to be still active. The Provider was notified and orders received to start a new antibiotic for seven days. An observation of Resident 1's left lower leg wound on 05/20/2024 at 2:30 PM with Staff A, Licensed Practical Nurse/Infection Control Preventionist, showed the area surrounding the small open area was bright red in color. The open area had some depth and slough was observed in the wound. On 05/24/2024 at 1:15 PM, Staff B, Administrator, stated at the exit conference, they had witnessed Resident 1's fall on 05/01/2024 in which they hit their head on the floor. Staff B stated Resident 1's skin tear injury to their outer, left, lower leg truly happened at the time of the fall when their left leg got caught on the footrest of their w/c. The resident was wearing sweatpants at the time of the fall. On 05/21/2024 at 4:40 PM, Staff C, Registered Nurse (RN), stated they were not involved with Resident 1 at the time of their fall on 05/01/2024 as they were on the other side of the facility. Staff C stated Staff D, RN, informed them they had taken care of the fall incident so Staff C stated they assumed Staff D had documented the incident in the PNs on 05/01/2024 and initiated an investigation. On 05/22/2024 at 8:20 AM, Staff D, stated the fall on 05/01/2024 occurred between 5:30 PM to 6:00 PM. Staff D stated they were in their office at the time of the fall and immediately went to assess Resident 1. Vital signs were taken and the back of the resident's head was assessed for injuries. Staff C was not present at the time of Resident 1's fall. Staff D stated they did not take over the care of the resident, but rather waited for Staff C to come. On 05/20/2024 at 2:44 PM, Staff A, stated Staff B had witnessed Resident 1's fall on 05/01/2024. Staff A stated that despite staff being aware of the resident's fall on 05/01/2024 and subsequent injury there was no documentation in the resident's medical record until 05/06/2024. At that time Staff E, Nursing Assistant, brought Resident 1 to Staff A's office so the left lower leg wound could be assessed. Staff A stated when they first saw Resident 1's open wound on 05/06/2024 there was redness and swelling from the left outer ankle to the left outer knee. At the time of the exit conference with the facility on 05/24/2024 at 1:15 PM, Resident 1 was observed as a resident in the facility despite initial plans to be discharged on [DATE]. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 08/19/2023.

Based on interview and record review, the facility failed to ensure staff provided adequate pain management for 1 of 4 residents (1), who requested narcotic pain medication and did not receive it timely. Failure to provide narcotic pain medication resulted in harm to Resident 1 due to the severity of pain and emotional distress. Findings included . Review of Resident 1's medical record showed they were admitted to the facility on [DATE] from the hospital, following surgery on 01/27/2023 for a left patellar tendon avulsion (a condition in which the tendon separates from the kneecap - caused by an overload to the tendon during activity in an individual at risk). Ten days prior to that surgery, the resident had a total left knee replacement surgery. Other diagnoses for the resident included anxiety. Review of hospital medication records showed between 01/27/2023 to 01/30/2023 Vicodin (narcotic pain medication) one to two tablets were ordered, to be administered to the resident every four hours as needed for pain. The order was written by the physician at 4:14 PM on 01/27/2023. Two tablets of the narcotic pain medication were administered as follows: 01/27/2023 - 5:49 PM, 9:42 PM 01/28/2023 - 5:51 AM, 11:10 AM, 5:35 PM, and 9:40 PM 01/29/2023 - 2:57 AM, 8:23 AM, 12:44 PM, 5:10 PM, 9:24 PM 01/30/2023 - 1:26 AM, 8:06 AM, 12:08 PM Review of the 01/30/2023 Nursing Admission Assessment, documented by Staff A, Licensed Practical Nurse (LPN), at 1:55 PM showed the resident had no cognitive deficits, required limited assistance with one staff for turning in bed, and extensive assistance with one staff for dressing, bathing, toilet use, transfers and walking. The assessment showed the resident had limited weight bearing to the left lower leg, due to the recent surgery, and that the resident had significant pain. An immobilizer (a removable device used to maintain stability of the leg) was in place to the left lower leg, with ice packs to be applied. Review of the resident's 01/30/2023 admission physician orders showed Vicodin one to two tablets was ordered to be administered every four hours as needed for pain, due to the recent surgery. In addition, Tylenol was prescribed to be administered every four hours as needed for pain. Review of the resident's pain assessment, completed on 01/30/2023 at 2:23 PM, showed the resident's pain level was 10 out of 10 (on a pain scale where zero would be no pain and 10 would be extreme pain) to their left knee, and both elbows. The resident stated pain medication and ice lessened the pain and movement made it worse. Review of a progress notes on 01/30/2023 at 2:35 PM showed the resident arrived to the facility via non-emergent ambulance and had significant pain complaints, chronic in nature, and had an immobilizer to their left lower leg with ice packs. Later that same day at 6:59 PM, the resident left the facility against medical advice (AMA). Per the notes, the resident was having complaints of pain and the wait time of being able to receive the medication was too long. Staff explained to the resident if they could wait 30 more minutes staff would be able to administer the narcotic pain medication. Review of the resident's Medication Administration Record for January 2023 showed they received Vicodin at 5:52 PM on 01/30/2023 (five hours and 44 minutes since their last dose). No Tylenol was administered to the resident. Review of the Edit Census Entry for the resident showed they left the facility AMA at 6:00 PM on 01/30/2023. Review of a 01/30/2023 facility Grievance Form, showed the resident was informed by staff the facility had no prescriptions for pain medication. The report, signed by Staff B, Administrator, showed the administration of the pain medication was delayed as the pharmacy needed an authorization code to enable staff to remove the medication from the facility emergency kit. The resident stated during a telephone interview on 02/09/2023 at 11:13 AM, that they had emergency surgery to their ruptured left kneecap on 01/27/2023, and were given narcotic pain medication on 01/30/2023 around noon by hospital staff, prior to their discharge. The resident stated they arrived at the facility at approximately 1:30 PM and were assisted to the bathroom at 2:00 PM. At 4:00 PM the same day, the resident requested pain medication and was informed by Staff D, Registered Nurse, the facility did not have their pain medication. The resident then called their spouse and stated staff was not giving them pain medication. At approximately 4:40 PM, the resident stated they also phoned another family member of the medication problem. Resident 1 stated they were in tears at that time due to the pain. Per the resident, Staff D again responded to the resident's request for pain medication stating it still was not available. At 5:00 PM the same day, the resident called their surgeon and told them no pain medication was being administered by staff. The resident stated they were frequently using their call light to request pain medication. When staff responded to the resident's call light at 5:45 PM, they were told that as soon as the resident's spouse arrived to the facility the resident was leaving to go home. Again, the resident was informed pain medication was not available. Shortly after 6:00 PM the resident was given the narcotic pain medication. They stated their pain level was beyond a 10 at that time. During the telephone interview, the resident stated staff lacked respect and empathy for them, and it was a horrible experience. During a telephone interview on 02/13/2023 at 2:42 PM with the resident's surgeon, they verified the resident had telephoned them on 01/30/2023. They stated the resident was very unhappy and had not gotten their pain medication. Staff C, Licensed Practical Nurse, stated on 02/13/2023 at 10:15 AM, that the resident was asking for pain medication almost every hour since they admitted to the facility. Staff C stated an access code was needed from the pharmacy which would allow staff to obtain the medication from the facility emergency kit. Staff C stated the resident's pain level ranged from 6 out of 10 to 10 out of 10, and at one point the resident stated they were in so much pain they were unable to move. Staff D stated on 02/13/2023 at 1:45 PM, that the resident wanted pain medication but staff was unable to provide the medication, as they did not have the pharmacy access code to obtain the narcotic from the facility emergency kit. The resident was stating their pain level was 10 out of 10. Staff D stated the resident refused to take the ordered Tylenol due to their liver enzymes. Staff D stated they talked with the resident three to four times regarding the inability to administer the pain medication. Staff received the needed access code from the pharmacy just prior to the resident leaving the facility AMA. Staff D stated the resident repeatedly stated, I can't do this, I can't be here. Reference (WAC) 388-97-1060(1)

Based on interview and record review, the facility failed to provide the necessary care and services following the administration of insulin to 1 of 3 sample residents (2), reviewed for diabetic medication management. This failed practice resulted in actual harm to Resident 2, who despite being a new admission and brittle diabetic (having severe swings in blood glucose levels), was not assessed by staff for 3.5 hours following the administration of insulin. As a result, the resident required emergent transport to the hospital, due to severe [CONDITION(S)] (low blood glucose levels - which is classified as a diabetic emergency). Findings included . Resident 2. Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's comprehensive assessment, dated 12/26/2021, showed they had no impairments with thinking, reasoning, or remembering. Review of 12/29/2021 progress notes by Staff B, Registered Nurse, showed at 7:30 AM the resident was responsive, awake and talking, with a blood glucose (BG) of 167 (normal BG levels in residents with diabetes before meals is 70-130). At 7:45 AM, [MEDICATION(S)] (a long-acting insulin that works up to 24 hours to lower BG levels) and Novolog insulin (a fast-acting insulin that works to lower BG levels, which requires the person receiving it to eat within five to ten minutes of administration) were given. Medication information regarding insulin showed that dangerously low BG levels (if not treated) could lead to unconsciousness, seizures, or even death. Per the record, at 11:30 AM the same day, Staff B went to assess the resident for noon treatments and diabetic care, and found them asleep, unable to arouse, and emergency services was notified. The resident's BG was significantly low at 38. Per the note, there was foam observed coming out of the left side of the resident's mouth. The resident was assisted with a packet of sugar in the gums, which improved the BG level slightly. Emergency medical personnel arrived, and transported the resident to the emergency room . Review of the hospital Discharge Summary, dated 12/30/2021, showed the resident received the standard and expected dose of insulin before breakfast on 12/29/2021, however they did not eat breakfast. Staff checked on the resident four hours later before the noon meal, and they were unresponsive. The resident's BG levels were in the 30-50 range. The document also showed the resident's admitting diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's BG levels (checked three times daily before meals) between 12/25-28/2021 showed the following: 12/25/2021 - 223, 223 12/26/2021 - 422, 306, 150 12/27/2021 - 102, 65, 375 12/28/2021 - 237, 172, 213 Staff B stated during an interview on 01/10/2022 at 9:30 AM, that the resident's BG levels were unstable from the time they were admitted to the facility (on 12/23/2021). Staff B stated they administered insulin ([MEDICATION(S)] and Novolog) to the resident at approximately 7:50 AM on 12/29/2021, and the breakfast tray was delivered at 8:00 AM. Per Staff B, when checking on the resident later that morning, they were unresponsive and foaming at the mouth. Staff B stated they observed the resident had not eaten any of the breakfast meal, and the resident's BG level was 38 at that time. Per Staff B, the resident's teeth were slightly clenched together, so sugar was placed in the resident's gums, emergency medical services was notified, and they arrived to the facility five minutes after being called. Staff C, Nursing Assistant (NA), stated at 7:10 PM on 01/10/2022, that they had brought in the resident's breakfast tray at approximately 8:30 AM on 12/29/2021, the resident was annoyed about being woken up, and was drowsy. At 9:30 AM Staff C peeked into the resident's room, and observed they were sleeping as their eyes were closed. Staff C stated the resident had not eaten any of their breakfast. Staff C stated they did not go into the resident's room, and were unaware the resident had received insulin prior to the breakfast meal. Staff C did not report their observations to licensed nursing staff. Staff D, Director of Nursing, stated on 01/10/2022 at 9:08 AM, that the resident was a very brittle diabetic. Per Staff D, the resident would always keep their door closed, and would usually use the call light for staff assistance. Staff D stated during a telephone interview on 01/18/2022 at 1:16 PM, that the licensed nurse should be directing nursing assistants to check on the diabetic residents to observe them and what they have eaten following meals, and report back to them. Staff D stated the resident had a care plan, accessible to nursing assistant staff, that specified the resident was a diabetic, and what to observe for. Resident 2 stated during an interview on 01/10/2022 at 1:50 PM, that the only thing they remembered the morning of 12/29/2021 was getting insulin, and then the breakfast meal tray being served. Per the resident, the meal tray got delivered at approximately the same time each day. Resident 2 stated they fell asleep and was out cold .in a diabetic coma (life threatening diabetes complication that causes unresponsiveness - usually caused by severe [CONDITION(S)]). Resident 2 stated, They should have checked on me, that's why I'm here [in the facility]. Reference (WAC) 388-97-1060(1) This is a repeat deficiency from the Statement of Deficiencies dated 09/10/2021.

Based on observation, interview, and record review, the facility failed to maintain an infection control program that included adequate, timely surveillance, oversight, and follow up of staff COVID-19 testing (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death). Failure to ensure all unvaccinated staff completed the required COVID-19 testing, put all residents at risk for COVID infection when staff continued to work with unknown COVID status. In addition, the facility failed to ensure infection control interventions intended to mitigate the risk for spread of communicable diseases, including COVID-19, were consistently implemented. Failure to ensure staff was properly wearing and/or sanitizing personal protective equipment (PPE), and screening for COVID-19 symptoms placed all residents at risk for exposure to a highly infectious disease. On 09/03/2021 at 3:09 PM, the facility's administrator was notified of an Immediate Jeopardy at F880, related to lack of adequate surveillance of staff COVID-19 testing. On 09/07/2021 at 3:35 PM, the IJ immediacy was removed when the facility provided documentation that a system of tracking COVID tests was implemented, and all staff and residents were tested for COVID-19 using proper procedures. Findings included . During an entrance conference on 08/26/2021 10:09 AM Staff B, Director of Nursing, stated the facility census was 23, and the facility did not have any staff or residents with confirmed or suspected COVID-19. Per Staff B, all but one resident and 67.6% of staff were vaccinated for COVID-19. COVID-19 TESTING In an interview on 09/03/2021 at 11:14 AM with Staff B, Director of Nursing, Staff C, Staff Development Coordinator, and Staff D, Nurse Consultant, Staff C stated that the facility was testing staff twice a week related to the county's high COVID-19 positivity rates. Staff C added the twice weekly testing had started the week before, and prior to that it was being done weekly. Per Staff C, both she and Staff B did all the testing. Per review of staff COVID-19 testing records provided by the facility, 12 staff that were either unvaccinated, or whose vaccine status was unknown, required testing based on the facility's county positivity rates. The documentation showed for the week of 8/22/2021 - 08/28/2021, four unvaccinated/vaccine status unknown staff (Staff E, Staff F, Staff G, Staff H) did not get tested as required, and were working at the facility during that time period. The documentation further showed for the week starting 08/29/2021, two unvaccinated/vaccine status unknown staff members (Staff E, and Staff I) who had worked that week, had not been tested as required. In a follow-up interview that same day, Staff B stated the facility was in a transition period, and Staff C was in the process of taking over as the facility's infection control nurse. Staff B stated that she had been tracking staff COVID-19 tests by printing out one list of staff names, and then entering the date they were tested . Per Staff B, testing was currently being documented on individual forms, with one form per staff member, instead of the master list they had been using. In an interview on 09/03/2021 at 3:09 PM, the testing documentation for the weeks 8/02/2021 and 08/28/2021 were reviewed with Staff A, Administrator. Staff A confirmed the missing tests for Staff E, F,G,H and I, as well as the fact that each of the staff members had continued to work despite not having been tested , and therefore potentially working while COVID-19 positive. PPE USE According to the Center for Disease Control (CDC) Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, updated on 03/29/2021, all healthcare workers should wear well-fitting source control (masks) that cover the mouth and nose at all times, while they are in the healthcare facility. In an observation on 08/30/2021 at 3:27 PM, Staff J, Registered Nurse, was observed walking into a resident room. Staff J wore a surgical mask that was fitted below the nose which covered only their mouth, as well as a face shield. Staff J then exited the room and entered a second resident room, still with their face mask fitted below the nose. The same day, Staff J was observed at 3:31 PM entering a resident's room to deliver medications, and at 3:58 PM at the nursing station, with the face mask fitted below the nose. Staff J had on a face shield while in the resident's room, but removed it while sitting at the nursing station where no residents or other staff were present. On 08/31/2021 at 1:57 PM and on 09/07/2021 at 2:26 PM, Staff J was observed at the nursing station, with a face shield on and their face mask once again fitted below the nose. On 09/02/2021 at 9:49 AM, observations of Staff J's surgical mask usage were shared with Staff B. Staff B stated that surgical masks should be worn over both the nose and mouth. On 09/07/2021 at 2:39 PM, Staff J was observed entering Resident 22 room to deliver medications without donning gown or gloves. The resident had a quarantine sign outside their room. Upon exiting the room Staff J did not sanitize or change their face shield. Similar observations of Staff J entering quarantine resident rooms without gown or gloves, and exiting without cleaning or sanitizing their face shield were made at 2:53 PM and 2:55 PM. In an interview on 09/03/2021 at 11:14 AM with Staff C, and Staff D, Staff C stated staff were to wear respirators (a device designed to protect the wearer from inhaling hazardous materials/airborne microorganisms), face shields, gowns and gloves in quarantine rooms. Per Staff C, the face shields were to be sanitized with a bleach wipe after exiting the room. In an interview on 09/07/2021 at 2:27 PM with Staff A, Staff B, Staff L, Regional Infection Control Preventionist, and Staff M, Regional Vice President, Staff B stated if staff came in contact with a resident or their belongings in a quarantine room, they needed to have on a gown and gloves. Staff B added face shields were to be sanitized with the provided wipes after leaving a quarantine room, if the staff member was closer than six feet to the resident while in the room. In an interview on 09/07/2021 at 4:00 PM, Staff J was asked about the PPE requirements for quarantine rooms. Staff J stated if they were going to have close contact with a resident in a quarantine room, they needed to wear a gown and gloves. Staff J defined close contact as touching a resident. When asked about face shields, Staff J stated they were unsure whether they needed to be sanitized after exiting a quarantine room, or just at the end of the day. Staff J added they would probably sanitize their face shield if they came in contact with the body fluids of a resident in quarantine. In an observation on 09/08/2021 from 9:17 AM - 9:34 AM, Staff I, Nursing Assistant/Housekeeping, was observed cleaning two different resident rooms that had quarantine signs posted outside. Staff I did not wear a gown while in either room. In an interview on 09/08/2021 at 9:46 AM, Staff H, Housekeeping Supervisor, stated housekeeping staff were to wear respirators, face shields, gowns, and gloves when cleaning a quarantine room. STAFF COVID-19 SCREENING Per the facility's Screening Visitors & Employees During the COVID-19 Pandemic policy, dated 10/27/2020, staff were to complete a screening tool prior to being allowed to enter the facility. Review of staff COVID-19 Screening Tools, and the work schedule provided by the facility for the week of 08/15/2021 - 08/21/2021 showed the following: Staff I worked on 08/17/2021 and 08/19/2021, but no COVID-19 screening documentation was provided. Staff J worked on 08/16/2021, but no COVID-19 screening documentation was provided. Staff E and Staff F worked on 08/21/2021, but no COVID-19 screening documentation was provided. In an interview on 09/03/2021 at 11:14 AM, Staff C stated that staff completed COVID-19 screening forms upon entry to the facility, at either the front or back doors. Staff C added that the facility audited the forms daily. In an interview on 09/09/2021 at 10:05 AM with Staff C and Staff D, missing COVID-19 screening documentation for Staff E, Staff F, Staff I, and Staff J was reviewed. Any additional documentation was requested. None was provided. Reference: WAC 388-97-1320 (1)(a)(2)(a)(b)(c)

Based on interview and record review, the facility failed to conduct COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death)specimen collection, per Centers for Disease Control and Prevention (CDC) guidance and manufacturer's instructions. Failure to collect nasal specimens from both nostrils increased the likelihood for inaccurate test results, and failure to identify COVID positive residents and staff. In addition, the facility failed to perform COVID-19 testing per the county positivity rate as required. These failures had the potential to affect all residents who resided in the facility. On 09/03/2021 at 3:09 PM, the facility's Administrator was notified that an Immediate Jeopardy at F886 was identified, related to improper collection of nasal specimens for staff COVID-19 testing. On 09/07/2021 at 3:35 PM, the IJ immediacy was removed when the facility provided documentation that staff was educated regarding proper testing techniques, and all staff and residents were tested for COVID-19 using proper procedures. Findings included . IMPROPER TESTING PROCEDURES Per review of the CDC Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19) (https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html) both nostrils are to be sampled with the same swab when collecting an anterior nasal specimen. Review of BinaxNOW COVID-19 Ag Card[Abbott],(a rapid [MEDICATION(S)] test that detects certain virus proteins) instructions showed, .Specimen Collection and handling .Inadequate specimen collection or improper sample handling/storage/transport may yield erroneous results. Refer to CDC interim guidelines for collecting .Nasal Swab .To collect a nasal swab sample, carefully insert the swab into the nostril exhibiting the most visible drainage, or the nostril that is most congested if drainage is not visible .Rotate the swab 5 times or more against the nasal wall then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril . According to the facility's undated guidelines/policy titled COVID [MEDICATION(S)] Testing - Binax NOW Card (Abbott), nasal specimens were to be collected from both nostrils, using the same swab. In an interview on 09/03/2021 at 11:14 AM with Staff B, Director of Nursing, Staff C, Staff Development Coordinator, and Staff D, Nurse Consultant, Staff C stated that she helped Staff B with performing COVID-19 testing. Staff C further stated that she usually collected the nasal specimen from one nostril only. When asked if she had received training regarding the proper procedures for performing COVID-19 testing, Staff C stated that she had observed how to do it at her previous place of employment. Staff C added that Staff B did most of the testing, and she only tested three to four staff a week. Both Staff B and Staff D confirmed nasal specimens needed to be collected from both nostrils. TESTING FREQUENCY Per review of Centers for Medicare and Medicaid Services (CMS) Quality Safety Oversight memo (QSO) 20-38-NH, revised 04/27/2021, facilities were required to perform routine COVID-19 testing of unvaccinated staff based on the facility's county positivity rate (as reported on data.cms.gov) for the prior week. Review of county positivity rates (data.cms.gov) showed the county rate was greater than 10% for each week the month of August 2021, which meant unvaccinated staff were to be tested twice weekly. According to staff COVID-19 testing documentation provided by the facility, staff were tested on ce the week of 08/22/2021 - 08/28/2021. In an interview on 09/03/2021 at 11:14 AM, Staff C stated the facility had increased their staff COVID-19 testing to twice weekly when the county turned red about a week ago. In an interview on 09/09/2021 at 12:13 PM Staff A, Administrator, confirmed the facility had not been referring to the correct data to determine frequency of testing, and had only been testing staff weekly until the week of 08/29/2021. Reference WAC 388-97-1780(1)

Based on observation, interview and record review, the facility failed to consistently monitor weights for 7 of 7 sample residents (13, 74, 7, 22, 19, 21, 174) reviewed for weight loss. In addition, the facility failed to timely implement recommended nutritional interventions for 5 of 7 sample residents (74, 13, 21, 22, 174) reviewed for weight loss. These failures resulted in significant weight loss and harm for Resident 74, and placed the other six residents at risk for preventable, unplanned weight loss. Findings included . According to the facility's Skin and Nutrition Outline policy, dated 10/2019, residents were to be weighed weekly for the first four weeks, and then monthly after that. RESIDENT 74 According to a 08/16/2021 admission assessment, Resident 74 admitted to the facility on [DATE], was severely cognitively impaired and required supervision and assistance of one staff member for eating. A nutrition care plan, initiated on 08/11/2021 and revised on 08/15/2021, directed staff to provide assistance with dining and weigh the resident at the same time of day weekly for four weeks and until stable, then monthly. Goals included no significant weight loss of 5% in 30 days, or 10% in 180 days. Review of a 08/18/2021 Nutrition Evaluation completed by Staff N, Registered Dietician, showed the resident's admission weight was 172 pounds (lbs.), and their ideal body weight was 162 lbs. Recommendations included [MEDICATION(S)] (calorie dense protein supplement) daily for seven days, Ensure (nutrition supplement drink) daily, and weekly weights for four weeks and until stable. Review of the resident's weight record showed the resident weighed 172 lbs. on 08/10/2021. The next documented weight was 152.4 lbs. on 09/02/2021 (more than 3 weeks later), which indicated the resident had an 11% weight loss. Per review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Per review of meal monitors for 08/10/2021 - 09/06/2021, the resident consumed less than half of their meals 52% of the time. A 09/03/2021 nutrition progress note acknowledged the resident's 11% weight loss and attributed it to insufficient nutritional intake related to the resident's dementia and behaviors. Recommendations for [MEDICATION(S)] and Ensure were again made, also with a request to update the resident's weight as soon as possible to confirm weight changes and rule out errors. Further review of the record showed the resident weighed 160 lbs. on 09/08/2021, and the 09/02/2021of 152.4 lbs. was struck out as an error. The new weight represented a 7% loss in the month the resident had been at the facility. On 09/01/2021 from 8:37 AM - 8:56 AM, the resident was observed in the dining room eating breakfast. Staff was sitting next to the resident encouraging, cueing, and assisting the resident to eat. The resident consumed approximately 25% of the meal. In an interview on 09/02/2021 at 11:44 AM, Staff N stated she came to the facility weekly. Per Staff N, residents were generally weighed daily for three days after admission, weekly for four weeks, and then at least monthly if stable. Staff N stated that if residents had weight loss, a nutrition progress note would be written and recommendations given to the Director of Nursing. Staff N added if the recommendation was just a supplement she would often cue the order up in the electronic ordering system so the staff just had to confirm the order. Per Staff N, a list of residents who needed an updated weight was periodically given to the Director of Nursing, which was last done on 08/19/2021. In an interview on 09/03/2021 at 9:23 AM, Staff O, Registered Nurse, stated both Ensure and [MEDICATION(S)] were given by the nurses and documented in the MAR. Per Staff O Resident 74 was not currently receiving any supplements, but had when they first admitted , although no documentation of that was found. In an interview on 09/03/2021 at 9:36 AM, Staff K, Nursing Assistant, stated the resident did not eat much and needed assistance when first admitted , but was currently eating pretty well. Staff K added staff mostly just kept an eye on the resident during meals because they sometimes spilled their beverages. In an interview on 09/03/2021 at 9:53 AM, Staff B, Director of Nursing, stated Staff N had provided a list of residents who needed updated weights on 08/19/2021. Staff B added the nursing assistants were responsible for weighing the residents and documenting them in the electronic health record. Per review of the resident's September 2021 MAR, [MEDICATION(S)] and Ensure were finally started on 09/04/2021 (two and a half weeks after originally recommended). In an interview on 09/08/2021 at 10:24 AM Resident 74's weight loss, missing weights, and unimplemented nutrition recommendations were reviewed with Staff A, Administrator, Staff B, and Staff D, Nurse Consultant. Staff B stated the resident had recently seen their primary care provider and the family was considering hospice care. RESIDENT 13 According to a 07/13/2021 admission assessment, Resident 13 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 07/21/2021 Nutrition Evaluation completed by Staff N, Registered Dietician, showed the resident had slight [CONDITION(S)] (accumulation of excess fluids in body tissues) to both legs upon admission. Per the evaluation, the resident had a current weight of 115.6 lbs, an ideal weight of 140 lbs., and reported a usual weight of 102 lbs. Staff N recommended a supplement twice a day between meals, and requested an updated weight as weight loss was anticipated secondary to the resident's [CONDITION(S)]. Per review of the resident's physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A nutrition care plan, initiated on 07/12/2021 and revised on 07/16/2021, directed staff to monitor the resident's intake each meal, assist the resident with meal set up, and weigh the resident per facility protocol. Goals included no significant weight loss of 5% in 30 days or 10% in 180 days. No mention of the resident's [CONDITION(S)] or anticipated weight loss was found in any care plan for the resident. Per a 07/10/2021 Admission Evaluation, the resident had no [CONDITION(S)] present. A progress noted dated 07/14/2021 referenced the resident being on alert for right knee swelling. Per a second note on 07/20/2021, the resident's knee was still swollen, but did not include information on the degree of swelling. No further mention of [CONDITION(S)] or swelling was found. Additionally, no documentation related to the monitoring of [CONDITION(S)]/swelling was found in the resident's record. Review of the resident's weight record on 09/07/2021 showed an admission weight of 115.6 pounds done on 07/10/2021. The resident was not weighed again until 09/02/2021 (2 months later) and showed the resident was now 96.4 lbs. (16.6% loss). A 09/03/2021 nutrition progress note identified the resident's weight loss. Per the note, the resident appeared to be eating sufficient calories, and while some weight loss had been anticipated due to [CONDITION(S)], the resident was now below her usual weight and weight gain would be beneficial. Recommendations were to reweigh the resident to confirm the loss and Ensure daily to promote weight gain. Further review of the resident's record showed the resident was re-weighed on 09/09/2021 and now weighed 102.2 lbs., which represented an 11.6% weight loss in the two months the resident had been at the facility. The 09/02/2021 weight of 96.4 lbs. was struck out as an error. In an interview on 09/03/2021 at 9:36 AM, Staff K, Nursing Assistant, stated the resident was independent with eating and generally ate most of each meal. Resident 13's missing weights, weight loss, and unimplemented nutrition recommendations were reviewed with Staff B, Director of Nursing, in an interview on 09/09/2021 at 11:16 AM. Staff B confirmed the 07/21/2021 order for Ensure had not been entered into the system. Staff B added that the resident had a swollen knee and leg when they admitted to the facility. RESIDENT 21 According to a 08/11/2021 Nutrition Evaluation, Resident 21 admitted to the facility on [DATE] and weighed 117.7 lbs. at that time. Recommendations were for an updated weight as soon as possible and a daily supplement drink. Review of the resident's weight record showed only the 08/05/2021 admission weight. No other weights were documented prior to the resident's discharge from the facility on 09/02/2021 (four weeks later) an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 09/08/2021 at 10:24 AM with Staff A, Administrator, and Staff B, Director of Nursing, Resident 21's supplement order and lack of weights was reviewed. Staff A confirmed documentation of the supplement should be on the MAR. Staff A added the resident had been eating well while in the facility and she had discussed the lack of need for the supplement with the dietician. Staff A further stated she thought there were more weights that were done and she would look for them. None were provided. RESIDENT 22 According to a 08/20/2021 admission assessment, Resident 22 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 08/18/2021 Nutritional Evaluation showed the resident's ideal body weight was 140 lbs., but currently weighed 124 lbs. Recommendations included updating the resident's weight as soon as possible. Review of a 08/27/2021 progress note written by Staff N, Registered Dietician, showed the resident had developed some skin breakdown. Per the note, Staff N recommended offering a liquid protein supplement daily for two weeks and requested an updated weight as soon as possible. The resident's weight record showed the 08/13/2021 admission weight of 124 lbs. The next weight was not done until 09/02/2021 (three weeks later) and showed the resident now weighed 145.2 lbs. That weight was later stricken out as an error, and a weight of 123.8 lbs. was added on 09/10/2021. Review of the resident's August - September 2021 MARs showed the liquid protein supplement recommended by the dietician was not started until 09/22/2021, two weeks after the recommendation was made. In an interview on 09/08/2021 at 10:24 AM, the missing weights for Resident 22 were reviewed with Staff A, Director of Nursing. Staff A stated that Staff N had given her a list of residents who needed updated weights a couple of weeks prior that she had then passed off to the nursing staff. Staff A confirmed the order for liquid protein had not yet been completed. RESIDENT 174 A 08/27/2021 Nutrition Evaluation showed Resident 174 admitted to the facility on [DATE] and weighed 125 lbs. on 08/18/2021. Per the evaluation, the resident's ideal body weight was 135 lbs., and the resident reported that her usual weight was 128 lbs. Recommendations included updating the resident's weight as soon as possible and for a Vitamin B-12 supplement to be given daily. Review of the resident's weight record on 09/07/2021 showed no weights documented, other that the admission weight on 08/18/2021 three weeks earlier. A weight of 119.6 lbs. was later added for 09/07/2021, and then struck out as an error and replaced with 122.6 lbs. on 09/10/2021. Review of the resident's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 09/01/2021 at 9:21 AM, Staff F, Nursing Assistant, stated that the resident did not eat a lot and frequently only wanted fruit or yogurt for lunch. In an interview on 09/08/2021 at 10:24 AM with Staff A, Administrator, and Staff B, Director of Nursing, Staff B confirmed the recommendation for Vitamin B-12 had not been implemented. Staff B added the resident had been weighed on 08/20/201 and was 119.6 pounds, although a weight on that date was not found in the resident's record. RESIDENT 7 According to a 09/01/2021 significant change assessment, Resident 7 admitted to the facility on [DATE], had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Per a 06/16/2021 nutrition assessment, the resident had some weight loss since admission, but their weight had been recently trending back up again. Recommendations included updating the resident's weight as soon as possible. Review of the resident's weight record on 09/07/2021 showed the most recent weight (124.8 lbs.) was done on 05/25/2021, and no new weight since the recommendation (almost three months prior). In an interview on 09/03/2021 at 9:53 AM Resident 7's weight record was reviewed with Staff B, Director of Nursing, and Staff D, Nurse Consultant. Staff B stated the facility weighed the resident the day before, but it appeared to be an inaccurate weight and she would look into it. Further review of the record showed a weight of 135.4 lbs. (over 10 lb. gain) was documented on 09/07/2021. RESIDENT 19 Per review of a 08/02/2021 Nutrition Evaluation, Resident 19 admitted to the facility on [DATE] and weighed 147.2 lbs. at that time, but had an ideal body weight of 150 lbs., and a usual body weight of 160 lbs. Recommendations included updating the resident's weight weekly. Review of the resident's weight record showed the original weight done on 07/27/2021. No other weights were documented through 09/01/2021 when the resident discharged (five weeks later). In an interview on 09/08/2021 at 9:50 AM, Staff F, Nursing Assistant, stated the resident had not required assistance with eating and generally ate 100% of the meal. In an interview on 09/08/2021 at 10:24 AM with Staff A, Administrator, and Staff B, Director of Nursing, the lack of weights for Resident 19 was reviewed. Staff A confirmed the policy was for residents to be weighed weekly for at least the first four weeks. Reference: WAC 388-97-1060 (3)(h)

Based on interview and record review, the facility failed to provide adequate supervision and monitoring following the administration of an [MEDICATION NAME] medication (a medication generally used to treat allergies [REDACTED].#1), reviewed for falls. This resulted in actual harm to Resident #1, who became excessively drowsy, fell forward from her wheelchair, and sustained a neck fracture and laceration to the forehead. Findings included . Resident #1. Review of the resident's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 02/09/19 comprehensive nursing assessment showed Resident #1 required limited one-person assistance with toileting, transfers, personal hygiene, eating, and ambulating in hallways. The assessment also showed she was cognitively intact. Resident #1's plan of care, revised on 02/22/19, showed she was at risk for falls due to balance/gait problems, and was unaware of safety needs. Review of a 02/27/19 progress notes showed [MEDICATION NAME] HCL (an [MEDICATION NAME] medication - also a sedative used to treat anxiety and tension - with adverse side effects including drowsiness, blurred vision, and dizziness) was ordered by the physician, to be administered to Resident #1 at bedtime for seven days for interstitial [MEDICATION NAME] (a chronic condition causing bladder pressure, and bladder and/or pelvic pain). The physician's orders [REDACTED].#1, the dosage could then be increased after the initial seven days. Resident #1's Medication Administration Record [REDACTED]. A review of the record, from the time the medication was first ordered, until the fall on 03/02/19 (see below) showed no side effect monitoring of the medication for Resident #1, who had a history of [REDACTED]. The nursing notes and care plan during that time were also reviewed, and showed no additional interventions, related to the use of a new medication, or any increased monitoring by nursing staff. Review of a facility investigation report showed on 03/02/19 at 4:28 AM, Resident #1 was yelling for help. Upon opening the door to the room (as it had been closed) staff found Resident #1 lying on the floor in front of her wheelchair, next to the bed. The report showed there was a laceration to her forehead, with a large amount of bleeding, and a significant amount of blood on the floor and bed frame. The investigation also showed the resident complained of severe neck pain with palpation (touch). Resident #1 stated she fell asleep in her wheelchair after returning from the bathroom. The investigation showed Resident #1 had a history of [REDACTED]. She was transferred to the emergency room immediately following the fall. Review of hospital records, dated 03/02/19, showed Resident #1 sustained a neck fracture and [MEDICAL CONDITION] from the fall. She returned to the facility later the same day with a cervical collar (a medical device used to support a person's neck), which she had to wear at all times. Per telephone interview on 03/24/19 at 8:13 PM with Resident #1, relative to the above fall, she stated that she was sleeping in her wheelchair facing the bed when she fell , hitting her head on the bed frame. The resident stated, I think it was the [MEDICATION NAME] I was taking for [MEDICATION NAME], as I got really sleepy. The medication knocked me on my butt .couldn't keep my eyes open, knocked me out. The resident stated that she put her head down and leaned forward in the wheelchair, causing her to fall and hit the floor real hard. In a telephone interview on 03/24/19 at 7:40 PM, Staff A, Registered Nurse, stated that Resident #1 often self-transferred to the bathroom, and sometimes wanted to stay up in her wheelchair. Staff A stated that at times Resident #1 would close the door to her room, due to the noise. Staff A also stated Resident #1 had a history of [REDACTED]. Staff A stated that she was unaware Resident #1 had started on the antihistaimine medication three days prior to the fall, and confirmed no additional supervision of Resident #1 had been implemented. Staff B, Director of Nursing, stated on 03/22/19 at 3:10 PM, regarding the [MEDICATION NAME] medication, we think that may have caused her (Resident #1's) fall. Staff B verified staff had not monitored for side effects of the [MEDICATION NAME] medication. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure two of three sample residents (#21, 9), reviewed for anticoagulant (blood thinning) medication, received adequate monitoring to ensure appropriate administration of the high risk medication. This failure resulted in Immediate Jeopardy for Resident #21, who did not receive timely laboratory testing and medication administration, which placed the resident at serious risk for blood clots and/or bleeding. Additionally, the facility failed to ensure one of two residents (#19), reviewed for use of an opiate antagonist medication (medication that blocks the effects of opioid/narcotic medications), received adequate monitoring to ensure appropriate use of the medication. This failure placed Resident #19 at risk for receiving an unnecessary medication. The State Agency informed the facility on 07/25/18 at 4:45 p.m. of the Immediate Jeopardy situation. The facility provided education to nursing staff, and performed an audit of all residents receiving anticoagulant medications. They then ensured there were no outstanding laboratory results, or ongoing medication errors. The jeopardy was removed as of 07/26/18 at 10:00 a.m. Findings included: 1. Per his admission assessment dated [DATE], Resident #21 admitted to the facility on [DATE], and had diagnoses which included [MEDICAL CONDITION] flutter (an irregularity in the way the heart pumps), which increased the resident's chance for blood clots. The assessment showed he received the anticoagulant [MEDICATION NAME] (a blood thinning medication), daily. According to the Nursing (YEAR) Drug Handbook (Wolters Kluwer, (YEAR), p.1495) Black Box Warning, [MEDICATION NAME] can cause major or fatal bleeding .Regularly monitor INR in all patients. Laboratory monitoring (INR) is used to determine if the anticoagulant medication is providing a therapeutic effect (evidenced by an INR within the goal range for the resident), and is required to ensure the resident is not receiving excessive doses, which would increase the risk of bleeding, or a lower than therapeutic dose, increasing the risk of blood clots. Resident #21's laboratory results, Medication Administration Records (MARs), progress notes, care plan and physician orders [REDACTED]. The INR was drawn on 06/27/18, with a result of 1.5 (below the resident's goal therapeutic range of 2.0 to 3.0, as listed on his care plan, dated 07/17/18). Review of a physician's orders [REDACTED].) daily, and re-check the INR on 06/29/18. However, the MAR indicated [REDACTED]. Review of the progress notes dated 06/29/18 through 07/13/18 did not address why the resident had not had a repeat INR, as ordered. Per a progress note dated 07/09/18, the resident experienced increased swelling and pain to his right shoulder, with a bruise surrounding the shoulder. Follow-up progress notes from 07/10/18 through 07/14/18 showed swelling to the shoulder was still present. The notes did not indicate nursing staff identified the joint swelling and bruising as a potential adverse side effect to his [MEDICATION NAME] (i.e. potential bleeding). Review of a pharmacist recommendation form, dated 07/12/18, showed Resident #21 did not have a current order for an INR in the record, and the pharmacist recommended the facility follow up with an INR on the next convenient lab day. A physician's orders [REDACTED]. On 07/14/18, there was a note that the resident declined to go to the hospital for an INR check. There were no notes on 07/15/18, related to the order to get the INR checked. On 07/16/18, a progress note showed the resident had the INR drawn, but it needed to be re-checked, due to a problem with the sample. On 07/17/18, the progress note showed his INR was 4.5, above the goal range. The note indicated the facility received a new order to hold the medication for two days, and then re-check the INR on 07/19/18. Per the MAR, the [MEDICATION NAME] was signed as given on 07/17/18, however, during an interview with Staff H, Licensed Practical Nurse, on 07/25/18 at 4:07 p.m., he stated he signed the medication in error, stating he remembered that he did not give it. A progress note from 07/19/18 showed the INR was critically high, (above the quantified measures, so no INR value was assigned), and the [MEDICATION NAME] was to continue being held, and an INR re-checked on 07/22/18. Review of the progress notes showed from 07/19/18, the resident began having swelling and pain to his right knee. Per the notes, nursing staff did not assess the swelling and/or pain as a potential adverse side effect of blood thinning medication. In an observation and interview on 07/22/18 at 4:10 p.m., Resident #21 was seated in a wheelchair in his room, with ice applied to his right knee with an elastic wrap. When asked about his knee, the resident said he was having pain, swelling, and decreased movement in the joint. Review of the record showed no available results for an INR on 07/22/18. The progress notes for 07/22/18 did not address the INR that was due on that date, and per the MAR, [MEDICATION NAME] 2.5 mg was given, without the INR level being drawn, as ordered. A progress note, dated 07/23/18, showed the INR would be checked at the doctor's office that day. Review of a physician's visit note dated 07/23/18 showed Resident #21 was seen at the clinic on that date, and was evaluated for swelling in his knee and shoulder. The note showed the resident had a persistently high INR, and documented I want to make sure that he is not having hemarthrosis (hemarthrosis is bleeding into a joint cavity, which can occur with [MEDICATION NAME] use, in the presence of elevated INRs). A physician's orders [REDACTED]. Review of the care plan for Resident #21 on 07/26/18 showed an anticoagulant care plan was not initiated until 07/17/18, and appropriate interventions, such as monitor for s/sx (signs/symptoms) of bleeding/bruising (every) shift, and PT-INR labs as ordered by MD, were not initiated until 07/25/18. Review of the Medication Administration Record [REDACTED]. In an interview on 07/25/18 at 11:24 a.m., Staff D, Registered Nurse, described the typical process for residents who received [MEDICATION NAME]. She stated when there was an INR drawn, they updated a log sheet, and entered new orders by 5:00 p.m. on the day the lab was checked, because that was the time they gave the medication. She stated when the nurse entered the new order for [MEDICATION NAME], he or she should also enter the next lab draw date in the MAR. When asked if Resident #21 had his INR checked on 06/29/18 as ordered, or any time before 07/17/18, Staff D could not locate any results. When asked about the MAR indicated [REDACTED]. She stated she needed to look into it more. In an interview on 07/25/18 at 2:19 p.m., Staff B, Interim Director of Nursing, was asked whether there had been any recent focus in the facility on the accuracy of administering [MEDICATION NAME], or checking INRs in a timely manner. She stated she had just started in the position of Director of Nursing, and was not aware of any focus on that issue. In an interview on 07/25/18 at 2:32 p.m., Staff F, MDS (assessment) Registered Nurse was asked whether there had been any recent education to nurses in the facility, related to monitoring INRs, or administering [MEDICATION NAME]. He stated he was not aware they had an issue with that. In an interview on 07/26/18 at 4:07 p.m., Collateral Contact Staff O, Clinic Licensed Practical Nurse, was asked whether the facility had notified the physician that the INR was not checked on 07/22/18, or that the [MEDICATION NAME] was documented as given on that date. She stated they had not been notified on 7/22/18 that the INR was not drawn, or that the medication was given. She stated the physician and clinic staff were very concerned about the INR staying high, and that they could not determine a cause. She stated they were unsure at this time whether the joint swelling was related to the resident's high INR, and stated they were performing more tests. In a follow-up interview on 07/26/18 at 4:22 p.m., Staff O stated the physician's office had not received any communication from the facility regarding INR levels, between 06/27/18 and 07/17/18. Failure to ensure Resident #21's laboratory results were obtained timely, as ordered, and new orders were obtained as necessary before the next dose of [MEDICATION NAME] was given, placed Resident #21 at risk for potentially dangerous bleeding. Delay of monitoring the resident's INR levels, without appropriate corrective actions in place prior to the survey, reflected an ineffective system to safely administer the high risk medication. 2. According to the admission comprehensive assessment, dated 05/28/18, Resident #9 was cognitively intact for daily decision-making, had diagnosed including: [DIAGNOSES REDACTED]. The admitting physician orders, dated 05/14/18, showed an order for [REDACTED]. A subsequent review of the (MONTH) and (MONTH) (YEAR) monthly physician orders [REDACTED]. Review of the record did not show the facility had developed an initial baseline care plan, or developed a comprehensive care plan, related to the use of an anticoagulant medication, appropriate interventions, such as monitoring for bleeding/bruising, and labs as ordered by the physician. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. In an interview on 07/25/18 at 2:59 p.m., Staff H, Licensed Practical Nurse, was asked why the resident was receiving [MEDICATION NAME]. He stated he had heard it could have been for an irregular heart rhythm, but he was not sure, as a [DIAGNOSES REDACTED]. In an interview on 07/26/18 at 7:52 a.m., Staff B, Director of Nursing, stated she realized the resident did not have a [DIAGNOSES REDACTED]. In an interview on 07/26/18 at 8:06 a.m., Staff J, Pharmacist, was asked if during her medication reviews, she had requested a diagnosis, from the physician, for the use of the [MEDICATION NAME]; she stated no. 3. Per the facility assessment, Resident #19 readmitted to the facility on [DATE], and had multiple medical diagnoses which included digestive problems, diabetes, and obesity. Review of the current physician orders [REDACTED].), and currently received one tablet daily. There was no diagnoses for the use of the medication. According to the Nursing 2009 Drug Handbook (Wolters Kluwer, 2009, .1360) showed the medication blocked the effects of opioids/narcotics, and was also used in combating alcohol dependence. Adverse reactions included dizziness, nausea, [MEDICAL CONDITION], constipation, and liver toxicity. In an interview on 07/25/18 at 9:40 am, Resident #19, when asked why she received the Naltrexone, stated she thought it was to curb her appetite, and stated the drug no longer worked, as she had gained several pounds. In an interview on 07/26/18 at 8:30 a.m., Staff J, Pharmacist, was asked about the lack of a [DIAGNOSES REDACTED].#19. She stated in (MONTH) (YEAR), nursing staff had informed her the physician wanted the resident to continue on the medication. Staff J stated she thought it was unusual, as the resident had an opiate/narcotic order, and the reason for the resident taking the medication needed to be explored more, and clarified by the physician. In an interview on 07/27/18 10:50, Staff C, Regional Nurse Consultant, confirmed the lack of [DIAGNOSES REDACTED].#19, had not been in place. Per Staff C, after the surveyor had brought the concern to their attention, the diagnoses for the use of the medication was received from the physician (appetite suppression). Reference: (WAC) 388-97-1060(3)(k)(i)

Based on observation, interview, and record review, the facility failed to ensure three of seven sample residents (#22,11, 9), reviewed for nutrition, received adequate weight monitoring, timely evaluation of weights, and implementation of effective interventions, to maintain adequate nutrition. This failure placed the residents at risk for ongoing weight loss and poor nutrition, and resulted in actual harm for Resident #22, who experienced severe weight loss. Findings included: Facility Dietary Guidelines Manual According to the facility's Skin and Weight Monitoring policy, newly admitted residents were to be weighed weekly, or until stable. The policy included instructions that if a resident's weight change was 3% or more for a weekly weight, staff should write a note, which included an evaluation of why the weight change may have occurred. Possible listed causes included refusals to eat, which per the policy, would indicate social services follow up was needed. 1. Per the 07/04/18 admission assessment, Resident #22 was admitted on [DATE], with [DIAGNOSES REDACTED]. The assessment also showed no swallowing problems, did not identify weight loss, or that the resident was on a mechanically altered diet (such as a diet with a softer or pureed texture). Documented assessments of her cognitive status on 07/11/18 and 07/25/18 showed she was cognitively intact. Review of the resident's weight record showed the following: ~ Initial weight of 171.6 pounds on 06/27/18 (upon admission). ~ The next recorded weight, on 07/17/18 was 146.0 pounds (nearly three weeks after the initial weight, and approximately a 15% difference). ~ On 07/24/18, 137.5 pounds (reflecting an approximate 20% overall weight loss). ~ One refusal to be weighed was documented in the progress notes, on 07/20/18. A progress note on 07/14/18 revealed that Resident #22's dentures were lost after she had removed them, and requested staff clean them. A follow-up note, related to the lost dentures on 07/15/18, showed the resident was started on a pureed diet (all food has been ground, pressed and/or strained, to a consistency of a soft, smooth, thick paste - similar to a thick pudding). Review of the meal monitors (where facility staff document food and fluid intake at meals) showed Resident #22 ate less as time went on, during her stay at the facility. Prior to the dentures being lost on 07/14/18, the resident ate 25% of the meal or less, for 10 of 50 documented meals (approximately 20% of the time). From the 07/14/18 dinner meal through 07/25/18, Resident #22 ate 25% or less at 23 of 33 documented meals (approximately 70% of the time). Review of a nutrition/dietary note, dated 07/12/18, showed the registered dietitian wrote Update weight needed to do nutritional assessment, and indicated weight loss was yet to be determined (after there was an updated weight/re-weigh). In an interview on 07/26/18 1:21 p.m. with Staff E, Registered Dietitian, the surveyor asked whether she assessed the cause of the weight loss for Resident #22. She stated she had not, because there was not a second weight available by the time of her first nutritional assessment (on 07/12/18), and after the weight on 07/17/18 which showed a large weight loss, she was waiting to see another weight, to determine what she thought about the weight loss. She said she needed to see if it was a true weight loss. In addition, the resident's record was reviewed, from the date of admission, through the time the first significant weight loss was identified. There was no assessment of causal factors for the weight loss by nursing staff, and/or the continued decline in intake, to include not having dentures, having a physical illness, or a mood decline (requiring follow-up from social services). When asked about the staff automatically changing the resident to a pureed diet after her dentures were lost, Staff E stated the resident should be evaluated to have a less restrictive diet if possible, and stated she had thought the resident would be getting dentures again soon, so she had not addressed the type of diet previously. Progress notes for 07/19/18 showed Resident #22 had vomited blood, and was sent to the hospital for evaluation. The resident returned to the facility with orders for anti-nausea medication as needed, and a medication to decrease stomach acid. The notes showed the resident's family member brought her back from the hospital, and stated they would make decisions about the resident's care, after an appointment with her primary physician the following week. Per the note, a family member requested to discontinue vitamins, as the resident was not eating, and staff documented they suggested starting her on an appetite stimulant medication, but the family member declined, as they awaited the appointment. Additional review of the progress notes showed the first evaluation of the resident's weight loss was dated 07/24/18, after the total weight loss of 34.1 pounds. The note identified the resident's pattern of inadequate intake, showed the facility notified the physician, and that staff were waiting for the outcome of a physician's visit, to determine a course of action. In an interview on 07/23/18 at 9:25 a.m., Resident #22 was asked about how much food she was eating. She stated she didn't eat, and said I'm bad. When asked if she had eaten her ice cream the previous evening, Resident #22 said she did, and that she also drank a lot of water. The resident did not verbalize the reason why she was not eating. In an interview on 07/24/18 at 8:43 a.m., Staff K, Nursing Assistant, stated Resident #22 refused meals. Observation of the breakfast meal tray at 8:45 a.m. showed the resident had pureed eggs and ham, and had taken only one bite of each. Staff K stated the resident does not drink the health shake supplement, because she states it is too sweet. In an interview on 07/25/18 at 11:11 a.m., when asked whether she was aware of Resident #22's weight loss, Staff D, Registered Nurse, stated she knew the resident had significant weight changes, due to declining to eat or drink. In an interview on 07/26/18 at 1:13 p.m., when asked about her role in monitoring weights, Staff E, Registered Dietitian, stated she used to review the weights via an electronic weight change report, but recently discovered if weights were not being entered, it would not be caught with that method, so they were working on a new process to review weights for each resident. In an interview on 07/26/18 at 2:02 p.m., Staff I, Dietary Manager, was asked if he was aware of any residents who were not eating the food. He stated he was aware of a couple residents, and stated he had tried to deliver the meal that day to Resident #22, but she had refused it. He stated she received pureed meals, and did not like the texture. The surveyor referenced the resident's care plan intervention, initiated 06/28/18 based on her dietary profile, which showed Resident #22 liked potatoes and cheeses, and asked if the facility offered residents such as Resident #22 favorite foods instead of the planned meals, if they were refusing. He stated that had not been done. Staff E additionally stated the facility used to have weekly skin and weight meetings, which had not taken place for a while, due to lack of a consistent director of nursing. She said she wrote recommendations each time she went to the facility, and gave them to the nurses to follow up with the physician, for any applicable orders. Staff E showed listed recommendations she submitted to facility staff requesting weights for Resident #22 three times: on 07/05/18, 07/12/18, and 07/18/18. Staff E stated weights were initially requested because there was not a second weight to complete the nutrition assessment, and then a weight was requested on 07/18/18, because of the large change in the numbers from 06/27/18 to 07/17/18, so the weight needed to be verified. When asked if the facility had alerted her about Resident #22's recent refusal to eat, Staff E stated they had not. In an interview on 07/26/18 at approximately 4:00 p.m., Staff A, Administrator, and Staff B, Director of Nursing, were asked whether Resident #22 received any psychosocial/mental health support, related to her refusals to eat or drink; they both answered they were not aware of any. At that time, the surveyor communicated concerns related to the facility's lack of consistent weight monitoring, and timely evaluation and interventions, related to weight loss. 2. The 05/24/18 change in condition assessment showed Resident #11 admitted to the faciity on 08/14/17, and had [DIAGNOSES REDACTED]. According to the 08/14/17 care plan, Resident #11 had the potential for nutritional problems, including weight loss. A review of Resident #11's weights showed: ~The resident weighed 192 pounds on 03/01/18. ~ No weight was documented for (MONTH) (YEAR). ~The resident weighed 191 pounds on 05/03/18. ~ No weight was documented for (MONTH) (YEAR). ~ No weight was documented for (MONTH) (YEAR). In an observation on 07/24/18 at 8:27 a.m., Resident #11 was in the dining room for breakfast. He had a hard-boiled egg, ham, and a cinnamon roll. He was able to cut up the meat, and feed himself independently. The resident ate 100% of the meal. In an interview on 07/24/18 at 3:29 p.m., Staff C, Regional Nurse Consultant, was asked about the inconsistent weight monitoring. He stated they had identified significant issues with weights and nutritional monitoring. Staff C further stated that everyone in the facility would be weighed that day. Resident #11's weight was documented at 187.4 (a decrease of 3.6 pounds). In an interview on 07/26/18 at 1:58 p.m., Staff E, Registered Dietician, stated she felt the resident was stable despite the drop in weight, however, the resident had consistently low [MEDICATION NAME] levels (a blood protein used to determine nutritional status), which would need to be monitored. Staff E was asked if she attended the nutrition-at-risk (NAR) meetings at the facility, when a resident needed to be followed nutritionally. She stated the facility has not had regular meetings, but would be starting them again soon. 3. Per the 05/28/18 admission assessment, Resident #9 admitted to the facility from home on 05/21/18, with [DIAGNOSES REDACTED]. A facility policy, titled Nutritional Assessment Policy, dated (MONTH) 2011, indicated .The Dietician, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission . Resident #9's weight on admission was documented as 158.8 pounds. Additional weight were: ~ No weight listed for (MONTH) (YEAR) ~ No weight listed for (MONTH) (YEAR) On 07/24/18, all residents in the facility were weighed. Resident #9's weight was documented at 154.2 pounds (a decrease of 4.6 pounds, or 2.98%) A review of the record showed the registered dietician had not assessed the resident upon admission, or for the month of (MONTH) (YEAR), to determine her nutritional risk. The record showed the dietary manager had done the assessment. In an interview on 07/25/18 at 10:20 a.m., Staff I, Dietary Manager stated he had done the initial nutritional assessment, and his assistant had put the information into the computer. Staff I further stated he was unaware the dietician had not seen the resident. In an interview on 07/26/18 at 2:02 p.m., Staff E, Registered Dietician, stated she was not aware the resident had not been assessed. She further stated since Staff I did the nutritional assessment, it did not trigger on her computer to do the evaluation, so it was missed. Reference: (WAC) 388-97-1060(3)(h)

Based on observation, interview, and record review, the facility failed to provide appropriate staff training and equipment necessary for emergency care. Staff failed to perform cardio-pulmonary resuscitation (CPR) in a timely manner, due to multiple transfers of the sample resident (#1), whose Physician order [REDACTED]. There was no system in place to ensure adequate supplies were available for an emergency. This failed practice resulted in an Immediate Jeopardy for eight residents in the facility, whose POLST forms designated CPR was to be performed, if found with no pulse and not breathing. The State Survey Agency informed the facility on [DATE] at 2:05 p.m. of the Immediate Jeopardy situation. The facility initiated immediate training of emergency procedures and supplies, and audited staff records for CPR certification. Emergency equipment was obtained, and routine monitoring of the code cart was established. On [DATE] at 9:20 a.m. the facility was notified of the removal of the Immediate Jeopardy. Findings included: Resident #1: Review of the resident's medical record showed a POLST form, dated and signed by the resident on [DATE], which showed the resident requested CPR to be performed, in the event the resident was without a pulse and not breathing. Review of the resident's current plan of care revealed the resident was on an air mattress, secondary to pressure ulcers. On [DATE] at 1:10 p.m., an air mattress was observed (the same type as utilized by Resident #1). There was a yellow colored strap, approximately seven inches in length, hanging at the top right hand side of the mattress with large letters, which read CPR. Per interview at that time with Staff A, Maintenance Supervisor, stated the strap needed to be pulled if CPR was to be performed, which immediately deflated the mattress, and allowed for a hard surface. Review of the facility investigation report, dated [DATE], showed when Staff B, Nursing Assistant, was assisting the resident to stand from the toilet, the resident became limp and unresponsive. Staff B lowered the resident back onto the toilet, and called for additional staff assistance. Staff C, agency Registered Nurse, entered the bathroom, and observed the resident to be unresponsive, with shallow, slow (less than eight per minute) respirations. The investigation report showed Staff C was unable to adequately assess the resident's heart rate, so the resident was lifted from the toilet to a wheelchair, and then lifted into the bed, by Staff B and C. Both staff were aware the resident was a full code (requested CPR), as noted per the POLST form, and a 911 call was made. The resident was moved from the bed to the floor via a mechanical lift, to initiate CPR. Staff C began CPR until emergency personnel arrived. The resident expired at the facility at 8:12 a.m. on [DATE]. Interviews with Staff B at 12:35 p.m. on [DATE], and 6:03 p.m. on [DATE] revealed she and Staff C transferred the unresponsive resident from the toilet to a wheelchair, and then to the bed, the morning of [DATE]. Staff B stated it was determined the resident was a full code, and staff were directed by Staff C to place her on the floor utilizing a mechanical lift, which was obtained by Staff D, Nursing Assistant. Staff B stated after the resident was placed on the floor, Staff C asked, Do I need to do chest compressions? to which Staff B responded, Yes, she's a full code. Staff B stated she was unaware of the CPR strap, located on the upper right corner of the air mattress. Per interviews with Staff D, Nursing Assistant, on [DATE] at 1:25 p.m., and [DATE] at 4:45 p.m., she stated she was asked by Staff C to obtain the facility code cart, which contained a portable defibrillator and other emergency supplies. When she returned with the code cart, she asked Staff C if she was going to use the defibrillator, to which Staff C stated, no. Staff D stated she was also directed by Staff C to obtain the mechanical lift, which was located on the other hallway, and took approximately one minute to retrieve. After the resident was placed on the floor per mechanical lift, Staff C asked, Should I start chest compressions now? Telephone interviews on [DATE] at 3:30 p.m. and [DATE] at 4:52 p.m. and 6:25 p.m. with Staff C, Registered Nurse, revealed when she entered the resident's bathroom the morning of [DATE], the resident was slumped over on the toilet and unresponsive; Staff B was holding the resident on the toilet. Staff C stated the resident was without pulse and heart tones, and her respirations were shallow. Staff C stated she was not able to perform a good assessment with the resident in that position, so they transferred her to a wheelchair and then to the bed. Staff C stated I wasn't sure at the time, regarding the need to perform CPR, and felt she needed a more accurate assessment of the resident. She stated she then assessed the resident's pupils, which were fixed and dilated. Staff C requested Staff D obtain the mechanical lift, to place the resident on the floor, as she (Staff C) had a bad back. She stated the resident weighed 124.6 pounds. Upon questioning, Staff C stated she was unaware of the CPR strap, located on the air mattress. She said chest compressions were performed (no breaths), during the CPR procedure by Staff C, as the resident had saliva over her mouth, and she did not have a pocket mask (a device used to safely deliver rescue breaths during a [MEDICAL CONDITION] or respiratory arrest) to utilize. Staff C stated she did not know the location of the code cart in the facility, or its contents, as she had never received any training. She stated she was aware of how to use a portable defibrillator, however it was not utilized during the CPR procedure. Review of the facility Emergency Procedure, revised (MONTH) (YEAR), included utilzing the automated external defibrillator (AED) as needed (a portable device used to treat sudden [MEDICAL CONDITION] - condition in which the heart suddenly and unexpectantly stops beating), and trained rescuers were to provide compressions with ventilation via an ambu bag (a hand-held device used to provide ventilation to a person who was not breathing), or manually, with a CPR pocket mask. Observation of the facility code cart on [DATE] at 1:15 p.m. showed the cart was located in a corner, just outside of the main dining room. The cart was completely covered with a plastic covering, and there was no sign designating the function of the cart. There was no evidence of an inventory list, or a back board (a board placed under a resident, prior to CPR, to enable a hard surface in which to perform CPR). An AED, ambu bag, and pocket mask were present on the cart. Observation of facility beds on [DATE] at 1:10 p.m. showed there were two different types. Headboards were removable with the new beds, and removal of the mattress on the old beds; both enabled a hard surface in which to perform CPR. Interviews on [DATE] at 1:10 p.m. and 1:50 p.m. with Staff E, Registered Nurse, revealed the facility used to have a back board on the crash cart, but it had not been used in over a year. Staff E stated she just became aware of it missing, upon questioning by the state investigator. Staff E was unaware of the location of an inventory sheet, noting the different emergency supplies contained on the cart. She stated someone used to routinely check the emergency supplies for availability, but that had not been done for quite some time. She was unaware of how to obtain a hard surface to perform CPR when a resident was in bed, not on an air mattress, and with no back board available. The facility had not provided training relative to the different types of beds in the facility, and/or the procedure regarding obtaining a hard surface, in the event a resident required CPR while in bed. On [DATE] Staff F, Licensed Practical Nurse, stated he started working at the facility on [DATE]. He indicated he was aware of the location of the code cart and presence of an AED device, however, was unaware there was no back board on the cart. Staff F stated he had not received training, and was therefore unaware of the CPR strap on the air mattresses, and was unsure how to provide a hard surface to perform CPR, utilizing the beds currently in the facility. Staff G, agency Registered Nurse, stated on [DATE] at 4:02 p.m., he was unaware of the location of the facility code cart and its contents. In addition, Staff G stated he had received no training on the two different types of beds, and how to utilize them to obtain a flat surface, during CPR. Per interview on [DATE] at 4:03 p.m. with Staff H, Registered Nurse, she stated she had never received training relative to the CPR strap associated with the air mattress, so she would have placed the resident on the floor. She stated she has never recalled seeing a back board on the code cart. Review of the nursing and nursing assistant orientation checklists showed staff was oriented only to the location of the code cart. There was no evidence agency staff was provided any training relative to the code cart. Review of facility records revealed no evidence staff received training relative to the contents on the code cart, different types of beds, and the air mattresses in the facility, as related to the provision of CPR. Reference (WAC) [DATE](3)(b-c)

Based on observation, interview and record review, the facility failed to ensure 1 of 2 residents reviewed for pain (#10) received the necessary care and services to provide optimum pain management during transfers. Failure to evaluate the cause of Resident #10's increased pain level, and provide care appropriate to her condition, resulted in actual harm to Resident #10 who was transferred repeatedly from her bed to the wheelchair while calling out in pain. In addition, based on interview and record review, the facility failed to ensure 1 of 5 residents reviewed for unnecessary medications (#10) received appropriate bowel management. Findings include: PAIN MANAGEMENT Resident #10 admitted to the facility in 2013 and had [DIAGNOSES REDACTED]. A care plan related to chronic pain printed 10/16/15 had a stated goal of (Resident #10) will not cry out with pain when transferred and repositioned through next review. Another care plan problem described, .At risk for pain, she is unable to make needs known to staff. Review of the progress notes revealed Resident #10 experienced increased pain, first identified 09/14/15, in a note that stated, Res(ident) has been moaning, restless, saying, 'ow,ow,' guarding R(ight) hip, and facial grimacing . Asking for MD advice. Will wait for MD response . Progress notes later on 09/14/15 showed Resident #10 was having the same pain symptoms. Increased pain with Activities of Daily Living (ADL) and/or transfers was identified in the progress notes on 09/15/15, 09/16/15, and 09/17/15. On 09/21/15, per progress notes, Resident #10 was yelling, crying, facial grimacing, guarding, saying ow, ow and did not experience relief with Tylenol (pain medication) administration. There is no indication in the progress notes that the doctor replied to the original notification of pain, or that staff re-attempted to contact the doctor on 09/15, 09/16, or 09/17 when they documented she continued to have pain. When the doctor was again contacted on 09/21/15, a new physician order [REDACTED].#10 had a decrease in her pain during care. On 09/24 and 09/25/15, progress notes stated Resident #10 was very painful upon getting out of bed, yelling and striking at staff, and that after the increased medication dose was given, the resident was smiling and happy. There is no indication of why the pain medication was not given before the resident was transferred. There is no documentation in the progress notes from 09/26-10/12/15 related to pain, other than on 09/30, when social services staff stated She has especially been more agitated during cares. A progress note entered 10/13/15 at 3:45 a.m. stated Resident #10 was experiencing increased pain, and that her daughter was called to determine appropriate action to take. The note stated (Resident #10's daughter) wishes nurses to give her mother Tylenol ([MEDICATION NAME]) every 4 hours and hoping (doctor) will give . more or different pain meds including possible pain patch. Notes further stated a [MEDICATION NAME] was ordered on the 10/13, and first applied on 10/14. Progress notes entered between when the daughter was called and the patch was applied, showed Resident #10 had signs of pain, including screaming, hitting, not supporting weight for transfer on 10/13/15. Review of the MAR indicated [REDACTED]. Observation on 10/15/15 at 10:38 a.m. revealed cries of Ow, Ow heard in the hallway. Upon knocking and entering, observation revealed Staff K and Staff J, nursing assistants, preparing to transfer Resident #10 from the bed to the wheelchair with a mechanical lift by placing the lift sling under the resident. Resident #10 was lying in bed on the right side and cried out Ow, Ow repeatedly every time Staff moved her from her position on the right side. At 10:39 a.m. Staff K stated she wondered whether Resident #10 had her pain medication yet that morning, but did not leave the room at that time to check. Staff K addressed Resident #10 saying, We have to roll you on your back. I know it's going to hurt . I know you want to get up. At 10:41 a.m. and 10:45 a.m., the nursing assistants rolled Resident #10 onto her back and she yelled Ow again, had a deeply furrowed brow and rolled back onto her right side. At 10:46 a.m. Staff K stated, you ready? It might hurt and tried to adjust Resident #10 in bed again. Resident #10 yelled Ow with each movement. At 10:49 a.m. Staff K stated, I know she's not comfortable. At 10:52 a.m., Staff D, a licensed nurse, entered and stated We're gonna turn you, I know it's gonna hurt a little bit. Resident #10 called out Ow as she was moved onto the sling, and when moved up in to the air and into the wheelchair. She then verbalized Ow as Staff J put on a shirt over her left arm. Resident #10 became quiet when in her chair and her arms and legs were not being touched. On 10/15/15, a nursing progress note stated: Resident does continue to yell and scream during ADL's, transfers, bed mobility and brief changes. Facial grimaces noted upon body movements. Subsequent observation on 10/16/15 from 11:16 a.m. to 11:32 a.m. revealed Staff J and Staff L, nursing assistants, providing personal care for Resident #10. They cleaned her private area, applied elastic stockings, and clothing. During the continuous observation, every time her legs were touched or when she was turned off of her right side, Resident #10 shouted Ow. When staff stopped touching her, she stopped vocalizing pain. Resident #10 also tightly gripped the mattress on her right side, and the staff's clothing when they attempted to turn her to the other side. At 11:26 a.m., Staff J stated She hates turning that side. Staff J and Staff L continued to attempt to turn Resident #10 off of her right side, and each time Resident #10 called out Ow. At 11:30 a.m. she also yelled out No. At 11:31 a.m. Staff B, Director of Nursing, entered and suggested Resident #10 might be agitated by the surveyor presence in the room. After receiving this information, the surveyor left the room; however, from 11:33 a.m. to 11:39 a.m., shouts of Ow were audible in the hallway nine times and grew louder and more intense at 11:36 a.m. and 11:38 a.m. In an interview on 10/16/15 at 12:05 p.m., Staff L stated the observation was typical of Resident #10's demeanor since she started working 2 weeks earlier, and stated Resident #10 was sometimes more aggressive. Staff L stated, Poor (Resident #10)'s just in a lot of pain. Always sad. If you touch her chair she starts to tear up. When asked if there was anything that helped, Staff L stated the nurse gives pain pills sometimes if the pain is severe. She stated when Resident #10 is better she smiles more, and scowls less. When asked if she knew whether the resident had a pain pill the morning of the observation, Staff L stated she did not know. She also stated she had been informed music helped. When asked if music was ever used during transfers, Staff L stated, No, because it's headphones. We need to get her a stereo and see if that helps. Record review of the Medication Administration Record [REDACTED]. In an interview on 10/16/15 at 3:47 p.m., Staff B, Director of Nursing, stated Resident #10 had a recent increase in pain that was worsened with activity. When asked, Staff B indicated Resident #10 had medication changes during that time, had not been seen by a doctor since the last Physician's note on 09/04/15, and had not had any assessments by physical or occupational therapy to assess transfer status. In an interview on 10/16/15 at 3:55 p.m. regarding pain interventions used for Resident #10, Staff B stated, Have to attempt to reapproach at a different time . Maybe 15 minutes, when calmed down. Try to medicate her as well as we can to anticipate the pain. When asked if there was a plan in place to pre-medicate Resident #10 before getting up for the day, Staff B stated she did not know whether it was timed related to when she gets up in the morning. Observation on 10/19/15 from 4:43 p.m. to 4:47 p.m. revealed Resident #10 was heard calling out Ow 37 times, which were audible from the hallway. There were no lengthy pauses in the vocalizations, and staff did not exit the room during that time to reapproach later. On 10/19/15 at 4:48 p.m., when asked to describe the sounds coming from the room, Staff E, Unit Manager, stated, It sounds like she's in pain right now. At 4:50 p.m., Staff E entered the room, and cries of Ow continued until 4:52 p.m., at which time Resident #10 was up in her wheelchair. In an interview on 10/19/15 at 4:59 p.m., Staff M, a nursing assistant who provided direct care for Resident #10, stated Resident #10 has problems with her hips, so whenever we turn her or even touch her she has pain . Staff M stated Resident #10 had always been in pain, but had been expressing more pain over about the last month. She stated Every time we transfer her she screams like that. Staff M indicated that Resident #10 sometimes clinched up and groaned when she was up in her wheelchair, but yelled out during transfers or when touched. A progress note dated 10/19/15 stated: Resident continuing to show increased (signs and symptoms of) pain/ behaviors, mostly while transferring and for 15-20 minutes after sitting in her wheelchair .Ice packs/ warm packs seem to provide little relief as area of pain is difficult to ascertain. Repositioning ineffective in improving (signs and symptoms of) pain. In an interview on 10/19/15 at 8:32 p.m. when asked whether Resident #10 was assessed to determine it was safe to transfer the resident out of bed with her vocalizations of pain, Staff B stated the decision was based on the family statement that the resident would not want to stay in bed. On 10/19/15 at 9:15 p.m., Staff B stated Resident #10 began to be transferred by a mechanical lift on 09/17/15 after it was documented on 09/16/15 that she was moaning and groaning. The progress notes revealed Resident #10 was seen by her physician in the facility on 10/20/15, over one month from the time the increased pain was first identified. The physician's note dated 10/20/15 noted Dementia with pain, and ordered an xray of the pelvis area. Record review of the pelvis x-ray completed 10/21/15 showed severe left hip [MEDICAL CONDITION] with chronic [MEDICAL CONDITION] changes. Information retrieved from The National Library of Medicine at https://www.nlm.nih.gov/medlineplus/[MEDICAL CONDITION].html described, ([MEDICAL CONDITION]) causes pain, swelling, and reduced motion in your joints . In an interview on 10/21/15 at 3:45 p.m. when asked whether anything beside medications was tried to improve Resident #10's pain, Staff G, Registered Nurse, stated staff attempted to reposition the resident, without improvement. An intervention listed in the Chronic pain care plan, printed 10/16/15, was for an Occupational Therapy evaluation. In an interview on 10/22/15 at 9:23 a.m., Staff B stated Resident #10 had not had an occupational therapy evaluation since the start of her increased pain, as they were waiting to rule out other things. Failure of the facility to assess underlying causes of Resident #10's pain in a timely manner, and persistence in transferring the resident from the bed to the wheelchair when she was calling out in pain, resulted in actual harm to Resident #10. BOWEL MANAGEMENT Resident #10 received medication management for multiple medical conditions from the facility. Per a 09/04/15 physician's note, Resident #10 had a history of [REDACTED]. The undated facility Bowel Protocol received 10/22/15 stated Residents assessed as having inadequate bowel function manifested by absence of regular bowel movement in excess of three days will have the following bowel protocol implemented as established by physician's orders [REDACTED]. Administration of laxatives/ bowel stimulants and c. Administration of enema. Resident #10 had physician's orders [REDACTED]. Resident #10's bowel monitor revealed she had no bowel movements between 09/05/15 and 09/10/15. Record review of the Medication Administration Report revealed a Fleet Enema was given on 9/10/15, but was not preceded by MOM and [MEDICATION NAME] per the physician's orders [REDACTED]. In an interview on 10/21/15 at 3:20 p.m., Staff E stated she was not sure why the enema would be given prior to any other bowel medications, and indicated the typical process was to give MOM, a suppository, and then the enema if those were not effective.

Based on interview and record review, the facility failed to identify significant weight changes and/or develop and implement interventions in a timely manner for 1 of 3 current residents (#1) reviewed for nutrition. This failure resulted in harm to the resident when he experienced a 6.4% weight loss in three weeks. Findings include: Resident #1 was readmitted to the facility on [DATE] after surgery. The resident was confused due to a history of [MEDICAL CONDITION]. The resident had a gastrostomy (tube inserted into the stomach through the abdominal wall). The resident had 5/23/11 physician orders [REDACTED]. The orders indicated the tube feeding provided 75% of the resident's daily nutrition. The resident also ate regular food by mouth during the day, but facility documentation said his appetite was poor. Facility policy for weights noted, "The charge nurse will notify the Dietary Manager and DON (Director of Nursing) of weight variances ... Gross weight gains or losses will prompt an immediate reweighing of the resident, and, if confirmed, notification of the physician." The policy also said a dietary consult was to be requested if a resident experienced gross weight gain or loss. On 6/23/11, the resident was not interviewable about his tube feeding due to his cognitive status. Review of weight sheets showed the resident weighed: 175.6 pounds on 5/27/11 180.6 pounds on 6/3/11 173.8 pounds on 6/10/11 166.2 pounds on 6/16/11, with a reweigh of 164.4 pounds on 6/17/11 Between 5/27/11 and 6/3/11, the resident gained 5.0 pounds, representing a 2.8% gain in one week. There was no documentation to show the resident was reweighed or any other action was taken. Handwriting on the resident's 6/7/11 weight report noted, "Desirable weight gain." The report was signed by Licensed Nurse (LN) A, the acting Director of Nursing Services (DNS) at the time. Documentation showed the Registered Dietitian (RD) evaluated the resident on 6/7/11. RD notes said the resident was stable with the current nutritional plan of care. Between 6/3/11 and 6/10/11, the resident lost 6.8 pounds, representing a 3.8% loss in one week. There was no documentation to show the resident was reweighed. The 6/14/11 weight report was signed by LN A and indicated the physician was asked to increase the resident's tube feeding. There was no documentation showing the physician responded to the request. There was no documentation showing staff made any additional attempts to contact the physician. There was no documentation indicating the RD was notified. Nursing notes indicated the resident missed an entire night of tube feeding on 6/14/11 because the tube feeding formula was not available. Between 6/10/11 and 6/16/11, the resident lost 7.6 pounds. The reweigh on 6/17/11 confirmed the resident had lost even more weight, a total of 9.4 pounds in seven days. In the three weeks between 5/27/11 and 6/17/11, the resident lost 11.2 pounds, or 6.4% of his body weight. The 6/21/11 weight report said the physician and the RD were contacted. The RD evaluated the resident and recommended a tube feeding increase, which the physician agreed to on 6/23/11. On 6/23/11 at 11:55 a.m., Restorative Aide (RA) B said the Dietary Manager (DM) gave her a sheet with a list of residents to weigh each week. RA B said she documented the weights then returned the sheet to the DM. At 12:42 p.m., the DM said she entered each resident's weight into the facility's computer system for weight reports. The DM said the weight report automatically calculated any change in each resident's weight, in terms of both pounds and percentage. The DM said a gross weight change was a gain or loss of 2%. The DM said she printed a weekly weight report for each resident and gave all reports to the DNS for review. The DM said the RD was based out of another city and came to the facility approximately twice a month. LN A was not available for interview. The current DNS had worked at the facility only four days and was being trained by the Corporate Nurse Consultant (CNC). At 1:00 p.m., the CNC described the resident's weight change between 6/3/11 and 6/10/11 as a "big loss." The CNC said he did not know the resident well enough to know if it was a "true" weight loss, so he waited an additional week before taking any further action to see if the resident had actually lost weight. The CNC said the DM was responsible for identifying a weight change of greater than 2% and arranging for the resident to be reweighed. The CNC said he was aware of the missed night of tube feeding but said one night would not account for a seven pound weight loss. At 1:05 p.m., the DM said she was not a dietitian. The DM said her main role was to input data into the weight report. The DM said she handed the reports to the DNS for follow up. The DM said she did not analyze the resident's weight changes or arrange for residents to be reweighed. On 6/24/11 at 11:38 a.m., the RD said it was the DM's responsibility to review weekly weights and request reweighs as indicated. The RD said the DM and the DNS were expected to review the weight reports together once a week and develop a plan. The RD said the facility should have contacted her when the resident's weight loss was identified on 6/10/11, but she had not been notified. The RD said the DNS and the DM should have noted the missed night of tube feeding as a possible factor contributing to the resident ' s weight loss. The RD said there was a system problem with weight monitoring at the facility. The facility failed to take prompt action when the resident's weight loss was identified on 6/10/11, which resulted in an additional 9.4 pound weight loss by 6/17/11.