Every finding on record at Transitional Care Of Seattle

Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice for 1 of 3 residents (Resident 1) reviewed for professional standards. The failure to follow, timely implement or implement and/or clarify physician orders and the failure to determine the reason for refusals, notify the provider of the refusals, and address the reasons for refusals placed all residents at risk for negative health outcomes, unmet care needs, and decreased quality of life. Findings included. <Resident 1>Review of the 01/04/2026 admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 had medically complex conditions including a history of blood clots, dementia, and vision problems. The MDS showed Resident 1 had significant loss in mental abilities, had verbal and physical behaviors directed towards others that did not interfere with the resident's care, and behaviors of rejecting care. The MDS showed Resident 1 was dependent on staff for eating, hygiene, toileting, bathing, bed mobility, and dressing.Review of an Activities of Daily Living (ADL) care plan, dated 12/29/2025, showed Resident 1 had self-care deficits related to dementia and weakness. The care plan showed interventions that directed staff to use two staff members for bed mobility (turning/repositioning in bed), was dependent on staff for dressing, and required two staff members to transfer using a mechanical lift into a wheelchair.<Failure to follow/implement and/or clarify Physician Orders>Review of a hospital Discharge summary, dated [DATE], showed Resident 1 admitted with two Pressure Injuries (PI, damage to the skin and underlying tissue caused by prolonged pressure, friction or shear), one on the right heel and one on the right buttocks. The discharge summary showed wound treatments orders for Resident 1's right heel PI to be completed every three days. A second wound treatment showed for Resident 1's right buttocks PI to be changed daily. The discharge summary showed physicians' orders that directed staff for Resident 1 to be out of bed three times daily and turned every two hours when in bed. Additional diet orders directed staff to provide Ensure (high quality protein shake) three times daily, and Juven (a specialized drink mix designed to support wound healing) twice daily. The discharge summary directed staff to transfer Resident 1 with a sit to stand mechanical lift to a manual tilt in space wheelchair (improves alignment and reduces pressure). Review of Resident 1's physicians' orders, dated 12/29/2026-02/02/2026, showed no indication staff implemented physician orders for Resident 1 to be out of bed three times daily. Review of physician's orders showed on 01/03/2026, six days after Resident 1 admitted staff implemented the Juven order, and on 01/18/2026 staff implemented the Ensure order three times daily, twenty days after Resident 1 admitted to the facility.Review of Resident 1's January Medication Administration Record (MAR) showed on 01/09/2026 evening shift through 01/12/2026 evening shift, Resident 1 did not receive the Juven. Staff documented the medication was on order and not available. Review of Resident 1's December 2025 and January 2026 Treatment Administration Record (TAR) showed staff entered Resident 1's wound treatment orders as the right heel to completed daily. The TAR showed the right buttocks treatment order was put in to be changed every three days.Review of Resident 1's medical chart and progress notes showed no documentation that facility staff clarified Resident 1's physician order to be out of bed three times daily. Review of 12/30/2025, 12/31/2025, 01/03/2026, 01/29/2026 provider notes showed the provider reviewed all of Resident 1's diagnoses and under PU's documented Resident 1 out of bed three times daily, turn in bed every two hours, and wound care per the wound provider. Review of Point of Care (POC, certified nursing assistance documentation) documentation for transfers out of bed, dated 12/29/2025-02/05/2026, showed no documentation that staff transferred Resident 1 out of bed. Review of POC documentation for bed mobility showed multiple days (01/02/2026 day and night shift, 01/04/2026 night or evening shift, 01/11/2026 night shift, 01/13/2026 night shift, and 01/17/2026 night shift) with no documentation from facility staff. The POC bed mobility documentation showed on multiple days (01/03/2026 night shift, 01/06/2026 day shift, 01/14/2026 day shift, 01/22/2026 night and day shift, 01/27/2026 day shift, 01/30/2026 evening shift, 02/05/2026 night shift ) staff documented staff gave no assistance or activity did not occur.During an interview on 01/16/2026 at 9:25 AM, Resident 1's Collateral Contact (CC) stated they have visited Resident 1 four times and stay for an average of three hours. The CC stated during their visits Resident 1 was always in bed and staff did not come in and reposition or turn Resident 1. The CC stated Resident 1 should have Ensure, they received it in the hospital, and was told it would be ordered at the facility. The CC stated Resident 1 was a slow eater, had difficulty seeing, needed staff to cut up their food and assistance with eating.In an observation and interview on 01/16/2026 at 1:15 PM, Resident 1 stated their behind hurt and they just finished lunch. Resident 1 was observed in bed on their back with the head of the bed slightly elevated. In an interview on 01/30/2026 at 1:03 PM, Staff C (Registered Nurse, RN) stated they had not seen Resident 1 out of bed. In an observation and interview on 01/30/2026 at 1:10 PM, Resident 1 stated their bed was uncomfortable and they wanted to move around like anyone else.During an interview on 02/11/2026 at 12:05 PM, Staff B (Director of Nursing) stated the facility did not put in orders for Resident 1 to be out of bed because it was a standard of care. When asked why the provider documented in their progress notes for the resident to be out of bed three times a day, Staff B stated they would have to clarify with the provider and all residents should be out of bed. Staff B stated Resident 1 refused to get out of bed. Staff B stated Resident 1 admitted to the facility with two pressure ulcers and facility staff did not implement the transfer orders for Ensure and Juven because when the resident admits they are seen by the dietician first to look at the resident's needs. Staff B stated Resident 1 was totally dependent and required two person assistance with bed mobility and that Certified Nurses Assistants (CNA) and nurses perform turning and repositioning. Staff B stated they would need to talk to staff about documenting activity did not occur, staff gave no assistance, that it could be refusals or staff were confused by terminology, and they would expect staff to complete documentation. <Failure to assess Refusals>Review of the comprehensive care plan showed a 12/29/2025 behavior care plan developed for behaviors that required intervention and psychotropic medication, and no specific behaviors or interventions were identified on the care plan.Review of Resident 1's medical record from 12/29/2025-02/05/2025 showed under meal intake documentation Resident 1 refused seventeen meals, under bathing documentation Resident 1 refused one bath, under behavior monitoring documentation Resident 1 had one episode of refusing care, refused weekly weights five times and refused medications at times. Review of Resident 1's progress notes dated 12/29/2025- 02/05/2026, showed on 01/08/2026, staff documented Resident 1 refused to swallow their medications. The note did not indicate what the staff did or who they notified. Review of a 01/16/2026 and a 01/18/2026 progress notes showed Resident 1 was cooperative with repositioning attempts but refused at times. Staff documented they provided education regarding the risks and benefits of turning and the resident verbalized understanding. Review of two progress notes, dated 01/19/2026 showed Resident 1 refused to have a bladder scan performed and staff documented they re-educated the resident but did not indicate if the provider or resident representative was notified. Review of a progress notes dated 0/19/2026 showed Resident 1 refused and spit out their antibiotic medication and their ensure. The note did not indicate what staff did in response to Resident 1's refusals or if the provider was notified of Resident 1's refusals. Review of progress notes dated 12/29/2025-02/05/2026 showed no indication the provider was informed of Resident 1's multiple refusals. In an interview on 02/11/2026 at 12:12 PM when asked if Resident 1 had the cognitive ability to understand the risks and benefits of not turning when staff re-educated them for refusing, Staff B stated no Resident 1 did not have the cognitive ability to understand. Staff B stated the provider should be notified, staff should document refusals in the record, and the behavior care plan should have current behaviors and interventions listed to direct staff how to manage refusals. Refer to F686REFERENCE: WAC 388-97-1060(1)(ii)(3)(b).

Based on observation, interview and record review the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for Pressure Injuries (PI, damage to the skin and underlying tissue caused by prolonged pressure, friction or shear) received the necessary care and services, consistent with professional standards of practice to promote healing, and prevent new PI's from developing. Failure to ensure PI's were consistently assessed to include wound characteristics and measurements, to evaluate the resident's compliance with the plan of care, and prevent new PI's from developing. This failure placed resident's at risk for prolonged wound healing, increased discomfort, diminished quality of life, and development of avoidable PI's.Findings included .According to the facility Skin Integrity policy, revised January 2026, a Licensed Nurse (LN) would document skin impairments that included the measurements of size, color, presence of odor, exudates, and presence of pain associated with the skin impairment on the weekly wound evaluation. The LN would notify the medical provider and the resident representative of the skin condition and the treatment plan, and the Registered Dietician would be notified. The policy showed when a wound failed to improve after two weeks of treatment or the wound deteriorated, the medical provider and the resident representative would be notified. <Resident 1>Review of the 01/04/2026 admission Minimum Data Set (MDS, an assessment tool) showed Resident 1 admitted to the facility on [DATE]. The MDS showed Resident 1 had medically complex conditions including a history of blood clots, dementia, and impaired vision. The MDS showed Resident 1 had significant loss in mental abilities, had verbal and physical behaviors directed towards others that did not interfere with the resident's care, and behaviors of rejecting care. The MDS showed Resident 1 was at risk for PI's, had two unhealed PI's that were unstageable and presented as Deep Tissue Injuries (DTI, purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure or shearing (skin is pulled in opposite directions injuring the skin layers). The MDS showed Resident 1 was dependent on staff for eating, hygiene, toileting, bed mobility, transfers, bathing, and dressing.Review of 12/29/2025, Braden Scale (an assessment tool used to predict PI risk) showed Resident 1 was assessed at moderate risk for PI's due to being bedfast (unable to leave bed), had very limited mobility and sensory perception. The assessment showed Resident 1 had adequate nutrition and ate over half their meals.Review of Resident 1's care plan, initiated 12/29/2025, showed the resident had actual impairments to their skin integrity to include a DTI to their right buttocks and right heel. An intervention, initiated on 01/18/2026, twenty days after Resident 1's admission, directed staff to frequently reposition the resident when resting. Review of an admission skin/wound evaluation showed it was created by staff on 01/05/2026 and dated for 12/29/2025. The evaluation showed Resident 1 was identified with two PI's on admission that were suspected DTI to the right heel and right buttocks. The evaluation did not include measurements, wound assessment, or pain associated with the wounds. Review of skin/wound evaluations showed no skin/wound evaluation completed on 01/05/2026 for both PI's and only the right heel PI was assessed on 01/12/2026. Review of a skin/wound evaluation dated 01/19/2026 showed a new unstageable PI was found to Resident 1's right upper back. The skin/wound evaluation showed the PI was identified on 01/14/2026, sixteen days after Resident 1 admitted to the facility. The skin/wound evaluation showed under registered dietician notification was left blank and no date was entered.During an interview and observation on 01/30/2026 at 1:20 PM Resident 1's upper back wound was observed as an oblong shaped open area. Observations of their right buttocks showed a large wound extending from the right buttocks to the tailbone. During the observation of the PI's, Resident 1 stated their buttocks hurt. Review of a facility investigation for the facility acquired PI to Resident 1's upper back, dated 01/14/2026, showed Resident 1 was at extreme risk for impaired skin integrity. The investigation showed the root cause analysis was due to the resident's profound immobility, deconditioning from sepsis, malnutrition and inadequate hydration. The investigation showed facility staff put interventions of documentation of frequent turns and a new order of Ensure three times daily. During an interview on 01/30/2026 at 1:41 PM Staff B stated Resident 1 refused to get out of bed and refusing most intakes by mouth. When asked why Resident 1 refused, Staff B stated it was resident driven and the staff were having difficulties getting care done. Review of Resident 1's medical record from 12/29/2025-02/05/2025 showed under meal intake documentation Resident 1 refused seventeen meals, under bathing documentation Resident 1 refused one bath, under behavior monitoring documentation Resident 1 had one episode of refusing care, refused weekly weights five times and refused medications at times.Review of progress notes, dated 12/29/2025-02/05/2026 showed no indication staff informed the provider of Resident 1's refusals or determined the reason for refusals.In an interview on 02/11/2026 at 12:20 PM, Staff B stated there should be weekly documentation of wounds including measurements and wound characteristics. When asked why the new PI to the back was not assessed until 01/19/2026, five days after it was found on 01/14/2026, Staff B stated they would have to ask the wound nurse and was not able to answer the question. Staff B stated that Resident 1 was at extreme risk for wounds, when asked why the Braden assessment showed moderate risk and which one was accurate, Staff B replied Resident 1 was at extreme risk. Staff B stated Resident 1 was dependent on staff for turning/repositioning in bed and for all transfers out of bed. Refer to F658Reference WAC: 388-97-1060

Based on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge for 4 of 10 residents (Residents 3, 13, 8, & 60) and report to receiving hospital for 2 of 10 residents (Residents 13 & 60) reviewed for hospitalization. Failure to ensure a written notification was provided to the resident and/or representative in a language and manner the resident and/or representative understood, notify the LTCO as required of the reasons for the discharge, and give a report to the receiving hospital on resident's condition placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care/preferences, and a break in communication and continuity of care.Findings included .<Facility Policy>Review of an updated May 2025 Transfer and Discharge policy showed when the facility transferred or discharged a resident they would document the transfer or discharge in the medical record and appropriate information would be communicated to the receiving care institution or provider. This policy showed when the transfer or discharge was initiated, the resident would receive written notice using the Resident Notice of Transfer or Discharge form. <Resident 3> According to a 07/03/2025 Discharge Minimum Data Set (MDS – an assessment tool), Resident 3 was transferred to an acute care hospital on [DATE] with their “return anticipated.” Review of a 07/03/2025 Nursing Home Transfer or Discharge Notice showed Resident 3 was being transferred to the hospital and was signed by Staff FF (Social Services) for the notice being provided to Resident 3. In an interview on 09/19/2025 at 1:35 PM, Staff FF stated they complete the Transfer/Discharge notice and fax it to the LTCO within 30 days of the transfer. Staff FF stated they did not provide the form to Resident 3 and/or their representative. <Resident 13> According to a 02/15/2025 Discharge MDS, Resident 13 was transferred to an acute care hospital on [DATE] with their “return anticipated.” Review of a 02/15/2025 progress note showed staff documented Resident 13 was having chest pain and was being sent to the hospital by emergency services. Staff did not document they called the hospital to give report of Resident 13’s status. Review of a 02/15/2025 facility hospital transfer form in Resident 13’s records was blank and not filled out by staff, including the section to document report was called to the hospital. In an interview on 09/23/2025 at 4:34 PM, Staff B (Director of Nursing) stated it was their expectation report be given to the receiving hospital to help prepare the hospital for a resident’s condition and background. Staff B stated staff should document the report was given in a resident’s records. Review of a 02/15/2025 Nursing Home Transfer or Discharge Notice showed Resident 13 was being transferred to the hospital and was signed by Staff FF for the notice being provided to Resident 13. In an interview on 09/19/2025 at 1:35 PM, Staff FF stated they complete the Transfer/Discharge notice and fax them to the LTCO within 30 days of the transfer. Staff FF stated they did not provide the form to Resident 13 and/or their representative. Staff FF stated they do not provide the forms to the residents and/or their representatives unless they were being discharged to the community. <Resident 8> According to a 09/14/2025 progress notes, Resident 8 was hospitalized after an unwitnessed fall. The note showed Resident 8 became short of breath and weak and was sent out by ambulance at 6:40 PM. Record review showed a 09/14/2025 Nursing Home Transfer/Discharge Notice showing Resident 8 transferred to the hospital because their needs could not be met at the facility, signed by Staff FF. In an interview on 09/19/2025 at 1:26 PM, Staff R (Social Services Director) stated when residents transferred emergently to the hospital, the facility's business office notified the State Long Term Care Ombudsman (LTCO) office of the transfer by sending out a batch of Nursing Home Transfer/Discharge Notices monthly. In an interview on 09/23/2025 at 3:09 PM, Staff FF stated they sent notification of Resident 8's transfer to the LTCO but did not notify the resident as required. <Resident 60> According to a 05/15/2025 progress note, Resident 60 was transferred emergently to the hospital that day after a change in their condition. Record review showed 05/15/2025 Nursing Home Transfer/Discharge Notice showing Resident 60 transferred to the hospital because their needs could not be met at the facility, signed by Staff FF. In an interview on 09/19/2025 at 1:35 PM, Staff FF stated they sent notification of Resident 60's transfer to the LTCO but did not notify the resident as required. Record review showed a 05/15/2025 Nursing Home to Hospital Transfer Form. This form had an area for nurses to document and sign off that a report was called in to the hospital. This section did not indicate who, if anyone notified the hospital of the resident's condition. In an interview on 09/23/2025 at 5:09 PM, Staff B reviewed the e-interact form and stated someone should have notified the hospital but there was no indication someone did. REFERENCE: WAC 388-97-0120 (2)(a-d) -0140, (1)(a)(b)(c)(i-iii).

Based on observation, interview, and record review the facility failed to ensure 4 (Residents 5, 67, 53, & 32) of 4 residents reviewed for respiratory care were provided care and services consistent with professional standards of practice. The facility's failure to implement stoma suctioning according to physician orders (Resident 5), obtain physician order prior to administering oxygen therapy (Resident 5), deliver oxygen therapy according to physician ordered flow rates (Resident 67 & 53), and maintain oxygen equipment (Residents 67, 53 & 32) placed residents at risk for potential negative outcomes such as over or under oxygenation, respiratory discomfort, infections, and a decreased quality of life.Findings included .<Facility Policy>Review of a December 2017 Respiratory Care; Oxygen Administration facility policy showed staff would provide oxygen therapy and respiratory care in accordance with physician's orders, state and federal regulation, and standards of practice, and replace cannulas when visibly soiled, and as needed.<Resident 5> According to a 06/25/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 5 had multiple medically complex diagnoses including cancer, required suctioning and stoma care (a surgical opening in the neck into the windpipe). The MDS showed Resident 5 was not assessed to require oxygen therapy. A review of the 09/16/2025 hospital discharge orders showed an order for a sterile triflow catheter and glove kit (a sterile kit used for gentle suctioning and to keep procedure germ-free) for stoma suctioning. In an interview and observation on 09/17/2025 at 9:07 AM Resident #5 stated they received 5 liters per minute (lpm) oxygen therapy via nasal cannula (a tube in the nose that delivers oxygen). Resident 5 stated they were not sure if they really needed oxygen. An observation on 09/17/2025 at 10:14 AM showed Resident 5’s oxygen set at 5 lpm and the nasal cannula was draped over Resident 5’s bedrail. Resident 5 stated they removed the oxygen therapy because they felt fine breathing on room air. A portable suction device was observed on the bedside cabinet with extension tubing connected to oral suction (a hard plastic tube with a rounded end used to remove secretions in the mouth). Observations on 09/18/2025 at 10:24 AM and 1:50 PM showed Resident 5 in bed receiving 5 liters of oxygen therapy via nasal canula. A portable suction device was on the bedside cabinet with extension tubing connected to oral suction. The suction container was observed to be full of dark pink suctioned fluids. An observation on 09/22/2025 at 8:33 AM showed Staff I (Registered Nurse) perform stoma suctioning with the oral suction setup. In an interview on 09/17/2025 at 12:47 PM, Staff H (Resident Care Manager) reviewed Resident 5's physician orders and stated no oxygen therapy was ordered. Staff H stated Resident 5 received oxygen not prescribed by the physician. In an interview on 09/23/2025 at 1:24 PM, Staff B (Director of Nursing) stated Resident 5 requested on admission that oral suctioning be available to them at bedside. Staff B stated they were unaware nurses were using oral suction for stoma suctioning. Staff B stated they expected nurses to clarify orders with providers prior to performing care. Staff B stated oral suction should only be used for mouth secretions and not stoma secretions. In an interview on 09/23/2025 at 1:30 PM, Staff CC (Physician Assistant-Certified) stated they implemented orders for Resident 5’s stoma care and suctioning in accordance with the hospital discharge orders. Staff CC stated they expected staff to clarify suctioning orders. In an interview on 09/23/2025 at 4:34 PM, Staff H reviewed Resident 5's physician order for suctioning and stated the orders lacked specific instructions including method and route. Staff H stated the hospital discharge instructions should have been followed. Staff H stated they were unaware Oral suction suctioning was for oral suctioning only. Staff H stated the hospital discharge orders should have been clarified by nursing and Resident 5’s care plan (CP) should reflect accurate physician orders. <Resident 67> According to the 09/05/2025 Annual MDS, Resident 67 had multiple medically complex diagnoses including heart and respiratory failure. Review of the 02/13/2025 altered respiratory status CP showed nurses were to ensure Resident 67’s oxygen setting was set to 2 lpm. Review of the September 2025 medication administration record (MAR) showed a 03/04/2025 order for the nurses to check oxygen was set to 2 lpm every shift and an order dated 04/09/2025 instructed to change the oxygen tubing as needed and change when visibly soiled. An observation on 09/17/2025 at 9:45 AM showed Resident 67’s oxygen setting was less than 2 lpm. There was no date on the oxygen tubing that showed when the last tubing was changed. In an observation and interview on 09/18/25 at 9:54 AM, the nasal cannula was observed unclean and with debris, the oxygen level was set less than 2 lpm, and the filter on the oxygen machine was covered in dust. Resident 67 stated the nasal cannula had debris on it for the last few days and did not recall when the oxygen tubing was changed. In an interview on 09/19/2025 at 11:06 AM Staff T (Licensed Practical Nurse) stated the oxygen setting was incorrect and was required to be set to 2 lpm. Staff T stated the filter was and they were not aware the filter needed to be cleaned. Staff T stated it was important to check resident’s oxygen settings as the resident may not have enough oxygen. Staff T stated the nasal cannula should not be soiled because there could be a risk of contamination. Staff T stated staff only replaced oxygen tubing when the resident asked and stated they were not aware Resident 67 had debris on their nasal tubing. In an interview on 9/22/2025 at 11:43, Staff B stated staff were required to follow physician orders, check oxygen settings every shift, and change the nasal cannula when soiled. Staff B stated there was no training provided to staff to clean the filters on the oxygen machine. Staff B stated the vendor cleaned the filters annually. <Resident 53> According to a Quarterly MDS Resident 53 had multiple medically complex diagnoses including lung disease, heart failure, and respiratory failure. An observation on 09/16/2025 at 12:30 PM showed Resident 53 lying in bed with an oxygen nasal cannula in their nose. The oxygen concentrator machine was running with the oxygen level set at 3 lpm. The humidifier water bottle was attached to the machine and was almost empty. An observation on 09/19/2025 at 7:54 AM showed Resident 53 with oxygen on running at 3 lpm and an empty humidifier water bottle attached to the machine. Review of an 08/07/2024 physician order showed Resident 53 was to be on continuous oxygen at 2 lpm for heart failure, not 3 lpm as observed on 09/16/2025 and 09/19/2025. There was a 12/12/2024 physician order to change the humidifier bottle as needed. In an interview on 09/19/2025 at 10:30 AM, Staff C stated staff was expected to follow physician orders for oxygen settings and was required to replace the humidifier water bottle when empty. In an observation and interview on 09/19/2025 at 10:52 AM, Staff C observed the oxygen level setting on Resident 53’s machine was set to 3 lpm and the humidifier bottle was empty. Staff C stated Resident 53’s oxygen physician orders needed to be clarified and the humidifier water bottle needed to be replaced. <Resident 32> According to a 06/16/2025 admission MDS, Resident 32 was cognitively intact and had multiple medically complex diagnoses including heart and respiratory failure. This MDS showed Resident 32 required the use of oxygen. An observation on 09/17/2025 at 9:44 AM showed Resident 32 was lying in bed with a nasal cannula in their nose that was brown-orange in color. There was no date on the nasal cannula to indicate when it was last changed. Resident 32’s oxygen concentrator machine had a filter on the back which had a layer of light grey debris covering the entire filter. In an interview on 09/19/2025 at 1:23 PM, Resident 32 stated the nasal cannula was dirty because they got tomato soup on it last week. Resident 32 stated the nasal cannula was changed “a month or two ago.” Review of a 06/12/2025 physician order showed directions to staff to change Resident 32’s oxygen tubing if it becomes damaged or visibly soiled as needed. In an interview on 09/19/2025 at 10:56 AM, Staff C observed the layer of debris on Resident 32’s oxygen concentrator filter. Staff C stated it needed to be cleaned. In an interview and observation on 09/19/2025 at 1:51 PM, Staff O (Resident Care Manager) confirmed Resident 32’s oxygen tubing was visibly soiled and needed to be changed. In an interview on 09/22/2025 at 1:02 PM, Staff B stated, after doing some research, it was their expectation the oxygen concentrator filters should be washed and dried as needed when dirty, and staff should do spot checking every two weeks to assure the filters are clean. REFERENCE: WAC 388-97-1060(3)(j)((iv)(v)(vi). .

Based on interview and record review, the facility failed to develop and implement a system to evaluate staff competencies in skills and techniques to ensure staff provided necessary care and responded to each resident's individualized needs for 7 of 7 sampled staff (Staff I [Registered Nurse - RN] Staff U [Certified Nursing Assistant - CNA], Staff V [CNA], Staff K [CNA], Staff L [CNA], Staff X [RN], & Staff Y [CNA]) reviewed for nursing competency. This failure placed residents at risk of receiving care from under-trained and/or under-qualified care staff, unmet care needs, and diminished quality of life.Findings included .<Facility Policy>The facility was unable to provide a nursing competency policy.<Staff I> According to a 06/25/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 5 had multiple medically complex diagnoses including cancer and required stoma care (a surgical opening). An observation and interview on 09/22/2025 at 8:33 AM showed Staff I (Registered Nurse) administer a toxic cancer therapy medication to Resident 5 without wearing two sets of gloves. Staff I stated they did not receive special instructions on handling toxic cancer treatments. Staff I performed stoma suctioning (a process to remove mucus). Staff I stated they did not receive specific training regarding stoma care or suctioning. Staff I stated they were unaware of any difference between oral and stoma suction techniques. In an interview on 09/23/2025 at 1:24 PM, Staff B (Director of Nursing) stated staff were trained on the proper handling of cancer treatment therapies but did not provide documentation to demonstrate Staff I attended. Staff B stated they expected nurses to understand the basic concepts of oral and stoma suctioning. Staff B stated staff were expected to utilize available training resources, if they were unsure of the requirements for stoma suctioning. <Staff U> Review of the facility’s employee list showed Staff U was hired on 04/11/2025. Review of Staff U’s training records showed a 04/11/2025 “Inservice Education Summary” form signed by Staff U. The form showed the curriculum was General Orientation and the content or summary of the in-service included: Dementia (a group of brain disorders causing a gradual decline in memory, thinking, language, and problem solving), Abuse and Neglect, Bloodborne pathogens (diseases spread through contaminated blood) training, effective communication, hand hygiene, and putting on and taking off Personal Protective Equipment (specialized clothing or equipment worn to protect a person from hazards and prevent exposure to harmful substances or conditions). Review of Staff U’s online training records showed no training regarding safe resident transfers and no documentation of Staff U’s CNA competencies on file. <Staff V> Review of the facility’s employee list showed Staff V was hired on 02/20/2025. Review of Staff V’s training records showed no documentation of CNA competencies on file. <Staff K> Review of the facility’s employee list showed Staff K was hired on 05/22/2025. Review of Staff K’s training records showed no documentation of CNA competencies on file. <Staff L> Review of the facility’s employee list showed Staff L was hired on 04/04/2025. Review of Staff L’s training records showed no documentation of CNA competencies on file. <Staff X> Review of the facility’s employee list showed Staff X was hired on 07/29/2025. Review of Staff X’s training records showed no documentation of nurse competencies on file. <Staff Y> Review of the facility’s employee list showed Staff Y was hired on 08/31/2023. Review of Staff Y’s training records showed no documentation of CNA competencies on file. In an interview on 09/23/2025 at 2:55 PM, Staff W (Staff Development) stated they provided new staff with an orientation checklist upon hire but did not collect them back from employees. Staff W stated they did not yet offer a skills workshop for new hires, but would “in the future.” In an interview on 09/22/2025 at 12:12 PM, Staff W stated assessing the competency of staff was important to make sure staff remained up to date on procedures and to provide safety for the residents by ensuring the facility had competent staff. Staff W stated their expectation was for yearly competencies to be completed. Staff W stated the last skills workshop for staff was held in July 2024, over a year prior. Staff W stated they did not have any documentation showing each staff’s competencies from July 2024 and only had a staff attendance record. Staff W stated they were unable to demonstrate how staff were assessed to be competent with their current process. Staff W opened a binder showing the last time staff competency checklists were completed was February 2023. In an interview on 09/23/2025 at 4:34 PM, Staff B stated having competent staff was important to ensure facility staff followed facility protocols and procedures, and were set up for success. Staff B stated the facility did not want nursing staff to be assigned to care they were not adequately trained for and competent with. Staff B stated they expected staff competency to be assessed on hire and annually thereafter with documentation available in the staff’s employee files. REFERENCE: WAC 388-97-1680. Refer to F689 Free of Accident Hazards/Supervision/Devices.

Based on observation, interview, and record review, the facility failed to ensure meals were prepared to maintain the palatability of the food served for 6 (Residents 16, 2, 60, 33, 53, & 9) of 9 residents reviewed for food. The failure to ensure the food provided looked and tasted palatable placed residents at risk for weight loss, frustration, and a diminished quality of life. Findings included .<Facility Policy>According to the facility's updated November 2018 Preparation and Service of Foods policy, foods should be prepared and served in a manner to provide food safety. <Resident Interviews> <Resident 16> In an interview on 09/16/2025 at 10:40 AM, Resident 16 stated they could not stomach the food the facility served. Resident 16 stated they needed to buy outside food to augment the diet provided at the facility to feel satisfied. Observation at this time showed cans of tuna, instant noodles, puffed corn snacks, and cans of condensed soup. <Resident 2> In an interview on 09/16/2025 at 2:00 PM, when asked about the food Resident 2 stated they complained so many times about the kitchen. Resident 2 stated some of the food served was unidentifiable. Resident 2 stated the menu was repetitive and the food served was bland, often lacking standard condiments such as toast with no butter. Resident Observation on 09/18/2025 at 1:20 PM showed Resident 2 eating taco salad, chips, beans, salsa, sour cream, and lettuce. The taco salad was visually unappealing with the layers of the salad added in a way that appeared spattered and haphazard, with no attention paid to presentation. <Resident 60> In an interview on 09/16/2025 at 12:37 PM Resident 60 stated they were dissatisfied with the food served and spoke with the kitchen but felt there was little dietary staff could do to improve the food. Resident 60 stated they were served the same meals repeatedly. <Resident 33> In an interview on 09/18/2025 at 10:22 AM, Resident 33 stated their main concern at the facility was the taste of the food served. Resident 33 stated the vegetables, especially the zucchini, were consistently mushy. In an observation and interview on 09/22/2025 at 1:46 PM, Resident 33 took their lunch meal apart in an effort to create a better tasting salad because their lunch was not good. Resident 33 stated they tried to put something together that would make the food taste better as the food at the facility did not taste good and neither did the alternative options on the menu. <Resident 53> In an interview on 09/16/2025 at 12:34 PM, Resident 53 stated they felt the food was lousy and “terribly disgusting.” Resident 53 stated they often turned away the food when offered. <Resident 9> In an interview on 09/17/2025 at 8:44 AM, Resident 9 stated they were unhappy with the food and stated, “the eggs are fake.” <Facility Kitchen> Review of the posted menu on 09/23/2025 showed the primary choice for lunch that day was roast turkey, bread dressing, and herbed green beans with wheat bread, and a dessert of baked apple slices. In an interview on 09/23/2025 at 11:12 AM, Staff S (Food and Nutrition Service Manager) stated the facility used a menu with a 35-day cycle. Staff S stated the facility still used the same seasonal menu started in02/18/2025 and was awaiting new menus from corporate. Staff S said the facility had two seasonal menus a year, spring/summer and fall/winter menus. <Test Tray> Observations of a test tray representing regular lunch service for the date on 09/23/2025 at 12:32 PM showed the tray included: -a slice of roast turkey. This slice had two distinct colors, half the slice was the color of standard turkey breast meat, and the other half was a much darker with a gray/brown/pinkish hue that was not appealing. This slice had a temperature of 102 degrees Fahrenheit (F). The turkey slice tasted very salty. - herbed green beans. These beans were [NAME] green in color and had a temperature of 121 F. These beans retained no bean flavor and had a strong, unpleasant garlic/onion/herb aftertaste. - a scoop of bread dressing. This dressing was gelatinous in texture and wobbled as the plate shook. The dressing was not easily identifiable as a particular dish and held the shape of the scoop it was served with on the plate. - a bread roll. - a glass of milk with a temperature of 55 F, too warm to be palatable. - a dessert of apple slices. These apples were brown/yellow in color white, retaining some crispness as if they were not cooked. The apples had a temperature of 59 F. - an unidentified blue cold drink. This drink tasted of sugar and had no other flavor. In total, the lunch tray both looked and tasted unappetizing as observed by four surveyors, confirming residents’ concerns. In interviews on 09/23/2025 from 2:14 PM to 2:20 PM Resident 16 and Resident 2 stated they did not enjoy the lunch they were served that day. In an interview on 09/23/2025 at 2:40 PM, Staff S stated it was important to serve residents meals they enjoyed. Staff S stated the budget they had for procuring ingredients affected the quality of the food they were able to provide. REFERENCE: WAC 388-97-1100 (1), (2).

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a clean environment to help prevent the transmission of communicable diseases for 2 of 2 residents (Resident 2 & 5) and failed to follow enhanced barrier precautions (EBP) for 1 for of 1 residents (Residents 58) and failed to follow standard precautions and wear protective eye covering for 1 of 1 resident (Resident 5) reviewed for Transmission-Based Precautions (TBP - airborne, contact, droplet and enhanced barrier precautions used to prevent the spread of transmissible diseases. The failure to wear PPE (Personal Protective Equipment - gowns, gloves etc.) when caring for resident on TBP and the failure to maintain a clean environment placed residents at risk for facility-acquired/healthcare-associated infections and related complications. Findings included <Facility Policy>According to the facility's updated March 2025 Transmission Based Precautions (TBP) policy, TBP was used in addition to standard precautions (use of personal protective equipment (PPE) such as gloves, gowns, masks, and proper handling of equipment and the resident's environment). The policy showed TBP included residents on contact, droplet, airborne or enhanced barrier precautions (EBP.) When residents were on EBP, staff were required to use gown and gloves during high-contact resident core activities. <Resident 2> According to the 08/28/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 2 used a urinary catheter (a device to assist draining the bladder of urine.) The MDS showed Resident 2 had a kidney condition. Observation on 09/16/2025 at 2:06 PM showed Resident 2's catheter bag hanging from their bedframe. The catheter bag had a slow, steady drip and small puddle of urine pooled in the floor beneath. In an interview on 09/23/2025 at 9:14 AM Staff F (Infection Preventionist) stated they expected both nurses and nurses' aides to prevent, identify, and address leaking catheters timely. <Resident 58> According to a 06/22/2025 annual MDS assessment, Resident 58 had diagnoses that included chronic congestive heart failure, localized edema (swelling) and history of bladder infections. Review of the 06/16/2025 Enhanced Barrier CP showed EBP signage was posted at the resident’s door related to a history of bacteria resistance to antibiotics. The signage was to be posted for high contact resident care such as dressing, bathing, changing linen and providing hygiene. Interventions showed staff were to use gown and gloves during high contact resident care. Observation on 09/18/2025 at 8:52 AM showed EBP signage on Resident 58’s door. Staff P (Certified Nursing Assistant) was observed to provide Resident 58 assistance with putting on their leg wraps to both legs. Staff P did not have a gown on while providing direct care to Resident 58. In an interview on 09/18/2025 at 11:13 AM Staff F stated whenever residents had a history of multidrug resistance, or had any lines or wounds, they would be on EBP. Staff F stated staff were to wear a gown and gloves when providing high contact care for infection control. Staff F stated staff were educated on EBP and should be following the instructions provided. <Resident 5> <Failure to wear eye protection> According to a 06/25/2025 Quarterly Minimum Data Set MDS, Resident 5 had multiple medically complex diagnoses and required stoma care (the cleaning and suctioning of mucus in a surgical opening in the neck) to clear out fluids and protect the airway. During an observation on 09/22/2025 at 8:33 AM, Staff I (Registered Nurse) performed stoma care wearing a gown, gloves, and a face mask, but no eye protection to protect from splashes of mucus during suctioning. In an interview on 09/22/2025 at 9:02 AM, Staff I stated they understood wearing eye protection was expected per facility policy for suctioning, but they had forgotten to wear them when suctioning Resident 5. In an interview on 09/23/2025 at 4:34 PM, Staff H (Resident Care Manager) stated they expected all staff to wear eye protection during the suctioning procedure <Mattress Cover> In an observation on 09/19/2025 at 1:20 PM, a large piece of Resident 5’s protective mattress cover was missing. In an interview on 09/19/2025 at 1:22 PM, Staff II (Certified Nursing Assistant) stated the mattress could not be disinfected due to the missing piece and should be reported to maintenance staff by entering a request into the logbook at the nursing station. Review of the maintenance logbook showed Resident 5’s mattress cover issue was not added. In an interview on 09/19/2025 at 1:23 PM, Staff H (Resident Care Manager) stated the mattress should not be missing the protective fabric because it could not be disinfected. Staff H stated the mattress would need to be replaced. Staff H stated staff were expected to report issues to maintenance when mattresses were torn. REFERENCE: WAC 388-97-1320 (1)(a), (2)(b).

Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) assessments were accurately completed prior to or upon admission to the facility or updated with changes with appropriate follow up with the State PASRR office for 3 of 6 (Residents 67, 60, & 68) reviewed for PASRRs. This failure placed residents at risk for inappropriate placement and/or not receiving timely and necessary services to meet their mental health care needs.Findings included . <Facility Policy>According to the facility's 01/01/2025 PASRR Process Policy, if a Level 2 evaluation was indicated on a Level 1 PASSR screening, the social worker would validate within a timely period that an evaluation should occur. This policy showed if there was a significant change affecting a resident's mental health needs, staff would complete and submit a new Level 1 screening.<Resident 67> According to a 09/05/2025 Annual Minimum Data Set (MDS - an assessment tool) Resident 67 had diagnoses including depression and anxiety. Review of Resident 67's record showed a 10/30/2024 Level 1 screening showing the presence of Serious Mental Illness (SMI) indicators including mood disorders and anxiety. The level I PASSR indicated a PASSR Level II referral was required due to the SMI. Resident 67's records did not show a referral for a PASRR Level II was made until 05/08/2025, seven months after the initial assessment. In an interview on 09/23/2025 at 2:06 PM Staff R (Social Services Director) stated a Level 2 PASSR evaluation was important so residents could receive the help they needed with their mental health. Staff R stated they did not make a referral until May 2025 for Resident 67 and did not demonstrate that a Level II referral was made prior to May 2025. <Resident 60> According to the 08/072025 Annual MDS, Resident 60 had medically complex diagnoses including anxiety and a mood disorder characterized by large changes in mood. The MDS showed Resident 60 took an antipsychotic medication. Review of the 04/16/2025 Level 1 PASRR showed Resident 60 was noted with an anxiety disorder and a mood disorder characterized by large changes in mood. This PASRR showed Resident 60 used an antipsychotic medication. Record review showed a 04/29/2025 email to the facility from the State PASRR office thanking the facility for submitting Resident 60's Level 1 screening. This email was a response to the facility's submission of a Level 1 evaluation. Nothing in the resident's record indicated the facility clarified with the State PASRR office that they already submitted the Level 1 or made further follow up regarding obtaining Level 2 services for Resident 60. In an interview on 09/23/2025 2:52 PM, Staff B (Director of Nursing) stated they would provide any information they could provide showing follow up on Resident 60's PASRR. No further documentation was provided. <Resident 68> According to a 07/11/2025 Quarterly MDS, Resident 68 admitted to the facility on [DATE] and had medically complex diagnoses including an anxiety disorder and required the use of an antidepressant medication during the assessment period. Review of a 04/01/2025 Level 1 PASRR showed hospital staff identified Resident 68 had a SMI indicator but did not identify on the form which SMI as required. This form showed Resident 68 required a Level 2 PASSR referral for having SMI indicators. According to the 04/02/2025 Level 2 PASRR evaluation, Resident 68 was determined not to have any SMI, including an anxiety disorder, due to “no known diagnoses of mental health per chart review” at the hospital. Review of Resident 68’s physician orders showed on 05/20/2025 an antidepressant medication was prescribed to treat an anxiety disorder. Resident 68 continued to receive medications for anxiety and a diagnosis of generalized anxiety disorder was added to the resident’s diagnosis list in the resident’s records. Review of Resident 68’s September 2025 Medication Administration Record (MAR) showed the resident still received an antidepressant medication twice daily for their anxiety disorder. In an interview on 09/23/2025 at 1:43 PM, Staff R stated it was their expectation Level 1 PASRRs were updated with any changes in diagnoses or SMI changes. Staff R stated accurate PASRRs were important to ensure a resident’s mental health needs were addressed. Staff R reviewed Resident 68’s records and stated a new Level 1 PASRR was required. REFERENCE: WAC 388-97-1915(1)(2)(a-c)(4).

Based on observation, interview, and record review the facility failed to ensure physician orders were followed for 4 residents (Residents 64, 67, 2, & 3), failed to ensure physician orders were clarified for 2 residents (Resident 68 & 3), and failed to obtain physician orders prior to providing treatment for 1 resident (Resident 32) of 19 residents reviewed. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes.Findings included .<Clarification of Orders> <Resident 68> Review of Resident 68’s September 2025 Medication Administration Records (MAR) showed two separate orders for a laxative suppository to be given as needed for constipation and two separate orders for a laxative enema (rectal administration of a medication) for constipation. There were no directions to staff to indicate which orders should be given over the other orders. In an interview on 09/23/2025 at 10:42 AM, Staff C (Resident Care Manager) stated duplicate orders should be clarified due to the risk of medication errors if administered together. <Resident 3> Review of Resident 3’s physician orders showed a 07/22/2025 order that the resident was to receive nothing by mouth and had a feeding tube (a tube which entered the stomach through a small opening in the abdomen to provide nutrition, fluids, and medications) for their route of medication administration. Review of Resident 3’s September 2025 MAR showed several medications were ordered to be administered by mouth. In an interview on 09/23/2025 at 10:42 AM, Staff C stated Resident 9 should not receive any medications by mouth and stated the orders should have been clarified. <Obtaining Orders> <Resident 32> According to a 07/16/2025 admission Minimum Data Set (an assessment tool), Resident 32 was at risk for pressure ulcers and had a pressure ulcer and a surgical wound. Observations of wound care on 09/18/2025 at 11:12 AM showed Staff EE (Licensed Practical Nurse) provided wound care to Resident 32’s left outer hip and buttocks. During the observation a bordered dressing, dated “9/16”, was observed to Resident 32’s left lower leg. When asked about the dressing to the left lower leg, Staff EE stated there used to be a wound but now the dressing was used only as precaution and for protection. Staff EE removed the dressing to the left lower leg and stated, “it looks like your leg opened again.” Observation showed a small amount of bleeding and superficial skin tear. Staff EE repositioned Resident 32 and two other undated dressings were observed on Resident 32’s right inner knee and right outer calf. Staff EE stated the dressings on the knee and calf were used for protection. Review of Resident 32’s physician orders showed no orders directing staff to apply, change, or monitor the dressings to the resident’s left and right lower legs or their right knee. In an interview on 09/23/2025 at 4:34 PM, Staff B (Director of Nursing) stated nurse staff were expected to obtain orders from a physician prior to applying dressings on residents. Staff B stated obtaining orders and monitoring skin areas under protective dressings routinely was important to ensure no skin breakdown occurred. <Following Physician Orders> <Resident 64> According to the 06/24/2025 Quarterly Minimum Data Set (MDS-an assessment tool) Resident 64 had medically complex conditions including central pain syndrome and partial paralysis. Review of a 12/16/2024 physician order, showed a pain medication film to be administered every 8 hours as needed for pain ranging from 6 to 10 on the pain scale. (1 being the least amount of pain to 10 being the highest level of pain. Review of the September 2025 Medication Administration Record (MAR) showed on, 09/5/2025, 09/16/2025, 09/18/2025, 09/21/2025, 09/22/2025,09/24/2025,09/25/2025, 09/26/2025 and 09/29/2025, staff gave Resident 64 the as needed pain film medication without documentation of their pain level. On 09/9/2025 and 09/12/2025 Resident 64’s was administered the pain film medication and pain level 5 was documented which was lower than the parameters shown on the physician order. Review of an 01/24/2025 physician order showed a pain medication was to be administered every 8 hours as needed for a pain level of 1 to 5 out of 10. Review of the September 2025 MAR, showed on 09/03/2025, 09/04/2025, 09/06/2025, 09/10/2025, 09/11/2025, 09/13/2025, 09/15/2025, 09/17/2025, 09/18/2025, 09/19/2025 and 9/28/2025, Resident 64 was administered the pain medication with a documented pain level above 5; which was above the parameters listed on the physician order. <Resident 67> According to the 09/05/2025 Annual MDS, Resident 67 had medically complex conditions including respiratory failure, heart failure and hypertension. Review of a 03/03/2025 physician order showed an order for pain medication to administer every 4 hours as needed for a pain level of 6 to 10 on a pain scale of 1 to 10. Review of September 2025 MAR showed the pain medication was given on day shifts on 09/15/2025, 09/17/2025, 09/18/2025 and on the evening shifts on 09/16/2025, 09/17/2025, 09/18/2025, when Resident 67 pain level was documented less than 6. In an interview on 9/22/2025 at 12:14 PM, Staff B (Director of Nursing) stated staff was expected to follow the physician order and administer medications within the prescribed parameters. <Resident 2> According to the 08/28/2025 Quarterly MDS Resident 2 was dependent on staff for toileting and was always incontinent of bowel. Record review showed Resident 2 had three different medications to treat constipation: a 02/13/2025 order for rectal medication every 24 hours as needed to treat constipation, a 07/17/2025 order for a soluble powder, give 17 grams every 12 hours as needed for constipation, and a 11/19/2024 order for an oral medication every 24 hours as needed for constipation. The three orders did not instruct staff which medication to give first, what order the medications should be given, how long to wait before determining whether the medication was effective, or when to try another treatment. In an interview on 09/23/2025 at 2:52 PM, Staff B stated that because of Resident 2’s refusals of medications, routine administrations were changed to “as needed.” Staff B stated staff should have clarified directions when new orders were received, but clarification was not done. <Resident 73> According to the 09/10/2025 admission Nursing Evaluation, Resident 73 was admitted to the facility on [DATE]. The evaluation showed Resident 73 required dialysis (a treatment for kidney disease). In an interview on 09/17/2025 at 10:37 AM Resident 73 stated they did not receive dialysis for 7 days, since admission on [DATE]. Review of Resident 73’s admission physician orders showed a 09/10/2025 order for “Dialysis Days: ___ Pick Up Time: ___ Dialysis Location: [Emergency Department] *Notify dialysis provider of refusal or missed treatment to determine orders needed.” A 09/17/2025 physician order showed “Dialysis PRN [as needed] at … Emergency Department” According to a 09/11/2025 nursing progress note, the facility received a call from a hospital inpatient dialysis department explaining Resident 73 was not an established patient at the hospital and could not be treated. The progress note showed the hospital only provided inpatient dialysis, not outpatient. In interview on 09/22/2025 at 12:36 PM, Staff B stated Resident 73’s dialysis orders were incomplete and should have been clarified by staff. Staff B stated the incomplete dialysis orders did not meet Resident 73’s dialysis needs. REFERENCE: WAC 388-97 -1900 (1), (6)(a-c).

Based on observation, activity, and record review the facility failed to ensure residents were provided a program of meaningful, life enriching activities for 2 (Residents 60 & 3) of 6 residents reviewed for activities. This failure placed residents at risk for boredom, frustration, a diminished quality of life, and social isolation. Findings included .<Facility Policy>According to the facility's July 2015 Activity Program policy, the facility would provide an ongoing program of activities designed to meet the interests of, as well as the physical, mental, and psychosocial needs of each resident. The policy showed the Activity Director was responsible for program implementation and showed the program should promote residents' physical, mental, and emotional wellbeing.<Resident 60> According to the 08/07/2025 A Minimum Data Set (MDS - an assessment tool) Resident 60 had moderate memory impairment and reported they felt down, depressed, or hopeless on 12-14 days of the assessment's 14-day lookback period. The MDS showed participating in their favorite activities was very important to Resident 60, and participating in group activities was somewhat important. The MDS showed Resident 60 was totally dependent on staff assistance to get out of bed. According to the revised 06/25/2025 Resident has stated a preference for independent activity in her own room. Enjoys going outside with group for socialization . Care Plan (CP), Resident 60 had a goal to socialize in a group setting at least 3 times per week . Review of the activity program charting showed from showed activities staff charted Resident 60 only participated in one-to-one visits and group activities from 08/24/2025 and 09/20/2025. There were no instances documented of Resident 60 participating in or refusing to attend group activities. According to an 08/26/2025 activity progress note Resident 60's favorite activities were watching movies, listening to music, using their tablet, watching television, and online shopping. In an interview on 09/16/2025 at 12:39 PM Resident 60 expressed dissatisfaction with the activities programs they were offered. Resident 60 stated when they used to smoke, they had more social interactions with other residents but since they returned from the hospital, they did not get out of bed anymore and needed more to do. Resident 60 stated all the Activities department did for them was deliver their mail and packages. Resident 60 stated it was really depressing. In an interview on 09/22/2025 at 12:13 PM, Staff M (Activity Director) stated the purpose of the activity program was to ensure residents had meaningful activities while at the facility as it was their home at the time. Staff M stated the activity program was a way to provide socialization, and ensure residents' leisure needs met, were especially for the residents confined to their room. Staff M stated group activities were important as they provided opportunities to socialize and engage with peers. Staff M stated for resident with mobility issues they coordinated with nurses' aides who helped get the residents to their activity of their preference. Staff M stated it was important to encourage and assist residents with barriers to activity participation, including shyness. Staff N stated all activities charting was done in the electronic chart and would include documentation of refusals to participate. Staff M reviewed Resident 60's activity charting and stated it was time to reassess Resident 60's activity needs. Staff M stated Resident 60 showed less interest in group activities lately, but they did not document any refusals for Resident 60. <Resident 3>According to 07/16/2025 admission MDS, Resident 3 had intact hearing and a severe memory problem. The MDS showed listening to music and participating in their favorite activities was very important to Resident 3. The MDS showed Resident 3 was unable to get out of bed at the time of the assessment due to safety concerns. According to the 07/17/2025 Activities CP, Resident 3 preferred in-room activities and had supplies for independent activities. This CP showed Resident 3 preferred classical, instrumental, piano, orchestral/symphonies, and religious music. Observation on 09/17/2025 at 9:21 AM showed Resident 3 lying in bed, sleeping, with no activity supplies available within reach. There was a rolled-up musical keyboard noted in a box out of reach of the resident on another bed. In an interview on 09/19/2025 at 10:36 AM Resident 3 stated they liked to play piano and would love to play every day. Resident 3 stated it had been some time since anyone offered them their keyboard to play. Resident 3 stated they wished to keep busier. At that time Resident 3’s keyboard was observed to remain rolled up inside the box it came in on the other bed. In an interview on 09/19/2025 at 1:10 PM Resident 3 expressed they had little to do. Resident 3 was observed staring at their ceiling with no stimulation. In an interview on 09/18/2025 at 9:51 AM, Resident 3’s spouse stated Resident 3 was a pianist prior to their change in medical status. Resident 3’s spouse stated the resident had a piano that fit on the overbed table and lit up when played. Resident 3’s spouse stated they hoped facility staff would help set it up for Resident 3 and wanted the resident to have more to do to keep their mind active. In an interview on 09/23/2025 at 2:12 PM Staff M stated they rounded with residents once a week and verbally checked in with them to see if they were satisfied with the activities available to them. Staff M stated they did not document these discussions with residents. Staff M stated Resident 3 was last provided access to their keyboard the prior week and was usually offered in-room activity assistance once a week. Staff M stated for residents unable to leave their room, once a week was not sufficient and more engagement would be appropriate. REFERENCE: WAC 388-97-0940 (1).

Based on observation, interview, and record review the facility failed to provide adequate supervision to prevent avoidable accidents for 1 of 3 residents (Residents 9) reviewed for falls. This failure placed residents at risk for additional falls, discomfort, and substantial injuries.Findings included .<Resident 9> According to a 07/14/2025 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 9 had clear speech, was understood, and was able to understand others. The MDS showed Resident 9 had multiple medically complex diagnoses including obesity and muscle weakness, required substantial assistance from staff to roll side to side in bed, and was dependent on staff for transfers from their chair to bed. Observation on 09/17/2025 at 9:04 AM showed Resident 9 lying in bed. In an interview at this time, Resident 9 stated they had previous falls but was unsure when the falls occurred. In an interview on 09/19/2025 at 8:00 AM, Resident 9 stated they had a fall the previous night when two staff members were transferring them to bed. Resident 9 stated staff were using a slide board for the transfer when the resident started slipping, and staff assisted them to the floor. Observation at this time showed a slide board in Resident 9’s room. Review of the revised 12/19/2022 fall Care Plan (CP) showed Resident 9 was at risk for falls and directed staff with an identified goal the resident would be free of falls through the next review. Review of a 10/20/2023 baseline CP showed directions to staff that Resident 9 was dependent on staff for transfers and used a mechanical lift for transfers. In an interview on 09/23/2025 at 10:28 AM, Staff AA (Certified Nursing Assistant - CNA) stated they review resident CPs to determine what care a resident required. Staff AA stated they transfer Resident 9 using a mechanical lift and stated the resident only transfers using a slide board when working with therapy. In an interview on 09/23/2025 at 10:42 AM, Staff C (Resident Care Manager) stated it was their expectation staff followed a resident’s CP and staff should be trained with a resident prior to performing transfers using a slide board. In an interview on 09/23/2025 at 2:22 PM, Staff Y (CNA) stated they were asked to assist another CNA with a transfer for Resident 9 on 09/19/2025. Staff Y stated Resident 9 was usually transferred using a mechanical lift but was told by the other CNA the resident used a slide board for transfers now. Staff Y stated Resident 9 began to slide during the transfer, so they assisted the resident, using a gait belt, to the floor and got a nurse. Staff Y stated they were not trained to use a slide board with Resident 9 for transfers. In an interview on 09/23/2025 at 2:28 PM, Staff BB (Director of Therapy) stated therapy was currently working with Resident 9 on slide board transfers and nursing was still using mechanical lifts for transfers. Staff BB stated therapy did not train nursing staff to use the slide board and they did not clear nursing staff to use the slide board for Resident 9 yet. In a phone interview on 09/23/2025 at 3:39 PM, Staff U (CNA) stated they were assisting with Resident 9’s transfer on 09/19/2025 using a slide board. Staff U stated Resident 9 told staff they used a slide board for transfers and there was a slide board in the resident’s room. Staff U stated Resident 9 started to slide during the transfer and was assisted to the floor. Staff U stated they did not receive training for slide board transfers from the facility but had used one previously. In an interview on 09/23/2025 at 4:34 PM, Staff B (Director of Nursing) stated it was their expectation staff follow a resident’s CP interventions, update and revise them as needed, and that staff were adequately trained to decrease the risks of injuries and accidents. REFERENCE: WAC 388-97-1060(3)(g). Refer to 726 Competent Nursing Staff.

Based on observations, interviews, and record review the facility failed to assess the resident for bowel and bladder needs or provide the necessary care and services to ensure bowel and bladder continence was improved or maintained for 1 of 1 residents (Resident 9) reviewed for bowel and bladder needs. This failure left the resident at risk for unmet care needs, avoidable incontinence, and decreased quality of life.Findings included .<Facility Policy>Requested policy on 09/22/2025 and 09/25/2025 regarding bowel and bladder assessments. Facility was unable to provide a policy as requested.<Resident 9>According to a 07/14/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 9 had clear speech, understands, and was understood by others. This MDS showed Resident 9 required substantial assistance from staff to roll side to side in bed, was dependent on staff for bed to chair transfers and toileting hygiene, had no rejection of care, and was always incontinent with bowel and bladder.Review of a 10/18/2025 urinary incontinence Care Area Assessment (CAA) showed Resident 9's CAA was triggered due to the resident always being incontinent of bladder and being dependent on staff for assistance with toileting. The type of incontinence section was left blank by staff.Review of a10/20/2023 baseline Care Plan (CP) showed the goal for Resident 9 was to have their toileting needs met. Interventions identified showed Resident 9 was incontinent for toileting and required substantial assistance from staff with toileting transfers. Review of a 01/18/2024 potential for development of incontinence CP showed interventions to manage Resident 9's incontinence with adult incontinence products.Observations on 09/17/2025 at 9:09 AM showed Resident 9 lying in bed. In an interview at this time, Resident 9 stated they had a hard time sleeping at night because they wore incontinence briefs. Resident 9 stated they could feel when they needed to use the bathroom and stated they have worn incontinence briefs since admission because the staff wanted the resident to wear them. Resident 9 stated the facility did not attempt a toilet training program with the resident.Review of Resident 9's 12/01/2022 admission evaluation showed the resident was continent of bowel and had regular urinary frequency. Review of the quarterly nursing review evaluations from 03/01/2023, 06/01/2023, 09/04/2023, 12/04/2023, 03/04/2024, 06/06/2024, 09/06/2024, and 12/06/2024 showed staff documented there were no changes noted for Resident 9's bowel and bladder since the past review.In an interview on 09/23/2025 at 10:28 AM, Staff AA (Certified Nursing Assistant) stated Resident 9 always used an incontinence brief and was incontinent of both bowel and bladder. Staff AA stated they never saw Resident 9 use a toilet or bedpan and were unsure if they were tried on a toileting program. Staff AA stated they offer to brief changes to Resident 9 and their brief was usually wet.In an interview on 09/23/2025 at 10:42 AM, Staff C (Resident Care Manager) stated the facility did not have bowel and bladder assessments and they relied on the CP to review a resident's bowel and bladder status. Staff C stated Resident 9 was incontinent and therefore was not tried on a toileting program. Staff C reviewed Resident 9's records and was unable to provide a bowel and bladder assessment or toileting plan.In a joint interview with Resident 9 and Staff C on 09/23/2025 at 11:00 AM, Resident 9 reported to Staff C they did not like wearing the incontinence briefs and had difficulty sleeping because they were uncomfortable. Resident 9 stated they were able to feel when they needed to use the toilet. When Staff C asked Resident 9 if they would be willing to try a toileting plan and/or use a bed pain, Resident 9 stated, yes and smiled.In an interview on 09/23/2025 at 4:34 PM, Staff B (Director of Nursing) stated the facility did not currently have a bowel and bladder assessment process in place. Staff B stated the assessments were important in order to put a proper CP in place and set a resident up for success. Staff B stated it was their expectation a bowel and bladder assessment was completed on admission and quarterly with their MDS.REFERENCE: WAC 388-97-1060(3)(c).

Based on observation and interview, the facility failed to ensure a safe, sanitary, and homelike environment was maintained for 1 (Resident 5) of 1 sampled resident. These failures left the resident at risk for a diminished quality of life and a less than homelike environment.Findings included .<Resident 5> Observation on 09/17/2025 at 9:07 AM showed Resident 5 lying in bed watching television. A 3-drawer cabinet was observed under the television with numerous packages of personal care items and medical supplies on top of the cabinet. Next to the cabinet was a bedside table with several boxes of medical dressing supplies. Underneath the bedside table was an open cardboard box with numerous supplies inside. Between the cabinet and the bedside table were two baskets with disposable medical supplies. The extra bed in the room had a green lift harness draped across the end of the bed with more supplies scattered across the bed. In an interview on 09/17/2025 at 9:33 AM, Resident 5 stated they felt the room was not orderly like they would expect to see at home. Resident 5 stated they would prefer the items remained easily available but not as disorganized and visible. In an observation on 09/18/2025 at 10:24 AM, Resident 5's room appeared unchanged with disorganized medical supplies and personal items. In an interview on 09/18/2025 at 10:42 AM, Staff H (Resident Care Manager) observed Resident 5's room and stated items had begun to pile up, but they thought Resident 5 preferred it that way. Staff H stated Resident 5's room appeared cluttered and disorderly with the lack of storage for supplies. Staff H stated they agreed there was room for improvement to achieve a homelike environment. REFERENCE: WAC 388-97-0880.

Based on interview and record review, the facility failed to facilitate quarterly care conferences for 2 of 3 residents (Resident 6 & 33) reviewed for care conferences. This failure placed residents at risk for unmet care needs, unnecessary care, frustration, and other negative health outcomes.<Resident 6>According to a 08/15/2025 re-entry Minimum Data Set (MDS-an assessment tool), Resident 6 had clear speech, understands, and was understood by others.In an interview on 09/16/2025 at 1:30 PM, Resident 6 stated no one at the facility talked to them about their care and stated they did not have a care conference recently.Review of Resident 6's records showed the last care conference was on 03/28/2025. A progress note dated 05/08/2025 showed the resident refused a care conference on that day. The progress notes did not show any further care conferences were scheduled.In an interview on 09/25/25 at 10:47 AM Staff GG (Social Services Director) stated care conferences were important to make sure everybody including staff and residents were on the same page. Staff GG stated during care conferences discussion were made about any updates to the care plan or discharge plan, and advanced directives were reviewed. Staff GG stated the care conference also provides an opportunity for the resident to ask questions about their care. Staff GG stated the facility conducted quarterly care conferences on all residents. Staff GG stated the last conference for Resident 6 was in March 2025 and no other conferences were scheduled for Resident 6. Staff GG stated they attempted a care conference in May 2025. Staff GG stated there was no upcoming care conferences scheduled at this time for Resident 6 but there should be. <Resident 33>According to the 07/10/2025 Quarterly MDS, Resident 33 had clear speech, understands, and was understood by others. The MDS showed Resident 33 had medically complex conditions.Review of the revised 01/30/2024 Depression Care Plan (CP) showed staff were to discuss with the resident, family, caregivers any concerns, fears, or issues regarding health or other subjects.In an interview on 09/18/2025 at 10:22 AM, Resident 33 stated they had many concerns about the food at the facility, was unsure if the facility had their family member listed as an emergency contact, and stated they would like to speak with a mental health specialist. Resident 33 stated the facility did not talk to them about their concerns.In an interview on 09/22/2025 at 1:46 PM, Resident 33 stated they did not talk with staff about their care. Resident 33 stated they only talked with the facility's physician assistant because the staff do not talk to them. Resident 33 stated the staff did not understand their panic and fear and wished they did.In an interview on 09/25/25 at 10:47 AM Staff GG stated Resident 33's last care conference was in February 2025, and the social services team missed scheduling a quarterly care conference since then. Staff GG stated they were not aware of any mental health behaviors Resident 33 was experiencing and were not aware of mental health providers following Resident 33 for their anxiety and panic behaviors, but there should be. REFERENCE: WAC 388-97-1020(2)(d-e),(4)(c-f),(5)(b).

Based on interview and record review, the facility failed to reassess the resident after a significant change in function lasting more than 14 days occurred for 1 (Resident 60) of 19 sample residents. The failure to identify the need for a Significant Change in Status Assessment (SCSA - an assessment tool) after Resident 60 had a decline in their condition placed the resident at risk for unmet care needs and a diminished quality of life. Findings included .<Resident 60>In an interview on 09/16/2025 at 12:56 PM Resident 60 stated they went to the hospital emergently because of bleeding. Resident 60 stated they used to get up and go outside to smoke but since returning from the hospital they could no longer get out of bed. Resident 60 was observed to be in bed at this time.Record review showed Resident 60 was hospitalized from [DATE] and returned to facility on 05/24/2025.According to the 08/07/2025 Annual Minimum Data Set (MDS - an assessment tool) Resident 60 was scored at 00 out of a possible 27 points on a scale indicating no current mood/depression concerns. This MDS showed Resident 60 rejected care one-to-three times during the assessment's lookback period. This MDS showed Resident 60 was totally dependent on staff assistance with upper body dressing, moving from lying to sitting/lying to sitting, and required partial/moderate assistance with rolling from side to side in bed.Review of the 03/31/2025 Quarterly MDS (the last MDS assessment completed prior to the 05/15/2025 hospitalization) showed this was the last MDS assessment completed prior to Resident 60's hospitalization. This MDS showed Resident 60 was scored at 10 out of a possible 27 points on a scale indicating the presence of mood/depression concerns. This MDS showed Resident 60 did not reject care during the assessment's lookback period. This MDS showed Resident 60 required partial/moderate assistance with upper body dressing, was independent with rolling from side to side in bed, moving from lying to sitting/lying to sitting.In an interview on 09/23/2025 at 10:08 AM Staff B (Director of Nursing) compared the information on the 03/31/2025 and 08/07/2025 MDSs and stated they believed Resident 60's declines in three care areas represented a significant change required a SCSA assessment.In an interview on 09/25/2025 1:47 PM Staff N (Corporate MDS Consultant) stated because Resident 60 had sustained declines in their mood, rejection of care, and functional abilities, a SCSA assessment should have been completed after 14 days, but was not.REFERENCE: WAC 388-97 -1000 (3)(b).

Based on observation, interview, and record review the facility failed to provide a comfortable, appropriately sized bed for 1 of 1 resident (Resident 64) reviewed for accommodation of needs. This failed practice placed the resident at risk for discomfort and skin issues.Findings included .<Resident 64>According to a 06/24/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 64 had multiple medically complex diagnoses including partial paralysis and a pain syndrome. The MDS showed staff assessed Resident 64 to have a functional limitation in their range of motion to both their arms and legs and was dependent on staff for their mobility with rolling side to side. In an interview on 09/18/2025 at 10:11 AM, Resident 64 was observed lying in their bed with their feet propped up on pillows over the top of the footboard and their head positioned higher than the top of their mattress. Resident 64 stated they were always uncomfortable when trying to sleep or eat in their bed and described their bed as too small. Resident 64 stated their mattress bowed like a banana with the foot and the head of the bed always raised compared to the middle. Resident 64 stated they asked staff multiple times to help with their mattress because they felt crunched up in bed. Resident 64 stated they were told by maintenance staff their bed was extended to make their bed longer, but the mattress was too small, and a foam spacer was used between the mattress and footboard to fill the extra space. Resident 64 stated the spacer sometimes fell out of place and slid under their mattress. Resident 64 stated they told several staff about this and were told there was nothing else they could do to fix the bed for them.At that time, the foot of the mattress was observed to tilt up and was placed on top of the foam spacer instead of in between the mattress and bed frame. Resident 64 demonstrated how they used the bed remote control to lower the foot of their bed so they could reposition themselves and demonstrated the foot of their bed could not go down to a fully flat position. The foam spacer was under Resident 64's mattress and prevented the mattress from lying flat. Resident 64 stated their bed was very uncomfortable because it was small and the foot of the bed being positioned upwards made it more difficult for the resident to position themself on the side of their bed.Observations on 09/18/2025 at 10:11 AM and 1:29 PM and on 09/19/2025 at 8:52 AM showed the foot of Resident 64's mattress was in an inclined position on top of the foam spacer instead of the spacer being between the mattress and the bed frame.In an observation and interview on 09/19/2025 at 8:52 AM Staff P (Certified Nursing Assistant) stated they were not aware of issues with Resident 64's bed. At this time, Resident 64 told Staff P they could only partially sit up because the foot of the mattress could not fully go down, making it harder for the resident to sit comfortably to eat. Staff P observed Resident 64's foot of bed was tilted upwards and stated there was nothing they could do to adjust the bed, and they would call maintenance to fix it. In an interview on 09/19/2025 at 9:12 AM Staff Q (Resident Care Manager) stated they knew Resident 64's bed mattress moved when they sat along the side of their bed. Staff Q stated the bed was extended as far as it could to accommodate Resident 64's height. Staff Q stated Resident 64's mattress was too small for the extended bed, and a spacer was used between the shorter mattress and the extended footboard. Staff Q stated they were not aware the spacer could slide under Resident 64's mattress making the foot of the bed elevated, and stated Resident 64 would have to call staff to fix the bed each time they were uncomfortable so they could adjust their bed. Staff Q stated there was nothing else they could do to fix Resident 64's bed as their bed was a standard facility bed. Staff Q stated even though Resident 64 was taller than the bed they should still be made comfortable. In an interview on 9/22/2025 at 12:14 PM Staff B (Director of Nursing) stated the facility changed the bed mattress several times and was not aware the bed could not be completely lowered with the foam spacer configuration. Staff B stated the spacer should not have caused problems for Resident 64 and stated the resident needed a longer, more comfortable bed without having to use a spacer. Staff B stated the facility had longer beds to accommodate residents who were taller, and Resident 64 should be provided with a longer bed for comfort and to accommodate their needs but was not. REFERENCE: WAC 388-97-0860(2).

Based on interview and record review, the facility failed to ensure thorough investigations were completed timely for 1 of 2 residents (Resident 6) reviewed for abuse and 1 of 1 (Resident 8) reviewed for falls. Failure to ensure investigations were thorough and completed timely placed residents at risk for further injuries, potential abuse/neglect, and other negative health outcomes.Findings included .<Facility Policy>According to the facility's updated October 2022 Abuse Investigation policy, the facility would complete a thorough investigation of any potential/suspected instances or allegations of abuse, neglect, or exploitation in accordance with state laws. <Resident 6> According to a 08/15/2025 re-entry Minimum Data Set (MDS - an assessment tool) Resident 6 had clear speech, could understand, and was understood by others. In an interview on 09/16/2025 at 1:19 PM Resident 6 stated a staff member was not very nice to them and took their charging power bank with a flashlight. Resident 6 stated they won the power bank in a facility activity, and they wanted the power bank back. Resident 6 stated they talked to Staff JJ (Activity Assistant) about this, and Staff JJ asked them why they kept bothering them about the power bank as the facility provided them with an cell phone with a flashlight and they should be happy about this. Resident 6 stated other staff and residents were in the activity room when the incident occurred and stated they felt Staff JJ was verbally abusive to them when they spoke to them in this manner. Resident 6 stated no one had talked to them about the incident again and they were still upset the power bank was not returned to them. In an interview on 9/18/2025 at 1:17 PM Resident 6 stated no one talked to them again about this incident and they feared retaliation by the staff. Review of investigation notes dated 09/17/2025 showed an investigation was started and called into the state per regulation. The completed investigation notes did not include a full investigation that included other resident interviews or interventions. The investigation did not include a staff background check for the staff involved. Review of the investigation did not show the care plan was updated or that staff was provided with education on reporting verbal abuse. The facility did not provide a full investigation of the incident upon request. <Resident 8> According to the 06/29/2025 Quarterly MDS, Resident 8 had diagnoses including heart failure and a progressive neurological disorder affecting movement, balance, and coordination. The MDS showed Resident 8 had intact hearing, vision, and memory. The MDS showed Resident 8 had no history of falling. According to 09/14/2025 progress notes, Resident 8 was overheard calling for help that afternoon and was found on the floor. Resident 8 stated they slid from their bed trying to get up and did not bump their head. The notes showed around 6:25 PM, Resident 8 reported shortness of breath and was noted to be unable to rise from their bed. Resident 8 was transferred to the hospital at that time. In an interview on 09/23/2025 at 9:29 AM, Staff Z (Registered Nurse) stated the facility did not complete an investigation into Resident 8's fall on 09/14/2025, nine days prior. Staff Z stated they returned from vacation the prior day and the facility had an unusually large number of incidents to investigate in their absence. Staff Z stated adequate arrangements were in place to manage their workload in their absence. REFERENCE: WAC 388-97-0640 (6)(a)(b).

Based on observation, interview, and record review, the facility failed to ensure a person-centered comprehensive Care Plan (CP) was implemented for 1 of 6 residents (Resident 1) whose CP was reviewed for assistance with Activities of Daily Living (ADLs). The failure to implement identified CP interventions for safety and adhere to individualized care of residents with identified behaviors affecting provision of ADL care placed residents at risk for potential abuse and/or neglect, inconsistent and/or inadequate care, worsening resident behaviors, and a decreased quality of life. Findings included . <Resident Assessment Instrument - RAI> The October 2023 Long-Term Care Facility RAI 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents) showed clinical competence, observational, interviewing and critical thinking skills, and assessment expertise form all disciplines were required to develop individualized CP's. The manual showed the CP (together with the established goals and interventions) become each resident's unique path towards achieving or maintaining their highest practical level of well-being. <Resident 1> According to the 08/15/2024 Annual Minimum Data Set (MDS - an assessment tool), Resident 1 had clear speech, intact memory, and with serious mental illnesses including anxiety, depression, and extreme shifts in mood. The MDS showed Resident 1 exhibited rejection of care behaviors and was administered both antipsychotic and antidepressant medications during the assessment period. A 10/11/2024 behavior CP showed Resident 1 had ineffective coping skills, was at risk for impaired psychosocial well-being, and had a history of unsubstantiated allegations involving staff regarding ADL care. A 10/11/2024 CP intervention instructed staff to perform care in pairs. In an observation and interview on 11/18/2024 at 11:32 AM, Resident 1 was observed lying in bed and a cares in pairs sign was posted on the wall. Resident 1 stated they informed the facility about a staff who was rough with them while providing incontinent care. Resident 1 stated the staff was alone when care was provided. Review of the 11/04/2024 facility incident report showed Resident 1 stated they were manhandled by Staff D (Certified Nursing Assistant - CNA) during ADL care. The report showed Staff D was providing Resident 1 incontinent care by themself, was dismissed by Resident 1 after the resident felt they were being mistreated, and Staff E (CNA) came and relieved Staff D. The report showed both Staff's D and E worked alone with Resident 1 and did not follow the resident's CP of providing care with two staff present. In an interview on 11/18/2024 at 1:06 PM, Staff B (Risk Manager) stated their investigation of Resident 1's concern regarding rough care by staff confirmed both Staff's D and E were alone and did not provide care in pairs. In an interview on 11/18/2024 at 2:25 PM, Staff C (Resident Care Manager) stated staff must use the CP as their guide in taking care of residents for safety. Staff C confirmed Resident 1 was to receive care in pairs and stated they expected all staff to follow the CP as written. Staff C stated they were aware both Staff's D and E did not follow the CP when they provided Resident 1 ADL care alone. In an interview on 11/18/2024 at 2:31 PM, Staff A (Director of Nursing) stated they expected CNAs to review the resident's Individual Service Plan (ISP) for the level of care needs necessary for safe care, follow the CP as written, and implement resident-specific interventions identified for the residents. Refer to F745- Provision of Medically-Related Social Services. REFERENCE: WAC 388-97-1020 (1), (2)(a).

Based on interview and record review, the facility failed to: Provide medically-related social services to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of residents; assist residents in obtaining resolution to their grievances regarding refusals of treatment and care; and advocate for residents in the assertion of their rights within the facility for 1 of 6 residents (Resident 1) reviewed for behavioral health. This failure placed residents at risk of unmet social service needs, unsafe care, psychosocial decline, and a diminished quality of life. <Facility Policy> The Comprehensive Resident Care Plan [CP] facility policy, revised July 2015, showed Social Services would review and update each resident CP quarterly, annually, and as mandated in the Resident Assessment Instrument process after MDS completion. The policy showed Social Services would review relevant resident information and determine appropriate care plan interventions. The Behavior Management facility policy, revised October 2022, showed residents exhibiting behavior symptoms would be evaluated by the facility. The policy showed the Interdisciplinary Team (IDT) would review the CP and the Minimum Data Set (MDS - an assessment tool) for appropriate interventions and management. The policy showed the facility used the Psychotropic Drug and Behavior Review Form to document the IDT review monthly and as needed. The Informed Consent Resident Refusal of Treatment/Care facility policy, revised November 2012, showed when a resident exercise their right to refuse specific treatment/care services, the IDT would schedule a meeting with the resident and/or their representative to discuss the resident's healthcare status, current plan of care, the choices the resident was choosing to exercise, reasons for those choices, and the risks and benefits of those choices. <Resident 1> According to the 08/15/2024 Annual MDS, Resident 1 had clear speech, intact memory, with serious mental illnesses including anxiety, depression, and extreme shifts in mood, and was administered an antipsychotic medication during the assessment period. The MDS showed Resident 1 exhibited behaviors including rejection of care. A 10/11/2024 behavior CP showed Resident 1 had ineffective coping skills, was at risk for impaired psychosocial well-being, and had a history of unsubstantiated allegations involving staff regarding the provision of ADL care. A 10/11/2024 CP intervention instructed staff to perform care in pairs. A 11/11/2024 CP intervention showed, Refer to Social Service Department [SSD] if resident expresses hard emotions, has concerns with staff, other residents, or care, and has any changes in mood. On 11/18/2024 at 11:32 AM, Resident 1 stated they informed the facility that a staff was rough with them while providing incontinent care. Resident 1 stated they do not agree with the facility having multiple staff help them all at once. Review of the 11/04/2024 facility incident report showed Resident 1 stated they were manhandled by Staff G (Certified Nursing Assistant - CNA) during ADL care. The report showed Staff G was providing Resident 1 incontinent care by themselves and was dismissed by the resident after feeling being mistreated. In an interview on 11/18/2024 at Staff B (Risk Manager) stated the facility investigation determined Resident 1 refused having care in pairs from staff, in contrast with the resident's CP. Staff B stated they referred Resident 1 to the SSD for appropriate behavior intervention and management. Review of Resident 1's medical records on 11/18/2024 did not show a Psychotropic Drug and Behavior Review Form was initiated for the resident's behavior determined by the facility in the 11/04/2024 incident report. Review of Resident 1's progress notes from 11/04/2024 until 11/18/2024 did not show any SSD documentation regarding the resident's behavior identified in the 11/04/2024 incident report. The facility was not able to provide any documentation to support Resident 1's refusal of care, specifically providing care in pairs, was addressed by the SSD. In an interview on 11/18/2024 at 2:25 PM, Staff C (Resident Care Manager) stated they expected SSD to address Resident 1's behaviors for safe care, .especially since [Resident 1] refuse care in pairs .[I] need to protect both my staff and the resident. In an interview on 11/18/2024 at 2:31 PM, Staff A (Director of Nursing) stated they were aware of Resident 1's refusal of care in pairs and was waiting for SSD to write their notes. Staff A reviewed Resident 1's medical records and confirmed there was no documentation from SSD. Staff A stated the expected SSD to be involved in dealing with residents' refusal of care, .especially since Resident 1 has a lot of behavior issues. Staff A stated they expected SSD to document, in the medical record, their interaction with residents timely. Refer to F656- Develop/Implement Comprehensive CP. REFERENCE: WAC 388-97-0960(1).

Based on interview and record review, the facility failed to ensure quarterly personal fund statements were provided to residents with personal fund accounts for 2 of 3 sampled residents (Residents 17 & 27) reviewed for personal fund accounts. This failure placed residents at risk of not having an accurate accounting of their personal funds held in trust by the facility. Findings included . <Facility Policy> According to a revised facility December 2021 Resident Trust Fund policy, the facility would maintain resident trust fund accounts in accordance with state and federal regulations. This policy showed the facility would prepare and distribute, at a minimum, quarterly statements to each resident/resident's responsible party. Copies of the statements were to be kept with the trust reconciliation file. <Resident 27> According to a 05/26/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 27 admitted to the facility on [DATE] had no memory impairment. In an interview on 06/05/24 10:39 AM, Resident 27 stated they had a trust account with the facility and reported they did not receive quarterly statements from staff. <Resident 17> According to a 05/16/2024 Annual MDS, Resident 27 was admitted to the facility on [DATE] and had no memory impairment. In an interview on 06/06/24 at 9:06 AM, Resident 17 stated they had a trust account with the facility and reported they did not receive quarterly statements from staff. In an interview on 06/12/2024 at 12:45 PM, Staff G (Business Office Manager) stated they did not provide statements to residents unless they ask for them and explained that some residents get overwhelmed and think they are bills. Staff G stated providing statements was not a standard thing they hand out, but would if someone asked for one. In an interview on 06/13/2024 at 1:47 PM, Staff G stated they do not routinely provide trust statements to the residents or resident representatives. In an interview on 06/13/2024 at 3:55 PM, Staff A (Administrator) stated their expectation was for staff to follow the facility policy and provide statements as required. REFERENCE: WAC 388-97-0340(3)(c).

Based on observation, interview, and record review, the facility failed to identify the risk of hot liquids, adequately supervise, and initiate interventions for the safe use of hot liquids for a resident who required staff assistance for 1 of 1 residents (Resident 1), reviewed for accidents. Resident 1 experienced harm when they sustained a burn to their left lower lip. Findings included . Review of the facility Microwave Reheating Guidelines dated October 2017 showed foods and fluids heated in the microwave were served to residents at safe temperatures. Safety steps listed included temperature is taken prior to service to the resident. Hot beverages and hot foods are served to residents at less than or equal to 150 degrees Fahrenheit. Directions to staff included to document the food temperature in the Microwave Reheating Log. <Resident 1> Review of the Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident was had medically complex conditions, was alert and oriented, with severely impaired vision. Resident 1 was assessed as able to feed themselves after set up by staff and felt it was very important to have snacks between meals. Review of Resident 1's Care Plan dated 12/28/2023 showed the resident ate meals after set up. In addition Resident 1's vision was poor with blindness in both eyes. Resident 1 was observed on 05/31/2024 at 12:15 PM with an injury to their left lower lip, with a layer of skin missing on the exterior and interior of the lip. In addition, there were small, dark crusted areas on the outer edge of the lip. During an interview at that time, Resident 1 stated they bought soup from the vending machine and asked a staff member to put water in it and microwave it to heat it up. Resident 1 stated they blew on the soup, they thought it was cool enough to eat, but they were hungry and they ate it too fast and bit their lip. Review of Resident 1's record showed a 05/31/2024 1:17 PM Nursing Progress Note written by a nurse that checked on Resident 1 following recent burn to lip. The area was noted to be healing with mild redness. Resident voiced biting and removing the scab. The nurse advised the resident to be careful to avoid burn from worsening. The Skin Observation Tool dated 05/31/2024 showed Resident 1's was assessed with an irregular shaped wound to their lower lip, measuring 3 centimeters (cm) long, 2 cm wide, and 0.1 cm deep. The degree of the burn was not specified. During an interview on 05/31/2024 at 2:29 PM, Staff B, Director of Nursing, stated Resident 1 asked for a cup of noodles during the night shift. A staff member heated it up too hot and the resident burnt their lip, then bit on their lip which caused it to bleed. According to Staff B they were unable to provide documentation to show the staff checked the food temperature prior to serving the soup to Resident 1 as they had not documented on the Reheating Log as expected. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review, the facility failed to provide sufficient supervision by ensuring. resident rooms were free from unapproved hazardous electrical appliances and equipment for 5 of 77 residents (Residents 1, 2, 3, 7, and 8). This failed practice caused harm to Resident 1 who spilled hot water from an electric kettle, experienced a burn their right foot, and placed all residents at risk for potential injury. Findings included . Review of the facility's Resident Handbook, revised June 2020, showed that some items, such as electrical appliances and equipment, are potential fire hazards and must be approved by the center prior to use. For safety reasons, the facility may not allow certain appliances or other equipment and may require the resident to remove an appliance or other equipment brought into the facility. <Resident 1> Review of the facility census showed that Resident 1 admitted to the facility on [DATE]. Review of the 03/22/2023 Admission Minimum Data Set (MDS - an assessment tool), showed Resident 1 was alert, oriented, and exhibited no behaviors. Review of the Care Plan (CP) dated 03/15/2023 showed Resident 1 was on fluid restriction and nursing assistants were directed to report all fluid intake to the Licensed Nurse (LN). Review of physician orders (PO) showed instructions to the LN to document total fluids consumed. Review of the CP dated 03/15/2023 showed Resident 1 required a safe environment, free from spills and/or clutter with personal items within reach. Review of the June 2023 Treatment Administration Record (TAR) showed PO for wound care to the right foot were obtained on 06/14/2023 at 10:15 AM. Review of the Weekly Skin Observation Tool (WSOT) dated 06/14/2023 at 7:09 PM, showed a new skin impairment, a blister, was noted to Resident 1's right foot. On 06/15/2023 at 10:57 AM, the facility reported to the State Agency (SA) that Resident 1 experienced a burn (7 centimeters [cm] x 7 cm blister) to their right foot, that occurred in the resident's room on 06/14/2023 at 9:00 AM. Review of a late entry wound note created on 06/19/2023, dated as 06/16/2023 at 6:02 PM, created on 06/19/2023 showed the LN documented that Resident 1 had a large open area to their right foot, open to air. Resident 1 reported he spilled hot water from his electric coffee maker in the early morning hours and removed the compression wrapping the resident had on their leg. The resident stated he informed staff but did not recall the name. The LN assessed the wound that presented as a large superficial open area 9 cm x 12 cm x 0.1 cm to the right dorsal (upper surface) foot extending to medial left great toe. The wound was described as shiny moist bright red base, tender, no blister or other lesions, no increased swelling at that time but difficult to assess as Resident 1 had chronic lymphedema (tissue swelling) to both legs. The LN applied Xeroform (non-adhering, absorbent, mesh with petrolatum) protective layer to prevent dressing from sticking to the wound as well as provide a cooling effect and Alginate to capture any exudate (drainage), and notified unit Resident Care Manager (RCM). During an interview on 06/15/2023 at 3:45 PM, when asked why the report to the SA was delayed, Staff C (Risk Management Nurse) stated the injury was identified during the weekly skin observation. Staff C confirmed the nurse did not complete an incident report, did not document notifying the physician and should have. According to Staff C, the management team first heard of the incident during the 06/15/2023 morning meeting. Staff C stated they searched Resident 1's room and found an electric kettle unplugged, under the resident's sink. Staff removed the kettle from the resident's room at that time. The empty electric kettle was observed on 06/15/2023 to be able to hold 1.7 liters of fluid. During an interview on 06/15/2023 at 5:00 PM, Resident 1 stated they were not previously aware that the kettle was not allowed in the facility. Resident 1 stated they ordered it online and it was delivered to their room by staff. Resident 1 stated they asked staff for a bedside table or tray to keep it on so it would be safer, and the staff told them they didn't have one. Resident's 1's room was observed with instant noodles (just add hot water), hot chocolate packets, and instant soup at bedside. Resident 1 stated when they spilled the hot water on their foot, staff came to the room, asked if Resident 1 needed something. Staff threw a towel to them. Resident 1 stated they put cold water on their foot right away. Resident 1 noted they had wraps on their feet from another condition, and if they hadn't been there, it would have been worse. Resident 1's right foot was observed wrapped in gauze. Resident 1 stated that it hurt a little bit more than a sunburn. <Resident 2> During an interview on 06/15/2023 at 3:45 PM Staff C stated they searched all the resident rooms, except those on One South. Staff C found a plug-in heating pad with Resident 2, which was removed. Review of Resident 2's clinical record showed no authorization, POs, assessment and/or plan for use for the heating pad or safety check prior to resident use of the device. <Resident 3> On 06/15/2023 at 4:14 PM Resident 3's room was observed with a coffee maker and juice maker on top of a bedside table. There were five one-pound bags of coffee, filters, four large creamers, three of which were approximately 75% empty. The multiple items were visible from the doorway of Resident 3's room. During an interview on 06/15/2023 at 4:21 PM, Resident 3 stated they had the coffee pot for quite a few months .I don't remember exactly. I've been using it for awhile. When asked if they were informed that they could not have personal appliances in their room, Resident 3 stated, Maybe when got here, I'm not sure. I'm [AGE] years old and not used to being babysat. Staff C educated Resident 3 and removed the appliances. <Residents 4, 5 & 6> On 06/15/2023 at 4:25 PM Staff B (Director of Nursing) asked the first floor RCMs to assist in conducting the room searches. At 4:27 PM Staff D (RCM) searched Resident 4's room but did not inform the resident of the purpose of the visit, did not provide the resident education, and did not ask the resident if they had any appliances, heating pads, or other devices that posed a hazard. At 4:30 PM, Staff C was observed to educate Staff D on their role in the room searches and actions to take if an item was found. At 4:32 PM, Staff D searched Resident 5's room without providing education or informing the resident why they were there. Similar observations were made with Resident 6's room search at 4:36 PM. At 4:41 PM, Staff B informed the surveyor that every room in the facility had been searched. <Resident 7> During a random room check on the second floor on 06/15/2023 at 4:49 PM, Resident 7 stated, I have a heating pad. Resident 7 was observed seated on a large heating pad. Resident 7 stated it was not plugged in. Review of Resident 7's clinical record showed no approval by the center prior to use/authorization, physician orders, assessment and/or plan for use. <Resident 8> Review of Resident 8's Personal Belonging Inventory showed an electric kettle was removed from the resident's room on 06/15/2023. Review of Resident 8's clinical record showed no approval by the center prior to use/authorization, physician orders, assessment and/or plan for use. Review of the facility investigation dated 06/19/2023 showed the facility removed similarly potential hazardous items from five resident rooms (Resident 1, 2, 3, 7, 8) as they had no approval by the center prior to use/authorization, physician orders, assessment and/or plan for use. REFERENCE: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure 4 (Residents 1, 2, 3 & 4 ) of 4 residents reviewed for hydration, maintained acceptable parameters of hydration status or were adequately monitored for hydration status. Failure to ensure accurate intakes were documented, accurately monitor fluid intake, and notify physicians of changes, placed the residents at risk for fluid imbalance, medical complications [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings included . Review of the facility Hydration Policy and Procedure updated October 2017, showed the nurses were directed to observe for signs and/or symptoms of dehydration and fluid loss (drying mucous membrane, poor skin turgor, coated tongue, amber urine, decreased urine output, lethargy, low blood pressure, etc.). Report to the physician, resident/resident's authorized representative, Nutrition Hydration Skin Committee signs and/or symptoms resulting in fluid imbalance and document in the medical record. Review of the facility Medication Administration Policy and Procedure updated June 2017, showed nurses were directed to obtain appropriate vital signs for designated medications (e.g. blood pressure for hypertensive medications, etc. as ordered by the physician). The Licensed Nurse (LN) was directed to follow parameters listed with the specific medication and notify the physician, as appropriate. During an interview on 09/30/2022 at 1:33 PM, Staff B (Director of Nursing) stated that when the physician has given parameters, the nurse should notify the physician if the medication was held. HYDRATION Resident 1 Review of the 07/14/2022 Quarterly Minimum Data Set (MDS - an assessment tool), showed Resident #1 was alert with clear speech and cognitively intact. The resident was noted to exhibit verbal and/or physical behaviors less than daily, which were assessed to not put the resident at significant risk of physical illness, injury or significantly interfere with the resident's care. In addition, the resident rejected care on four to six days of the seven-day assessment period. Resident 1 was assessed to require one-person extensive physical assist with eating. The resident had an indwelling catheter. Resident 1 weighed 161 pounds (lbs) with no significant weight loss or gain. Review of the Discharge assessment dated [DATE], showed Resident 1 had an unplanned discharge to an acute hospital on 09/08/2022. Review of the 02/07/2022 Nutrition and Hydration Care Plan (CP) showed the resident was at risk but none of the listed goals (to promote skin integrity, resident will tolerate diet texture and no unplanned significant weight loss) addressed hydration. Interventions listed included no thin liquids at bedside, observe for signs and symptoms of dehydration and report to nurse, offer liquids between meals, offer 120 ml thickened liquids at med pass time and LN to document acceptance in ccs (cubic centimeter which is equal to milliliter - ml), and Assist with fluids as needed. Review of the 02/08/2022 Indwelling Catheter CP showed directions to staff to monitor/record/report to physician for signs/symptoms of a Urinary Tract Infection ([CONDITION(S)]): pain, burning, blood tinged urine, cloudiness, no urine output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and/or change in eating patterns. During an interview on 09/30/2022 at 1:24 PM, Staff G (Resident Care Manager - RCM) stated that the Nursing Assistants (NAs) should empty the urine from the catheter bags and give the nurse the amount. The nurse would then document the output on the Treatment Administration Record (TAR). During an interview on 09/30/2022 at 1:33 PM, Staff B (Director of Nursing) stated that the NAs documented the output, and it should be a task to document in POC (Point of Care - electronic Nursing Assistant charting). Review of the resident's record showed no recent documented monitoring of the Resident 1's urine output or urine characteristics. During an interview on 09/22/2022 at 11:36 AM Staff D (Licensed Practical Nurse - LPN) stated they worked with Resident 1 a week prior to the resident being sent to the hospital. Staff D stated that they were told in report that Resident 1 was not eating much, but was taking medications with thickened water and juice. When asked about Resident 1's catheter and urine, Staff D was not aware of any difference and stated that the nursing assistant emptied it on the day they worked. Review of the Annual Nutrition Evaluation dated 02/07/2022 showed Resident 1 was ordered mildly thick liquids, consumed 180-480 ml of fluids/meal. Resident 1's estimated daily fluid needs were assessed as greater or equal to 2025 ml per day. The resident was assessed as a Nutrition/hydration risk related to thickened liquids, swallowing difficulties, and a history of enteral (feeding tube) nutrition as needed for inadequate oral intakes Review of a Quarterly Nutrition Note dated 07/19/2022 showed the resident continued on mildly thick liquids and fluid intake taken was 140-360 ml/meal. The review did not address the resident's hydration status or decrease of 25% in fluid intake. Review of the last medical provider visit note dated 08/22/2022 showed nursing staff reported Resident 1 was functioning at baseline and their vital signs were stable. The resident refused a physical examination and had no acute medical symptoms. Review of fluid intake documented by the NAs showed only two of three meal fluid intakes were documented on 09/01/2022, 09/04/2022, 09/05/2022, and only one of three meal fluid intakes were documented on 09/06/2022. Review of documented fluid intake, by the Nursing Assistants, showed on 09/01/2022, Resident 1's fluid consumption was 600 ccs., on 09/02/2022 840 cc, 09/03/2022 960 cc, 09/04/2022 408 cc, 09/05/2022 480 cc, 09/06/2022 360 cc, 09/07/2022 840 cc and 09/08/2022 600 cc. Review of the September 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, staff documented they administered 120 ml of thickened liquids with medication pass at 9:00 AM, 3:00 PM, 9:00 PM for 360 cc a day. During an interview on 09/30/2022 at 2:07 PM, Staff C (Registered Nurse - RN) stated that facility staff discussed how to ensure Resident 1 received enough fluids. Resident 1 was not safe to drink thickened liquids alone, and orders were in place to offer fluids intermittently throughout the day. Adding the intakes documented by the nursing assistants and the nurses showed the following 24 hour totals: 09/01/2022 (1,140 cc), 09/02/2022 (1,380 cc), 09/03/2022 (1,500 cc), 09/04/2022 (948 cc), 09/05/2022 (1,020 cc), 09/06/2022 (900 cc), 09/07/2022 (1,380 cc) and 09/08/2022 (1,020 cc), all of which were substantially lower than the Resident's assessed fluid needs of 2025 ccs per day. Staff failed to ensure the resident received the fluids they were assessed to require. Review of Nursing Assistant Point of Care documentation showed directions to check Resident 1's blood pressure (BP) every shift and as needed. On 09/07/2022 at 12:39 PM the resident's BP measured 135/92, at 8:45 PM 107/76. On 09/08/2022 at 5:43 AM Resident 1 refused and at 1:59 PM it was 96/72. Review of the September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medication was not administered on 09/08/2022 at 9:00 AM or 3:00 PM as the vitals were outside of parameters for administration. Review of the September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The medications were documented as held on 09/08/2022 as the vitals were outside of parameters for administration. Review of the Nursing Progress Notes showed no notes dated 09/07/2022. Review of the resident's record showed no documentation that the physician was notified that Resident 1's medications were held on 09/07/2022 and 09/08/2022. Review of the staff schedule showed Staff E (Nursing Assistant - NA) was assigned to care for Resident 1 on 09/08/2022 dayshift. During an interview on 09/22/2022 at 11:45 AM, Staff E stated that the Foley catheter didn't work, the resident was always wet. Staff E stated that Resident 1 usually could eat and drink themselves, but on 09/08/2022 Resident 1 was weak and couldn't hold the cup to drink, so they helped the resident to drink. Staff E stated they reported this change to the nurse (Staff F, RN) who went in the room, saw and talked to the resident. During an interview on 09/30/2022 at 12:57 PM, Staff F (RN) confirmed Staff E reported a concern to them, they checked on the resident, who talked and responded. Staff F stated that it was their first time working with Resident 1, they did not know their baseline, other than they were told the resident was feisty, but he was calm, so I thought that was good. Review of a 09/08/2022 7:13 PM facility Nursing Progress Note showed Resident 1 was alert and oriented during the day shift. All the BP medications were outside the prescribed parameters and were withheld. Resident 1 responded well while awake. Resident 1 took all their medications with 120 ml med pass. The Vital Signs (VS) were BP 96/72, Pulse 80, and Temp 98.1 degrees Fahrenheit (dF). During an interview on 09/30/2022 at 12:57 PM, Staff F stated that Resident 1's BP was low and the medications were held. When asked if the physician was notified, Staff F stated, No, I did not. Staff F stated, I should have notified the doctor. Review of a 09/08/2022 9:32 PM facility Nursing Progress Note showed after report change one of the NAs called a nurse. Resident 1 was sweating, kussmaul (deep, labored) breathing and when called didn't open their eyes. Vital signs were BP 62/45, oxygen 85%, T 96.7 dF. Oxygen was administered and the Nurse called 911. Review of a 09/09/2022 Fire Department Incident Report showed upon arrival to the facility Resident 1's urine Foley bag had what looked like melted dark chocolate that was diluted with a little bit of water. Resident 1 was transported to the hospital. Review of Emergency Department (ED) note dated 09/08/2022 at 11:00 PM showed Resident 1 was brought in by Medics for low blood pressure, altered mental status and unresponsive except intermittently to pain. Per the ED note, Medics were not given a full report and found a urinary catheter with dark brown thick urine. The resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Critical Care Medicine Initial Note dated 09/09/2022 at 1:04 AM showed that they received a report that Resident 1 was normal on 09/07/2022, but not eating or drinking on 09/08/2022 and Emergency Medical Services was called and brought the resident to the ED in profound shock, grossly putrid urine with frank pus; initially urine felt to be almost black per ED provider, Foley changed in ED. On ICU (Intensive Care Unit) arrival resident was emergently intubated. The physical examination showed the resident had very dry mucous membranes with yellow film over tongue. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 was observed in bed at the hospital on 09/27/2022 at 11:16 AM with intravenous fluids running into their right arm and a nasalgastric (from nose to stomach) tube. The resident was not able to answer specific questions. FLUID RESTRICTIONS Review of the facility Hydration Policy and Procedure updated October 2017, showed staff offers fluids to residents unless contraindicated by a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the facility Fluid Restriction Worksheet updated November 2012 showed the Care Plan is updated to reflect fluid restriction. Resident 2 Review of the Admission MDS dated [DATE] showed Resident 2 admitted [DATE]. Resident 2 was assessed as alert and oriented, required only set up assistance with eating and drinking and received a diuretic (water pill) on seven days of the seven day assessment period. Review of POs showed a 09/14/2022 order for a fluid restriction of 1500 cc/24 hours. Instructions listed were for Dietary to provide 960 cc/24 hrs, Nursing to provide 540 cc/24 hrs followed by DAY 540 cc, EVE 540 cc, NOC (Night Shift) 420 cc. Additional instructions were for every shift to enter total liquids consumed per shift AND every night shift to add nursing and dietary daily cc's (from POC tasks) and record the total 24 hour fluid intake. Review of the 09/16/2022 Nutrition Evaluation showed Resident 2 was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The evaluation did not include or address the physician ordered fluid restriction, listed a goal of greater than 75% of fluids offered and a plan to monitor intakes. Review of the 09/16/2022 Nutrition Hydration CP showed a goal that Resident 2 would consume greater than 75% of fluids provided at meals. The CP did not indicate the resident was on a fluid restriction. Review of the dietary fluid intake from POC tasks showed fluid intake was documented for only two meals on 09/15/2022, 09/26/2022 and no intake was documented at all on 09/17/2022 and 09/18/2022. Review of the dietary daily ccs of fluid intake from POC tasks showed the resident's fluid intake per date as: 09/15/2022 (780 cc), 09/16/2022 (960 cc), 09/19/2022 (1,000 cc), 09/20/2022 (1,200 cc), 09/21/2022 (1,230 cc), 09/22/2022 (900 cc), 09/23/2022 (840 cc), 09/24/2022 (1,440 cc), 09/25/2022 (840 cc), 09/26/2022 (520 cc), and 09/27/2022 (720 cc). The resident's fluids allocated for meals exceeded the planned 960 cc on five days. Review of the September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The 24 hour totals documented did not accurately reflect the previously documented fluid intakes as instructed. The facility failed to identify the resident exceeded the physician ordered fluid restriction on 09/15/2022 (1,680 cc), 09/16/2022 (1,760 cc), 09/19/2022 (2,000 cc), 09/20/2022 (2,100 cc), 09/21/2022 (2,080 cc), 09/22/2022 (1800 cc), 09/23/2022 (1,600 cc), 09/24/2022 (2,280 cc), 09/25/2022 (1,680 cc ) and 09/27/2022 (1,560 cc). During an interview on 09/30/2022 at 12:14 PM Resident 2 was observed with a water pitcher at the bedside with 12 oz (354 cc) of water. Resident 2 stated the staff filled the pitcher with water when I run out. When asked about the fluid restriction, Resident 2 was unaware and stated, Nobody told me that. On 09/30/2022 Staff K (NA) was observed providing care to Resident 2. During an interview on 09/30/2022 at 12:19 PM, Staff K stated that they were covering the other NA's lunch break. Staff K stated that they fill the resident's water pitchers with ice and water, whenever a resident requests. Staff K was not aware Resident 2 was on a fluid restriction. During an interview on 09/30/2022 at 1:15 PM, Staff H (NA) verified they were assigned to care for Resident 2. When asked about Resident 2's fluid restriction, Staff H stated, I don't know anything about her fluid restriction. Is she on fluid restriction? Resident 3 Review of the Admission MDS dated [DATE] showed Resident 3 admitted [DATE]. Resident 3 was assessed as alert and oriented, requiring only set up assistance with eating and drinking. Review of POs showed a 09/15/2022 order for a fluid restriction of 1500 cc/24 hours. Dietary to provide 960 cc/24 hrs. Nursing to provide 540 cc/24 hrs. DAY 360 cc, NOC 180 cc. Instructions included every shift enter Total Fluids per Shift AND every night shift Night Shift to add nursing and dietary daily cc's (from POC tasks) and record the total 24 hour fluid intake. Review of the baseline plan of care, dated 09/01/2022 showed the resident was on a 1500 ml fluid restriction. Review of the 09/15/2022 Nutrition Hydration Functional Decline CP did not address the resident's hydration status or fluid restriction. Review of a Fluid Restriction Worksheet dated 09/15/2022 showed the total fluids ordered by (Medical Doctor) as 1500 cc/24 hrs, Remove bedside water pitcher. Nursing needs for medication passes was assessed as 540 cc/24 hours. Subtract nursing needs for medication passes from total fluids ordered per MD to determine Dietary Distribution Plan which left 960 cc/24 hours available to Dietary. The planned Dietary Distribution Plan was 360 cc for Breakfast, 360 cc for lunch and 240 cc for dinner. Comments included, No ice cream, soup, jello, popsicles, watermelon. On 09/30/2022 at 12:38 PM, Resident 3 was observed in bed with a water pitcher at the bedside with 400 cc of water. During an interview at that time, Resident 3 stated It's been sitting there for days. I fill it with ice and let it melt. Resident 3 was aware they were on a fluid restriction of 1,500 cc/24 hours and stated they just drank what they were served at breakfast, lunch and dinner. When asked about fluids with medication pass, Resident 3 stated, most of the time I have that and pointed to the water pitcher. Review of the dietary daily ccs of fluid intake from POC tasks showed only one meal was documented on 09/18/2022, 09/20/2022, only two meals were documented on 09/22/2022, 09/23/2022, 09/25/2022. Further review of the dietary daily ccs of fluid intake from POC tasks showed the resident's fluid intake per meal frequently exceeded the amount allotted. For example the resident was allotted 360 cc of fluids for breakfast, and staff documented the resident received 720 cc on 09/19/2022, 600 on 09/22/2022, 480 on 09/27/2022. Similar findings were noted for lunch and dinner. Review of the September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . For example, on 09/16/2022 (720 cc), 09/22-23/2022 (560 cc), 09/25/2022 (1,260 cc), 09/26/2022 (1,800 cc) and 09/27/2022 (1,800 cc). During an interview on 09/30/2022 at 12:46 PM, Staff J (LPN), stated that when they passed medications to Resident 3 they served them the water from the pitcher in the resident's room. Staff J explained they documented the amount the resident drank in their shift, and stated that the Nursing Assistants tell the nurse how many times the resident asked for water in the pitcher. When asked if that included fluids served with meals, Staff J stated, no. Review of the September 2022 MAR for the documented total 24 hour fluid intake showed staff documented totals of 360 cc on 09/16/2022, 180 cc on 09/17-20/2022, 1660 cc on 09/21/2022, 200 cc on 09/22-23/2022, and 900 cc 09/25-09/27/2022. Resident 4 Review of the Quarterly MDS dated [DATE] showed Resident 4 was assessed as alert and oriented, requiring only set up assistance with eating and drinking and received a diuretic (water pill) on four days of the seven day assessment period. Review of POs showed a 09/21/2022 fluid restriction for 1500 cc/24 hours. Instructions included 1500 cc fluid restriction/24 hrs. Dietary to provide 1080 cc/24 hrs. Nursing to provide 420 cc/24 hrs. Day 220 cc, Noc 200 cc. every shift for suspected CHF (Congestive Heart Failure) Enter Total Fluids per Shift. The 08/16/2022 Nutrition & Hydration CP did not include a fluid restriction. Interventions included offer liquids between meals, and encourage fluid intake. Review of the resident's record showed no Fluid Restriction Worksheet. Review of the September 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . There was no documented 24 hour total. Review of the dietary daily ccs of fluid intake from POC tasks showed fluid intake was documented for only one meal on 09/21/2022, 09/25/2022, two meals on 09/26/2022 and 09/27/2022. On 09/30/2022 at 12:20 PM, Resident 4 was observed in bed with a water pitcher at the bedside with a 32 ounce (oz) (946 ml/cc) water pitcher. Resident 4 stated they were aware they were on a water restriction and drank one water pitcher a day and whatever they got with meals. According to Resident 4 the beverages provided with meals were as follows: Breakfast 8 oz (236 ml) milk, 8 oz juice, 6 oz (177 ml) juice, coffee, Lunch 8 oz juice, coffee, Dinner 8 oz juice. Resident 4 stated with medications the nurse gave them a small clear plastic glass of water filled 1/2-1/3 full. Resident 4 pointed to the water pitcher and stated, Before the fluid restriction, I had this filled two to three times a day, so this is quite restrictive. During an interview on 09/30/2022 at 1:15 PM, Staff H (NA) verified they were assigned to care for Resident 4. When asked about Resident 4's fluid restriction, Staff H stated, I didn't know about it and commented that the nurses would usually let them know if there were changes in care during the morning meeting. During an interview with the nurse assigned to care for Resident 2 and Resident 4 on 09/30/2022 at 1:23 PM, Staff I (RN) stated that the residents had water pitchers at the bedside and they were all aware they were on fluid restrictions. REFERENCE: WAC 388-97-1060(3)(i)

Based on observation, interview and record review the facility failed to ensure 1 of 4 (Residents 1) residents reviewed for pressure ulcers, received the necessary treatment and services consistent with professional standards of practice and/or had appropriate and timely interventions in place based on individual risks, to promote healing of existing pressure injuries and prevent new pressure injuries from developing. These failures contributed to Resident 1 experiencing discomfort and a pressure ulcer and placed residents at risk of extended healing time, and development of additional pressure ulcers/skin issues. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear (shifting, dragging). The tolerance of soft tissue for pressure and shear may also be affected by moisture/heat, nutrition, blood flow, diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] Unstageable - Full thickness skin and tissue loss in which the base of the injury is obscured by slough (dead skin cells) and/or eschar (dead tissue). Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact) eschar on the heels serves as the body's natural (biological) cover and should not be removed. Resident 1 Resident #1 admitted to the facility on [DATE] as their own responsible party. Review of the 03/30/2022 Hospital Discharge Summary and Skilled Nursing Facility Transfer Orders showed an alternating pressure reduction mattress required for pressure wound prevention. Review of the 03/30/2022 Admission Nursing Evaluation (ANE) showed Resident 1's skin was intact without pressure ulcers or other skin issues. Review of Nursing Progress Notes showed on 03/30/2022 Resident 1 declined the skin assessment and told staff they could assess when they lay down. On 03/31/2022 Resident 1 slept in the wheelchair and stated, I need an air mattress . Further review of the progress notes showed, on 04/01/2022 Resident 1 remained in their wheelchair all day and declined staff efforts to assist them to bed. During an interview on 06/02/2022 at 1:22 PM Resident 1 stated when they admitted to the facility they had a bed but it was hard and smaller. Resident 1 stated, I kept telling them this is the wrong bed. Resident 1 stated the bed was changed. During an interview on 06/02/2022 at 1:45 PM, Staff C (Registered Nurse - RN) stated that when Resident 1 was admitted they had a regular bed and Resident 1 said they needed an air bed, although they did not have an order, they did rent an air bed quickly. On 06/16/2022 the facility provided a Durable Medical Equipment receipt which indicated the air mattress was delivered to the facility 03/30/2022 at 2:13 PM. Staff C indicated the mattress was placed at time of delivery. Review of the April 2022 Treatment Administration Record (TAR) showed a specialty low air loss mattress was started on 04/20/2022 for wound prevention, set for patient comfort level #3. Review of a 05/24/2022 Nursing Progress Note showed Resident 1 was asking staff to change bed settings of air mattress and the nurse educated the resident that the setting of the mattress was set on a therapeutic level, that changing it was not allowing the mattress to work especially in regards to offloading (transfer of pressure and stress) from the buttocks. On 06/03/2022 at 1:18 PM Resident 1 was observed in an alternating, low loss airflow bed which was set at comfort level 1. According to the 04/06/2022 Admission Minimum Data Set (MDS - An assessment tool) the resident required two person extensive assistance with bed mobility, had no Pressure Ulcers (PU), was at risk for PUs, had pressure reducing devices for the bed and chair, was not on a turning or repositioning program, received no nutrition or hydration interventions to manage skin problems and exhibited no rejection of care. Review of the 04/06/2022 Care Plan (CP) showed the resident had the potential for impairment to skin related to impaired mobility and paralysis. Interventions included, monitor/document location, size, and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to MD (Medical Doctor). Review of the 04/06/2022 MD History & Physical - Amended showed the resident had pressure ulcers on heels, resolved. The MD urged frequent turning and repositioning, at least every two hours to prevent pressure injury from happening and also recommended routine skin integrity check. Review of Evaluations conducted showed Weekly Skin Observation Tools (WSOT) were done on 04/06/2022 and 04/13/2022 with no new skin impairments. Review of MDS data, showed Resident 1 was discharged to the hospital, return anticipated on 04/14/2022. Review of hospital records showed Resident 1 was admitted to the hospital on 04/14/2022 with bilateral buttock deep tissue pressure ulcers. Review of the 04/18/2022 Inpatient Wound Consult showed a wound to right buttocks measured approximately 6 centimeter (cm) x 6 cm with mostly intact non blanching maroon skin and small open partial thickness wounds with base of non blanching maroon and pink non granulating tissues. The wound to the left buttocks measured approximately 3 cm x 1 cm of intact non blanching maroon skin. The assessment was of deep tissue pressure injuries, present on admission. Review of the hospital Wound Care Recommendations and discharge orders dated 04/19/2022 showed instructions to staff to cleanse Sacrum with soap and water, pat dry and apply no-sting barrier film and allow to dry. Apply an absorbant foam dressing upside down to the sacrum to prevent contamination. Change every three days or sooner if soiled. Encourage resident to turn frequently in bed. Review of Nursing Progress Notes showed on 04/19/2022 Resident 1 readmitted to the facility and refused initial skin check. Review of the 04/19/2022 Readmission Nursing Evaluation, which was signed 04/20/2022, showed Resident 1 had no pressure ulcers or other skin issues and had no wound dressings. Review of a Nurse Practitioner Admit Note dated 04/21/2022 showed the provider was aware the Resident was noted to have bilateral buttock DTI (Deep Tissue Injury), and made no wound care recommendations. Review of the Care Conference dated 04/22/2022 showed nursing reported no skin issues and provided no education regarding wound care. Review of the 04/27/2022 MD History & Physical showed Resident 1 had pressure ulcers and the MD documented that they ordered wound care. Review of the April 2022 TAR showed no wound or PU treatments were ordered or documented as performed in April 2022. There was no facility documented skin observation until 05/03/2022 which showed the resident had an unstageable Deep Tissue Injury to the right buttock, measuring 3 cm x 3 cm x 0.1 cm deep, with 100% eschar. Review of a facility investigation showed that on 05/03/2022 at approximately 6:00 PM Resident 1 reported they had a pressure area to buttocks noted during a provider appointment that day. Review of 05/03/2022 provider appointment showed the resident was assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . The edges were debrided and antiseptic applied. The documented plan was to apply antiseptic swab to the black eschar daily, and cover with a 4 x 4 guaze and tape, change daily, the wound boarder debrided weekly, needs to have air flow mattress, sitting time should be two hours at the time with every 30 minutes full pressure relief, tilt backward, full turn to 90 degree position, Nursing Facility needs to monitor and help resident with compliance and needs to reposition patient at night or when in bed every two hours. Review of the May 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the May 2022 TAR showed order started on 05/04/2022 to cleanse right buttock with Normal Saline or wound cleanse, pat dry, apply Nickel sized amount of medicated ointment to wound bed, cover with foam dressing every day shift and as needed. The Impaired Skin Integrity CP was revised with actual impairment on 05/03/2022 pressure ulcer to right buttock with instructions to staff to encourage resident to limit time up in chair until pressure ulcer resolved, encourage resident to allow compliance with frequent turning and repositioning side to side. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . On 06/02/2022 at 12:35 PM Resident 1 was observed in bed, on an alternating air mattress, on their right side, facing the window. Resident 1 was in the same position at 1:22 PM. In an interview at that time, Resident 1 stated that the doctor told them they needed to be readjusted every two to three hours, and That's not happening. During an interview on 06/02/2022 at 1:45 PM Staff D, (Licensed Practical Nurse - LPN) stated Resident 1 was turned every two hours, sometimes more because of pain. Staff D stated that there was only one nursing assistant on the unit, and another nursing assistant was coming over to help, It's been hard. Review of a 06/02/2022 Weekly Skin Evaluation showed the right buttock PU was worsening. The PU measured 3 cm x 4 cm x 1 cm, irregular in shape, with 100% eschar, with serous drainage. The PU was unstageable. During an interview on 06/02/2022 at 1:45 PM, Staff C stated that the Pressure Ulcer was acquired at the facility. REFERENCE WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to address Drug Regimen Review (DRR) recommendations for 2 (April and May 2021) of 2 months reviewed. The facility's failure to ensure the DRR recommendations for Resident 1's blood thinning medication was provided to and reviewed by the physician, resulted in Resident 1 suffering a debilitating stroke that left Resident 1 unable to articulate words, formulate ideas, and understand the spoken word. In addition, Resident 1 suffered numbness, tingling, and weakened legs. This failure placed all other residents at risk for harm, related to inappropriate medication dosages, inappropriate drug administration, and/or lack of clinical and/or laboratory monitoring. In addition the facility failed, for 26 of 44 residents (3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28), to review DRRs to ensure pharmacist's recommendations were provided to, reviewed by, and acted upon by the physician. This failure prevented prompt treatment of medical diagnoses, placing the residents at risk for harm related to inappropriate medication dosages, inappropriate drug administration, and/or lack of clinical and/or laboratory monitoring. On 06/28/2021 at 12:50 PM, the Facility was notified of an Immediate Jeopardy related to Drug Regimen Review. Findings included . Review of a November 2016 Medication Regimen Review (MRR) policy showed that the consultant pharmacist performed a comprehensive MRR at least monthly for each resident, to include evaluating a resident's response to medication therapy, to help prevent or minimize adverse consequences related to medication therapy. Medication irregularities, including identification of unnecessary drugs and relevant recommendations, were reported to the Director of Nursing (DON), the attending physician, and the Medical Director and/or Administrator. An additional MRR Policy, dated March 2016, showed that the pharmacist would report recommendations to the the DON or designee prior to leaving the facility. An email report was sent, with any irregularities identified, to the attending physician, Medical Director, and DON. This policy showed that, once the recommendation was reviewed by the facility, the facility was to respond to the recommendation within a two to four week time frame for physician recommendations, and two weeks for nursing requests. Additionally, when the pharmacist identified a critical or urgent recommendation, the facility would respond immediately to the identified issue. Furthermore, this policy showed that the pharmacist reviewed responses from the physicians, and reported the physician responses to the QA (Quality Assurance) committee as appropriate. RESIDENT 1 Review of a 06/15/2021 Discharge Minimum Data Set (MDS, an assessment tool), showed Resident 1 was admitted to the facility on [DATE], had a diagnosis of [CONDITION(S)] (a heart condition that can lead to blood clots or stroke), and was on an anticoagulant (a blood thinner). This assessment showed Resident 1 had moderately impaired cognition, and required supervision for most of his Activities of Daily Living, to include walking and transfers. Review of a 06/11/2021 Social Services note showed that the facility was looking at a 06/16/2021 discharge for Resident 1 to a lesser care facility. A 06/15/2021 Discharge Planning note also confirmed the planned discharge for 06/16/2021 to a lower level of care. Review of Resident 1's 01/28/2021 admission medical record showed that Resident 1 was admitted with an order for [MEDICATION(S)], (an anticoagulant that required frequent blood monitoring to ensure a therapeutic dose) for the diagnosis of [CONDITION(S)]. Review of 03/31/2021 physician orders showed that, the physician replaced the [MEDICATION(S)] with [MEDICATION(S)] (an anticoagulant that did not require blood monitoring) 2.5 milligrams (mg) twice a day. Review of Resident 1's medical records showed that the pharmacist conducted a DRR on 04/16/2021 and 05/14/2021 for Resident 1. These DRRs showed that, based on Resident 1's weight and creatinine clearance (a measure of kidney function), the recommended dose of [MEDICATION(S)] was 5mg twice daily for most patients. The pharmacist requested of the physician to, Please review current dose [of 2.5 mg twice daily] and adjust if appropriate, which would have doubled the dose being administered. In an interview on 06/25/2021 at 10:04 AM, Collateral Contact 1, Staff Pharmacist, stated that, although Resident 1 met the age criteria to be at the [MEDICATION(S)] dose of 2.5 mg twice a day, [Resident 1] did not meet other criteria to keep [Resident 1] at 2.5 mg twice a day. [Resident 1] weighed more than 60 kilograms [or 132 pounds], and the creatinine (level) was less than 1.5. CC1 stated that there were no drug interactions to keep the [MEDICATION(S)] dose at 2.5 mg twice daily. In an interview on 06/25/2021 at 2:41 PM, CC2 (Pharmacy Consultant) confirmed that Resident 1 met the parameters for (an increased dose of [MEDICATION(S)]), It would be 5 mg twice a day because he is over 80, but weighed more than 132 pounds, and his creatinine hadn't reached the 1.5 (which was below the necessary recommended level). Review of April, May, and June 2021 Medication Administration Records, showed Resident 1 continued on the original [MEDICATION(S)] dose of 2.5 mg twice a day. Review of the resident's medical record showed no documentation that the staff addressed the April or May 2021 DRRs with the physician. Review of a 06/15/2021 progress note showed that Staff C, Resident Care Manager, was notified by a therapist that Resident 1 had a change in condition. After a physical assessment, Resident 1 reported pain and tingling to the right foot all morning. When Resident 1 was working with therapy, [Resident 1's] strength changed from 06/14/2021. Resident 1 was noted to have right sided weakness, weakness of the legs, and was barely able to lift the feet off the ground. Resident 1 was normally independent, able to get up and walk around the unit with or without a cane. Review of 06/15/2021 hospital records showed Resident 1 had right foot drop and mildly diminished sensation of his foot. In addition, the records showed the [MEDICATION(S)] dose was increased to 5 mg twice a day as Resident 1 did not meet the creatinine and weight criteria for 2.5 mg twice daily. A 06/17/2021 hospital discharge planning assessment showed, Resident 1 was receiving a lower dose of [MEDICATION(S)] prior to the hospital admission, which was not the correct level for the resident. Review of a 06/18/2021 hospital progress note showed, Resident 1 knew their diagnosis was a head injury. This progress note showed the hospital staff observed Resident 1 to have difficulty in articulating words, mild loss in ability to articulate ideas or understand others, lower extremity weakness, and numbing and tingling to the extremities. Review of a 06/17/2021 neurologist note showed Resident 1 received imagining studies that identified a subacute left frontal stroke . The physician wrote, .Stroke most likely 2/2 [secondary] to inadequate dosing of [MEDICATION(S)]. Management: [MEDICATION(S)] 5mg BID [in bold by neurologist]. In an interview on 06/29/2021, Resident 1's Resident Representative stated, [Resident 1's] level of mobility is not the same as before the stroke. [Resident 1's] enjoyment, (was) to get up and walk and be around everybody. He feels like he's lost a lot of his independence. The facility failed to respond to two consecutive DRRs that required the physician to address Resident 1's anticoagulant dose; a dose deemed inadequate for sufficient anticoagulation based on the resident's weight and creatinine levels. This failure resulted in Resident 1 suffering a stroke, a transfer and stay at the hospital, a decreased level of function, a transfer to another nursing home, and a delay in Resident 1's initial plan to return to a lower level of care on 06/16/2021. OTHER RESIDENTS On 06/25/2021 at 11:21 AM, the Surveyor requested, of CC3, Pharmacy Office Manager, the DRRs for April and May 2021, as the facility submitted to the Surveyor only partial recommendations on 06/21/2021. CC3 stated that they knew of a call on this particular building was received on Monday (06/21/2021), and the facility requested the recommendations the pharmacy consultant performed. CC3 stated there was a turn-over of management staff at the facility in recent history. CC3 stated the pharmacist e-mails the reports to the facility, so copies of all of those emails are retained. CC3 stated DRR reports are provided to the Director of Nursing and a corporate contact, and all of the reports were sent as soon as completed. Review of the April 2021 Pharmacy Consult Reports showed 44 residents received recommendations, to include monitoring of anticoagulant, drug to drug interactions, appropriate drugs, clinical monitoring, and laboratory monitoring. The report also showed that the facility's follow-up rate for the previous month's DRR recommendations was 64.2%, suggesting the facility did not provide the required recommendations to the physician or ensure the physician acted upon the recommendations. Record review showed that staff did not address the April 2021 DRR recommendations for 20 of the 44 residents that required physician notification (Residents 3,4,5,6,7,8,9,10,11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, and 22). Similarly, record review showed that staff did not address the May 2021 DRR recommendations for 23 (Residents 3, 5, 6, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 20, 21, 22, 23, 24, 25, 26, 27, and 28) of the 40 residents that had physician recommendations made. Review of the May 2021 Pharmacy Consult Reports showed that the facility's follow-up rate for the April 2021 DRR recommendations was 33.3%, supporting the facility did not ensure DRRs were provided to the physician and/or acted upon by the physician. The following Residents were placed at an increased risk for harm when the physician did not address the DRRs: Resident 7 - April 2021 DRR recommended a [MEDICATION(S)] level as the resident was on [MEDICATION(S)] (an antipsychotic that required careful monitoring of its blood levels to prevent toxicity and serious side effects) Resident 9 - April and May 2021 DRR showed the resident had been on [MEDICATION(S)] (medication for acid reflux) 20 mg since 01/2021, and guidelines suggested a review and for the physician to document why it should be used for longer than 12 weeks. Long term use of this medication was associated with [CONDITION(S)], and increase risk of C. difficile [a highly contagious, debilitating, and potentially dangerous gastrointestinal infection], and low magnesium levels. Resident 13 - April 2021 and May 2021 DRRs recommended to check an HgbA1c [a blood test] in order to monitor the resident's diabetic therapy. Additionally, both April and May 2021 DRRs identified in a warning in bold, that the concurrent use of [MEDICATION(S)] (a cardiac agent) and a [MEDICATION(S)] (blood thinning medication), may result in the decreased effectiveness of the [MEDICATION(S)], which could lead to an increased risk of thrombotic events, like a stroke. The DRR asked the physician to use caution when the drugs were used in combination, and to weigh the risks and benefits of continuation of these two drugs. Resident 16 - April 2021 DRR recommended to check an HgbA1c in order to monitor the resident's diabetic therapy. This was requested again in May 2021 DRRs. Resident 17 - April 2021 DRR recommended to check an HgbA1c in order to monitor the resident's diabetic therapy. This was requested again in the May 2021 DRR. Resident 18 - April 2021 DRR identified the resident was on two antipsychotic drugs, which had the potential of increased side effects, and asked the physician to address the duplicate therapy. This was requested in the May 2021 DRR. Resident 19 - April 2021 DRR identified the resident was on three antidepressants, which had the potential for increased side effects, and asked the physician to address this duplicate therapy. Resident 20 - May 2021 DRR identified low [MEDICATION(S)] (a cardiac agent requiring blood level monitoring) levels two days in a row, and asked the physician if they would like to re-test. Resident 22 - April and May 2021 DRRs recommended to check an HgbA1c in order to monitor the resident's diabetic therapy. In addition, the pharmacist recommended to the physician to address the use of two antidepressants, which had the potential of increased side effects, in the April and May 2021 DRR. Resident 24 - May 2021 DRR identified the resident was on two antidepressants, which had the potential for increased side effects, and asked the physician to address this duplicate therapy. Resident 25 - April 2021 DRR showed the resident had been on [MEDICATION(S)] (medication for acid reflux) 40 mg since 01/2021, and guidelines suggested a review and documentation from the physician to document why it should be used for longer than 12 weeks. Long term use of this medication was associated with [CONDITION(S)], and increased risk of C. difficile, and low magnesium levels. SYSTEMS FAILURE The above findings were shared with Staff A, Administrator, and Staff B, Interim Director of Nursing on 06/25/2021 at 3:24 PM. Staff B stated in an interview on 6/25/2021 at 3:24 PM, that the facility provided the investigator with all the DRRs that were requested on 06/21/2021. Staff B stated there was no documentation to support the physician addressed the April and May 2021 DRRs for Resident 1's [MEDICATION(S)] dose. Staff B stated that DRRs are all provided to the physician and acted upon. Staff B stated that problems with this system were unclear for previous administrations. Staff B could not identify what systems previous administrations used to process DRRs in a timely manner In an interview on 6/25/2021 at 3:31 PM, Staff A stated, We know we need to have better follow-up with pharmacy recommendations. It's a subject for QAPI [Quality Assurance Performance Improvement] to sit down and figure out where the breakdown in the system is. Clearly we have an issue. When asked if she was aware the consults were not getting to the doctors or where the breakdown in the system occurred, Staff A stated, No, I was not aware of it. But we have had an interim DON for a six week period before that, and before that another interim. I wonder if during that turn-over, we struggled. Reference WAC 388-97-1060(3)(k)(i)(iii).

Based on observation, interview, and record review the facility failed to offer, to provide and/or coordinate administration of the vaccination for COVID-19 (an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death.) to seven (Residents 4, 1, 2, 3, 7, 8 & 14) of ten residents reviewed for vaccinations. In addition, the facility failed to monitor Resident 9 for potential adverse reactions following the resident receiving the vaccination from an outside source. Failure of the facility resulted in serious harm to Resident 4 who required hospitalization for serious persistent life threatening complications related to contracting COVID while in the facility, and harm to Resident 1 who contracted COVID-19 while in the facility. And placed all unvaccinated residents at risk of infection, serious long term side effects and death. Findings included . Resident 4 Review of the 04/23/2021 Quarterly Minimum Data Set (MDS-an assessment tool) showed Resident 4 had conditions which placed the resident at risk for illness related to COVID-19, including over age 70, heart failure, and hypertension (high blood pressure). Review of facility COVID-19 Vaccination Logs showed the facility had a vaccination clinic on 01/27/2021 and 02/17/2021. Review of Resident 4's record showed the resident was admitted on [DATE]. On 06/07/2021 Resident 4's family stated that Resident 4 admitted to the facility in January 2021, Since then, for more than four months, as her Power of Attorney, I was constantly asking to vaccinate (resident) from the COVID-19 .I even offered to take (resident) to vaccine clinic myself, but was told that was not necessary, since the facility can do it on the spot. Review of COVID-19 Vaccination logs provided by the facility did not include Resident 4's name. Review of the resident's electronic medical record revealed no documentation the resident/representative was offered or declined the COVID-19 vaccination. Review of the facility line listing dated 06/11/2021 showed Resident 4 was tested for COVID-19 using a point of care (POC), rapid test on 06/01/2021 which was negative. On 06/03/2021 Resident 4 was symptomatic with shortness of breath. Review of a Nursing Progress Note date 06/03/2021 at 12:36 PM showed Resident 4 was placed on 5 liters per minute of oxygen. Review of Provider Notes showed Resident 4 was seen 06/03/2021 as nursing reported the resident desaturated down to 83% on room air. The resident was placed on 5 liters of oxygen with saturation up to 93%. A 06/04/2021 POC test was positive for COVID-19. A Polymerase Chain Reaction (PCR- test to detect virus) test was performed 06/04/2021 and Resident 4 was confirmed positive for COVID-19. A 06/04/ Nursing Progress Note showed that Resident 4 was transferred to the hospital due to positive COVID-19 testing. The resident was lethargic (drowsiness, lack of energy and mental awareness), with oxygen saturation levels 87% on 10 liters per minute of oxygen. In an interview on 06/23/2021 at 1:00 PM, Resident 4's family stated that Resident 4 remained in Intensive Care Unit on a ventilator (use of machine to force oxygen into lungs). During an interview on 06/10/2021 at 1:25 PM, Staff E, stated that Resident 4, wanted and didn't receive the COVID-19 vaccine. Staff E, Social Services Director, stated, I believe (Staff H, Scheduler) was working on that, but I'm not sure. Resident 1 Resident 1 admitted to the facility on [DATE]. Review of the 03/20/2021 Admission MDS showed Resident 1 had conditions which placed the resident at risk for illness related to COVID-19, including over [AGE] years of age, hypertension, and diabetes. Review of the resident's record showed no documentation the COVID-19 vaccine was offered or refused. Review of the facility undated COVID-19 Vaccine Rosters showed Resident 1 was not listed as vaccinated, unvaccinated, offered or refused. Review of facility line listings dated 06/11/2021 showed on 05/30/2021 Resident 1 was symptomatic for COVID-19 with a sore throat, and on 06/01/2021 tested positive for COVID-19. Resident 1 was observed on the facility COVID-19 positive on 06/10/2021 at 1:45 PM walking from the bathroom to the bed with stand by assistance of staff. Resident 2 Resident 2 admitted to the facility on [DATE]. Review of the 04/09/2021 Admission MDS showed Resident 2 had conditions which placed the resident at risk for illness related to COVID-19, including over age 70, heart failure, and hypertension. Review of a Grievance dated 06/03/2021 showed that Resident 2's family stated that Resident 2 should have been vaccinated by now. The action documented as taken was Notified scheduler to coordinate vaccination. The Grievance was not signed off as resolved. During an interview on 06//10/2021 at 1:25 PM, Staff E stated that Resident 2's family requested the COVID-19 Vaccine. Staff E spoke to Staff D, Infection Preventionist, and Staff D spoke to the resident's family who wanted to wait so the resident could get both shots since the resident was discharging in a week. A late entry Nursing Progress Note dated 06/10/2021 at 3:33 PM, showed that Staff D, called resident's responsible party (RP) regarding consent to administer COVID-19 vaccine. The RP stated that they did not feel comfortable with the vaccine to be given to Resident 2. The nurse provided education about the risk and benefits, and the plan for monitoring residents after vaccine is administered to ensure residents' safety. The nurse informed the RP to call us with any questions in case they change their mind. Resident 2 discharged from the facility on 06/11/2021. Resident 3 Resident admitted to the facility on [DATE]. Review of the 05/08/2021 Quarterly MDS showed Resident 3 had conditions which placed the resident at risk for illness related to COVID-19, including over age 70, heart failure, hypertension, kidney disease, and diabetes. Review of the COVID-19 Vaccination Record Card showed Resident 3 received the PFIZER Vaccination on 02/17/2021 at the facility. In a letter dated 05/27/2021 Resident 3's family member wrote, to date (Resident 3) has not received the 2nd shot. The social services director, (Staff E) was called twice by (resident's) family to inquire when the 2nd shot was to be scheduled. No return call was ever received. During an interview on 06/10/2021 at 1:25 PM, Staff E, had no recollection of receiving the call or having a conversation with Resident 3's family member. Staff E stated that Staff H, scheduler, was coordinating the vaccine appointments. Resident 8 Resident 8 admitted to the facility on [DATE]. Review of the 03/25/2021 Admission MDS showed Resident 8 had conditions which placed the resident at risk for illness related to COVID-19, including over age 70, metastatic cancer, hypertension, and diabetes. Review of COVID-19 Vaccine Roster showed Resident 8 was unvaccinated and vaccine was not offered or refused. Review of Nursing Progress notes on 06/16/2021 showed no indication that Resident 8 was offered or refused the COVID-19 vaccine. Resident 7 Resident 7 admitted to the facility on [DATE]. Review of the 04/19/2021 Admission MDS showed Resident 7 had conditions which placed the resident at risk for illness related to COVID-19, including over age 70 and diabetes. Review of COVID-19 Vaccine Roster showed Resident 7 was unvaccinated and vaccine was not offered or refused. Review of Nursing Progress notes showed no documentation the resident was offered or refused the COVID-19 vaccination until 06/10/2021. A Nursing Note dated 06/10/2021 at 4:00 PM showed that Staff N, Resident Care Manager (RCM) spoke with Resident 7's Guardian regarding the facility offering the COVID-19 vaccine and that Resident 7 wanted to have the vaccine. Resident 7's Guardian in agreement with Resident. Resident 14 Resident 14 admitted to the facility 02/04/2021. Review of the 04/02/2021 Quarterly MDS showed Resident 14 had conditions which placed the resident at risk for illness related to COVID-19, including over age 65, heart failure, diabetes, and lung disease. During an interview on 06/10/2021 at 12:05 PM, when asked if vaccinated for COVID-19, Resident 14 stated, No, but I said I would like to get one. Resident 14 stated that each time staff came to conduct test for COVID-19, I say I'd like to get the vaccine. I don't want to catch the virus. Review of the resident record showed no documentation the resident was offered the COVID-19 vaccination. Resident 9 Resident 9 was admitted to the facility on [DATE]. Review of the 06/02/2021 Quarterly MDS showed Resident 9 had conditions which placed the resident at risk for illness related to COVID-19, including over age 65, kidney failure and diabetes. Review of COVID-19 Vaccine Roster showed Resident 9 was vaccinated. Review of Resident 9's Immunization Record on 06/16/2021 showed the Resident received the first COVID-19 vaccine on 04/21/2021 and the second dose of the COVID-19 vaccine on 05/12/2021. Review of the Nursing Progress Notes and May 2021 Treatment Administration Records showed no indication of side effect monitoring following the 05/12/2021 vaccine. During an interview on 06/10/2021 at 9:50 AM, Staff A, Administrator stated that they were to obtain the COVID-19 vaccine from the pharmacy. They were working on scheduling a clinic and hoped to get it going next week. When asked if the facility had any difficulty obtaining the vaccine, Staff A stated, No. They've had it available for the last month, we just wanted to make sure we had our paperwork in place. Refer to WAC: 388-97-1780(1)(2)(b)(c)(d).

Based on interview, and record review, the facility failed to ensure two (Residents 1 & 2) of five residents reviewed, received the necessary care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Failure of the facility caused residents to experience a decline in medical status and quality of life related to unmet care needs. The facility failed to provide the type of wheelchair Resident 1 was assessed to require, which caused the resident's injury fall during transport. The facility failed to follow appropriate diet recommendations for Resident 1, which caused Resident 1 to experience symptoms of aspiration and placed the resident at risk for choking, aspiration and requiring lifesaving interventions. The facility failed to ensure Resident 2 received emergency services timely, after experiencing a change in condition including decreased mentation, that prevented prompt treatment that resulted in hospitalization and a continuous unconscious mental state. Findings included . Resident 1 Review of the [DATE] Admission Minimum Data Set (MDS - an assessment tool) showed Resident 1 admitted to the facility [DATE], with unsteady balance, required two person extensive assist with transfers, impaired range of motion to upper extremities, pain to lower extremities, one fall since admission with injury, coughing or choking during meals or when swallowing medication, feeding tube, and a mechanically altered diet. Injury Fall in van During an interview on [DATE] at 4:13 PM, Resident 1's spouse stated that on [DATE] Resident 1 went to an appointment in a wheelchair that was too big for him, he kept saying I'm slipping, I'm slipping and no one did anything so he fell on the floor. Resident 1's spouse stated that they had a facility escort with him who put Resident 1 back in the chair. In an interview on [DATE] at 1:49 PM, Staff H, Registered Nurse (RN) stated that on [DATE] Resident 1 went out to a neurology appointment related to an inability to feel lower legs. Review of the Physical Therapy Evaluation dated [DATE] showed the resident had trunk weakness, upper & lower extremity weakness, was unable to sit unsupported for 30 seconds with feet flat on floor and no back support, was a fall risk and prior to admission the resident utilized a Tilt in Space wheelchair. In an interview on [DATE] at 11:55 AM, Resident 1 stated that he was sitting in a wheelchair in the van. Staff were seated in the front seats, and the resident was in the middle of the van, wheelchair secured. Resident 1 stated he said, It's sliding, I'm sliding out of the wheelchair, then it's like I'm gone. I'm on the floor. Resident 1 stated that the driver was finally able to pull over on the freeway and he was assisted back into the wheelchair. Resident 1 stated My foot was bent backwards while I was on the floor. It didn't show anything, then all of a sudden there were bruises all over. Resident 1 stated, about the injury to the ankle, It hurt the whole time I was on the floor of the van. In an interview on [DATE] at 1:39 PM Staff B, Risk Management, stated that the driver of the facility van demonstrated how the resident was buckled in the van, and was able to slide under buckle, and landed in front of the wheelchair, foot twisted under him. Review of a Nursing Progress Note dated [DATE] at 2:25 PM showed Resident 1's left foot was assessed after complaining of pain following the fall. The dorsal surface of the left foot has light purple bruising and is painful to touch. No remarkable swelling noted at this time. Ice pack provided for comfort and foot is elevated on a pillow. LN on duty provided resident with PRN Oxycodone and Tylenol. Non-pharmacological pain interview done and interventions identified as follows: Sleeping on back is comfortable .he is able to tell staff what level is comfortable for him, legs elevated . Review of the [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 experienced increasing pain of the injured ankle. The [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1 did not receive any pain medication on [DATE], received one dose [DATE], one dose [DATE], and on [DATE], [DATE], [DATE] received three doses for pain levels ranging from ,d+[DATE], with an average of 8 out of 10. In addition, on [DATE] the resident received Tylenol 650 mg for ankle pain. Review of a [DATE] 11:19 PM Nursing Progress Note showed that Resident 1 complained of left ankle pain, pain managed with as needed (PRN) Tylenol and Oxycodone as well as a [MEDICATION(S)] patch and ice. The facility obtained and X-ray of the injured ankle revealing no fracture. Review of a [DATE] 6:01 PM Nursing Progress Note showed the resident complained of pain ,d+[DATE] to left lower extremity site of the injured ankle. The resident was offered non pharmacological interventions, which the resident declined and requested Oxycodone. Review of a Nursing Progress Note dated [DATE] at 2:25 PM showed the author called and spoke with provider and obtained new order for ,d+[DATE] view X-ray for the left foot, [MEDICATION(S)] patch to left foot X 3 days, and cold packs to left foot as needed. Also- monitor neuro checks and left foot, notify provider if bruising gets worse or if neuro checks are abnormal. During an interview on [DATE] at 1:49 PM Staff H stated that Resident 1 was on a blood thinner, that doesn't cause bleeding and that Resident 1's spouse was concerned that Resident 1 had hit his head when he fell . Staff H stated Resident 1 denied hitting his head, and stated that if Resident 1 had hit his head we would have done neuro checks . Review of the resident's record showed no neuro checks. On [DATE] at 9:35 AM neuro checks were requested from the facility. On [DATE] at 12:34 PM, Staff B stated The facility did not initiate neuros post fall due to witnessed fall with no head strike. Review of a [DATE] 1:34 PM Interdisciplinary Note showed that : IDT met to discuss allegation that staff were not trying to prevent him from slipping and ultimately resulted in a fall in the wheelchair van on ,d+[DATE]. Staff in attendance and had pulled over multiple times for readjustment as he commented he was slipping. Resident was wearing seatbelt in the wheelchair van, total lift with total lift pad under resident caused for slippery surface coupled with generalized weakness in the resident, he is unable to stop himself from sliding. Resident slid from wheelchair to knees in wheelchair van. X-ray negative to ankle r/t bruise noted. Resident with no increase in pain, care plan reviewed in relation to the fall report, therapy working on obtained tilt and space chair for positioning. Review of the facility investigation dated [DATE] showed that Resident 1, was given standard wheelchair for transport with feet rests, resident able to rest feet on the foot rests but staff noted that if he (his) feet fell /slid from them related to no control over BLE (bilateral lower extremities) then he would start to slide forward in the chair .upon return therapy asked to eval for his wheelchair appropriateness. Therapy stated that a tilt and space wheelchair would be better than standard due to physical health and medical conditions . There was no data, in this document, to support the facility considered alternative means of transport, in light of the absence of an appropriate Tilt n Space wheelchair, such a a stretcher. In an interview on [DATE] at 1:39 PM, when asked why Resident 1 was not provided a Tilt in Space wheelchair at admission, Staff B stated I know we don't have one in house. Staff B said the facility tried to rent or borrow one and were unable to procure one prior to Resident 1's discharge. When asked why the facility had not used an alternate means of transportation, Staff B stated, Nursing was not aware that a regular chair would not be safe. The conversation never came up in morning meeting. Not until after (the incident). The facility failed to ensure the resident was safely transported to an appointment, by procuring a Tilt in Space wheelchair the resident was assessed to require or transporting the resident via an alternate method causing an injury and increasing pain. Choking episode Review of the plan of care dated [DATE] showed the intervention Aspiration Precautions. Review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Speech Therapy Treatment Encounter Note dated [DATE] showed the resident was seen for skilled dysphasia treatment in the resident's room. Speech Therapist (ST) analyzed resident's diet on thin liquids and resident demonstrated coughing and choking on first attempt when in fully upright position given maximum verbal cues. Resident demonstrated safe swallow on therapeutic trials of nectar/mildly thick liquids. Educated resident on safe swallow precautions including resident is an aspiration risk on thin liquids. Diet recommendations include nectar thick liquids, upright 90 degrees for intake, and supervision during meals requiring maximum verbal cues. Coordinated care with Resident Care Manger (RCM) regarding diet recommendations. RCM contacted POA to confirm consent for diet modification. Review of a progress note dated [DATE] showed Staff H, spoke with Resident 1's spouse regarding the ST evaluation. Resident 1's spouse stated he wanted the facility to continue giving the nectar thick liquids. Review of POs showed a [DATE] 1:49 PM order for, .Mildly Thick liquid consistency, Aspiration Precautions .upright 90 degrees for intake, supervision during meals, and if pt (patient) coughs have him wait one minute before letting him take another bite/sip. Review of Speech Therapy Treatment Encounter Note dated [DATE] showed the ST was gowning up in the hallway and heard resident coughing and choking and was found with a cup and jug of thin water on bedside table. Educated resident and nursing regarding safe swallow precautions including resident's diet for pleasure feedings include nectar/mildly thick liquids, no water or ice, upright 90 degrees for intake and resident requires setup assistance for intake. Review of a [DATE] Interdisciplinary Note showed that the care plan was updated for fluids not at bedside due to need for supervision with safety along with need to encourage resident to allow appropriate thickness of fluids. During an interview on [DATE] at 1:49 PM, Staff H stated Resident 1, was supposed to have thickened liquids and he did not like it .We were doing everything possible to keep him safe. Review of the facility investigation dated [DATE] showed the root cause identified was that staff were unaware of diet change and the resident had thin liquids at the bedside. Diet change never made it to communication board/alert board for nursing staff, reminder given to RCM staff, causing Resident 1 to experience symptoms of aspiration. Resident 2 Review of the [DATE] Quarterly MDS showed Resident 2 was cognitively intact, with medically complex diagnoses. Review of the face sheet showed the resident was their own responsible party/own decision maker. The [DATE] Care Plan did not address the resident's advance directives. During an interview on [DATE] at 12:25 PM Staff G, Social Services Director, stated that Resident 2 was their own responsible party, that Resident 2 told the staff that mom helps out, and no power of attorney documents were provided to the facility. During an interview on [DATE] at 4:52 PM, Resident 2's mother stated, no one had discussed advanced directives, or life-sustaining treatment with her and noted, I would want it all. (Resident 2)'s not even [AGE] years old. Review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The POLST was signed by Resident 2. Further review of the POLST dated [DATE] showed Resident 2's instructions to staff were to attempt resuscitation/Cardiopulmonary Resuscitation (CPR) if no pulse and not breathing. The POLST instructed staff, when not in cardiopulmonary arrest, go to part B. Part B of the POLST form included, Medical Interventions: Person has pulse and or is breathing, showed Resident 2 wanted Full Treatment - primary goal of prolonging life by all medically effective means which included transfer to a hospital if indicated. During an interview on [DATE] at 11:15 AM, Staff E, RN was asked to review Resident 2's POLST and when asked what it meant, stated, We can attempt CPR and full treatments. Review of Progress Notes dated [DATE] at 6:41 AM showed at approximately 4:30 AM, Staff C, RN observed the resident unsafely seated in his wheelchair (w/c), nodding off. The back of resident's shirt was damp, with cold clammy skin. Resident 1 was alert and oriented and able to make needs known. On inquiry, resident reported feeling tired and a little out breath. Resident denied chest pain, dizziness, cough and feeling feverish. On assessment pulse oximetry oxygen level (Sp02) 88% on room air. On further assessment, bilateral lungs were clear with diminished breath sounds in bilateral lung bases and heart sounds were normal. Resident was then transferred from w/c to bed, offered care and made comfortable. Supplemental oxygen was administered at 2 liters per minute (l pm) via nasal cannula. Call was placed to the on call provider who was notified of resident's condition and the supplemental oxygenation. On call provider was agreeable with the order and recommended close monitoring of the resident during the shift and to report any changes for further orders. Staff C then handed over the shift to the AM nurses with all instructions. Review of POs showed an order was obtained on [DATE] at 4:00 AM, created in the computer at 06:45 AM, for supplemental oxygen at 2 lpm to maintain Sp02 above 90%. Review of the [DATE] Treatment Administration Record (TAR) showed no documented monitoring of oxygen saturation levels, and no documentation of oxygen administration or rate of administration according to the PO. Review of the documented 02 sats summary showed staff documented monitoring of Resident 2's oxygen level on [DATE] at 5:35 AM as 100% with oxygen via nasal cannula, and on [DATE] at 7:00 AM at 78% with oxygen delivered by mask. Review of Progress Notes written by Staff D, RN, dated [DATE] at 8:07 AM, showed at 7:00 AM, Staff D, RN received a call from another RN, and when Staff D entered the room, Resident 2 was lying on back in semi-fowler position and unresponsive, placed resident in 90 degree position while in bed. Vital Signs were checked and Sp02 was 61 with 3 lpm via nasal cannula. The medical provider was called and an order received to place resident oxygen via face mask (Sp02 78 with 4L/min via face mask) and to ask the family and send res to emergency room (ER). At 7:10 AM, Resident 2's mother was called and agreed to send resident to ER. At 7:15 AM 911 was called. Review of the facility investigation dated [DATE] showed that the medical provider asked the nurse to remove the [MEDICATION(S)] patch that was replaced on [DATE] at 8:00 PM and administer [MEDICATION(S)]/call 911 to have [MEDICATION(S)] administered. The medical provider noted that the staff were unsure of the code status during the call and the provider told them to check the POLST form and if comfort to call the family and ask what they would like done and if not comfort to send to ER. During an interview on [DATE] at 11:15 AM, Staff E, RN stated that by the time they (Staff D & E) came on change of shift, at 6:30 AM, Resident 2 was unresponsive, could open eyes, oxygen was low at 60. Staff E recalled that Staff C had called the doctor when Resident 2's oxygen was low during the prior night. Staff E stated, We called back the doctor and the doctor told us to call the family first before send to hospital. Staff E stated that afterwards they called the family, who said to call 911. The medics came in, assessed Resident 2, took oxygen, vital signs and transported to the hospital. There was no documentation to suggest staff were keenly aware of Resident 1's need for close monitoring, more advanced treatments, or emergent care as suggested by Resident 1's choices noted on the POLST form. Rather staff called the doctor implementing a telephone call to family before calling 911 and transporting Resident 1 to a local hospital. During an interview on [DATE] at 4:52 PM, Resident 2's mother stated that morning the facility called, said Resident 2 was unresponsive, with an oxygen level less than 61% and they wanted to know if I wanted them to call 911! Of course I did! During an interview on [DATE] at 11:15 AM, when asked why, if Resident 2 was a full code, and found unresponsive, why the staff did not call 911 first, Staff E stated that the resident's pulse and respiratory rate were ok, the problem was only the oxygen at that time. During an interview on [DATE] at 11:20 AM, Staff F, Resident Care Manager stated that if a full code resident was found unresponsive staff were expected to call 911. A [DATE] 6:22 PM progress note showed that Resident 2 was admitted in Intensive Care Unit and placed on assisted ventilation. During an interview on [DATE] at 4:52 PM, Resident 2's mother stated, I was able to face time with my (Resident 1) at (hospital) today. (Resident 1) non responsive. The nurse opened (Resident 1's) eyes for me. Review of the facility investigation dated [DATE] showed that the facility identified training for staff needed on how to determine code status of a resident and what to do in an emergency. Reference: (WAC) [DATE] (1)

Based on observation, interview, and record review, the facility failed to ensure residents at risk of falls had preventative measures implemented, falls were thoroughly investigated to determine the circumstances of resident accidents and failed to develop and implement measures to prevent further falls with injury, for 4 of 4 Residents (10, 7, 2 & 3) reviewed for accidents. Failure to thoroughly investigate falls and re-evaluate fall risks and interventions, resulted in a fall with a pelvic fracture to Resident 10, and a fall with an ankle fracture to Resident 7, both of which constituted harm. Findings included . Review of the facility Fall Evaluation and Management Policy dated March 2018 showed that at Admission, a licensed nurse completed the Morse Scale, if the score was greater than 45, the resident was considered as having High Potential for falls and staff implemented appropriate care plan interventions for fall management. Resident 10 Review of the 03/16/2021 Admission Minimum Data Set (MDS - an assessment tool) showed Resident 10 admitted to the facility 03/10/2021, skilled Occupational and Physical Therapy stated 03/11/2021, and the resident required two person extensive assistance with bed mobility, transfers, toilet use, and was only able to stabilize with staff assistance. Review of the Morse Fall Scale dated 03/10/2021 showed the resident was assessed with a score of 65, indicating a High Risk for falls. Review of the 03/10/2021 Admission Nursing note showed the resident was on fall precautions and had been educated on the the call light system. Review of the Baseline Care Plan (BCP) dated 03/10/2021 showed the resident had a history of falls, but listed no interventions in place to prevent falls or minimize injury from falls. According to the 03/11/2021 MD (Medical Doctor) Admission History and Physical (H & P), Resident 10 was deemed high fall risk due to accommodation of at least two of the following: Balance/gait imbalance, visual impairment, and/or medications. In addition, the resident had an abnormal CT (computerized x-ray) bladder scan and a non emergent referral to urology for further work-up was ordered. The MD recommended plan included, Fall precautions as appropriate per facility protocol. In an interview on 04/13/2021 at 2:00 PM Staff K, Interim Director of Nursing stated that after the Morse Scale Evaluation was conducted, then interventions were based on that assessment to create a safe environment with the goal of no falls. Staff K stated that the facility did not have standing orders, the fall precautions developed were based on the Morse Scale and resident's individual characteristics. Review of the March Treatment Administration Record (TAR) showed the staff did not document scheduling the referral when directed on 03/11/2021, 03/12/2021, 03/13/2021 or 03/14/2021. Review of 03/14/2021 Nursing Progress Notes showed Resident 10 sustained a fall at 9:00 PM. The Certified Nursing Assistant (CNA) found the resident face down on the floor beside the bed. Resident 10 refused to be turned or moved by staff, reported generalized pain and was found with a fever. The facility called 911 and the resident was sent to the emergency room . Review of the 03/14/2021 facility fall investigation showed the investigation did not indicate if the bed was in the lowest position when the resident was found on the floor. The investigation did not indicate when the resident was seen last and what the resident was doing at that time. The investigation noted that last cares provided near 1800 (6:00 PM), but did not indicate what care was provided or by whom. The investigation concluded the resident ambulated without assistance and fell at the bedside, but did not indicate the location of the walker, the call light, the blankets, footwear or data to support that conclusion or rule out that the resident may have rolled out of bed. Review of the plan of care showed the problem of High Risk for falls, and interventions for fall precautions were not initiated until 03/15/2021, after the resident sustained a fall. Review of the facility fall investigation dated 03/15/2021 showed after investigation and root cause analysis, conclusion was that the resident fell at bedside related to weakness and deconditioning and that current Urinary Tract Infection (UTI) and electrolyte abnormalities contributed to poor safety awareness. According to the facility fall investigation a referral to urology was in place. Review of a 04/01/2021 4:23 AM Nursing Progress Note showed Resident 10 was found on the floor holding a urinal and had poured urine on the floor. The resident complained of right hip pain, was assessed with a right knee abrasion, 911 was called and the resident transported to the emergency room . Review of the Incident Follow-up & Recommendation Form dated 04/04/2021 showed the resident was using a walker at the time of the fall, wearing slipper socks, call light was at bedside within reach but not engaged, and resident was last toileted around 9:00 PM. The root cause identified was that the resident was not following recommendations using appropriate level of assistance during time of the fall and appears to have been bringing urinal towards bathroom. During an interview on 04/05/2021 at 1:00 PM, Staff B, Director of Nursing stated the resident was found on the floor, with urinal in hand, between the bed and the bathroom. Resident 10 did not ring for assistance and was not safe to get out of bed without assistance. It appeared the resident was going to empty the urinal. Staff B stated according to staff, Resident 10 refused offers for care, including emptying the urinal. Further review of the Incident Follow-up & Recommendation Form dated 04/04/2021 showed staff indicated that the resident frequently refused check and change's. Upon return facility will need to review and update care plan including behavioral care plans to ensure measures in place to attempt to prevent reoccurrence of fall with major injury. Review of the resident record showed Resident 10 readmitted to the facility on [DATE]. Review of the hospital discharge records showed the resident was diagnosed with a right pelvic fracture. In addition, the resident was diagnosed with urinary retention, a Foley catheter was placed on 04/03/2021. Transfer orders included Urinary Catheter Management, status temporary, and an Urology follow up appointment. Review of the nursing assistant documentation for urinary care did not show documented refusals. Review of the resident record showed no behavior monitoring. Review of the care plan on 04/08/2021 at 2:37 PM showed no problem addressing refusals and no changes or updates to the plan of care. Resident 7 Review of the 03/02/2021 Admission MDS the resident had experienced one non injury fall since admission. The resident was assessed to required two person extensive assist with toileting, bed mobility and transfers. Review of the 03/16/2021 Discharge MDS showed since the prior MDS, the resident had one non injury fall, one injury fall, and one fall with major injury. Review of the 03/09/2021 Care Plan (CP) showed the resident was a high risk for falls related to deconditioning, gait/balance problems, poor safety awareness, right below the knee amputation, left lower extremity contractures and a history of falls. Resident 7 was observed on 04/05/2021 at 12:08 PM sitting sideways on the side of the bed, with the head of the bed elevated, left leg on the floor. No staff were present in the room, but a caregiver was observed at the doorway donning personal protective equipment in preparation for providing care. Review of the March 2021 Event Log showed Resident 7 had a non injury fall on 03/08/2021 at 4:30 PM. Review of the facility fall report dated 03/08/2021 showed the resident was found on the floor. The resident stated he was reaching for the cell phone while sitting on the commode and fell . No immediate interventions were put in place to prevent reoccurrence. Review of progress notes dated 03/08/2021 at 9:55 PM showed the resident sustained a fall without apparent injuries while sitting on the commode. Further review of progress notes dated 03/09/2021 at 4:11 AM showed Resident 7 was sitting on the commode, hit the dresser with the tip of nose and sustained a skin tear on the nose bridge. The skin tear was cleaned and gauze secured to put pressure on the skin tear to avoid excessive bleeding. On 03/09/2021 at 9:19 AM a message was left with the resident's representative that the resident bumped their nose on the dresser. Review of the March 2021 Event Log showed no entry for the 03/09/2021 incident and no notation of injury sustained. Further review of the facility investigation of the 03/08/2021 fall, dated 03/09/2021 showed the CP was updated to include ensuring Resident 7 had commonly used personal items within reach before leaving the room and toileting safety to provide stand by assist, privacy and remain close to the care area. Review of the facility fall report dated 03/14/2021 at 5:58 AM showed Resident 7 sustained a non injury fall on 03/14/2021 at 1:45 AM. The resident was found sitting on the floor beside the bed and stated he was reaching for something and fell . The investigation failed to determine if the care staff had implemented the plan of care to have commonly used items within reach. No immediate interventions were put in place to prevent reoccurrence. Review of the facility fall report dated 03/14/2021 showed on 03/14/2021 at 1:30 PM Resident 7 was found on the floor. Resident 7 stated, I slid out of the bed. Review of a 03/14/2021 5:07 PM Nursing Progress Note showed the resident slid out of bed and landed on the floor in their room. Resident 7 was found lying on their right side facing the closet. The wound on the left leg was bleeding after the fall and the dressing was changed. Review of the March 2021 Event Investigation Log showed Resident 7 had a non injury fall on 03/14/2021 at 1:45 AM, and a fall with significant injury on 03/14/2021 at 1:30 PM and the Department was not notified of the significant injury as required. Review of the facility fall investigation dated 03/16/2021 showed that on 03/15/2021 the resident complained of left ankle pain and some swelling was noted. X-ray results showed a fracture in the medial malleolus (ankle) and distal fibula with minimal displacement. According to the investigation, It is likely that the left ankle fracture is related to one of the two falls, though it is unclear when the trauma occurred since no acute ankle pain was noted at the time of either of the falls. Resident 2 Review of the Admission MDS dated [DATE] Resident 2 was at risk of falls. Review of the Morse Fall Scale dated 03/10/2021 showed the resident was assessed with a score of 60, indicating a High Risk for falls. Review of the BCP dated 03/01/2021 showed the resident had a history of falls, but listed no interventions in place to prevent falls or minimize injury from falls. Review of the facility fall investigation dated 03/29/2021 showed Resident 2 was found laying on the floor by the bed on 03/27/2021 at 4:10 AM. According to the investigation the resident is incontinent and last incontinence cares provided at 1951 (7:51 PM). The investigation did not indicate when Resident 2 was last observed, or indicate why the resident had not been offered care for eight hours. The care plan was updated to include a toileting schedule, at bedtime, every shift and as needed. According to the facility fall investigation the resident stated that they slid out of the bed and could not control themselves from sliding and falling. Other information included resident likes sleeping near the edge of the bed. But is usually repositioned in the center During an interview on 04/06/2021 at 2:58 PM Resident 2's representative stated that Resident 2 fell out of bed a week ago. Resident 2's representative stated, When I asked what needed to be done differently they didn't have an answer. Resident 2's representative stated that they later spoke to Staff B who stated the bed had been lowered as low as it could go and Staff B would look to be sure there was a fall mat. Review of the CP showed interventions to address the resident's high fall risks were not initiated until 03/29/2021, after the resident's fall. In addition, the CP did not address the resident's propensity to sleep near the edge of the bed. The interventions listed included, bed in low position when in bed and unattended, and bilateral fall mats when resident is in bed. On 04/05/2021 at 12:22 PM Resident 2 was observed in bed, in a low position, with no fall mats in place. Resident 3 Review of the 02/22/2021 High Risk for Falls CP showed interventions listed to Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter or remove any potential causes if possible. Educate resident/family/caregivers/IDT (Interdisciplinary Team) as to causes. During an interview on 04/13/2021 at 2:00 PM, Staff K stated that a fall was defined as an unplanned change in elevation. Review of Nursing Progress notes dated 02/26/2021 at 5:25 PM Showed, Resident had a fall this morning .Resident was educated how to use the call light and call for help whenever he needed Review of a 02/26/2021 Medical Provider Skilled Follow Up Visit showed, Patient seen and examined today at bedside on 2/26/2021 .Patient states that he slipped and landed softly in his knee earlier today while he was looking for his shoe . Review of a Nursing Progress Note dated 03/15/2021 at 6:54 AM showed, At around 8 PM patient was seen crawling out of bed. This patient was advised to go back to bed but patient crawled until he reached the hallway . Fall incident investigations were requested for all of Resident 3's falls. No investigation was provided for either the 02/26/2021 or the 03/15/2021 incident. Record review showed no IDT Post Fall Reviews were conducted following either incident. Review of the 03/16/2021 Restlessness plan of care showed on 03/17/2021 the intervention was added to include, Resident behavior purposeful as placing himself on mattress on floor for sleeping, crawling around per resident statements. REFERENCE WAC 388-97-1060(3)(g).