Every finding on record at Valley View Skilled Nursing and Rehabilitation

Based on observation, interview and record review, the facility failed to obtain approval from the Department of Health Construction Review Services program, prior to removing carpets and installing laminate flooring in the facility. The failure to obtain the required approval prior to starting remodeling project, put residents at risk for illness, injury, and unsafe living conditions. Findings included . <Facility Policy>According to the facility's revised 01/2026 Safe and Homelike Environment policy, the facility would provide a safe, clean and comfortable and homelike environment. The facility would ensure residents would receive care and services safely and the physical layout of the facility would maximize resident's independence and would not pose as a safety risk. On 05/28/2026 at 10:55 AM, Staff A (Administrator) reported the facility had recent renovations made to second floor west unit. Staff A stated the renovations included patient room remodeling and new flooring replacement. Staff A stated the second-floor west unit remodeling work had already been completed and while the remodeling was being done, residents were moved to another unit. Staff A stated they were not aware if the facility had asbestos or other hazards before starting the renovations but thought they would have obtained instructions if there were hazards. Review of an undated facility Upcoming Flooring Project notices given to residents, showed beginning at 7:00 AM on 12/10/2025, the facility was replacing the flooring in on the first-floor carpeted hallway and on 12/15/2025 would be replacing the flooring in the [NAME] 2 carpeted hallway. Review of an undated Attention Residents notice given to residents showed starting January 1st, 2026, Maintenance staff would be replacing the flooring on the second-floor resident rooms and residents should expect loud rumbling and scraping sounds throughout the day. Observations on 5/28/2026 at 11:40 AM, showed second floor west had wood laminate flooring in the hallway and all resident rooms on the second-floor west unit had new wood flooring. In an interview on 5/28/2026 at 11:50 AM, Resident 1 stated they were moved to another unit on the second floor while remodeling was being done and it took at least two weeks or more before they were returned to their own room. Resident 1 stated they did not like moving to the temporary room, because it did not have the same window view or conveniences of their own room. A review of the Washington State Department of Health, Construction Review services online search on 05/28/2026 showed the facility had applied for a review of floor construction project with an initial review on 3/24/2026 and a resubmittal review on 5/11/2026. As of 5/28/2026 the online search showed the facility's flooring project status showed as pending approval. In an interview on 05/28/2026 at 12:50 PM, Staff A stated they were not aware of the construction review process and were not aware the facility's project showed as pending in status. Staff A stated the second-floor west unit remodeling was already completed, and although the workers were not currently remodeling areas in the facility, they would be back to restart the project. Staff A stated they knew they had to notify residents of the upcoming remodeling plans, and have plans in place in case of emergencies, but was unaware of state requirements for safety prevention to prevent hazards to residents as part of the construction review process. In an interview on 06/05/2026 at 1:36 PM Staff B (Regional Plant Operations Director) stated they were responsible for obtaining construction review approval with the Department of Construction Review for the facility and acknowledged the status of the approval was still pending approval. Staff B stated they were unsure of the approval process and did not receive notification that the facility could not start the flooring remodeling work without receiving approval. Staff B stated they signed an acknowledgement of risk from the construction review process and thought they were able to start the remodeling work but were unsure of the process of obtaining an approval or impacts on resident safety if an approval was not obtained first. REFERENCE: WAC-97-2060 (2)(3)(4).

Based on observation and interview, the facility failed to ensure residents were provided a homelike environment for 2 of 4 units (100 Unit and 200 East Unit) and 1 of 1 dining room. The failure to ensure resident rooms were free of wall scrapes, broken or missing window screens, and unpleasant stains, and ensure dining areas were free of clutter, placed residents at risk for a less than homelike environment and a diminished quality of life.Findings included.<Facility Policy>According to the facility's January 2026 Safe and Homelike Environment policy, the facility would provide a safe, clean, comfortable and homelike environment. A determination of homelike should include the resident's opinion of the living environment.<100 Unit>Observation of room [ROOM NUMBER] on 03/18/2026 at 10:16 AM showed significant wall gouges behind bed 2 where the head of the bed scraped the wall. Observation of room [ROOM NUMBER] on 03/18/2026 at 1:25 PM showed the flyscreen was missing from the right side of the window. There was nothing to prevent pests from entering the room if a resident wanted to open their window. The wall behind bed 1 had significant dark wall gouges where the head of the bed scraped the wall. Observation of room [ROOM NUMBER] on 03/19/2026 at 10:40 AM showed the flyscreen to the left side of the window was torn and frayed. This left a whole large enough for pests to enter the room if a resident wanted to open their window and was not homelike. In an interview and observation on 03/24/2026 at 1:12 PM Staff A (Administrator) observed the wall scrapes and missing/torn flyscreens on the 100 unit and stated the missing/torn screens did not prevent pests from entering if the window was open and was not homelike. Staff A stated the wall scrapes were not homelike and needed to be fixed. <200 East> In an observation and interview on 03/19/2026 at 10:07 AM, room [ROOM NUMBER] showed a white double closet with doors labeled A and B within Resident 69's view from their bed. On the closet door labeled B, there was a dark red vertical line approximately six inches long, with a dried drip at the bottom of the line. The closet door handle contained dried smears of dark red matter. Resident 69 stated their previous roommate had blood and feces in their shared room, and there was still blood on the roommate's closet door. Resident 69 stated they thought it was gross, and they were concerned someone was going to touch the blood on the closet door handle. Resident 69 stated they reported this to various managers, social workers, and nurses a couple of weeks earlier and no one took care of it. Observation on 03/23/2026 at 8:59 AM showed the same dark red vertical line on the closet door and smears on the closet door handle. In an interview on 03/24/2026 at 10:58 AM, Staff G (Resident Care Manager) observed the same dark red vertical line on the closet door and smears on the closet door handle. Staff G stated it was important to clean the stains on the closet door because Resident 69 expressed they were not happy about it. <Dining Room> Observation of facility's dining room on 03/20/2026 at 11:53 AM showed the facility's dining room was laid out in an offset shape. In addition to two resident tables set up with green tablecloths, the narrower half of the dining room was used to store facility equipment, and remodeling supplies including: four tables, one stacked upside down on top of another; a first-aid mannequin with a paper wound attached to the left lower leg lying across the other two tables; a treatment supply cart, two mechanical lifts, a palate with remodeling supplies and a palate jack, an old steam table with several iced tea dispensers and coffee urns placed on top, two fall mats and foam spacers used to secure resident mattresses on the bedframe, some bagged items, a milk crate on top of the palate with vases inside, and three other palates with remodeling supplies. Behind the steam table were two long wide areas of mismatched paint consistent with cabinetry removal. In an interview and observation on 03/24/2026 at 1:14 PM Staff A stated the ad hoc storage in the dining room did not contribute to a homelike environment. Staff A stated the facility invested a lot of resources into improving the living environment for residents but there was still work to do. REFERENCE: WAC 388-97 -0880, -2040.

Based on interview and record review, the facility failed to properly prepare 1 of 1 resident (Resident 106) reviewed for discharge and complete the appropriate transfer notifications for 7 of 7 residents (Residents 104, 24, 8, 13, 2, 69, & 85) reviewed for hospitalization. The failure to offer bed holds (Residents 8, 2, & 85), provide a written transfer notice (Residents 2 & 85), provide report to receiving facilities (Residents 104, 8, 24, 13, 2, 69, & 85) and prepare resident for discharge (Resident 106) placed residents at risk for a disruption in their continuity of care, an undesired room change upon readmission, not having the opportunity to make informed decisions about their transfer/discharge rights, and inappropriate transfers.Findings included .<Policy>According to the facility policy titled, Bed Hold, dated 01/2026, the facility would inform Residents and/or resident representative of the facility's bed hold policy prior to transfer/discharge. The facility would provide a written transfer notification at the time of transfer/discharge and maintain a signed and dated copy in the resident's record. The Bed Hold policy showed it applies to all residents regardless of payment source.According to the facility policy titled, Transfer and Discharge (including AMA), dated 01/2026, showed transfers must occur in a manner that ensures resident health, safety, and continuity of care needs are met. The facility would evaluate resident needs, communicate, and coordinate the transfer appropriately. <Resident 106> According to the 12/27/2025 admission Minimum Data Set (MDS -an assessment tool) Resident 106 admitted to the facility on [DATE]. The MDS showed Resident 106 had diagnoses of respiratory disease, heart failure, cancer, and kidney failure. Review of Resident 106's health records showed a nurse progress note the resident discharged on 12/28/2025 Against Medical Advice (AMA). Resident 106's records showed no documentation of the provider notified, no documentation of a discharge summary offered or provided, no documentation of arrangements for medications, oxygen therapy, or home health care services offered or provided. Resident 106's records showed no documentation of a follow up appointment scheduled with the residents' primary care provider for continuation of care. In an interview and record review on 03/24/2026 at 9:23 AM Staff E (Resident Care Manager -RCM) reviewed Resident 106's records and stated there was no documentation of the provider notified of the AMA discharge, no documentation prescriptions/medications, or oxygen were offered or arranged for Resident 106. Staff E reviewed Resident 106's records and stated there was no documentation of the resident's Primary Care Provider (PCP) follow up appointment scheduled or home health therapy offered and/or arranged but should be. Staff E stated it was important to notify the facility provider of AMA discharges, offer and/or arrange medications, oxygen, home health therapy, and arrange a follow up appointment with the resident's PCP to ensure the residents safety and prevent rehospitalization. <Resident 104> According to the 03/01/2026 Discharge Return Anticipated MDS, Resident 104 admitted to the facility on [DATE]. The MDS showed Resident 104 discharged to the hospital on [DATE]. Review of Resident 104's health records showed no documentation of a report to the receiving hospital for the 03/01/2026 transfer. In an interview and record review on 03/23/2026 at 10:44 AM Staff B (Director of Nursing) stated they expected staff to provide a written transfer notification at time of transfer, review the bed hold policy with the resident, and call the receiving facility to give nurse-to-nurse report on the resident's condition. Staff B reviewed Resident 104's records and stated there was no documentation of report to the receiving facility provided for the 03/01/2026 transfer. Staff B stated it was important to give report to the receiving facility for continuity of care. <Resident 8> According to the 03/10/2026 Quarterly MDS, Resident 8 admitted to the facility on [DATE]. The MDS showed Resident 8 had falls with injury since admission to the facility. Review of Resident 8's records showed a hospital transfer on 06/24/2025. Resident 8's records showed no documentation of report to the receiving facility or bed hold offered for the 06/24/2025 transfer. In an interview and record review on 03/23/2026 at 10:44 AM Staff B reviewed Resident 8's records and stated there was no documentation of nurse-to-nurse report to the receiving facility or bed hold offered for the 06/24/2025 transfer but should be. <Resident 24> According to the 01/14/2026 Quarterly MDS Resident 24 admitted to the facility on [DATE]. The MDS showed Resident 24 had no memory impairment. Review of Resident 24's records showed they were transferred to the hospital on [DATE], 11/07/2025, and 11/13/2025. Resident 24's records showed no documentation of report to the receiving facilities for the 08/05/2025, 11/07/2025, and 11/13/2025 transfers. In an interview and record review on 03/23/2026 at 10:44 AM Staff B reviewed Resident 24's records and stated there was no documentation of a nurse-to-nurse report to the receiving facilities for the 08/05/2025, 11/07/2025, and 11/13/2025 transfers but should be. <Resident 13> According to the 01/06/2026 Annual MDS Resident 13 admitted to the facility on [DATE]. The MDS showed Resident 13 had no memory impairment. Review of Resident 13's records showed 02/04/2025, 03/22/2025, 09/29/2025, 10/28/2025, and 12/27/2025 transfers to the hospital. Resident 13's records showed no report to the receiving hospitals was provided. In an interview and record review on 03/23/2026 at 10:44 AM Staff B reviewed Resident 13's records and stated there was no documentation of report to the receiving facilities for the 02/04/2025, 03/22/2025, 09/29/2025, 10/28/2025, and 12/27/2025 transfers. <Resident 2> According to the 12/26/2025 Significant Change MDS, Resident 2 admitted to the facility on [DATE]. The MDS showed Resident 2 had memory impairments and medically complex conditions. Review of Resident 2's records showed a hospital transfer on 12/19/2025. Resident 2's records showed no documentation of a nurse-to-nurse report to the receiving hospital for the transfer, no documentation of a bed hold offered, and no documentation of a written transfer notification provided to Resident 2 or their representative. In an interview and record review on 03/24/2026 at 10:20 AM, Staff G (RCM) reviewed Resident 2's records and stated there was no documentation of a nurse-to-nurse report provided to the receiving hospital, no documentation of a bed hold offered, and no documentation of a written transfer notification provided for the 12/19/2025 hospital transfer. Staff G stated sometimes nurses forgot the required documentation in an emergency, and it was a work in progress. <Resident 69> According to the 02/12/2026 Quarterly MDS, Resident 69 admitted to the facility on [DATE]. The MDS showed Resident 69 had no memory impairments. Review of Resident 69's records showed a hospital transfer on 11/10/2025. Resident 69's records showed no documentation of a nurse-to-nurse report to the receiving hospital for the 11/10/2025 transfer. In an interview and record review on 03/24/2026 at 10:20 AM, Staff G reviewed Resident 69's records and stated there was no documentation of a nurse-to-nurse report provided to the receiving hospital. Staff G stated nurses should document their attempts to reach hospital staff, and document to whom a report was given, but they did not. <Resident 85> According to the 03/09/2026 admission MDS, Resident 85 admitted to the facility on [DATE]. The MDS showed Resident 85 had diagnoses of traumatic spinal cord dysfunction and renal insufficiency/failure. Review of Resident 85's health record showed they were transferred out of facility to a hospital on [DATE], 01/04/2026, 02/26/2026, and 03/19/2026. Resident 85's health record showed no documentation to support a bed hold offered to the resident and/or resident representative at the time of transfer on 12/19/2025. Resident 85's records showed no documentation of report to the receiving facilities for the 12/19/2025, 01/04/2026, 02/26/2026, and 03/19/2026 transfers. In an interview and record review on 03/23/2026 at 1:37 PM Staff B reviewed Resident 85's medical record and stated there was no documentation a bed hold was offered to the resident or resident representative at time of transfer on 12/19/2025. Staff B reviewed Resident 85's records and stated there was no documentation of report to the receiving facilities for the 12/19/2025, 01/04/2026, 02/26/2026, and 03/19/2026 transfers but should be. Reference: WAC 388-97-0120(1)(2)(a)-(d)(3)(a)(4)(b)(5), -0080, -0140(1)(a)-(c)(i)-(iii).

Based on interview and record review, the facility failed to ensure Preadmission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the mental health conditions for 1 of 6 residents (Resident 10) and PASRR level 2 referrals were coordinated timely for 2 of 6 residents (Residents 11 & 8) reviewed for PASRRs. This failure placed residents at risk of inappropriate nursing home placement and/or not receiving timely and necessary services to meet their mental health needs.Findings included.<Policy>According to the facility policy titled, Resident Assessment-Coordination with PASRR Program, dated 01/2026, the facility would coordinate assessments with the PASRR program to ensure individuals with mental disorder, intellectual disability or a related condition received the care and services in the most integrated setting appropriate to their needs. The policy showed PASRR 1 would be completed prior to admission and a positive PASRR 1 necessitated a PASRR 2 evaluation prior to admission to the facility. The policy showed social services would keep track of each resident's PASRR screening status and refer to appropriate authority. The policy showed any resident with behavioral, psychiatric, or mood related symptoms suggesting the presence of mental disorder would be referred promptly for a PASRR 2. <Resident 10> According to the 02/17/2026 admission Minimum Data Set (MDS - an assessment tool) Resident 10 had a traumatic brain injury and a cognitive communication deficit. The MDS showed Resident 10 took an antidepressant medication. Review of the 01/23/2026 Hospital History and Physical report showed Resident 10 had a history of Alcohol Use Disorder ([NAME]). Review of the 01/26/2026 Level 1 PASRR screening showed Resident 10 was flagged with Serious Mental Illness (SMI) indicators of mood and anxiety disorders. This Level 1 screening did not capture Resident 10's [NAME] status. Record review showed on 02/28/2026 the facility submitted a corrected Level 1 PASRR for Resident 10 that now included an SMI indicator of Substance Use Disorder (SUD). In an interview on 03/24/2026 at 1:38 PM, Staff C (Social Services Director) stated the nursing department was responsible for making sure residents' PASRR screenings were updated when something changed or if errors were identified with the Level 1 PASRR screening. Staff C stated reviewing PASRRs prior to admission was handled by the Admissions department. In an interview on 03/24/2026 at 1:48 PM, Staff Z (Admissions Director) stated they verified the accuracy of Level 1 PASRR screening prior to admit by ensuring all the boxes were complete and a referral for Level 2 services was indicated as needed. Staff Z stated they did not look at other admissions documentation from the receiving hospital to ensure the information provided was accurate, as required. <Resident 11> According to the 01/26/2026 Annual MDS Resident 11 admitted to the facility on [DATE]. The MDS showed Resident 11 had diagnoses of anxiety, depression, and post-traumatic stress disorder. Review of Resident 11's records showed a 03/26/2025 PASRR 1 with referral for a PASRR 2 required. Resident 11's records showed no PASRR 2 was completed. <Resident 8> According to the 03/10/2026 Quarterly MDS Resident 8 admitted to the facility on [DATE]. The MDS showed Resident 8 had diagnoses of non-Alzheimer's dementia, anxiety, depression and post-traumatic stress disorder. Review of Resident 8's records showed a 07/18/2025 PASRR 1 with referral for a PASRR 2 required. Resident 8's records showed no PASRR 2 was completed. In an interview and record review on 03/24/2026 at 1:45 PM Staff C reviewed Resident 11 and 8's records and stated PASRR 2 was not completed. Staff C stated timely follow up on the PASRR 2 referrals was not done so they were missed. Staff C stated it was important to ensure PASRR 2 was completed to make sure the residents received optimal individualized mental health care. Reference: WAC 388-97-1915(1)(2)(a-c).

Based on observation, interview and record review, the facility failed to ensure accurate and complete pre/post Hemodialysis (HD- mechanical way of eliminating waste from the body when the kidneys no longer functioned) for 3 of 3 residents (Residents 86, 24, & 13) reviewed for Dialysis. This failure placed the residents at risk for unintended health consequences and decreased quality of life.Findings included.<Policy>Review of the facility's 08/01/2025 HD policy showed that the facility would ensure that each resident received care and services for the provision of HD including ongoing assessment of the resident's condition and monitoring for complications before and after dialysis treatment. The facility's 08/01/2025 HD policy states that residents would not receive blood pressures on the arm that a HD device is located. <Resident 86> Review of the 02/20/2026 admission Minimum Data Set (MDS – an assessment tool) Resident 86 admitted to the facility on [DATE] with diagnoses of End Stage Renal Disease (ESRD -Permanent impairment of kidney function often requiring transplant or HD), dependence on HD and a history of kidney transplant failure. Resident 86 was on HD during the assessment period. Review of Resident 86's records showed a physician order to complete HD pre/post assessments on their HD treatment days Monday, Wednesday, and Friday. The physician orders showed Resident 86 had an HD fistula (an HD access device) present to the left arm, right arm, and right thigh. Review of Resident 86's 02/15/2026 HD Care Plan (CP) showed not to take blood pressure on limbs with a HD access device. The CP did not state where Resident 86's HD access devices were located. Review of Resident 86's records titled NSG-Dialysis Review Pre/Post (an assessment tool used by the facility to document pre and post HD assessments) showed HD assessments on the following dates: 02/16/2026, 02/18/2026, 02/20/2026, 02/21/2026, 02/23/2026, 02/25/2026, 02/27/2026, 03/04/2026 were inaccurate and/or incomplete. In an interview on 03/19/2026 at 11:50 AM Resident 86 stated that staff check their blood pressure on either arm. In an observation and interview on 03/20/2026 at 11:08 AM Staff F (Licensed Practical Nurse) completed the pre-dialysis assessment for Resident 86 checking their blood pressure on the resident's right arm. Staff F stated that HD assessments need to be completed before and after HD and included checking Resident 86's fistula for function and taking vital signs. In an interview on 03/24/2026 at 9:45 AM Staff E (Resident Care Manager) stated HD assessments for Resident 86 should include checking the vital signs, checking the fistula for function, and checking for signs of bleeding when returning from HD. Staff E stated blood pressure should not be taken on the limb with a HD access device as it could cause complications needing medical intervention. Staff E stated that staff should know where to check Resident 86's blood pressure as it would be on their CP to inform staff. Staff E reviewed Resident 86's health records and stated that the information was not on the CP and that the vitals record showed that Resident 86's blood pressure was checked on either arm all but three times since admission. Staff E reviewed the HD assessments for Resident 86 and stated they were inaccurate and missing information and did not meet expectations. Staff E stated it was important to complete pre/post HD assessments for Resident 86 to monitor for low blood pressure, signs of bleeding, and sign of infection. In an interview on 03/24/2026 at 11:49 AM Staff B (Director of Nursing) stated that Resident 86's pre/post HD assessments should have been filled out completely, accurately, and timely but were not. <Resident 24> According to the 01/14/2026 Quarterly MDS Resident 24 admitted to the facility on [DATE]. The MDS showed Resident 24 had a diagnosis of ESRD and required HD treatment. Review of Resident 24's 01/01/2026, 01/02/2026, 01/05/2026, 01/07/2026, 01/09/2026 x2, 01/12/2026, 01/14/2026, 01/16/2026, 01/17/2026, 01/19/2026, 01/21/2026, 01/26/2026, 01/28/2026 x2, 01/31/2026, 02/02/2026 x2, 02/04/2026, 02/06/2026, 02/09/2026, 02/11/2026, 02/13/2026 x2, 02/16/2026, 02/18/2026, 02/20/2026, 02/23/2026, 02/25/2026, 02/27/2026 x2, 03/02/2026, 03/04/2026, 03/06/2026, 03/09/2026, 03/09/2026, 03/11/2026, 03/13/2026, 03/16/2026, 03/18/2026, and 03/20/2026 pre/post HD assessments showed the assessments were incomplete and inaccurate. Resident 24's pre/post HD assessments showed the HD site was not assessed, and historical vital signs and weights were used and not checked pre/post HD treatment. <Resident 13> According to the 01/06/2026 Annual MDS Resident 13 admitted to the facility on [DATE]. The MDS showed Resident 13 had a diagnosis of ESRD and required HD treatment. Review of Resident 13's 01/01/2026 x2, 01/03/2026, 01/04/2026, 01/06/2026, 01/08/2026 x2, 01/10/2026 x2, 01/13/2026, 01/15/2026 x2, 01/20/2026, 01/22/2026, 01/27/2026, 01/31/2026, 02/03/2026, 02/05/2026, 02/07/2026, 02/10/2026, 02/12/2026, 02/14/2026, 02/17/2026, 02/19/2026, 02/21/2026, 02/24/2026, 02/26/2026, 02/28/2026, 03/04/2026, 03/05/2026, 03/07/2026, 03/10/2026, 03/12/2026, 03/14/2026, 03/17/2026, 03/19/2026 x2, and 03/21/2026 pre/post HD assessments showed the assessments were incomplete and inaccurate. Resident 13's pre/post HD assessments showed the HD site was not assessed, and historical vital signs and weights were used and not checked pre/post HD treatment. In an interview and record review on 03/23/2026 at 10:44 AM Staff B reviewed Resident 24 and 13's HD pre/post assessments and stated they were incomplete and inaccurate. Staff B stated they expected staff to complete the pre/post HD assessments and obtain current vitals and weights with each assessment. Staff B stated they expected staff to thoroughly assess the residents HD sites for function, identify the location, bleeding, dressings, and for any signs of infection or complications. Refer to F656 Develop/Implement Comprehensive Care Plan. Reference: WAC 388-97-1900(1), (6)(a-c).

Based on observation, interview, and record review the facility failed to: ensure staff used appropriate Hand Hygiene (HH) during resident care for 3 residents (Resident 85, 110, & 6) who were observed for care; ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 1 (Resident 85) and 1 supplemental resident (Resident 96) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms); and ensure staff prevented clean linens from coming into contact with soiled surfaces. These failures placed residents and staff at risk for exposure to and development of contagious, communicable infectious diseases.Findings included .<Facility Policies>According to the facility's Hand Hygiene policy, revised 01/2026, all staff would perform proper HH procedures to prevent the spread of infection. Staff would perform HH after handling items contaminated with body fluids, secretions, or excretions, and during resident care when moving from a contaminated body site to a clean body site.According to the facility's Enhanced Barrier Precautions policy, revised 01/2026, staff would use a gown and gloves during high-contact resident care activities for residents with an order for EBP.According to the facility's Infection Prevention and Control Program policy, revised 12/23/2025, laundry and direct care staff would handle, store, process, and transport linens to prevent the spread of infection. <Hand Hygiene> <Resident 85> Observation on 03/19/2026 at 9:31 AM showed Staff T (Licensed Practical Nurse) and Staff U (Certified Nurse Assistant - CNA) providing ileostomy (a surgical opening in the abdomen allowing stool to pass through to an external pouch), suprapubic catheter (surgically placed tube below the belly button allowing urine to pass through to an external pouch), and incontinence care to Resident 85. Staff T was observed to use a single glove to perform care tasks. Staff T used a wet gauze and wiped Resident 85's ileostomy site. Without changing gloves and performing HH, Staff T took a new ileostomy pouch and secured it to the ileostomy opening. Wearing the same, soiled gloves, Staff T took clean gauze and secured it over Resident 85's suprapubic catheter. Staff T removed the old catheter bag and old tubing while wearing the same gloves, and grabbed a new catheter tube, a new catheter bag, and a pair of scissors. Staff T did not remove their soiled gloves and did not perform HH. While wearing the same gloves, Staff T cut the new catheter tubing in half, inserted it into the catheter, and secured it to Resident 85's leg. Staff T removed their soiled gloves and performed HH. Staff U assisted with changing Resident 85's brief. Staff U removed the soiled brief from Resident 85. While wearing the same gloves, Staff U opened Resident 85's drawer, grabbed a clean brief, and placed it on the resident. Staff U removed their gloves, performed HH and left the resident's room. In an interview on 03/19/2026 at 9:48 AM Staff T stated it was important to perform HH and to change gloves between care tasks to prevent the spread of infection. <Resident 110> Observation on 03/18/2026 at 1:03 PM showed Staff L (CNA) providing incontinence care to Resident 110. Staff L removed Resident 110's wet and soiled incontinence brief and used wipes to clean Resident 110's skin. While wearing the same gloves and without performing HH, Staff L applied a clean incontinence brief, adjusted Resident 110's clothing and bed linens, and adjusted the position of the bed using the bed controller. Observation on 03/24/2026 at 9:23 AM showed Staff N (CNA) providing incontinence care to Resident 110. Staff N removed Resident 110's wet and soiled incontinence brief and used wipes to clean Resident 110's skin. While wearing the same gloves and without performing HH, Staff N placed clean bed linens underneath Resident 110, bagged up garbage, and waited for Staff O (Registered Nurse) to complete a wound treatment. While wearing the same gloves and without performing HH, Staff N applied a clean incontinence brief, dressed Resident 110 in a clean hospital gown and placed a sling for a mechanical lift underneath Resident 110. <Resident 6> Observation on 03/20/2026 at 8:38 AM showed Staff I (CNA) and Staff J (Restorative Aide) providing incontinence care to Resident 6. Staff I and Staff J wiped Resident 6's skin and without removing their gloves, Staff I took the resident's top sheet and placed it under the resident. Staff J removed their soiled gloves and put on new gloves without performing HH. Staff J removed Resident 6's urine-soaked bed linens, placed them in a bag, removed their gloves, and put on new gloves without performing HH. Staff J grabbed the package of incontinence wipes and wiped the mattress down while Staff I assisted Resident 6 to lie on their side. Staff J grabbed the door handle, went to the hallway and grabbed disinfecting wipes while wearing the same gloves used to handle the urine-soaked linens. Staff J removed disinfecting wipes from the container and wiped down Resident 6's mattress. Staff J removed their gloves and put on new gloves without performing HH. Staff J grabbed clean linens and made Resident 6's bed. Staff I wiped Resident 6 once more with incontinent wipes and placed a clean brief on the resident. Staff I removed their soiled gloves, took new gloves out of their shirt pocket and put them on without performing HH. Staff I and Staff J removed Resident 6's gown and placed a clean gown on the resident. Staff I and Staff J used wipes to wipe down Resident 6's underarms and face while wearing the same gloves. Staff I and Staff J removed the garbage and bag of soiled linen and performed HH upon exiting Resident 6's room. In an interview on 03/23/2026 at 11:05 AM, Staff D (Infection Preventionist) stated staff should perform HH after glove use and in between dirty to clean tasks. Staff D stated they expected staff to perform HH between glove use. <Enhanced Barrier Precautions> <Resident 85> Review of a 01/21/2026 Resident requires EBP. care plan showed Resident 85 required the use of EBPs by staff to reduce the risk of spreading infection. Observation on 03/23/2026 at 10:05 AM showed Staff Y (CNA) remove soiled linens from Resident 85's bed. Staff Y was wearing gloves but did not have a gown on. Staff Y took a clean wipe and wiped down Resident 85's mattress. Wearing the same, soiled gloves, Staff Y grabbed clean linens and made Resident 85's bed. Staff Y placed the soiled linens in a trash bag, removed their gloves and performed HH before leaving the room. Staff Y did not wear PPE as directed. In an interview on 03/24/2026 at 1:11 PM, Staff B (Director of Nursing) stated they expected staff to wear proper PPE, including a gown, when changing residents' bedding who were on EBP. <Resident 96> Review of Resident 96's order summary showed a 10/29/2025 order for EBP. Review of a 10/31/2025 care plan for EBP showed Resident 96 required EBP due to an indwelling medical device. Resident 96's care plan instructed staff to wear a gown and gloves when providing high-contact care. Review of Resident 96's March 2026 medication administration record showed from 03/01/2026 - 03/24/2026 nurses signed the order twice daily that the resident was on EBP precautions. Observation on 03/18/2026 showed Resident 96 sitting in their wheelchair receiving enteral nutrition (a method of providing a nutritionally complete diet through a feeding tube surgically placed into the stomach). There was no sign posted outside the door to show Resident 96 was on EBP, or PPE supplies provided for staff at the entry to their room. In an interview on 03/20/2026 at 10:11 AM Staff S (CNA) stated residents on EBP had a sign outside their door that indicated the requirement for PPE. In an interview on 03/23/2026 at 10:30 AM Staff D stated Resident 96 should be on EBP due to their indwelling medical devices and enteral nutrition. Staff D inspected the room and stated that Resident 96 was not on EBP but should be. <Linen Handling> Observation on 03/20/2026 at 11:53 AM of the facility's laundry room showed Staff K (Laundry Staff) folding clean linens. Staff K was observed folding flat sheets and was not using the folding table. Staff K held the sheet out in front of them and as they folded, the flat sheet dragged across the laundry room floor and the tops of their shoes. Staff K proceeded to take the folded sheet and place it on the clean linen cart used to transport linens to the resident units. Similar observations were made when Staff K proceeded to fold an additional flat sheet, two fitted sheets, and two resident gowns. In an interview on 03/23/2026 at 11:09 AM, Staff D stated it was their expectation clean linens did not touch the floor and should only touch clean surfaces. REFERENCE: WAC 388-97-1320 (1)(a)(c), (3).

Based on observation, interview, and record review the facility failed to ensure proper storage and labeling of medications for 2 of 4 medication rooms (West I and [NAME] II units), 2 of 4 medication carts (Central Medication Cart and [NAME] I Unit Medication Cart), and 1 of 4 treatment carts (West II Treatment Cart) reviewed for medication storage. This failure placed residents at risk for receiving incorrect medications, ineffective treatment, accidental ingestion of medication, and a diminished quality of life.Findings included.<Facility Policy>According to the facility's 01/2026 Medication Storage policy, the facility would ensure all medications were stored in locked compartments or rooms. The policy showed that medications with missing labels would be destroyed.<West I Medication Cart> Observation on 03/19/2026 at 1:20 PM of the [NAME] I unit medication cart showed two loose pills in the top drawer. Observation on 03/23/2026 at 9:24 AM of the [NAME] I medication cart showed the lower right drawer was unlocked and unattended with no staff supervising the cart. The drawer of the cart contained a bottle of medicated laxative powder, packs of syringes, a pack of smoking cessation patches, a tube of medicated pain-relieving cream, packs of testing kit, and a small pair of scissors. In an interview on 03/23/2026 at 9:57 AM, Staff R (Registered Nurse - RN) stated the medication cart should be locked so that no one can have access to it. Staff R stated it was important to protect residents from having access to medications and risk for ingesting inappropriate medications. <West I Medication Storage Room> Observation on 03/19/2026 at 1:52 PM of the [NAME] I unit medication storage room showed an open bottle of eye drops that did not indicate which resident they belonged to and an open bottle of pills that did not indicate which resident they belonged to. In an interview on 03/19/2026 at 1:39 PM Staff Q (Resident Care Manager - RCM) stated the medications should be labeled with the resident's name and date of opening. Staff Q stated it is important for resident safety. <West II Medication Storage Room> Observation on 03/20/2026 at 9:18 AM of the [NAME] II medication storage room showed a tube of pain-relieving cream that did not indicate a resident name, pain patches that did not indicate a resident name, and a box of smoking cessation gum without a resident name. In an interview on 03/20/2026 at 9:18 AM, Staff E (RCM) stated the opened medications should be separated from the unopened medications to distinguish them and remind staff of medication expiration date. In an interview on 03/23/2026 at 1:11 PM, Staff B (Director of Nursing) stated they expected the nurses to lock the medication cart before they leave it unattended. Staff B stated medications used in the medication storage room should be labeled with an open date, a resident name and room number to ensure safety. <Central Medication Cart> Observation on 03/19/2026 at 9:27 AM showed the central medication cart unlocked and unattended with no staff nearby monitoring. In an interview on 03/19/2026 at 9:30 AM Staff P (RN) came out of room [ROOM NUMBER] and stated they were assigned to the central medication cart but forgot to lock the cart before leaving it unattended. Staff P stated they should lock the medication cart before leaving it unattended for resident safety. In an interview on 03/23/2026 at 1:18 PM Staff B stated they expected nurses to lock medication and treatment carts before walking away. Staff B stated it was important to lock the medication and treatment carts to ensure resident safety. <West II Treatment Cart> Observation on the [NAME] II unit on 03/20/2026 at 10:46 AM showed the treatment cart was unlocked. The key was in the open lock, and no licensed staff were near the cart. The top drawer of the cart contained two tubes of medicated honey used for wound healing, two different pain-relieving creams, a bottle of medicated shampoo, two containers of medicated wound packing material, a small pair of scissors, and a box of medicated wipes. The second drawer of the treatment cart contained a bottle of medicated shampoo, antifungal creams, and antimicrobial wound gel, and a tube of medicated honey used for wound healing. The third drawer contained two bottles of medicated shampoo and two tubes of pain-relieving gel. The fourth drawer contained two types of antiseptic solution, a box of wound cleansers, and a canister of powerful surface cleaning wipes. In an interview on 03/20/2026 at 10:51 PM, Staff F (Licensed Practical Nurse) stated the treatment cart should be locked. Staff F stated there were treatments and supplies that residents should not have access to. REFERENCE: WAC 388-97-1300(2).

Based on observation, interview, and record review the facility failed to ensure informed consents explaining the potential risks, benefits, and alternatives of the use of bed mobility rails, vaccines, and/or treatment at the facility were obtained from the resident or their representative prior to implementation for 1 of 2 residents reviewed for physical restraints (Resident 82), and 1 of 5 residents (Residents 2) reviewed for immunizations. In addition, the facility failed to ensure Resident 2 had the cognitive ability to understand the risks prior to signing informed consents. These failures placed residents and/or their representatives at risk of not being fully informed of the potential risks, benefits, and alternatives to treatments, including vaccines and mobility devices.Findings included .<Resident 82> According to the 03/05/2026 Quarterly Minimum Data Set (MDS – an assessment tool) Resident 82 had moderately impaired cognition (memory and decision-making facility) and usually understood others in conversation. The MDS showed Resident 26 had diagnoses including heart failure and dementia and required no restraints or alarms. Review of Resident 82's 10/20/2025 Safety Device Assessment showed therapy recommended the use of grab bars to assist with bed mobility and transfers and promote independence. This assessment showed the grab bars would not be a restraint for Resident 82 but did not show why. This assessment showed the risks and benefits of the grab bars were not discussed with Resident 82 or their representative and did not explain why this was not discussed. Observation on 03/18/2026 at 10:22 AM showed quarter rails (grab bars) in place on Resident 82's bed. At this time Resident 82 was observed to not be able to speak to the specifics of their care. In an interview on 03/24/2026 at 10:54 AM, Staff B (Director of Nursing) reviewed the assessment and stated the risks and benefits of the grab bars should be but were not discussed with Resident 82. <Resident 2> According to the 11/07/2025 admission MDS, Resident 2 admitted to the facility on [DATE] with diagnoses including multiple fractures and developmental delay (a condition that could affect physical, cognitive, communication, social, or emotional skills). Resident 2's Brief Interview for Mental Status (a quick screening tool to assess cognitive function) indicated they had severe cognitive impairment. Review of a Capacity for Medical Decisions form, signed on 11/03/2025, showed a physician's professional opinion was Resident 2 was unable to comprehend the risks, benefits, and alternatives to medical decisions, and could not make medical decisions on their own behalf due to their developmental delay. The form showed that according to the Washington State Hierarchy of Medical Decision Makers, Resident 2 had two family representatives that were their legal decision makers. Review of Resident 2's January 2026 Medication Administration Record (MAR) showed staff administered a vaccine for pneumonia (an infection of the lungs) on 01/02/2026. Immunization documentation showed staff confirmed they provided education and obtained consent for the pneumonia vaccine on 01/02/2026. No documentation was found to show who received the education and who provided consent. Review of Resident 2's March 2026 MAR showed staff administered a vaccine for Respiratory Syncytial Virus (RSV - a respiratory illness that typically caused mild cold-like symptoms but could lead to severe respiratory illness) on 03/05/2026. Immunization documentation showed staff confirmed they provided education and obtained consent for the vaccine on 03/05/2026. Review of Resident 2's progress notes showed staff attempted to contact Resident 2's representatives on 02/28/2026, 03/01/2026, and 03/02/2026 to obtain consent for the RSV vaccine, but were unsuccessful. A progress note dated 03/02/2026 showed Resident 2 gave consent for the RSV vaccine. Review of a Consent to admission and Treatment form, dated 12/22/2025, showed Resident 2 signed that they voluntarily consented to treatment, understood the risks, and agreed to the facility's terms. The form was also signed by a facility representative. Observation on 03/18/2026 at 12:02 PM showed two staff assisted Resident 2 to transfer from their wheelchair to their bed. Resident 2's bed was equipped with mobility bars on the right and left sides, near the head of the bed. Review of an Informed Consent for Use of Mobility (Grab/Enabler) Bar form, dated 12/23/2025, showed Resident 2 signed that they understood the risks and benefits of mobility bars and consented to their use. In an interview on 03/24/2026 at 1:41 PM, Staff X (Director of Rehab) stated they discussed the use of mobility bars with Resident 2's representative during a care conference on 11/21/2025. Staff X did not find documentation showing Resident 2's representative received education regarding risks and benefits of mobility bars or that they consented to their use. In an interview on 03/24/2026 at 1:03 PM, Staff B stated Resident 2's representative was their decision maker, and staff sometimes had difficulty contacting them by phone. Staff B stated Resident 2's representative previously made a statement that whatever facility staff thought Resident 2 needed would be fine if Resident 2 agreed; no documentation was provided. Staff B stated they expected staff to follow up with Resident 2's representative to obtain informed consent when consent was required. Reference: WAC 388-97-0260.

Based on Observation, Interview, and record review the facility failed to ensure that Care Plans (CP) were comprehensive and person-centered for 3 of 21 sample residents reviewed (Resident 86, 26, & 5) This failure placed residents at risk for unmet care needs, frustration, and negative health outcomes.Findings Included .<Facility Policy>According to the facility's 08/01/2025 Hemodialysis (HD) policy the facility would provide the necessary care and treatment to meet the special medical and nursing needs of the residents receiving hemodialysis. The policy showed residents would not receive blood pressures on the arm that a hemodialysis device was located. <Resident 86> Review of the 02/20/2026 admission Minimum Data Set (MDS – an assessment tool) Resident 86 admitted to the facility with diagnoses of End Stage Renal Disease (Permanent impairment of kidney function often requiring transplant or dialysis), Dependence on Renal Dialysis (mechanical way of eliminating waste from the body when the kidneys no longer functioned), and a history of kidney transplant failure. Resident 86 was on HD at the time of admission. Review of the 02/15/2026 HD CP for Resident 86 stated do not draw blood or take blood pressure on arm with graft (a HD device). The HD CP does not state where the grafts were for Resident 86. Review of Resident 86's Physician Orders showed 02/15/2026 orders for three HD devices, one in the left arm, one in the right arm, and one in the right thigh. In an interview on 03/19/2026 at 11:50 AM Resident 86 stated that staff took their blood pressure on either arm. In an observation on 03/20/2026 at 11:08 AM Staff F (Licensed Practical Nurse) completed the pre-HD assessment for Resident 86 and checked their blood pressure using their right arm. In an interview on 03/24/2026 at 10:11 AM Staff E (Resident Care Manager) stated that when caring for Resident 86 staff should take blood pressure on their left leg. Staff E stated staff should know where to take the blood pressure as it should be on the CP and the Kardex (a short form version of the CP used to communicate care needs to staff). Staff E reviewed the vitals report and CP for Resident 86 and found blood pressures were usually taken on either arm and the CP did not show where the HD devices were for Resident 86. Staff E stated that staff should not take a blood pressure on the same limb as a HD access device as it can cause complications with the device which may need medical intervention. In an interview on 03/24/2026 at 11:49 AM Staff B (Director of Nursing) stated that residents on HD should have blood pressures taken on the limb without a HD access device. Staff B stated that staff would know where the HD access devices were for Resident 86 by seeing it on the CP or Kardex. Staff B reviewed Resident 86's medical records and stated the CP does not communicate where HD access devices were. Staff B stated that Resident 86's CP does not meet expectations. <Resident 26> According to the 02/12/2026 admission MDS Resident 26 had impaired vision, intact cognition, and had a fall with no injury since admission. The MDS showed Resident 26 was frequently incontinent of bladder and always incontinent of bowel. The MDS showed Resident 26 took an anti-seizure medication. Record review showed Resident 26 had a 02/07/2026 physician's order to check the placement of fall mats on both sides of their bed when unattended. This order was discontinued on 03/12/2026. Observation on 03/18/2026 at 1:55 PM showed fall mats placed on both sides of Resident 26's bed while the resident lay in bed. According to a 03/12/2026 Interdisciplinary Team (a group of facility managers) progress note showed Resident 26 stopped trying to get out of bed independently and no longer required the fall mats. This note showed Resident 26's CP was updated to reflect this change. Review of Resident 26's risk for falls. CP showed this CP included a 03/18/2026 intervention for Resident 26 to have mats on both sides of their bed. Review of the Kardex (direct care instructions) as of 03/19/2026 showed for safety, Resident 26 needed mats on both sides of their bed. In an interview on 03/24/2026 at 11:01 AM, Staff B stated the mats were no longer required. Staff B stated the mats should be removed from the CP in order to make the CP comprehensive and accurate, and removed from the Kardex. <Resident 5> According to the 02/12/2026 admission MDS, Resident 5 was dependent on staff for Activities of Daily Living (personal hygiene, eating, bathing etc.) and moving in bed. The MDS showed Resident 5 received their nutrition through a feeding tube and received physical therapy, occupational therapy, and speech-language pathology therapy. In an interview on 03/18/2026 at 12:01 PM Resident 5 stated they preferred some therapists over others and stated they had to stop therapy early that day because they became short of breath. Review of Resident 5's comprehensive CP showed no CP developed describing what therapies Resident 5 required, the schedule or frequency of therapy services. Review of Resident 5's Kardex showed no information provided describing what therapies Resident 5 required, the schedule or frequency of therapy services, or if/when/how nurses' aides should prepare the resident for therapy. In an interview on 02/24/2026 at 10:44 AM Staff B stated CPs should reflect residents' care needs. Staff B stated CPs and Kardex should be comprehensive. Staff B reviewed Resident 5's CP and Kardex and stated there was no CP developed outlining Resident 5's therapy services. Staff B stated those details should be included on the CP. Refer to F698 Dialysis. REFERENCE: WAC 388-97-1020(1)(2)(a)(b).

Based on observation, interview, and record review the facility failed to ensure the following: Administration of bowel care protocol in accordance with physician orders, administration of medications within the parameters set by physician orders, and completion of treatments for devices and wounds per physician orders for 3 of 21 sample residents (Residents 9, 107, & 110). These failures placed residents at risk for medication errors, untreated pain, and poor health outcomes.Findings Included .<Facility Policy>According to the facility's January 2026 Care and Maintenance of Central Venous Catheter (CVC - flexible tube inserted into a large vein and threaded towards the heart) policy, the facility staff would change the dressings on central lines based on the type of dressing every seven to ten days.According to the facility's revised January 2026 Wound Treatment Management policy, wound treatments would be provided in accordance with physician orders, including the type of dressing and frequency of dressing changes. Dressing changes would be provided as needed if the dressing was dislodged, wet, soiled, or feces seeped underneath the dressing. <Administration of Bowel Care Protocol> <Resident 9> Review of the 02/16/2026 Annual Minimum Data Set (MDS – An assessment tool) for Resident 9 showed that they re-admitted to the facility on [DATE] with diagnoses of a progressive neurological disorder that affected movement, muscle weakness, and a seizure disorder. Review of Resident 9's order summary showed a 12/23/2023 physician order directing staff to administer a laxative medication if the resident did not have a bowel movement for three days. Review of Resident 9's February 2026 Activities of Daily Living (ADL) documentation showed they did not have a bowel movement from 02/25/2026 until 03/01/2026, four days later. Review of Resident 9's February 2026 and March 2026 Medication Administration Record (MAR) showed staff did not administer the laxative medication as ordered. Review of nursing notes for Resident 9 showed staff offered the laxative medication on 03/01/2026, the fourth day without a bowel movement. In an Interview on 03/18/2026 at 10:15 AM Resident 9 stated they had no concerns related to bowel care. In an interview on 03/24/2026 at 9:45 AM Staff E (Resident Care Manager - RCM) stated if a resident did not have a bowel movement for three days, staff should follow the provider ordered bowel protocol and administer the laxative medication. Staff E reviewed Resident 9's record and confirmed staff did not administer the laxative as ordered to Resident 9. In an interview on 03/24/2026 at 11:49 AM Staff B (Director of Nursing) stated staff should have offered the ordered laxative medication to Resident 9 to prevent potential medical complications from constipation, but staff did not. <Medications Administered Outside the Parameters> <Resident 9> Review of Resident 9's 02/16/2026 Annual MDS showed they re-admitted to the facility on [DATE] with diagnoses of a progressive neurological disorder that affected movement, muscle weakness, and a seizure disorder. The MDS showed Resident 9 had pain almost constantly. Review of Resident 9's physician orders showed they received a narcotic pain medication patch every seven days, and a non-narcotic pain medication every eight hours as needed for pain on a scale of one to five out of ten. In an Interview on 03/18/2026 at 10:10 AM Resident 9 stated that their pain was well controlled, though did occasionally use a non-narcotic pain medication as needed. The March 2026 MAR showed staff administered the non-narcotic pain medication to Resident 9 on the following days for pain levels above the ordered parameter: 03/01/2026 at 11:55 AM for a pain level of seven out of ten, 03/04/2026 at 2:30 PM for a pain level of seven out of ten, 03/11/2026 at 12:57 PM for a pain level of six out of ten, 03/14/2026 at 8:44 AM for a pain level of six out of ten, and 03/22/2026 at 11:23 AM for a pain level of seven out of ten. In an interview on 03/24/2026 at 11:49 AM Staff B stated staff should have followed the parameters of the physician orders and notified the physician if pain levels were above the ordered parameter to ensure Resident 9 had adequate pain control. <Completion of Treatments for Devices and Wounds> <Resident 107> Review of Resident 107's 02/02/2026 Quarterly MDS showed that Resident 107 re-admitted to the facility on [DATE] with diagnoses of muscle weakness, difficulty speaking, and a history of a non-traumatic brain bleed. Review of Resident 107's physician orders showed they had a CVC. The physician orders directed staff to change Resident 107's CVC dressing every seven days. Review of Resident 107's March 2026 treatment administration record showed the CVC dressing change was to be completed the morning of 03/11/2026. Observation on 03/18/2026 at 8:32 AM showed Resident 107's CVC dressing was in place and dated 03/09/2026. In an interview of 03/24/2026 at 9:45 AM Staff E stated they saw the 03/09/2026 overdue date on the CVC dressing for Resident 107 on 03/18/2026. Staff E stated it was important to change the dressings every seven days as ordered since the catheter went to heart and without dressing changes, there was an increased risk for infections. In an interview on 03/24/2026 at 11:49 AM Staff B stated staff should have followed the physician orders for Resident 107 and changed the CVC dressing on 03/11/2026. <Resident 110> According to the 03/17/2026 admission MDS, Resident 110 readmitted to the facility on [DATE], had an unhealed pressure injury requiring treatment, and was dependent on staff for ADLs, including bed mobility, dressing, and toileting hygiene. In an interview on 03/18/2026 at 10:17 AM, Resident 110 said they had a sore on their bottom and staff sometimes put some cream on it for them. Record review showed Resident 110 had a 03/12/2026 physician order instructing staff to apply a medicated topical cream to the buttocks and rectum and place an ABD pad (a highly absorbent sterile dressing designed for covering large, heavily draining wounds) in the gluteal fold (the horizontal crease just below the buttocks) every shift. The 03/12/2026 order was discontinued on 03/19/2026. Record review showed a 03/19/2026 physician's order instructing staff to cleanse the pressure injury to Resident 110's rectum, apply a thick layer of medicated topical cream, and place an ABD pad to the area with every peri-care (toileting hygiene). Observation on 03/18/2026 at 1:03 PM showed Staff L (Certified Nursing Assistant – CNA) provide peri-care for Resident 110. Observation showed Resident 110's incontinence brief was soiled with liquid feces, they had an open wound to their rectal opening, and no ABD pad was found. Staff L cleansed the area and applied a clean incontinence brief. No medicated topical cream or ABD pad was provided at that time. Observation on 03/23/2026 at 9:05 AM showed Staff M (CNA) provide a bed bath and peri-care for Resident 110. Observation showed Resident 110's incontinence brief was soiled with liquid feces, they had an open wound to their rectal opening, and no ABD pad was found. Staff M confirmed there was no ABD pad in place and stated they would inform the nurse. In an interview on 03/23/2026 at 10:19 AM, Staff O (Registered Nurse) stated Resident 110 had a wound to their rectum and they were to cleanse it and apply a medicated topical cream daily. Staff O said they were supposed to apply an ABD pad, but the ABD pad did not work well because it would become soiled with feces and did not stay in place. Staff O reviewed Resident 110's orders and confirmed the treatment was to be done with every peri-care. Staff O stated they did not perform the treatment yet today because they were passing medications. Observation on 03/24/2026 at 9:20 AM showed Staff N (CNA) provide peri-care for Resident 110. Observation showed Resident 110's incontinence brief was soiled with liquid feces, they had an open wound to their rectal opening, and no ABD pad was found. Staff N confirmed there was no ABD pad in place. In an interview on 03/24/2026 at 9:58 AM, Staff O stated they informed Staff B last week that Resident 110's ABD pads were not staying in place. Staff O stated they did not notify the provider or request a new treatment order. In an interview on 03/24/2026 at 10:20 AM, Staff G (RCM) stated they expected nurses to call the provider and obtain a new physician's order if the existing order was not working. REFERENCE: WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i).

Based on observation, interview, and record review the facility failed to ensure 1 supplemental resident of 1 resident (Resident 6) reviewed for non-pressure skin alterations and 1 of 1 resident (Resident 5) reviewed for constipation/diarrhea (loose stools) were provided quality care and services. The failure to ensure resident skin issues were assessed, treated, and/or monitored, and the failure to initiate the facility bowel care protocol left residents at risk for unmet care needs, pain/discomfort from constipation, and a decreased quality of life.Findings included.<Facility Policy>Review of the facility's Wound Treatment Management policy, revised 01/2026, showed the facility would promote the healing of various types of wounds. The policy showed licensed staff would notify the physician and obtain treatment orders for wounds without treatment orders.<Non-Pressure Skin> <Resident 6> According to the 01/07/2026 Quarterly Minimum Data Set (MDS – an assessment tool), Resident 6 had diagnoses including a progressive disorder causing cognitive decline, poor blood circulation to their lower legs, and muscle weakness. This MDS showed Resident 6 had impairment in range of motion to both arms and both of their legs. The MDS showed Resident 6 did not have any current skin conditions but was at risk for developing pressure ulcers. Review of Resident 6's physician orders showed a 02/01/2026 order directing staff to perform a weekly skin check to identify new skin issues. The order directed staff to document yes or no, make a progress note, and complete a weekly skin check assessment. Observation on 03/20/2026 at 8:38 AM showed Staff I (Certified Nursing Assistant - CNA) and Staff J (Restorative Aide) provided incontinent care to Resident 6. Observation at this time showed both of Resident 6's legs were contracted, bent severely at their knees and turned to the right side of the bed. At that time, Resident 6 told Staff I and Staff J their foot hurt. The inside edge of Resident 6's left foot and outside edge of their right foot were resting directly on the mattress. A reddened area was observed on the inner ball of their left foot below their great toe. Observation on 03/20/2026 at 9:04 AM showed Staff I and Staff J finished the incontinent care with Resident 6 and prepared to exit their room. Resident 6 stated they needed to see the nurse because their foot hurt. Staff J asked Resident 6 which foot hurt and Resident 6 stated their left foot hurt. In an interview on 03/20/2026 at 12:27 PM, Staff P (Registered Nurse) stated they were the nurse for Resident 6 that day. Staff P stated they were unaware of any new skin issues for Resident 6. Review of a 03/21/2026 weekly skin assessment showed licensed staff performed a skin check for Resident 6. The assessment showed no documentation related to redness on Resident 6's left foot. Observation on 03/23/2026 at 1:36 PM showed Resident 6 lying in bed, legs contracted and turned to the right side of the bed. At that time, Staff N (CNA) and Staff V (CNA) provided care to Resident 6. Observation showed the reddened area remained on the inner ball of their left foot below Resident 6's great toe. In an observation and interview on 03/24/2026 at 10:35 AM, Resident 6 stated their foot hurt while they were resting/sleeping in bed. Resident 6 stated the bottom of their left foot bothered them. Observation at that time with Staff W (Licensed Practical Nurse) showed Resident 6's left inner foot resting directly on the mattress. Staff W confirmed the reddened area and observed a second reddened area to the outside edge of Resident 6's left foot. Staff W gently pushed onto the reddened areas which were blanching (generally indicating healthy blood flow). In an interview at that time, Staff W stated the physician should be notified, the reddened areas should be monitored by staff, and staff needed to implement pressure relieving measures. In an interview on 03/24/2026 at 12:46 PM, Staff B (Director of Nursing) stated the process for weekly skin checks was for the nurse to perform the assessment, document any new skin issues and report the findings to the provider. Staff B stated they expected any reddened areas to be captured on the skin assessment so staff could obtain orders as needed and monitor the redness for changes. <Resident 5> According to the 02/12/2026 admission MDS, Resident 5 was dependent on staff for toileting and moving in bed. The MDS showed Resident 5 was always incontinent of bowel and had diagnoses including malnutrition and weakness and admitted to the facility with an open pressure wound (bed sore) with full thickness tissue loss and received their nutrition through a feeding tube. Record review showed Resident 5 had physician's orders for two regularly scheduled medications to treat constipation: a 02/06/2026 order for a powdered constipation medicine twice a day through the resident's feeding tube, and a 02/06/2026 order for a constipation medication in tablet form twice a day through the resident's feeding tube. According to the 02/09/2026 tube feeding Care Plan (CP) staff should monitor and report any diarrhea. According to the 02/10/2026 weekly skin assessment, Resident 5 had a dressed, opened wound on their coccyx (tailbone area). According to the revised 02/19/2026 at risk for bowel incontinence. CP, Resident 5's goal was to be free of skin breakdown caused by incontinence. The CP showed staff should help clean Resident 5 after every incontinence episode. According to the actual impairment to skin integrity. CP, staff should keep Resident 5's skin clean and dry. According to the revised 03/16/2026 self-care performance. CP Resident 5 required total assistance from staff for toileting care. In an interview 03/18/2026 12:07 PM, Resident 5 stated they got constipated but took treatment that helped. Resident 5 denied loose stools. Observation at that time showed Resident 5 in bed, lying on their side with a pole to hold a feeding tube formula bag next to the bed. Review of bowel charting showed Resident 5 was documented to have loose stools on 02/20/2026 at 6:18 PM, on 02/23/2026 at 5:12 AM, on 02/26/2026 at 3:07 AM, on 03/01/2026 at 5:59 AM and on 03/02/2026 at 5:17 AM. Review of the February 2026 Medication Administration (MAR) showed Resident 5 was given both bowel medications in the morning on 02/20/2026 and 02/23/2026. Review of the March 2026 MAR showed Resident 5 was given both bowel medications in the morning on 03/01/2026 and 03/02/2026 In an interview on 03/24/2026 Staff B stated when a resident had a full thickness open wound, loose stools were a problem they could soil the dressing and the wound. Staff B stated it was important to avoid loose stools, including holding medications when the physician's order directed. Staff B stated the constipation medication should have been held on the above dates but were not. REFERENCE: WAC 388-97 -1060(1)-(3) .

Based on observations, interviews, and record review the facility failed to ensure residents were free of accident hazards for 3 of 7 (Residents 26, 19, & 9) residents reviewed for accidents. This failure to ensure resident rooms were free of no longer needed safety interventions, resident mattresses were placed correctly on bed frames, and periodic safety assessments were completed placed residents at risk of injury, unmet needs, and diminished quality of life.<Facility Policy>According to the facility's revised 01/2026 Incidents and Accidents policy, falls and accidents would be investigated and new interventions determined to be necessary to prevent recurrence would be documented in the resident's record.Findings included. <Resident 26> According to the 02/12/2026 admission Minimum Data Set (MDS – an assessment tool), Resident 26 had impaired vision and intact cognition, and had a fall with no injury since admission. The MDS showed Resident 26 was frequently incontinent of bladder and always incontinent of bowel. The MDS showed Resident 26 took an anti-seizure medication. Record review showed Resident 26 had a 02/07/2026 physician's order to check the placement of fall mats on both sides of their bed when unattended (discontinued on 03/12/2026) and a 02/09/2026 order for an anti-seizure medication prescribed for nerve damage/pain. According to the revised 02/19/2026 at risk for falls. CP showed Resident 26 needed two therapists for practicing transfers and required the help of two staff to transfer with a mechanical lift. The CP showed Resident 26's bed should be kept in a low position and included a 03/18/2026 intervention for fall mats on both sides of the bed. According to the 03/04/2026 fall risk assessment Resident 26 was at high risk for falls. The assessment showed Resident 26 fell on [DATE] and had fall risk factors including a fall within the last 90 days, highly/severely impaired vision, incontinence, attempts to get up/reposition from their chair/bed, and the use of medications associated with increased fall risk. According to the facility's 03/04/2026 witnessed fall investigation, Resident 26 had an assisted fall during therapy. Resident 26 ended up with their knees on the ground and their upper body resting on their bed with their wheelchair behind them. Resident 26 told the nurse after grabbing the rail on their bed to transfer from their wheelchair, their leg locked up and they went down to the floor, stabilized by the therapist. Resident 26 stated they were not hurt and the investigation showed they were assessed with no injury. The investigation showed Resident 26 should now have two therapists to assist them with transfers and to continue therapy. According to 03/12/2026 Interdisciplinary Team (a group of facility managers) progress note, Resident 26 no longer tried to get out of bed unassisted and was more compliant with care directions. This progress note showed Resident 26 no longer needed floor mats, and they should be discontinued and the CP updated, and showed Resident 26 was agreeable to the change. 03/18/2026 at 1:55 PM showed Resident 26 in bed with fall mats on both sides of their bed. In an interview at that time, Resident 26 expressed frustration that the facility required them to wait for staff to help them out of bed. Resident 26 stated they wanted to use a commode to toilet independently. Observation on 03/19/2026 at 9:55 AM showed Resident 26 in bed with no fall mats. The mats were again not present when Resident 26 was observed in bed on 03/20/2026 at 1:00 PM. In an interview on 03/24/2026 at 11:01 AM, Staff B (Director of Nursing) stated fall mats were necessary when Resident 26 first admitted because they were unpredictable and could roll out of bed. Staff B stated the facility determined they were no longer needed for Resident 26's safety and were discontinued. Staff B stated the charge nurse the prior weekend did not know the mats were discontinued and put them back in place. Staff B stated they were not sure where the charge nurse found the mats or if they were still in Resident 26's room when the charge nurse placed them back beside the bed. Staff B stated because the mats were no longer assessed to be necessary, they should not have been in place on 03/18/2026 when observed. <Resident 19> According to the 01/08/2026 Quarterly MDS Resident 19 had severely impaired cognition, and diagnoses including high blood pressure, dementia (a decline in mental abilities) and a vision problem. The MDS showed Resident 19 used a wheelchair and a walker and transferred from their bed to their wheelchair independently. The MDS showed Resident 19 used a diuretic (water pill) medication. According to the 02/03/2020 fall risk evaluation Resident 19 had fall risk factors including high blood pressure and use of a diuretic medication. Record review showed Resident 19 had active orders for two different diuretic medications both dated 12/15/2023. According the revised 07/06/2023 fall risk. Care Plan (CP) Resident 19 was at risk for falls related to their diuretic use, impaired cognition, and impulsiveness. The CP showed staff should assess Resident 19's fall risk quarterly and as needed. According to the revised 03/11/2024 self-care deficit. CP, Resident 19 was independent with transfers and bed mobility. Observation on 03/19/2026 at 10:38 AM showed some bundled fabric (consistent with clothing of some sort) wedged between the left corner of Resident 19's mattress and bedframe (as observed from the foot of the bed). This caused the left side of the mattress to be elevated five inches above the frame at the head of the bed and caused the mattress to slope to the right side at the top. Observations on 03/19/2026 at 12:58 PM and on 03/20/2026 at 8:18 AM showed the same bundle of cloth still elevated the left corner of the mattress from Resident 19's bedframe. Observation on 03/20/2026 12:52 PM showed Resident 19 making their bed independently. Observation on 03/20/2026 at 12:56 PM showed the bundled fabric still elevated the mattress from the bedframe. In an interview at that time, Staff A (Administrator) observed Resident 19's bedframe and mattress and stated the placement of the fabric bundle was an accident hazard and made the bed less safe. Staff A stated it was possible Resident 19 place the bundle under the mattress themselves, but they expected nursing staff to notice such potential hazards and correct them. <Resident 9> Review of Resident 9's 02/16/2026 Annual MDS showed Resident 9 re-admitted to the facility on [DATE] with diagnoses of a progressive neurological disorder that affected movement, muscle weakness, and a seizure disorder. The MDS showed Resident 9 used an electric wheelchair. In an observation and interview on 03/18/2026 at 10:10 AM Resident 9 was seen sitting up in their electric wheelchair with a seat belt in use. Resident 9 stated that the facility had not checked the seat belt, that it had come with the chair. Resident 9 stated they do not remember being assessed for use of the seat belt or ability to self-release the seat belt. In an interview on 03/24/2026 at 9:32 AM Staff H (MDS Coordinator) stated that a safety assessment of Resident 9's wheelchair seat belt should have been completed quarterly to ensure it was still an appropriate device. Staff E stated that due to Resident 9's neurological disorder their ability to self-release the device could diminish and result in Resident 9 being restrained in the chair. Staff E reviewed the health record for Resident 9 and found that they had safety device assessments on 10/05/2024 and 03/16/2026. In an interview on 03/24/2026 at 11:49 AM Staff B stated safety assessments of enabler/restraints should be completed quarterly by therapy if the devices are appropriate based on the residents' abilities and needs. Staff B reviewed the records for Resident 9 showed that safety assessments for their wheelchair seat belt were conducted in 2024 and 2026 and not quarterly. REFERENCE: WAC 388-97-1060(3)(g).

Based on interview and record review, the facility failed to ensure 1 of 3 residents (Resident 1) reviewed for Pressure Ulcer/Pressure Injury (PU/PI) was provided with the necessary treatment and services consistent with professional standards of practice to promote healing and/or prevent worsening. The failure to establish a routine monitoring procedure necessary when using an air mattress (a specialized bed surface with inflatable air chambers that inflate and deflate in cycles to continuously redistribute a person's weight, preventing pressure sores [bedsores] by improving circulation and relieving sustained pressure on vulnerable areas like hips, shoulders, and heels, especially for bedridden individuals) and ascertain its proper functioning placed residents at risk for deterioration in skin condition, pain, and a diminished quality of life. Findings included.<Facility Policy>The facility policy titled, Pressure Injury Prevention and Management, revised 11/2024, showed the facility was committed to provide treatment and services to heal PU/PI and to prevent avoidable PU/PI, unless clinically unavoidable. The policy showed, after completing a thorough assessment/evaluation, evidence-based interventions for PU/PI management and prevention would be implemented for all residents who were assessed at risk or who had a PU/PI present. The policy showed the facility would provide basic or routine care interventions including pressure redistribution measures to promote healing. <Resident 1>According to the 11/17/2025 Admission/readmission Assessment, Resident 1 had clear speech, memory impairment, and had multiple medical conditions including heart disease, respiratory failure, systemic infections, unstable blood sugar levels, and bilateral leg amputations. The assessment showed Resident 1 had two Stage 4 PU (the most severe type of PU/PI, involving full-thickness tissue loss where the wound extends down to exposed bone, muscle, tendon, or ligament) on their buttocks area. The assessment showed Resident 1 was confined in bed; with limited mobility to move or change their position independently for pressure relief. Review of Resident 1's 11/17/2025 baseline Care Plan (CP) showed the resident had actual skin impairment. A CP intervention listed to address this nursing problem was the use of a specialty mattress to maintain and/or prevent further skin breakdown. The 11/17/2025 Safety Device Assessment showed Resident 1 was assessed for the safe use of an air mattress as a pressure relieving measure. The assessment showed the risk and benefits of its use was discussed with the resident and their representative. On 12/09/2025 at 8:32 AM, Resident 1's representative stated they observed the air mattress on Resident 1's bed was deflated and the resident appeared to be lying on the metal bars of the bed during their visit on 11/25/2025. The representative stated they called for assistance and the staff who came into the room did not even notice or acknowledge the air mattress was not on/working. The representative stated, when the wound nurse checked Resident 1's skin the following day on 11/26/2025, they observed the resident's whole back was red and was getting worse so the representative insisted to send Resident 1 out to the hospital for further evaluation and treatment. In an interview on 12/09/2025 at 2:19 PM, Staff C (Social Services Director) stated, on 11/25/2025, Resident 1's representative called them for assistance regarding the air mattress. Staff C confirmed the air mattress was unplugged when they entered Resident 1's room. In an interview on 12/09/2025 at 2:29 PM, Staff D (Certified Nursing Assistant) stated they were with Staff C during the incident on 11/25/2025 and confirmed the air mattress was unplugged when they entered Resident 1's room. Staff D stated they do not know the last time when Resident 1's air mattress was checked for proper functioning. Review of the November 2025 Treatment Administration Record showed there was no physician order in place directing nursing staff to monitor Resident 1's air mattress for proper function and setting until 11/26/2025; after the incident occurred. In a joint interview and record review on 12/23/2025 at 12:02 PM with Staff A (Administrator) and Staff B (Director of Nursing), Staff A stated the use of an air mattress was important for wound healing. Staff B stated the nursing staff was responsible for checking the air mattress every shift for proper function and setting. Both staff reviewed Resident 1's medical records. Staff B stated they could not determine when Resident 1's air mattress was checked last because there was no order to monitor the device prior to the incident on 11/25/2026. Staff B stated the order should have been, but was not, initiated on 11/17/2025; the day the air mattress was put in place according to the safety device assessment. REFERENCE: WAC 388-97-1060(3)(b)

Based on observation, interview, and record review, the facility failed to prepare and serve food under sanitary conditions for 1 of 4 nursing units (West One Unit) observed during mealtime. Failure to cover food items, secure lids of the dirty wash rag bin, ensure staff distributed and served food under sanitary conditions, and maintained a clean/sanitary meal cart placed residents at risk of acquiring food-borne illnesses and a diminished quality of life. Findings included . <Facility Policy> According to the facility policy titled, Food Preparation and Service, revised April 2019, the food and nutrition services employees would prepare and serve food in a manner that complied with safe food handling practices. The policy showed appropriate measures were used to prevent food contamination and that both the food and nutrition services staff and the nursing services personnel would adhere to proper hygiene and sanitary practices to prevent the spread of food-borne illness including washing their hands before serving food to residents and when handling food trays. <Uncovered Food and Bin> Observation of the meal preparation in the kitchen on 05/09/2025 at 11:33 AM for lunch service showed the plated ready-to-eat green salad and desserts for [NAME] One Unit were left uncovered when they were placed on resident meal trays for distribution. There were small, black insects observed flying around the kitchen area next to the uncovered food. In an interview on 05/09/2025 at 11:34 AM, Staff H (Clinical Dietician) stated the facility was experiencing infestation issues of small, flying insects and had ongoing services from a pest control company. On 05/09/2025 at 11:45 AM, a bin of wet, dirty wash rags was observed sitting next to the hand washing sink without a lid/cover. There were small, black insects observed flying around the uncovered bin. In an interview on 05/09/2025 at 11:46 AM, Staff D (Dietary Manager) stated the facility was dealing with fruit flies [a small fly or insect] issues. Staff D stated it was important to ensure wet and dirty bins had lids and remained covered because fruit flies love wet and dirty stuff and could cause food-borne illnesses. Staff D stated the kitchen staff should have, but did not cover the dirty bin. Observation on 05/09/2025 at 12:29 PM showed Staff E (Certified Nursing Assistant - CNA) parked the meal tray cart between room [ROOM NUMBER] and the soiled linen room in [NAME] One Unit, took a meal tray out, and walked down the hallway to room [ROOM NUMBER] with the salad bowl and dessert plate left uncovered. There were several rooms on isolation (Transmission-Based Precautions) along the hallway passed over by Staff E with the food left uncovered. In a joint interview on 05/09/2025 at 12:31 PM with Staff's E, F, and G (CNAs), Staff G stated the salads and desserts usually came uncovered from the kitchen to the nursing units for meal service. Staff F stated the observation noted was not the first time it [uncovered food] happened. <Hand Hygiene> Observation and interview on 05/09/2025 at 12:26 PM showed Staff E brought a meal tray to room [ROOM NUMBER]-B, set the tray on the overbed table, touched the bed controller, assisted the resident to sit up and position in bed to eat, came out of the room, took another tray out from the meal cart, and brought it to room [ROOM NUMBER] without performing hand hygiene between residents. In an interview on 05/09/2025 at 12:28 PM, Staff E stated hand hygiene was important to prevent cross-contamination during meal service and to avoid the spread of infection from room to room. Staff E stated they should perform proper hand hygiene while serving the meal trays in between residents but they forgot. <Meal Tray Cart> Observation on 05/09/2025 at 12:12 PM showed the meal cart used for lunch service was parked by room [ROOM NUMBER]; the cart was dirty with dried up liquid spills and brownish sediments that lined the bottom of the cart. In an interview on 05/09/2025 at 12:37 PM, Staff A (Administrator) confirmed that the meal cart was dirty. Staff A stated they expected the dietary staff to keep the meal cart clean and sanitary for food safety. REFERENCE: WAC 388-97-1100(3), -2980. .

Based on observation, interview, and record review the facility failed to prepare and serve food under sanitary conditions in 1 of 1 kitchen. Failure to perform proper hand hygiene and glove use, properly clean kitchen equipment, adequately monitor food cooking temperatures, and ensure staff distributed and served food under sanitary conditions. These failures placed residents at risk of decreased nutritional intake, cross contamination leading to food-borne illness, and a diminished quality of life. Findings included . <Hand Hygiene> <Facility Policy> Record review of the facility's 5/21/2021 policy titled, Food Safety Requirements, showed staff would adhere to hygienic practices that prevent contamination of foods from hands or physical objects by proper hand washing and the appropriate use of gloves including changing them to reduce cross contamination. Observations on 12/11/2024 at 9:20 AM, showed Staff CC (Dietary Cook) preparing food. They removed their gloves, and, without performing hand hygiene, put on new gloves to continue preparing food. At 12/11/2024 at 9:26 AM, Staff CC was observed opening the garbage can with their gloved hand, picked up food that was dropped on the floor, removed gloves, put on new gloves without performing hand hygiene and resumed food preparation. Observations on 12/11/2024 at 10:03 AM, showed Staff CC went over to the sink to wash their hands. Staff CC turned on the water, rinsed their hands in the water, did not apply any soap, then got some paper towels to dry their hands. Staff CC then returned to the service area to continue preparing food. Observations on 12/11/2024 at 10:19 AM, showed Staff CC go over to the hand washing sink, turn the water on, touch the water with their hands, then immediately after, took some paper towels to dry their hands, and used the paper towels to turn off the water. Staff CC did not use soap when performing hand hygiene. Staff CC then returned to the service area to continue preparing food. Observations on 12/11/2024 at 11:44 AM, showed Staff CC preparing to start lunch meal service, Staff CC went to the sink to do hand hygiene, rinsed their hands in water, did not use soap, dried their hands with paper towels, and put on gloves. Staff CC began dishing up and serving meal trays. During meal service on 12/11/2024 at 12:02 PM, Staff CC removed their soiled gloves and put on a new set of gloves without performing hand hygiene. In an interview on 12/11/2024 at 1:09 PM, Staff K (Dietary Manager) stated it was their expectation staff perform hand hygiene when entering the kitchen, between tasks, if they touch any potentially contaminated surfaces, and between glove changes. Staff K stated staff should wash their hands for at least 20 seconds and to use soap and water. <Cross-contamination> <Facility Policy> Record review of the facility's 5/21/2021 policy titled, Food Safety Requirements, showed the facility would implement additional strategies to prevent cross-contamination of foods. Suggested strategies included washing hands before handling clean containers, touching only the outside surfaces and handles of tableware, and storing food items in a manner to prevent deterioration or contamination. Observations on 12/11/2024 at 9:01 AM showed a staff's personal phone placed inside a bin full of salt and pepper condiment packets in the area where food was cooked and prepared for tray line service. Observations on 12/11/2024 at 9:16 AM, Staff DD (Dietary Aide) filling cups with juice and putting on lids. During the process, Staff DD was placing their fingers inside the cup ledge when picking up the cups to carry to the juice machine. Observations on 12/11/2024 at 9:28 AM showed Staff CC putting raw chicken into a food bin with a gloved hand. Staff CC picked up a bottle of oil and drizzled it on the raw chicken while they used their gloved hands to spread the oil over the raw chicken. With the contaminated gloves, Staff CC picked up a bottle of seasoning and used on the chicken, mixed the chicken up with their gloved hands, and covered the container with tin foil. Staff CC opened the oven, using the same contaminated gloves, touched oven knobs, and put the chicken inside. Staff CC removed their gloves, washed hands less than 20 seconds and put on new gloves. On 12/11/2024 at 9:54 AM, Staff CC was observed to touch and move the contaminated bottle of seasoning, with their bare hands, so they could fill a pot of water from the sink. Staff CC then carried the pot of water to the stove using the handles with their contaminated hands. Staff CC removed their gloves, washed hands less than 20 seconds and put on new gloves. Observations on 12/11/2024 at 9:31 AM, showed Staff CC using gloved hands to place frozen hamburger patties on a tray. Staff CC wrapped the remaining hamburger up, touched the freezer door handle with their contaminated gloves, and placed the hamburger inside. Staff CC removed their gloves, and without performing hand hygiene, put on a new pair of gloves and began stirring some meat on the stove. Staff CC did not sanitize the freezer door handle after it was contaminated from touching the hamburger patties. Observations on 12/11/2024 at 12:14 PM, showed Staff CC touched the front of their face mask with their gloved hands, pick up a clean plate with their contaminated hand, and dish up food on the plate to serve. Staff CC continued to prepare plates of food for residents during meal service, while at times, touching the area of the plate where the food will be placed. On 12/11/2024 at 12:31 PM, Staff K gave directions to Staff CC to go wash their hands. Staff CC went to the sink to perform hand hygiene, rinsed hands in water without using soap, dried their hands, and returned to continue food preparation. Observations on 12/11/2024 at 12:36 PM, showed the resident meal tray tickets sitting on a dirty cart used for holding the clean plates. Staff K was touching the tickets with their bare hands and handing them to Staff CC to prepare the food. Once the plate was prepared, Staff CC would put the plate up on a counter with the ticket under the plate. Staff DD would take the plate, the ticket would fall into a bin of rolls, touching the food. Staff DD would pick up the ticket and place it on a tray. Staff DD would use tongs, without gloves, and pick up a roll to place on the resident's tray. The tongs kept falling into the bin with the handles coming in contact with the rolls. Staff K gave directions to Staff DD to be careful with the tongs and make sure they do not fall into the bin with the rolls. The tongs continued to fall into the bin. Observations on 12/11/2024 at 12:44 PM showed Staff EE (Dietary Aide) take a paper menu, which a resident had written their food choices on, and placed it on a bin of clean and partially peeled cucumbers in the food preparation area. The paper was touching the food. In an interview on 12/11/2024 at 1:09 PM, Staff K stated staff's personal items should not be in the food preparation or service area in order to reduce the risk of cross-contamination. Staff K stated staff should not touch the rim of cups or the food area of plates with their bare hands or soiled gloves because there would be a risk of cross-contamination. Staff K stated this was important as the resident drinks out of the cup and eats the food from the plate. Staff K stated it was their expectation staff do not touch surface areas after handling raw meat and without performing proper hand hygiene, routinely sanitizing equipment area, and not touching food-ready surfaces with bare hands. <Food Temperatures> <Facility Policy> According to a 05/21/2021 facility, Food Safety Requirements policy, when preparing food, staff should take precautions in the food preparation process to prevent, reduce, or eliminate potential hazards. This policy showed when cooking foods, the foods should be prepared as directed until the recommended temperatures for the specific foods were reached. Review of the facility's beef stroganoff over noodles recipe, provided by staff on 12/11/2024, showed directions the beef's final internal cooking temperature should be 165 degrees Fahrenheit prior to turning off the heat, adding the remainder of the ingredients, and holding until ready to serve. Observations on 12/11/2024 at 10:02 AM, showed Staff CC removing noodles, beef, and vegetables from the ovens, and placed them on the steam table. Staff CC did not check the final food temperatures when they finished cooking the food. In an interview on 12/11/2024 at 10:11 AM, Staff CC stated they only check the temperatures of food prior to tray line service. In an interview on 12/11/2024 at 10:11 AM, Staff K stated it was their expectation staff check the temperatures of meats when they are pulled out of the oven, to assure the food got to the appropriate temperatures. Staff K stated they expected staff to check the temperatures of all foods again, just prior to starting tray line service. Staff K stated Staff CC should have checked the temperature of the meats when they moved them from the oven to the steam table. Review of a December 2024 facility food temperature log on 12/11/2024 at 10:18 AM, showed no food temperatures were logged for the lunch food items once cooking was completed. During tray line service on 12/11/2024 at 11:17 AM, Staff CC and Staff K were checking food temperatures of all food prior to meal service. Staff K instructed Staff CC to put many of the food products, including some meats, back in the oven and/or on the stove to get the temperatures higher. <Soiled Surface Areas> <Facility Policy> Record review of the facility's 5/21/2021 policy titled, Food Safety Requirements, showed the facility would follow food service safety throughout the entire food handling process from procurement to service of food. All equipment would be cleaned and sanitized to prevent contamination. Observations on 12/11/2024 at 10:13 AM, showed the dish cart holding the clean plates for tray service had dried food and debris on the top next to the clean plates and many dried drips were going down the sides of the cart. In an interview on 12/11/2024 at 10:13 AM, Staff K observed the soiled dish cart and confirmed it needed to be cleaned and stated, I need to add that to the cleaning rotation. At 12:08 PM on 12/11/2024 staff were using clean plates from the soiled cart during the lunch meal service. In an interview on 12/11/2024 at 1:09 PM, Staff K stated sanitary conditions were important to prevent residents from getting sick and to decrease the risk for potential exposure to food-borne illnesses. Refer to 803- Menus Meet Resident Needs/Prepared in Advance/Followed. Refer to 804- Nutritive Value/Appearance, Palatable/Preferred Temperature. REFERENCE: WAC 97-388-1100(3), -2980.

Based on observation, interview, and record review, the facility failed to ensure the menu was followed for 3 of 6 residents (Residents 83, 3, & 16) whose meals were observed during tray line. Failure to follow the menu as directed, according to the dietician approved spreadsheet, and provide accurate portion sizes, placed residents at risk of unmet nutritional needs, and potential negative outcomes. Findings included . <Facility Menu> Review of the facility's menu showed for lunch on 12/11/2024 beef stroganoff over noodles, buttered brussel sprouts, peach cobbler made from fresh, peeled, pitted, and sliced thin peaches, and a dinner roll would be served. The 12/11/2024 lunch menu showed low concentrated sweet diets had a canned peach cobbler instead of the fresh peach cobbler. <Following Menu> According to the facility's diet spreadsheet form provided by staff on 12/08/2024, all residents, except those who were on the low concentrated sweets diet, should receive a full serving of the peach cobbler dessert, which was to be made with fresh, peeled, pitted, and sliced thin peaches, according to the recipe provided by staff on 12/11/2024. Observations on 12/11/2024 starting at 11:45 AM, during lunch service showed staff were serving a canned fruit version of peach cobbler to all residents. There was no dessert available to serve which was made from fresh, peeled, pitted, and sliced thin peaches as directed on the spreadsheet. All of the peach cobbler desserts available to serve, were the same size, none were prepared with half of the amount, as directed on the spreadsheet, for the residents on a low concentrated sweets diet. <Portion Sizes> <Resident 83> Observations of meal service on 12/11/2024 starting at 11:57 AM, showed Staff CC prepared Resident 83's lunch tray. Staff CC used a green scoop when dishing up the brussel sprouts. When asked, Staff K (Dietary Manager) stated the green scoop was a 3 ounce (oz) serving size. After Resident 83's tray was served, Staff K changed the scoop size for the brussel sprouts to a 4 oz serving. Review of the spreadsheet showed Resident 83 should have received a 4 oz serving, rather than the 3 ounce scoop which was used. <Resident 3> Observations of meal service on 12/11/2024 starting at 11:57 AM, showed Staff CC prepared Resident 3's lunch tray without providing large portions of all the food as directed on the tray ticket. <Resident 16> Observations of meal service on 12/11/2024 starting at 11:57 AM, showed Staff CC prepared Resident 16's lunch tray without providing large portions of all the food as directed on the tray ticket. During the meal service observations on 12/11/2024 starting at 11:57 AM, Staff K (Dietary Manager) stopped Staff CC (Dietary Cook) four times from serving trays without the large portions as directed. In an interview at this time, Staff K stated they were not usually standing at the tray line reading the resident meal tickets but indicated they were instructed to stay during meal service during survey observations. In an interview on 12/13/2024 at 8:46 AM, Staff C (Regional Administrator) stated it was their expectation staff follow the recipes and menus as directed by the dietician on the spreadsheet. Staff C stated the recipes were important to follow as they were designed for different diets and restrictions. Staff C stated they expected the cook to follow the diet orders and provide portion sizes as directed. Refer to 804- Nutritive Value/Appearance, Palatable/Preferred Temperature. Refer to 812- Food Procurement, Store/Prepare/Serve- Sanitary. REFERENCE: WAC 388-97-1180(1), -1200(1).

Based on observation, interview and record review, the facility failed to prepare food in a manner that ensured meals were appetizing and palatable for 4 of 6 residents (Resident 43, 6, 74, 85) reviewed. This placed residents at risk for a decreased nutritional intake and dissatisfaction with meals. Findings included . Review of the facility's December 2024 food temperature log form showed directions to staff to place food on the tray line no more than 30 minutes prior to meal service. <Resident Interviews> <Resident 43> In an interview on 12/08/2024 at 10:18 AM, Resident 43 stated the quality of the food was not good at the facility. <Resident 6> In an interview on 12/08/2024 at 12:53 PM, Resident 6 stated they were unhappy with the food at the facility. <Resident 74> In an interview on 12/08/2024 at 1:30 PM, Resident 74 stated they were very unhappy with the food and stated it was too bland and often overcooked. <Resident 85> In an interview on 12/09/2024 at 9:15 AM, Resident 85 stated, this is the worst food, and stated they ordered food from outside the facility most of the time. Resident 85 stated the food was very bland, and the brussel sprouts were too plain and were served too often. <Meal Preparation> Review of the facility's menu showed for lunch on 12/11/2024 beef stroganoff over noodles, buttered brussel sprouts, peach cobbler, and a dinner roll would be served. Observations of meal preparations on 12/11/2024 starting at 9:01 AM showed staff putting a pot of water on the stove and began cooking brussel sprouts for the lunch service. Staff CC (Dietary Cook) finished cooking the noodles and put them on the steam table at 10:02 AM, an hour and a half prior to when the tray line service was scheduled to begin. <Meal Service> Observations on tray service started on 12/11/2024 at 11:45 AM, an hour and 45 minutes after the noodles were placed on the steam table. Observations on 12/11/2024 at 12:08 PM, two hours after the noodles were placed on the steam table, showed brown crusted noodles stuck to the bottom of the bin, Staff CC scraped the bottom of the bin, scooped the noodles onto a resident's plate, added the beef, and then served them. <Test Tray> Observations of the test tray received from lunch service on 12/11/2024 at 1:04 PM, two hours after tray line started, showed beef with noodles, pale colored brussel sprouts, and a dessert. The brussel sprouts were mushy with no taste and some of the noodles had hard, dry, brown areas. In an interview on 12/13/2024 at 8:46 AM, Staff K (Dietary Manager) stated it was their expectation food would be on the steam table no more than 30 minutes before service starts. Staff K stated having the food on the steam table longer could affect the food quality and the nutritional value of the food. In an interview on 12/13/2024 at 10:30 AM, Staff V (Dietician) stated 30 minutes prior to meal service was the goal for moving foods on to the steam table. Staff V stated the food was at risk for losing nutrient quality the longer the heat was on the food. Refer to 803- Menus Meet Resident Needs/Prepared in Advance/Followed. Refer to 812- Food Procurement, Store/Prepare/Serve- Sanitary. REFERENCE: WAC 388-97-1100(1), (2).

Based on observation and interview, the facility failed to maintain a homelike environment for 17 of 67 resident rooms (Rooms 204, 215, 245, 100, 112, 101, 107, 242, 243, 246, 251, 253, 254, 256, 224, 240, & 241), 1 of 1 dining rooms (Main Dining Room), and 1 of 4 shower rooms (West 2 Shower Room) reviewed. These failures left residents at risk for a diminished quality of life and a less than homelike environment. Findings included . <room [ROOM NUMBER]> An observation on 12/08/2024 at 9:54 AM showed room [ROOM NUMBER]'s door did not latch and was unable to close completely. In an interview on 12/13/2024 at 9:51 AM Staff N (Regional Plant Operation Manager) stated it was important for the doors to latch and close completely for resident privacy and fire safety. <room [ROOM NUMBER]> An observation on 12/09/2024 at 9:28 AM showed a 3 inch diameter shallow hole in the floor tile between beds A and B. In an interview on 12/13/2024 at 9:51 AM Staff N stated it was important to make the repairs to the floors timely to maintain a homelike environment for the residents. <room [ROOM NUMBER]> An observation on 12/10/2024 at 12:00 PM showed room [ROOM NUMBER]'s window open without a screen. In an interview on 12/13/2024 at 9:51 AM Staff N stated they were aware of the missing screen. At this time Staff L (Maintenance Aide) stated they had measured for the screens and Staff N had ordered them a couple of months ago. Staff N stated they received the mesh screen material already but needed to purchase the frames. Staff N stated it was important to make repairs timely to maintain a homelike environment for the residents. Staff N stated the continued pest problems could be a result of the screens missing with the windows open. 43642 <room [ROOM NUMBER]- Bathroom> Observations on 12/08/2024 at 9:39 AM and 12/09/2024 at 2:12 PM showed a long screw with a pointed sharp tip sticking out of the wall between the toilet and the sink. In an interview on 12/13/2024 at 9:51 AM, Staff L stated there was a missing hook that should be covering the screw. <room [ROOM NUMBER]> Observations on 12/08/2024 at 10:04 AM showed room [ROOM NUMBER] bed B with deep gouges and exposed drywall under the resident's wall light. In an interview and observation on 12/13/2024 at 9:51 AM, Staff L stated the area needed to be repaired. <room [ROOM NUMBER]> Observations on 12/09/2024 at 8:48 AM showed room [ROOM NUMBER] bed B with deep gouges and exposed drywall on the wall at the head of resident's bed. In an interview and observation on 12/13/2024 at 9:51 AM, Staff L stated the area needed to be repaired. <room [ROOM NUMBER]> Observations on 12/09/2024 at 10:30 AM showed room [ROOM NUMBER] bed A with deep gouges and exposed drywall on the wall at the head of resident's bed. In an interview and observation on 12/13/2024 at 9:51 AM, Staff L stated the area needed to be repaired. <Dining Room> Observations on 12/08/2024 at 12:36 PM showed a long cabinet underneath a countertop in the dining room against the wall next to the kitchen. This cabinet had multiple drawers and doors with peeling and missing paint with warped and cracked wood surfaces. In an interview on 12/13/2024 at 10:47 AM, when asked if the dining room cabinet was in good repair, Staff C (Regional Director) stated the cabinet was not, cosmetically appealing. Staff C stated the cabinet would not be something they would want to look at every day. Staff C stated having an environment in good repair was important as the facility was the resident's home. 45941 <room [ROOM NUMBER]> Observation on 12/08/2024 at 10:09 AM showed room [ROOM NUMBER] walls had scratches and different color patches on the walls. Resident stated staff removed the hand sanitizer from the wall and never painted the wall. <room [ROOM NUMBER]> Observation on 12/08/2024 at 10:16 AM showed room [ROOM NUMBER] walls had scratches behind the head of bed A and bed B. Observation showed the wall had a hole size of a door knob behind the entrance door inside the room. <room [ROOM NUMBER]> Observation on 12/08/2024 at 11:46 AM showed room [ROOM NUMBER] walls had scratches, tiles on the floor were chipped and had black stains on them. <room [ROOM NUMBER]> Observation on 12/08/2024 at 11:51 AM showed in room [ROOM NUMBER], resident's clothes, linens and other belongings were scattered on the floor. <room [ROOM NUMBER]> Observation on 12/08/2024 at 12:06 PM showed room [ROOM NUMBER], privacy curtain between bed A and B, was dirty, multiple stains of coffee or juice. <room [ROOM NUMBER]> Observation on 12/08/2024 at 12:45 PM showed room [ROOM NUMBER] was not clean and had strong urine odor. Resident stated they did not clean the room yet. <room [ROOM NUMBER]> Observation on 12/08/2024 at 8:55 AM and 12/09/2024 at 12:53 PM showed room [ROOM NUMBER] had no toilet in the bathroom and had a big hole in the bathroom wall. <West 2 Shower Room> Observation on 12/08/2024 at 12:50 PM showed [NAME] 2 shower room door was broken with multiple dents. Shower room had mold on the ceiling. In an interview on 12/13/2024 at 9:51 AM, Staff N stated they were aware of scratches on the walls, holes on the walls, chipped tiles in resident's rooms, missing toilet in resident's room, and broken shower door. Staff N stated it was important to make repairs timely to maintain a homelike environment for the residents. Staff N stated they needed to fix all these environmental issues. 50511 <room [ROOM NUMBER]> Observation on 12/08/2024 at 9:00 AM showed room [ROOM NUMBER]'s window had missing blinds allowing sunlight to come through the window when the blinds were fully closed. The bathroom in room [ROOM NUMBER] showed the faucet was dripping, although it was shutoff, and brownish black dirt soiled the bathroom floor. Observations at this time showed boxes stacked on top of the closet with a mattress pad partially folded up on top of the closet, inches below the ceiling. <room [ROOM NUMBER]> Observation on 12/8/2024 at 10:18 AM, showed room [ROOM NUMBER] had several dirty, mismatched and chipped tiles on the floor. Observations of room [ROOM NUMBER] on 12/10/2024 at 1:25 PM showed a damaged hole-like area to the surface of the bathroom door. <room [ROOM NUMBER]> Observation on 12/10/2024 at 9:22 AM, showed room [ROOM NUMBER] had mismatched tiles, brown and black dirt was observed in the grout between the tiles. Broken tiles were chipped and some had chips in the corner of the tiles making the tiles uneven to walk on. In an interview on 12/13/2024 at 9:51 AM, Staff L stated they completed daily rounds of the facility and kept a list of repairs needed, however Staff L stated they did not have the authority to order supplies to make repairs to the facility. In an interview on 12/13/2024 at 9:51 AM Staff N stated repairs were important and were needed to keep the facility homelike for residents. Staff N stated the tiles should be fixed in rooms [ROOM NUMBERS]. Staff N stated, they were aware of missing blinds in room [ROOM NUMBER] and the facility was looking at different options for the vertical blinds as they were not good. Refer to F925 - Maintains Effective Pest Control Program REFERENCE: WAC 388-97-0880.

Based on interview and record review, the facility failed to ensure newly admitted residents were informed in a timely manner (prior to or upon admission) of their rights and responsibilities and provided services as a resident in the facility for 3 (Resident 85, 139, & 339) of 5 residents reviewed. This failure placed residents at risk of not understanding their rights, a reduced ability to self-advocate, and a diminished quality of life. Findings included . Review of the facility's 03/17/2022 Admission Packet provided by staff, showed information and consent forms for the admission policies, resident rights, rules and operations of the nursing home, grievance process, right to choose their physician or contact information for the facility physician, charges for services, advanced directives and designation of a resident representative, privacy practices, healthcare privacy act, consent for release of medical information, bed hold policy, facility-initiated discharge policy, designation of funeral home, laundry services, policy on personal property, vaccination policies and consent, smoking policy, trust fund policy, arbitration agreement, information on state and local contacts for the State Hotline for abuse/neglect/complaints, contact for the State Ombudsman Program, Adult Protective Services, Medicaid Fraud Office, and information on the benefits/rights under Medicare. The admission packet contained multiple areas for the resident to sign acknowledgement to the facility policies, procedures and provide consent to the facility for specified care. <Resident 85> According to a 11/07/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 85 admitted to the facility on [DATE]. Review of Resident 85's records on 12/12/2024, over 30 days after the resident's admission, showed no admission packet was completed by staff upon admission. <Resident 139> According to a 12/03/2024 Admission MDS, Resident 139 admitted to the facility on [DATE]. Review of Resident 139's records on 12/12/2024, over two weeks after the resident's admission, showed no admission packet was completed by staff upon admission. <Resident 339> According to a 12/11/2024 Admission MDS, Resident 339 admitted to the facility on [DATE]. Review of Resident 339's records on 12/12/2024, two weeks after the resident's admission, showed no admission packet was completed by staff upon admission. In an interview on 12/12/2024 at 1:52 PM, Staff O (Vice President for Business office) stated having a resident and/or their representative review and sign an admission packet was important so residents would be informed of their rights and understand the services they would be offered or receive in the facility. Staff O stated they were behind in getting admission packets done timely due to staffing changes. Staff O stated it was their expectation an admission packet be reviewed and signed with a resident and/or their representative within 72 hours from the date of admission. REFERENCE: WAC 388-97-0300(1)(a), (7)(b).

Based on interview and record review, the facility failed to ensure the arbitration agreement was explained in a form and manner that the resident and/or their representative understood for 3 of 3 residents (Resident 49, 23, and 43) reviewed for arbitration (a procedure used to settle a dispute using an independent person mutually agreed upon by both parties) agreement. This failure placed residents at risk for lacking understanding of the legal document signed, forfeiture (loss or giving up of something) of the right to a jury or court, and a diminished quality of life. Findings included . <Facility Policy> The facility's 08/08/2022 Binding Arbitration Agreements policy showed the facility would explain to residents and their representatives the arbitration agreement upon admission to the facility in a form and manner that the resident understood, including in a language they understood. The policy showed the admissions coordinator was responsible for any questions the resident may have about the contract. <Resident 49> According to the 11/27/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 49 was alert and oriented, and their memory was intact. The assessment showed Resident 49 had adequate vision and hearing and had clear speech during communication. Review of a 06/05/2024 electronically signed arbitration agreement showed Resident 49's name was captured in the signature line and indicated the resident was bound by the terms and condition of the agreement. In an interview on 12/11/2024 at 6:40 AM, Resident 49 stated they did not know about the arbitration agreement, and no one explained to them about this agreement. Resident 49 stated they did not know about 30 days revoking period for the arbitration agreement because they did not know that they entered into one. <Resident 23> According to the 11/14/2024 Quarterly MDS, Resident 23 was alert and oriented, and their memory was intact. The assessment showed Resident 23 had adequate vision and hearing. Review of Resident 23's arbitration agreement showed the contract was electronically signed by the resident on 07/08/2023. In an interview on 12/12/2024 at 12:08 PM, Resident 23 stated they did not remember signing an arbitration agreement or know what an arbitration agreement was about. Resident 23 was presented with a copy of their signed arbitration agreement and Resident 23 stated they did not remember any staff talking to them about this agreement. <Resident 43> According to the 10/03/2024 Quarterly MDS, Resident 43 was alert and was able to make their own decisions. The assessment showed Resident 43 had adequate hearing, impaired vision, and had clear speech during communication. Review of a 08/27/2024 electronically signed arbitration agreement showed Resident 43's name was captured in the signature line and indicated the resident was bound by the terms and condition of the agreement. In an interview on 12/11/2024 at 10:24 AM, Resident 43 stated they signed a lot of papers during their readmission from the hospital. Resident 43 stated they did not know what the arbitration agreement was for. Resident 43 asked if any staff could explain what an arbitration agreement was. In an interview on 12/12/2024 at 11:22 AM, Staff B (Director of Nursing) stated admission coordinator was responsible for the facility's arbitration agreement process, and they assisted residents to sign the admission papers including the arbitration agreement upon admission. In an interview on 12/12/2024 at 2:22 PM, Staff O (Vice President for Business office) stated the admission coordinator who assisted residents to sign arbitration agreement was not an employee in the facility anymore. Staff O stated staff should have explained the details about an arbitration agreement to residents/their representatives before they signed an arbitration agreement. Staff O stated they were unsure where the disconnect was with the resident's arbitration agreement and they needed to do a better job explaining the contract in a form and manner that the resident's best understood. REFERENCE WAC: 388-97-1620(2)(a)(b)(i), -0180(1-4).

Based on interview and record review the facility failed to have systems in place that ensured basic life support was initiated, including Cardio-Pulmonary Resuscitation (CPR- an emergency procedure consisting of chest compressions combined with giving breaths of air) when one of one residents reviewed for emergency situations (Resident 1) was found unresponsive and required immediate staff action. The failure of facility staff to initiate basic life support, including CPR potentially contributed to the residents unsuccessful response to CPR when initiated by 911 emergency responders and increased the likelihood/risk of serious imminent harm for all residents who choose to have CPR initiated in an emergency. On [DATE] at 5:13 PM, the facility was notified of an immediate jeopardy in F678. The facility removed the immediacy on [DATE] by re-educating the facility staff on policies and procedures for CPR, which included mock code drills, and an audit of staff CPR cards, an audit of deaths in the past 30 days, and an audit of all resident Portable Orders for Life-Sustaining Treatment (POLST- a form that directed medical staff what to do if the resident had a medical emergency) forms and identified CPR certified staff on the daily schedule which ensured an effective system was in place to provide needed services when residents require life-saving measures. Findings included . Review of a [DATE] facility Cardiopulmonary Resuscitation (CPR) policy showed if a resident experienced cardiac arrest (a medical emergency when the heart stops beating) the staff would provide basic life support, including CPR, prior to the arrival of emergency medics. CPR certified staff would be available at all times and staff would maintain current CPR certification. Resident 1 According to the [DATE] Quarterly Minimum Data Set (an assessment tool) Resident 1 admitted to the facility on [DATE] and had medically complex conditions including; diabetes, dementia, and chronic kidney disease. Resident 1 had a life expectancy of six months or more. Review of Resident 1's medical record showed a [DATE] POLST form signed by Resident 1 and the Physician. The POLST form showed Resident 1 chose CPR and full treatment if they were found without a pulse or breathing. Review of Resident 1's physician's orders (PO) showed a [DATE] PO for Full Code (if a person's heart stopped beating or they stopped breathing, all resuscitation procedures will be provided to keep them alive). Review of a [DATE] Advanced Directive (a legal document that specifies what actions should be taken for their health when a resident was not able to make that decision) care plan (CP) showed Resident 1 had a POLST completed and was a full code. The CP showed staff would understand and follow the healthcare directive. Review of Nursing Progress Notes (NPN) showed on [DATE] at 11:30 PM Staff C (Licensed Practical Nurse-LPN) documented that Staff E (Hospitality Aide) and Staff F (Certified Nursing Assistant - CNA) went to Resident 1's room at 9:23 PM and found the resident non-responsive. The NPN showed Staff C checked Resident 1, confirmed they were non-responsive and called 911 for emergency assistance. A supplemental note on [DATE] at 11:40 PM showed that paramedics arrived, and Resident 1 passed away at 10:00 PM. In an interview on [DATE] at 10:58 AM Police Officer 1 stated they (Police Officer 1 and 2) received a call at 9:30 PM for an unresponsive individual and arrived at the facility at 9:33 PM. Upon their arrival to the building they were delayed entering the building, due to the front door being locked and no staff available in the facility lobby to let them in the building. Once Officers arrived to Resident 1's room they observed 5 staff members (Staff C, Staff D, Staff G, Staff F, and Staff J (CNA) , Resident 1 on the floor, and no staff performing any CPR or life-saving measures. Police Officer 2, a certified Emergency Medical Technician (EMT specially trained and certified to administer basic emergency services), asked the facility staff about a DNR (Do Not Resuscitate) order for Resident 1 and was told the Resident did not have one. Police Officer 2 questioned why CPR was not started if Resident 1 was a full code and proceeded to check Resident 1 who was still warm to the touch, and began chest compressions at 9:36 PM. Police Officer 1 stated all but 1 staff member left the room and when they asked for help by staff, a staff member directed another staff member to help with compressions and that staff member left the room. Police Officer 2 requested an oxygen mask. The facility staff attempted to give it to Police Officer 2 who was performing chest compressions instead of putting the oxygen mask on the Resident themselves. When EMT's arrived they took over resuscitation efforts that were unsuccessful and Resident 1 passed away at 9:57 PM. In an interview on [DATE] at 4:27 PM Staff C stated they asked Staff E and Staff F to check on Resident 1 and obtain vital signs. On [DATE] at 9:23 PM Staff E and Staff F found Resident 1 to be unresponsive and notified Staff C. Staff C stated they went to Resident 1's room and checked for a pulse, no pulse was detected and they directed Staff E and Staff F to get the crash cart and inform the other nurses on the floor that help was needed with Resident 1. Staff C stated they called 911 from the nurses station and Staff D (Registered Nurse-RN) and Staff G (LPN) went to Resident 1's room with the crash cart. Staff C stated they did not initiate CPR for Resident 1 because they were on the phone with 911. Staff C stated they were preparing the transfer paperwork (pertinent resident medical information that it sent to the hospital with the resident) and did not see if Staff D or Staff G initiated CPR. Review of a [DATE] facility provided Detailed History for fire incident from the local police and fire dispatch department showed at 9:28 PM police and fire were dispatched to the facility for an unresponsive resident. Police arrived on scene first at 9:33 PM. This revealed that facility staff called 911 at 9:28 PM, five minutes after Resident 1 was found not breathing or with a heart rate. Police arrived on scene at 9:33 PM and per Officer 1's statement, Officer 2 initiated CPR at 9:36 PM, leaving an additional 8 minutes the staff failed to render emergency care to Resident 1, for a total of 13 minutes. In an interview on [DATE] at 9:37 AM Staff D stated at approximately 9:40 PM on [DATE] Staff F informed them that Staff C needed urgent help with Resident 1 because the resident was not breathing. Staff D stated they locked their medication cart and went to Resident 1's room where they met Staff C in the hallway pushing the crash cart. Staff D told Staff C finish the transfer paperwork and they [Staff D, Staff G, and Staff F) would initiate CPR. Staff D had staff clear the room of equipment and placed Resident 1 on the floor. Staff D stated they were about to kneel down and start compressions when officers arrived on scene. Staff D stated they did not start compressions on Resident 1. Attempts were made to contact other staff, present at the time police arrived and that were not involved in CPR. None of these staff responded to these attempts to obtain first hand information about what transpired the care of Resident 1. In an interview on [DATE] at 2:00 PM Staff B (Director of Nursing) stated there was a miscommunication between the aides (Staff F and Staff E) and Staff C. The aides informed Staff C that Resident 1 was unresponsive, not that they were not breathing or had no heart rate. When asked why Staff F and Staff E who found Resident 1 unresponsive didn't start CPR, Staff B was not sure. When asked which staff member initiated CPR, Staff B stated Staff C and Staff D did initiate CPR. Staff B was asked why Staff C & Staff D's statements and interviews showed they did not initiate CPR, Staff B replied that Staff C called 911 first to get Resident 1 help faster. Staff B acknowledged there was a delay in initiating CPR for Resident 1 and the staff who found the Resident unresponsive should have initiated CPR immediately and had another staff member call 911. REFERENCE: WAC [DATE](1)

Based on observation, interview, and record review the facility failed to provide adequate supervision to ensure resident safety for 4 (Resident 1, 2, 3 & 4) of 5 residents reviewed for accidents. The failure to conduct fall risk assessments, identify and implement fall prevention interventions, conduct root cause analyses after resident falls resulted in harm for Resident 1 who sustained a [CONDITION(S)] and head injury on two separate unsupervised falls, harm for Resident 2 who sustained a [CONDITION(S)], psychosocial harm for Resident 3 who fell after distress caused by the behavior of their roommate, and placed all residents at risk for repeated falls, the potential for significant injury, and diminished quality of life. Findings included . Resident 1 According to the 07/01/2022 Admission Minimum Data Set (MDS - an assessment tool) Resident 1 admitted to the facility with diagnoses of stroke, dementia, repeated falls, and traumatic fractures. Resident 1 had severe cognitive and daily decision-making impairments, no behaviors, and no rejection of care. The resident was incontinent of bowel and bladder and required extensive assistance for bed mobility, transfers, and toileting. The 06/26/2022 Fall Care Plan (CP) showed Resident 1 was at risk for falls and a goal to not sustain serious injury from falling. The CP showed interventions to keep the call light within reach, meet the care needs and follow the facility Fall Protocol. The CP did not include any person-centered specific fall interventions to help prevent falls. Fall One Review of a 06/30/2022 Nurse Progress Note showed Resident 1 was having episodic behaviors, was independent with bed mobility, and was ambulating with staff short distances using a front wheeled walker (FWW). Review of a 07/02/2022 Nurse Progress Note showed Resident 1 was sent to the hospital after an unwitnessed fall and possibly sustained a [CONDITION(S)]. The progress note did not specify details of the event or injury. Review of the 07/12/2022 Hospitalist Discharge Summary showed Resident 1 was admitted to the hospital on 07/02/2022 from the skilled nursing facility (SNF) after sustaining a fall with [CONDITION(S)]. Resident 1 required surgical repair of the fractured hip and was discharged back to the SNF on 07/12/2022 for continuation of short-term rehabilitation. Review of Resident 1's clinical record showed the resident was not re-assessed for Fall Risk after readmission to the facility. Review of the 07/18/2022 5 Day MDS incorrectly showed Resident 1 had not fallen since the previous 07/01/2022 MDS Assessment. Review of the July 2022 Facility Incident Reporting Log (a required reporting log) showed Resident 1 had a non-injury fall on July 2, 2022 at 9:50 AM in the resident's room, the origin of the fall was established, and the care plan was updated. Review of the 07/14/2022 updated Fall CP showed a recent fall on 07/02/2022 with a [CONDITION(S)] and no new person-centered CP interventions or revisions to prevent falls. Fall Two According to a 7:00 PM 07/22/2022 Incident Note Resident 1 had an unwitnessed fall at 3:30 PM. The resident was found lying face down and had hit their head. The responder stated the resident's bed was in the high position and the Resident's roommate reported Resident 1 was observed playing with their bed controls causing the bed to go to a high position, then rolled over the edge of the bed to the floor. Resident 1 was provided first aid for the wound to their head. An observation on 07/29/2022 at 12:03 PM showed Resident 1 sitting up in a wheelchair being escorted by 2 visitors. The resident had significant bruising to the entire left side of their face and a tan colored bandage on the left cheek. The visitors pushed the resident's call light to summon staff to assist the resident and at 12:04 PM a caregiver answered the light and assisted the resident to bed. A 07/29/2022 review of Resident 1's clinical record showed no post Fall Assessment to re-evaluate the resident's fall risk and the Fall CP showed no updates or revisions to the resident's fall interventions to prevent falls. In an 08/01/2022 interview at 12:35 PM Resident 1's Responsible Party (RP) stated the facility notified them the resident fell on [DATE]. The RP stated the facility said they would make sure the bed control was stored out of the resident's reach. The RP stated during visits they noticed the bed control was not stored out of the resident's reach. The RP stated they had a conference with the facility on 07/27/2022 and the facility said they wanted to move Resident 1 to a room closer to the Nurses' station to help prevent falls but it had not happened yet. Observations on 07/29/2022 at 12:39 PM and 08/01/2022 at 1:58 PM showed Resident 1 lying in bed and the bed control remote clamped to the bottom sheet. Review of the 07/28/2022 Written Notice of Room Change form showed the effective date of the room change as 07/29/2022 due to medical necessity for better monitoring. This room change did not occur. The observation on 08/01/2022 at 1:58 PM showed Resident 1 in the same room. Review of the census showed the resident was in the same room since 07/12/2022. Fall Three During the 08/01/2022 interview at 12:35 PM, Resident 1's RP stated their last visit with Resident 1 was on 07/30/2022. While driving to the facility they were notified via telephone that Resident 1 fell from the wheelchair. Review of Resident 1's clinical record showed a 07/31/2022 Physician Order (PO) that Resident had a non-injury fall on 07/30/2022 and directed nursing to make a progress note twice daily for 3 days to assess for further injury and continue Neurological checks (an assessment tool to rule out a brain injury) until complete. Review of Resident 1's Nursing Progress Notes on 08/01/2022 showed twice daily nursing post fall evaluations were not documented in the clinical record. Further review of the resident's record showed no post Fall Assessment re-evaluation and no CP updates or revisions implemented to prevent falls. On 08/01/2022 at 3:45 PM, Facility Incident Investigations for Resident 1's three falls were requested. A 07/02/2022 Fall Incident Report was provided by Staff B (Director of Nursing) on 08/01/2022 at 4:00 PM. The Incident Report was not complete. There was no investigation into the root cause of the fall, no acknowledgement of the injury sustained from the fall or that the resident was hospitalized , no re-assessment of the resident's fall risk, no identified plan of action to help prevent future falls, no indication of CP considerations, and no summary of findings that abuse and neglect had been ruled out. Staff B was not able to provide an investigation for the falls on 07/22/2022 or 07/30/2022. In an interview on 08/01/2022 at 4:23 PM Staff B stated the facility did not complete a root cause analysis and Investigation for Resident 1's falls on 07/02/2022, 07/22/2022, or start an investigation for the fall on 07/30/2022 but they should have. Staff B was unable to provide documentation of re-assessment of the resident's fall risk or additional interventions implemented after each fall. Staff B was unable to provide a rational for why Resident 1 had not been moved to a room closer to the nurse station on 07/29/2022 as planned, which may have contributed to Resident 1's fall on 07/30/2022. Resident 2 Review of the 06/25/2022 Admission MDS showed Resident 2 required extensive two person assistance with bed mobility and had no falls prior to admission. The 07/12/2022 Discharge return anticipated MDS showed Resident 2 had moderately impaired cognition. Review of the 07/19/2022 Entry Tracking MDS showed the resident readmitted to the facility following a hospital stay with less than six months to live. During an interview on 08/01/2022 at 2:05 PM, Staff B stated the nursing staff were expected to complete an All-Inclusive Admission Assessment (AIAA) with each admission, readmission, and quarterly. Staff B stated the AIAA included the fall risk assessment and when completed generated the Baseline Care Plan (BCP). Staff B stated fall risk assessments were also done after each fall, triggered when the incident report was initiated in the electronic record. During an interview on 08/01/2022 at 2:37 PM, Staff B stated the 06/18/2022 AIAA for the Resident 2's first admission was the only AIAA completed. Staff B was unable to provide an AIAA for the 07/19/2022 readmission. Review of the 06/18/2022 AIAA showed Resident 2 was assessed as a high fall risk. The associated 06/18/2022 BCP listed a goal that resident would not sustain serious injury through the review date. Interventions included, follow facility fall protocol. During an interview on 08/01/2022 at 2:05 PM, Staff B stated the facility fall protocol was standard; assess the resident for injury, report to the doctor, notify family, begin the investigation process and put interventions in place. Review of the resident's record showed the 06/18/2022 CP was discontinued or deactivated on 07/15/2022. Review of the 07/28/2022 CP showed a problem of Poor Safety Awareness and the only intervention listed was instructions for staff to leave bed in low position while unattended, which was added on 07/29/2022. During an interview on 08/01/2022 at 2:37 PM, Staff B stated that they did not find a safety or fall CP initiated before the resident's fall on 07/21/2022. Review of the 07/21/2022 Un-witnessed Incident Investigation showed Resident 1 fell out of bed at 7:30 PM and was transported to the hospital where the resident was diagnosed with right femur (thigh bone) fracture. Review of the 07/21/2022 Fall Scene Investigation Report report showed interventions to prevent future falls included, placement of mobility bars on both sides of the bed to help them change position. Review of the 07/24/2022 Summary/Conclusion showed the planned intervention upon the resident's return to the facility to issue a specialized air mattress with bolsters or anything to prevent the resident from rolling out of bed while sleeping. On 07/29/2022 at 1:46 PM, Resident 2 was observed in bed with their RP at bedside. Resident 2 was not able to answer questions asked, but moaned and acknowledged they were in pain with movement. The bed was observed without side rails or grab bars, no fall mats were observed on the floor, and no specialized mattress with bolsters in pllace. During an interview on 07/29/2022 at 1:46 PM, Resident 2's RP stated on 07/21/2022 at 10:30 PM they received a call that Resident 2 fell out of the bed and was enroute to the hospital. The RP stated Resident 2 was in the hospital until 07/28/2022, and discharged to the facility with orders for bed rails and fall mats while at the facility. The RP stated on the evening of 07/28/2022 the facility staff said they would find the resident bed rails and fall mats but it has not happened yet. During an interview on 07/29/2022 at 4:00 PM, Staff A (Administrator) stated they would make sure the resident received the ordered equipment. Review of 07/28/2022 Physician Orders showed directions to install bilateral side rails to enhance bed mobility, and a low air loss mattress with side bolsters and mobility bars for increased independence. Review of the July 2022 Treatment Administration Record (TAR) showed directions to install bilateral side rails, which was initialed as done on 07/29/2022 at 1:20 AM. Review of at 07/30/2022 3:21 AM Nurses Note showed the bed was delivered with air mattress and bed mobility bars but not installed. According to the note, Resident is difficult to move and only 2 staff here tonight so will wait until day staff come and help. During an interview on 08/01/2022 at 2:47 PM Staff B stated they called hospice on 07/29/2022 to verify they were going to deliver the bed which was a delayed a bit. The current bed was to be in the low position and staff were to conduct frequent rounding for safety until the new bed was delivered. During an interview on 08/01/2022 at 2:47 PM Staff B stated that the nurse should have, but did not call and notify them of staffing concerns. Resident 2 passed away at the facility on 07/31/2022. Resident 3 According to the 07/08/2022 Quarterly MDS Resident 3 had mild cognitive impairment, verbal behaviors that significantly disrupted the care and living environment of others, and diagnoses including stroke with paralysis, depression, and anxiety. Resident 3 had no falls, was incontinent of bowel and bladder, and required extensive assist with bed mobility, transfers, and toileting. The 06/09/2022 Fall CP showed Resident 3 was at risk for falling and the goal was to be free from falls. The CP showed one intervention dated 06/09/2022 that the resident had been educated to use the call light for all needs. In an interview on 07/29/2022 at 11:37 AM, Resident 3 stated they fell on the weekend and split open the back of their head. Resident 3 stated that their roommate, Resident 1, got up out of bed alone and walked over to the wall and pulled out the electrical cords for Resident 3's bed control and air mattress the the electrical socket. Resident 3 stated that Resident 1 then walked over to Resident 3's bedside table and threw all of Resident 3's belongings on the floor. Resident 3 stated this was very distressing to them and so they tried to roll over toward their paralyzed side to pick up their belongings off the floor, fell off the bed, and hit their head on the baseboard heater. Resident 3 stated the nurse called an ambulance and they spent the remainder of that day in the emergency room . Resident 3 stated the facility did nothing to help prevent Resident 1 from touching their belongings and wanted Resident 1 moved. In an interview on 07/29/2022 at 11:45 Staff E (Certified Nursing Assistant) stated on 07/24/2022 at around 9:30 AM they heard Resident 3 yelling. Upon entering Resident 3's room, Staff E stated Resident 3 was on the floor between the window and the bed and there was blood on the floor. Staff E stated Resident 3 told them they fell trying to pick up their personal belongings off the floor because Resident 1 threw their belongings on the floor and unplugged their bed and air mattress. Staff E stated they went and got the Nurse and the Nurse called 911. Staff E verified the devices were unplugged and Resident 3's belonging were on the floor at the time of the fall. Review of 07/24/2022 Physician Order directed Nursing staff to monitor the laceration to the back of Resident 3's head until the wound had resolved. A 07/24/2022 Fall Risk Assessment showed Resident 3 was a high risk for falling. The clinical record showed no evidence of root cause findings or additional CP interventions to help prevent future falls and ensure the safety of both Resident 1 and Resident 3. In an interview on 08/01/2022 at 2:30 PM Staff B stated the facility investigation for Resident 3's 07/24/2022 fall was not completed and should have been. Staff B stated there were no interventions added to Resident 3's CP and implemented to help prevent future falls but there should have been. Resident 4 Review of the 06/23/2022 Admission MDS showed Resident 4 was alert and oriented, required one-person extensive assist with bed mobility, two-person extensive assist with transfers, and had not history of falls. Review of the 06/20/2022 CP showed Resident 4 was at risk for falls and listed standard interventions done for all residents, not person-centered specific fall interventions to help prevent falls or injuries from falls, based on the resident risks. During an interview on 07/29/2022 at 2:23 PM, Resident 4 stated that they had a [CONDITION(S)] while in bed, fell on the floor and hit their head. Review of a 07/16/2022 6:41 AM Nurse Progress Note showed at 6:15 AM Resident 4 was found on the floor next to the bed. Resident 4 appeared to have had a [CONDITION(S)] and rolled off the bed. Three staff assisted the resident back to bed. The resident had a small trickle of blood coming from left side of mouth that the nurse contributed to biting themselves during the [CONDITION(S)]. Review of the Fall Risk Assessment Worksheet dated 07/17/2022 showed Resident 4 was assessed as a high fall risk. The assessment showed the resident did not have any cognitive or behavior indicators including periods of altered perception or awareness of surroundings, no periods of lethary, and no episodes of disorganized speech. Review of the 07/16/2022 incident report showed the bed was in a low position. The 07/18/2022 incident summary showed the resident sustained no injury and denied hitting their head. Interventions included educating the resident on pre-[CONDITION(S)] signs and symptoms, to report those signs to the nurse, conducting frequent rounding, to ask resident if they need anything, and provide assistance as needed. The use of a fall mat at bedside due to a history of seizures was not added to the CP until 07/18/2022. The CP was not revised to include the additional interventions identified in the incident summary. During an 08/01/2022 interview at 2:07 PM Staff B stated it was their expectation that a resident fell be re-assessed for fall risk and have specific interventions implemented to help prevent falls. Staff B stated the residents should be assessed for fall risk on admission, quarterly, and as needed when they fall. Staff B stated it was their expectation that the resident's CP address their fall risk, be updated with the appropriate interventions based on the root cause of the fall, the resident to be placed on alert to monitor their condition, and the investigation process initiated. Staff B stated they were responsible for ensuring the fall investigations process was completed. During an interview on 08/01/2022 at 2:07 PM, Staff C (Corporate Nursing Officer) stated they recently identified issues with fall investigations and had a new post fall incident and reporting form, which they planned to implement. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review the facility failed to ensure the residents' environment was free from accident hazards, including securing portable oxygen tanks (contains compressed oxygen). The failure to secure portable oxygen tanks in 3 (Resident 90, 84 & 66) resident rooms and in an oxygen storage room placed the residents at risk for serious adverse outcomes if oxygen tanks fell or tipped over, with the potential for an explosion and/or serious bodily injury, and constituted an immediate jeopardy (IJ). On 04/22/2022 at 10:57 AM an IJ was identified and the Provider was informed. On 04/25/2022 at 12:00 PM, the facility removed the immediacy by ensuring all portable oxygen tanks were secured, all resident rooms, offices, therapy gyms, and closets were audited to ensure oxygen tanks were properly stored and secured, and staff were trained on oxygen storage and handling. Additionally, the facility failed to identify potential accident hazards, assess potential hazards, and provide interventions for 2 (Resident 84 & 81) residents, one of whom smoked a cigarette while the portable oxygen tank flow was on, and one resident who used a heating pad. Additional accident hazards were identified in common resident areas, to include sharp metal filings in the resident activity room, unsecured stairwell door, unattended cookies and a cookie baking oven easily accessible to residents, and one (Resident 67) resident room with multiple stacked boxes, all of which had the potential to result in avoidable accidents and/or injury to the residents. Findings included . Review of the 04/22/2022 facility Oxygen Safety policy showed oxygen cylinders (tanks) would be properly chained or supported in racks or carts to prevent tanks from falling. The policy directed staff to protect tanks from damage by not storing portable oxygen tanks in locations where they could tip over. The policy showed No Smoking rules will be strictly enforced while oxygen was in use, including removal of smoking materials from residents receiving oxygen. Compressed Oxygen Tanks Unsecured Resident 90 Review of the 03/23/2022 Admission Minimum Data Set (MDS an assessment tool) showed Resident 90 had diagnoses including [CONDITION(S)] ([CONDITION(S)]), required oxygen, and was not a smoker. Resident 90 was assessed with moderately impaired cognition, was capable of making their own decisions, and required limited assistance from staff for bed mobility, transfers, dressing, toilet use and personal hygiene. Review of Physicians Orders (PO) showed a 03/18/2022 PO that directed staff to titrate (continuously measure and adjust) oxygen (O2) 1-5 L (liters) to keep O2 saturations (indicates the amount of oxygen in blood) between 88-92%. An observation on 04/21/2022 at 8:38 AM showed Resident 90 sitting in a wheelchair at their bedside table trying to rearrange a very long oxygen tube. There was a portable oxygen tank standing on the floor near the resident's feet. The tank was not in a cart, rack or secured in any way. In an interview on 04/21/2022 at 8:44 AM, Staff Q (Licensed Practical Nurse) stated Resident 90's oxygen tank was not secured and it should be in a cart. On 04/21/2022 at 8:45 AM Staff T verified Resident 84's oxygen tank should not be on the floor or on the seat of the walker and placed the oxygen tank in the bag under the seat to secure it from falling. Staff Q removed the immediacy of potential harm. Resident 84 Review of the 03/18/2022 Quarterly MDS showed Resident 84 had diagnoses including [CONDITION(S)], required oxygen, and was not a smoker. The resident was assessed with mildly impaired cognition, was capable of making their own decisions, and required staff supervision for bed mobility, locomotion on and off the unit, dressing, eating, toilet use, and personal hygiene. Review of PO's showed a 01/31/2021 PO that directed staff to administer O2 at 2 L per minute via a nasal cannula (tubing used to deliver oxygen) and remind the resident to keep it on. An observation and interview on 04/21/2022 at 8:46 AM showed Resident 84 was sitting on their bed with their four-wheeled walker observed at the foot of the bed, a portable oxygen tank was observed standing on the floor next to the wheel of the walker. Resident 84 stated they did not have an oxygen holder to secure the tank and usually laid the tank on the seat of the walker when ambulating. In an interview and observation on 04/21/2022 at 8:53 AM, Staff T (Certified Nursing Assistant) stated the oxygen tank was usually on the seat of Resident 84's walker and not on the floor. Staff T placed the tank on the seat of the walker. Resident 66 Review of the 03/17/2022 Medicare 5 Day MDS showed Resident 66 had diagnoses including Congestive Heart Failure, and did not use oxygen. The resident was assessed as cognitively intact, was able to make their own decisions, and required extensive assistance from staff for bed mobility, dressing, toilet use, and personal hygiene. Review of PO's showed a 03/21/2022 PO that directed staff to titrate O2 1-2 L to keep O2 saturations greater than 93%. Observation on 04/22/2022 at 8:42 AM and 9:22 AM showed an oxygen tank standing upright on the floor of Resident 66's room, unsecured and next to the oxygen concentrator. 200 East Hall Oxygen Storage Room Observation on 04/22/2022 at 8:52 AM showed an unsecured oxygen tank sitting on the cement floor inside the door of the oxygen storage room on the 200 East Hall. Unlabeled Oxygen In Use Signs In an interview on 04/22/2022 at 11:25 AM, Staff CC (Chief Nursing Officer) verified Resident 6, Resident 90, and Resident 84 used oxygen in their rooms. Staff CC acknowledged there was no sign at the resident's door instructing staff that oxygen was in use In an interview on 04/21/2022 at 8:50 AM, Staff BB (Certified Nursing Assistant) stated it was their second day at the facility and to ask someone else how to secure portable oxygen tanks. On 04/22/2022 at 10:57 AM Staff EE (Chief Executive Officer- CEO), Staff A (Administrator), Staff B (Director of Nursing), and Staff C were informed of the unsecured portable oxygen tanks and took immediate action to remove the immediacy and acknowledged portable oxygen tanks must be secured in a rack, cart, or holder to prevent tipping or falling over. On 04/22/2022 at 11:25 AM the Fire Marshall identified nine unsecured oxygen tanks in a crate in the back of the 200 East Hall oxygen room. At 11:45 AM on 04/22/2022 the Fire Marshall identified 12 portable oxygen tanks and an oxygen re-filling tank located in the physical therapy gym that were unsecured. On 04/22/2022 at 11:46 AM Staff DD (Administrator in Training) and Staff EE were made aware of the unsecured oxygen tanks in the physical therapy gym and started relocating the oxygen tanks to the 100 hall oxygen room. Smoking and Oxygen Use Resident 84 Observations on 04/28/2022 at 10:23 AM showed Resident 84 walked down the driveway, through parked cars to a small stairwell. At 10:30 AM, Resident 84 sat on the concrete parking curb with the oxygen tank secured to the walker and the oxygen tubing in their lap. The oxygen regulator was open, and oxygen was flowing from the tank. Resident 84 had a burning cigarette in their hand and a package of cigarettes sitting on the ground next to them. Resident 84 confirmed the oxygen was flowing and they usually turned it off, but not this time. In an interview on 04/28/2022 at 12:55 PM Staff V (Receptionist) identified Resident 84 as a smoker who went outside to smoke. Staff V could not recall if Resident 84 used oxygen or carried an oxygen tank. In an interview on 04/28/2022 at 1:01 PM Staff C and Staff B stated they were not aware that Resident 84 was a smoker or went off the facilities property to smoke. On 04/28/2022 at 1:22 PM Resident 84 stated they knew smoking while using oxygen was not allowed, knew the facility was non-smoking, and confirmed they were smoking the same pack of cigarettes since February 2022. Heating Pad Resident 81 According to the 03/20/2022 Medicare 5 Day MDS, Resident 81 had diagnoses including Acute Respiratory Failure. The resident was assesed as cognitively impaired and able to make their decisions, and required extensive assistance from staff with bed mobility, dressing, toileting, personal hygiene, and bathing. A review of the 03/14/2022 CP showed Resident 81 required extensive assistance from staff for bed mobility, dressing, toileting, and bathing. Observation and interview on 04/24/2022 at 11:02 AM, showed Resident 81 lying on their bed on their back with an electric heating pad under their neck and upper back area. Resident 81 stated their family brought the heating pad from home to relieve their back pain. In an interview on 04/24/2022 at 11:50 AM, Resident 81 stated they were independently putting the heating pad under their back. A review of the visitor sign in log on 04/24/2022 at 12:23 PM, showed Resident 81's family visited Resident 81 on 04/22/2022 at 2:57 PM. Observations on 04/24/2022 at 12:57 PM showed no skin issue on Resident 81's back. Resident 81 stated the heating pad shuts off automatically after 2 hours. The temperature of the heating pad was noted at 93 degrees Fahrenheit by thermometer. During an interview with Staff B and Staff C on 04/24/2022 at 1:23 PM, Staff C stated Resident 81 could reposition themselves in bed and the CP was inaccurate. Staff B stated they were not aware Resident 81 used a heating pad and stated the facility policy prohibited the use of heating pads by residents because they could cause [CONDITION(S)]. Activity Room Sliding Door On 04/24/2022 at 10:08 AM, the sliding door from the Activities room was noted to be bolted shut. A screw hole in the handle was noted with sharp metal filings extending from the drill hole. During environmental rounds and interview conducted on 04/29/2022 at 7:34 AM, Staff D (Maintenance Director) stated the metal filings represented a potential accident hazard to a resident trying to open the door and needed to be removed so a resident doesn't cut themselves on the sharp metal pieces. Staircase Magnetic Lock Mechanism On 04/25/2022 at 10:38 AM, the magnetic door fastener at the top of the stairway located next to the Activities Room was observed to be fastened with duct tape and was not secured. During environmental rounds and interview conducted on 04/29/2022 at 7:34 AM, Staff D stated the mechanism was not but should be secured to remove a potential accident hazard if a resident was able to go through the door into an unsupervised stairwell. Room Storage Resident 67 On 4/28/2022 at 12:07 PM, residents' personal items were noted on top of the closet. A sign was observed on the side of the closet that stated DO NOT PLACE ANYTHING ABOVE THIS LINE PER FIRE REGULATION. During environmental rounds conducted on 04/29/2022 at 7:34 AM, Staff D stated that the items should not be there. Cookie Baking Oven On 04/22/2022 at 12:13 PM a cookie baking oven was observed in the second floor activity room, unplugged and not in use. A sticker on the front door stated, Caution Hot. Next to the oven was an unlocked clear box that contained 4 cream colored cookies, easily accessible to any resident. During an interview on 04/22/2022 at 12:34 PM, when asked about the cookie oven, Staff X (Activities Assistant) stated they never used it and When I came in the morning, I was surprised to see that, We don't usually leave food sitting out. On 04/22/2022 at 12:35 PM an empty cardboard box the size of the oven, with the name of the cookie company was observed in the Activity office. The box had a shipping label dated 04/04/2022, and was addressed to Staff FF (Food Service Manager from a sister facility). During an interview at that time, Staff X stated, It showed up in our office the other day. On 04/22/2022 at 12:39 PM Staff FF confirmed they brought the cookie oven to the facility in the box. When asked if staff training was provided, Staff FF stated that the user only needed to engage the on/off switch. Staff FF stated that the activity staff were given a diet roster two days prior to verify the residents who could eat the freshly baked cookies. Staff FF stated that they expected the cookies to be given out under staff supervision. On 04/22/2022 at 1:01 PM Staff Y (Activities Director) stated they used the oven the day before and when it was plugged in the fan broke so the cookies were baked in the kitchen oven. Staff Y stated that they passed out the cookies and did not have any cookies leftover. On 04/22/2022 the kitchen staff baked cookies again. According to Staff Y who stated, The ones I had left over, I left there in the activity room. Staff Y acknowledged that food should not be left unattended. On 04/22/2022 at 1:14 PM Staff FF plugged in and turned on the cookie oven. The oven was observed heating up, and the front door warm to touch. At 1:17 PM the oven started making loud noises and sounded like the fan was malfunctioning. REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review the facility failed to ensure 3 (Residents 36, 251 & 153) of 17 residents reviewed, received the necessary care and services in accordance with professional standards of practice and their comprehensive person-centered care plan. The failure to implement monitoring and interventions for skin care (Resident 251),and air mattress settings (Resident 153) resulted in the potential for unmet care needs and diminished quality of life. The failure to provide physician ordered treatments for 1 (Resident 36) of 3 residents reviewed for non-pressure skin issues resulted in worsening of the skin condition, discomfort, and psychological distress to the resident. Findings included . Non-Pressure Skin Resident 36 The 04/27/2022 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 36 was cognitively intact, able to make themselves understood and understand others. Resident 36 was identified as high risk for skin injuries and had moisture associated skin damage with applications of ointments and medications to the skin. A review of the Physician Orders (PO) showed: 1. 01/17/2022 an antifungal powder that directed staff to apply to skin folds topically two times a day for itching 2. 01/17/2022 a barrier paste that directed staff to apply to skin folds topically two times a day for itching 3. 01/17/2022 an anti-[CONDITION(S)] ointment that directed staff to apply topically to affected area every 12 hours as needed for itching. 4. 01/17/2022 a lotion that directed staff to apply to affected area topically every eight hours as needed for itching three times a day 5. 01/19/2022 a topical solution that directed staff to apply to skin folds topically as needed for excess moisture two times a day as needed. 6. 02/23/2022 treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 04/2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Anti-fungal Powder ordered for twice daily was not administered seven times on day shift and 12 times on evening shift between 04/01/2022 and 04/21/2022. 2. Barrier paste ordered for twice daily was not administered nine times on day shift and 17 times on evening shift. 3. Anti-[CONDITION(S)] ointment, lotion and topical solution was not administered at all in the month of April 2022. 4. The anti-[CONDITION(S)] and anti-fungal powder and moisturizing cream with bed sheets in skin fold daily on Monday, Wednesday and Friday was not administered on Friday, 04/22/2022 as scheduled. A review of the 03/02/2022 wound specialist note showed the left flank with a rash and maceration (broken skin from moisture) noted to skin fold with a treatment prescribed- anti-[CONDITION(S)] ointment and anti-fungal powder followed by a moisturizer daily, place pillowcase between folds. These recommendations were not found on the physician orders to replace the 01/17/2022 and 02/23/2022 treatment orders. Review of the 04/2022 Kardex (care instructions) showed no instructions to staff to clean Resident 36's skin daily or place the pillowcases between the skin folds. A review of the weekly wound evaluation assessments for Resident 36 showed the last assessment for the left flank wound was completed on 03/10/2022 at 8:44 AM. There were no assessments of the left flank wound after 03/10/2022 to indicate the facility was managing the wound care with updated orders or ensuring daily skin hygiene. The 04/01/2022 Care Plan (CP) directed staff to administer treatments as ordered and monitor for effectiveness, if the resident refuses treatment, confer with the resident to determine why and try alternative methods to gain compliance, document alternative methods. There was no CP for the left flank skin care or hygiene. In an interview on 04/22/2022 at 2:25 PM, Resident 36 stated they had redness under the arms in the skin folds that was itchy, painful, and not being taken care of by the staff. Resident 36 stated the doctor ordered daily cleaning and an ointment and a powder. Resident 36 raised their left arm and moved the fold of skin which showed bright red, moist, bumpy skin that had patches of white. The rash spanned from the chest to the back and covered the entire inner skin fold. Resident 36 stated the area was not cleaned or a treatment applied since Monday, 3 days earlier. Resident 36 stated the nurse often came between 11:00 PM and 1:00 AM to do the treatment while they were already asleep, and they would refuse and send the nurse away. Resident 36 stated, the nurse should come when I am awake, I am tired of them waking me in the middle of the night. Resident 36 stated , with tears in their eyes, no one should have to live like this. In an interview on 04/25/2022 at 12:22 PM, Resident 36 stated the facility got rid of the shower aide and made the caregivers do the showers. Resident 36 stated they had not had a shower since the beginning of March and only had bed baths. Resident 36 showed under their arm and the skin was redder and flakier and had drips of moisture than what was observed on 04/22/2022 at 2:55 PM. Resident 36 stated their sheets were all wet and it was that way all night. Resident 36 said they told the staff that morning about the sheets, but the staff did not change the sheets yet. Observation showed the sheets were wet, spanning the entire width of the resident from mid back down to where the resident was sitting in the bed. Resident 36 stated, I want to have a shower, I need them to take care of my skin, I am on the low priority for wound care. When they don't do the wound treatments the rash gets worse, and it hurts, In an interview on 04/27/2022 at 12:38 PM, Staff F (RCM & MDS Nurse) stated physician orders for wound care was not obtained or administered as prescribed. Staff F stated the facility wound care nurse resigned three or four weeks ago and the position was not filled. In an interview on 04/28/2022 at 2:13 PM, Staff C (Chief Nursing Officer) confirmed the orders written by the wound specialist on 03/02/2022 was not updated in the resident's record and the prior orders were not discontinued. Staff C acknowledged the treatments were not administered when Resident 36 was awake to avoid refusal of treatments. Resident 251 Resident 251 was admitted to the facility on [DATE]. According to a 04/15/2022 Admission MDS, Resident 251 had multiple medically complex diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This MDS assessed Resident 251 to be at risk of Pressure Ulcers/Injuries and had two venous ulcers (wounds on the leg or ankle caused by abnormal or damaged veins). According to the 04/21/2022 Pressure Ulcer/Injury Care Area Assessment, Resident 251 was identified on admission with two small open skin areas on the left lower leg and was receiving treatment per the April 2022 TAR. Review of the April 2022 TARs showed an order that directed staff to apply compression bandages used for the management of venous ulcers to both lower legs in the morning and to remove at night. Observations on 04/23/2022 at 9:53 AM showed Resident 251's legs partially wrapped with loose sagging woven gauze and no compression bandage. Similar findings of Resident 251 without compression bandages was observed on 04/25/2022 at 8:05 AM and 04/27/2022 at 10:05 AM. In an interview on 04/29/2022 at 7:33 AM, Staff C stated it was their expectation that staff complete Resident 251's treatments as ordered. Air Mattress Settings Resident 153 According to the 04/07/2022 Quarterly MDS, the resident had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 153 was assessed at risk for pressure ulcers and required a pressure reducing device for the bed. Review of PO's showed a 10/04/2021 PO for a specialty mattress, and directed staff to check function every shift. Green light equals proper functioning. LN (Licensed Nurse) initials indicates functioning as per order. Review of a 12/31/2020 Potential for skin breakdown/pressure injury CP showed an intervention that resident requires a pressure relieving device on the bed. On 04/24/2022 at 9:08 AM the resident was observed lying on an air mattress. The air mattress settings were observed on alternating and the weight setting was at 450 lbs (pounds). Similar observations were made on 04/25/2022 at 9:13 AM and 12:26 PM, 04/26/2022 at 9:36 AM, and 04/27/2022 at 10:08 AM. Review of the resident's weight record showed on 04/25/2022 the resident weighed 107.5 Lbs. In an interview on 04/28/2022 at 9:53 AM Staff C stated they expected the air mattress to be set at the appropriate weight, and acknowledged Resident 153 did not weigh 450 lbs. REFERENCE: WAC 388-97-1060(1).

Based on observation, interview and record review the facility failed to ensure care is provided consistent with professional standards of practice to prevent and/or provide treatment and services for pressure ulcers for 3 of 8 (Resident 3, 97, & 76) residents reviewed for Pressure Ulcers (PU). Failure to identify and assess changes in skin condition, notify the practitioner to obtain orders for treatment, and complete weekly documentation of PU progress caused harm to Resident 3 who obtained two stage four PUs on the right hip, one stage 4 PU on the right outer ankle and one stage 4 PU on the right outer foot. Failure to implement preventative measures (Residents 97 &76) such as positioning, placed residents at risk for deterioration in skin condition. Findings included . According to the 05/17/2021 facility policy titled, Pressure Injury Risk Assessment, residents determined as at risk for developing pressure injuries would have interventions documented in the Care Plan (CP) based on specific factors identified in the risk assessment. According to the National Pressure Injury Advisory Panel (NPIAP) PU stages are defined as; Stage 1 PI: intact skin with a localized area of non-blanchable (discoloration of the skin that does not turn white when pressed), Stage 2 PI: partial thickness loss of skin with exposed dermis (second layer of skin), may present as an intact or ruptured serum-filled blister, granulation tissue (indicates healing), slough (yellow/white material in wound bed) and eschar (dead tissue) are not present. Stage 3 PI: full thickness loss of skin, in which adipose (fat) is visible, slough and/or eschar may be visible. Stage 4 PI: full thickness skin and tissue loss with exposed or directly fascia (connective tissue), muscle, tendon, ligaments, cartilage, or bone in the ulcer. Resident 3 The 02/10/2022 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 3 was admitted to the facility on [DATE] and was on hospice care. Resident 3 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3 was assessed as high risk for PU development and the assessment only identified one PU on the MDS. Resident 3 was assessed to require extensive assistance with bed mobility and total dependence with transfers using a mechanical lift. A review of the 03/16/2022 wound specialist notes showed Resident 3 only had one PU on the low back that was a stage 4 with increased breakdown to the ulcer edges with more dead skin cells in the wound. The recommended treatment was to be completed daily. A 03/17/2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Change daily by floor nurse except Wednesday when wound specialist sees the resident. The treatment was scheduled to be performed every night shift. A review of the 03/23/2022 nurse progress note showed Resident 3 refused wound care by the wound specialist on the 03/23/2022 weekly rounds. There is no documentation of nursing staff assessment or care provided to the PU's on 03/23/2022. The 03/23/2022 CP showed Resident 3 had a stage 4 pressure ulcer on the low back. The interventions directed staff to assess, record, and monitor wound healing weekly including measurements, status of the wound, and healing progress. The CP specified use of foam boots on both feet and an air mattress with settings to be checked every shift. The CP directed staff to refer assessments and treatment recommendations to the wound specialist. The CP directed staff to inform the resident, family, and caregivers of any new area of skin breakdown. A review of the 03/25/2022 nurse progress note showed the Resident Care Manager (RCM) called the hospice nurse to come and see Resident 3 for a new red area on the right hip. The RCM wanted the hospice nurse to help with a plan to prevent PUs. The 03/29/2022 weekly skin observation assessment identified the ankle and right outer foot pressure ulcers. The assessment showed these PU were not new and further assessment was not required. There was no documentation to show the nurse staff notified the physician on this assessment information. There was no documentation or PO for treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] A review of the 03/30/2022 nurse progress note showed Resident 3 refused wound care, a second time, by the wound specialist on the weekly rounds and the Director of Nursing and Hospice was notified. There is no documentation that the facility nursing staff provided assessment or PU care to the current five (1-low back, 2-right hip, 3-right hip, 4-right ankle, 5-right foot) PUs on 03/30/2022. A review of the 04/01/2022 nurse progress note showed the RCM called hospice to inform them the wound specialist would no longer be visiting Resident 3 because of hospice services. The RCM asked the hospice nurse to manage wounds and was waiting for a call back. A review of the 04/01/2022 hospice nurse visit notes showed the facility did not report any concerns at this visit. The hospice nurse validated and verified that the caregiver demonstrates and verbalizes understanding of the plan of care and will notify hospice with falls, uncontrolled symptoms, changes in condition, questions, concerns. The hospice nurse was still uninformed about the status of the right hip, new right ankle, and new right foot PUs. A 04/06/2022 nurse progress note showed the hospice nurse visited Resident 3 but Resident 3 did not allow the hospice nurse to assess the right hip area. The nurse note showed the plan was to continue current treatments to the low back only and reposition resident as they allow. A review of the 04/06/2022 hospice nurse visit notes showed the RCM called and requested the hospice nurse visit because a new open area on the right hip was identified. The 04/06/2022 hospice note showed Resident 3 refused to let the nurse assess the right hip PU, so the hospice nurse did not give treatment recommendations to the facility for care of the PU. Resident 3 also did not allow the hospice nurse to complete a full skin check, thus the hospice nurse did not identify the additional PUs on the right ankle or right foot. There were no recommendations for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . An observation on 04/21/22 at 11:18 AM showed Resident 3 was lying on their right side on the air mattress that was set to 400 pounds, and not wearing foam boots. Resident 3 did not appear to be 400 pounds. The last weight recorded on 01/24/2022 was 107 pounds. The 04/22/2022 hospice nurse visit notes showed no concerns or issues reported by the floor staff at this visit. The hospice nurse validated and verified that the caregiver demonstrates and verbalizes understanding of the plan of care and will notify hospice with falls, uncontrolled symptoms, changes in condition, questions, concerns. The hospice nurse was still uninformed about the right ankle and right foot PUs. An observation on 04/23/22 at 10:56 AM showed Resident 3 was lying on their back, no foam boots and air mattress setting at 400 pounds. An observation on 04/25/2022 at 8:59 AM showed Staff S (Registered Nurse) in the middle of providing wound care to Resident 3. Resident 3's right ankle and right foot were covered with a clean foam dressing. There was a PU at the base of the back and two PU on the right hip that had a paste surrounding the wound on the intact skin. Staff S placed the packing material in the low back wound and covered with a foam dressing. Staff S placed an ointment in both hip wounds and covered with a foam dressing. When asked, Staff S stated the right foot, right ankle, low back, and two right hips PU were all stage 4 PU. Staff S stated the wound specialist comes on Wednesdays and that is when the wounds are measured and evaluated for a change in treatment. Staff S was not aware the wound specialist was no longer directing wound care for Resident 3. Staff S confirmed there were no PO for treatments for the right hip, right ankle and right foot and there should be PO obtained. A 04/25/2022 nurse progress note identified the PU on the low back, right hip, right outer ankle, and right outer foot. The note showed staff would report the new PU to the care team, hospice nurse, and the physician. A 04/27/2022 in person physician visit note showed provision of wound care changed from the wound specialist to hospice services. The physician documented Resident 3 had a long history of a low back PU and referenced the 04/25/2022 nurse progress note. The physician did not mention changes in PU assessment or treatment plan for the hip, ankle, or foot pressure ulcers. A review of the nursing progress notes from 03/29/2022 to 04/27/2022 showed no documentation the physician was notified of the two hip, one ankle and one foot ulcers. There was no documentation the hospice nurse was notified of the ankle or foot ulcers. In an interview on 04/27/2022 at 12:38 PM, Staff F (RCM & MDS nurse) stated when the new PU was identified the physician and the hospice nurse were expected to be notified. Staff F stated a treatment order was expected to be obtained and must be in place before the nurse could provide the treatment. Staff F reviewed Resident 3's record and was not able to find any documentation that the physician or hospice nurse were notified. Staff F reviewed the POs and stated there were no treatment orders for the hip, ankle, or foot. Staff F observed Resident 3's hip, ankle, and foot and confirmed the placement of a dressing on all three areas. In an interview on 04/27/2022 at 12:36 PM Staff E (Staff Development Coordinator) stated the facility performed competency checks for all nurses who provided wound care. Staff E was unable to provide a competency evaluation for Staff S who was observed providing wound care without orders on 04/25/2022. Staff E was not able to provide a competency evaluation for wound care for Staff U (RCM) responsible for coordinating care and treatment with the wound specialist, hospice nurse, and the physician. In an interview on 04/27/2022 at 3:21 PM Staff B (Director of Nursing) stated the nurses are expected to identify and assess changes in skin condition, notify the practitioner to obtain orders for treatment, and complete weekly documentation of wound progress. Staff B acknowledged the nurses did not follow the expectation and resulted in Resident 3's PUs not being treated. Resident 97 Resident 97 was admitted to the facility on [DATE]. According to the 03/25/2022 Quarterly MDS Resident 97 had multiple medically complex diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . This MDS assessed Resident 97 to require extensive physical assistance from staff for bed mobility, transfers, and dressing. Observations on 04/21/2022 at 10:38 AM showed Resident 97 asleep sitting in wheelchair (w/c) next to their bed. On 04/21/2021 at 12:41 PM and 1:50 PM showed Resident 97 remained sitting up in w/c at side of bed. According to a 12/19/2021 PU Care Area Assessment (CAA) associated with Resident 97's 12/14/2021 Admission MDS, showed staff documented Resident 97 had preventative measures in place, which included repositioning and stated, .will proceed to plan of care. Review of Resident 97's CP on 04/22/2022 revealed no identified concerns or interventions related to the resident being at risk for developing PUs. In an interview on 04/23/2022 at 8:47 AM, Staff Z (Certified Nursing Assistant- CNA), indicated Resident 97 had no skin risks or concerns. Observations on 04/25/2022 at 10:41 AM with Staff AA (Registered Nurse - RN) showed Resident 97 had redness noted to bilateral buttocks. In an interview at this time, Staff AA indicated Resident 97 was at risk for developing PUs and should be repositioned frequently. In an interview on 04/29/2022 at 7:33 AM, Staff C (Chief Nursing Officer) stated staff should have but did not update and revise Resident 97's CP to include interventions to prevent the development of PU. Resident 76 According to the 03/15/2022 Quarterly MDS Resident 76 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was assessed to be at to be at risk for developing PUs and currently had no PUs. A 03/21/2022 nursing progress note showed staff identified an open and unopened blister to the right lateral thigh during the weekly skin assessment that caused Resident 76 mild pain to the area. Staff documented they were unsure how the blister developed. Review of a 03/21/2022 Weekly skin observation assessment showed no new skin issues. Additional notes showed Resident 76 had a right lateral upper thigh open skin area that measured 8 x 4.5 cm (centimeters) and a fluid filled blister on the right upper lateral thigh that measured 3.5 cm x 2.5 cm. Review of a 03/21/2022 Incident report showed, the root cause analysis presents that the resident has large friction rub and provider agreed. The investigation did not determine what caused the large friction rub. A 03/22/2022 Physician note showed the resident presented with an apparent large friction blister to the right lateral thigh. The resident informed the physician they did not experience acute trauma to the area. Review of a 03/22/2022 Potential for impairment to skin integrity related to [CONDITION(S)], fragile skin, redness to the bi-lateral lower extremities, and an actual skin impairment of a open blister to the lateral right thigh. The CP interventions included educate resident and caregivers of causative factors and measures to prevent skin injury, and to monitor the open and unopened blister to the right lateral thigh. There were no identified interventions on the CP to prevent the wound from worsening or reoccurring. A 03/30/2022 nursing progress note showed the resident missed the wound provider visit and the PU was assessed by facility staff. Staff documented the PU measured 4.5 cm x 9 cm x 0.1 cm, had no odor but did have yellowish colored slough. A 03/31/2022 wound provider assessment showed the cause of the resident's right lateral thigh PU was an abrasion with partial thickness injury of the skin. On 04/27/2022 at 10:04 AM Resident 76 was observed in their power wheelchair, the wheelchair controls were observed on the right side of the chair, making contact with the residents right lateral thigh, where the PU was located. In an interview on 04/27/2022 at 11:12 AM the contracted wound provider stated the CAUSE may be from pressure caused by the resident's wheelchair. Refer to F849 Hospice Services. Refer to F726 Competent Nursing Staff. REFERENCE: WAC 388-97-1060(3)(b).

Based on observation, interview, and record review the facility failed to ensure bowel and bladder care and catheter care was provided according to professional nursing standards for 3 (Residents 65, 13 & 67) of 7 residents reviewed. Failure to identify and provide care for diarrhea (Resident 13) and failure to provide appropriate catheter care (Resident 67) left residents at risk for dehydration, urinary tract infection, skin breakdown, and negative health outcomes. Additionally, the failure to implement catheter care and monitoring to Resident 65 according to professional nursing standards resulted in hospitalization for a blood infection, bladder and kidney infection. The harm caused to Resident 65 caused a decline in condition which may have contributed to the death of Resident 65. Findings included . Resident 65 The closed record review for Resident 65 showed they admitted to the facility on [DATE] for rehabilitation for a left lower leg fracture and a bowel infection. Other diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The 02/24/2022 admission practitioner note showed Resident 65 had a (urinary) catheter and directed staff to change catheter and drainage bag together using aseptic technique as needed for disconnection, leakage, obstruction, bleeding, or infection. The practitioner also directed staff to continue skilled nursing care and maintenance of the catheter. The 02/24/2022 Admission Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The 02/26/2022 nursing baseline Care Plan (CP), completed two days after admission showed Resident 65 had a catheter for urination. No instructions for care or monitoring were shown on the care plan. Resident 65's 02/2022 and 03/2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The 02/2022 and 03/2022 Kardex (caregiver directions) and flowsheets showed no documentation of hygiene care was provided to the catheter for Resident 65. The 03/03/2022 Minimum Data Set (MDS- an assessment tool) showed Resident 65 required a urinary catheter. The 03/03/2022 Care Area Assessment (CAA) showed the facility triggered further care planning for the catheter. The CAA provided direction to the licensed nurses to plan interventions for the care of the urinary catheter, including following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The 03/02/2022 CP for bladder dysfunction and use of a catheter was initiated 26 days after admission. The CP goal showed Resident 65 would be free of infection related to the urinary catheter. There were no interventions initiated to meet the defined goal. There were no interventions for care and monitoring of the catheter or urinary function. The daily nursing skilled progress notes on 03/13/2022, 03/14/2022, 03/15/2022, and 03/16/2022 described Resident 65's urine in the catheter bag as amber and cloudy. There was no documentation in the progress notes of notification of the provider about the assessment of abnormal urine color and clarity to identify a possible urinary tract infection. The 03/17/2022 provider note showed the nursing staff emergently contacted the provider about the resident's change in condition, including unresponsiveness, an elevated blood sugar of 400, high blood pressure 180/117 (a hypertensive crisis is greater than 180/120), and pulse was 148 (normal pulse is 60-90). There was no report to the provider of the change in urine color and clarity in the catheter bag. The provider directed staff to transfer Resident 65 to the emergency room . The 03/17/2022 hospital records showed Resident 65 presented to the emergency room with altered mental status, elevated blood sugar, abnormal heart rate and an abnormal heart rhythm. The hospital physician documented the urinary catheter contents were red, abnormal, and positive for infection. The urine lab results showed a urinary infection. The blood lab results showed a serious infection. The resident was placed on intravenous fluids and antibiotics for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 04/27/2022 at 12:14 PM, Staff F (RCM & MDS Nurse) stated POs for catheter care, maintenance, monitoring and care directions to staff are required for residents with a catheter. In an interview on 04/27/2022 at 3:21 PM with Staff B (Director of Nursing) and Staff C (Chief Nursing Officer), Staff B acknowledged Resident 65 did not have an order from the physician for use of a catheter, there were no interventions in place to care for and monitor the catheter which resulted in hospitalization for a blood, bladder and kidney infection. Staff B and Staff C agreed the care and monitoring interventions should have been in place to prevent infection, timely identify an infection, and prevent hospitalization and declined condition. Resident 67 According to the 03/07/2022 Quarterly MDS, Resident 67 was cognitively intact, had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the 10/13/2019 Suprapubic Catheter CP, nurses should monitor and document Resident 67's fluid intake and output (I&O) and should flush Resident 67's catheter with 30 cc (cubic centimeters) of normal saline each shift. Review of the April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . In an interview on 04/28/2022 at 9:36 AM, Staff C stated they expected the catheter to be flushed every shift as ordered. In an interview on 04/28/2022 at 4:02 PM, Staff C stated the facility was not but should be monitoring Resident 67's I & O. Resident 13 According to the 04/06/2022 Quarterly MDS, Resident 13 was cognitively intact. The MDS showed Resident 61 was always incontinent of bowel and bladder. In an interview on 04/22/2022 at 12:11 PM, Resident 13 stated that they sometimes experienced diarrhea and stated they believed it might be a side effect of their medications. According to the resident's records, between 03/28/2022 and 04/25/2022, Certified Nursing Assistants (CNAs) documented Resident 13 had loose stools (diarrhea) on 04/01/2022, 04/07/2022, 04/09/2022, 04/11/2022, 04/16/2022, 04/17/2022, 04/18/2022, 04/19/2022 and twice on 04/21/2022. Review of Resident 13's progress notes from 03/28/2022 to 04/25/2022 revealed no evidence CNAs reported the loose stools to the nurse. Review of Resident 13's POs showed no orders for an antidiarrheal medication or any other orders to treat Resident 13's loose stools. In an interview on 04/28/2022 at 3:59 PM, Staff C stated that CNAs should have, and did not, report the loose stools to the nurse, that this omission prevented the nurse from notifying the physician, and prevented Resident 13 from receiving the treatment they required. REFERENCE: WAC 388-97-1060 (3)(c).

Based on observation, interview, and record review, the facility failed to ensure three (Residents 1, 9 & 8) of three 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. The facility failed to ensure Resident 1 received acute medical interventions timely, after experiencing a change in condition including decreased mentation, increased abdominal distention, that prevented prompt treatment that resulted in hospitalization and may have contributed to the resident's death. In addition, the facility failed to monitor and treat non-pressure wounds for 3 of 3 residents (Residents 1, 9 & 8) reviewed for non-pressure wounds. Failure of the facility placed residents at risk for delay in care and treatment, increased risk of poor outcome and diminished quality of life. Findings included . Resident 1 Review of the facility's undated Change in a Resident's Condition or Status Policy, showed that the facility should promptly notify the resident, attending physician, and representative of changes in the resident's medical/mental condition and/or status. The policy showed that the nurse will notify the resident's attending physician or physician on call when there has been a(an): significant change in the resident's physical/emotional/mental condition; refusal of treatments or medications two or more consecutive times; and/or need to transfer the resident to a hospital. Review of Resident 1's POLST (Physicians's Order for Life-Sustaining Treatment), showed on [DATE] the Resident signed the POLST and chose CPR (Cardiopulmonary Resuscitation) with Full treatment including the use of antibiotics if life can be prolonged, long term medically assisted nutrition by tube, and hospital transfer. According to the [DATE] 5 Day Minimum Data Set (MDS- an assessment tool) Resident 1 was readmitted to the facility from a local hospital on [DATE] after having surgery to fix a right femoral fracture on [DATE]. According to the MDS, Resident 1 had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Care Plan for Diabetes Mellitus, initiated on [DATE] showed interventions to monitor, document, report as needed any signs or symptoms of [CONDITION(S)] (increased blood sugar), such as fatigue, dry skin, abdominal pain, increased thirst and appetite. Interventions included to monitor, document, report as needed any signs or symptoms of [CONDITION(S)] (decreased blood sugar), such as sweating, confusion, slurred speech, lack of coordination and increased heart rate. Review of [DATE] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Inpatient Nephrology Consult Note from the hospital dated [DATE], showed an abdominal ultrasound was done on [DATE]. Results showed a large amount of ascities (abnormal fluid build up in the abdomen due to liver disease) and a paracenthesis (removal of fluid) was performed on [DATE] at 4:53 PM. Review of the facility Nursing Admission/Readmission Evaluation dated [DATE] at 4:27 PM showed Resident 1 had a paracentesis (fluid removal) drainage site with dressing to the right abdomen. Review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Nursing Progress notes showed no indication Nursing Staff clarified with the Physician for orders to monitor and treat the wound. Review of the Nursing Care Plan (dated [DATE]) for Resident #1, showed no interventions for the resident's liver disease. On [DATE] at 3:21 PM, Resident 1 was observed laying in bed, with bruising and a scab to right knee, a dressing and bruising to right hip. Attempts to interview Resident 1 at that time were unsuccessful due to the resident's confusion. Review of a Medical Doctor (MD) re-admission note dated [DATE] showed that Resident 1 appeared to be alert and oriented to self and place with abdominal distention that was not present on previous admission. According to the MD note, the resident was seen for a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The MD noted the resident should continue on [MEDICATION(S)] (medication used to treat complications of elevated blood [MEDICATION(S)] levels), [MEDICATION(S)] (medication to reduce HE) and [MEDICATION(S)] (medication used to treat fluid retention). Review of the [DATE] Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Documentation showed [MEDICATION(S)] (medication used to treat complications of liver disease) was refused on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE], [DATE]. Documentation showed [MEDICATION(S)] (medication to reduce HE) was refused on ,d+[DATE], ,d+[DATE], ,d+[DATE], ,d+[DATE] and [DATE]. Sprionolactone (medication used to treat fluid retention) was refused on ,d+[DATE], [DATE]. The Nursing Skilled Progress note dated [DATE] at 12:45 AM, showed Resident 1 to be alert to person, with normal bowel sounds, warm skin with good skin turgor (assess dehydration) and no behaviors observed. Review of the MD Encounter -MD Admission History and Physical Note dated [DATE], the resident was seen and the MD noted Resident 1's abdomen was quite distended. The MD planned to obtain a baseline CMP (Comprehensive metabolic profile- measures, glucose level, electrolyte and fluid balance, kidney and liver function) and H3 (detects the presence autoantibodies- proteins that attack the immune system) and a CBC (Complete blood count - evaluate the cells that circulate in the blood and overall health). Review of POs orders for [DATE] showed the facility had not carried out Physician recommendations for labs as stated in the MD Encounter note on [DATE]. Review of Lab Results showed no labs were drawn or results received for labs planned [DATE]. On [DATE] at 01:43 AM a Nursing Skilled Progress note showed Resident 1 was confused, observed with abdominal distention, poor po (by mouth) intake, and warm skin with sluggish skin turgor. Per the summary, the Licensed Nurse (LN) showed, Resident has not been awake enough to take medications. Will let the MD know by the communication book. Review of the MD Communication and Order Sheet, signed on [DATE] by the LN showed the problem/concern was, the resident never awake enough to take food or medications. The communication was noted by the Physicians Assistant (PA) on [DATE] with no new orders given. On [DATE] at 01:08 AM a Nursing Skilled Progress note showed Resident 1's need for skilled care to be resident is very ill with liver disease . has not been eating or taking medications. Rests in bed and when awake talks to people who are not there. Resident 1 was documented to be confused, with abdomen very swollen from liver disease, poor po intake with GI (Gastrointestinal) complications being abdominal distention and hypoactive (sign that intestinal activity has slowed) bowel sounds. Skin warm with sluggish turgor, which might be related to dehydration. Resident 1 was not receiving therapy services because the resident was not able to perform therapy requirements. The Nursing Skilled Progress note summarized Resident 1 continued to be confused, often talked to someone who was not there and was sleeping most of the time. The facility notified the physician that the resident was not eating or taking fluids and was not taking medications. Review of the MD Communication and Order Sheet dated [DATE], unsigned by an LN showed the problem/concern was patient is refusing medications and fluids, poor appetite. On [DATE] it was noted by the PA with orders to; please have speech therapy and dietician evaluate. Review of a [DATE] at 01:57 AM a Nursing Skill Progress Note showed Resident 1 was not alert, won't eat or take fluids. Refuses medications. Bed ridden and very ill due to liver disease. LN documented Resident 1 was confused, their abdomen was distended and swollen, mucous membranes were dry sticky and was not consuming oral fluids, and had hypoactive (decreased) bowel function and skin that was warm, and dry with sluggish skin turgor, supporting dehydration. Skin was documented to be yellow in color (jaundice- excess of the pigment billirubin, caused by liver disease). Staff documented the resident was experiencing hallucinations (perceptual experiences in the absence of real external sensory stimuli) and delusions (misconceptions or beliefs that are firmly held, contrary to reality). The resident was unable to participate in therapy services and the LN summarized that Resident 1 continued to refuse to take fluids, and if staff attempted to get the resident to take a drink the resident spit it out, and was unable to take medications. Staff notified the MD Resident 1 was refusing food, fluids and medications and the resident's abdomen was getting bigger. Apparently the resident's urinary output was unusually low because staff documented the resident normally voids (urinates) once a shift. A Nursing progress note dated [DATE] at 5:22 PM showed Resident 1 was refusing medication, poor appetite and provider notified, indicating a significant decline in condition. But staff documented, No acute changes at this time indicating staff failed to identify a significant decline in medical condition. Despite the resident's decline and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE] at 01:25 AM a Nursing Skilled Progress Note showed Resident 1 to be confused with hallucinations, not eating, drinking or taking medications with a large protruding abdomen and poor po intake. Resident 1's skin was documented as warm, dry, yellow in color with sluggish skin turgor, indicating dehydration. The resident was not able to participate in therapy due to inability to follow directions. The LN summarized the note as Resident 1 was not alert, was unable to state their name, refused all attempts to get the resident to eat or drink, only took ,d+[DATE] cup of apple juice today and that is all. The resident refused medications, by clamping their teeth and wouldn't open their mouth. The resident would at times call out for their mother or dad and sometimes spouse. The resident would sometimes sing nursery rhymes, and seemed to be having hallucinations and spoke to someone they thought was in the room when no one was there. A nursing progress note dated [DATE] at 01:51 AM showed the LN documented a plan to let the MD know that the resident was not eating or drinking or taking medications. the day shift nurse left a note for the MD as well. Review of MD orders showed on [DATE] at 2:27 PM an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The labs were collected at [DATE] at 5:25 PM. According to the lab report the Resident had a critical elevated Sodium level, the lab documentation showed, Critical Sodium was called to the facility and read back by the Stat Coordinator at [DATE] at 9:27 PM. Results showed Resident 1 had a GFR (Glomerular filtration rate- a blood test that checks kidney function) of 16, indication of a low kidney functioning. Per the lab GFR reference range, less than 15 indicated renal failure. There was no indication staff continued monitoring the resident during the day and evening shifts on [DATE], according to the resident's electronic medical record. On [DATE] at 12:40 AM a Nursing Skilled Progress Note showed Resident 1 continued to be confused, was not eating, drinking or taking medications. A Nursing Progress Note at 01:45 AM showed, Resident 1 was given apple juice by request but spit out all medication. The facility was notified by the lab tech at 2400 (Midnight) about critical lab value serum Sodium 165. Staff notified the on-call physician, who ordered to push fluids but the resident refused; suggesting staff did not communicate the resident's dire condition. The on-call physician said to send Resident 1 to the hospital via a non-emergent ride to treat the sodium level at the ER (emergency room ) as the facility did not have the required treatment available, (D5W, Intravenous sugar solution in water) because the medication systems were not functioning, making the treatment inaccessible to the facility staff at the time it was needed. Resident 1's spouse stated in an interview on [DATE] at 1:34 PM that the resident passed away. During an interview on [DATE] at 3:56 PM, Staff B, Director of Nursing stated that a change of condition was any change from the resident's baseline and the LN should have adequately conveyed the resident's decline in condition when notifying the provider, to ensure timely effective treatment was provided. The LN said staff should have notified the responsible party and documented actions taken. Non-Pressure Wounds Review of the facility's undated policy for Skin Breakdown, showed that the nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sores. In addition, the nurse shall describe and document the following: full assessment including location, stage, length, width, depth, presence of exudates (drainage) or necrotic tissue (dead skin), pain assessment, residents mobility status, current treatments, including support services and all active diagnoses. For treatments and management of the wound, the physician will authorize pertinent orders related to the wound treatment, including wound cleansing and debridement (removal and cleaning) approaches, dressings and applications of topical agents if indicated for type of skin alteration. Resident 1 Review of the 5 Day MDS (Minimum Data Set- an assessment tool) dated [DATE], showed resident had no [CONDITION(S)] present. Review of the hospital Discharge Placement Report, dated [DATE], under Medical Problems, showed Resident 1 had a diabetic ulcer on part of right foot and a diabetic ulcer of left foot with fat layer exposed associated with an underlying condition due to diabetes mellitus, both noted on [DATE]. An Admission/Readmission Evaluation dated [DATE] at 4:27 PM showed Resident 1 had skin issues present on admission, to include; the right abdomen had a paracentesis (a procedure to remove abnormal build up of fluid in the abdomen) drainage site with dressing, rear of right thigh with twenty staples on the right hip, extensive bruising to the right thigh, bruising to both arms, scattered scabs to both of the lower legs and left foot/toe and plantar (sole of foot) blackened calluses and two blackened calluses to right foot plantar. Review of PO from [DATE] through [DATE] showed no orders to monitor or treat the right paracenthesis drainage site, the staples, bruising and incision to the right hip, bruising to the arms, and calluses to both feet. Review of nursing notes showed no documentation of contacting Medical Doctor (MD) to obtain these orders. Review of the [DATE] Treatment Administration Record showed no non pressure wound care or monitoring was performed. Review of the Skin Integrity Nursing Care Plan (CP) dated [DATE] for Resident 1 showed the skin impairments were not addressed on the plan of care. In addition there were no interventions to prevent further skin breakdown. Review of the Diabetes Mellitus CP initiated on [DATE] showed instructions for the nurse to monitor for foot care needs, and document findings. Review of Skilled Nursing Notes and Nursing Progress Notes from readmission on [DATE] until discharge on [DATE] showed no documented wound care to the drainage site or the right hip staples. Resident 9 According to the Entry MDS dated [DATE], Resident 9 admitted to the facility on [DATE]. According to the hospital Discharge Placement Report, dated [DATE] Resident 9's medical problems consisted of [CONDITION(S)] (infection of skin tissues) of lower extremities, [CONDITION(S)] of both lower extremities and venous stasis (slow blood flow in the veins) ulcer to both the right and left lower leg with fat layer exposed. Further review showed no discharge orders for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] Review of the Resident's Nursing Care Plan dated [DATE] showed that resident 9 had the potential for skin impairment but did not include the actual wounds the resident had on their lower extremities. Review of the Kardex dated [DATE] showed no skin impairment or directions to nursing staff on how to care for the residents wounds. Review of the Nursing Admission/Readmission Evaluation dated [DATE] showed staff were unable to determine the resident's skin condition on admission. The following day the resident was assessed to have two open areas, one on each leg, the left lower lateral and back of right calf. Review of the [DATE] Weekly Skin Observation, showed that the resident had a right lateral calf wound 6 cm (centimeters) x 3 cm open area red, no sign or symptoms of infection, and back of left calf open area 11 cm x 8 cm. Red open area and no sign or symptoms of infection. Some bleeding when dressing was changed. Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . Suggesting staff performed a dressing change without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Review of an MD Progress Note dated [DATE] at 09:13 AM, showed the MD documented a plan to continue wound care to the left and right lower extremity stasis ulcers. The physician wanted staff to notify the medical provider if signs of infection developed. Review of the clinical record showed no documentation between [DATE]- [DATE] that supported staff contacted the physician to obtain treatment orders for wounds. Resident 9 was seen by a wound team on [DATE] according to the wound assessment and treatment plan. At this time treatment recommendations were made. Review of the MD Orders showed the wound team recommendations were not ordered until [DATE]. The treatment order was scheduled for that day at 10:00 PM. Review of the [DATE] MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the administration progress note showed the Resident refused dressing changes at that time because the dressings were already changed. Resident 8 On [DATE] at 11:35 AM Resident 8 was observed at the bedside with dressings to the bilateral lower extremities. In an interview at that time, Resident 8 stated that he had stasis ulcers to both legs. Review of POs showed on [DATE] treatment orders were obtained for the left leg wound, every 48 hours and for the right leg wound every night shift every other day. Review of the [DATE] TAR showed the right leg wound dressing was documented as done [DATE], but not [DATE] as resident was sleeping. Review of the [DATE] TAR showed on [DATE] the right leg wound dressing was documented as done as scheduled, but the left wound dressing was not. Review of the nursing administration progress note dated [DATE] at 1:47 AM showed, Not able to do tonight. No reason was provided. Review of a [DATE] Grievance Form dated [DATE] showed Resident 8 reported wound dressing were not done. Further review of the [DATE] TAR showed no dressings to the left or right legs were documented as completed on [DATE] as scheduled. Review of the nursing administration progress note dated [DATE] at 10:30 PM showed, Not able to do this tonight. But no reason was provided. Review of POs showed [DATE] orders for Daily wound care BLLE wounds to include dressing change. There were no directions specified for the order. Review of the resident's record showed the order was not present on the [DATE] TAR suggesting the dressings were not changed. Review of a Grievance Form dated [DATE] showed Resident 8 stated, Nursing has not changed my bandages in the past three days. According to the grievance documentation, Upon inspection notable bloody discharge seeping through bandages and odor. During an interview on [DATE] at 3:17 PM, Staff B stated that the wound team made rounds at the facility on Wednesday, completed dressing changes and documented in their own electronic medical record. For a resident to be seen by the wound team, there needed to be a referral and a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . REFERENCE WAC [DATE](1)

Based on observation, interview, and record review, the facility failed to ensure six (#s 20, 57, 49, 62, 69 & 72) of 19 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. The facility failed to ensure two (#s 62 & 57) of three residents reviewed received services related to [MEDICAL CONDITION], four (#s 69, 72, 62 & 57) of eight residents reviewed received services related to non-pressure skin issues, and one (# 49) of five residents reviewed received services related to bowel management. These failures placed residents at a risk of decline in medical status and quality of life related to unmet care needs. Additionally, failure to ensure Resident #20 did not receive medically contraindicated medications, in accordance with professional standards of practice, resulted in a severe medical reaction. Findings included . Refer to CFR 483.12(c)(2)-(4), F-610, Investigate Abuse/Neglect RESIDENT #20 Record review showed Resident #20 admitted to the facility on [DATE]. According to the 11/13/18 Quarterly Minimum Data Set (MDS- an assessment tool), the resident had [MEDICAL CONDITION], diabetes and [MEDICAL CONDITION] (a progressive and painful neuromuscular disease), and required the use of antidepressants and opioid medications on each day of the assessment period. The resident was assessed as cognitively intact, and had no identified hallucinations, delusions, behaviors or refusal of care. Observations on 04/26/19 at 11:50 AM, revealed Resident #20 being transferred from bed to wheelchair via a mechanical lift. In an interview at 12:15 PM, Resident #20 indicated she recalled medication changes which made her, sick a few months past, but did not recall details. According to the (MONTH) (YEAR) Medication Administration Records (MARs), Resident #20 received Duloxetine 30 mg (milligrams) twice a day for depression. Review of Pain Clinic notes, dated 12/26/18, showed a recommendation for the resident to start, [MEDICATION NAME] (a medication to treat pain) 50 mg QID (four times a day). According to the 12/26/18 progress notes, the [MEDICATION NAME] order triggered a drug protocol alert/warning of, The system has identified a possible drug interaction with the following orders: Duloxetine. The alert indicated a possible severe interaction that, may result in the development of Seretoni[DIAGNOSES REDACTED] (eg. agitation, altered consciousness, ataxia (altered movement), [DIAGNOSES REDACTED] (stiffened muscles), overactive reflexes, shivering). According to a 12/26/18 MD communication and order sheet, staff notified the physician that, The system indicates a severe drug interaction of [MEDICATION NAME] and Duloxetine. Kindly address. Staff L, Primary Physician, noted the interaction and directed staff to D/C (discontinue) Duloxetine; (start) [MEDICATION NAME] (a different antidepressant), continue [MEDICATION NAME] 50 mg QID as per pain clinic recommendation. According to the (MONTH) (YEAR) MARs, the [MEDICATION NAME] was initiated and the Duloxetine was discontinued, on the evening of 12/27/18. However, progress notes dated 12/28/18 indicated, Res(ident) refused to take ([MEDICATION NAME]) at this shift, Res stated I want to know why they (discontinued) Duloxetine, I am not going to sign the consent Redirected but not successful. Message left to provider. Despite Resident #20 clearly asking why the Duloxetine was discontinued, there was no indication staff informed and/or educated the resident about the risks/benefits of declining the discontinued Duloxetine. A computerized physician prescription, dated 12/28/18, indicated Staff L ordered the Duloxetine to be restarted at 30 mg twice a day, which was implemented on the evening of 12/28/18. According to the (MONTH) (YEAR) MAR, the resident received both the [MEDICATION NAME] and Duloxetine starting on 12/28/19. There was no indication facility staff offered alternative care options and/or took steps to minimize any physical decline associated with the identified severe drug interaction, causing a negative outcome, and placing the resident at risk for Serotoni[DIAGNOSES REDACTED]. A 12/29/18 note, handwritten by Staff L, indicated, [MEDICATION NAME] contraindicated with Duloxetine. Suggested switching resident to [MEDICATION NAME]. She chose to stay on Duloxetine instead of being on [MEDICATION NAME]. There was no indication facility staff clarified with Staff L, based on this note, if the intent was to discontinue the [MEDICATION NAME], as the Duloxetine was ordered the previous day. There were no progress notes regarding the reinstitution of the Duloxetine, and no indication that staff monitored or evaluated the resident's response to the use of these medications, or considered the potential severe interactions of the concomitant use of the Duloxetine and [MEDICATION NAME]. There was no documentation to support either the physician or facility staff provided education regarding the potential severe interactions with these medications. Record review revealed no risk versus benefit regarding keeping the resident on these contraindicated combination of drugs. In an interview on 04/26/19 at 8:53 AM, Staff C, Nurse Consultant, indicated the clinical record did not provide information to support why the resident was restarted on the Duloxetine, despite clinical contraindication, on 12/28/18. Staff C confirmed staff should have, but did not monitor for the signs and symptoms associated with the contraindication (Serotoni[DIAGNOSES REDACTED]). Progress notes dated 01/02/19 indicated, Res(ident) on alert for new pain medication, [MEDICATION NAME]. No (signs symptoms) of sedation noted. Progress notes dated 01/03/19 indicated, Res tolerating dose change of [MEDICATION NAME] without sedation. No c/o pain at this time. The next progress note which addressed either of these medications was dated 01/04/19, showing, New order received, D/C (discontinue) (Duloxetine) at 30 mg, start (Duloxetine) at 20 mg. There was no clinical rationale in the record to support why this change was made. Progress notes reflected the resident experienced a fall on 01/05/19. A nurse's note on 01/06/19 indicated, Resident noted on floor around (3:00 PM) .she thought she is at home, tried to get up from bed, so fell , was also confused . A 01/07/19 physician's note written by Staff L, showed, .(Resident #20) presenting for a monthly follow up visit and evaluation for a change in mental status .Staff report confusion and disorientation, accompanied by non-injury slips/falls from WC (wheelchair). Today, resident dressed only in adult diaper, with blankets pulled to the side, c/o feeling hot, appears drowsy, oriented to person, month and year but not oriented to place, some auditory hallucinations, as she claims to hear her son calling her name out. Limbs appear more rigid. Of note, resident is taking [MEDICATION NAME] 50 mg TID (three times a day) (physician was incorrect-according to the MAR, resident received this medication QID), whilst at the same time on Duloxetine 30 mg qd (each day), despite my having stopped this drug combination by recommending [MEDICATION NAME] in place of Duloxetine, to avoid potential for Serotoni[DIAGNOSES REDACTED]. Bedside blood sugar (BS), 98/mg/dL (milligrams per deciliter) (not eaten all morning), resident BS normally averages above 200 mg/dL. Resident given high energy drink, more alert within minutes, demanding food. Repeat BS 138 mg/dL. Resident can now recognize me as her physician . The 01/07/19 physician note documented a plan of, Resident who had been on Duloxetine 30 mg for depression, started on [MEDICATION NAME] 50 mg TID (physician was incorrect-according to the MAR, resident received this medication QID), for the past week and a half, now exhibiting, confusion, disorientation, increased muscle tone, heat intolerance and slipping out of WC. Is diabetic, was not able to eat leading to low BS. Rebounded somewhat after administration of high calorie drink but not back to baseline, suggested impending and/or evolving Serotoni[DIAGNOSES REDACTED] as the initial case of CMS (Change in Mental Status). Plan: d/c Duloxetine. Start [MEDICATION NAME] 15 mg (each day) for depression. Monitor vitals. Monitor mental status. Alert OPTUM provider (facility contracted medical provider) notified for any change in mental status, muscle rigidity, [MEDICAL CONDITION], markedly elevated body temperature. Progress notes on 01/07/19 showed, Res alert with confusion, res BS (blood Sugar) 308, 176 and at 2 pm 93, res did not eat anything, deep in sleep, did not take noon medication, OPTUM notified and he saw resident, new order to d/c (Duloxetine) and start [MEDICATION NAME] (an antidepressant). The resident continued to experience changes per a subsequent 01/07/19 progress note of, BS before dinner 80, orange juice 120 ml (milliliters) given .received call from OPTUM notified about BS and held insulin, resident did not take evening meds . Another 01/07/19 6:59 PM progress note indicated, Consent form for [MEDICATION NAME] filled but resident not able to sign this time in deep sleep. On 01/08/19 at 5:22 AM staff documented, Resident in bed eyes closed, she has been very drowsy and sleepy. Some narcotics has (sic) been held. Vital signs and blood sugar monitored as she has not been able to eat well . On 01/09/19, staff documented the resident remained, confused. In an interview on 04/25/19 at 12:44 PM, Staff O, Medical Director, indicated a clinical rationale should be documented when changing medications, and in the event of implementing contraindicated medications, a risk benefit analysis should be considered. Staff O indicated that one might have considered discontinuation of the [MEDICATION NAME]. Facility staff failed to implement resident-directed care and treatment consistent with the resident's preferences and professional standards of practice, causing a negative outcome of experiencing identified severe medication interactions. In an interview on 04/26/19 at 8:53 AM, when asked for contact information for Staff L, Staff B indicated Staff L was not returning to the facility. In an interview on 04/26/19 at 11:54 AM, when asked about Staff L's performance, Staff Z, an OPTUM representative, indicated Staff L was asked not to return .he's not coming back. NON PRESSURE SKIN ISSUES RESIDENT #57 Record review revealed Resident #57 admitted to the facility on [DATE] and according to the 03/22/19 Admission MDS, had moderate cognitive impairment and required diuretic medications on six of seven days of the assessment period. Observations on 04/19/19 at 9:39 AM revealed, Resident #57 had [MEDICAL CONDITION] to the right hand, which was noticeably larger than the left hand, and according to the resident, limited the ability to range the fingers on the right hand. The resident reported at this time he had lower extremity [MEDICAL CONDITION]. Observations on 04/24/19 at 8:45 AM revealed Staff H performed an [MEDICAL CONDITION] assessment for Resident #57. There were noted indentations in the skin of the left lower leg upon removal of the sock, that did not resolve within four minutes. Similar observations were noted for the right leg. According to Staff H the resident had, [MEDICAL CONDITION] from toes to knees, that took longer than 20 seconds to rebound. Staff indicated the resident had 2+ [MEDICAL CONDITION], the left LE worse than the right. Record review revealed no indication facility staff monitored the resident's [MEDICAL CONDITION]. In an interview on 04/24/19 at 8:49 AM, Staff H confirmed staff should, but did not, assess or monitor the resident's [MEDICAL CONDITION] of the lower extremities or the right arm. RESIDENT #69 Resident #69 admitted to the facility on [DATE], and according to the 04/01/19 Admission MDS, had the ability to understand and be understood in conversation, and was at risk for the development of PU, had skin tear/s, and required the application of ointments/medications other than to feet. Observations on 04/19/19 at 8:20 AM revealed Resident #69 had multiple open, bleeding scabs on the face and arms. Similar observations of open bleeding [MEDICAL CONDITION] were noted on 04/22/19, 04/23/19, 04/24/19 and 04/25/19. According to the weekly skin assessment dated [DATE], the resident was identified with skin that was dry and warm, with scattered scabs over face and arms. The form queried if any of these skin issues were new to which staff responded, no. According to the weekly skin assessment dated [DATE] the resident had dry and warm skin, with no skin issues identified. The weekly skin assessment dated [DATE] identified no open bleeding [MEDICAL CONDITION] but described the skin as, dry and warm. In an interview on 04/25/19 at 1:14 PM, Staff H, Resident Care Manager, confirmed the resident had open bleeding [MEDICAL CONDITION], and when asked if the weekly skin assessments should reflect the resident's skin issues, replied, yes. RESIDENT #62 Resident #62 admitted to the facility on [DATE] with care needs related to heart, liver and kidney disease, diabetes and respiratory disease. According to the Admission MDS dated [DATE], the resident was assessed as cognitively intact, able to understand and be understood in conversation, and did not require the use of diuretic mediation. Observations on 04/18/19 at 1:30 PM, showed a linear area on the left forearm, which was scabbed and other small scattered scabs along the left wrist (three total). There was bruising noted to the right hand and upper arm and anticubital area, and scabs noted on the left foot, second and third toes. The resident's lower extremities were [MEDICAL CONDITION], with multiple small fluid filled blisters on the anterior left lower leg. In an interview at this time, the resident stated that he had lots of [MEDICAL CONDITION] in both legs. Record review showed the resident had a brief emergency room visit on 04/11/19 and was identified with leg swelling both legs ([MEDICAL CONDITION]) and marked scrotal [MEDICAL CONDITION]. Physician notes dated 04/18/19 indicated the resident had, 3+ LE (lower extremity) [MEDICAL CONDITION] to the feet, including testicles and upper thighs. Record review revealed no indication facility staff were assessing or monitoring the resident's [MEDICAL CONDITION]. According to progress notes dated 04/21/19, Resident noted with 1.5 x 1 cm skin tear to Lt(left) forearm. noted a dry scab to edge of skin tear. Resident reported he was itch (sic) where old scab is, so he scratched on it and developed a skin tear . Observation on 04/22/19 at 1:20 PM, with Staff H, showed the resident had an island border gauze dressing to the left arm. The resident indicated he admitted to the facility with the left arm injury stating, It's the same skin tear, I just lost the scab .it was dripping blood. Staff H confirmed at this time the resident had 3+ [MEDICAL CONDITION] up to the thigh, and upon observing the left lower leg stated, it looks like it's going to start weeping, and confirmed the presence of fluid filled blisters. In an interview on 04/22/19 at 1:51 PM, Staff H, Resident Care Manager, indicated staff should have, but did not assess/monitor the resident's non pressure skin issues, including the left forearm, or [MEDICAL CONDITION]; and once identified did not provide interventions or notification of the physician for the [MEDICAL CONDITION]. Record review revealed no objective monitoring of the resident's [MEDICAL CONDITION] (blisters, scabs) or [MEDICAL CONDITION]. In an interview on 04/22/19 at 1:51 PM, Staff H indicated staff should, but did not, monitor the resident's [MEDICAL CONDITION] and non pressure skin issues. Staff H stated, We should have a weekly skin observation form (for the left arm wound) done, but we sure didn't. Computerized CNA skin observation documents from 04/13/19 through 04/22/19 revealed that on one shift (04/20/19), staff identified, red area, one staff member, on 04/19/19, identified discoloration and on 04/18/19, one staff identified a skin tear. These skin issues were noted once, and not again by staff on subsequent shifts. In an interview on 04/22/19 at 1:01 PM, Staff H was asked about the CNA skin monitoring section and what it meant. Staff H explained it was the expectation that the aides answer those questions on the form stating, Yes, it's on their task list, if they identify something they should notify their nurse. Staff H indicated each aide on each shift should document any skin issue identified and report it. Upon determining the CNA skin documents did not match observations or nursing documentation, Staff H stated, It's not an effective system . RESIDENT #72 Resident #72 admitted to the facility on [DATE]. According to the 03/22/19 MDS, the resident had one venous ulcer, and required treatment with non-surgical dressing and ointments/medications. Review of the (MONTH) 2019 Treatment Administration Record (TAR) showed, a 03/15/19 order to cleanse wound to left lower extremity with normal saline, pat dry, cover with bordered foam dressing, and change every Monday, Wednesday, Friday, and as needed. Record review showed, a 03/20/19 Weekly Skin Log (WSL) assessment that indicated the resident had a vascular ulcer to her left anterior lower leg-reopened. According to this assessment, the wound was 3 cm (centimeters) by 1.1 cm by 0.1 cm, the wound base was 100% granulated (Granulation tissue is new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process), and the wound had no drainage. Another WSL was not completed until 04/10/19 (21 days later). According to the 04/10/19 WSL, the vascular ulcer to the left anterior lower leg, now measured 2 cm by 0.5 cm by 0.1 cm, the wound bed was 100% granulated with no drainage. Further record review showed Resident #72 was also being followed by a consulting wound care agency. According to the record, the resident was seen by the consultant on 03/12/19, but not again until 04/10/19. During an interview on 04/29/19 at 9:15 AM, Staff I explained the facility measured and assessed wounds weekly to include, type of wound, location, tissue type, drainage, increasing or decreasing in size, and whether the wound was responding to the current treatment. When asked if there was any indication this occurred for Resident #72, Staff I acknowledged there was no assessment or measurements of Resident #72's left lower extremity wound, for the 21 day period between 03/20/19 and 04/10/19. When asked if failure to assess/measure the wound could detract from staffs' ability to determine if the wound was improving, declining, or responding to the current treatment Staff I stated, Yes . Additionally, a 03/23/19 grievance form was completed by Resident #72's sister on her behalf. The grievance stated, (Resident #72) has a severe rash to her diaper area and this is the 3rd Saturday the aides were saying 'you need some antifungal cream.' Since it has been worse by the week it's apparent there was no fungal (sic) cream applied .Staff P, Licensed Practical Nurse, brought in a tube (of anti-fungal cream) and applied it . The outcome of this grievance stated, (Resident #72) has a small amount of redness {to her groin), Staff P noted it and got an order for [REDACTED].>Review of the (MONTH) 2019 physician's orders [REDACTED]. Nor, was there any direction to staff to assess and monitor the area. During an interview on 04/26/19 at 9:45 AM, Staff I acknowledged staff failed to obtain the treatment order for an anti-fungal, as the resident was assessed to require. When asked if staff were monitoring the rash Staff L stated, It appears we were not. When asked if staff should have been Staff I stated, Absolutely. BOWELS RESIDENT #49 According to Physician Orders, staff were directed to administer, Milk of Magnesia (MOM) every 24 hours as needed for constipation, [MEDICATION NAME] tablet delayed release .give by mouth every 24 hours as needed for constipation, [MEDICATION NAME] suppository .every 24 hours as needed for constipation not relieved by MOM, Fleet enema insert one .every 24 hours as needed for bowel care if [MEDICATION NAME] suppository is ineffective. Review of bowel records revealed Resident #49 went without any bowel movement (BM) from 02/23/19 though 03/01/19. Record review revealed nursing staff failed to administer any of the prescribed bowel medications. In an Reference WAC 388-97-1060 (1) on 04/24/10 at 11:22 PM, Staff K, Resident Care Manager, confirmed nursing staff should have, but did not administer bowel medications, or provide a bowel assessment based on the absence of BMs. REFERENCE: WAC 388-97-1060 (1).

Based on interview and record review, the facility failed to ensure 1 of 4 sampled residents (#1) was free from physical and verbal abuse when two caregivers used aggressive force, derogatory and inappropriate language, while providing care. This failure resulted in psychological harm to the resident,and diminished quality of life. Findings include: RESIDENT #1 Resident #1 was initially admitted to the facility 01/10/14 with multiple health conditions which included muscle weakness and [MEDICAL CONDITION] with behavioral disturbance. Resident #1's quarterly Minimum Data Set (MDS), a comprehensive assessment tool dated 02/01/18, indicated the resident had impaired cognition and required extensive physical assistance of two persons for activities of daily living including transfers and personal hygiene. Review of Resident #1's Care Plan (CP) revealed, Resident #1 was resistive to care. This CP instructed staff to use alternative caregivers and report to the nurse and/or notify family if the resident was resistive to care. Review of an Incident Report dated 03/01/18, revealed, on the night of 01/03/18 approximately 8:30 p.m., two student CNAs (student CNAs assigned to shadow facility licensed staff as part of the school curriculum), observed two Certified Nurse's Aides (CNA) Staff H and Staff I provide care to Resident #1. According to witness statements written by the two student CNAs dated 03/01/18, they observed Staff H grabbing Resident #1's wrist and vigorously pulling her in the bed like a bag of potatoes. Staff H held Resident#1's hands so hard that the resident called out in pain and stated Ow, that hurts. Staff H responded and said No it did not. Further review of the student CNA witness statements documented Staff H shoved Resident #1 on her back. Staff H, then grabbed Resident #1's right upper thigh hitting the armrest of the chair, as Resident #1 screamed in pain and said Owww. Staff H, again responded to Resident #1 and said That didn't hurt. Then both Staff H and Staff I aggressively shoved Resident #1's legs apart while the resident screamed in pain. Staff H and Staff I then proceeded to provide care to Resident #1 even when Resident #1 clearly indicated not wanting to be changed. Review of the facility investigation findings dated 03/04/18 documented that the facility had substantiated reported allegations of abuse. The facility terminated employment for Staff H (alleged perpetrator), as an intervention to prevent further abuse, however, the facility did not terminate the employment of Staff I (the other alleged perpetrator) who assisted Staff H with providing care to Resident #1. On 04/05/18 approximately 4:00 p.m., when Staff I was asked how she protected Resident #1 and other residents from physical and verbal abuse, she stated I was just following instructions by Staff H. Staff I continued and said, We did not have a choice, but to do what we had to do to clean the resident, as she always fights during care. On, 04/05/18 approximately 4:10 p.m., when Staff I was asked if he had identified his actions and that of Staff H while providing care to Resident #1 contituted to abuse. Staff I did not respond. When Staff I was asked if had received education regardng abuse and neglect. Staff I acknowledged she had received abuse/neglect education when she was first hired by the facility. On 04/06/18 at 10:00 a.m., when Staff B was asked how the facility had addressed allegations of abuse by Staff I to Resident #1, Staff B said that she did not identify Staff I as an alleged perpetrator and stated, Staff I was just following instructions by Staff H. The failure for Staff I to identify inapropriate actions while providing care to Resident #1 caused psychological harm to Resident #1 and placed residents at risk for continued abuse and diminisshed quality of life. WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to ensure an environment that was free from accidents for one (#1) of four sample residents reviewed for accidents. The facility failed to implement preventative interventions to prevent further falls for Resident #1. This failure caused lacerations to the upper lip and forehead of Resident #1 requiring sutures to the forehead. Findings include: RESIDENT # 1 According to the admission Minimum Data Set (MDS) assessment, dated 07/06/17, Resident #1 admitted to the facility on [DATE] with medically disabling conditions that including altered mental status, [MEDICAL CONDITION] with visual disturbance (legally blind), Alzheimer's and dementia. This MDS identified the resident had impaired cognition and required one person physical assistance for all Activities of Daily Living (ADLs), including mobility and transfers. Review of Resident #1's Incident Investigation Report dated 11/25/17 revealed Resident had fallen in his room and was found on the floor behind his bed. The resident was found to be incontinent at the time of incident. Review of the undated care plan printed on 01/03/18, revealed the resident was identified as a fall risk, and instructed staff to offer Resident #1 toileting every two hours. Review of the Incident Investigation Report conclusion dated 11/25/17 documented, Resident continue to be found incontinent, Will place resident on a toileting program and offer toileting every two hours. Review of Resident #1's medical record could not find documented evidence Staff had been offering Resident #1 toileting as care planned in order to prevent the resident from falling. In an interview on 01/23/18, at 11:00 a.m., when Staff D, the Resident Care Manager (RCM) was asked to provided evidence Resident #1 was offered toileting every two hours as care planned, Staff D could not provide evidence. Review of the nurse's progress notes dated 11/29/17 (four days after earlier fall) revealed Resident #1 had another fall. Resident #1 was found in his room standing close to his bed. The resident was bleeding from his head. According to nurse's progress notes, blood was noted on the floor at the entrance to Resident #1's room. Resident #1 was send out to the hospital for further evaluation. Resident #1 sustained a laceration to the forehead requiring sutures. Review of the facility's Incident Log (IL) for (MONTH) (YEAR), found the facility had logged Resident #1's fall incident on 11/29/17, but the facility could not provide evidence of investigation of incident. On 1/24/17 at 11:30 a.m., when Staff D was asked if the fall incident dated 11/29/17 was investigated in order to prevent further accidents for Resident #1, Staff D, said she was not aware of the incident. On 01/24/18 at 3:00 p.m., when the Regional Corporate Nurse consultant Staff G, was asked to provide an IIR for Resident #1's fall on 11/29/17, Staff G, said she could not find it. Review of nurse's progress notes dated 12/14/17 revealed Resident #1 was assessed to require 1:1 care at all times to prevent Resident #1 falling and wondering into other resident's rooms. Review of the IIR dated 12/19/17, revealed Resident #1 had a unwitnessed fall in the conference room ( not his room). Resident #1 was found on the floor with his face down bleeding from his upper lip. The resident sustained [REDACTED]. Review of the nurse's progress notes dated 12/19/17 ( day of the all incident) documented, Resident #1 did not have 1:1 care at the time of the fall incident, inconsistent with Resident #1's care plan which instructed to provide 1:1 care for the resident. Resident #1 was transferred to the hospital for treatment. On 01/24/18 at 3:00 p.m, review of Resident #1's care plan revealed Resident #1's care plan had not been revised since admission to reflect identified hazards and interventions with each fall incident to instruct staff how to care for Resident #1 to prevent further falls. In an informal exit meeting on 01/24/18 at 4:00p.m., Staff C, the facility's interim Director of Nursing Services (IDNS) and Staff A, the facility's administrator acknowledged, licensed staff should have revised the care plan to reflect identified hazards and preventative interventions to allow staff know how to prevent accidents for Resident#1. The failure to implement accident preventative measure to prevent Resident #1 from falling caused injuries to upper lip and forehead of Resident #1 requiring sutures. Additionally, the facility's failure to investigate and identify accident hazards and implement interventions to prevent further falls, placed resident #1 and all residents at risk for recurrent falls resulting in serious harm. Reference: WAC 388 97-1060(3) (g)

Based on observation, interview and record review, the facility failed to conduct initial and periodic comprehensive assessments related to elopement risk, for 5 of 6 residents (#1, 2,3,4 & 6) reviewed for risk of elopement. This failure resulted in unmet needs pertaining to elopement prevention and constituted an immediate jeopardy situation, when a cognitively impaired resident with a known elopement history left the building unattended. Findings include: ELOPEMENT/ EXIT/SEEKING EVALUATION POLICY: Review of the facility's elopement /Exit seeking evaluation policy read: Directions: Complete this form for each resident on admission as indicated from the Nurse's Evaluation, quarterly if identified as an risk and if there is a change or for residents identified with wandering/Exit seeking behaviors not previously exhibited. RESIDENT #1 Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED].#1's BIMS score was 5 out of 15. The 03/23/17 Annual Minimum Data set (MDS) indicated Resident #1's BIMS score was 9 out of 15 on the Brief Interview for Mental Status (BIMS), indicating the level of cognitive impairment was moderate, unable to make his own decisions. In addition, the resident was assessed as independent of transfers and mobility. Review of the Elopement/Exit Seeking Evaluation form revealed, Resident #1 was assessed for elopement risk beginning May 2014 and was reassessed quarterly in 2014. The 2014 elopement risk assessments indicated the resident had a history of [REDACTED]. According to the 05/05/15 elopement risk assessment, Resident #1 was identified as having a history of wandering and exit seeking or elopement, was at risk of getting into an unsafe situation, and was cognitively impaired. Review of the 2/8/2016 elopement risk assessment, revealed an inaccurate assessement that was inconsistent with the resident's actual behaviors. This assessment indicated Resident #1 did not have a history of wandering or exhit seeking which, was inconsistent with the Admission Elopment assessment dated [DATE], that identified Resident #1 had a history of [REDACTED]. Although the elopement policy directed staff to assess the resident quarterly, the resident was not assessed quarterly. In addition, the resident was inaccurately assessed as not at risk of elopement. Record review could not find documentation Resident #1 had been re-assessed since 02/08/16 for elopement risk until 07/31/17 after he eloped. Observation on 08/09/17 at 4:35 p.m., noted Resident #1 wandering on the unit aimlessly without supervision of staff. In an attempt to interview Resident #1, the resident was not clearly understood and was not able to be interviewed. In an interview on 08/10/17 when Staff B, was asked if Resident #1 had a wander guard on when he eloped, Staff B, stated No and further said that the wander guard was discontinued 05/28/14, as the resident did not exhibit any wandering or seeking behaviors per facility policy. Staff B explained that according to the facility policy, wander guards were discontinued after 6 months if the resident did not exhibit exit seeking behaviors. Review of medical record, revealed the wander guard was discontinued six months later after admission on 05/22/14. In interview on 08/10/17 at 6:30 p.m., Staff B, the Director of Nursing said Resident #1 was cognitively intact and had the right to go wherever he wanted to go. Staff B said the resident was independent of mobility and if the resident wanted to go outside, he should be allowed. Review of the elopement risk assessment signed by Staff B on 2/8/16 indicated, Staff B assessed the resident as not having a history of wandering and exit seeking, not unsafe, and not having cognitive impairment. Staff B's statement in interview was consistent with her assessment of Resident #1's elopement risks, however, it did not reflect the resident's actual behavior status. When Staff B, was asked if Resident #1 could have signed himself out, she said he was not able to sign himself out or back in, according to the policy for allowing residents to leave the facility. Staff B stated that the resident could not have signed himself out, as he had an impaired cognition. The failure to accurately assess Resident #1 prevented staff to determine if the resident required frequent monitoring and or wanderguard to alert staff if the resident was exit seeking or was trying to leave unaccompanied. RESIDENT #2 Resident #2 was admitted to the facility 01/21/17. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was admitted with multiple [DIAGNOSES REDACTED]. On 08/14/17 at 3:40 p.m., in an interview Staff F,stated that on 07/28/17 approximately 4:00 p.m., Resident #2 had wheeled herself from the 2nd floor to the 1st floor, and was noted heading to the exit door. When Resident #2 was asked by Staff F (LPN), were she was going, the resident said she did not know. Staff F wheeled Resident # 2 back to her unit on the second floor where she resided. RESIDENT #3 Resident #3 was admitted to the facility 04/04/17 with [DIAGNOSES REDACTED]. Admission MDS assessment dated [DATE], identified the resident had an impaired cognition and required one person physical assistance with activities of daily living and cuing when wandering on the unit to prevent her from going into unsafe areas. On 08/10/17 in an interview, when Staff L (CNA), and M (CNA), were asked, they stated Resident #3 had always wandered on the unit since she was admitted . Although Resident #3 was identified with an impaired cognition and a history of wandering, review of the Elopement/ Exit Seeking Evaluation flow sheet could not find documentation the resident was assessed for risk of elopement on or after admission. After the resident attempted to elope on 07/31/17, the resident was assessed, contrary to facility protocol which, instructed staff to assess all residents for risk elopement on admission. On 08/10/17 at 6:30 p.m., when Staff D, the Resident Care Manager (RCM) was asked if Resident #3 was assessed for elopement risk, Staff D did not provide evidence the resident was assessed on admission, and stated it was not done. RESIDENT #5 Resident #5 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Significant Change MDS dated [DATE] identified the resident had a severely impaired cognition and required staff assistance with most activities of daily living. Observation on 08/09/17 between 5:00 p.m. and 6:00 p.m., found Resident #5 wandering on the unit and being cued by staff to sit in her wheel chair. Observation on 08/10/17, at 5:30 p.m., revealed the resident was trying to get on to the elevator and was redirected by staff. When a staff member asked Resident #5 what she wanted, Resident #5 stated, I want to go home Although Resident #5 had a history of [REDACTED]. The failure to accurately assess Resident #1,2,3, and #5, prevented staff to determine if the residents required other interventions such as, frequent monitoring or wanderguards to alert staff when the residents were exit seeking or were trying to leave unaccompanied. Additionally, this failure placed the residents at risk for eloping and wandering in unsafe areas which could potentially cause injury or death. WAC 388-97-1000(1)(b)

Based on observation, interview and record review, the facility failed to ensure 5 (#1,2,3,4,5) of 6 residents received adequate supervision and failed to include interventions in the comprehensive care plan to address potential elopement, resulting in an immediate jeopardy situation when a cognitively impaired resident with a known elopement history left the building unsupervised, and for 2 hours the staff were unaware the resident was missing. The local law enforcement responded to neighbor reports and escorted the resident back to the facility. RESIDENT#1 Resident #1 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the 03/23/17 Annual Minimum Data set (MDS), the resident had an impaired cognition, scoring 9 out of 15 on the Brief Interview for Mental Status (BIMS) indicating a decline in cognition. The resident was independent of transfers and mobility. Record review, revealed Resident #1 was assessed and identified as an elopement risk on admission in 2014. A wander guard was placed to the resident's lower extremety to alert staff if the resident was exit seeking or was trying to leave the facility unaccompanied. Review of the medical record, revealed, the wander guard was discontinued on 05/22/14 - 6 months later as the resident did not exhibit any signs of eloping from the facility (per facility policy). Review of the Elopement/Exit Seeking Evaluation dated 05/05/15 revealed Resident #1 had a history of [REDACTED].#1 required to prevent elopement. The inconsistency and inaccuracy of the assessments, prevented the facility from imple implementing the required amount of supervision for the resident, which resulted in the resident eloping from the facility. RESIDENT #4 Observation on 08/09/17, between 10:00 a.m., and 11:00 a.m., found Resident #4 wandering on the unit, was standing by the elevator multiple times, stating I want to go home. On 08/15/17 at 10:00 in an interview, Staff K, (designated 1:1 companion) stated Resident #4, always stated that she wanted to go home since she was admitted . When staff K, was asked if the resident could walk independently, she stated that, the resident could walk independently, always had supervision. Review of Resident #4's medical record, could not find documented evidence the facility had adquately addressed interventions Resident #1 required to meet resident's needs, to prevent elopement. The failure to assess and implement a care plan with interventions to prevent elopement, prevented staff from implementing adquate amount of supervision the resident required to prevent elopement. RESIDENT #2, #3, & #5. Resident #2, #3, and #5, were identified as wandering and exit/seeking. Although the residents exhibited wandering and exit seeking behaviors, record review revealed the facility initiated elopement care plans, for the resident which were identical to each other, and did not address specific individual resident needs related to elopement. The Care Plans did not address resident's specific individual resident's needs to prevent elopement. WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to implement abuse neglect policies for 3 (#1, #2,& #3) of 6 Residents related to thorough investigations of elopement incidents, analyzing occurrences to determine what changes are needed to prevent further occurrences, and on-going training of staff pertaining to elopement awareness, and preventions. This created the likelihood of recurring elopements with cognitively impaired residents without adequate preventions and constituted an immediate jeopardy situation. Findings include: RESIDENT #1 Resident #1 admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the 03/23/17 Annual Minimum Data set (MDS) assessment, the resident had an impaired cognition, scoring 9 out of 15 on the Brief Interview for Mental Status (BIMS), indicating a decline in cognition. The resident was independent with transfers and mobility. According to the Incident Investigation Report (IIR) dated 07/31/17, Staff said the last time Resident #1 was last seen in the facility was 7:30 p.m. At approximately 9:15 p.m., the local law enforcement (LLE) notified the facility staff, that Resident #1 had been found 1.6 miles away from the facility. The LLE escorted Resident #1 back to the facility at 9:30 p.m., two hours after the resident got up the dining room and walked out of the facility. Review of the Police Report (PR) dated 07/31/17 revealed, the resident was located 1.6 miles away from the facility. Further review of the PR documented Resident #1 did not answer when he was sked by the LLE who he was. This PR documented the resident was possibly confused and walked from the door step then to the street. Review of the IIR dated 07/31/17, could not find documentation to show the facility conducted a thorough investigation that included the police report, how long the resident had been been out of the facility, and how far the resident was when found by the LLE. The facility did not determine the circumstances of the elopement event and did not determine how to prevent further recurrences for residents with similar supervision needs and risks. On 08/10/17 at 5:30 p.m., in an interview, Staff B was asked if the facility had provided training related to elopement awareness and prevention for facility staff since Resident #1 eloped from the facility, she said she did not. The facility did not investigate whether neglect occurred or how to prevent neglect. RESIDENT #2 Resident #2 was admitted to the facility 01/21/17. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed, the resident was admitted with multiple [DIAGNOSES REDACTED]. Review of the Incident Investigation Report dated 07/28/17, revealed, Resident #2 had left the unit, and was found by Staff I, behind the facility wheeling herself up a steep hill in her wheelchair at approximately 4:45 p.m. Review of the witness statement dated 07/30/17, written by Staff H, a Certified Nurse's Aide (CNA) revealed, earlier in the shift on Friday 07/27/17 Resident # 2 was roaming in the hallway saying she needed to leave. This witness statement also revealed that, on the same day, Resident # 2 attempted to leave through the emergency exit (no alarm) but was stopped by Staff H. Review of the IIR did not include an investigation summary detailing and analyzing factors surrounding the incident. Additionally, this investigation did not include interventions to prevent further occurrences, although, Staff F (Licensed Practical Nurse (LPN), and Staff H (CNA), provided witness statements, indicating Resident #2 attempted to leave multiple times on 07/27/17. This investigation did not indicate the facility had followed up with staff who witnessed the resident attempting to leave. The facility did not find out more details related to the resident's elopement, in order to implement preventative measures. RESIDENT #3 Resident #3 was identified with a history of wandering and exit seeking, according to the elopemen risk assessment dated [DATE]. Review of the IIR revealed the resident left the unit and eloped through the main dining room exit to the balcony of the facility located on the second floor. Staff noted her outside on the balcony, after the alarm went off. On 08/10/14 at 5:00 p.m., when Staff A, the facility's administrator was handed a copy of each resident's completed investigation to review, he acknowledged the IIRs was not thorough and did not analyze the incidents, to determine what changes were needed to prevent recurrences. WAC 388-97-0640(2)(a)(b)

Based on interview and record review, the facility failed to ensure one of four sample residents (#5) was free of significant medication errors. Failure to administer the correct medications as ordered by a physician resulted in Resident #5 experiencing an acute change in condition which resulted in harm when Resident #5 went into [MEDICAL CONDITION] and required intensive care hospitalization with intubation. Findings include: POLICY Review of the facility's Medication Administration quick reference guide, last updated July 2014, revealed: During medication pass, the nurse completes the following .: The Nurse follows the 5 Rights of Medication Administration: (a) Right person i. Validated via photo, wristband, and/or asking resident name with Date of Birth. ii. Only prepare for one resident at the time (b) Right medication i. Validation via the Medication Administration Record [REDACTED] ii The nurse triple checks the medication ordered during the medication administration process: iii. Check the medication card/ bottle / tube and compare to MAR/TAR upon removal from the drawer, immediately before pouring/ removal, after pouring/ removal . Resident #5 initially admitted to the facility in 03/11 with disabling conditions which included [MEDICAL CONDITION] and diabetes. The Minimum Data Set (MDS) assessment dated [DATE] identified Resident #5 had severely impaired cognition and depended on staff for activities of daily living which included medication administration. Review of a facility Incident Report, dated 09/05/16, revealed Licensed Nurse (LN) Staff C, administered medications to Resident #5 that were ordered and intended for Resident #7. The incorrectly administered medications were [MEDICATION NAME] (an opioid / narcotic), [MEDICATION NAME] (an anti-anxiety), [MEDICATION NAME] ([MEDICAL CONDITION] treatment) and [MEDICATION NAME] (anti-nausea). The LN identified her error and notified the physician, who gave orders for the resident to immediately be sent to the emergency room for further treatment for [REDACTED]. In an interview on 09/08/16 at approximately 2:30 p.m., Staff C stated that on the date of the incident, 09/05/16, Resident #5 approached her and requested her afternoon medications. Staff C prepared the medications for Resident #5. When she was ready to administer the medications, she noticed that Resident #5 had wheeled herself back to her room. Staff C placed the unlabeled medication cup containing Resident #5's medications in the top drawer of the medication cart. Staff C then prepared medications for Resident #7. When Staff C was ready to administer medications to Resident #7, she observed the resident had wheeled herself to the dining room. Staff C placed the unlabeled medication cup containing Resident #7's medications in the top drawer of the medication cart. Resident #5 then returned from her room and again requested her medications. Staff C opened the top drawer of the medication cart and retrieved the medication cup that contained Resident #7's medications and gave them to Resident #5. She stated she knew immediately she had given the wrong medications to Resident #5. Review of hospital records revealed the ambulance was called to transport Resident #5 to the hospital emergency department for evaluation. Within minutes, during transport, Resident #5 experienced a change of condition. Her vital signs started to decline and she became unresponsive. Resident #5 went into [MEDICAL CONDITION] with subsequent arterial fibrillation and a flutter (malfunction of the heart veins and arteries), and required intubation to assist her breathing, due to the the ingestion of [MEDICATION NAME] and [MEDICATION NAME]. In an interview on 09/08/16 at approximately 2:45 p.m., Staff C acknowledged the medications errors. Staff C acknowledged she should have more carefully verified the medications prior to administration. In an interview on 09/08/16 at approximately 2:50 p.m., Staff B, verified that on 09/05/16 the LN mistakenly administered another resident's medications to Resident #5. Staff B acknowledged the resident remained in the hospital in Intensive Care due to complications as a result of the medication errors. In an interview on 09/08/16 at approximately 4:00 p.m., Staff D, Corporate Nurse, acknowledged the medication error was significant.

Based on interview and record review the facility failed to ensure one of two residents (Resident #1) reviewed for pressure ulcer prevention and treatments received accurate assessment, consultation or treatment to prevent an unstageable pressure ulcer. This failure prevented prompt physician based treatment and wound healing and placed Resident #1 at risk for compromised health. This failure had the potential to affect all residents at risk for pressure ulcers. Findings included: RESIDENT #1 The facility's July 2014 Skin Integrity policies included: "The resident's skin integrity is evaluated using the Braden Scale...the resident's skin is inspected daily...changes in the resident's skin are reported to the Licensed Nurse (LN)...ongoing evaluation continues weekly with the LN completing a full body skin audit...upon discovery of newly identified skin impairment (abrasion, bruise, burn, excoriation, pressure sore...the LN completes..documents the following:...measurements of size, color, presence of odor, exudates, and presence of pain...notifies the physician and obtains Treatment Order...document on the Treatment Administration Record...Notifies Responsible Party... of skin condition and treatment plan...Implements interventions and documents on the resident's care plan and Care Directive...The DNS (Director of Nursing Service) and/or designee complete a comprehensive review of the resident's medical record to evaluate if the Pressure Ulcer was avoidable or Unavoidable...documented in the Nurse's Notes...Weekly Wound Rounds are to be completed by a team...are evaluated, measured and documented on the Wound Evaluation...If a wound fails to improve after 2 weeks of treatment or the condition of the wound deteriorates...re-evaluates POC (Plan of Care and resident's condition..." According to the 11/08/2014 Minimum Data Set (MDS) Resident #1 was admitted to the facility in 2005 but had recently experienced a fall with a fracture requiring surgical repair and a change in condition. Resident #1 was readmitted to the facility on [DATE]. Staff assessed Resident #1 to be severely impaired for decision-making, rarely or never was able to express needs or wants or understand others. The MDS indicated Resident #1 required two person total assistance for bed mobility and toileting and was no longer able to transfer from one surface to another, walk or move between locations within the facility. Staff indicated on the MDS the facility assessed Resident #1's skin using a "formal assessment instrument" (Braden Scale) and at the time of the assessment had no skin issues or pressure ulcers. The Resident, reviewed as a closed record, was discharged from the facility and was not available for observation or interview. Staff documented on the 10/26/2014 readmission nursing progress note "Resident has 3 post surgical sites...Old scar and open abrasion .5 x. 5 cm (centimeters). Treatment book updated specifically with appropriate measurements of wounds." However staff did not document the location of the abrasion, whether it was pressure related, a description of the wound bed and etc. or what was done to prevent further skin issues according to the 07/2014 Skin Integrity Policy. The 10/26/2014 Nursing Admission Evaluation form indicated staff identified the "old scar" and multiple bruises but no abrasion. The facility was unable to provide data to explain this discrepancy. On 03/12/2015 at 10:00 a.m. the facility was asked for documentation to support staff monitored the abrasion and implemented treatments but none was provided. Review of the 10/26/2014 Braden Scale (Formal Assessment Instrument for assessing an individual's risk of developing pressure ulcers) revealed staff identified Resident #1's ability to respond to painful stimuli was impaired, the resident could not communicate discomfort, was unable to make frequent or significant changes in body position independently and Resident #1 was bedfast. Staff scored Resident #1's risk of acquiring pressure ulcers at a 12, placing Resident #1 at High Risk. According to a 10/30/1014 nursing progress note Resident #1 required an overnight hospital stay for "close observation". The 11/02/2014 Re-Admission Nursing Evaluation form indicated Resident #1 had bruising and surgical wounds. Staff reassessed Resident #1 using the Braden Scale resulting in an identical assessment to that of 10/26/2014, placing Resident #1 at High Risk for the development of pressure ulcers. Review of the 11/06/2014 physician's note revealed Resident #1 had, "Stage 2 sacral ulcers". A Stage 2 pressure ulcer is a partial thickness loss of dermis presenting as a shallow open ulcer with a re-pink wound bed without slough. Wound/Skin Evaluation and Documentation was requested from the facility on 03/12/2015 at 10:00 a.m. to support the physician's data was acted upon and the pressure ulcers were monitored according to the facility's 07/2014 Skin Integrity policy. The first facility Would/Skin Evaluation and Documentation Form the facility could provide was dated 11/12/14 six days after the physician's note. Staff circled the coccyx, measured the wound at "1.4 cm x 1 cm" and described the wound as "pink/beefy red". Staff did not stage the pressure ulcer. Staff documented on an 11/12/2014 nursing progress note, "Bed Sore found 1.4 cm x 1 cm.". The facility was unable to provide any explanation as to the discrepancies between the physician assessment of multiple pressure "ulcers" and the facility assessment of a single ulcer. Staff documented on a 11/13/2014 nursing progress note, "will continue to use barrier cream with each incontinent episode and monitor wound". A barrier cream is a pressure ulcer preventative measure, used between incontinent episodes to protect the skin. The barrier is used prior to the development of a pressure ulcer. An additional 11/13/2014 Wound/Skin Evaluation and Documentation Form note indicated the "( left) coccyx (pressure ulcer was) 1 x 1 x 0.2 cm, pink/beefy red and a stage (two)". An 11/16/2014 nursing progress note included, "This nurse has been putting barrier cream on bed sore located in tail bone area. educated aids on barrier cream as well.". There was no indication staff considered the stage two to required any other treatment than the barrier cream. The facility provided no data to support why nursing staff used a preventative treatment (barrier cream) for existing pressure ulcers or why non-nursing staff, (Certified Nursing Assistants), were instructed to provide pressure ulcer treatment. Staff documented the size of the wound increased to 2.2 x 1.0 x 0.2 (cm), in a 11/18/2014 nursing note. There was no staging of the wound, description of the wound bed or other specific assessment that would have suggested the wound conditions as the facility's 07/2014 Skin Integrity policy instructed. Staff documented the treatment for [REDACTED]. An 11/19/2014 Wound/Skin Evaluation and Documentation Form entry indicated the left coccyx pressure ulcer was a stage two and had an appearance of "pink/beefy red" and a size of "2.2 x 1.0 x .02 cm." Yet an 11/24/2014 Wound/Skin Evaluation and Documentation Form indicated staff measured the wound at 4 cm x 2.5 cm and no depth or other description according to facility policy but wrote, "open area on previous scar tissue. Applied barrier cream...monitor". This preventative treatment was documented as provided despite the 11/18/2014 physician's order for specific pressure ulcer treatment. An 11/26/2014 entry on the Wound/Skin Evaluation and Documentation Form indicated the stage two left coccyx pressure ulcer size as "1 x 0.8 x 0.2 cm" and described the skin as "Normal for skin". The facility was unable to provide data to support why staff considered the wound normal despite the presence of a stage two pressure ulcer (s). Staff documented they monitored the pressure ulcer(s) again on 12/1/2014 but did not describe the wound at all. There was no staging, no description of the wound bed, assessment of tunneling or undermining and etc. according to facility policy Staff only documented the skin was, "Impaired". There were no additional physician orders and no physician notes suggesting physician assessment provided by the facility. An additional entry dated 12/1/2014 on the Wound/Skin Evaluation and Documentation Form included a hand written note, "Open areas on bottoms. Applied Barrier Cream." There was no mention of the number of "areas" or description of the "areas" and only one measurement was hand written on the diagram of the human body and, "1 x 4". There were no additional physician orders and no physician notes to indicate any communication between the health care provider and facility staff. On 12/2/2014 staff documented on the Wound/Skin Evaluation and Documentation Form the stage two pressure ulcer had enlarged and was 4.0 x 3.0 x 0.2 cm with a wound bed that was, "Normal for skin". An additional 12/2/2014 entry on the Wound/Skin Evaluation and Documentation Form indicated Resident #1 had a previously unidentified unstageable pressure ulcer measuring 2 x 1.5 cm with an undetermined depth on the right coccyx. An unstageable pressure ulcer is when the skin is so compromised staff are not able to assesses's the severity of the wound. A 12/2/2014 nursing progress note indicated staff would "use foam (dressing) to cover it (the pressure ulcer)". Again there was no documentation provided by the facility to suggest the physician was aware, had assessed or agreed to additional or more progressive treatments for a wound that was not stageable. According to Treatment Administration Records (TAR) the pressure ulcer treatment was altered at least nine different times from 12/2/2014 through 02/11/2015 without any indication of physician involvement. This included an order for [REDACTED]. With the exception of the original 11/18/2014 physician's orders for pressure ulcer treatment and a physician's order for an alternating pressure mattress on 12/10/2014 with the wound care treatment for [REDACTED]. When asked, on 03/12/2015 at 10:00 a.m., about facility policy and process related to assessment and treatment of [REDACTED]." Staff B was asked what education these staff possessed that allowed them to treat a resident without physician involvement. Staff B responded, "Well, I'm wound certified." In a subsequent interview on 3/18/2015 at 11:15 a.m. Staff B indicated they did not have prescriptive authority for treatments or medications even with the wound certification. On 02/11/2015 Resident #1 was discharged to a local hospital for a change in condition that required surgical intervention of the unstageable pressure ulcer before other treatments could be rendered. RESIDENT #2 According to the 03/09/2015 MDS, Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Staff assessed Resident #2's skin, using the Braden Scale on 03/05/2015 (three days after admission) and 03/12/2015, as at Moderate Risk for the development of pressure ulcers. Resident #2 was discharged to a local hospital and not available for interview. Resident #2 was reviewed as closed record. Staff documented on a 03/02/2015 admission nursing note, "...skin assessment is done. redness on the coccyx 8x5cm. small open spot on left side of neck 0.5x0.5 properly procedure purpose. dark scap (scab) under his left leg 6x4cm. multiple purple bruise on bilateral arm and hand. hard clot under his left leg 8x9cm.[MEDICAL TREATMENT] shun(t) on his left arm..." A 03/12/2015 nursing note included, "...Multiple skin impairment from scratching legs and arms to excoriate on his bottom...barrier cream at each incontinent episode..." Staff documented on 03/16/2015, "...still with skin excoriation on his bilateral lower and upper extremities, on his buttocks due to excessive scratching by resident..." Review of 03/04/2015, 03/07/2015, 03/09/2015, 03/10/2015 and 03/17/2015 physician notes revealed Resident #2 had, '"...echymoses (bruises).", + multiple excoriations on (scratches) all 4 extremities...", "+BLLE (bilateral lower extremity): Scabbed [MEDICAL CONDITION]/healing excoriations to BLLE; LLE: induration+ pain on posterior aspect...stable. Nursing to monitor." Review of Resident #2's TAR's revealed staff assessed Resident #2's skin on the day of admission 03/02//1015 and on 03/09/2015 and 03/16/2015. However review of the detailed Weekly Assessment Head to Toe computer record revealed staff identified they completed the assessments on 03/10/2015 and 03/17/2015 signifying Resident #2 had skin issues with the word "plus" but no detailed information about the wound size, or substance as outlined in the facility's skin policy. The facility was asked for the documents indicating the monitoring of each wound identified by staff and the physician from 03/02/2015 to the day of discharge 03/17/2015 actually occurred but none were provided. According to Staff B, interviewed on 03/23/2015 at 11:10 a.m. said,staff performing the assessment, "are supposed to put all that on the Wound Assessment (Wound/Skin and Evaluation Form) form and I didn't see that in the computer." When asked who was to document the data Staff B replied, I'm not going to name a person it's a team (effort)."

Based on observation, interview and record review the facility failed to supervise staff to ensure that care planned interventions were implemented to mitigate injury falls for two (Resident #1 and #2) of six residents who were at risk for falls and injury. This failure resulted in harm to Resident #1's who experienced an avoidable head injury and placed other residents at risk for injury. In addition the facility failed take steps to ensure that resident's environment including the type of mattresses used on three resident (Resident #1, #3 and #4)beds were evaluated for safe use. Findings included: RESIDENT #1 Observation of the Resident #1, on 3/22/13 at 1:30 p.m., revealed the resident to be alert and able to describe a 3/11/13 fall. The resident indicated she fell head first onto the hard floor while trying to get out of bed, resulting in a head injury with laceration. The resident indicated fall mats were not in place at the time of the 3/11/13 fall and that is why she hurt her head. The resident directed the surveyor to stitches, observed on top of the head. The resident also indicated to get out of bed she had to climb over the sides of the Air Loss Mattress (ALM). The ALM is used to assist in prevention and treatment of [REDACTED].#1's case or may not. The bolsters are to assist in maintaining the resident's position centered in the bed or if a resident is at risk for rolling out of bed, but are not advantageous when trying to transfer the resident or when the resident is trying to exit the bed alone. The material used in the construction of the mattress nylon reinforced and can be slippery. According to the 10/15/12 Restraint/Device Evaluation and Consent staff assessed the resident to have a history of falls, poor impulse control and lack of safety awareness. The same form indicated the resident had a pressure ulcer for which the facility implemented a "Low Air Loss" (ALM). The benefit of the device was listed as "Potentially protects res (resident) from injury." There was no indication staff performed an assessment of the resident's ability to use the ALM safely only as it pertained to the prevention of pressure ulcers. In fact the assessments indicated the resident consistently attempted self-transfer. Similar data was obtained for Resident's #3 and #4. The 1/9/13 Fall/Restraint/Device Evaluation and Consent indicated the resident had a history of [REDACTED]. Staff added to this form "Alarm in bed" on 1/22/13 and "Bilateral Fall mats" but no date of implementation was documented. Staff added a written note to this document, "To use fall mats to help protect resident from injuries r/t (related to) falls." An alarm alerts staff to the actions of a resident. In Resident #1's case the resident made attempts to self transfer as indicated by a 2/17/13 assessment where staff documented on a Risks and Benefits form, "Self-transferring. NOT calling for help...Resident have [DIAGNOSES REDACTED]." Review of the 1/13/13 care plan for "At Risk for Falls" indicated staff were to implement a perimeter mattress, bilateral fall mats, a reminder sign and high low bed. On 1/22/13 staff added to the care plan, "Alarm to bed to alert staff to resident rising unassisted." Absence of the alarm allowed the resident to attempt self transfer without alerting staff. Review of the facility's 3/11/13 evidence of investigation revealed staff failed to implement the bilateral fall mats, perimeter mattress and the bed alarm allowing the resident to get out of bed without alerting staff and to land head first onto the hard floor. There was no discussion in the investigation as to how the ALM aided in the fall but the resident indicated she had to climb out over the sides of the bed. Staff documented the resident suffered a, "3 cm (centimeter) laceration over the mid section top of the head." The resident required emergency room treatment for [REDACTED]. Staff D was asked if therapy staff had any responsibility for assessment of residents safe use of ALM. Staff D response was, ""...not done an assessment of ALM..." At 2:15 p.m. on 3/22/13 staff E and F indicated there was no other assessment of the ALM for safe use. According to the Director of Nursing (DNS) Interviewed on 3/25/13 at 2:00 p.m. staff did not implement assessed interventions including the fall mats and the bed alarm. When asked if the facility's investigation indicated whether the ALM played a part in the fall the DNS indicated "It does not." RESIDENT #2 Resident #2 was observed in bed on 3/22/13 at 1:40 p.m. There was no sensor, bed alarm visible. The resident said the sensor alarm was in the closet. Review of the resident's clinical record revealed a 2/25/13 Fall/Restraint/Device Evaluation and Consent that indicated the resident was at risk for falls and staff were to implement a hi/low bed, bed against the wall, bed alarm and perimeter mattress. According to the "At Risk for Falls" care plan the resident had at least ten non-injury falls and one fall with injury during the past year. According to the care plan staff were to implement multiple interventions including the sensor, bed alarm. On 3/22/13 at 1:45 p.m. Staff C was asked to locate the sensor bed alarm and determine if it was functional. Staff C could not locate the sensor bed alarm on the resident's bed or in the closet. Staff D said the resident sometimes removes the alarm. The DNS, interviewed on 3/25/13 at 2:00 p.m., said the resident sometimes removes the alarm. Staffs failure to implement care planned interventions to prevent falls and injury, resulted in Resident #1 falling head first out of bed onto a hard floor. Staff were not alerted to the resident actions because the alarm was not sounding and the absence of the fall mat was implicated by the presence of the injury. Resident #2 had no senor, bed alarm,and Resident's #3 and #4 both had ALM which staff failed to consider as contributors to falls, placing all three residents at potential risk for injuries as Resident #1.

Based on observation, interview and record review the facility failed to ensure that staff followed the facility policy (manufactures instructions) for one (Resident #79) of three sampled residents who were transferred with a mechanical lift, to demonstrate the actions of a qualified caregiver. Failure to follow the instructions when using the mechanical lift resulted in the resident falling from the lift and sustaining multiple injuries. Findings Include: Resident #79 was admitted to the facility with multiple medical conditions that affected her mobility. A review of the resident ' s comprehensive assessment, done by the facility and dated 7/2/10 revealed that Resident #79 was dependent on the staff for all activities of daily living including feeding. The comprehensive assessment reported that Resident #79 had problems with short and long term memory. The resident ' s care plan dated 10/24/09 and the comprehensive assessment reported that Resident #79 was transferred from bed to chair and back with a mechanical lift. A review of Resident #79 ' s record, the Interdisciplinary Progress Notes dated 9/1/10, reported that Resident #79 " ...fell off the sling of Hoyer (mechanical lift) during transferring. " According to the investigation done by the facility Resident #79 ... " slid out and fell forward hitting her head on the mat on the floor. " The investigation also reported that "Injuries that resident (Resident #79) sustained are broken ribs, punctured lungs, chipped collar bone and hematoma (a collection of blood outside the blood vessel) of brain." The Resident Care Manager (RCM) who was in charge of the unit that Resident #79 was on was interviewed on 9/2/10 at 2:30 P.M. She reported that " ...all straps were in place but front straps were not crossed. Crossing the front straps holds the residents ' trunk in the sling, the front straps were not crossed that was the problem. " The RCM reported " I ask the caregivers how did she fall they explained she fell out of sling forward slid forward rolled and hit her head landed on the mat. " A copy of the facility policy and procedure was requested on 9/2/10 at 4:30 P.M. Administration reported that the facility used the manufactures instructions as their Policy and Procedure for transferring residents. According to page 12 of the instructions the person transferring the resident is instructed to cross the straps that go between the legs of the resident before attaching the sling to the mechanical lift. In interviews on 9/2/10, and 9/3/10 with Staff A who is responsible for in servicing staff on the use of the mechanical lift it was reported that staff are taught to cross the straps of the sling and to keep their eyes on the resident at all times when transferring with the mechanical lift. The facility conducted an investigation into Resident #79 ' s fall on 9/1/10. Statements from staff involved in the transfer revealed that the sling straps were not crossed and the resident slid off the sling onto the floor. The investigation done by the facility concludes that the staff did not use the equiptment properly. Staffs failed to demonstrate the actions of a qualified caregiver during the mechanical lift transfer. Resident #79 was transported to the hospital with multiple injuries. Failure to use the mechanical lift correctly resulted in substantial harm to Resident #79.