Every finding on record at Washington Odd Fellows Home

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from sexual abuse by Resident 1 for 1 of 5 residents (Resident 2) reviewed for abuse. This failure placed the residents at risk for continued abuse, injury, and emotional distress.Findings included. Review of a policy titled, Abuse, Neglect and Exploitation, dated 08/27/2025, showed the facility would provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse and neglect. Abuse means the willful infliction of injury or intimidation with resulting physical harm, pain or mental anguish, which can include resident to resident altercations. Sexual abuse is non-consensual (a physical act or contact that occurs without clear, voluntary, and affirmative agreement) sexual contact of any type with a resident. Resident 1Review of the medical record showed Resident 1 was admitted to the facility with diagnoses including a cerebral infarction (a loss of blood flow to part of the brain that can cause brain damage), major depressive disorder (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), and anxiety disorder (a mental health condition characterized by excessive and/or persistent fear or worry). The 05/04/2026 comprehensive assessment showed Resident 1 required assistance of one to two staff members for activities of daily living (ADLs, activities related to personal care). The assessment also showed Resident 1 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 2Review of the medical record showed Resident 2 was admitted to the facility with diagnoses including bipolar schizoaffective disorder (a chronic mental health condition combining symptoms like psychosis, delusions, or hallucinations with extreme mood swings) and dementia (a decline in mental ability severe enough to interfere with daily life). The 04/13/2026 comprehensive assessment showed Resident 2 required assistance of one to two staff members for ADLs. The assessment also showed Resident 2 had a severely impaired cognition. Record review of an investigation dated 06/22/2026 at 3:40 PM, showed Staff C, Registered Nurse, observed Resident 1 sitting in the dining room in their wheelchair facing Resident 2, who was seated in a chair at their table. Resident 1 had their right hand on Resident 2's upper back, then took their left hand and ran it over Resident 2's left breast. Staff C separated the residents and informed Resident 1 that they witnessed them touching Resident 2's breast and that was inappropriate behavior. Staff C asked Resident 1 if they understood and they responded yes. Staff C went back to Resident 2 and asked them what happened. Resident 2 stated Resident 1 had touched them, and they did not want Resident 1 to do that. Record review of Resident 1's care plan last reviewed on 06/23/2026, showed a focus area, dated 06/15/2022, identifying Resident 1 had touched nursing assistants inappropriately during cares and may engage in sexual behaviors with themselves. Staff should ask Resident 1 to go to their room and close the curtain during those times. Staff should immediately document the inappropriateness of Resident 1's sexual behaviors to nursing and the social worker. During a concurrent observation and interview on 07/06/2026 at 10:49 AM, Resident 2 sitting in the dining room. They stated Resident 1 had came into the dining room and started to touch me. They stated Resident 1 started rubbing my (breast) and demonstrated by grasping their left breast. Resident 2 stated they were kind of scared. They stated the nurse came over and told Resident 1 to leave me alone. Resident 2 stated they did not want Resident 1 to touch them. During an interview on 07/06/2026 at 10:57 AM, Staff D, Nurse Manager, stated they completed the facility investigation for the resident-to-resident altercation between Resident 1 and Resident 2. They stated they had completed investigations in the past related to Resident 1, as they had a history of inappropriate sexual behaviors. Staff D stated Resident 2 did tell them the touching was non-consensual. Staff D stated the touching violated Resident 2's boundaries. During an interview on 07/06/2026 at 11:07 AM, Staff C stated they were at their medication cart outside of the dining room when the altercation occurred. They stated they saw Resident 1 place their hand over Resident 2's left breast. Staff C stated they separated the two residents and assessed Resident 2 for harm. They stated Resident 2 told them they did not want Resident 1 to do that to them. Staff C stated what they observed was intentional and identified the incident as sexual abuse. During an interview on 07/06/2026 at 1:13 PM, Staff A, Administrator, stated they were aware that Resident 1 grabbed Resident 2's chest. They stated Resident 2 was ok with it at first then changed to say they were uncomfortable. Staff A stated they did not see the incident as abuse as Resident 2 was fine with it, then not. During an interview on 07/06/2026 at 1:40 PM, Staff B, Director of Nursing Services, stated the facility did everything right and they disagreed with the findings related to abuse. Reference: WAC 388-97-0640(1)

Based on interview and record review, the facility failed to ensure professional standards of practice were followed when nursing staff failed to accurately document insulin (an injectable medication used to regulate blood sugar levels) administration for 1 of 3 residents (Resident 1) reviewed for medication administration. This failure placed the residents at risk for unstable blood sugars, duplicate administration of the medication, and adverse outcomes. Findings included. Review of the Lippincott Manual of Nursing Practice, 11th edition, copyright 2019, Chapter 2, showed professional nursing had standards of practice that set minimum levels of acceptable performance for which practitioners were accountable. Departure of standards of care included failure to make prompt, accurate entries in a medical record. Review of the medical record showed Resident 1 was admitted to the facility on [DATE] with diagnoses including breast and colon cancer, malnutrition, and diabetes (a group of diseases that result in too much sugar in the blood). The 01/02/2026 comprehensive assessment showed Resident 1 was independent with activities of daily living (activities related to personal care) and required substantial assistance of one staff member for showering. The assessment also showed Resident 1 had an intact cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Record review of Resident 1's physician orders dated 09/29/2025, showed an order for Insulin.inject 1 unit (a measurement of medication) subcutaneously (under the skin) after meals.for every 10 grams (a unit of measurement) of carbs [carbohydrates (a nutrient the body uses for quick energy)] eaten. Total daily dose of 40 units. Record review of Resident 1's Medication Administration Records (MAR) from September 2025 through 02/11/2026, showed no documentation of the amount of carbs Resident 1 had consumed or the amount of insulin administered. During an interview on 02/11/2026 at 1:20 PM, Staff B, Licensed Practical Nurse, stated before administering Resident 1's insulin, they would look at the resident's meal tray and determine how many carbs the resident ate. They stated they would administer 1 unit of insulin for every 10 grams of carbs consumed. Staff B stated they did not document the number of carbs eaten or the amount of insulin they administered. Staff B stated there needed to be a place on the MAR to document the number of units given. During an interview on 02/11/2026 at 1:52 PM, Staff C, Nurse Manager, stated dietary services provided the total carb count for the meal and documented that number on the tray card. Dietary staff then saved the meal tray for nursing to observe the amount of carbs eaten and the nursing staff would calculate the amount of insulin to administer. Staff C stated there was no process in place for documenting the carb count or the corresponding amount of insulin that was given. During an interview on 02/11/2026 at 11:58 AM, Staff D, Medical Director, stated documentation for the insulin administration should include documenting the total carb count and the amount of insulin given each time, and a rationale as to how much insulin was administered. During an interview on 02/11/2026 at 2:18 PM, Staff A, Director of Nursing Services, stated the process for Resident 1's insulin administration included dietary staff documenting the total carb count on the meal tray and nursing staff determining how many carbs Resident 1 consumed. Nursing staff should calculate the number of insulin units to administer and should document that administration in the progress notes. Staff A stated there was no process to consistently document the carb count and insulin administered. Reference: WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i)

Based on observation and interview the facility failure to ensure food was prepared and served for (1 of 1 kitchen) in accordance with professional standards of safety. Facility kitchen staff did not wear facial hair restraints and beard restraints while serving residents food. This failure left residents at risk of food contamination and food-borne illness. Findings included . Observations on 08/06/2025 at 11:55 AM, food service of the noon meal began in the kitchen. Staff O, Dietary Supervisor, (DS), Staff P, Cook, Staff Q, Dietary Assistant, (DA), and Staff R, DA, were in the kitchen tray line while food was served. All staff identified had beards and long exposed facial hair over an inch long, and none wore facial hair/ beard restraints: During the same observations on 08/06/2025 at 11:55 AM, Staff O had a full beard and a moustache and walked around the steam table with uncovered food and the preparation area where desserts, sandwiches, and other foods were located. Staff P had served food from the steam table to residents' plates with an uncovered full beard. Additionally, Staff P was working over other food preparation surfaces without a beard hair restraint. Staff Q had handled food utensils and placed them on resident trays with facial hair exposed. Staff R handled resident trays and had exposed facial hair. During an interview on 08/06/2025 at 12:10 PM, Staff U, Dietary Manager, stated they had a supply of facial hair/beard restraints, but staff had not worn them. Reference WAC: 388-97-1100(3)

Based on observation, interview, and record review the facility failed to review and validate the Preadmission Screening and Resident Reviews (PASARR, an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities are not inappropriately placed in nursing homes for long term care) were correct on admission and had a required level two referral if residents had a positive level one PASARR for 4 of 7 residents (Residents 41, 1, 5, and 30) reviewed for PASARR. This failure placed the residents at risk for not receiving the care and services appropriate for their mental health needs. Findings included. Resident 41 Review of Residents 41's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include anxiety (a feeling of worry, nervousness, or unease), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the comprehensive assessment dated [DATE], showed the resident's cognition was moderately impaired, able to understand, and make their needs understood. Review of Resident 41's PASARR, dated 10/02/2024 showed SMI indicators, in section 1A, were check marked for Resident 41's diagnosis of depression, anxiety and Post Traumatic Stress Disorder (a condition that develops after experiencing or witnessing a traumatic event). The PASARR showed no level two referral or evaluation was completed. Review of an undated facility PASARR audit showed Resident 41 admitted on [DATE] as a hospital exempted [level two not required unless the resident's stay goes beyond 30 days] stay. The audit showed Resident 41 needed a level two evaluation and referral, but the audit showed no referral had been submitted (nine months after the 30-day stay was up, and the admitting PASARR did not show it was an exempted stay). Resident 1 Review of the resident's medical records showed they admitted with diagnoses of depression and dementia (a group of symptoms that affect memory, thinking, and behavior) with anxiety. Review of the 06/14/2025 comprehensive assessment showed Resident 1's cognition was moderately impaired and received treatment for depression and an antipsychotic (a type of medication used to stabilize mood and reduce anxiety in SMI) medication. Review of Resident 1's 10/24/2024 PASARR showed no SMI were identified on admission therefore a level two evaluation was not obtained. Resident 5 Review of the resident's medical records showed they admitted with diagnoses of schizoaffective disorder (a mental health condition where individuals experience periods of emotions ranging from joy to rage and hallucinations (false perceptions/or sensory experiences that are not real) or delusions (false beliefs that persist despite evidence that they are not real), dementia with anxiety, and insomnia (the inability to sleep). The 07/21/2025 comprehensive assessment showed Resident 5's cognition was moderately impaired and received antipsychotic medications. Review of Resident 5's 08/21/2024 PASARR showed Resident 5 had SMI indicators for schizoaffective disorder, but no level two evaluation was indicated on the form. Review of an undated facility PASARR audit showed Resident 5 admitted on [DATE] and was determined to needing a level two evaluation but the referral was not sent until 01/20/2025 (nearly five months after identification of SMI and admission on [DATE]). Resident 30 Review of the resident's medical records showed they admitted with diagnoses to include depression and dementia with agitation (a state of severe restlessness or inner tension). The 05/12/2025 comprehensive assessment showed Resident 30's cognition was severely impaired and received antipsychotic (a medication that changes the balance of chemicals in the brain and used to treat psychosis, a condition where a person has difficulty knowing what is real and what is not) and antidepression (a medication that alters the brain chemistry to alleviate symptoms associated with depression) medications. Review of the 02/03/2025 PASAAR showed Resident 30 had SMI and a level two evaluation was required. Review of an undated facility PASARR audit showed Resident 30 admitted on [DATE] and a PASARR level two evaluation was needed. The audit showed the referral for the level two evaluation was not sent until 04/03/2025 (two months after admission). During an interview on 08/06/2025 at 11:42 AM, Staff N, Social Services Director, stated they reviewed PASARRs prior to admission and for any changes. Staff N stated they kept an audit to remind them when someone needs a level two referral and when the level two should be completed. Staff N stated they were behind but had caught them up, and that could have been the reason for the late submissions for the level two referrals. During an interview on 08/08/2025 at 12:35 PM, Staff B, Director of Nursing Services, stated Staff N and the admissions nurse reviewed the PASARRs prior to the resident's admission and if they required a level two evaluation, they would have the referral sent by the hospital. Staff B stated they assumed that process was being followed. Reference WAC: 388-97-1915 (1)(2)

Based on observation, interview, and record review, the facility failed to provide adequate supervision, revised care plan interventions for efficacy, and ensured care planned interventions were consistently followed to prevent avoidable repeated falls for 3 of 3 residents (Residents 51, 15, and 28) reviewed for falls. This failure placed the residents at risk for unsupervised self-transfers leading to falls, serious injury, and a decline in health status. Findings included . Review of the facility's undated policy titled Fall Prevention Program, showed residents would be assessed for fall risk upon admission and received care and services in accordance with their risk level (low, moderate, or high risk) to reduce the likelihood of falls. Interventions included increased frequency of rounds, accessible call lights, and scheduled toileting assistance. Resident 51 Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including a bladder infection treated at the hospital, falls, supranuclear palsy (a neurological disease that affects movement, balance, eye function and cognitive abilities), osteoporosis (brittle bones), and hearing loss. The 05/05/2025 comprehensive assessment showed the resident had memory issues but was alert and able to make their needs known. Resident 51 required substantial assistance to transfer from their wheelchair. The resident was discharged from the facility on 05/21/2025. Review of the 04/29/2025 nurses progress notes showed at 5:06 PM Resident 51 had fallen after being left alone seated at the side of their bed while a Nursing Assistant (NA), went down the hall to retrieve items to change the resident. The progress notes also showed the resident was on the floor with a swollen right eye. Review of the 04/29/2025 at 5:06 PM fall incident report showed Resident 51, shortly after admission, had an unwitnessed fall from their bed after a NA left them unattended to get some supplies. Resident 51 sustained a swollen eye with a bruise around the eye. Review of the 04/29/2025 Fall Risk assessment showed Resident 51 was at high risk for falls related to their cognition, required hands on assistance, not able to stand independently, and exhibits loss of balance. Review of Resident 51's 04/29/2025 baseline care plan did not include fall risk preventions until 05/01/2025 where positioning bars were added to the bed and a fall mat at bedside. During an interview on 08/07/2025 at 10:06 AM, Staff M, Resident Care Manager, stated that another Licensed Nurse (LN) completed the incident report and was no longer at the facility. Staff M stated Resident 51, who was reviewed as a high fall risk, was left on the side of the bed without supervision and sustained a fall with an abrasion and bruise over their right eye. Staff M stated they had to get permission from the family for the resident to use positioning bars on their bed and it took some time. Staff M stated Resident 51 should not have been left seated on the side of their bed without safety measures in place and the resident fell. Resident 15 Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses including dementia (impaired cognition), repeated falls, history of bladder infections, and spinal stenosis (narrowing of the spinal canal which caused pressure on spinal cord nerves). The resident's 07/24/2025 comprehensive assessment showed the resident was cognitively impaired and only spoke in their native language but understood some English and could respond with basic yes or no answers. The assessment showed the resident required substantial assistance with all activities of daily living. During an observation on 08/04/2025 at 12:20 PM, Resident 15 was seated in their wheelchair in the dining room being assisted by NA staff. The resident acknowledged a question asked, smiled but did not respond verbally. There was a fall alarm clipped to the back of their shirt and connected to the back of Resident 15's wheelchair. Review of the 07/22/2025 fall incident report showed Resident 15 was left in their wheelchair in their room after an NA had assisted the resident to the bathroom. At 6:15 AM the NA called the LN to Resident 15's room. Resident 15 was on the floor and sustained a fall with a large hematoma (localized swelling with blood) to the back of the right side of their head. The 07/22/2025 fall interventions showed the resident was placed as a one-on-one staff observation, frequent checks when sleeping, and not to be left unattended. Review of the 08/01/2025 fall incident report showed Resident 15 was in the dining room without supervision when a dietary aide who had been cleaning up after breakfast, reported to nursing staff that Resident 15 was on the floor. A new fall intervention was Dycem (a non-slip mat) was placed in the resident's wheelchair, and the resident was not to be left unattended. An observation on 08/06/2025 at 10:16 AM, Resident 15 was left alone in the dining room by themselves in their wheelchair, unsupervised, and the resident had their eyes closed. Resident 15 was leaning forward with their head down until 10:50 AM when staff was notified Resident 15 was unsupervised in the dining room. During an interview on 08/07/2025 at 10:04 AM, Staff M stated Resident 15 had multiple falls at the hospital. The resident's 07/21/2025 admission time was delayed because the resident fell at the hospital while waiting for transfer to their facility. Resident 15 was admitted to the facility on [DATE] at 1:00 PM and the care plan at the facility, after Resident 15 arrived, was to not leave the resident unattended. The resident was left unattended in their room on 07/22/2025 at 6:00 AM that morning and fell out of their wheelchair sustaining a bump to the back of their head. During an interview on 08/07/2025 at 10:06 AM, Staff M stated that on 08/01/2025 at 8:58 AM, Resident 15 was in their wheelchair in the dining room unsupervised when a dietary aide who was cleaning up after breakfast, saw Resident 15 on the floor and notified nursing staff. During an interview on 08/07/2025 at 10:30 AM, Staff Z, NA, stated they came to work on 07/22/2025 before their shift began on the day shift. Staff Z stated they did not know who Resident 15 was but assisted the resident to the bathroom. Staff Z stated they assisted the resident back to the wheelchair in their room and left the room to get information on the resident. Staff Z stated when they returned to the room, Resident 15 was on the floor and had a large bump on the back of their head. Resident 28 Review of the resident's medical record showed Resident 28 was admitted to the facility on [DATE] with diagnoses to include atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), a hereditary bleeding disorder, and repeated falls. Review of the comprehensive assessment dated [DATE] showed the resident's cognition was moderately impaired and was on a toileting program. Resident 28 was dependent on staff for toileting hygiene and required substantial assistance from sit to stand. During an observation and concurrent interview on 08/05/2025 at 10:05 AM, Resident 28 was self-propelling their wheelchair and stated they were on the way to play games. The resident's bed had been made, a carpet mat was located in the front of their bed, and their call light was in the top drawer of the nightstand. During an observation on 08/06/2025 at 11:00 AM, Resident 28 stood up in their restroom facing their wheelchair, with their left hand grabbing the grab bar on the wall to their left. Then, Resident 28 with their right hand, on the right arm of their wheelchair, proceeded to push the wheelchair while ambulating to grab the door frame, then turned and sat down in the wheelchair. There were no staff members in the restroom to supervise the resident's transfer. This surveyor notified the staff that the resident needed assistance. During an observation and concurrent interview on 08/07/2025 at 3:28 PM, Resident 28 was standing up in their restroom holding onto the sink, their pants on the floor, and they had fecal matter all over themselves and their shirt. The resident stated they needed some assistance, and there were no staff members in the restroom to supervise the resident's transfer. This surveyor notified the staff that the resident needed assistance. Review of the facility incident log, dated from February 2025 through July 2025, showed Resident 28 had 12 fall incidents and two resulted in injury. During an interview on 08/06/2025 at 2:56 PM, Staff Y, Nursing Assistant, stated their procedure when a resident had a fall, was they notified the nurse, assisted the resident up and kept them safe until the nurse arrived. Staff Y stated they would document the incident on the computer and fill out an incident report. During an interview on 08/06/2025 at 3:30 PM, Staff M stated the fall process was the NA would notify a nurse, and the nurse would do their assessment. Staff M stated involved staff would complete a witness statement and the nurse would talk with the NA to assist with filling out the incident reporting. Staff M stated the nurse would complete an incident report, a progress note, and alert charting for 72 hours. Staff M stated they had been working on streamlining the incident report process to make it easier for the staff to be compliant, but it was a work in progress. During an interview on 08/08/2025 at 1:05 PM, Staff B, Director of Nursing Services, stated their expectation was staff followed resident care plans to do what was best for the resident. Reference: WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to ensure visitation rights were protected for 1 of 2 residents (Resident 5) when their friend was restricted from talking to the resident without their knowledge. This failure placed the resident at risk of isolation, abandonment, and the ability to be independent regarding their own visitor choices. Findings included . Resident 5 Review of the resident's medical records showed they were admitted to the facility with diagnoses to include schizophrenia (a mental health condition where individuals experience periods of emotions ranging from joy to rage and hallucinations (false perceptions/or sensory experiences that are not real) or delusions (false beliefs that persist despite evidence that they are not real). Review of the 07/21/2025 comprehensive assessment showed Resident 5's cognition was moderately impaired and required staff supervision or touching assistance with most activities of daily living (ADLs). During an interview on 08/04/2025 at 4:02 PM, Resident 5 stated they enjoyed writing letters and would write their friend often, but their friend had just dumped them and did not understand why they had not heard from them or had seen them. Review of Resident 5's 06/25/2021 Care Profile (special instructions about the resident's care needs), showed [Resident 5's friend] is not to talk to [Resident 5] at this time per POA (Power of Attorney, a legal authorization that gives the agent or attorney-in-fact the authority to act on behalf of an individual) request. Review of Resident 5's POA document, dated 02/14/2014, showed the POA did not provide the authority to override personal and health care decision making by Resident 5, unless Resident 5 was determined to be incapacitated (a person who is unable to make decisions for themselves due to mental or physical limitations). Review of Resident 5's medical records showed no information that Resident 5 had been deemed incapacitated. During an interview on 08/05/2025 at 10:01 AM, the POA stated they had restricted Resident 5's friend from talking with them a long time ago because they were concerned the friend would take advantage of Resident 5 and would bum money or cigarettes from them. The POA stated the restriction could have been removed because Resident 5 had not smoked in a few years and they no longer left enough money to worry about with Resident 5. The POA stated they had not discussed restricting the resident's friend with Resident 5 prior to placing the restriction on their friend. During an interview on 08/06/2025 at 3:34 PM, Resident 5 stated they had not been talked to by the facility or the POA about restricting their friend from talking with them. Resident 5 stated their friend had dropped them like they were nothing and no longer came to see them and could not understand why. Resident 5 stated they would have wanted to see and talk to their friend and that restriction should not have been placed. During an interview on 08/07/2025 at 10:55 AM, Staff B, Director of Nursing Services, stated the restriction of Resident 5's friend was a long time ago, years ago and because they were a vulnerable adult with mental health issues, they felt the POA was acting in the best interests of Resident 5. Staff B stated the facility did not discuss the restriction with Resident 5 and assumed the POA had done that at the time the restriction was placed. Staff B stated the facility had not normally followed up on restrictions put into place periodically to see if they still applied to the residents' current situation/condition. Reference WAC: 388-97-0520 (1)(2)

Based on interview and record review, the facility failed to ensure residents personal fund accounts were, A) deposited in an interest bearing account for 4 of 5 residents (Residents 25, 23, 8, and 28) reviewed for personal funds accounts, and B) made available to residents on the weekend for 2 of 5 residents (Residents 8 and 28) reviewed for personal funds. This failed practice caused residents not to receive or have access to monies owed to them. Findings included . Review of the facility's policy titled, Resident Personal Funds, dated 08/21/2023, showed the facility would deposit any resident's personal funds in excess of $100 ($50.00 for Medicaid residents) in an interest-bearing account. Review of the facility's undated guidelines titled, Trust Fund Petty Cash Instructions: (for when the business office is closed), showed, .residents must be allowed access to trust funds when the business office is closed. The nurse supervisor on duty will be responsible for maintaining the petty cash (a small amount of cash on hand by a facility to cover minor expenses) for residents when the business office is closed. Resident 25 Review of the medical record showed the resident was admitted on [DATE] with diagnoses including dementia (a progressive disease that destroys memory and other important mental functions) and heart complications. The 04/21/2025 comprehensive assessment showed the resident had severely impaired cognition. Resident 23Review of the medical record showed the resident was admitted on [DATE] with diagnoses including dementia and a history of a stroke (when blood flow to the brain is interrupted). The 07/15/2025 comprehensive assessment showed the resident had severely impaired cognition. Resident 8Review of the medical record showed the resident was admitted on [DATE] with diagnoses including heart and lung complications. The 06/30/2025 comprehensive assessment showed the resident was cognitively intact and able to make their needs known. During an interview on 08/04/2025 at 4:42 PM, Resident 8 stated the facility office staff were not working on the weekends so they would be unable to pull money out of their personal trust funds account. Resident 28 Review of the medical record showed the resident was admitted on [DATE] with diagnoses including history of a stroke. The 06/16/2025 comprehensive assessment showed the resident had moderately impaired cognition but was able to make their needs known. During an interview on 08/05/2025 at 9:42 AM, Resident 28 stated they had personal funds that the facility held onto and had used it to pay for haircuts but did not think they could pull out money on the weekend if they needed it. Review of the facility's personal resident funds account, provided by Staff I, Business Office Manager, showed on 08/04/2025 11 residents (including Residents 25, 23, 8 and 28) had funds in the account and eight of the residents had balances greater than $50.00. Review of the resident pooled funds account summary statements for January 2025 through July 2025 showed that no interest had been accrued (received in regular amounts over time) in June 2025 or July 2025 and the last time interest had been accrued for the resident pooled funds account was in May 2025. During an interview on 08/04/2025 at 11:00 AM, Staff I and Staff H, Chief Financial Officer, both in charge of managing the facility's resident funds account, stated that no interest had been allocated to the resident pooled personal funds account in June 2025 or July 2025. Staff H stated they would be contacting the bank to discuss why the personal funds account had not gained interest in those months. During an interview on 08/05/2025 at 3:50 PM, Staff H, stated they had talked with the facility's bank about the resident pooled funds account and were informed that the account had been switched and was not an interest-bearing account since May 2025. During an interview on 08/07/2025 at 9:58 AM, Staff G, Registered Nurse (RN), stated they had worked as a nursing supervisor on the weekends. Staff G stated residents who had funds in the pooled account were unable to get money on the weekends because the office staff did not work on the weekend. During an interview on 08/07/2025 at 10:01 AM, Staff K, RN, stated they had worked the weekends before. Staff K stated they were unaware if residents were able to get money from their personal funds account or what the process was. During an interview on 08/08/2025 at 10:48 AM, Staff A, Administrator, also present, Staff B, Director of Nursing Services, stated that resident funds needed to be in an interest-bearing account and the correct process wasn't followed. Staff B stated the residents should have access to funds even on the weekend and nursing staff should have been aware of how to get residents funds. Staff B stated the correct process was not being followed. Reference: WAC 388-97-0340(3)(a)

Based on interview and record review, the facility failed to implement 4 of 8 components (identify, protect, report, and investigate) of their abuse/neglect policy/procedure after allegations of abuse were reported as a grievance (a formal complaint that highlights a violation of contract terms or policy) to the facility for 2 of 3 residents (Residents 8 and 41) reviewed for abuse/neglect. This failure placed the residents at risk for further abuse, fear, and unmet care and services. Findings included . Resident 41 Review of Residents 41's medical record showed the resident admitted to the facility on [DATE] with diagnoses to include anxiety (a feeling of worry, nervousness, or uneasiness), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). Review of the comprehensive assessment dated [DATE], showed the resident's cognition was moderately impaired, able to understand, and make their needs understood. During an interview on 08/05/2025 at 10:15 AM, Resident 41 stated there had been a nursing assistant (NA) who had been very rude to them, had an attitude, and talked down to them (later identified as Staff BB, NA). Resident 41 stated they could not remember the NAs name, but that they had reported it to Staff S, NA, and they knew who they were. During an interview on 08/06/2025 at 10:23 AM, Staff S stated, the resident was very upset and the resident had told them that Staff BB had talked down to them and was very rude. Staff S stated they believed they had reported to the medication nurse. Staff S stated the incident happened last week. Staff S stated they were aware they were a mandated reporter. During an interview on 08/08/2025 at 10:55 AM, Staff BB stated they worked with Resident 41 the previous Wednesday. Staff BB stated they had a good rapport (close relationship)with the resident and were surprised by the resident's complaint. During an interview on 08/08/2025 at 11:07 AM, Staff AA, Licensed Practical Nurse, stated they were aware of the incident, and they had overheard the conversation in the dining room during dinner. Staff AA stated neither the resident nor the NA reported the incident to them, but that they had gone to Resident 41 after their dinner and asked if they were okay. Staff AA acknowledged they were a mandated reporter and stated they had not filled out an incident report because the resident stated they were okay. Staff AA did not recognize the incident as potential abuse. During an interview on 08/06/2025 at 3:55 PM, Staff B, Director of Nursing Services, stated the incident overheard by Staff AA was not reported to them, written up, or investigated as potential abuse. Resident 8 Review of the resident's medical records showed they admitted to the facility with diagnoses to include respiratory and heart failure. The 06/30/2025 comprehensive assessment showed Resident 8's cognition was intact, and they were dependent on staff assistance for toileting, personal hygiene, transfers, bathing, and dressing. During an interview on 08/04/2025 at 4:37 PM, Resident 8 stated they had issues with a few of the NAs being too rough and rushing me. Resident 8 stated they reported the issue to the facility, and the facility told them there was education provided to the nursing assistants and it was taken care of but then continued to happen. Resident 8 was able to identify two staff by name and possibly a third with a partial name (later identified as Staff CC, NA, Staff DD, NA, and Staff EE, NA). Review of the grievance log showed on 07/16/2025 a concern was reported to the Social Services Director (SSD) that the night NAs were rushing with [Resident 8]. The concern showed there was education provided to the NAs during their mandatory meeting on 07/22/2025. The grievance did not identify staff involved. During an interview on 08/07/2025 at 3:56 PM, Staff N, SSD, stated Staff F, Registered Nurse, had received a concern via an electronic mail (email) from Resident 8's Resident Representative (RR) on 07/08/2025. Staff N stated they were not sure what came out of that concern but was told education was going to be provided to the NA staff. Staff F entered the office during this interview and stated they did not identify the staff involved in the concern, nor did they investigate the concern, and they stated they had forwarded the email to the Director of Nursing Services (DNS) for them to handle. Review of the 07/08/2025 through 07/10/2025 emails showed: The RR emailed the facility on 07/08/2025 at 9:16 AM. The email showed the RR reported that Resident 8 had an incident involving three NAs the day prior (07/07/2025) or possibly the day before that (07/06/2025) that involved three named NAs. The email showed the staff were rude and rushed [Resident 8] when the resident requested help with toileting. The RR reported that during this time, Resident 8 had dribbled urine onto the floor while being transferred with a mechanical lift (a machine used to transfer a person from one surface to another surface) and asked to be placed on the toilet. The email showed that when Resident 8 asked that question, one of the NAs replied with why do you need the toilet you already went on the floor? The email showed Resident 8 had felt humiliated and had been very upset about it. The email showed Resident 8 wanted the RR to contact the State Ombudsman (a government employee who investigates and tries to resolve complaints, usually through recommendations or mediation) but the RR wanted to give the facility the chance to resolve the situation first. On 07/08/2025 at 9:36 AM, Staff F replied to the RR and informed them they would be forwarding the concern to the DNS and the Administrator for them to take action on this matter. On 07/10/2025 at 8:23 AM, the RR emailed Staff F to follow up with the reported concern because Resident 8 had not heard anything and was pretty anxious about it. On 7/10/2025 at 11:04 AM, Staff F replied to the RR that they had added Staff N to the email because they were the staff that followed up with Resident 8 and that the DNS and the scheduler had followed up with the NAs. Staff F wrote Resident 8 did not want [Staff CC, NA] to provide them care any longer and was removed from their care. On 07/10/2025 at 11:48 AM, Staff N replied to the RR and stated they had spoken with Resident 8 and informed them that Staff CC would no longer be their NA. During a review of the incident investigation log, for July 2025 showed no incident had been logged regarding Resident 8's concern or investigated as a possible allegation of abuse. During review of the staff meeting minutes on 07/22/2025 showed no education had been provided to NAs regarding being rude or rushing residents during care, nor did the signatures of the staff present during that meeting show the three named staff (Staff CC, Staff DD, and Staff EE) that were involved in the incident. During an interview on 08/08/2025 at 12:12 PM, Staff B, DNS, stated the person who received the reported concern was responsible for investigating the concern. Staff B stated upon receiving the email, they did not interview the resident or the staff themselves and would have expected Staff F or Staff N to complete those interviews. Staff B stated they would investigate a reported concern as a possible allegation of abuse if the concern caused the resident psychological harm, such as if they were distraught [deeply upset and agitated] or still dwelling.or worked up about it [the incident]. Staff B stated they would have expected a follow-up with Resident 8 by Staff N and for that follow-up to be documented. Staff B stated the follow up was usually verbal, but they were working on improving that process. Staff B also stated Staff N was responsible for writing up the grievance and ensuring the process was followed. Staff B stated they would have expected education to be completed as the grievance report showed, and was unaware that did not happen. Staff B stated if they would have read the notes for Resident 8 and seen they were still having issues regarding the treatment received by the NAs, they would have investigated it deeper. Reference WAC: 388-97-0640 (2)(a-b)

Based on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure residents dependent on staff received consistent showers for 2 of 5 residents (Residents 6 and 41) reviewed for activities of daily living (ADLs) care provided for dependent residents. This failed practice placed the residents at risk for unmet care needs, impaired skin integrity, and embarrassment. Findings included . Resident 6Review of the medical record showed Resident 6 was admitted to the facility on [DATE] with diagnoses including dysfunction of the bladder, muscle weakness, and cervical spondylotic myelopathy (a condition where age-related wear and tear on the spine in the neck causes spinal cord compression). Review of the comprehensive assessment dated [DATE] showed the resident's cognition was intact and required assistance of two staff members for toileting hygiene, showering, and lower body dressing. Review of Resident 6's care plan dated 07/21/2025, showed the resident preferred two showers per week. Review of the facility's undated shower schedule showed Resident 6's shower days were Sunday and Wednesday. An observation on 08/06/2025 at 8:17 AM, showed Resident 6 was lying in their bed, dressed in a pink gown, with their hair greasy and their legs covered with a sheet. During an observation and concurrent interview on 08/07/2025 at 9:45 AM, Resident 6 was lying in bed, their hair greasy, disheveled (unkempt), wearing a gray t-shirt, a brief, and blue socks. The resident stated they were unsure when their last shower was and they were to get a shower the day prior, but they had not received their shower. During an observation and concurrent interview on 08/07/2025 at 12:07 PM, Resident 6 was up in their wheelchair, and they stated they were coming back from their exercises. The resident's hair was greasy, uncombed and they were wearing the same gray t-shirt as observed at 9:45AM earlier that day. Review of Resident 6's June 2025 nursing task sheet, showed no documentation of a shower from 06/09/2025 through 06/14/2025 (six days without a shower). Further review showed no documentation of a shower from 06/23/2025 through 06/29/2025 (six days without a shower). Review of Resident 6's July 2025 nursing task sheet, showed no documentation of a shower from 07/01/2025 through 07/12/2025 (12 days without a shower). Further review showed no documentation of a shower from 07/17/2025 through 07/23/2025 (seven days without a shower). Resident 41Review of the medical record showed Resident 41 admitted to the facility on [DATE] with diagnoses to include heart disease, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a feeling of worry, nervousness, or unease) and intervertebral disc degeneration (a condition caused by the breakdown of one or more discs that separate the bones of the spine). The comprehensive assessment dated [DATE] showed Resident 41's cognition was intact and dependent on staff for toileting hygiene, showering, and transfers. During an interview on 08/05/2025 at 10:36 AM, Resident 41 stated they were scheduled to have showers two days a week. The resident stated that last week they only received one shower, and the week before they did not have a shower. Resident 41 stated that it was not their choice to go without a shower but that there was no one to give them a shower. The resident stated they thought that their last shower was a week ago on Tuesday (07/29/2025). Review of Resident 41's care plan dated 05/06/2025, showed the resident preferred two showers a week. Review of the facility's undated shower schedule showed Resident 41's shower days were Tuesday and Friday. Review of Resident 41's June 2025 nursing task sheet, showed no documentation of a shower from 06/01/2025 through 06/10/2025 (ten days without a shower). Review of Resident 41's July 2025 and August 2025 nursing task sheet, showed no documentation of a shower from 07/01/2025 through 07/08/2025 (eight days without a shower). Further review showed no documentation of a shower from 07/26/2025 through 08/03/2025 (nine days without a shower). During an interview on 08/08/2025 at 9:37 AM, Staff V, Nursing Assistant, stated they were assigned to do the showers but at times would also be pulled from that task to work on the floor. Staff V stated they had a shower schedule for residents that they used as a guide. Staff V stated they offered bed baths when a resident did not get their shower. Staff V stated if a resident were to refuse a shower they reported to their floor nurse. During an interview on 08/08/2025 at 1:05 PM, Staff B, Director of Nursing Services, stated the expectation for staff were to follow the residents' shower schedule, care plans, and the showers were to be documented even if refused or not given. Reference: WAC 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to ensure Trauma-Informed Care related to assessing trauma and identifying trigger-specific (a psychological stimulus that prompts recall of a previous traumatic event) interventions for residents with a history of trauma for 1 of 1 resident (Resident 41) reviewed for trauma informed care. Findings included . Review of the facility's undated policy titled, Trauma Informed Care showed the facility would identify a resident's history of trauma, as well as cultural preferences. The facility would identify triggers which may re-traumatize residents with a history of trauma. Trigger specific interventions would identify ways to decrease the resident's exposure to triggers which re-traumatize the resident, as well as identify ways to decrease the effect of the trigger on the resident and the triggers would be added to the care plan. Resident 41 Review of Resident 41's medical record showed the resident was admitted to the facility on [DATE] with diagnoses to include heart disease, depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety (a feeling of worry, nervousness, or unease), and intervertebral disc degeneration (a condition caused by the breakdown of one or more discs that separate the bones of the spine). The comprehensive assessment, dated 07/07/2025, showed Resident 41's cognition was moderately impaired, required extensive assistance from two staff members for transfers. Review of a provider progress note dated 12/16/2024 showed Resident 41 had a history of Post Traumatic Stress Disorder (PTSD, a mental disorder that develops from experiencing a traumatic event). The progress note showed the resident experienced PTSD symptoms such as flashbacks, nightmares, and increased anxiety when triggered. The progress note showed Resident 41 could be triggered by yelling and screaming, Review of Resident 41's care plan, dated 04/01/2024, showed no focused areas, goals, or interventions related to Resident 41's PTSD. During an interview on 08/08/2025 at 9:53 AM, Resident 41 stated they had experienced childhood sexual and mental abuse. The resident stated that yelling and screaming increased their PTSD triggers of anxiety. Review of the Trauma Informed Care assessment dated [DATE], showed the resident had PTSD with triggers when they heard yelling and screaming. During an interview on 08/08/2025 at 11:46 AM, Staff N, Social Services Director, stated the TIC assessments were done on admission, and they did not recognize Resident 41 had a diagnosis of PTSD. Reference: WAC 388-97-1060(3)(e)

Based on interview and record review the facility failed to implement and ensure their system of records for controlled substances (categories of drugs, regulated and classified based on their potential for abuse, potential to cause physical or psychological dependence) disposition (the process of returning and/or destroying unused medications) and accurate reconciliation (a system of recordkeeping that ensures an accurate inventory of controlled substances received, administered or destroyed) was completed in sufficient detail to enable the accurate accounting with these types of medications for 1 of 2 medication carts reviewed and 1 of 1 narcotic (a type of medication for pain relief or sedation and is a category within controlled substances) destruction logbook reviewed for storage/disposition of controlled medications. This failure placed residents at risk for potential financial loss, uncontrolled pain, and possible drug diversion (the abuse of prescription drugs used for purposes other than intended by the prescriber). Findings included .During an interview on 08/06/2025 at 3:25 PM, Staff F, Registered Nurse (RN) and Staff B, Director of Nursing Services, stated the facility's process for the disposition of residents controlled substances was to place them in the Drug Buster (a medication disposal system designed to safely/effectively deactivate and dispose of unwanted medications) and document the specific resident/medication information in their narcotics destruction logbook. Staff B stated that two RNs would sign together in the narcotics destruction logbook to show that an accurate reconciliation was documented/completed regarding the disposition of the controlled substance. Review of January 2025 through August 2025 controlled substance shift count verification logbooks showed 24 nursing shifts on 20 different days did not have the required two nursing staff signatures in order to verify that the narcotics count was completed and accurate. Additionally, the logbook showed that on 03/11/2025 no count had been completed by any staff. During an interview on 08/06/2025 at 3:42 PM, Staff G, RN, stated that two nurses completed a narcotics count of all the controlled substances in the medication cart every shift and both nurses would sign a shift count verification logbook (a book that showed a complete and accurate count of narcotics by two nurses). Staff G stated that nursing staff signatures were missing throughout the logbook, .they should be signing off with another nurse every time they are working . Review of the facility's narcotics destruction logbook showed that on 04/02/2025, five controlled substances from three residents were destroyed, with one staff nursing signature noted and a blank spot where the second staff nurse was supposed to sign but had not. During an interview on 08/06/2025 at 4:09 PM, Staff B and Staff A, Administrator, stated that the controlled substance shift count verification logbook was not filled out correctly and that the process of having two nurses verify that the controlled medication count was not being followed. Additionally, Staff B stated the correct process for the accurate accounting of the three resident's narcotic disposition, done 04/02/2025, was not followed. Reference: WAC 388-97-1300(1)(b)(ii)

Based on observation, interview, and record review, the facility failed to develop/implement components of their infection prevention and control precautions regarding, A) Legionella (a bacteria that can cause a severe respiratory disease) testing protocols, identification of areas at risk and procedures for when control measures (actions or steps taken), adopted to reduce the potential growth/spread of pathogens (bacteria, virus or other microorganisms that can cause diseases) in water, were not met for 1 of 1 water management program (WMP) reviewed for infection control, and B) Nursing Staff hand hygiene and glove change for 1 of 3 residents (Resident 3) reviewed for infection control. The failure to implement the infection control components placed residents at an increased risk for exposure to cross contamination (harmful spread of diseases) and transmission of infectious diseases. Findings included . Review of the facility's policy titled, Legionella Management Program, dated 06/03/2025, showed the facility identified two areas at risk for legionella growth, the ice machines and hot water storage (which was monitored at a set temperature). The policy showed the ice machines routine control measures were to have the machines cleaned/sanitized weekly with a full deep clean/filter change completed every three months. No other control measures were identified. The policy did not include documentation of what corrective actions would be taken when the facility's control measures were not maintained or within acceptable ranges and stated .refer to appendix (a section or table of additional matter at the end of a book or document). Review of the Center for Disease Control and Prevention (CDC) toolkit titled, Developing a WMP to Reduce Legionella Growth and Spread in Buildings, dated 06/24/2021, showed a facility's WMP should identify areas or devices in the building where Legionella might grow or spread to people so the risk can be reduced. The toolkit showed that parts of a building water system that were a risk for spreading contaminated water included water storage tanks, water heaters, shower heads/hoses, infrequently used equipment like eye wash stations, ice machines, and decorative fountains. Additionally, the toolkit showed that water stagnation (something that does not change or move) encouraged biofilm (a community of bacteria that stick together and to a surface forming a protective layer) growth, which can protect Legionella from heat/disinfectants and was common in water devices that went unused or infrequently used. During an interview on 08/05/2025 at 2:20 PM, Staff D, Director of Environmental Services, stated they took part in the development of the WMP for the facility along with the facility's Infection Preventionist (IP). Staff D stated the water management team identified two control measures for the facility. Staff D stated the facility decorative water fountain, nor the residents' infrequently used bathtub, were identified as areas of risk. When inquired about the facility's policy to reference an appendix for intervention when control limits were not met, Staff D stated that it referenced the CDC legionella toolkit. Staff D stated they were unsure of the facility's process when control measures were not met. During a concurrent observation and interview on 08/06/2025 at 10:29 AM, Staff E, Maintenance Supervisor, stated that dietary staff were responsible for the weekly cleaning/disinfection of the ice machines and maintenance staff were responsible for quarterly (every three months) deep cleaning and changing of the water filter on the ice machines. When Staff E and the surveyor observed the ice machines, one showed a date of 03/05/2025 (62 days past the quarterly control measures scheduled change) and the second showed a date of 02/12/2025 (86 days past the quarterly control measures scheduled change). Staff E stated the maintenance staff did not flush the facility's eye washing stations routinely and that it was not part of their process. Staff E stated the eye washing stations were infrequently used and would be a potential risk for spreading contaminated water. During an interview on 08/06/2025 at 11:40 AM, Staff C, Infection Preventionist/Treatment Nurse, and Staff D stated the WMP's team did not identify flushing of the infrequently used devices like the eye washing stations or the resident's bathtub nor that control measures were not within acceptable ranges with the facility's ice machines. Staff D stated the WMP should have developed/implemented what corrective actions would need to be taken when the facility's control measures were not maintained, and the correct process was not being followed. During an interview on 08/06/2025 at 11:45 AM, Staff A, Administrator, and Staff B, Director of Nursing Services, stated the facility should be identifying where legionella could grow like the decorative water fountain and areas of water stagnation. Staff A and Staff B were unaware that the ice machines' control measures were not being completed quarterly. Staff A and Staff B stated the process needed to be fixed. Hand Hygiene and Glove Change Resident 3 Review of the medical record showed Resident 3 had been admitted to the facility on [DATE], with diagnoses to include heart disease, diabetes, foot ulcer and depression. The comprehensive assessment dated [DATE] showed the resident cognition was intact and dependent on staff transfers. During an observation on 08/05/2025 at 11:52 AM, Resident 3was sitting up in their wheelchair in the dining room. The resident was fully dressed, wound dressings to both feet, and both covered with boot heel protectors. In an interview on 08/06/2025 at 9:46 AM, Resident 3, stated on Tuesdays they went to a local wound clinic for dressing changes and an evaluation by a physician. Resident 3 stated the nurses completed dressing changes twice a week; Thursdays and Saturdays. During an observation on 08/07/2025 at 10:06 AM, Staff C, IP/TN with their clean gloves began to remove Resident 3's right foot wound dressing and then removed the left foot dressing. Staff C removed their gloves after use, sanitized their hands and applied clean gloves. Staff C then grabbed gauze, sprayed the gauze with wound cleanser and then began wiping the resident's left side of the foot wound with the same gauze and cleansed the left big toe wound. Staff C did not remove their gloves or performed hand hygiene. With their contaminated gloves, Staff C grabbed clean gauze, soaked it with wound cleanser and placed the soaked gauze to the resident's left heel. Staff C in their soiled gloves grabbed clean gauze, soaked it with wound cleanser and placed the soaked gauze to the resident's right heel. Staff C then grabbed clean gauze with their contaminated gloves, sprayed the gauze with wound cleanser and began wiping the resident's right foot on the side where there were two wounds. During an interview on 08/07/2025 at 12:13 PM, Staff C, IP/TN, acknowledged their infection control break during Resident 3's wound care. Staff C stated they were nervous with someone watching them. Staff C stated they realized their breach once they went from the left foot to the right foot. During an interview on 08/08/2025 at 1:05 PM, Staff B, Director of Nursing Services, stated the expectation was that staff follow the orders, policies and procedures. Staff B stated they were aware of the infection control breach with Resident 3's wound care. Reference: WAC 388-97-1320(1)(a)(2)(b)

Based on observation and interview, the facility failed to provide a clean sanitary environment for 1 of 1 Kitchen floor area that had an uncleanable surface. This failed practice of an uncleanable surface could potentially placed staff and residents at risk of illness. Finding included . During an interview and concurrent observation on 08/04/2025 at 9:25 AM, Staff O, Dietary Supervisor, observed in the thresh hold entryway to the dry goods food storage room, the flooring had cracked, damaged and missing linoleum. Staff O stated the floor had been that way for some time and difficult to clean. An observation on 08/04/2025 at 9:35 AM, the tilt skillet/stove (commercial cooking equipment used to prepare large batches of food for grilling and braising), which stood three feet above some broken tiled floor. The tile floor, under the tilt skillet showed a four-foot by three-foot area of broken/loose tile with missing and loose grout (mortar poured between cervices to consolidate and seal areas) in between several individual tiles. The tiles were wet due to the steam produced from the heated tilt skillet when in use. The area was uncleanable and there was an accumulation of water between the broken tiles and the missing grout. During an interview on 08/04/2025 at 9:40 AM, Staff O stated the tiles had been coming up and there were places of missing grout between the tiles, and they needed to be replaced and repaired. During an interview on 08/08/2025 at 11:36 AM, Staff D, Director of Environmental Services, stated they were unaware the tile under the tilt stove in the kitchen needed repaired/replaced or the linoleum in the entryway to the dry goods room was in disrepair. Reference WAC 388-97-3220(1)

Based on interview and record review, the facility failed to periodically inform residents of their rights after residents were admitted to the facility for 7 of 10 residents (Residents 2, 5, 8, 10, 16, 28, and 31) and 1 of 1 Resident's Representative (RR, Resident 19) reviewed for resident rights. This failure placed residents at risk of not being informed of their rights and/or to make informed decisions regarding their rights. Findings included. During a Resident Council meeting on 08/06/2025 at 2:30 PM, Resident 19's RR stated they would be asked to leave the room while staff cared for Resident 19. The RR stated they never asked Resident 19 if that's what they wanted or if that was okay. The RR stated they had not had Resident Rights reviewed with them since admission, nor did they know where they could access them or find them. Residents 2, 5, 8, 10, 16, 28, and 31 were all in attendance at the Resident Council meeting and all agreed with Resident 19's RR. Review of the resident council meeting minutes for January 2025 to August 2025 showed there had been no review of Resident Rights, written or verbally, during the resident council meetings. During an interview on 08/06/2025 at 3:19 PM, Staff W, Activities Director, stated they did not review Resident Rights with the residents during the monthly resident council meetings or periodically after admission, nor did they discuss where they could be found or accessed. During an interview on 08/08/2025 at 12:12 PM, Staff B, Director of Nursing Services, stated they reviewed Resident Rights with staff during [NAME] Hall Meetings but had not with the residents. Reference WAC: 388-97-0300 (1)(a)

Based on observation, interview, and record review, the facility failed to provide the required contact information to resident advocacy resources (ombudsman, State Agency (SA), Aging and Long Term Care), or how to file a complaint with the SA for 7 of 11 residents (Residents 2, 5, 8, 10, 16, 28, and 31) and 1 of 1 Resident Representative (RR, Resident 19) reviewed for required notices and contact information. This failure placed the residents at risk of abuse, neglect, and not having resources available to them. Findings included. During a resident council meeting on 08/06/2025 at 2:37 PM, Resident 8 stated they had wanted to get in contact with the ombudsman regarding some concerns they had but did not know where to find that information. Residents 2, 5, 10, 16, 28, and 31 and Resident 19's RR all agreed. The Residents also did not know how to file a complaint with the SA, nor did they know that was an option. During an interview on 08/06/2025 at 3:19 PM, Staff W, Activities Director, stated they did not know where the information for the resident advocacy resources was posted. During an interview on 08/06/2025 at 3:55 PM, Staff A, Administrator, stated Staff W had access to the Ombudsman information hung up in their cubicle but was not visible to all residents, RRs, or visitors. An observation on 08/07/2025 at 10:40 AM showed upon entrance into the main door of the facility, a sign with contact information for the resident advocacy resources but not visible to the residents in the long-term care area of the facility where the residents resided. During an interview and concurrent observation on 08/07/2025 at 10:51 AM, Staff B, Director of Nursing Services, stated the only signage they were aware of were the Mandatory Reporter [contact information for staff when they have a suspicion of abuse/neglect, misappropriation, or exploitation) signs. The signs did not include contact information for the resident advocacy resources. Reference WAC: 388-97-0300 (7) (c-d)

Based on observation, interview, and record review, the facility failed to ensure the nursing staff posting was posted daily and/or reflected the actual nursing staff hours worked during 4 of 5 days (08/04/2025 through 08/07/2025) of the survey period. This failed practice prevented residents, family members, and visitors from knowing the facility's actual number of available nursing staff. Findings included . Observations on 08/04/2025 at 11:40 AM, 08/05/2025 at 8:44 AM, and 3:31 PM, and 08/06/2025 at 8:50 AM, showed inaccurate postings for actual nursing staff hours worked. On 08/07/2025 at 10:02 AM, the nursing staff posting across from the nurses' station showed it was dated 08/03/2025 (four days prior) and did not show any actual adjustments or changes to the nursing staff hours posted. During an interview on 08/07/2025 at 12:20 PM, Staff S, Nursing Assistant (NA), stated they were responsible for the daily staff posting. Staff S stated they were off on 08/04/2025 and 08/06/2025, and that the second lead NA was responsible for the posting on the weekends. Staff S stated if any changes were needed, the changes were entered into the computer and re-posted. During an interview on 08/07/2025 at 12:45 PM, Staff T, Staffing Coordinator, stated the staffing levels were based on the facility census and Staff S was responsible for the daily nursing staff postings. During an interview on 08/07/2025 at 1:07 PM, Staff A, Administrator, and Staff B, Director of Nursing, acknowledged the daily nurse staff postings were outdated and incorrect. Reference: WAC 388-97-0020

Based on observation, interview and record review, the facility failed to ensure infection control interventions intended to prevent the spread of communicable disease during a COVID-19 (infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) outbreak were consistently implemented for the use of: personal protective equipment (PPE) during COVID-19 testing for 3 of 3 staff (Staff G, J, and K); National Institute for Occupational Safety and Health (NIOSH) approved respiratory protective device (N95) fitted masks (a respirator mask used to achieve a very close facial fit and very efficient filtration of airborne particles) for 5 of 5 staff (Staff B, D, F, H, and I) when entering a COVID-19 positive resident room; and face shields for 4 of 4 staff (Staff F, G, H, and I), reviewed for infection control practices. Additionally, 2 of 2 staff (Staff J and K) did not wait the required time for COVID-19 testing results prior to returning to work. These failures placed all residents at risk for facility acquired or healthcare associated infections and related complications. Findings included . Review of the Center for Disease Control and Prevention (CDC) guidance titled, Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, updated 03/18/2024, showed when staff entered a room with suspected and/or confirmed COVID-19, they were to wear PPE that included approved N95 mask, gown, gloves, and eye protection. Review of the CDC's guidance titled Strategies for Conserving the Supply of Eye Protection (face shields), dated 05/09/2023, showed eye protection should be cleaned and disinfected after each patient encounter. Review of the undated guidance from the Washington State Department of Health titled, Respiratory Protection Program for Long-term Care Facilities, showed the N95 mask protected the user when the seal around the person's nose and mouth was tight enough to prevent the respiratory hazards from leaking into their breathing space and facial hair should not cross under the respiratory sealing surface. Review of the CDC's Guidance for SARS-CoV-2 Rapid Testing in Point-of-Care Settings. dated 06/25/2024, showed when COVID-19 specimens were collected, PPE should be worn including an N95 mask or higher-level respirator, eye protection, gloves, and gown. Review of the policy titled Personal Protective Equipment, dated 08/02/2024, showed staff must wear a NIOSH N95 respirator for airborne pathogens. Staff were to wear the appropriate size of the N95 per their fit test. Record review of the facility's N95 respirator fit test records showed Staff B, D, H and I had incomplete fit test records. The records did not show the make, model, approval number, or size of the N95 mask they were fitted for. During an interview on 08/20/2024 at 9:37 AM, Staff B, Infection Control Registered Nurse, (ICRN), stated all staff were to wear full PPE when entering a COVID-19 resident room. This included a gown, gloves, face shield, and a N95 mask. Staff B further stated when staff performed their COVID-19 test, they were to wear a gown, gloves, face shield, and a N95 mask. During an observation and interview on 08/20/2024 at 10:27 AM, Staff D, Licensed Practical Nurse, stated they had been fit tested for an N95 mask. Staff D picked up a box of KN95 (not approved by NIOSH) masks and stated they were fit tested with that mask. An observation on 08/20/2024 at 11:58 AM, showed Staff B had donned a KN95 mask and entered a COVID-19 resident's room. An observation and interview on 08/20/2024 at 12:03 PM, showed Staff H, Nursing Assistant, (NA), and Staff I, NA, preparing to enter a COVID-19 resident room by donning KN95 masks, gown, gloves, and removed face shields from a hanging PPE holder on the resident's door, placed the elastic strap around their head with the foam cushion against their forehead and the plastic shield over their face. Staff H stated the sign on the resident's door showed the PPE they were required to wear upon entering the room. The sign showed everyone must wear a fit-tested N95 respirator mask, eye protection, gown, and gloves. Upon exit from the resident's room, Staff H and Staff I, removed their face shields and placed them back into the PPE holder on the door, without cleaning them, and tossed their KN95 masks in the trash. Staff H and Staff I stated they were fit-tested for the KN95 masks. An observation and interview on 08/21/2024 at 10:36 AM, showed Staff F, NA, obtain an N95 mask and placed over their bearded face. Staff F continued to place additional PPE on, including a gown, gloves, and a face shield that was hanging in a PPE holder on a Covid-19 resident's room. Upon Staff F's exit from the resident's room, they removed the used face shield and without cleaning, placed it back into the hanging PPE holder and threw the N95 in the trash. At 11:05 AM, Staff F stated they were fit-tested for that N95 and had a beard during their fit-test and passed. Staff F stated the N95 they had worn was what the facility had for use for staff. Staff F stated the PPE holder on the resident door was to place the face shields into so they could be reused when they entered a COVID-19 room. At 11:05 AM, Staff F stated they did not disinfect the face shield after use. During an interview on 08/21/2024 at 11:19 AM, Staff D, Rehabilitation Aide, stated they performed the N95 mask fit testing for staff. Staff D stated that most of the staff wore the same N95 mask, the green one. Staff D further stated that staff could have a beard for testing, however, not where the seal would be on their face. Staff D stated when a staff member had a beard, they should shave to ensure proper fit of the N95. An observation and interview on 08/21/2024 at 11:28 AM, showed Staff G, Certified Dietary Manager, performing a COVID-19 nasal swab test for Staff J, Dietary Aide, (DA). Staff G was wearing a surgical mask and gloves and handed Staff J the nasal swab and instructed Staff J to swab each nostril 15 times. Staff J then handed the used nasal swab to Staff G. Staff G placed the nasal swab into the COVID-19 testing solution, swirled the swab, and stated the results would be available in 30 minutes. Staff J stated they were returning to work while the test was resulting. Upon Staff J's exit, Staff K, DA, entered the COVID-19 test room. Staff G handed them a nasal swab and told them to swab each nostril 15 times. Staff J handed the used nasal swab to Staff G. Staff G placed the nasal swab into the COVID -19 testing solution, swirled the swab, and stated the result would be available in 30 minutes and they may return to work. Staff G stated they had been trained by Staff C, Staff Coordinator, and this was their first day performing the COVID-19 tests. Staff G stated they were instructed to perform the COVID-19 nasal tests and the PPE they needed to wear was a surgical mask and gloves. During an interview on 08/21/2024 at 11:58 AM, Staff C, Staff Devlopment, stated they trained Staff G and instructed them to wear an N95 mask and gloves. Staff C stated they should have instructed them to also wear a gown and eye protection. Staff C stated once the COVID-19 test swab was completed, staff were not to return to work and were to wait for their results in the adjoining conference room. During an interview on 08/21/2024 at 12:26 PM, Staff B stated the PPE holder on the COVID-19 resident's door was for staff to place their face shields into for reuse, after they were cleaned. Staff B also stated they were unaware that there was difference between KN95 masks and N95 masks, and they would need to repeat fit testing for staff and PPE retraining. During an interview on 08/21/2024 at 2:52 PM, Staff A, Administrator, stated staff should be wearing the appropriate PPE for COVID-19 residents and testing. Staff A stated staff had been fit tested for N95 masks and should be wearing the correct one they tested for. Staff A stated staff with facial hair would have been required to shave to ensure a correct seal during N95 fit testing and when required to wear an N95. Staff A further stated KN95 masks and N95 masks were not the same. Reference WAC: 388-97-1320(1)(a)(2)(a)(5)(b)

Based on observation, interview, and record review, the facility failed to ensure treatment and care was provided in accordance with professional standards of practice and the comprehensive, person-centered care plan for 5 of 5 residents (Residents 54, 11, 38, 36, and 13) reviewed for quality of care, in the areas of constipation/urinary bladder assessment, fluid restrictions, and timely implementation of physician orders. Resident 54 experienced harm when they did not have a bowel movement for four days and did not have a timely urinary bladder assessment, that resulted in pain, constipation, a small bowel obstruction (a blockage in the intestines), and a urinary bladder infection that required hospitalization . These failed practices placed residents at risk for a delay in treatment and unmet care needs. Findings included . Review of the facility policy titled, Bowel Routine for Preventing Constipation, dated 09/23/2023, showed that scheduled medicines for bowel routine helps with regular bowel movements. Being constipated can make residents feel ill. Constipation can be a side effect of pain medication and other medications. Things that make constipation worse were not drinking enough fluids, some anti-nausea medications and eating less than normal. Prevention of constipation is easier than treating it. The goal was to have a bowel movement every three days. Before each shift, the licensed nurse was to obtain a bowel list in the computer. If there were no bowel movements and/or no medium normal bowel movements, the licensed nurse would initiate the bowel protocol. <Constipation/Urinary Bladder Infection> <Resident 54> Review of the medical record showed the resident admitted to the facility with diagnoses including diarrhea, urinary retention, falls with fractures, and high blood pressure. Review of the 06/16/2024 comprehensive assessment showed Resident 54 was cognitively impaired but able to make most needs known. Resident 54 needed staff assistance and oversight for transfers and assistance to the bathroom. During an observation on 07/15/2024 at 9:00 AM, the resident was lying in their bed with eyes closed, and stated they had pain in their lower back and stomach. Resident 54 stated they felt bad and preferred to just rest. Review of the July 2024 Medication Administration Record (MAR), showed Resident 54 received a narcotic pain medication on 07/15/2024 at 6:16 AM. The 07/15/2024 8:02 AM MAR entry showed a narcotic pain medication was ineffective. Resident 54 received additional doses of the narcotic pain medication on 07/15/2024 at 4:25 PM, and on 07/16/2024 at 1:20 AM, 10:04 AM, and 6:34 PM. During an observation and concurrent interview on 07/16/2024 at 10:00 AM, showed Resident 54 was in bed lying on their left side and stated they had pain in their lower back that was very uncomfortable. The resident also stated they felt ill. The resident stated they were unable to eat food. Review of the July 2024 MAR showed on 07/16/2024 at 1:06 AM, the resident complained of general pain all over and a narcotic pain reliever was given. During an observation and concurrent interview on 07/17/2024 at 8:39 AM, Resident 54 was in bed with their eyes closed and a plastic basin beside them. The resident stated they had been nauseated and throwing up since the previous night. The resident's breakfast tray at their bedside was untouched and the resident stated they were not hungry. The plastic basin at the bedside contained some vomitus of yellow type of fluid. The resident stated they were miserable and complained of right upper side pain. Staff I, Licensed Practical Nurse (LPN), gave a medication for dizziness and nausea. During an observation on 07/17/2024 at 11:55 AM, Resident 54 stated they had tenderness and sensitivity in their right side, severe pain, and their stomach and back hurt. The resident stated they were feeling worse. During an interview on 07/17/2024 at 12:00 PM, Staff E, Charge Nurse, was asked to look at Resident 54. Staff E then documented that the resident was in pain and nauseated and called for an order from the provider for an anti-nausea medication to give to the resident. Staff E asked Resident 54 if they had their gall bladder and the resident stated it was removed. There was no documentation of further assessment in the medical record and there were no other licensed nurse assessments. The resident complained of pain and a narcotic pain reliever was given to the resident. Review of Resident 54's bowel movements showed the resident had not had a bowel movement since 07/14/2024 and still had no bowel movement on 07/18/2024. Additionally, the resident had been nauseated and did not eat or drink many fluids. There were no bowel protocols initiated or thorough assessments of Resident 54's complaints of pain. During an interview on 07/18/2024 at 11:51 AM, Staff O, Nursing Assistant (NA), stated the resident would say they had a bowel movement, and they did not. Staff O stated that morning, the resident did not have a bowel movement when they took Resident 54 to the bathroom. Staff O stated they told the nurse that the resident was constipated and in pain. Staff O stated the resident got more confused when they were in pain. Staff O stated the resident probably had an impaction. Review of the July 2024 MAR, showed an entry on 7/18/2024 that the resident received Colace (a stool softener) at 6:20 AM. There were no entries of a bowel movement. Review of a nursing progress note dated 07/18/2024 at 12:53 PM, showed Resident 54 was transferred to the hospital for abdominal pain. Review of the 07/18/2024 hospital emergency department notes showed the resident had nausea and vomiting with a small bowel obstruction and a urinary tract infection. Review of the 07/22/2024 hospital physician's progress note showed the resident had an abnormal heartbeat and had to be cardioverted (a procedure where electroshock and medications are used to convert irregular heartbeats back to normal). <Fluid Restriction> <Resident 11> Review of Resident 11's medical record showed the resident was admitted with diagnoses including dementia, chronic kidney failure (chronic disease of the kidneys causing kidney failure), and congestive heart failure (a condition in which the heart doesn't pump enough blood to meet the needs of the body which can lead to fluid overload). Review of the most recent comprehensive assessment, dated 6/11/2024, showed the resident was cognitively impaired and exhibited poor judgement and decision-making skills. Review of a physician's order dated 06/11/2024, showed the resident had orders to restrict their daily fluid intake to 1800 milliliters (ml - a unit of fluid measurement). The orders showed nursing was allotted 1080 ml and dietary 720 ml, including meals. During multiple observations on 07/15/2024 at 9:30 AM, 07/16/2024 at 8:40 AM, 07/17/2024 at 8:30 AM, 07/18/2024 at 1:00 PM, and 07/19/2024 at 10:15 AM showed Resident 11 had a pitcher containing 950 ml of water on their bedside table. The bedside water was not calculated in their current fluid restrictions and put them potentially over 950 ml per day. During an interview on 07/17/2024 at 11:46 AM, Staff G, Registered Nurse, stated Resident 11 was not on an official intake monitoring. Staff G stated the resident was on a slightly restricted fluid intake which did not require monitoring. Staff G further stated they were not aware that Resident 11 had a water pitcher at their bedside as their fluid intake was already calculated and did not include any additional fluids. <Resident 38> Review of the medical record showed Resident 38 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, high blood pressure, and anxiety. The 06/16/2024 comprehensive assessment showed Resident 38 required partial/moderate assistance of one staff member for activities of daily living (ADLs). The assessment also showed Resident 38 was cognitively intact. An observation on 07/15/2024 at 1:15 PM, showed Resident 38 sitting in a recliner in their room. There was a 32-ounce cup of water on the bedside table. Resident 38 stated the staff came by and filled it up a few times a day. Resident 38 stated they had access to fluids throughout the day and did not know if they had a fluid restriction. Review of a physician order dated 06/25/2024, showed Resident 38 had an 1800 ml fluid restriction (720 ml from dietary and 1080 ml from nursing). Review of Resident 38's fluid intake records dated 06/26/2024 through 07/15/2024, from dietary and nursing, showed Resident 38 exceeded the maximum recommended fluid intake 15 out of 20 days. During an interview on 07/23/2024 at 8:34 AM, Staff E, Charge Nurse, stated fluid intake was monitored by the floor nurses. They stated Resident 38 was non-compliant with fluid intake and a risk/benefit with education should have been completed. Staff E stated the physician should have been notified. Review of Resident 38's medical record showed there was no documentation that risks and benefits were discussed with the resident. There was no documentation of a risk/benefit form or that the resident's physician had been notified. <Physician Orders> <Resident 13> Review of the medical record showed Resident 13 was readmitted to the facility on [DATE] with diagnoses including heart failure, iron deficiency anemia, and hypothyroidism (a condition in which the thyroid gland doesn't produce enough thyroid hormone, disrupting such things as heart rate and body temperature). The 04/29/2024 comprehensive assessment showed Resident 13 required substantial assistance of one to two staff members for ADL's and had a severely impaired cognition. Review of a physician progress note dated 02/05/2024 at 3:23 PM, showed orders for lab work, that included rechecking Resident 13's thyroid stimulating hormone [(TSH) a test that measures the amount of thyroid hormone in the blood), iron studies (blood tests that measure the amount of iron in the blood and other cells), and a medication change. Review of Resident 13's medical record showed no results for the ordered lab work, and the medication change had not been completed. During an interview on 07/22/2024 at 10:28 AM, Staff E stated Resident 13 often refused to have lab work completed. Staff E stated they typically tried to get the labs twice, then another nurse would try. Staff E stated it looked like that process had not been done. During an interview on 07/22/2024 at 11:27 AM, Staff D, Resident Care Manager, stated all provider notes were reviewed by the charge nurse. Any new orders would be updated by the end of the day by the charge nurse. Staff D stated when a resident refused to have lab work done by facility staff, they would send them out to the lab for completion of the orders. Staff D stated they did not see the medication change or the completed lab work in the record. During an interview on 07/22/2024 at 2:10 PM, Staff C, Assistant Director of Nursing Services, stated the process for obtaining lab work for difficult residents included multiple attempts at different times by different staff. If the staff were still unable to obtain the sample, the facility would send the resident out to the lab to obtain the sample. Staff C stated they did not see documentation on that missed lab draw in the system. Staff C stated the Charge Nurse was responsible for reviewing physician notes after they round in the facility. They stated the physician typically entered their own orders into the system, but the charge nurse should go back and review the notes to make sure those orders were completed. Staff C stated they did not see that the medication order had been changed and that the charge nurse should have caught that. <Resident 36> Review of Resident 36's medical record showed they were admitted to the facility on [DATE] with diagnoses including fracture of left leg, peripheral vascular disease (PVD-a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), and diabetes (a group of diseases that result in too much sugar in the blood). The 04/16/2024 comprehensive assessment showed Resident 36 was dependent on two staff members for ADLs and mobility. The assessment also showed the resident had an unstageable (full-thickness tissue loss covered by dead tissue and/or scab) pressure injury (PI-localized injury to skin and underlying tissues) and an intact cognition. Record review of Resident 36's wound assessment dated [DATE], showed the provider's plan was to refer the resident to an outside wound care clinic to establish care and receive further treatment for their unstageable pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure) on their left heel. Further review of Resident 36's record showed a signed, 05/29/2024, physician's order for the referral to the outside wound care clinic. Review of Resident 36's medical record showed their first appointment with the outside wound care clinic was on 07/18/2024, 50 days after the physician referral. During an interview on 07/15/2024 at 1:29 PM, Resident 36's Representative (RR), stated the resident had developed their left heel pressure wound since they had been at the facility and were waiting for an appointment to see the outside wound clinic for treatment. The RR stated the plan was to have Resident 36 move back home with them when their PU was healed. During an interview on 07/18/2024 at 11:09 AM, Staff E, Charge Nurse, stated the process for referrals for residents was reviewing the providers notes, filling out an order slip and having the provider sign it. They would then give the order slip to Staff K, Medical Records, to complete the referral. Staff E further stated that 07/18/2024 was Resident 36's first appointment to the wound clinic and the delay was on the facility but was unsure why there was a delay. During an interview on 07/19/2024 at 10:39 AM, Staff K stated they sent in four different resident referrals, including Resident 36's, to the outside wound clinic in early June 2024. Staff K stated all the residents were scheduled in June for their appointments and were unsure why it took so long for Resident 36 to be scheduled. Staff K stated they did not call the wound clinic to inquire about the delay, as it was their process to have the wound clinic call the facility when they were ready to schedule. Reference: WAC 388-97-1060(1) 39652 45117 46722

Based on observation, interview, and record review, the facility failed to provide the necessary treatment and services to prevent the occurrence of an avoidable pressure ulcer (PU-injury to skin and underlying tissue resulting from prolonged pressure) and implement wound care and services timely to avoid worsening of a PU for 3 of 5 residents (Residents 48, 108, and 13) reviewed for PU's. Resident 48 experienced harm when the facility failed to follow physician orders to ensure healing of their avoidable Stage 4 PU (a full thickness tissue loss of tissue with exposed bone, tendon, or muscle) to their coccyx (tailbone) and obtain pain control measures during wound care. Resident 108 experienced harm when the facility failed to recognize and modify treatment of an unstageable PU (full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen) on their left great toe and a Stage 2 PU [partial thickness skin loss with exposed dermis (the top inner layers of skin)] on their left heel. These failures placed residents at risk for PU development, continued deterioration of pressure ulcers, infection, and pain. Findings included . Review of the National Pressure Injury (ulcer) Advisory Panel (leading expert in pressure ulcer/injuries/wounds) guidance, dated September 2016, defines pressure ulcer/injury stages as follows: Stage 1 Pressure Injury has intact skin with a localized area of non-blanchable erythema (redness). Stage 2 Pressure Injury is partial thickness skin loss with exposed dermis (the top inner layers of skin). Stage 3 Pressure Injury is full thickness loss of skin, in which adipose (fat) tissue is visible in the ulcer. Slough (dead tissue) and/or eschar (dried blood and tissue) may be visible, granulation tissue and epibole (rolled or curled under edges) may be present, with undermining (a pocket of dead space under the visible wound edges) and tunneling (a passageway under the wounds surface which may be shallow or deep and impairs wound closure). Stage 4 Pressure Injury is full thickness loss of skin and tissue, with exposed or directly palpable fascia (a layer of connective tissue), muscle, tendon, ligament, cartilage, or bone in the ulcer. Epibole, undermining and tunneling often occur. Unstageable Pressure Injury is full thickness skin and tissue loss to which the extent of the tissue damage cannot be seen. Review of the facility's policy titled, Pressure Injury Prevention and Management, dated 02/14/2024, showed the facility would provide treatment and services to heal pressure ulcers and prevent the development of additional pressure ulcers. The policy also showed an avoidable pressure ulcer meant the resident developed the pressure ulcer at the facility and did not .implement interventions consistent with resident needs, goals and professional standards of practice .monitor or evaluate the impact of interventions . and/or revise the interventions. <Resident 48> Review of Resident 48's medical record showed they were admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), Chronic Inflammatory Demyelinating Polyneuropathy [(CIDP) - a disorder that damages the protective layer of nerves, causing weakness, numbness, and pain in the limbs), and diabetes (a group of diseases that results in too much sugar in the blood). The 07/01/2024 comprehensive assessment showed Resident 48 required maximal assistance of one to two staff members for activities of daily living (ADLs) and dependent of two staff members for transfers. The assessment also showed Resident 48 had moderately impaired cognition. Review of Resident 48's 04/05/2023 admission comprehensive assessment. showed they did not have a PU and were at risk of development of PUs. Review of the 01/03/2024 comprehensive assessment showed the resident had an unstageable (full-thickness tissue loss covered by dead tissue and/or scab) PU. Further review of the resident's 04/05/2024 comprehensive assessment showed the resident had a Stage 4 PU. Review of Resident 48's 12/13/2023 skin/wound evaluation, showed the resident had an in-house acquired unstageable coccyx (tailbone area) PU that presented with slough covering the wound bed. Additional review of Resident 48's skin/wound evaluations showed their coccyx PU was documented as a Stage 4 and not an unstageable PU. Review of Resident 48's 03/01/2024 Staff GG, Advanced Registered Nurse Practitioner, (ARNP) note, showed nursing management confirmed a wound vac (a machine that helps wound healing by pulling wound edges together) had been ordered for the resident. Further review of the medical record showed no documentation that the wound vac had been ordered. Review of Resident 48's physician orders showed a referral, dated 04/25/2024, to obtain a surgical consult to evaluate and treat their Stage 4 coccyx PU (56 days after the practitioner's note that a wound vac had been ordered). Further review of the medical record showed no documentation the resident had a surgical consult. An observation and interview on 07/16/2024 at 9:02 AM, showed Resident 48 lying in their bed, on their back, with pillows under each side of their rib area. Resident 48 stated they had been to the wound clinic yesterday, their bottom was very sore, and their pain was a 10 out of 10 on the pain scale (a measurement of pain, 0 no pain and 10 is severe pain). Resident 48 stated that if they did not move their position much, their pain would remain a 5 out of 10. Resident 48 further stated when the nurses changed their wound dressing on their bottom, they did not provide pain medications before or after and it was a painful process. During an interview on 07/16/2024 at 2:12 PM, an outside wound care consultant (OWCC), stated Resident 48's first appointment with the wound clinic was on 06/17/2024 (53 days after the surgical consult was ordered). The OWCC stated Resident 48 stated they were in pain during their wound care treatments at the facility. The OWCC stated during the treatment at the wound clinic, the resident did moan and groan during the clinic treatment. The OWCC continued to state that the provider at the wound clinic had ordered a wound vac on this appointment and called the facility nursing director for instructions for submitting the wound vac order. During an observation and interview on 07/17/2024 at 8:54 AM, Resident 48 was lying in bed on their back with the head of their bed up. Resident 48 stated they had a wound dressing change earlier that morning and it was very painful, above a 10 on the pain scale. Resident 48 stated they told the nurse it hurt, yet they did not receive pain medication. During an interview on 07/17/2024 at 9:23 AM, Staff Y, Nursing Assistant (NA), stated they assisted the nurses with wound dressing changes. Staff Y stated Resident 48 would complain of pain during the wound dressing change. During an interview on 07/17/2024 at 9:51 AM, Staff I, Licensed Practical Nurse (LPN), stated Resident 48's pain medications consisted of scheduled Tylenol (a medication to treat mild to moderate pain) 1000 milligrams (mg-unit of measure) three times a day. During an observation and concurrent interview on 07/17/2024 at 10:19 AM, Staff G, Registered Nurse (RN), and Staff Q, Infection Control Nurse (ICRN), performed Resident 48's pressure ulcer dressing change. Staff Q stated they had been performing the pressure wound treatment for a month and stated the wound had remained the same. Staff Q stated that healing was slow. During the pressure wound treatment, Resident 48 yelled out in pain when Staff Q was measuring the wound tunnelling. Staff Q continued with the wound care treatment and did not address Resident 48's pain. After the pressure wound treatment, Resident 48 stated to Staff G and Staff Q their pain during the procedure was a 12/10 and Tylenol did not help with their pain during the procedure. Staff Q and Staff G did not acknowledge Resident 48's complaint. During an interview on 07/17/2024 at 10:56 AM, Staff G, stated they were aware the PU wound dressing changes were painful for Resident 48. Staff G stated the resident should have pain medication prior to the dressing changes and their current pain management was not effective. During an observation, interview, record review, on 07/17/2024 at 2:12 PM, Resident 48 was in their bed, on their back, and the head of their bed elevated. Resident 48 stated their pain level was an 8/10 on their bottom where their wound was. Resident 48 stated they did not receive any additional medication for pain. Review of Resident 48's Medication Administration record showed they were administerd Tylenol 1000 miligrams (unit of measure) at 8:00 AM, 12:00 PM and their next dose was due at 6:00PM. During an interview on 07/17/2024 at 2:27 PM, Staff G stated they did follow up with Resident 48 for their pain after the earlier wound care. Staff G stated when they asked the resident how their pain was, Resident 48 just looked at them and gave no response. Staff G stated the resident received scheduled Tylenol for pain and the upcoming dose was close to being administered. During an interview on 07/18/2024 at 9:29 AM, Resident 48's Representative, (RR), stated the resident's PU had developed at the facility and had been worsening without improvement. The RR stated Resident 48 did complain of pain during the wound care treatments and the resident was not provided any additional pain medications. Resident 48's RR stated they had observed the resident decline in their health, as the resident did not want to get out of bed and participate in any activities or visit outside like they used to due to their pain. During an interview on 07/19/2024 at 8:53 AM, Staff D, Resident Care Manager, stated Resident 48's coccyx PU healing had stalled (stopped making progress). Staff D also stated they had performed the resident's wound dressing changes, and they were aware Resident 48 was in pain during the wound care, as the resident would grunt and tell them to be careful. Staff D stated pain medications had not been administered before or after the wound care and they had not requested any additional pain medication from the provider for Resident 48. During an interview on 07/19/2024 at 12:10 PM, Staff E, Charge Nurse, stated the process for referrals was to send to the referral to medical records for completion. Staff E stated they were unaware of Staff GG notes dated 03/01/2024, for Resident 48's ordered wound vac that was confirmed by nursing management. Additionally, Staff E stated they were aware of the order placed for the surgical consultation referral on 04/25/2024 but did not follow-up and was unsure of the outcome of the referral. 31168 <Resident 108> Review of the medical record showed the resident resided at the facility for many years. Resident 108's last readmission was 07/01/2024, with diagnoses including dementia (cognitive impairment), heart disease, kidney disease, diabetes (when the body does not enough produce insulin-a hormone that regulates blood sugar), and pressure ulcers to the resident's left heel and left great toe with ongoing cellulitis (bacterial infection of the skin layers) to their left heel/foot. The 07/04/2024 comprehensive assessment showed that Resident 108 was cognitively impaired but could make their needs known, such as pain. Resident 108 required assistance to transfer to and from different areas, such bed to wheelchair, bathing, oral care and personal hygienic care. During an observation and concurrent interview on 07/16/2024 at 9:50 AM, Resident 108 was in bed and watching television. Their left foot had a dressing over it and the foot was elevated on a pillow. The resident stated they were sleepy and wanted to take a nap. During an observation on 07/17/2024 at 9:02 AM, Staff Q, during a wound dressing change, removed the old dressing on the resident's left heel. The resident's left heel PU wound bed was white in color (could not visualize the wound bed). Additionally, the skin that surrounded the wound was red with extremely dry with flakey skin. The treatment was applied, and the dressing covered the left heel PU. Staff Q then cleansed the resident's scabbed left great toe and applied the treatment. Staff Q stated that the resident's pressure ulcer to the left great toe had gotten worse and had not improved. During an observation on 07/17/2024 at 9:27 AM, Resident 108 complained of significant pain in their left heel. The resident became restless and moaning that their foot was cold and freezing. Staff Q went to the get Tylenol and gave it to the resident. Staff Q stated they did not pre-medicate the resident before the dressing change. Continuing the 07/17/2024 observation at 10:20 AM, Resident 108 was pleading and crying in pain in their left foot and for someone to help them. The Director of Nursing Services (DNS) was notified and obtained a physician's order for a narcotic pain reliever for the resident. During an interview on 07/17/2024 at 10:50 AM, Resident 108 stated the pain increased in intensity from intermittent to constant stabbing pain. During an interview on 07/17/2024 11:40 AM, Staff C, Assistant Director of Nursing Services (ADON), stated the resident had developed a left foot PU to their heel due to their shoes being too tight on their left heel and it rubbed against their heel. The resident was not to wear the shoes again, but the tight shoes were not removed from Resident 108's room and the resident continued to wear them. This was around the end of January 2024. The Resident Representative (RR) was notified of this, and the facility asked them to bring different shoes for Resident 108. The RR brought new shoes according to Staff C, but the new shoes were open toe shoes and rubbed against the large great toe, which caused another PU to the left great toe that had not improved. The left heel pressure ulcer and the left great toe pressure ulcer were acquired at the facility. Staff C stated the left great toe PU was discovered around 02/25/2024. Review of the 02/06/2024 interdisciplinary meeting notes, showed the resident developed a Stage 2 pressure ulcer on their left heel. Additionally, the 02/05/2024 and 02/06/2024 nurses progress note showed the RR was notified that Resident 108 needed larger sized shoes. Review of the 01/26/2024 Clinical Skin and Wound Evaluation (CSWE), showed identification of a Deep Tissue Injury [(DTI) - purple or maroon area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear] to the left heel. The 07/17/2024 CSWE showed the left heel was a Stage 2 PU. Additionally, the CSWE, dated March 26, 2024, showed the DTI to the left great toe. The 07/17/2024 showed Resident 108's left great toe PU had not improved. The updated care plan dated 07/08/2024 through 07/23/2024, showed the resident had acquired two PUs to the left foot, an unstageable PU to the left great toe, and a Stage 2 PU to the left heel. The resident's care plan goal was to have intact skin, free of redness, blisters, or discoloration by/through the review date. A Velcro boot to the left foot and air overlay for the mattress were added to the care plan. There were previously no identified PU on the care plan. There was a statement to use the preventative measures policy for checking feet for diabetes. Review of the 03/27/2024 wound nurse health status note showed the wounds to the left heel, left great toe, and the middle of the left foot was red/purple in color with swelling. There was suspected cellulitis (a bacterial infection of the skin that becomes red, swollen and painful) to the toe and an antibiotic was ordered for seven days. The resident had to change their shoes. Review of the 04/22/2024 nursing progress note showed wounds to Resident 108's left great toe and left heel since March 2024. They had progressively gotten worse to the point of needing further treatment that day. The resident had cellulitis and was sent to the emergency room for treatment. Review of a 07/11/2024 x-ray showed the resident's left foot had osteomyelitis (infection of the bone spreading from nearby tissue.) During an interview on 07/16/2024 at 9:40 AM, Staff B, Director of Nursing Services (DNS) stated Resident 108 had declined and saw a physician who recommended amputation of the left foot due to the decline. Staff B stated the resident's RR would probably not want Resident 108 to have that surgery. During an interview on 07/19/2024 08:26 AM Staff D, stated Resident 108's PU started on the heel due to the resident's tight shoes. The podiatrist (foot doctor) worked on the residents' foot and there were no preventative interventions to keep the shoes away from Resident 108 or from having the shoes placed on the resident's feet. The RR was the one who removed the shoes from the resident's room. The resident had edema (swelling) and continued to have edematous feet, which caused tightness of the shoes. The new shoes that were brought by the resident's RR were used and continued to be placed on the resident's feet, which resulted in the left great toe's skin break down and PU. 45117 <Resident 13> Review of the medical record showed Resident 13 was readmitted to the facility with diagnoses including Alzheimer's disease, dementia with behavioral disturbance (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), and weakness. The 04/29/2024 comprehensive assessment showed Resident 13 required substantial assistance of one to two staff members for ADLs and had a had a severely impaired cognition. Record review of a nursing progress note dated 06/22/2024, showed Resident 13 had two deep PU along their outer right foot, one slightly above their lateral (to the side of or away from the body) ankle and one along the outer middle of the right foot, with a red circle slightly below their pinky toe. The provider was notified and ordered float feet using pillows and monitor. Record review of a physician order dated 06/24/2024, showed Apply Opti-Foam (a foam dressing used to cover the wound and reduce friction) to right lateral foot on all three sites, every day shift, every three day(s) for wound care. During observations on 07/15/2024 at 10:10 AM, 07/16/2024 at 9:26 AM, 07/18/2024 at 2:03 PM, and 07/19/2024 at 10:30 AM, showed Resident 13 lying in bed on their right side with their right outer foot against the mattress. Their feet were not floated on pillows and there were no padded boots on their feet. A concurrent observation and interview on 07/16/2024 at 3:15 PM, showed Resident 13 sitting in their wheelchair in their room. Staff R, RN, removed the resident's sock from their right foot. There was a foam dressing on the outer middle right foot. There was no dressing on the outer right ankle or toe wounds. Staff R peeled back the foam dressing and exposed a dime size area on the outer middle right foot that had yellow slough and a small amount of drainage. The right ankle had a dime size reddened area, and a red area at the base of the right small toe. Staff R stated they tried to float the resident's feet on pillows or put the padded boots on, but the resident kicked them off. Staff R stated they had asked Staff D, Resident Care Manager, for a specialized air mattress several weeks ago but was unsure why the resident did not receive one. Record review of a skin and wound assessment dated [DATE], showed new wounds were identified as pressure, deep tissue injury, and facility acquired. The wound on the outer right foot measured 0.94 centimeters [(cm) a unit of measurement] long and 0.63 cm wide. The surrounding tissue was fragile with erythema (an abnormal redness of the skin) and pain/tenderness to the touch. There were additional areas of concern on the right ankle and outer base of the right small toe. There were no measurements of these additional wounds. The document showed there was no dressing applied to the wound area, and the residents' feet were to float on pillows. Review of a skin and wound assessment dated [DATE], showed the outer right foot wound measured 15 cm in length and 1.91 cm in width. The wound was described as a deep pressure sore with the middle open. The surrounding tissue was described as fragile with erythema. The document showed the deep pressure sores were painful to the touch. Treatment orders showed the primary dressing was foam and to float both feet with pillows. The progress was described as deteriorating. Review of a skin and wound assessment dated [DATE], showed the outer right foot wound had measured 13.42 cm long and 1.3 cm wide. The wound was 80% slough with a light amount of exudate (fluid that leaks out of blood vessels into nearby tissues). The treatment included use of a foam dressing and float both feet using pillows. The progress was described as deteriorating. Review of a nursing progress note dated 06/22/2024, showed Resident 13 refused to float their feet on pillows and nursing staff placed their feet in padded boots for pressure relief. During an interview on 07/22/2024 at 11:22 AM, Staff D stated Resident 13 was non-compliant with the use of pillows and padded boots. Staff D stated an air mattress might help - they could probably use one. Staff D stated there were additional interventions that could have been implemented besides the pillows and padded boots. During an interview on 07/22/2024 at 2:05 PM, Staff C, stated the provider had reassessed the wound that day and were changing the treatment to a medicated ointment and gauze dressing. Staff C stated an air overlay mattress would be beneficial since Resident 13 was non-compliant with the pillow positioning or padded boots. Staff C stated if interventions for pressure relief were not working, they expected the staff to notify the physician and advocate for the resident for increased interventions. During an interview on 07/22/2024 at 3:17 PM, Staff B, DNS stated they would have expected nursing staff to report the concerns with non-compliance with the pressure relieving interventions. Reference: WAC 388-97-1060(3)(b) This is a recurring deficiency previously cited in the Statement of Deficiencies dated September 14, 2023.

Based on observation, interview, and record review, the facility failed to provide the assessed level of supervision required to prevent avoidable accidents for 1 of 1 resident (Resident 54) reviewed for falls with injuries. Additionally, the facility failed to identify active smokers, and the level of supervision required to smoke safely, for 3 of 3 residents (Resident 214, 216, and 212) reviewed for smoking. Resident 54 experienced harm when they fell while using their front wheel walker with a right sided platform attachment (a support that attaches to the walker to support the forearm and shoulder) when walking to the bathroom unsupervised that resulted in a laceration above the right eyebrow and fractured right ribs. The failure to identify potential hazards and implement adequate supervision placed the residents at risk for falls, injury, and an unsafe living environment. Findings included . <Fall With Injury> Review of the policy titled Fall Prevention Program dated 09/05/2023, showed the facility was to ensure each resident would be assessed for fall risk and receive care services in accordance with their individualized level of risk to minimize their likelihood of falls. <Resident 54> Review of the medical record showed Resident 54 was admitted to the facility on [DATE] with diagnoses including osteopenia (a reduction of bone mass that causes brittle bones), therapy after a significant fall with multiple fractures of the right wrist, lower spine and the lower pelvic bone, thrombocytopenia (a low platelet count which can lead to excessive bleeding during an injury), high blood pressure and a urinary bladder infection. The 06/16/2024 comprehensive assessment showed the resident was impaired cognitively but able to voice their needs. The resident needed help/partial assistance with activities, such as directions on use of their walker. Resident 54 was impaired physically on one side due to a previous fracture and had unsteadiness when walking. The resident was frequently incontinent of bladder. During an observation and concurrent interview on 07/15/2024 at 9:00 AM, Resident 54 was lying in their bed moaning. The resident was curled up and complained of right upper side and back pain. There was a laceration over their right eyebrow and a Velcro wrist brace to their right wrist. The resident's head of the bed was up, and the resident's wheelchair was located by their bed within the resident's reach. The resident's walker was located on the other side of the resident's bedside table. The resident stated they had their walker by the bed and tried to get out of bed to go to the bathroom and fell . Review of the 06/12/2024 care plan showed Resident 54 required assistance with transfers, bed in a low position, hourly safety checks and a scheduled toileting program. The resident wore disposable briefs for dignity for bladder incontinence. The admission fall risk assessment dated [DATE], showed the resident was a moderate risk for falls. Review of the 07/01/2024 nurses progress notes, showed Resident 54 went to the emergency room (ER) for an unwitnessed fall and sustained a laceration over the right eyebrow, right hand, a bruise to the left knee and had returned to the facility. On 07/02/2024 the resident continued to complain of pain, and an x-ray was ordered. The results from the x-ray showed right rib fractures due to the 07/01/2024 fall. Review of the 07/01/2024 fall investigative report showed Staff L, Licensed Practical Nurse (LPN), entered Resident 54's room at 5:30 AM to give medications. Staff L observed the walker by the resident's bed with the bed control cord wrapped around the legs of the walker and the walker on its side on the floor. The resident was in bed on their side under a blanket. Staff L turned on the light in the room and saw blood on Resident 54's face and hands. The resident stated ouch when the nurse looked at the resident. The 07/01/2024 investigation showed the resident stated, after their fall, they placed themselves back in bed. The 07/01/2024 investigative report showed the last time the resident was observed was at 4:00 AM. Night staff had not heard or observed if the resident had fallen or was bleeding until Staff L entered the resident's room. The 07/01/2024 update to the care plan included a scheduled toileting program, a cue card placed on the resident's room which stated for Resident 54 to use their call light when needing assistance, and to continue safety checks. During an interview on 07/16/2024 at 11:40 AM, Staff P, Physical Therapy Assistant/Rehabilitation Director, stated the resident was on therapy for weakness and falls at home. Resident 54 was given a front wheeled walker with a platform attached to the right side of the walker for stability due to their fractured right wrist. Additionally, the resident had difficulty understanding how to use the platform on the walker to stabilize their right wrist and used poor judgement to safety in ambulation by not carefully walking purposefully, but hurried, and that was unsafe. Staff P continued to try to educate the resident on safety and not placing weight on right wrist, but it was not successful, and they discharged the resident from therapy. Nursing staff was notified. During an interview on 07/18/2024 at 8:58 AM, Staff O, Nursing Assistant (NA), stated Resident 54 had become weaker and now only used a wheelchair. Staff O stated when the resident was first admitted they used a walker and required assistance. Staff O stated that the resident needed more assistance after the fall on 07/01/2024. Additionally, Staff O stated that there was a conversation with the night NAs, and they assisted the resident to bed after the 07/01/2024 fall. During an interview on 07/19/2024 at 8:35 AM, Staff D, Resident Care Manager, (RCM), stated that Resident 54 was unsafe, used their walker in the room, did not wait for staff, and did not use their call light. There were two NAs on the east wing and two NAs on the west end at night, and it was hard to supervise due to the fact they were in two separate buildings. During an interview on 07/19/2024 at 9:02 AM Staff L, stated when they came to work on the morning of 07/01/2024, they went into the resident's room and found Resident 54 with blood on their face and arm. Staff L stated Resident 54 stated they fell on night shift while trying to use the walker to go by themselves to the bathroom. Resident 54 stated they did not use the call light and they usually did not use the call light. Resident 54 stated that the cord was wrapped around the bottom of their walker, and they tried to undo it and fell , hitting their head right above the eyebrow that caused a laceration, and then got back into bed. Staff L was asked if they observed the walker on its side on the floor with the bed cord wrapped around the legs of the walker. Staff L said they did not witness the placement of the walker and the cord around the legs of the walker, but just reported what the resident had stated. <Smoking Hazard> Review of a policy titled, Smoke Free Facility, dated 09/05/2023, showed smoking was prohibited in all areas of the facility and the facility grounds. Residents would be informed of the facility's smoke free policy during the pre-admission/admission process and would be required to sign acknowledgement of the policy upon admission. All residents would be asked about tobacco use during the admission process and those with a history of smoking would be further assessed to determine whether or not interventions were needed to help them cope with the smoke free policy. Review of an undated document titled, Memorandum of Understanding [([NAME]) a type of agreement between two parties that defines how each party will work together and lays out expectations and understandings] Regarding Smoking Policy for Residents at the [NAME] Odd fell ows Home, showed smoking was not permitted anywhere on the premises. Cigarettes and lighters must be stored in a designated locked area when not in use. A risk/benefit form would be completed by a facility team member. A smoking assessment would be completed by a team member. <Resident 214> Review of the medical record showed Resident 214 was admitted to the facility on [DATE] with diagnoses including a urinary tract infection, kidney failure, and psychoactive substance dependence (a strong desire or compulsion to take/use alcohol, caffeine, nicotine, marijuana, and certain pain medications). Resident 214 was able to make their needs known. An observation on 07/15/2024 at 3:45 PM, showed Staff V, NA, escort Resident 214 outside to smoke, off facility property. Resident 214 was observed sitting on their front wheeled walker, with cigarette ash falling onto their sweatpants. When Resident 214 completed their cigarette, they asked Staff V where to put the butt. Staff V stated they would have to throw it away when they returned to the building. Staff V escorted Resident 214 back to the building and waited for facility staff to open the locked door. Resident 214 and Staff V entered the building, Staff V walked towards the left upon entering and Resident 214 walked to their room to the right. During an interview on 07/15/2024 at 4:24 PM, Resident 214 stated Staff V had taken the extinguished cigarette butt, placed it in a glove, and threw it in the trash. Resident 214 stated they had their cigarettes and lighter in their pocket and had planned on smoking while at the facility. Resident 214 stated a man that works here took me out earlier today to smoke. During an interview on 07/15/2024 at 4:26 PM, Staff V stated they took the cigarette butt from Resident 214 and wrapped it in a glove, then threw it in the trash can (and pointed to a trash can at the NA charting station). Staff V asked, was that wrong? During an interview on 07/16/2024 at 9:29 AM, Resident 214 stated they did not know they could not smoke at the facility. They stated no one had asked to hold their cigarettes or lighter in a locked area for them. During an interview on 07/22/2024 at 10:45 AM, Staff D, RCM, stated the process for smoking included identifying current residents that smoked prior to admission. They stated they were aware that Resident 214 smoked cigarettes but did not know they were currently smoking. Staff D stated the facility policy disallowed for staff to escort residents outside to smoke. They stated they were not aware that Resident 214 had cigarettes and a lighter in their possession and had not asked that question on admission. They stated the process for securing cigarettes and lighters included placing them in a locked area until the resident was discharged for safety. Staff D stated my process should have been to ask if they had the cigarettes and lighter and discuss options. Review of the medical record showed an undated [NAME] for smoking had been completed with Resident 214. A smoking assessment was completed on 07/19/2024 at 4:06 PM, that showed Resident 214 required supervision while smoking and the facility needed to store the resident's lighter and cigarettes. <Resident 216> Review of the medical record showed Resident 216 was admitted to the facility on [DATE] with diagnoses including sepsis (a serious condition in which the body responds improperly to an infection), anxiety disorder, and tobacco use. The resident was able to make their needs known. During an observation and interview on 07/17/2024 at 2:05 PM, Resident 214 was observed standing in the doorway of their room with their walker and a cigarette and a lighter in their right hand. Resident 214 stated before that nurse comes back, I am going to sneak outside to smoke - before the alarm goes off. Resident 214 walked to the exit door at the end of the hall near room [ROOM NUMBER], placed the unlit cigarette in their mouth, pushed random buttons on the security keypad and waited for the door lock to release. They walked out of the facility with the cigarette in their mouth, lit the cigarette, and proceeded to smoke outside the facility door. Facility staff responded to the alarming door, Staff W, NA, silenced the alarm, observed Resident 214 outside smoking, and walked away from the door, without addressing the resident or smoking. Resident 214 finished smoking and was escorted back into the building by Staff C. During an interview on 07/17/2024 at 2:34 PM, Staff N, Registered Nurse, (RN), stated they were aware that Resident 214 was going outside to smoke. They stated Resident 214 was okay to smoke outside with family but was not told that they had to go off property. Staff N stated the facility was not storing the resident's cigarettes or lighter. Review of the medical record showed a smoking assessment was completed on 07/19/2024 at 4:13 PM, two days after Resident 214 was observed smoking independently on facility property. The assessment showed the resident required supervision for smoking, and the facility needed to store their cigarettes and lighter. There was an undated [NAME] for smoking in the record signed by the resident and Staff H. During an interview on 07/22/2024 at 11:03 AM, Staff D stated they were not aware that Resident 214 was actively smoking until they received that information during shift hand-off report. Staff D stated they allowed the resident to go outside several times on their shift and observed them going beyond the facility sidewalk. Staff D stated they did not know if Resident 214 had been assessed for safe smoking or if an assessment had been done to allow them to be outside alone. Staff D stated they were not aware that Resident 214 had cigarettes and a lighter. Staff D stated they should have looked at assessing for safety, ambulation, and the resident's cognitive status to ensure they were safe to smoke alone. During an interview on 07/19/2024 at 11:55 AM, Staff C, Assistant Director of Nursing Services (ADON), stated the process was to screen for smoking status during the referral process. They stated Resident 214, and Resident 216 snuck by. Staff C stated they could not have staff escort residents off property to smoke and there was no process in place to secure cigarettes and lighters for residents. <Resident 212> Review of the medical record showed Resident 212 was admitted to the facility 07/12/2024 with diagnoses including schizophrenia (a chronic brain disorder that causes delusions, hallucinations, disorganized speech, trouble thinking, and lack of motivation) and major depressive disorder. Resident 212 was able to make their needs known. During an observation on 07/22/2024 at 12:21 PM, Resident 212 approached Staff N at the medication cart and requested their cigarettes and lighter so they could go outside to smoke. Staff N stated they did not have them. During an interview on 07/22/2024 at 12:37 PM, Resident 212 stated the facility took their cigarettes on 07/21/2024. Resident 212 stated they went out on 07/21/2024 to smoke, and when returning to the facility, the staff stated they needed to take their cigarettes and lighter per state policy. Resident 212 stated they understood that they could not smoke on facility property and had not. They stated staff told them they could have their cigarettes whenever they wanted, but that had not happened yet. Resident 212 stated if they knew they would not have access to their cigarettes, they would not have allowed the facility to take them. Review of the medical record showed an undated [NAME] signed by the resident and Staff H, Executive [NAME] President of Marketing. A smoking assessment dated [DATE] at 1:16 PM, showed the resident did not need supervision for smoking and the facility did not need to store the resident's cigarettes or lighter. During an interview on 07/22/2024 at 3:33 PM, Staff H, stated when they reviewed the resident record before admissions, and read they were actively smoking, they let the hospital case managers know that the resident could not smoke in the facility. They stated they did not always look at the case managers notes prior to the residents arriving to the facility to ensure the non-smoking information had been discussed. They stated they reviewed the non-smoking policy during the admission process but did not know Residents 214 and 212 were actively smoking. They stated they were aware that Resident 216 was currently smoking. Staff H stated their process included reviewing the smoking policy and ensuring residents signed the [NAME] regarding smoking. They stated they informed the residents that their cigarettes and lighters would be placed in a locked cabinet and had placed Resident 216's items in a locked cabinet with the resident present. Staff H stated they had notified facility staff of Resident 214's and 216's smoking status after completing the admission paperwork and [NAME]'s. During an interview on 07/23/2024 at 8:17 AM, Staff A, Administrator, stated the facility staff needed to come together as a team to formulate a process for residents that smoke, that included completing the [NAME], the assessment, and communicating the policy to the resident, their representative, and the staff. Reference: WAC 388-97-1060(3)(g) This is a recurring deficiency previously cited in the Statement of Deficiencies dated September 14, 2023. 45117

Based on observation, interview and record review, the facility failed to ensure three of three sampled residents (24, 58, 69) were free from abuse after the facility became aware of several staff to resident abuse allegations that were logged as grievances. Additionally, due to the facility's lack of identifying these occurrences as abuse allegations, they failed to immediately implement interventions toward the protection of residents (24, 58, 69) from further abuse when identified Staff (F, G) continued to work with unsupervised access to all residents from 06/19/2022 to 07/20/2022. The Resident Representative (RR) for Resident 24 stated that Resident 24 continued to express fear of Staff F's ongoing, persistent verbal expressions of dehumanization/humiliation when they entered their room. Furthermore, the facility had knowledge of Staff F's continued intimidating/demeaning approach without adequate intervention. These failures placed residents at risk for further physical/psychosocial harm and placed all the residents at risk for abuse. The failure of the facility to ensure residents were free and protected from abuse resulted in an Immediate Jeopardy (IJ) on 07/20/2022. On 07/20/2022 at 7:10 PM, the facility was notified of an IJ at CFR 483.12 (a)(1) F600 related to the facility's failure to immediately protect residents from identified staff in allegations of abuse that have had continued unsupervised direct care/access to Residents 24 and 58. The facility removed the immediacy on 07/27/2022 with an onsite verification from investigators by, removing Staff (F, G) from working with residents pending an investigation, re-educating all staff (prior to working their next scheduled shift) regarding abuse policies and procedures, to ensure an effective system was in place to keep residents free from abuse. Findings included . Review of the facility policy titled, Abuse, Neglect and Exploitation (to take advantage of), dated 03/11/2022, showed, The facility will make efforts to ensure all residents are protected from physical and psychosocial harm . and that possible indicators of abuse include, .Resident, staff or family report of abuse .Verbal abuse of a resident overheard .Psychological (affecting the mind) abuse of a resident .Sudden or unexplained changes in behaviors and /or activities such as fear of a person . Review of the Washington State Department of Social and Health Services guidelines titled, Nursing Home Guidelines, or The Purple Book, updated January 2020, showed the definition of abuse is the willful action or inaction that inflicts injury .intimidation, or punishment on a vulnerable adult. All allegations of abuse were to be thoroughly investigated and during that time the facility needed to protect residents' by ensuring that the suspected or accused staff person does not have unsupervised access to any resident. Additionally, the guidelines showed possible/actual indicators of various types of abuse also known as Key Triggers for timely action, which include, but were not limited to, .residents report of being verbally, emotionally, or mentally mistreated .use of demeaning statements .insults, humiliation, or intimidation .Sudden change in the resident's usual behavior . Resident 24. Review of the medical record showed the resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 04/21/2022 assessment showed the resident's memory was intact with some short-term memory loss but able to make their needs known. Review of a 06/21/2022 Grievance/Concern form showed the RR witnessed and reported an abusive verbal exchange with Staff F, Registered Nurse (RN) and Resident 24. This was reported to Staff D, Human Resource Director (HRD). During an interview on 07/20/2022 at 12:07 PM, the RR stated that on 06/19/2022, Staff F, RN, on multiple occasions stated the resident's recliner being too big and needed to get rid of it and commented on a hanging picture of Resident 24 and stated that the resident was really fat and that the RR should not bring in food for the resident. According to the RR, in the same interview, the resident felt intimidated and ridiculed about the continual gruff (a rough/harsh voice) and inappropriate language Staff F used to talk with the resident. Additionally, Resident 24 had lost 30 pounds in the last year and RR told Staff F they did not want to hear about the food anymore. The RR had reported previously to Staff H, Licensed Practical Nurse (LPN), about Staff F's gruff and rude behaviors and that the RR/resident did not want Staff F in the resident's room any longer. Even so, the RR further stated, Staff F still decided to re-entered the resident's room and stated to the resident we get along just fine now, don't we? According to the RR the Resident 24 was scared and looked at Staff F (RN) eerily (in a strange and frightening manner). During an interview on 07/20/2022 at 2:16 PM, Staff H, LPN, was aware that Staff F's approach had been an issue with residents and that Staff F had no filter sometimes, doesn't say the right thing. Staff H further stated they had multiple complaints about Staff Fs tone of voice and word choices and had previously talked to Staff F about that. Resident 58. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 05/30/2022 assessment showed the resident had impaired memory but was able to express their needs. Review of the 06/22/2022 Grievance/Concern Form showed that an abusive action was witnessed on 06/19/2022 by a visitor that observed, Staff F, LPN, having a loud verbal outburst directed at Resident 58 and abruptly pushed the resident's wheelchair forcibly down the hallway. During an interview on 07/20/2022 at 12:20 PM, RR (for Resident 24), stated they witnessed Resident 58 who had wheeled themselves over to the medication cart by Staff F. The visitor then overheard Resident 58 stating that they wanted something else to eat, in which Staff F replied with [Resident 58], you need to go back to your room, and forcibly pushed the resident in their wheelchair down the hallway towards Resident 58's room, (yelling) you need to just eat what your daughter ordered for you off the menu. Staff F also, stated to the resident you are just picky and won't eat it. During an interview on 07/20/2022 at 12:25 PM, Staff D, HDR, stated they had worked on 06/19/2022 (a Sunday) and Resident 24's RR reported that Resident 24 was very uncomfortable with Staff F caring for them. Additionally, the RR for Resident 24 had witnessed the incident with Resident 58 and reported that something needed to be done immediately. Staff D then gave them a grievance form to fill out and shared it with the nursing administration the next day. They did not recognize the allegations as abuse and stated that the Director of Nursing Services should have done that. Staff D stated that the nursing staff spoke to Staff F about their bedside manner but nothing else was done. Resident 69. The resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was alert/oriented and able to make needs their known. Resident 69 discharged on [DATE]. Review of Resident 69's comprehensive assessment care plan from 06/15/2022 to 07/02/2022 showed, Resident is blind and can only see shapes/shadows. Please identify yourself with name and title .explain each task .include resident in discussions regarding health care. Additionally, it directed staff to refer to the facility's Vision Loss Protocol for more guidance. Review of the facility's Severe to Total Vision Loss Protocol, dated 06/15/2020, showed staff to .explain all care and procedures before starting .do not rearrange belongings without telling the resident .explain how you want the resident to assist with care . Review of a Grievance log for June 2022 showed that on 06/21/2022 Resident 69 reported to Staff C, Assistant Director of Nursing Services (ADNS), felt Nursing Aid (NA) cared for her roughly. Review of the 06/20/2022 Grievance/Concern form (completed by, Staff C, ADNS) showed that Resident 69 stated that Staff G had roughly removed their shirt by yanking it off and was slamming things around. Then Resident 69 stated, you don't like me much, do you? to which Staff G replied with Well I'm taking care of you, aren't I. It was then stated by Resident 69 that Staff G had left the room and did not return. Furthermore, the resident stated that they had been to this facility previously for rehabilitation stays and has never had a problem with staff until [Staff G]. This incident was logged as a grievance, and Staff C, failed to recognize this incident as an allegation of abuse, thus did not rule out abuse. During an interview on 07/20/2022 at 10:38 AM, Staff C, stated that they had conducted the investigation/interviews with Resident 69 and Staff G. When asked if they saw Resident 69's statements as an allegation of abuse, Staff C stated no and that they were told that it was a grievance, but after discussion of Resident 69's allegations, Staff C stated, now I do. Furthermore, Staff C stated that they would have needed to rule out abuse with this allegation but did not (therefore Staff G still have unsupervised access to all residents). Refer to: F-607, F-609 Reference: WAC 388-97-0640 (1)

Based on observation, interview and record review, the facility failed to ensure prevention of pressure injury development, worsening of existing pressures injuries and prevent the development of additionally pressure injuries for three of four residents (74, 84 and 39) reviewed for pressure injuries. This failure caused harm to Resident (74) when their pressure injury worsened to a Stage IV (four) pressure injury to their leg/ calf, a worsened pressure injury to the right heel and a new pressure injury to the left heel which resulted in pain and discomfort and potentially other medical complications. Additionaly the facility failed to identify, assess and develope wound treatment orders in a timely manner for two of two residents (84 and 39). These failures resulted in harm for Resident 84 and placed resident (84 and 39) at risk for avoidable and untreated pressure injuries and a diminished quality of life. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Ulcer (Injury) Stages include: * Stage I: Intact skin with non-blanchable (skin does not turn white when pressed) redness of a localized area usually over a bony prominence. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. May indicate at risk persons. *Stage II: Partial thickness loss of dermis (the thick layer of living tissue below the epidermis) presenting as a shallow open ulcer with a red, pink wound bed, without slough (A layer of dead tissue separated from surrounding living tissue). May also present as an intact or open/ruptured fluid filled blister *Stage III: Full thickness tissue loss. Subcutaneous (under the skin) fat may be visible, but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. * Stage IV: Full thickness skin loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) and tunneling (when a wound progresses to form passageways underneath the surface). *Unstageable: Full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (a dry tan, brown or black scab) in the wound bed. Resident 74. Review of the medical record showed the resident was a long-term stay resident with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 01/03/2022 annual comprehensive assessment showed the resident exhibited no rejection of care, required two person extensive assistance with bed mobility, transfers, dressing, toileting, had functional limited Range of Motion (ROM) on the left side. The resident was assessed as at risk of pressure ulcers, and without pressure ulcers. According to the assessment the resident did have boggy left and right heels but wore protective boots to offload pressure. Review of the Resident's Skin and Wound evaluations showed: * An initial assessment dated [DATE] of a left heel pressure injury which measured 8.2 centimeters (cm), 3.9 cm in length and 2.9 cm in width. * An initial assessment of the right calf pressure injury dated 03/20/2022, measuring 2.0 cm in area by 2.4 cm in length and 1.2 cm in width as noted as Unstageable. * An incomplete initial assessment (only measurements) dated 03/04/2022 of a right heel pressure injury which measured 2.6 cm area, 2.2cm in width and 1.6 cm in width. Review of a 05/11/2022 order showed the resident was seen by a wound specialist for the right lateral calf wound which had worsened and was assessed as a Stage 4 pressure injury. Review of a 05/25/2022 wound specialist's assessment showed a request was given to nursing to start offloading that leg. Review of a 06/01/2022 wound specialists assessment showed it does appear nursing had the leg rests exchanged, possibly had more pressure prior to this. Review of a 06/06/2022 skin and wound note showed the wound to the calf was assessed at 4 cm area, 3 cm width with 2.5 cm undermining. The note showed the injury had necrotic (dead) tissue with bone and tendon exposed, foul odor, large amount of drainage. Additionally, a new area of pressure was identified below the initial injury which measured 4 cm by 2 cm was dark purple and non-blanchable. Review of the 03/25/2022 Kardex (directive to Nursing Assistants) showed to place pressure reducing device: Boots (cushioned heel protection) on while up in wheelchair and to float right lower extremity at all times, no pressure to right lateral calf. During an observation on 07/20/2022 at 11:45 AM, the resident was observed in a wheelchair, assisted into the dining room for the noon meal. The resident's legs were elevated 45 degrees and pillows were observed beneath the knee and foot of the right leg. The resident's feet had socks on them, and the heels were resting on a pillow, no protective boots were on the resident's feet. During an interview on 07/20/2022 at 12:52 PM, Staff MM, Nursing Assistant (NA) stated that they had worked at the facility for five years and regularly cared for Resident 74. Staff MM stated that NA staff used a pillow under the residents heels and had been directed by nursing staff that it was more effective, for this resident, to use a pillow under the feet/heels rather than protective boots. During an interview on 07/20/2022 at 1:09 PM Staff EE Registered Nurse/ Wound Treatment stated the position of treatment nurse had been vacant for several weeks, and they had been hired into the position a week ago. Resident 74 had a large open pressure injury on their right calf that was slow healing, a reoccurring pressure areas to the left and right heels and blisters on the inner area of their thighs due to an accidental burn from hot liquid. Staff EE stated that the record did not show an incident report had been completed for the right calf, however an assessment showed the pressure injury was the result of an ill-fitting wheelchair where the resident's calf was pressing against the metal bar on the leg rest. Staff EE stated it was the facility's protocol to complete an incident report but was unsure why one had not been completed. When asked why the resident was not wearing the ordered boots for protection of the heels, Staff EE stated the boots were not effective and that staff placed a pillow under the heels instead. During an observation on 07/21/2022 at the noon meal, Resident 74 was observed in the dining room, legs elevated, feet rested on a pillow. During an observation on 07/26/2022 at the noon meal, Resident 74 was observed with legs elevated, feet rested on a pillow. During an observation and interview on 07/26/2022 at 9:30 AM, the resident was observed seated upright in a wheelchair in the common area near the central nurse's station. The upper part (near the knee) of the resident's calf was pressing against the metal frame of the wheelchair. The resident's feet had non-skid purple socks, no protective boots and both heels were resting directly on the wheelchair foot pads. On 07/26/2022 at 9:40 AM, Staff JJ, Licensed Practical Nurse (LPN) Agency Licensed Nurse (LN) wheeled the Resident 74 into their room and stated they would be providing wound treatment to the resident's calf injury. Staff JJ stated that the resident was given Tylenol prior to the treatment because the procedure was very painful, and the resident would yell out of threaten to hit Staff JJ. Staff JJ observed the resident's calf against the wheelchair frame and stated that the resident had a shower in the morning and was in a different wheelchair. Staff JJ stated that the resident's feet should have boot protectors on and that the calf should not be pressing against the metal frame of the wheelchair. Staff JJ looked about the room and stated that the protective boots were missing, and they did not know where they were. On 07/26/2022 at 9:47 AM, Staff JJ lifted the resident's leg to which the resident winced and moaned. As the treatment continued Staff JJ began irrigating the open wound, the resident began moaning and put their hand to their mouth, eyes squeezed shut stated ooooh, oh my God. At that time Resident 74 looked at Staff JJ and said, I'm going to punch you. During an interview on 07/26/2022 at 2:00 PM, Staff EE stated that when the wound specialist observed the wound, they stated nursing staff were not packing the wound well enough, which may have led to the worsening of the wound. Resident 84. Review of the medical record showed the resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 06/07/2022 comprehensive assessment showed the resident required extensive assistance of one to two persons with repositioning, transferring, and activities of daily living (ADL's). The resident had one Stage II pressure injury and was at risk for potential pressure ulcers related to their limited mobility and incontinence. Review of the medical record showed the resident was admitted to the hospital on 05/26/2022 and readmitted to the facility on [DATE]. The Readmission nursing assessment dated [DATE] showed the resident had a Stage II pressure injury to the sacrum (back side of buttocks) no other skin issues were identified by facility. Review of a 07/08/2022 Incident report showed a Licensed Nurse documented Resident 84 had right heel wound greenish black in color and measured 3 cm (centimeters) x 1.5 cm. No other assessment of the heel was noted from 06/01/2022- 07/08/2022. Review of a 07/10/2022 Skin and Wound evaluation showed right heel wound measured area of 13.0 cm, length 5.1 cm, width 3.4 cm. The Treatment Administration Record (TAR) showed treatments to the heel started on 07/14/2022. During an observation on 07/14/2022 at 9:15 AM, Resident 84 was seated in a wheelchair, fully dressed, with their feet hanging off the foot pedals. The leg extensions of the wheelchair were not long enough to support the resident's leg/feet. During an interview on 07/14/2022 at 9:17 AM, Staff GG Physical Therapist (PT) was observed exiting the resident's room. Staff GG stated the that they were obtaining measurements to fit the resident for a new wheelchair to assist the resident with comfort and mobility and that the current wheelchair was too small for Resident 84. During a concurrent observation and interview on 07/19/2022 at 1:33 PM, Staff W, Licensed Practical Nurse (LPN) and Staff FF, Nursing Assistant (NA) were observed repositioning Resident 84 for wound care. Staff W cleansed a blackened area of dead tissue on the right heel. Staff W, then applied wound treatment/medicated pad and covered the gauze and secured with tape. Staff W changed gloves and removed old dressing to the sacrum with normal saline. Staff W changed gloves and the applied thin skin duoderm. Both staff members repositioned the resident on his side prior to leaving the room. During an interview on 07/20/2022 at 10:28 AM, Staff EE, Registered Nurse (RN), Quality Assurance Nurse (QAN) responsibilities: incident reports, wounds, skins assessments, falls and incontinence. Stated that Staff SS, Wound Care Specialist, Advanced Registered Nurse Practitioner (ARNP) takes care of our wounds here. Staff EE stated that I believe that those wounds could have been avoidable. We just got a new order change for wound care; the nurses were not using the correct dressing to the sacrum. During an interview on 07/21/2022 at 12:55 PM Staff B, Interim Director of Nursing Services (DNS) stated when they saw the pictures of the wound for Resident 84, I was wondering how this was a blister by the way it looked, I was just so surprised. During an interview on 07/21/2022 at 1:35 PM, Staff H, LPN, Charge Nurse stated they did not know how long the resident had the wound to the heel and stated I believe it was noted on the (July)11th. I'm not sure I was out of the facility until the 07/14/2022. I'm not sure when Staff SS was consulted but, was told that they had seen the resident's right heel and was taking of care of it. The sacral wound was noted on 06/01/2022 when the resident came back from a hospital stay of four to five days. Review of nurse progress notes dated 07/08/2022 showed the resident had a deep tissue injury to the right heel, the record showed there was no follow-up for treatment orders until 07/11/2022 (three days later). The wound was assessed and debrided on 07/14/2022 (seven days after the wound was found/identified). Review of the progress note dated 07/14/2022 showed that the wound care specialist determined that the wound to the right heel was Unstageable pressure injury and debrided the wound. Resident 39. Review of the medical record showed the resident readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the annual comprehensive assessment dated [DATE], showed the resident required two-person extensive assistance with transfers and bed mobility, and a one-person total assist with toileting due to long term placement of urinary catheter and [CONDITION(S)]. The resident was assessed to be without pressure ulcers, but at risk for the development of them. Further review of the medical record showed a progress note dated 06/24/2022 that stated, 60 day visit no changes. 2 open areas noted this afternoon on either side of the coccyx (tailbone). Covered with foam dressings, notified MD [medical director], gave orders to place dressings. The progress note and physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Skin and Wound evaluations showed no initial assessment of the open areas to the resident's coccyx, no documentation of size or dimensions of the open areas nor any follow-up assessments of these areas. The last entered Skin and Wound assessment was dated 04/14/2022 for the healed skin abrasion to the resident's left elbow. During an interview on 07/22/2022 at 10:22 AM, when asked what the process was for documenting a new skin concern, Staff EE, Quality Assurance Nurse (QAN)/Wound Nurse, stated once the Nursing Assistant (NA) verbalized the skin concern to the Licensed Nurse (LN), it is assessed, documented on a Skin and Wound Assessment, photo taken, doctor notified, and treatment orders obtained. Additionally, they said an incident report should be initiated. When asked if this process was completed for the open areas identified on the resident as of 06/24/2022, Staff EE stated, no, but it should have. In an interview on 07/22/2022 at 10:49 AM, when asked about the skin issues for Resident 39, Staff V, Licensed Practical Nurse (LPN)/Charge Nurse, stated the resident's coccyx area had been red and the previous treatment was application of moisture barrier cream. Staff V stated they were not certain of when the skin broke down and opened. When asked to describe the process of documenting a new or changed skin issue, Staff V said the expectation was the LN to take measurements, a picture, write a progress note or complete a Skin and Wound Assessment, notify the doctor, and obtain new orders if necessary. When asked if this process was done for the open areas next to the coccyx of Resident 39, Staff V stated they did not personally do it and if it was not in the chart, then probably not. Observed wound care performed on 07/22/2022 at 10:40 AM by Staff N, LPN. Noted [MEDICATION(S)] dressing (a type of wound dressing that has a sterile foam pad with surrounding adhesive applied to a wound to promote healing), a packet of moisture barrier cream, gauze, and normal saline on bedside table. No barrier between table and supplies. When asked if the wounds and surrounding skin looked moist, Staff N said yes. Glove change after cleansing the wounds. Observed Staff N spreading the moisture barrier cream directly on the foam of the dressing using a gloved finger. When asked if there was an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . When asked to clarify, Staff N said this is how they liked to do this dressing change. Reference: WAC 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to recognize, thoroughly monitor, assess and take timely action in accordance with professional standards of practice for one of one resident (25) reviewed for bowel care and management. These failures resulted in harm to Resident 25 and potentially resulted in the hospitalization and subsequent death from [CONDITION(S)] secondary to pan-sensitive E. coli (a bacteria found in the human intestinal system) aspiration pneumonia (inhalation of gastric contents into the lungs). Findings included . Review of the document titled Resident Care Approaches/Protocols dated [DATE], showed a list of care interventions that are considered routine unless noted otherwise on the residents' care plan.Bowel monitor; report to LN [Licensed Nurse] no BM [Bowel Movement] in two days or any changes in stool consistency or frequency, i.e. diarrhea. Notify of any change in bowel or bladder status. Additionally, it stated Constipation/Stool Approaches with the following interventions: .Nursing Assistant Certified (NAC) is never to remove stool manually, nurse to monitor effectiveness of [MEDICATION(S)] for BM, and nurse to assist resident with manual stool removal as needed. Resident 25. Review of the medical record showed the resident was readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Minimum Data Set (MDS) assessment, dated [DATE], identified the resident to have impaired cognition and memory, required one-person extensive assistance with cares and toileting. During an interview on [DATE] at 3:22 PM, Resident 25 stated they had issues with constipation at times and sometimes felt when she asked for bowel medication, they [nursing staff] were slow to give it to her. She stated that feeling constipated was part of why she had a decreased appetite. Review of the Care Plan, dated [DATE], showed the resident was at risk for constipation related to decreased mobility and lack of privacy with goals stated that the resident will have a normal, soft, and formed bowel movement at least every three days. The interventions included: encourage resident to sit on toilet to evacuate bowels if possible, follow facility bowel protocol for bowel management, monitor medications for side effects of constipation, keep physician informed of any problems, and monitor/document/report to Medical Doctor (MD) PRN (as needed) signs and symptoms of complications related to constipation: new onset of confusion, sleepiness, inability to maintain posture, agitation, [CONDITION(S)] (slow, low heart rate), abdominal distention, tenderness, guarding, rigidity; vomiting, small or loose stools, fecal smearing, diaphoresis (sweating), absent bowel sounds, or fecal compaction. Review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident had orders for three different oral laxatives as needed for constipation. Review of the bowel monitor and Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . As needed constipation medication was given on [DATE]; three days of no BM before an intervention was taken. Review of the bowel monitor and MAR for [DATE] showed no BM documented for the following: *[DATE] to [DATE], As needed constipation medication was given on [DATE] and [DATE]; seven days of no BM before an intervention was taken. *[DATE] to [DATE], As needed constipation medication was given on [DATE]; four days of no BM before an intervention was taken. *[DATE] to [DATE], No as needed medication given during this time; four days of no BM with no intervention taken to treat constipation. *As needed constipation medication was given on [DATE] per the resident's request. Review of the bowel monitor and MAR for [DATE] showed no BM (with the exception of small BMs) documented for the following: *[DATE] to [DATE], As needed constipation medication was given on [DATE] and [DATE]; three and six days of no BM before intervention was taken. No other follow-up documented. *[DATE] to [DATE], No as needed medication was given during this time; six days of no BM with no intervention taken to treat constipation. *[DATE] to [DATE], As needed constipation medication was given on [DATE]; five days with no BM before an intervention was taken. *[DATE] to [DATE], As needed constipation medication was given on [DATE]; three days with no BM before an intervention was taken. Review of the bowel monitor and MAR for [DATE] until day of discharge, [DATE], showed no BM (with the exception of small BMs) for the following: *[DATE] to [DATE], As needed constipation medication was given two times on [DATE]; five days with no BM before an intervention was taken. *[DATE] to [DATE], No as needed medication was given during this time; six days of no BM with no intervention taken to treat constipation. During an interview on [DATE] at 12:53 PM, Staff B, Registered Nurse (RN)/Interim Director of Nursing Services (DNS), when asked about a facility house bowel protocol or program, she stated she had not been able to find a house bowel protocol since she had been there. She stated she was told that the nurses monitored the BMs and administered individual PRN bowel medication. In an interview on [DATE] at 2:46 PM with Staff V, Licensed Practical Nurse (LPN)/Charge Nurse when asked about a house bowel protocol, she stated they did not have one. When she was asked to explain the process of bowel monitoring and intervention, she stated they used a Third Day List which was a list of residents who had not had a BM in three days or more. The list was created by the night shift Licensed Nurse (LN) who reviewed the bowel monitor documentation daily. This list was added to the nurses' report sheet and the intervention taken was based on the LN assessment of the resident. Each resident had their own PRN medications for constipation. Staff V stated her expectation would be the LN provide constipation intervention for any resident on the Third Day List and continue with follow up as necessary until they have effective results. Review of a clinic visit note, dated [DATE], with the resident's outside primary care provider shows the physician's notation to include, .The only complaint that I can get from her is that she complains of constipation. She had been on [MEDICATION(S)] [[MEDICATION(S)]] Monday, Wednesday, Friday half of a scoop [routinely] and apparently that was changed to PRN only. They [nursing staff from facility] did not send a MAR, so I do not know how frequently she has gotten any of her laxatives, but she wants to go back on a regular dosing. Review of a form titled Record of Outside Service, dated [DATE], showed new written orders from the outside physician to include a.) please send MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] ½) scoop by mouth Monday, Wednesday and Friday in water or juice, c.) hold for diarrhea, d.) may continue (½) to 1 scoop by mouth everyday as needed for constipation. Review of the MAR for [DATE], showed the above routine [MEDICATION(S)] order was started on [DATE]. During an interview on [DATE] at 11:47 AM, Staff S stated that the resident was admitted to the hospital on Saturday [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the medical record showed no alert charting documentation for this resident in the days leading up to this hospitalization . During an interview on [DATE] at 12:35 PM, Staff V stated the resident continued to be in the hospital on high-flow oxygen (alternative non-invasive respiratory therapy that uses a high concentration of oxygen to help reduce the effort needed for breathing) with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . During a follow up interview with Staff V on [DATE] at 2:46 PM, they stated this resident was not placed on alert charting as of the end of their shift on Friday [DATE] (between 4:,d+[DATE]:00 PM). In an interview on [DATE] at 3:09 pm, Staff U, LPN said they were the nursing supervisor this past weekend and sent the resident to the hospital for altered mental status, multiple emesis (vomiting) and increased oxygen needs. They stated the NAC woke the resident and obtained vital signs in the afternoon. At that time, the resident was afebrile but seemed different from their baseline. When the resident started vomiting, they required more assistance to sit up on edge of bed (indicating weakness). Staff U stated she noted the vomit to be thick and brown in color. When asked if it appeared the resident had vomited while laying down, Staff U stated no. When asked if the resident had been laying flat, Staff U stated yes. Review of the medical record showed on the Admission assessment dated [DATE], the resident was assessed to have no chewing or swallowing issues and the diet order dated [DATE] was for regular diet, regular texture. Review of the care plan dated [DATE], showed the resident had Gastro-[CONDITION(S)] Reflux Disease [(GERD) a disease caused by the back flow of stomach acid into the throat usually causing a burning sensation] with interventions stated to .Monitor/document/report to MD PRN signs or symptoms of GERD: belching, coughing/choking when laying down, heartburn, nausea, vomiting, regurgitation . and to .keep HOB [head of bed] elevated. Encourage to stand/sit upright after meals. During an interview on [DATE] at 10:39 AM, Staff S, Registered Nurse (RN) stated the resident complained of constipation often. When asked what circumstances occurred for Staff S to administer a PRN [MEDICATION(S)], they stated either the resident would come to nurse and ask because they had hard stools, or the resident was on the Third Day List. When asked if the resident complained of stomach upset (nausea, vomiting), Staff S stated not very often. When asked if the resident showed difficulty with swallowing, Staff S stated no, the resident would take their pills whole, two at a time with a sip of water. In an interview on [DATE] at 10:41 AM, Staff V stated constipation and toileting overall were frequent issues for the resident. They stated that the resident would ask for PRN bowel medication frequently and many of their falls occurred while using the bathroom. When asked how frequent the resident would request bowel medication, Staff V stated at least weekly if not more. When asked if the resident complained of nausea or vomiting, Staff V stated no. Review of the document titled Discharge Summary dated [DATE], discharge diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The source of infection was determined to be respiratory when cultures resulted in E. coli and other cultures were negative. Furthermore, the discharge summary stated that a day after completing antibiotics, the resident's .condition worsened and [they] again had increased need for oxygen supplementation .it was elected to transition to comfort care .this AM [[DATE]] at 0630 AM, they [the resident] died peacefully. During an interview on [DATE] at 10:25 AM, with Staff WW, Medical Director, it was asked if E. coli was a common bacteria found in respiratory secretions or sputum. Staff WW stated no its not common although it is possible. When asked if it were possible for a person to inhale stomach contents while vomiting, Staff WW stated yes that could cause aspiration pneumonia. Reference: WAC [DATE] (1)

Based on observation, interview and record review the facility failed A) to adequately supervise and initiate interventions for safe use of hot liquids for one of two dependent residents (74) who were dependent on staff to safely check temperature of hot liquids before giving them to residents. This failed practice resulted in harm for Resident 74 who sustained second degree [CONDITION(S)] (blisters) both thigh areas, and B) to assess risk factors and develop planned interventions to address resident falls for one of three residents (62) for accidents. This failed practice resulted in harm to Resident 62 who sustained a fall on their face from their wheelchair to the floor and sustained bruising and fracture to the left eyebrow. Findings included . Resident 74. Review of the medical record showed the resident was a long-term stay resident with diagnoses which included dementia, diabetes and heart failure. The 06/13/2022 comprehensive assessment showed the resident required extensive assistance for transfers, bed mobility and activities of daily living (ADLs) and had severely impaired cognition. Review of the resident's 06/26/2022 care plan showed the resident required assistance with eating and staff provided oversight and supervision for all meals in the dining room. The care plan showed the resident was at risk for injury from hot liquids. Review of an incident report dated 06/26/2022 at 10:44 AM showed the resident was seated in the lobby of the facility and was drinking coffee which accidentally spilled into their lap resulting in substantial . redness and three blisters to their right and left inner thighs. The wound area measured 16.6 centimeters (cm) was 6.5 cm in length and 3.3 in width. The incident report showed no pain assessment was conducted and no witness statements were obtained. Cold compresses were applied to the injured area throughout the shift. Review of a 06/28/2022 progress note showed the resident was at increased risk for [CONDITION(S)] due to their diagnosis of dementia, left hand weakness/shakiness and poor safety awareness. At that time (two days later) care plan interventions and updates showed to assist the resident as needed with hot beverages. The care plan was updated on 06/28/2022 to included that all hot beverages be placed in a firm cup with lid and staff were to add ice too cool down the liquid. During an observation and interview on 07/25/2022 at 3:38 PM, Staff HH, Certified Dietary Manager, stated that they had worked in dietary for four years. The process for coffee was that kitchen staff brewed the pot of coffee in the west wing satellite kitchen prior to each meal then the coffee was placed into two carafes. Staff HH stated that between meals the Nursing Assistants (NAs) were to heat coffee in the microwave because the coffee would cool down in the holding carafes. Staff HH stated that the satellite kitchen did not contain a thermometer for staff to test hot liquids nor had NA staff received training to ensure safety of hot liquids. During an interview on 07/25/2022 at 3:22 PM, Staff JJ, Licensed Practical Nurse (LPN) stated that they were working on the shift and had assessed the [CONDITION(S)] after the accident from hot coffee. The resident was seated in the lobby area when the [CONDITION(S)] occurred. [Resident 74] is always shakey (sic) on both sides (arms/hands) and was concerned why staff had served coffee at a temperature to cause the [CONDITION(S)]. Staff JJ stated they did not know which staff had served the coffee to the resident. During an interview on 07/25/2022 at 3:45 PM Staff II, NA stated that they (NA Staff) warm up coffee between meals for 35 - 45 seconds in the microwave, because the coffee cooled down in the carafes. Staff II stated there was no thermometer in the kitchen to ensure safety of beverages nor had they received training to temperature check those liquids heated in the microwave. During an interview on 07/26/2022 Staff KK stated they regularly worked on the west wing and had never received training on how long to heat up beverages in the microwave. We put in the microwave for 30 seconds or longer and that it (time in microwave) depended and varied on how long the coffee had been sitting in the carafes after meals. During an observation and interview on 07/26/2022 at 8:35 AM, Staff LL, NA stated they had worked at the facility for six years and had never been trained to temperature beverages from the microwave. Staff LL observed the area in the satellite kitchen with this surveyor and stated that the satellite kitchen did not have a thermometer. During an interview on 07/27/2022 at 8:55 AM, Staff RR, Designee stated that they would expect that staff follow policy and procedure and temp all food and beverages as indicated in the facility's policy. Staff RR stated the facility implemented a process where all staff would be trained to temperature check liquids and food to ensure resident safety. Resident 62. Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses of a stroke with left sided paralysis, high blood pressure and diabetes (condition where the body does not use glucose (sugar) properly). Review of the 06/02/2022 assessment showed the resident had some cognitive impairment, required extensive assistance with activities of daily living and was totally dependent with transfers to and from their tilt-in-space wheelchair with a Hoyer lift mechanical device. The resident was dependent on staff for mobility in their wheelchair. Review of the 06/01/2022 Fall report showed the resident was at far end of the dining room in their wheelchair. At 9:50 AM a resident notified staff that the resident had fallen in the dining room. The resident was found face down in a pool of blood. The resident stated the wheelchair slipped from under them and they hit their head. The dining room was not supervised by staff thus an unwitnessed fall. The resident had a blood pressure of 166/109, (normal 120/80), and their pulse was116, (normal 60-100). There was no assessment for mobility/risk for falls. Review of the 06/01/2022 Emergency Department physician's assessment showed the resident presented with swelling and bruising to the left eye due to a fall and wounds to the legs. The resident was dependent on their wheelchair for mobility. The resident had sustained a fracture of the left eyebrow area and was to have follow-up with another physician. The plan for left eyebrow fracture was to apply ice packs three times a day for the next three days. Continued the resident on [MEDICATION(S)] (blood thinner) and aspirin. During an interview on 07/19/2022 at 12:39 PM, Staff H LPN stated the resident was baseline and knew of the fall on 06/01/2022. Staff H saw the resident last week and placed the resident on 30-minute checks. Staff H knew the resident had poor trunk control and was working with therapy but was unaware of the resident's fracture on the left eyebrow. During an interview on 07/20/2022 at 10:30 AM, the resident stated he had been in his room during mealtimes because they felt sick. They remembered the fall and stated they were reaching for something and fell on their face and it hurt a lot. During an observation and concurrent interview on 07/22/2022 at 10:51 AM, the resident was playing with their bed control putting the bed up and down, foot of the bed up and down, as well as the head of the bed up and down. The Resident's Representative (RR) was present in the room explained since the resident had a stroke, they fidget and had fidgeting devices to use to occupy them so they did not try to do things impulsively. The RR stated the resident fell because the staff had placed the resident and the wheelchair straight up instead of tilted back. Since the resident's center body core was not strong, he fell out of the wheelchair. The RR stated they were concerned about the resident's increased anxiety and increased impulsiveness. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure an assessment was completed for appropriate fit and safety of an assistive lap tray when one of one resident (#13) in an electric wheelchair (w/c) received a hot beverage that was placed onto a tray that was ill fitting. This failure caused harm to the resident who sustained second [MEDICAL CONDITION] his thighs and genitalia due to the hot beverage spilling on him. Findings included . Resident #13. Review of the 07/01/19 comprehensive assessment showed the resident admitted on [DATE] with [DIAGNOSES REDACTED]. The assessment showed the resident needed supervision for eating and drinking and had functional impairment on both sides of his upper and lower extremities. The resident was cognitively intact. Review of the Resident's care plan dated 07/01/19 showed the resident has potential/actual impairment to skin integrity due to fragile skin and history of recurrent . coffee and heating [MEDICAL CONDITION] upper thighs . The care plan was not developed to include the potential for resident accidents related to [MEDICAL CONDITION] interventions for prevention of accidents. On 09/19/19 at approximately 11:00 AM, the resident was observed in his room, in bed. He stated that he was in constant pain and managed his own medications. He stated that he recently acquired a new electric power chair and that facility staff had done some adjustments for his comfort. Record review of a 09/12/19 nurse progress note showed that on 09/12/19 (at an unknown time), the resident had spilled a hot beverage between the thighs. The area was noted to be red and blistered on both thighs with the left thigh measuring 6 centimeters (cm) x 5 cm and the right thigh 3 cm x 2 cm. Blisters were indicated as not open and the area was left open to air. During an interview on 09/25/19 at approximately 11:00 AM with Staff L, Registered Nurse/Treatment Nurse, reviewed the documentation regarding the resident's skin condition and treatments, following the burn. She stated that pictures had been taken of the burn sites. After reviewing the pictures, she stated there were black spots along with multiple areas of blanched white skin on the resident's genitalia. Review of a 09/13/19 physician visit showed a treatment plan for the second degree burn wash the burn with antiseptic soap and then cover it with [MEDICATION NAME] ointment and some light gauze and do that twice a day until this has healed. The record showed that the physician had explained to the resident the real risk of infection and non-healing of this. Review of a 09/13/19 progress note, showed the resident requested that maintenance make him a new board for his lap that was bigger than the previous one that he had. He has a new w/c and would like it to fit better. During an interview on 09/24/19 at 2:26 PM, Staff N, Licensed Practical Nurse/Restorative Nurse Manager, provided a copy of an incident report dated 9/17/19 which showed a follow up to incident on 09/12/19. She stated that the resident recently got a new power chair and they've been making adjustments. She stated that the day of the hot beverage spill was the resident's the first day in the new chair. The seating is different, he says it splays his legs more and with limited motor skills . the tray doesn't sit right with his legs being out more. She stated that following the spill of hot soup maintenance got him a new tray that fits his lap better. During an interview on 09/24/19 at 4:20 PM, Staff V, Nursing Assistant (NA), stated that she worked the evening shift on the day the resident sustained [REDACTED]. She stated that the resident likes the broth really hot and that she prepares it by getting it from the hot water tap of the beverage dispenser, then placing in the microwave for one additional minute. She stated It concerns me that there was potential for injury, due to the liquid being so hot. During an observation and interview on 09/25/19 at approximately 1:00 PM, Staff HH, Dietary Manager utilized the kitchen's thermometer to take the temperature of the beverage dispenser hot water tap in the West dining room kitchenette (where staff obtain hot water for residents). She stated the temperature was set at certain level by the vendor and the machine was serviced routinely. The temperature of the water was observed to be 175 degrees. During an interview on 09/25/19 at 9:28 AM, with Resident #13, he stated that the reason the beverage spilled was because the tray did not fit his new wheelchair and that's been fixed. On 09/25/19 at 11:03 AM, during an interview with Staff B, Director of Nursing Services, she stated that the lap tray had not been assessed to the fit of the new wheelchair. Reference WAC 388-97-1060(3)(g)

Based on interviews and record review the facility failed to ensure one of ten residents (#1) reviewed was free from neglect when staff failed to provide timely care per the resident's plan of care. Resident #1 was transferred to the emergency room (ER) due to a significant change in condition. Despite the unresponsive condition of the resident, hospital staff determined she had not received care for several hours based on her physical appearance and the condition of the indwelling [MEDICAL CONDITION] catheter. The resident had not received catheter and perineal care for approximately 15.5 hours. This failed practice resulted in actual harm to Resident #1, who was diagnosed with [REDACTED]. Findings included: Resident #1. Review of the resident's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's plan of care, reviewed by staff on 01/11/19, showed she had a [MEDICAL CONDITION] catheter; skin breakdown to the spine and coccyx area; sat in a recliner chair per her preference as she refused to lie in bed; required two person assistance with turning/repositioning every two hours, toileting, and transfers; and one person assistance with personal hygiene. The resident was independent with eating after staff set up her meal tray. The plan of care also stated the resident would pull at her catheter tubing at times, thus Licensed Nurses (LNs) were to ensure the catheter was patent and in place. Progress Notes, dated 01/01/19, showed the indwelling urinary catheter was not draining and was leaking urine around the insertion site. The catheter was irrigated with no results. Upon the insertion of a new catheter a large amount of urine was obtained. An inspection of the old catheter showed there were several mucous plugs obstructing it. On 01/29/19 a physician's orders [REDACTED]. Review of the resident's Medication Administration Record [REDACTED]. There were no catheter irrigations documented as being done on 02/04/19 and 02/05/19. The Resident Care Approaches/Protocols showed the following items were considered to be routine care for all residents as applicable: 1) morning care consisted of washing face, underarms, and hands; perineal care; oral hygiene; dressing in day clothing 2) evening care consisted of perineal care; washing face and hands; oral hygiene; and dressing in night clothes 3) residents with [MEDICAL CONDITION] catheters were to have catheter care every shift. Progress Notes, dated 02/05/19 at 11:14 AM, showed the resident was transported to the ER due to a change in condition. On 02/08/19 at 5:30 PM a telephone interview was conducted with the ER Licensed Nurse (LN), who cared for the resident upon her arrival to the ER. She stated the resident was dressed in a night gown that was soaked with urine. The urinary drainage bag had brown urine in it and smelled of pus, (thick fluid containing dead tissue, cells, and bacteria produced due to an infection). She stated despite the catheter being changed on 01/17/19 (as told to her by Staff A, Director of Nursing) it appeared to not be changed in a long time. Upon removal of the resident's [MEDICAL CONDITION] catheter it was noted to be caked with dried pus. A new catheter was inserted and 500 milliliters (mls) was immediately obtained with a large amout of sediment. When the resident's disposable brief was removed there were old raisins stuck to her. Pus was observed all over the perineal area. She stated the smell just hit me. She had been a LN for [AGE] years and she had never smelled anything that bad. Upon rolling the resident to her side she observed a blue cough drop stuck to the open pressure ulcer on the coccyx, and a television remote control fell out from between the folds of her buttocks. The resident was diagnosed with [REDACTED]. Staff B, Nursing Assistant (NA), stated during a telephone interview on 02/20/19 at 2:23 PM, she was the assigned caregiver for the resident the morning of 02/05/19. She stated she did not provide any care to the resident that morning (02/05/19) as usually the resident would put her call light on between 9:00-10:00 AM to receive care, and she had not done so that morning. She was approached by Staff J, NA at 8:40 AM on 02/05/19 regarding the resident, but did not understand what she was saying. Staff B did not go and check on the resident as she was passing drinks in the dining room. Staff B returned from her break at 10:15 AM and was seated at the nursing station preparing to chart when Staff C, Licensed Practical Nurse (LPN), questioned her at 10:30 AM if she had checked on the resident. Staff B and Staff C entered the resident's room and found her unresponsive at that time. Per interview with Staff C on 02/15/19 at 12:37 PM, she stated upon seeing the resident slumped forward in her recliner at 10:30 AM on 02/05/19 she approached Staff B regarding when the last time Staff B had seen the resident. Staff B responded, I haven't been in there yet. She stated Staff B required more staff supervision than the other NAs she worked with. At the end of the day she would have to question Staff B if she had performed all her duties. Staff C stated the first time she observed the resident was at 10:30 AM the morning of 02/05/19. When questioned regarding administration of medications (review of the resident's Medication Administration Record [REDACTED]. Telephone interviews were conducted on 02/19/19 at 8:30 AM with Staff D, NA, and 02/18/19 at 10:40 PM with Staff E, NA. Both staff stated they cared for the resident as a team between 10:30 PM on 02/04/19 to 1:30 AM on 02/05/19 and did not perform catheter care or perineal care. Per telephone interview with Staff F, NA on 02/18/19 at 8:00 PM, stated she was assigned to provide care to the resident between 3:00 to 5:00 AM on 02/05/19. She stated she did not perform catheter care. She drained approximately 175-200 mls of urine from the drainage bag. Staff F stated the urine was not normal in color as it was noted between a light and dark yellow color. Telephone interviews were conducted on 02/18/19 with Staff G, Registered Nurse, at 7:10 PM and Staff H, LPN, at 10:37 PM. Both staff stated they were assigned to the resident at different times during the night shift starting on 02/04/19 and ending on 02/05/19. Neither LN had entered the resident's room that night, however, did observe her from the hallway. Staff I, NA, stated during a telephone interview on 02/20/19, she did perineal care and catheter care on the resident at approximately 7:00 PM on 02/04/19. The urine in the resident's drainage bag was tea colored, and there was no leakage from the catheter. Reference (WAC) 388-97-0640(1)

Based on interviews and record review the facility failed to observe and perform timely assessments for one of five residents (#1) reviewed for assessments. This failed practice resulted in actual harm to Resident #1, due to a delay in obtaining medical treatment in response to the resident's significant change in condition. Resident #1 was transported to the hospital where she was diagnosed in septic shock (life-threatening condition [MEDICAL CONDITION], which is an extreme reaction to an infection in the body), and acute [MEDICAL CONDITION] (sudden and severe kidney infection which can be life-theatening). Findings included: Resident #1. Review of the resident's medical record showed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's plan of care, reviewed by staff on [DATE], showed the resident had an indwelling [MEDICAL CONDITION] catheter, open pressure ulcers, slept in her recliner at night per her choice, was nonambulatory, utilized a call light to alert staff of her needs, had unclear speech at times, could make her needs known and was able to understand others appropriately, was independent with decision making, and had no memory issues. Progress Notes, dated [DATE] at 11:14 AM, showed the resident had a change of condition that morning. She was lethargic, had her eyes open but was not verbally responding. Vital Signs (Blood Pressure, Pulse and Respirations) were not normal for her, and she had an elevated body temperature of 102.8 degrees tympanic (ear - normal tympanic temperature is 99.5 degrees). Review of the resident's Weights and Vitals Summary form between [DATE] to [DATE] showed the following history of vital signs: Blood Pressure reading was between ,[DATE] to ,[DATE], Pulse rate between 78 to 88, Respiratioins were between 18 to 20, and body temperature between 98.0 to 98.2 degrees. An ambulance was called and the resident was taken to the emergency room (ER). Review of ER records, dated [DATE], showed the resident was unresponsive, and febrile with a low blood pressure. She was diagnosed with [REDACTED]. The resident's family decided on comfort measures, thus she was transferred back to the facility and expired on [DATE]. The facility investigation report showed Staff A, Director of Nursing, was approached by Staff C, Licensed Practical Nurse (LPN), at 10:40 AM on [DATE] stating the resident was having a change in condition as evidenced by Cheyne-Stokes breathing (repetitive abnormal breathing with progressively deeper and sometimes faster breathing following by a gradual decrease that results in a temporary cessation of breathing [MEDICATION NAME] 30 seconds to two minutes) with a respiratory rate of 44 breaths per minute. She had an elevated body temperature of 102.3 degrees with a decreased level of consciousness. When Staff B, Nursing Assistant (NA), was questioned by Staff A as to when she last provided care to the resident she stated at 6:15 AM she took linens into the resident's room and noticed she was breathing funny but thought she was snoring. She did not report her observation to a Licensed Nurse (LN). Staff J, NA, stated she observed the resident at 8:40 AM on [DATE] breathing funny, not responding to questions, and not drinking her milk when she passed meal trays. Staff J also did not report her observations to a LN. Per telephone interview with Staff B on [DATE] at 2:23 PM, she stated she observed the resident at 6:20 AM on [DATE] and she was snoring louder than usual. At 8:40 AM Staff J came to Staff B regarding something about the resident but she was unable to understand her. She did not check on the resident at that time as she was passing drinks in the dining room. Staff B stated she was questioned by Staff C at 10:30 AM as to when she had last checked on the resident, which had been earlier at 6:20 AM. Staff B and Staff C then entered the resident's room and found her unresponsive. On [DATE] at 12:37 PM Staff C stated she was the medication nurse/team leader on the day shift for [DATE]. She stated the first time she observed the resident on [DATE] was at 10:30 AM when she walked past the resident's room and noted she was slumped forward in her recliner, as normally she sat back in the recliner with her feet elevated. The resident's feet were ice cold, and she thought by her appearance she had a stroke. The resident was unresponsive with puffing type of respirations. Her milk was off to the side and it had not been touched by the resident. She stated the resident frequently smelled of urine and always urinated around the catheter. Despite medications ordered to be specifically administered at 6:30 AM and 7:30 AM Staff C stated she had not administered them. Per interview with Staff A at 12:00 PM on [DATE], she stated facility policy was staff could administer medications ordered during the day between 6:30 AM to 3:00 PM unless they were ordered by the physician to be administered at a specific time. Staff J, NA, stated on [DATE] at 12:00 PM, she observed the resident at approximately 8:30 AM on [DATE]. The resident was breathing like she was sick, wheezing. When she questioned the resident about being sick the resident did not respond but had her eyes open. The wheezing sound was not normal. She did not report her observations to a LN. On [DATE] at 11:15 AM Staff K, Registered Nurse (RN) /Charge Nurse stated she did not observe the resident the morning of [DATE]. Interviews on [DATE] with Staff G, RN at 7:10 PM and Staff H, LPN, at 10:37 PM, stated they both worked the night shift, prior to the resident being transferred to the hospital on [DATE], and only observed the resident from the hallway. A paramedic, who transported the resident to the hospital on [DATE], stated during a telephone interview on [DATE] at 3:30 PM, the resident was in a recliner upon his arrival to the facility. She was unresponsive, head slumped to the left side, and sputum running from her mouth. He stated when he questioned staff as to what was the last time the resident was at her normal baseline level they reported to him it was prior to breakfast, but were unable to give him a specific time. He stated the resident's blood pressure dropped enroute to the hospital. Refer to F600 for further information. Reference (WAC) [DATE](1)

Based on observation, interview and record review the facility failed to ensure interventions were in place to prevent an avoidable accident for one of three residents (#1) reviewed for falls with injuries. This failure cased harm to the resident when a position alarm was removed without prior assessment or monitoring that resulted in an unwitnessed fall when the resident ambulated unassisted on night shift approximately 90 feet into the dining room, fell breaking her left hip and lay in the dining room for an undetermined amount of time until discovered. Findings included: Resident #1. Record review revealed the resident was admitted on [DATE] without a history of falls. Review of the 11/12/17 quarterly assessment indicated the resident had dementia with severe cognitive impairment and occasional delusions. She required extensive assistance from staff for transfers, toileting and ambulation in her room. She used a wheelchair for locomotion and had no falls since admission. There were daily chair and floor mat alarms in place. A 08/23/17 wandering risk assessment documented the resident had intermittent episodes of disorientation with delusional thinking. She occasionally wanders through the care center during these episodes. She does not exit seek. Staff remain alert to her whereabouts during these episodes. A 11/12/17 positioning device assessment indicated the resident had position alarms in place to help prevent falls. Included in the comments revealed the resident has dementia and is often impulsive/forgetful and self transfers without calling for assist. She has floor and w/c (wheel chair) alarm . On 02/12/18 at 12:40 PM Resident #1 was observed seated in her wheel chair at a dining room table. A bandage was noted on her right wrist and dark purple bruising on her left wrist. She stated she fell on e night. I was not supposed to get up, but I did. The same day at 2:30 PM the resident's family member was visiting and stated Resident #1 had a fall a couple weeks ago during the night. She walked all of the way from her room to the dining room, fell and broke her left hip, she had to have a total hip replacement, this should not have happened. Further she stated the resident had not had a fall in the facility before this and believed it was because staff would get to her when she tried to self transfer. She used to have a floor mat that alarmed when she would try to get up, but that mat was removed a couple of months ago because she had not had a fall for a year and there was some rule. The family member also stated she was notified when the mat was removed and expressed her concerns at the time because she observed Resident #1 trying to get out of bed or her chair when visiting, she was still forgetful and impulsive. Review of progress notes dated 01/30/18 revealed that at 5:00 AM Resident #1 was found laying in the dining room. Apparently had walked in there and lost her balance and fell to the floor .Complaining of severe pain in left hip and leg. The resident was transported via medics and admitted to the hospital with [REDACTED]. Another progress note written at 15:00 (3:00 PM) revealed the resident would often self transfer, and had safety checks in place, as well as a walking program to maintain strength and a toileting schedule to help staff assess her needs. However, the alarms had been removed d/t (due to) her having never fallen. On 01/13/18 at 10:30 AM, Staff C Registered Nurse (RN), stated she discontinued Resident #1's position alarms because she had not had any falls; however, she did not remember the date because she did not document it or change the plan of care. Further she stated the decision was not made with the input of the team. She stated she notified the resident's family and their concerns were expressed. The RN stated she did not monitor or assess how often the resident's position alarms were responded to by staff prior to removal. At 10:35 AM, Staff D Social Services, stated she had caught Resident #1 walking down the hall toward the dining room without her walker. She stated she ran and got the resident's wheel chair and assisted her to sit down. Staff D did not recall when this happened, did not report to a nurse or document the occurrence. At 10:40 AM, Staff E Nursing Assistant (NA) she would hear Resident #1's position alarm go off several times and I would find her trying to self transfer. She stated she was not aware the alarms were gone and only helped out in that room. At 10:45 AM, Staff F Rehabilitation NA (RA), stated she estimated the distance between Resident #1's bed and the dining room was approximately 90 feet. The resident had a walking program, using her walker, with a goal of 150 feet. She added the resident could walk at a good pace some days. The RA stated she had caught the resident walking independently in the hall and would go get her wheel chair. This happened as often as twice a week. At 10:50 AM, Staff G NA, stated she worked with Resident #1 regularly. She stated the resident would get confused sometimes and forget to put her call light on for help. She would hear the resident's position alarm and go in to assist her. She was not aware of the resident removing her alarms or being bothered by them. No one asked her how often the resident's alarm would go off and she was not sure when the mat was removed, no one told me. The facility removed an intervention that had been shown to be effective in preventing falls for Resident #1, yet did not evaluate the impact of removing that intervention or initiate other interventions to negate the removal of the alarms. Reference WAC: 388-97-1060(3)(g) This is a repeat deficiencies from Statement of Deficiency dated 09/13/17 and 07/21/17.

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (#65), reviewed for pressure ulcers, received the care and services required to prevent a pressure ulcer from developing, and to provide ongoing monitoring of the wound to ensure healing. This failure caused actual harm to Resident # 65, who developed a Stage 3 pressure ulcer (full thickness tissue loss; fat may be visible but bone, tendon or muscle is not exposed) while residing in the facility. Findings include: Resident #65. According to her 03/14/17 admission assessment, she did not have any pressure ulcers, but was at risk for pressure ulcers. The assessment also identified that the resident was cognitively intact, and required extensive physical assistance with bed mobility, transfers, and toileting. The associated Care Area Assessment worksheet indicated the resident's pressure ulcer risk would be addressed on the comprehensive care plan. The 03/15/17 comprehensive assessment notes related to pressure ulcers stated, .admitted with no pressure ulcers .She did arrive with bilateral buttocks, groin, inner thigh, and slightly under abdominal fold excoriation (raw or chafed skin) .She is using a (specialized) overlay on mattress and a cushion wheelchair for comfort and pressure relief. She receives good peri-care after any bowel incontinence. She receives a head to toe skin check daily with cares and a thorough skin inspection on shower days. Plan is to continue to monitor and protect any potential skin breakdown. Review of the nursing progress notes revealed a nursing assistant found a tunneling wound to coccyx on 05/15/17, and that the nursing assistant reported it was fragile yesterday, but not open. The note further described that after the wound was discovered, staff put an air overlay on the bed, initiated a specialty cushion for the wheelchair, and encouraged the resident to lie down off of her coccyx between meals. In an initial interview on 07/13/17 at 9:24 a.m., Staff Member B, a charge nurse, stated Resident #65 had a Stage 3 pressure ulcer on her coccyx area (base of the spine, where buttocks meet). Review of the 3/15/17 care plan on 07/17/17 revealed there was no comprehensive skin care plan, including measurable goals and outcomes, for Resident #65 related to her pressure ulcer risk, or current pressure ulcer. In an interview on 07/18/17 at 10:02 a.m., Resident #65 was asked about the development of her pressure ulcer. She stated a nursing assistant first noticed it, and that she typically got the dressing changed early every morning. When asked if the wound caused her pain, she stated it was sore. She said the pad she had on the wheelchair now (after development of the pressure ulcer) was better than her previous pad. She said her current routine was to sit up in her wheelchair in the morning, and lie down after lunch. In an interview on 07/19/17 at 5:36 a.m., Staff Member U, a night shift Licensed Nurse, who routinely provided wound care for Resident #65, described the wound as slow healing. Review of the wound documentation forms the facility utilized, called e-z graph assessments, revealed the first measurements of the wound were documented on 05/19/17 as 2.25 centimeters (cm) long x 1.5 cm wide x 2.5 cm deep (four days after the wound had been discovered by a nursing assistant who cannot assess wounds). Review of the record also showed Resident #65 was evaluated by a nurse practitioner for wound care on 05/18/17. Her note indicated the resident's wound had gray, non-viable tissue (not able to grow), and that she had an unstageable coccyx pressure ulcer (pressure ulcers are not assigned a stage if the wound bed cannot be visualized). Another note by the nurse practitioner on 05/24/17 indicated she would follow up the next week, however there were no further notes in the record detailing her evaluations between 05/24/17 and 07/19/17. By 05/27/17, the wound was described on the e-z graph assessment as declining, and measured as 11.2 cm long x 2.2 cm wide x 2.1 cm deep, with an odor, and categorized as a Stage 3 pressure ulcer. While e-z graph forms were partially filled out on 06/03/17, 06/10/17, 06/17/17, 07/01/17, and 07/08/17, no further measurements were documented on the e-z graph assessments until 07/14/17, when the wound had again worsened to be 7.7 cm long x 2.0 cm wide x 3.5 cm deep. (The depth had increased by 1 inch by 1.5 inches.) Observation of the wound, and wound care, on 07/19/17 from 9:48 a.m. to 9:55 a.m. revealed the resident had a round wound on the coccyx area, extending down into a linear opening where the buttocks met. The observed open area to her coccyx area was consistent with the sizes documented on the 07/14/17 wound assessment. During the observation of wound care, Staff Member G cleansed the wound, applied the ordered ointment, and packed it with gauze. When asked by the surveyor if she experienced pain during the dressing change, Resident #65 indicated she was sore. In an interview on 07/19/17 at 12:40 p.m., Staff Member B, a charge nurse, was asked about what routine skin monitoring was provided in the facility. She stated shower aides looked at the skin head to toe on the resident's shower day every week, and if there was a problem, alerted the nurse on duty. She stated there were no routine nursing skin assessments other than the one upon admission, and the resident's skin breakdown risk was assessed quarterly. Per the task documentation, nursing assistants were checking the resident's skin during cares every day, but there were no head to toe skin assessments by licensed nurses done routinely prior to the pressure ulcer development. During the interview, Staff Member B called Staff Member C, a resident care manager, to assist with answering questions. She asked Staff C if the resident had an air overlay on her bed, and asked if Staff C recalled the resident not wanting to lie down during the day. After they both reviewed the care plan together, Staff Member C said the resident had an air overlay for pressure relief on her bed mattress at this time, and prior to developing the pressure ulcer, it was a pillowtop overlay. Staff Members B and C showed that the interventions were documented in the fall risk portion of the care plan, there was not a separate skin care plan. On 07/19/17 at 1:01 p.m., when asked about what was provided for offloading pressure from Resident #65's bottom when she was sitting up in her chair prior to developing the wound, Staff Member C said she just had a basic foam or gel top cushion on the wheelchair, and stated she could not recall exactly what was on there. She stated she now had a rojo type specialty cushion for pressure relief. When asked how much time the resident spent sitting in her wheelchair before the wound developed, Staff Member B stated she thought the resident was one that didn't like to get into bed. She said I don't think she realized what could happen with that. The Kardex (an abbreviated care plan with interventions to be provided by the nursing assistants) instructed staff to assist the resident to lie down between meals. When asked, Staff Member B and Staff Member C determined that intervention started on 05/15/17, after the wound developed. Although the resident was dependent upon staff for transfers and positioning, and had admitted with skin excoriation, there was no indication in the record that staff were encouraging position changes and time out of the wheelchair before she developed the pressure ulcer. On 07/19/17 at 12:56 p.m. Staff Member B confirmed that the resident did not have a care plan related to pressure ulcers at that time, and stated she would create one. On 07/19/17 at 1:03 p.m., Staff Member B confirmed there was no additional documentation from the wound care nurse practitioner available at that time. On 07/20/17 at 11:41 a.m., the surveyor reviewed e-z graph documentation with Staff Member B. Staff Member B confirmed measurements were not in place from 05/27/17 to 07/14/17. The resident developed a Stage 3 pressure ulcer in the facility, in the absence of a comprehensive, individualized care plan to prevent pressure ulcers when she was identified as at risk. Reference: (WAC) 388-97-1060(3)(b)

Based on record review and interviews the facility failed to identify and provide adequate supervision to prevent falls for 2 of 3 sampled residents (#'s 1,2) reviewed for falls. This deficient practice resulted in Resident #1 being transferred to the emergency room (ER) due to complaints of hip pain where x-rays revealed a hip contusion (bruise). Findings include: Resident #1: admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's plan of care revealed she was at high risk for falls due to confusion, and gait/balance problems. A tag alarm system was utilized while she was in bed and in her wheelchair to alert staff to her needs and aid in fall prevention. She required extensive assistance with toileting. Review of a facility investigation report dated 2/12/14 revealed the resident fell to the floor when she attempted to self transfer from her bed to the wheelchair. The investigation noted the resident frequently attempted to self transfer without the use of her call light. Review of Progress Notes dated 3/9,11,16/2014 and 4/30/14 noted the resident made attempts to get out of bed on the night shift. Review of a facility investigation report dated 5/9/14 at 2:15 a.m. noted staff found the resident lying on her left side on the bathroom floor. She had a large skin tear to her left arm. Staff A (Nursing Assistant) had heard her tag alarm and upon entering the resident's room noted she had self transferred into a wheelchair. The resident informed Staff A she needed to use the bathroom, thus was assisted onto the toilet. Staff A then left the resident unattended on the toilet while she proceeded to check on another resident. Staff A had just left the room when she heard the resident fall and hit the floor. The investigative report stated the incident was reasonably related to the resident's poor safety awareness and impulsive attempts. Later that afternoon at 5:30 p.m. the resident began complaining of left hip pain, thus was transferred to the ER Review of ER records noted the resident's hip pain was "sharp and severe." X-rays revealed a hip contusion (bruise). A telephone interview on 6/4/14 at 5:38 a.m. with Staff A revealed the resident self transferred into her wheelchair frequently on the night shift and was very confused. Despite the resident's cognitive impairment, frequent attempts to self transfer, impulsive behavior, poor safety awareness, balance/gait problems, and recent fall on 2/12/14; staff failed to supervise the resident while seated on the toilet. Resident #2: admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's plan of care noted he required extensive assistance for toileting with transfers. He was at high risk for falls due to unaware of safety needs, confusion, and impaired gait and balance. He utilized a tag alarm system when in bed and the wheelchair to alert staff to his needs and aid in fall prevention. review of the resident's medical record revealed [REDACTED]. Review of a facility investigation report revealed on 5/28/14 at 1:45 p.m. the resident was left unattended on the toilet in the shower room. Staff B (Nursing Assistant) had left him to obtain clean pants and when she returned to the shower room the resident was on the floor. He had attempted to self transfer off the toilet when he fell . He sustained a skin tear to his right elbow. An interview on 6/3/14 at 1:45 p.m. with Staff B revealed she was aware of the resident's history of attempts to self transfer. She stated she had instructed a student Nursing Assistant (NA) to stay with the resident until she returned from obtaining clean pants for him. When she returned she found the student NA outside the door of the shower room, unaware of the resident's activities. When she opened the door she observed the resident on the floor. Despite the resident's significant fall history with attempts to self transfer; confusion; impaired balance and gait; and unawareness of safety needs; staff failed to supervise the resident while seated on the toilet.

Based on observation, interview and record review, the facility failed to complete assessments for potential skin breakdown and/or ensure appropriate interventions were in place for 1 of 1 resident (#50) in the sample who a developed pressure ulcer. Findings include: Resident #50. admitted directly from a hospitalization due to "not thriving" in his own home. The 01/03/12 comprehensive assessment identified intermittent confusion, poor judgment and some self-directing behavior. The assessment also documented he was admitted without pressure ulcers, but was at risk as he required a one-person extensive assist with bed mobility. Review of the 'quarterly care conference' notes revealed on 04/01/12 and 07/01/12, the resident's skin was intact with preventative measures in place. No further evaluations of skin were completed, including the resident's preference for wearing shoes in bed (which caused pressure on the heel). An 08/18/12 skin assessment documented an onset of a right heel ulcer that was unstageable due to black eschar (a scab-like covering hiding the actual wound bed). There was no further assessment as to the cause of the ulcer. On 08/24/12, a wound consultant evaluated the right heel wound and documented a 3 centimeter (cm) circular, open decubitus (pressure ulcer) wound with black wound bed and fixed edges. The consultant documented her 09/21/12 that the wound had changed to 2x2 cm with black adhered tissue (eschar) over the open wound. The wound consultant debrided (cut away) part of the 100% coverage of the wound with black eschar leaving 50% of eschar covering the ulcer. She noted the heel ulcer was "responding slowly to wound care." On 10/16/12 at 8:50 a.m., the charge nurse, Staff Licensed Nurse A, was asked about the cause of the pressure ulcer. She stated the resident had refused to take his shoes off in bed and he had spent "a good deal of day" in bed with his shoes on. The back of the shoe where the seam lies was directly over where the ulceration occurred. As far as she knew, this was how it had been since he was admitted . She had viewed the heel when it was debrided and it was a large ulcer that once debrided was not very deep. On 10/16/12 at 11:00 a.m., Staff Member B stated she usually cared for the resident during the day and he would go back to bed after breakfast and again after lunch. She stated she tried to remove his shoes, but he would refuse, especially in the morning. In the afternoon, she would tell him he needed to rest his feet and was successful in taking them off at times. She said, after he had the pressure ulcer, he no longer wears shoes, but soft boots. She also stated at times the resident had kicked at her when she attempted to remove his shoe and he did not like to lie on his side, preferring to lie on his back. The current plan of care identified a potential loss of his skin integrity due to his age and poor vision. The plan directed staff to reposition the resident every two hours during the day and evening and every three hours at night, apply lotion to dry skin, and place a pressure reduction mattress (which the shoes would interfere with reducing the pressure on the feet). Although the resident frequently left his shoes on while in bed during the day, there was no assessment regarding that specific area for skin possible breakdown. There was no development of a care plan to address this specific issue that could and did cause a heal ulcer. The plan of care was not revised until 08/18/12, when staff was to place heel protectors on the resident when in bed and discourage the resident from wearing a shoe on the right foot.