Every finding on record at Wesley Homes Des Moines Health Center

Based on observation, interview, and record review the facility failed to ensure Level 2 Pre-admission Screening and Resident Review (PASRR) determinations (a process to determine whether mental health services were required after a Level 1 PASRR screening identified the need for a Level 2 review) were obtained for 3 (Residents 3, 9, & 63) of 5 residents whose PASRRs were reviewed. This failure placed residents at risk for not receiving necessary mental health care and services. Findings included . <Facility Policy>Review of the facility's revised 02/11/2026 Resident Assessment-Coordination with PASRR program showed the facility must screen residents using the State's Level I screening process and refer any resident who had a mental disorder, intellectual disability, or related condition to the appropriate state designated authority for a Level 2 PASRR evaluation and determination. The Level 2 resident review must be completed within 40 calendar days of admission. The Social Services Director would be responsible for keeping track of each resident's PASRR screening status and referrals to the appropriate authority.<Resident 3> According to the 12/26/2025 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 3 had Post-Traumatic Stress Disorder (PTSD), and a mood disorder. The MDS showed Resident 3 received an antidepressant medication. Review of Resident 3's 03/12/2025 Level 1 PASRR showed the resident was reassessed for mental health conditions due to a change in their medical diagnoses to include anxiety. The corrected Level I PASRR showed Resident 3 had a mental disorder of a mood disorder and anxiety and should be referred for a Level 2 evaluation. Review of Resident 3's medical records, Care Plan (CP) and progress notes showed no indication that a Level 2 PASRR determination was obtained until 1/26/2026, ten months after the initial Level 2 referral was indicated. In an interview on 02/12/2026 at 10:30 AM, Staff C (Director of Social Services) stated if a resident was identified to have serious mental illness indicators (SMI), the facility would submit a Level II PASSR evaluation and verify and document any communication with the evaluators to obtain an assessment. Staff C stated there was a delay in processing Level 2 PASRR evaluations and there should be emails discussing the pending status but was unable to provide copies of emails from March 2025 through October 2025. <Resident 9> According to the 12/19/2025 Quarterly MDS, Resident 9 had diagnoses including PTSD, a mood disorder, a mental health condition with symptoms such hallucinations, delusions, and disorganized speech affecting their mood, and dementia. The MDS showed Resident 9 took an antipsychotic medication. Record review showed the most recent PASRR Level 1 screening for Resident 9 was completed on 08/21/2025 and indicated Resident 9 had SMI indicators of PTSD, a mood disorder, and the other mental health condition identified on the MDS. This Level 1 screening showed Resident 9 had dementia and required a Level 2 referral. No corresponding Level 2 evaluation or invalidation was found in Resident 9's record. In an interview on 02/12/2026 at 10:19 AM, Staff C stated they sent out the 08/21/2025 Level 1 screening for a Level 2 determination and stated they followed up to inquire on the status on 11/14/2025 but did not document the conversation. Staff C stated they were familiar with the requirement for follow-up when a facility was waiting for a decision regarding a Level 2 evaluation. Staff C stated Resident 9 was on their assistant's case load and they would follow up with the assistant to determine if they had further documentation to demonstrate follow-up for the Level 2 referral. No further documentation was provided demonstrating follow-up for Resident 9. <Resident 63> According to the 01/16/2026 Quarterly MDS, Resident 63 had diagnoses including dementia and psychosis. The MDS showed Resident 63 took an antipsychotic medication. Review of Resident 63's most recent Level 1 PASRR dated 10/29/2024 showed the resident was identified with SMI of a psychotic disorder and delusional disorder and had a dementia diagnosis. The Level 1 PASRR showed a Level 2 evaluation referral was required. No corresponding Level 2 PASRR evaluation or invalidation was found in Resident 63's chart. In an interview on 02/12/2026 at 10:19 AM, Staff C stated Resident 63 was on their assistant's case load who was unavailable and could not immediately demonstrate what efforts the facility made to follow up with the Level 2 referral. Staff C stated they would reach out to their assistant and provide whatever additional information they could to demonstrate the facility followed up monthly. Staff C later sent information showing the facility confirmed the Level 2 referral was received by the PASRR agency on 10/03/2025, and evidence of an email sent by their assistant on 11/06/2025 providing clinical documentation to the evaluator's office. There was nothing to demonstrate follow up after 11/06/2025. REFERENCE: WAC 388-97-1915(1)(2)(a)-(c).

Based on observation, interview, and record review, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional standards of practice. The facility failed to: (1) label medications properly and dispose of expired medications and medical supplies timely for 1 of 2 medication carts (300 West) and 2 of 2 storage rooms (300 East and 300 West) reviewed; and (2) monitor medication refrigerator temperatures for 2 of 2 storage rooms (300 East and 300 West) reviewed. These failures placed residents at risk of receiving compromised medications with reduced or no potency, receiving care with degraded supplies, and experiencing an overall decline in quality of life.Findings included .<Facility Policy>According to the facility's 11/10/2022 Medication Storage policy, the facility would remove and dispose of expired medications and equipment promptly, and medication refrigerators would be monitored per the facility's procedure for ensuring temperatures remained within the required range.<300 East Medication Storage> <Medication Refrigerator> Review of the facility's Temperature Log for Refrigerator form, located in the 300 East medication room, showed the staff were to monitor the temperature during AM and PM shifts each day and act if the temperature was below 36 degrees Fahrenheit (F) or above 46F. Review of the February 2026 refrigerator temperature log from 02/01/2026 until 02/09/2026 showed 5 of 17 temperatures were not monitored (one AM and four PM shifts). Observation on 02/09/2026 at 10:32 AM with Staff J (Registered Nurse - RN, Team Leader) showed there were temperature-sensitive medications located inside the 300 East medication refrigerator including insulin (a medication to help lower blood sugar), antianxiety medication, and testing supplies. Staff J stated it was important to monitor the refrigerator temperature to ensure medications remained effective. Staff J reviewed the February 2026 temperature logs and stated staff should have monitored the refrigerator temperature consistently as expected, but they did not. Observation at that time showed a box containing an open vial of tuberculosis (an infectious, airborne disease affecting the lungs) testing solution was not dated to indicate when the bottle was opened or when it needed to be discarded. Staff J stated the vial should be discarded. <Expired Medications and Medical Equipment> Observation on 02/09/2026 at 10:32 AM with Staff J in the 300 East medication storage room showed expired medication and medical supplies ranging from 2019 to 2025, including 22 insulin syringes, 10 blood collection syringes, 37 blood collection tubes, 14 anticlotting test kits, 10 specimen collection kits, 1 urine drainage bag, 1 oxygen tubing set and 1 full bottle of Vitamin D tablets. At that time, Staff J confirmed all the expiration dates and stated the items should have been discarded but were not. In an interview on 02/12/2026 at 10:15 AM, Staff B (Director of Nursing Services) stated it was their expectation all medications were labeled with the date they were opened. Staff B stated it was their expectation all medications and medical supplies were discarded prior to the expiration date on the packaging. <300 [NAME] Medication Storage> <Medication Refrigerator> Observation of the medication refrigerator temperature log on 02/09/2026 at 9:33 AM showed no temperature readings documented on 02/01/2026 and 02/08/2026. <Medication Cart> Observation on 02/09/2026 at 9:52 AM, showed the medication cart had one bottle of a magnesium supplement with an expiration date of December 2025, one bottle of a pain reliever with a strength of 200 milligram with an expiration date of January 2026 and one bottle of a non-steroidal, anti-inflammatory drug with an expiration date of January 2026. In an interview on 02/09/2026 at 9:52 AM, Staff H (RN, Team Leader) stated expired medications should not be on the cart, available for administration. Staff H stated all nurses were responsible for checking their medication carts for expired medications, but these expired medications should have been discarded but were not. In an interview 02/09/2026 at 12:47 PM, Staff F (RN, Resident Care Manager) stated medications should be stored at the correct temperatures in the medication refrigerator and staff should check the temperature daily but did not. Staff F stated, for residents' safety, expired medications should not be on the cart to prevent errors and to make sure medications were safe. REFERENCE: WAC 388-97-1300(1)(b)(ii)(2).

Based on observation, interview, and record review the facility failed to: ensure staff posted and followed Transmission Based Precautions (TBP - a set of infection control practices used to prevent the spread of infectious agents, in addition to standard precautions) for 1 of 4 residents (Resident 40) reviewed for TBP; ensure staff used appropriate Personal Protective Equipment (PPE - disposable barriers such as gloves, eyewear, and gowns used to prevent exposure to infectious materials) for 1 of 4 residents (Resident 44) reviewed for Enhanced Barrier Precautions (EBP - an infection control intervention designed to reduce the transmission of multidrug-resistant organisms); and ensure staff used appropriate Hand Hygiene (HH) during meal service. These failures placed residents and staff at risk for exposure to and development of communicable infectious diseases.Findings included .<Facility Policy>Review of the facility's revised 07/26/2024 Transmission-Based Isolation Precautions policy showed the facility would implement TBP to prevent the spread of pathogens (organisms that enter the body and cause disease) based on the way the pathogens' spread (airborne, contact or droplet) to prevent or control infections.Review of the facility's revised 07/26/2024 Management of C. Difficile Infection policy showed the facility would implement facility-wide strategies to prevent the spread of Clostridioides difficile (C. diff - a type of bacteria found in stool that causes diarrhea and swelling of the large intestine). Staff were to implement TBP's when C. diff infection was suspected and until test results were confirmed but no less than 48 hours after diarrhea had resolved. The facility policy showed staff were expected to wear gloves and a gown upon entry into the resident's room and perform all hand hygiene with soap and water. Staff would use disposable equipment whenever possible and disinfect reusable items with a sporicidal disinfectant (chemical to kill bacteria with a tough protective shell).Review of the facility's revised 01/19/2025 Enhanced Barrier Precautions policy showed the facility would implement EBP's to prevent the spread of multidrug-resistant organisms for residents with wounds such as chronic venous stasis ulcers. Staff were to perform hand hygiene and wear gloves and a gown when performing high-contact care activities including wound care with any skin openings requiring a dressing.<TBP/C. Diff> <Resident 40> According to a 01/29/2026 admission Minimum Data Set (MDS - an assessment tool), Resident 40 had multiple medically complex diagnoses including a C. diff infection and was at risk for malnutrition and dehydration. Review of Resident 40's February Medication Administration Record showed a 01/31/2026 physician order to start isolation precautions for C. diff and an order for vancomycin (an antibiotic medication to treat C. diff) which ended with a final dose on 02/03/2026 at 9:00 PM. Review of a 02/05/2024 at 9:55 AM nursing progress note showed Resident 40 had completed antibiotic treatment for C. diff and continued to experience loose stools. The note showed staff received a physician's order to send a stool sample to the laboratory to recheck Resident 40 for C. diff. Review of Resident 40's Order Summary Report showed a 02/05/2026 physician's order instructing staff to collect and submit a stool sample to re-check for C. diff. Observation on 02/05/2026 at 10:14 AM showed Resident 40's room displayed a Contact Precautions (infection control measures used in healthcare settings to prevent the spread of germs transmitted by direct or indirect contact with a resident or their environment) sign outside the door instructing everyone to clean their hands before entering and upon leaving and showing an image of hand sanitizer gel. The sign directed staff to wear gloves and a gown before entering and remove them before exiting, and required the use of dedicated or disposable equipment, with all reusable items to be disinfected. In an interview on 02/05/2026 at 10:16 AM, Staff N (Registered Nurse - RN, Team Leader) stated Resident 40 finished the prescribed antibiotic treatment for C. diff but still had loose stools. Staff N stated a stool sample was sent to the laboratory and the facility procedure was to continue precautions until test results were confirmed. Observation on 02/05/2026 at 12:22 PM showed Staff I (Certified Nursing Assistant) handed a meal tray to a nursing student and pointed toward Resident 40's room. The student entered Resident 40's room without performing hand hygiene or putting on a gown or gloves, placed the meal tray containing reusable dishware on the bedside table, adjusted the head of the resident's bed, and removed the reusable tray lid. The student left Resident 40's room without performing hand hygiene, placed the lid on top of other lids on the meal cart, and entered the 300 East nursing station. The student took a spice packet from the nursing station and reentered Resident 40's room without performing hand hygiene, did not put on a gown or gloves, finished setting up the meal tray, and left the room without performing hand hygiene. Observation on 02/06/2026 at 08:17 AM showed Resident 40's room signage was changed to Contact Precautions Special Enteric. The sign instructed visitors to report to the nursing station before entering. The sign instructed everyone to wash their hands with soap and water before entering and leaving the room and showed an image of hands washing with soap under a water faucet. The sign directed staff to wear gloves and a gown upon entry and remove them before exiting, use disposable equipment when possible, and disinfect reusable items. Observation on 02/06/2026 at 12:10 PM showed Resident 40's meal tray was placed on top of the meal cart in the 300 East hallway. Resident 40's meal was on a tray inside disposable containers and cups with disposable utensils on the side. In an interview on 02/12/2026 at 12:20 PM, Staff B (Director of Nursing Services) and Staff K (Infection Preventionist) stated they expected staff and visitors to read and follow precaution signs posted outside resident rooms. Staff B stated students were expected to follow the instructions on the precaution signs in the same way staff would and ask questions when instructions were not clear. Staff K stated standard Contact Precautions were not appropriate for C. diff infections. Staff K stated Contact Precautions Specific Enteric were appropriate to prevent the spread of C. diff. to other residents and staff. Staff K stated hand sanitizer was an ineffective form of hand hygiene against C. diff and expected staff to wash their hands with soap and water. Staff B stated they expected appropriate signage to be posted and followed according to the infectious disease type, but they were not. Staff B stated they expected nursing staff to coordinate with kitchen staff to provide Resident 40 with disposable dishware that could be discarded inside the room, but they did not. In an interview on 02/12/2026 at 1:32 PM, Staff K stated they identified on 02/05/2026 the Contact Precaution signage outside Resident 40's room would not be effective to prevent the spread of C. diff and changed it to the Contact Precaution Specific Enteric. Staff K stated they should post the appropriate signage outside Resident 40's room but they did not. Staff K stated it was important to post the appropriate signage to identify specific techniques to prevent the spread of infection. <EBP/Wound Care> <Resident 44> According to the 12/19/2025 admission MDS, Resident 44 had venous insufficiency (a chronic condition where the leg veins do not send enough blood back to the heart) and a surgical wound. Review of a 01/31/2026 physician order showed Resident 44 was to receive wound care for their right ankle. Staff were to clean and dry the wound, apply a foam dressing, and cover the wound every other day shift. Observation on 02/10/2026 at 10:52 AM, Resident 44's room had an EBP sign posted on their door instructing staff to wear gloves and a gown while providing direct care. Observation showed Staff H (RN, Team Leader) providing wound care to Resident 44's right ankle wound. Staff H did not perform hand hygiene between changing from soiled to clean gloves. Staff H cut a piece of foam dressing using scissors that were not sanitized prior to use. After using the scissors, Staff H picked up the soiled wound dressings with the same hand that carried the scissors and put the scissors back into the nurse's treatment cart without sanitizing the scissors. In an interview on 02/10/2026 at 10:52 AM Staff H stated, they should have sanitized their hands between changing from soiled to clean gloves but did not. Staff H stated they should have sanitized the scissors prior to using them for wound care for Resident 44 but did not and should not have put the scissors back into the treatment cart without sanitizing them for infection control. In an interview on 02/10/2026 at 12:25 PM Staff K stated staff should anticipate the needs for supplies ahead of time and should sanitize all equipment for wound care before and after use to prevent the spread of infections. REFERENCE: WAC 388-97-1320(1)(a)(c)(2)(b).

Based on observation, interview, and record review the facility failed to ensure resident concerns were dealt with timely, verbal grievances were identified as such, resident rights were promoted periodically as required, and residents were provided the opportunity to make a grievance anonymously for 1 of 1 Resident Council groups reviewed. These failures placed residents at risk for unmet needs, frustration, untimely resolution of grievances, and a diminished quality of life.Findings included .<Facility Policy>According to the facility's [DATE] Resident Council Meetings policy, the Activity Director would facilitate Resident Council Meetings. The policy showed the facility would act upon concerns and recommendations of the Council . According to the facility's [DATE] Resident and Family Grievances policy, a resident could make an anonymous grievance. The policy showed notices of residents' rights regarding grievances [would] be posted in prominent locations throughout thefacility. The policy showed all staff involved in the grievance process would make prompt efforts to resolve the grievance and return the grievance form to the Grievance Official . This included both acknowledgment of the complaint/grievance and actively working toward a resolution of that complaint/grievance.Review of the facility's monthly Resident Council meeting minutes from [DATE] through [DATE] showed the following: - In the [DATE] meeting Resident 13 stated they felt like a prisoner in the facility. In the [DATE] meeting Resident 13 stated they felt a serious lack of freedom as a resident of the facility and wanted more access to the rest of the building. In the [DATE] meeting Resident 13 stated they continued to feel a serious lack of freedom and wanted more access to the rest of the building. - In the [DATE] meeting Resident 75 expressed frustration their room was not tidied at a reasonable time which embarrassed them when they had company. Resident 75 brought the same concern up a second time during the [DATE] meeting, stating their bed was not made until the afternoon, nor their room tidied before they received visitors. In the [DATE] meeting Resident 75 weekend staff did not make their bed up until after dinner.-None of the six months of Resident Council meeting minutes reviewed indicated there was any discussion of residents' rights while living at a nursing home. Review of the facility's [DATE] Grievance Log showed facility staff did not log Resident 75's housekeeping concern from Resident Council that month. The [DATE] Grievance Log did not include an entry for Resident13's concern with a lack of freedom or Resident 75's housekeeping concern from Resident Council that month. The [DATE] Grievance Log did not include Resident13's concern with a lack of freedom from Resident Council that month. The [DATE] Grievance Log did not address Resident 75's concern related to their bed not being made up until after dinner In a meeting regular attendees of the Resident Council on [DATE] at 10:44 AM, all the attendees, including Resident 13 and Resident 75, stated they were unclear on how to file a grievance. None of the four residents recalled any discussion of residents' rights during Resident Council meetings. None of the residents knew where information regarding the State's Long-Term Care Ombuds office was posted in the facility. In an interview on [DATE] at 12:02 PM Resident 13 stated after repeatedly expressing their sense of a lack of freedom in Resident Council Meetings, facility staff eventually explained the reason for the restrictions was their safety, but the concern was not addressed in a timely manner. Observation on [DATE] at 12:10 PM showed no signs posted discussing residents' right to file a grievance, no Grievance forms available for residents to complete without requesting a form, and no box or other receptacle where residents could leave a completed Grievance form without staff identifying who completed the form. In an interview on [DATE] 8:39 AM, Staff D (Activity Assistant) stated they started working with the facility's activity department in [DATE]. Staff D stated they previously worked in the restaurant industry. Staff D stated their training on hire was sparse but they were shown how to complete a Grievance Form. Staff D stated when concerns came up in Resident Council, they sent them to the Director of Nursing Services or Staff A (Health Services Administrator). Staff D stated they did not make time at Resident Council meetings to discuss residents' rights. In an interview on [DATE] at 8:53 AM Staff A stated grievance forms were available at the nurse station. Staff A asked the nurse inside the nurse station (a small room with one door, with windows where staff could observe the floor while charting) are inside the nurse station. The nurse passed Staff A grievance form from a paper organizer at the furthest end of the nurse station from the door. Staff A stated residents were not supposed to enter the nurse station. Staff A stated residents had the right to file a grievance they were unsure how a resident could file an anonymous grievance if they needed to ask for a form and there was no place to leave it anonymously. REFERENCE: WAC 388-97-0920(1)-(6).

Based on observation, interview, and record review, the facility failed to ensure residents' medication regimens were free of chemical restraints for 1 of 5 (Resident 11) residents whose medication regimens were reviewed. This failure left residents at risk for unneeded psychotropic medications, sedation, and a diminished quality of life. Findings included . <Facility Policy>According to the facility's revised 02/19/2025 Use of Psychotropic Medications policy, psychotropic medications affected brain function and should only be used to treat a specific, diagnosed, and documented condition for which the medication was beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication. The policy showed when a resident needed a psychotropic medication, their record must include a rationale for use, and the effects of the use of a psychotropic medication must evaluated on an ongoing basis.<Resident 11>According to the 12/30/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 11 was sometimes understood others and was understood in conversation. The MDS showed Resident 11 had severely impaired cognition and diagnoses including dementia (a condition characterized by a progressive or persistent loss of intellectual function), anxiety, depression, and a psychotic disorder. The MDS showed Resident 11 took an Antipsychotic (AP) medication and admitted to the facility on [DATE]. Review of the physician's orders showed a 12/09/2025 order for an AP medication give 37.5 Milligrams (MG) at bedtime for unspecified dementia, unspecified severity. without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and a 12/10/2025 order for the same AP medication, give 25 MG in the morning for unspecified dementia, unspecified severity. without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The same medication was previously ordered on 10/09/2025 for dementia with psychosis, and on 10/17/2025 and 11/10/2025 for a neurocognitive disorder with psychotic features. The physician's orders also included a 10/10/2025 order for staff to monitor three different behaviors related to their dementia with psychosis diagnosis: delusional thinking, hallucinations, agitation. There was no order directing staff to monitor Resident 11 for orthostatic hypotension (the lowering of blood pressure when moving from lying to sitting or sitting to standing - a risk factor for falls that could be caused by AP medications). Record review showed Resident 11 was diagnosed on [DATE] (the date of their admission to the facility) with brief psychotic disorder.Review of the revised 10/10/2025 Mood Problem Related to a Diagnosis of Dementia with Psychosis CP showed the facility developed a goal for Resident 11 to have improved mood state as evidenced by a happier, calmer appearance, no [signs or symptoms] of depression, anxiety or sadness . This CP showed staff should monitor Resident 11's mood patterns for signs of depression, anxiety, and a sad mood. This CP showed staff should review Resident 11's behaviors, interventions, alternate therapies attempted, and their effectiveness with the physician and Resident 11's family.Review of the October 2025 Medication Administration Record (MAR) showed staff documented Resident 11 displayed a behavior of delusional thinking, hallucinations, or agitation on 11 of 64 shifts that month when the resident was in the facility. The October 2025 MAR did not indicate which of the three behaviors was observed by staff on a given occasion.Review of the November 2025 MAR showed Resident 11 displayed a behavior of delusional thinking, hallucinations, or agitation on two of 90 shifts that month. Review of the December 2025 MAR showed Resident 11 displayed a behavior of delusional thinking, hallucinations, or agitation on four of 93 shifts that month.Review of the January 2026 MAR showed Resident 11 displayed a behavior of delusional thinking, hallucinations, or agitation on three of 90 shifts that month.Review of the February 2026 MAR showed Resident 11 displayed no behaviors between 02/01/2026 and 02/08/2026 (the time of review).Review of the progress notes from admission on [DATE] through 02/09/2026 showed no staff documentation of any delusional behavior or hallucinations. The only behaviors discussed in progress notes were agitation (including yelling and screaming) and wandering. Observation on 02/05/2026 11:42 AM showed Resident 11 sitting in the chair next to their spouse. When asked by a surveyor if the person next to them was their spouse, Resident 11 became confused.Observation on 02/05/2026 1:19 PM showed Resident 11 walking towards their spouse's room. Resident 11 showed no signs of a diminished mood or any indication of distress. Observation on 02/09/2026 8:32 AM showed Resident 11 leaving their bedroom following an aide, with no signs of a diminished mood or any indication of distress. In an interview on 02/11/2026 at 1:00 PM Staff B (Director of Nursing Services) stated unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety was not an adequate rationale for the use of an AP medication. Staff B stated they expected staff to document all behaviors of concern related to psychotropic use, and if staff did not document such behaviors, they did not happen. Staff B stated the higher frequency of Resident 11's behaviors on admission was likely due to adjustment difficulty.In an interview on 02/12/2026 at 10:34 AM, Staff B stated it was important to monitor residents' orthostatic blood pressure when they took AP medications to help prevent falls.REFERENCE: WAC 388-97-1060(3)(k)(i), -0620(1)(a).

Based on observation, interview, and record review the facility failed to ensure residents received the care and services necessary to ensure their safety for 1 (Resident 11) of 1 residents reviewed for elopement risks. The failure placed the resident at risk for elopement, lack of supervision, and accidents.Findings included .<Facility Policy>According to the facility's revised 07/26/2024 Elopement and Wandering Residents policy, the facility would ensure all residents who wandered or were assessed to be at risk for elopement would receive the supervision they needed to prevent accidents. The policy showed residents would be assessed for wandering risk upon admission and a person-centered Care Plan (CP) with interventions developed to minimize risks associated with wandering.<Resident 11>According to the 12/30/2025 Quarterly Minimum Data Set (MDS - An assessment tool) Resident 11 sometimes understood others and was sometimes understood during conversation. The MDS showed Resident 11 was assessed to have severely impaired cognition and behavior including wandering. The MDS showed Resident 11 had diagnoses including dementia. According to the 10/06/2025 Elopement Risk Assessment, Resident 11's dementia diagnosis placed them at risk for wandering. This assessment showed Resident 11 could ambulate independently, verbalized their desire to go home from the facility, had an elopement history at their prior residence and at the facility, and took medications that altered their mental status. Review of the physician's orders showed a 10/07/2025 order for staff to check the placement of a wander alarm (a device placed on the resident's body that made a sound when the resident got to close to an exit) on Resident 11's anklefor resident is at wander risk. There was no order for staff to check the function of the alarm. According to the 10/07/2025 elopement risk CP, Resident 11's goals were to not leave the facility unattended, and to maintain their safety. This CP included an intervention of a wander alarm. The CP identified the wander alarm as a safety device. Observation on 02/05/2026 at 1:20 PM showed Resident 11 wandering on their unit near their spouse's room without any clear purpose.In an interview on 02/12/2026 at 10:34 AM, Staff B (Director of Nursing Services) stated when a resident was assessed to require a wander alarm, it was important to check the device frequently to ensure it was working correctly. Staff B stated wander alarms should be checked each shift. Staff B stated Resident 11 should have an order in place for staff to check the function of the wander alarm, but there was no such order.REFERENCE: WAC 388-97-1060(3)(g).

Based on observation, interview, and record review, the facility failed to ensure adequate monitoring for fluid overload and edema (an abnormal buildup of fluid in bodily tissue) for 1 (Resident 38) of 2 residents reviewed for edema and failed to monitor oxygen therapy for 1 (Resident 38) of 2 residents receiving oxygen therapy. These failures to monitor for edema and to provide oxygen monitoring left residents at risk for respiratory discomfort, oxygen-related accidents, infection, and a decreased quality of life. Findings included. <Facility Policy>Review of the facility's revised 07/26/2024 Edema management policy showed the facility would manage edema by assessing the resident and following the medical practitioner's orders.Review of the facility's revised 07/09/2024 Oxygen Administration policy, showed oxygen therapy should be administered under orders of a physician. The policy showed staff would document the ongoing assessment of the resident's conditions warranting oxygen and their response to oxygen therapy. Staff were to document how often to administer oxygen such as continuous or intermittent and when to discontinue oxygen therapy. The policy showed to monitor oxygen saturation levels as ordered.<Resident 38> <Edema> According to the 01/02/2026 Quarterly Minimum Data Set (MDS-an assessment tool), Resident 38 had diagnoses including heart failure, high blood pressure, and generalized edema. Review of the 09/29/2025 Fluid Overload or Potential Fluid Volume Overload related to Heart Failure Care Plan (CP) showed staff would monitor, document, and report symptoms of fluid overload such as edema, coughing, shortness of breath, or difficulty breathing while lying flat. Observation on 02/11/2026 at 9:05 AM showed Resident 38 coughing repeatedly. At that time, Resident 38 stated they had a deep cough and could not get rid of it. Resident 38 stated they wished they had cough medicine because they could not sleep last night because of coughing and shortness of breath. In an interview on 02/12/2026 at 8:50 AM, Resident 38 stated they coughed throughout the previous night. Resident 38 stated they raised the head of their bed up so they could breathe better because lying flat made them cough more. Resident 38 stated they were dizzy and lightheaded during the night. At that time Resident 38 was observed with a productive cough and had shortness of breath while talking. Review of the February 2026 Medication Administration Record (MAR) showed staff gave Resident 38 cough medication on 02/11/2026 and staff indicated it was effective. No further documentation was found to show a respiratory assessment was completed, or other interventions were provided to Resident 38 for their cough. The residents' record did not show Resident 38's provider was notified of the increase in coughing or shortness of breath. In an interview on 02/12/2026 at 9:10 AM, Staff E (Registered Nurse - RN, Team Leader) stated they were aware Resident 38 had a cough the prior day. Staff E stated Resident 38's vitals were checked that day, and their blood pressure was low. In an interview on 02/12/2026 at 9:39 AM, Staff F (RN, Resident Care Manager), stated Resident 38 had chronic heart failure, edema, and a long-term cough. Staff F stated Resident 38 could easily get sick and their coughing should be assessed due to their medical conditions. Staff F stated staff should have assessed Resident 38's cough, checked for edema, and notified the provider of a change in condition related to fluid overload but did not. In an interview on 02/12/2026 at 10:21 AM Staff B (Director of Nursing Services), stated staff should have monitored Resident 38 for edema and fluid overload, and stated they expected nurses to document their findings and notify the provider, but did not. <Oxygen Monitoring> Review of the revised 09/29/2025 altered respiratory status/difficulty breathing related to shortness of breath due to heart failure CP showed the goal for Resident 38 was to not have complications related to their shortness of breath. Interventions on the CP showed staff would monitor symptoms of respiratory distress and report symptoms of abnormal breathing patterns to Resident 38's provider. Review of Resident 38's physician's orders showed a discontinued oxygen order for 2 liters per minute of oxygen to be provided as needed. There was no current order for oxygen therapy in Resident 38's medical record. Review of the February 2026 MAR did not show an oxygen order and did not show staff were to monitor Resident 38's oxygen levels. Observation on 02/05/2026 at 12:52 PM showed Resident 38 had an oxygen concentrator (a medical device that filters surrounding air to deliver medical-grade oxygen to treat low blood oxygen saturation). At that time, Resident 38 stated they used oxygen only at night. In an interview on 02/12/2026 at 8:50 AM, Resident 38 stated they used their oxygen concentrator the previous night and could not recall the rate the concentrator was set to. In an interview on 02/12/2026 at 9:10 AM, Staff E stated they were aware Resident 38 had breathing treatments twice that day and had oxygen in their room. In an interview on 02/12/2026 at 9:39 AM, Staff F stated if a resident used oxygen there should be a current physician's order for the oxygen and the nurses should monitor the oxygen usage, oxygen saturations, and observe for shortness of breath. Staff F stated they did not know there was not a current order for oxygen usage for Resident 38 and stated nurses should have noticed and obtained orders from the provider but did not. In an interview on 02/12/2026 at 10:12 AM, Staff B stated an order for oxygen should have been in place for Resident 38 but was not. Staff B stated since Resident 38 had an oxygen concentrator in their room and received breathing treatments, the nurses should have checked for oxygen orders, assessed Resident 38, and notified the provider to ensure oxygen levels were correct for Resident 38. REFERENCE: WAC 388-97-1060(1).

Based on observation, interview, and record review the facility failed to ensure residents received the assistance they were assessed to require with Activities of Daily Living (ADL) for 1 (Resident 78) of 2 residents reviewed for ADL. This failure placed residents at risk for poor hygiene, odors, skin irritation, and a diminished sense of self-worth.Findings included .<Facility Policy>According to the revised 07/26/2024 ADL Policy, the facility would provide the care and services residents were assessed to require related to bathing, dressing, and grooming. The policy showed residents who could not carry out their own ADL would receive the help they needed.<Resident 78>According to the 12/15/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 78 had moderately impaired cognition and limited range of motion in their left arm and leg. This MDS showed Resident 78 was dependent on staff for transferring from their bed to a chair and was always incontinent of bowel and bladder. The MDS showed bathing preferences were very important for Resident 78.In an interview on 02/06/2026 at 9:15 AM Resident 78 stated they were unable to do much for themselves. At this time Resident 78 was in bed in a gown with their hair unkempt and a stained pink neck pillow supporting their head.Observation on 02/09/2026 at 12:25 PM showed Resident 78 in bed watching television, not dressed, with the same stained pink neck pillow around their neck and messy hair.Review of the physician's orders showed a 02/21/2025 order showing SHOWER DAY Document if patient received Shower or Bed-Bath or Refused. If refused, please place progress note with reason for refusal . The order directed staff to document notification of refusals to the resident's representative every Saturday.According to the 09/09/2020 ADL self-care performance deficit . Care Plan (CP), Resident 78 required total assistance from one staff for bathing and showering.Review of the bathing records showed from 01/23/2026 through 02/12/2026 showed no showers, baths, or bed baths provided and no documented refusals of bathing for Resident 78. Review of the progress notes showed no notes written by staff to document a bath or a shower was provided to Resident 78 over that period, and no documentation of any bathing refusals. In an interview on 02/12/2026 at 10:34 AM Staff B (Director of Nursing Services) stated Resident 78 should be provided bathing as ordered and care planned. Staff B stated they expected staff to document any care provided and note any refusals. REFERENCE: WAV 388-97-1060(2)(c).

Based on interview and record review, the facility failed to ensure care and services were provided within professional standards of nursing for 2 (Residents 8 & 63) of 5 residents whose medication regimen was reviewed. The failure to ensure orders were clarified when needed placed residents at risk for unneeded care and unmet care needs. Findings included . <Facility Policy>According to facility's 02/19/2025 Use Of Medications(s) policy, psychotropic medications should only be used after a practitioner determined that the medication(s) was appropriate to treat a resident's specific, diagnosed, and documented condition.<Clarifying Orders><Resident 8>According to the 11/22/2025 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 8 had diagnoses including a stroke history, an intestinal obstruction, and a history of digestive surgery. The MDS showed Resident 8 had an ileostomy (a surgical hole through which waste passes directly from the small intestine). Record review showed the following physician's orders for Resident 8: a 11/19/2025 order to change Resident 8's colostomy (a surgical hole through which waste passes directly from the colon - not an ileostomy) bag; a 11/19/2025 order to change Resident 8's ileostomy wafer (a specialized dressing for ostomy care) that showed Wafer size ____. Change wafer every 7 days and did not specify what size wafer to use.Review of the February 2026 MAR showed the orders for the wafer change and ostomy bag change were not included. There was nowhere for nurses to document the care provided.In an interview on 02/11/2026 10:03 AM, Staff G (Registered Nurse, Team Leader) stated when changing Resident 8's wafer they would review the order to see what size wafer to use.Observation on 02/06/2026 at 9:34 AM showed Resident 8 in bed with an ileostomy bag connected to their torso. Resident 8 stated staff cared for the ileostomy well.In an interview on 02/11/2026 at 1:30 PM, Staff B (Director of Nursing Services) stated the wafer order should specify what size wafer, and nurses should have identified the order needed clarifying but did not. Staff B stated nurses should have identified the colostomy bag order needed to be changed to an ileostomy bag but did not. Staff B stated both orders should have been added to the MAR but were not. <Resident 63>According to the 01/16/2026 Quarterly MDS, Resident had severely impaired cognition and altered level of consciousness. The MDS showed Resident 63 had diagnoses including vascular dementia and a psychotic disorder. Review of the physician's orders showed the following: a 09/26/2025 order for an antipsychotic medication, give 12.5 mg by mouth in the morning for vascular dementia; a 09/26/2025 order for an antipsychotic medication, give 25 mg by mouth in the evening for vascular dementia.In an interview on 02/11/2026 at 1:15 PM, Staff B stated the rationale for the antipsychotic medication was incorrect. Staff B stated the order should show Resident 63's psychotic disorder was the rationale for the medication, and nurses should have, but did not identify the error.REFERENCE: WAC 388-97-1620(2)(b)(i)(ii)(6)(b)(i).

Based on observation, interview, and record review the facility failed to ensure comprehensive Care Plans (CPs) were developed and implemented for 5 (Residents 85, 44, 38, 10, & 9) of 20 sample residents reviewed. The failure to ensure all care needs were addressed by the CP placed residents at risk for unmet care needs, and frustration. Findings included .<Resident 85> According to the 02/10/2026 admission Minimum Data Set (MDS - an assessment tool) Resident 85 admitted to the facility after a surgical procedure involving their digestive system. The MDS showed Resident 38 had lower abdominal pain and a surgical wound. Review of Resident 85's comprehensive CP showed no directions to staff to provide post-surgical care of, or interventions for staff to monitor Resident 38's digestive system In an interview on 02/06/2026 at 7:57 AM, Resident 85 stated they had new pain in their abdomen and thought it could be related to gas pain from a surgery of their colon. Resident 85 stated some of the staff were very helpful in assisting them, however others did not seem to know them. Resident 85 stated one nurse stated they should lay flat for pain and another nurse told them to keep their knees up while in bed. Resident 85 stated it was as if the staff did not know what their needs were. In an interview on 02/10/206 at 8:46 AM, Resident 85 stated they had a bowel movement recently however it was not much. Resident 85 stated their bowel movements were still not as they expected them to be and they were unsure if staff monitored this. In an interview on 02/12/2026 at 9:14 AM with Staff F (Registered Nurse, Resident Care Manager) stated they expected Resident 85's CP to be comprehensive and sufficiently detailed so staff knew what to do to help with Resident 85's care issues. Staff F stated bowel monitoring should have been included in the CP, especially since Resident 85 had a recent bowel surgery, but was not. In an interview on 02/12/2026 at 9:59 AM Staff B (Director of Nursing) stated Resident 85's care needs should be addressed in their CP to provide staff direction all the resident's needs including pain and bowel monitoring. <Resident 44> According to the 01/19/2026 admission MDS, Resident 44 had Chronic Obstructive Pulmonary Disease (COPD - a respiratory disease) and required oxygen therapy. Review of the 01/26/2026 Pneumonia (a lung infection) CP showed staff were to provide oxygen per the physician orders. The CP did not include directions to monitor Resident 44's oxygen saturation (measurement of oxygen in the blood) levels. Review of a 01/28/2026 physician order, showed supplemental oxygen should be provided every shift with a goal of oxygen saturation over 88% for shortness of breath. Observation on 02/09/2026 at 8:49 AM showed Resident 44 not receiving supplemental oxygen at that time. Resident 44 stated they took the oxygen tubing off because the tubes bothered them. Review of Resident 44's oxygen saturation rates showed staff did not document oxygen saturation rates on 02/08/2026, 02/09/2026 and 02/10/2026. In an interview on 02/12/226 at 9:32 AM Staff F stated staff should implement the CP and check oxygen saturations every shift and monitor and document Resident 44's oxygen levels. In an interview on 02/12/2026 at 10:12 AM, Staff B stated staff should check oxygen saturations for any resident on oxygen and document their progress per the CP. <Resident 38> According to the 01/02/2026 Quarterly MDS, Resident 38 had diagnoses that included heart failure, hypertension, and generalized edema. Review of the revised 09/29/2025 Altered Respiratory Status/Difficulty breathing related to Shortness of Breath due to Heart Failure CP showed staff should monitor for symptoms of respiratory distress and report symptoms of abnormal breathing patterns to Resident 38's provider. Observation on 02/11/2026 at 9:05 AM showed Resident 38 coughing repeatedly. In an interview on 02/12/2026 at 8:50 AM, Resident 38 stated they coughed all night the previous night. Resident 38 stated they raised the head of their bed up so they could breathe better and not cough, and stated they were dizzy and lightheaded during the night. Resident 38 was observed with a productive cough and had shortness of breath while talking. Review of Resident 38's progress notes did not show their provider was notified of increase in coughing or shortness of breath. In an interview on 02/12/2026 at 9:39 AM, Staff F stated staff should be following directions as shown on the CP. In an interview on 02/12/2026 at 10:16 AM, Staff B stated if a resident had edema or coughing, staff were expected to call the provider and give an update. Staff B stated if there were any changes in directions, that should also be reflected in the CP. <Resident 10> According to the 01/23/2026 admission MDS, Resident 10 had diagnoses including atrial fibrillation (irregular heart rhythm) and took a blood thinner. Review of a 01/26/2026 physician order showed Resident 10 took a blood thinner medication daily and staff should observe for discolored urine, black tarry stools, headache, nausea, vomiting, shortness of breath, and nose bleeds and document the results every day. Review of Resident 10's comprehensive CP showed the CP did not reflect Resident 10's blood thinner medication use and did not show what side effects to observe for. Review of the February 2026 Kardex (caregiver task sheet) did not identify the side effects of blood thinner medication and what care staff should observe and report. In an interview on 02/12/2026 at 9:37 AM, Staff F stated staff should monitor for side effects of the blood thinner as blood thinner could easily cause bleeding. Staff F stated the side effects should be listed on the CP and Kardex but were not. In an interview on 02/12/2026 at 10:14 AM Staff B stated blood thinner side effects should be on the CP and Kardex for staff to know what to look for and what to report on but were not. <Resident 9> According to the 12/19/2025 Quarterly MDS, Resident 9 had diagnoses including a mental health disorder. The MDS showed Resident 9 took an antipsychotic medication. Review of the physician's orders showed two 01/08/2026 orders for an antipsychotic medication: give 12.5 Milligram (MG) by mouth in the morning related to their mental health disorder; give 25 MG tablet by mouth at bedtime related to their mental health disorder. Record review showed a revised 08/28/2025 Resident uses psychotropic medications . CP. This CP's only goal was to remain free of drug-related complications from the treatment. No goal related to any potential benefit of the medication was developed. In an interview on 02/11/2026 at 1:20 PM, Staff B reviewed the CP and stated the only goal was to avoid complications. Staff B stated the CP should include a goal addressing the potential benefit of the treatment. REFERENCE: WAC 388-97-1020(1)(2)(a)(b).

Based on interview and record review, the facility failed to implement a facility-wide system for Antibiotic (ABO) Stewardship (a program to improve how ABO medications are prescribed, treating bacterial infections, and reduce the inappropriate use of ABO medications). The facility failed to implement an accurate surveillance method to track all resident infections, identify the source of infections, collect diagnostic data for organisms and ensure correct ABO treatment, identify residents' symptoms and use nationally recognized assessment criteria for prescribing ABO medications, monitor isolation precaution timelines, identifying trends in types infections or similar organisms, analyze data collected to provide ABO and infection reports to the prescribers of antibiotics. This failure placed residents at risk for potential adverse outcomes associated with the inappropriate/unnecessary use of ABOs and an increased risk for ABO resistant organisms. Findings included . Review of the facility policy Antibiotic Stewardship Program dated 07/10/2024 showed the facility implemented an ABO Stewardship program to optimize the treatment of infection and reduce the adverse events associated with ABO use. The policy showed nurses assess residents, notify the physician for laboratory testing if indicated, nurses would conduct an ABO time out to determine continued ABO use or need for adjustments, the facility used national standard surveillance tools and published criteria to meet the criteria for ABO treatment. The policy showed ABOs would be monitored for indications for use according to lab reports, response to treatment, and review of prescribed ABO outside of the facility for appropriateness. The policy showed monthly antibiotic review would be completed by the pharmacist and monthly measurements of ABO prevalence, tracking infections and ABO use with outcome measures, and ABO resistance. The policy showed the facility would maintain documentation for assessments, ABO use protocols, data collection for ABO use, process and outcome measures, ABO Stewardship meeting minutes, feed back reports, records related to education of physicians, staff, and residents, and annual reports. The policy showed the ABO stewardship monitoring activities were discussed in the Quality Assurance and Process Improvement (QAPI) meetings. In an interview on 10/28/2024 at 2:32 PM, with Staff B (Director of Nursing) and Staff D (Infection Control Preventionist), Staff D stated they were new to the position starting in 08/2024. Staff D provided a binder labeled ABO Stewardship with printed materials for 08/2024, 09/2024, and 10/2024. Staff D stated they did not have a data collection analysis or summary for the resident infections in 08/2024 or 09/2024. Staff D showed where the ABO cases are loaded in an online tracking program. Staff D was not able to print or provide data reports according to the ABO stewardship policy. Staff D stated they did not know how to gather the reports and needed to ask for assistance to obtain the documents. Staff B and Staff D were asked to provide surveillance logs showing the data collection for infections, tracking and trending documentation for infections, documentation of analysis of resident ABO use, and any data reports or summary for the prior four months of infections and ABO use. Review of the facility ABO Stewardship binder for the months of 09/2024 and 10/2024 showed printed physician orders for individual resident's antibiotic use, a copy of the medication administration record for the ABO, and some had laboratory reports. The documents listed in the facility policy were not provided in the binder. In an interview on 10/29/2024 at 9:25 AM, Staff D stated they were told there was a printed surveillance spreadsheet in the ABO stewardship binder provided on 10/28/2024. A review of the spreadsheet for 09/2024 and 10/2024 with Staff D showed incomplete with many blanks in the columns for infection etiology, evaluation of infection, laboratory results, infection type and location, organism, resident symptoms, and whether the infection met the criteria for ABO treatment. In an interview on 10/29/2024 at 11:02 AM, Staff A (Administrator) reviewed the facility infection surveillance spreadsheet. Staff A stated they saw much of the data was not documented. Staff A stated the ABO stewardship program should not have blank areas on the spreadsheet. Staff A stated the spreadsheet should be completed and accurate to include resident's symptoms, identifed organisms causing infection, confirmation of lab cultures, and analysis of the infection to ensure it met the criteria for ABO treatment. Staff A stated the ABO stewardship program was not intact and did not meet the ABO stewardship program policy requirements. REFERENCE: WAC 388-97-1320(1)(a)(2)(a-c).

Based on interview and record review the facility failed to ensure nurse and nurse aide staff had the appropriate competencies and skill sets to provide nursing and related services, to assure resident safety, and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident according to the facility assessment, resident-specific assessments and resident plans of care for 7 of 7 staff (Staff H, I, J & K - Nurse Aids and Staff E, G, & R - Licensed Nurses) reviewed for competency. The failure to develop and implement a process to evaluate staff's competency and skills to perform job expectations, including medication pass evaluation of competency, placed residents at risk for medication errors, accidents, injuries, infections, diminished quality of life, and diminished quality of care. Findings included . The 2024 Facility Assessment review date 09/08/2024 showed training/education and competencies of nurses and nurse aides that were necessary to provide support and care to the residents of the facility. Registered Nurse (RN) training and education needs for competency: training in assessments, medication management, emergency response, change in condition, identify medical interventions, care planning, care coordination, supervising and mentoring licensed nurses and nurse aids, regulatory compliance, communication skills, cultural competency, and emergency protocols. Licensed Practical Nurse (LPN) training and education needs for competency: basic clinical skills, nursing tasks, medication administration, vital sign monitoring, care documentation, emergency response, communication, compassionate care, regulatory knowledge, cultural competency, and emergency protocols. Nurse Aide (NA) training and education needs for competency: personal care skills, vital sign monitoring, safety and mobility, communication and empathy, infection control, emergency protocols, and cultural competency. In an interview and record review on 10/28/2024 at 1:09 PM with Staff M (Human Resources Director) and Staff A (Administrator) training and education documents were requested for Staff G, H, I, J, and K. Documents were not found in the staff's records. Staff A was asked how staff is evaluated for competency in the required skills to provide care to residents. Staff A stated the Administrator, Director of Nursing and the Staff Development Specialist were all new in their positions. Staff A stated a system needed to be developed and implemented to evaluate RN, LPN and NA staff competency in the areas identified on the Facility Assessment. Refer to F759 Free of Medication Error Rate 5 Percent or More Refer to F947 Required Inservice Training for Nurse Aides REFERENCE: WAC 388-97-1080(1).

Based on interview and record review, the facility failed to develop, implement and maintain an in-service training program that ensured 4 of 4 Nursing Aides (Staff H, I, J & K) completed the required training, including dementia care management and training for special needs of residents, to ensure continued competency when providing resident care. The failure to provide nurse aides the required training on hire, provide no less than 12 hours of continuing education annually, and perform annual performance evaluations to address weak areas for additional training placed residents at risk for less than competent care and services from nurse aide staff. Findings included . The 2024 Facility Assessment (FA), review date 09/08/2024, showed Nurse Aides (NA) would require training/education and competency to provide support and care needed to the resident population. The FA listed the following training/ education needs: basic personal care skills, vital signs monitoring, safety and mobility, communication and empathy, infection control, emergency protocols, and cultural competency. The FA stated required in-service training for NAs must be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year, must include dementia management training and resident abuse prevention training, must address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff, and for NAs providing services to individuals with cognitive impairments, training must address the care of the cognitively impaired. In an interview and record review on 10/28/2024 at 1:09 PM with Staff M (Human Resources Director) and Staff A (Administrator), Staff A stated NA training was completed in an on-line program and through staff meetings for all staff. Staff A stated there was a checklist NAs completed during orientation and on the floor training with an experienced staff person to verify competency. Staff A stated the checklist was completed by the experienced staff person and returned to the supervisor for the staff records. A request was made for the training checklists, online training and all staff meeting documentation for NA Staff H, I, J and K. In an interview on 10/28/2024 at 2:16 PM, Staff B (Director of Nursing) stated there was not a system in place for annual evaluations of NA skills for competency verification. In an interview on 10/29/2024 at 9:25 AM, Staff D (SDS, Staff Development Specialist) stated NA staff completed a training checklist while training with an experienced NA staff. Staff D did not have any of the completed NA checklists and stated they did not track the completion of the checklists. Staff D was not able to provide any information about the required training for NAs on hire or 12 hours annually. Staff D stated they were new to the SDS role and to check with the Administrator about NA training. In an interview on 10/29/2024 at 11:09 AM, Staff A stated there were no training checklists for NA Staff H, I or J. Staff A stated training documentation requested for Staff H, I, J and K were not able to be located. Staff A stated the NA training program was not developed or implemented and needed work to meet the requirement of required training on hire, 12 hours of continuing education annually, and annual performance evaluations to address weak areas for additional training. Refer to F726 Competent Nursing Staff REFERENCE: WAC 388-97-1680 (2)(a)(b)(i-ii)(c).

Based on observation, interview, and record review the facility failed to implement an infection prevention and control program to prevent, identify, report, investigate, and control infections and communicable diseases according to national standards. The failure to implement a system of surveillance designed to identify possible communicable diseases and infections before they could spread to other persons in the facility, implement Enhanced Barrier Precautions (EBP) to prevent the spread of infections for 2 of 5 residents (Residents 33 & 212), and ensure staff used Personal Protective Equipment (PPE) as required placed all residents at risk for facility-acquired or healthcare-associated infections and related complications. Findings included . <Infection Prevention and Control Program (IPCP)> Review of the Facility Assessment, revised 09/08/2024, showed the facility infection prevention and control (IPC) program would effectively prevent, identify, report, investigate, and control infections and communicable diseases. The FA showed the facility used a surveillance system that included tracking infections, monitoring infection rates and trends to detect potential outbreaks and identify the effectiveness of the current IPC measures. Review of the facility policy titled Infection Surveillance dated 07/26/2024 showed a system of infection surveillance served as a core activity of the facility's IPC. The policy showed the facility would maintain documentation of incidents, findings, and corrective actions made by the facility. The policy showed the facility adhered to a nationally recognized surveillance criteria to identify infections. The policy showed all infections for residents, staff, and volunteers would be tracked and outbreaks would be investigated. The policy showed the facility would monitor surveillance activities, collect identified data on infections, staff observations and identify outcomes, trends and patterns. The policy showed data would be captured and reported monthly using charts and data comparisons over time using formulas for calculating infection rates. In an interview on 10/28/2024 at 2:02 PM with Staff B (Director of Nursing) and Staff D (Infection Control Preventionist) records of the facility infection surveillance was requested. Staff B and Staff D were asked to provide the data for infection tracking infections, monitoring infection rates, and any other data analysis or summaries used in the facility IPCP for the months of 07/2024, 08/2024, and 09/2024. Staff B and Staff D stated they would need assistance and time to gather the information requested. In an interview on 10/29/2024 at 9:25 AM, Staff D stated all the information the facility had for infection surveillance was in the antibiotic stewardship binder and no other data was available. Staff D stated the data for the months of 07/2024, 08/2024 and 09/2024 could not be located or provided for review. Staff D reviewed the binder and was not able to find the information requested in the binder. In an interview on 10/29/2024 at 11:02 AM, Staff A (Administrator) stated the requested information for the infection surveillance for 07/2024, 08/2024 and 09/2024 was not completed. Staff A stated the infection control systems were not intact and needed improvement. 50511 <Enhanced Barrier Precautions (EBP)> Review of the facility policy Enhanced Barrier Precautions dated 07/26/2024 showed the facility implemented EBP to prevent the transmission of multi-drug resistant organisms (MDRO). The policy showed staff would recognize the need for EBP thorough training of EBP precautions, high risk activities, common organisms that require EBP and staff were expected to comply with all designated EBP signage posted outside the resident room, use designated Personal Protective Equipment (PPE) for direct care, and hand hygiene. The policy showed nurses would implement EBP for residents with certain conditions or devices, obtain physician orders for EBP for residents that have wounds, indwelling medical devices or has a MDRO infection or colonization. <Resident 33> According to the 07/26/2024 Admission Minimum Data Set (MDS-an assessment tool), Resident 33 admitted to the facility on [DATE] with open pressure ulcers on their right heel, right hip, and left hip areas and had an indwelling catheter to drain urine. Observations on 10/25/2024 at 9:50 AM showed Resident 33's room did not have a EBP sign posted outside their room or supplies easily available outside the room for staff use. <Resident 212> Review of Resident 212's 10/07/2024 Baseline Care Plan, Resident 212 was admitted to the facility on [DATE] and had an indwelling urinary catheter. Observations on 10/22/2024 at 11:01 AM showed Resident 212 room did not have a EBP sign posted outside their room or supplies easily available outside the room for staff use. In an interview on 10/23/2024 at 10:11 AM, Staff D stated any resident with wounds, indwelling catheter, tube feeding, or an ostomy (opening in abdomen for bowel elimination) should be on EBP precautions. 45941 <Personal Protective Equipment (PPE)> Reveiw of the facility policy titled Personal Protective Equipment dated 07/26/204 showed the facility promoted the use of PPE to prevent the transmission of pathrogents to residents, visitors and staff. The policy showed staff would receive traning on why, what, how to use PPE on hire, annually, when new products are introduced and as needed. Review of the facility policy titled Transmission Based Precautions (TBP) dated 07/26/2024 showed there facility would use standard approaches as defined by the CDC (Center for Disease Control) for TBP. Staff would follow CDC guidance for the use of a fit-tested N-95 respirator. Observation on 10/21/2024 at 8:30 AM showed Staff Z (Certified Nursing Assistant) was wearing two masks (an N-95 respirator on top of a surgical mask) over their nose and mouth. Staff Z had gown, gloves, hair cover, and face shield on and went into a room with droplet precaution isolation sign on the door to deliver a breakfast tray. Staff Z came out of the room, removed gloves and gown and sanitized their hands. Staff Z was not observed to clean their face shield. In an interview on 10/21/2024 at 8:38 AM, Staff Z stated they had to wear a surgical mask under the N-95 respirator because they were allergic to N-95 respirator. Staff Z stated they were supposed to clean their face shield when they came out of the isolation room, but they forgot and did not clean the face shield. Observation on 10/22/2024 at 8:31 AM showed Staff Z was delivering the breakfast trays in resident's rooms and was wearing N-95 respirator only. In an interview on 10/22/2024 at 8:40 AM, Staff Z stated they were not wearing two masks, like they were on the day before, because Staff D provided Staff Z with a different N-95 respirator to try. Staff Z stated they did not get any rashes on their face with the new N-95 respirator. Staff Z stated they were not fit tested for the new N-95 respirator. In an interview on 10/29/2024 at 1:45 PM, Staff D stated Staff Z should not wear two masks at the same time. Staff D stated the facility expectation was all staff should be fit tested before using a N-95 respirator. Staff D stated Staff Z should have, but did not, have fit testing done before using the new N-95 respirator. REFERENCE: WAC 388-97-1320(1)(a)(2)(a-c)(5).

Based on observation, interview, and record review the facility failed to provide assistance with Activities of Daily Living (ADL), related to cleanliness and grooming for 5 (Residents 2, 3, 24, 35, & 37) of 17 sample residents reviewed for ADLs. Facility failure to provide residents who were dependent on staff for assistance with showers, shaving, and nail care, placed the residents at risk for poor hygiene, long facial hair, embarrassment, and diminished quality of life. Findings included . <Facility Policy> According to the facility policy titled, Activities of Daily Living, revised 07/26/2024, the facility would provide ADLs in accordance with resident's comprehensive assessment, Care Plan (CP), and resident's needs and choices to ensure a resident's ADL abilities would not deteriorate unless deterioration in function was unavoidable. <Resident 2> According to the 07/30/2024 Quarterly Minimum Data Set (MDS - an assessment tool), Resident 2 had weakness on right side of the body related to a stroke and required maximal assistance with personal hygiene including showers. The MDS showed Resident 2 had no behavior of refusing care during the assessment period. Observations on 10/21/2024 at 11:02 AM, 10/22/2024 at 2:48 PM, and 10/24/2024 at 10:57 AM showed Resident 2 had long facial hair on chin area and long fingernails on right contracted hand. According to the 12/19/2022 ADL self-care performance deficit CP, Resident 2 was dependent on staff for personal hygiene including showers. In an interview on 10/24/2024 at 11:17 AM, Staff O (Registered Nurse) stated they expected staff to check all resident's preferences related to ADLs and provide assistance as needed every morning. Staff O stated staff should have shaved Resident 2's facial hair and clipped fingernails. <Resident 3> Observations on 10/21/2024 at 9:02 AM, 10/22/2024 at 12:25 PM, and 10/25/2024 at 10:01 AM showed Resident 3 was lying in bed, had long fingernails and greasy hair. According to the revised 11/12/2023 ADL self-care performance deficit CP, Resident 3 was dependent on staff for personal hygiene including shower related to poor balance and left side vision blind. The CP included the interventions for the staff showed Resident 3 preferred a shower twice a week and required maximal to total assistance with shower, and one person assistance with nail care. In an interview on 10/29/2024 at 1:00 PM, Staff F (Resident Care Manager) stated Resident 3 refused the care at times. Staff F reviewed Resident 3's record and confirmed no shower was provided and documented for the last 30 days. Staff F Stated staff should have provided showers and nail care on scheduled shower days but they did not. <Resident 24> According to the 09/23/2024 Quarterly MDS, Resident 24 was required total assistance with personal hygiene and showers. The MDS showed Resident 24 had no behavior of refusing care during the assessment period. Observations on 10/22/2024 at 1:20 PM, 10/24/2024 at 11:07 AM, and 10/25/2024 at 9:52 AM showed Resident 24 was up in their wheelchair and had long fingernails and greasy hair. According to the revised 10/30/2023 ADL self-care performance deficit CP showed Resident 24 was dependent on staff for showers and personal hygiene including nailcare. In an interview on 10/28/2024 at 1:18 PM, Staff F stated Resident 24 was scheduled to have a shower once every week. Staff F reviewed Resident 24's record and confirmed no shower was documented for the last 30 days. Staff F stated staff should provide showers and nail care as scheduled, but they did not. <Resident 35> According to the 09/28/2024 Quarterly MDS, Resident 35 had intact memory, weakness on one side of the body, and required one person assistance with showers and personal hygiene. The MDS showed Resident 35 had no behavior of refusing care during the assessment period. In an interview on 10/22/2024 at 10:37 AM, Resident 35 stated they had not received a shower for a month. According to a 12/01/2023 ADL self-care performance deficit CP, Resident 35 needed one person assistance with shower and personal hygiene. In an interview on 10/28/2024 at 12:37 PM, Staff F reviewed Resident 35's record and stated staff should provide showers to Resident 35 as scheduled, but they did not. <Resident 37> According to the 09/17/2024 Admission MDS, Resident 37 had an intact memory, and required total assistance with showers and personal hygiene from staff. The MDS showed Resident 37 had no behavior of refusing care during the assessment period. Observations on 10/22/2024 at 12:30 PM, 10/24/2024 at 9:21 AM, and 10/25/2024 at 10:10 AM showed Resident 37 was lying in bed and had greasy hair. According to the 09/16/2024 ADL self-care performance deficit CP, Resident 37 was totally dependent on staff for showers and personal hygiene care needs. In an interview on 10/28/2024 at 1:37 PM, Staff F reviewed Resident 37's record and stated staff should have provided showers to Resident 37 as scheduled, but they did not. In an interview on 10/29/2024 at 12:34 PM, Staff B stated they expected staff to check all resident's preferences related to ADLs and provide assistance as needed every morning including oral care, shaving facial hair, and nail care. Staff B stated they expected staff to provide showers to residents as scheduled. REFERENCE: WAC 388-97-1060(2)(C).

Based on interview and record review, the facility failed to ensure a Pre-Admission Screening and Resident Review (PASRR - a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment) assessment was accurate to reflect the resident's mental health condition for 1 of 3 (Resident's 14) residents reviewed for PASRR. This failure placed residents at risk for inappropriate nursing home placement and /or not receiving timely and necessary services to meet their mental health needs. Findings included . <Resident 14> According to a 09/19/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 14 admitted to the facility on [DATE]. The assessment showed Resident 14 had diagnoses of, but not limited to, non-Alzheimer's dementia, Seizure disorder, Psychotic disorder, delusional disorders, and unspecified mental disorder due to unknown physiological condition. The MDS showed Resident 14 received antipsychotic medications during the assessment period. Review of Resident 14's records showed a 01/28/2024 physician order for an antipsychotic medication to be administered every morning and a 09/05/2024 antipsychotic medication to be administered in the evening. Records review showed an 08/06/2021 Level I PASRR for Resident 14. This PASRR listed psychotic disorder and delusional disorder as Serious Mental Illness (SMI) indicators. The PASRR I was marked no level II evaluation indicated. In an interview on 10/29/2024 at 9:38 AM Staff C (Social Service Director) stated Resident 14 should have been referred for a Level II PASRR but was not. REFERENCE: WAC 388-97-1915(1)(2)(a-c).

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR) process (a federal requirement to help ensure that individuals who had a mental disorder or intellectual disabilities were offered the most appropriate setting for their needs [in the community, a nursing facility, or acute care setting]; and received the services they need in those settings), was followed for 1 of 4 residents (Resident 213) sampled for PASRR review. This failure placed residents at risk for not receiving specialized mental health services, unidentified mental health needs and a decreased quality of life. Findings included . <Resident 213> According to the 10/05/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 213 admitted to the facility on [DATE] with multiple complex conditions that included psychiatric mood disorder and confusion. Review of Care Area assessment dated [DATE] showed resident had confusion, behavior and mood disorder. Review of physician orders dated 10/4/2024 showed resident had a diagnosis of depression and anxiety. Review of 10/04/2024 Cognitive Care Plan (CP) showed Resident 213 had impaired cognitive function, and impaired thought processes. Goals listed on the CP was the resident would be free of delirium. Interventions listed on the CP was staff was to report new onset of delirium symptoms such as disorientation, restlessness, agitation and altered sleep cycle and to redirect and reorient to person, place and time as required. Review of the Pre-Admission Screening and Resident Review (PASRR) CP dated 10/4/2024 showed Level 1, Level 2 referral not indicated. Goals were to monitor for significant change and update the PASRR as needed, interventions listed was for staff to monitor for significant changes and to update the PASSR. Review of the clinical record on 10/24/2024 showed the admission PASRR was signed by hospital staff on 09/28/2024. Section 1 of the PASRR form did not have any Serious Mental Illness Indicators checked off for mood or anxiety disorders. Section IV of the form was left blank with no boxes marked to designate if a Level II evaluation was needed or not. No updated PASSR was found since. In an interview on 10/29/2024 at 9:59 AM, Staff C (Social Services Director) verified the PASRR I form was not fully completed by the hospital. Staff C stated the resident did have an increase in antidepressant medication and the resident did wander at night, therefore may need a PASRR II. Staff C stated a PASRR I should have been fully completed as PASRR was important for the resident to be properly assessed and to determine if there were any additional services or interventions needed for the resident. REFERENCE: WAC 388-97-1915 (1)(2).

Based on interview and record review, the facility failed to ensure a system by which residents/representatives received required written notices at the time of transfer/discharge, or as soon as practicable for 3 of 4 residents (Residents 16, 35, & 46) reviewed for hospitalization s. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences. Findings included . <Facility Policy> A facility policy titled, Transfer, and Discharge (including AMA) revised on 08/08/2024, showed a notice of transfer/discharge must be provided to the resident/representative when an emergency transfer to an acute care facility is ordered. The policy showed the notice would include the specific reason and basis for transfer, date of transfer, and name of the hospital to which the resident was transferred or discharged . <Resident 16> Review of Resident 16's 03/31/2024 Discharge Return Anticipated Minimum Data Set (MDS- an assessment tool) showed the resident was transferred to an acute care hospital on 03/31/2024. Record review on 10/23/2024 showed no documentation staff provided the required written notification to Resident 16 and/or their representative regarding their transfer to the hospital. <Resident 35> Review of Resident 35's 02/12/2024 Discharge Return Anticipated MDS showed Resident 35 discharged to an acute care hospital on 02/12/2024. Record review on 10/23/2024 showed no documentation staff provided the required written notification to Resident 35 and/or their representative regarding their discharge. In an interview on 10/28/2024 at 12:55 PM, Staff F (Resident Care Manager) stated they did not know about the process for written notification, and they were not being provided to any of the residents transferred to the hospital In an interview on 10/29/2024 at 12:34 PM, Staff B (Director of Nursing) stated it was important to provide a written transfer notification to ensure the resident or resident representative was informed of the reason for transfer and to ensure the transfer was in alignment with the resident's stated goals for care and preferences, but the facility did not follow the facility policy. 50511 <Resident 46> Review of Resident 46's 08/31/2024 Discharge Return Anticipated MDS showed the resident was transferred to an acute care hospital on 08/31/2024. Record review showed an unedited, unsigned, and blank Nursing Home Transfer or Discharge Notice form dated 8/31/2024 in Resident 46's record. No documentation in record that staff provided the required written notification to Resident 46 and/or their representative regarding their transfer to the hospital. In an interview on 10/29/2024 at 12:34 PM, Staff B stated it was important to provide a written transfer notification to ensure the resident or resident representative was informed of the reason for transfer and to ensure the transfer was in alignment with the resident's stated goals for care and preferences, but the facility did not follow the facility policy. REFERENCE: WAC 388-97-0120 (2)(a-d).

Based on interview and record review, the facility failed to thoroughly investigate and rule out abuse/neglect for 1 of 1 sampled resident (Resident 31) reviewed for abuse investigations. Facility's failure to complete a thorough investigation and provide feedback regarding the resident's concerns placed residents at risk for potential abuse and other negative health outcomes. Findings included . <Facility Policy> Review of the facility policy titled, Abuse, Neglect and Exploitation, revised June 10 2024, showed the facility would implement processes to prevent and prohibit all types of abuse or neglect and establish a safe environment. The facility would rule out abuse and neglect by use of identification, assessments, and care planning for appropriate interventions. The policy showed the facility would monitor residents with needs and behaviors which might lead to conflict, and the facility would provide information to staff and residents on how and to whom concerns would be reported. The policy also showed the facility would provide feedback regarding the concerns that were expressed by the resident. <Resident 31> According to the 09/23/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 31 admitted to the facility on [DATE] with multiple complex conditions that included kidney insufficiency, high blood pressure and heart failure. The MDS showed Resident 31 could communicate needs, be understood by others, had weakness and was dependent on the staff to move and transfer. In an interview on 10/22/2024 at 12:37 PM Resident 31 stated the resident from the room next door opened their door and came into their room at 3:30 am the other morning. Resident 31 stated they told staff, but nothing happened, and no one came and talked to them regarding their concern. In an interview on 10/24/2024 at 9:49 AM Resident 31 stated at 3:30 am yesterday, the other resident came into their room again. The other resident had on underwear and t-shirt, came into their room, turned their room light on and asked for a garbage can. Resident 31 stated they called downstairs at 3:30 to let the facility know that a resident came into their room. Resident 31 stated they left a message for the Administrator, and they still have not come to talk to them about this. Resident 31 stated they heard the staff yelling with each other in the hallway about the other resident wandering into rooms. Resident 31 stated on the first occurrence the same resident went to their room and turned the light on and went through their drawers. Resident 31 stated they were a victim of domestic violence, and this was very scary for them. The staff told Resident 31 the other resident roamed around at night and does not sleep. Resident 31 stated nobody had ever talked to them about either of these events and they feel they don't matter to the staff at all. In an interview on 10/24/2024 at 11:13 AM Staff B (Director of Nursing) and Staff C (Social Services Director) stated all staff should fill out a grievance report when an incident was reported by a resident. Staff B and Staff C stated they did not have any grievance reports for Resident 31. In an interview on 10/24/2024 at 1:38 PM Staff A (Administrator) stated they did not hear about a previous occurrence happening and said staff are now working on a grievance report for the most recent event. Staff A stated the staff should have started the grievance report when the resident first notified staff of the event but did not. REFERENCE: WAC 388-97-0640(6)(a)(b).

Based on interview and record review the facility failed to ensure informed consent (a process explaining the risks and benefits of a treatment prior to use) was obtained prior to administration of psychotropic (affecting mental state) medications for 3 of 5 residents (Resident 53, 212, & 213) reviewed for unnecessary medications. This placed residents at risk for unwanted treatment. Findings included . <Facility Policy> According to a facility policy titled, Use of Psychotropic Medication, revised 07/02/2024, the facility would develop psychotropic medication regimens in collaboration with residents/resident representatives. The policy showed residents/resident representatives would be educated on the risks and benefits of psychotropic drug use, as well as alternative treatments/nonpharmacological interventions. According to a facility policy titled Promoting/Maintaining Resident Self-Determination, revised 07/29/2024, the facility would ensure each resident had the opportunity to exercise their autonomy. The policy showed the residents rights to determine what, if anything, they would prefer to do or not to do each day would be honored in accordance with physician orders. <Resident 53> Review of Resident 53's records showed a 10/06/2021 Durable Power of Attorney (DPOA) paperwork that designated a Resident Representative (RR) to make decisions for them regarding their healthcare. According to a 09/13/2024 Admission Minimum Data Set (MDS - an assessment tool), Resident 53 was severely cognitively impaired. The MDS showed the primary information source was provided by Resident 53's RR. The assessment showed Resident 53 had diagnoses of, but not limited to, anxiety disorder, depression, and age-related cognitive decline. Review of Resident 53's records showed a physician order for an antianxiety medication started on 09/17/2024 and stopped on 10/25/2024. These physician orders showed Resident 53 was ordered another antianxiety medication on 10/28/2024 to be administered twice daily for seven days then double the dose starting on 11/05/2024. Resident 53's records showed no consent was obtained for either medication prior to administration. <Resident 212> Review of Resident 212's physician orders showed a 10/07/2024 antidepressant medication prescribed for sleep, two 10/08/2024 antidepressant medications prescribed for depression and anxiety, and a 10/08/2024 antipsychotic medication prescribed for Parkinson's psychosis. Review of Resident 212's records showed consent forms with no signatures from Resident 212. Resident 212's records had consent forms with verbal consent typed in resident signature area on two separate 10/10/2024 consent forms for the two antidepressants prescribed for depression. Resident 212's records had consent forms with verbal order typed in resident signature area on a 10/10/2024 consent form for an antidepressant prescribed for sleep and an antipsychotic medication prescribed for psychosis. <Resident 213> According to a 09/13/2024 Admission MDS, Resident 213 was moderately cognitively impaired. The assessment showed Resident 213 had diagnoses of, but not limited to, anxiety disorder and depression. The MDS showed Resident 213 was receiving antidepressant medications during the assessment period. Review of Resident 213's records showed a 10/02/2024 physician order for a hypnotic medication and a 10/23/2024 antidepressant medication. Review of Resident 213's records showed three consent forms, a 10/03/2024 for an antianxiety medication with resident signature box left blank and a first name with RR, DPOA typed in authorized persons name & relationship box, a 10/03/2024 for a hypnotic medication with verbal consent from RR typed in under the resident signature box, and a 10/03/2024 consent form for an antidepressant medication with the first name and RR, DPOA typed under the RR or DPOA box. The 3 consent forms for Resident 213 were all signed by Staff E without a witness signature for the verbal consents. In an interview on 10/29/2024 at 12:14 PM Staff E (Registered Nurse, Resident Care Manager) stated consent was not obtained for either antianxiety medication for Resident 53 prior to administration but should have been. Staff E stated they were expected to print the consent forms and obtain a signature, then scan the signed consent forms into the resident's records. Staff E stated when they obtained a verbal consent, they were expected to have two staff/witness sign the consent form. REFERENCE: WAC 388-97-0260.

Based on observations, interviews, and record review the facility failed to provide adequate supervision, implement care interventions, and/or complete a thorough investigation of accidents for 2 of 2 residents (Residents 1 & 2) reviewed for falls with fractures. The failure to supervise and implement interventions for care needs resulted in harm to Resident 1 including a wrist fracture, severe pain, emotional distress, and diminished quality of life. The failure to ensure residents receive supervision to prevent accidents placed residents in the memory care unit at risk for falls and injury. The failure to identify the root cause of the resident falls detracted the facility from preventing future falls, placing residents at continued risk for falls and injury. Findings included . <Supervision> The 11/04/2022 facility Fall Prevention Policy showed each resident will receive care and service to minimize the likelihood of falls. The 11/04/2022 facility Accidents and Supervision Policy showed each resident will receive adequate supervision and staff will implement interventions based on the residents' assessed needs to prevent accidents. In an interview on 03/09/2023 at 4:15 PM, Staff A, Director of Nursing, stated residents on the memory care unit required supervision to prevent falls and the facility provided enough staff in memory care to meet the resident's assessed supervision and care needs. In an interview on 03/09/2023 at 3:32 PM, Staff B, Resident Care Manager- Memory Care Unit, stated the staff was expected to supervise the common areas, including the TV sitting area, in the memory care unit at all times. In an interview on 03/15/2023 at 1:39 PM, Staff D, Licensed Practical Nurse-Memory Care Nurse, stated the memory care unit were always supposed to be supervised and the memory care staff rotated responsibility to watch residents in the common areas. An observation on 03/09/2023 at 12:49 PM thru 1:05 PM, showed one resident in the common TV area staring at the TV with a table with lunch in front of them, another resident was walking in the hallway. There was no staff present for 16 minutes of the observation. Observation on 03/21/2023 at 8:50 AM to 9:00 AM in the common TV area of the memory care unit was the same resident sitting in a chair with a table and breakfast in front of them, the same second resident was walking in the hallway. There were no staff present for 10 minutes. On both observations the staff were in the dining room at the end of the hall or behind a closed door of a resident room. Investigation The undated facility Investigation of Injuries Policy showed all injuries would be assessed and sufficient details of the clinical findings would be documented in the clinical record. The facility would ensure that all injuries are investigated and documented with the help of all persons who had contact with the resident during the prior 48 hours. Investigations would follow the process set forward in the Abuse Investigation and Reporting Policy. The 03/2021 facility Abuse Investigation and Reporting Policy showed facility management would complete thorough investigations; the investigator would interview staff and determine events leading up to the incident, document interviews and agencies would be provided a written report of the findings of the investigation within five working days of the incident. In an interview on 03/09/2023 at 4:15 PM, Staff A stated a fall investigation should include a timeline of events, interviews of staff, and a conclusion summary. Staff A stated the investigation should be completed within five days. <Resident 1> The 02/09/2023 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 had dementia, poor balance, impaired range of motion, and was frequently incontinent of bowels and bladder. Resident 1 was assessed to require extensive physical assistance from staff with walking, bed mobility, transfers (moving from standing or sitting position), toileting, incontinence, and locomotion using a wheelchair (WC). The 02/23/2023 Care Plan (CP) showed Resident 1 required one-to-two-person extensive assistance with use of the toilet, hygiene, and transfers and showed a toileting plan that included toileting upon resident request, upon waking, before or after all meals, before bedtime and every two to three hours as needed. The CP showed Resident 1 required one-person physical assist for transfers and sometimes two-person assistance with transfers to stand for safety during times of increased weakness. The CP showed Resident 1 used a WC for locomotion and required extensive assistance with short and long distances in the WC. The 03/02/2023 8:00 AM fall incident report showed Resident 1 resided in the memory care unit of the facility and was found at 8:00 AM by Staff C, (Certified Nursing Assistant - CNA) sitting on the floor in the common area TV room next to the sofa. Resident 1 was alone, crying and screaming while holding their left hand. There were no residents or staff present around Resident 1. The incident report showed Staff C heard Resident 1 screaming from the hallway while they provided care to another resident in a room with the door closed. The report showed Staff C notified the nurse and the other CNA that Resident 1 was hurt and sitting on the floor crying. In an interview on 03/15/2023 at 1:32 PM, Staff C stated the Resident 1 was dressed by the night shift and was sleeping on the bed during 6:00 AM rounds. Staff C stated they changed Resident 1's brief at about 6:50 AM but did not take Resident 1 to the toilet, as directed in the CP. Resident 1 was tired and planned to stay in their bed until breakfast. Staff C stated at 8:00 AM, Resident 1 was on the floor screaming, there were no staff in the common area, and no one saw what happened to Resident 1. Staff C stated they did not know how Resident 1 got from their bed into the common area or how they fell . Staff C stated they found the nurse in another resident's room down the hall and the second CNA was in a room with a resident on the other side of the hall. Staff C stated Resident 1 was not supervised at the time of their fall. In an interview on 03/09/2023 at 3:32 PM, Staff B, stated Resident 1 had an unwitnessed fall and fractured two bones in their left wrist. Staff B stated they suspected Resident walked from their bed to the sofa, then fell . Staff B stated Resident 1 was found sitting on the floor with a broken wrist and no one witnessed the incident as there was no one around Resident 1 at the time of the incident. Staff B stated the staff was expected to supervise the common areas in memory care at all times. Staff B stated they did not know why there was no staff in the area to help Resident 1 before they fell . In an interview on 03/15/2023 at 1:39 PM, Staff D stated no staff was supervising Resident 1 or the common areas at the time of Resident 1's fall. Staff D stated they were in a room with another resident and both staff were helping residents in other rooms. In an interview on 03/09/2023 at 3:32 PM, Staff B was asked about the investigation of Resident 1's fall. Staff B was not able to answer questions about the incident or the investigation. Staff B stated they did not interview the night shift or the day shift staff and did not complete a lookback timeline for events leading up to the fall. Staff B was not able to determine if Resident 1's care needs were met prior to the fall, including if Resident 1 used the toilet earlier in the shift or if Resident 1 was looking for a person to help them. Staff B stated the incident report showed Resident 1 was incontinent of urine at the time of the fall. Staff B stated the investigation was finished but the report was not complete. Review of the 03/02/2023 Nurse Practitioner (NP) progress note showed Resident 1 was seen for a fall with immediate pain and crying while guarding their left wrist. The NP assessment showed Resident 1 had pain, swelling, bruising, and bleeding from the left wrist, suspecting a left wrist fracture. The note showed no hospitalization would be implemented and Resident 1 was placed on hospice (end-of-life) care with two orders for narcotic medications to manage severe pain. The NP note showed discussion with Resident 1's representative identifying risk for permanent disability and nerve damage to the wrist if no intervention to correct the fracture was implemented. In an interview on 03/09/2023 at 4:15 PM, Staff A stated if Resident 1 was supervised and was assisted with locomotion, they would not have fallen and fractured their wrist. <Resident 2> The 03/01/2023 Quarterly MDS showed Resident 2 had multiple diagnoses including stroke with left hemiparesis (weakness on one side of the body), and dementia. Resident 2 was assessed with frequent incontinence of bladder and was not on a toileting program. Resident 2 had unsteady balance requiring staff assistance when moving from a seated to standing position, when turning around, and with moving on and off the toilet. Resident 2 was assessed to require extensive physical assistance with walking, bed mobility, transfers, toileting, and incontinence. The 12/19/2022 Comprehensive CP showed Resident 2 was a high fall risk related to generalized weakness, unsteady gait/balance, incontinence of bladder/bowel, fatigue, decreased functional mobility, decrease/poor safety awareness secondary to dementia, transfer self, wanders, diagnosis of stroke with left hemiparesis, and impulsive behavior. The CP showed Resident 2 toilets self at times but not consistently and directed staff to provide reminders, cues and extensive 1-person assistance with toileting. The CP showed Resident 2 required variable assistance with transfers including supervision and extensive two-person assistance to boost to stand for safety, gait, and balance. A 03/08/2023 4:00 AM fall incident report showed Resident 2 was provided incontinent care at 2:00 AM and was observed in bed eating a snack at 3:30 AM. At 4:00 AM Resident 2 was yelling from their bed for help and stated they had pain in their left leg (on their stroke side) and reported they fell . Resident 2 was wet from urine incontinence. In an interview on 03/15/2023 at 1:39 PM, Staff D stated an x-ray was ordered, completed, and showed Resident 2 had a fractured left hip and swollen soft tissues around the hip. Staff D stated the practitioner directed staff to give one dose of a narcotic pain medication and send Resident 2 to the hospital. Further review of the fall incident report showed staff statements were dated 03/10/2023, two days after the fall. The investigation summary did not contain a root cause analysis to show when, where, why, or how Resident 2 fell , fractured their hip, and got back into bed independently. In an interview on 03/21/2023 at 9:20 AM, Staff B stated they were the investigator for the fall on Resident 2. Staff B stated they interviewed Staff E, Registered Nurse-Memory Care Unit. Staff B stated the interview information was not, and should have been, in the investigation report. Staff B stated the investigation showed neuro checks were completed but the form was still at the nurse's desk and was not reviewed as part of the investigation. In an interview on 03/21/2023 at 9:25 AM, Staff A stated the timeframe of the fall was narrowed down to 3:30-4:00 AM because of a movement report on the bed sensor. Staff A stated the report was not included in the investigation and should have been noted. Staff A stated the incident investigation was incomplete since the physical assessment was not done, the neuro assessment was not reviewed, the movement report was not declared in the summary, and the staff interview information was not documented or considered in the summary. REFERENCE: WAC 388-97-1060(3)(g).

Based on observations, interviews, and record reviews the facility failed to ensure one of two residents (Resident 2) reviewed for falls with fractures, received care and services according to professional standards. The failure to thoroughly assess and timely identify a hip fracture after a fall including a delay of emergency treatment and the omission of an ordered narcotic pain medication prior to medical transport to the emergency room resulted in harm to Resident 2 and diminished quality of life. Findings included . The undated facility Investigation of Injuries Policy showed all injuries would be assessed and sufficient details of the clinical findings would be documented in the clinical record. In an interview on 03/21/2023 at 9:20 AM, Staff A, Director of Nursing, stated nurses are expected to complete a physical assessment from head to toe and check the resident's movement in arms and legs after a resident fall. The nurse is expected to complete detailed documentation of their assessment. If there is an injury from the fall, Staff A stated the nurse is expected to discuss the assessment with the practitioner, obtain any needed orders for treatment, implement practitioner orders, and initiate monitoring of the resident. <Resident 2> The 03/01/2023 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 2 had multiple diagnoses including stroke with left hemiparesis (weakness on one side of the body), and dementia with severe cognitive impairment. The 12/19/2022 Comprehensive Care Plan (CP) showed Resident 2 was a high fall risk related to decreased functional mobility, decrease/poor safety awareness secondary to dementia, diagnosis of stroke with left hemiparesis, and impulsive behavior. The CP directed staff to monitor for presence of pain, including non-verbal signs of pain and administer medications as ordered. A 03/08/2023 4:00 AM fall incident report showed Resident 2 was provided incontinent care at 2:00 AM, and was observed in bed eating a snack at 3:30 AM. At 4:00 AM Resident 2 was yelling from their bed for help and stated they had pain in their left leg (on their stroke side) and reported they fell . The report showed the nurse on duty assessed Resident 2 and did not find visible injury, gave a mild pain medicine, and initiated neuro checks (to identify a head injury in the event the resident hit their head). The report showed the physician was notified at 5:32 AM (an hour and a half after the fall) with no new treatment orders, and the family member was notified at 5:50 AM (two hours after the fall). In an interview on 03/15/2023 at 1:39 PM, Staff D, (Licensed Practical Nurse- Memory Care Nurse), stated they received verbal shift report from the night shift nurse on 03/08/2023 about 6:00 AM, two hours after the incident. The night nurse reported that Resident 2 reported a fall and complained of left leg pain and received pain medication. Staff D stated they went to assess after shift report and noted Resident 2 looked different, their face was pale, and they complained of pain in the left hip. Staff D stated Resident 2's hip was swollen, the resident could not move their leg, and would not allow staff to move the leg because of pain. Staff D stated they thought Resident 2 had a fracture and notified the practitioner. Staff D stated an x-ray was ordered, completed, and showed Resident 2 had a fractured left hip and swollen soft tissues around the hip. Staff D stated the practitioner directed staff to give one dose of a narcotic pain medication and send Resident 2 to the hospital. Review of a 03/08/2023 nurse progress note showed Resident 2 was not administered the narcotic medication prior to discharge to the hospital. The 03/2023 Medication Administration Record (MAR) showed Resident 2 only received regular Tylenol for the pain from their hip fracture. During the onsite visit on 03/13/2023, Resident 2 was still in the hospital and not available for observation or interview. On 03/21/2023 at 8:50 AM, Resident 2 was observed in bed, uncovered, wearing a gown. Resident 2's breakfast tray was in front of them, and their eyes were closed. Upon entrance to the room, Resident 2 stated, I don't know you twice and waived the surveyor out of the room. In an interview on 03/21/2023 at 9:20 AM, Staff B, Resident Care Manager- Memory Care Unit, stated that Staff E, Registered Nurse- Memory Care Unit, stated Resident 2 reported falling and was in so much pain and was yelling, so Staff E did not move the resident and did not assess for a hip fracture. In an interview on 03/21/2023 at 9:25 AM, Staff A, stated the nurse was expected to complete a head-to-toe assessment including range of motion after Resident 2's fall. Staff A stated Staff E either did not do a complete assessment or did not document the assessment on Resident 2 as expected. Staff A stated if the nurse completed an assessment of the hip that specifically included observation of leg length, rotation of the foot, swelling and severity of pain, the practitioner should have been notified that an x-ray was indicated. Staff A acknowledged the incomplete nurse assessment which delayed the emergency care for Resident 2. Staff A acknowledged Resident 2's fall occurred at 4:00 AM, and Resident 2 did not leave for the hospital until 10:30 AM (6.5 hours later). Staff A stated Resident 2 should have received the narcotic pain medication for the fractured hip and significant pain that was ordered by the practitioner. REFERENCE: WAC 388-97-1060 (1)

Based on observation, interview and record review the facility failed to ensure timely skin/wound assessments to monitor and evaluate residents skin and to implement interventions to prevent a coccyx pressure ulcer (PU) for 1 of 3 sampled residents (Resident 1) reviewed for pressure ulcer/injury. These failures resulted in the development of Resident 1's avoidable unstageable pressure ulcer. Findings included . Review of the 02/2022 facility policy titled Pressure Injury, Prevention and Management policy showed the assessment of pressure injuries would be performed by a licensed nurse (LN) and documented on the (fill in blank form designated form). The staging (the type of tissue visualized or palpated) of PU would be clearly identified to ensure correct coding of the MDS (minimum data set). The RN (Registered Nurse) Unit Manager, or designee, would review all relevant documentation regarding skin assessments, pressure injury risk, progress towards healing, and compliance at least weekly, and document a summary of findings in the medical record. Resident 1 According to the 04/13/2022 Admission MDS Resident 1 admitted to the facility on [DATE]. The assessment showed Resident 1 had medically complex diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's Admission assessment dated [DATE] showed Resident 1 was A/Ox 3 (alert and oriented) with some forgetfulness and had a traumatic injury on the (R)ight shin measuring 4.0 x 7.0 x 0.1 cm (centimeters). A review of the Skin Body diagram dated 04/10/2022 showed Resident 1 presented with a (R)ight lower leg wound that was 7 x 4 cm and BLE (bilateral lower extremity) discoloration. A review of Resident 1's Care Plan (CP) dated 04/11/2022, Potential/Alteration in skin integrity potential for pressure ulcers development, showed Resident 1 required a pressure reducing mattress and assistance to turn and reposition frequently. Staff were directed to follow facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the Skilled Wound Care Communication Log Dated 05/02/2022, 22 days after admission to the facility, showed Resident 1 had a PU on their coccyx (tailbone) that measured 3 x 2 cm. The wound bed had 100 percent slough (dead tissue separating from living tissue) with a moderate amount of serosanguinous (both blood and liquid part of blood) drainage. A 05/02/2022 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 05/04/2022 at 10:35 AM, showed Staff F LPN measure and describe Resident 1's wound as 3 cm x 1.9 cm x 0.4 cm. The peri wound (tissue surrounding the wound) was red, and the center of the wound was covered in slough. According to Staff C LPN, Resident Care Manager (RCM), present for the observation and interview on 05/04/2022 at 10:35 AM, they were not sure when the wound developed. Staff C stated, I was on vacation on 04/25/2022 thru 04/27/2022, when I returned from vacation on 04/28/2022, I was informed Resident 1 had a PU. On 05/04/2022 at 10:41 AM, Staff B Director of Nursing (DON) stated, Resident 1, was admitted to the facility on [DATE], without any pressure related injuries. Staff B, stated, I believe the resident was given a shower on 04/20/2022 and there was not any mention of a PU on the resident's coccyx. According to Staff B, LNs conducted a skin assessment on 04/21/2022, eleven days after admission, and found a wound 2.9 cm x 3 cm on Resident 1's coccyx. Staff B was asked what contributed to the development of Resident 1's PU. Staff B stated the resident was unable to maintain toe touch transfer (toes may rest on the ground but refrained from placing any weight on the leg, this explains why they used the sliding board). The use of a sliding board may have contributed to the development of a PU due to pressure and shear. On 05/05/2022 at 8:59 AM, Staff D Certified Nurse Assistant (CNA), stated, .I did not work with (Resident 1) until 04/26/2022. Staff D, stated I remember because it was hard for me to conduct a skin assessment, (Resident 1) was given a [MEDICATION(S)] and I couldn't see her skin that well because (Resident 1) had diarrhea so there was no time to check her bottom. A review of bathing documentation showed no indication that Resident 1 was provided a bath or given bathing assistance between 04/10/2022 and 04/19/2022. According to Staff B, interviewed on 05/05/2022 at 9:22 AM Resident 1's care was provided by [agency staff], I have no idea what tasks they performed or did not perform. I don't know if a skin assessment was done for this resident or not. Staff B, stated I became aware of the wound on 04/25/2022, 15 days after admission, when Resident 1's representative reported Resident 1 had a PU on their coccyx. On 05/05/2022 at 9:35 AM Staff E, LPN stated they were made aware that Resident 1 had a PU on the coccyx when she assessed the resident's skin on 04/21/2022. Staff E stated there was a little flap of skin that was attached with a break in the center, the wound bed was pink and there wasn't any slough. On 05/05/2022 at 9:47 AM Staff F LPN stated, The resident's skin was intact on 04/11/22, one day after admission. The next time Staff F and E assessed Resident 1's skin on 04/21/22, the skin around the wound was partially detached, the wound bed was pink in color, and had no odor, slough, or drainage. Staff F stated the wound was cleaned and covered with a dry foam dressing at that time and they notified the MD of the change in condition. Treatment orders were obtained on 04/21/2022. On 05/05/2022 at 10:34 AM Staff C stated, the skin assessment should be done once a week and documented on the skin diagram located in the Electronic Medical Record (EMR), staff should create a nursing progress note, notify the DON, Residential Care Manager, Medical Doctor, and the resident's representative of a pressure injury/skin issues. Staff C, stated, I wasn't aware of the PU until Staff B showed me a photo of the area when I returned from vacation on 04/28/2022. According to Staff C Resident 1 had decreased mobility and was frequently in bed. The staff failed to turn and reposition the resident as often as they should have and that may have contributed to the development of the PU. On 05/05/2022 at 11:05 AM, Staff G Physical Therapist (PT) stated, Resident 1 was toe touch weight bearing but due to the injuries, staff attempted to use a sliding board for transfers. According to Staff G, they were told Resident 1 developed a PU. Staff G stated they stopped using the sliding board to avoid further injury. Staff G was asked if the use of the sliding board contributed to the resident developing a PU. Staff G stated, No, it's not likely that using a sliding board caused this particular injury based of the location of the injury (on the resident's coccyx (tailbone). If an injury were to occur from the use of a sliding board it would potentially be caused by shearing (skin moving in opposite directions on the buttocks). Reference: (WAC) 388-97-1060(3)(b)

Based on observation, interview and record review, the facility failed to provide a safe environment for one (#1) of 11 residents reviewed for accidents. The facility failed to put measures in place to prevent Resident #1 from rolling out of bed and making contact with an adjacent base-board heater. This failure caused actual harm to the resident who incurred substantial burns, with subsequent pain and diminished quality of life. Findings included . A 01/14/2021 Quarterly Minimum Data Set (MDS - an assessment tool) showed Resident #1 was admitted to the facility on [DATE], had unclear speech, highly impaired vision and wore no corrective lenses, severely impaired cognitive skills for daily decision making, and required extensive assistance of two people for bed mobility and transfers. Observation on 02/02/2021 at 5:49 AM, showed Resident #1 in bed, eyes closed, unshaven, and in no obvious distress. His bed was approximately two feet away from an electric baseboard heater. A 09/15/2020 Falls Risk Evaluation showed, a total score of 10 or greater should be considered at high risk for potential falls. The score was a 5. Evaluations dated 10/19/2020 and 01/11/2021 showed Resident #1's risk for potential falls increased to a score of 9, due to the number of predisposing conditions. These evaluations identified the resident as having adequate vision, contrary to the MDS assessment. Review of a 09/16/2020 Falls Care Plan (CP) showed Resident #1 was at risk for falls due to confusion, poor communication/comprehension, unaware of safety needs, cognitive impairment, incontinence, unaware of surroundings with poor judgment and safety awareness. Interventions dated 09/18/2020 included, The resident needs a safe environment with even floors free from spill and/or clutter, adequate glare free light, a working and reachable call light, handrails on walls, and personal items within reach. This CP showed no documentation the facility addressed the resident's increased risk for falls identified in the 10/19/2020 and 01/11/2021 evaluations. Review of a 01/30/2021 progress note showed, At 0530 (5:30 AM) the aide reported to me (Resident #1) was on the floor. Upon entering the room I noticed the resident was left-side lying on the floor with the bed spread covering his arms, chest, and part of his face. Resident was assessed and three injuries were found. MD and family notified . L (left) buttock first degree burn with skin tear in several areas . A 01/30/2021 skin assessment showed the staff assessed Resident #1 to have, Left trochanter (hip) Burn 33 cm (centimeters) x (by) 9.5 cm and Left buttock burn 6.0 cm x 1.2 cm. This assessment identified the buttock wound was a first degree burn (only the outer layer of the skin was affected), and the thigh wound a second degree burn (the first and second layer of the skin are burned). In an interview on 02/02/2020 at 5:49 AM, when asked what happened the morning of 01/30/2021, Staff C, Licensed Practical Nurse, stated, The aide called me. Found him at 5:30 AM. The last time the resident was checked was at 2:00 AM. I saw (Resident #1) on the heater, his left side on the heater. The bed was pretty close to the heater, about 18 inches. I don't recall if it was always that close. The aide heard him moan and scream and went to check the resident. When asked how the resident ended up on the floor, Staff C stated, Honestly, I don't know. When asked how often staff checked the resident at night, Staff C stated, Should be every two hours. When asked if he had been checked accordingly, Staff C stated, He should have been. In a direct observation with the use of a measurement tape, Staff C showed the Surveyor the bed was 18 inches from the heater when the resident was found lying against the heater on 01/30/2021. In an interview on 02/03/2020 at 11:04 AM, Staff D, Agency Certified Nursing Assistant (CNA), stated he was assigned to Resident #1 once in a while. Staff D stated there was maybe two feet between the heater and the resident's bed. Staff D recalled Staff C had administered to the resident something to enhance the bowel activity. Staff D stated that around 2:30 AM, he changed the resident's brief and left him on his right side, facing towards the door, away from the baseboard heater. Staff D stated, At 5:30 AM I heard the scream or yelling sound, so I ran there and saw the patient was already on the floor. He was incontinent of bowel and bladder, had a bowel movement. His left side was facing up, that's when I noticed the skin looked like it had peeled off. That's how it looked. When asked how the resident's skin peeled off, Staff D stated, The heater. In an interview on 02/02/2021 at 1:38 PM with Staff B, Maintenance Director, and Staff A, Director of Nursing Services, Staff B stated the facility did not perform temperature checks to determine how hot the heaters get. When asked how the facility prevented injury associated with the use of a baseboard heater, for residents who may roll out of bed, fall out of bed, and have poor safety awareness or sensory impairment, Staff B stated, Keep them hopefully distanced away enough from the wall. Staff A stated, If the resident understands, and they are not getting out of the bed on that side then, yes, we can prevent that. When asked how the facility compensated for a resident who was impaired at multiple levels, Staff A stated, If it's being reported there is an issue we can actually put in a perimeter mattress. When asked if waiting for an issue to be reported prevented accidents, Staff A stated, No. We are assessing all residents right now. A 02/03/2021 physician progress notes [REDACTED]. Mostly deep-partial thickness (deep second-degree burns) as a result of (Resident #1) falling against a wall heater . Watch carefully for signs of infection, given location on buttocks and propensity [MEDICAL CONDITION] get colonized with (bacteria). A 02/03/2021 Wound Consultant report showed, (Resident #1) appears to be in pain during wound cleansing. Review of progress notes between 01/31/2021 to 02/03/2021, showed Resident #1 suffered pain and necessitated an increase and change in pain medication from an over-the -counter to a narcotic, the start of intravenous (by vein) fluids to compensate for fluid loss from [MEDICAL CONDITION] increased level of sleepiness, an increased frequency of topical antibiotic usage, and debridement (cleaning of a wound to remove any dead tissue and prevent infection) of the burn wounds. REFERENCE: WAC 388-97-1060 (3)(g).

Based on interview and record review, the facility failed to provide adequate supervision to ensure resident safety for two (#s 1 & 2) of seven resident's reviewed for accident hazards. The facility failed to ensure care planned interventions to provide supervision and assistance to Resident #2 were consistently provided. Failure to ensure care planned interventions to provide supervision was consistently provided, contributed to Resident #1's elopement which placed Resident #1 at risk of harm. Failure of the facility contributed to Resident #2 sustaining a fracture which constituted harm. Findings included . INJURY OF UNKNOWN ORIGIN RESIDENT #2 Review of the Quarterly Minimum Data Set (MDS, an assessment tool), dated 06/02/2020, showed Resident #2 was assessed to require extensive assist with two plus staff with transfers, toileting, and bed mobility. The resident Care Plan (CP) initiated 04/16/2018 included the following directives: Transfers, requires two people assist using Hoyer lift. Review of an undated Nursing Care Directive showed, Transfers: Two people extensive assist using Sarah lift. Dressing: Extensive one person assist with upper/lower dressing/undressing shoes/socks; two people assist as needed. According to investigative documents dated 06/08/2020 at 4:00 PM Staff C, NA (Nursing Assistant) requested the nurse to check on the Resident's foot. Upon checking, resident is noted with swollen left foot, warmth to touch, with bluish discoloration, and painful to touch. The X-ray result dated 06/09/2020 revealed acute horizontal fracture through the proximal third and fourth metatarsal bones. Acute non displaced [MEDICAL CONDITION] of the fifth metatarsal bone . Review of the facility investigation conclusion dated 06/17/2020, showed Left foot injury of unclear cause. Resident unable to tell what happened, very confused. Per the assessment of Advanced Registered Nurse Practitioner (ARNP) the injury seems plausible that her foot was run over by her wheelchair, dorsiflexed (the backward bending and contracting of the foot.) her toes against something or plantar flexed (a movement in which the top of your foot points away from your leg) her toes as she was rolling around in her wheelchair. Reveiew of the resident's Care plan dated 04/16/2018 showed limited physical mobility related activitity intolerance impaired balance, limited mobility and cervical stenosis. Interventions; Uses wheelchair for locomotion on/off the unit and requires extensive assistance with short as well as long distance propulsions. The investigation did not include information to support the facility conclusion, including but not limited to statements from staff on duty between 06/07/2020 and the injury being noted on 06/08/2020 regarding the resident's mobility, if and/or when the resident was observed self-propelling in the wheelchair. An Incident Investigation Questionnaire (IIQ) showed Staff C, Nursing Assistant (NA) documented, I provided care for resident at 3 PM on 06/07/2020. During care, which consisted of changing her brief and getting her ready for dinner. I assisted the resident with dressing, from her blouse, pants, socks, and sandals. The resident didn't have any redness or swelling or bruising on her body. She didn't complain of any pain or discomfort. Resident's care plan indicates to transfer via sit to stand, which I did. During an interview on 07/09/2020 at 2:15 PM, Staff C, stated that she had taken care of Resident #2 for two months, and on 06/07/2020 she used a sit to stand to transfer resident from bed to wheelchair and wheelchair to bed. When asked if she was assisted by another staff to transfer the resident, Staff C stated, No. When asked how she knew, how the residents transferred, she stated, nursing care directives. The investigation did not include a return demonstration to assess if Staff C properly used the sit to stand when transferring Resident #2. Nor did the investigation identify Staff C failed to follow the resident's CP and transferred Resident #2 alone, without two people as directed. During an interview on 07/09/2020 at 2:30 PM, Staff B, Director of Nursing confirmed that Resident #2 required two staff assist to transfer. When asked how staff knew how the resident transferred, Staff B stated that the nursing staff were expected to use the care plan and nursing care directives to care for residents. When asked if Resident #2's transfer guidelines were followed, Staff B stated, No. Not ensuring staff followed the care plan directive to have two staff present during care, contributed to the resident experiencing an injury. ELOPEMENT RESIDENT #1 Resident #1 admitted to the facility on [DATE] and according to the 04/07/2020 Quarterly MDS, had major [MEDICAL CONDITIONS] with behavioral disturbances, cognitive communication deficit, increased confusion in the evening and fair to poor safety judgement. According to this assessment, staff determined the resident demonstrated wandering behavior daily and was determined as independent with locomotion off unit. Review of a Risk of Elopement/Wandering Review (REWR) dated 04/15/2019, showed the resident was identified as being cognitively impaired with poor decision-making skills (i.e. intermittent confusion, cognitive deficits or disoriented), propel her wheelchair, and having pertinent [DIAGNOSES REDACTED]. According to a CP dated 08/13/2017, the resident was identified with an issue of elopement risk/wanders related to wandering, exit seeking and elopement. The CP did not specify any goals or interventions in place to address the resident's elopement /wandering needs. The CP revealed that Resident #1 had history of elopement on 04/05/19. While the CP indicated the resident was assessed to previously require a Wander Guard (a device worn by residents which alarm doors/exits to alert staff of elopements), the CP indicated the Wander Guard was discontinued per family request on 03/05/2019 and re- initiated on 04/15/19. Review of April, May, and June 2020 Treatment Administration Records (TARs) showed direction for staff to, Check placement and function of the Wander Guard BID (twice a day). Wander Guard is located on ankle every day and evening shift for Wandering Risk. Review of April and May TARs directed staff to Replace Wander Guard on expiration date. Enter new expiration date and create new order on TAR when replacing Wander Guard (Expiration Date) 04/14/2020. According to these TARs there was no indication the Wander Guard was replaced on 04/14 /2020. According to a nursing progress note dated 06/07/20 at 5:07 PM, an employee notified the nursing staff at around 3:15 PM that Resident #1 was in the parking lot. According to investigative document dated 06/15/2020, the resident exited through the front door from the facility. Review of the facility investigation conclusion, showed The urinary tract infection could have contributed to Resident #1 exiting the facility. During an interview on 07/07/2020 at 11:00 AM Staff D, Facility Security officer, stated that he was in charge of the reception/front door area when the resident wheeled herself through the front door, Staff D stated that he didn't know if Resident #1 was allowed to go outside alone but elaborated that residents who were assessed to require Wander Guards would set off an alarm when attempting to leave the building. When asked if he checked if the resident was allowed to go outside, Staff D stated, No. During an interview on 07/07/2020 at 11: 45 AM Staff E, Licensed Practical Nurse, stated that she was notified by a nursing assistant that the house keeping staff was calling for a resident in the parking lot. Staff E stated that Resident #1's Wander Guard was not functioning when the resident went through the front door. Resident #1 had a Wander guard on but it did not alarm when the resident eloped through the door. During an interview on 07/08/20 at 12:50 PM, Staff B, confirmed that the resident's wander guard was not active when the resident eloped and when returned back to the facility. When asked if Resident #1's wander guard was replaced on 04/14/20 as ordered, Staff B stated, No. Facility staff were aware of the resident's walking/wandering behavior, and developed a care plan on 08/13/2017 which identified the resident was at increased risk for elopement but failed to provide adequate supervision to prevent elopement which placed the resident at risk for injury. Reference WAC 388-97-1060 (3) (g)

Based on observation, interview and record review, the facility failed to ensure staff provided adequate supervision to protect the safety of one of three residents (#1) sampled for supervision and hazards. This failure resulted in harm to the resident related to second [MEDICAL CONDITION] when a caregiver handed the resident a hot cup of coffee without a lid, and subsequently the hot coffee spilled onto the resident. Findings included . Review of Resident #1's 09/05/19 Quarterly Minimum Data set (MDS-assessment tool), showed that the resident required extensive assistance of one person for eating. Review of the Nursing Care Directives (NCD) showed that Resident #1 required a lid to cover all hot beverages and drinks.The NCD last review dated was 09/23/19. Review of the Dining Room Care Directives showed that Resident #1 needed extensive assistance during meals due to the resident's [DIAGNOSES REDACTED]s. Observation on 10/24/19 at 6:45 PM found Resident #1 had a clean, dry dressing on her right (R) forearm. Observation on 10/29/19 at 1:15 PM when the dressing was removed from Resident #1's R forearm, there was loss of skin and leaking fluid on the top of the forearm, and there was deep reddening of the skin. On the medial aspect (inside the forearm) there was an open blister and deep reddening of the skin. The resident complained of pain and discomfort on removal of the dressing. Review of the skin assessment dated [DATE] showed that, Resident #1 had diffuse light red on the R breast over an area measuring 7.5 by 4 (measurements did not specify if centimeters (cm) or inches which are larger than cm). The note further stated that Resident #1 had an injury from spilled coffee with noted red discoloration on the R arm. Record review of the skin assessment dated [DATE] showed that, there was a blister on the back of the R hand measuring 3.0 centimeters (cm) by 2.5 (cm), a second area on the back of the R hand with an open blister measuring 1.0 cm by 1.5 cm, a third open blister on the back of the R hand measuring 1.0 cm by 2.0 cm, and a fourth open blister on the back of the R hand measuring 2.5 cm by 2.0 cm. In addition, on the R inner arm there was one intact blister and three areas of open blisters. The note further stated that the R breast was intact with diminishing reddened area. In addition, the note stated that this was due to an incident on 10/23/19 of spilled coffee. In interview on 10/24/19 at 6:30 PM, Staff A stated that she started to provide direct care in (MONTH) 2019, and recently completed nursing assistant training. Staff A said she was expecting to take the test for a nursing assistant certification, and that currently, she held a Nursing Assistant Registration (NAR). In addition, Staff A stated that she was never assigned to Resident #1 to provide care, however, Staff A said she was assigned to the dining room (DR) table where Resident #1 sat with other residents. When asked how Resident #1 acquired burn injuries, Staff A stated that she handed Resident #1 a hot cup of coffee without a lid during the lunch meal on 10/23/19. Staff A stated that she became aware of Resident #1's NCD during her training and orientation, and forgot to place a lid on the hot cup of coffee before handing it to the resident on 10/23/19 during the dinner meal. In interview on 10/24/19 at 6:55 PM, Staff B, Licensed Practical Nurse (LPN), Resident Care Manager (RCM) stated that extensive assistance meant cueing for Resident #1 during meals, and acknowledged the resident required a lid for all hot beverages. She stated that Resident #1 fed herself and drank her own liquids, and required staff assistance with cutting, slicing, opening, and preparation for meals. In interview on 10/29/19 at 1:10 PM, Staff C, Culinary Assistant Director stated there was no policy pertaining to serving hot liquids to residents and that the facility did not have a policy for checking the temperatures of hot beverages or hot liquid drinks before serving to the residents. In interview on 10/29/19, Staff D, Interim Director of Nursing, stated that Staff A received coaching, and all nursing assistants and licensed nurses including Staff A completed an in-service related to providing care in the dining room based on residents' level of functioning. Staff D explained that checking temperatures of hot liquids before serving them for residents to drink will be required, and that the facility would develop a written policy pertaining to hot liquids. Review of the completed facility investigation documentation showed that the interdisciplinary team, indicated as IDT in the paperwork, requested dietary to check temperatures of coffee in the thermos before serving it to the residents. REFERENCE WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors when diabetic medication orders were omitted, and the resident was hospitalized with [MEDICAL CONDITION] (high blood sugar), for one of four sampled residents (Resident #1) reviewed for medication administration. This failure caused harm to Resident #1 who experienced a change in condition and needed to be hospitalized for [REDACTED]. Findings included . Resident #1 was admitted to the facility on [DATE] after an acute hospitalization with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS), an assessment tool, dated 09/01/19, documented Resident #1 had no cognitive impairment and required assistance of staff for all Activities of Daily Living (ADL) including medication administration, and blood sugar monitoring. Review of Resident #1's hospital discharge orders from dated 08/28/19, showed, Resident #1 was prescribed Insulin: [MEDICATION NAME] U-100 15-16 units under the skin daily every night (HS), [MEDICATION NAME] Insulin 10-14 units two times a day before meals (breakfast and dinner). Orders were faxed to the facility on the morning of 08/28/19 at 9:37 AM, prior to the resident's admission to the facility. The resident presented with an admission packet containing additional discharge orders for treatment of [REDACTED]. Record review on 09/13/19 did not show the facility's staff transcribed the insulin orders as required, or monitored blood glucose levels. Further review of Resident #1's Medication Administration Record (MAR) did not show staff administered insulin to Resident #1 before meals and at night as ordered, to prevent [MEDICAL CONDITION] (high blood sugar). On 10/03/19 at 1:40 PM, in interview, Resident #1's representative said when an outside provider contacted Resident #1 in the morning of 09/01/19, they found the resident with increased confusion and inability to communicate properly. In interview on 10/03/19 at 2:30 PM, Staff G, a Registered Nurse (RN) said, on the afternoon of 09/01/19 at 12:15 PM, Resident #1 experienced a change in condition. Resident #1 was confused and unable to communicate properly to a family member who visited him. According to the facility's Incident Investigation Report (IIR) dated 09/01/19, staff omitted Resident #1's ordered insulin for treatment of [REDACTED]. The medical record showed, on the early morning of 09/01/19 (four days since admission) at 1:00 AM and 3:40 AM, Resident #1 experienced an episode of extreme spasms which lasted about one minute. When the assigned Licensed Nurse Staff G, a Registered Nurse (RN) assessed the resident, including checking the resident's blood sugar, Resident #1's glucose meter showed a reading of HIGH (indicating a reading of over 600 mg/DL). Staff again checked the resident's blood sugar at 5:00 AM, 1:30 PM and 4:55 PM. Resident #1's blood sugar reading was still indicating HIGH (over 500 mg/DL), despite staff administering insulin and water to lower the blood sugar of Resident #1. Resident #1 was transferred to the hospital for further evaluation and required hospitalization for a total of five days. On 09/13/19 at 10:00 AM, Staff F, a Licensed Practical Nurse (the assigned nurse at the time Resident #1 was admitted to the facility) said she did not check the admission packet the resident presented with on 08/28/19, to ensure the orders were transcribed as required. The admission packet contained additional hospital discharge orders and documents including insulin orders. On 09/25/19 at 5:30 PM, staff [NAME] said, that although he was assigned to complete an admission process for Resident #1, he had not been trained on the admission process and he had only been hired in the last two months (June 2019). Staff [NAME] further said he did not review all the discharge orders, but only reviewed two pages which listed part of the ordered medication. On 09/13/19 at 10:00 AM, Staff C, the facility's Assistant Director of Nursing (ADNS) stated that on admission, all residents' orders were required to be transcribed and entered into the MAR and treatment administration record (TAR). Staff C stated that Resident #1's admission paperwork was not noticed by the staff, so the orders were not transcribed and that is how the blood sugar monitoring and insulin administration was missed since admission on 08/28/19. At 3:30 PM, Staff C and Staff I, the facility's Admissions coordinator acknowledged failed practice. Reference WAC 388-97-1060 (3) (k) (iii)

Based on observation, interview and record review the facility failed to provide services to maintain the highest practicable physical well being for three of six residents reviewed. Failure of nursing to coordinate services with therapy and assess the possible role pain had in her therapy regimen caused Resident #187 (one of three residents reviewed for pain) to experience pain inducing therapy without benefit of as needed pain medication. This resulted in actual harm to Resident #187 related to the role pain caused in her declination of therapy services. Additionally, failure to ensure staff assessed and reported non pressure related skin issues for two of three residents (#s 53 and 110) placed them at risk for delayed treatment. Findings include: PAIN RESIDENT #187 Resident #187 was admitted to the facility on [DATE] with care needs related to [MEDICAL CONDITION], chronic pain and therapy needs related to difficulty walking. According to her 01/27/13 Minimum Data Set (MDS) assessment, Resident #187 was assessed to require a scheduled pain medication regimen and had received as needed (PRN) pain medication and non-medication interventions for pain. The resident reported frequent moderate pain which made it hard to sleep at night and limited day to day activities. Observations on 04/26/13 at 9:45 a.m. revealed a well groomed elderly woman sitting in a wheelchair at her bedside. The resident was observed on 04/29/13 to require extensive two person assistance utilizing a mechanical lift, for transferring her from or to her wheelchair. Record review revealed an undated Care Plan (CP) which indicated the resident had "Mobility impairment r/t (related to) bilateral knee pain left greater than right." The goals related to this problem addressed maintaining mobility only, and did not address goals related to pain or how the resident experienced pain with walking. An alteration in comfort CP indicated the resident had bilateral knee pain with interventions that included, "monitor and record any complaints of pain: location, duration, quality and quantity, alleviating factors, aggravating factors; administer medications (Tylenol 650 mgs as needed for pain) . . . return to assess effectiveness." Record review revealed the resident had a regularly scheduled order for the narcotic pain medication [MEDICATION NAME] two times a day for 30 milligrams (mgs) each time. Additionally, the resident had a PRN order for Tylenol 650 mgs for pain. There were no indications of how frequently nursing staff could administer the Tylenol; only that it not exceed 3 grams in 24 hours. There was no PRN narcotic pain medication ordered. According to an initial Occupational Therapy assessment dated [DATE], Resident #187 experienced "Pain at rest = 0/10; pain with movement = 2/10 (Pt stated currently pain at max is a 2/10 sometimes its up to a 14/10 (staff documented 14/10). Pain mainly in L(eft) knee." (A zero to ten pain scale was utilized by the facility to assess resident's pain. A pain level of zero is no pain, a pain level of five is moderate and a pain level of ten is considered "Worst Possible Pain.") On 01/22/13, Physical Therapy (PT) staff documented, "(Patient) fearful with complaint of (c/o) left knee pain with onset of treatment . . .". On 01/26/13, PT documented "Continued to complain of right knee buckling and pain in left knee of 8/10." The resident received no PRN pain medication on either of these days even though PT staff documented Resident #187's pain was significant. PT notes dated 01/29/13 documented "pt (patient) c/o pain with gait and standing 9/10 'sharp pain'. Nursing states that pt receives [MEDICATION NAME] at 9:00 a.m. and 5 p.m. can have add(itional) Tylenol PRN. Gait training after lunch pt c/o shaking painful knees." According to the January 2013 Medication Administration Records (MARs), the resident received no PRN pain medication on 01/29/13 even though Resident #187 experienced significant pain. On 01/31/13, PT staff documented, "Fewer c/o pain with standing today." On 02/01/13, "pt unable to scale pain . . . pt asked about cortisone shot, referred question to nursing. very limited by pain." Staff documented the administration of PRN Tylenol at 4:06 p.m., but there was no indication this was administered prior to, or in response, to pain surrounding therapy. On 02/04/13, PT staff documented Resident #187 was "Unable to scale pain but able to bear minimal weight . . . Pt limited by pain in left knee." According to the February 2013 MARs, the resident received no PRN pain medication prior to or in response to pain experienced related to therapy on this day. Review of the facility's Care Plan review notes, dated 02/05/13, revealed "Physical Therapy- knee pain . . . (Resident) doesn't want to put weight on it because of pain . . .". This document also stated, "knee is barrier . . . Trouble on and off shower bench - once knee pain is addressed, should do well." A pain assessment developed the same date as the CP indicated, "(R)esident is current working with PT, report to staff that resident c/o L knee pain when ambulating with them." Record review revealed there was no indication facility staff acted on the knowledge the resident consistently experienced pain with therapy or that they considered the potential benefit pre-medicating Resident #187 with PRN Tylenol prior to therapy might elicit for the resident. Nor did the facility consider rearranging therapy to times when Resident #187's regularly scheduled narcotic pain medication was received in order to maximize the potential relief the reduced pain level might have on the therapy experience for Resident #187. PT staff documented the following: On 02/08/13, "Pt refused to bear wt on left lower extremity stating it felt like it would buckle and too painful." On 02/09/13, "still not bearing weight on LLE (Left Lower Extremity) . . . premedicate secondary to left knee pain? pt c/o left knee pain . . . 4-(to) 8/10." On 02/12/13, a note indicated, "pain decreased from 8/10 to 4/10." During each of the above days, there was no indication Resident #187 received any PRN pain medications. On 02/13/13 PT staff documented, "declined gait today secondary to left knee pain . . . due to increased confusion today (patient) not able to scale pain." On 02/14/13: "Due to pt's pain with mobility she will benefit from wheelchair mobility training." On 02/15/13: "Pt declining to attempt any activity that involves using her legs secondary to left knee pain." On 02/16/13, "assist with lower extremity secondary to knee pain . . . decrease weight tolerance secondary to left knee pain." On 02/17/13: "Pt was very hesitant to start (treatment) and (complained of) pain in left lower extremity . . . standing at rail still caused pain 8/10, pt was unable to extend knee." Review of the 02/13 MARs revealed the resident received no PRN pain medication on any of these days. Facility staff failed to identify the resident might have benefited from medication related to the pain which was clearly and consistently induced by therapy. Physical therapy notes dated 02/25/13 indicated the resident had, "refusal to bear weight on the left lower extremity due to fear of buckling and pain . . ." and "due to patient's refusal to bear weight on left leg for gait she was unable to progress with transfers and gait." The resident was subsequently discontinued from therapy services and referred to Restorative therapy. In an interview at 2:25 p.m. on 05/01/13 Staff I (Physical Therapy Assistant-PTA) indicated she had worked with the resident when she received Physical Therapy and "her pain rating was very high." In an interview on 05/01/13 at 2:35 p.m., Staff J (Physical Therapist) indicated the resident was evaluated for therapy on 01/21/13 and therapy was discontinued on 02/25/13. Staff J stated that on some days the resident, "wouldn't want to walk (related to) the knee pain." In an interview on 05/07/13 at 4:05 p.m. Staff J indicated she provided therapy in the morning after the resident received her regularly scheduled [MEDICATION NAME], but there was no mechanism in place to verify the times other staff members provided therapy. Staff established and documented the resident experienced pain, recognized the resident's refusals were related to pain, but failed to identify and act on the resident's pain needs not being met. In an interview on 05/02/13 at 8:40 a.m., Staff C (Resident Care Coordinator) stated for a resident for whom pain could be anticipated during therapy,"we would give the medication a half hour to 45 minutes before the therapy." While quarterly pain assessments were completed, they did not identify the resident experienced pain with mobility/ambulation. Staff C was unable to explain why Resident #187, who staff documented experienced predictable pain, did not receive PRN pain medication. Staff B, in an interview on 05/02/13, confirmed there was a lack of coordination between therapy and nursing regarding the resident's pain. Record review revealed the resident received a Restorative program which included range of motion and a walking program six days a week. The Walking RA (Restorative Aide) goal was, "to increase strength on bilateral LE and increase mobility endurance." In an interview on 05/02/13 Staff M, the Restorative Coordinator, stated "therapy never said anything about her refusing because of knee pain, but they did say she needs more encouragement." In an interview on 05/02/13 at 8:11 a.m. Staff P, Restorative Aide, stated the resident, "participates in everything but the walking . . . (she) doesn't want to do the walking, she says she can't and doesn't want to." In an interview on 5/02/13 at 8:22 a.m., Resident #187 stated she did not do the walking because she had a bad knee. "It hurts" and "It gives out." Review of Restorative documents revealed the resident participated in the ambulation program on six of 28 opportunities in March 2013 and refused all ambulation in April 2013. There was no indication staff assessed the reasons behind the refusals or considered offering an as needed pain medication prior to the initiation of the resident's restorative program. There was no indication facility staff recognized the resident's refusals were related to fear of experiencing what had become predictable pain or reevaluated what presented as an ineffective pain management program. RESIDENT #53 Observations on 04/25/13 at 2:07 p.m. revealed Resident #57 sitting on the edge of her bed. The resident was noted to have peeling skin, which appeared red and irritated, at the base of both thumbs. The top layer of skin on the palm of the right hand had separated from the rest of the skin creating the appearance that it could be peeled off in a sheet. Similar observations were noted on 04/26/13 and 04/29/13. According to the weekly skin assessment sheets dated 04/24/13, the resident had no skin issues. Review of progress notes revealed no documentation to support facility staff were aware of Resident #53's skin issues until a Physician's Assistant (PA) saw the resident on 04/29/13 and documented the resident had, "what appears to be deroofed blister in right palm and at base of left thumb." According to Telephone orders dated 04/29/13 the PA requested: "Please fit (resident) for fingerless gloves to be used when exercising to protect palms . . . use lotion on palms to promote healing." RESIDENT #110 Observation on 04/26/13 at 10:27 a.m. revealed Resident #110 sitting in a Gerichair. What appeared to be an abraded area was noted on the right forehead, red and slightly raised approximately 0.5 cm (centimeters) to 1.0 cm area surrounded by flaky skin. Observation on 04/29/13 at 2:15 p.m. revealed similar findings. Review of weekly skin assessments revealed the resident had no noted skin issues on 04/25/13. Review of progress notes revealed no documentation to support staff were aware of the lesion on the resident's forehead. On 04/30/13 at 2:10 p.m. Staff C was requested to assess the resident' skin and stated, "It looks like a growth, I will have (the physician) look at it." According to a physician's note, dated 04/30/13, " . . .approximately 1/2 by 1 1/2 cm, elevated slightly erythromatic with some scaling . . . consistent with seborrertic [DIAGNOSES REDACTED] right forehead area." In an interview on 05/02/13 Staff B indicated skin issues could be identified through the weekly skin assessment done by licensed nurses, baths provided weekly by NAs (Nursing Assistants) or when provided care by NAs through the course of the day. Staff B indicated facility staff should have identified and reported these skin issues. She indicated there would be monitoring to determine if the issue became better or worse. Failure to identify and report skin issues placed residents at risk for delayed treatment. .

Based on observation, interview and record review the facility failed to develop a system by which residents assessed to be at risk for incontinence received individualized care in a manner that enhanced each resident's dignity. Failure to provide individualize incontinent care and toileting for Residents (#1-33) on the Special Care Unit, prompted night staff to wake residents for toileting, caused Resident #1 to become angry, upset and combative and placed all other residents at risk for loss of dignity, sleep deprivation, and behaviors. Findings include: Refer to CFR 483.10(b)(4), F-155, Refuse Treatment and CFR 483.13(b)(c)(1)(iii)(2)(3)(4) Abuse Policies and Procedures, F-226 According to the facility's August 2007 Nursing Care Protocols, Certified Nursing Assistants (CNA) were to toilet residents according to, "...assigned program when indicated." The facility's Resident Plan of Care policy indicated, "The (CNA) are to follow the plan of care as outlined in the Nursing Care Directives that have been individualized for each resident and posted...this includes procedures for ADLs and toileting...Toileting is every 2 hours unless as indicated by plan of care/(Nursing Care Directive, NCD)." Resident #1 According to the 02/27/13 quarterly Minimum Data Set, Resident #1 was cognitively impaired related to dementia but was able to respond to simple verbal communication. Staff developed the 02/27/13 Care Plan (CP) that included instruction to staff indicating the resident was incontinent, wore briefs and "offer and provide assistance to toilet (every) two (hours and (as needed)." The Nursing Care Directives (NCD) instructed Nursing Assistant staff to "Toileting (every) (two hours and as needed)." Staff added a hand written note to the NCD, "Offer (and) assist (with) toileting (every) (two hours) (and as needed)". When discussing the 03/17/13 toileting incident, Staff E, a (CNA), said, in an interview on 04/8/13 at 8:20 a.m., "About 4:00 a.m. to 4:30 a.m. I told Resident #1, I was going to take her to the bathroom, but in the process she said "no no no" (and became) "combative". So I got Staff D to help. I put the gait belt around her, and walked her to the toilet." Staff E confirmed Resident #1 said "let go of my head" at least twice during toileting, while Staff D restrained the resident." Staff E, interviewed on 04/11/13 at 4:15 p.m., said the resident was asleep prior to being awakened for toileting and was, "ticked off"(after being awakened). On 04/11/13 at 4:15 p.m., Staff E said most of the residents on the Special Care Unit (SCU) were incontinent and the Certified Nursing Assistant (CNA) staff had to make sure resident's did not toilet themselves. (The SCU is provided for residents who are more cognitively impaired). Staff E said staff reviewed the NCD located in each resident's room for instruction on the provision of cares. Interviewed on 4/12/13 at 9:35 a.m., Staff E said she got Resident #1 up at 4:00 a.m. because, "I didn't want a flood (of urine)." Staff E indicated, "I get in trouble of I don't chart, the resident toileted every two hours, it didn't happen." Review of the most recent CP for each of the 32 other residents (#2-33) on the SCU revealed instruction to staff on toileting, "See Nursing 'Care Directives (NCD) and protocols for all NAC (CNA) interventions. Review of Resident's NCDs revealed staff were to toilet or check and change the briefs, of 26 Residents, (#2, 4, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20, 22, 23, 24, 25, 28, 29, 30, 32 & 33), every two hours. The goal of changing briefs or toileting residents every two hours is not to change bowel or bladder function but for resident's skin to stay dry. Three residents (#5, 21 & #26) were to receive toileting before and after meals, at bed time and as needed. There was no toileting schedule instruction to staff for three Residents (3, #27 & #31). Resident #3's CP instructed staff to, "Allow to sleep in..." The NCD for Resident #3 instructed staff to, "Please ask if in pain, offer toileting or food when restless," suggesting the resident required toileting or a brief change only when the resident was restless. According to Resident's clinical records, 15 Residents (#5, 9, 10, 11,13, 14, 15, 17, 19, 21, 25, 30, 31, 32 & 33) had symptoms of [MEDICAL CONDITION]/confusion and five Residents (#11, 18, 29, 30 &31) exhibited behaviors such as resisting care placing them at higher risk for experiencing trauma when placed in similar situations as Resident #1. The Director of Nursing and the Assistant Director of Nursing said, in an interview on 04/11/13 at 10:55 p.m., CNA staff are to toilet or change resident's briefs every two hours. These staff said if there was a deviation in this directive it would be on the NCD for the resident. Staff were observed to implement this directive on 04/11/13 at 9:00 p.m. until 12:30 a.m. on 4/12/13 in the SCU. Residents (#6, 7, 16, 8, 9, 11, 31, 32, 13, 14, & 10) who were sleeping were roused and either toileted or provided with a brief check and/or change. Staff failed to allow Resident #1 to refuse toileting at 4:00 a.m. on 3/17/13. Resident #1 and two other residents (#11 & #16), observed on 4/12/13 at 11:00 p.m. and 11:25 p.m. respectively, on the same unit, who were cognitively impaired, were awakened from a sound sleep, removed from their beds and taken to the toilet. None of these residents were on a formalized toileting program with the goals to obtain normal bladder function and control. Instead multiple residents were awakened from their sleep approximately every two hours during the night and removed from their beds to be taken to the toilet. This was determined to represent a failure on the facility's part to ensure that each of these residents were living in an environment that respected their individual needs for uninterrupted sleep.

Based on interview and record review the facility failed to ensure one of two residents reviewed for resident rights, was allowed to refuse care. Failure to stop the provision of care at the time Resident #1 indicated they wanted care to stop caused the resident to lose autonomy and experience fear and anguish. Findings include: According to the 02/27/13 quarterly Minimum Data Set, Resident #1 had a [DIAGNOSES REDACTED]. Resident #1 was observed on 3/28/13 at 8:40 a.m. in the dining room. The resident was able to speak but when asked specific questions about staff treatment the resident was unable to express her thoughts. Review of the resident's Care Plan revealed instruction to staff, related to the resident's potential for refusing care and a history of combative behavior. Approaches included, "...Keep environment and routine as consistent as possible...Avoid over-stimulation..." When discussing the 03/17/13 toileting incident, Staff E, a (CNA) said in an interview on 4/8/13 at 8:20 a.m., "About 4:00 a.m. to 4:30 a.m. I told (Resident #1), I was going to take her to the bathroom, but in the process she said "no no no," and became "combative". So I got Staff D to help. I put the gait belt around her, and walked her to the toilet." Staff E confirmed Resident #1 said "let go of my head" at least twice during toileting, while Staff D restrained the resident. According to interview with Staff E and Staff E's statement, Resident #1 did not want assistance with her toileting needs especially being held in the position which the staff had her in. Resident #1 was clearly able to express her dislike of the care that was being delivered. The facility failed to ensure Resident #1 was not over-stimulated and their right to refuse care was implemented, when Resident #1, twice refused toileting.