**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record reviews, the facility failed to assess/monitor the position of a catheter tubing (a flexible tube inserted into the bladder to remove urine and attached to a drainage bag) during catheter care and bed mobility/positioning to prevent the occurrence of an avoidable pressure ulcer (PU) and provide ordered treatment for the PU for 1 of 3 residents (Resident 3) reviewed for PU's. Resident 3 experienced harm when they developed an avoidable Stage III PU (full-thickness skin loss of skin, which is when fat is visible in the ulcer and granulation tissue which is new connective tissues and microscopic blood vessels, and rolled wound edges are often present. Slough, nonviable tissue, and/or eschar, dead or devitalized tissue, may be visible. Undermining -destruction of tissue or ulceration extending under the skin edges and tunneling - a passageway of tissue destruction under the skin surface that has an opening at the skin level from the edge of the wound) which caused pain and discomfort.Findings included .The National Pressure Ulcer Advisory Panel (NPUAP) April 2016, showed a PU/Pressure Injury (PU/PI) definition and stages as:-A PU is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury occurs because of intense and/or prolonged pressure or pressure in combination with shear (a combination of downward pressure and friction).-Medical device related PU/PIs were a result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant pressure injury generally conforms to the pattern or shape of the device. The injury should be staged using the staging system.- Moisture Associated Skin Damage (MASD) was superficial skin damage caused by sustained exposure to moisture such as incontinence, wound exudate, or perspiration. Resident 3 admitted to the facility on [DATE] with diagnoses to morbid obesity and PU's to their buttocks and sacral region (at the base of the spine to the coccyx).Review of an in-service training dated 06/19/2025 showed Nursing Assistants (NA's) were educated on urinary catheter care and directed the staff to assess the securing device daily and change it when clinically indicated.Review of Resident 3's progress note, dated 07/18/2025 at 2:00 PM, showed a urinary catheter was placed by the Assistant Director of Nursing Services and the floor nurse. Resident 3 expressed pain in their groin and genital area.Review of Resident 3's wound care assessment provided by an outside wound healing company, dated 07/23/2025, showed a newly developed facility acquired 5.0 centimeter(cm) by 7.0 cm by 0.3 cm stage III PU. The documentation showed this was caused by a medical device (Foley). The resident had MSAD in multiple locations . due to incontinence and sweat. The treatment recommendations were to apply a wound gel and foam dressing every day and as needed.Review of Resident 3's progress note, dated 07/23/2025, showed the resident's catheter tubing was found under their right thigh, with no securement device, along with a stage III PU where the tubing was found.Review of Resident 3's current care plan had a focus problem of a Foley device related stage III PU on the right buttock. Interventions included: treatment as ordered by the physician and weekly skin checks (initiated on 11/29/2024), pressure redistribution mattress (initiated on 07/25/2025), and to ensure catheter securement device was in place and the Foley catheter was properly hung on the bed (initiated on 07/29/2025).Review of Resident 3's July 2025 Treatment Administration Record showed wound care to stage III right posterior thigh every day. The nurse was instructed to clean the wound, apply wound gel and a foam dressing. Wound care was to be completed every 24 hours and as needed.In an interview and observation on 07/31/2025 at 12:12 PM, Resident 3 was observed lying on their back with the head of the bed in the upright position. There was a catheter bag attached to the right-hand side of the bed. When asked by the surveyors if they had any skin breakdown, the resident stated they had skin breakdown all over their body. Resident 3 stated they recently had their indwelling catheter replaced and the staff had placed the tubing under their leg rather than over their leg. The resident was asked if the indwelling catheter tubing was now being secured. Resident 3 proceeded to remove their sheet and expose their right leg and part of their left thigh. The catheter tubing was observed to be secured in a removable device on their upper right thigh. The resident showed an open area on the right middle upper inner thigh between a skin fold. The wound was approximately five inches long, open, wound bed was pink, and the surrounding skin was intact. The resident showed the upper inner part of both thighs. There was a brief in place, the skin was red, irritated appearing, an open wound was observed on the right inner thigh located close to the bottom of, the skin was moist, and there was no evidence of an application of a cream/ointment (that was MASD related, not r/t to the PU). This area was hard to visualize completely without assistance from staff. The resident stated the area between their upper thighs caused them discomfort (MASD).In an observation on 07/31/2025, with Staff E, Registered Nurse, and Staff F, NA, Resident 3's skin was observed. Staff E and F assisted Resident 3 onto their left side with theirbuttocks and posterior (back side) right thigh exposed. Staff F positioned the resident to ensure their skin was able to be viewed. There was an open wound approximately five inches long on the posterior right upper thigh. The wound bed was pink with no signs of active drainage. The surrounding skin around the wound was red and blanchable. There was no evidence of cream, ointment or a dressing on her upper thighs or buttocks. The right and left buttock were bright red, irritated, with two quarter size shaped wounds that were not open but had fragile skin covering both wounds. The resident had multiple red non fluid filled bumps on scatted on their back and upper part of their thighs. When asked Staff E what this could be caused by, Staff E and the resident both stated they were not sure.In an interview on 07/30/2025 at 2:23 PM Staff B, Director of Nursing Services, stated Resident 3's PU were found by an outside wound care service, and the assistant director of nursing was investigating how they occurred. Staff B stated they had been off the three days after Resident 3's PU was found. No other information was provided. Reference WAC 388-97-1060 (3)(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to protect the resident's right to be free from neglect when they failed to conduct a thorough assessment, communicate a change in condition timely to the physician and notify other nursing staff to respond correctly to a medical emergency for 1 of 1 resident (Resident 1) reviewed for abuse and neglect. Resident 1 experienced harm when they had a change in condition, several caregivers were aware of the change from the resident's baseline, which worsened when nursing staff failed to take timely action; the resident became unresponsive, required cardiopulmonary resuscitation (CPR), and an unexpected death occurred. These failures placed all residents at risk of unmet care needs and potential neglect. Findings Included . Review of the facility policy titled, Abuse Identification, reviewed [DATE] documented the facility would identify abuse, neglect, and exploitation of residents and misappropriation of resident property. This includes but is not limited to identifying and understanding the different types of abuse and possible indicators. The facility defined deprivation by staff of goods or services as abuse, which included failure to provide goods and services necessary to attain or maintain physical, mental, and psychosocial well-being. Staff had the knowledge and ability to provide care and services, but chose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident(s). Resident 1 admitted to the facility on [DATE] with diagnoses to include congestive heart failure (condition in which the heart doesn't pump blood as well as it should) and cellulitis (bacterial skin infection) of the left and right lower limbs. According to the admission Minimum Data Set (MDS- an assessment tool) assessment dated [DATE], the resident was cognitively intact. Review of Resident 1's Electronic Medical Record (EMR) documented weights on [DATE] that showed they weighed 324.8 pounds (lbs.) and on [DATE] they weighed 343.5 pounds (lbs.), a weight gain of 18.7 lbs. in a 24-hour period. Further review showed no documentation the physician had been notified of the resident's significant weight increase. Review of Resident 1's Medication Administration Record (MAR) dated [DATE], showed a physician order dated [DATE] for daily weights before breakfast and staff were to report a three-pound weight gain in a day or five-pound weight gain in a week to the physician. The weight documented on [DATE] was 324.8 lbs., and on [DATE] the weight was 343.5 lbs. There were no documented weights for [DATE]. Review of Resident 1's MAR for [DATE], dated [DATE], showed a monitor for edema (swelling that occurs when fluid builds up in the body's tissues) and a documented 3 + (a moderate to severe degree of swelling). [DATE] MAR showed no refusals for Resident 1's Lasix (a medication to treat fluid retention). Review of Resident 1's progress notes dated [DATE] at 5:31 PM showed an entry by Staff B, Registered Nurse (RN), that the resident had developed difficulty breathing at 3:20 PM and was assessed (oxygen saturations at 96 percent-a measurement of how much oxygen the blood is carrying), resident's oxygen was increased to four liters (L) per minute (lpm-flow rate of oxygen administered to a patient) and provided a nebulizer treatment. The progress note showed Resident 1 stabilized for about an hour, then developed shortness of breath again and given an inhaler (a device that delivers medication directly to the lungs). At 5:30 PM Resident 1 condition was noted to deteriorate and the NAC's reported they had no pulse. Emergency services were contacted and Resident 1 passed away at 6:18 PM at which time the Director of Nursing Services (DNS) was notified and the provider. No other interventions and assessments were found to be completed with Resident 1. There was no documentation found in the EMR that the resident's physician or any other medical professional had been notified of the change in condition. Review of Resident 1's MARs dated [DATE], documented that the resident had an order for Ipratropium-Albuterol solution 3 milliliters (mL) inhaled orally via nebulizer two times daily AM and bedtime. The review showed that on [DATE], [DATE] and [DATE] at AM the resident refused this medication. Staff B documented in their progress note dated [DATE] at 5:31 PM that nebulizer was provided to the resident, however this is not reflected on the MAR. The [DATE] MAR also documented an order for continuous oxygen to be administered at two L per minute. There was no order or documentation the physician was notified with request to increase the resident's oxygen to four L as documented in Staff B's progress note on [DATE] at 5:31 PM. In an interview on [DATE] at 11:12 AM Staff A, Nursing Assistant Certified (NAC), stated Resident 1 was not acting themselves, presented with slurred speech, a swollen left arm, and was not able to track with their eyes. Staff A stated they notified their nurse, Staff B at around 9 AM and again around 12 PM. Staff A stated they knew something was Really wrong with Resident 1 and Staff B was not paying attention. Staff A stated Staff B had not checked on Resident 1 during their shift. Staff A stated they did not notify any other nursing staff of Resident 1's change of condition. In an interview on [DATE] at 12:16 PM Staff B stated they were the assigned nurse to care for Resident 1 on [DATE] and had worked a double shift that day, 6:00 AM-10:00 PM. Staff B stated they recalled Resident 1 and their diagnoses of Chronic Obstructive Pulmonary Disease (COPD-a group of chronic lung diseases) and high blood pressure. Staff B stated they were notified at approximately 3:00 PM on [DATE] of Resident 1's change of condition by an NAC. Staff B stated they assessed Resident 1's lungs and they were clear, and they oxygen saturations were at 90%. Staff B stated Resident 1 used continuous oxygen therapy, had shortness of breath and provided breathing treatment by inhaler per physician orders. Staff B stated they directed the NAC to keep a close eye on Resident 1. Staff B stated they were called back to Resident 1's room between 4-5 PM and stated they had deteriorated and was pulseless. Staff B stated they checked Resident 1 for a pulse, found one, and provided them with an ordered nebulizer (physician ordered treatment which administers a fine mist of respiratory medication through a medical device to improve breathing) breathing treatment before exiting the room and calling 911. Staff B stated Resident 1 passed away in the facility after CPR was provided by the NAC's and emergency medical services (EMS). Staff B stated Resident 1 had refused medication for the last two shifts, which included Lasix and Albuterol. Staff B stated they had not called the physician during their shift regarding Resident 1 but had notified the Resident Care Manager and the Director of Nursing Services after they passed away. When asked about swelling in Resident 1's limb, Staff B stated Resident 1 had swelling in their left arm for a while. In an interview on [DATE] at 2:02 PM Staff C, NAC stated on [DATE] at the start of their shift at approximately 3:30 PM they attempted to get Resident 1's weight. Staff C stated Resident 1 looked terrible and was trying to say something, but they could not understand them. Staff C stated they had to demand that Staff B go to Resident 1's room to assess them. Staff C stated an inhaler was administered to Resident 1 by Staff B. Staff C stated when they checked on Resident 1 again at approximately 4:00 PM, their color and breathing pattern had changed. Staff C stated they had to demand Staff B contact 911 or they were going to. Staff C stated they initiated CPR with other NAC's. Staff C stated Staff B did not assist and did not provide direction to the NAC's present. Staff C stated Resident 1's vitals were taken by the NAC's and no pulse was found. Staff C stated after Resident 1 passed away they spoke with Staff G Director of Nursing Services (DNS), by telephone and expressed concerns about Staff B's lack of urgency, assessment, and assistance during Resident 1's change of condition. In an interview on [DATE] at 4:50 PM Staff G stated Resident 1 had respiratory failure and then got a respiratory illness. Staff G stated NACs assisted Resident 1 with all their activities of daily living. Staff G stated Resident 1 did not have a history of refusing care or treatments and their death was not expected. Staff G stated they were unaware of any weight changes for Resident 1, changes in weight were to be reported to the provider, and the provider should have been notified of their weight increase from 05/01-[DATE]. Staff G stated they completed an investigation related to Resident 1's death, under risk management, did not make a report to the state hotline, and the death had not been reported to the coroner's office. Staff G stated they had provided all the documents related to their investigation, however when asked about statements from staff they stated they would need to find those. When asked why the statements were not part of their investigation, Staff G stated they guessed they should have been. Review of the incident report dated [DATE] at 6:18 PM, documented CPR was started on Resident 1 by the facility licensed nurse in addition to defibrillator use. EMS services arrived and were unable to resuscitate Resident 1. The notes section of the incident report showed Resident 1 passed away unexpectedly in the facility potentially related to a respiratory illness and other comorbid conditions. There were no other documents, statements or interviews attached, referenced or included with the incident investigation report. The investigation did not document that the physician had been notified of Resident 1's unexpected death. Review of the written statement by Staff J, NAC, dated [DATE] with an event time of 5:40 PM documented they were serving dinner when they were notified Resident 1 was unresponsive and came to assist. Staff J, according to their statement, attempted to get Resident 1's vitals and could not get an oxygen reading, while Staff B returned to the room with a nebulizer treatment. Staff J indicated they were directed to start CPR by a nurse from another unit. Staff J wrote that Staff B was not in the room until EMS arrived. Review of the written statement by Staff K, NAC dated [DATE] at 5:40 PM showed they had asked the assistance of Staff C to obtain a weight for Resident 1 earlier in the day. Resident 1 was described as responsive but nonsensical in their speech. Staff K indicated later vital signs were taken of Resident 1 and there was no pulse and no oxygen. Staff K wrote that the other aides had to push Staff B to contact 911. In an interview on [DATE] at 12:45 PM Anonymous Staff E, LPN stated Staff C, NAC had come to them visibly upset over the passing of Resident 1. Staff E stated it was reported to them that Staff B had been told several times about Resident 1's deteriorating condition and they did not address it. Staff E stated they attempted to discuss the staff's concerns regarding Staff B with Staff G and they were told they needed to keep their mouth shut. In an interview on [DATE] at 1:00 PM Staff F, Administrator stated Resident 1 was a full code status. Staff F stated the facility staff had performed CPR and used the defibrillator on [DATE] and had no concerns. Staff F stated information had come to them about Resident 1 after they passed away. Staff F stated they did not complete an interview with Staff B and relied upon their progress note in Resident 1's EMR. Staff F stated they did not think Staff B notified the doctor, did not contact them, and lacked communication with the proper individuals regarding Resident 1's change of condition. Staff F stated they did not know why the NACs did not seek out another nurse after informing Staff B of Resident 1's change of condition and getting no response. Staff F stated Staff B had been terminated. Cross Reference F684 Refer to WAC 388-97-0640(1)(3)(c)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** <NEUROLOGICAL CHECKS> Resident 121 admitted to the facility on [DATE] with diagnosis to include a stroke, vascular dementia, unspecified protein calorie malnutrition. Review of Resident 121 incident report dated 04/22/2024 showed that Resident 121 had an unwitnessed fall in their room. The incident report contained a form for neurological flow sheet which was dated 04/22/2024 and contained 15-minute neurological checks every 15 minutes from 2:45 AM until 3:30 AM and 30-minute neurological checks every 30 minutes from 4:00 AM until 4:30 AM. The neurological flow sheet was empty for the one hour, four hour and 3 days following the fall. In an interview on 04/24/2024 at 3:55 PM Staff C stated they did not have additional information to provide for the investigation. When asked about the neurological checks, Staff C, stated the only checks completed were on the neurological flow sheet however, there were some progress notes addressing Resident 121's overall status as they were on alert charting. This is a repeat citation from survey 12/04/2023. Refer to WAC 388-97-1060 (1) monitor, assess, and take timely action in accordance with professional standards of practice for 17 of 32 resident's (Residents 59, 47, 5, 55, 1, 14, 23, 27, 31, 34, 40, 50, 58, 62, 63, 69 and 70) reviewed for bowel care and management, 1 of 1 resident (Resident 49) for a hospice referral and 1 of 1 resident (Resident 121) for neurological checks. These failures resulted in harm to Resident 59 when they experienced discomfort, pain, and hospitalization for a bowel impaction (the result of constant constipation when poop was stuck inside of the rectum). These failures placed the residents at risk for constipation, discomfort, a worsening of their condition, and a delay in receiving hospice care and services. Findings included . Review of the facility policy titled, Bowel Protocol, revised 09/12/2023, showed to provide interventions for signs and symptoms of constipation that are consistent with current standards of practice. The policy directed staff to record in the electronic health records (EHR), each time a resident had a bowel movement. The facility in coordination with the residents attending practitioner will implement standing orders to address a lack of bowel movement. The protocol noted the orders may vary within the facility for each attending practitioner and depend on the individual needs of the resident. <BOWEL MANAGEMENT> RESIDENT 59 Resident 59 was readmitted to the facility on [DATE] with diagnoses to include collapsed and displaced vertebrae (back bones) multiple myeloma (cancer of plasma cells that weakens bones), torticollis (condition where neck muscles contract), and emphysema (lung disease with shortness of breath). A review of the resident's admission Minimum Data Set (MDS- an assessment tool) assessment, dated 03/05/2024, identified the resident to have moderately impaired cognition and memory, and they did not reject care. The MDS assessment showed the resident was always continent of bowel, was not on a bowel toileting program and did not have constipation present. During an interview on 04/22/2024 at 10:53 AM, Resident 59 was in bed with a pained expression (grimacing, furrowed brow, and look of displeasure) on their face. They stated they had constipation and now they thought they were headed the other way (loose stools). Resident 59 said they needed to try to have a bowel movement (BM). Review of the care plan, dated 04/22/2024, showed there had been no constipation care plan developed until 04/22/2024. The care plan showed Resident 59 was at risk for constipation related to oxycodone (narcotic) use. The care plan did not document other narcotics with a potential to increase constipation or specify the resident's usual bowel patter or goals. The care plan goal said the resident would pass soft, formed stool but did not include the resident goals and preferred frequency of BM's through the review date. The care plan was incomplete with SPECIFY FREQ (a place marker in the software that directs the staff to specify the frequency) was still in place The interventions included: follow facility bowel protocol for bowel management, observe for medication side effects of constipation, and to keep the physician informed of any problems. Additional interventions included to observe for reported as needed (PRN) signs and symptoms of complications related to constipation. Change in mental status, new onset: confusion, sleepiness, inability to maintain posture, agitation, Bradycardia (slow, low pulse), Abdominal distension, vomiting, small loose or stools, fecal smearing, Bowel sounds, Diaphoresis, Abdomen: tenderness, guarding, rigidity, fecal compaction. The care plan included an incomplete intervention directing staff to teach the resident/family/caregivers the relationship between constipation and food, fiber intake, medicine, treatment regimen, disease process (SPECIFY) and psychosocial factors. Teach the resident/family/caregivers to identify and avoid causative factors (SPECIFY: lack of exercise, not enough fiber). Review of physician's orders, dated 04/22/2024, showed Resident 59 received three narcotics with a known side effect of constipation (Dilaudid every four hours PRN, Oxycodone 15 milligrams (mg) every three hours routinely and Oxycontin 20 mg two times a day routinely). Review of the bowel medications directed the licensed nurse to implement the following: - Order, dated 03/01/2024, if the resident had no BM in three days give Milk of Magnesia (MOM - a laxative) at bedtime. Administer a Dulcolax (a laxative) suppository PRN if no results from the MOM. Administer a Fleet (a laxative) enema PRN if not results from the suppository. - Dilaudid 2 mg to 4 mg every four hours PRN, dated 03/19/2024. - Oxycontin two times a day, dated 04/10/2024. - Oxycodone 10 mg to 15 mg every three hours PRN, dated 04/10/2024. - The facility received orders on 04/10/2024 to add Senna once daily. - MiraLAX (a laxative) 17 grams was ordered PRN daily for constipation on 04/23/2024 at 10:23 AM. -MiraLAX 17 grams was ordered every Wednesday, Friday, and Sunday for constipation on the day after the resident was sent out to the hospital (04-24-2024). Review of Resident 59 bowel monitor and Medication Administration Record (MAR) for March 2024, showed the following: -The resident had a BM's on ten days of the month. - There was no BM documented from admit, 03/01/2024 until 03/07/2024, a total of at least six days (review of the clinical record showed there was no information on when the residents last BM was prior to admit) documented with no BM. - On 03/16/2024, a PRN constipation medication was given three days of no BM before an intervention was taken which was effective. - On 03/20/2024, MOM was administered after four days with no BM since 03/16/2024, and the MOM was effective. - On 03/26/2024, the resident received senna after no bm for four days which was documented in the MAR to be effective, although the bowel monitor (a separate record used to document BM's) did not show the resident had a BM. - On 03/27/2024, and the resident received senna. The nurse documented the medication was ineffective. No additional medications were administered when the medication was documented as ineffective. - The resident had three days with no BM, from 03/29/2024 until 04/01/2024, and no bowel medications were given. Review of the bowel monitor and MAR for April 2024, showed no BM documented from 04/04/2024 to 04/10/2024, a PRN constipation medication was given on 04/02/2024 which was ineffective. No additional medications were administered when the medication was ineffective. On 04/07/2024, a PRN medication was given and was ineffective. On 04/08/2024 MOM was given with no results, and then on 04/10/2024 MOM was given a second time and ineffective. No additional medications were administered when the medication was ineffective. The resident then received a Dulcolax suppository on 04/10/2024 which was documented as effective in the MAR although no BM was documented as occurred. In an interview on 04/23/2024 at 9:00 AM, Resident 59 was observed in bed with a pained expression on their face (grimacing, furrowed brow, and look of displeasure), and their knees were drawn up towards their chest. The breakfast tray was observed on their over bed table untouched. There was a bath basin near their side, and they said they were too sick to eat. The resident said they were having terrible abdominal pain and nausea and were miserable. Review of a progress note, dated 04/23/2024 at 7:16 AM, showed Resident 59 was nauseated and the nurse administered Ondansetron (anti-nausea medication) for nausea. Review of a nursing progress note, dated 04/23/2024 at 2:57 PM, showed Resident 59 was complaining of constipation and abdominal pain. Their abdomen was assessed to be rigid (hard) and tender to the touch. Staff F, Licensed Practical Nurse (LPN)/Resident Care Manager (RCM), documented they were still awaiting the STAT (urgently) x-ray to be taken before proceeding with a suppository or enema. Staff F noted the provider was notified that morning and had started the resident on routine MiraLAX and senna daily. Review of nursing progress note, dated 04/23/2024 at 3:03 PM, showed Resident 59 was nauseated and the nurse administered Ondansetron. The medication was ineffective as the resident had an emesis (vomiting). Review of the progress note, dated 04/23/2024 at 7:06 PM, showed Resident 59 had an emesis (vomited) around 4:30 PM. Staff D, Registered Nurse (RN), asked the resident to roll over, the resident reported abdominal pain with turning, and the nurse observed so hard stool coming out of the resident rectum. The nurse asked the resident if it was okay to be sent out to the hospital as the x-ray was going to take a while and an enema or suppository would not be effective due to the symptoms as the LN (licensed nurse) documented a suspected impaction at this point. Review of the facility's Nursing Home to Hospital Transfer Form, dated 04/23/2024 at 6:25 PM, showed Resident 59 was transferred to the hospital for constipation and had a pain level of six (on a zero, no pain, to 10 severe pain scale) in their abdomen. The resident's last BM was on 04/22/2024. In an interview on 04/24/2023 at 7:32 AM, Staff F said Resident 59 went out to the hospital last night. Staff F said they heard the resident had a bowel impaction, but they hadn't verified that on the hospitals electronic health record (EHR) yet. Review of the nursing progress notes from 04/01/2024 to 04/21/2024, showed no documentation the physician was notified or consulted regarding Resident 59's constipation until 04/23/2024. In an interview on 04/25/2024 at 9:01 AM, Staff D said they were the nurse who sent Resident 59 out to the hospital last night. Staff D said the resident had been having small BM's every day and did not trigger on the bowel alert (an alert system within the facility's EMR to notify staff of no bowel movement in 72 hours). Staff D said the resident complained of abdominal pain, they gave them prune juice, and MiraLAX. Staff D said the resident had vomited brown emesis. Staff D said they positioned the resident on their side to see a very hard stool.: Staff D said they had orders for an enema or suppository but there was a hard BM present, so they couldn't administer these medications. Staff D said they had already received an order for the abdominal x-ray, but it had not been taken yet. Staff D said at that time, they encouraged the resident to go out to the hospital for treatment and to get the x-ray sooner and they refused. Staff D called the residents family member who talked with them, and they agreed to go. Review of the history and physical from the emergency department physician, dated 04/23/2024, showed there was mild tenderness to palpation and the fecal load (BM filled intestines) was evident on abdominal palpation. Review of Resident 59's hospital emergency department dictation, dated 04/23/2024, showed the resident was seen for abdominal pain. The present illness showed the resident was on multiple pain medications. The resident reported they were given prune juice as they had not had a bowel movement for the past week. The resident threw up the prune juice and felt the urge to vomit since. The resident complained of abdominal pain and a history of a hernia (bulging of an organ or tissue through an abnormal opening) repair. The physician noted diffuse (spread over a wide area) abdominal tenderness. Review of the hospital's abdominal Computed Tomography (CT -exam of internal images of the body) scan results, dated 04/23/2024 at 10:24 PM, showed Resident 59 had a marked amount of fecal material in the rectum with wall thickening possibly related to stercoral colitis (occurs when a resident has chronic constipation leading to stagnant fecal matter). The CT showed distension (abnormally swollen) in the small bowel. Review of the emergency department admission report, dated 04/23/2024, showed Resident 59 presented with a concern for worsening abdominal pain, lack of a bowel movement, and vomiting. The resident had been receiving significant amounts of opioids (narcotics) for discomfort. Review of Resident 59's emergency department note, dated 04/23/2024, showed the CT scan was reviewed with the surgeon who said this did not require surgical intervention and would be appropriate for medical admission with enema and bowel preparation. They attempted manual disimpaction (a procedure to remove trapped stool by breaking it up and removing it) and were able to remove a small amount of stool however the procedure was discontinued per resident request due to the degree of discomfort. The plan was for several enemas to loosen and remove stool which may require recurrent attempts at manual disimpaction, depending on success and fullness of enema. The resident diagnoses were fecal impaction and stercoral colitis. Review of a hospital note, dated 04/24/2024, showed Resident 59 had a repeat x-ray that continued to show a large fecal load (large presence of stool in the intestines). Review of a hospital noted, dated 04/25/2023 at 5:44 PM, showed Resident 59 continued passing soft stool throughout the night, requiring multiple (incontinent) brief changes. In an interview on 04/26/2024 at 9:15 AM, Staff B, Registered Nurse (RN)/Director of Nursing Services, provided Resident 59's bowel monitors beginning 03/01/2024 and said they (the bowel records) were concerning. Staff B said they reviewed the current bowel protocol and were now working on changing the order to reflect the Medical Director's standing orders for constipation. Staff B said they have reviewed every resident's chart for bowel pattern and constipation and in serviced nursing staff to review the BM monitors twice a day. <RESIDENT 47> Resident 47 was admitted on [DATE] with diagnoses to include colon cancer, protein calorie malnutrition (the body lacks enough protein and energy to function properly) and gastroesophageal reflux disease. Review of the admission MDS assessment, dated 01/12/2024, showed the resident was cognitively intact, occasionally incontinent of bowel, was not on a toileting program, and had no constipation. Review of a nursing progress note, dated 03/28/2024 at 2:40 AM, showed communication with a physician as the nurse noticed Resident 47 had been requesting Zofran (anti-nausea medication) lately, their bowel movements were not regular, and occasionally there was no BM for three days. The note showed the resident vomited a small amount of brown emesis and complained of right abdominal pain. The nurse noted the resident was on routine Oxycontin, Oxycodone, and Tylenol which were prone to cause constipation. Resident 47 was not on any routine laxatives, and the nurse inquired about routine laxative medication and a test to rule out bowel obstruction. Review of a nursing progress note, dated 03/28/2024 at 4:12 AM, showed Resident 47 received a Dulcolax suppository which was effective. Review of a nursing progress note, dated 03/31/2024 at 10:44 PM, showed at 5:10 PM Resident 47 was experiencing an altered mental status, complained of abdominal pain, and nausea and vomiting. At 9:30 PM, the resident was experiencing involuntary movement in all extremities and weakness. The resident reported they had abdominal pain of a 10 out of 10 and felt like someone was pushing on it. The 8:00 pm and 9:00 pm medications were held for the new symptoms. The resident continued to vomit thick saliva. The on-call provider was called, and the resident went to the hospital at 10:10 PM. Review of the readmission physician orders, dated 04/03/2024, showed Resident 47 was receiving Morphine Sulfate twice a day, a narcotic with known side effect of constipation. There were orders for MOM to be given if there was no BM in three days to be administered at bedtime, then a Dulcolax suppository PRN if no results from MOM daily, and then Fleet enema a PRN if no results from the suppository. There was also an order for Senna twice a day PRN for constipation. Review of the April 2024 bowel monitors showed Resident 47 had no BM from 04/03/2024 to 04/07/2024 and no BM from 04/13/2024 to 04/17/2024. Review of the April 2024 MAR showed Resident 47 received PRN MOM on 04/06/2024 at 9:19 PM after no bowel movement for five days. The results of this intervention was documented as unknown. The MAR showed no additional bowel medications were administered when the MOM did not elicit a bowel movement. Review of Resident 47's nursing progress note, dated 04/07/2024 at 8:05 AM, showed the administration of the PRN MOM was unknown. There was no additional assessment or information documented. Review of the current care plan showed there was no constipation care plan developed for Resident 47 until 04/24/2024. In an interview on 04/30/2024 at 12:06 PM, Resident 47 said they had struggled with constipation since they admitted . The resident said their usual bowel pattern was daily and they would like to go daily. In an interview on 05/01/2024 at 11:01 AM, Resident 47 was in bed on their right side and stated they did not feel well, their stomach was upset, and they were constipated. Review of the bowel monitor on 05/01/2024, showed Resident 47's last BM was on 04/28/2024. <RESIDENT 5> Resident 5 admitted on [DATE] with diagnoses to include left sided paralysis. The annual MDS assessment, dated 02/11/2024, showed the resident was frequently incontinent of bowel and did not have constipation. The resident was nonverbal and communicated by hand gestures. Resident 5's care plan showed they were at risk for constipation related to decreased mobility and a diminished appetite. The goal was for the resident to pass soft, formed stool at the preferred frequency of every two to three days. The care plan directed staff to follow the facility bowel protocol and observe for medication side effects of constipation and inform the physician of any problems. The staff were to record the bowel pattern each day. Review of the physician's orders, dated 12/14/2023, showed Resident 5 received a Bisacodyl suppository every other day routinely for constipation and could receive an additional suppository daily PRN. The resident had an order for a Fleet enema every 72 hours PRN for constipation, MOM PRN daily if no BM in three days, and MiraLAX daily PRN. Review of the 04/01/2024 through 04/25/2024 bowel monitors, showed Resident 5 had no BM's from 04/08/2024 until 04/13/2024, five days. Review of the bowel records from 04/01/2024 to 04/25/2024 showed the resident had bowel movements on eight days. Review of the 04/01/2024 through 04/25/2024 MAR's, showed Resident 47 did not receive any PRN medications as ordered for constipation. <RESIDENT 55> Resident 55 re-admitted on [DATE]. A review of the resident's admission MDS assessment, dated 03/05/2024, identified the resident to have moderately impaired cognition and memory and they did not reject care. The MDS assessment showed the resident was occasionally incontinent of bowel, was not on a bowel toileting program and did not have constipation present. Review of the bowel monitor and MAR, dated 04/08/2024 through 04/24/2024, showed Resident 55 had no BM documented from 04/13/2024 until 04/17/2024, a total of four days with no BM. There was no BM documented from 04/18/2024 until 04/24/2024. Review of a nursing progress note dated 04/17/2024 at 5:56 PM, showed Resident 55 was offered MOM PRN they refused the offer, and reported they had a BM yesterday. Review of the bowel monitor did not include the BM on 04/16/2024 as reported by Resident 55. In an interview on 04/29/2024 at 11:55 AM, Staff B said they had not been following the current signed bowel policy. Staff B said there were batch orders (orders to automatically be put in) on admission for bowels management that included MOM, then a suppository then Fleets enema but that order was not automatically checked and needed an (physician) order. Staff B said residents on narcotics should have the bowel protocol marked and an order for Docusate in case they need it. Staff B said they did not know why the batch orders would not have been addressed for residents on narcotics or if no BM was recognized. In an interview on 04/29/2024 at 2:29 PM, Staff D said they thought Resident 55 had regular BM's and the aides were not documenting their BM's accurately. Staff D said the bowel protocol was to give MOM if there was no BM in three days. Staff D said if the resident triggered on the no BM report (report that indicated when a resident has not had a BM in 72 hours), they would go interview the resident to validate accuracy. Staff D said that they did see BM's for Resident 59, but the facility had temporary and agency staff who did not chart BM's, so the charting may be wrong. Staff D said for resident's who took narcotics, were not very active, they would obtain an order for a routine medication to treat the constipation. Staff D said they did reach out to the Resident 59's doctor and received routine bowel medication orders the morning of 04/23/2024. During Quality Assurance Performance Improvement (QAPI) interview on 05/01/2024 at 1:30 PM, Staff A, Administrator, Staff B, Staff C, RN/Assistant Director of Nursing, Staff T, Regional Director of Clinical Services and Staff U, Divisional Director of Clinical Services were present. Staff B said they had not been aware there was an issue with bowel monitoring. Staff B said they were now running the bowel report every day and would be implementing a new bowel protocol that should be reviewed and signed by the Medical Director today (05/01/2024). Staff B said the nursing staff were to review the report twice a day and this was an audit that will not go away. In an interview on 05/02/2024 at 11:34 AM, Collateral Contact 5 (CC5), Advanced Registered Nurse Practitioner (ARNP), stated their expectation for constipation notification is that the facility notifies them on day 4. CC5 said that if a resident had not had a bowel movement for three days and all interventions had been tried such as a suppository or enema they could help. CC5 stated that they had been getting notified of no BM's on day five through written communication, which did not work. In an interview on 05/02/2024 at 11:45 AM, Staff M, Registered Dietician (RD), stated they looked for nausea, vomiting, appetite and if there was any constipation or loose stools on their visits. Staff M said they would work with the provider for medications that could assist with these constipation issues. <RESIDENT 1> Review Resident 1's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 1 had no BM's from 04/18/2024 until 04/23/2024, for five days. Review of the April 2024 MAR, showed Resident 1 did not receive medications to relieve their constipation. <RESIDENT 14> Review Resident 14's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 14 had no BM's from 04/05/2024 until 04/08/2024, for four days. Review of the April 2024 MAR, showed Resident 14 did not receive medications to relieve their constipation. <RESIDENT 23> Review of Resident 23's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 23 had no BM's from 04/02/2024 until 04/06/2024, for five days. Review of the April 2024 MAR, showed Resident 23 received MOM on 04/05/2024 at 9:12 AM that was effective although there was no BM documented on the bowel monitor. <RESIDENT 27> Review of Resident 27's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 27 had no BM's from 04/20/2024 until 04/25/2024, for five days. Review of the April 2024 MAR, showed Resident 27 received constipation medications, Miralax on 04/24/2024 at 4:33 AM and Senna at12:54 AM, that were documented to be ineffective. No additional bowel medications were administered when the resident did not have results. <RESIDENT 31> Review of Resident 31's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 31 had no BM's from 04/18/2024 until 04/22/2024, for five days. Review of the April 2024 MAR, showed Resident 31 did not receive medications to relieve their constipation. <RESIDENT 34> Review of Resident 34's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 34 had no BM's from 04/06/2024 until 04/10/2024, for four days. Review of the April 2024 MAR, showed Resident 34 did not receive medications to relieve their constipation. <RESIDENT 40> Review of Resident 40's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 40 had no BM's from 04/19/2024 until 04/22/2024, for four days. Review of the April 2024 MAR, showed Resident 40 did not receive medications to relieve their constipation. <RESIDENT 50> Review of Resident 50's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 50 had no BM's from 04/13/2024 until 04/16/2024, for four days. Review of the April 2024 MAR, showed Resident 50 did not receive medications to relieve their constipation. <RESIDENT 58> Review of Resident 58's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 58 had no BM's from 04/19/2024 until 04/23/2024, for five days. Review of the April 2024 MAR, showed Resident 58 did not receive medications to relieve their constipation. <RESIDENT 62> Review of Resident 60's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 62 had no BM's from 04/12/2024 until 04/15/2024, for four days. Review of the April 2024 MAR, showed Resident 62 did not receive medications to relieve their constipation. <RESIDENT 63> Review of Resident 63's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 63 had no BM's from 04/06/2024 until 04/09/2024, four days. Resident 63 did not have a BM from 04/12/2024 to 04/16/2024, for five days. Review of the April 2024 MAR, showed Resident 63 did not receive medications to relieve their constipation on 04/08/2024. Resident 63 did receive MOM on 04/15/2024 with no BM results from the medication. No additional medications were administered when the resident did not have a BM. <RESIDENT 69> Review of Resident 69's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 69 had no BM's from 04/01/2024 until 04/04/2024, for four days. Review of the April 2024 MAR, showed Resident 69 did not receive medications to relieve their constipation. <RESIDENT 70> Review of Resident 70's bowel monitors, dated 04/01/2024 through 04/26/2024, showed Resident 70 had no BM's from 04/10/2024 until 04/14/2024, for four days. Review of the April 2024 MAR, showed Resident 70 did not receive medications to relieve their constipation. <HOSPICE> Resident 47 admitted on [DATE] with cancer, hip fracture and protein calorie malnutrition. Review of a nursing progress note for Resident 47 dated 04/11/2024 at 12:03 PM showed that an order to consult hospice was entered. There were no other progress notes about hospice. In an interview on 04/22/2024 at 2:27 PM, Resident 47 said they were unsure about the plans for their stay or discharge. The resident stated they had a lot going on and they never stop worrying. The resident said I am dying and that is a lot to deal with. I do not want chemo anymore. My quality of life is terrible. The resident said they had not seen any hospice staff yet but would like them to help with their grief and coping. In an interview on 04/24/2024 at 10:45 AM, Staff I, Social Services Director (SSD), stated the local hospice agency was not able to provide services until Resident 47 was on a certain type of medical insurance. In an interview on 04/25/2024 at 10:53 AM, Collateral Contact (CC) 3, Referral Center Manager for the hospice agency, said they had not heard about Resident 47 since they were at the hospital in late December 2023 or January 2024. CC3 said they had not heard from this facility, but they could accept the resident under their current pending financial/payor source as their payor source was not a barrier to utilize hospice services. In an interview on 04/26/2024 at 9:15 AM, Staff B said there was a reason Resident 47 could not go on hospice and to talk with Staff I. In an interview on 04/26/2024 at 9:28 AM, Staff A said the facility wanted Resident 47 on hospice services and they felt they would benefit from it, but they had always been told the hospice agency would not accept residents that were pending their financial/payor source. Staff A said they would look into the lack of documentation regarding the referral and follow up. Review of a progress note on 04/26/2024 at 10:32 AM, showed Staff I sent the hospice referral to the local hospice agency via fax. In an interview on 04/29/2024 at 11:30 AM, Resident 47 said they were going to go on hospice services now since it looked like they were going to be going that way.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to comprehensively assess and ensure timely and appropriate services/interventions were provided to maintain, increase and/or prevent a decrease in range of motion (ROM - was the extent that a joint can move within the expected [normal] range of values) for 2 of 5 sampled residents (Resident 29 and 5) reviewed for ROM and restorative nursing services. Resident 29 experienced harm when they developed a significant, potentially avoidable, left-hand contracture (a permanent tightening of the muscles tendons, skin that causes joint to shorten and become stiff which prevents normal movement a body part affected) and placed other residents at risk for developing new contractures and/or worsening of existing contractures. Findings Included . <RESIDENT 29> Resident 29 admitted to the facility on [DATE] with diagnoses that included vascular dementia (brain damage from impaired blood flow to the brain that causes changes in reasoning, planning, memory, and judgement), muscle weakness, atrial fibrillation (irregular heartbeat), and high blood pressure. Review of Resident 29's Quarterly Minimum Data Set (MDS - an assessment tool) assessment, dated 02/03/2024, showed the resident had no impairment in their functional ROM of their upper and lower extremities during the prior seven days. Review of Resident 29's care plan, dated 10/25/2022, showed the resident required Activities of Daily Living (ADL - dressing, bed mobility, transfers, toileting, personal hygiene, etc.) assistance and therapy service to maintain or attain their highest level of function with the goal of attaining their prior level of function. The care plan interventions included cueing and supervision with Resident 29's mobility and ADL's as needed, and therapy services as ordered. In an observation on 04/23/2024 at 1:58 PM and 04/25/2024 at 2:32 PM, Resident 29 was lying in bed on their left side, and their left hand was observed in a rigid (unable to bend or be forced out of shape; not flexible) fist position. In an interview and observation on 4/25/2024 at 2:32 PM, Staff Q, Physical Therapist/Director of Rehabilitation, asked Resident 29 to open their left hand fully. Staff Q extended Resident 29's thumb, pointer finger and when attempted to extend the other three fingers (middle, ring, and pinky), Resident 29 stated that it hurt. Resident 29's middle finger, ring finger and pinky finger were fixed in a seized/clutch like position. Staff Q stated Resident 29 had a contracture of their left hand. On 04/26/2024 at 10:08 AM, Resident 29 was observed walking back to their room with the use of a walker. Resident 29 held the walker with both hands, their left hand holding the handle differently than the right. Resident 29 held the walker handle with their thumb and pointer finger. Resident 29's middle finger, ring finger, and pinky finger were observed fixed in a seized clutch like position. In an interview on 04/25/2024 at 2:32 PM, Staff Q stated Resident 29 did not have any documentation of past therapy at the facility and did not have a documented contracture. Review of the Facility Assessment, dated 03/17/2024, showed the facility's workforce profile had 0.08 hours allotted per patient day (PPD) of restorative certified nursing assistant care with and emergency PPD of 0.05 hours. If the hours were not able to be staffed by an employee of the facility, agency staff was identified as the backup. In an interview on 04/26/24 9:01 AM Staff A, Administrator, stated the facility did not have a restorative program (person centered nursing care designed to improve or maintain the functional ability of residents) related to staffing challenges during the COVID-19 (an infectious disease-causing respiratory illness with symptoms including cough, fever, new or worsening malaise [a general feeling of discomfort/uneasiness], headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) pandemic. In an interview on 04/25/2024 at 2:41PM, Staff S, Nursing Assistant Certified (NAC), stated they assisted Resident 29 during the evening shift. Staff S stated Resident 29 had some arthritis (swelling and tenderness of one or more joints) and used their right hand more than their left. Staff S stated they had not provided Resident 29 with any passive range of motion (PROM when someone physically moves or stretches a part of your body) services. In an interview on 04/25/2024 at 2:50 PM, Staff R, NAC, stated they were not aware of any differences in Resident 29's right and left hand. In an interview on 04/29/2024 at 11:02 AM Staff E, Registered Nurse (RN)/MDS Coordinator, stated they collect information for the MDS assessment through nurse and nursing aide interviews, utilization review meetings, and chart reviews. When asked how a resident's ROM was determined, Staff E stated they rely on the nursing staff and therapy. Staff E stated they do not complete an in-person assessment with the resident regarding their ROM. Staff E stated they were unaware of Resident 29's left hand contracture and did not know for how long they had it. Staff E stated the facility did not have a restorative program. Review of an Occupational Therapy (OT) evaluation, dated 04/26/2024, showed Resident 29's left hand middle, ring and pinky fingers had impaired extension and a contracture which resulted in Resident 29 having a decreased ability to grasp objects with their left hand. <RESIDENT 5> Resident 5 admitted to the facility on [DATE] with diagnoses that included intracranial injury with loss of consciousness (brain injury), unspecified convulsions (involuntary contraction of muscles), unspecified voice and resonance disorder (inability to communicate with voice), contracture of the left ankle and left upper arm. Review of the OT evaluation, dated 04/04/2022, showed Resident 5's left upper extremity (LUE) had spastic hemiplegia (muscle tightness and involuntary contractions) resulting in the shortening and tightening of their shoulder, elbow, wrist, and hand. A PROM of their LUE with daily application of a hand/wrist splint by nursing aides were recommended to prevent further contractures. Review of the OT Discharge summary dated [DATE], recommended Resident 5 continue with upper extremity PROM and splint applications. Review of Resident 5's medical record from 04/28/2023 through 4/22/2024, showed they had not received any additional OT services. Review of Resident 5's care plan, dated 06/30/2021, showed the resident had a focus on ADL Self-Care Deficit as they used a left-hand splint, were at risk for contractures, had limited ROM and impaired voluntary movements of all extremities left worse than right side and neck due to history of their brain injury. The goals were Resident 5 would not have worsening of their upper extremity contracture and they would actively participate in splinting program. Interventions included: -Restorative program left hand orthoses (splints). Nursing to put on at the beginning of the night shift and it is to remain on for 6 hours initiated 5/26/2022. -Application of a brace on their right hand in the morning and off at night and use of a right leg splint and neck brace when up in their wheelchair initiated 02/13/2019. -Application of a brace to left hand and neck brace in the morning (0700) and off at night (2000) when up in the wheelchair daily. Perform PROM three to six times a week for at least 15 minutes initiated 06/30/2021. -Passive ROM/gentle stretching to left upper and lower extremity with left hand splint placement, Active Assistive ROM (AAROM - a type of exercise that involves moving a joint with some help from an external force) to right upper and lower extremity three to six times a week for at least 15 minutes initiated 03/04/2019. Review of Resident 5's Treatment Administration Record (TAR) for March 2024 and April 2024, showed on order for PROM with gentle stretching to their left upper and lower extremity, apply a left-hand splint, provide AAROM to right upper and lower extremity and head with neck splint placement three to six times a week for at least 15 minutes. The order directed the unit nurse to monitor compliance and completion of the program every day shift for Functional Mobility Maintenance starting 06/11/2021. This treatment was marked as not completed for the months of March and April 2024. Review of Resident 5's medical record from 06/05/2023 through 04/22/2024, showed no documentation to indicate the resident received PROM during routine nursing care. In an interview on 04/22/2024 at 2:39 PM, Collateral Contact 1 (CC1), Resident 5's family member, stated Resident 5 had not received therapy anymore and they used to get therapy at least yearly. CC1 stated they felt Resident 5 had declined in their ROM and they used to be able to do more. In an observation on 04/22/2024 at 2:39 PM Resident 5's left, and right hands were observed without a hand splint, their left hand rested on an arm trough (a provided support needed for resident's whose arm has little or no function). In an observation on 04/30/2024 at 2:35 PM, Resident 5's left, and right hands were observed without a hand splint and their left hand rested on an arm trough. In an interview and record review on 04/29/2024 at 3:14 PM, Staff F stated the facility did not have a restorative program. Reviewed Resident 5's March and April 2024's TAR with Staff F, and they stated the licensed nurse documented a n on the TAR for the resident's PROM indicated the treatment was not done. Staff F stated they did not know how ROM was being assessed, the risk to the resident if the PROM was not provided, or the process for obtaining a referral for therapy services. Refer to WAC 388-97-1060 (3)(d)(j)(ix) .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview, and record review the facility failed to provide timely pain management and follow pain management orders for 2 of 3 residents (Resident 8 and 4) reviewed for pain. This failed practice resulted in harm to Resident 8 when they were not provided pain medication per physician orders which resulted in unmanaged pain. This failed practice placed all residents at risk of the potential for poor pain management and diminished quality of life. Findings included . Review of facility policy titled, Pain Assessment and Management, revised 09/15/2023, showed the facility must ensure residents receive the treatment and care in accordance with professional standards of practice. <RESIDENT 8> Resident 8 admitted to the facility on [DATE] with diagnoses to include femur (upper leg bone) fracture, generalized anxiety disorder, panic disorder, and depression. Review of Resident 8's admission Minimum Data Set (MDS- and assessment tool) assessment, dated 09/23/2023, showed, under the health conditions section, the resident received scheduled and as needed (PRN) pain medications, and had frequent pain identified. Review of Resident 8's September 2023 physician orders showed the resident had an order dated 09/22/2023 for oxycodone 5 milligrams (mg) one tablet every four hours as needed for a pain rating of a four to six, and two tablets for pain rating of seven to ten on a pain scale of one to ten (one equals mild pain and ten equals severe pain). Review of Resident 8's September 2023 Medication Administration Record (MAR), showed the resident received oxycodone 10 mg on 09/26/2023 at 2:45 AM, 9:04 AM, and 8:48 PM Review of facility nurse staffing form, dated 09/26/2023, showed Staff D, Licensed Practical Nurse (LPN), worked from 1:06 PM until 6:58 PM on the north hall, where Resident 8 resided. In an e-mail, dated 09/29/2023, Resident 8's family member wrote on 09/26/2023 Resident 8 received oxycodone at 9:00 AM, but no other doses were given until 10:00 PM. They stated the resident used their call light several times that day. They stated the resident was experiencing a lot of pain from a recent hip fracture and surgery. In an interview on an undisclosed date and time to protect identity of Anonymous Reporter (AR1), AR1 stated Staff E, LPN, gave Resident 8 oxycodone at approximately 9:00 AM on 09/26/2023. AR1 stated Resident 8 had reported extreme pain later that day and had been very upset when the assigned nurse, Staff D had not given oxycodone when they requested, and did not receive oxycodone again until 8:48 PM. On 10/02/2023 at 2:45 PM, Resident 8 stated they had been experiencing problems with pain management, especially during the previous week. They stated they specifically had a difficult time getting pain medications one afternoon last week from a staff nurse. Resident 8 stated they were in a lot of pain that afternoon and stated they had not received pain medication until bedtime from a different nurse. Resident 8's husband was present for the interview and could not recall the exact date but recalled the situation and nurse as well. Resident 8 stated their daughter would likely know the date as they had talked to them about it. Review of Resident 8's MAR for October 2023 showed on the following dates, the resident was given 5 mg instead of 10 mg oxycodone as ordered for pain levels seven to 10: - On 10/03/2023 at 4:22 AM, pain level was a nine. - On 10/06/2023 at 9:35 AM, pain level was a seven. - On 10/06/2023 at 1:32 AM, pain level was a seven. The nurse documented the pain medication administered was ineffective. - On 10/11/2023 at 10:12 PM, pain level was a seven. - On 10/12/2023 at 4:13 AM, pain level was a seven. - On 10/16/2023 at 7:11 PM, pain level was a seven. During observations on 10/06/2023 between 1:45 PM and 2:10 PM, Resident 8 was sitting in their wheelchair in their room with verbalizing they were in pain, they had a distressed look on their face, they were grimacing, their face was flushed, they were noted to reposition themselves frequently to get into a comfortable position and the resident stated they were upset about their hip pain. Resident 8 stated they had a pain pill recently (at 1:32 PM), and they had requested more pain medication earlier but Staff A, agency Registered Nurse (RN), stated it was too early and they had to wait four hours from the previous dose given at 9:35 AM. Resident 8 stated their ARNP (Advanced Registered Nurse Practitioner) had visited earlier and stated they should have been given two oxycodone tablets (10 mg) instead of one tablet (5 mg) for their pain level of seven out of 10. Resident 8 stated for the dose they had just received (1:32 PM), the nurse had not asked their pain level which they stated was again at seven out of 10. In an interview on 10/06/2023 at 2:35 PM, Staff A stated when they arrived at the facility in the morning, Resident 8 had only two oxycodone 5 mg tablets remaining, therefore, Staff A stated to extend the medication they had given just one instead of the ordered two oxycodone. Staff A stated each time they administered oxycodone 5 mg they also gave Tylenol 500 mg. Staff A stated if oxycodone did not arrive with the pharmacy delivery, due approximately at 5:00 PM today, they would get authorization to get the medication from the pyxis machine (automated medication dispensing system). Staff A stated the oxycodone had been available in the pyxis machine all day, however, did not state the reason they did not access the oxycodone. In an interview on 10/06/2023 at 2:45 PM, Staff K, Director of Nursing Services, was informed Resident 8 had reported their pain level at a seven twice on this date, 10/06/2023, and had orders to administer 10 mg of oxycodone, however had only received 5 mg each time. Staff K was informed of Resident 8's observation of pain exhibited, and replied they would investigate the resident's pain management. In an interview on 10/06/2023 at 3:35 PM, Staff K stated they had investigated Resident 8's pain concerns and stated they felt better knowing the resident was also prescribed other medications to include Tylenol, tizanidine (medication for muscle spasms), and gabapentin (medication for nerve pain). Review of facility investigation, dated 10/06/2023, showed Staff A failed to give the correct dose of oxycodone on 10/06/2023. <RESIDENT 4> Review of a progress note, dated 08/18/2023 at 4:42 PM, showed Resident 4 had admitted to the facility on [DATE] with diagnoses to include cellulitis (a bacterial infection of the skin) from right leg with incision and drainage of the great toe and depression. Review of Resident 4's admission MDS assessment, dated 08/21/2023, showed the resident was cognitively intact. Review of the MDS, under the health conditions section, showed the resident received a PRN medication, no routine medication or non-medication intervention for pain, and they reported frequent pain impacting their sleep and activity over the past five days. Review of Resident 4's pain Care Area Assessment, dated 08/21/2023, showed they had frequent complaints of pain due to cellulitis and wounds on both feet and they took oxycodone fairly regularly. Review of Resident 4 August 2023 physician orders and MAR showed the resident had an order for oxycodone (narcotic pain medication) 10 milligrams (mg) every three hours PRN for pain. Resident 4 did not receive their first dose of oxycodone, after they admitted to the facility until the following day, 08/19/2023 at 12:05 PM. In an interview on 09/20/2023 at 3:15 PM, Resident 4 stated it had taken so long to get pain medication when they arrived at the facility. Resident 4 stated they had severe pain in their foot that moved up their leg. The resident described the pain as really bad, and stated they did not even get any pain medication until the second day they were at the facility. On an undisclosed date and time to protect the identity of AR1, AR1 stated Resident 4 had not received their ordered oxycodone for pain due to lack of supply at facility other than the pyxis machine (automated medication dispensing system). In an interview on an undisclosed date and time to protect the identity of AR3, AR3 stated every time they informed Staff D residents needed pain medication, Staff D stated I'm busy, I'll get to it. AR3 stated they would return to Staff D and inform them the resident was still waiting for their pain medication, which would upset Staff D. AR3 stated they did not know if it had been intentional or if Staff D had forgotten residents pain medication requests. AR3 stated Resident 4 had complained numerous times that Staff D had not brought pain medication or had not brought it timely. In an interview on 09/20/2023 at 3:04 PM, Staff B, RN, stated when they needed medications for a new resident or for a resident with new orders, they sent the prescription to the pharmacy and called the pharmacy to get an authorization code to get the medication from the pyxis machine. In an interview on 10/17/2023 at 1:45 PM, Staff K stated their expectation was for residents to be administered pain medications as soon as possible when they experienced acute pain and under 20 minutes for chronic pain. Staff K stated nurses were expected to administer all medications according to the provider's orders. On 10/17/2023 at 5:30 PM, the Administrator and Staff K were informed of concerns expressed by multiple anonymous staff regarding Staff D. Reference (WAC) 388-97-1060(1) .