Columbia Crest Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to implement its abuse prohibition policy and mandated reporting requirements after an allegation of physical abuse involving Resident 1. The facility’s written policy, dated 10/24/2022, prohibited abuse, defined physical abuse as including hitting and slapping, and required any staff who witnessed suspected abuse to immediately tell the abuser to stop and report the incident to a supervisor, who in turn was to immediately notify the Administrator. The policy also designated all employees as mandated reporters who must immediately report any reasonable suspicion of a crime against a resident, required the immediate removal from duty of any employee alleged to have committed abuse, and required the Administrator to report allegations to the State Survey Agency and local authorities within two hours of receiving a report. Resident 1 had multiple significant medical conditions, including stroke with hemiparesis, dementia, bipolar disorder, and an anxiety disorder, and required extensive assistance with bed mobility and toilet hygiene. The resident had an indwelling urinary catheter, bowel incontinence, and a Stage 4 sacral pressure ulcer requiring dressing changes. During a dressing change following a bowel movement that soiled the wound dressing, Staff D, a NA in training, reported observing Staff B, the Director of Nursing Services, slap Resident 1 on the bare buttock after completing the dressing change. Resident 1 reportedly asked what the slap was for, and Staff B replied it was “just to let you know I was done.” Staff D stated they felt very uncomfortable with what they witnessed and later told the other two NAs in the room they intended to report the incident to the hotline, but did not do so until about 30 days later, after leaving employment at the facility. Multiple staff who were aware of the incident did not follow the facility’s abuse reporting policy. Staff E and Staff F, both NAs present in the room, acknowledged witnessing Staff B slap the resident’s bare buttock but stated they did not consider it abuse and therefore did not report it to the Administrator or the state hotline. Staff C, an RN Resource Clinician, stated that Staff B later told them they had tapped Resident 1 on the butt cheek and that the staff in the room looked at them “funny,” but Staff C did not take the matter further. The Administrator reported having received no prior reports of inappropriate behavior by Staff B and was unaware of the incident until informed by the surveyor. As a result, the facility did not identify the incident as a reportable allegation of abuse, did not immediately notify the Administrator or SSA, and did not remove the alleged perpetrator from duty or initiate an investigation in accordance with its policy and WAC 388-97-0640.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from physical abuse when the Director of Nursing Services (Staff B) slapped the bare buttock of a resident following a dressing change. The facility’s abuse prohibition policy, dated 10/24/2022, defined abuse as the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, and specified that physical abuse included hitting and slapping. The policy also stated that the Administrator was responsible for operationalizing abuse-prevention policies, that any employee alleged to have committed abuse would be immediately removed from duty pending investigation, and that anyone witnessing suspected abuse must report it to outside agencies such as the state survey agency and local law enforcement. Resident 1 had multiple diagnoses including stroke with hemiparesis, dementia, bipolar disorder, and anxiety disorder, and required extensive assistance with bed mobility and toilet hygiene. The resident had an indwelling urinary catheter, bowel incontinence, and a Stage 4 sacral pressure ulcer requiring dressing changes. On or before 12/23/2025, during a dressing change after the resident had a bowel movement that soiled the wound dressing, Staff B completed the dressing change and then slapped the resident on the bare buttock. Three NAs (Staff D, E, and F) were present; two reported witnessing the slap, and one reported that the resident questioned the action and Staff B replied it was “just to let you know I was done.” Staff B later told the RN Resource Clinician (Staff C) they had “tapped” the resident on the buttock and that staff in the room reacted. Staff C spoke with the resident hours later, did not interview the staff witnesses, and did not report the incident further at that time, despite later acknowledging it should have been reported sooner.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The deficiency involves the facility’s failure to ensure that staff immediately reported suspected abuse to the State Survey Agency and the Administrator as required by federal regulation and the facility’s Abuse Prohibition policy. The policy, dated 10/24/2022, designated all employees as mandated reporters who must immediately report any reasonable suspicion of a crime against a resident, required anyone witnessing suspected abuse to report it immediately to a supervisor, and required the notified supervisor to immediately inform the Administrator, who in turn must report to the SSA and local authorities within two hours of the allegation. Despite this policy, multiple staff members who either witnessed or were informed of an incident involving a resident were aware of their reporting obligations but did not report the suspected abuse in a timely manner. The resident involved had a history of stroke, hemiparesis, dementia, bipolar disorder, and anxiety disorder, with a comprehensive assessment showing moderately impaired cognition, dependence on two staff for bed mobility, bowel incontinence, and a Stage 4 sacral pressure ulcer requiring dressing changes. On a day in late December, during a dressing change performed by the DON after the resident had a bowel movement that soiled the wound dressing, three NAs were present in the room. One NA reported that while they were holding the resident during the treatment, the DON slapped the resident on the bare buttock after completing the dressing change. The resident questioned the action, asking what it was for, and the DON responded that it was “just to let you know I was done.” The NA who witnessed this stated they felt very uncomfortable and later told the other two NAs they intended to report the incident to the hotline, but did not actually report it until about 30 days later, after leaving employment at the facility. Two other NAs present during the incident confirmed witnessing the DON slap the resident’s bare buttock but did not report the event. One NA stated they did not think it was abuse and believed it was playful behavior, and therefore did not report it to the Administrator or the hotline. The other NA, who understood the concept of being a mandatory reporter and knew about the state hotline, stated they did not call because the NA in training said they were going to report it. Additionally, a RN/Resource Clinician reported that the DON later told them they had “tapped” the resident on the buttock and that staff in the room had reacted with concern; the RN spoke with the resident hours later and noted the resident did not seem aware of the action, but the RN acknowledged they should have reported the incident that day and did not. The Administrator confirmed they had received no reports of inappropriate behavior by the DON and were unaware of this incident until informed by the surveyor, demonstrating that the required immediate reporting to the Administrator and SSA did not occur.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to establish a valid basis for discharge for two residents who were not permitted to return after hospitalization or therapeutic leave, contrary to facility policy and regulatory requirements. For the first resident, who had chronic conditions including COPD, stroke, and polyneuropathy, the facility issued a 30-day discharge notice for non-payment, which was appealed and overturned by the state. Despite this, after the resident was hospitalized for respiratory distress, internal communications revealed the facility decided not to readmit the resident due to financial reasons, even though the resident's care needs had not changed and the discharge assessment indicated an anticipated return. For the second resident, who had diabetes, a right below-knee amputation, and COPD, and was cognitively intact and independent with an electric wheelchair, the facility failed to allow return after a therapeutic leave. The resident had planned to return after the leave but was directed by the DON to be evaluated in the ER due to a fall and skin breakdown. After ER evaluation, the facility informed the hospital that the resident would need to be reviewed as a new admission and could not return until the next day, despite no significant change in care needs being documented. Interviews with facility staff confirmed that the first resident was denied readmission due to financial issues, not changes in care needs, and that the second resident was not permitted to return after ER evaluation, with staff expressing uncertainty about the rationale. Facility policy required residents to be permitted to return after hospitalization or therapeutic leave unless their needs had changed and could not be met, which was not followed in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a sanitary and homelike environment in resident rooms and with bedside urinals for two residents. For one resident with chronic obstructive pulmonary disease, cachexia, and major depressive disorder, observations revealed a room with used gloves in the garbage, soiled and sticky floors, dried food on the floor, and a fly present. The resident’s bathroom had a strong urine odor and personal medical equipment, including two specialized bedside urinals, which were visibly soiled with a thick layer of dried sediment. Staff reported cleaning these urinals only with water, as the resident disliked the smell of cleaning chemicals, and no disinfecting solutions were used. The resident’s care plan did not document any preferences or interventions regarding cleaning solutions or the maintenance of personal equipment. Staff interviews confirmed that the cleaning process for the specialized urinals did not meet infection control expectations, and the infection preventionist was unaware of the specialized urinal or any plan for its cleaning, disinfecting, or storage. Housekeeping staff also reported using only hot water to clean the room due to the resident’s aversion to cleaning solution odors and had not attempted to use odorless or fragrance-free products. The daily cleaning routine was further complicated by the presence of numerous personal belongings in resident rooms, making it difficult to clean all surfaces effectively. For another resident with diabetes, circulatory complications, and a foot ulcer, observations found the room cluttered with personal belongings, food wrappers, empty soda bottles containing chewing tobacco and spit, and a fly present. The resident stated that their room was cleaned only two to three times per week and that housekeeping did not remove garbage unless it was placed in the trash can. The resident also reported that the counter and sink had not been cleared or wiped down in a long time. These findings indicate that facility policy for cleaning resident rooms and personal equipment was not followed for both residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement, monitor, and modify interventions to reduce the risk of avoidable accidents related to alcohol consumption for a resident with alcohol dependence and other significant health conditions. Despite a physician's order for a gradual reduction in alcohol intake and a plan involving staff supervision and documentation, there was no evidence that these interventions were put into practice or documented in the Medication Administration Record (MAR) or Treatment Administration Record (TAR) for several months. The resident was allowed to store alcohol in their room and personal vehicle, and staff did not consistently track or supervise the amount of alcohol consumed as required by facility policy and physician orders. Interviews with staff revealed that documentation of alcohol dispensation was inconsistent and that staff were not reviewing the total daily intake. The resident did not use the facility sign-out sheet when leaving the premises, and staff were only aware of their absences through verbal reports. The Director of Nursing confirmed that the required monitoring and documentation should have been implemented earlier, and the Administrator was unaware that the reduction plan was not being followed. These lapses in supervision and documentation placed the resident at risk for negative outcomes related to excessive alcohol consumption.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident was able to use a personal possession, specifically a refrigerator, in accordance with facility policy and the resident's rights. The resident, who was cognitively intact and required assistance for personal care due to multiple sclerosis and depression, purchased a refrigerator online and had it delivered to the facility. The administrator informed the resident that they could not have the refrigerator in their room, without providing a clear explanation of the facility's policy. The resident subsequently arranged for family to pick up the refrigerator, but staff were unable to locate it, and the resident was not updated about the missing property. Further review revealed that the facility policy allowed residents to have a small refrigerator (2 cubic feet or less) in their room, and this was not clearly communicated to the resident. The refrigerator purchased by the resident exceeded the size limit, but this was only clarified after the resident expressed concerns about feeling retaliated against and not being allowed to have a refrigerator at all. Observations confirmed that other residents had personal refrigerators in their rooms, and the resident in question was only able to use a much smaller refrigerator without a freezer component.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and monitoring for a resident with a history of hemiparesis, epilepsy, and moderately impaired cognition, who was assessed as unsafe to smoke independently. Despite a care plan and smoking evaluation indicating the need for supervised smoking, the resident was repeatedly observed smoking without staff supervision, obtaining cigarettes from other residents and visitors, and searching for discarded cigarettes in designated smoking areas and the parking lot. Staff interviews confirmed that the resident was not safe to smoke independently and that current interventions, which focused on encouraging smoking cessation and education, were ineffective in preventing unsupervised smoking. The resident sustained two separate injuries related to unsupervised smoking: a burn to the inner thigh and a fluid-filled blister, both attributed to dropped cigarettes while smoking alone. Observations and staff interviews revealed that the resident was able to leave the facility unaccompanied and smoke without supervision, contrary to the facility's policy requiring supervision for residents deemed unsafe to smoke independently. The lack of effective supervision and failure to modify interventions placed the resident at increased risk for further smoking-related injuries.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement its abuse and neglect policies and procedures effectively, as evidenced by the lack of identification, investigation, and reporting of abuse and neglect allegations. Three residents reported allegations of abuse and neglect through grievance forms, but these were not appropriately followed up. Resident 2 alleged that a Licensed Practical Nurse (LPN) was rude and verbally abusive, withholding pain medication. Resident 38 also reported similar issues with the same LPN, feeling that their requests for pain medication were ignored. Resident 62 reported missing medication for Parkinson's disease, which was later found in the medication cart, indicating a pattern of alleged medication errors by the LPN. The facility's grievance forms from June to November 2024 revealed additional allegations of abuse and neglect involving seven residents. These included residents being left unattended, not being repositioned, and experiencing rough treatment by staff. Despite these grievances, the facility did not recognize them as abuse or neglect, and no thorough investigations were conducted. The facility's incident reporting log showed no investigations into these allegations, indicating a systemic failure to address and report potential abuse and neglect. Interviews with facility staff, including the Administrator and Senior Director of Nursing, confirmed that no incident investigations had been completed related to the allegations against the LPN. The Administrator acknowledged the broken system for reporting abuse and neglect allegations, admitting that they were unaware of some grievances. This lack of awareness and action placed residents at risk and constituted an immediate jeopardy, as the facility did not protect residents or conduct timely investigations into the allegations.

Removal Plan

• Conducting facility wide interviews with residents and/or families specific to abuse or neglect to identify if any additional allegations were made to provide the necessary follow up.
• Providing education to staff on the grievance process and how to immediately identify and report abuse or neglect allegations to include protection of the resident during the investigation.
• Ensuring education was completed with all staff.
• Ensuring that all staff were trained on identifying and reporting abuse.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect Resident 35 from neglect, resulting in harm due to the staff's inaction in providing necessary care. Resident 35, who was admitted with diagnoses including Clostridium Difficile, malnutrition, and severe sepsis with septic shock, was dependent on staff for daily activities and had moderately impaired cognition. On multiple occasions, staff ignored Resident 35's requests for water, leaving the resident without hydration for an extended period. Despite the resident's visible distress and repeated calls for water, staff members either did not respond or delayed their response, resulting in a 31-minute wait before the resident received water. Additionally, the facility failed to assess and address Resident 35's skin excoriation in a timely manner. Staff documented extreme skin breakdown and excoriation of the perineum, but there was a delay in assessing and treating the condition. Despite reports of skin maceration and bleeding, the wound was not properly assessed until four days after the initial report. This lack of timely intervention contributed to the resident's discomfort and potential for further skin damage. Furthermore, the facility did not adhere to Resident 35's advance directive regarding pain management. Despite the resident's evident pain and a provider's order for pain medication, staff failed to administer the necessary medications consistently. The resident was left without adequate pain relief for 17.5 hours before passing away, contrary to their advance directive that emphasized the importance of being kept pain-free and comfortable. This neglect in pain management further exemplifies the facility's failure to provide appropriate care and comfort to Resident 35.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide an environment free from avoidable accident hazards, resulting in harm to Resident 4. Resident 4, who required substantial assistance for activities of daily living, reported an injury to their right foot after hitting it on a roommate's bed while being pushed in a wheelchair. Despite Resident 4's complaint of pain, the injury was not promptly assessed or reported by staff. It was only after a state surveyor's intervention that the injury was properly evaluated, revealing a fracture in the fifth toe. The delay in assessment and reporting of the injury indicates a failure in following the facility's accident/incident policy. Additionally, the facility did not ensure a safe smoking environment for Residents 13, 27, and 45. The designated smoking area lacked protection from weather conditions, leading residents to smoke in unauthorized areas. Resident 13, who was supposed to have their smoking supplies stored at the nursing station, kept them in their room and smoked outside the designated area due to inadequate shelter. Similarly, Resident 45 smoked outside the designated area, and Resident 27 kept smoking supplies in their room, contrary to the facility's smoking policy. The facility's failure to enforce its smoking policy and provide a safe smoking environment placed residents at risk. The lack of adherence to the policy was acknowledged by the facility's administrator, who noted that residents did not comply with the smoking policy. This non-compliance with established procedures for accident reporting and smoking safety highlights significant deficiencies in the facility's management of resident safety and policy enforcement.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient numbers of competent nursing staff to meet the needs of all residents, impacting their rights, social services, activities, and restorative nursing programs. This deficiency was evident in the experiences of 12 residents who were unable to exercise their right to vote, participate in dining room activities, or receive necessary social services and restorative care. Residents expressed disappointment and frustration over their inability to vote due to lack of assistance from staff, and some were not informed about voting procedures or given help to complete their ballots. The shortage of staff also affected residents' dining experiences, as the facility was unable to open dining rooms due to insufficient staff to assist with meals. Residents expressed a desire to eat in the dining room and socialize, but were confined to their rooms for meals. Staff confirmed that the dining rooms remained closed because there were not enough nursing assistants to cover both floor duties and dining room assistance. Additionally, the facility failed to provide individualized, meaningful activities for residents, leaving them bored and isolated. Residents reported spending most of their time in bed watching TV, with little to no engagement in activities they enjoyed. The lack of a restorative program further exacerbated the situation, as residents did not receive necessary exercises to maintain their range of motion and mobility. Staff acknowledged the absence of a restorative program and the overall staffing challenges, which affected the quality of care and services provided to residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the contracted Dietary Manager (DM) was certified and qualified for the position, which placed residents at risk of receiving unsafe dietary services. The facility's policy required that if a qualified dietician or other clinically qualified nutrition professional was not employed full-time, a DM of food and nutrition services who met the necessary qualifications would be employed. However, during an interview, Staff T, the DM, admitted they had not taken the certification test despite completing the course a long time ago. Furthermore, Staff A, the Administrator, acknowledged being aware since late September 2024 that Staff T was not certified and that the Registered Dietician was only part-time, providing no oversight to the DM.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that four residents were able to exercise their right to vote during the 2024 Presidential election. Resident 62, who has Parkinson's disease and depression, was not asked if they wanted to vote and expressed disappointment at not being able to participate. Resident 26, who has spinal stenosis and incomplete quadriplegia, completed their ballot but was unable to have it mailed despite asking staff for assistance. Resident 49, with chronic obstructive pulmonary disease and anxiety, was interested in voting but did not receive information on how to register or vote. Resident 8, who suffered a stroke and has diabetes, was unable to see their ballot and did not receive the necessary assistance to fill it out, leading to feelings of being cheated out of their rights. The facility lacked a structured process to support residents in exercising their voting rights. Staff H, the Activities Director, mentioned that the process involved including voter registration information in the resident newsletter and delivering ballots to some residents' rooms. However, Staff H admitted to forgetting to assist Resident 8 with reading their ballot and was unaware of any residents who did not vote. The Administrator, Staff A, acknowledged the absence of a formal process to ensure residents could vote and had relied on Staff H to manage this responsibility. This oversight resulted in several residents being unable to participate in the election, causing disappointment and frustration.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were informed about the State Long-Term Care Ombudsman program, which is an advocate for residents' rights in long-term care. This deficiency was identified through observations, interviews, and record reviews, revealing that five residents were not provided with accessible information about the ombudsman. The residents involved had various medical conditions, including dementia, stroke, multiple sclerosis, and Alzheimer's disease, with some having intact cognition while others had moderate cognitive impairments. During a Resident Council meeting, the residents expressed that they were unaware of what an ombudsman was, the services provided, or how to contact them. The facility's Activities Director admitted to not reviewing ombudsman information with the residents and was unaware of the ombudsman's role. The facility's Administrator stated that all staff were required to know about the ombudsman and how to direct residents to their advocate, indicating a lapse in staff training and communication regarding this requirement.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate allegations of abuse and neglect for six residents, placing them at risk for further harm. Resident 2, who had mild cognitive impairment, reported that an LPN refused to administer pain medication and was verbally abusive. The investigation conducted by the Senior Director of Nursing was incomplete, as it only included interviews with Resident 2 and their spouse, without interviewing other residents or staff to identify a pattern of abuse. Resident 62, diagnosed with Parkinson's Disease, reported not receiving an evening dose of medication, which led to increased tremors and anxiety. The investigation lacked an initial interview with the resident and failed to include interviews with other residents or staff. Similarly, Resident 38, who had chronic pain, filed a grievance against the same LPN for being rude and refusing pain medication. The investigation did not include interviews with other residents or staff to rule out abuse or neglect. Other residents, including Resident 4, 52, and 49, also reported incidents of abuse or neglect, such as rough handling and inappropriate behavior by staff. Investigations into these allegations were incomplete, as they did not include interviews with other residents or staff to substantiate or rule out abuse. The facility's failure to conduct thorough investigations and recognize patterns of abuse involving specific staff members highlights significant deficiencies in addressing and preventing abuse and neglect.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide individualized, meaningful activities for several residents, leading to risks of boredom, social isolation, and depression. Resident 5, diagnosed with multiple sclerosis and cerebellar ataxia, was observed to be consistently in bed watching TV without any activity supplies. Despite expressing interest in playing card games and going outside, Resident 5 reported that staff did not engage them in activities, and the Activities Director admitted to not having communicated with the resident or their representative about activity participation. Resident 14, with congestive heart failure, expressed a desire to participate in group activities such as bingo and crafts but reported that staff did not remind them of activity times. The resident was unable to read the small print on the activity schedule and stated that no one from the facility had interviewed them about their activity preferences. Similarly, Resident 51, who was cognitively intact, was observed sitting alone in a dark room and expressed feelings of loneliness and a lack of engagement in activities. Resident 41, with heart disease, dementia, and depression, was often found in bed or sitting by the nurse's station without participating in activities. The resident expressed interest in music and sports but was not informed about activity schedules. Staff members, including nursing assistants, were unaware of the activities happening in the facility and did not encourage residents to participate. The Activities Director acknowledged a lack of resources and communication with corporate support, while the Senior Director of Nursing and the Administrator recognized the broken system in place for resident activities.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement restorative nursing services programs for four residents, leading to a deficiency in maintaining or improving their range of motion (ROM) and mobility. Resident 5, diagnosed with Multiple Sclerosis and cerebellar ataxia, had no restorative nursing programs in place despite requiring assistance with activities of daily living (ADLs) and having impairments in both upper and lower extremities. The resident and their representative expressed concerns about the lack of therapy or exercises provided, indicating that the resident spent most of their time in bed without any form of exercise. Resident 9, who had suffered a stroke and had diabetes, also lacked a restorative nursing program despite having impairments in one side of their upper extremities and both sides of their lower extremities. The care plan noted a risk for contractures, but no preventative measures or treatments were implemented. The resident reported that while a splint was applied to their right hand, no stretching or ROM exercises were performed by the nursing assistants. Resident 19, with a traumatic brain injury and stroke, required assistance with ADLs and had impairments in both upper and lower extremities. Although the care plan indicated a need for ROM exercises during dressing and bathing, staff interviews revealed a lack of training and implementation of these exercises. Resident 50, who had diabetes and diabetic neuropathy, was given a home exercise program upon discharge from skilled therapy services but received no assistance from staff, making it challenging for them to perform the exercises independently. Staff interviews confirmed the absence of a restorative nursing program due to staffing issues, with no training provided to staff on performing ROM exercises.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure proper disposal of expired and/or discharged residents' medications in three medication storage rooms and did not secure a medication cart when left unsupervised. In the East Hall, a medication cart was observed unlocked and unattended by nursing staff, with visitors passing by, which violated the facility's policy requiring medication carts to be locked when not in use or under direct supervision. In the North Hall medication room, discontinued medications for expired residents were found mixed with active medications for current residents on a dusty countertop. Staff R, an LPN, was unaware of the process for returning or disposing of these medications. Similarly, in the East Hall medication room, bins contained expired and discontinued medications alongside newly delivered medications, with Staff J, an RN, also unaware of the proper disposal process, indicating a lack of adherence to the facility's medication storage policy. The [NAME] Hall medication room contained non-medical items such as a coffee maker and coffee supplies, alongside expired medications and unlabeled cigarette packs. Staff B, the Senior Director of Nursing, acknowledged the improper storage and disposal practices, noting that the medication rooms were not being checked regularly due to staffing issues. The facility's administrator confirmed the presence of expired medications and non-medical items in the medication rooms, which were not clean and did not comply with the facility's policies.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility administration failed to effectively manage the facility in compliance with state and federal regulatory requirements, leading to several deficiencies. The administration did not implement the abuse prohibition policy adequately, failing to address five of eight key components necessary for preventing and identifying abuse and neglect. This included not recognizing allegations communicated through grievances, not protecting residents, and not reporting or investigating allegations in a timely manner. Staff interviews revealed a broken system for reporting abuse/neglect, with grievances not being reviewed by the responsible parties, and staffing issues contributing to burnout among staff. Additionally, the facility failed to prevent avoidable accidents, as residents were not supervised properly, and safety measures were not enforced in designated smoking areas. The activities program was inadequate, failing to support residents' physical, mental, and psychosocial well-being, with nursing assistants not bringing residents to activities as expected. The facility also did not provide sufficient restorative nursing services to prevent a decline in residents' physical function. Staffing levels were insufficient to meet residents' needs, affecting dining services, restorative therapy, and overall quality of care, with reliance on expensive agency staff due to staffing challenges.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement effective infection control interventions for three residents, leading to a risk of cross-contamination and transmission of infectious diseases. Resident 320, diagnosed with colon cancer and Clostridioides difficile (C-Diff), was placed under contact precautions. However, staff failed to adhere to these precautions. A nursing assistant was observed removing personal protective equipment (PPE) and carrying it with bare hands to a soiled utility room without washing hands with soap and water, as required. Additionally, a hospice service provider did not dispose of PPE in the resident's room due to the absence of a trash can and used hand sanitizer instead of washing hands with soap and water. Resident 35, who had C-Diff, malnutrition, and severe sepsis, was also under contact precautions. Despite this, staff did not consistently follow hand hygiene protocols. During incontinent care, staff members were observed removing PPE and leaving the room without performing hand hygiene with soap and water. One staff member handled a package of wipes with ungloved hands and placed it on the resident's sink, further compromising infection control measures. Another staff member removed gloves and put on clean ones without washing hands, and a nursing assistant handled a resident's water jug with soiled gloves. Resident 19, with a spinal cord injury, dementia, and a bladder infection, required a urinary catheter. Staff providing care to this resident also failed to maintain proper hand hygiene. A nursing assistant was observed using soiled gloves to handle various items, including the resident's air mattress and clothing, without changing gloves or washing hands. Additionally, a registered nurse did not perform hand hygiene after removing gloves and before administering an intramuscular injection, further highlighting the facility's failure to adhere to infection control protocols.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a homelike dining experience by not allowing residents to eat in the dining room, which was closed since a COVID-19 outbreak. This affected four residents who expressed a preference to eat in the dining room. Observations from 11/13/2024 to 11/19/2024 showed no residents were provided meals in the dining room. Resident 9, with moderate cognitive impairment, expressed missing dining with friends. Resident 14, also with moderate cognitive impairment, was unsure why the dining room was unused and preferred to eat there. Resident 51, cognitively intact, was observed eating alone in their room and expressed loneliness. Resident 2, with mild cognitive impairment, stated a desire to socialize in the dining room but was restricted to eating in their room. Interviews with staff revealed the dining room closure was due to staffing shortages, preventing the facility from providing assistance in both the dining room and resident rooms. Staff MM, a Nursing Assistant, and Staff F, an LPN Unit Manager, confirmed the dining room had been closed since the COVID outbreak due to insufficient staff. Staff B, the Senior Director of Nursing, acknowledged the residents' right to choose to eat in the dining room and recognized the issue with their rights. The facility's inability to reopen the dining room due to staffing constraints led to the deficiency, impacting residents' socialization and dining preferences.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to return the balance of funds to the Office of Financial Recovery (OFR) for three residents who had expired, as required by state regulations. The policy titled 'Resident Funds' mandates that when a resident passes away, any remaining funds in their trust account must be refunded via check with a final accounting within 30 days of death. However, for Resident 232, Resident 60, and Resident 231, the funds were either sent to the Genesis Healthcare Abandoned/Unclaimed Property account or a check was made out to the resident with the facility address, all actions occurring beyond the 30-day requirement. Interviews with staff revealed a misunderstanding of the process for returning funds. Staff GG, the Business Office Manager, stated that they would wait 30 days for a State Recovery letter from the Department of Social and Health Services (DSHS) before taking action. If no letter was received, they would contact DSHS to verify if the funds needed to be returned. If not, the funds would be sent to the next of kin or Power of Attorney, or to the Genesis Healthcare Abandoned/Unclaimed Property account if no next of kin/POA was available. Staff A, the Administrator, acknowledged that the expectation was for the funds to be returned to the OFR within 30 days of a resident's death, indicating that the process was not followed as required.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure a resident's right to privacy, security, and confidentiality when a video/audio camera was placed in the room of a resident with chronic obstructive pulmonary disease and anxiety, who required substantial assistance for daily activities and had moderately impaired cognition. The camera was installed by the resident's representative without the resident's knowledge, and the facility's administrator did not obtain consent from the resident, despite acknowledging that the resident had moments of clarity. The camera, which had live streaming and recording capabilities, was placed to monitor the resident's care due to concerns about inadequate attention from staff. Staff members were aware of the camera's presence but expressed concerns about privacy for the resident and others, as the camera had audio and recording capabilities. Some staff members turned the camera away or covered it during care to maintain privacy. The administrator admitted to not being informed about the camera's installation and did not verify its capabilities. The lack of consent and awareness of the camera's presence by the resident and some staff members led to a breach of privacy and confidentiality, as the resident was not informed or asked for consent regarding the monitoring device.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a sanitary and homelike environment in several areas, including three shower rooms, a hall kitchenette, and multiple resident rooms. Observations revealed that the North Hall shower room had an overflowing trash can with soiled resident briefs, a mound of hard substance on the shower floor, and holes in the shower wall. The West Hall shower room had a torn rubber baseboard, a toilet with fecal matter, and a sink with crust and yellow substance. The East Hall shower room had a peeled rubber baseboard, exposed drywall, and debris. The East Hall kitchenette had a sink with standing water and food debris, and a cabinet covered in black-brown sludge. In the resident rooms, one bathroom had an overflowing trash can with soiled briefs, fecal matter on the toilet, and broken tiles with exposed debris. Another room had a wall with deep gouges and unpainted patches, while a third room had holes in the bathroom door and an unfitted toilet lid. Interviews with staff revealed that maintenance issues had not been addressed, and the areas were not considered homelike or in good condition. The Maintenance Director acknowledged the need for repairs and replacements, while the Infection Preventionist and Administrator were unaware of some of the issues. The facility's policy on Resident Rights Under Federal Law, revised in February 2023, states that residents have the right to a safe, clean, comfortable, and homelike environment. However, the observations and interviews indicate that the facility did not adhere to this policy, resulting in unsanitary and unpleasant living conditions for the residents. The staff's lack of awareness and failure to address maintenance issues contributed to the deficiencies observed during the survey.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a Level II comprehensive evaluation was obtained for a resident as required by the Pre-Admission Screening and Resident Review (PASARR) program. This deficiency was identified during a review of the medical records for a resident who was admitted with diagnoses including dementia, major depressive disorder (MDD), and post-traumatic stress disorder (PTSD). The resident's PASARR, updated in August 2024, indicated the need for a Level II evaluation due to serious mental disorder indicators, which was not completed or documented in the medical record. During an interview, the facility's administrator was unable to confirm whether the required Level II PASARR screening form had been referred for evaluation, as there was no determination found in the resident's medical record. This oversight placed the resident at risk of not receiving necessary mental health care and services, as the PASARR process is designed to ensure appropriate placement and care for individuals with mental health needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a baseline care plan within 48 hours of admission for four residents, as required by their policy. This deficiency was identified during a review of the facility's records and interviews with staff. The baseline care plan is essential for providing effective and person-centered care, and its absence placed residents at risk for unmet care needs and possible complications. Resident 62 was admitted with multiple diagnoses, including Parkinson's Disease, kidney failure, and pneumonia. Despite requiring substantial assistance for activities of daily living (ADLs) and having severely impaired cognition, the baseline care plan was not completed. Key elements such as ADLs, social services, psychotropic medication use, PASARR recommendations, dietary, and therapy orders were either delayed or missing from the care plan. Similarly, Resident 35, who was admitted with Clostridium Difficile, malnutrition, and severe sepsis, did not have social services documented in their care plan until six days post-admission. Resident 26, with heart failure, a seizure disorder, diabetes, and incomplete quadriplegia, lacked documentation on dietary orders in their baseline care plan. Resident 55, admitted with COPD, coronary artery aneurysm, and high blood pressure, had delays in documenting physician and dietary orders. The facility's administrator acknowledged the failure to follow the process for baseline care plans.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that staff responsible for providing cardiopulmonary resuscitation (CPR) had current CPR certification, as evidenced by two staff members, Staff C and Staff G, lacking up-to-date certification. This deficiency was identified during a review of the facility's policies and procedures, which required CPR-certified staff to be on duty at all times. The absence of current CPR certification for these staff members posed a risk of inadequate response during emergencies. The incident involved Resident 69, who was admitted with diagnoses including kidney failure, diabetes, and a stroke, and required partial/moderate assistance for activities of daily living. The resident's Portable Orders for Life-Sustaining Treatment (POLST) form indicated a wish for CPR in the event of cardiac arrest. On the day of the incident, Resident 69 was found unresponsive by Staff C, who then sought assistance from other staff members. There was a delay in initiating CPR, as it took approximately five minutes from the time the resident was found until CPR was started. Additionally, there was confusion and inconsistency in the documentation of the CPR/AED flow sheet, with discrepancies in the recorded times and personnel involved. Interviews with staff revealed a lack of clarity and adherence to the facility's emergency response procedures. Staff members reported that there was no overhead announcement of a code blue, and the process for recording events during the code was not followed. Staff JJ, who completed the flow sheet, did so based on information provided by others rather than direct observation. Furthermore, there was no post-code meeting to review the process, and the unexpected death of Resident 69 was not documented in the reporting log, nor was an investigation conducted as required by regulations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that dialysis services met professional standards of care for a resident with end-stage renal disease (ESRD) who required dialysis. The deficiency was identified through a review of the facility's policy and the resident's medical records, which revealed a lack of effective communication and coordination between the facility and the offsite dialysis center. Specifically, the facility did not maintain complete and accurate documentation of the resident's condition before and after dialysis sessions, as evidenced by 22 out of 50 incomplete communication forms. This lack of documentation placed the resident at risk for complications and unmet care needs. Interviews with facility staff highlighted the ongoing struggle to ensure that pre/post dialysis communication forms were completed and returned to the facility. The Unit Manager indicated that if the dialysis book containing the forms was not returned, nurses were expected to call the dialysis center to obtain the necessary information. However, the Senior Director of Nursing acknowledged the difficulty in consistently achieving this expectation, indicating a systemic issue in the communication process between the facility and the dialysis center.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide trauma-informed and culturally competent care for Resident 62, who was identified as a trauma survivor. Resident 62, admitted with diagnoses including Parkinson's Disease, kidney failure, and depression, had a history of trauma related to the deaths of their son and daughter-in-law. Despite this, the facility did not accurately assess, monitor, or incorporate the resident's trauma history and potential triggers into their care plan. The comprehensive care plan lacked focus areas, goals, interventions, or triggers related to the resident's trauma, which could lead to re-traumatization. Interviews with facility staff revealed a breakdown in the process for trauma-informed care. Staff B, the Senior Director of Nursing, acknowledged that the process involved social services completing an assessment and communicating findings with the nursing department. However, this process was not followed for Resident 62, as their trauma and triggers were not care planned or discussed in morning meetings. Staff A, the Administrator, confirmed that the facility's process for trauma-informed care was not adhered to, resulting in the failure to document and plan for the resident's identified trauma and triggers.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain registry verification to ensure that two staff members, Staff N and Staff OO, met competency evaluation requirements before allowing them to serve as nursing assistants. Staff N was hired on 09/23/2024, and Staff OO was hired on 05/20/2024, but neither had documentation of OBRA registry verification in their personnel files. This oversight was identified during interviews with Staff I, the Scheduler/NA responsible for maintaining accurate human resources files, and Staff A, the Administrator, who confirmed that the new hire process, which includes verifying OBRA registry status, was not followed for these staff members. This failure placed residents at risk for abuse, neglect, and unmet care needs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide meals that were palatable and served at an appetizing temperature for three residents. Resident 17, who had diabetes and cancer, reported that their meals were usually cold, and specifically mentioned that their pureed eggs were like ice. Resident 13, with diabetes, heart disease, and an absence of the left lower leg, stated that the facility's food was tasteless and never hot, leading them to rely on outside food deliveries. Resident 19, who had a traumatic brain injury and stroke, was observed with a breakfast tray containing cold coffee, eggs, and milk, which were confirmed to be below safe temperature ranges by the Dietary Manager. Observations of the facility's steam table and test trays revealed that both hot and cold foods were not maintained at safe temperatures. The steam table showed apple juice, milk, apple sauce, red baked potatoes, pureed chicken, and mashed potatoes all outside the safe temperature range. Similarly, a test tray showed pizza, broccoli, orange juice, and milk also not within safe temperature ranges. The Dietary Manager acknowledged that the foods were not within the acceptable temperature range and stated that the process for addressing this would be to reheat the food to a safe temperature.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor food preferences for two residents, leading to dissatisfaction with their dining experience. Resident 17, who has diabetes and cancer, requested eggs with gravy for every meal but reported that their meal trays were often returned to the kitchen due to unmet preferences. The resident's medical record lacked documentation of dietary preferences, and no Food Preference Interview assessment was completed. The care plan also did not list any dietary preferences, indicating a failure to document and accommodate the resident's specific requests. Resident 22, with a diagnosis of non-traumatic brain dysfunction and severely impaired cognition, was reported by their representative to prefer Japanese foods, yet the facility only provided American foods. The representative occasionally brought preferred foods for the resident. The resident's diet order did not document any preferences, and the last Food Preference Interview assessment was outdated, having been completed in 2021. The Dietary Manager acknowledged the process for updating dietary preferences was not consistently followed, contributing to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and maintain a current hospice plan of care (POC) in collaboration with contracted hospice services for Resident 17, who was receiving hospice care due to esophageal cancer. The facility's POC did not incorporate the hospice orders or input, which is a requirement to ensure the resident's highest practicable physical, mental, and psychosocial well-being. This oversight was identified during a review of the resident's medical records and the facility's policies. Resident 17 was admitted to the facility with a diagnosis of esophageal cancer and had moderately impaired cognition, requiring assistance from one to two staff members for activities of daily living. Despite being placed on hospice services, the facility's POC for Resident 17 was not tailored to the specific needs of hospice care. During an interview, the facility's administrator acknowledged that the process for integrating the hospice POC into the facility's POC was not followed for this resident.

Penalty

Fine: $11,81034 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary care and services for residents dependent on staff for assistance with activities of daily living (ADLs), specifically bathing and grooming. This deficiency was observed in five out of seven residents reviewed. The facility's policy required each resident to be assessed for the amount of assistance needed for ADLs, and their care plan should address how these services would be provided. However, the records showed that residents were not receiving adequate bathing assistance, with some residents receiving assistance only once or twice in a month, and others not at all. Resident 1, with moderate cognitive impairment, was observed with unkempt hair and facial hair growth, indicating a lack of grooming. Resident 2, who was cognitively intact, expressed dissatisfaction with the lack of bathing and grooming assistance, which they felt contributed to a persistent rash. Resident 3, also cognitively intact, reported not having received a shower since admission, citing insufficient staff as a reason for unmet care needs. Resident 4, with moderately impaired cognition, received bathing assistance only once in the month, and Resident 5, who was cognitively intact, received no bathing assistance before their discharge. Interviews with staff revealed consistent understaffing issues, particularly in the short-term rehabilitation halls, which affected their ability to provide basic care, including showers. Staff members acknowledged the importance of bathing for skin health and the role of nursing assistants in observing signs of skin breakdown during personal care. The facility's failure to provide adequate staffing and ensure proper documentation of care contributed to the deficiency in meeting residents' ADL needs.

Penalty

Fine: $11,81034 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly assess and monitor skin integrity concerns for a resident, leading to a deficiency in care. Resident 2, who was admitted with conditions including an amputation, cellulitis, and diabetes, developed an itchy rash on the trunk and arms. Despite being prescribed an antihistamine, there were no treatment or monitoring orders documented in the Treatment Administration Records (TARs) for the rash. Nursing progress notes indicated the rash persisted, but there was no follow-up with a facility medical provider as recommended by an emergency room evaluation. Interviews with staff revealed a lack of reassessment and communication with the medical provider regarding the ineffectiveness of the antihistamine treatment. Staff acknowledged that the resident should have been evaluated by a facility medical provider, as the rash continued for 38 days with little improvement. The interim administrator confirmed that follow-up on identified skin concerns was not being conducted properly, contributing to the deficiency in care for Resident 2.

Penalty

Fine: $11,81034 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly and accurately assess pressure-related skin impairments for Resident 4, as per professional standards of practice. Resident 4 was admitted with a history of aspiration pneumonia, muscle weakness, and falls, and had experienced an unwitnessed fall at home leading to rhabdomyolysis. This condition likely contributed to the development of several skin impairments, including a deep tissue injury on the right heel and unstageable pressure injuries on the left lower back and right upper back. However, the facility's admission assessment documented only the right heel and left lower back injuries, omitting the right upper back wound. The facility's Treatment Administration Records (TARs) for October 2024 showed a lack of treatment and monitoring orders for the identified skin impairments until 12 days after admission. This delay in initiating treatment and monitoring orders for the pressure injuries was a significant oversight. The initial consultation by a contracted wound provider later identified two wounds requiring treatment, including a Stage 4 pressure injury on the thoracic spine and an unstageable pressure injury on the left lumbar spine. Interviews with facility staff revealed gaps in the wound management process. Staff E, the RN-Wound Nurse Manager, returned from personal leave and initiated the wound management process for Resident 4, but was unsure who was responsible during their absence. Staff F, the LPN-Unit Manager, stated that the admission process required a complete and accurate skin assessment on the day of admission, but was unaware of any concerns regarding Resident 4. Staff H, the RN-MDS Coordinator, emphasized the importance of thorough and accurate skin assessments on admission to trigger appropriate follow-up, highlighting a breakdown in communication and responsibility among the staff.