Every finding on record at Avalon Care Center at Northpointe

Based on interview and record review, the facility failed to implement their Abuse and Neglect Prohibition Policies to include not reporting allegations of abuse to facility administration and the State Agency (SA) within the required timeframe, and completing thorough investigations, for 5 of 7 sampled residents (Resident 5, 38, 69, 117, and 131), reviewed for abuse/neglect. This failure placed the residents at risk for unidentified abuse/neglect. Findings included .Review of the facility's policies titled Preventing and Prohibiting Abuse and Abuse Reporting and Responsibilities of Covered Individuals, revised 09/13/2022, showed staff were to report alleged abuse to the facility administrator and SA immediately, but not later than two hours after the allegation was made if abuse was alleged and there was serious bodily injury. All other allegations were to be reported within 24 hours. Additionally, the facility would investigate the allegation and document evidence of the investigation.Review of a handwritten note by Staff G, Registered Nurse, dated 05/25/2026, showed that day Staff U and BB, Nursing Assistants (NA), had reported concerns with Staff CC, NA, to Staff G. The concerns included an allegation that Staff CC left the building at an unidentified time and did not provide care to multiple residents including Residents 5, 38, 69, 117, and 131 for an unidentified period. Additionally, it was alleged that Residents 5 and 117 were completely soaked and food debris from the prior day was under Resident 5. Per the note Resident 38 stated they fell and hurt their arm and reported the fall to Staff CC, which was not reported to the nurse. Review of the May and June 2026 facility incident logs showed no reported abuse allegations for Residents 5, 38, 69, 117, and/or 131 after 05/25/2026.In an interview on 06/23/2026 at 1:20 PM Staff B, Director of Nursing, stated the handwritten note by Staff G was placed under the door to their office, and they did not receive it until 05/26/2026. Staff B stated they followed up with Residents 5, 38, 69, 117, and 131 on 05/26/2026 and provided a handwritten note dated the same. The note did not address all the allegations listed by Staff G and did not include all the components of a thorough investigation. In an interview at 1:30 PM the same day, Staff A, Administrator, confirmed the abuse allegations in the handwritten note dated 05/25/2026 by Staff G were not investigated and reported as required. Reference WAC 388-97-0640(2)(a)(b)

Based on observation, interview, and record review, the facility failed to ensure that lorazepam liquid (a controlled anti-anxiety medication with potential for abuse) was monitored adequately to minimize risk of loss or diversion, in 2 of 3 medication rooms inspected (Med room [ROOM NUMBER] - East and Med room [ROOM NUMBER] - West). Additionally, the facility failed to discard 2 vials of an expired Tuberculin PPD (a solution injected under the skin to test for exposure to tuberculosis, a contagious respiratory disease) in 1 of 3 medication rooms inspected (Med room [ROOM NUMBER] - West). These failures placed the facility at risk of diversion of controlled medications and residents at risk of receiving expired test solution, inaccurate test results and possible adverse health consequences. Findings included. <Lorazepam> During an inspection of the Med room [ROOM NUMBER] -West on 05/28/2026 at 11:47 AM, Staff D, Registered Nurse (RN) opened the locked box in the medication refrigerator, which contained the following two medications:A bottle of lorazepam liquid (controlled substance used for anxiety) for Resident 8. There were markings on the side of the bottle, that showed the approximate amount remaining in the bottle. The level of liquid showed 28 milliliters (ml, a unit of measurement) remaining in the bottle. Another bottle of lorazepam liquid for Resident 35, with approximately 8 ml remaining in the bottle. During a concurrent interview, Staff D stated that two nurses counted the controlled medications at every change of shift. The nurse coming on-shift would look at the medications in the locked drawer of the medication cart, then tell the nurse going off-shift the page number that the medication was in the narcotic book. Together they would verify the amount of medication remaining and matched the count in the book. When the narcotic book was reviewed, the lorazepam remaining for Resident 8 was documented as 29.5 ml (Staff D and this surveyor observed 28 ml.) The lorazepam remaining for Resident 35 was documented as 13.2 ml (Staff D and this surveyor observed 8 ml). Staff D stated, that is a problem. They stated they were unaware the lorazepam was in the refrigerator, had never included them in the count, nor had any nurse they counted with mentioned checking the refrigerator. Staff D stated, I will be doing that from now on. During an interview on 05/28/2026 at 12:20 PM, Staff V, RN, stated that during the medication count at shift change, they also had to count the refrigerated medications and wished there was a better way to remember that. During an inspection of Med room [ROOM NUMBER] -East on 05/28/2026 at 12:39 PM, Staff Y, RN, opened the locked box in the medication refrigerator, which contained four bottles of lorazepam liquid. Two of the bottles were labeled for a current resident and were counted every shift. The amount remaining for these bottles matched the narcotic book. The other 2 bottles were both unopened with an intact seal, and the labels read Omnicell (an automated, secure medication dispensing machine, that staff accessed medications with a secure code.) During a concurrent interview, Staff Y stated when the nurses count the controlled medications at shift change, they should go page by page through the narcotic book, so nothing was missed (like medications locked in the refrigerator). Staff Y stated that since the 2 bottles of lorazepam labeled Omnicell were not assigned to any resident, they were not included in the change of shift count, instead they were counted monthly with the pharmacy staff. When asked if a staff took the Omnicell lorazepam when accessing the same lockbox as resident medications, how would anyone know, if it was only counted once a month? Staff Y responded that is a good question. I understand why it is a concern. During an interview on 05/28/2026 at 2:08 PM, Staff I, Unit Manager, stated they had been informed by Staff D of the discrepancy of the amounts remaining of the lorazepam and that it had not been included in the change of shift count. Staff I stated they had informed Staff B, Director of Nursing (DON), and they were following up on it. Staff I was informed of the inspection of the Med room [ROOM NUMBER] - East findings with the Omnicell lorazepam and interview with Staff Y. Staff I acknowledged that all controlled substances needed to be counted during shift change to avoid diversion. During an interview on 05/28/2026 at 3:11 PM, Staff A, Administrator, and Staff B, DON, acknowledged that the lorazepam liquid should have been counted every shifty to minimize the risk of diversion and identify any discrepancies quickly. <Tuberculin PPD>During an inspection of the Med room [ROOM NUMBER] -West on 05/28/2026 at 11:27 AM with Staff Z, Unit Manager, two Tuberculin Purified Protein Derivative (PPD a medication used to detect a tuberculosis infection) vials were observed in the medication refrigerator. One vial was opened on 03/11/2026 (over two months ago) and the other was opened on 02/08/2026 (over three months ago). According to the 11/09/2020 Food and Drug Administration Tuberculin PPD package insert, https://www.fda.gov/media/74866/download, opened multi-dose PPD vials must be discarded 30 days after the initial puncture or after their expiration date. During an interview on 05/28/2026 at 3:39 PM, Staff B stated the Tuberculin PPD testing solution should be discarded 30 days after it is opened and it should have been discarded. Reference: WAC 388-97- 1300(2)

Based on observation, interview and record review, the facility failed to ensure staff implemented Enhanced Barrier Precautions (EBP, use of gowns and gloves during high contact resident care activities) during 3 of 5 resident care observations (Resident 112, 144, 15) and failed to ensure gloves were worn during an insulin injection for 1 of 3 medication administration observations. These failures placed residents and staff at risk of spreading infectious bacteria, and exposure to blood or body fluids.Findings included. The Centers for Disease Control (CDC) 04/02/2024 Implementation of Personal Protective Equipment (PPE, gloves, disposable gowns, eye protection or masks, for example) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/ppe.html recommended the use of EBP as an infection control intervention. EBP recommended the use of gowns and gloves during high contact resident care activities when other types of precautions did not apply for residents with wounds and/or indwelling medical devices. High contact care activities included dressing, bathing/showering, transferring, changing linens, providing hygiene, wound care, assisting with toileting and device care that included central intravenous (IV) lines, urinary catheters, and feeding tubes. <Tube Feeding Flush> Review of the 04/14/2026 admission comprehensive assessment documented Resident 112 had diagnoses that included stroke from a bleed into the brain, inability to move the right side of the body and difficulty swallowing. Resident 112 was severely cognitively impaired, had a urinary catheter (a catheter inserted into the bladder that allowed urine to drain) and received greater than 51% of their nutrition via a gastrostomy tube (g-tube, a feeding tube inserted surgically through the abdomen into the stomach that allowed safe delivery of nutrition.) Resident 112 was dependent on staff for most of their activities of daily living. The 04/13/2026 provider order instructed staff to use EBP when caring for Resident 112 related to their urinary catheter and their feeding tube. On 05/20/2026 at 11:32 AM, Resident 112 was observed lying in bed. A urinary catheter collection bag was hung on the bedframe, and a tube-feeding pole was next to the head of the bed. An orange CDC EBP sign hung on the door at the entrance to the resident's room. It had a picture of two red stop signs at the top, and instructed staff to clean their hands before entering and when leaving the room, and instructed staff to wear a gown and gloves (PPE) for high contact resident care activities that included care or use of central lines, urinary catheters, and feeding tubes. A plastic bin that contained gowns and gloves and other PPE was also at the entrance. On 05/21/2026 at 9:02 AM, Resident 112's g-tube was observed being flushed with water with Staff S, Licensed Practical Nurse (LPN). Resident 112 was lying in bed and Staff S put on gloves and exposed Resident 112's g-tube on their abdomen. A large plastic syringe was filled with tap water and injected into a port on the g-tube. After Staff S replaced the residents gown and covers, they removed their gloves, washed their hands, and exited the resident's room. At this time, the signage on the door was reviewed with Staff S. Staff S stated they were not aware they were to wear a gown when flushing the resident's g-tube; they thought the gown was worn for more in-depth care. <Antibiotic Administration via a Central IV Line> Review of the 05/18/2026 comprehensive admission assessment documented Resident 144 had diagnoses that included bacteremia (blood infection) and Streptococcal arthritis (inflammation of a joint from a Streptococcus bacterial infection) of the left hip. Resident 144 was mildly cognitively impaired and received antibiotics daily. The 05/15/2026 care plan documented Resident 144 required antibiotics via a peripherally inserted central catheter (PICC, a long flexible tube inserted into a large vein in the neck, chest or arm and advanced until the tip rests near the heart; also known as a central line) for their Streptococcal arthritis. On 05/15/2026, an order was given to administer cefazolin (an antibiotic) via the PICC three times daily. On 05/18/2026 at 3:16 PM, Resident 144 was observed resting on top of his bed. A CDC EBP sign was hung on the door, and a bin of PPE was right inside the door. A central line was observed on Resident 144's chest inserted just under the collar bone and was covered in a transparent dressing. The insertion site was visible and had no visible signs of infection or redness. Resident 144 stated they had the central line for about two months. On 05/26/2026 at 8:36 AM, Staff Q, LPN, was observed administering medications to Resident 144. Staff Q had prepared the medications at the medication cart then entered Resident 144's room. Staff Q put on a pair of gloves. After Resident 144 took their oral medications, Staff Q hung a bag of IV antibiotics on a pole, inserted the tubing in the pump, used an alcohol swab to clean the ends of the central line, and connected the antibiotic tubing to the central line and started the infusion. Staff Q then removed their gloves, washed their hands and exited the room. Staff Q stated they had received education regarding EBP and staff knew who needed EBP by hearing in morning report, or by seeing the signage on the door. Staff Q reviewed the EBP signage outside the residents door and stated they should have put on a gown when administering the antibiotic in the central line. During an interview on 05/28/2026 at 1:20 PM, Staff F, Resident Care Manager, stated staff were expected to wear gowns for those residents requiring EBP. The gowns protected staff from spreading bacteria to other residents and helped prevent infections. <Insulin injection> In an observation on 05/26/2026 at 6:46 AM, Staff X, LPN, entered Resident 7's room to administer an insulin injection. Staff X sanitized their hands, cleansed Resident 7's abdomen with an alcohol wipe and gave the injection. Staff X did not wear gloves as required for the injection. In an interview on 05/26/2026 at 7:59 AM, Staff X stated gloves needed to be worn when having direct contact with bodily fluids and it was important to prevent the spread of infection. <Catheter care> In an observation on 05/22/2026 at 1:16 PM, Staff W, Nursing Assistant (NA), entered Resident 15's room to empty their suprapubic catheter (a flexible tube inserted directly into the bladder used to drain urine). Staff W put on a pair of gloves and emptied Resident 15's catheter, no gown was worn as required. In an interview on 05/22/2026 at 1:20 PM, Staff W pointed to the enhanced barrier sign outside of Resident 15's room and stated they should have worn a gown. Staff W stated it was important to wear a gown for infection control. In an observation on 05/27/2026 at 12:28 PM, Staff T, NA, entered Resident 15's room to cleanse their suprapubic catheter. Staff T put on a pair of gloves and wiped the area surrounding the catheter with a sanitizing wipe. Staff T did not wear a gown as required. In an interview on 05/27/2026 at 12:28 PM, Staff T stated they should have worn a gown and it was important to prevent the spread of germs. In an interview on 05/28/2026 at 2:32 PM, Staff C, Infection Preventionist, stated that staff not wearing gloves during insulin injections put them at risk for blood exposure and the residents at risk for germs. Staff C stated their expectation was for staff to wear gowns when caring for residents with drains and tubes. Reference: WAC 388-97-1320, 1620(2)(b)(i)(ii)

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment for 1 of 3 units (Unit 1 - North Unit), observed for environment. This failure resulted in residents being unable to have a clear view to the outside through several windows. Findings included.During an interview on 05/19/2026 at 1:05 PM, the resident council stated the facility did not clean the windows, they were too dirty and unable to see outside.During observation on 05/21/2026 at 9:12 AM, on Unit 1 - North Unit, both windows in room [ROOM NUMBER] had a white film, similar to hard water residue (chalk, white mineral spots), on the outside of the windows which made the whole window blurry to look out of. During observation and interview with Resident 78 on 05/21/2026 at 11:16 AM, the windows in their room (310) were observed. Resident 78 stated the windows had been blurry with a white film on the outside since they admitted in mid-April 2026 and they were unsure if housekeeping cleaned them. Similar observations were made on 05/21/2026 at 2:04 PM, and 3:23 PM, on 05/22/2026 at 9:10 AM and 11:42 AM, on 05/26/2026 at 5:17 AM, and on 05/27/2026 at 9:50 AM. During observations on 05/21/2026 at 10:13 AM, five out of eight windows on the Unit 1 - North Unit, the common television room had a white film on the outside which made the windows blurry to look out of. Similar observations were made on 05/21/2026 at 2:06 PM and 3:24 PM, on 05/22/2026 at 11:43 AM, on 05/26/2026 at 4:53 AM and 6:36 AM, and on 05/27/2026 at 9:51 AM.During observation on 05/21/2026 at 10:15 AM, the windows in room [ROOM NUMBER] had a white film on them, which made the whole window blurry to look out of. Similar observations were made at 2:04 PM and 3:24 PM, on 05/22/2026 at 9:11 AM and 11:44 AM, on 05/26/2026 at 4:51 AM, and on 05/27/2026 at 9:50 AM. During observation and interview on 05/27/2026 at 9:54 AM, Staff J, Nursing Assistant, stated the housekeepers cleaned residents' room daily, including the windows in the rooms. Staff J observed the windows in room [ROOM NUMBER]. Staff J acknowledged the windows had a white film on them that made it difficult to look out of. Staff J was unsure how long the windows were in that condition.During observation and interview on 05/27/2026 at 10:06 AM, Staff K, Housekeeper, stated the facility was full service and cleaned whatever needed to be cleaned, including the inside windows. Staff K observed the windows in room [ROOM NUMBER]. Staff K acknowledged many windows along the Unit 1 - North Unit of the 300 unit had a hard water film on them from the sprinkler water hitting the windows. Staff K further stated they attempted to clean the outside windows once, but it was difficult and were only able to clean a small corner of one window. Staff K was unsure if professional cleaning had been scheduled.During observation and interview on 05/27/2026 at 10:17 AM, with Staff L, Maintenance Director, the windows in rooms [ROOM NUMBERS] were observed. Staff L acknowledged the windows had a hard water film on them that made them blurry to look out of caused by the sprinkler water hitting the windows along the North side of the building.During an interview on 05/28/2026 at 12:23 PM, Staff A, Administrator, acknowledged windows on the Unit 1 - North Unit side of the facility had a hard water film on them that made them blurry to look out of. Staff A stated they expected staff to maintain a clean, comfortable, and home-like environment.Reference WAC 388-97-1060 (1)-(3)

Based on observation, interview and record review, the facility failed to ensure medications were administered as ordered for 2 of 5 sampled residents (Residents 5 and 11) reviewed for medication administration. Specifically, medications were not held or administered when indicated, according to parameters ordered by the provider. This failure placed residents at risk for adverse health complications and diminished quality of life. Findings included. <Resident 5> A quarterly assessment, dated 03/31/2026, documented that Resident 5 had diagnoses of heart failure and high blood pressure. The resident was alert and made their needs known. Resident 5 had the following blood pressure medication orders: Lisinopril daily, hold for systolic blood pressure (SBP, the top number of a blood pressure reading) less than 110 or heart rate (HR) less than 60 beats per minute. Metoprolol ER (extended release) daily, hold for SBP less than 110 or HR less than 60. A review of the residents April and May 2026, Medication Administration Record (MAR) documented that the Lisinopril and Metoprolol ER was given three times outside of the ordered parameters. On 04/18/2026, the HR was 57 and both medications were given. On 04/23/2026, the HR was 56 and both medications were given. On 05/18/2026, the HR was 57 and both medications were given. The MAR showed the Lisinopril and Metoprolol ER medications were not held when the HR was less than 60. There was not documentation in the residents medical chart on those dates that showed why the medications were given outside the ordered parameters. During an interview on 05/27/2026 at 9:08 AM, Staff G, Registered Nurse (RN) stated that medications should not be given if the vital signs (VS, which included the BP and HR) were outside of the parameters. Staff G stated if the reading was close, they would recheck the BP or HR, and document the result in an additional note, along with why they gave the medication. During an interview on 05/27/2026 at 3:03 PM, Staff H, RN, stated that on evening shift, they would obtain a recent set of VS to determine if a medication should be given or held. During an interview on 05/27/2026 at 3:30 PM, Staff I, Unit Manager, stated that if VS are outside of parameters to administer a medication, the nurse should manually check the results themselves. If the recheck was within the parameters to give the medication, the nurse should add a note with the repeated result that showed why it was given. Staff I stated medications should not be given if their VS were outside of the ordered parameters. During an interview on 05/28/2026 at 3:11 PM, both Staff A, Administrator, and Staff B, Director of Nursing acknowledged that the blood pressure medications for Resident 5 should not have been given when the VS were outside of the ordered parameters. <Resident 11> The 03/12/2026 quarterly assessment documented Resident 11 had diagnoses that included high blood pressure and dementia. Resident 11 had moderate cognitive impairments. Resident 11 had the following medication orders: 1. Clonidine daily for high blood pressure, hold for SBP less than 110 or HR less than 60. 2. Hydralazine three times a day for high blood pressure, hold for SBP less than 110 or HR less than 60. 3. Losartan Potassium twice daily for high blood pressure, hold for SBP less than 110 and HR less than 60. A review of the residents April 2026 MAR documented that the Clonidine, Hydralazine and Losartan Potassium was given seven times outside of the ordered parameters. On 04/29/2026, the SBP was less than 110 and the HR was less than 60 and Clonidine was given. On 04/20/2026 and 04/23/2026 when the HR was less than 60, Hydralazine was given. On 04/03/2026 and 04/08/2026, Losartan Potassium was not given when the SBP and HR were above the ordered parameters. On 04/23/2026 the HR was less than 60 and the Losartan Potassium was given. On 04/29/2026 when the SBP was less than 110 and the HR was less than 60, Losartan Potassium was given The MAR showed the Lisinopril and Metoprolol ER medications were not held when the HR was les than 60. In an interview on 05/27/2026 at 12:15 PM, Staff V, Registered Nurse, stated Resident 11 had blood pressure parameters in place and medications were provided based on the residents blood pressure and pulse. In an interview on 05/28/2026 at 10:49 AM, Staff B stated Resident 11 should have received their medications per the provider ordered parameters. Staff B stated this was important to prevent cardiac complications. Reference: WAC 388-97-1060(3)(k)(iii)

Based on observation, interview, and record review, the facility failed to implement interventions to prevent weight loss for 2 of 8 sampled residents (Residents 11 and 62) reviewed for nutrition. This failure resulted in the residents being at risk for further weight loss and a decline in their health. Findings included .<Resident 11>The 12/05/2025 revised nutrition care plan stated Resident 11 had the potential for nutritional problems related to their history of malnutrition and dementia. The care plan did not instruct nursing staff on what to do for poor intake at meals.The 03/12/2026 quarterly assessment documented Resident 11 had diagnoses that included dementia and malnutrition. Resident 11 had moderate cognitive impairments and was able to make their needs known. A review of Resident 11's weights showed the following:-11/19/2025: 214.2 Pounds (lbs.)-02/18/2026: 207.1 lbs.-04/04/2026: 205.4 lbs.-05/04/2026: 197.8 lbs. The residents weight records showed a 3.7% loss in one month, a 4.49% loss in three months and a 7.66% loss in six months.Resident 11's meal intake was reviewed from 04/21/2026 through 05/20/2026 and showed the following:-0-25% was consumed for 21 meals-26-50% was consumed for 13 meals-51-75% was consumed for 17 meals-76-100% was consumed for 26 mealsIn an observation and interview on 05/18/2026 at 3:36 PM, Resident 11 was sitting on their bed. Resident 11 stated the food was below average and lacked flavor. In a continuous observation on 05/22/2026 from 12:09 PM to 1:30 PM, Resident 11 was sitting on their bed, and their lunch tray was in front of them. At 12:29 PM, an unidentified nursing assistant (NA) entered Resident 11's room and asked them if they wanted to drink their cranberry juice and the resident declined. Resident 11 did not consume any of their meal and unidentified NA removed the tray. Resident 11 was not offered anything else to eat. The unidentified NA did not notify the nurse of Resident 11's refusal to consume their meal. At 1:30 PM, Resident 11 was not offered an alternate meal or a nutritional supplement. The meal intake record for Resident 11 showed they ate 26-50% of their lunch meal on 05/22/2026. During a continuous observation on 05/27/2026 from 11:45 AM to 1:35 PM, Resident 11 received their lunch and stated they were not going to eat it. At 12:22 PM, an unidentified NA entered Resident 11's room and picked up their untouched meal tray and the resident was not offered anything else to eat. The unidentified NA did not notify the nurse of Resident 11's refusal to consume their meal. At 1:35 PM, Resident 11 was not offered an alternate meal or a nutritional supplement. <Resident 62>The 05/11/2026 quarterly assessment documented Resident 62 had diagnoses that included diabetes, depression and malnutrition. Resident 62 was cognitively intact and able to make their needs known. The 02/06/2020 nutrition care plan stated Resident 62 had potential for nutritional problems due to diabetes, heart failure, history of malnutrition and swallowing difficulty. The care plan did not instruct nursing staff on what to do for poor intake at meals.A review of Resident 11's weights showed the following:-11/19/2025: 138.6 lbs.-02/03/2026: 142.2 lbs.-04/15/2026: 130.2 lbs.-05/04/2026: 117.2 lbs.A 9.98% loss in one month, 17.58% loss in three months and a 15.44% loss in six months. Resident 62's meal intake was reviewed from 04/27/2026 through 05/25/2026 and showed the following:-0-25% was consumed for no meals-26-50% was consumed for four meals-51-75% was consumed for 45 meals-76-100% was consumed for 36 mealsDuring an interview on 05/18/2026 at 3:15 PM, Resident 62 was sitting in their wheelchair. Resident 62 stated they were losing weight because they did not like the food.In a continuous observation on 05/21/2025 from 9:14 AM to 2:07 PM, Resident 62's meal tray was on their tray table. Resident 62 ate three quarters of their oatmeal, none of their French toast or bacon. At 10:48 AM, Resident 62 was not offered anything else to eat or a nutritional supplement. At 12:00 PM Resident 62 was in their wheelchair eating lunch. The resident was served beef with gravy, rice, Brussel sprouts and lemonade cake. At 12:31 PM, an unidentified NA entered Resident 62's room and asked if they had finished eating and removed the meal tray. Resident 62 ate approximately 30% of their rice and nothing else. Resident 62 was not offered an alternate meal or supplement. At 2:07 PM, Resident 62 had not been offered an alternate meal or nutritional supplement. The meal intake record for Resident 62 showed they ate 76-100% of their breakfast and lunch. In a continuous observation on 05/22/2026 from 12:09 PM to 12:41 PM, Resident 62 was eating their lunch. The resident was served cod, potatoes and green beans. At 12:41 PM, Resident 62 put their meal tray in the cart, and an unidentified NA observed the meal tray. Resident 11 consumed their potatoes, a quarter of their fish and no green beans. Resident 42 was not offered an alternate meal or a nutritional supplement. In a continuous observation on 05/26/2026 from 8:04 AM to 9:30 AM, Resident 62 was sitting in their wheelchair eating breakfast. The resident was served oatmeal, sausage, and a muffin. At 8:36 AM Resident 62 brought their meal tray to an unidentified NA. Resident 62 consumed only oatmeal and was not offered an alternate meal or nutritional supplement. The nurse was not notified of Resident 62's poor intake. At 9:30 AM, Resident 42 had not been offered anything else to eat or a nutritional supplement. The meal intake record for Resident 62 showed they ate 76-100% of their breakfast. In a continuous observation on 05/27/2026 from 11:48 AM to 1:45 PM, Resident 62 was sitting in their wheelchair having lunch. The resident was served pasta, meatballs, vegetables and cake. At 12:26 PM, Resident 62 ate approximately 30% of their lunch. An unidentified NA removed the tray and Resident 62 was not offered anything else to eat or a nutritional supplement. The nurse was not notified of Resident 62's poor intake. At 1:45 PM, Resident 62 had not been offered an alternate meal or a nutritional supplement. The meal intake record for Resident 62 showed they ate 76-100% of their lunch. In an observation on 05/28/2026 at 11:33 AM, Resident 62 was asleep in their recliner. Resident 62's breakfast tray was on the tray table. Resident 62 was served a bowl of oatmeal, French toast and bacon. Resident 62 only consumed the oatmeal. The meal intake record for Resident 62 showed they ate 50-75% of their breakfast. In an interview on 05/27/2026 at 12:06 PM, Staff U, NA, stated they reported poor meal intake to the nurse. Staff U stated Resident 11 ate approximately 51-76% of their meals. Staff U stated Resident 11 had a banana for breakfast and picked what they wanted to eat. In an interview on 05/27/2026 at 2:26 PM, Staff AA, NA, stated when meal trays were picked up, the amount of food consumed was documented in the resident's record. Staff AA stated poor meal intake was reported to the nurse and residents were encouraged to eat. Staff AA stated Resident 62's meal intake was variable and at times they did not like the food. In an interview on 05/28/2026 at 10:21 AM, Staff I, Resident Care Manager, stated the expectation was for nursing assistants to notify the nurse of poor meal intake and to offer an alternate meal. In an interview on 05/28/2026 at 10:28 AM, Staff B, Director of Nursing, stated when residents had poor meal intake the nursing assistants were to notify the nurse, and a note was made in the resident's record. Staff B stated they reviewed the 24-hour report and concerns were discussed with the interdisciplinary team. The team contacted the Registered Dietician and provider. Staff B stated their expectation was for residents to be offered an alternate meal and if they declined, a nutritional supplement was to be provided. Staff B added their expectation was nursing staff would document the amount of meals consumed accurately and this was important to ensure the residents were getting the proper nutrition and for their overall health. Reference: WAC 388-97- 1060(3)(h)

Based on observation, interview and record review, the facility failed to ensure a resident was evaluated to safely self-administer their medication for 1 of 6 sampled residents (Resident 3) reviewed for medication administration. This failure placed the resident at risk for unintended health consequences.Findings included.A quarterly assessment, dated 05/01/2026, documented that Resident 3 had diagnoses of Chronic Obstructive Pulmonary Disease (COPD, a lung condition), chronic pain and constipation. The resident was alert, oriented and made their needs known. During an interview and observation on 05/19/2026 at 1:09 PM, Resident 3 stated they had some problems with constipation, but bought some stool softeners from Amazon and had no further issues since starting them. Resident 3 stated they were not sure if facility staff were aware, but since the medication was over the counter, it should be fine. The resident stated they also took their Lactaid (Lactase, an enzyme that helps to break down lactose in dairy products) from the bedside, because it took a long time to get it from the nurses. The resident stated the stool softeners were kept in their nightstand drawer and their Lactaid packets were observed on their bedside table.During an interview and observation on 05/27/2026 at 8:55 AM, Resident 3 stated that they took Lactase every time they ate dairy, nearly every day, but had not needed the stool softener for a couple of months. The top drawer of their nightstand was partially opened with a bottle of Tums (an antacid) visible. Resident 3 reported that they did not inform staff when they took the Lactaid and staff were aware, but acknowledged staff may not have been aware they took the stool softeners. Review of the Medication Administration Record (MAR) for May 2026 showed Resident 3 had numerous medications that could be given if needed for constipation and none were marked as given. The MAR also showed an order for Lactase, three tablets every eight hours if needed for lactose intolerance. No doses were marked as given. There was no provider order that showed the resident could take their own medications, nor any order for Tums was found.As of the morning of 05/27/2026, there was no evaluation of Resident 3s ability to self administer medication found in their medical record and their care plan did not show they were authorized to administer their own medications. During an interview on 05/27/2026 at 3:03 PM, Staff H, Registered Nurse, stated that the facility would need a provider order for a resident to take their own medications. There were no residents authorized to take on their own medication and facility staff needed to administer them. During an interview on 05/27/2026 at 3:30 PM, Staff I, Unit Manager stated that in order for a resident to self-administer their medications, they required a doctor's order. Next, they needed an evaluation to determine if they were able to safely and responsibly take the medication on their own. When informed about the interview and observations of Resident 3's medication in their room. Staff I stated they would immediately ask the resident about it, talk to the doctor and do an evaluation. Staff I confirmed that Resident 3 should not have medications at the bedside without the evaluation and order from their doctor. During an interview on 05/28/2026 at 3:11 PM, both Staff A, Administrator and Staff B, Director of Nursing acknowledged that Resident 3 should have been evaluated for safety to administer their medications and that a provider order should have been obtained.Reference: WAC 388-97-1060 (3)(l)

Based on interview and record review, the facility failed to ensure Pre-admission Screening and Resident Review (PASRR) Level II evaluations were completed timely for 1 of 5 sampled residents (Resident 7) reviewed for PASRR. This failure placed the resident at risk for unmet care needs and a decline in condition. Findings included .According to a 04/30/2026 annual assessment, Resident 7 was cognitively intact and had diagnoses that included depression (a mood disorder that caused a persistent feeling of sadness and loss of interest) and bipolar disorder (a mental health condition that caused extreme, unusual shifts in mood, energy, activity levels, and concentration). Review of Resident 7's medical record showed a PASRR Level I (screening tool to determine if a resident required further evaluation for serious mental illness or intellectual disability) was completed prior to admission on [DATE] that indicated no Level II evaluation (evaluation that identified any specialized services the resident required) was needed as Resident 7 did not have a diagnosis of serious mental illness at that time. Further record review indicated that Resident 7 was diagnosed with bipolar disorder on 11/20/2025 and depression on 12/24/2025 which would require a PASRR Level II evaluation to be completed. No documentation of a PASRR Level II was found in the resident's electronic record and no information was provided. In an interview on 05/26/2026 at 11:33 AM, Staff D, Social Services Director, confirmed that no PASRR Level II was completed for Resident 7 as required. Staff D further stated that a PASRR Level II was important to complete so the facility could care plan to address mental health issues for the resident. In an interview on 05/28/2026 at 11:24 AM, Staff A, Administrator, and Staff B, Director of Nursing, stated a PASRR Level II was expected to be completed when a resident had a diagnosis of serious mental illness. Reference: WAC 388-97-1915(4)

Based on observation, interview and record review, the facility failed to revise comprehensive care plans for 1 of 3 sampled residents (Resident 65) whose care plan was reviewed for accident hazards. This failure placed the resident at risk for burns and a diminished quality of life. Findings included . The 02/27/2026 quarterly assessment documented Resident 65 had diagnoses that included dementia and weakness. The resident had severe cognitive impairments and required set up assistance for meals.The 11/27/2024 care plan documented Resident 65 had an activity of daily living self-care performance deficit related to weakness, loss of balance and deconditioning. The interventions were for Resident 65 to eat in the hallway close to the nurse's station and to provide set up assistance for eating. In an observation on 05/18/2026 at 1:16 PM, Resident 65 was sitting in their wheelchair across from the nurse's station. The resident was holding a mug of coffee in their hand, and their hand was very shaky. Resident 65 stated their pants were soaked and they spilled every cup of coffee they were given. Resident 65's shirt and pants were visibly soiled with coffee. Resident 65 denied burns and discomfort.In an observation on 05/21/2026 at 9:00 AM, Resident 65 was sitting in their wheelchair across from the nurse's station with their breakfast tray in front of them. Resident 65 had a coffee mug in their hand and was having difficulty consuming the coffee due to the shakiness of their hand. In an observation on 05/26/2026 at 12:05 PM, Resident 65 was sitting in their wheelchair. Resident 65 had coffee in a mug and was having difficulty holding it due to their hand being shaky. In an interview on 05/27/2026 at 12:38 PM, Staff T, Nursing Assistant (NA), stated when a resident was having difficulty holding their cups, they notified the nurse and kitchen to get adaptive equipment. Staff T stated Resident 65 had been having difficulty holding their cups and were given spout cups (cups with lids that prevented fluids from spilling) to consume their fluids. Staff T stated the spout cups were not on the Kardex (a part of the residents' care plan that NAs used to provide care). In an interview on 05/27/2026 at 12:45 PM, Staff G, Registered Nurse, stated Resident 65's hands were shaky and they were given a cup with a lid. Staff G stated the cup with the lid needed to be on the care plan so staff were aware, otherwise they would not know if the cup was to be used. In an interview on 05/26/2026 at 11:07 AM, Staff B, Director of Nursing, stated they were unaware Resident 65 was having difficulty holding their cups. Staff B stated there was no adaptive equipment on the resident's care plan. Staff B stated a hot beverage assessment was completed upon admission, quarterly and with changes in condition. Staff B stated Resident 65 should have had an assessment and adaptive equipment added to their care plan. Staff B stated this was important to ensure no injuries occurred. Reference: WAC 388-97-1020(2)(c)(d)

Based on observation, interview and record review, the facility failed to ensure a peripherally inserted central catheter (PICC, a long flexible intravenous [IV] tube inserted into a vein that was advanced to a large vein near the heart, also called a central line) was maintained as ordered for 1 of 1 sampled residents (Resident 144) reviewed for antibiotic use. Additionally, the bowel management protocol was not implemented when indicated for 1 of 5 sampled residents (Resident 11) reviewed for medication regimen reviews. These failures placed the residents at risk of unintended health consequences and decreased quality of life. Findings included. The Omnicare Central Vascular Access Devices pharmacy policy revised 06/01/2024 documented the catheter insertion site was a potential entry site for bacteria that may cause a catheter-related infection. Sterile dressing changes with a transparent dressing (one that allowed the insertion site to be visualized and protected the catheter) were to be completed on admission, at least weekly, or if the dressing had become wet, loose or soiled. If the transparent dressing was clean, dry, intact and dated, the admission dressing change was able to be omitted and scheduled for seven days from the date on the dressing. Chlorhexidine gluconate (CHG, an antiseptic that killed bacteria) saturated antimicrobial discs were to be placed, with a provider order, under the transparent dressing. Needleless connectors (caps attached at the end of the catheter where tubing or needleless syringes screwed on and accessed the central line for administration of flushes and medications) were potential sites for contamination and required careful attention to infection prevention procedures. Needleless connector caps were to be changed upon admission and at least every seven days, before and after blood samples were drawn or any time the connector integrity was in question. <Central Line Care> The 05/18/2026 comprehensive admission Assessment documented Resident 144 was admitted on [DATE] and had diagnoses that included dementia, fracture around the artificial left hip joint and Streptococcal arthritis of the left hip (inflammation and infection of the joint caused by Streptococcus bacteria). Resident 144 was mildly cognitively impaired and received antibiotics daily. The 05/15/2026 care plan documented Resident 144 had Streptococcal Arthritis that required antibiotics via a PICC. On 05/18/2026 at 3:16 PM, Resident 144 was observed resting on their bed. They wore a shirt that was unbuttoned. On their right chest area under the collarbone, a central line (a long, flexible, and durable medical tube inserted into a large vein) was observed. The central line was covered with a transparent dressing that was dated 05/12/2026. The skin at the insertion site was visible and was without redness or drainage. The central line had two tubes; each tube was capped at the end. Resident 144 stated they had the central line for approximately two months and got antibiotics through it. The 05/28/2026 Order Summary Report documented Resident 144's orders included the following: -05/15/2026 Cefazolin (antibiotic) 2 grams via IV (in the vein) three times daily through 05/28/2026. -05/15/2026 Flush each tube of the PICC with 10 Milliliters (ml) of normal saline before and after each medication administration and every shift -05/15/2026 Monitor PICC site, dressing/date, and injection caps every shift. -05/19/2026 PICC line sterile dressing change every 7 days on dayshift and as needed using an antimicrobial disk and transparent dressing. Document external catheter length (the length of catheter exposed from the point of insertion at the skin to the end of the catheter hub to prevent potential complications). The orders did not include instructions for changing the needleless connector caps. Review of the May 2026 Medication and Treatment Administration Records (MAR/TAR) showed a PICC dressing change was to be completed on 05/19/2026. The area to document the completion of the dressing change had a number 9 entered. The code at the bottom of the MAR showed that an entry of number 9 was defined as see progress note. There was no place on the MAR to document the needleless end cap changes. Review of 05/19/2026 progress notes documented one tube on Resident 144's PICC was clogged and did not flush. Staff F, Resident Care Manager (RCM) and provider were notified. Orders were obtained to inject Alteplase, an enzyme that dissolved clots into the PICC. Approval was given to give the afternoon dose of antibiotic late. The note did not document whether the dressing change due on 05/19/2026 was completed. On 05/21/2026, an entry was documented on the MAR that the PICC dressing change was completed at 8:00 PM, nine days after the dressing change of 05/12/2026. An additional order was entered on the MAR to apply an antimicrobial disk to the PICC site topically every seven days for PICC dressing changes. There was no entry that documented the application of the antimicrobial disk was completed. On 05/26/2026 at 8:38AM, Staff Q, Licensed Practical Nurse, was observed administering the antibiotic through Resident 144's PICC line. Resident 144 was lying on their bed. Their PICC line on their right chest was visible. The dressing was dated 05/21/2026, and there was no antimicrobial disk under the dressing at the catheter insertion site. Staff Q changed the needleless end caps at this time and connected the antibiotic infusion tubing to the central line and started the infusion. Staff Q stated the end caps were changed every four days. During an interview on 05/28/2026 at 1:03 PM, Staff E, Registered Nurse (RN), stated when a resident with a central line had antibiotics ordered, the pharmacy called and discussed this with the nurses. At that time, staff ordered the antimicrobial disk, and the pharmacy sent them with the dressings, replacement end caps and antibiotic doses and these were all kept in the medication room. Staff E stated needleless end cap changes were usually part of the order for the central line dressing changes. Staff E reviewed the resident's orders and acknowledged there was no order to change the end caps and no place to document these changes on the MAR. Staff E stated the dressing and needless end caps were to be changed every seven days and the caps were to also be changed if blood had been drawn through the central line. Staff E observed Resident 144 at this time and confirmed there was no antimicrobial disk present at the catheter insertion site under the dressing. Staff E stated the resident was at risk of infection if dressings and end caps were not changed as ordered. During an interview on 05/28/2026 at 1:20 PM, Staff F, RCM, stated dressing and end cap changes were part of an order set. They acknowledged the PICC dressing should have been changed on 05/19/2026 and the order to place a antimicrobial disk at the insertion site should have been followed. They expected staff to change the dressing and end caps and document that they were done. Staff F stated failure to maintain the PICC line as ordered placed the resident at risk of infection. <Resident 11> The 03/12/2026 quarterly assessment documented Resident 11 had diagnoses that included Parkinson's disease (a progressive disorder of the central nervous system that affected movement and worsened over time), and kidney failure. The resident had moderate cognitive impairments and was independent with toileting. The 10/06/2025 care plan documented Resident 11 was at risk for constipation related to medication use and had a history of constipation. The care plan instructed nursing staff to follow the facility bowel protocol for bowel management. Review of Resident 11's provider orders showed the following: -Miralax as needed for constipation (no frequency when the medication was to be given) -Senna as needed for constipation (no frequency when the medication was to be given) Review of Resident 11's bowel record from 04/01/2026 through 05/22/2026 showed no bowel movement (BM) from 04/20/2026 to 04/23/2026 (four days), and 04/25/2026 through 04/29/2026 (five days). In an interview on 05/27/2026 at 12:06 PM, Staff U, Nursing Assistant, stated BMs were monitored every shift and documented in the resident's record. In an interview on 05/28/2026 at 8:51 AM, Staff V, RN, stated the bowel protocol was to be initiated for no bowel movement after 48 hours. Staff V stated Resident 11 did not have the bowel protocol orders in place but had as needed bowel medications ordered that should have been offered. In an interview on 05/28/2026 at 10:49 AM, Staff B, Director of Nursing, stated the bowel protocol was initiated when the resident had no BM in 48 hours. Staff B stated small BMs did not count. Staff B stated their expectation was for nursing to give the medications as ordered and to monitor for nausea, vomiting, and distension. Staff B acknowledged Resident 11 did not have bowel protocol orders in place. Reference: WAC 388-97-1060(1)-(3)

Based on observations, interview and record review, the facility failed to maintain a pressure- reducing mattress on the ordered setting, for 1 of 3 residents (Resident 5) reviewed for pressure ulcer/injury (wounds from unrelieved pressure). This failure placed residents at risk of worsening pressure ulcers and possible delayed wound healing. Findings included.A quarterly assessment, dated 03/31/2026, documented Resident 5 had diagnoses of quadriplegia (partial or complete paralysis of both arms and legs) and had significant pressure ulcers on their coccyx (tailbone) and left ankle. The resident was totally dependent on staff to position them in bed. The resident was alert and made their needs known.An order for moon boots (a pressure relief foot covering, worn in bed) and air mattress was written on 04/29/2026.An order for an alternating pressure relieving mattress, with instructions for the licensed nurse to check function and adjust the setting, as needed every shift, was written on 05/07/2026.The 11/14/2025 care plan showed the intervention for the alternating pressure mattress order was added on 05/07/2026.The May 2026 Treatment Administration Record (TAR) showed the order for the alternating pressure mattress and instructions to check the function and adjust the setting. This was initialed as completed by the nurses twice daily since ordered, with no missing entries. On 05/21/2026 at 1:19 PM, Resident 5 was observed on their bed. The control panel for the air mattress showed that the setting was on Static and not on Alternating. The panel lock icon was locked.On 05/22/2026 at 10:24 AM, the control panel showed the air mattress was on the Static setting and the panel was locked. When asked if the air mattress ever inflated and deflated, the resident stated they did not think so. During an observation of Resident 5's wound care on 05/26/2026 at 6:20 AM, Staff O, consultant for an outside wound care company, was asked how the air mattress settings worked. Staff O noted that it was on Static and said it should be on Alternating. Staff O turned the power off and back on again, and pressed the panel lock button, but was unable to adjust the mattress settings.On 05/26/2026 at 11:26 AM, Resident 5's air mattress was observed on Static and the panel was locked. On 05/27/2026 at 9:37 AM, observed Resident 5's air mattress was on Static and the panel was locked. During an interview on 05/26/2026 at 8:29 AM, Staff P, Licensed Practical Nurse (LPN), was asked if they checked the function and adjusted the setting on the air mattress when documenting on the TAR. Staff P stated they made sure it was turned on and filled with air. They further clarified that it would show on the order, if it should be on alternating pressure. During an interview on 05/26/2026 at 8:54 AM, Staff Q, LPN, was asked if they checked the function and adjusted the setting on the air mattress when documenting on the TAR. Staff Q stated that they made sure the air mattress was on and inflated. They further stated that when the air mattress was delivered, the settings were already programmed and was locked, so they could not be changed. They further stated, if they are on an air mattress, it should be alternating pressure. During an interview on 05/27/2026 at 9:50 AM, Staff R, Central Supply Manager stated that they did not mess with the settings on the air mattresses at all. They just brought it to the room, and the nurse or Unit Manager set it up. During an interview on 05/27/2026 at 3:03 PM, Staff H, Registered Nurse, was asked if they checked the function and adjusted the setting on the air mattress when documenting on the TAR. Staff H stated that they just plugged it in, made sure it was on, and had air and stated, the resident would know if it was not working. During an interview on 05/27/2026 at 3:30 PM, Staff I, Unit Manager, stated that the nurse should verify the unit (air mattress) was plugged in, inflated and functioning as it should. When asked about the instruction to check settings on the TAR, what setting was it referring to, Staff I stated it might be about resident's weight, which affected the inflation and comfort. Staff I stated that they had just looked at Resident 5's mattress, stated that it should have been on Alternating, and it did not match the current provider order. During an interview on 05/28/2026 at 3:11 PM, both Staff A, Administrator and Staff B, Director of Nursing acknowledged that the setting on the air mattress for Resident 5 did not match the order. During a telephone interview on 06/01/2026 at 9:23 AM, the service technician for the mattress manufacturer, stated that the Static setting meant that the constant airflow kept the mattress at the same, steady pressure. The Alternating setting meant that every other tube (that made up the mattress) inflated and deflated to alternate the pressure on the body. Reference: WAC 388-97-1060(3)(b)

Based on interview and record review the facility failed to routinely encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for 2 of 25 sampled residents (Residents 132 and 41), reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS, a required assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life.Findings included .Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 revised October 2025, showed the RAI consisted of three basic components: the MDS, the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three components of the RAI yields information about a resident's functional status, strengths, weaknesses, and preferences, as well as offered guidance on further assessment once problems were identified. Nursing homes are required to submit Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source. All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications. When the transmission file was received by iQIES, the system performs a series of validation edits to evaluate whether the data submitted met the required standards. MDS records were verified to ensure clinical responses were within valid ranges and were consistent, dates were reasonable, and records were in the proper order regarding records that were previously accepted by iQIES for the same resident. The provider was notified of the results of this evaluation by error and warning messages on a Final Validation Report. <Resident 132>Review of the 01/27/2026 admission assessment showed Resident 132 admitted to the facility on [DATE]. The assessment further showed an assessment reference date (ARD) of 01/27/2026, CAA care planning documentation was completed on 02/04/2026 and the MDS signed by the RN coordinator as competed on 02/04/2026.During interview and record review on 05/27/2026 at 1:33 PM, Staff N, MDS Coordinator, reviewed Resident 132's medical record. Staff N acknowledged Resident 132's admission MDS dated [DATE], was completed on 02/04/2026 but was late and had not been submitted to CMS yet.<Resident 41>Review of the 01/12/2026 admission assessment showed Resident 41 admitted to the facility on [DATE]. The assessment further showed an ARD of 01/12/2026, CAA care planning documentation was completed on 01/12/2026 and the assessment was signed by the RN coordinator as completed on 05/08/2026.Review of the 05/18/2026 MDS final validation report showed a batch of 52 MDS assessments was submitted and accepted, including Resident 41's admission MDS dated [DATE].During interview and record review on 05/27/2026 at 1:18 PM, Staff N, stated an MDS needed to be submitted to CMS 14 days after the ARD. Staff N reviewed Resident 41's medical record. Staff N acknowledged the 01/12/2026 admission MDS was submitted late on, 05/18/2026. During an interview on 05/28/2026 at 12:23 PM, Staff A, Administrator, stated they expected staff to submit MDS assessments per the required timeframes. Reference WAC 388-97-1000(4)(b)(5)(a)(e )(i)-(iii)

Based on interview and record review, the facility failed to coordination with the opioid treatment program provider to change dosage of medications for opioid use disorder (MOUD) for 1 of 1 sampled residents, (Resident 1), reviewed for MOUD. This failure placed the resident at risk for medical complications, unintended health consequences and diminished quality of life.Findings included .Per the Code of Federal Regulations Title 42 Section 8.12 (h)(1) opioid treatment programs (OTP; a specialized clinic that provides medication-assisted treatment for individuals with opioid use disorder) must ensure that medications for opioid use disorder (MOUD) are administered or dispensed only by a practitioner licensed under the appropriate State law and registered under the appropriate State and Federal laws to administer or dispense MOUD, or by an agent of such a practitioner, supervised by and under the order of the licensed practitioner and if consistent with Federal and State law. (2) OTPs shall use only those MOUD that are approved by the Food and Drug Administration under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) for use in the treatment of OUD. In addition, OTPs who are fully compliant with the protocol of an investigational use of a drug and other conditions set forth in the application may administer a drug that has been authorized by the Food and Drug Administration under an investigational new drug application under section 505(i) of the Federal Food, Drug, and Cosmetic Act for investigational use in the treatment of OUD. Currently the following MOUD will be considered to be approved by the Food and Drug Administration for use in the treatment of OUD: (i) Methadone; (ii) Buprenorphine and buprenorphine combination products that have been approved for use in the treatment of OUD; and (iii) Naltrexone.Review of Washington State Department of Health (DOH) Opioid Treatment Program Approved by Substance Abuse and Mental Health Services Administration (SAMHSA), dated October 9, 2024, documented in Page 53 under Procedures for Dosing CFR 8.12 (h) (3) (i) (ii), The program provider is the only practitioner authorized to order and/or change a patient's dosage of methadone (long-acting opioid medication used to reduce withdrawal symptoms in people addicted to narcotic drugs that may sometimes be used as a pain reliever) or buprenorphine. The provider must make an individualized decision informed by up-to- date product labeling and clinical judgment.Review of the 02/28/20205 care plan showed Resident 1 used methadone for an opioid use disorder (OUD), and the dosage was managed at weekly outpatient appointments with a local OTP. The care plan included a diagnosis list which showed the resident had Hepatitis B and Hepatitis C (serious liver conditions that can be acute or chronic).Review of a hospital after-visit summary dated 03/28/2025 showed Resident 1 was treated for an opioid overdose and hospital staff coordinated with the OTP for the resident to receive 35mg (milligrams; unit of measurement) of methadone for the following two days (03/29/2025 and 03/30/2025), which was half of the resident's previous dose (70mg). The after-visit summary showed the resident was to go to the OTP on 03/31/2025 for further dosing.Review of the methadone chain of custody record started 03/31/2025 showed Resident 1 received 50mg of methadone at the OTP that day, and facility staff to administer 60mg on 04/01/2025, then 70mg daily starting 04/02/2025. In an interview on 07/22/2025 at 2:10 PM, Staff A, Director of Nursing, stated after Resident 1's suspected overdose on 03/28/2025 the facility received orders from the OTP to taper the resident's methadone dose back up to 70mg daily, but the order was changed to 50mg daily by Staff B, Physician Assistant. Staff A stated Staff B gave a verbal order for the dose change due to recommendations by the resident's hepatology clinic (branch of medicine that focuses on diseases affecting the liver, gall bladder, bile ducts, and pancreas) to reduce or eliminate the methadone use on 04/02/2025. Review of Resident 1's April 2025 Medication Administration Record showed facility staff administered 50mg of methadone to the resident daily from 04/01/2025 to 04/12/2025, except for 04/08/2025 when the resident received their methadone during their appointment at the OTP. Further review showed no record of coordination with the opioid treatment program provider to change dosage of MOUD. On 05/30/2025 at 2:55 PM Collateral Contact 1 (CC1) stated when Resident 1's methadone vials were returned to the OTP in April 2025 the vials should have been empty, but instead still had dose amounts remaining. Per CC1 the facility did not report giving the resident less methadone than ordered by the OTP until the OTP staff asked about the remaining dose amounts.In an interview on 07/22/2025 at 12:52 PM, Staff D, Administrator, stated the facility did not have a specific policy related to residents who utilized an OTP, but the facility followed the OTP provider's orders for methadone use. Staff D further stated that Resident 1's case was difficult due to medical providers at the hospital and other appointments expressing concerns with the resident's use of methadone with their other underlying medical conditions.Review of a provider progress note dated 04/02/2025 showed Resident 1 was to continue receiving 70mg of methadone daily and that Staff B would follow-up with the resident through the next several days regarding the hepatology team's recommendations. There was no documentation the OTP was consulted about the resident's methadone dose and/or attempts to coordinate care between the OTP medical provider(s) and the resident's hepatology provider(s).Staff B was not available for interview during the course of the survey.In an interview on 09/17/2025 at 3:53 PM, Staff C, Medical Director, stated which type of medical provider was responsible for managing methadone doses was dependent upon the resident's diagnosis. Per Staff C, if methadone was used for pain facility providers could adjust the dose, but if the methadone was used for OUD then the facility should send the resident to the OTP for dosing. Staff C stated if there were multiple types of providers involved in a resident's care who disagreed on treatment, they would coordinate with the various providers directly. Staff C clarified they were not the medical director during April 2025 and had no additional information related to Resident 1's methadone order changes.Reference: (WAC) 388-97-1060 (3)(k)(iii)

Based on interview and record review, the facility failed to administer methadone consistent with the dosage prescribed by Opioid Treatment Program provider and as a part of medications for opioid use disorder (MOUD) for 1 of 8 residents (Resident 1) reviewed for medication administration. This failure placed the resident at risk for medical complications, unintended health consequences and diminished quality of life.Findings included .Per the Code of Federal Regulations Title 42 Section 8.12 (h)(1) opioid treatment programs (OTP; a specialized clinic that provides medication-assisted treatment for individuals with opioid use disorder) must ensure that medications for opioid use disorder (MOUD) are administered or dispensed only by a practitioner licensed under the appropriate State law and registered under the appropriate State and Federal laws to administer or dispense MOUD, or by an agent of such a practitioner, supervised by and under the order of the licensed practitioner and if consistent with Federal and State law. (2) OTPs shall use only those MOUD that are approved by the Food and Drug Administration under section 505 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) for use in the treatment of OUD. In addition, OTPs who are fully compliant with the protocol of an investigational use of a drug and other conditions set forth in the application may administer a drug that has been authorized by the Food and Drug Administration under an investigational new drug application under section 505(i) of the Federal Food, Drug, and Cosmetic Act for investigational use in the treatment of OUD. Currently the following MOUD will be considered to be approved by the Food and Drug Administration for use in the treatment of OUD: (i) Methadone; (ii) Buprenorphine and buprenorphine combination products that have been approved for use in the treatment of OUD; and (iii) Naltrexone.Review of Washington State Department of Health (DOH) Opioid Treatment Program Approved by Substance Abuse and Mental Health Services Administration (SAMHSA), dated October 9, 2024, documented in Page 53 under Procedures for Dosing CFR 8.12 (h) (3) (i) (ii), The program provider is the only practitioner authorized to order and/or change a patient's dosage of methadone (long-acting opioid medication used to reduce withdrawal symptoms in people addicted to narcotic drugs that may sometimes be used as a pain reliever) or buprenorphine. The provider must make an individualized decision informed by up-to- date product labeling and clinical judgment.Review of the 02/28/20205 care plan showed Resident 1 used methadone for an opioid use disorder (OUD), and the dosage was managed at weekly outpatient appointments with a local OTP. The care plan included a diagnosis list which showed the resident had Hepatitis B and Hepatitis C (serious liver conditions that can be acute or chronic).Review of a hospital after-visit summary dated 03/28/2025 showed Resident 1 was treated for an opioid overdose and hospital staff coordinated with the OTP for the resident to receive 35mg (milligrams; unit of measurement) of methadone for the following two days (03/29/2025 and 03/30/2025), which was half of the resident's previous dose (70mg). The after-visit summary showed the resident was to go to the OTP on 03/31/2025 for further dosing.Review of the methadone chain of custody record started 03/31/2025 showed Resident 1 received 50mg of methadone at the OTP that day, and facility staff to administer 60mg on 04/01/2025, then 70mg daily starting 04/02/2025. Further review showed the actual dose of methadone given to Resident 1 was 50mg daily each day from 04/01/2025 to 04/07/2025. In an interview on 07/22/2025 at 2:10 PM, Staff A, Director of Nursing, stated after Resident 1's suspected overdose on 03/28/2025 the facility received orders from the OTP to taper the resident's methadone dose back up to 70mg daily, but the order was changed to 50mg daily by Staff B, Physician Assistant. Staff A stated Staff B gave a verbal order for the dose change due to recommendations by the resident's hepatology clinic (branch of medicine that focuses on diseases affecting the liver, gall bladder, bile ducts, and pancreas) to reduce or eliminate the methadone use on 04/02/2025.Review of Resident 1's April 2025 Medication Administration Record showed facility staff administered 50mg of methadone to the resident daily from 04/01/2025 to 04/12/2025, except for 04/08/2025 when the resident received their methadone during their appointment at the OTP. On 05/30/2025 at 2:55 PM Collateral Contact 1 (CC1) stated when Resident 1's methadone vials were returned to the OTP in April 2025 the vials should have been empty, but instead still had dose amounts remaining. Per CC1 the facility did not report giving the resident less methadone than ordered by the OTP until the OTP staff asked about the remaining dose amounts.In an interview on 07/22/2025 at 12:52 PM, Staff D, Administrator, stated the facility did not have a specific policy related to residents who utilized an OTP, but the facility followed the OTP provider's orders for methadone use. Staff D further stated that Resident 1's case was difficult due to medical providers at the hospital and other appointments expressing concerns with the resident's use of methadone with their other underlying medical conditions.Review of a provider progress note dated 04/02/2025 showed Resident 1 was to continue receiving 70mg of methadone daily and that Staff B would follow-up with the resident through the next several days regarding the hepatology team's recommendations. There was no documentation the OTP was consulted about the resident's methadone dose and/or attempts to coordinate care between the OTP medical provider(s) and the resident's hepatology provider(s).Staff B was not available for interview during the course of the survey.In an interview on 09/17/2025 at 3:53 PM, Staff C, Medical Director, stated which type of medical provider was responsible for managing methadone doses was dependent upon the resident's diagnosis. Per Staff C, if methadone was used for pain facility providers could adjust the dose, but if the methadone was used for OUD then the facility should send the resident to the OTP for dosing. Staff C stated if there were multiple types of providers involved in a resident's care who disagreed on treatment, they would coordinate with the various providers directly. Staff C clarified they were not the medical director during April 2025 and had no additional information related to Resident 1's methadone order changes.Reference: (WAC) 388-97-1060 (3)(k)(iii)

Based on observation, interview, and record review, the facility failed to ensure acceptable parameters of nutrition were maintained for 2 of 2 sampled residents (Residents 4 and 14) reviewed for nutrition. Resident 4 experienced harm when they had a significant weight loss of 7.9% in approximately three months and 14.29% in six months. Resident 14 experienced harm when they had a significant weight loss of 8.51% in one month and their weight loss was not reported to the dietician. This failure placed the residents at risk for further decline in their weight, unintended consequences of poor nutrition, and decreased quality of life. Findings included . Review of the facility policy titled, Nutrition and Hydration dated 01/22/2021, showed residents would be provided with the nutrition and hydration needed to attain or maintain a healthy nutritional status, to the extent possible, and to identify residents with special needs or at risk for nutritional deficiencies. Residents whose nutritional screen indicated a risk for nutritional deficiencies, or current nutritional deficiencies, will be further evaluated by the Registered Dietician (RD) to identify nutritional needs and potential interventions. Meal intake will be documented following each meal to assist in early identification of reduced intake. A resident who takes less than 50% of a meal will be offered an alternate meal. A resident with consistently low intake of meals may be referred to the RD for evaluation and recommendation. A significant weight loss is defined as a 5% loss in one month, a 7.5% loss in three months and a 10% loss in six months. <Resident 4> Per the 12/05/2024 quarterly assessment, Resident 4 had diagnoses which included malnutrition (reduced availability of nutrients that leads to changes in the body composition and function), depression and dementia. The resident was cognitively intact, did not reject cares, and was able to eat with set up assistance and had no weight loss. Resident 4's 10/04/2022 comprehensive care plan had the following care areas implemented: -Activities of daily living (ADL) self-care performance deficit, the resident is independent for eating with set-up assistance. -Risk for alteration in nutritional status related to increased nutritional needs secondary to healing needs as evidenced by bone fracture and surgical incision, altered metabolism (glucose) as evidenced by diabetes, irritable bowel syndrome, gastroesophageal reflux disease (a digestive disease in which stomach acid or bile irritates the food pipe lining), chronic obstructive pulmonary disease (a group of lung diseases that makes it difficult to breathe), hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone which disrupts your metabolism), increased risk for disordered eating patterns secondary to anxiety and depression; interventions included to give diet as ordered-regular textures, regular/thin consistency of fluids, provide and serve supplements as ordered, updated 12/08/2024 to give a nutritional shake three times per day, weights per protocol, encourage fluids, Registered Dietician to evaluate and make diet change recommendations as needed. A 03/07/2024 Nutritional Screen assessment by the Registered Dietitian (RD) documented Resident 4 was 59.7 inches tall and weighed 146.6 lbs.; was eating 75-100% of their meals and there was no usual body weight listed. Resident 4 had no edema, and their weight was relatively stable with minimal fluctuations over the past quarter to year. A 11/09/2024 Nutritional Evaluation assessment by the RD documented Resident 4's weight was 138.6 lbs., and the resident was consuming 50-74.9% of their meals and 25-49.9% of their snacks. The RD stated weight was relatively stable with minimal fluctuations past quarter to year, down 9.8% this past year, beneficially, ongoing weight monitoring in place. A 12/08/2024 Nutritional Evaluation assessment completed by the RD documented Resident 4 weighed 138 lbs. and their weight had been stable over the past quarter to year with a gradual downward trend considered beneficial. The resident was eating 25-49.9% of their meals. The weight loss was attributed to fluid loss post-surgery for hip fracture. The weight was relatively stable with minimal fluctuation over the past quarter to year, down 9.8% this past year. Resident's intake poor to fair since readmission. A review of the record showed Resident 4 had lost 14.29% in 6 months and 7.9% in approximately 3 months. The resident had the following weights listed: 1/29/25 123.6 lbs. 12/27/24 123.4 lbs. 11/5/24 134.2 lbs. 7/26/24 144.2 lbs. Per the medication administration record, a nutritional shake was ordered on 12/13/2024 to be given three times a day. The record showed there had been no evaluation to determine whether other interventions would be beneficial for Resident 4's weight loss although they had continued weight loss from July 2024-December 2024. In an observation on 01/31/2025 at 12:03 PM, Resident 4 was sitting in their wheelchair with their lunch in front of them. Resident 4 was eating a roll and had not touched anything else on their tray. At 12:20 PM, Resident 4 was eating the roll and had a bite of fish. At 12:38 PM, the resident stated the fish and vegetables were not good and was eating a few bites of cake. The resident did not consume anything else on their tray and was not given an alternate meal or a nutritional shake by staff. In an observation on 02/03/2025 at 12:05 PM, Resident 4 was asleep in bed and had no meal tray in their room. At 12:32 PM, 1:35 PM, 2:03 PM and 2:55 PM, the resident remained asleep, and no lunch or nutritional shake was offered to the resident. At 2:03 PM, 2 nursing assistants entered the resident's room and stated Resident 4 was not feeling good. In an interview on 02/07/2025 at 9:04 AM, Staff C, Resident Care Manager, stated weight loss interventions should have been implemented prior to 12/12/2024. Staff C stated they could have added a nutritional supplement and monitored Resident 4 to ensure they were getting adequate nutrition. Staff C added this could have prevented some of Resident 4's weight loss. During an interview on 02/07/2025 at 10:13 AM, Staff B, Director of Nursing, stated when a resident had experienced weight loss, nutritional supplements and snacks would be encouraged, weight loss would be monitored, weight loss triggers assessed, and the RD would make a recommendation. Staff B stated nursing can also put interventions in place for weight loss. Staff B stated Resident 4 took snacks, not routinely, had no edema (swelling), and had no orders in place for weight loss and was unsure why they did not. Staff B added putting an intervention in place prior could have prevented some of Resident 4's weight loss. <Resident 14> Per the 12/03/2024 quarterly assessment, Resident 14 had diagnoses which included malnutrition (reduced availability of nutrients that leads to changes in the body composition and function), depression and anxiety. The resident was severely cognitively impaired and needed set up to touching assistance with meals and had no weight loss. Resident 14's 11/27/2024 comprehensive care plan had the following care areas implemented: -Resident has a nutritional problem or potential nutritional problem, and will maintain adequate nutritional status as evidenced by maintaining weight and no signs and symptoms of malnutrition through the review date, this was updated on 12/10/2024; interventions included to give diet as ordered-regular textures soft and bite sized, regular/thin consistency of fluids, provide and serve diet as ordered, monitor intake and record every meal, weigh and record per provider order and facility protocol, and RD to evaluate and make diet change recommendations as needed. A 12/02/2024 Nutritional Screen assessment by the RD documented Resident 14 was 65 inches tall and weighed 116.4 lbs.; was eating 50-74.9% of their meals and there was no usual body weight listed. Resident 14 had no edema, and their weight might fluctuate status post hospitalization for a fracture. A 12/02/2024 Nutritional Evaluation assessment by the RD documented Resident 14's weight was 116.4 lbs., and the resident was consuming 50-74.9% of their meals and 25-49.9% of their snacks. The RD stated weight was relatively stable with minimal fluctuations past quarter to year, down 9.8% this past year, beneficially, ongoing weight monitoring in place. The resident might benefit from gradual weight gain or stability of weight given current body mass index and ideal body weight. A review of the record showed Resident 14 had lost 8.51% in 1 month. The resident had the following weights listed: 12/26/24 106.5 11/27/24 116.4 A 12/11/2024 provider note stated Resident 14 was at risk for malnutrition due to dementia, poor intake, altered texture, was malnourished, and had end stage dementia and hospice was to see the patient on 12/12/2024. Review of the record showed no evaluation was completed to determine the need for further interventions for Resident 14's significant weight loss. In an observation on 01/31/2025 at 11:17 AM, Resident 14 was sitting in the dining room and was taking bites of their dessert. The resident had not consumed any other food on their tray. The nursing assistant explained to the resident what was on their tray, and they declined to eat. The licensed nurse in the dining room stated the resident liked Boost (a nutritional supplement). At 11:29 AM, Resident 4 was not given a nutritional supplement or alternate meal. Resident 14 was asked if they wanted to go back to their room and they stated yes. At 11:32 AM, the nursing assistant brought the resident to the nurse and reported that they did not eat their lunch. On 1/31/2024 at 11:36 AM, the doctor assisted Resident 14 to their room for an assessment. At 12:09 PM, the resident was given a shower. At 12:41 PM the resident was assisted to sit in the hall and no nutritional supplement or alternate meal had been given to the resident. At 2:06 PM, the resident was asleep in their wheelchair. During an observation on 02/03/2025 at 11:06 AM, Resident 14 was sitting in the dining room and taking bites of their food independently. At 11:11 AM a nursing assistant asked if the resident needed help to eat and moved their dessert closer to them. At 11:16 AM, the resident had consumed three quarters of a glass of milk and approximately five percent of their food. At 11:26 AM, the resident had stopped eating and had not consumed any further food. At 11:29 AM, the nursing assistant brought Resident 14 back to their hall, placed them in their room and got a stand aid to assist them to the restroom. At 11:36 AM, the nursing assistant left the hall and did not report poor meal intake to the licensed nurse. On 02/03/2025 at 11:49 AM, Resident 14 was assisted to bed and was not offered an alternate meal or nutritional shake. On 02/06/2025 at 4:21 PM, Staff G, Nursing Assistant, stated when a resident had poor intake they were offered an alternate meal, the nurse was notified and would decide if a nutritional shake was needed. In an interview on 02/06/2025 at 4:24 AM, Staff H, Registered Dietician, stated Resident 14 had lost 10 lbs. in one and a half weeks, had a low body mass index and probably needed weight gain. Staff H stated the resident was evaluated by the other dietician before they started working at the facility, so it was hard to catch everything when you're stepping in, so the resident slipped through the cracks. Staff H stated it would have been good for the nursing assistants and unit manager to bring the weight loss to their attention. Staff H added Resident 14 should have had interventions such as a nutritional supplement and nutritionally enhanced meals added. Staff H stated they should have been notified since they were new to the building. In an interview on 02/07/2025 at 8:15 AM, Staff C stated the dietician was new and believed they checked the weights and if not, they were discussed in their weekly nutrition at risk meeting. Staff C added interventions should have been added for Resident 14's weight loss and nursing could have obtained orders for a supplement from the provider. Staff C was unsure why Resident 14 was never seen by hospice. Reference: WAC 388-97-1060(3)(h)

Based on observation, interview, and record review the facility failed to store, discard and distribute food, and monitor temperatures of foods being served in accordance with professional standards for food safety for 1 of 1 facility kitchens, reviewed. This failure placed residents at risk for food borne illness and diminished quality of life. Findings included . Review of the U.S. Food and Drug Administration (FDA) Food Code 2022 revised [DATE], showed that food must be labeled with the date the food was prepared, the package opened, and the date the food must be discarded as directed by the food manufacturer's use-by-date. The U.S. FDA Food Code 2022 also showed that there was an increased risk of contamination when food was held, cooled and reheated at improper temperatures. Thus, temperatures of food must be taken and monitored. Records must be maintained to verify food temperatures are within the parameters required for food safety. <Food Storage> During a kitchen observation and interview on [DATE] at 9:07 AM, the walk-in refrigerator contained a crate of approximately 36 pasteurized eggs with an expiration date of [DATE]. Staff W, Dietary Manager, acknowledged that the eggs were expired and quickly disposed of the crate of eggs. In an interview on [DATE] at 12:00 PM, Staff W stated the eggs should have been discarded. Staff W stated that it was important for the prevention of bacterial growth and resident illness. <Food Preparation and Service> During an observation of a tray line service held in the dining room on [DATE] at 10:54 AM, Staff FF, Assistant Dietary Manager, began using a digital thermometer to check the temperatures of the food items resting in the steam table. Staff FF checked the food temperatures for the food items being served from the steam table. In an observation and interview on [DATE] at 11:10 AM, a resident was observed eating a chef's salad in the dining room. Staff FF did not check the temperature for the chef's salad. Staff W stated the salad was brought out of the refrigerator in the kitchen. During an observation of a tray line service held in the kitchen on [DATE] at 11:18 AM, Staff FF unloaded the food items that were served in the dining room off a cart and onto the steam table in the kitchen. No staff checked the temperatures of the food from the steam table before the start of tray line. When prompted by the surveyor, Staff W stated the facility did not check temperatures at the steam table in the kitchen. In an interview on [DATE] at 11:45 AM, Staff W stated the facility did not check temperatures of foods after the first tray line was completed in the dining room. They stated the second tray line completed in the kitchen consisted of randomly checking temperatures of various foods and those temperatures were not documented. Staff W stated that it was important to monitor temperatures for prevention of food contamination and bacterial growth. Record review on [DATE] of the temperature logs from [DATE] through [DATE] for both serving locations (dining room and kitchen) showed no documentation of temperatures for the kitchen tray line. Reference: WAC [DATE](3), -2980

Based on interview and record review the facility failed to routinely encode and transmit resident assessment data to the Centers for Medicare & Medicaid Services (CMS) within the required timeframe for 4 of 11 sampled residents (Residents 7, 12, 86 and 90), reviewed for timeliness in encoding and transmission of Minimum Data Set (MDS - an assessment tool). This failure affected federal health information data gathering and placed residents at risk for inaccurate monitoring of the residents' progress over time, untimely comprehensive review of residents' health data/information, and a diminished quality of life. Findings included . Review of the Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.19.11 revised October 2024, showed the RAI consisted of three basic components: the MDS, the Care Area Assessment (CAA) and the RAI utilization guidelines. The utilization of the three component of the RAI yielded information about a resident's functional status, strengths, weaknesses, and preferences, as well as offered guidance on further assessment once problems were identified. Nursing homes were required to submit Omnibus Budget Reconciliation Act (OBRA) required MDS records for all residents in Medicare- or Medicaid-certified beds regardless of the payer source. All Medicare and/or Medicaid-certified nursing homes and swing beds, or agents of those facilities, must transmit required MDS data records to CMS' Internet Quality Improvement and Evaluation System (iQIES). After completion of the required assessment and/or tracking records, each provider must create electronic transmission files that meet the requirements detailed in the current MDS 3.0 Data Submission Specifications. For submission, the MDS data must be in record and file formats that conform to standard record layouts and data dictionaries, and pass standardized edits defined by CMS and the State. Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion Date. When the transmission file was received by iQIES, the system performed a series of validation edits to evaluate whether or not the data submitted met the required standards. MDS records were verified to ensure clinical responses were within valid ranges and were consistent, dates were reasonable, and records were in the proper order with regard to records that were previously accepted by iQIES for the same resident. The provider was notified of the results of this evaluation by error and warning messages on a Final Validation Report. <Resident 86> According to the 08/25/2024 discharge assessment, Resident 86 discharged from the facility on 08/25/2024 with a return not anticipated. The assessment further showed it was signed as completed on 08/29/2024. <Resident 7> According to the 10/25/2024 discharge assessment, Resident 7 discharged from the facility on 10/25/2024 with a return not anticipated. The assessment further showed it was signed as completed on 10/29/2024. <Resident 12> According to the 12/19/2024 quarterly assessment, Resident 12 was able to perform most activities of daily living independently. The assessment further showed the assessment observation end date was 12/19/2024 and was signed as completed on 02/04/2025. Review of the 12/20/2024 discharge assessment showed Resident 12 discharged from the facility on 12/20/2024 with a return not anticipated. <Resident 90> According to the 01/14/2025 quarterly assessment, Resident 90 required moderate assistance of staff to complete most activities of daily living. The assessment further showed the observation end date was 01/14/2025 and was signed as completed on 02/01/2025. Review of the 02/04/2025 MDS validation report showed 79 files were submitted with 49 error messages, 23 out of 79 accepted filed were submitted late, 14 days beyond the assessment completion date. The report included Resident 86's 08/25/2024, Resident 7's 10/25/2024, and Resident 12's 12/20/2024 discharge assessments and Resident 12's 12/19/2024 and Resident 90's 01/14/2025 quarterly assessments as accepted late submissions. In an interview on 02/05/2025 at 12:09 PM, Staff E, MDS Director, explained MDSs needed to be submitted to CMS and/or the health insurance providers within 14 days of the assessment reference or observation end date. Staff E acknowledged the facility was late on submitting MDS assessments as required. In an interview on 02/05/2025 at 12:29 PM, Staff B, Director of Nursing, acknowledged the facility had submitted MDS assessments late but they should be submitted per the required RAI timelines. In an interview on 02/05/2025 at 12:37 PM, Staff A, Administrator, stated they expected staff to submit MDS's per the required RAI timelines. Reference WAC 388-97-1000 (4)(b), (5)(b) Refer to F641 for additional information.

Based on interview and record review the facility failed to provide a bed-hold notice, a notice that informed the resident of their right to pay the facility to hold their room/bed while they were hospitalized , to the resident and/or their representative at the time of discharge or within 24 hours of transfer to the hospital for 5 of 5 sampled residents (Resident 4, 30, 46, 71 and 90), reviewed for hospitalization . This failure placed residents at risk for a lack of knowledge regarding the right to a bed-hold while they were hospitalized . Findings included <Resident 4> The 12/05/2025 discharge assessment documented Resident 24 was cognitively impaired and unable to make decisions regarding their care, and had diagnoses which included diabetes, anxiety and depression. An 11/23/2024 progress note showed the resident had increased behaviors and was sent to the hospital. Additional record review found no documentation that showed the resident or their representative had been provided a bed-hold notice. <Resident 46> The 11/23/2024 discharge assessment documented Resident 46 was cognitively intact and able to make decisions regarding their care, and had diagnoses which included diabetes, anxiety and chronic obstructive pulmonary disease (a group of lung diseases that made it difficult to breathe). Review of Resident 46's record showed an 11/23/2024 nursing progress note which documented the resident had a fall and was unable to recall what happened and was sent to the hospital. An 11/25/2024 progress note showed Resident 46 was called about a bed hold, two days after their discharge. In an interview on 02/06/2025 at 11:09 AM, Staff A, Administrator, stated bed holds were offered when residents discharged to the hospital. Staff A stated admission staff notified the resident or their representative within the 24-hour time frame. Staff A stated it was important to offer the bed hold because the resident had a right to return to their room. 47328 <Resident 90> According to the 01/14/2025 quarterly assessment, Resident 90 required moderate staff assistance to complete most activities of daily living including transfers and ambulation. Resident 90 had severe cognitive impairment. Review of nursing progress notes showed Resident 90 was transferred to the hospital on the evening of 11/22/2024 for evaluation after a fall occurred, returning to the facility the same day, and again on the evening of 11/23/2024 returning the following day. No documentation was found to show a bed hold was explained or offered to the resident's representative, as required. <Resident 30> According to the 01/21/2025 admission assessment, Resident 30 admitted to the facility on [DATE] with diagnoses including stroke with weakness and/or paralysis affecting one side of the body. Resident 30 was cognitively intact and able to clearly verbalize their needs. Review of the January 2025 nursing progress notes showed Resident 30 was found on the floor on 01/18/2025 at 1:15 AM. The resident was sent to the hospital for further evaluation. No documentation was found to show a bed hold was explained or offered, as required. 50027 <Resident 71> Per the 12/11/2024 admission assessment, Resident 71 had diagnoses which included renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids) and diabetes (a group of diseases that result in too much sugar in the blood). The resident was cognitively intact to make decisions regarding their care. Review of Resident 71's record showed a 12/27/2024 progress note documented the resident had experienced vomiting, fever and high blood sugar. Resident 71 was assessed and sent to the hospital for evaluation. No documentation was found to show a bed hold was explained or offered, as required. In an interview on 02/07/2025 at 9:49 AM, Staff U, Resident Care Manager, reviewed Resident 71's medical record. Staff U confirmed there was no documentation a bed-hold was offered, as required. Staff U further stated a bed-hold should have been offered and this was important because residents had a choice if they wanted to keep their bed once they were discharged to a hospital. Reference WAC 388-97-0120(4) Refer to F623 for additional information.

Based on interview and record review the facility failed to ensure the resident and/or the resident's representative was informed of and consented to a new medication for 2 of 3 sampled residents (Residents 54 and 90), reviewed for care planning. This failure disallowed the resident and/or the resident representative to make an informed decision regarding treatment and placed the resident at risk of diminished quality of life. Findings included Review of the facility policy titled, Resident Rights Notification of Changes of Condition dated July 2018, showed the facility would keep the resident and/or the resident representative informed of changes in health status. <Resident 90> According to the 11/26/2024 admission assessment Resident 90 had diagnoses including dementia, traumatic brain injury (TBI- brain damage caused by an external force), anxiety, and depression. Resident 90 had severe cognitive impairment with fluctuating inattention, disorganized thinking and no altered level of consciousness. Review of the 11/20/2024 hospital discharge medication list showed Resident 90 was to be administered Seroquel (antipsychotic, medication that affected the mind, emotions, and behaviors) 25 milligrams (mg) twice daily after discharge. Review of the 11/21/2024 facility order summary showed Resident 90 was to be administered Seroquel 25 mg twice daily for psychophysical visual disturbances, violent behavior, restlessness and agitation. Review of the 11/21/2024 provider progress note showed Resident 90 was started on low dose Seroquel due to dementia with behavioral disturbances. The provider's treatment plan included continued use of Seroquel at 25 mg twice daily. The provider's note also included the following general recommendations for environmental treatment of agitation: frequent orientation with cues, staffing consistency, communicate with short clear statements and requests, maintain day/night structure especially with lighting, minimize noise/stimuli especially at night, ensure the resident had freedom of mobility within confines of medical treatment and plan, ensure pain was addressed related to resident may not be able to vocalize which may lead to agitation, and correct any sensory deficits by ensuring the resident wore hearing aides and/or glasses as needed. Review of the 11/20/2024 self-care performance deficit care plan showed Resident 90 required partial staff assistance to perform most activities of daily living including bed mobility and transfers. The 11/21/2024 psychotropic medication use care plan instructed staff to administer medications as ordered, monitor for adverse side effects, orient to reality and clarify mistaken beliefs. The 11/27/2024 delirium (sudden and severe state of confusion) care plan instructed staff to call Resident 90 by their preferred name, encourage resident family, friends, and care givers to be at bedside during episodes of confusion. The 11/30/2024 impaired cognitive function care plan instructed staff to administer medications as ordered, monitor for potential side effects and medication effectiveness. Review of the 11/25/2024 provider progress note showed Resident 90 sustained a fall, was transferred to the hospital for evaluation and returned with multiple recommendations for behaviors. The provider's note further showed the hospital increased Resident 90's Seroquel from 25mg to 50mg twice daily and advised continued increase by 25 mg twice daily to reduce hyperactivity and agitation until symptoms were controlled or max dose of 750 mg/ 24 hours was reached. The provider noted Resident 90 was currently on Seroquel 75mg daily with reported increased fatigue and Resident 90 was more sedated today. The hospital also recommended starting use of Ativan (antianxiety medication) orally for anxiety and in an injectable form for severe agitation and combativeness. Review of the 12/10/2024 provider progress note showed Resident 90 reported intermittent sleep issues. The provider's plan was to increase Seroquel to 100mg twice daily and continue the as needed Ativan. The provider note did not document any behaviors Resident 90 experienced, if any. Review of the 01/08/2025 provider progress note showed Resident 90 had increased behaviors and impulsiveness. Resident 90 had been making more sexual inappropriate gestures, comments and just inappropriateness. Resident 90 had another fall due to impulsiveness. The provider's plan was to increase the Seroquel to 100 mg three times daily due to impulsiveness which leads to falls, inappropriate behaviors, and sexual inappropriateness. The note further showed the as needed Ativan was not effective at managing impulsiveness, Resident 90 continued to be a fall risk, and the provider scheduled Ativan 1 mg twice daily routinely. Review of the 01/22/2025 provider discharge summary showed Resident 90 sustained repeated falls secondary to impulsiveness. Resident 90 discharged the facility with provider orders to administer Seroquel 100 mg three times daily, Ativan 1 mg routinely twice daily and Ativan 1 mg every four hours as needed for agitation. Review of November 2024 through January 2025 nursing progress notes showed Resident 90 was alert to self, not redirectable, was short with staff, cursed at times, self-transferred often, unsteady gait, experienced frequent falls, was confused, and anxious at times. The notes further showed Resident 90 was administered as needed Ativan for restlessness and anxiousness, minimal vague documentation was found to show what non-medication interventions were attempted prior to medicating, intervention effectiveness and/or specific details of the behaviors Resident 90 experienced. No documentation was found to show Resident 90's resident representative was informed of the numerous Seroquel dose increases or Ativan medication changes. In an interview on 02/05/2025 at 2:28 PM, Resident 90's POA stated the facility informed them Resident 90 was being administered medication to help with behavioral outbursts, the facility did not ask for medication consent. Resident 90's POA further stated they felt Resident 90 was overmedicated. The POA explained Resident 90 admitted to the facility requiring one person transfer assist using a walker but upon discharge Resident 90 could barely hold their head up and it took three persons to stand pivot transfer Resident 90 out of the wheelchair. The POA further stated they were not informed of Resident 90's psychotropic medication changes and were not aware Resident 90 had as needed medication ordered for an injectable medication. The POA stated the facility had a major communication issue. In an interview on 02/06/2025 at 12:38 PM, Staff L, Social Service Director, explained psychotropic medication use required consent prior to administering medication. Staff L explained consent was obtained from the resident if they were cognitively intact and the resident representative if the resident had cognitive impairment. Staff L acknowledged Resident 90's POA should have been notified of all the medication changes. In an interview on 02/26/2025 at 3:58 PM, Staff N, Registered Nurse, explained when medication changes occurred, the resident and/or their resident representative would be notified, a progress note documented, and the resident placed on alert charting to monitor the resident's tolerance to the medication changes, potential adverse side effects or complications. In an interview on 02/07/2025 at 8:47 AM, Staff C, Resident Care Manager, explained the nurse was expected to inform a resident or the resident representative when medication changes occurred and document a progress note. Staff C acknowledged Resident 90's POA should have been notified of all of Resident 90's medication changes because a POA could not fully participate in a resident's care if they were not being informed. In an interview on 02/07/2025 at 9:11 AM, Staff B, Director of Nursing, explained a self-responsible resident would be informed of medication changes, a POA was notified of changes if a resident had cognitive impairment, and a progress note was to be documented. Staff B stated they expected staff to notify a resident and/or resident representative each time a medication was changed. Staff B acknowledged a resident and/or resident representative could not fully participate in their care if they were not informed of changes made. <Resident 54> Review of the 10/22/2024 quarterly assessment showed Resident 54 had diagnoses which included multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves and causes pain), chronic pancreatitis (a progressive disease when the pancreas is permanently damaged by inflammation and causes abdominal pain), and depression. The resident was cognitively intact and able to make their needs known. In an interview on 01/28/2025 at 11:42 AM, Resident 54's representative stated the resident had times of confusion and that's why they became the power of attorney (POA- a person that assists with making health care decisions for a person with cognitive impairments). The representative stated the resident's pain medication had been decreased and they were unaware. Review of the December 2024 Medication Administration Record (MAR) showed an order for Xtampa (a medication used to treat pain) to be decreased from 18 mg to 13.5 mg was entered on 12/06/2024. Review of the December 2024 nursing progress notes showed no notes the resident or their representative had been notified of the decrease of the Xtampa. In an interview on 02/05/2025 at 2:26 PM, Resident 54 stated they were not aware changes had been made to the Xtampa. During an interview on 02/06/2025 at 2:05 PM, Staff C, RCM, stated when a medication was changed, the resident was placed on alert charting and the resident, or their representative was notified, and a progress note was made. In an interview on 02/06/2025 at 2:57 PM, Staff B, DNS, stated the resident or their representative should have been notified of the change in medication and a progress note should have been made to reflect this. Staff B stated this was important because they may not have wanted the medication changed. Reference WAC 388-97-0300 (3)(a), -0260, -1020(4)(a-b) Refer to F758 for additional information. 47328

Based on interview and record review the facility failed to ensure the Office of the State Long-Term Care Ombudsman (a person who acted as an advocate for residents that lived in long-term care) received written notification of a hospital transfer and/or discharges, as required for 5 of 6 sampled residents (Resident 4, 30, 46, 71 and 90), reviewed for hospitalization and discharge. This failure placed residents at risk of not having access to additional advocacy services from the State Long-Term Care Ombudsman, unmet needs, and diminished quality of life. Findings included . Review of the facility policy titled, Admission, Transfer and discharge date d July 2018, showed the notifications to the Ombudsman office would occur before or as close as possible to the actual time of a facility-initiated transfer or discharge. The policy further showed emergency transfer notifications would be sent to the Ombudsman at least on a monthly basis. <Resident 4> The 12/05/2025 discharge assessment documented Resident 4 was cognitively impaired and unable to make decisions regarding their care, and had diagnoses which included diabetes, anxiety and depression. An 11/23/2024 progress note showed the resident had increased behaviors and was sent to the hospital. Additional record review found no documentation that showed the State Long-Term Care Ombudsman had been notified of the resident's transfer to the hospital. <Resident 46> The 11/23/2024 discharge assessment documented Resident 46 was cognitively intact and able to make decisions regarding their care, and had diagnoses which included diabetes, anxiety and chronic obstructive pulmonary disease (a group of lung diseases that made it difficult to breathe). Review of Resident 46's record showed an 11/23/2024 nursing progress note which documented the resident had a fall and was unable to recall what happened and was sent to the hospital. Additional record review found no documentation that showed the State Long-Term Care Ombudsman had been notified of the resident's transfer to the hospital. In an interview on 02/06/2025 at 11:09 AM, Staff A, Administrator, stated they were unaware the Ombudsman needed to be notified for hospital discharges and stated that was not a practice they were currently doing. 50027 <Resident 71> Per the 12/11/2024 admission assessment, Resident 71 had diagnoses which included renal insufficiency (a condition in which the kidneys lose the ability to remove waste and balance fluids) and diabetes (a group of diseases that result in too much sugar in the blood). The resident was cognitively intact to make decisions regarding their care. Review of Resident 71's record showed a 12/27/2024 progress note documented the resident had experienced vomiting, fever and high blood sugar and was sent to the hospital. Additional record review found no documentation that showed the State Long-Term Care Ombudsman had been notified of the resident's transfer to the hospital. 47328 <Resident 90> According to the 01/14/2025 quarterly assessment, Resident 90 required moderate staff assistance to complete most activities of daily living including transfers and ambulation. Resident 90 had severe cognitive impairment. Review of nursing progress notes showed Resident 90 was transferred to the hospital on the evening of 11/22/2024 for evaluation after a fall occurred, returning to the facility the same day, and again on the evening of 11/23/2024 returning to the facility the following day. No documentation was found to show the Ombudsman was notified of the hospital transfers, as required. <Resident 30> According to the 01/21/2025 admission assessment, Resident 30 admitted to the facility on [DATE] with diagnoses including stroke with weakness and/or paralysis affecting one side of the body. Resident 30 was cognitively intact and able to clearly verbalize their needs. Review of the 01/18/2025 provider progress note showed Resident 30 sustained a fall around 1:00 AM with redness and swelling noted to the right side of the head. Resident 30 reported 5 out of 10 pain (on a scale of 0-10, 0 being no pain and 10 being worst pain experienced). Resident 30 was transferred to the hospital for additional testing. Review of the January 2025 nursing progress notes showed Resident 30 was found on the floor on 01/18/2025 at 1:15 AM. The provider was notified of Resident 30's fall that morning, the provider assessed Resident 30, and Resident 30 was transported to the hospital for further evaluation. No documentation was found to show the Ombudsman was notified of the hospital transfers, as required. In an interview on 02/04/2025 at 2:32 PM, the Ombudsman stated the facility was not notifying them of hospital transfers or discharges, as required. The Ombudsman further stated the facility had only notified them when they presented a resident with a 30-day notice of eviction. In an interview on 02/05/2025 at 4:03 PM, Staff Q, Licensed Practical Nurse, stated they were unsure how the Ombudsman was notified of hospital transfers and/or discharges. In an interview on 02/06/2025 at 9:48 AM, Staff C, Resident Care Manager, stated they were unsure how the Ombudsman was notified of hospital transfers and/or discharges. In an interview on 02/06/2025 at 12:06 PM, Staff L, Social Service Director, stated the facility only informed the Ombudsman if and/or when the facility gave a resident a 30-day eviction notice. Staff L further stated Ombudsman transfer and/or discharge notifications were new to the facility and it was rarely done. In an interview on 02/06/2025 at 1:50 PM, Staff A, Administrator, acknowledged the facility had only been notifying the Ombudsman when a facility-initiated discharge occurred. Reference WAC 388-97-0120 (2)(a-d) -0140 (1)(a)(b)(c)(i-iii) Refer to F625 for additional information.

Based on interview and record review, the facility failed to provide supervision for 1 of 3 sampled residents (Resident 1) reviewed for accidents. Resident 1 was harmed when they wandered unassisted in to the hall, intercepted fall (occurs when the resident would have fallen if they had not caught themself or had not been intercepted by another person - this is still considered a fall) and sustained a fractured humerus (the upper arm bone). This failure put residents at risk for injuries and decreased quality of life. Findings included . A review of the 08/22/2024 admission assessment documented Resident 1 had diagnoses including dementia and anxiety. Resident 1 was moderately cognitively impaired, had disorganized thinking and inattention, had verbal and other behaviors, rejected care and wandered. The resident required substantial assistance for bed mobility, going from sitting to standing positions and transfers from bed to a chair. The 08/17/2024 care plan documented the following care areas: -Activities of Daily Living (ADL) self-care deficit; the resident required substantial/max assistance of one staff for transfers using an Apex (a mechanical device that helps a resident transfer from their bed to a chair or wheelchair). On 08/20/2024, the care plan was updated to include the resident required touching assistance of one staff for transfers. -Risk for falls related to confusion, deconditioning, gait/balance problems and unaware of safety needs; staff were instructed to anticipate and meet the resident's needs, be sure the call light was in reach and the resident was encouraged to use it for assistance as needed. The resident needed prompt response to all requests for assistance, bed against the wall, fall mat, ensure commonly used items were within reach prior to leaving the resident's room, and ensure the resident was wearing appropriate footwear when ambulating. On 08/19/2024, the care plan was updated to include conduct frequent rounding (checking on the resident's condition or whereabouts). A review of nursing progress notes documented Resident 1 arrived at the facility on 08/16/2024 at approximately 4:30 PM for therapy and strengthening needs and was anxious. The resident was educated on the use of their call light and staff were to anticipate the resident's needs. On 08/17/2024 at 6:28 PM, the resident was found lying on their fall mat with a pillow under their head. The resident appeared comfortable, did not know how they got there and had no injuries. The resident was toileted then placed near the nurse's station in their wheelchair. A review of the 08/17/2024 fall investigation documented Resident 1 was found on their fall mat resting their head on a pillow with their pants partially down. The resident had been incontinent of stool, was provided care, and was positioned in their wheelchair within eyesight of the nurse. The cause of the fall was documented as a lack of safety awareness. The care plan was updated to include frequent rounding on 08/19/2024. Review of progress notes documented on 08/19/2024 at 12:16 PM, Resident 1 was very anxious and cooperative with staff and that staff did at times anticipate the resident's needs. On 08/20/2024 at 6:05 AM, staff documented the resident was restless most of the night and was in their wheelchair with the nurse; the resident tried to get out of bed and ambulate without assistance. The resident verbally repeated sentences over and over for two hours and was given medication for anxiety, then eventually slept for two hours. At 7:13 AM, the resident was medicated for anxiety as they were very anxious, tried to get out of their chair and repeated the same sentences over and over. At 9:57 AM, the resident was very anxious, repeated things over and over and was not easily redirected. The same day it was noted that the resident had difficulty adjusting to the facility and the resident's family representative had been contacted, an interdisciplinary care plan (IDT) meeting was scheduled for 08/21/2024 and the family representative had agreed to stay with the resident until they adjusted to the facility. On 08/23/2024, progress notes indicated the facility called other facilities to attempt to have the resident transferred but none had accepted Resident 1. The census section of the electronic medical record documented that on 08/20/2024 Resident 1 was moved from room [ROOM NUMBER], a semi-private room near the nurse's station to room [ROOM NUMBER], a private room further down the hall away from the nurse's station. A review of the 08/21/2024 IDT Care Plan Conference note documented Resident 1's family representatives were present, as well as Staff C, Social Worker, Staff D, Physical Therapy Aide (PTA), and Staff E, Resident Care Manager. The care plan was updated to reflect the resident's difficulty adjusting to the facility and the family desired a discharge to a memory care facility. There was no documentation regarding the level of supervision the resident required to prevent further falls. Review of a progress note, dated 08/24/2024 at 6:39 PM, showed Resident 1 had been one on one with staff; the resident stood up from their wheelchair and ran through the halls. Staff requested the family come sit with the resident. Resident 1 was given anti-anxiety medications that were only effective after the family arrived. Resident 1 was unable to follow simple commands. On 08/25/2024 at 2:56 AM, the nurse on duty documented they heard a loud noise and found Resident 1 standing in the corner of their room. Resident 1 began to stumble, tried to use the wall to steady themself and was assisted to the floor. The resident was assisted back to bed, was not injured, and stated they had been attempting to go to the bathroom. At 3:00 AM, Resident 1 got out of bed and ambulated halfway to the nurse's station. Per the documentation, Resident 1 seemed to have an altered level of consciousness momentarily and was leaning all their weight into a staff member's lower legs. The resident was lowered to the floor until staff could retrieve the resident's wheelchair. The resident was assisted into their chair by three staff and began to complain continuously of right arm pain. At 3:37 AM, an order was received to obtain an x-ray of the resident's arm and to give the resident medication for their anxiety. The staff were directed to send the resident to the emergency room if the medication was ineffective. Resident 1's Power of Attorney was notified at 3:58 PM that the resident's upper arm was broken and was to be transferred to the local emergency department. The resident left the facility at 5:04 PM via emergency medical services. Review of progress note dated 08/25/2024, documented acute humeral neck fracture. A review of the 08/25/2024 fall investigation documented Resident 1 fell because of the recent change in their room. During an interview on 09/30/2024 at 5:20 AM, Staff I, Nursing Assistant, stated they had helped provide care to Resident 1. They stated Resident 1 would be seated in their wheelchair, and then would suddenly take off running. They had staff stay with the resident 1 to 1 for one night, then stated there was not enough staff. Staff I stated the resident's family was supposed to help but were not always there. They positioned Resident 1 by the desk but Resident 1 was unable to follow instructions. During an interview on 09/30/2024 at 8:00 AM, Staff C, Social Worker, stated an IDT meeting had been held with Resident 1's family on 08/21/2024 and the family representatives had concerns about the level of supervision being provided for the resident. Staff C stated at that time, the family requested Staff C look at other placement arrangements. During an interview on 09/30/2024, Staff F, Licensed Practical Nurse (LPN), stated they provided care for Resident 1. Staff F stated Resident was very impulsive and would jump up from their wheelchair and take off running. Staff F stated someone made a decision to place Resident 1 in a private room to enable the family to sit with the resident because the facility did not provide 1 to 1 supervision, but Staff F was uncertain how often the family came to the facility. During an interview on 09/30/2024 at 8:57 AM, Staff G, LPN, stated they cared for Resident 1 the evening of 08/24/2024, which was the same night the resident fell a second time. Staff G stated Resident 1 was not able to understand what their call light was for and did not follow instructions. Staff G stated on 08/24/2024, Resident 1 had been grabbing at something in the air. Staff G checked, and Resident 1's oxygen saturation was low at 85%. (Normal oxygen saturations, the amount of oxygen available in the blood, range from 95-100% on room air.) Staff G applied supplemental oxygen to the resident and their saturation improved. Resident 1's family member was present at that time, but the family did not stay with Resident 1 at all times. Staff G had not notified the provider of the low oxygen saturation. During an interview on 09/30/2024 at 10:10 AM, Staff E, LPN, Resident Care Manager, stated they had been told that Resident 1's family would be with the resident everyday but when that had not happened, Staff E asked and was told by Administration staff that there was no law that required the family to be there. Staff E stated they had discussed the level of supervision Resident 1 required with the resident's family during the 08/21/2024 IDT meeting. Staff E stated Resident 1 was impulsive and ran down the hall at times, but the facility did not provide 1 to 1 supervision and Staff E stated it was their understanding that was why the family agreed to sit with the resident. Staff E stated it was the facility's responsibility, however, to provide the appropriate level of supervision the residents required. During an interview on 09/30/2024 at 10:43 AM, Staff D, Physical Therapy Aide (PTA), stated they had been present at the 08/21/2024 IDT meeting and recommended that Resident 1 needed 1 to 1 supervision for their safety. Resident 1 was impulsive, and very anxious. When ambulating, Resident 1 abandoned their walker, was unsteady and unable to understand how to use their call light. The resident's family questioned whether the facility was able to provide the correct level of supervision the resident required, so had requested the resident be transferred. During an interview on 09/30/2024 at 11:30 AM, Staff H, LPN, stated they provided care for Resident 1 on 08/25/2024 when they fell . Staff H stated Resident 1 would become fixated on a phrase and repeat it constantly and would only remain reoriented for about 5 seconds. Staff H stated on the night the resident fell , Resident 1's family was not present, the activity on the unit was chaotic and staff were unable to keep their eyes on the resident at all times. Staff H heard a loud noise and saw Resident 1 in their room in the corner. They had knocked over their oxygen concentrator. The resident kept taking off their oxygen and their oxygen saturation was low so Staff H and an NAC helped the resident back to bed and reapplied their oxygen. Staff H stated before they got back down the hall to the nurse's station, Resident 1 was out of bed running down the hall and the NAC that was near by helped lower the resident to the floor. Staff H stated after that Resident 1 complained of their arm hurting and the provider was notified of the arm pain but Staff H did not remember telling the provider the resident's oxygen saturations were low. During an interview on 10/02/2024 at 10:02 AM with Staff A, Administrator and Staff B, Director of Nursing, Staff B stated Resident 1 was impulsive, lacked safety awareness and had trouble acclimating to the facility. Staff had been instructed to provide frequent rounding, and to keep Resident 1 in areas where more staff were present. Staff A stated the facility did not provide 1 to 1 supervision and there had been confusion among some of the staff regarding providing 1 to 1 supervision but it was the facility's responsibility to provide the appropriate level of supervision for their residents safety. During a telephone interview on 10/02/2024 at 11:39 AM, Resident 1's Representative stated Resident 1 was admitted on a Friday to a room next to the nurse's station and had a roommate. When they came in the next morning, they were notified Resident 1 had fallen. Resident 1 was very agitated and had a terrible Sunday. On Monday, 08/19/2024, they waited over 5 hours for information regarding the resident's plan of care and were unable to talk to the Social Worker. On 08/20/2024, they were called and told they had to have someone stay with Resident 1 twenty-four hours a day and Resident 1 was moved away from the nurse'sstation to a room at the end of the hall where they were alone. Then during the IDT meeting on 08/21/2024, the Representative stated Staff D and Staff E disagreed about what level of supervision Resident 1 needed and what level the facility was able to provide, so the family requested the resident be transferred and the resident fell , broke their arm and was sent to the hospital before the arrangements were made. Reference: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to conduct COVID-19 specimen collection per Centers for Disease Control and Prevention (CDC) guidance, manufacturer's instructions, and facility policy and procedure. Failure to collect nasal specimens from both nostrils as required, increased the likelihood for inaccurate test results, and resulted in the failure to identify COVID positive residents and staff. This failure had the potential to affect all residents who resided in the facility. On 12/16/2020 at 4:15 PM, the facility's Administrator was notified that an Immediate Jeopardy at F886 was identified, related to improper collection of nasal specimens for resident and staff COVID-19 testing. Findings included . Per review of the CDC Interim Guidelines for Collecting, Handling, and Testing Clinical Specimens from Persons for Coronavirus Disease 2019 (COVID-19) (https://www.cdc.gov/coronavirus/2019-nCoV/lab/guidelines-clinical-specimens.html), both nostrils were to be sampled with the same swab, when collecting an anterior nasal specimen. Review of BinaxNOW COVID-19 Ag Card(Abbott), (a rapid [MEDICATION NAME] test that detects [MEDICAL CONDITION] proteins) instructions showed, .Specimen Collection and handling .Inadequate specimen collection or improper sample handling/storage/transport may yield erroneous results. Refer to CDC interim guidelines for collecting .Nasal Swab .To collect a nasal swab sample, carefully insert the swab into the nostril exhibiting the most visible drainage, or the nostril that is most congested if drainage is not visible .Rotate the swab 5 times or more against the nasal wall then slowly remove from the nostril. Using the same swab, repeat sample collection in the other nostril . According to the facility's undated guidelines/policy titled COVID [MEDICATION NAME] Testing - Binax NOW Card (Abbott) and the facility's Competency Check - Binax NOW form dated 09/22/2020, nasal specimens were to be collected from both nostrils, using the same swab. In an interview on 12/16/2020 at 11:20 AM, Staff C, Staff Development/Infection Control Nurse, stated he regularly tested residents and staff for COVID-19 using both PCR (a molecular test that detects genetic material of [MEDICAL CONDITION]) tests and Abbott rapid [MEDICATION NAME] tests (BinaxNOW COVID-19 Ag Cards). Per Staff C, nasal specimens were obtained from only one nostril for both tests. Staff C added the facility followed the guidance from the lab that supplied their PCR test kits for the specimen collection process. Manufacturer's directions for the Abbott rapid tests were reviewed with Staff C, and showed both nostrils were to be swabbed. Staff C stated the facility had updated guidance from the manufacturer. Staff B, Director of Nursing, joined the interview at 11:29 AM, and stated the facility procedure used to process their PCR tests did not give them any instructions on collecting samples, so the facility was using guidance from CDC, which was to use only one nostril. Staff B stated the facility was using the guidance on their corporate competency for the Abbott rapid tests, which per Staff B, was to use one nostril. The corporate competency form was then reviewed with Staff B, and she confirmed it showed nasal specimens were to be collected from both nostrils. Staff B stated staff were only collecting specimens from one nostril for both the PCR tests and the Abbott rapid tests, which they had been using since the beginning of November 2020. In a follow-up interview on 12/18/2020 at 11:30 AM, Staff B stated the facility originally used nasopharyngeal swabs (sample of secretions from the back of the nose and throat), which only required the use of one nostril, for their PCR testing. Per Staff B, sometime in July 2020, the facility had switched to nasal swabs (which required using both nostrils), but continued to use only one nostril. Staff B stated she trained the other staff members who performed COVID-19 testing, and had misunderstood that specimens from both nostrils were required for nasal swabs. Per Staff B, 69 residents and 34 staff had tested positive for COVID-19 since the beginning of the facility's current outbreak, which started the beginning of November 2020. REFERENCE WAC 388-97-1780(1)(2)(c)(d)-Policies and procedures.

Based on observation, interview, and record review, the facility failed to ensure two of 12 sample residents (#5, 6) remained free from abuse, when a facility Certifed Nursing Assistant, (Staff F) engaged in physical and verbal abuse. This failure resulted in harm to both residents, and placed other residents at risk for abuse. Findings included: 1. A review of the 06/28/18 quarterly assessment showed Resident #5 was severely cognitively impaired, had clear speech, was able to make himself understood, and understood others. The resident displayed verbal behavior that did not interfere with care, or put him at risk for physical injury, and had wandering behavior. Additionally, the resident required extensive assistance of one staff for most activities of daily living. According to the resident's care plan, related to an allegation of physical abuse on 07/06/18, staff were directed to provide care in pairs, preferably with female staff, provide 1:1 conversation, back away if the resident became combative, and re-approach with a different caregiver 15 minutes later. Review of a facility incident report by Staff G, Registered Nurse, dated 07/08/18 at 4:45 p.m., showed a family member informed her that on 07/06/18, Staff F, Certified Nursing Assistant, restrained the resident, who now had bruising on his arms. Staff G documented the resident hit Staff F on the thigh, and attempted to hit him again. Staff F placed his hands on the resident's wrists, to prevent the resident from hitting, then let go of the resident, and left the room. Additionally, Staff G documented she had not noticed any bruising when she provided resident care on 07/06/18 and 07/07/18. The note by Staff G showed on 07/08/18, the resident had a two inch purple bruise on the left wrist, and bruising on the right outer arm, with no size/color description. Additionally, Staff G documented she informed Staff F not to provide care to the resident the remainder of the shift on 07/08/18, and informed the on-call manager by telephone. According to a written statement by Staff F, dated 07/09/18, he assisted Resident #5 in getting ready for bed on 07/06/18. Per the statement, Staff F moved the resident's wheelchair to assist the resident, and the resident punched him in the upper right leg. Staff F wrote he intentionally grabbed the resident's forearms, to give himself time to move away, immediately left the room, and notified Staff G. Staff F was not available for interview during the investigation. According to a witness statement dated 07/09/18, the resident was asked by Staff I, Social Services Assistant, if any staff member ever hurt him physically. The resident gave several verbal responses, including that this one lad used too much pressure on his arms, referring to the arm bruises. During observation and interview on 07/12/18 at 4:05 p.m., the resident was in bed. He had a bright red bruise on the right forearm, and a brown bruise on the left forearm. When asked about the bruises, the resident stated they were where he put pressure on my arms. The resident did not give a verbal response to other questions. In an interview on 07/12/18 at 4:50 p.m., with Staff A, Administrator, and Staff B, Director of Nursing, Staff A stated the facility investigation confirmed Staff F had physically abused the resident, and was terminated from facility employment on 07/09/18. Additionally, both Staff A and Staff B confirmed Staff F worked the evening shifts of 07/06, 07/07, and 07/08/18, without being suspended from providing resident care. 2. A review of the 05/29/18 admission assessment showed Resident #6 was moderately cognitively impaired, had clear speech, was able to make herself understood, and usually understood others. The assessment showed the resident displayed no behaviors. Additionally, the resident required extensive assistance of two staff for most activities of daily living. According to the resident's undated care plan related to transfers and mobility, staff was directed to provide extensive assistance of one staff person. In an interview on 07/12/18 at 2:00 p.m., Staff I, Social Services Assistant, stated on 07/09/18, she interviewed Resident #6, who stated that on 07/08/18, Staff F, Certified Nursing Assistant, was mean and handled her roughly, when she went to the bathroom. Staff I stated the resident could not remember Staff F's name, but provided an accurate physical description. On 07/15/18 at 4:10 p.m., the resident was observed and interviewed. The resident was hard of hearing, but was able to communicate with the surveyor speaking into her left ear. The resident stated Staff F was mean to her, stated it happened all the time, and said he shouldn't be working in a nursing home. During a telephone interview with Staff A, Administrator, and Staff B, Director of Nursing, on 07/16/18 at 10:38 a.m., Staff A stated the facility investigation determined Staff F was verbally abusive to the resident. When asked, Staff B confirmed the incident happened on the evening shift of 07/08/18, the same evening Staff G, Registered Nurse, was informed about another resident allegation of physical abuse, involving Staff F. The facility failed to protect Resident #5 from physical abuse, and Resident #6 from verbal abuse, by Staff F. Refer to F609 for additional findings. Reference (WAC) 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure one of four sample residents (#11), reviewed for abuse, remained free from sexual abuse by another resident (#9), who displayed recent sexually inappropriate behaviors. Failure to consistently implement adequate interventions and supervision for Resident #9, resulted in harm to Resident #11, who experienced unwanted inappropriate touching, and placed other residents at risk for episodes of unwanted inappropriate touching. Findings included: A review of the 03/21/18 quarterly assessment showed Resident #11 was severely cognitively impaired, had clear speech, was usually able to make herself understood, and usually understood others. A review of the 04/06/18 significant change assessment showed Resident #9 was moderately cognitively impaired, had clear speech, was able to make himself understood, and understood others. According to the record, on 03/12/18, Resident #9 showed sexually inappropriate behavior toward another resident. On 03/20/18, the facility initiated additional supervision interventions, including every 15 minute checks. A review of an Interdisciplinary Team (IDT) note, dated 04/16/18, showed the facility evaluated the resident's supervision interventions, and determined the resident no longer required 15 minute checks. Review of the facility inservice record titled, Avalon Mandatory Inservice, dated 04/16/18, showed staff was informed that Resident #9 was no longer on every 15 minute checks, and directed that the resident could mobilize throughout the facility, including to other units, but staff were to keep him in supervised areas, and monitor closely any interactions with female residents. According to a witness statement with the date 04/19/18 at 11:15 a.m., on 04/19/18, Staff A, Hair Stylist, exited the beauty salon with another resident. Staff A observed both residents (#9, 11) in the west hallway, to the left of the beauty salon. Resident #9 was removing his hand from under Resident #11's blouse. Staff A observed Staff B, Activity Director, come out of her office with Staff D, Activity Assistant. Staff A reported she overheard Staff B tell Resident #9 to keep his hands to himself, upon which the resident became upset. Per the statement, Staff B brought Resident #11 into the beauty salon with Staff A until 11:50 a.m., when staff assisted the resident to lunch. In an interview on 04/24/18 at 10:30 a.m., Resident #11 had no memory of the incident. When asked how she was doing, the resident stated she was fine, then added there was a lot of investigating going on, and could not explain further. Later in the interview, the resident was asked if she knew any ladies at the facility; the resident stated a few. The resident was asked if she knew any men at the facility; she stated no, said she ignored them, and did not want anything to do with them. During observation on 04/24/18 at 11:15 a.m., Resident #9 wheeled independently in the west hallway. During a brief interview, he greeted the surveyor, and stated, no, when asked for an interview. In an interview on 04/24/18 at 11:55 a.m., Staff B, Activity Director, showed the surveyor that the far side of the west hallway is visible from the beauty salon and activity office. Staff B stated she saw the two residents there when she exited the activity office. When she reached the residents, she stated she saw no staff in the hallway. In an interview on 04/24/18 at 3:45 p.m., Staff A confirmed she saw Resident #9 remove his hand from under Resident #11's blouse. Staff A stated Resident #11 did not appear upset. During an interview on 04/24/18 at 4:25 p.m., Staff C, Director of Nursing, was asked for additional information related to Resident #9's supervision plan, after 15 minute checks were discontinued on 04/16/18; and when staff last observed the resident prior to the incident with Resident #11 on 04/19/18. In a follow-up telephone interview on 04/25/18 at 12:25 p.m., Staff C stated staff was to have heightened awareness, to monitor, and know Resident #9's whereabouts. Additionally, Staff C did not have information related to when staff last checked Resident #9's whereabouts, prior to 11:15 a.m. on 04/19/18. The facility failed to ensure a resident with severe cognitive impairment was protected from being sexually abused by another resident. Once discovered, the facility took immediate action to prevent further reoccurence. Refer to F610 for additional findings. Reference (WAC) 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure one of one sample resident (#46), reviewed for abuse, remained free from sexual abuse by a resident who had displayed past sexually inappropriate behaviors. After an incident of non-consensual sexual contact, the facility failed to ensure the resident who initiated the contact (#9) was adequately monitored to prevent a reoccurrence, and that all staff in the facility were aware of the incident. This failure constituted an immediate jeopardy situation. The jeopardy was removed on 03/22/18, after the facility provided education to all facility staff regarding supervision of location and activities for a resident with sexually inappropriate behaviors, and the facility reviewed resident-to-resident incidents, to ensure necessary education and inservicing was provided to all applicable staff. Additionally, the facility failed to implement a comprehensive process to determine residents' capacity to choose to engage in sexual contact with their peers, for two of two sample residents reviewed. This failure placed residents in the facility identified as participants in a romantic relationship (including Resident #9 and Resident #23), at risk for unwanted sexual contact, and constituted an immediate jeopardy. The jeopardy was removed on 03/22/18, after the facility developed a system to assess residents with cognitive impairment's abilities to consent to sexual contact, audited the facility for other residents who required assessment of their ability to consent, and provided education to staff, related to evaluating the ability of cognitively impaired residents to consent to an intimate relationship. Findings included: Non-Consensual Sexual Contact Review of a facility investigation related to a 03/12/18 incident, revealed Staff I, Nursing Assistant, witnessed male Resident #9 place his hand inside female Resident #46's shirt. The investigation showed: This male resident is cognitively impaired and does not understand boundaries with female residents. Observations throughout the survey, including observation of personal care on 03/26/18 at 7:54 p.m., showed Resident #46 was alert and made vocalizations, but did not speak in a manner which could be understood. Additionally, the observations showed she utilized a wheelchair, and was dependent upon staff for all transfers and mobility. Observation showed, on 03/20/18 at 8:40 a.m., Resident #9 was in the hallway by the front lobby, propelling his wheelchair independently. At 1:13 p.m., the resident was observed propelling himself independently down the east hallway by rooms 223-232. Similar observations of Resident #9 propelling himself independently in his wheelchair were made on 03/21/18, 03/23/18, 03/26/18 and 03/28/18. In an interview on 03/27/18 at 3:04 p.m., when asked about the incident of 03/12/18, Staff I confirmed she witnessed Resident #9 place his hand inside Resident #46's shirt, through the neckline. She stated Resident #9 was not able to differentiate who wanted attention from him, and who did not. When asked about Resident #46's reaction to the contact, Staff I stated she was not able to react. In an interview on 03/20/18 at 11:36 a.m., Staff H, Nursing Assistant, who was working on the West hallway (the area in which both Resident #9 and Resident #46 resided), was asked if she was aware of the incident when Resident #9 sexually touched Resident #46. She stated she had not heard anything about it. In an interview on 03/20/18 at 1:34 p.m., Staff F, Licensed Practical Nurse working on the East hall, stated staff would not know to specifically supervise Resident #9 around female residents, and stated there were inservices (education) provided when there was something to watch for, but she had not received any inservice education about Resident #9 recently. She was not aware of any incidents involving Resident #9. In an interview on 03/20/18 at 1:40 p.m., Staff K, Nursing Assistant working on the East hall, was asked if she was familiar with Resident #9. She stated she was not familiar with the resident, and indicated she would not know of any specific care needs for residents from the other side of the building unless the nurse informed her. In an interview on 03/20/18 at 1:48 p.m., Staff L, Nursing Assistant, stated Resident #9 came to the East side of the building to the day room at times, and he was not aware of any recent incidents involving the resident. Review of the facility's team huddle sheet for 03/12/18 showed 12 staff members were educated after the incident with Resident #9 and Resident #46 that . Male residents displaying sexual behaviors should not be in unsupervised areas with females who are vulnerable or unable to consent. The interviews showed one staff member on the West unit where the residents resided, and three staff members on the East unit where Resident #9 often traveled to, were not aware of Resident #9 touching Resident #46 inappropriately, or the need to ensure he was not left with vulnerable female peers unattended. The staff members who were interviewed and unaware of the situation were not listed among those educated. Resident #9's progress notes also showed he had a history of [REDACTED]. A 07/03/16 progress note showed, Resident went up to female resident in common area, began touching her neck and shoulders outside her clothing, asking for a hug. Female resident . (#29) repeatedly asked him to stop, which he did not . The note further stated that the nurse needed to intervene to stop Resident #9's advances. Per his behavior monitoring record, Resident #9 had sexually inappropriate behaviors between 03/01/17 and 03/20/18 documented on seven occasions. Review of the progress notes described the sexually inappropriate behavior on 03/10/17, showing the resident made explicit sexual comments toward a nursing assistant. A note related to sexually inappropriate behavior on 03/12/18 showed it was referring to Resident #9 touching Resident #46. The other five dates in which sexually inappropriate behaviors were documented did not have an associated progress note describing the behavior. The facility did not provide adequate interventions and supervision of Resident #9, who had displayed previous sexually inappropriate behaviors, to prevent non-consensual sexual contact between Resident #9 and Resident #46. Additionally, after the contact occurred, the facility did not ensure all staff were aware of the incident and alert to the requirement to protect vulnerable residents from unwanted sexual contact by Resident #9. Establishing Capacity to Consent to Sexual Contact A review of Resident #9's care plan identified the resident wished to have physical contact with a consenting female peer, and included the following interventions (initiated 11/04/16): provide a private spot for the resident and female peer, and respect the resident's wishes to have consensual physical contact with female peer. A review of the 03/15/18 quarterly assessment showed Resident #9 was moderately cognitively impaired, had clear speech, was able to make himself understood, and understood others. An assessment dated [DATE] showed Resident #23 had a [DIAGNOSES REDACTED]. The assessment further indicated the resident wandered in the facility. A review of Resident #23's care plan identified the resident wished to have physical contact with a consenting male peer, and included the following interventions dated 11/04/16: provide a private spot for the resident and male peer, and respect the resident's wishes to have consensual physical contact with male peer. In an interview on 03/20/18 at 11:24 a.m., Staff G, Medication Assistant, stated Resident #23 was Resident #9's girlfriend. When asked what sexually inappropriate behaviors Resident #9 exhibited, Staff G stated touching in the hallway. She stated when Resident #9 touched Resident #23 in the common areas by going up (her) shirt or when he would try to go down below with hands, they would take them to a private area, at which point the residents would typically go their own ways. In an interview on 03/20/18 at 1:38 p.m., Staff D, Social Services Director, confirmed that Resident #23 and Resident #9 were in a relationship. When asked how the facility assessed the residents' ability to consent for a physical relationship, Staff D stated she needed to get back to the surveyor with that information. In an interview on 03/20/18 at 1:39 p.m., Resident #23 was asked how long she had been a resident at the facility. She stated she did not know. When asked if she had any special friendships in the facility, she replied in a manner which indicated she did not understand the question. When asked if she had a relationship with any man in the facility, she stated she did not. In an interview on 03/20/18 at 2:10 p.m., Staff A, Administrator, and Staff B, Director of Nursing, were asked how residents in the facility were assessed for their ability to consent to sexual contact. Staff A replied there was no specific assessment which was utilized. The facility policy, related to how the facility assesses a cognitively impaired resident's ability to consent to a relationship with sexual contact, was requested from Staff A. Any assessment of Resident #9's ability to consent to a relationship with sexual contact, as well as assessment of any of his partners was requested. No policy or assessments were provided on 03/20/18. The facility's failure to ensure cognitively impaired residents, who desired to enter into a relationship including sexual contact, were thoroughly assessed for their ability to consent to the relationship, placed the residents at risk for sexual abuse. Reference: (WAC) 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure falls were thoroughly investigated, and fall prevention interventions, specific to resident needs were identified and consistently implemented, for three of six sample residents (#76, 43, 59), reviewed for accidents. Failure to identify possible root causes, and implement effective interventions to prevent frequent falls, resulted in recurrent falls for Resident's #43, 76, 59, and actual harm for Resident #76, who had a fall with fracture. Findings included: 1. According to Resident #76's admission assessment dated [DATE], the resident had a history of [REDACTED]. Per the assessment the resident was not steady on her feet, and required the assistance of one person to transfer and ambulate. An admission fall risk assessment, dated 11/09/17, documented the resident was a fall risk due to having a history of multiple falls, dementia, potential side effects from medication, and decreased muscle coordination. A care plan related to the resident's risk for falls was initiated on admission, with the goal for the resident to be free of falls. The care plan directed staff to: ensure the resident's call light was in reach, encourage the use of the call light, respond promptly to requests for assistance, keep commonly used items within reach, anticipate and meet the resident's needs, keep floors free from spills and clutter, keep bed in low position at night, and have physical therapy evaluate and treat the resident as ordered/needed. The care plan did not include individualized interventions related to the resident's risk factors. Review of the facility's investigation log showed Resident #76 had fallen five times, in the four and a half months since she had been at the facility. Review of a facility investigation revealed on the morning of 11/19/17, the resident was found in her room lying on her side. It was determined the resident had been attempting to self-transfer from her wheelchair to the bed. The resident was assessed to have no injuries from the fall. There was no mention of the resident's footwear at the time of the fall, if the resident's call light had been within reach, or when the resident had last been toileted or seen by staff. The care plan was revised to encourage the resident to remain in an area of high visibility (to provide increased supervision). On 11/30/17, the resident had a second fall. Review of the facility investigation revealed the evening shift nurse entered the resident's room to administer medication, and found the resident sitting on the floor of her room, with her back to the closed bathroom door. The resident did not have a shirt or shoes on. The resident told the nurse she fell trying to get dressed, insisting it was morning. A superficial scratch was observed on her right shoulder. Poor lighting, improper footwear, and the resident's impaired memory were determined to be pre-disposing factors in the fall. There was no mention of when the resident had last been seen by staff. The resident's care plan was revised to include keeping the drapes in the resident's room open to help orientate her to the time of day, offer her an early bed time (between 7:00 - 9:00 p.m.), and ask family to bring in a talking clock, to help cue the resident to the time of day. Despite identifying improper footwear as a factor in the fall, no interventions related to this were added to the resident's care plan. On 12/01/17 (the next morning) Resident #76 had a third fall. The investigation showed the resident was found on the floor next to her bed, calling for help. The resident suffered a scratch to her upper back, and had a bloody nose. The resident stated she had been trying to reach her slippers, and fell out of bed. Care plan revisions included placing the resident's bed against the wall, providing a lipped mattress and a non-skid mat on the floor, as well as providing the resident with a more sensitive call light. Staff was also directed to put the resident's footwear in the closet while the resident was in bed. On 01/27/18 the resident had a fourth fall. Per review of the facility investigation, the resident was found by staff on the floor of her room. The resident stated she was attempting to go to the bathroom by herself, and fell . The resident initially complained of only mild left hip pain, and was assisted to her wheelchair. The investigation did not include an analysis of when the resident had last been toileted or seen by staff, or if care plan interventions had been implemented at the time of the fall (blinds open, call light in reach, etc.). The resident's care plan was revised, and directed staff to offer toileting upon awakening, before and after meals, and at bedtime. Later that evening, the resident complained of increased pain, and was sent to the emergency room . According to a progress note dated 01/28/18, the resident returned to the facility from the emergency room early that morning, after being diagnosed with [REDACTED]. The resident had a fifth fall on 02/25/18. According to the facility investigation, the resident was found on the floor of her bathroom, in a pile of stool. The resident's shoes, pants, and soiled brief were found outside the bathroom, in the resident's wheelchair. The investigation did not include any information regarding when the resident had last been toileted, or seen by staff. Not until after this, her fifth fall, was the care plan revised to direct staff to ensure the resident was wearing non-skid socks at all times. On 03/26/18 at 3:32 p.m., an unidentified male nursing assistant was observed propelling Resident #76 in a wheelchair from her room, with bare feet. The staff member left the resident in her wheelchair in the hallway near the nurse's station, and walked away. In an interview on 03/26/18 at 7:43 p.m., Staff M, Nursing Assistant, stated the only fall prevention measure in place for the resident was to use a gait belt when assisting the resident with transfers. On 03/27/18 at 3:13 p.m., the resident was observed lying in bed with her eyes closed. The window blinds were closed, despite the care plan intervention to keep them open. On 03/28/18 at 8:56 a.m., Resident #76 was observed seated in her wheelchair in her room, with bare feet. On 03/28/18 at 9:32 a.m., Staff N, Nursing Assistant, stated the only fall prevention intervention in place for the resident was to check on her every 30 minutes. On 03/28/18 at 9:45 a.m. when asked what fall precautions were in place for the resident, Staff O, Nursing Assistant, stated staff needed to keep a close eye on the resident, but stated the resident was not on frequent checks. On 03/29/18 at 9:49 a.m., Staff P, Nursing Assistant, stated a non-skid mat, a low bed, and keeping the resident in an area of high visibility, were the only fall prevention measures in place for the resident. In an interview on 03/29/18 at 2:21 p.m., Staff Q, Resident Assessment Coordinator, confirmed she had done the investigations following Resident #76's falls. When asked why interventions such as a toileting program and non-skid socks were not put in place when the resident first admitted , as the resident had a history of [REDACTED]. She explained she tried to relate any new interventions to the specifics of each fall. In an interview on 03/29/18 at 3:21 p.m., Resident #76's falls were discussed with Staff E, Unit Manager. The observations of the resident's fall prevention interventions not being implemented, as well as the interviews revealing staff were not aware of the interventions that were in place, were shared with Staff E. Staff E stated more staff education was needed. In an interview on 03/30/18 at 9:34 a.m., with Staff A, Administrator, and Staff Y, Regional Nurse Consultant, Staff A stated the facility was aware there were issues with falls and fall investigations, and the facility was working on implementing some changes. Staff A stated the facility had been looking at resident falls in isolation, and not always considering the big picture. 2. According to an admission assessment dated [DATE], Resident #43 had [DIAGNOSES REDACTED]. An admission fall assessment dated [DATE] identified the resident was at risk for falls due to a history of falls, visual impairment, decreased muscular coordination, dementia, and potential medication side effects. According to a facility investigation, on 11/15/17 (the day she admitted ) the resident was found sitting on the floor, with her back against her bed. The resident was unable to state what had happened; no injuries were found. The investigation did not include any information regarding the location of the resident's call light, if the resident was wearing any socks/shoes, or when the last time staff had observed or toileted the resident, to try and determine if any of these factors may have contributed to the fall. A care plan related to falls, directing staff to keep the resident's bed in the lowest position against the wall, ensure the call light was within reach and answered promptly, ensure commonly used items were within reach, provide activities that minimize potential for falls while providing diversion and distraction, ensure the floor was free from spills/clutter, and provide adequate lighting, was initiated on 11/16/17. Review of the facility's incident log showed Resident #43 had fallen 10 more times in the first three months she had been at the facility. The subsequent fall investigations revealed the following: 11/19/17 - found on floor in room Resident stated she had been trying to get out of her wheelchair, but was unsure why. No information regarding the call light, footwear, toileting, or analysis of any other factors that may have contributed to the fall. Care plan was updated with the intervention to encourage the resident to remain in a high visibility area. 12/1/17 - fell from wheelchair in hallway Resident stated she was trying to go to the bathroom. No information regarding when the resident had last been toileted. Toileting program was added to the resident's care plan. 12/16/17 - found on floor in room next to wheelchair Resident states she must have slipped out of my chair. No information regarding whether the resident's toileting program was being followed, or any other analysis of why or how she slipped from the wheelchair. Resident's care plan was not revised after this fall. 12/21/17 - found sitting on the floor by her bed Resident stated she was attempting to sit up in bed at the time. No information regarding the resident's call light, footwear, location of her wheelchair, or when she was last toileted or seen by staff. Staff directed to ensure the resident was the first up for dinner and placed in a common area for close observation. 01/17/18 - found on fall mat in room Resident was unable to state why she had been trying to get up. No information regarding when the resident had last been toileted, or analysis of a possible root cause. Care plan was revised to encourage the resident sleep in a recliner in one of the common areas. 01/19/18 - found lying on the floor in her room Resident was unable to state why she had been trying to get up. She had been observed by nursing staff sleeping in her bed (not in a recliner, per her care plan) 20 minutes prior. The investigation did not address why the care plan had not been followed. 01/26/18 - found on fall mat in room Resident had been observed by staff less than 10 minutes prior, sleeping in her bed, not in the recliner, per her care plan. Investigation determined the care plan had not been followed. Care plan was revised to include putting a sign over the resident's bed to remind staff that the resident was to sleep in a recliner in the common area. 02/01/18 - found on floor in hall in front of wheelchair Another resident had attempted to assist Resident #43 to get out of her wheelchair. No information regarding when the resident had last been toileted, or analysis of a why resident attempting to get out of her chair. Care plan revised to include directing staff to provide care if resident is calling out. 02/03/18 - found sitting on floor in front of recliner in common area Resident pulled the lever to drop the foot rest on the recliner, attempted to get up, and fell . No information regarding when the resident had last been toileted, or analysis of why resident was attempting to get out of her chair. Care plan revised to instruct staff to place resident in an electric recliner. 02/23/18 - found sitting on floor in front of recliner Resident stated wanted to go downstairs. No information regarding when the resident had last been toileted or seen by staff, or if resident had been in the proper recliner. Care plan revised updating the sign in the resident's room to indicate which recliner the resident was to use. In an interview on 03/29/18 at 2:21 p.m., Staff Q, Resident Assessment Coordinator, confirmed she had done the investigations following Resident #43's falls. Staff Q added she was no longer doing fall investigations, that Unit Managers had recently taken that job over. Resident #43's falls were reviewed with Staff Q. Staff Q stated the resident just wouldn't stay in bed, kept crawling out, and couldn't comprehend anything. Staff Q did confirm the resident was supposed to be in a recliner in the common area, when she fell on [DATE]. In an interview on 03/30/18 at 9:34 a.m., with Staff A, Administrator, and Staff Y, Regional Nurse Consultant, Staff A stated the facility was aware there were issues with falls and fall investigations, and the facility was working on implementing some changes. 3. Per record review, Resident #59 had a [DIAGNOSES REDACTED]. The resident's comprehensive assessment, dated 03/14/18, indicated the resident was alert, oriented, and able to make her needs known. The assessment also identified the resident needed limited assistance from staff with walking in her room and in the hallway. Review of the 12/07/17 incident report showed the resident fell on [DATE], when she tripped over the wheel of a four-wheeled walker, when walking by herself in her room. The investigation determined the fall was unavoidable, as the resident was cleared to ambulate independently in her room at that time. The resident's care plan was revised to include having therapy re-evaluate the resident, and to recommend treatment for [REDACTED]. Review of the therapy notes dated 02/28/18 showed therapy recommended the resident should ambulate to and from the bathroom with stand-by assistance, using the four-wheeled walker, and ambulate to/from the dining room with stand-by assistance, using the four-wheeled walker. The therapy recommendation was added to the resident's care plan for physical mobility on 03/05/18. Observation of the resident on 03/23/18 at 11:58 a.m. showed the resident was sitting in the west dining room, waiting for lunch. Later that day at 1:33 p.m., the resident was observed pushing her four-wheeled walker, ambulating down the hallway by herself. A staff member met the resident halfway, and walked with her to the beauty shop, to have her hearing aids adjusted. On 03/28/18 at 11:15 a.m., the resident was observed standing in her room; the walker was by the sink. The resident walked over to closet to get a hairbrush, and when walking back to the sink, tripped on the back wheel of the walker, but regained her balance and did not fall. At 11:31 a.m. the same day, she walked to the dining room by herself, and sat down at a table. When asked about her fall on 12/06/17, the resident stated she should have had staff walking with her, but stated that was not possible, because they (staff) did not have the time. On 03/28/18 at 1:48 p.m., Staff T, Nursing Assistant, stated she occasionally assisted Resident #59 with care, and said the resident needed guidance from staff with ambulation. Staff T did not state the resident needed stand-by assistance, when ambulating to/from the dining room. On 03/28/18 at 1:57 p.m., Staff R, Nursing Assistant, stated the resident needed limited assistance from staff when ambulating. When asked what instructions staff received regarding fall prevention for Resident #59, Staff R did not identify the resident needed stand-by assistance, when walking to/from the dining room for meals. On 03/28/18 at 2:12 p.m., Staff S, Nursing Assistant, stated the resident needed stand-by assistance from staff when she ambulates, but said the resident usually didn't use her call light to ask for assistance. Staff S indicated the resident was not stable on her feet, and needed staff assistance. On 03/28/18 at 3:24 p.m., Staff AA, Occupational Therapist, stated following the fall on 12/06/17, therapy did not want the resident walking by herself, and recommended staff walk with her. Staff AA stated this was part of the resident's mobility care plan, which was posted in her room. On 03/29/18 at 11:08 a.m., the resident was observed walking to the dining room with her four-wheeled walker, and no staff assistance. On 03/29/18 at 1:05 p.m., Staff C, Unit Manager, confirmed the resident was cleared by therapy following the fall to walk with staff, using her four-wheeled walker. Observations of the resident ambulating without staff assistance were shared with Staff C. Staff C stated staff were expected to follow the resident's plan of care, which directed stand-by assistance with ambulation (as a fall prevention measure). Reference WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to implement resident-directed care, according to the resident's stated preference, for one of three residents (#3), reviewed for quality of care. Failure to honor Resident #3's expressed caregiver preference, following an incident of alleged staff to resident verbal abuse, caused psychosocial harm to Resident #3. Findings included: Per the State Operations Manual, November 2017 (Appendix P, Section IV, E, Psychosocial Outcome Severity Guide, Severity Level 3) shows noncompliance resulting in actual harm, can include but may not be limited to clinical compromise, decline, or the resident's inability to maintain and/or reach his/her highest practicable well-being. Examples of negative psychosocial outcomes, as a result of the facility's noncompliance, may include but are not limited to: tearfulness, chronic or recurrent fear/anxiety that has compromised the resident's well-being and that may be manifested as avoidance of the fear-inducing situation(s) or person(s); and/or verbal expressions of fear. Resident #3 admitted to the facility in February 2017. Review of her 11/02/17 facility assessment showed she had multiple medical [DIAGNOSES REDACTED]. The assessment also showed she required assistance from staff for most activities of daily living, including toileting and medication administration. On 01/23/18, the facility assessed the resident as cognitively intact. Review of a facility investigation regarding alleged verbal abuse, dated 01/03/18, revealed Staff H, Medication Assistant-Certified (MAC), was rude to Resident #3, and spoke to her in a brusque manner. The investigation also showed Resident #3 asked for Staff H to discontinue providing medications or care to her. The most current care plan, dated 01/08/18, included interventions related to the allegation, but no specific information related to a caregiver preference. Further review of the facility's investigation, showed a 01/03/18 social service progress note. The note read in part: Resident #3 was told by staff person she was impatient and spoiled. Resident #3 reported that Staff H, MAC, spoke to her in a brusque manner, and would prefer not to receive care from Staff H. The 01/03/18 investigation ruled out verbal abuse by Staff H, MAC, but an action plan was developed, to be implemented upon her return to work (she had been suspended pending the outcome of the investigation). In the plan, Staff H was told she was able to return to work, with the restriction of not caring for Resident #3. In an interview with Resident #3 on 01/23/18 at 1:45 p.m., the resident stated during a day sometime before Christmas, she needed to use the restroom, and put on her call light. The resident stated Staff H, MAC, entered the room, and in a rude tone, called Resident #3 impatient and a spoiled brat. Resident #3 stated she had a difficult time over the holidays (stating she was in a slump), and reported the incident to staff on 01/03/18. After discussing the incident with staff, she requested Staff H no longer provide care and/or medications to her. Resident #3 stated she was worried about getting her medications from Staff H, who she thought was mad at her (for reporting the incident on 01/03/18). Resident #3 was tearful during the interview, and stated despite her request, Staff H had continued to provide medications to her for several shifts. During an interview on 01/23/18 at 5:10 p.m., Staff G, Nursing Assistant-Certified (NAC) stated she worked on the same hallway as Staff H, MAC, which included Resident #3's room. Staff G confirmed Staff H regularly provided medications to all the residents on the hallway, which included Resident #3. In an interview with Resident #3's family member on 01/25/18 at 1:05 p.m., she stated she was aware of the allegation reported by Resident #3 on 01/03/18. The family member stated facility staff had contacted her following the reported incident, and told her Staff H, MAC, would not provide care or medications to Resident #3. In an interview on 01/24/18 at 1:34 p.m., a staff member who wished to remain anonymous stated, a meeting was held the evening of 01/23/18 (after the surveyor left the facility). During the meeting, Staff C, Registered Nurse, was instructed to alter Resident #3's medication record, if Staff H's initials appeared on 01/03/18 (the date the resident initially reported the incident), or any day afterwards. On 01/24/18 at 1:51 p.m., Staff E, Registered Nurse (RN), provided a facility Medication Administration Record [REDACTED]. Staff H's initials were struck out on the report, and Staff C's initials were underneath - dated 01/23/18, with time stamps between 19:00 to 19:07 (7:00 to 7:07 p.m.) The report revealed Resident #3's Medication Administration Record [REDACTED]. The facility failed to ensure the resident did not receive care and/or medication from Staff H, as she requested, after an incident which caused her distress. As a result, Resident #3, who tearfully recounted the incident several weeks later, continued to have anxiety because Staff H remained involved in her care, and the resident expressed fear of retaliation. (For additional information, see CFR 483.21(b)(3)(i), F-658 - Services Provided Meet Professional Standards) Reference: (WAC) 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to monitor weights, and implement and/or re-evaluate interventions related to weight loss, for 5 of 7 residents (#118, 131, 182, 227, 229) reviewed for nutrition, in a sample of 36. This failure resulted in harm for Resident #131, who lost an additional 25% in 7 weeks, after being identified with significant weight loss, and Resident # 229, who had a 20% weight loss in 11 days. Findings include: 1. Resident #131 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident required assistance with some activities of daily living, was able to make her needs known, and received [MEDICAL TREATMENT] (a process to filter blood to maintain kidney function) three times a week. Per the facility's Dietary Guidelines Manual, dated January 2014, residents were to be weighed weekly for the first four weeks after admission. Weekly weights were also indicated for residents who had significant weight loss. Weights for [MEDICAL TREATMENT] residents were to come from the [MEDICAL TREATMENT] center. A Mini Nutritional assessment dated [DATE] documented the resident weighed 179 pounds (lbs.). An undated care plan, related to nutrition and hydration, included the interventions: to monitor the resident's weight routinely, and report significant weight changes to the physician and dietician. An undated care plan for activities of daily living included an intervention to obtain weights weekly. An undated care plan for [MEDICAL TREATMENT] included interventions to monitor the resident for fluid volume deficit and/or excess. Review of Resident #131's record revealed the following documented weights: 11/25/15 - 169.4 lbs., 11/28/15 - 169.4 lbs., 12/01/15 - 166.8 lbs. A progress note from Staff L, Registered Dietician (RD), dated 12/01/15, indicated the resident had a 5% weight loss, which was identified as significant. The weights used to determine this loss were not documented in the note. Staff L's goal for the resident was weight maintenance, and she recommended large portions to help the resident meet nutritional needs in regards to [MEDICAL TREATMENT]. The order was written on the same day. A nutrition progress note dated 01/12/16, indicated the resident had lost approximately 3 more pounds. The weights used to determine this loss were not in the note. There had been no other weights documented in the record since 12/01/15. The next documented weight in the resident's record was 125 lbs. on 01/18/16 - seven weeks after the resident's initial weight loss had been identified. This represented an additional 25% weight loss. There was no documentation found regarding any weights obtained by the [MEDICAL TREATMENT] center. A progress note dated 01/25/16 revealed Staff J, Dietary Manager, believed the facility's weights from November and December 2015 were inaccurate, and contacted the [MEDICAL TREATMENT] center to obtain a current weight. Per the [MEDICAL TREATMENT] center, the resident weighed 118.5 lbs. as of 01/22/16. There was no indication the facility confirmed whether or not the November and December 2015 weights were accurate or inaccurate, by contacting and obtaining weights from the [MEDICAL TREATMENT] center, until 01/22/16. A nursing progress note on 02/02/16 revealed the resident's physician had been notified of the weight loss. an order for [REDACTED]. In an interview on 02/09/16 at 9:47 a.m., Staff L, the RD, said she routinely gets a weekly report, identifying residents with weight loss. She then makes recommendations, and gives them to the Unit Manager, Director of Nursing, and Administrator. It is the Unit Manager who then follows up on the recommendations, and ensures any additional monitoring. She confirmed the facility should have been monitoring Resident #131's weight more closely. On 02/10/16 at 10:37 a.m., Staff I, Unit Manager, stated the resident had significant [MEDICAL CONDITION] (accumulation of excess fluid in body tissues), when first admitted , and had been receiving [MEDICATION NAME] (a medication that promotes fluid loss). She explained the [MEDICAL TREATMENT] center generally took the resident's weight pre/post [MEDICAL TREATMENT], but the facility had been having a difficult time communicating with the center. Review of the resident's [MEDICAL CONDITION] monitor from 11/17/15 through 1/31/16 documented [MEDICAL CONDITION] in the resident's lower extremities, ranging from none to 1+ (slight). In addition, a Physician's Progress Note, dated 12/16/15, indicated the resident had no [MEDICAL CONDITION]. There was no care plan or assessment, found in the record, regarding expected and/or planned weight loss, due to treatment for [REDACTED]. Upon questioning by the surveyor, facility staff provided a weight report from the [MEDICAL TREATMENT] center, which they received on 02/08/16. The report confirmed the weights the facility had for November and December 2015 were accurate. Per the [MEDICAL TREATMENT] weights, Resident #131 had a weight loss of 53 pounds (30%), from the date of admission through 02/02/15, when the physician was notified. On 02/11/16 at 8:57 a.m., Staff I said after residents were identified with significant weight loss, the Medical Director would be consulted for orders. Weights would then be done weekly. When asked about the lack of documented weights for Resident #131 between 12/01/15 and 01/18/15, Staff I stated she did not know what happened, and the facility had just missed it. 2. Resident #229 admitted on [DATE], with [DIAGNOSES REDACTED]. Review of Resident #229's hospital discharge orders, dated 01/21/16, revealed the resident was to continue with the current diet orders, which included a supplement drink three times a day, with each meal. Review of the facility's diet memo and diet orders, dated 01/21/16, revealed the order for the supplement did not get transcribed onto the current orders for care at the facility. On 02/08/16 at 3:32 p.m., Staff F, LN (Licensed Nurse), confirmed she processed Resident #229's admission orders [REDACTED]. Additionally, record review revealed on 02/02/16, there was a nutritional assessment completed by a Registered Dietitian, which identified the resident had a weight loss of 2% in 7 days. In addition to other interventions, the Dietitian recommended a trial of supplements for this resident (which she should have been receiving since 01/21/16). Review of the current treatment orders (February 2016) documented the resident was started on a supplement 02/05/16 (3 days after the Dietitian made the recommendation, and approximately 14 days since it was originally ordered upon admission to the facility). On 02/09/16 at 3:31 p.m., Staff I, Nurse Manager, confirmed she does the follow up with the Dietitian's recommendations, but did not do so in a timely manner in this instance. When asked about the processing of the dietary order from the hospital, Staff I stated they also missed the original supplement order. Review of the facility's weight monitoring record revealed that on 01/21/16, the resident weighed 98 lbs. On 01/25/16 the resident weighed 93 lbs. (a 5 pound weight loss in 4 days), on 02/01/16 77.8 lbs. (a 15 pound weight loss in 7 days), and on 02/08/16, the resident's most recent weight was 77.2 lbs. The comprehensive assessment dated [DATE] referenced the resident's weight on admission of 98 pounds. This assessment did not identify the resident had a weight loss of 5 pounds on 01/25/16, when she weighed 93 lbs. (which was a 5% weight loss in 4 days). The 01/21/16 nutrition plan of care included interventions such as: allowing the resident enough time to eat her meals, and to feed or cue the resident to eat as needed. Staff were to monitor the resident's food intake, and inform the doctor and dietician of significant changes in intake. In addition, staff were to monitor the resident's weight routinely and report significant weight changes to the doctor and dietitian. On 02/08/16 at 12:35 p.m., Staff G, Director of Social Services, was observed delivering Resident #229 her lunch tray, and left the room. The resident was in bed, her eyes were closed, her lunch tray was on the bedside table, and the main dish was left covered. At 12:42 p.m., the resident was still in bed, her eyes were closed, and her lunch tray was untouched. At 1:02 p.m., the resident was still in bed with her eyes closed, her lunch was untouched. At 1:14 p.m., Staff S, nursing assistant, checked on the resident to see how she was doing with her lunch. Review of the meal intake monitor provided by Staff I, Unit Manager, on 02/08/16 revealed the resident ate 50% of her lunch earlier that day. In addition, there was documentation of the resident's meal intake for only 11 out of the 17 days the resident was in the facility. On 02/08/16 at 3:02 p.m., Staff J, Dietary Manager, stated she enters resident weights into the electronic record. Staff J confirmed she monitors resident weights, and notifies the RD and the Unit Manager if there was a concern about weight changes. Review of the progress notes for the resident revealed on 02/01/16 Staff I, Unit Manager, documented the resident's physician was notified of a weight loss, from 98 lbs. on admission, to 93 lbs. on 01/25/16. There was no indication the physician was notified of the further weight decline, to 77.8 lbs. on 02/01/16. Additional record review revealed on 02/02/16 there was a nutritional assessment completed by a Registered Dietitian (RD). This assessment was based off the resident's weight of 93 lbs. on 01/25/16, rather than the most recent weight 77.8 lbs., as of 02/01/16. It was identified on this assessment that the resident had a weight change of 2% in 7 days, which was inaccurate. The nutrition goal at that time was to maintain the resident's weight, and to add nutritionally enhanced meals, try smaller portions, and to start a trial of supplements. On 02/09/16 at 10:27 a.m., Staff L, a RD, stated she was at the facility once a week, and sometimes it would be 14 days before she could do an inital nutritional assessment on a newly admitted resident (the resident was admitted on [DATE], and the RD assessed the resident on 02/02/16). Staff L said she was not aware of the resident's weight change on 02/01/16. On 02/09/16 at 3:31 p.m., Staff I, Unit Manager, stated she was not aware of the resident's weight change from 01/25/16-02/01/16. Staff I confirmed there was a problem with the process, because the we6ight information should have been communicated to her and the RD sooner. In addition, Staff I said she expects staff to consistently monitor meal intake for residents who have that as part of their care plan (and are at high risk for weight loss). The facility failed to provide nutritional supplements timely as ordered, monitor weights and food intake as ordered, and assess significant weight loss timely. 3. Resident #227 admitted to the facility on [DATE], and had care needs related to medical conditions including malnutrition. Review of the record revealed Resident #227 received all of her nutrition from tube feeding; however, her care plan of 02/08/16 instructed staff to allow the resident enought time to eat, encourage her to drink fluids, and to offer snacks. The care plan also directed staff to monitor weights routinely, and report significant weight changes to the doctor and dietitian, but did not specify how often routine weights should be done. In an interview on 02/11/16 at 12:26 p.m., Staff N, Registered Nurse, stated the interventions including allowing time to eat, and allowing food preferences were not appropriate for this resident. She stated the care plan addressed her tube feeding site under skin integrity, but said, I don't really see where she has (a care plan) to address specifics of her tube feed (and) nutrition. According to the facility Dietary Guidelines Manual, revised 01/14, indications requiring residents to be weighed weekly included: if they were under 100 pounds, on a tube feeding (until they were stable), and new admissions for four weeks (or until they were stable). According to the computerized weight documentation for Resident #227, the facility only obtained one weight between her admission on 01/14/16, and 02/11/16. The weight was 84.2 lbs. on 01/27/16, showing the resident was significantly underweight. Although the resident met several criteria that would require weekly weights per the policy, she was not weighed again until staff was asked what the current weight was by the surveyor on 02/11/16. A nutrition note by Staff L, the RD dated 01/26/16 reported Resident #227 was at her normal weight. In an interview on 02/09/16 at 3:26 p.m., Staff L confirmed there was not a facility weight recorded prior to that time, and stated she may have based her assessment on the hospital weight, which may be incorrect. In an interview on 02/10/16 at 3:49 p.m., Staff H, Unit Manager, stated newly admitted residents should be weighed within 24 hours of admission. She confirmed the only weight recorded for Resident #227 was on 01/27/16, almost 2 weeks after she admitted . When asked the appropriate length of time between weights for Resident #227, Staff H indicated the resident should be weighed weekly. 4. Resident #118 admitted to the facility in September 2014, and had [DIAGNOSES REDACTED]. Observation during the survey period, including on 02/08/16 at 6:16 p.m. and 02/09/16 at 9:13 a.m. revealed Resident #118 required cueing and occasional physical assistance with meals. Review of the weight record for Resident #118 revealed significant weight loss, from 100.8 lbs. on 12/07/15, to 93.8 lbs. on 12/28/15 (a 7% loss), and then a further decrease to 89.8 lbs. on 01/08/16, and 89.6 lbs. on 01/11/16 (a total loss of 11%). The weight record printed 02/08/16 showed no weights recorded after 01/11/16. No notes in the record were found to show the weight loss on 12/28/15 was identified, or that new interventions were put in place in a timely manner for Resident #118. In an interview on 02/09/16 at 3:24 p.m., Staff L stated she followed Resident #118 monthly. She said she reviewed weights early in the morning weekly, when she was in the facility, and sometimes the weights were entered into the computer after she had finished her review so she did not see them. In an interview on 02/11/16 at 8:50 a.m., Staff I, Unit Manager, confirmed there were no notes indicating the weight decrease on 12/28/15 was identified, or that staff followed up on the issue until 01/08/16. 5. Resident #182 admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. According to the facility Dietary Guidelines Manual, weekly weights should be obtained for new admissions until they were stable, and If the change (loss or gain) is 2% or more on weekly weights; then a narrative note needs to be completed . the main information that needs to be documented is why the change . Review of the weights for Resident #182 revealed she was 180 lbs. on admission (08/30/15), and decreased to 173.2 lbs. on 09/18/15, a change of 3.8 %, with no weekly weights in between. The first note in the record, which mentioned her weight, was on 10/08/15, and did not address the weight loss. In an interview on 02/11/16 at 8:42 a.m., Staff I indicated she was not aware of any reason Resident #182 would not have weekly weights upon admission. A progress note on 10/27/15 by Staff J indicated the weight recorded on 08/30/15 was from the hospital so not sure we have a loss. This would indicate the resident was first weighed in the facility almost 3 weeks after admission. Per the record, Resident #182 experienced another weight loss, from 173.4 lbs. on 11/09/15, to 164.4 lbs. on 12/02/15, a 5.2% change. A nutrition note dated 12/07/15 referenced the 173.4 pound weight, but did not identify the weight loss on 12/02/15. Per the notes, the doctor was notified of a weight loss on 12/14/15, 12 days after the fact. In an interview on 02/11/16 at 8:40 a.m., Staff I confirmed no follow-up was documented related to Resident #182's weight loss between 12/02/15 and 12/14/15. Further review of the record revealed the RD saw the resident for the first time on 12/21/15, although she had an initial weight loss on 09/18/15, and another decrease on 12/02/15. In an interview on 02/09/16 at 3:21p.m., Staff L confirmed Resident #182's nutritional concerns and weight loss were first brought to her attention on 12/21/15.

Based on interview and record review, the facility failed to provide necessary supervision, and use compatible equipment, to ensure that 1 of 3 sample residents (#1), was transferred according to facility policy and the plan of care. This failed practice resulted in actual harm to Resident #1, who fell out of a mechanical lift onto the floor, and sustained injuries. Findings included: Resident #1 had [DIAGNOSES REDACTED]. According to the most recent facility comprehensive assessment dated [DATE], the resident required maximum assistance for transfers. Per review of the most recent care plan, dated 06/27/14, Resident #1 required total assist of 2 staff, using a passive mechanical lift (an assistive device used to transfer using a sling and hydraulic power). Facility policy indicated two staff were required for all passive mechanical lift transfers. According to the record, Staff #A was assisting Resident #1 out of bed using the mechanical lift, and a sling she had taken from the facility laundry. As soon as the resident was lifted off the bed, the sling straps detached from the lift, causing the resident to fall to the bed, and then to the floor, striking her head. The resident was transported to the hospital, and diagnosed with [REDACTED]. Per the facility investigation, the sling used in the transfer was not compatible with the lift. The sling used for the transfer came from the hospital, and was not an approved product. According to Staff #A's statement, she had not used that type of sling previously. The noncompatible sling had black plastic clips, compared to the nylon straps of the compatible slings. It was also confirmed she did not have the second staff member assisting with the transfer. Per interview with Staff #B on 06/10/15 at 3:10 p.m., after the incident, 3 noncompatible slings were removed from the facility, and all staff were re-educated on the use of compatible slings, as well as the requirement of 2 staff with passive mechanical lift transfers. The facility analysis verified Resident #1 was injured, as a result of Staff #A not using the correct sling, and not having a second staff person present at the time of transfer. The facility failed to ensure Resident #1 was safely transferred with a passive mechanical lift, following both facility standard of care, and care plan directive. As a result, the resident fell and required hospitalization for injuries.

Based on observation, interview, and record review, it was determined the facility failed to ensure that 1 of 11 sample residents reviewed for medications (#1) was free from significant medication errors. Resident #1 received doses of short-acting and long-acting insulin, and blood pressure medication in error that were ordered for Resident #2. This significant medication error resulted in harm to Resident #1 who required hospitalization to treat symptoms of low blood pressure and low blood sugar. Findings include: See F281 Services Provided Meet Professional Standards of Quality for additional details. Resident #1 had [DIAGNOSES REDACTED]. Per record review, the resident had memory problems. The resident's medication orders included one blood pressure medication and a diuretic every morning. Resident #2 was Resident #1's room-mate. Resident #2 had [DIAGNOSES REDACTED]. Per record review, the resident had no memory problems. The resident's medication orders included long-acting insulin injections twice daily, short-acting insulin injections before each meal, 3 blood pressure medications each morning, and one heart medication twice daily. Per record review, on 3/21/13 at 8:00 a.m., Staff #A was passing medications to residents on the West unit long hall. A student nurse approached Staff #A and stated she was checked off to give medications and check blood sugars. Staff #A asked the student nurse to check Resident #2's blood sugar, draw up the resident's insulin, and administer medications. Staff #A (a licensed nurse) prepared Resident #2's oral medications; including 3 blood pressure and one heart medication. He watched the nursing student draw up 30 units of short-acting insulin in one syringe and 30 units of long-acting insulin in a separate syringe. He checked the syringes, gave the student nurse the syringes and the oral medications he had prepared, and instructed the student nurse to administer the medications to Resident #2. Staff #A did not accompany the student nurse to the resident's room to ensure the student nurse had identified the right resident prior to administering the medication. Per record review, the student nurse returned to Staff #A a few minutes later with questions about how the resident took the insulin. Staff #A responded to the questions. The nursing student went back to the resident's room and returned a few minutes later with additional questions. Staff #A met the nursing student in the residents' room and found Resident #2 asleep. The nursing student called Staff #A to Resident #1's bedside and identified Resident #1 as the resident she administered insulin to, Staff #A immediately notified the supervisor. Per record review, by 9:00 a.m., the resident experienced low blood sugars and low blood pressure. The physician ordered intravenous fluids. By 11:00 a.m., the resident was difficult to arouse and was transferred to the hospital for treatment. Review of hospital records dated 3/21/13 revealed the resident was treated for [REDACTED]. and slow heart rate, all related to receiving incorrect medications. In an interview on 3/25/13 at 1:30 p.m., Resident #1 was in a wheelchair and responded positively to his name. In an interview on 3/25/13 at 4:00 p.m., Resident #2 was alert & oriented; he reported no problems with his medications. In an interview on 3/25/13 at 4:50 p.m., Staff #B stated Staff #A should have administered the medications he prepared to Resident #2 and not handed them to the student nurse to administer. The facility's failure to ensure all licensed staff safely administered medications and supervised nursing students administering medications resulted in a signifcant medication error and harm to Resident #1.

Based on interview and record review, it was determined the facility failed to ensure licensed nurses followed professional standards of quality related to safe medication administration when a licensed nurse prepared oral medications for a resident and handed them to a nursing student to administer. In addition, the licensed nurse did not ensure the student identified the right resident prior to administering the oral medication and 2 doses of insulin in error. As a result, Resident #1 received doses of short-acting and long-acting insulin and blood pressure medication in error, that were ordered for Resident #2. The facility's failure to implement professional standards of practice related to medication administration resulted in harm to Resident #1 who required hospitalization to treat symptoms of low blood pressure and low blood sugar. Findings include: See F333 Residents Free From Significant Medication Error for additional details. The facility policy General Guidelines for Medication Administration included the following: -The person who prepares the dose for administration is the person who administers the dose. -Residents are identified before medication is administered. Methods of identification include: A. Checking identification band. B. Checking photograph attached to the medical record or the medication administration record. C. Calling resident by name. D. If necessary, verifying resident identification with other facility personnel. During the investigative visit, the facility did not have a written policy/procedure that addressed licensed staff responsibilities for ensuring student nurses consistently followed facility procedures for safe medication administration. Resident #1 had [DIAGNOSES REDACTED]. The resident's medication orders included one blood pressure medication and a diuretic every morning. Resident #2 was Resident #1's room-mate. Resident #2 had [DIAGNOSES REDACTED]. The resident's medication orders included long-acting insulin injections twice daily, short-acting insulin injections before each meal, 3 blood pressure medications each morning, and one heart medication twice daily. Per record review, on 3/21/13 at 8:00 a.m., Staff #A (a licensed nurse) was passing medications to residents on the West unit long hall. A student nurse approached Staff #A and stated she was checked off to give medications and check blood sugars. Staff #A asked the student nurse to check Resident #2's blood sugar, draw up the resident's insulin, and administer medications. Staff #A prepared Resident #2's oral medications, including 3 blood pressure and one heart medication. He watched the nursing student draw up short-acting insulin in one syringe and long-acting insulin in a separate syringe. He checked the syringes, gave the student nurse the syringes and the oral medications he had prepared, and instructed the student nurse to administer the medications to Resident #2. Staff #A did not accompany the student nurse to the resident's room to ensure the student nurse had identified the right resident prior to administering the medication. Per record review, the student nurse administered all the medications to Resident #1 rather than Resident #2. Staff #A discovered the error when he met the student nurse in the residents' room to respond to the student nurse's additional questions about the medications. Staff #A immediately notified the supervisor. Per record review, the resident experienced complications and was transferred to the hospital before noon, where he was treated for [REDACTED]. In an interview on 3/25/13 at 4:50 p.m., Staff #B stated Staff #A should have administered the medications he prepared to Resident #2 and not handed them to the student nurse to administer. Regarding student nurses in the facility, Staff #B stated student nurses were in the facility for clinical training on Thursdays. Each student had assigned residents they were prepared to care for. The facility licensed nurse responsibilities for supervising a student nurse included the student only administering medications to the residents to which they were assigned and only under the direct supervision of the facility licensed nurse. Staff #B stated during investigation of the medication error, Staff #A stated he did not know he was not supposed to ask students to administer medication he prepared, and was supposed to watch the nursing students administer medications to the residents. When asked by the surveyor, Staff #B stated the facility had no written procedures and/or instructions about licensed nurse responsibilities for supervising student nurses. In an interview on 3/25/13 at 12:13 p.m., Staff #C stated she learned about supervising student nurses while in facility orientation from the licensed nurse who oriented her to medication pass. In an interview on 3/25/13 at 12:40 p.m., Staff #D stated nursing students only passed medications to residents to whom they were assigned. He stated he relied on the student nurses to inform him if they were observing or if they were approved by the nursing instructor to pass medications with his supervision. In an interview on 3/25/13 at 2:10 p.m., Staff #E stated the nursing instructor told her when the students were approved to pass medications. She stated usually the nursing students were not approved to administer insulin right away. She stated sometimes nursing students asked to do more than pass medications to their assigned residents but she told them no. In an interview on 3/26/13 at 7:50 a.m., Staff #A stated he worked evening shift until a few weeks ago and 3/21/13 was the first time he had supervised a student nurse. He stated the nursing student told him she was signed off on medication pass. He stated he did not check with the nursing instructor about what the nursing student could safely do before asking the nursing student to administer medications. The facility's failure to ensure all licensed staff consistently followed professional standards of quality related to safe medication administration, including ensuring nursing students consistently followed the same professional standards of quality for medication administration, resulted in harm to Resident #1.