Every finding on record at Avalon Healthcare Bellingham

Based on observation, interview, and record review, the facility failed to provide the necessary care and services related to restorative nursing programs (RNPs) for 3 of 5 residents (Resident 47, 65, and 67) reviewed for positioning, mobility, and range of motion. The failed practice placed residents at risk for a decline in function, contractures (shortening and hardening of muscles, tendons leading to deformity and rigidity of joints), pain and increased dependency on caregivers.Findings included . Review of the facility policy titled Restorative Nursing Programs dated June 2018 documented the facility provides services, care and equipment to assure that a resident maintains and/or improves his/her level of range of motion and mobility unless a reduction is clinically unavoidable. The facility guidelines showed residents would be routinely assessed for the need of a formalized RNP. Care and assistance will be provided, consistent with the resident's goals and preferences, for devices. According to the Resident Assessment Instrument Manual (provides guidance for completion of the Minimum Data Set - MDS) the following criteria must be met for RNPs: - The program must have measurable objective goals and interventions must be documented in the care plan and in the medical record. - There needs to be evidence of periodic evaluation by the licensed nurse that must be present in the resident's medical record. - Nursing Assistants (NAs) must be trained in the techniques that promote resident involvement in the activity; and - A Registered Nurse (RN) or a Licensed Practical Nurse (LPN) must supervise the activities in an RNP. <RESIDENT 47> Resident 47 was admitted to the facility on [DATE], with diagnoses to include hemiplegia and hemiparesis (paralysis and weakness on one side) following cerebral infarction affecting the left non-dominant side, weakness and impaired physical mobility. Review of the quarterly MDS assessment, dated 11/11/2025, showed Resident 47 utilized a wheelchair and had limited range of motion in one side of upper and lower extremities. The resident received splint or brace assistance, active and passive range of motion (AROM) on two days of the seven-day lookback period, and they did not reject care. Review of Resident 47's current care plan directed staff to provide a RNP to maintain ROM and maintain functional mobility secondary to decreased mobility related to stroke. The nursing staff were to provide ROM to left hand, including fingers and wrist, provide hygiene and gentle stretching to left hand prior to donning palm protector to their left hand as tolerated for 15 minutes. Nursing staff were to provide gentle prolonged stretch and passive ROM to their hips/knee/ankle. The staff were to provide passive ROM to bilateral upper extremities (shoulder, elbow, and wrist) for 5-10 reps at each joint, for 15-20 minutes or as tolerated with morning and bedtime cares. The goal was to maintain range of motion and have no change in joint mobility. The care plan did not specify how many days the program was to occur. Review of the clinical record showed the last evaluation of the RNP was completed on 01/10/2025. The note showed physical therapy (PT) demonstrated the resident's new arm straightener a metal piece with three Velcro straps that was to be worn ideally for 4 to 6 hours daily. The note did not include an assessment of the resident's current function, participation, tolerance to orthotic devices or range of motion. There were no further evaluations documented. Review of the occupational therapy (OT) evaluation and plan of treatment on 11/11/2025 documented Resident 47 had impaired ROM to their left wrist, hand, thumb, index finger, middle finger, ring finger and little finger. Staff H, OT documented that while a therapist provided general orthotic recommendations based on current presentation, Resident 47 would benefit from further assessment by a specialist with advanced orthotic fabrication skills to determine most appropriate splint design and fit. Splint/orthotic options were: - Functional position splint indicated for chronic flexion synergy, no active wrist extension, -Elbow extension orthosis indicated for elbow flexion contracture, -Combo of 1 and 2 options using functional splint during the day and elbow extension at night. Review of the physician's orders directed staff to apply a left elbow extension splint on for 6-8 hours during the day, complete daily skin check/hygiene, wash sleeve in the sink when soiled and hang to dry every day shift for contracture of Resident 47's left arm beginning 02/05/2025. Review of a physician's order directed the nurse to apply Resident 47's splint program. This included moisturizing hand, massaging lotion completely, and gentle stretches to hand then apply a resting hand splint to the left hand at bedtime and as tolerated daily. Nurses were to complete a skin check after removal in the morning and monitor for signs of increased redness, pain or edema in the morning after removal of the device beginning 11/12/2025. In an observation on 12/01/2025 at 11:59 AM, Resident 47 was resting in bed. Their 3rd, 4th and fifth digits were fixed with their fingertips up to the palm of their hand. The resident was unable to move their left fingers from their position. The resident stated they had worn a splint in the past, but it had been missing and must be on vacation in Hawaii. The resident stated the contractures began with their stroke. There was no splint, palm protector or elbow extender in place. In similar observations at 1:53 PM, there was no palm protector, splint or elbow extender in place. In observations on 12/02/2025 at 9:00 AM, 11:20 AM, 1:12 PM, 2:27 PM and 3:02 PM, the resident did not have the palm protector, splint, elbow extender on their left upper extremity. In observations on 12/03/2025 at 8:39 AM and 10:19 AM, Resident 47 was up in their wheelchair without any orthotics on their left upper extremity. They stated maybe their splint was in their closet. At 1:17 PM, the left hand splint was on for the first observation but there was no palm protector or elbow extender in place. In observations on 12/04/2025 at 8:16 AM, 10:11 AM, and 11:57 AM, Resident 47 did not have their palm protector, splint or elbow extender on. The splint was located on their nightstand. At 1:14 PM, 2:34 PM and 4:21 PM, they were observed with no devices on. In observations on 12/05/2025 at 9:02 AM, 10:00 AM, 11:09 AM and 12:38 PM, Resident 47 was observed without devices on, and the splint was observed on their nightstand. Observations on all dates of the survey (12/01/2025, 12/02/2025, 12/03/2025, 12/04/2025, and 12/05/2025), showed Resident 47 was not observed to receive RNP services. Review of Resident 47's clinical record showed the resident did not receive their RNP as care planned. In an interview on 12/04/2025 at 10:22 AM, Staff C, Registered Nurse (RN)/Resident Care Manager, stated Resident 47 wore a left hand splint for their left hand contracture. In an interview on 12/04/2025 at 1:29 PM, Staff F, RN stated Resident 47 was supposed to have a left arm splint on in the morning and off at night. Staff F stated nurses were expected to check to make sure the splint was on, but the aides were to put the splint on. In an interview on 12/04/2025 at 2:34 PM, Staff E. Licensed Practical Nurse/MDS nurse stated they were responsible for oversight of the restorative program. Staff E stated the programs were being completed by the NAC's on the floor as part of their duties. Staff E stated they were to review the RNP quarterly and annually. They stated Staff G, restorative aide, had been pulled to the floor since September. In an interview on 12/05/2025 at 8:48 AM, Staff G, Nursing Assistant Certified (NAC) stated they were no longer the restorative aide related to staffing. Staff G stated the responsibility lies with the floor aides to incorporate the RNP with their care. Staff G stated they did work with Resident 47 in the past and their left hand was contracted and was tight. Staff G stated Resident 47 was agreeable to ROM, the palm protector and a resting splint at night. Staff G stated Resident 47 did not refuse care or splint placement. In an interview on 12/05/2025 at 10:48 AM, Staff H, OT was asked about their recommendations for Resident 47 on 11/11/2025. Staff H stated they did an evaluation on the resident and they recommended special orthotic devices for the resident and for them to see an actual specialist. Staff H was asked what steps were taken after they made the recommendations on 11/11/2025. Staff H stated they just document it in their note and do not do anything past that. Staff H stated they did not discuss the recommendations with the Director of Rehabilitation (DOR), RCM, or any other nursing staff. In an interview on 12/05/2025 at 10:54 AM, Staff I, DOR stated that they had read the 11/11/2025 note and then sent an email to nursing. Staff I stated there had been conversations about the recommendation and the OT that evaluated the resident was not a hand specialist. Staff I stated they had another OT coming in tomorrow that has made specialized hand splints, and they were going to ask that OT to look at the resident. Staff I stated that there was no documentation in resident 47's medical record as to the plan and discussions with the interdisciplinary team. In an interview on 12/05/2025 at 12:55 PM, Staff A, Administrator and Staff B, Director of Nursing Services, stated the company did not have a restorative position or program and the expectation was the NACs were to provide the RNP's. <RESIDENT 67> Resident 67 admitted [DATE] following a stroke with residual right sided hemiparesis (weakness on one side of the body). The resident was also diabetic. According to the admission Minimum Data Set (MDS, a required assessment tool) assessment dated [DATE], the resident required extensive assistance or was totally dependent for activities of daily living such as bed mobility, transfers, and toileting. The MDS further showed Resident 67 had impaired range of motion impacting one side of the upper extremities and both sides of the lower extremities. In a joint interview on 12/04/2025 at 1:00 PM, with Resident 67 and CC1 (spouse of Resident 67), Resident 67 stated they were no longer getting therapy because the insurance ended. CC1 stated Resident 67 was not getting exercises other than going to the dining room to a group program. CC1 verbalized frustration that Resident 67 will never get strong enough to come home if they are not doing any exercise. Resident 67 stated they could not recall the last time they had done any exercises other than in the dining room. Review of Resident 67's therapy Discharge summary dated [DATE], showed they were discharged from both skilled physical and occupational therapy services on 08/27/2025 with recommendations for the following RNP: ACTIVE Range of motion (ROM Program): Lower extremities: Sitting exercises (see handout) 3-6x/week to maintain [NAME] strength, 1) Bilateral Knee Flexion sitting with red Thera-band 2 sets x15-20 reps, 2) Bilateral Hip Flexion sitting with 3# ankle weight 2 sets x15-20 reps each leg, 3) Bilateral Knee Extension sitting with 3# ankle weight 2 sets of 15-20 reps each leg. PASSIVE ROM (PROM) Program: Gentle PROM Right Upper Extremity (UE): all joints/all planes x10 reps each 3-6x/week to improve, contractures and ROM of affected UE, Document #minutes they are actively engaged in the program. NURSING RESTORATIVE: Active ROM Supported Standing Frame with Harness: (2-3 minute duration, 2-3 reps- increase as tolerated) to maintain static standing balance, maintain weight bearing through bilateral [NAME]. 3-6x/week, Document # of minutes they were actively engaged in the program. Review of Resident 67's medical record on 12/04/2025, showed the RNP programs were included on the resident's care plan and in the nursing assistant task documentation. Review of the documentation showed no documentation the programs were being completed. In observations on 12/02/2025 and 12/03/2025 between 11:00 AM and 11:30 AM, Resident 67 was observed sitting up in their wheelchair in the main dining room in a group setting with a TV showing seated exercises for residents to follow along. Resident 67 was observed to follow the TV instructions and participated as able which included active movement of their left upper and lower extremity. In an interview on 12/04/2025 at 2:57 PM, Staff C, Registered Nurse, Unit Manager, stated Resident 67 met their goals for therapy and was doing RNP programs and attended the group exercise program. Staff C reviewed the documentation and confirmed there was no documentation of the programs. In an interview on 12/05/2025 at 10:01 AM, Staff B, Director of Nursing Services (DNS), stated Resident 67 had an RNP program in the tasks and was supposed to be in the point of care (POC) for the nursing assistants to document. Staff B clarified that there was no dedicated RNP staff, and the dining room program did not provide passive range of motion or dedicated one on one assistance. Staff B stated it was discovered for Resident 67 that the RNP programs had been created as needed rather than routine and therefore have not been documented. <RESIDENT 65> Resident 65 admitted to the facility on [DATE] with diagnoses to include Parkinson's Disease (progressive neurological disorder affecting the nervous system). Review of Resident 65's care plan dated 08/27/2024 documented they had a restorative program to maintain function related to risks for decline in range in motion due to their Parkinson's Disease. Interventions included a set of exercises and stretches three to six times a week as tolerated. Review of Resident 65's progress notes documented no information regarding their restorative program. In an interview on 12/04/2025 at 2:12 PM Staff C, Registered Nurse/Unit Manager stated Resident 65 was not on a restorative program. Reference: (WAC) 388-97-1060 (3)(d)(j)(ix)

Based on interview and record review the facility failed to ensure residents were free from unnecessary psychotropic medications for 1 of 5 residents (Resident 5) sampled for medication review. This failure placed residents at risk for unrecognized adverse effects of psychotropic medications.Findings included.Resident 5 admitted on [DATE] with diagnoses which included pneumonia and newly diagnosed metastatic (distant spread) cancer.On 10/21/2025, Resident 5's medical record documented an order for a new antidepressant medication related to a new diagnosis of depression. Review of Resident 5's care plan showed the care plan was not updated to include a problem, goals or interventions until 11/20/2025. The depression care plan instructed staff to identify and monitor for target behaviors of depression every shift. Resident 5's care plan further identified potential adverse effects of the medication with instruction for staff to monitor and document in the record every shift. Review of Resident 5's medical record on 12/04/2025 showed no documentation of the care planned interventions having been implemented. There were no identified target behaviors for the resident's depression, no behavior monitors and no adverse side effect monitors for the antidepressant medication found in Resident 5's record.In an interview on 12/04/2025 at 2:51 PM, Staff C, Registered Nurse, Unit Manager, stated all residents with psychotropic medications should have monitors set up at the time the orders were received and the residents were reviewed monthly at the facility psychotropic meeting. In an interview on 12/05/2025 at 9:55 AM, Staff B, Director of Nursing, stated there was supposed to be a process to review new orders and review for all the pieces such as an appropriate order, consent, target behaviors and monitors were in place and confirmed that pieces of the process were missed for Resident 5. Refer to WAC [PHONE NUMBER] (3)(i)

Based on observation, interview and record review, the facility failed to ensure interventions to prevent pressure ulcers were implemented for one of one residents (Resident 67) reviewed for house acquired pressure ulcers. Failure to ensure preventative measures were implemented resulted in Resident 67 developing a stage 2 pressure injury and placed the resident at risk for delay in healing or additional pressure ulcers.Findings included. Review of the facility policy titled: Skin Integrity (dated 08/2018) documented a resident identified as at risk of developing Pressure ulcers and/or injuries (PU/PI) will have individualized interventions implemented to attempt to prevent PU/PI from developing. Interventions will be monitored for effectiveness. The resident's care plan will reflect the interventions. Repositioning or relieving constant pressure is an effective intervention for treatment or prevention of PU/PIs. Repositioning plans will be addressed in the resident's comprehensive care plan. Resident 67 admitted [DATE] following a stroke with residual right sided hemiparesis (weakness on one side of the body). The resident was also diabetic. According to the admission Minimum Data Set (MDS, a required assessment tool) assessment dated [DATE], the resident admitted with no skin impairments and the resident was assessed as at risk for pressure ulcers/injuries. Review of Resident 67's care plan dated 03/18/2025 instructed staff to utilize pressure relieving/reducing mattress, pillows to protect the skin while in bed. Resident 67's medical record showed a stage 2 (partial skin loss involving the outer layer of the skin) measuring 2 centimeters (cm) x 1cm was identified on the left outer ankle area on 10/23/2025. The care plan was updated on 10/24/2025 to include: elevate BLE (bilateral lower extremities) with pillows or wear foam boots for additional pressure relief and to document acceptance or refusals. Review of Resident 67's record on 12/04/2025 showed no documentation of implementation of the care planned interventions or documentation that indicated acceptance or refusals. In an observation on 12/01/2025 at 11:39 AM, Resident 67 was observed lying in bed with their feet/ankles directly on the mattress. There were a pair of green foam boots observed sitting on the seat of the resident's wheelchair. In an observation on 12/02/2025 at 1:00 PM, Resident 67 was lying in bed with their feet observed flat on the mattress and green foam boots were again observed on the wheelchair and not in place on the resident's feet. In an observation on 12/03/2025 at 1:33 PM, Resident 67 was observed in bed asleep with their legs flat on the mattress. In an interview on 12/03/2025 at 2:04 PM, Resident 67 stated they had a sore on their ankle and did not know how it got there or how long it had been there. Resident 67 stated they had a band aid on the wound that gets changed but they were unsure how often. Resident 67 stated they did not know why they did not have the foam boots on but stated they sometimes did. In an interview on 12/03/2025 at 2:11 PM, Staff O, Nursing Assistant-Certified, stated they worked evenings and knew the resident well. Staff O stated Resident 67 was cooperative and would 'go with what happens', Staff O stated if you put the boots on they will wear the boots. Resident 67 did not refuse care.and would agree, so staff just had to put them on. Staff O stated the resident was not able to take the boots off themselves and needed extensive assistance for mobility and positioning. In an interview and observation of wound care with Staff P, Registered Nurse (RN) on 12/04/2025 at 12:54 PM, Resident 67 was observed to have a foam bandage over their left outer ankle which was removed to reveal a small open area over the bony aspect of the left outer ankle approximately the size of a pencil eraser. The wound appeared superficial and pale in color. There was no drainage on the old dressing. Staff P stated the dressing was changed every Tuesday, Thursday and Saturday, and the foam was protective. Staff P stated the resident should have their heels and feet offloaded when they were in bed. In an interview on 12/04/2025 at 2:50 PM, Staff C, RN, Unit Manager, stated Resident 67 had a wound on their ankle, was at risk for further skin breakdown and should have the foam boots or pillows placed when they were in bed. Refer to WAC 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent accidents for one of one residents (Resident 5) reviewed for smoking. Failure to comprehensively assess and care plan the resident's smoking history and behaviors placed Resident 5 at risk for burns or injury related to unsupervised smoking and placed other residents at risk for injury related to unsecured smoking materials in the facility. Findings included.Review of the facility policy titled smoke free facility with a revised date of 03/2019, stated residents, visitors, contractors and staff were not permitted to smoke on the property at any time. The policy stated former smokers would be offered smoking cessation. Resident 5 admitted on [DATE] and was a current smoker. Resident 5 was alert and oriented with mild short term memory loss. Review of the resident's admission smoking screen, dated 07/25/2025, documented that Resident 5 smoked greater than 10 cigarettes per day, morning, afternoon and night. The remainder of the smoking screen was marked N/A, this is a non-smoking facility. A second smoking screen dated 11/05/2025 was blank. Review of Resident 5's level 1 PASSR stated the resident had a substance abuse history and listed smoking. Review of the Resident 5's physician's orders dated 07/25/2025, showed the resident had orders for a smoking cessation patch and nicotine gum as needed. The record showed these medications were discontinued in October 2025. Review of Resident's 5's care plan dated 07/25/2025 did not address the resident's current or former smoking aside from the mention that it contributed to the resident's respiratory disease. Review of Resident 5's medical record revealed progress notes dated 11/08/2025 showing the resident had smelled of cigarettes, admitted to going outside and smoking and possessed smoking materials. The progress notes stated the resident stated I know when reminded that the facility property was non-smoking, and the resident declined resumption of smoking cessation. The resident's smoking materials were willingly given to the staff. An updated smoking screen was completed on 11/19/2025 which identified the resident smoking and included goals and interventions, which included: Instruct resident about smoking risks and hazards and about smoking cessation aids that are available. Instruct resident about the facility policy on smoking: locations, times, safety concerns. Notify charge nurse immediately if it is suspected the resident has violated facility smoking policy. Observe clothing and skin for signs of cigarette burns. Notify nurse immediately if present. The facilities smoking policy was reviewed and accepted by the resident and /or resident family. Review of Resident 5's care plan revealed the care plan had not been updated or revised to include the 11/19/2025 smoking screen interventions. In an interview and observation on 12/01/2025 at 1:27 PM, Resident 5 was somewhat evasive, and initially reluctant to discuss their smoking status, and stated they had cut down. Resident 5 stated they still smoke here and there but denied possessing any smoking materials. Resident 5 stated they only smoked when family took them out of the facility now and family provided the smoking materials at the time. Resident 5 stated they used to use the patches but did not want to use them because you are not supposed to smoke if you are using them, and they still wanted to be able to smoke when they wanted to. Resident 5 was observed to be able to self propel in their wheelchair, using their feet to pull themselves along. In an interview on 12/04/2025 at 3:28 PM, Staff C, Registered Nurse, Unit Coordinator, stated the assessments should auto-populate to the care plans and did not know why the smoking information was not on Resident 5's care plan. Staff C stated the care plans should be reviewed to ensure that they are complete.In an interview on 12/05/2025 at 9:50 AM, Staff B, Director of Nursing Services stated when Resident 5 admitted they had agreed to the non-smoking policy and were on a smoking cessation patch. Staff B stated the resident had several months with no issue until family brought them in a pack of cigarettes and a lighter. Staff B stated there should have been an update when the resident was identified as having smoked, and stated the updated smoking screen interventions should have automatically updated to the care plan, but for some reason it did not. Refer to WAC 388-97-1060 (3)(g)

Based on observation, interview and record review, the facility failed to ensure that two (44 and 49) of three residents reviewed for respiratory care, were provided care consistent with professional standards of practice. Failure of the facility to maintain respiratory equipment, including Continuous Positive Airway Pressure (CPAP), placed residents at risk for unmet needs and potential negative outcomes for sleep deprivation, respiratory distress, discomfort or skin breakdown of the ears/nostrils/face. Findings included .According to the facility policy Respiratory Care Policy dated July 2018, a resident with Obstructive Sleep Apnea (OSA-collapse of the upper airway during sleep) would have on-going assessments of the resident's respiratory status and response to therapy documented in the medical record. The Physician would provide orders, indication of use, equipment settings, when to use the equipment and the care plan would reflect the Physicians' orders. Additionally, the facility would implement infection control measures during care, handling, cleaning, storage and disposal of respiratory equipment. <RESIDENT 44>According to the 09/03/2025 Annual MDS (Minimum Data Set- an assessment tool) revealed Resident 44 was admitted on [DATE] and was assessed as cognitively intact.Review of Resident 44's physician orders directed staff to apply CPAP when sleeping, wash CPAP tubing with warm water and baby shampoo, rinse well and dry. Verify CPAP was off in the morning. At bedtime, empty humidifier chamber, dry and refill with distilled water and assemble the unit for obstructive sleep apnea.In an interview on 12/01/2025 at 10:37 AM, Resident 44 stated they had never had their CPAP cleaned in the entire year they had been here. The resident stated they had not had any new tubing, head gear or nasal pillows since admission. The CPAP was on the nightstand, and the back filter was fluffy and grey. The resident stated they were unaware there was a filter there and that it needed to be changed every 2 weeks. In a follow up interview on 12/03/2025 at 2:00 PM, Resident 44 stated their CPAP had still not been cleaned and they inquired if there was follow up and the cleaning would get done. Review of Resident 44's care plan initiated on 12/03/2024, showed the resident used a CPAP at prescribed pressure setting via full face mask when sleeping. Staff were directed to bleed in oxygen at 2 liters a minute when they were utilizing the CPAP. Review of the care plan did not address the residents' CPAP supply vendor, contact information, brand of CPAP, manufacturers guidelines and when the equipment was required to be replaced. The care plan did not address cleaning the humidifier chamber. <RESIDENT 49>According to the 11/12/2025 Quarterly MDS revealed Resident 49 was admitted on [DATE] and was assessed with moderate cognitive impairment.In an interview on 12/01/2025 at 1:30 PM, Resident 49 was in bed and stated they slept with their CPAP machine. A black Phillip's brand CPAP was at the foot of the bed with visible dust on it. The resident stated they had taken out the filter and would like new tubing and a new face mask. The resident stated they replaced the hose six months ago due to a break in the tubing. The resident stated they had not had a new face mask since admission. They stated they had repeatedly asked staff and they hoped maybe their wife can get them one. In an interview and observation on 12/04/2025 at 11:10 AM, Resident 49 stated they had not had their CPAP cleaned in a long time. In an observation on 12/05/2025 at 11:25 AM, Resident 49 was in bed asleep, CPAP was off of them. The unit had dust on it.In an interview on 12/04/2025 at 4:14 PM, Staff J, Licensed Practical Nurse stated they usually clean Resident 44 and 49's CPAP and fill the water at night. Staff J was unaware of the replacement schedule and when or if the masks, tubing and headgear had been replaced. Staff J stated the cleaning and equipment replacement should be on the physician's order, Treatment Administration Record (TAR) and on the care plan.In an interview on 12/05/2025 at 9:28 AM, Staff C, Registered Nurse (RN)/Resident Care Manager stated they knew they had two residents on their unit with CPAP's (Resident 44 and 49) Staff C stated they knew the nurses filled the reservoir with distilled water. Staff C stated Resident 44's was to be cleaned on Sunday night shift. Staff C was informed of the dirty filter and stated the filter should be cleaned every Sunday. Staff C stated they were unsure who their CPAP vendor was or if the head gear, mask, tubing and reservoir had been replaced for Resident 44 and 49. In a follow up interview on 12/05/2025 at 11:28 AM, Staff C, RN stated they did not have manufacturer's guidelines for the CPAP's. Staff C stated they thought Resident 49's CPAP model had a recall on it and they were trying to find out about it. Staff C stated they used AI (artificial intelligence) to learn about it as they did not have the information on it. At 11:40 AM, Staff C provided the correct user manual they had just printed off. Staff C stated they were not sure if there was a recall on it but that if there was the manufacturer should notify the resident.In a joint interview on 12/05/2025 at 12:55 PM, Staff A, Administrator and Staff B, Director of Nursing, were informed of the interviews and observations with Resident 44 and 49. Staff A and B confirmed the cleaning, equipment changes should occur per the manufacturer's recommendations and instructions should be on the orders, care plan and TAR's. Reference: WAC 388-97-1060 (3)(j)(vi)

Based on interview and record review the facility failed to ensure the baseline care plan included the minimum healthcare information necessary to properly care for the residents for 2 of 5 residents (Residents 5 and 77) reviewed for baseline care plan. These failures placed residents at risk for clinical complications, not receiving person centered care and being at risk of unmet care needs. Findings included .Review of the facility policy titled baseline care plan, with a revision date of 11/2017, documented the baseline care plan was developed within 48 hours of admission and should include a minimum health information necessary to care for the resident which included but were not limited to: initial goals based on admission orders, dietary orders, therapy services, social services, and PASSR recommendations, if applicable. <RESIDENT 77> Resident 77 admitted to the facility on [DATE] with diagnoses to include quadriplegia (partial or total loss of function in all four limbs and the torso). In an interview and observation on 12/01/2025 at 10:00 AM, Resident 77 was observed to have swollen left and right hands. Resident 77 stated they had compression gloves (snug fitting gloves which provide pressure to improve blood flow and reduce swelling) to wear for the swelling but had the staff remove them earlier. Review of Resident 77's admission Evaluation competed 11/24/2025 documented they had no edema (fluid retention/swelling). Review of Resident 77's Treatment Administration Record for November 2025 documented an order for compression gloves to both hands for edema management. Review of Resident 77's baseline care plan dated 11/25/2025 had no documentation regarding the need for compression gloves to manage their edema. In an interview on 12/01/2025 at 3:36 PM Staff D, Resident Care Manager/ Registered Nurse stated baseline care plans were developed with the use of the admission Evaluation. Staff D stated the baseline care plan was used to communicate care a resident required. Staff D stated the baseline care plan should include a head-to-toe assessment to include edema management. Staff D stated they were in the process of reviewing Resident 77's care plan for edema. <RESIDENT 5> Resident 5 admitted on [DATE] and was a current smoker. Review of the resident's admission smoking screen, dated 07/25/2025, Resident 5 smoked greater than 10 cigarettes per day, morning, afternoon and evening. The remainder of the smoking screen was marked N/A, this is a non-smoking facility. Review of Resident 5's level 1 PASSR stated the resident had a substance abuse history and listed smoking. Review of the Resident 5's physician's orders dated 07/25/2025, showed the resident had orders for a smoking cessation patch and nicotine gum as needed. Review of Resident's 5's baseline care plan revealed that the resident's risk to smoke, smoking history, goals and interventions were not included in the baseline care plan. In an interview on 12/04/2025 at 3:28 PM, Staff C, Registered Nurse, Unit Coordinator, stated the assessments should auto-populate to the care plans and did not know why the smoking information was not on Resident 5's care plan. Staff C stated the care plans should be reviewed to ensure that they are complete. Reference WAC 388-97-1020(3)

Based on interview and record review, the facility failed to follow physician's orders to obtain monthly weights for 1 of 2 residents (Resident 11) reviewed for nutrition. This failed practice placed residents at risk of not receiving adequate care and services and a decline in health and/or mobility.Findings included .Resident 11 admitted to the facility on [DATE] with diagnoses to include obesity and high blood pressure. Review of Resident 11's Medication Administration Record documented a physician's order for a monthly weight. Review of Resident 11's care plan dated 10/24/2024 documented the goal was for them not to have significant weight loss of more than five percent in 30 days or ten percent in 180 days. Review of Resident 11's electronic health record contained no documentation regarding their weight from September, October or November 2025. In an interview on 12/03/2025 at 12:50 PM Staff L, Registered Dietician, stated Resident 11 was triggered for review as they had not had a documented weight since August 2025. In an interview on 12/03/2025 at 3:02 PM Staff K, Licensed Practical Nurse stated they had just obtained Resident 11's weight. Staff R stated weights were typically done around the first of the month and reported to them by the nursing assistants. In an interview on 12/03/2025 at 3:04 PM Staff C, Registered Nurse/Unit Manager stated Resident 11 was missing weights for September, October and November of 2025. Staff C stated Resident 11 has a history of refusals and was unable to locate any documentation that they had refused their weight being taken in September, October, November of 2025. In an interview on 12/03/2025 at 3:17 PM Staff B, Director of Nursing Services, stated they were made aware of Resident 11 not having weights done for September, October, November of 2025. Reference: (WAC) 388-97-1060(1)

Based on observation, interview and record review, the facility failed to ensure that all drugs and biologicals were labeled in accordance with professional standards for 1 of 2 medication carts (Cart 2 B-wing) reviewed for medication storage. The failure to remove expired items from the medication carts placed residents at risk to receive expired or ineffective medications and a decreased quality of life.Findings included .In an observation on [DATE] at 1:32 PM, a review of medication cart #2 on B wing was completed and Narcan (medication to reverse life-threatening opioid overdose) nasal spray was found with an expiration date of 08/2024. In an interview on [DATE] at 1:41 PM, Staff N, Licensed Practical Nurse (LPN) confirmed the Narcan had an expiration date of 08/2024. In an interview on [DATE] at 1:23 PM, Staff B, Director of Nursing Services (DNS) stated the pharmacy had just completed medication cart audits in [DATE] and staff nurses were asked to audit the carts on [DATE] and they were unsure how the expired medication got missed. Reference WAC: 388-97-1300(1)(b)(ii)(2)

Based on interview and record review, the facility failed to ensure influenza and pneumococcal immunizations were offered, up to date and risks and benefits of the immunizations were provided to 3 of 6 residents (Resident 67, 54 and 80) reviewed for immunization and infection control. This failure placed the residents at risk for illness, lack of knowledge to make medical decisions, and spread of communicable diseases.Findings included.Review of the facility policy titled, Infection Prevention and Control, Influenza and Pneumococcal Immunizations, dated 02/2025 showed the facility will provide influenza and pneumococcal immunizations.residents and/ representatives will receive information related to the risk and benefits of immunizations. the medical record will reflect the provision of education and administration or refusal of the immunization.residents who have previously been offered or given a pneumococcal will be offered necessary follow up immunizations according to national guidelines (Center for Disease and Control – CDC). <RESIDENT 80>Resident 80 was admitted to the facility on [DATE] with diagnoses that included respiratory failure, and anoxic (lack of oxygen) brain damage. The Minimum Data Set (MDS – an assessment tool) dated 11/28/2025 documented the resident had moderate cognitive impairment. Review of Resident 80's medical record documentation, with an upload date of 11/21/2025 the resident had two individuals listed for them as a durable power of attorney in the event the resident could not make their own decisions about their health care. Review of Resident 80's immunization record, print date 12/04/2025, documentation showed the resident had refused influenza and pneumococcal vaccinations. Review of Resident 80's electronic immunization consent evaluation, dated 11/21/2025 showed Resident 80 had declined the influenza and pneumococcal immunizations. The consent section titled, C. Acknowledgement and Informed Consent was left blank under all three sections:- I have received and read the vaccine information for the risk and benefits, - I am unaware of any allergies, - I am aware the provider may order based on vaccine recommendations. The evaluation asked, If unable to obtain signed consent, was verbal consent received? and was answered no. The section for the residents or representatives to sign had Resident 80's name electronically printed in the box. <RESIDENT 54> Resident 54 admitted [DATE]. Review of Resident 54's immunization consent information on admission documented refusal of the influenza vaccination with the reason stated as already received. There was no documentation of the resident's prior immunization history dates. <RESIDENT 67> Resident 67 admitted on [DATE]. Review of Resident 67's immunization consent information dated 09/18/2025 showed the resident consented to receive the seasonal influenza vaccination. The consent did not address the resident's pneumococcal vaccine status. The immunization tab on admission stated only refused with no corresponding immunization historical data related to the resident's pneumococcal vaccine status. In an interview on 12/05/2025 at 9:39 AM, Staff B, Director of Nursing Services, stated the facility is able to utilize the state immunization portal, the hospital documentation or request records from the resident's provider to determine immunization history and determine if residents are up to date. Staff B reviewed Resident 54's records and stated the hospital documentation was included and showed the last influenza vaccine was in 2022. Staff B stated they would need to look further to determine whether Resident 67 was up to date on their pneumococcal vaccine. Reference WAC 388-97-1340(1)(2)(3)

Based on interview and record review, the facility failed to ensure COVID-19 (a viral illness that caused fever, difficulty breathing or possibly death) immunizations were offered, up to date and risks and benefits of the immunizations were provided to 2 of 6 residents (Resident 54 and 80) reviewed for immunization and infection control. This failure placed the residents at risk for illness, lack of knowledge to make medical decisions, and spread of communicable diseases. Findings included.Review of the facility policy titled, Infection Prevention and Control, COVID-19 Immunization, dated 12/07/2023 documentation showed the facility will offer COVID-19 vaccinations to residents.prior to offering the facility will educate resident and/or representative on benefits, risk and potential side effects of the vaccine.education will be provided prior to requesting consent for administration.documentation in the medical record will include provision of education and offer of vaccine, date of education and offering, who received the education, name of representative who is authorized to make decisions for resident, and if they will accept or refuse. <RESIDENT 80> Resident 80 was admitted to the facility on [DATE] with diagnoses that included respiratory failure, and anoxic (lack of oxygen) brain damage. The Minimum Data Set (MDS – an assessment tool) dated 11/28/2025 documented the resident had moderate cognitive impairment. Review of Resident 80's medical record documentation, with an upload date of 11/21/2025 the resident had two individuals listed for them as a durable power of attorney in the event the resident could not make their own decisions about their health care. Review of Resident 80's immunization record, print date 12/04/2025, documentation showed the resident had refused COVID-19 vaccinations. Review of Resident 80's electronic immunization consent evaluation, dated 11/21/2025 documentation showed Resident 80 had declined the COVID-19 immunizations. The consent section titled, C. Acknowledgement and Informed Consent was left blank under all three sections: - I have received and read the vaccine information for the risk and benefits, - I am unaware of any allergies, - I am aware the provider may order based on vaccine recommendations. The evaluation asked, If unable to obtain signed consent, was verbal consent received? and was answered no. The section for the residents or representatives to sign had Resident 80's name electronically printed in the box. <RESIDENT 54> Resident 54 admitted [DATE]. Review of Resident 54's immunization consent information on admission documented refusal of the COVID-19 vaccination with the reason stated as already received. There was no documentation of the resident's prior immunization history dates. In an interview on 12/05/2025 at 9:39 AM, Staff B, Director of Nursing Services, stated the facility is able to utilize the state immunization portal, the hospital documentation or request records from the resident's provider to determine immunization history and determine if residents are up to date. Staff B reviewed Resident 54's records and stated the hospital documentation was included and did not show information related to Resident 54's Covid vaccination status. Reference WAC 388-97-1620(2)(b)(i)(ii)

Based on interviews and record reviews, the facility failed to consistently reposition, assess and monitor skin integrity timely & implement pressure offloading interventions to prevent the occurrences of avoidable pressure ulcers (PU) for 1 of 3 residents (Resident 1) reviewed for pressure ulcers. Resident 1 experienced harm when they developed unstageable PU (later diagnosed as Stage 4 pressure ulcer) to their sacrum that became infected and required hospitalization . Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) states a pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present itself as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. Further definitions include but not limited to: - Stage 4 Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. - Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. - Deep Tissue Pressure Injury (DTI): Persistent non-blanchable deep red, maroon or purple discoloration. Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation revealing a dark wound bed or blood-filled blister. This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. Review of facility policy titled Skin Integrity, dated ,d+[DATE] documented the facility, based on a resident's comprehensive assessment, will provide care, consistent with professional standards of practice, to prevent pressure ulcers and promote healing, prevent infection and prevent new ulcers from developing unless the resident's clinical condition demonstrates that they were unavoidable. Guidelines include but not limited to: 10. Resident's care plan will reflect the preventive strategies for residents identified as at risk for developing PU/PI. 15. Prevention and treatment plans will be individualized and consistently provided. 22. Repositioning or relieving constant pressure is an effective intervention for treatment or prevention of PU/PIs. Repositioning plans will be addressed in the resident's comprehensive care plan. 30. The IDT will develop a relevant care plan that includes measurable goals and interventions for prevention and management of PU/PIs. Identified interventions will be implemented. 34. Daily monitoring of PU/PI will include: a. Evaluation of the PU/PI, if no dressing is present; b. Evaluation of the status of the dressing, is present; c. Status of the area surrounding the PU/PI (without removing existing dressing); d. Presence of possible complications; e. If pain is present, is it being controlled. 35. A weekly evaluation of the PU/PI will be documented, to include: a. Location and staging; b. Measurements, including the depth and any undermining or tunneling; c. Exudate, if present (type, color, odor, amount); d. Wound bed status; e. Description of wound edges and surrounding tissue. Resident 1 was admitted to the facility on [DATE] with diagnoses to include right hip fracture, major depressive disorder, muscle weakness, spina bifida (birth defect that affects the spinal cord and nerves, potentially leading to paralysis, and sensory loss), chronic pain, and need for assistance with personal care. Review of Resident 1's Admission Minimum Data Set (MDS-an assessment tool) Care Area Assessment (CAA), dated [DATE], documented they were at risk for developing PU's, currently had no PU's, had a surgical wound, and required substantial/maximal assistance from staff for rolling in bed. Review of Resident 1's quarterly MDS assessment dated [DATE], documented through a clinical assessment the resident was at risk of developing PUs, currently had no PU's or other skin conditions and required pressure reducing devices for their chair and bed, and they were cognitively intact. Review of Resident 1's BRADEN scale (scale for predicting PU risk) assessment dated [DATE] documented a score of 16 indicating the resident was considered to be at risk for the development of PUs. Review of Resident 1's care plan documented: - Focus area ADL (Activities of Daily Living) self-care performance deficit, initiated on [DATE], revised on [DATE]. Interventions included Resident requires 2 staff max assist to turn and reposition in bed, initiated [DATE], revised [DATE]. - Focus area Skin integrity and the resident was at risk for pressure ulcer development related to decreased mobility secondary to hip fracture and chronic deficits related to spina bifida with impaired sensation, initiated on [DATE]. The care plan was revised on [DATE], and documented the resident had an unstageable pressure ulcer to the coccyx/sacrum area. The care plan was then updated again on [DATE], and documented the unstageable PU was surgically debrided (surgically remove dead, damaged tissue or infected tissue from a wound or area) and was now a Stage 4 pressure ulcer, and a Stage 2 on their left heel and a DTI to the right heel. The goal documented on the care plan was that Resident 1 would not develop any further avoidable skin breakdown, initiated on [DATE]. Interventions included: o Follow facility policies/protocols for the prevention/treatment of skin breakdown (initiated/revised on [DATE]). o Monitor skin for any changes or impairments (initiated/revised on [DATE]). o Reposition Resident 1 with rounds and cares (initiated on [DATE], revised on [DATE]). o Low air loss mattress in place to relieve pressure (initiated [DATE]). o Resident requires pressure relieving/reducing device on bed/chair (initiated [DATE], revised [DATE]). - Focus Area Resistive to care/interventions, initiated [DATE]. Review of Resident 1's Kardex (care plan directive for nursing assistants) documented: - As of [DATE]- Resident required one person staff assist to turn and reposition in bed. There were no other skin/pressure prevention interventions documented. - As of [DATE]- The resident requires one staff assist stand by to turn and reposition in bed. - As of [DATE]- Resident requires pressure relieving/reducing device on bed/chair; they require one person staff set-up to stand by assist to turn and repositioning in bed. There were no care information/directives related to Resident 1's current PU's. - As of [DATE]- Resident requires pressure relieving/reducing device on bed/chair; they require two staff max assist to turn and reposition in bed and two persons assist with offloading (relieve pressure). There were no care information/directives related to Resident 1's current PU's. Review of Resident 1's Documentation Survey Report v2 Nursing Assistant Certified (NAC documentation) for January, February and [DATE] showed the resident had no refusals documented for the task of rolling right and left in bed. Review of Resident 1's progress note, dated [DATE] at 4:37 PM, documented the resident was noted to have a 9 centimeter(cm) by 9 cm sore to their sacrum area. Review of Resident 1's physician progress note, dated [DATE], documented the resident had an unstageable sacral ulcer that had been found a few days prior. Review of Resident 1's progress note dated [DATE] at 11:01 AM documented that they had been seen by wound care in the facility and their pressure area to sacrum had been debrided (surgical removal of dead or damaged skin/tissue from a wound). Review of a wound care note, dated [DATE], documented Resident 1 had an unstageable sacral wound that measured 10.7 cm x 8.8 cm, with tunneling of 2 cm. Review of Resident 1's progress note, dated [DATE] at 3:00 PM, documented that the resident was lethargic, with low blood pressures (BP- normal range ,d+[DATE]) of ,d+[DATE] and ,d+[DATE], and low oxygen readings (normal ,d+[DATE]%) from 67% to 92%. The facility provider was notified and called 911 for the resident to be transferred to the hospital. Review of Resident 1's hospital records dated [DATE] to [DATE] documented the resident was diagnosed with septic shock, (life-threatening condition that is the most severe stage of sepsis), urinary tract infection or osteomyelitis (bone infection, usually caused by bacteria) related, and a Stage 4 sacral pressure ulcer. Review of the facility investigation dated [DATE], completed by Staff A, Registered Nurse (RN)/Director of Nursing Services (DNS) documented interventions in place prior to sacral ulcer were Activities of Daily Living (ADL) assist for turn/reposition as indicated. Staff A documented the unstageable pressure injury to Resident 1's sacrum was identified on [DATE]. Staff A documented that based on measures identified, care planned and implemented, interventions that were in place upon admission and prior to skin impairment should have been sufficient and reasonable to prevent the formation of pressure ulcers. Staff A documented that upon review of the resident clinical picture, the pressure ulcer suspected to be unavoidable related to previous decrease in frequency of repositioning, decrease in sensation with spina bifida, recent refusals of care and history of pressure injuries In an interview on [DATE] at 2:05 PM, Resident 1 stated that they had never had any pressure ulcers before and that they can't believe that this happened. Resident 1 stated that they are unable to feel in the sacrum area due to their spina bifida. Resident 1 stated when their insurance ran out and therapy was finished, the staff just let them lay in the bed. Resident 1 stated that no staff came to change their position or turn them in bed, and no staff came to remind them to do it independently, they had no idea about repositioning until after this pressure ulcer was found. Resident 1 stated they need help and that is why they were in the facility. The resident stated that the staff did not know that this was happening to their skin, and they could have died from the infection. In an interview on [DATE] at 4:43 PM, Resident 1 family member (CC1) stated after Resident 1's insurance ran out or they were discharged from physical therapy that the facility was not providing any therapy services or assisting the resident. CC1 stated that they were notified by the surgeon that the infection had gone into their bones from the PU and that the healing process may affect the rest of their life. CC1 stated Resident 1 does not have sensation and can't feel the area of their body where the PU is located, and they have never had any previous PU's. CC1 stated that the facility was not providing the care that Resident 1 required or deserved. In an interview on [DATE] at 1:11 PM, Staff B, Nurse Aide Certified (NAC), stated that they follow the Kardex to know what level of assistance a resident requires. Staff B stated they alert the licensed nurse if the resident refuses any care, and it can be documented in the resident's electronic medical record (EMR) related to the task that was refused. Staff B stated that one person assist, or one person stand by assist with bed mobility, rolling left and right, meant it required one staff to partially assist resident to complete the task and set up for whatever they need to accomplish. Staff B stated that residents who have skin issues or are at risk for skin issues have interventions for floating the area, reposition, and change their position. In an interview on [DATE] at 1:22 PM, Staff C, NAC, stated they review the care plan or Kardex to know what care is required for a resident. Residents who have skin issues or are at risk for skin issues usually have interventions to float the affected area, special mattress, and frequent turning and repositioning. Staff C stated that all resident care tasks have an option to document for a resident refusal of care. Staff C stated they report to the licensed nurse if the resident refused care. Staff C stated that one person assist or standby assist for bed mobility requires one staff to assist the resident to reposition and stated they were not sure what a standby assist for bed mobility was. Staff C stated that Resident 1 had not refused care from them. In an interview on [DATE] at 1:33 PM, Staff D, Registered Nurse (RN), stated they review the care plan to know what assistance the resident requires. Staff D stated that interventions for residents who have skin issues are that staff complete frequent checks, provide reposition care every two hours, and offload the pressure areas of concern. Staff E stated if a resident refused care, they would attempt three times and then complete notifications to the resident power of attorney (POA) or responsible party, notify the provider, and complete a progress note with the refused care and complete teaching with resident of risks and benefits of the care they have refused. Staff D stated that if a resident required one person assist for bed mobility, then one staff should assist with that care. In an interview on [DATE] at 2:52 PM, Staff E, RN/Resident Care Manager (RCM), stated they were aware Resident 1 had refused to get out of bed for meals, unsure about bed mobility or to be repositioned. Staff E stated that Resident 1 had never been considered independent with their bed mobility, repositioning or care needs and that they were aware that the resident had previously refused to get out of bed and sit up for meals. Staff E stated that they did not recall knowing that the resident had refused being repositioned. Staff E stated that a one person or one person stand by assist for bed mobility and repositioning would be one staff member to assist or be there to see what assist the resident required and then stated that a standby assist for bed mobility does not really make sense. Staff E stated that if a resident had refused care or is known to refuse frequently, it should be documented by NAC's and Licensed Nurses (LN), and they were unsure of where it would be documented. Staff E stated that Resident 1's care plan should have been updated related to refusals of care and assessed to see why Resident 1 had refused care. In an interview on [DATE] at 4:34 PM, Staff A stated that if a resident had a skin issue or was at risk to develop a skin issue, the expectation is that there are interventions in the care plan and those interventions should be implemented. Staff A stated that Resident 1 had stated that they previously had some skin issues or a wound in the same area, although their clinical record did not indicate that in their history when I reviewed it. Staff A stated that Resident 1 was identified at risk related to immobility due to the hip fracture and sensation loss related to spina bifida. Residents who are at risk or have skin integrity care plans should be turned and repositioned on staff rounds and with care provided by NAC's. If a resident has refused care, it should be documented by NAC's and LNs in the EMR, it should also be documented in their EMR that staff review risks and benefits related to refused care. Staff A stated their expectations for care plans are that they are updated when there is a change. Requested additional information related to documentation of resident refusal of bed mobility, being repositioned or care plan updates, no further information was provided. Reference WAC: [DATE] (3)(b)

Based on interviews and record review, the facility failed to ensure that notification of changes had been communicated to the resident and/or resident representative for 1 of 3 (Resident 1) residents reviewed for notifications of change. These failures placed residents and/or representatives at risk of not being informed of resident changes in health status or transfers out of the facility. Findings included . Resident 1 admitted to the facility on [DATE], with diagnoses to include schizoaffective disorder (condition that includes schizophrenia and a mood disorder symptoms), encephalopathy (brain disease that alters brain function or structure), major depressive disorder and anxiety. Review of Resident 1's medical record showed a Guardian listed as their responsible party and emergency contact. Review of a Resident 1's progress notes dated 12/20/2024 showed notifications were not documented as being made related to abnormal lab values or their transfer to the hospital on 12/20/2024. In an interview on 01/13/2025 at 10:57 AM, CC1, Guardian of Resident 1, stated the facility had not communicated with them when the resident had abnormal lab values or when Resident 1 was transferred to the hospital. CC1 stated they received the information from the hospital staff after Resident 1's arrival. CC1 stated the facility had an option to leave a voicemail for them at any time during the day or night and there was also an option to talk with whomever was on call for any emergencies. CC1 stated neither of these options were utilized. In an interview on 01/13/2025 at 2:07 PM, Staff C, Licensed Practical Nurse (LPN), Unit Manager stated they attempted to call CC1's Guardian, but did not make contact before the resident was transferred to the hospital. Staff C stated they did not wait to leave a message or utilize the on-call option for emergencies. Staff C stated they spoke with CC1's office when someone from the office called after being notified by the hospital that Resident 1 had been transferred. In an interview on 01/13/2025 at 3:20 PM, Staff B, Registered Nurse (RN), Director of Nursing Services (DNS) stated it was their expectation that any resident changes, medical or psychosocial changes, and transfers would be communicated to the Resident's representative. Reference WAC: 388-97-0320 (1)(b)(d)

Based on record review and interview, the facility failed to ensure the facility's activity program was directed by a trained and qualified activities professional for the ongoing assessment, development, and/or revision of individualized activity programs for the current activities scheduled in the facility for 1 of 1 Recreation/Activity Directors (Staff S) reviewed for activities professional qualifications. This failure placed residents at risk for unmet recreation needs, boredom, and decreased quality of life. Findings included . Review of a facility document titled, Job description: Recreation Director, dated 2022 showed the role was to ensure the development, organization and coordination of facility and community resources to provide comprehensive Therapeutic Recreation Services and programs that fulfill the basic psychological, physical, social, cultural, emotional, spiritual and recreational needs and interests of each resident .with required education and experience to have certification as a Therapeutic Recreation Specialist or as an activities professional by a recognized accrediting body; or have two years of experience in a social or recreational program within the last five years, one of which was full-time in a patient activities program in a health care setting; or was a qualified Occupational Therapist or Occupational Therapy Assistant; or have completed a training course approved by the state. In an interview on 12/02/2024 at 11:21 AM, Resident 34 stated they prefer to not leave their room for activities. Resident 34 stated they only have three staff and no time to spend with residents that prefer to have activities in their room. Resident 34 stated they only have time for quick visits, and on the weekends sometimes it never happens. In an interview on 12/02/2024 at 1:54 PM, Resident 19 stated they were bored a lot, they had some magazines to look at but that was all. Resident 19 stated they missed their cat at home, and they wished the facility had animals that visited. In an interview on 12/02/2024 at 2:24 PM, Resident 215 stated they felt like they were going stir crazy. They stated there was nothing ever to do but watch television. In an observation on 12/03/2024 at 3:20 PM, there was a scheduled activity of flower arranging occurring in the activity room, there were only 3 residents that participated out of 64 residents. In an observation on 12/04/2024 at 10:33 AM, there was a scheduled exercise group activity occurring in the dining room. There were 6 residents that attended the group out of 64 residents. The staff directing the group followed a self-made video on the television screen, no engagement was observed with the residents, the music was faint to hear, and during the session 1 resident left the group. In an observation on 12/04/2024 at 1:52 PM, there was a scheduled activity of Christmas crafts occurring in the activity room, there were only 3 residents that participated out of 64 residents. In an interview on 12/05/2024 at 12:23 PM, Staff T, Recreation Assistant stated they have a set routine every day. They will do one-to-one visit with residents that do not wish to attend activities. Staff T stated they attempt to see everyone, but that's not possible most days. Staff T stated the one-to-one visits will usually consist of offering magazines, books, puzzles and handing out the daily chronicle. In an interview on 12/05/2024 at 1:49 PM, Resident 47 stated during resident council meeting that there are usually only 3 to 4 resident that show up for the activities in the facility. In an interview on 12/05/2024 at 2:33 PM, Staff S, Recreation Director stated they have been in the role as the director for about six months. Staff S stated they have an associate's degree in arts and science and worked at a memory care facility for a year and half where they helped with activities. Staff S stated they had not been told they needed to have any type of certification or certain qualifications for this position. Staff S stated when a resident refused to participate in an activity, that was the residents right to refuse, Staff S stated they did not usually pressure or inquire with the resident as to why they did not want to participate. Staff S stated they had noticed that the attendance for the activities was low, and that the residents did not seem to be interested in what was offered. Staff S stated they had not brought this issue up in the Quality Assurance and Improvement Committee (QAPI) meeting. In an interview on 12/06/2024 at 11:05 AM, Staff A, Administrator stated they were aware that Staff S was not qualified to fill the role as Recreation Director. Staff A stated they were supporting Staff S and had a plan that they were going to get them into a program at some point, but at this time there was no active plan. Reference WAC 388-97-0940 (3)(a-c)

Based on observation, interview and record review, the facility failed to ensure 5 of 6 resident's (Resident 6, 23, 24, 29 and 53) received care and treatment in accordance with professional standards of practice and received the necessary care and services to attain or maintain their highest practicable level of well-being. This placed residents at increased risk of unmet care needs, medical complications and decreased quality of life. Findings included . <RESIDENT 6> Resident 6 admitted to the facility on [DATE] with diagnoses to include congestive heart failure, and cerebral infarction (stroke). Review of Resident 6's physician order dated 10/19/2023 directed staff to apply a dot bandage to the right side of the resident's nose to cushion their skin and prevent skin breakdown. Review of Resident 6's physician order dated 05/16/2024 directed staff to weigh the resident every Monday and Thursday day shift related to edema. Review of Resident 6's Medication Administration Records (MAR) for September, November and December 2024 showed there were no weights obtained as ordered on 09/09/2024, 11/04/2024, 11/28/2024 and 12/02/2024. In an observation on 12/02/2024 at 9:38 AM, Resident 6 was observed in the hallway with no bandage on their nose. In subsequent observations on 12/03/2024 at 9:47 AM, 12/04/2024 at 8:43 AM, and 12/05/2024 at 8:37 AM, the resident did not have a bandage on their nose. Review of the December MARS showed the nurses initialed the daily bandage to the nose had been completed. In an interview on 12/05/2024 at 10:22 AM, Staff N, Social Services stated Resident 6 refused denture care, but they were not aware of any other care refusals. In an interview on 12/06/2024 at 9:11 AM, Staff C, Licensed Practical Nurse (LPN)/Unit Manager stated the expectation was that nurses weighed the residents as ordered. Staff C stated that they are supposed to obtain the weight, attempt to re-weigh if the resident refuses and if they refuse, they are to attempt the next shift and day until the weight is obtained. In an interview on 12/06/2024 at 12:00 PM, Staff B, Director of Nursing (DNS) stated the nurses should not initial treatments as completed when they did not complete them. <RESIDENT 24> Resident 24 admitted to the facility on [DATE] with diagnoses to include kidney disease. Review of Resident 24's physician order dated 01/24/2023 directed the staff to obtain a Depakote (medication used to treat seizures) level and Complete Metabolic Panel every three months on the 25th. Review of Resident 24's clinical record on 12/06/2024 showed the last Depakote level and CMP were obtained on 07/25/2024. In an interview on 12/06/2024 at 9:06 AM, Staff C was asked about the missed CMP and Depakote level on 10/25/2024. Staff C was unaware of the missed labs and stated they would notify the provider. Staff C stated the expectation is the nurses get the order, then print the slip and it goes into their lab book and the lab tech would draw the sample. Staff C stated the lab comes up on our dashboard in the computer system until the process is completed. Staff are to view it, print it and notify the doctor of the results. In an interview on 12/06/2024 at 10:00 AM, Staff B stated they changed lab providers but were able to utilize their prior lab as needed during the transition. Staff B stated they were unaware of missed labs, and they would complete an audit and get a better system going. Review of Resident 29's physician orders dated 01/15/2023 showed the resident was to have a Depakote level and CMP lab obtained every three months. The physician directed staff to administer Divalproex Sodium/Depakote two times a day for bipolar disorder since 05/09/2024. Review of Resident 29's progress note dated 12/01/2024 at 12:27 PM showed the resident refused their Depakote capsule that morning and stated, I don't want it until they check my level explained risk and benefits. The note showed the resident had a lab draw scheduled for tomorrow to check their Depakote level. Review of Resident 29's progress note dated 12/01/2024 at 8:05 PM, showed the resident accepted only one capsule of medication. Review of Resident 29's progress note dated 12/03/2024 at 8:34 AM showed the resident refused Depakote medication and stated, I don't want to take this capsule; it gives me tremors explained risk and benefits. Still refused. Provider aware. In an interview on 12/04/2024 at 2:28 PM, Staff C was asked about Resident 29 refusing their Depakote medication or asking for a decreased dose until they had a lab drawn to check their levels. Staff C stated they were going to ask the provider about a Depakote level but had forgotten. In a follow up interview on 12/04/2024 at 2:54 PM, Staff C stated they met with Resident 29 who said they had been taking Depakote for years after a psychiatrist ordered it but they had only been on one pill a day. When Staff C was asked about the progress note from 12/01/2024, that showed the resident would have a Depakote level drawn the next day, but the level was not drawn. Staff C said they would look into it but did not know if there was an order for a lab draw. Staff C was unaware the resident had multiple other labs except Depakote drawn on 12/02/2024. In an interview on 12/04/2024 at 3:20 PM, Staff C said the provider was going to taper the Depakote to 125 milligrams (MG) daily for 7 days and then evaluate. Staff C stated they would check a level to see how the resident does on the lower dose. Staff C stated the lab was ordered for 12/01/2024 but when the nurse transferred the order to the lab slip, they missed selecting the Depakote box and that lab was missed. Staff C stated they would draw the lab now. In an interview on 12/05/2024 at 10:07 AM, Resident 29 stated they would be getting their Depakote level lab drawn this morning. Review of Resident 29's clinical record on 12/06/2024 at 9:00 AM showed the Depakote level had not yet been drawn. In an interview on 12/06/2024 at 9:06 AM, Staff C stated the provider did not want the Depakote level drawn for Resident 29 now. 37890 <RESIDENT 53> Resident 53 admitted to the facility on [DATE] with diagnoses to include a traumatic brain injury and pressure ulcers. Review of the Minimum Data Set (MDS- an assessment tool) dated 10/15/2024 showed Resident 53 had an unstageable pressure injury to the sacrum and pressure injuries to both heels, present on admission. The resident was documented as being seen weekly by the wound specialist consultant and received daily wound treatments with goals and recommendations to increase nutrition for wound healing. Review of the Registered Dietician's (RD) assessment dated [DATE] showed Resident 53 was assessed as a nutritional risk related to weight loss, diminished ability to feed themself and pressure ulcers with recommendations to add nutritional supplements which included Prosource (a protein supplement drink) twice a day which was initiated on 11/04/2024. Review of Resident 53's clinical record on 12/04/2024 showed the resident had a hospital stay on 11/09/2024 and readmitted on [DATE]. The resident had experienced significant weight loss upon re-admission; however, goals of treatment focused on overall comfort and weights were ordered monthly. The resident would continue with weekly visits from the wound specialist consultant with goals continuing to be consistent with increasing nutritional support for wound healing. Review of Resident 53's note titled Skin and nutrition dated 11/19/2024 showed Prior recommendations had fallen off, will continue with previous RD recommendations. Review of Resident 53's skin and nutrition note dated 12/03/2024 showed Prior recommendations had fallen off, will continue with previous RD recommendations. Review of Resident 53's administration records on 12/04/2024 showed that the prior RD recommendations for Prosource twice daily were not resumed until 12/03/2024. Review of Resident 53's record showed no documentation of weekly wound visit notes from the consultant wound specialist. In an interview on 12/06/2024 at 9:40 AM, Staff G, Registered Nurse/Unit Manager, stated that there should be notes in the clinical record from the wound specialist and the facility wound nurse (Staff Q, LPN) assisted the wound specialist with rounds and made a note. Staff Q would update the orders and recommendations at the same time. Staff G stated they did not know where the wound notes were located in the record and had not reviewed them. In an interview on 12/06/2024 at 9:43 AM, CC2, wound specialist consultant- stated they were aware their notes were no longer appearing in the facility records stating, Since the new company took over. CC2 stated they had notified their IT department and were told that the facilities new ownership had to request access again and they have been made aware. CC2 stated the primary goal for Resident 53 was to maximize comfort, but we are still treating with antibiotics and continuing treatments, seeing them weekly, there are still daily wound treatments and we continue to make changes and recommendations, but it makes no sense that we are sending notes that don't go anywhere (since August). Staff Q stated they did not have access to the wound notes in the system but believed that the Director of Nursing (Staff B) and another one of the unit managers were able to access them. Staff Q stated they made a summary note in the progress notes and updated the treatment orders. In an interview on 12/06/24 at 9:49 AM, Staff B stated there are notes in the system titled skin and nutrition which is like our nutrition at risk notes. The system should work for the wound notes. (Resident 53) has been seen weekly by the wound consultant. Staff B stated the wound notes should be in the resident's charts. In a joint interview on 12/06/2024 at 9:55 AM, Staff B questioned Staff R, Medical Records asking if they had been receiving wound consultant notes for residents. Staff R stated that since the transition, they had not seen any. Staff B stated they were not aware that the wound consultant notes had not been received for residents which included wound recommendations, nutritional recommendations, etc. Staff B stated Staff Q also wrote a note and would input the recommendations at the time of the visit. Staff B stated they had talked about Resident 53 and their goals of care had changed but had not been aware the resident's nutritional recommendations had not resumed upon re-admission, which had been noted by facility staff and documented in wound round notes as well as potential for other missed recommendations related to lack of review of the notes by facility staff and discrepancies in the orders. 47047 <RESIDENT 23> Resident 23 admitted to the facility on [DATE] with diagnoses that included lung cancer, cirrhosis of the liver (a chronic liver condition where scar tissue replaces healthy liver tissue and prevents the liver from functioning properly), chronic obstructive pulmonary disease (COPD-a common lung disease that makes it difficult to breathe), and a condition where fluid builds up in the body's tissues, causing swelling. Review of Resident 23's Quarterly MDS dated [DATE] showed the resident was cognitively intact and had no refusals of care. Review of Resident 23's care plan dated 06/17/2024 showed the residenty had a left heel ulcer which resolved 06/25/2024. Review of Resident 23's Treatment Administration records for October and November 2024 showed: 1) an order dated 10/04/2024 for Resident 23 to have knee high TED hose (stockings/socks that help prevent blood clots) on in the am and off at night every day and evening shift for lower extremity edema. 2) an order dated 06/25/2024 for Resident 23 to have their heels offloaded when in bed with 2 pillows in one case. Heels should be hanging over the pillow every shift for prevention. Review of Resident 23's progress notes for November 2024 showed they had refused to wear their TED hose on 11/30/2024, no other instance found. In observations on 12/03/2024 at 9:25 AM, 12/04/2024 at 8:30 AM, and 12/05/2024 at 12:58 PM Resident 23 was in bed not wearing TED hose nor had their feet offloaded, their feet were uncovered and bare. In an interview on 12/05/2024 at 1:00 PM Resident 23 stated they had told the staff they will not wear the TED hose provided by the facility because they make their legs itch and then they scratch causing sores. Resident 23 stated there was no alternatives offered besides what was initially offered. Resident 23 stated they wore TED hose at home routinely, prior to coming to the facility. In an interview on 12/05/2024 at 1:30 PM Staff D, LPN stated Resident 23 has edema and their legs are elevated, and they have TED hose as interventions. Staff D stated the provider should be notified of Resident 23's refusals to wear the TED hose. Staff D stated they reposition Resident 23 throughout the day. In an interview on 11/06/2024 at 8:58 AM Staff C stated they expected staff to complete and follow physician orders as prescribed. Staff C stated they had not discussed any other options with Resident 23 for TED hose preference and was planning on speaking with the provider that day. Refer to WAC 388-97-1060(1), (2)(3)(b)(h)

Based on observation, interview and record review, the facility failed to ensure 1 of 1 resident (Resident 49) reviewed for incontinence, received the care and services necessary to maintain and avoid loss of bowel and bladder functions. This failure placed the resident at risk for continued decline in bowel and bladder function, skin issues, and feelings of frustration and embarrassment. Findings included . Review of the facility policy titled, Quality of Care Incontinence Urinary Incontinence dated 11/2017 showed residents would receive necessary care and services to maintain continence. The policy contained guidelines which included an assessment at admission and ongoing. Resident 49 admitted to the facility on [DATE] with diagnoses that included stroke, history of heart attack, post-polio syndrome (a condition that can affect people who have had polio). Review of Resident 49's Quarterly Minimum Data Set (MDS- an assessment tool) assessment dated [DATE], showed the resident was cognitively intact, did not exhibit behaviors, had not had any refusal of cares and was dependent on staff for toileting needs. Review of Resident 49's care plan initiated 06/21/2024 showed they required two-person maximum assistance using a Hoyer (a patient lift used by caregivers to safely transfer patients) for toilet use. Interventions included a toileting schedule and referred to Nursing Assistant Certified (NAC) tasks. Review of Resident 49's Kardex (a reference guide, derived from the care plan that provides direction on how to care for a specific resident) dated as of 12/03/2024 showed they had a toileting schedule which was toileting upon rising, by 8 am, dressing personal hygiene and breakfast, toilet at 10 am, lunch, toilet at 2:30 PM and 4:30 PM and toilet as needed at night and throughout the night. In an interview on 12/02/2024 at 11:17 AM Collateral Contact 1 (CC1), Resident 49's representative, stated toileting Resident 49 has been an issue in the facility. CC1 stated they will sit for an hour before getting assistance, was recently moved to a different room to get better attention, and they had made multiple complaints. CC1 stated the staff turn off the call light which ensures the system does not register the hour Resident 49 is waiting. CC1 stated Resident 49 is continent of urine and was able to identify when they need to urinate and have a bowel movement. In an observation on 12/02/2024 at 11:17 AM there was a noticeable smell of urine in Resident 49's room. In continuous observations on 12/03/2024 from 2:34 PM through 3:31 PM the following occurred: -At 2: 34 PM Resident 49 was in their room with CC1. Resident 49 was sitting upright in their wheelchair. -At 2:40 PM met with Resident 49 and CC1 and they stated they had not had any care or toileting since around 12-12:30 PM and had not been offered any care since. -At 3:03 PM CC1 asked Staff H, Licensed Practical Nurse (LPN) to help Resident 49 with toileting. Resident 49's call light was on, and Staff H used the walkie talkie to call for assistance with Resident 49's toileting needs. -At 3:08 PM Resident 49's call light was turned off. -At 3:10 PM Resident 49's call light was turned on. -At 3:15 PM Resident 49's call light was turned off and not provided any care. -At 3:18 PM Resident 49's call light was turned on. -At 3:19 PM Staff I, NAC, entered Resident 49's room and turned off the call light. When asked why Resident 49's call light was on, Staff I stated they needed to use a bed pan and they were waiting for their colleague to get the Hoyer lift. Staff I stated they had answered Resident 49's call light not that long ago and they had turned the call light off then left to go find someone to help them. -At 3:25 PM Resident 49's call light was turned on. -At 3:26 PM Resident 49's light was answered by Staff J, NAC, who stated they would be right back to assist resident and left their call light on. -At 3:30 PM Staff H, LPN used their walkie talkie to call for Staff K and was told they were in another room assisting another resident and would be an additional ten minutes. -At 3:31 PM Staff C, Unit Manager-LPN, entered Resident 49's room and asked them what they needed. Resident 49 explained to Staff C they were waiting to use the bed pan and the aides kept turning their light off and they had been waiting. Staff C told Resident 49 let's do this and did not address Resident 49's verbalizations. Staff J reentered Resident 49's room with the Hoyer lift and Staff C remained to assist in the process of placing them on the bedpan. In an observation on 12/04/2024 at 8:22 AM Resident 49 was in their bed, laying on their back, with their eyes closed. On 12/04/2024 at 8:33 AM Staff C. LPN entered Resident 49's room and woke them up asking them if they wanted to have breakfast. In an interview on 12/04/2024 at 12:51 PM Staff F, NAC, stated they had assisted Resident 49 with getting dressed after breakfast to include use of the bed pan around 9:30 AM. Staff F stated they know how to care for a resident by reviewing their care plan and Kardex as well as information provided by other staff and the family. When asked if Resident 49 was on a toileting program, Staff F stated for them they use the bedpan before and after every meal and when they call. Staff F stated Resident 49 was mostly continent and at times had small accidents. In an interview on 12/06/024 at 8:46 AM Staff C, LPN, stated Resident 49 had transitioned to their unit just recently. Staff C stated the times noted on the Kardex for Resident 49's toileting was by direction of CC1 and they did not go back and have a discussion with CC1 about time frames versus specific times. Staff C stated they expected their staff to answer call lights within 10 minutes and preferred staff to leave the call light on when finding equipment or another staff to assist. Staff C stated they had not conducted a bladder assessment on Resident 49. Reference WAC 388-97-1060 (3)(c)

Based on interview and record review the facility failed to ensure an appropriate delegation of resident rights for decision making and informed consent was completed and followed for 1 of 4 residents (Resident 53) reviewed for Advance Directives. This failure placed Resident 53 and their representative at risk for lack of knowledge related to risks, benefits and alternatives to proposed health care and for financial or other exploitation related to lack of capacity to make informed decisions. Findings included . Review of the facility's policy titled Resident Rights- Advance Directives dated ,d+[DATE] showed the facility would identify the primary decision-maker which included assessing the resident's decision-making capacity and identifying or arranging for an appropriate representative for a resident assessed as unable to make relevant health care decisions. Resident 53 was admitted to the facility on [DATE] with diagnoses which included traumatic brain injury following a fall. Review of Resident 53's clinical record on [DATE] showed no Advance Directives, no decision-making hierarchy, and no legal or medical documents that addressed decision making capacity or competency. The available scanned records only included a POLST (Physicians orders for Life Sustaining Treatment) form dated [DATE] showing a selection of No CPR, and Comfort measures only, which was hand signed by the resident on [DATE]. Review of Resident 53's Admission Minimum Data Set (MDS- an assessment tool) dated [DATE] showed the resident's decision making was severely impaired and showed the Brief Interview for Mental status (BIMS- a 15-point test to determine memory recall and cognition) was scored at 99 indicating the resident received no score (the resident did not respond to the questions.) The care area assessment (CAA) related to cognition stated the resident had experienced a significant cognitive decline following a fall with head injury and loss of consciousness and the resident had difficulty processing information. Review of a progress note dated [DATE] Showed Resident 53's daughter was the resident's POA (Power of Attorney) and they had requested a copy of the paperwork. Review of Resident 53's care plan dated [DATE] showed the resident's designated POA, who was a family friend, not the daughter, had, in fact, passed away and the resident had not designated a secondary POA. The care plan stated the daughter was the next of kin. In an attempted interview on [DATE] at 11:38 AM, Resident 53 was not able to respond to questions and made only repetitive verbal vocalizations. Review of Resident 53's clinical record showed the residents signature in the form of a single initial was on the facility legal admission agreements (dated [DATE]), and arbitration agreements (dated [DATE]) (agreement to settle disputes through an arbitrator, rather than court.) Review of Resident 53's clinical record showed the resident was sent to the emergency department for a fall and change of condition on [DATE]. Review of a hospital palliative care note dated [DATE] showed Resident 53 was unable to make complex medical decisions and per WA state law, the patients next of kin was the daughter. The resident readmitted to the facility on [DATE] and review of the resident's medical record showed again, the resident's initial was hand signed at the bottom of the facility readmission agreement dated [DATE] and signed by Staff M, Admissions. In an interview on [DATE] at 12:20 PM, Staff M stated they reviewed Advance Directives during the admission process/paperwork. Staff M stated that they reviewed paperwork with the resident or the responsible party if the resident was not able to sign. Staff M stated they were not the one who determined if the resident was competent to sign the admission paperwork and they were not as familiar with the new paperwork since the change of ownership. Staff M stated they could not recall reviewing paperwork specifically with Resident 53. In an interview on [DATE] at 10:16 AM, Staff G, Registered Nurse/Unit Manager, stated that Resident 53 was at their baseline. Staff G stated the resident could not make decisions or sign their own documents. Staff G stated Resident 53 was able to communicate some needs, will say yes/no and staff have become familiar with them, and they must anticipate Resident 53's needs. Staff G stated the resident had declined further in their cognitive ability since their hospitalization and readmission and the goals were comfort focused. Staff G stated they had been told to contact Resident 53's daughter for consents but stated they were not aware of what the process was when a resident did not have clear Advance Directives and there were concerns that the resident did not have capacity to give consent for care or treatment. In an interview on [DATE] at 11:27 AM, Staff L, Social Services, stated they had called Resident 53's daughter who stated they would come in and sign something saying they were willing to assume decision making. Staff L stated they were not aware of whether the resident's provider had been or needed to be involved or not, stating there was probably a process, but they did not know what it was. On [DATE] the facility provided a letter dated [DATE] signed by the facility medical director stating that the resident lacked the capacity to make health care decisions due to their inability to understand the nature and consequences of a health condition, the proposed treatment, including non-treatment and reach an informed decision. Reference: (WAC) [DATE]

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 2 of 3 residents (Residents 51 and 215) reviewed for discharge planning, 1 of 1 resident reviewed for Rehab and Restorative Services (Resident 54) and 1 of 2 residents (Resident 6) reviewed for skin issues. Failure to develop and implement individualized goals or approaches placed residents at risk for decreased quality of care and unmet care needs. Findings Included . Review of the facility policy titled Comprehensive Care Plans, dated 11/2017, showed the facility Interdisciplinary Team (IDT) will develop and implement a comprehensive, person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, physical, mental, and psychosocial needs that are identified in the comprehensive assessment. <RESIDENT 6> Resident 6 admitted to the facility on [DATE] with diagnoses to include chronic congestive heart failure. In an observation on 12/02/2024 at 9:38 AM, Resident 6 was observed to have swelling (edema) in both feet and wearing tight fitting slippers. In subsequent observations on 12/03/2024 at 9:07 AM, 12/04/2024 at 8:43 AM, 12/05/2024 at 8:37 AM and 12/06/2024 at 9:29 AM, the resident was observed to have edema with TED hose (stockings/socks that help prevent blood clots) and tight-fitting slippers on. Record review of Resident 6's care plan dated 06/01/2023 and revised on 07/31/2024 showed there were no specific interventions noted to address the resident's congestive heart failure (CHF) and edema. The care plan had one intervention to monitor/document/report to the physician any signs of CHF such as dependent edema of legs and feet, periorbital edema, shortness of breath (SOB) upon exertion, cool skin, dry cough, distended neck veins, weakness, weight gain unrelated to intake, crackles and wheezes upon auscultation of the lungs, Orthopnea, weakness and/or fatigue, increased heart rate (tachycardia) lethargy and disorientation. In an interview on 12/06/2024 at 9:11 AM, Staff C, Licensed Practical Nurse (LPN)/Unit Manager stated they would update Resident 6's CHF care plan to include interventions. In an interview on 12/06/2024 at 10:45 AM, Staff B, DNS stated that Resident 6 had edema, and they had adjusted their diuretics (medication to help with edema). Staff B stated that Staff C would be updating the care plan to include the interventions. 37890 <RESIDENT 51> Resident 51 admitted to the facility on [DATE] with diagnoses to include heart and liver problems and a history of alcohol use disorder. Review of the Admission Minimum Data Set (MDS-an assessment tool) assessment dated [DATE] showed the resident had intact cognition, resident was at facility for a short stay, with a goal to return to community, and that they had an active discharge plan. Review of Resident 51's care plan on 12/02/2024 through 12/05/2024 showed no focus area for discharge planning. In an interview and observation on 12/02/2024 at 10:09 AM, Resident 51 was ambulating throughout the facility with a walker, at a quick pace, observed to be steady on their feet, observed to ambulate from one end of the facility to the other multiple times. Resident 51 stopped in the hallway, said hello and wanted to talk, stating they did not know why there were not able to discharge home. The resident stated that they were no longer receiving any therapy and felt they were ready to go home. Resident 51 stated they had some stairs at their apartment, but they could do the stairs and they were agreeable to some help at home if that was what they needed. Resident 51 stated they were stressed out because they wanted to know what the plan was. <RESIDENT 54> Resident 54 admitted to the facility on [DATE] with diagnoses to include COVID 19 illness, history of falls, and diabetes. Review of the Admission MDS dated [DATE] showed Resident 54's discharge was unknown and there was an active discharge plan in place. In an interview on 12/02/2024 at 11:46 AM, Resident 54 stated they were working with therapy, and they knew they needed to improve their strength. The resident stated they had requested to have a predictable schedule for things like therapy because it helped them be productive with other things they needed to do, stating I like to have an organized day. Resident 54 stated they were not sure when they would discharge or if they were going to have to move or not. Review of Resident 54's care plan on 12/02/2024 through 12/05/2024 showed no focus area for therapy goals or discharge planning. In an interview on 12/05/2024 at 9:51 AM, Staff L, Social Services Director (SSD), stated they did care conferences with residents within 48 of their admission and they talk about goals, it starts on day one. Staff L stated they encourage residents to have a plan B. Staff L stated Resident 51 was ready to go, but the family had been in favor of an adult family home or other assisted option instead of the previous apartment and the resident needed a new bed. Staff L stated the process was changing and the notes, which had been in the progress notes, will now be found in the assessments section under discharge plan. Staff L stated this information should be on the care plan and acknowledged that the prior progress notes and care plans were lacking for some residents including Resident's 51 and 54. 44110 <RESIDENT 215> Resident 215 admitted to the facility on [DATE] with diagnoses to include left arm fracture, high blood pressure, and muscle weakness. The Admission MDS dated [DATE] showed Resident 215 had intact cognition, was at facility for a short stay, with a goal to return to community, and that they had an active discharge plan. Review of Resident 215's care plan on 12/02/2024 through 12/05/2024 showed no focus area for discharge planning. In an interview on 12/02/2024 at 2:23 PM, Resident 215 stated they have not talked to any facility staff regarding their discharge plan, and it was stressing me out a bit. Resident 215 stated it will be a big change, so they hope there was a good plan. In an interview on 12/05/2024 at 9:51 AM, Staff L stated the expectation was to meet with the newly admitted resident within 48 hours to review their plan of care. Staff L stated that was when the care plan was updated to reflect the discharge plan and would build from there throughout their stay. Staff L confirmed that the discharge plan had not been developed in Resident 215's care plan. In an interview on 12/06/2024 at 11:05, Staff B stated their expectation was discharge planning started on the day of admission, and that the SSD was updating the care plan to reflect the resident's current goals and preferences. Reference WAC 388-97-1020(1)(2)(a)

Based on observation, interview and record review, the facility failed to assist 1 of 3 dependent residents (Resident 6) with routine activities of daily living. Failure to provide routine grooming and clothing changes placed residents at risk for poor hygiene, discomfort, dignity issues, and diminished quality of life. Findings included . Review of facility policy titled, Quality of Life-Activities of Daily Living (ADL's), revised on 11/2017, showed A patient who is unable to carry out ADL's will receive the necessary level of ADL assistance to maintain good nutrition, grooming, and personal and oral hygiene. In the case of a resident with cognitive impairment who refuses care, the facility staff are responsible to attempt to identify the underlying cause of the refusal/declination of care. Resident 6 admitted to the facility on [DATE] with diagnoses to include stroke with hemiplegia (paralysis to one side of the body) and hemiparesis (a condition that causes weakness or partial paralysis on one side of the body) affecting their right dominant side, congestive heart failure, dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) and depression. Review of Resident 6's Quarterly Minimum Data Set (MDS- an assessment tool) assessment dated [DATE], showed the resident had impaired range-of-motion to both sides of their upper and lower extremities and they did not refuse care. Review of the ADL Care Area Assessment (CAA) dated 01/24/2024 showed Resident 6 had chronic weakness and deconditioning with some right sided deficits along with cognitive impairments secondary to dementia with limited activity tolerance are primary factors contributing to self-care and mobility deficits. Resident 6 continues to require primarily supervision/touching assistance with most cares due to their cognitive deficits with limited insight/awareness of their care needs with occasional partial/moderate assistance r/t balance deficits and/or fatigue. Review of Resident 6's care plan initiated on 04/28/2016 directed staff to assist the resident in choosing clothing and provide one person partial or moderate assistance to dress. The care plan directed staff that if they noticed facial hair to assist Resident 6 twice a week with shaving. In an observation on 12/02/2024 at 9:38 AM, Resident 6 was observed in the hallway wearing a pink shirt with a white cross on it. The resident was observed to have 3/4 inch long white chin hair. In an observation on 12/03/2024 at 9:47 AM, Resident 6 was observed in the hallway wearing a pink shirt with a white cross on it. There were multiple food and/or fluid spills on the upper chest area of the shirt. The resident was observed to have 3/4 inch long white chin hair. In an observation on 12/04/2024 at 8:43 AM, Resident 6 was getting assistance back to their room wearing the same pink shirt with a white cross on it. There were multiple food and or fluid spills on the upper chest area of the shirt. Their blue slacks had some food or fluid particles on both thighs. The resident was observed to have 3/4 inch long white chin hair. In an observation on 12/05/2024 at 8:37 AM, Resident 6 was in the hall outside their room wearing the same pink soiled shirt. Their blue sacks were heavy soiled with white and tan spots on both thighs. The white chin hair remained. In an observation on 12/06/2024 at 9:29 AM, Resident 6 was in the hallway outside their room with two streaks of chocolate running down their mouth to their chin. Resident 6 was wearing the same pink soiled shirt since Monday (12/02/2024). Their blue sacks were heavily soiled with white and tan spots on both thighs. The long white chin hair remained. Review of the progress notes beginning 09/01/2024 through 12/05/2024 did not contain any documentation that Resident 6 refused ADL care. In an interview on 12/05/2024 at 10:22 AM, Staff N, Social Services stated Resident 6 refused denture care, but they were not aware of any other care refusals. In an interview on 12/05/2024 at 1:17 PM, Staff O, Nursing Assistant Certified (NAC) stated Resident 6 needed help with ADL's including grooming, and changing clothes and they did not refuse care. In an interview on 12/05/2024 at 1:18 PM, Staff P, NAC stated Resident 6 got finicky with oral care and no longer walked to dine. Staff P stated staff have to assist the resident with changing their clothing. Staff P stated the resident needed assistance with ADL's including shaving. In an interview on 12/06/2024 at 9:11 AM, Staff C, Licensed Practical Nurse/ Unit Manager stated their expectation was that grooming be provided and the aides will change residents' clothing daily. In an interview on 12/06/2024 at 10:45 AM, Staff B, Director of Nursing stated they had heard about Resident 6 wearing the same shirt for five days. Staff B stated Resident 6 would wear the same thing over and over and their care plan did not reflect the resident's refusals of care. Reference: WAC 388-97-1060 (2)(c).

Based on observation, interview and record review, the facility failed to provide supervision to ensure residents were free from avoidable accidents for 2 of 3 residents (Resident 1 and 2) reviewed for accident hazards. Resident 1 experienced harm when they fell from bed and sustained a head injury that required sutures and hospitalization when facility staff did not follow the resident's individualized care plan (CP) that required two staff assistance/supervision for incontinence care. This failed practice placed Resident 2 at risk for injury when they wandered outside the facility without staff supervision. Findings included Review of the policy titled Quality of Care- Accident Hazards, supervision, devices dated 07/2018 showed resident specific interventions will be reflected in the residents person-centered, individualized care plan. <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnoses that included history of a stroke with left sided hemiparesis (weakness or partial paralysis affecting one side of the body) and generalized weakness. Review of the 07/02/2024 quarterly Minimum Data Set (MDS-an assessment tool) showed Resident 1 had intact cognition, no behaviors, no rejections of care and required extensive assistance with bed mobility and was dependent on staff assistance for toileting hygiene and rolling side to side in bed. Resident 1 had no recent history of falls. Review of Resident 1's current care plan showed an intervention dated 07/30/2024, that instructed staff that Resident 1 required staff participation to turn and position in bed, two person assist with a further clarification that the resident was able to turn right to left with one person extensive assistance. An intervention dated 07/10/2024 instructed staff that resident 1 required two person extensive assistance for incontinence care or bed pan. Review of the resident record on 08/16/2024 showed Resident 1 had a witnessed fall out of bed on 08/13/2024. Review of the facility investigation showed that Staff D, Certified Nursing Assistant (CNA) was assisting Resident 1 with incontinence care and bedding change without a second CNA assisting per the care plan. Review of a signed written statement provided by Staff D dated 08/14/2024 stated they had rolled the resident on their left side and turned their back (leaving the resident unsupported) to retrieve supplies, turned back around and witnessed Resident 1's weight shift to the left, their right shoulder came forward and they rolled off of the left side of the bed and onto the floor, striking the back of their head on the floor. The statement stated there was blood seen on the back of Resident 1's head and Staff D called on their walkie talkie for other staff to assist. Resident 1 was transferred to the Emergency Department (ED) on 08/13/2024, where they were found to have a scalp laceration requiring sutures. Imaging reports were obtained at the ED and showed a subdural hematoma (a head injury where blood collects between the skull and the surface of the brain). The resident was admitted to the Intensive Care Unit and required a total of seven days of hospitalization . In an interview on 08/22/2024 at 12:13 PM, Staff F, Licensed Practical Nurse (LPN) stated Resident 1 required 2 staff assistance for care, stating Resident 1 was weak and could barely move their body. In an interview on 09/03/2024 at 12:47 PM, Staff B, Director of Nursing Services stated Resident 1 had weakness due to a stroke and their left side was weaker than their right side. Staff B stated when they had interviewed Staff D following the fall, Staff D knew Resident 1's care plan very well and knew that they only needed one person to roll them to the left so that was why they had rolled Resident 1 in that direction. Staff B stated Staff D did not have a second staff member assisting them with Resident 1 but did not review that further with Staff D or include those factors in the incident investigation or conclusion of root cause. Staff B stated they had Staff D walk them through the care provided and Staff D was very specific about Resident 1 being able to roll to their left and that Staff D felt they were following the care plan. 43954 <RESIDENT 2 > Resident 2 admitted to the facility on [DATE], with diagnoses to include hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body) of left side, muscle weakness, and difficulty in walking. Review of Resident 2's current care plan showed the resident required supervision with one person assistance for transfers and required supervision with one person assistance for hallway ambulation with a wheelchair to follow, initiated on 07/24/2024. Review of a progress note dated 08/18/2024 at 3:57 PM showed Resident 2 was found outside of the facility, in the community by the police at the hospital emergency room entrance and they had called the facility to alert them. Review of Resident 2's elopement investigation, dated 08/18/2024, signed by Staff B, showed no staff witnessed the resident leave the facility. Staff E's, Licensed Practical Nurse (LPN), statement dated 08/20/2024 at 12:51 PM showed they observed Resident 2 at approximately 1:00 PM leaving the dining room and assisted them part way down the hall and then directed Resident 2 to B wing. Staff E was notified by reception around 2:00PM that Resident 2 was found at the hospital emergency room entrance two blocks away. In an interview on 09/03/24 at 12:05 PM, Staff E stated they observed Resident 2 on 08/18/2024 after 1:00 PM. Staff E stated they ambulated with Resident 2 part of the way and then directed them to B wing, which was down the hallway. Staff E stated that Resident 2 did not require supervision or assistance with ambulation and use of a walker. In a joint interview/record review on 9/3/2024 at 12:50 PM, Staff B, DNS stated when they complete facility investigations, they review the care plan. Staff B stated their expectation is that staff follow residents' care plans. Staff B stated Resident 2's care plan showed they required supervision and one person assist with transfers and ambulation with a wheelchair to follow. Reference WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure a resident's right to privacy, security, and confidentiality when a staff member relayed confidential information to a visiting family member for 1 of 1 resident (Resident 1) reviewed for personal privacy/confidentiality of records. This failed practice placed residents at risk for the loss of confidentiality and privacy and the right to have their preferences honored. Findings included . Review of the facility policy titled, Resident Rights- Privacy and Confidentiality dated 07/2024 showed the facility will respect the residents' right to personal privacy and the right to secure and confidential personal and medical records. Resident 1 admitted to the facility on [DATE] and according to the Admission Minimum Data Set (MDS- an assessment tool) assessment dated [DATE], the resident was alert and oriented. In an interview on 08/16/2024 at 11:50 AM, Collateral Contact 1 (CC1- Resident 1's Power of Attorney [POA]) stated a person (CC2) that was visiting the facility on or about 08/14/2024, was given a copy of Resident 1's care plan and CC2 was not on Resident 1's release of information and should not have been given any of Resident 1's private/confidential information. CC1 stated Staff C handed the care plan to CC2 and was told to give it to them (CC1). Review of Resident 1's clinical record on 08/21/2024 showed CC1 was the resident's POA for Healthcare and Financial matters. Review of the facility face sheet for Resident 1 showed CC1 was listed as the POA and the primary emergency contact. CC2 was not listed in Resident 1's record as any type of authorized representative or contact. In an interview on 08/22/2024 at 12:20 PM, Staff C, Licensed Practical Nurse, Unit Manager, stated they had given the care plan to CC2 who was supposed to give it to CC1. Staff C stated they believed it was ok to share information with CC2 relating to Resident 1. Refererence (WAC) 388-97-0360

Based on observation, interview, and record review, the facility failed to develop a plan of care, and implement interventions to prevent Pressure Ulcer/Pressure Injury (PU/PI) development for 1 of 1 resident (Resident 1) who was admitted without a PU/PI, but who had multiple co-morbidities with an increased risk for PU/PI development. The facility failed to provide staff education, ensure competency on the correct use of a bone stimulator (an external medical device that generated a radio frequency energy to the bone), prevent skin breakdown, and monitor ongoing skin integrity with the application of the bone stimulator. This failure resulted in physical harm to Resident 1 when they developed a stage III PI to their left foot from a medical device. Findings included . Review of the Minimum Data Set (MDS, an assessment tool) 3.0 Resident Assessment Instrument manual, v1.12.1, showed a PU defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. A stage III PU is defined as full thickness tissue loss, subcutaneous fat may be visible, but bone, tendon or muscle is not exposed. Slough (non-viable [dead] tissue) may be present but does not obscure the depth of tissue loss. Review of the National Pressure Injury Advisory Panel (NPIAP) literature, dated January 2020, showed PU that reach full thickness, are considered never events, (should never happen). Medical device related PIs result from the use of devices designed and applied for diagnostic or therapeutic purposes. The resultant PI generally conforms to the pattern or shape of the device. The injury should be staged using the staging system. The literature showed the standard of best practices for prevention of medical device-related pressure injuries in long term care included: - Inspect the skin under and around the device at least daily (if not medically contraindicated). - Reposition devices (if feasible). - Educate the staff on correct use of devices and prevention of skin breakdown. - Be aware of edema (swelling) under device(s) and potential for skin breakdown. Review of a facility policy titled, Prevention of Pressure Injuries, dated April 2020, showed the facility would reposition all residents at risk of PIs on an individualized schedule determined by the interdisciplinary care team, select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice, and review medical devices with consideration to minimize tissue damage, including the application and ability to secure the device. Resident 1 admitted to the facility on [DATE] with diagnoses to include cardiac, kidney and respiratory disease. According to the Quarterly MDS assessment on 04/13/2023, the resident had moderately impaired cognition and required extensive assistance from staff to complete activities of daily living (ADL). The resident had no PU/PI present but was at risk of developing PU/PIs. Review of Resident 1's admission orders, dated 12/15/2022, showed to apply a bone stimulator device to the resident's left foot for three and a half hours every night. Review of the manufacture's bone stimulator literature, revised 01/08/2021, showed the device was indicated for the treatment of an established non-union fractures (failure of a fractured/broken bone to heal and mend over time) acquired secondary to trauma. In rare instances the device could cause reversible minor discomfort. The device could be cumbersome or uncomfortable, cause tingling or pain and a minor skin rash had been reported. The device use and care area of literature showed the device was to be inspected prior to each use for wear, deterioration, or damage. For safe usage, the literature directed the user to follow the manufacturer's instructions. Review of Resident 1's Treatment Administration Records (TAR) beginning 12/15/2022, showed the resident was to have a bone stimulator applied for three hours at night due to the resident's dislocated left ankle. The TAR directed nurses to place the device centered over the left ankle, bring the strap around the ankle, and fasten on the opposite end of the device, switch the power button on, it would run for three hours, then remove the device. The TAR did not include specifics on when to apply the device nor warnings or contraindications of the device. There were no directions for the nursing staff to assess the resident's skin or check for edema before or after application of the bone stimulator. Review of Resident 1's care plans dated 12/15/2022 through 05/15/2023, showed the absence of guidance for the bone stimulator device. Resident 1's care plan, dated 05/16/2023, was the first entry which documented that a bone stimulator was initiated, and showed that the bone stimulator was placed on hold for five days (until 05/21/2023), pending orthopedic reevaluation of continued need. Review of the progress note, dated 01/29/2023 at 4:25 PM, showed Resident 1 returned from their orthopedic appointment and the notes included x-rays showing stable alignment of the fractures. No revision surgery was recommended. Review of Resident 1's orthopedic surgeon visit note, dated 01/19/2023, showed the resident was there for a follow up visit and was last seen in the clinic on 11/10/2022. The note, dated 11/10/2022, stated there was evidence of a non-union fracture on Computed Tomography (computerized imaging). On 01/19/2023, the orthopedic surgeon documented the resident may be weight bearing as tolerated and the bone stimulator could be discontinued. Review of Resident 1's Braden Scale (assessment tool to predict PU risk), dated 04/13/2023, showed a score of 16 (mild risk for predicting PU risk was a score between 15 to 18) indicated the resident was at mild risk for PU development. Review of Resident 1's progress note, dated 05/15/2023 at 7:09 AM, showed at 6:45 AM, Staff H, Certified Nursing Assistant (CNA), notified Staff D, Licensed Practical Nurse (LPN), there was an open area on the top of the resident's left ankle joint measuring 0.5 centimeters (cm) by 0.5 cm. Staff D documented the open area was on the ankle that the bone stimulator was on. Review of Resident 1's skin and wound evaluation, dated 05/16/2023 at 10:11 AM, showed a new left lateral (side) malleolus (ankle) wound that was a medical device related PI, acquired in-house at a stage III with full thickness skin loss measuring 1.2 cm in length by 0.9 cm in width, by 0.1 cm depth. The wound bed had 50% granulation (new skin) tissue and 50% slough (non-viable tissue). Review of a progress note on 05/16/2023 at 3:49 PM, showed the factors contributing to the event/incident were Resident 1 had a bone stimulator on their left ankle to support healing after previous fracture. The note stated that the strap of the stimulator went over the open area and the pressure and friction from the device likely caused the skin breakdown. Resident 1had edema (swelling) to the foot and ankle that would contribute to higher risk of skin breakdown. The analysis was the facility determined the wound was a device related PI from the bone stimulator they wore for three hours each night shift. The device centered over the lateral malleolus with the strap wrapping around the ankle. The device vibrated and caused the strap to push and rub on edematous (swollen) skin. Review of Resident 1's clinical record, dated 05/15/2023 at 7:40 AM, Staff I, contracted Physician's Assistant, documented the resident was seen today for evaluation of the wound on the crease of her foot. The wound team saw yesterday and felt like it was getting worse and requested a hold on the patient's bone stimulator. However at this time referred back from the patient's orthopedic and they have indicated that it can be discontinued. At this time the patient has a small wound in the crease of her ankle. We have been adjusting diuretics and the patient's legs do feel softer with less pitting edema (swelling) however the feet are still fairly swollen. The patient is good about wearing her compression socks however at this time we need to continue to monitor this wound. The patient continues to complain of foot pain on the left side and the foot that she broke. The patient has a small open area of the skin where her bone stimulator was placed. The area was approximately 1.2 cm and is small. There is some slough present and as such yesterday I put in orders for Medihoney (a type of wound gel). There is no surrounding signs of cellulitis or significant concern. Continue with the current medical regimen and monitor daily for any other concerns. In a joint interview on 05/24/2023 at 2:55 PM, with Staff B, Consultant Registered Nurse (RN), and Staff A, Director of Nursing Services (DNS). Staff B stated the PI was device related and they felt the resident's edema contributed to the development of the wound. Staff B said they had identified that the facility had no process in place on when the device was to be applied, removed, and there was no area for skin inspection pre and post device application. Staff B said the facility failed to have the literature on the bone stimulator and there was no care plan in place regarding the bone stimulator until after the injury occurred. Staff B said the facility had been unaware there was an order to discontinue the device on 01/19/2023. Staff B said they had received a handwritten note from the provider after the visit. They were unaware there was a full dictation note from the visit until it was faxed on 05/19/2023. Staff B said staff called the orthopedic surgeon's office and they said the bone stimulator had been discontinued on 01/19/2023. Staff B said the facility identified this doctor visit process as another area for improvement. Staff A and Staff B stated there was no process or competency in place regarding the bone stimulator device, but they were working on that now. In an observation of the dressing change on 05/29/2023 at 4:03 PM, Resident 1 was lying in bed. The resident's left foot had edema with an open area and a marked indentation that measured approximately 0.9 cm by 0.4 cm by 0.1 cm. The wound bed was pink and consistent with epithelial tissue. The resident stated Ouch, that hurts during the application of the Medihoney. Staff C, LPN, stated the wound looked better than when they had seen it several days ago. Staff C said the edema was worse especially with the discontinuation of the resident's compression stockings. In a phone interview on 05/31/2023 at 1:59 PM, Staff D stated the bone stimulator did not vibrate at all, it was radiofrequency. Staff D confirmed the resident had edema to their feet. Staff D said that Staff H, NAC, found the open area the day before Staff D did when they removed the resident's compression stockings. Staff D stated Staff H reported the open wound to Staff E, LPN. Staff D stated they would place the bone stimulator on at 3:00 AM and then the day shift aide would take it off when the resident got up in the morning. Staff D said they never removed the device or inspected the skin after the treatment. Staff D stated they were interviewed about the wound several days ago and notified Staff A and Staff F, LPN/Staff Development Coordinator, the wound was originally identified on 05/14/2023. Staff D stated when they first observed the wound on 05/15/2023 it looked like a yellow, wet scab and measured 0.5 cm by 0.5 cm. Staff D stated they had been applying the bone stimulator in the same way for almost a year. Staff D said they received no training on the device but did read the pamphlet before they started applying it. In an interview on 05/31/2023 at 2:50 PM, Staff A stated there had been no recent PU prevention education. They said it was on the calendar to begin in June 2023. Review of the facility's training records, printed on 05/31/2023, showed that six of twenty-four NACs had received the prevention of PI/PUs training. There were no licensed nurses documented to have completed the training. In a phone interview on 05/31/2023 at 2:38 PM, Staff E, LPN, stated they had just talked to Staff A about the wound. Staff E said they were notified of redness to Resident 1's left foot on 05/14/2023. Staff E said they were busy and did not go assess the resident's leg that night. Staff E said they had received no training on the bone stimulator. In a phone interview on 06/02/2023 at 8:12 AM, Staff J, RN, stated they last applied the bone stimulator to Resident 1 last on May 6th or 7th, 2023. Staff J said they would usually put the device on at 1:00 AM or 3:00 AM depending on how their night went. Staff J said if they placed it on at 1:00 AM they would take it off, but they relied on the aides to remove it if it was placed at 3:00 AM. Staff J said they would have to wake the resident up to put it on them and the last time they did, the resident told them, Don't put that on too tight. Staff J said the resident had more edema since admitting to this facility. Staff J said they had not seen the wound but had heard about it. Staff J said they had no training on the device but had learned about them briefly in nursing school. Staff J said the expectation was that when an open area or skin issue was found, they were to clean the area with normal saline, call the doctor to notify them, and obtain a treatment order, document to the wound in the progress notes, start an incident report, place the resident on alert, and notify the responsible party and DNS. This was a repeat deficiency from 01/26/2022 and 07/29/2022. Reference (WAC) 388-97-1060 (3)(b)

Based on observation, interview, and record review the facility failed to prevent neglect and abandonment of one of one resident (1) who was discharged to a motel, while they were still a resident of the facility, without ensuring arrangements were made to provide care for the resident's Stage IV pressure injury (PI) to their right buttock, unstageable pressure injuries to their right heel, right lateral (to the side away from the middle) calf, and left heel along with a wound to their right knee or set up any services to address the resident's nutritional needs. Additionally, the facility failed to ensure there were services in place to assist the resident with their bowel and bladder incontinence or medical management of the resident's multiple comorbidities. This failed practice placed the resident at risk of serious adverse outcomes due to the facility's identified resident's medical care needs and subsequently sent to the hospitalization for the severe deterioration of the resident's Stage IV PI of their right buttock and hospitalized for severe protein caloric malnutrition and right gluteal sacral decubitus osteomyelitis and cellulitis. An Immediate Jeopardy (IJ) was called on 03/02/2023 at 4:21 PM, at F600- Freedom from Abuse, Neglect, and Exploitation when the facility was found to have discharged Resident 1 to a motel without ensuring arrangements were made for the resident's medical, personal and nutritional needs. The facility removed the immediacy on 03/07/2023, by the return of the resident to the facility, personal care was provided to the resident along with wound assessment and treatment. The facility in-serviced the staff on Abuse Prohibition and Neglect along with Discharge Planning. Findings included . The National Pressure Ulcer Advisory Panel (NPUAP) Pressure Injury (Ulcer) definition and stages include: -A pressure injury is localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities, and condition of the soft tissue. -Stage IV Pressure Injury: Full-thickness skin and tissue loss. Full-thickness skin and tissue loss with exposed or directly palpable fascia, (thin casing of connective tissue that surrounds and holds every organ, blood vessel, bone, nerve fiber and muscle in place), muscle, tendon, ligament, cartilage, or bone in the ulcer. Slough and/or eschar may be visible. Epibole (rolled edges), undermining and/or tunneling often occur. Depth varies by anatomical location. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. -Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e. dry, adherent, and intact without erythema or fluctuance) on the heel or ischemic (a shortage of blood supply to a part of the body) limb should not be softened or removed. Review of a Level 1 Preadmission Screen and Resident Review (PASRR) Notice of Determination dated 02/17/2023 for Resident 1, showed a Level II evaluation referral required for significant change with diagnoses of depressive disorder, psychoactive substance use and nicotine dependence. The Level II evaluation was not completed prior to the resident's discharge. Review of a Social Service Note dated 02/22/2023, showed that Staff B, Social Service Assistant, documented that along with the Administrator they met with Resident 1 to discuss their discharge plan, refusals of therapy, suspected substance use and withdrawn behavior. The resident was noted to have stated that they had not been refusing therapy or any assistance from staff. Resident 1 was noted to have reported that they would like to discharge to a motel once therapy services were over instead of (named community homeless center). Staff B noted that they reviewed with the resident that when the resident did discharge, they would be discharged with Home Health, physician follow up, medication and [NAME] (Meals on Wheels). Review of a Nursing Home Transfer of Discharge Notice signed but undated by Resident 1 and signed and dated 02/23/2023 by the facility's Administrator with the explanation that the resident overdosed after smoking Fentanyl in their rest room and continued concerns related to drug use within the facility. The location to which the resident was to transfer, or discharge was to be determined by the Home and Community Services (HCS) caseworker and the resident. Review of an Encounter note dated 02/24/2024 at 00:00 (12:00 AM),documented by Staff A, Nurse Practitioner, noted that the resident left against medical advice (AMA) and refusal of care with discharge condition as fair/stable, discharge medication reconciliation, instructions to both the resident and resident's family to return to the emergency room if there was any change in the resident condition and to follow up with primary care provider within a week and a referral to the wound clinic as an outpatient. Review of a Social Services Note dated 02/24/2023 at 9:36 AM, Staff B documented that they went in to follow up on the list of drug rehab facilities that was provided to the resident and the resident had stated that they were not interested in going to inpatient drug rehab and preferred to go to a motel. Review of a Social Services Note dated 02/24/2023 at 10:24 AM, Staff C, Social Service Director, documented that they called the resident's sister who was not able to support the resident at discharge and was not able to get in touch with the resident's daughter. Staff B documented that they were working with the resident on discharge planning and the resident was agreeable to go to a motel with services. Review of a Nursing Care Note dated 02/24/2023 at 11:38 AM, showed the Director of Nursing Services (DNS) documented that they were notified that Resident 1 was interested in an AMA discharge. The DNS noted that they asked Resident 1 if they wished to discharge AMA. The DNS explained what that meant, which included not being discharged with narcotics, but would be sent with all other medications. The DNS noted that the resident was informed the facility would set up a Primary Care Provider appointment, would refer them to home health, would reach out to the community homeless outreach program, and would notify HCS. The DNS noted that Resident 1 was informed that with an AMA discharge, the police would be notified for a wellness check and Adult Protective Services would be notified. The DNS documented, Resident kept saying 'Fine I'll go' but never stated [the resident] wanted to go. Due to not stating [the resident] wants to go, AMA cancelled for today. Review of the AMA-Leaving Against Medical Advice form with a date of 02/24/2023 at 12:09 PM, documented Resident 1, was not able to take care of themselves independently at that time and continued to need increased level of assistance for personal care. Further deterioration of medical conditions due to no physician follow up, lack of resources in the community to assist with personal care and no monitoring related to drug abuse issue and no mental health assistance which was signed on 02/27/2023. Review of a Social Services Note dated 02/24/2023 at 12:16 PM, Staff C documented that they spoke with HCS related to the resident leaving AMA and had wanted to go to a motel. Per review of a Nursing Care Note dated 02/27/2023 at 11:42 AM, the DNS documented that they along with the Social Service Assistant and the Resident Care Manager addressed the report that the resident had drug paraphernalia in their room. The DNS noted that the resident continued to deny that they had anything and then stated that the resident wanted to leave. The DNS documented that they asked the resident if they wanted to discharge AMA and the resident stated Yes, I want to get out of here. The DNS documented that the facility would get a motel set up along with transportation and noted that the provider was signing orders, home health referral was already sent. The DNS documented that the home health agencies had declined to see the resident due to the resident's prior history and a wound clinic referral was set up. The DNS noted that the SSA was reaching out to the Community Outreach for the homeless. The DNS noted that Resident 1 agreed and had stated they were wanting to get out of there. Review of the 02/27/2023 Discharge Minimum Data Set (MDS) assessment, showed that the facility assessed Resident 1 required extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and total dependence with bathing. Per review of an email the facility's DNS sent on 02/27/2023 at 12:17 PM, to the HCS supervisor regarding the discharge of Resident 1. A Home Health referral was sent but Home Health would not be taking Resident 1 for home care, a referral to a wound clinic was made and the resident was discharged with their medication with the exception of their narcotic pain medication. In a phone interview on 03/01/2023 at 4:30 PM, Resident 1, stated that their care at the facility was, not to swift. Resident 1 stated that the staff had reported that they had refused care, but they had been ill with nausea and vomiting and was unable to eat for four days. The resident stated they felt they had been coerced to leave the facility but that they did sign the discharge paperwork as it was frustrating when the facility staff lied and complained that they were refusing care. Resident 1 stated that they just finally agreed with them and said they would go. The resident stated that one of the staff members of which they did not know their name or title had told them they would be discharged to a motel with home care, [NAME], and wound care. Resident 1 stated that they had not had any home care, wound care or any meals provided to them since they had been discharged four days ago. The resident continued to state that the facility staff had told the resident that they would have wound care treatment and meals set up, yad-da yad-da yad-da, but had received nothing. Resident 1 stated that one of the staff members at the facility knew what was going on and how it went down. The resident stated that there were staff that were saying that they did not have to leave the facility and then there were staff in the background saying that they had refused care and it was frustrating and had pissed the resident off. The resident stated that the facility had given him a 30-day thing for discharge, and it was then that they had started talking about setting them up with a motel and that they could go to the motel that day. Resident 1 stated that there were even a couple of male staff that were encouraging them to leave and had told the resident that everything was going to be good and fine. In an interview on 02/28/2023 at 1:40 PM, Staff D, Registered Nurse/Resident Care Manager, stated that the resident had been, Flip flopping, about discharging and if the discharge was not safe, they were going to keep the resident in the facility. Staff D stated that they had told the DNS that the resident would not be safe to discharge on 02/24/2023 and the resident had agreed to stay at the facility. In an observation and interview on 03/02/2023 at 4:51 PM, the resident was lying in a bed in a pair of sweatpants in an unkept motel room with items scattered on the bed, floor, and tables. The resident was observed to have excess sweat on their face and chest. The resident stated that they felt coerced to leave the facility when the staff had them sign a 30-day paper and told them that they did not have to wait the 30 days but could leave that day. Resident 1 stated that there was a staff member who was by their room at the facility that told the resident to not let the other staff do that to them when the staff were telling the resident to leave. Resident 1 stated that they were coerced to leave when a staff person told them that they would get treatment, food, [NAME] and would not have to worry about nothing. Resident 1 stated that nursing and physical therapy were supposed to come see them at the motel and that was the only reason why they had left the facility. Resident 1 stated that all the stuff they were saying would happen did not happen. Resident 1 stated that they had a bowel movement in their incontinent brief, and they had tried to use the wipes that they were sent with to clean themselves. The resident pulled their sweatpants to reveal there was no dressing to their right buttock wound, there was a dry partially adhered dressing to their right knee and the resident was unable to remove their socks to reveal their reported wounds to their heels or feet. In an interview on 03/02/2023 at 3:16 PM, Collateral Contact (CC) 1, Motel Staff, stated that Resident 1 had been begging for food from other motel guests. CC 1 stated that it was the motel's policy that they were not allowed to clean the motel rooms while they were occupied by a guest. In an interview on 03/02/2023 at 3:20 PM, CC 2, Motel General Manager, stated that the motel had been reserved and paid through 03/06/2023 by Staff E, Facility's Senior Regional Administrator. CC 2 stated that they had not seen or had any calls from any home care agencies or delivery staff for meals on wheels. CC 2 stated that Resident 1 had been calling to other guest rooms at the motel attempting to get help. In a follow up phone interview on 03/03/2023 at 12:05 PM, Staff D, stated that the Administrator had directed them to go to the motel to provide wound care to Resident 1 but did not feel comfortable as they did not have active wound care orders. Staff D stated that on Friday, 02/24/2023 that they, definitely felt, the resident was coerced to leave the facility. Staff D stated that they had told the resident that it was their right to stay at the facility and the resident had stayed on Friday, but Staff D had not worked on Monday, 02/27/2023. In an interview on 03/07/2023 at 1:38 PM, Staff M, Licensed Practical Nurse, stated that Resident 1 was sent to the hospital that morning for osteomyelitis (inflammation or swelling that occurs in the bone)and worsening of their buttock and heel ulcer. Review of the Hospital History and Physical dated 03/07/2023, showed that the resident was hospitalized for severe protein caloric malnutrition, and right gluteal sacral decubitus osteomyelitis and cellulitis (bacterial skin infection that causes redness, swelling, and pain in the infected area of the skin). Reference: (WAC) 388-97-0640 (1)(3)(c)

Based on observation, interview and record review, the facility failed to provide adequate supervision for three of three residents (4, 7 and 21), reviewed for altercations. The facility failed to ensure appropriate interventions were implemented to prevent falls with injury for one of three residents (32), reviewed for falls. This failed practice resulted in harm for Resident 32 who obtained a right [CONDITION(S)] that required surgical intervention, and a right shoulder fracture that resulted from a fall. The facility failed to recognize the high risk for the repeat behavior of verbal aggression of Resident 4 and analyze all individual risk factors or provide the necessary supervision/monitoring for one of two residents (Resident 4) reviewed for supervision. The failure to adequately supervise Resident 4 and address a known history of verbal aggression towards other residents, resulted in harm to Resident 7 and 21 who endured unwanted verbal assault. This failure placed the residents at risk for fear, isolation, physical and psychological injury, lack of feelings of safety and decreased quality of life. Findings include . <Falls> Review of the facility's policy titled, Fall and Fall Risk, managing, revised March 2018, stated staff will identify interventions related to the resident's specific risks and causes to prevent the resident from falling. RESIDENT 32 Resident 32 admitted to the facility on [DATE] with diagnosis to include Diabetes, [CONDITION(S)] (disease of the liver), and pressure ulcers to sacrum (portion of your spine between your lower back and tailbone). Review of the Admission Minimum Date Set (MDS) assessment dated [DATE] that was started on 07/09/2022, showed the resident required two persons assist for transfers. The resident had moderate impaired cognition with no rejection of care. Review of the hospital discharge summary dated 07/13/2022 showed that the resident had been admitted to the hospital after a fall that occurred at the facility. The summary showed the resident was admitted for a closed fracture to the right hip that required surgical repair and a fracture of the right upper arm. Review of the resident care plan with a focus dated 07/08/2022 showed the resident had Activities of Daily Living (ADL) related to deconditioning with interventions to include transfers to be a stand pivot into a wheelchair or chair, toileting maximum assist with cleaning their private area and clothing management, and ambulation to only occur with therapy department. Review of the residents fall risk assessment dated [DATE] showed that the resident was high fall risk. Review of the Occupational Evaluation and Plan of Treatment dated 07/08/2022 showed that toileting should be contact guard assist with a transfer from wheelchair to toilet. Review of the investigation fall summary dated 07/09/2022 showed that Staff T, Nursing Assistance Register (NAR), reported that the resident had fallen in the restroom after they had walked the resident to the restroom from their bed with a front wheeled walker (FWW) on 07/09/2022 at 1:40 AM. Staff T stated that as the resident was pulling their pants down, they lost their balance and fell forward onto the floor. In an interview on 07/28/2022 at 8:55 AM, Staff U, Nursing Assistant Certified (NAC) stated that they were present on the day the resident admitted to the facility on [DATE]. Staff U stated they recalled the therapist was in the room on 07/08/2022 conducting an assessment on the resident. Staff U stated that the therapist explained to them that the resident should only ambulate with therapy at this time as the resident would lose their balance. The therapist stated to Staff U, if the resident needed to use the restroom to transfer the resident using a stand and pivot to the wheelchair and take into the restroom, then to stand and pivot on to the toilet. Staff U stated they recalled reporting this conversation with the therapist to the next shift when they gave report at the end of their shift that day. In a phone interview on 07/28/2022 at 9:31 AM, Staff E, Licensed Practical Nurse (LPN) stated they were the nurse on duty when the resident had their fall on 07/09/2022. Staff E stated that Staff T, NAR flagged them down and told me Resident 32 had fallen in the bathroom. Staff E stated that Staff T had taken the resident to the restroom, when they looked away the resident fell forward and landed on their right side. In a phone interview on 07/28/2022 at 3:13 PM, Staff T, NAR stated that they review all the Kardex's (Care guide for floor staff) for their residents at the beginning of their shift. Staff T stated when the resident requested to use the restroom, and they saw the FWW in the room, they assumed the resident was able to ambulate and walked the resident to the restroom. Staff T stated that the resident then lost their balance and fell forward. In an interview on 07/28/2022 at 2:00 PM, Staff V, Director of Rehabilitation (DOR) stated they agreed with the assessment made by the Occupational Therapist evaluation that was completed on 07/08/2022 that determined the resident should only ambulate with the therapy department. In an interview on 07/28/2022 at 12:28 PM, Staff F, Director of Nursing (DNS) stated that Staff T, NAR had ambulated the resident from the bed to the restroom with only an FWW. Staff F confirmed that the residents care plan was specific that they were to only ambulate with the therapy department due to the resident had balance issues. Staff F confirmed that Staff T, did not follow the care plan, which resulted in the resident had lost their balance, fell on to the bathroom floor, and obtained a right [CONDITION(S)] that required surgical intervention, and a right upper arm fracture. RESIDENT 4 Review of the undated Admission Record in the electronic medical record (EMR) under the Profile tab revealed Resident 4 was admitted to the facility on [DATE]. Resident 4's diagnoses included [CONDITION(S)] and [CONDITION(S)] following cerebral infarction (stroke) affecting right dominant side, muscle weakness, impulse disorder, [CONDITION(S)] left eye, repeated falls, shortness of breath, anxiety disorder, and history of traumatic brain injury. Review of the quarterly Minimum Data Set with an assessment reference date (ARD) of 04/22/2022 revealed Resident 4 was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of 5 out of 15 (score of 0-7 indicates severe cognitive impairment). Resident 4 required supervision for transfers, locomotion on the unit, and walking in the room. Resident 4 required limited assistance walking in the corridor. Resident 4 required extensive assistance for toilet use and dressing. Resident 4 was not steady moving on and off the toilet and only able to stabilize with assistance; and they were not steady with surface-to-surface transfer (transfer between bed and chair or wheelchair) but able to stabilize without assistance. Resident 4 had experienced one fall without injury during the prior MDS assessment. Review of a Nursing Care Note dated 07/22/2022 at 6:38 PM in the EMR under the Progress Notes tab revealed, this LN [licensed nurse] was called to resident room and found resident on the laying on the floor on their left side by their bed and their w/c [wheelchair] was by their closet. The resident was wearing regular socks and no shoes, pajama bottom and a shirt. The resident was unable to relate to what happened and could not remember how they got to the floor. The resident was assessed for any injuries, and none were found at that time, no bruising, swelling, or bleeding. The resident was assisted up and back to their bed, the resident able to bear weight to their LE [lower extremities] and able to move both UE [upper extremities]. The staff changed their socks to non-skid socks and lowered the bed. The resident did not remember hitting their head on the floor and denied any pain at this time. The resident's brother was notified via phone call and left a message, placed a fax communication to the nurse practitioner, the resident was placed on alert charting to monitor latent injuries, and started neurological checks and vital sign checks, and reported to next shift. Review of a Fall Risk Evaluation dated 07/25/2022 in the EMR under the Assessment tab revealed Resident 4 was at moderate risk for falls, had experienced one to two falls in the past six months, was frequently incontinent, was unsteady, and experienced a loss of balance while standing. Review of a Nursing Care Note dated 07/26/2022 in the EMR under the Progress Notes tab revealed, IDT [interdisciplinary team] meets to discuss fall for Resident 4 this weekend. Identified that they were not wearing non-skid footwear when attempting to get up from bed and prefers to wear regular socks when in bed contributing to them slipping at bedside. TELs [maintenance request/tracking system] order placed for non-skid strips next to bed to provide a non-skid surface and prevent slipping . Care plan updated. Review of the Care Plan dated 10/28/2020 in the EMR under the Care Plan tab revealed a problem of Resident 4 is at moderate risk for falls related to history of falls, vision impairment: (L) [left] side, [CONDITION(S)]. The goal was they will not sustain injury from falls. Interventions included in pertinent part, Resident 4 has a history of refusing to wear non-skid footwear and throwing their call light when it is placed next to them. Encourage Resident 4 to wear non-skid footwear and use their call light. Place their call light within reach was initiated on 07/27/2022 . Non-skid strips applied to floor next to bed was initiated on 07/25/2022. Observations during the survey revealed non-skid strips were not applied to the floor in Resident 4's room: -On 07/26/2022 at 10:51 AM, Resident 4 was lying on the bed in their room. There were no non-skid strips applied to the floor. -On 07/27/2022 at 12:00 PM, Resident 4 was lying on the bed in their room. There were no non-skid strips applied to the floor. -On 07/28/2022 at 10:00 AM, 10:47 AM and 11:10 AM, Resident 4 was lying on the bed on their side. There were no non-skid strips applied to the floor. During an interview on 07/28/2022 at 12:44 PM, Staff B, the Maintenance Director, stated they ordered and just received the non-skid strips today. Staff B stated they were planning to install the non-skid strips this afternoon in Resident 4's room. During an interview on 07/29/2022 at 8:33 AM, Staff A, Registered Nurse (RN) Resource Nurse, stated Resident 4 should have minimum assistance from staff when transferring but had a history of self-transferring. Staff A stated Resident 4's room was in the main hall for increased supervision. Staff A stated Resident 4 did not use the call light very often and was blind on one side. Staff A stated re-educating Resident 4 was hard to do based on their cognition. Staff A stated non-skid strips had been applied to the floor in Resident 4's room on 07/28/2022 as a new measure to prevent falls. Review of the Work Orders Report for 07/22/2022 - 07/29/2022, provided by the facility, revealed a work order was placed for non-skid strips applied next to the bed in Resident 4's room. Review of the Completed Work Orders report dated 07/27/2022 - 07/29/2022 and provided by the facility, revealed the non-skid strips had been applied to the floor in Resident 4's room. Continued observations and interviews revealed non-ski strips were not applied to the floor in Resident 4's room: -On 07/29/2022 at 9:14 AM, Staff C, housekeeper, was cleaning Resident 4's room. The surveyor did not see non-skid strips on the floor in Resident 4's room. Staff C confirmed there were no non-skid strips on the floor. -On 07/29/2022 at 10:06 AM, Staff D, the Administrator, and Staff B went into Resident 4's room. Both Staff D and Staff B confirmed non-skid strips were not applied. Staff B stated they had applied the non-skid strips in the wrong room, the room next door. An observation was made in the room next door and the strips had been installed in the room next door and not in Resident 4's room. <SUPERVISION> RESIDENT 4 Resident 4 was a long-term resident who admitted on with traumatic brain injury, impulse disorder, pseudobulbar effect (uncontrollable laughing and or crying), major depressive disorder, and anxiety. According to the Quarterly Minimum Data Set assessment dated [DATE], the resident had significant cognitive impairment with verbal behavioral symptoms directed toward others (threatening others, screaming at others, cursing at others) occurred one to three days, same as last assessment. Review of Resident 4's care plan developed on 12/16/2020, showed problematic behavior characterized by ineffective coping with history of resident to resident (altercations) derived from Cognitive impairment due to cerebral infarction (stroke) and history of traumatic brain injury (TBI) and Pseudobulbar Affect (PBA). The goal updated on 04/28/2022 was for reduced incidents of agitated behavior verbal & physical aggression and abuse, history of agitation resulted in refusals of care and medications. One of the interventions implemented on 05/02/2022 was for staff to provide one on one care as needed. Review of an incident report on 06/16/2022 at 5:25 PM, showed Resident 4 was sitting in the solarium door when Resident 7 asked Resident 4 to move so they could get through. Resident 4 became verbally aggressive towards the other resident, observed by the licensed nurse who was at the nurse's station. The nurse and other staff on the floor immediately separated both residents. The DNS was notified, and the resident was placed on alert. The incident report showed Resident 4 had been experiencing mood and emotional changes secondary to diagnosis and repeatedly declining [CONDITION(S)] medications. Recommendations were staff to check on resident's routinely when they were out of their room or propelling their wheelchair to ensure Resident 4's pathway was clear from obstacles. Maintenance and safety committee were to address the solarium area to ensure this area is set up for management of high resident flow in doorway. Activities was to consider taking group activities to the large dining room with transportation escort assistance for increased participation and safety. The investigation noted Resident 4 had physically aggressive behavior on 07/30/2021 and 08/19/2021. Review of a progress note dated 06/27/2022 at 3:00 AM, showed Resident 4 continued to have overwhelming emotions overnight, crying and laughing at the same time then having swift mood changes to yelling and aggressive behaviors. One on one time spent, refused evening meal out of anger. Note place in physician box to assess and advise as resident behaviors are steadily escalating and they have refused most of their medications. Review of the progress note dated 07/04/2022 at 11:48 PM, showed Resident 4 was ambulating with their walker around the unit living room area when several patients were watching television quietly when Resident 4 began calling Resident 7, a c**ks****r and saying You are a monster! You should not even be here! Staff CC, LPN, Staff BB, NAC and Staff Z, RN, all ran when they heard the angered words exchanged. Resident 4 then stood up quickly and started to walk toward Resident 7 in anger. Staff Z put themselves in between the two. Staff BB grabbed Resident 4's wheelchair and stood behind them and redirected them back to their room. Staff E, LPN was assigned to be one on one with Resident 4. Resident 7 came to the nurse's station several times overnight to make snide comments about the situation that occurred. The nurse documented they could not tell which resident had started the aggression first and both residents have had verbal exchanges before. Review of an incident report dated 07/04/2022 at 5:45 PM, showed the nurse found Resident 4 in the solarium with another resident (7) shouting at each other. There was a table in between them and Resident 4 was visibly irritated. The nurse noted they got between the two residents and escorted the other resident out into the backyard. Resident 7 was taken out of the solarium by a CNA. They were given ice cream and 1 on 1, resident calmed down. The plan was for Resident 4 to be placed on every 15-minute checks pending further interventions. The resident was to be redirected away from solarium if Resident 7 was in there. Resident's 4 and 7 were to be supervised continuously if they attempted to enter the solarium concurrently and could not be redirected away. Social Services requested a significant change Pre-admission Screening and Resident Review (PASRR) for Resident 4. The care plan was updated on 07/05/2022 to include 15-minute checks to monitor interactions between Resident 4 and Resident 7. The report showed Resident 4 and 7 had a history of altercations in solarium when self-propelling, Resident 4 was allowed to enter the solarium per their request. Staff were directed to ensure Resident 7 was not in the solarium with Resident 4 and, if the residents were in the solarium staff were to attempt to divert them. Residents were to be supervised continuously if they attempted to enter the solarium. Review of a progress note on 07/05/2022 at 4:56 AM, Staff E, LPN documented on 07/04/2022 at or around 1800, Resident 4 was the recipient of an unprovoked verbal assault with another resident. Resident was supervised 1:1 to provide safety and emotional support after the altercation. Physical altercation was after initial supervision resident was assessed Q15 on the hour until resident went to sleep. No further instances of unprovoked assault reported for the rest of the night. Review of a progress note dated 07/05/2022 at 11:02 PM, showed Staff Y, RN was at the nurse's station receiving report when Resident 7 walked by the nurses' station. Resident 4 was sitting in the solarium and had a verbal altercation with this resident earlier, Resident 4 became verbally aggressive toward Resident 7. Resident 4 stood up from their wheelchair and started cussing loudly and chasing Resident 7 into the hallway. Immediately the staff members intervened, stood between them, and redirected them to their rooms. Review of an interdisciplinary (IDT) meeting nursing care note for Resident 4 on 07/05/2022 at 2:48 PM, stated the resident was going to be on-going 15-minute checks related to recent verbal altercation with another resident. 15-minute checks were to be performed whenever the resident was outside of their room until their planned room move was complete to reduce interaction with other resident involved in verbal altercation. Care plan was Resident 4 was to be monitored continuously while in the Solarium if resident (7) was present. Review of the incident report investigation on 07/05/2022 showed there were repeated verbal resident to resident altercations between Resident 4 and Resident 7. The care plan was to try and prevent future negative verbal interactions and completed 15-minute checks when they are out of their room. The investigations showed both residents appear to be triggered by the presence of the other one. Long term intervention was that Resident 4 required distant supervision for meals in the solarium with staff present. The corrective action was to be completed on 07/13/2022. Review of a progress note for Resident 4 by Staff AA, Physician's Assistant on 07/08/2022 at 12:26 PM, showed a psychological assessment for impulse disorder and pseudobulbar affect. The provider noted the resident had increased behaviors recently, and had altercations with another resident, possibility of turning violent and need to be better controlled. Residents' behaviors had been getting progressively worse since discontinuation of [MEDICATION(S)] on 04/13/2022. Resident 4 was on 15-minute checks August 2021 to April 2022 and was no longer receiving this level of supervision Review of a progress note for Resident 4 on 07/25/2022 at 11:33 PM, Staff E, LPN, documented, On or around 10 to 11 PM (07/25/2022) Resident 4 had an outburst against another resident (Resident 21) coming out of their room. Resident 4 became hostile and started yelling, Your bad, your bad. Resident 4 was redirected/distracted while the Resident 21 was being comforted. RESIDENT 7 Resident 7 was a long-term resident with delusional disorder and generalized anxiety. According to the 05/06/22 Quarterly MDS showed the resident is independent with Activities of Daily Living. The resident demonstrated verbal behavioral symptoms directed toward others the past 1 to 3 days. Review of the care plan developed on 12/06/2021 for Resident 7 showed the resident had a potential psychosocial well-being problem related to poor interaction with other residents. In an interview and observation on 07/26/2022 at 9:55 AM, Resident 7 was sitting on the edge of their bed stating they were going to shoot the [NAME]. In observations on 07/26/2022 at 11:08 AM, 07/27/2022 at 9:58 AM, 07/29/2022 at 9:02 AM, Resident 7 was up ambulating independently with their 4wheeled walker in the halls with no staff supervision. In an interview on 07/28/2022 at 2:15 PM, Staff N, RN stated there were no residents on 15-minute checks at this time. In an interview on 07/28/2022 at 2:31 PM, Staff A, RN stated Residents 4 and 7 are not on one-to-one supervision or every 15-minutes checks. Staff A said Resident 7 had a history of resident-to-resident altercations and spent most of the time in their room but came out in the evenings. Staff A said Resident 4 had a history of resident-to-resident altercations and liked to go to the solarium in the evening time. In an interview on 07/28/2022 at 2:36 PM, Staff M, RN agency, stated Residents 4 and 7 are not supposed to be in proximity of each other. Staff M stated they had seen both residents babble at each other but no physical aggression. Staff M stated Resident 7 was more mobile and comes and goes from their room and Resident 4 was more active in the night but does come out sometimes in the day. They stated supervision of the residents was easier on day shift as there is extra help with administration there. They said staffing was low at night but on day shift they can manage appropriately. In an interview on 07/28/2022 at 3:12 PM, Staff F, DNS stated Residents 4 and 7 had resident to resident altercations on 06/21/2022, 07/04/2022 and 07/05/2022. They stated Resident 7 was evaluated and has calmed substantially and was not agitated now. Staff F stated Resident 4 was to be on Q 15 minutes checks for supervision after the 07/05/2022 incident. Staff F commented that Residents 4 and 7 got irritated just with line of sight of each other and they both had robust care plans for their behaviors. Staff F was asked how the staff were to provide adequate supervision with Resident's 4 and 7 who are ambulatory and had altercations in the solarium, which was a high traffic area, across from the nurse's station. Staff F said the first altercation in June was thought to be isolated, but they have definitely established a pattern now. Staff F stated the staff were to supervise both residents when they are near each other. Staff F acknowledged the three incidents occurred between 5:25 PM and 6:00 PM which was a busy time for staff related to dinner and shift change. Staff F could not state how the staff was to ensure another resident to resident did not occur between these same two residents. In an interview on 07/29/2022 at 9:22 AM, Staff R, NAC stated Resident 7 has behaviors and runs around the hallways yelling at staff. Staff R stated Resident 7 and Resident 4 interacting does not work well. In an interview on 07/29/2022 at 11:42 AM, Staff Q Regional Director of Clinical Services, (RDCS) stated they were unsure why Resident 4 came off 15-minute checks and the facility should have a plan in place to keep residents safe and maintain their safety. Staff Q confirmed there was a pattern of altercations with Resident 4 and 7 and they occurred during a busy time. Staff Q acknowledged more could be done to prevent altercations and suggested staff could do distant supervision or place carts by their rooms. Staff Q stated their expectation was more supervision for these residents. In an interview on 07/29/2022 at 12:45 PM, Staff I, Social Services stated Resident 7 was more the victim with Resident 4. Staff I said the altercations occurred in the solarium and Resident 4 is there more that Resident 7. Review of a care plan problem for Resident 7 initiated on 03/08/2022 showed problematic behavior in which the resident acts characterized by ineffective coping: verbally aggressive, and pounds their walker. The goal will be reduced incidents of agitated behavior. Staff were directed to always approach resident calmly and unhurriedly, be careful to not invade residents' personal space, redirect, remain calm, assure safety of residents and staff, and refer to social services and monitor for verbal aggression toward staff, pounding walker against doors and perseverating on discharging. Resident 7 did recall the 07/04/2022 altercation with Resident 4 and came out of their room several times during the night to discuss it. The reasonable person would not want to be yelled at in their home. RESIDENT 21 Resident 21 admitted on [DATE] with diagnoses to include Alzheimer's disease. According to the 06/22/2022 Quarterly MDS, the resident had severe cognitive impairment. Review of a witness statement by Staff E, LPN on 07/25/2022 stated the nurse could recall that around 9 to 10 PM Monday they were at their medication cart documenting the care of another resident when they heard Resident 4's voice. The resident was in their wheelchair attempting to go back to their room. As Resident 4 turned the corner to go back out of the solarium, the nurse stated they assumed (Resident 4) was startled by Resident 21. Staff E documented they did not see the beginning of the altercation. Staff E noted Resident 21 began yelling aggressively, You get away, you're bad, get away. Staff E documented possibly two or three Nursing Assistant Certified (NAC) discreetly separated the residents and added those NACs were privy to the whole situation. In an interview on 07/29/2022 at 11:42 AM, Staff Q, stated they heard there was a verbal altercation involving Resident 4 and 21. Staff Q stated the expectation when resident to resident altercations occur was staff are to protect the residents, maintain safety of all residents, report to the hotline, investigate and develop a plan to keep them safe and evaluate the plan. The resident was to go on alert charting and the provider was notified. Review of a progress note dated 07/29/2022 at 11:23 PM, included with the investigation of the altercation between Resident 4 and 21 on 07/25/2022, showed Resident (21) was verbally assaulted by another resident. Resident 21 wheeled themself from their room and was heading for the solarium when another resident in the hall (4) became agitated and swung their fist at the resident. Resident 4 was separated from Resident 21, however at 10:50 PM, while Resident 4 was in the solarium, the same resident (Resident 4) came around the corner and began shouting, Shoot her! Shoot her quick before she gets away!' Resident 4 was quickly removed so both residents could be safe without escalation. The facility failed to implement appropriate fall interventions for Resident 32, that resulted in major injury. The facility failed to provide adequate supervision for Resident 4, who had a known pattern of aggressive behavior and who showed verbal aggression to Resident's 7 and 21. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure two of four residents (1 and 21), were free from abuse. The facility failed to protect and adequately assess Resident 1 after an allegation of abuse. The facility failed to obtain an agency nurse's aides background check and ensure adequate preparation and abuse training to meet the resident's needs. This failure resulted in harm for Resident 1 who voiced complaints of physical injury and emotional distress from endured abuse/mistreatment from a Nursing Assistant Certified (NAC). The facility staff failed to protect residents from the agency staff member with an identified allegation, which allowed potential abuse to continue. The facility failed to protect Resident 1 from an agency staff member and Resident 21 from (Resident 4) who the facility identified with a pattern of aggression who recently emotionally abused Resident 21. These failures showed a willful disregard of safety, left all residents vulnerable to continued abuse and resulted in harm for Resident 1 and 21 and placed all residents at risk for abuse, physical injury, fear, mental anguish, agitation, isolation intimidation, and feelings of victimization. Findings included . Review of facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed each resident has the right to be free from abuse including verbal, mental and physical abuse. The facility was to protect residents from abuse, neglect by anyone including facility staff and other residents. The facility was to conduct employee background checks, identify and investigate all possible incidents of abuse and protect residents from any further harm during investigations. Review of the facility's policy, Alert charting guidelines for abuse & neglect, undated, directed staff they must intervene and protect the resident(s), notify the on-call nurse manager, contact the DNS (Director of Nursing Services)/ADM (Administrator), call hotline (or ensure DNS or Admin will be calling), notify family/Power of Attorney (POA), place the resident on alert status. RESIDENT 1 Resident 1 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note on 07/10/2022 at 11:22 PM, showed Resident 1 reported that yesterday (07-09-2022) a Nurse's Aide Certified, (NAC) grabbed them by their arm from the toilet to their wheelchair (w/c) and left a bruise. They stated that it was a man who helped them. An (unidentified) NAC reported this to the nurse that the resident had a bruise on their left deltoid (upper arm) area. The bruise was 2.5 centimeters (cm) long and 0.05 cm wide. The bruise was pink/blue in color. The resident was to be assessed for latent injuries. The nurse on call, the DNS and the resident's daughter was notified. Review of a progress note on 07/11/2022 at 6:37 PM, showed a skin assessment done today, the resident had purple discoloration on their left deltoid (which measured 9 centimeters by 5 centimeters), a 9 centimeter (cm) by 1 cm to their left upper chest and a 2 cm by 2 cm bruise to their right knee. Review of the facility report to the state hotline on 07/10/2022 at 11:15 PM, showed Resident 1 reported to their nurse, that yesterday on 07/09/2022, Staff O, Agency NAC, grabbed them by their arms from the toilet to their wheelchair (w/c) and left a bruise. The report showed Staff O was off the floor during the investigation. In an interview on 07/28/2022 at 2:17 PM, Staff N, Registered Nurse (RN), stated that Resident 1 had no skin issues or bruises right now. Staff N stated when there was an abuse allegation, staff were to start a risk management, get statements from staff, report the allegation to the state, the DNS, and Administrator. Staff were to protect the resident. The person who was involved needed to be suspended until the investigation was complete. The resident was placed on alert charting to monitor them. In an interview on 07/28/2022 at 2:57 PM, the DNS stated they started the investigation on 07/09/2022. The DNS stated Staff O had not been suspended as they did not have clear insight from the resident. The DNS stated Resident 1 was unsure of the staff's gender, skin tone and type of hat the staff wore. The DNS stated Staff O continued to work at the facility since then. The DNS acknowledged there was no background check obtained for Staff O upon hire and until 07/27/2022. They acknowledged that there was no review of the employee file or background information as part of the investigation. The DNS was asked about bruising to Resident 1's left chest and right knee discovered on 07/11/2022. The DNS stated they were unaware of those bruises and confirmed they were not included in the investigation. The DNS stated Resident 1's skin was very fragile due to chronic [MEDICATION(S)] use and they considered the blood pressure cuff could have been the cause of the bruising. The DNS agreed the resident thought this incident to occur and remained consistent in reporting that staff grabbed them and caused the bruising. The DNS acknowledged other resident's skin was not assessed to ascertain if other residents were affected at the time of the investigation. In an observation and interview on 07/29/2022 at 9:38 AM, Resident 1 was in bed watching TV. They stated their left arm bruise was about gone. There was a 2 cm by 2 cm dark purple bruise on their left upper arm. Resident 1 stated the bruise was from some man that jerked them off the toilet. The resident stated they did not know their name. They stated the man wore a stocking cap and at first, they could not tell if it was a man or a woman so when they were on the toilet, they asked if they were a man or a woman. Resident 1 stated, At that time, he responded man then jerked me by the arm. I thought I was going to die. He hurt me. My nurse came into give me pills after and I had my pajama top on, and they saw the bruise. I told them about the man. I do not want them back here. Everyone knows my skin was fragile. I have been on [MEDICATION(S)] for years. I can barely get a bump and I will get a bruise. When asked about the right knee bruise. Resident 1 stated, Do you know what that is from .they bang my knee on the bathroom door when coming out. They need to be careful; my skin is fragile. A review of Staff O's employee file revealed date of first shift was 07/05/2022. Staff O had no background check obtained until 07/27/2022, twenty-two days after beginning work unsupervised around vulnerable residents. Review of the schedule showed Staff O worked the following shifts on evening and nights when there was less supervision and oversight; night shifts on 07/05/2022, 07/06/2022, 07/07/2022, 07/08/2022, and 07/09/2022, and double shifts (PM and night shift) on 07/12/2022 PM, 07/13/2022 PM, 07/14/2022, 07/15/2022, 07/16/2022, 07/19/2022, 07/20/2022, 07/22/2022 and night shift only on 07/23/2022. RESIDENT 21 Resident 21 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a progress note on 07/26/2022 at 12:42 AM, showed on or around 10 PM to 11 PM, Resident 4 had an outburst against another resident coming out of their room. Resident 4 became hostile and started yelling, Your bad, your bad. Resident 4 was redirected/distracted while Resident 21 was being comforted. There were no interventions documented to protect Resident 21 or other residents from Resident 4. Review of a social services note on 07/26/2022 at 4:54 PM, showed Resident 21 was placed on alert charting for potential signs of psychosocial harm related to resident-to-resident interaction. Social services had informed the guardian of the allegation the following day after the incident. RESIDENT 4 Resident 4 admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the Quarterly MDS on 04/22/2022, they had severe cognitive impairment, and were able to go on and off the unit with supervision. Review of the state hotline report on 07/27/2022 at 7:44 AM by the DNS, stated Resident 4 had an outburst directed towards Resident 21. The progress note read that Resident 4 yelled at Resident 21 coming out of their room in the hall Your bad, your bad. Resident 4 was redirected away from the resident. The DNS reported the incident was a pattern of behavior that had occurred three times in last few months. The action reported to prevent reoccurrence was the residents were immediately separated. There was no other plan or interventions in place to protect Resident 21 or other residents from Resident 4. Review of Resident 21's care plan directed staff to assure Resident 21 was safe but did not inform staff to supervise Resident 4 or attempt to keep Resident 4 away from Resident 21. In an observation on 07/26/2022 at 9:40 AM, Resident 4's room was located across the hall and down one door from Resident 21's room. In an interview on 07/29/2022 at 9:18 AM, Staff R, NAC stated they tried to keep Resident 4's door closed to keep them away from Resident 7. Staff R stated there was no warning when Resident 4 was going to get upset. They commented Resident 4 gets irritated easily, it was sudden, and the resident can be joking around with you then yell. Staff R stated they were unaware of any recent altercations with Resident 4 but commented Resident 4 had just been placed on every 15-minute checks again. Staff R stated, the resident had been on 15-minute checks for a super long time prior. Staff R said they attempt to redirect them when they were around them. In an interview on 07/29/2022 at 11:29 AM, Staff S, NAC, stated Resident 4 was in and out of their room and sometimes gets set off. Staff S said they placed Resident 4 back on 15-minute checks to monitor the resident and to prevent a resident-to-resident altercation. Staff S stated there was no warning with the resident, they just (made snapping motion with their fingers). They stated it can be hard to watch the resident as they have a lot of residents who require two-person assist or require all care to be completed in pairs. In an interview on 07/29/2022 at 12:40 PM, Staff I, Social Services stated Resident 4 was impulsive and has had verbal aggression against other residents. Staff I stated the resident was placed on 15-minute checks again. Staff I stated they put interventions in place on the care plan. In an observation on 07/29/2022 at 11:11 AM, Resident 21 was in the solarium when Resident 4 self-propelled into the room in their wheelchair. No staff were present. Staff were observed to be outside of the solarium and were not aware the residents who had been involved in a resident-to-resident altercation were alone, unsupervised in the solarium from 11:11 AM until 11:33 AM. In an interview on 07/29/2022 at 11:42 AM, Staff Q, Regional Director of Clinical Services, stated the expectation for resident-to-resident altercations was staff are to protect the resident, maintain safety of all residents, report to the hotline, investigate and develop a plan to keep them safe and then evaluate the plan. The residents would go on alert charting and the provider was to be notified. Staff Q stated they identified a pattern with Resident 4, and they had been on every 15 minutes checks. Staff Q was unsure when and why Resident 4 was no longer on 15-minute checks. Staff Q stated Resident 4 would be irritated with one-on-one supervision, but the staff could do distant supervision or place medication carts by their rooms . something. Staff Q acknowledged that the recent resident altercations occurred during busy dinner time and change of shift when staff are preoccupied. Staff Q stated they expected Resident 4 to have more supervision. Staff Q acknowledged they had heard Residents 4 and 21 were just found unsupervised in the solarium. Review of the incident report investigation for 07/26/2022, included a progress note for Resident 4 on 07/29/2022 at 11:23 PM. The progress note showed, Resident 21 had been verbally assaulted by another resident. The resident wheeled themself from their room and was headed for the solarium when another resident in the hall (Resident 4) became agitated and swung their fist at resident. The other resident was separated from the resident, however at around 10:50 PM, while they were in the solarium, the same resident came around the corner and began shouting, Shoot her, shoot her quick before she gets away! The resident who shouted at Resident 4 was quickly removed so both residents could be safe without further escalation. The incident investigation on 07/26/2022 included a plan to prevent Resident 4 from other residents they are triggered by but did not include how. The investigation did not include consideration of room moves to protect Resident 21 for further altercations with Resident 4 who leaves their room and often self-propels past their room. Although, Resident 21 had cognitive impairment and may not be able to express their feelings, a reasonable person in similar circumstances would not want to be yelled You're bad, you're bad when at their doorway, have a fist swung at them or hear Shoot her! Shoot her quick before she gets away. The reasonable person would feel uneasy, upset, and unsafe. Reference: (WAC) 388-97-0640 (1)

Based on observation, interview and record review the facility failed to ensure one of one resident (1) reviewed for Post-Traumatic Stress Disorder ([CONDITION(S)]) treatment and services to attain their highest practicable mental and psychosocial wellbeing and failed to receive recommended psychiatric evaluation prior to a gradual dose reduction (GDR) regarding their [CONDITION(S)] medications. This failure caused Resident 1 harm in the form of undue psychological distress and placed other residents with behavioral health care at risk of unmet psychological care and treatment. Finding included . Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a State Hot Line Report dated 05/12/2022 at 9:41 AM, showed Resident 1 had reported that they were concerned that they had extensive [CONDITION(S)]. The resident stated that it took the psychiatrist, and staff years to get her medication tapered down. Their medication was decreased due to their therapy. The resident stated that they had reach 3 milligram (mg) and that was their limit and that they had told the facility. The resident stated that they took [MEDICATION(S)] ([MEDICATION(S)]), an antianxiety medication, and was on 1mg a day. The resident stated that they should be on 3 mg. The resident stated that they had yelled at people today because their medication was not correct. The resident stated that they now would lose their train of thought. The resident stated that the facility staff was not listening to them of the need to increase their medication. The resident stated that the staff did not inform them of the change and the decrease in their daily medication. The resident stated that they were losing their ability to keep themself together. The resident stated that would be alleviated if they had the correct medication dosage. The resident stated that they had found a dosage that worked for them, and the facility was not listening to their needs. In an observation and interview on 05/12/2022 at 2:24 PM, Resident 1 was lying in bed and stated that they were sick and tired. Resident 1 stated that they were extremely angry over the reduction of their [MEDICATION(S)] which affected them psychologically. The resident stated that they had asked for an appointment with the doctor about their medication and not one nurse had advocated for them. The resident stated that they had been on [MEDICATION(S)] for years, back in the 1990's they were on 15 mg as they were a walking psychopath. The resident stated that they had undergone therapy and was able to gradually reduce the dose to 3 mg daily. The resident stated that now with the current reduction of the [MEDICATION(S)], they were a blubbering idiot. The resident stated that they had not been involved in the discussion of the dose reduction of the [MEDICATION(S)] but was told the State required it to be tested down. The resident stated that they felt like wrecking their room, like a five- or six-year-old. The resident stated that they were on the [MEDICATION(S)] as they had severe [CONDITION(S)]. The resident stated with description that their [CONDITION(S)] was from horrible and traumatic childhood sexual assaults and molestations. Resident 1 stated that the nurses at the facility knew their history as well as the Administrator and the Director of Nursing Services (DNS). The resident continued to express their thoughts and made statements about their life going from one topic to another without consistency in the topic. The resident stated that they had been having so much trouble and felt like they were losing their mind with the reduction of their [MEDICATION(S)]. Resident 1 stated, I am terrified about repercussions from the [CONDITION(S)], had heard a staff member was a sadist from others. Resident 1 stated, I do not want to go off on someone. I do not want to strike them. I do not want to get upset. I am scared, and pointed to a sign on wall which had the [MEDICATION(S)] dose as twice daily. The resident stated to this day they cannot stand to have anyone behind them, that they were hypervigilant as their [CONDITION(S)] was so severe. The resident stated that their dosage 10 mg of [MEDICATION(S)], 3 mg of [MEDICATION(S)] and usually [MEDICATION(S)] Root worked, but they had cut down their medication and now they were not sleeping well. The resident stated that in the past they had gotten themself off the [MEDICATION(S)] but did not sleep for 10 months. The resident stated that they thought they did not need it, that was back . it was a long time ago in their late 30's and early 40's. The resident stated that they would wake up out of nodding off all night long, and their provider had asked why the hell did you do that, coming off [MEDICATION(S)]. Resident 1 stated that their prior provider had said it was imperative to stay on the [MEDICATION(S)]. The resident stated, I am embarrassed about the way I am, but I am the way I am. I just want to go to sleep and have good thoughts. The resident repeated themselves and again stated, I just want to go to sleep and have good thoughts. Review of the resident's Level II Preadmission Screening and Resident Review (PASRR) dated 08/12/21, showed the reviewing Psychiatrist noted that decreasing a benzodiazepine ([MEDICATION(S)]/[MEDICATION(S)]) by 50% would not likely be tolerated and consultation with psychiatry prior to attempt to taper and taper very slowly. Review of the Significant Change Minimum Data Set (MDS) depression section assessment dated [DATE], showed the resident scored a '3' which was indicative of minimal to normal depression. Review of the Quarterly MDS depression section assessment dated [DATE], three months later, showed the resident had a scored of '9' which was of a decline in mood from minimal/normal depression to mild depression. Review of the resident's Care Plan printed on 05/23/2022, showed no noted intervention related to the recommended psychiatry consult prior to decreasing the resident's [MEDICATION(S)]/[MEDICATION(S)]. Review of the February 2022 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The Behavior Monitor Record (BMR) showed 115 episodes of anxiety behaviors of which 10 shifts for the month were not documented related to the use of the resident's [MEDICATION(S)]/[MEDICATION(S)]. Review of the [CONDITION(S)] Medication Review dated 03/01/2022 showed an incomplete assessment with no noted assessment of the frequency of the resident's behaviors, psychoactive medication, or side effects. Noted that the DNS made medication suggestions related to decreasing the resident's [MEDICATION(S)]. The team members who contributed to the psychoactive medication review did not include Psychiatry. Review of the Progress Note dated 03/19/2022, showed Primary Care Provider okayed recommendations to discontinue [MEDICATION(S)] 1 mg every eight hours as needed and ordered [MEDICATION(S)] 1 mg every 12 hours as needed. The resident was noted to have anxiety with difficulty redirecting and was needing this medication to help with their anxiety, so discontinuation was not an option. The resident was noted to be informed of the change in frequency. Review of the Progress Note dated 03/20/2022, the resident stated they were not informed with the change in their [MEDICATION(S)] order. The resident stated that they were going to call the State and was going to [NAME] the facility. The resident stated, What don't they understand about [CONDITION(S)]?! Review of the Staff C, Advanced Registered Nurse Practitioner (ARNP), Internal Medicine Progress Note dated 03/22/2022, showed that nursing had reported that the resident had been having increased outbursts. The resident also endorsed recent increased anxiety attacks since recent [MEDICATION(S)] dose reduction. Psychiatric evaluation was recommended for further evaluation. Review of Staff D, ARNP, Internal Medicine Progress Note dated 03/23/2022, showed the resident endorsed anxiety mostly due to [CONDITION(S)] from history of childhood abuse. The note showed the resident reported increased anxiety attacks since the [MEDICATION(S)] dose adjustment and staff also reported increased behaviors. Review of Staff C, ARNP, Internal Medicine Progress Note dated 03/30/2022, showed the resident continued to request an increase in [MEDICATION(S)] due to worsening anxiety from [CONDITION(S)]. The resident reiterated previous management with the higher dose provided much benefit and did not think the current regimen was effective. Review of Staff B, Psychiatric Specialty Physician Assistant (PA) Progress Note dated 03/31/2022, showed the resident continued to request an increase in [MEDICATION(S)] due to worsening anxiety from [CONDITION(S)]. The resident reiterated previous management with the higher dose provided much benefit and did not think the current regimen was effective. Review of the March 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The BMR showed 189 episodes of anxiety behaviors of which 10 shifts were not documented related to the use of the resident's [MEDICATION(S)]/[MEDICATION(S)]. (There was no documentation of medication administration or behavior monitoring from the evening of 03/21/2022 through 03/24/2022) Review of the [CONDITION(S)] Medication Review dated 04/02/2022, showed an incomplete assessment and with a noted recommendation to hold the resident's [MEDICATION(S)] for seven days. No psychiatric staff participated in the GDR meeting. Review of Staff B, Psychiatric Specialty PA, Progress Note dated 04/08/2022, showed the resident continued to request for an increased [MEDICATION(S)] dose due to worsening anxiety from [CONDITION(S)]. The resident continued to reiterate the previous management of [MEDICATION(S)] 1 mg three times daily proved much benefit and did not think current regime was effective. The [CONDITION(S)] med review decided to hold [MEDICATION(S)] (an antidepressant) for seven days which was an abrupt withdrawal of an SSRI (selective serotonin reuptake inhibitor) which could cause rebound symptoms and the [MEDICATION(S)] would be restarted. Additionally, it was noted Staff B did not want the resident off their [MEDICATION(S)] while the resident's anxiety symptoms were uncontrolled. The resident's mood and affect were noted to be angry. Review of the Psychiatric Specialty PA Progress Note dated 04/15/2022, showed that the resident continued to request their [MEDICATION(S)]/[MEDICATION(S)] be increased due to worsening anxiety from [CONDITION(S)]. The resident continued to reiterate previous management with [MEDICATION(S)] of 1 mg three times daily provided much benefit and did not think the current regime was effective. Review of the April 2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The BMR showed 236 episodes of which two shifts for the month were not documented related to anxiety behaviors related to the use of the resident's [MEDICATION(S)]/[MEDICATION(S)] Review of the May 2022 MAR from 05/01/2022 through 05/15/2022 showed the resident had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The Behavior Monitor Record (BMR) showed 101 episodes of which five shifts reviewed for half of the month were not documented related to anxiety behaviors related to the use of the resident's [MEDICATION(S)]/[MEDICATION(S)] In a follow up interview on 05/20/2022 at 10:49 AM the resident stated that they had been waking up with night terrors for the last three nights, having flashbacks reliving things from their past. (Indicative of exacerbation of [CONDITION(S)] symptoms). The resident had expressive flight of ideas from one topic to another. The resident stated that their agreement was that when the [MEDICATION(S)] (MS) was gone it was all on them and asked meds to be taken out of their formulary on conditions. The resident stated that they had been off the MS as of yesterday or day before, and they were supposed to reduce [MEDICATION(S)] and they took a whole med away. The resident stated that they were promised once the MS was discontinued, the facility would give them back the [MEDICATION(S)] the following day. Reviewed the resident's [MEDICATION(S)] order which was as needed (PRN), the resident stated that it should have been scheduled and was going back to the hospital's clinic. The resident stated that they were not med needy but would ask for pain medication. The resident stated that they had said, Let's see how far they could go down on pain meds till unable to handle. The resident stated that they would like to get their old doctor and psychiatrist back. The resident stated, I think it is cruel and unusual punishment. In an interview on 05/24/2022 at 12:02 PM, Staff A, Licensed Practical Nurse/ Resident Care Manager (RCM), stated that the facility had a GDR quarterly review with residents who were on psychoactive medications. Staff A stated that annually they would try to get resident's psychoactive medications to the lowest dose with a trial and the resident would be on alert for one to two weeks. Staff A stated that if the nursing documentation showed the GDR was not working, they would inform the physician, reassess and if provider felt the need to go back to the prior dose, they would make a note the GDR failed. Staff A stated that they review behaviors on the Behavior Monitor Documentation (BMD) and progress notes in relations to the medications purpose, example an antidepressant to monitor for signs and symptoms of depression. Staff A stated that Social Services would do the preparation for GDR meetings with review of the resident's the BMD and progress notes. Staff A stated that the GDR meeting would have the pharmacist, DNS, RCM, and Social Service Director (SSD) in the meeting. Staff A stated that they were trying to coordinate new psychiatric provider as well now. Staff A reviewed and confirmed the 03/01/2022 [CONDITION(S)] Medication Review for Resident 1 was not complete and had no noted targeted behaviors, but they should be noted. Staff A stated that all psychoactive medications should have been reviewed and stated that were a lot of missing pieces that were not noted as reviewed. Staff A stated that the SSD and DNS in correlation would review in GDR and have pharmacist review, but someone should be documenting everything. Staff A reviewed the progress notes from 03/01/2022 and stated that it was a pre generated note from the GDR UDS, that there was no but could add addition items. Staff A reviewed the resident's PASSR level II recommendations and confirmed no there was documentation it had been reviewed. Staff A stated the resident's 04/02/2022 GDR had no indication the PASRR level II was reviewed, and no psychiatric consult was obtained. Staff A stated they felt SSD should review the PASSR recommendations and bring up during the GDR meeting, the RCM usually would not review the PASRR during GDR but would with the resident's care conference. Staff A confirmed the PASRR level II had noted a psychiatric consult prior to attempted [NAME] and [NAME] slowly was recommended. Staff A stated that there had not been a psychiatric consult prior to the resident's GDR. Staff A stated that the facility's policy was to do a GDR regardless, and not everything was reviewed. In an interview on 05/20/2022 at 12:27, Staff B, Psychiatric Specialty Physician Assistant stated that they had not been previously told about resident's GDR meetings and often there would be a discontinuation of the residents' psychoactive medications without talking to the resident and then they would see the resident and they would want to get back on their medications. Staff B stated that the facility had recently had a change in positions since the prior DNS and SSD. Staff B stated that Resident 1 had a [CONDITION(S)] assessment score that supported the routine use of [MEDICATION(S)] 1 mg three times daily. In an interview on 05/25/2022 at 2:02 PM, the DNS stated that they had been with the facility for a couple of weeks. The DNS stated that their expectation was to have monthly GDR meetings. The DNS stated that the upcoming Friday would be their first GDR with the facility. The DNS stated that they would have social services, pharmacy clinician, the psychiatric provider and would review long term residents and admissions. The DNS stated they would document in the meeting for appropriateness, necessity, and medication effectiveness. The DNS stated that they would review who they could provide a lower medication dose. The DNS stated that they would review general behaviors, would create a robust care plan tailored to the resident. The DNS stated that they review resident behaviors and [CONDITION(S)] usage. In conclusion the facility failed to ensure Resident 1, who had a long history of [CONDITION(S)] from childhood sexual trauma, received accurate and complete assessments of their behaviors in association with GDR of their mental health medications and failed to ensure the resident receive the recommended psychiatric evaluation prior to receiving a dose reduction of their mental health medications resulting in harm related to unnecessary increased anxiety and undue distress. Reference WAC 388-97-1060(1)(3)(e)

Based on observation, interview, and record review, the facility failed to operationalize all components of the infection control program when there were multiple breaches in the program. The facility failed to ensure the staff were compliant with Infection Prevention and Control Guidelines and standards of practice for two of two wings. The facility failed to ensure oversight and implementation of screening visitors as required during a Coronavirus Disease 2019 (COVID-19) outbreak, to ensure the appropriate Transmission Based Precautions (TBP) were implemented with COVID-19 positive residents, failed to ensure the staff appropriately used personal protective equipment (PPE), failed to ensure appropriate hand hygiene practices, failed to ensure the staff cleaned and disinfected reusable medical equipment and failed to ensure clean linen were stored appropriately. These failures resulted in spread of COVID-19 infection throughout the facility with 44 COVID-19 positive residents, four hospitalization s (3, 35, 413, and 420) and the death of two Residents (2, and 3) related to COVID-19 infections constituting harm and placed all residents, and staff at risk for the spread of the COVID-19 virus in the facility and out into the community. Findings included . RESIDENT 3 Resident 3 admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 3's Documentation Survey Report v2 (Report of the residents' functional abilities) for December 2021, showed the resident had been independent with bed mobility, transfers, eating, and ambulation. Review of Resident 3's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of facility Minimum Date Set (MDS) Assessment note dated 01/01/2022 at 6:55 PM, showed the resident was alert and orientated to person, place, and time. They were independent with bed mobility, transfers, and personal care. Review of a facility progress note dated 01/02/2022 at 3:33 PM, showed the resident had tested positive for the COVID-19 virus. Review of a facility progress note dated 01/03/2022 at 10:04 AM, showed the resident had a decline in their oxygen saturation below a normal baseline, and the resident was placed on oxygen that the resident had not required prior to infection. Review of facility progress notes for 01/04/2022 showed no documentation of the residents' health status in relation to their COVID-19 infection. Review of a facility medication administration note dated 01/05/2022 at 5:25 PM, showed the resident was too drowsy to administer their blood pressure medication. There was no documentation of the residents' health status in relation to their COVID-19 infection. Review of a facility medication administration note dated 01/06/2022 at 10:38 AM, showed the residents bowel regulatory medications were held due to loose stool. There was no documentation of the residents' health status in relation to their COVID-19 infection. Review of a facility progress note dated 01/07/2022 at 3:45 AM, the resident had increased respiratory rate, was having difficulty breathing, blood pressure was below a normal baseline, and not responsive to questions. The resident was transported to the hospital. Review of the PeaceHealth Critical Care Admission Note dated 01/07/2022 at 10:12 AM, Resident 3 was critically ill due to septic shock most likely due to bacterial superinfection of COVID-19, severe brain disfunction, respiratory failure, with imminent threat of death. In an interview on 01/25/2022 with Staff A, Registered Nurse/Resident Care Manager, informed that Resident 3 had passed away from COVID-19 at the hospital. RESIDENT 2 Resident 2 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of facility Minimum Date Set (MDS) Assessment note dated 12/29/2021 showed resident was pleasant and cooperative with cares, no discomfort, required one person assist for bed mobility and transfers. Review of a facility progress note dated 01/02/2022 at 2:14 PM, noted resident had been exposed to COVID-19 and had tested positive for the virus. Review of a facility progress note dated 01/03/2022 at 10:06 AM, showed the resident had experienced a decline in the oxygen saturation level below the baseline amount ordered. Review of a facility progress notes dated 01/04/2022 through 01/09/2022 showed no documentation of the residents' health status in relation to their COVID-19 infection. Review of a facility progress note dated 01/10/2022 at 12:32 PM, showed the resident had reduced lung sounds, was lethargic, not following direction. Review of a facility progress note dated 01/11/2022 at 6:38 PM, showed the family had requested the resident be sent to the hospital but not using emergency services. Review of a facility progress note dated 01/12/2022 at 12:01 PM, showed the resident had a thready pulse, overall decline, and new onset of weakness. Review of a facility progress note dated 01/12/2022 at 11:55 PM, showed the resident passed away. RESIDENT 420 Resident 420 was admitted to the facility 07/06/2017, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge summary from Peace Health Medical Center dated 01/12/2022, Resident 420 was admitted to the hospital for fatigue and shortness of breath related to COVID-19 infection they contracted at the facility. The discharge summary stated resident was admitted to the hospital for ten days with discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RESIDENT 413 Resident 413 admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge summary from Peace Health Medical Center dated 01/12/2022, Resident 413 was admitted to the hospital for cough and difficulty breathing related to COVID-19 infection they contracted at the facility. The discharge summary stated resident was admitted to the hospital for ten days with discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] RESIDENT 35 Resident 35 admitted to the facility on [DATE], with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the discharge summary from Peace Health Medical Center dated 01/21/2022, Resident 35 was admitted to the hospital for fever, altered mental status, and low oxygen in the blood related to COVID-19 infection they contracted at the facility. The discharge summary stated resident was admitted to the hospital for thirteen days with discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] <INFECTION SURVEILLANCE> Review of facility policy titled, Infection Prevention and Control Program, revised October 2018, showed: - The Infection Prevention and Control Program (IPCP) were coordinated and overseen by an Infection Prevention specialist (someone trained in infection control). - Process surveillance (adherence to infection prevention and control practices) and outcome surveillance (incidence and prevalence of healthcare acquired infections) are used as measures of the IPCP effectiveness; and - Surveillance tools are used for recognizing the occurrence of infections .i.e., detecting outbreaks and epidemics, monitoring employee infection and adherence to infection control practices. Review of facility policy titled, COVID-19 Infection Control Manual, Management During the Pandemic, revised 01/04/2022 stated: - The screening staff are responsible for reviewing each entrant's screening answers and temperature reading. - The staff that are designated to perform the screening oversight process will receive training and successfully complete the demonstrated competency with their supervisor or the Infection Preventionist (IP) prior to staffing the location; and - The screener will assure this is followed and notify the IP or Director of Nursing Services (DNS) and the screener's supervisor when facility access is denied. In an interview on 01/03/2022 at 2:30 PM, Staff E, Registered Nurse (RN)/Regional Nursing Consultant (RNC), stated they had 25 positive COVID-19 residents, and 11 positive COVID-19 staff members. The current IP had placed their two weeks' notice to the facility and had not been at the facility. Staff E stated they were not sure how they were going to set up the building to manage the positive COVID-19 residents, nor did they know where the source of the COVID-19 outbreaks had started. The facility was unable to provide their infection surveillance plan for the current COVID-19 outbreak. The facility was unable to provide a system for tracking current infections in the facility. In an interview on 01/04/2022 at 11:45 AM, Staff E stated the current IP would not be returning to the facility. The facility had hired a new IP, who would be training at another facility. A line listing was requested regarding the current COVID-19 outbreak, which was not provided. On 01/06/2022, the facility had not provided a surveillance and tracking system for current infections in the facility. In an observation on 01/12/2022 at 8:15 AM, the surveyor placed on a N-95 respirator mask and face shield before entering the building, there was no staff observed at the front desk monitoring for visitors. In an interview on 01/12/2022 at 1:30 PM, Staff N, Nursing Assistant Certified (NAC), stated they were supervising the front desk where visitors enter. Staff N stated the desk was not supervised at night; their shift started at 8:00 AM. In an observation on 01/13/2022 at 6:45 AM, the surveyor placed on a N-95 respirator mask and face shield before entering the building, there was no staff observed at the front desk to monitor for visitors entering the facility. In an observation on 01/14/2022 at 8:31 AM, the surveyor placed on a N-95 respirator mask and face shield before entering the building, there was no staff observed at the front desk to monitor for visitors. On 01/18/2022, the facility had not provided a surveillance and tracking system for current infections in the facility. On 01/21/2022 at 9:15 AM, the facility had not provided a surveillance and tracking system for current infections in the facility. On 01/24/2022 at 9:30 AM, the facility had not provided a surveillance and tracking system for current infections in the facility. On 01/25/2022 at 9:30 AM, the facility had not provided a surveillance and tracking system for current infections in the facility. In an interview on 01/25/2022 at 9:30 AM, Staff E stated the newly hired IP had not been onsite in the facility since their hire date. Staff E stated the facility's current IP was not really anyone, there are some nurses here doing some of the things like reporting but we do not have enough staff right now so we are just doing what we can. Staff E stated the newly hired IP, Staff O, RN/IP, who had been training with another staff member offsite, had been working remotely on their infection tracking system. In an interview on 01/25/2022 at 1:26 PM, Staff E stated Staff O, was responsible for the infection control practices in the facility. Staff E stated Staff O had tracked the last three weeks of infections in the facility, and prior to that the facility had completed some of the infection control tracking. Staff E stated that they were unclear if the infection control tracking was completed and was unable to locate any surveillance that was done by the facility prior to December 2021. On 01/26/2022 at 2:30 PM, the facility had not provided a surveillance and tracking system for current infections in the facility. <PERSONAL PROTECTIVE EQUIPMENT> Review of policy titled, COVID-19 Transmission-based Isolation Precautions PPE Reminders for Healthcare Personnel (HCP), updated 01/04/2022, showed: - Before entering the resident's room, the required PPE is gown, gloves, eye protection, and a N-95 respirator mask. - Discard gown before exiting the resident's room; and - A gown and gloves should not be worn outside of the resident's room. Review of facility policy titled, COVID-19 Infection Control Manual, Management During the Pandemic, revised 01/04/2022, showed: - To only use the respirator model and size for which the staff member had been fit tested . N95 respirators vary by model and size. Improper fit will likely result in inadequate protection. Respirator should not be used if damaged; and - Residents should wear face masks that cover their nose and mouth, in accordance with Center for Disease Control (CDC) recommendations. Review of BYD Care manufactures product guidance, undated that was provided by the facility showed proper use of facility approved N95 respirator BYD2232 straps were to be placed behind neck and crown of head. If elastic bands were damaged do not use as the respirator would be ineffective. In an interview on 01/04/2022 at 1:23 PM, Staff II stated they were unsure which residents in the facility had tested positive for COVID-19 and had not been instructed on when they should wear PPE. In an interview on 01/04/2022 at 2:02 PM, Staff GG stated they had not been instructed on when to wear PPE. In a phone interview with the Department of Health for Washington State on 01/06/2022 at 1:30 PM, with Collateral Contact (CC) 8 Epidemiologist, and CC 9 Epidemiologist, stated they had instructed the facility that all direct care givers should be wearing full personal protective equipment, that included a fit tested N95 respirator, proper eye protection, an isolation gown, and gloves. They stated they instructed the facility they would need to remove and apply a new isolation gown for every resident regardless of COVID-19 status. In an observation on 01/06/2022 at 12:23 PM, Staff B, RN, was observed to have a teal N95 (BYD2232) respirator in place and the straps were noticeably cut and tied behind their ears. In a continuous observation on 01/06/2022 at 1:04 PM, Staff P, RN/Regional Educator, was observed to exit a COVID-19 positive resident room wearing a PPE isolation gown. Staff P then shut the door of the resident's room and stood in the hallway and spoke to another staff member. Staff P was observed to remove their gown and gloves at the same time, opened the COVID-19 positive resident room door and placed the items into a trash can inside the resident room. Staff P then shut the resident's door, walked across the hall two doors down and used hand gel and performed hand hygiene. In an observation on 01/07/2022 at 1:15 PM, Staff Q, Restorative Aide (RA), had a teal N95 (BYD2232) respirator on, the straps were noticeably cut, and tied behind their ears. In an observation on 01/07/2022 at 1:29 PM, Staff B was observed to have teal N95 (BYD2232) respirator on, the straps were noticeably cut, and tied behind their ears. In an observation on 01/07/2022 at 2:12 PM, Staff B was observed to exit a known COVID-19 positive resident room and had a teal N95 (BYD2232) respirator on, the straps were noticeably cut, and tied behind their ears. In an observation on 01/07/2022 at 2:14 PM, Staff R, Environmental Assistant (EA), was observed to be wearing gloves while they pushed a known COVID-19 positive resident in their bed down the hall from one wing to another wing. The resident was observed to not have a face mask on in the hallway during the transfer. In an observation on 01/07/2022 at 2:35 PM, Staff Q was observed to have a teal N95 (BYD2232) respirator on, the straps were noticeably cut, and tied behind their ears. In an observation on 01/13/2022 at 8:25 AM, Staff I, Licensed Practical Nurse (LPN), was observed to enter a known COVID-19 positive room and did not put on the appropriate PPE before entering the resident's room. A Special Contact Droplet isolation precautions signage was next to the resident's door that directed staff to place gloves, an isolation gown, a respirator, and eye protection on before entering the room. An accessible PPE bin (a place for staff to easily access PPE before entering a room) was observed to be present. In an observation on 01/13/2022 at 8:45 AM, Staff I was observed to enter a known COVID-19 positive room and did not put on the appropriate PPE before entering the room. There was a Special Contact Droplet isolation precautions sign posted next to the resident door. In an observation on 01/14/2022 at 12:12 PM, Staff Q was observed to have a teal N95 (BYD2232) respirator on, the straps were noticeably cut, and tied behind their ears. In an observation and interview on 01/20/2022 at 10:09 AM, Staff S, NAC, exited a resident's room, their N95 was observed to not be worn correctly as both straps were towards the bottom of their neck. Staff S stated they could not wear the respirator correctly because they were unable to put their hair up to keep the respirator strap in place. In an observation on 01/20/2022 at 10:11 AM, Staff B was observed to have a teal N95 (BYD2232) respirator on, the straps were noticeably cut, and tied behind their ears. In an observation on 01/21/2022 at 9:11 AM, Staff B was observed to have a teal N95 (BYD2232) respirator on, the straps were noticeably cut, and tied behind their ears. In an observation on 01/24/2022 at 9:11 AM, Staff B was observed to have a teal N95 (BYD2232) respirator on, the straps were noticeably cut, and tied behind their ears. In an observation on 01/24/2022 at 9:12 AM, Staff T, NAC, was observed to have a white N95 respirator on, the straps were noticeable cut, and tied behind their ears. In an interview on 01/24/2022 at 10:50 AM, Staff U, RN, was observed to not be wearing a N95 respirator and their mask was sliding off their face exposing their nose and top of their mouth. Staff U stated they were fit tested for a N95 at another facility, however this mask was their personal one brought from home. In an observation and interview on 01/24/2022 at 2:50 PM, Staff V, (LPN), was observed to have their N95 with cut straps, and it was tied behind their ears. The mask was observed to poorly fit to their face. In an interview on 01/25/2022 at 1:26 PM, Staff E stated all staff were required to wear a fit tested approved N95 respirator at this time. <TRANSMISSION BASED PRECAUTIONS> Review of the facility policy titled, COVID-19 Transmission-based Isolation Precautions Personal Protective Equipment (PPE) Reminders for Healthcare Personnel (HCP), updated 01/04/2022, showed: - Special Contact/Droplet Precautions directed staff to place gloves, an isolation gown, a respirator, and eye protection on before entering the room for COVID-19 infected, suspected or who have been exposed to COVID-19 cases; and - COVID-19 positive resident's room doors should be closed. In an observation on 01/04/2022 at 12:25 PM, room [ROOM NUMBER] had no visible signage to communicate to staff the type of precautions and the appropriate PPE to be used. The facility reported that room [ROOM NUMBER] was a COVID-19 positive room. In an observation on 01/04/2022 at 12:56 PM, room [ROOM NUMBER], a designated COVID-19 positive room, had no visible signage to communicate to the staff the type of precautions and the appropriate PPE to be used. The nearest PPE observed was located on the other side of closed fire doors and was not readily available near the entrance to the resident's room. In an observation on 01/04/2022 at 12:57 PM, room [ROOM NUMBER] had a special Droplet/Contact isolation sign on the wall next to the door. The signage directed staff to keep the resident's door shut, the door was observed to be open, and Resident 29 was observed in the room. Review of Resident 29's care plan showed no safety assessment had been completed and there was no direction to staff to keep the resident's door open. In an observation on 01/04/2022 at 12:58 PM, room [ROOM NUMBER] had no visible signage to communicate to staff the type of precautions and the appropriate PPE to be used. The facility stated room [ROOM NUMBER] was a COVID-19 positive room. In an observation on 01/04/2022 at 12:59 PM, room [ROOM NUMBER] was designated to be a COVID-19 positive room and there was no visible signage present to alert staff of the appropriate PPE to be used. There was no signage to communicate to staff what type of precautions or what appropriate PPE should be used. In an observation on 01/04/2022 at 1:00 PM, room [ROOM NUMBER] was designated to be a COVID-19 positive room. There was no signage to communicate to staff what type of precautions or what appropriate PPE should be used. In an observation on 01/04/2022 at 1:01 PM, room [ROOM NUMBER], which was identified as a COIVD-19 positive room, had no visible signage to designate to staff the type of precautions and the appropriate PPE to be used. The door was observed to be open. Review of Resident 56's care plan showed no safety assessment had been completed and there was no direction to staff to keep the resident's door open. In an observation on 01/04/2022 at 1:02 PM, room [ROOM NUMBER], which was identified as a COVID-19 positive room, had no visible signage to designate to staff the type of precautions and the appropriate PPE to be used. In an observation on 01/04/2022 at 1:03 PM, room [ROOM NUMBER], which was identified as a COVID-19 positive room, had no visible signage to designate to staff the type of precautions and the appropriate PPE to be used. Per facility provided list Resident 28 was assigned to room [ROOM NUMBER] and was positive for the COVID-19 infection. In an observation on 01/04/2022 at 1:04 PM, room [ROOM NUMBER], which was identified as a COVID-19 positive room, had no visible signage to designate to staff the type of precautions and the appropriate PPE to be used. Per facility provided list Resident 1 was assigned to room [ROOM NUMBER] and was positive for the COVID-19 infection. In an observation on 01/04/2022 at 1:05 PM, room [ROOM NUMBER], which was identified as a COVID -19 positive room, had no visible signage to designate to staff the type of precautions and the appropriate PPE to be used. According to the facility provided list, Resident 18 was assigned to room [ROOM NUMBER] and was positive for the COVID-19 infection. In an observation on 01/04/2022 at 1:07 PM, room [ROOM NUMBER], which was identified as a COVID-19 positive room, had no visible signage to designate to staff the type of precautions and the appropriate PPE to be used. The door was observed to be open. Review of Resident 55's care plan showed no safety assessment had been completed and there was no direction to staff to keep the resident's door open. Per facility provided list Resident 55 was assigned to room [ROOM NUMBER] and was positive for the COVID-19 infection. In an observation on 01/04/2022 at 1:09 PM, room [ROOM NUMBER], which was identified as a COVID-19 positive room, had no visible signage to designate to staff the type of precautions and the appropriate PPE to be used. The door was observed to be open. Review of Resident 12's care plan showed no safety assessment had been completed and there was no direction to staff to keep the resident's door open. Per facility provided list Resident 12 was assigned to room [ROOM NUMBER] and was positive for the COVID-19 infection. In an interview on 01/04/2022 at 1:23 PM, Staff II, NAC stated they were unclear as to exactly which residents were positive. Staff II stated it kept changing throughout their shift. In an observation on 01/13/2022 at 7:36 AM, room [ROOM NUMBER] had a special Droplet/Contact isolation sign on the wall next to door. The signage directed staff to keep the resident's door shut, the door was observed to be open, privacy curtain pulled, lights are off, audible snoring heard from room. In an observation on 01/21/2022 at 9:08 AM, room [ROOM NUMBER] had a special Droplet/Contact isolation sign on the wall next to door. The signage directed staff to keep the resident's door shut, the door was observed to be open, and Resident 52 was observed in the room. Review of Resident 52's care plan showed no safety assessment had been completed and there was no direction to staff to keep the resident's door open. <HAND HYGIENE> In an observation on 01/12/2022 at 9:20 AM, Staff S, NAC, and Staff W, NAC, performed incontinent care on Resident 10. While the resident was on their back the staff unattached the resident's adult incontinent brief and cleaned the front groin area. Staff S turned the resident while Staff W cleaned the residents bottom, a small amount of brown feces was visible. Staff W then placed a clean adult incontinent brief on resident, turned the resident onto their back to secure the brief, and arranged the residents bedding, all without taking off the feces contaminated gloves. Staff W was asked and did not respond why their contaminated gloves where not changed. In a continuous observation on 01/24/2022 at 9:36 AM, Staff X, Housekeeper (HK), was observed to push a housekeeping cart down the hallway with gloves on both hands. Staff X parked the cart in front of a resident occupied room, grabbed a blue sponge from the cart and entered the resident's room with same gloved hands. At 9:41 AM, Staff X exited the room with same gloved hands and reached into their pocket and grabbed a set of keys. With the same contaminated gloved hands opened the drawer on the cart and removed a basket with bottles and brushes and entered the resident's room. At 9:46 AM, Staff X exited the resident's room with the same gloved hands, reached into their pocket, grabbed a set of keys, and opened a drawer on the cart to return the basket. Then Staff X was observed with the same contaminated gloves placed a blue sponge into a trash bag that was attached to the housekeeping cart then grabbed a broom and a dustpan and entered a resident's room. Staff X exited the room without changing their gloves or performing hand hygiene, placed the broom and dustpan back on the housekeeping cart. Staff X then was observed to remove their gloves, apply hand gel to their hands, placed another pair of gloves on and pushed their housekeeping cart down the hall to another room. <UNIVERSAL MEDICAL EQUIPMENT> Review of the facility policy titled, COVID-19 Infection Control Manual, Management During the Pandemic, revised 01/04/2022, stated shared medical equipment should be cleaned and disinfected between residents. In an observation and interview on 01/24/2022 at 10:34 AM, Staff U, was observed to remove a pulse oximeter (gadget to take the resident's pulse and oxygen levels) off Resident 19's finger and placed the device in their top pocket of their shirt and exited the resident's room. Staff U stated that universal medical equipment (which included a pulse oximeter) was to be cleaned after each use but did not have any disinfectant present. Staff U was not able to respond why the pulse oximeter was placed into their pocket without being cleaned. <LAUNDRY SERVICE> In an observation on 01/21/2022 at 10:17 AM, a laundry bin was seen to be overflowing with clean hospital gowns and sitting directly next to a hand washing station. There was a large clear trash bag full of clean transfer slings (a device used to transfer a resident using a mechanical lift) was sitting directly on the ground under the sink of the hand washing station. In an observation on 01/21/2022 at 11:01 AM, a laundry bin was seen to be overflowing with clean hospital gowns and placed next to a hand washing station and a large clear trash bag was full of clean transfer slings and sitting directly on the ground under the sink of the hand washing station. In an interview on 01/21/2022 at 11:21 AM, Staff Y, Housekeeping Manager, stated the clean gowns and slings were from the hospital, however they could not guarantee staff were aware to not use them and stated it would be possible for a staff member to walk in and remove to use on a resident. In an observation on 01/24/2022 at 11:03 AM, an open laundry bin of clean gowns was sitting next to the hand washing station, and a large clear trash bag of clean transfer slings was sitting on the floor next to a laundry bin. In an interview on 01/25/2022 at 2:37 PM, Staff E, Regional Nurse Consultant stated the outbreak included 44 residents that tested positive for COVID-19. The facility failed to ensure there was lack of infection surveillance and tracking of infections throughout the facility, there was failure to ensure staff properly donned PPE within close contact with COVID-19 positive residents, there was failure by staff to perform proper hand hygiene, and failure to properly disinfect universal equipment after direct contact with a resident. These breaches in infection prevention and control practices led to the spread of COVID-19 virus throughout the facility that subsequently led to the outbreak of 44 residents with COVID-19, which resulted in the hospitalization of four residents (3, 35,413, and 420) and the death of Resident 3, and Resident 2. These failures were a continuation of non-compliance for the facility regarding their infection prevention and control practices from 11/10/2021. Reference WAC 388-97-1320 (1)(a)(c)(2)(a)(b)(c)(3)(5)(c)(e) This is a repeat citation from Statements of Deficiencies, dated 11/10/2021 and 01/19/2021.

Based on observation, interview, and record review, the facility failed to implement, or consistently ensure that care planned interventions were in use, to prevent the development of pressure ulcers (wound from pressure to a part of the body) in three of four residents (19, 10, 39) reviewed for pressure ulcers (PU). These failures caused harm to Resident 19 as the resident acquired two avoidable PU's while residing at the facility and placed other residents at risk for developing a PU. Findings included . Review of a facility policy titled, Prevention of Pressure Injuries, dated April 2020, showed the facility would: - Review medical devices with consideration to minimize tissue damage, including its application and ability to secure the device; - Reposition all residents at risk of pressure injuries on an individualized schedule determined by the interdisciplinary care team; and - Select appropriate support surfaces based on the resident's risk factors, in accordance with current clinical practice. Review of a facility policy titled, Oxygen Administration, dated October 2010, showed that staff were to anchor the (O2) tubing so that it doesn't rub or irritate behind the resident's ears. According to the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument manual, v1.12.1, a PU was defined as a localized injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of intense and/or prolonged pressure or pressure in combination with shear. The pressure ulcer/injury can present as intact skin or an open ulcer and may be painful. A stage two pressure ulcer is defined as partial thickness loss of dermis that presented as a shallow open ulcer with a red-pink wound bed, without slough (non viable tissue) or bruising. RESIDENT 19 The resident most recently admitted to the facility on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Review of a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order had been in place since 05/15/2021. Review of the Weekly Skin Audit documented on the TAR showed that the resident had no skin issues on 01/11/2022. In an observation on 01/12/2022 at 2:05 PM, Resident 19 was using O2, and there was no padding on the tubing. In an observation on 01/13/2022 at 9:57 AM, Resident 19 was using O2, and there was no padding on the tubing. Resident 19 had a dried brownish red substance behind their right ear. In an observation and interview on 01/13/2022 at 10:44 AM, Staff A, Registered Nurse (RN)/Resident Care Manager (RCM), assessed behind Resident 19's ears. Staff A stated that there were pressure ulcers behind both ears. Staff A acknowledged the O2 tubing did not have any padding in place to protect the resident's ears. Review of the Skin and Wound evaluation assessments, completed 01/13/2022, showed Resident 19 had a facility acquired Stage two PU on their right and left ears. Review of a progress note, dated 01/13/2022 at 2:24 PM, showed that Resident 19 had a stage two PU on the left ear that measured 1.46 centimeter (cm) length by 0.55 cm width and a stage two PU on the right ear that measured 1.22 cm length by 0.43 cm width. Review of a progress note, dated 01/13/2022 at 4:29 PM, showed that there were wounds (PU) behind both ears and that they were related to the O2 tubing where it rested behind Resident 19's ears. Review of a physician order, dated 01/13/2022, showed that the nurse was to monitor the PU's twice a day and ensure that padding was on the O2 tubing. In an observation on 01/20/2022 at 2:00PM, Resident 19 was using oxygen, and there was no padding on the O2 tubing. This was observed again at 2:51 PM. In an observation and interview on 01/20/2022 at 3:36 PM, Staff C, RN, acknowledged that there was no padding on the O2 tubing. RESIDENT 10 The resident admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to the annual MDS assessment, dated 10/12/2021, the resident had severe cognitive impairment, and needed 2-person extensive assistance with bed mobility, dressing and toilet use, and was on a turning/repositioning program. Review of the resident's care plan, print date 01/11/2022, showed the resident was care planned for a self-performance deficit with activities of daily living, and needed 2-person maximum assistance with bed mobility. Review of bed mobility documentation that directed staff to record the number of times assistance with bed mobility occurred during the shift, print date 01/11/2022, showed the resident was documented as this occurring: 01/01/2022 - zero times, 01/02/2022 - two times, 01/06/2022 - three times, 01/07/2022 - zero times, 01/08/2022 - two times, 01/09/2022 - two times. In observations on 01/21/2022 at 8:55 AM, 11:04 AM, 12:04 PM, the resident was observed to be on their back in bed. In an interview on 01/21/2022 at 12:43 PM, Staff AA, Registered Nurse/Minimum Data Set Nurse, stated she could not answer any questions regarding turning/repositioning for this resident. In an interview on 01/21/2022 at 12:57 PM, Staff BB, Nursing Assistant Certified, stated he didn't know anything about a turning/repositioning program for this resident. In observations on 01/24/2022 at 9:40 AM, 10:19 AM, 11:15 AM, and 1:25 PM, the resident was observed to be on their back in bed. RESIDENT 39 Resident 39 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . According to their Significant Change MDS assessment dated [DATE], the resident had severe cognition impairment and required two-person extensive assist for bed mobility. Review of the Skin at Risk Assessment completed on 10/08/2021 showed the resident was a high risk for skin breakdown. Review of the Hospice Service Note dated 12/15/2021 showed the resident was supposed to have an Alternating Pressure Pad (APP) with a start date of 12/06/2021. In observations done on 01/07/2022, 01/10/2022, 01/12/2022, 01/13/2022, 01/14/2022, 01/19/2022, 01/20/2022, 01/21/2022, 01/24/2022, and 01/25/2022 the resident was observed to be lying in bed on their back with no APP mattress in place. In an interview on 01/25/2022 at 11:00 AM, Staff A stated that the RCM was responsible for ordering the durable medical equipment for residents and would update the care plan accordingly. Staff A was unaware of the order listed on the Hospice Service Note dated 12/15/2021 showing Resident 39 was to have an APP mattress. Staff A offered no other information as to why the order was not completed. Reference WAC 388-97-1060 3(b) This is a repeat deficiency from 08/05/2021.

Based on observation, interview and record review, the facility failed to provide adequate supervision and ensure appropriate interventions were implemented to prevent falls with injury for one of three sample residents (1), reviewed for accidents. In addition, the facility failed to evaluate the effectiveness of the implemented interventions. This failed practice resulted in two separate hospitalization s for Resident 1 that sustained a brain bleed and a fractured rib after two subsequent falls. The lack of adequate supervision and accident prevention placed all residents at risk for injury. Findings include . Review of the facility's policy titled, Falls and Fall Risk, managing revised March 2018, stated staff would identify interventions related to the residents' specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling if the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. Resident 1 admitted to the facility on [DATE] with diagnosis of swelling of the brain from an infection which caused dizziness, impaired balance, coordination, and cognition impairment. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident required two-person extensive assist for transfer and ambulation. Resident 1 had severe cognition deficit. Review of Care Area Assessment (CAA) triggered from the admission MDS assessment, showed the resident was at risk for falls. Findings included the resident had multiple previous falls prior to admission to the facility related to diagnosis of brain swelling. Falls would be addressed on the care plan to avoid complications and minimize the risk to the resident. Review of hospital admission paperwork from 07/23/2021, showed Resident 1 had worsening impaired coordination and balance, and increased confusion. Nursing documentation from the hospital showed Resident 1 was a fall risk, unsteady on their feet, and was unable to call for assistance. Interventions implemented at the hospital included the use of a bedside alarm, and a remote video monitoring system. Review of the care plan with a focus dated 07/21/2021 (resident admitted [DATE]), showed resident was at risk for falls related to diagnoses of dizziness, impaired balance, and coordination. Interventions to include call light within reach, always wear non-skid footwear when out of bed, monitor for decline or improvement in mobility, and review and update fall risk assessment quarterly, post any fall and as needed. Review of Fall Risk assessment dated [DATE], showed the resident was high risk for falls. Review of an incident report dated 07/25/2021, showed the resident had an unwitnessed fall at 5:26 PM in their room. Resident 1 was found on the floor with the door closed. An intervention added was to include diversional activities when they were restless. Review of Physician Assistant (PA) progress note dated 07/26/2021, showed resident was cognitively impaired and needed fall precautions for impaired balance and coordination. Review of a skilled nursing note dated 07/25/2021 through 07/30/2021, showed safety concerns of the resident making several attempts to self-transfer, did not use their call light, and had multiple falls. Review of an incident report dated 08/02/2021, showed the resident had an unwitnessed fall at 7:44 PM in their room. The resident was found on floor. An intervention was added to move resident closer to the nurse's station. Review of an incident report dated 08/03/2021, showed resident had fallen at 3:30 PM in their room. Per the summary, the resident self-transferred from their wheelchair and fell backwards and hit their head on the floor. Resident 1 was sent to hospital resulting in a head injury. An intervention was added to install an anti-roll back device (the device prevents chair from rolling backwards) to wheelchair when the resident returned from hospital. Review of PA progress note dated 08/03/2021, showed the resident continued to experience recurrent falls with their wheelchair, still tried to get up and falls. Review of the Admission Nursing Database assessment dated [DATE] (Resident 1 readmitted on [DATE]), showed the resident had previous falls, and was not steady with transfers. Review of a Fall Risk assessment dated [DATE], showed the resident was a high risk for falls. Review of a physical therapy assessment dated [DATE], showed the resident was at risk for falls related to physical impairments and associated functional deficits, resident was unstable and unpredictable. Review of a care plan goal for falls dated 08/10/2021, showed the resident would not have any substantial injuries secondary to falls. The care plan interventions were not updated based on the risk factors identified upon the resident's re-admission; the anti-roll back device was not added to care plan. Review of an incident report dated 08/11/2021, showed the resident had an unwitnessed fall at 7:40 PM in their room. The resident was found on the floor. An intervention was added to place bed against the right side of room to create boundaries. Review of a skilled nursing note dated 08/11/2021, showed the resident continued to attempt to self-transfer and did not use call light when needing assistance. Review of a PA progress note dated 08/12/2021, showed Resident 1 was hospitalized for seven days related to a brain bleed (resident was readmitted on [DATE]) sustained after fall and continued to experience recurrent falls. Review of a skilled nursing note dated 08/12/2021, showed the resident was a fall risk, did not remember to use call light. Review of a purchase order provided by facility; the anti-roll back device was not ordered until 08/13/2021. Review of an incident report dated 08/14/2021, showed the resident had an unwitnessed fall at 3:45 PM in their room. Resident was found on floor. A new intervention was added to place a sign in the resident's room to use their call light (even though it was documented the resident did not use their call light). This intervention was added to the care plan five days after the fall. Review of an incident report dated 08/15/2021, showed resident had an unwitnessed fall at 4:30 PM in their room. The nurse documented the resident was confused. Per the investigative summary, the resident was impulsive and had poor safety awareness with an inability to estimate their self-limitations. A new intervention was added to allow compassionate care visits daily, which was added to the care plan four days after the fall. Review of a PA progress note dated 08/16/2021, showed the resident had multiple falls and was very difficult to redirect with poor balance. Review of an incident report dated 08/17/2021, showed the resident had a fall at 12:20 PM in their room. The resident was found on floor; fall was unwitnessed and call light was not on. Per the investigative summary, an intervention was added to place resident on 15-minute checks, which was added to the care plan three days later. Review of the 15-minutes check forms showed empty entries, incomplete forms, undated pages, and one page was dated after resident discharged from the facility. Review of a PA progress note dated 08/17/2021, showed the resident continued to be a serious fall risk and very confused with cognition impairment. Review of an incident report dated 08/19/2021, showed the resident had a fall at 3:45 PM in their room, call light was not on. The nurse documented that the resident appeared to grab at something on ground and was wearing one shoe. The summary stated the resident was severely cognitively impaired. An intervention included to have therapy to assess the resident to use a grabber device and educated staff to ensure resident was always wearing non-skid footwear. The care plan did not reflect the intervention for therapy to assess the resident for the use of the grabber device. The care plan already reflected non-skid footwear as a previous intervention from admission on 07/23/2021. Review of care plan on 08/27/2021 showed the anti-roll back device was added to care plan on 08/19/2021. Review of a PA progress note dated 08/20/2021, showed Resident 1 had multiple falls and difficulty with redirection, poor balance, and falls. Review of a skilled nursing note dated 08/20/2021, showed the resident continued to attempt to self-transfer and did not use call light when needing assistance. In a phone interview on 08/23/2021 at 3:17 PM, with collateral contact (CC), stated sadly the resident was a tragic victim to the COVID vaccine, they were splitting their own firewood in May and now could not walk, they fall as soon as they stand. CC stated they had moved here to be closer, as the resident was having so many falls. Review of an incident report dated 08/23/2021, showed the resident had a fall at 4:20 PM in their room, unwitnessed, and the call light was not on. Per the investigation summary no neglect was identified because the care plan was being followed due to the anti-roll back device was functioning and in place. Review of an incident report dated 08/24/2021, showed the resident had a fall at 8:40 AM, and the call light was not on. Per the incident report, the resident stood up from their wheelchair, fell and received an enlarged bump to their forehead. Resident 1 was sent to the hospital via ambulance and was admitted to the hospital for rib fracture and collapsed lung. In an observation of the resident's room on 08/25/2021 at 8:45 AM, revealed Resident 1 was in the hospital. There was a wheelchair in the room, with no anti-roll back device observed on the wheelchair in the room, the bed against the wall, a front wheel walker, and a bed side commode with curved handles. There was a sign on bathroom door to remind the resident to use call light. In an interview on 08/25/2021 at 9:26 AM Staff A, Licensed Practical Nurse (LPN), stated the floor nurse does not update the care plans. If the resident was a high risk for falls upon admission, it would be reflected on the care plan. Staff A stated interventions were never removed they just add as a new one after each fall. Staff A stated, Resident 1 had a lot of falls, they were unable to follow directions. Staff A stated they had informed Staff E, Central Supply, to order the anti-roll back device for Resident 1; however, it had not been placed on the residents wheelchair as of this interview. Staff A confirmed the wheelchair in the room was Resident 1's. In an interview on 08/25/2021 at 10:59 AM, Staff F, Nursing Assistant Certified (NAC), stated Resident 1 was falling all the time, and the staff had difficulty figuring out what to do. Staff F stated, Resident 1 was a huge fall risk; staff would leave Resident 1 alone for five minutes and they would fall. In an interview on 08/25/2021 at 11:22 AM, Staff G, NAC, stated the care plan reflected if a resident was a high fall risk and what the interventions were. Staff G stated, Resident 1 would attempt to self-transfer often and had a lot of falls, staff would try to watch them from their doorway. In a phone interview on 08/26/2021 at 11:11 AM, Staff H, NAC, stated residents who admit as high fall risks were usually placed in rooms near the nurse station. Staff H stated Resident 1 fell all the time and staff would place the resident in their wheelchair near the nurse cart, but they would just stand up and staff would need to run and get them. Staff H stated, They (Resident 1) really needed constant supervision, like a 1:1. In an interview on 08/27/2021 at 9:25 AM, Staff E, stated the anti-roll back device was delivered yesterday, however due to the resident was out of the facility they placed it on another resident's chair. Staff E confirmed they ordered the device on 08/13/2021 and this was standard delivery time for that item. In an interview on 08/27/2021 at 10:08 AM, Staff I, Occupational Therapist (OT), stated Resident 1 was unpredictable, was quick without warning and was not able to communicate their needs. Staff I stated the resident needed to be in the staff direct view for supervision. In an interview on 08/27/2021 at 11:48 AM, Staff B, Registered Nurse (RN), stated Resident 1 was a very high fall risk and the staff tried to check on them every 15 minutes. Staff B stated, I think they probably needed one on one because they could fall in 15 minutes it was very hard to work with them, it's hard to observe them and I have to leave the medication cart, I am always moving I can't watch them all the time. In an interview on 08/27/2021 at 11:59 AM, Staff J, NAC, stated residents who were a high fall risk staff tried to check on them every 15-30 minutes. Staff J stated Resident 1 was different, they had only a two-minute memory otherwise they would try to get up and walk. Staff J stated, Resident 1 probably needed someone with them one on one. In an interview on 08/27/2021 at 12:50 AM, Staff K, LPN/Resident Care Manager (RCM), stated when a resident admitted from the hospital it was the RCM's job to review hospital notes, and the admission History and Physical (H&P). Staff K acknowledged Resident 1 was a high fall risk upon admission based on their medical history and information provided by the hospital. Staff K, stated they placed high fall risk residents in the rooms near the nurse station, provided frequent checks, fall mats, and non-skid footwear. Staff K stated they were not able to place Resident 1 in a room near the nurse station on admission as there were none available at the time. Staff K acknowledged the only high-risk intervention implemented to Resident 1 upon admission was non-skid footwear. Staff K acknowledged the anti-roll back device was not ordered until 08/13/2021 and did not provide any information as to what the facility did to ensure safety until the anti-roll back device was installed. Staff K did not offer a response when informed the 15-minute checks were not completed, were undated, and missing signatures. Staff K acknowledged they were responsible for completion of the summary for the fall on 08/23/2021, which included the anti-roll back device was operational. Staff K acknowledged they identified a trend, that Resident 1 was falling in the evening, however Staff K stated, they did not address this in the interventions. Staff K did not acknowledge or deny when informed the staff expressed Resident 1 needed a one to one as they were impulsive, quick and they were unable to watch them all the time. In an interview on 08/27/2021 at 1:30 PM, the Director of Nursing Services (DNS) stated the expectations for fall investigations was the cart nurse would initiate the incident report, gather witness statements from all staff working on the unit, and initiate an immediate intervention. The RCM was to assess the information based on the witness statements and evaluate effectiveness of the intervention(s) and updated the care plan. The DNS said they had not been reviewing fall trends, they had implemented a fall committee to start with the first meeting on day of this interview. The DNS acknowledged they reviewed hospital notes, and admission paperwork in addition to the assessments that were required and completed when a resident was admitted determining a resident's risk for falls. The DNS acknowledged Resident 1 should have been placed in a room near the nurse station, however stated there were none available at the time of admission. The DNS stated they could not control when the anti-roll back device was delivered and stated, if we don't have it, we can't add to the chair we can't be responsible for how long it takes to ship. The DNS did not provide any information as to what the facility was putting in place until the anti-roll back device was installed. The DNS acknowledge resident had several unwitnessed falls after returning from the hospital on 08/10/2021 and there was no way to determine if anti-roll back device would have affected the falls. The DNS acknowledged the intervention to place a sign for resident to use their call light was inappropriate, based on the nursing documentation that Resident 1 was unable to follow directions or use a call light. The DNS did not offer a response when informed of the 15-minute checks were not completed, were undated, and missing signatures for the fall on 08/17/2021. The DNS did not acknowledge or deny when informed the staff expressed Resident 1 probably needed a one to one as they were impulsive, quick, and unable to monitor all the time. The DNS acknowledged Resident 1 had twelve falls, two with significant injuries with hospitalization in the twenty-four days of their admission. The DNS acknowledged the interventions implemented were not specific or effective for Resident 1. Reference: (WAC) 388-97- 1060 (3)(g)

Based on observation, interview, and record review the facility failed to provide care and services to prevent pressure ulcers for two of three sampled residents (2, and 3) reviewed for pressure ulcers (PU). The facility failed to implement, monitor, and evaluate effectiveness of interventions for Resident 2 who was identified to be at risk for pressure ulcers on admission. This failure caused harm when Resident 2 developed two Stage III pressure wounds to their coccyx (tailbone). Resident 3 was identified to be bed ridden and at risk for pressure ulcers on admission and the facility did not implement, monitor, or evaluate interventions for Resident 3 resulting in a Stage II blister to their heel. This failed practice caused harm to Resident 2 and placed Resident 3 and other residents at risk for the development of a pressure ulcer. Findings included . The Resident Assessment Instrument (RAI) Manual defined the stage of a PU as followed: - A Stage II PI (ulcer) was described as a partial thickness loss of the skin. - A Stage III PI (ulcer) was described as a full thickness loss of the skin. Review of facility policy titled, Avamere Living-Weekly Skin Audit Guidelines, revised 08/25/2020, showed on admit, the licensed nurse will perform a skin assessment for early identification of skin breakdown or areas that are at risk for development of pressure injuries. Review of the facility's policy titled, Prevention of Pressure Injuries, revised in April 2020, showed the purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .Review the residents care plan and identify the risk factors as well as interventions .Reposition all residents with or at risk of pressure injuries on an individualized schedule, as determined by the interdisciplinary care team .Select appropriate support surfaces based on the residents risk factors, in accordance with current clinical practice .Review the interventions and strategies for effectiveness on an ongoing basis. RESIDENT 2 Resident 2 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident's Admission Minimum Data Set Assessment (MDS) dated [DATE], showed the resident required two-person extensive assistance for bed mobility, transfers, dressing, and toilet use. They were incontinent of bowel and bladder. A Care Area Assessment (CAA) trigger (areas that required care plan interventions) revealed the resident was at risk for developing a PU's and this concern would be addressed on the care plan. Review of the resident's nursing admission assessment completed on 05/07/2021, showed Resident 2 admitted with surgical skin impairment to their right knee and right hip. Review of the resident's Braden Scale for Predicting Pressure Sore Risk (an assessment tool to determine a resident's risk for developing PU's), dated 05/07/2021, showed the resident was at risk for PU development. Review of the care plan focus problem dated 05/07/2021, stated the resident was admitted to the facility with actual impairment to skin integrity related to their surgical wound (R) BKA. Interventions included to report any new skin impairment to the licensed nurse, complete weekly skin assessment, and to keep their skin clean and dry. The care plan did not identify the resident was at risk for PU development. Review of a progress note dated 05/11/2021 at 11:45 PM, showed the resident had refused cares, required reapproaching and education on skin care. The refusal of care or education to the resident was not addressed on the care plan. Review of May 2021 Documentation Survey Report v2 (a type of computerized report) showed the resident was offered a bath or shower eleven times and refused nine times. Refusal of care was not addressed on the care plan. Review of incident report dated 07/13/2021 at 6:30 AM, showed the resident had two new PU's to their coccyx area. The incident report stated the resident spent extended amounts of time in bed throughout the day and evening. Review of a progress note dated 07/13/2021 at midnight, Staff H, Physician's Assistant (PA), documented there was a decubitus ulcer near coccyx most likely related to resident continuously sitting. Review of a wound team progress note dated 07/20/2021, showed Staff G, wound physician, documented the resident had two PU's near the coccyx area. Wound one measured 1.2 centimeter (cm) x 1.5 cm x 0.1 cm and was staged as a Stage III PU. Wound two measured 3.5 cm x 2.0 cm x 0.1 cm and was staged as a Stage III PU. In an interview on 07/27/2021 at 11:06 AM, Staff A Nursing Assistant Certified (NAC), stated they used the care plan to provide the correct type of care for residents such as positioning, and turning schedules. Staff A stated if the resident had a skin issue it would be on the care plan, or the nurse would let them know. In an observation and interview on 08/02/2021 at 9:38 AM, Resident 2 was sitting in their chair. The resident stated they did not come into the facility with a sore on their bottom. They said one of the staff members informed them and they (staff) were doctoring it now. The resident stated the wound had been there for a few weeks and was painful when they change the dressing. The resident reported they were in their wheelchair or bed most of the time. Resident 2 had pain to the right hip, so staff encouraged them to not lie on the sore hip, so they laid on their back instead. The resident reported nurses do not look at all their skin weekly, they just look at wounds when they had one. In an interview on 08/02/2021 at 9:56 AM, Staff B, NAC, stated they use the interventions on the care plan for skin prevention. Staff B stated for prevention they made sure the resident was dry. The residents with current skin impairments or pressure ulcers would be repositioned and have an alternating pressure mattress (APM). In an interview on 08/02/2021 at 10:05 AM, Staff C, NAC, stated Resident 2 was lying in bed a lot for a long time, recently they had become more independent and were now in their wheelchair (w/c) a lot. Staff C reported the resident could be reluctant to change positions, once they are up, they are up. In an interview on 08/02/2021 at 12:05 PM, Staff D, Licensed Practical Nurse (LPN), reported they have skin prevention interventions such as repositioning, and weekly skin checks. Staff D stated if a resident was at risk for skin impairment, they would put in the care plan for repositioning, weekly skin checks, and notify of any changes. If a resident had a new PU, nursing would complete a skin/wound assessment and refer the resident to the wound team for further evaluation and treatment. Staff D stated the shower aids completed the skin check form and gave it to the nurse weekly. In an interview on 08/02/2021 at 1:20 PM with Staff E, Registered Nurse (RN)/MDS nurse, stated if there was a PU CAA triggered, they check to ensure the issue was addressed on the care plan or they would communicate to the Resident Care Manager (RCM) to see if these issues needed to be addressed on the care plan. We all know it only takes two hours for a PU to develop, so if a resident had multiple triggers the issue needed to be addressed on the care plan as soon as possible. In an interview on 08/02/2021 at 1:32 PM, Staff F, RN/Resident Care Manager, RCM, stated they identified residents at risk for skin impairment on admission using the Braden Assessment and assessing the residents risk factors. They would address this in the care plan. Staff F stated if a resident was at risk for PU's, they should implement a positioning schedule, sage boots (a type of pressure relieving foot device) or a APM (alternating pressure mattress) to decrease pressure. Staff F stated if the MDS assessment triggered the resident was at risk for PU's, the MDS nurse would contact the RCM to address it in the care plan. Staff F agreed Resident 2 triggered to be at risk for PU development on their admission MDS assessment, and no interventions were addressed on the care plan for prevention. In an interview on 08/03/2021 at 2:39 PM, Staff G stated Resident 2 had a lot of stuff going on and was not very mobile for a long time. In an observation and interview on 08/05/2021 at 8:58 AM, the resident was in their w/c and expressed frustration regarding an open area to their BKA site which was preventing the use of prosthetic device and working with therapy. The resident did not admit to the facility with a pressure ulcer and was identified at risk on their admission assessment. The facility failed to implement an individualized care plan to direct caregivers to prevent two stage III PU's two months after the resident admission. RESDIENT 3 Resident 3 admitted to the facility in 04/15/2021, transferred from another facility, with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Admission MDS assessment dated [DATE], showed the resident was a two-person extensive assistance for bed mobility, dressing, toileting, and personal hygiene. The resident had severe cognitive impairment and was identified as at risk for developing a PU. The CAA triggered for PU's to be addressed on the care plan. Review of History and Physical dated 04/09/2021 showed resident was bed ridden. Review of the admission Braden assessment completed on 04/15/2021, showed the resident was at risk for skin impairment. Review of a care plan focus problem dated 04/16/2021, showed the resident was at risk for impairment to skin integrity related to deconditioning and had fragile skin. Interventions included to keep the skin clean and dry, Licensed Nurse (LN) to complete weekly skin assessment, and report new impairments to the nurse. No preventative care plan interventions were addressed such as repositioning, or supportive devices to relieve pressure or what the CAA assessment identified. Reviewed of Resident 3's Nursing Admission assessment dated [DATE], showed no open skin areas to resident's right heel. Review of the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the skin/wound evaluation dated 07/13/2021, showed the resident had a new Stage II PU to their right heel measuring 3.4 cm x 2.8 cm. Review of care plan on 07/27/2021, did not address the resident's refusals to get out of bed. In an interview on 07/27/2021 at 1:15 PM, Staff I, NAC/shower aide, stated they did not discover the PU to the resident's right heel, another staff member had, but was unable to remember who. In an interview on 07/27/2021 at 1:05 PM, Staff K, Nursing Assistant Registered, stated the staff would report any new skin issues to the nurse. Staff K stated Resident 3 refused repositioning a lot. In an interview on 08/02/2021 at 10:15 AM, Staff J, NAC, stated that skin prevention was in the resident's care plan and new changes would be given to them in report. Staff J stated Resident 3 refused to get out of bed often. The staff had difficulty encouraging them to get out of bed or repositioning. Staff J reported they were informed to elevate the resident's foot after the resident developed pressure injury. In an interview on 08/02/2021 at 12:05 PM, Staff D stated the shower aide found the resident's blister and informed nursing staff. Staff D stated the resident did not have repositioning, or supportive devices to relieve pressure until after the PI was discovered. Staff D stated the resident would only accept care in bed, which was not addressed in the care plan. In an interview on 08/02/2021 at 1:32 PM, Staff F stated the resident admitted with risk factors included lack of mobility and a decline in cognition. Staff F stated based on the resident's admission assessments they should have implemented scheduled repositioning, APM, sage boots and to elevate the resident's heels. Staff F stated the previous MDS nurse did not inform RCM's regarding CAA triggers who were responsible to update care plans based on results of the assessment. In an interview on 08/05/2021 at 1:12 PM, the Director of Nursing Services (DNS) stated the expected process for skin prevention was nursing would complete a Braden Risk assessment on admission and they put interventions in place to prevent, such as positioning, and additional interventions if they were needed. If the MDS assessment identified the resident was at risk, this was another opportunity to address the risk factors and then care planned them accordingly. The DNS stated the CAA triggers were previously completed by the MDS nurse; however, this was not effective and now the expectation was the MDS nurse would email the RCM's and they would determine if they needed to be addressed on the care plan. The DNS stated the process for addressing PU's would be to notify all parties, get a treatment order, wound referral, and create an incident report in risk management to rule out neglect. Reference: (WAC) 388-97-1060 (3)(b)

Based on observation, interview and record review the facility failed to ensure two of two residents (#2 and #3) were free from physical and sexual abuse. The facility failed to ensure allegations of abuse were reported timely, a thorough investigation was conducted, residents' behavioral interventions were followed and residents were adequately supervised. These failures constituted an Immediate Jeopardy (IJ) on 08/17/2020. An IJ was called on 08/17/2020 at 2:00 PM. The facility removed the IJ on 09/01/2020 at 3:23 PM, after the facility completed all staff training on Abuse and Neglect, reporting and investigation process including interviewing all staff involved, working with residents with abusive behaviors, parameters and expectations of supervision and following the resident care plans, placed the identified resident on a one to one supervision at all times, reassessed residents for abusive behaviors that affected other residents, and reviewed identified residents for appropriate interventions. Findings included . Review of the facility policy titled, Abuse Prevention Policy and Procedure, with a revised date of 07/01/2020, included: · Each resident has the right to be free from abuse; · Residents must not be subjected to abuse by anyone; · Abuse may include any physical injury to a resident, and sexual contact; · All incidents, including injuries of unknown origins such as bruising, resident to resident contact will be identified and incident reports in order to initiate an investigation; · The interdisciplinary care plan process shall be used to target those residents with needs and behaviors that might lead to conflict; · Staff are responsible for monitoring secluded areas of the building to ensure that abuse does not occur; · As soon as a report of alleged or suspected abuse is received, the investigation shall begin in order to rule out or identify abuse; · The investigation would include identification of the parties involved, identification of witnesses, and interview of all parties involved; and · Mandated Reporters are to immediately report to their onsite supervisor and the State Hotline when they have reasonable cause to believe abuse has occurred. RESIDENT #1 Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1's Care Plan showed the following focus problems. The resident was dependent on staff for activities, cognitive stimulation, and social interaction related to physical limitations, dementia, and language barrier and wandering, revised on 06/23/2020. The interventions included the resident was to not be left alone with female residents. The resident also had a communication problem related to language barrier problem dated 02/10/2020. The interventions included arranging for a Spanish translator as necessary to communicate with the resident, assign a Spanish speaking male caregiver when available. RESIDENT #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 04/22/2020, Quarterly MDS assessment showed the resident was cognitively intact and able to communicate without difficulties. RESIDENT #3 Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated , 07/01/2020, showed the resident was assessed to have severe cognitive impairment but able to understand others and make herself understood. RESIDENT #1 TO RESIDENT #2 ALLEGATION OF PHYSICAL ABUSE Review of Resident #1's progress notes showed the following: · On 07/02/2020 at 12:49 PM, the resident was on alert monitoring for threatening and aggressive gestures; · On 07/03/2020 at 10:11 PM, the resident was on alert for wandering and intrusive behavior; · On 07/04/2020 at 11:04 PM, Staff A, Registered Nurse (RN), documented that male Resident #1 became agitated with female Resident #2, when she did not want him to be sitting too close to her while she was listening to her iPad music. (This incident occurred on 07/04/2020 at approximately 8:30 PM, per witness statements.) Review of Resident #2's progress note dated 07/04/2020 at 10:59 PM, documented by Staff A, showed Resident #2 became agitated with Resident #1, when she felt he was sitting to close to her while she was listening to her iPad music. (This incident occurred on 07/04/2020 at approximately 8:30 PM, per witness statements.) Review of Resident #1's progress note dated 07/05/2020 at 3:18 AM, documented by the Director of Nursing Services, (DNS), showed that another resident (resident was not identified) made an allegation of unwanted touching toward Resident #1. The note indicated that the incident was reported to the Department of Social and Health Services (DSHS), implying the State Hot Line was notified. The Power of Attorney, the Advanced Registered Nurse Practitioner (ARNP), DNS and Administrator were notified of the incident. Additionally, Resident #1, was placed on alert to monitor for behaviors. (This incident occurred on 07/04/2020 at approximately 8:30 PM, per witness statements.) Review of Resident #2's progress note dated 07/05/2020 at 4:15 AM, documented by Staff B, Licensed Practical Nurse, (LPN), showed that Resident #2 had reported to her assigned Certified Nursing Assistant, (CNA), at 2:00 AM, that Resident #1 touched her arm while she was sitting outside her room in the evening while listening to music. Staff B went to take Resident #2's statement but she was asleep. Staff B documented that the CNA had reported that Resident #1 had touched Resident #2 without hurting Resident #2, and Resident #2 asked Resident #1 to not touch her three times but Resident #1 did not stop. Resident #2 was concerned that another resident (resident was not identified) always stares at her and would speak something in Spanish.(This incident occurred on 07/04/2020 at approximately 8:30 PM, per witness statements.) Review of Resident #2's progress note dated 07/05/2020 at 9:04 AM, documented by Staff C, LPN, RCM, showed that Staff C instructed the dayshift nurse to place Resident #1 on one on one supervision until further notice from the management team on Monday 07/06/2020. Review of Resident #1's progress note dated 07/05/2020 at 12:12 PM, documented by Staff C, RCM, showed that the RCM, immediately instructed that Resident #1 was placed on one on one supervision (even though Staff C documented the resident was placed on one to one supervision three hours prior) due to alleged sexual assault and inappropriate touching of female resident (female resident was not identified). Review of Resident #2's progress note dated 07/05/2020 at 5:26 PM, showed the resident was noted to have dark purple in color bruises on her left arm above her elbow and she reported that Resident #1 grabbed her left arm. Resident #2 noted that she believed the bruises were caused from the incident from the prior day. Review of Resident #2's Incident Report which was initiated on 07/05/2020 at 3:50 AM, showed on 07/08/2020 the facility was unable to substantiate the allegation of physical abuse or unwanted touching. Additionally, bruising to Resident #2's left arm was noted to be unclear of the origin (an injury of unknown source), even though Resident #2 stated she felt the bruise was caused by Resident #1. Review of the Witness Statements from Resident #2's Incident Report dated 07/05/2020, showed the following: · Staff D, CNA, reported that she was told to watch Resident #1 around Resident #2 as he was fighting with her. Resident #2 reported to her on 07/05/2020 at 2:00 AM, that Resident #1 came by her door and would stare at her, He watches everything going on in my room. Resident #2 reported that Resident #1 kept touching her arm, he touched her three times even though she told him not to and to stop. · Staff A, RN noted that on 06/04/2020 at approx. (approximately) 2030 (8:30 PM), Resident #1 was sitting behind and to the left of Resident #2, listening to Resident #2's iPad which was playing music. Resident #2 was heard to tell Resident #1 to move that she did not want him there and he was too close to her. Staff A attested that she did not witness nor receive a report from Resident #2 that Resident #1 had grabbed her arm. Staff A's witness statement had a signature date of 04/05/20. · Additionally, further residents' interview statements and what appear to be staff interview statements with only staff first names had no date or time of the statements. Review of Resident #1's Incident Report initiated on 07/05/2020 at 3:50 AM, showed on 07/08/2020, the facility was unable to substantiate the allegation of unwanted touching as the incident was not witnessed and previous interaction was witnessed and residents were redirected of which no physical touching occurred. In a continued observation on 08/10/2020 starting at 12:08 PM to 12:17 PM, Resident #2 was sitting in the hallway, talking on her cell phone across from room [ROOM NUMBER]. Resident #1 was observed to be sitting in his wheelchair slightly behind Resident #3, no staff were observed in the area. In an interview and continued observation on 08/10/2020 at 12:17 PM, Resident #2 stated that she had a problem with the resident who was sitting behind her (Resident #1) who just left. Resident #2 stated that Resident #1 got right in her face and she told him not to and he grabbed her arm. She stated the staff had to come and help her, including a nurse that was working and a couple of CNAs. The resident stated that it had been a month or so ago and occurred in the late afternoon when she played her music. Resident #2 stated that he would come and sit and look at her. She recalled a time she was fixing her underpants and did not know Resident #1 was directly behind her. She stated that he was not supposed to be down here, they moved him but he comes down here about once a day. Resident #2 stated that she did not feel real safe as the facility was always short staffed and had new staff that were not used to taking care of her. Resident #2 stated that the staff were there when Resident #1 touched her and that he took his hand and made a fist at her as she demonstrated making a fist with her left hand. In a phone interview on 08/11/2020 at 3:59 PM, Staff A, RN, stated that on 07/04/2020, Resident #2 was listening to country music and Resident #1 was sitting behind her listening to her music. She stated that she thought he might have been looking at her iPad and she got irritated and told him to go away and get away which in turn agitated him. Staff A stated that Resident #1 got into Resident #2's personal space, I think she said he grabbed her but did not see that, one of the NACs (CNA) saw it start to escalate but unsure . no one told me they saw him grab her. In a phone interview on 08/11/2020 at 5:47 PM, Staff F, CNA, stated that she knows the care needs of the residents per their Care Plans and Kardex (a care guide for direct care staff). Staff F stated that she was familiar with Resident #1, he had dementia and he had been on one on one supervision for a while. Staff F stated that she thought he was on one on one supervision because he had been wandering into other residents rooms. Staff F was asked if she recalled the incident which occurred on 07/04/2020. Staff F stated, Oh yeah, I remember, it was right before he (Resident #1) was put on one to one. The staff came and got me to translate. Staff F stated that Resident #2 had been playing her music and Resident #1 had his hand on her shoulder, and she was telling him to not touch her. Staff F stated that she told Resident #1 in Spanish to not touch Resident #2 and he became aggressive and rude and said in Spanish do you want me to hit her and he put his arm back as if to hit her. Staff F stated that she translated in the moment to the nurse, Staff A, RN, what Resident #1 said. Staff F stated that Staff A was aware that Resident #1 touched Resident #2. Staff F stated that she did not witness the incident but she guessed she should have reported the incident but thought Staff A was going to do it. Staff F stated that she was not asked to provide a witness statement of the incident. In a phone interview on 08/13/2020 at 4:00 PM, Staff G, CNA, stated that Resident #1 was slightly independent and they had to keep an eye on him and supervise him so he did not go into another resident's room. Staff G stated that they changed Resident #1's room when he grabbed another resident's arm. Staff G stated that he was there when it happened but did not see the incident. Staff G stated that Resident #1 was sitting by his room and Resident #2 had a tablet and was listening to music. Staff G stated that Resident #1 went closer to listen to her music and Resident #2 told Resident #1 to go away. Staff G stated that Resident #1 insisted on being there. Staff G stated that Resident #2 told the nurse (Staff A), that Resident #1 grabbed her and Staff A asked Staff G if he witnessed the incident which he had not. Staff G stated that they had Staff F translate for Resident #1 and after that Resident #1 was on one on one supervision. Staff G stated that it was the end of his shift that night and recalled reporting off that Resident #1 was on supervision and to check on the resident every 15 minutes. Staff G stated that if they were to notice anything out of the ordinary they were to report, and he did report to the nurse. Staff G stated that the nurse (Staff A), reported that Resident #2 insisted that Resident #1 grabbed her but the nurse was not there and she did not know if that actually happened and neither did Staff G. In a phone interview on 08/14/2020 at 1:58 PM, Staff C, LPN (Licensed Practical Nurse), RCM, stated that she was the On-Call Manager on 07/04/2020. She said she directed Staff H, RN, the dayshift nurse on 07/05/2020, to place Resident #1 on one on one supervision. Staff C was asked why Resident #1 did not have one on one supervision later on in the afternoon on 07/05/2020. Staff C stated that she was not in the facility and directed Staff H, on the morning shift, to place Resident #1 on one on one supervision. In a phone interview on 08/14/2020 at 3:23 PM, the DNS stated that there were no staff who were aware of the 07/04/2020 incident between Resident #1 and Resident #2. She stated that Resident #1 self-propelled in his wheelchair and the facility tried to provide the best supervision. She stated that Resident #1 came out of his room and was attracted to the music Resident #2 was playing. The DNS stated that Resident #1's Care Planned Intervention, to not to be left alone with female residents was not realistic. The DNS stated that Resident #1 was not placed on one on one supervision until Monday, 07/06/2020, and was unable to speak to the progress note that indicated that the resident was placed on one on one supervision prior, as it did not make sense to her. The DNS stated that the conversation that she had with Staff A, RN, did not substantiate the incident between Resident #1 and Resident #2 and was not able to speak to why Staff A did not report Resident #2's allegation of abuse on the evening of 07/04/2020. RESIDENT #1 TO RESIDENT #3 ALLEGATION OF SEXUAL ABUSE Review of Resident #1's progress note dated 07/05/2020 at 2:15 PM, showed the nurse went to the location where she heard someone say, Hey Stop. The nurse observed that there were two nurses and two CNAs in the hallway where Resident #3 was sitting in her wheelchair eating her lunch and Resident #1 was sitting in his wheelchair in front of Resident #3. The CNAs' reported that Resident #1 was seen rubbing Resident #3's chest area. Resident #1 was noted to be agitated and was noted to be currently on one on one staff supervision. Review of Resident #3's progress note dated 07/05/2020 at 6:24 PM, showed the nurse heard a CNA screaming in the hallway and went to the hallway and observed a CNA separating Resident #1 from Resident #3. The CNA reported that Resident #1 was observed to be rubbing his hand on Resident #3's chest area. Resident #1 was currently on one on one supervision. (This incident occurred on 07/05/2020 at approximately 2:00 PM, per witness statements.) Review of Resident #3's Incident Report dated 07/05/2020 at 3:15 PM, showed CNAs reported that Resident #1 was observed using his hands to rub the chest area of female Resident #3. Resident #1 was on one on one supervision. (This incident occurred on 07/05/2020 at approximately 2:00 PM, per witness statements.) Review of the witness statement dated 07/05/2020, showed Staff E, CNA, noted on 07/05/2020, that around 2:00 PM, she turned onto the 140 Hallway and witnessed Resident #1 touching Resident #3's chest. Review of Resident #1's Incident Report dated 07/05/2020 at 2:15 PM, showed CNAs reported that male Resident #1 was seen using his hand to rub the chest area of female Resident #3. Resident #1 was currently on one on one supervision. Review of the one to one supervision documentation showed the one to one supervision began on 07/05/2020 at 3:00 PM, six hours after it was documented the resident was to be on one to one supervision after the first abuse allegation. The facility failed to follow Resident #1's Care Plan Intervention to not be left alone with female residents, failed to timely report Resident #2's allegation of abuse, failed to ensure Resident #1 was placed on one to one supervision after the evening on 07/04/2020 as directed by the On Call Manger, Staff C, failed to ensure Resident #1 was adequately supervised and failed to conduct a complete and through investigation of the incident on 07/04/2020. Reference: (WAC) 388-97-0640 (1)(5)(a)(6)(a)(b)(7)(a)

Based on observation, interview and record review, the facility failed to ensure eight of twelve residents (#32, #29, #21, #30, #12, #20, #38, and #3) remained free of unnecessary [MEDICAL CONDITION] medications. Failure to: 1) respond timely when a resident experienced potential [MEDICAL CONDITION] medication-related adverse side effects, 2) to have responsive systems in place to identify, monitor for, document, and respond to the presence of potential medication-related adverse side effects, 3) to ensure residents received Gradual Dose Reductions (GDRs), 4) to ensure residents received [MEDICAL CONDITION] medications for the shortest duration necessary and in the lowest dose necessary, 5) to ensure all residents had monthly medication regimen reviews done by the consultant pharmacist, 6) to consider the impact of side effects of opioid [MEDICATION NAME] on a resident who also experienced similar potential side effects of [MEDICAL CONDITION] medications, 7) to perform comprehensive [MEDICAL CONDITION] medication reviews, 8) to ensure medication-related documentation was done consistently and thoroughly, 9) to ensure doctor and nurse practitioner progress notes were accurate, 10) to ensure monthly medication regimen review (MRRs) irregularities were acted on timely, 11) to ensure the benefits of treatment with [MEDICAL CONDITION] medications exceeded the risks, 12) to ensure physicians/nurse practitioners provided progress notes reflecting treatments/goals/risks and benefits of treatment with [MEDICAL CONDITION] medications, and 13) to ensure PRN (as needed) [MEDICAL CONDITION] medication orders were limited to 14 days per regulations, all placed residents at risk for medication-related adverse side effects. Resident #32 was harmed when the facility failed to respond when she exhibited potential medication-related adverse side effects and the facility continued to treat her with the same medications for several months. On admission, the resident was able to walk, she was able to communicate effectively, she was able to feed herself, and she had no skin pressure injuries. After several months of treatment with multiple [MEDICAL CONDITION] and opioid medications, the resident was no longer able to walk, no longer able to communicate effectively, no longer able to feed herself, no longer able to get in/out of bed, she developed heel and coccyx pressure injuries, she had a left hand/wrist contracture, she developed significant weight loss, she had declines in her bowel and bladder continence, she had decreased activity participation, and she had multiple falls. These failures resulted in an Immediate Jeopardy (IJ) related to multiple failures in medication management for Resident #32 and for other residents. An IJ was called on 02/13/2020 at 2:18 PM. The facility: -had the consultant pharmacist review each resident's medication records and consulted with physicians/nurse practitioners on irregularities, -provided physician education, -had the physician review each resident's psychoactive medications and complete clinical assessments, -revised facility practice for reviewing side effect monitoring, progress note review, and alert charting, -revised psych review meeting processes to include nurse practitioners, physicians, and pharmacists, -reviewed residents that had recent change of conditions, -educated/trained nurses, nurse managers, nursing assistants, and the Director of Nursing Services (DNS) on pharmacy procedures/follow-ups, -implemented auditing and validation of [MEDICAL CONDITION] medication management procedures to include behavior monitoring, GDRs, and adverse side effects. This all resulted in the removal of the IJ on 02/28/2020 at 12:45 PM. Findings included . DEFINITIONS: Adverse side effects/consequences of medications: [REDACTED]. It may include various types of adverse drug reactions or interactions (e.g. medication-medication, medication-food, and medication-disease). Side effects of Antipsychotic medications include: movement disorders, blood pressure fluctuations, drowsiness, elevated pulse, sedation, dizziness, blurred vision, [MEDICAL CONDITION], dry mouth, nausea, constipation, urine retention, blood disorder, headaches, weakness, jaundice, agitation, restlessness, slurred speech, anorexia, rash, confusion, unsteady gait, frequent falls, refusal to eat, difficulty swallowing, depression, [MEDICAL CONDITION], social isolation, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, vomiting, behavioral symptoms not usual to the person. Side effects of antidepressant medications include: constipation, hand tremors, blood cell abnormalities, arrhythmias, sedation, confusion, excitement, blurred vision, rash, dry mouth, dry eyes, [MEDICAL CONDITIONS], jaundice, psychotic episodes, anxiety, [MEDICAL CONDITION], weight loss, nervousness, loss of appetite, suicidal ideation, mood change, change in normal behavior, hallucinations/delusions, social isolation, decline in ability to help with/do ADLs (activities of daily living), no voiding, rigid muscles, difficulty ambulating, balance problems, accidents, dizziness, falls, movement problems, tremors, diarrhea, fatigue, weight loss, muscle cramps. Side effects of mood stabilizer medications include: extreme drowsiness, fatigue, muscle aching or weakness, dry mouth, constipation or diarrhea, loss of appetite, nausea, skin rash, headache, dizziness, tremors, abdominal pain, and upset stomach. Side effects of Opioid Medications include: drowsiness, weakness or lack of energy, lightheadedness, dizziness, headache, constipation, nausea and vomiting, itching, dry mouth, and trouble falling or staying asleep. RESIDENT #32 The resident admitted to the facility on [DATE] for rehabilitation after having a fall at home resulting in a left wrist fracture. On admission the resident had [DIAGNOSES REDACTED]. According to the resident's admission Minimum Data Set (MDS) assessment, dated 05/23/2019, Resident #32 had severe cognitive impairment, and for activities of daily living (ADLs) she required only limited assistance with bed mobility, transfers and personal hygiene. The MDS indicated the resident required only supervision with eating and walking. For bowel and bladder, the MDS indicated she was occasionally incontinent of urine and always continent of bowels. Review of the quarterly MDS, dated [DATE], revealed severe cognitive impairment, and for ADLs, Resident #32 required extensive assistance of 1-2 persons with bed mobility, transfers, and personal hygiene. Walking did not occur during this MDS time period. For bowel and bladder, the MDS indicated the resident was always incontinent of bowel and bladder. Review of the Admission Nursing Data Base (nursing assessment), dated 05/16/2019: -she had clear speech, -weighed 153.8 lbs -was always continent of bowel and bladder, -had no pressure ulcers, -had a pleasant mood. Review of a progress note, dated 05/16/2019 (day of admit) at 5:57 PM, revealed the resident had attempted to leave the facility, and was assessed to be a high elopement risk. Review of a progress note, dated 05/17/2019 at 1:43 PM, revealed the resident stated she wanted to return home with her spouse, and the spouse also had a poor memory and may not be able to meet resident's needs at home. Review of a progress note, dated 05/19/2019 at 2:57 PM, revealed the resident was alert and oriented, but had confusion and wandered around the hallways. Review of a progress note, dated 05/21/2019 at 5:12 AM, revealed the resident had an unwitnessed fall. Review of a progress note, dated 05/21/2019 at 2:27 PM, revealed the resident was placed on alert for increased behaviors and had increased agitation. She was exit-seeking and had set off the alarms to multiple emergency exit doors multiple times. Resident #32 had been walking into other residents' rooms and taking items out with her, and had frequent visual hallucinations. Review of a progress note, dated 05/22/2019 at 3:37 AM, revealed the resident was on alert for inappropriate behaviors, exit-seeking, and for the fall. The resident could not recall events of the previous day, and was oriented to self, but not time, place or situation. She denied pain and had constant episodes of confusion. Review of a progress note and a report titled View [DIAGNOSES REDACTED]. The nurse contacted the doctor and got an order for [REDACTED]. Review of the resident's clinical record revealed no progress notes or assessment were available from Staff BB, Physician, regarding the unspecified [MEDICAL CONDITION] diagnosis. Review of the resident's Level 1 Pre-admission Screening and Resident Review (PASRR), dated 05/16/2019, revealed the resident had a [DIAGNOSES REDACTED]. Review of another Level 1 PASRR, dated 05/20/2019, revealed the facility had revised the Level 1 PASRR to now include the resident had a [MEDICAL CONDITION]. Review of a progress note, dated 05/26/2019 at 8:06 AM, revealed the resident was difficult to redirect, had been in another resident's room and was difficult to redirect out of that resident's room, and was confused and aggressive during cares. Review of a progress note, dated 05/28/2019 at 2:30 PM, revealed the resident was very mobile and had difficulty following tasks and cueing safely. Resident #32's son reported the resident had been living with her significant other alone in an apartment and had a history of [REDACTED]. The facility discussed with the resident's family that it would not be safe to return home, and the recommendation was for 24/7 care and the resident would benefit from a placement in an adult family home or in a memory care setting. Review of the May 2019 Medication Administration Records (MARs), revealed in May, Resident #32 was started on [MEDICATION NAME] (an antipsychotic medication) for unspecified [MEDICAL CONDITION], [MEDICATION NAME] (an antidepressant medication) for [MEDICAL CONDITION], and she was receiving [MEDICATION NAME] (an opioid pain medication) for pain for 10 days. Review of the June 2019 MARs revealed the resident's [MEDICATION NAME] got re-ordered, the [MEDICATION NAME] dosing was increased (multiple times), and [MEDICATION NAME] (mood stabilizer/anticonvulsant medication) was added for unspecified [MEDICAL CONDITION], and the Trazadone was continued. The target behaviors being monitored for [MEDICATION NAME] and [MEDICATION NAME] (behaviors not individualized, they were grouped together for these two medications) included agitation, refusals of care and verbal aggression towards others (no behaviors were being monitored for any hallucinations or delusions). Review of the MARs for 2019 revealed ongoing treatment with [MEDICAL CONDITION] medications and [MEDICATION NAME] as follows: -[MEDICATION NAME] 50 mg (milligrams) daily at 9 AM - 06/20/2019 - 01/03/2020 -[MEDICATION NAME] 100 mg daily at 3 PM - 06/21/2019 - 01/03/2020 -[MEDICATION NAME] 100 mg daily at 9 PM - 06/20/2019 - 01/03/2020 -[MEDICATION NAME] (multiple dose changes, starting in June 2019) 250 mg twice daily at 9 AM & 1 PM - 07/25/2019 - ongoing as of 02/06/2020 -[MEDICATION NAME] 500 mg daily at 9 PM, 07/24/2019 - ongoing as of 02/06/2020 -[MEDICATION NAME] 25 mg daily at 9 PM - 05/29/2019 - 02/12/2020 -[MEDICATION NAME] PRN (as needed) - 06/25/2019 - 01/03/2020 Review of Behavior Monitoring records dated May 2019 through January 2020 revealed: In May 2019 sleep monitoring for Trazadone use found the resident slept 8-11 hours a day. In June 2019, although antipsychotic behaviors were being monitored for use of [MEDICATION NAME], there were 10 shifts with no behavior monitoring, and no behaviors were monitored in June for [MEDICATION NAME] use. No sleep monitoring for the use of Trazadone was conducted between June 26, 2019 and June 30, 2019; and behaviors not listed as being associated with a medication included: exit seeking and attempting to go into others' rooms. In July 2019, there was no documentation of behavior monitoring for the use of [MEDICATION NAME] between 07/01 and 07/23/19. For [MEDICATION NAME] there was no behavior monitoring on 07/01 and 07/23/19. There was no sleep monitoring between 07/01 and 07/21/19 to validate use of Trazadone. In August 2019, there were 10 shifts with no behavior monitoring for [MEDICATION NAME] and [MEDICATION NAME] use. For July 2019 through September 2019 behaviors not associated with medication use were exit seeking and attempting to go into others' rooms. In October 2019 and November 2019, refusals of care was added to exit seeking and wandering into others' rooms as behaviors not associated with medication use. PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN'S ASSISTANT NOTE REVIEW: According to the hospital discharge summary dated 05/16/19, Resident #32 was alert and oriented to person, place and time. There were no orders for [MEDICAL CONDITION] medications. The orders did include [MEDICATION NAME] for 10 days for pain management related to wrist facture and surgery. The physician noted dated 05/20/19 indicated Resident #32's pain was well controlled and the resident denied any pain. The resident was ordered to have physical therapy (PT) and occupational therapy (OT). According to the note, Resident #32 was speaking in full sentences and was pleasant and appropriate in her demeanor, with normal affect and mood. According to the Nurse Practitioner note dated 06/06/2019, Resident #32 was placed on [MEDICATION NAME] (antipsychotic) for behaviors which included exit seeking, wandering, sundowning, and hallucinations, and had a [DIAGNOSES REDACTED]. This note stated that the resident was assessed to have late onset [MEDICAL CONDITION]. Although, [MEDICATION NAME] was already started on 05/24/2019. There were no physician notes explaining this, and Trazadone was already started for a sleep aid on 05/20/19 and there was no physician note explaining that either. In a nurse practitioner note dated 06/10/19, there was no mention of treatment with [MEDICATION NAME] or the plan or therapeutic goals of treatment [MEDICATION NAME]. In a nurse practitioner note dated 07/31/19, Resident #32's [MEDICATION NAME] had already been increased and it did not elaborate on what necessitated the treatment with [MEDICATION NAME] the resident was now on. The note stated the resident had no evidence of pain, however, the resident continued on [MEDICATION NAME] and the previous provider note was dated over six weeks ago. In a physician assistant note dated 08/01/19, the noted stated that Resident #32 was on a high dose of [MEDICATION NAME] and suggested reevaluating appropriate medication. The note also stated that the resident was on [MEDICATION NAME], and that no psychiatry notes were available. The physician assistant recommended following up with psychiatry for medication management. In a Nurse Practitioner note, dated 08/16/2019, it showed that Resident #32 was on [MEDICATION NAME] and [MEDICATION NAME], and it did not address the resident's behaviors ongoing between July 2019 and August 2019. In a nurse practitioner note dated 09/20/19, it showed the nurse practitioner was aware the resident was more wheelchair bound, however, it did not address why the resident may have been more wheelchair bound. The nurse practitioner did not address how the resident's medications may have contributed to the general decline in Resident #32's condition. Further, the nurse practitioner did not provide an accurate review of the September 2019 MARs related to the extremely high dosing of the antipsychotice medications, [MEDICATION NAME] and [MEDICATION NAME]. The nurse practitioner did not address the ongoing treatment with [MEDICATION NAME] and Trazadone, and the side effects of all the medications combined which may have contributed to the resident's overall decline and change in condition. The nurse practitioner note dated 09/25/19 mentioned the resident was more wheel chair bound at this time, however, did not indiate clinical concerns with the effects the medications may have had on Resident #32. In a physician note dated 10/17/2019, the physician did not address the effects of the antipsychotic drugs together with the pain medications on the resident related to the resident notably being more wheelchair bound. In addition, physician did not provide an accurate review of the October 2019 Mars which indicated the resident was on extremely high dosages of [MEDICATION NAME] and [MEDICATION NAME]. In a nurse practitioner note dated 12/04/19, the nurse practitioner noted the resident was generally lethargic with decline, somnolent (sleepy) throughout the day, experiencing decline in cognition and energy, however, there was no mention that side effects of the medications the resident was on may have contributed to the resident's change in condition. The resident was on [MEDICATION NAME] at elevated doses, [MEDICATION NAME] at elevated doses, Trazadone, [MEDICATION NAME]. The resident's sleep monitor records indicated she was sleeping 8-13 hours a day. In a nurse practitioner note dated 01/03/2020, the nurse practitioner noted Resident #32 leaning forward in her wheelchair, poor oral intake and planned to reduce the antipsychotice dosaging. However, without a pain assessment, the narcotic pain medication was increased. The resident's weight had decreased 20 pounds since the 12/04/19 note. The nurse practitioner did not address the side effects of the pain medication such as nausea and vomiting, lack of energy, drowsiness, dizziness, and how it impacted the the resident's decline In a nurse practitioner note dated 01/07/2020, the nurse practitioner identified that the recent decrease in [MEDICATION NAME] did not change the resident's hypersomnolence (increased sleepiness) and planned to decrease [MEDICATION NAME] as well. According to this note, the nurse practitioner started another antidepressant to the resident's regime ([MEDICATION NAME] for appetite stimulation) in addition to Trazadone (for sleep). According to the nurse practitioner note dated 01/14/2020, the nurse practitioner identified that although [MEDICATION NAME] had been down titrated, the resident remained slelepy throughout the day, so futher decreased the [MEDICATION NAME] to encourage the resident to be more active during the day. In a note dated 01/22/2020, the nurse practitioner noted some improvement in the resident that day, although was now at risk for aspiration and choking. According to a nurse practitioner note dated 02/04/2020, the resident now had pressure injury related to being wheel chair bound and decreased nutrition and water intake. The nurse practitioner noted the resident's decline had worsened and that hospice was considered. Review of Resident #32's clinical record did not find psychiatry notes, however, there were notes from Staff CC, mental health nurse consultant. According to Staff CC's 06/11/19 note, the psychiatrist (medical doctor) was wondering if Resident #32 had a dementia workup. According to the note, [MEDICATION NAME] was increased. According to Staff CC's 06/18/19 note [MEDICATION NAME] was increased, was exit seeking, verbally and physically aggressive toward staff. In addition, Staff CC noted the resident's family stated that the resident did better when they had her at home over the weekend than in the facility. According to Staff Cc's 06/25/19 note, [MEDICATION NAME] was increased and [MEDICATION NAME] was started as well as Trazadone at bedtime. The 07/02/19 showed that the resident was getting around well and the resident's spouse took her on an outing. The note dated 07/23/19 showed Staff CC found the resident dozing at the nursing station. When awakened wanted to go back to sleep and after breakfast would nap until later in the day. The resident had behaviors of exit seeking and wandering and had a fall, sleeping a lot in the a.m. According to the 08/27/19 note, Staff CC found the resident was all over the place today. Staff CC stated in the note that the resident was on a list for a more appropriate skilled nursing facility . In progress note reviews for dates between June 2019 and January 2020, Resident #32 had increasing aggressive behaviors toward staff, that occurred more as noted in the progress notes when the resident was awake more. The facility provided interventions by increasing [MEDICATION NAME], and [MEDICATION NAME]. The resident experienced falls and pressure injuries requiring wound consultants, and the facility did not identify side effects of all the medications the resident was receiving that could have contributed to further decline in her condition including falls, decreased intake, and weakness. Instead, staff continued to document that there were no side effects of the medications in progress notes. Interdisciplinary team notes did not make any recommendations to change the resident's medication regime or care plan. There was no indication the facility attempted non drug intervention for the resident with a [DIAGNOSES REDACTED]. There was no indication the facility had the resident on an individualized activity program. Instead, the facility continued to increase antipsychotic drug dosaging, with antidepressants, and narcotic pain medication, although there were no pain assessments completed to warrant the need for narcotic pain medication. Review of Consultant Pharmacist Monthly Medication Regimen Review (MRR) reorts showed the following: On 08/20/2019, the pharmacist identified an irregularity related to [MEDICATION NAME] for sleep. Resident #32 on Trazadone, an antidepressant since 05/19. The pharmacist notified the physician that a gradual dose reduction (GDR) should be considered. However, the resident's physician/nurse practitioner continued the medication with no change, and the required rationale was left blank. On 09/26/2019, the pharmacist identified an irregularity related to the ongoing treatment with [MEDICATION NAME] for sleep, and a recommendation was made to consider a GDR. The rest of this form was blank, there was no documentation the resident's physician/nurse practitioner had ever even seen it, it was never acted on. Provider notes in 09/19 reflected the resident was more wheelchair bound and not ambulating as she had in the past, and was lethargic, and not extremely responsive. On 10/25/2019, Resident #32's name was on a list with other residents that were reviewed by the consultant pharmacist, but did not require any recommendations. There was no documentation the physician/nurse practitioner had ever addressed the [MEDICATION NAME] irregularity/GDR request, even though it had been made twice in recent months. The resident had been noted by her nurse practitioner/physician to be lethargic, not ambulating as she had in the past, more wheelchair bound, yet no recommendations or irregularities were identified by the consultant pharmacist during this review. In November 2019, no MRR was found in Resident #32's clinical record. Although the past few months doctor/nurse practitioner notes reflected lethargy, not extremely responsive at this time, more wheelchair bound, somnolent, there were no irregularities identified by the consultant pharmacist. There was a note in PCC (PointClickCare (electronic health record)), Pharmacist Acknowledgement, dated 11/19/19, that no irregularities noted. On 12/23/2019, the pharmacist documented that the resident was due a GDR for [MEDICATION NAME] and [MEDICATION NAME]. The pharmacist note indicated if current therapy was to be continued, please provide a brief risk vs benefit assessment for state survey. The nurse practitioner wrote we are down titrating for sleepiness, but did not state which medication/s were being down titrated. There was nothing documented about lethargy, somnolence, hypersomnolence, more wheelchair bound, not ambulating as Resident #32 had in the past, which was all reflected in provider notes in recent months. On 02/14/2020 (two notes to Attending Physician/Prescriber) the Pharmacist wrote the PRN [MEDICATION NAME] was limited to 14 days of treatment, as of 02/18/2020 it was not yet signed by the physician/nurse practitioner. There were no indications or [DIAGNOSES REDACTED]. On another form, there was a note Per IDT (interdisciplinary team) meeting on 02/17/2020 (with Social Services, Nursing, MD, Pharmacy): Previous substantial psych issues, followed by somnolence, 66% decrease in [MEDICATION NAME] and [MEDICATION NAME] has been d/ced. Resident was able to respond to MD since reduction of medications. Facility [MEDICAL CONDITION] Medication Reviews: On 08/20/2019, there was no mention of contributing factors like pain or medication interactions, even though there were spaces for this on the review. The IDT team recommended no changes in [MEDICAL CONDITION] medications. On 11/16/2019, the facility marked No, under the question Are there signs/symptoms of medication side effects? Although, Resident #32 had changes in condition that included wheelchair bound and not ambulating, somnolent, lethargic, had four falls this quarter, yet no medication side effects was marked. Pain and [MEDICAL CONDITION] medication interactions were not marked as potential contributing factors for the resident's changes in condition. [MEDICATION NAME] dosing was incorrect on the form, it only listed [MEDICATION NAME] 50 mg once daily, resident was also getting [MEDICATION NAME] 100 mg at 3PM and 100mg at 9PM. [MEDICATION NAME] dosing was also incorrect on that form, it incorrectly listed [MEDICATION NAME] 125 mg two times daily, she was actually getting 250mg daily at 9AM, 250mg at 1PM, and 500mg at 9PM. IDT recommended no changes, although Social Services and pharmacy noted medications contributed to the assessment, nursing and the physician/nurse practitioner did not. On 02/21/2020, the facility listed the incorrect dose of [MEDICATION NAME], the dose was listed as 7.5 mg, but review of the MARs revealed the resident was actually taking 15mg daily since 01/13/2020. Medication side effects: Are there any signs/symptoms of medication side effects? Facility marked No, even though Resident #32 had since the last review, experienced significant weight loss, hypersomnolence, lethargy, was wheelchair-bound, could no longer walk, could no longer feed herself, and could no longer transfer herself, and the facility had been decreasing her [MEDICAL CONDITION] medications and her [MEDICATION NAME] for pain. The review said the resident's weight is stable, and behaviors still consistent, when the resident had no behaviors because she was unable to do anything for herself anymore. The form indicated they should choose a [DIAGNOSES REDACTED]. OBSERVATIONS In random observations on 02/04/2020, the resident was observed asleep in bed. In an observation on 02/05/2020 at 9:46 AM, the resident was asleep in bed. In an observation on 02/05/2020 at 10:22 AM, the resident was asleep in bed. In an observation on 02/19/2020 at 8:41 AM, the resident was being fed breakfast by a staff member at the assisted table in the dining room. In an observation on 02/19/2020 at 12:37 AM, the resident was in the dining room, a staff member was helping her to drink by holding a glass to her mouth. In an observation on 02/20/2020 at 9:02 AM, the resident was in the dining room, a staff member was feeding her by bringing the silverware to her mouth. STAFF INTERVIEWS In an interview on 02/12/2020 at 12:28 PM, the Director of Nursing Services (DNS) and Staff B, Licensed Practical Nurse (LPN)/Resident Care Manager, and later Staff A, Social Services, Staff C, Registered Nurse (RN) and Staff FF, RN, joined the interview after the DNS left the room, were interviewed: the DNS stated Staff CC, Registered Nurse (RN)/Mental Health Nurse Consultant, was managing the resident's [MEDICAL CONDITION] medications. The DNS stated Staff CC consulted with her psychologist. The DNS was asked for Staff CC's notes, she was able to provide notes until 08/27/2019, which she said was the last time Staff CC saw the resident. The DNS stated the resident got the [DIAGNOSES REDACTED]. Staff B stated medication adverse side effects were to be documented in progress notes. She stated the side effects to be monitored for medications were listed on resident care plans. Review of the resident's care plan (print date 02/06/2020) revealed, there were side effects listed for the [MEDICATION NAME], but none for the [MEDICATION NAME] REsident #32 had been taking since 06/19. The care plan indicated staff were to monitor for side effects of [MEDICATION NAME] and [MEDICATION NAME] (two medications the resident had not been on while in the facility), but none were listed for [MEDICATION NAME]. The care plan also did not list side effects of [MEDICATION NAME], which Resident #32 had been taking since 05/19. Staff were asked whether the [MEDICATION NAME] was for convulsions or a mood disorder, Staff B stated the resident did have a [DIAGNOSES REDACTED]. Staff were asked whether medications had been assessed to see if medication side effects were contributory to the resident being wheelchair-bound and lethargic, the DNS and Staff B did not answer that question, Staff A stated the resident was still having hundreds of behaviors. Staff were asked about the 08/20/2019 MRR that had no rationale documented for the pharmacist's GDR request, they were unable to provide any information. Staff were asked about the 12/23/2019 MRR that requested a risk vs benefits assessment for the current [MEDICAL CONDITION] medication regimen, they were unable to provide any information. Staff were asked about the many doctor/nurse practitioner notes that listed somnolence and lethargy as a problem and the relative lack of documentation regarding this in nurse progress notes, they were unable to provide any information. The DNS stated taht the facility documented the presence of adverse side effects by exception, Staff FF stated that there was no space to document adverse side effects in the behavior monitors. Staff were asked if they had performed a sleep assessment to see why the resident wasn't sleeping, they didn't know of one being done. Staff were asked about the 10 shifts in 06/19 with no documented behavior monitoring for the antipsychotic medication [MEDICATION NAME], Staff A stated that it looked like they (nurses) weren't charting. Staff were asked about the 02/20 [MEDICATION NAME] order with no end date, Staff B stated it was because the resident was on comfort care. Staff were asked about the seven shifts in 06/19 with no documentation in the sleep monitor, they were unable to provide any information. Staff were asked about the resident not being able to ambulate anymore, Staff C stated when the resident first admitted she was ambulatory until about the end of October 2019, then she was moved over from rehab to the long-term care wing. Staff were asked about the lack of documented behavior monitoring for the [MEDICATION NAME] from 07/01/2019 - 07/23/2019, Staff C stated they switched from eight hour shifts to 12 hour shifts and the nurses didn't know how to do that properly. Staff were asked about the 06/19 behavior monitoring being grouped together for [MEDICATION NAME] (antipsychotic medication) and [MEDICATION NAME] (mood stabilizer) medication, Staff A stated she changed that when she started working at the facility. Staff were asked about the resident's change in condition in late 09/19 when she needed more assistance with ADLs, Staff C stated it manifested with the resident not being ambulatory and needing more

Based on observation, interview and record review, the facility failed to ensure seven of eleven sample residents (#3, #58, #66, #70, #28, #32 and #64), were free from abuse and neglect. The facility failed to adequately assess residents, provide adequate supervision, and interventions or implement procedures to prevent unsafe residents from leaving the facility unsupervised. The facility failed to investigate or report allegations of sexual assault and to adequately monitor for verbally and physically aggressive behavior, or behaviors that may provoke a reaction by residents or others, which included, wandering into other's rooms/space. These failures by the facility caused residents to be subject to possible emotional, verbal and physical abuse and placed all the residents at risk for abuse and neglect. This failure resulted in an immediate Jeopardy (IJ) related to neglect on 02/05/2020. The facility placed alleged perpetrator on one to one supervision, assessed residents, completed investigations, revised processes, and provided training to all staff, which led to the removal of the IJ on 02/28/2020. Findings included . Neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of facility's policy titled, Abuse Prevention Policy and Procedure, revised 08/11/2017, showed each resident has the right to be free from abuse, see definitions: -Instances of abuse of residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish and can include verbal, sexual, physical and mental abuse; -All incidents, accidents and injuries of unknown origins and resident to resident contacts will be identified through the 24-hour report and incident reports in order to initiate an investigation; -The facility shall maintain a staffing plan that represents the needs of the residents and -The interdisciplinary care plan process should be used to target those residents with needs and behaviors that might lead to conflict or neglect such as residents with a history of aggressive behaviors, and residents who have behaviors such as entering other resident's rooms. Investigations- As soon as report of alleged or suspected abuse is received, the investigation shall begin in order to rule out or identify abuse. ELOPEMENT- RESIDENT #3 Resident #3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #3's clinical record revealed a nursing note, dated 01/30/2020 at 6:17 PM, showed: Resident went out of the facility for shopping without telling staff, and resident located by Trader Joes (store) on the street. Staff went to get her, but resident was sent to the hospital by emergency medical services (EMS). Facility staff called the hospital and confirmed resident was there, having some tests and would return to the facility. According to the Annual Minimum Data Set assessment (MDS), an assessment tool, dated 01/05/2020, showed that Resident #3 was moderately cognitively impaired, suffered from delusions (misconceptions or beliefs that are firmly held, contrary to reality), and required supervision to walk in room or hallways and with locomotion on and off the unit. During an initial observation and interview on 02/05/2020 at 11:27 AM, Resident #3 was observed sitting in her room on the bed. The resident had a front wheel walker next to her bed with a wander guard device observed attached to the right side bar of the walker. The resident did not have a wander guard on her person, either upper or lower extremities at the time of the observation. During the initial interview, Resident #3 made an allegation of sexual assault, which was immediately reported to the facility administration. During a joint interview and record review, on 02/05/2020 at 3:40 PM, the Director of Nursing Services (DNS) and Staff F, Administrator in Training (AIT), were both notified of the resident's allegation of sexual assault and elopement from the facility on 01/30/2020. Both staff members stated that the resident was safe to leave the facility independently and that the resident had a history of [REDACTED]. This information was inconsistent with the care plan for supervision and wander guard. Review of progress note, entered by AIT on 02/05/2020 at 5:02 PM, documented: Clarification to note made on 01/30/2020 at 6:17 PM. Facility was aware that resident had gone out shopping, they had checked in with the front desk at 10:30 AM and got a ride at the bus stop. Later the resident called around 12:30 PM to the main phone line asking to be picked up she was able to provide the address of her location. She did not wait and had decided to walk back. Upon arrival staff was notified that EMS had picked up resident and she was located at the emergency room . The AIT was unable to provide an assessment that deemed the resident safe to leave the facility independently. During a joint interview and record review on 02/05/2020 at 5:41 PM, the DNS stated that on 01/30/2020, Resident #3 went to the front desk and told receptionist she was going out of the facility. The DNS stated that Resident #3 was her own responsible person, stating that she often left the facility to shop but always returned. The DNS also stated Resident #3 had a cell phone that she used to call the facility when she needed to. On the day of 01/30/2020 the DNS stated the resident called the facility and gave the address of where she was and needed a ride back. When facility staff arrived to that address the resident was not there. DNS confirmed that the resident ended up at the emergency room but was unaware of exactly how she got there. The DNS stated that she did not complete an investigation related to this issue because the resident always went out and came back, stating I asked the Administrator and he told me it wasn't an investigation. The DNS was unable to provide an assessment that deemed Resident #3 safe to leave the facility unsupervised. During an interview on 02/05/2020 at 5:51 PM, Staff H, stated that she was aware Resident #3 frequently left the facility independently and she was told that this was ok for the resident to do. Staff H stated that on 01/30/2020, the resident approached the front desk and stated she was leaving the facility to go shopping. Staff H stated that she told Resident #3 to let the nurses know and to sign out in the book at the nurses station. She stated that on 01/30/2020 after the resident had left the faciity on the bus, she called down to the nurse's station and was told that Resident #3 had not notified staff she was leaving and had not signed out in the book. Staff H further stated that Resident #3 did not have a cell phone that she knew of and had told her several times that she did not have a cell phone. During an interview on 02/05/20 at 5:59 PM, Staff Y, Registered Nurse (RN), stated that she did not think the resident had a cell phone of her own, she would have to check the inventory sheet in the resident record. Staff Y also stated that whenever Resident #3 needed to make a call she would come to the nurses station and ask for help getting a phone number and help with dialing the phone. Review of Resident #3's inventory sheet, dated 01/14/2018, showed Resident #3 did not have a cell phone. This information was inconsistent with the DNS statement. Further review of a nursing progress note dated 02/02/2020 at 1:51 PM, documented: Front door sensor alarm was going off. Found resident walking on side walk towards the hospital, went to redirect and resident stated, I came for a walk it was nice and sunny outside, I will do my walk again tomorrow if it will be sunny like this. On 02/05/2020 at 5:15 PM, the DNS when asked to provide a completed copy of the incident report for the elopement out of the facility on 02/02/2020, she stated There was not one completed for that incident. During a joint interview, on 02/05/2020 at 6:14 PM, with Facility Administration, RCS Field Manager, Staff F (AIT) and Staff AA, Regional Director of Operations (RDO), details of the Immediate Jeopardy (IJ) were discussed including the residents involved. Staff AA was also notified at this time that Resident #3 had made an allegation of rape during initial screening and that she stated she had reported to the facility staff multiple times and they did not do anything. Facility administration confirmed that there were multiple progress notes that documented reported allegations, but that there were no investigations completed by the facility to rule out abuse or neglect, Staff AA stated, Yeah I know there is nothing. The facility administration was also notified that the wander guard device was located on the right bar of her walker and not actually on the resident's body, Staff AA confirmed this to be true. Discussed that there were no investigations completed for allegations of rape or the elopement from the facility and Staff AA stated I honestly don't even know what to say right now, every training we do, staff should know that all of these concerns should be taken seriously, reported and followed up on. The DNS stated that during the interview with the Resident #3 today (02/05/2020), regarding the allegation of assault, Resident #3 verbalized a name of a specific resident that had hurt her. The DNS confirmed that there was a resident fitting the description Resident #3 provided near the resident's room who was placed on a 1:1 observation while the facility completed the investigation. During an observation, on 02/06/2020 at 2:45 PM, the resident was observed sitting in a chair near the front exit. The wander guard device was observed on the right bar of the walker near the resident. There was no wander guard device observed at that time on the resident's body. During a dining observation and interview on 02/07/2020 at 7:53 AM, the resident was observed sitting at a table in the dining room. The resident was wearing a wander guard bracelet on her right wrist, which was noted to be extremely loose. The resident stated I wear this so they know where I am going. The resident also stated that It's always loose, and proceeded to remove the bracelet and place on the table during the interview, stating I take this off sometimes. Review of current State incident reporting log received and grievance log on 02/04/2020 showed no investigations and/or grievances were completed for Resident #3 related to leaving the facility unsupervised on 01/30/2020. Review of Resident #3's care plan printed on 02/07/2020 showed: Focus area- Resident used anti-psychotic medications related to behavior management due to [MEDICAL CONDITION]. Interventions included: Monitoring behaviors of attempts to make unplanned unsafe trips out of the facility (Initiated on 11/15/2019). Focus area- Resident is at high risk for elopement related to Elopement risk score of >8 (Date initiated 08/27/2019 with revision on 02/03/2020). Interventions included: Check wander device daily, located on right side of her front wheeled walker (initiated on 02/03/2020); Implement Code Pink Protocol (initiated on 02/03/2020); Assist with setting up an outing with staff member for shopping needs (initiated on 08/30/2019) The wander guard will be checked each shift for battery life and placement every shift- under walker and right wrist (initiated on 02/03/2020, revised 02/17/2020). Further review of the care plan showed that Resident #3 had been identified as a High Elopement Risk resident in August 2019 and was being monitored for making unplanned, unsafe trips out of the facility since November 2019. The care plan also showed that interventions that were implemented related to elopement included a wander guard device on the right side of the front wheel walker which was not initiated until 02/03/2020, four days after the resident left the facility unsupervised on 01/30/2020. The care plan also showed that the resident needed assist to set up outings and staff member assist for shopping needs (initiated 08/30/2019). During a joint record review and interview on 02/05/2020 at 5:59 PM, the DNS stated that she was told by administration that she did not need to complete an investigation when Resident #3 left the faciity on [DATE]. The DNS stated after she went through trauma training, she then knew that the assault allegations made by Resident #3 should have been investigated. The DNS further stated she was told that Resident #3 was ok to leave the facility independently and was not aware of staff accompanying her during outings. Review of current Physician orders [REDACTED]. - Check if wander guard in place and functioning every shift located on the right hand and under her walker (initiated on 02/07/2020), eight days after the resident left the facility unsupervised. Review of Medication Administration Record [REDACTED] - Check if wander guard in place and functioning every shift (Order dated 02/02/2020) Staff documenting either Yes (Y) or No (N). The order does not specify where the wander guard device is located. Review of the elopement risk evaluation, dated 02/07/2020, showed Resident #3 was a High Risk for wandering. The evaluation was completed eight days after the resident left the facility unsupervised on 01/30/2020. The evaluation describes the resident as forgetful/short attention span, exhibits/expresses fear and/or anxiety, and known wanderer/history of wandering. This was the only elopement risk evaluation completed in Resident #3's clinical record. Review of facility form titled Code Pink Guidelines dated 10/2015, showed the purpose of this assessment was to identify residents at risk for Elopement, establish a safe environment and develop an individualized plan of care. The guidelines showed: - An elopement/exit seeking/wandering assessment, called Code Pink documentation tool is completed at the time the resident is identified as at risk for elopement/exit seeking/wandering. - Definitions: B. Elopement- A resident exiting the building into an unsecured area without direct supervision who has been deemed not safe to do so. Review of Code Pink assessment dated [DATE] (completed date of 02/03/2020), showed: - Triggers that indicate elopement attempts- Resident used a front wheel walker for mobility, the resident likes to take walks on sunny days. - Known successful interventions- was blank and incomplete - Types of supervision- visual checks - Other comments- the resident in the past can go out of facility on her own. Due to her Dementia progressing and not remembering where she lives at, she now needs an escort when leaving facility as of 02/02/2020. Review of a second Code Pink Assessment with the same initiation date of 02/01/2020 (completed date of 02/07/2020), showed: - Triggers that indicate elopement attempts- same as previous assessment - Known successful interventions- redirection, and wander guard on right hand and under her walker - Types of supervision- resident walks around facility be aware of resident as she is approaching exits. - Other comments- same as previous assessment. The first Code pink assessment did not list any known successful interventions, whereas the second one completed and closed six days after it was initiated, and after the elopement was identified by State surveyors showed interventions of wander guard on right hand and under her walker. This was found to be inaccurate as the wander guard device was only observed on Resident #3's walker until the facility was notified and then a wander device was placed on the resident's body on 02/07/2020. Review of the Safety device assessment and consent initiated on 02/01/2020, (locked/completed) on 02/10/2020, nine days after it was started, showed: -Type of device: Wander guard on right hand at all times, date initiated 02/01/2020. -Reason resident requires devices- Elopement. The first observation of Resident #3 wearing a wander guard device on her body was not until 02/07/2020, which made the information in this assessment inaccurate. Review of the ER notes dated 01/30/2020 showed: Resident's chief complaint was dizziness. Per triage notes the resident stated she went on the bus today to go shopping and then decided to walk back to the facility but got lost, was then picked up by EMS and noted that she felt dizzy and tired. The ER Doctor (MD), documented in notes that he suspected the majority of the residents symptoms are due to overexertion. MD stated that after observation in the ER and treatment with small bolus of intravenous (IV) fluid, the resident felt improved and was able to ambulate without return of symptoms. Documentation showed the resident received an IV bolus 500 milliliters of fluids in the ER. Follow up interview/record review on 02/06/2020 at 10:28 AM, the DNS confirmed Resident #3 did go to theER on [DATE], but was unable to provide any further information regarding that. The DNS stated that she hadn't actually received or reviewed the paperwork from the hospital encounter. Summary: Resident #3 left the faciity on [DATE] to a store that was approximately 1.5 miles away from the facility. Resident attempted to walk back to the facility, became fatigued and EMS was called by someone outside the facility to transport resident to the ER. The facility failed to accurately assess the resident's safety to be out of the facility independently, failed to implement appropriate interventions timely, to prevent elopement, and failed to properly investigate the situation. The facility also failed to assess Resident #3's clinical status [REDACTED]. UN-INVESTIGATED ALLEGATIONS OF SEXUAL ASSAULT During an interview and observation, on 02/05/2020 at 11:27 AM, Resident #3 stated, My back hurts because he raped me all the time. The resident continued by stating, It hurts [MEDICAL CONDITION] did it all the time on my back, pointing to her lower back. Resident #3 stated, He got someone younger to do it to me in the front and they raped me, all summer long this happened. When Resident #3 was asked if she knew who had hurt her she stated, Yes it was (Resident #6), he lives down the hall a few doors, makes me sick thinking there is a rapist in a place like this. The resident stated that these things happened at the facility, and she told the nurses here but they don't care, they don't do nothing. The resident again repeated, He would get someone younger to do the front, rape me from the front and continued stating, I told him I was going to report this to the police but he didn't care. Resident #3 denied being fearful of anyone at the facility currently, stating, Everyone is nice here. During a joint interview and record review on 02/05/2020 at 3:40 PM, the DNS and Staff F, AIT, were both notified of the resident's allegation of sexual assault. Both staff members stated that the resident had a history of [REDACTED]. Review of Resident #3's clinical record revealed the following nursing progress notes: - 08/25/2019- Resident woke and stated, I was raped. The resident told the nurse, It happened just now. LN documented she reported to oncoming nurse for continued monitoring - 09/16/2019- Resident came to LN cart pointed at a male resident and stated, He raped me last night. LN documented resident is known to make accusations against males. Reported to night shift nurse. - 09/22/2019- Resident stated to nurse that a male resident who she accused before had raped her once. LN documented resident has history of accusing other male residents and aides about rape, stating she suffers from [MEDICAL CONDITION] (Post-Traumatic Stress Disorder) of sexual abuse. - 11/03/2019- Resident approached nurse stating she had been raped by two men during the middle of the night and her butt hurt very much. The nurse assessed and found resident with hemorrhoids. The nurse documented per care plan when resident had hemorrhoids it can trigger a [MEDICAL CONDITION] response. The nurse explained the hemorrhoids to resident and that was why her butt hurt and she had blood on her night gown. On call nurse contacted and stated this was in her care plan and to monitor further for [MEDICAL CONDITION]. - 11/16/2019- Resident came to the nurse with allegations of men coming to her room and assaulting her. Resident complained of having sore bottom and requested cream. Resident redirected as has history of these kind of allegations. Nurse Manager informed. - 12/24/2019: Resident reported she felt men had come into her room last night which caused the new bruise to her arm 2.5 cm (centimeter) x 2 cm in size. Bruise appears to be light purple in color. Resident then later stated she must have hit her arm on something. Will place monitoring order on bruise. Review of current State incident reporting log and grievance log received on 02/04/2020, showed no investigations and/or grievances were completed or logged for the multiple allegations of assault and/or rape that were documented in the progress notes. During a joint record review and interview, on 02/05/2020 at 5:15 PM, the DNS confirmed multiple notes documenting reports of sexual allegations were in the resident's clinical record, however she was unable to provide any further information regarding the notes and stated that there were not incident reports completed for these allegations because she had a history of [REDACTED]. Review of current comprehensive care plan printed 02/06/2020 showed: Focus Area- Trauma: Past trauma of childhood/young adulthood sexual abuse as manifested by hemorrhoid pain. Allegations of sexual assault 02/05/2020 (initiated 01/30/2020, revised on 02/18/2020). Interventions included: - During weekly skin checks ask resident if she was having any rectal pain (initiated on 02/06/2020) - Has traumatic child hood/young adult hood history of sexual abuse. Per mental health provider crisis plan: Resident will talk about past abuse as if it was a recent occurrence. Interventions included 1:1 visits with staff, rest and space, engage in crafts and visits with staff members who she had a good rapport with. Helpful to engage with resident in a gentle manner and acknowledge concerns and clarify what she wants/needs- Graduated from mental health services on 01/01/2019, new referral sent on 02/06/2020 (initiated on 01/30/2020, revised on 02/09/2020). Focus Area- Resident has acute pain related to migraines, recurrent hemorrhoids (initiated on 01/16/2018, revised on 02/09/2020). Interventions included: -Resident has history of hemorrhoids that she associates with pain from past trauma. When she brings up traumatic events notify nurse or care manager so that she can be assessed (initiated on 05/14/2019). The facility failed to address the resident's past history of sexual assault with appropriate interventions present on admission 01/14/2018. The care plan regarding trauma was not initiated until 01/30/2020. Even after the facility administration had knowledge of the allegation of rape on 02/05/2020, and planned to protect Resident #3 by providing alleged perpetrator, Resident #6, with 1:1 supervision during investigation, the facility failed to ensure that 1:1 was done consistently. 1:1 Monitoring: In an observation and interview, on 02/07/2020 at 4:50 AM, there was an empty chair outside Resident #6's room (resident was on 1:1 monitoring for allegations of rape), Staff PP, RN, stated Staff CCC, NA, was supposed to be doing 1:1 monitoring of Resident #6, but he also had other duties including helping take care of other residents. In an interview, on 02/07/2020 at 5:03 AM, Staff CCC said he was supposed to be keeping an eye on Resident #6. He stated, No, when asked if he was supposed to leave the resident to do other work without monitoring him. In a review, on 02/07/2020 at 4:52 AM, the 1:1 monitoring form being used to document monitoring of Resident #6 by Staff CCC, had no documentation of monitoring after 4:00 AM. RESIDENT TO RESIDENT INTERACTIONS RESIDENT #58 Resident #58 admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 12/29/2019, showed he had no behaviors and was cognitively impaired but could make his needs known. He was independent in his mobility off the unit. Review of the care plan, initiated on 02/24/2016, showed a history of inappropriate sexual behavior as evidenced by inappropriate touching of self in public, behaviors of inappropriate touching of female staff and residents, exposing or touching of genitals in public spaces and aggressive hand gestures and verbalization. The care plan was revised on 02/08/2020 to include intrusive wandering into female rooms. The care plan directed staff to identify places he may wander to, redirect him when he attempts to go into female rooms and remind him of boundaries. Resident will be supervised during activities to maintain safety for resident and others. Review of the care plan, on 02/14/2020, did not include the new intervention for one on one supervision. Review of a 07/02/2019 at 3:53 PM activity progress note revealed, This res (Resident #58) and another female res (#66) were sitting near each other in an activity. Noticed that they were holding hands, and this res (#58) began to pull her hand closer to him and it seemed as if he was pulling toward his lap/private area. I intervened before anything happened and told res to stop. Other female res was laughing and smiling, was not upset about the situation. Residents were separated and no further behaviors noted at that time. Review of a 07/25/2019 progress note, showed Residents #58 and #66 were observed sitting in the solarium kissing. Review of a progress note, dated 09/18/2019 at 6:59 AM, Inappropriate mutual behaviors between this resident (#58) and female resident (#66). Residents separated and brought to their perspective rooms. Review of a progress note, on 09/26/2019, Resident #58 was visiting Resident #66 from the hallway. Resident #70 asked him to leave repeatedly. Resident #58 swore at her. RESIDENT # 70 Resident #70 admitted on [DATE]. She was alert and oriented and able to make her needs known. Review of a progress note for Resident #70, on 01/13/2020 at 5:00 PM, showed Resident # 58 had gone into (Resident #66's) room that he was told he cannot be alone with. The female resident's roommate (Resident #70 ) was raising her voice, telling him that he needed to get out of our room. Resident #58 was refusing to do so and attempted to kick at the roommate, but did not make contact .escorted the female resident and her roommate to the dining room. (Resident #58) again kicked at the roommate but again did not make contact. Resident #70 was very upset and stated that the male resident had come into her room to be with her roommate and she told him he needed to leave. Resident then stated the male resident then tried to kick her multiple times . Review of a progress note, dated 02/13/2020 at 3:00 PM, showed Resident #70 was resting in her room when another resident (Resident #58) coming down hallway stopped in front of this resident's door way and began shouting profanities (in Spanish) towards resident. After shouting a few words, specifically f*ck you, this resident then left doorway (self-propelling himself in wheelchair) down hall towards dining room and or activities. This behavior happened more than once and witnessed x1 by shower aide. Resident has been placed on a 1:1 and will be watched for any negative behaviors during this time. Review of a progress note, on 02/18/2020, from Staff CC, Mental Health Consultant, showed Resident #58's English is limited but easily makes needs known & holds appropriate basic conversations. Resident is impulsive and disinhibited .Bx (behavior) monitor displayed some inappropriate bx's including unwanted touching In an interview on 02/14/20 at 9:58 AM, Staff SS, RN, confirmed Resident #58 was on one to one supervision. She said At night, (Staff XX) was doing one on ones . I believe. (Resident #58) does not like (Resident #70) and he will target her and go by her room and swear. He did this a couple times yesterday. This had been going on for a long time actually. In an interview on 02/14/2020 at 10:23 AM, Staff VV, NAC, said Resident #58 was on one on one supervision for swearing at residents in Spanish. She said he had issues with one lady and he had a relationship with her roommate (Resident #66). Staff VV stated the roommate (Resident #70) did not like him. In an interview of 02/14/2020 at 10:30 AM, Staff SS, RN, provided the 15-minute check sheet. Staff XX, NAC had initialed noc shift including at 0600, 0610 and 0620. From 0640-0820, Staff SS, had signed the 15 minute checks. She was observed caring for her other residents during these entries. She had not been observed providing the one on one supervision. When asked she stated, Staff XX did one on ones then I did it a couple hours. In an interview on 02/14/2020 at 10:50 AM, Staff AA, Staff II, Staff U, and the Director of Nursing were informed Resident #58 did not receive one on one supervision from 0600 to 0820. Staff AA, had been unaware Resident # 58 was on one to ones. The DNS stated she would have to look into what happened and why he was not receiveing one on one supervision. In an interview on 02/14/2020 at 11:40 AM, Staff AAA, NAC stated she arrived at work at 8 AM and noticed she was assigned to one on ones with Resident #58 although she was unaware why. In an interview on 02/20/2020 at 2:18 PM, Staff I, NAC, stated, He is one on one now. He was visiting and going into other rooms .He is absolutely cognizant. He knows what is going on absolutely. He flirts with other women. He knows what he is doing and does not think it is wrong. We were in-serviced we have to sign on one on ones to protect the residents. RESIDENT #66 Resident #66 admitted on [DATE] with dementia with behavioral disturbance and cognitive communication deficit. She was cognitively impaired and unable to make her needs known. According to the Annual MDS, dated [DATE], she wandered 4 to 6 days in the seven-day look back period. Review of her Activities care plan dated 02/12/2020, showed unobtrusive wandering, dementia and flirtatious behavior toward some male residents; a specific male resident and she had a flirtatious relationship. (Resident #66) and male resident are unable to give consent if both residents would like to participate in an activity together, they must be under supervision. Review of a progress note on 06/26/2019, showed, Resident #66 was seen touching another resident inappropriately during group activity. I spoke with her and the other resident explaining that their behaviors were inappropriate. Informed the nurse of the situation. Review of a progress note on 07/02/2019 at 3:59 PM, This res and another male were sitting near each other in an activity. Noticed that they were holding hands, and other res began to pull her hand closer to him and it seemed as if he was pulling toward his lap/private area. I intervened before anything happened and told other resident to stop. This res was laughing and smiling . Review of a progress note on 07/05/2019 at 12:00 PM, the activity staff came and told this LN (licensed nurse) that during activitie (TRUNCATED)

Based on observation, interview and record review, the facility failed to ensure two of seven residents (#32, #29) remained free of unnecessary drugs. Failure to: 1) ensure opioid pain medications were used for the shortest duration necessary, 2) to provide comprehensive medication side effect monitoring, 3) to evaluate the presence of adverse consequences which indicated opioid pain medications may need to be reduced or discontinued, 4) to respond timely to the presence of potential medication-related adverse side effects (ASEs), 5) to consider the impact of side effects of [MEDICAL CONDITION] medications in a resident who also experienced similar side effects of opioid pain medications, 6) to perform accurate and comprehensive pain evaluations, 7) to ensure the consultant pharmacist identified medication-related irregularities and performed monthly Medication Regimen Reviews (MRRs), 8) to ensure residents that received [MEDICAL CONDITION] medications had comprehensive [MEDICAL CONDITION] medication reviews that took pain management into consideration, and 9) to not increase opioid pain medications in a resident who was already identified as having somnolence/lethargy that was already adversely impacting her life. Resident #32 was harmed when the facility failed to respond when she exhibited potential medication-related ASEs and the facility continued to treat her with the same medications for several months. Then, even after the resident had been identified as being lethargic & somnolent, the facility increased her [MEDICATION NAME] (opioid pain medication) which resulted in even more sedation. On admission, the resident was able to walk, able to communicate effectively, able to feed herself, and she had no skin pressure injuries. After several months of treatment with multiple [MEDICAL CONDITION] and opioid medications, the resident was no longer able to walk, no longer able to communicate effectively, no longer able to feed herself, no longer able to get in/out of bed, she developed heel and coccyx pressure injuries, she developed a left hand/wrist contracture, she developed significant weight loss, she had declined in her bowel and bladder continence, she had decreased activity participation, and she had multiple falls. These failures resulted in an Immediate Jeopardy (IJ) related to multiple failures in medication management for Resident #32 and for other residents. An IJ was called on 02/13/2020 at 2:18 PM. The facility: -had the consultant pharmacist review each resident's medication regimens and meet with the Interdisciplinary Teams (IDTs) and physicians regarding irregularities, -had the nurse managers and Director of Nursing Services (DNS) review and complete comprehensive pain assessments on each resident on opioid medications and consulted with physicians for further review and medication adjustments, -had staff assess and evaluate each resident on opioid medications for appropriate [DIAGNOSES REDACTED]. -reviewed care plans to include adverse side effects monitoring and non-pharmacological interventions, -trained the nurse managers, nurses, DNS, and nursing assistants on identification of signs/symptoms of pain, over-sedation, non-pharmacological interventions, and steps to take if issues identified, -revised facility practice for monitoring for and documenting adverse side effects of opioid medications, -implemented auditing of medication management procedures. This all resulted in removal of the IJ on 02/28/2020 at 12:45 PM. Findings included . DEFINITIONS: Adverse side effects/consequences of medications: [REDACTED]. It may include various types of adverse drug reactions or interactions (e.g. medication-medication, medication-food, and medication-disease). Side effects of opioid medications include: drowsiness, weakness or lack of energy, lightheadedness, dizziness, headache, constipation, nausea and vomiting, itching, dry mouth, and trouble falling or staying asleep. Side effects of Antipsychotic medications include: movement disorders, blood pressure fluctuations, drowsiness, elevated pulse, sedation, dizziness, blurred vision, [MEDICAL CONDITION], dry mouth, nausea, constipation, urine retention, blood disorder, headaches, weakness, jaundice, agitation, restlessness, slurred speech, anorexia, rash, confusion, unsteady gait, frequent falls, refusal to eat, difficulty swallowing, depression, [MEDICAL CONDITION], social isolation, diarrhea, fatigue, [MEDICAL CONDITION], loss of appetite, weight loss, muscle cramps, vomiting, behavioral symptoms not usual to the person. Side effects of antidepressant medications include: constipation, hand tremors, blood cell abnormalities, arrhythmias, sedation, confusion, excitement, blurred vision, rash, dry mouth, dry eyes, [MEDICAL CONDITIONS], jaundice, psychotic episodes, anxiety, [MEDICAL CONDITION], weight loss, nervousness, loss of appetite, suicidal ideation, mood change, change in normal behavior, hallucinations/delusions, social isolation, decline in ability to help with/do ADLs (activities of daily living), no voiding, rigid muscles, difficulty ambulating, balance problems, accidents, dizziness, falls, movement problems, tremors, diarrhea, fatigue, weight loss, muscle cramps. Side effects of mood stabilizer medications include: extreme drowsiness, fatigue, muscle aching or weakness, dry mouth, constipation or diarrhea, loss of appetite, nausea, skin rash, headache, dizziness, tremors, abdominal pain, and upset stomach. RESIDENT #32 The resident admitted to the facility on [DATE] for rehabilitation after having a fall at home resulting in a left wrist fracture. On admission the resident had [DIAGNOSES REDACTED]. According to the resident's Admission Minimum Data Set (MDS) assessment, dated 05/23/2019, she had severe cognitive impairment, and for activities of daily living (ADLs) she required only limited assistance with bed mobility, transfers and personal hygiene. The MDS indicated she required only supervision with eating and walking. For bowel and bladder, the MDS indicated she was occasionally incontinent of urine and always continent of bowels. Review of the Quarterly MDS, dated [DATE], revealed severe cognitive impairment, and for ADLs, she required extensive assistance of 1-2 persons with bed mobility, transfers, and personal hygiene. Walking did not occur during this MDS time period. For bowel and bladder, the MDS indicated she was always incontinent of bowel and bladder. Review of the Admission Nursing Data Base (nursing assessment), dated 05/16/2019 found the following: -Resident #32 had clear speech, -weighed 153.8 lbs -was always continent of bowel and bladder, -had no pressure ulcers, -had a pleasant mood. Review of a progress note, dated 05/17/2019 at 1:43 PM, revealed the resident stated she wanted to return home with her spouse. Review of a progress note, dated 05/22/2019 at 3:37 AM, revealed the resident was on alert for inappropriate behaviors, exit-seeking, and for the fall. She could not recall events from the previous day, and was oriented to self, but not time, place or situation. She denied pain and had constant episodes of confusion. Review of a progress note, dated 05/28/2019 at 2:30 PM, revealed the resident was very mobile and had difficulty following tasks and cueing safely. Resident #32's son reported she had been living with her significant other alone in an apartment and had a history of [REDACTED]. The facility discussed with the resident's family that it was felt she would not be safe to return home, and the recommendation was for 24/7 care and she would benefit from placement in an adult family home or in a memory care setting. Review of the May 2019 Medication Administration Records (MARs), revealed in May, she was started on [MEDICATION NAME] (an antipsychotic medication) for unspecified [MEDICAL CONDITION], [MEDICATION NAME] (an antidepressant medication) for [MEDICAL CONDITION], and she was receiving [MEDICATION NAME] (an opioid pain medication) for pain for 10 days. Review of the June 2019 MARs revealed the resident's [MEDICATION NAME] got re-ordered, the [MEDICATION NAME] dosing was increased (multiple times), and [MEDICATION NAME] (mood stabilizer/anticonvulsant medication) was added for unspecified [MEDICAL CONDITION], and the [MEDICATION NAME] was continued. Review of the MARs for 2019 and 2020 revealed ongoing treatment with [MEDICAL CONDITION] medications and [MEDICATION NAME] as follows: -[MEDICATION NAME] 50 mg (milligrams) daily at 9 AM - 06/20/2019 - 01/03/2020 -[MEDICATION NAME] 100 mg daily at 3 PM - 06/21/2019 - 01/03/2020 -[MEDICATION NAME] 100 mg daily at 9 PM - 06/20/2019 - 01/03/2020 -[MEDICATION NAME] (multiple dose changes, starting in June 2019) 250 mg twice daily at 9 AM & 1 PM - 07/25/2019 - ongoing as of 02/06/2020 -[MEDICATION NAME] 500 mg daily at 9 PM, 07/24/2019 - ongoing as of 02/06/2020 -[MEDICATION NAME] 25 mg daily at 9 PM - 05/29/2019 - 02/12/2020 -[MEDICATION NAME] PRN (as needed) - 06/25/2019 - 01/03/2020 -[MEDICATION NAME] changed from PRN, to a scheduled basis, three times daily on 01/03/2020. PHYSICIAN/NURSE PRACTITIONER/PHYSICIAN'S ASSISTANT NOTE REVIEW: A hospital discharge summary, dated 05/16/2019 revealed the pain management plan included orders for [MEDICATION NAME] as needed for pain X 10 days with a physician note stating patient does require opioid pain medicine for this hospital diagnosis, pain medicine to be managed upon discharge by PCP (primary care physician), the usual duration of need for opioid pain medicine for this condition is 4-5 days. The discharge rders did not include [MEDICAL CONDITION] medications. A doctor note, dated 05/20/2019 stated patient was readmitted (to the hospital) for altered mental status and her pain was well-controlled with [MEDICATION NAME]. As per PT and OT (physical therapy and occupational therapy), patient was transferred to skilled nursing rehab for deconditioning and unsteady gait. Denies any pain. Assessment: presented with left wrist fracture, status [REDACTED]. A Nurse Practitioner note, dated 05/22/2019 stated dementia, anxiety, pleasantly confused, she seems to be very comfortable with her pain scale. She did not manifest any pain on assessment. Continent of bowel and bladder. A Nurse Practitioner note, dated 06/06/2019 stated chief complaint: routine follow-up [MEDICAL CONDITION], dementia with hallucinations and behaviors. Assessment: late onset [MEDICAL CONDITION], [MEDICATION NAME] will be initiated, she has been seen by psychiatry. [MEDICATION NAME] and adjust her regimen and follow-up with psych's recommendation if need be. Pain is controlled, stable for now. A Nurse Practitioner note, dated 06/10/2019 stated objective: left hand swelling with pain, Review of systems: psychiatric: positive for agitation, behavioral problem, confusion, decreased concentration, depressed mood, hyperactive and memory loss, Assessment: Late onset [MEDICAL CONDITION]. According to a Nurse Practitioner note dated 07/31/2019, Resident #32 had no evidence of pain, yet the resident continued to receive [MEDICATION NAME]. The resident continued on pain medication, although there was no indication the resident was assessed to require pain management. The previous provider note was six weeks prior. A Physician Assistant note, dated 08/01/2019 did not address treatment with [MEDICATION NAME], the provider did write to start [MEDICATION NAME] 400 mg every eight hours, however, review of the August 2019 MARs revealed it did not get started. Progress notes review revealed, there was no documentation in the progress notes to explain why the [MEDICATION NAME] was not initiated. In a Nurse Practitioner note dated 09/20/2019, there was no mention about the ongoing treatment with [MEDICATION NAME] (that had side effects of drowsiness/sedation) and [MEDICATION NAME] (which Resident #32 was taking to aid sleep). The note did not address potential side effects of [MEDICATION NAME] (side effects included drowsiness, tiredness, lack of energy) or [MEDICATION NAME] (side effects of extreme drowsiness, dizziness, weakness) either. According to Nurse Practitioner notes dated 09/25/19, 10/30/19, 12/04/19, and 01/03/2020 and a doctor note dated 10/17/19, Resident #32 was lethargic, hypersomnolent, not ambulating, wheelchair bound, with pressure ulcers, and had significant weight loss, and a general decline was noted. Although the resident's pain was not assessed in these notes, one note stated the resident did not ask for pain medication, however, [MEDICATION NAME] was increased. Although side effects from Ocycodone use included drowsiness, dizziness, nausea/vomiting and lack of energy, this resident's dosage was increased from PRN doses in 12/19 to routing at 3X daily. In addition, Nurse Practitioner notes dated 01/14/2020, 01/22/2020 and 02/04/2020 described the resident's general decline to include weight loss and pressure injury, lethargy, wheelchair bound, there were no pain assessments, yet the resident remained on narcotic pain management regime, along with antipsychotic medications. Further reviews of facility progress notes, on 08/14/19 a note indicated [MEDICATION NAME] was now being used for unresolved back pain, although there was no evidence of a pain assessment. In a Social Services note describing the interdisciplinary team (IDT) recommendations for the resident's care plan, side effects to medications was not addressed. The 08/29/2019 progress note stated that the resident was showing signs and symptoms of pain, however the resident was unable say where the pain was. It wasn't clear how the pain was assessed. The resident was on multiple antipsychotice drugs, was weak, and had general decline needing more assistance, sleeping more and was lethargic and there were some reported falls (see 09/01/19, 09/17/19, and 10/28/19 progress note). Further review of progress notes indicated staff attempted to give the resident Tylenol as well. According to a 11/29/19 note, the resident complained of pain and was unable to say where the pain was, there was no documentation to show how the resident was assessed to have pain. Further progree note reviews showed that on 12/20/19 Resident #32 was found on the floor, and on 12/25/19 was noted as refusing to wake up for medication. According to progress notes dated 01/04/2020 and 01/05/2020, Resident #32 had [MEDICATION NAME] held for increased sleepyness and the staff documented that there were no adverse side effects to the medications. In addition, the 01/06/2020 progress note stated Resident #32 was now on an increased dose of [MEDICATION NAME], although the note also stated that the resident was sleeping most of the time and staff documented no adverse side effects. There was no indication the resident required [MEDICATION NAME] for pain management. In a progress note dated 01/06/2020 at 9:52 PM, it stated [MEDICATION NAME] give 5 mg by mouth three times a day for pain, hold for hypersomnolence. Resident has been sleeping since dinner time. According to the January 2020 MARs, [MEDICATION NAME] was given although Resident #32 had been sleeping. After [MEDICATION NAME] was held, a 01/07/2020 at 12:47 PM showed that the resident was able to bet up in a wheel chair, was awake and more alert. However, after taking her medications was put back to bed at 10:00 AM that morning. The note further stated that Resident #32's medications were held at noon time including [MEDICATION NAME] and that the ARNP was to be notified for possibly reducing the [MEDICATION NAME]. According to progress notes dated between 01/08/2020 and 01/15/2020, Resident #32's [MEDICATION NAME] was held related to increased sleepiness. On 01/16/2020, an order was written to discontinue the AM dose of [MEDICATION NAME] related to the resident's sleepiness throughout breakfast meal. The resident was more alert and awake after the narcotic pain medications were held according to the p;rogress notes, and the documentation showed there was no breakthrough pain. According to 01/21/2020 progress notes, Resident #32 was given Tylenol for pain. Review of consultant pharmacist monthly medication regimen review (MRR) for reports between August and September 2019 showed that there was no documentation to address the ongoing treatment with [MEDICATION NAME], even though it was originally prescribed for acute pain related to the wrist fracture on admission in May 2019. On 10/25/2019, the resident's name was on a list of other residents reviewed by the consultant pharmacist, and did not require any recommendations. The resident had been noted by her nurse practitioner/physician to be lethargic, not ambulating as she had in the past, more wheelchair bound, yet no recommendations or irregularities were identified by the consultant pharmacist, related to sedation or pain. On November 2019, no MRR was found in Resident #32's clinical record. There was a note in PCC (PointClickCare (electronic health record)), pertaining to a Pharmacist Acknowledgement, dated 11/19/19, that showed no irregularities noted. Although recent progress notes from doctor/nurse practitioner reflect lethargy, not extremely responsive at this time, more wheelchair bound, somnolent, yet there were no irregularities identified by the consultant pharmacist during November 2019. On 12/23/2019: the pharmacist wrote: resident was due a GDR for [MEDICATION NAME] and [MEDICATION NAME]. The pharmacist note indicated if current therapy was to be continued, please provide a brief risk vs benefit assessment for state survey. The nurse practitioner wrote we are down titrating for sleepiness, but did not state which medication/s were being down titrated. There was nothing documented about lethargy, somnolence, hypersomnolence, more wheelchair bound, not ambulating as was stated in the past provider notes. In the pharmacist note dated 08/20/2019 there was no mention of contributing factors like pain or medication interactions, even though there were spaces for this on the review. Resident #32 was started on Opioid pain medication for acute pain, then the opioids were extended for months. The IDT recommended no changes in [MEDICAL CONDITION] medications. In a note dated 11/16/2019, the facility marked No, under the question Are there signs/symptoms of medication side effects? Resident #32 was now wheelchair bound and not ambulating, somnolent, lethargic, and had four falls that quarter, yet no medication side effects were marked. Pain and medication interactions were not marked as potential contributing factors, and the IDT recommended no changes. In a note dated 02/21/2020 the facility documented as follows: -Medication side effects: Are there any signs/symptoms of medication side effects? Facility marked No, although the resident had experienced side effects since the November 2019 review, experienced significant weight loss, hypersomnolence, lethargy, was wheelchair-bound, could no longer walk, could no longer feed herself, and could no longer transfer herself, and the facility had been decreasing her [MEDICAL CONDITION] medications and her [MEDICATION NAME] for pain. The review said her weight is stable, and behaviors still consistent, when she had no behaviors because she was unable to do anything for herself anymore. PAIN EVALUATIONS REVIEWED: In a note dated 05/16/2019 the facility documented as follows: Question: Should pain assessment interview be conducted? No. There were no indicators noted of pain or possible pain. There were no comments noted. Resident #32 discharged from the hospital to the facility in May 2019 with an order for [REDACTED]. A note dated 07/18/2019 the facility documented as follows: -Question: Should pain assessment interview be conducted? No. -Question: Over the past 5 days, has pain made it hard for you to sleep at night? No. -Question: Over the past 5 days, have you limited your day-to-day activities because of pain? No. -Pain intensity: Unable to answer. For pain management, there was very little information documented. The resident was on scheduled Tylenol every six hours, however, the pain assessment had no information whether that was effective. Resident #32 was also receiving [MEDICATION NAME] every six hours as needed, yet there was a section on the Pain Evaluation for PRN pain medications, but it was blank, the facility provided no information. This pain evaluation was lacking information to show why the resident was continued on [MEDICATION NAME] for pain, when she was admitted in May 2019 with acute pain related to her fractured wrist/surgery, and was to receive [MEDICATION NAME] for 10 days for the acute pain. Now according to the facility documentation, the resident required opioid pain medications for two months and it was continuing. In a note dated 08/21/2019 the facility documented as follows: -Question: Should pain assessment interview be conducted? No. -Received scheduled pain medication regimen, describe treatment? . the facility response was no side effects, The resident was taking Tylenol every six hours, but this information was not included in the pain assessment, and the effectiveness of the Tylenol was not addressed. Resident #32 received PRN [MEDICATION NAME] as needed every six hours, there was no side effect information documented regarding this in the assessment. In a note dated 11/14/2019 the facility documentation showed that Resident #32 was receiving [MEDICATION NAME] as needed every six hours, the pain evaluation form indicated side effects and effectiveness were to be documented regarding this PRN pain regimen, however, there was no documentation to indicate effectiveness of the pain medication, or of any side effects, although, the resident was experiencing somnolence, lethargy, and was wheelchair-bound, yet no assessment of potential side effects. OBSERVATIONS In random observations on 02/04/2020, the resident was observed asleep in bed. In an observation on 02/05/2020 at 9:46 AM, the resident was asleep in bed. In an observation on 02/05/2020 at 10:22 AM, the resident was asleep in bed. In an observation on 02/19/2020 at 8:41 AM, the resident was being fed breakfast by a staff member at the assisted table in the dining room. In an observation on 02/19/2020 at 12:37 AM, the resident was in the dining room, a staff member was helping her to drink by holding a glass to her mouth. In an observation on 02/20/2020 at 9:02 AM, the resident was in the dining room, a staff member was feeding her by bringing the silverware to her mouth. STAFF INTERVIEWS In an interview on 02/12/2020 at 12:28 PM, the Director of Nursing Services (DNS) and Staff B, Licensed Practical Nurse (LPN)/Resident Care Manager, and later Staff A, Social Services, Staff C, Registered Nurse (RN) and Staff FF, RN, joined the interview after the DNS left the room, were interviewed: Staff B stated medication adverse side effects were to be documented in progress notes. She stated the side effects to be monitored for medications were listed on resident care plans. In reviewing the resident's care plan (print date 02/06/2020), staff were to monitor for side effects of [MEDICATION NAME] and [MEDICATION NAME] (two medications the resident had not been on while in the facility), but none were listed for [MEDICATION NAME]. For [MEDICATION NAME], the only side effect listed on the care plan was constipation, it did not list any other side effects. Staff were asked whether medications had been assessed to see if medication side effects were contributory to the resident being wheelchair-bound and lethargic, the DNS and Staff B did not answer that question, Staff A stated the resident was still having hundreds of behaviors. Staff were asked about the lack of information documented on the 05/16/2019 Pain Evaluation, they were unable to provide any information. Staff were asked about the lack of information on the 08/21/2019 Pain Evaluation, they were unable to provide any information. Staff were asked about the lack of information on the 11/14/2019 Pain Evaluation, and what pain was being treated, they were unable to provide any information. Staff were asked about the many doctor/nurse practitioner notes that listed somnolence and lethargy as a problem and the relative lack of documentation regarding the nurse progress notes, they were unable to provide any information. The DNS stated that the facility documented the presence of adverse side effects by exception, Staff FF stated that there was not a space to document adverse side effects in the behavior monitors. Staff were asked about the four shifts in June 2019 with no pain assessment documented, they were unable to provide any information. Staff were asked about the resident not being able to ambulate anymore, Staff C stated when the resident first admitted she was ambulatory until about the end of October 2019, then she was moved over from rehab to the long-term care wing. Staff were asked about the resident's change in condition in late 09/19 when she needed more assistance with ADLs, Staff C stated it manifested with the resident not being ambulatory and needing more assistance with cares. Staff C stated they changed pharmacists about that time. Staff were asked about the limited nursing documentation in the progress notes related to the resident's lethargy and hypersomnolence, they were unable to provide any information. Staff were unable to provide any information about what pain was being treated or what necessitated the ongoing treatment with [MEDICATION NAME], even though she was admitted with a plan for [MEDICATION NAME] for only 10 days. to treat acute pain. In an interview on 02/12/2020 at 3:23 PM Staff GG, Advanced Registered Nurse Practitioner (ARNP): Staff GG stated her medical group took over the resident's care in August/September 2019, and the resident was still ambulatory then. Staff GG stated she thought the resident actually worked at the facility. Staff GG thought the resident was typically a sleepy person, and she thought that was due to the resident's [MEDICAL CONDITION], then she transitioned over to long-term care, and she didn't need to be seen for 30-60 days, then 5-6 weeks ago she seemed more sleepy, so she took a look at her medications and started to make adjustments. Staff GG stated she kept the resident on her [MEDICATION NAME] for sleep, even when she was somnolent because she was not sleeping at night, and that she was considering sundowning (a symptom of [MEDICAL CONDITION] also known as late-day confusion, confusion and agitation can worsen in late afternoons and evenings). She stated she did not get a lot of reports on that (from nursing staff). She stated she worked closely with Staff CC (Mental Health Nurse Consultant), whose last progress note was dated 08/27/2019. Staff GG was asked about the resident's current physical condition, inability to ambulate, unable to self transfer, needing a Hoyer lift for transfers, inability to feed herself, all things she could do when she admitted to the facility. Staff GG stated the resident was very deconditioned right now. Staff GG was asked if the resident was getting better from the treatment with all of the [MEDICAL CONDITION] medications, she stated the resident was the same, that she didn't see her very much because she went to long-term care, from rehab, and that she trusted the staff to know what to monitor for and what side effects to monitor for. Staff GG was asked about the ongoing pain management pertaining to the long term use of [MEDICATION NAME] for acute pain related to a wrist fracture and surgery, and she didn't have any information to offer. When asked if the resident was still having postoperative wrist pain, Staff GG stated she didn't know for sure, she stated she thought the resident's pain was all over. She stated the resident wasn't really talking much. Staff HH, physician/Medical Director, joined the interview. Staff HH was asked about the facility's adverse side effect monitoring program, he stated they relied heavily on self-report from the nurses. He didn't offer much information except to state they follow what the nurses reported to them. Staff HH was shown the admission pain evaluation with nothing documented, he stated he thought the resident hurt all over, and that some residents have pain just sitting in bed or in their wheelchairs. In an interview on 02/14/2020 at 10:10 AM, Staff E, RN, stated the resident wouldn't open her mouth for breakfast or medications that morning. She stated that was too bad because when the resident resided on the rehab wing she had a voracious appetite and staff would even buy her chips and sodas between meals, but since she had been moved to the long term care wing she had not had much of an appetite. In an interview on 02/14/2020 at 10:41 AM, Staff II, Regional Consultant, stated the pain assessments lacked pertinent information, and that this resident should have had another pain assessment after the first 10 days of the [MEDICATION NAME]. She stated it didn't look like staff really put a lot of time into the pain assessments. She stated she had been investigating this resident's issues and there weren't many staff that had been there very long to know the residents very well. In a phone interview on 02/18/2020 at 10:01 AM, Staff R, Consultant Pharmacist, and Staff S, Consultant Pharmacy Clinical Manager stated: We were notified of the IJs related to [MEDICAL CONDITION] medications and opioids, we made a 300+ page report, there were many responses to pharmacy recommendations, a lot of recommendations that were not addressed or responded to appropriately, we sent some back to the facility for review, we met over the weekend with the facility and two providers. We had repeated recommendations that weren't addressed appropriately, so we spoke with the nursing director and a corporate representative, they did not know why the MRRs were not responded to. If MRRs were not responded to, we may make a repeat recommendation, or we may speak with facility staff. Staff R stated that that the first month he did MRRs, he met with the DNS, but he didn't get follow up until the next month, so he had no trends, especially with recommendations that were not followed up on. Staff R stated we are now implementing a percentage rate for the recommendations that were followed up on. Staff R stated typically I go there for meetings with staff monthly. Staff R and S were asked what was done if there was a recommendation for a GDR and the physician declined without documenting a rationale, he stated he typically reminded the nurse managers that rationales needed to include some kind of concrete details, especially related to behaviors residents exhibited. When asked if it's an expectation that rationales were completed, Staff S stated in their meetings, they emphasized that just saying no to a GDR was not good enough, that concrete details in the documentation was encouraged. He stated that pharmacist consultants tried to draw the line without being too intrusive, but at the same time they needed information, and Risk vs Benefit should also be specific and customized. Staff R and S were asked what was the facility's system for monitoring for potential adverse side effects of medications, and stated unfortunately, I am not familiar with their systems, I haven't gotten to the details of where they track side effects. Staff R and S were asked about the facility's system for monitoring side effects of opioids, and stated that the side effects of opioids were more subtle in older people, it's difficult to pinpoint ASEs, some places have a sticker that states what the ASEs are. For opioids there is a long list of ASEs and we rely on progress notes, they will put a little face, those are the things we look for in systems, but they are not always in place. I do look at progress notes to see what would trigger issues.

Based on interview and record review, the facility's Administration failed to take action to reports of deficient practice and did not investigate all allegations of abuse or elopement that they had knowledge of. Failure to take action for reported allegation of Rape/abuse, failure to reassess a resident with [DIAGNOSES REDACTED]. FAILURE TO INVESTIGATE ALLEGATIONS OF ABUSE: Review of facility's policy titled, Abuse Prevention Policy and Procedure, revised 08/11/2017 showed each resident had the right to be free from abuse. Investigations- As soon as a report of alleged or suspected abuse was received, the investigation shall begin in order to rule out or identify abuse. During a joint record review/interview on 02/05/2020 at 5:15 PM, the Director of Nursing Services (DNS) confirmed multiple notes documenting reports of sexual allegations were in Resident #3's clinical record, however she was unable to provide any further information regarding the notes and stated that there were no incident reports completed for these allegations because the resident had a history of [REDACTED].#3) had a past history of sexual trauma as a young person and she often would state that someone raped her, that's normal for her. RESIDENT REQUIRING emergency room VISITS: Resident #3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a progress note entered by Administrator in Training (AIT) on 02/05/2020 at 5:02 PM, documented: Clarification to note made on 01/30/2020 at 6:17 PM. Facility was aware that resident had gone out shopping, they had checked in with the front desk at 10:30 AM and got a ride at the bus stop. Later the resident called around 12:30 PM to main phone line asking to be picked up, she was able to provide the address of her location. She did not wait and had decided to walk back. Upon arrival staff was notified that EMS has picked up resident and she was located at the emergency room . During a joint interview/record review on 02/05/2020 at 5:41 PM, the DNS (director of nursing services) stated that on 01/30/2020, Resident #3 went to the front desk and told receptionist she was going out of the facility. The DNS confirmed that the resident ended up at the emergency room , but was unaware of exactly how she got there. The DNS stated she did not complete an investigation related to this issue because the resident always went out and came back, stating I asked the Administrator and he told me it wasn't an investigation. Follow up interview/record review on 02/06/2020 at 10:28 AM, revealed the DNS confirmed Resident #3 did go to theER on [DATE], but was unable to provide any further information regarding that. The DNS stated that she hadn't actually received or reviewed the paperwork from the hospital encounter. Review of the ER notes dated 01/30/2020 showed: Resident's chief complaint was dizziness. Per triage notes the resident stated she went on the bus today to go shopping and then decided to walk back to the facility but got lost, was then picked up by EMS and noted that she felt dizzy and tired. Per ER Doctor (MD) he suspects the majority of the resident's symptoms were due to overexertion. Review of the care plan showed that Resident #3 had been identified as a High Elopement Risk resident in August 2019 and was being monitored for making unplanned, unsafe trips out of the facility since November 2019. The care plan also showed that the resident needed assist to set up outings and required a staff member to assist with shopping needs (initiated 08/30/19). Administration staff knew resident was leaving the building unsupervised despite having had [DIAGNOSES REDACTED]. PHARMACY RECOMMENDATIONS: In a phone interview on 02/18/2020 at 10:01 AM, Staff R, Consultant Pharmacist, and Staff S, Consultant Pharmacy Clinical Manager: We had repeated recommendations that weren't addressed appropriately, so we spoke with the nursing director and a corporate representative, they did not know why the monthly Medication Regimen Reviews (MRR) were not responded to. Staff R stated that the first month he did MRRs, he met with the DNS, but he didn't get follow up until the next month, so he had no trends, especially with recommendations that were not followed up on. Staff R stated we were notified of concerns related to [MEDICAL CONDITION] medications and opioids, we made a 300+ page report. There were many responses to pharmacy recommendations; a lot of recommendations that were not addressed or responded to appropriately, we sent some back to the facility for review. In addition, Staff R stated we are now implementing a percentage rate for what recommendations that were followed up on. Summary of Consultant Pharmacist's Reviews, dated February 13-15, 2020, showed: -MD follow up rate from previous months: 40% -Nursing follow up rate from previous months: 10% This is a repeat deficiency from 02/13/2019. Reference: (WAC) 388-97-1620 (1)

Based on interview and record review, the facility failed to ensure they had effective Medication Regimen Review (MRR) processes for 7 of 10 residents (#32, #29, #12, #20, #30, #3, and #68) reviewed. The failure: 1) to ensure all residents had MRRs conducted monthly, 2) to ensure medical providers documented rationales for declining Gradual Dose Reductions (GDR), 3) to ensure the consultant pharmacists conducted comprehensive MRRs to ensure pertinent resident issues and irregularities were addressed in the MRRs, 4) to ensure GDRs were done or considered, as required by regulation, 5) to ensure irregularities were acted on in a timely manner, and 6) to ensure adverse side effects of medications were accurately detected, documented, reported, and appropriately resolved in a timely manner, all placed residents at risk for medication-related adverse outcomes. Resident #32 was harmed when the facility and/or pharmacist failed to identify polypharmacy of multiple psychoactive medications, identify somnolence and lethargy as possible side effects of psychoactive medications, and when the pharmacist did request GDR, the facility did not provide rationale of why GDR did not occur. After several months of treatment with multiple [MEDICAL CONDITION] and opioid medications, the resident was no longer able to walk, feed herself, communicate effectively, and became incontinent of bowel and bladder. These declines led to heel and coccyx pressure injuries, left hand/wrist contracture, weight loss and she had multiple falls. Findings included . RESIDENT #32 The resident admitted to the facility on [DATE]. The resident had [DIAGNOSES REDACTED]. According to the resident's admission Minimum Data Set (MDS) assessment, dated 05/23/2019, she had severe cognitive impairment, and for activities of daily living (ADLs) she required only limited assistance with bed mobility, transfers and personal hygiene and required only supervision with eating and walking. For bowel and bladder, the MDS indicated she was occasionally incontinent of urine and always continent of bowels. Review of the quarterly MDS, dated [DATE], revealed severe cognitive impairment, and for ADLs, she required extensive assistance of 1-2 persons with bed mobility, transfers, and personal hygiene. Walking did not occur during this MDS time period. For bowel and bladder, the MDS indicated she was always incontinent of bowel and bladder. Review of the Admission Nursing Data Base (nursing assessment), dated 05/16/2019: -weighed 153.8 lbs -was always continent of bowel and bladder, -had no pressure ulcers, -had a pleasant mood. Review of the May 2019 Medication Administration Records (MARs), revealed in May, she had been started on [MEDICATION NAME] (an antipsychotic medication) for unspecified [MEDICAL CONDITION], [MEDICATION NAME] (an antidepressant medication)for [MEDICAL CONDITION], and she was receiving [MEDICATION NAME] (an opioid pain medication) for pain. Review of the June 2019 MARs revealed the resident's [MEDICATION NAME] got re-ordered, the [MEDICATION NAME] dosing was increased (multiple times), and [MEDICATION NAME] (mood stabilizer/anticonvulsant medication) was added for unspecified [MEDICAL CONDITION], and the [MEDICATION NAME] was continued. Review of the MARs for 2019 and 2020 revealed ongoing treatment with [MEDICAL CONDITION] medications and [MEDICATION NAME] as follows: -[MEDICATION NAME] 50 mg (milligrams) daily at 9 AM - 06/20/2019 - 01/03/2020 -[MEDICATION NAME] 100 mg daily at 3 PM - 06/21/2019 - 01/03/2020 -[MEDICATION NAME] 100 mg daily at 9 PM - 06/20/2019 - 01/03/2020 -[MEDICATION NAME] (multiple dose changes, starting in June 2019) 250 mg twice daily at 9 AM & 1 PM - 07/25/2019 - ongoing as of 02/06/2020 -[MEDICATION NAME] 500 mg daily at 9 PM, 07/24/2019 - ongoing as of 02/06/2020 -[MEDICATION NAME] 25 mg daily at 9 PM - 05/29/2019 - 02/12/2020 -[MEDICATION NAME] PRN (as needed) - 06/25/2019 - 01/03/2020 A Nurse Practitioner note, dated 06/06/2019 indicated Resident #32 had dementia with hallucinations and behaviors, exit seeking, wandering and sundowning, and going into other resident's rooms. The resident was diagnosed with [REDACTED]. Pain is controlled, stable for now. A Nurse Practitioner note, dated 07/31/2019 stated that Resident #32 had late Alzheimer's dementia, behavior problems, wandered a lot, was getting into people's room, a little agitated occasionally, needed frequent redirection and occasionally one-on-one supervision. Also evaluating for fracture of left wrist with routine healing. Independent with feeding, assist with dressing and hygiene, mixed incontinent of bowel and bladder. She had a large blister on heels, she is independent with ambulation, no concerns with that. She looks well-nourished, no evidence of pain. Plan: Late Alzheimer's dementia, associated with increased anxiety, frequent agitation and frequent redirection, very confused, wandering around, sundowning and occasionally one-on-one supervision, patient has been seen by psych nurse, currently on [MEDICATION NAME], no change. She is at her baseline. The note did not indicate that the resident's Seroquesl doses had already been increased several times, and did not explain what necessitated the treatment with [MEDICATION NAME] Resident #32 was now on. In a Nurse Practitioner note, dated 09/20/2019, it stated that Resident #32 was lethargic, not real responsive, more wheelchair bound, and had dementia with behavioral disturbance. Patient appears to be stable on [MEDICATION NAME] and [MEDICATION NAME] at this time. Continue [MEDICATION NAME] 50 mg tab once daily as well as [MEDICATION NAME] 500 mg once daily. The note did not mention anything about the ongoing treatment with [MEDICATION NAME] (that had side effects of drowsiness/sedation) and [MEDICATION NAME] (which the resident was taking to aid sleep). The note did not address potential side effects of [MEDICATION NAME] (side effects included drowsiness, tiredness, lack of energy) or [MEDICATION NAME] (side effects of extreme drowsiness, dizziness, weakness) either. According to a Nurse Practitioner note, dated 09/25/2019, Resident #32 was still not ambulating as the resident had been in the past. According to a doctor note, dated 10/17/2019, Resident #32 was going to receive ongoing medical management for chronic pain, and a history of psychiatric disorders. [MEDICATION NAME] and [MEDICATION NAME] were to be continued. Although nurse practitioners notes dated 10/30/19, 11/29/19, and 12/04/19 indicated the resident was lethargic, had low blood pressure, had increased sleepiness throughout the day, and had overall decline, weakness, low energy, and decline in cognition, the nurse practitioner did not address the potential side effects of medications, and the resident remained on Seroqel, [MEDICATION NAME], Trazadone, [MEDICATION NAME]. The sleep monitored showed Resident #32 was sleeping 8-13 hours every day. In a nurse practitioner note, dated 01/07/2020, it was identified the resident had increased sleepiness, and weight loss, and was on [MEDICATION NAME] three times every day. The note indicated pain medications were made routine. Adjustments to [MEDICATION NAME] have been ineffective and patient remains extremely tired. Will discontinue midday [MEDICATION NAME]. We will also down titrate [MEDICATION NAME] to twice daily dosing. This nurse practitioner started the resident on a second antidepressant to stimulate the appetite, as the resident was already on an antidepressant as a sleep aid. Nurse Practitioner notes, dated 01/14/2020 and 02/04/2020 identified the need to reduce medictations to help improve extreme sleepiness and change in condition, and now the resident had pressure injuries along with weight loss. A 01/09/2020 Nursing Care Note by Nurse Manager showed that Resident #32 had a change in condition as follows: The resident was unable to sit upright in her wheelchair, speech therapy had difficulety evaluating the resident due to the resident's lethargy and difficulty staying awake during meals. When awake, the resident had difficulty eating and swallowing her food. Report from NOC (night) nurse resident sleeps throughout the night with zero difficulty. Resident mobility has declined drastic where she is now w/c (wheelchair) bound and hoyer transfer lift and dependent with feeding. Noted even with a decrease of her medications, resident is still very sleepy with difficulty staying awake.Reached out to social services to get in contact with son POA (Power of Attorney) to discuss changing current POLST (Physician order [REDACTED]. Nurse manager called this day with no answer and will follow up with son again to discuss and review current POLST status and possibly hospice as an option. Primary care provider aware of resident change and declining condition. Passed on report and care plan updated r/t resident decline in condition. Resident added on alert charting for decline in condition. CONSULTANT PHARMACIST MONTHLY MEDICATION REGIMEN REVIEW (MRR) REPORTS REVIEWED Dated 08/20/2019 - an irregularity was identified by the pharmacist related to [MEDICATION NAME] for sleep she was on since 05/19, the pharmacist notified the physician that a gradual dose reduction (GDR) should be considered, the resident's physician/nurse practitioner continued the medication with no change, the required rationale was left blank. Dated 09/26/2019 - an irregularity was again identified related to the ongoing treatment with [MEDICATION NAME] for sleep, and a recommendation was made to consider a GDR. The rest of this form was blank, there was no documentation the resident's physician/nurse practitioner had ever even seen it, it was never acted on. Dated 10/25/2019 - the resident's name was on a list of other residents that were reviewed by the consultant pharmacist, but did not require any recommendations. The resident had been noted by her nurse practitioner/physician to be lethargic, not ambulating as she had in the past, more wheelchair bound, yet no recommendations/irregularities identified by the consultant pharmacist. November 2019 - No MRR found in clinical record. There was a note in PCC (PointClickCare (electronic health record)), Pharmacist Acknowledgement, dated 11/19/19, that no irregularities noted. Even though the past few months doctor/nurse practitioner notes reflect lethargy, not extremely responsive at this time, more wheelchair bound, somnolent (sleepy), yet there were no irregularities identified by the consultant pharmacist. Dated 12/23/2019: the pharmacist wrote resident was due a GDR for [MEDICATION NAME] and [MEDICATION NAME]. The pharmacist note indicated if current therapy was to be continued, please provide a brief risk vs benefit assessment for state survey. The nurse practitioner wrote we are down titrating for sleepiness, but did not state which medication/s were being down titrated. STAFF INTERVIEWS In an interview on 02/12/2020 at 12:28 PM, the Director of Nursing Services (DNS) and Staff B, Licensed Practical Nurse (LPN)/Resident Care Manager, and later Staff A, Social Services, Staff C, Registered Nurse (RN) and Staff FF, RN, joined the interview after the DNS left the room, were interviewed: -Staff B stated medication adverse side effects were to be documented in progress notes. When asked whether medications had been assessed to see if medication side effects were contributory to the resident being wheelchair-bound and lethargic, the DNS and Staff B did not answer that question, Staff A stated the resident was still having hundreds of behaviors. When asked about the 08/20/2019 MRR that had no rationale documented for the pharmacist's GDR request, the staff interviewed were unable to provide any information. When asked about the 12/23/2019 MRR that requested a risk vs benefits assessment for the current [MEDICAL CONDITION] medication regimen, they were unable to provide any information. When asked about the many doctor/nurse practitioner notes that listed somnolence and lethargy as a problem and the relative lack of documentation regarding this in nurse progress notes, staff interviewed were did not provide any information. The DNS stated that the facility documented the presence of adverse side effects by exception, Staff FF stated there was not a space to document adverse side effects in the behavior monitors. When asked about the resident's change in condition in late September 2019 when she needed more assistance with ADLs, Staff C stated it manifested with the resident not being ambulatory and needing more assistance with cares. Staff C stated they changed pharmacists about that time. When asked about the 12/23/2019 MRR that listed three medications, and the nurse practitioner wrote We are downtitrating for sleepiness, but it did not list what was being downtitrated, Staff were unable to provide any information what was being downtitrated. When asked if the physician had documented Lowest effective dose - No GDR order, for any of the resident's medications, staff were unable to provide any information. In an interview on 02/12/2020 at 3:23 PM Staff GG, Advanced Registered Nurse Practitioner (ARNP): Staff GG stated her medical group took over the resident's care in August/September 2019, and the resident was still ambulatory then. Staff GG stated that she thought the resident actually worked at the facility. She stated she thought the resident was typically a sleepy person, and she thought that was due to the resident's [MEDICAL CONDITION], then she transitioned over to long-term care, and she didn't need to be seen for 30-60 days, then 5-6 weeks ago she seemed more sleepy, so she took a look at her medications and started to make adjustments, but she didn't make any adjustments until just recently when she started to look at her stuff. Staff GG stated she kept the resident on her [MEDICATION NAME] for sleep, even when she was somnolent because she was not sleeping at night, and that she was considering sundowning (a symptom of [MEDICAL CONDITION] also known as late-day confusion, confusion and agitation can worsen in late afternoons and evenings). Staff GG stated she did not get a lot of reports on that (from nursing staff). She stated she worked closely with Staff CC (Mental Health Nurse Consultant)(who's last progress note was dated 08/27/2019). When asked if nursing staff had been reporting any side effects of the [MEDICAL CONDITION] medications, Staff GG stated No, I don't get a detailed report of that. When asked what the [MEDICATION NAME] was treating, Staff GG stated to treat the behaviors and [MEDICAL CONDITION] from the dementia, as she would refuse cares, and she had a distrust. When asked if [MEDICATION NAME] was known to be effective at treating behaviors and [MEDICAL CONDITION] from dementia, Staff GG stated she didn't like using it for that, but that the resident was already on a lot of [MEDICATION NAME] when she took over her care. Staff GG said if the facility needed her at the GDR meetings, then she should be invited to them. When asked about the 08/20/2019 MRR with no GDR being done, and no documented rationale for no GDR, Staff GG stated she went with the nursing input, that she had been getting better at documenting rationales. When asked about the pharmacist's request for a risk vs benefit assessment on the 12/23/2019 MRR, Staff GG stated she didn't do one, but she has started doing them recently. She stated she didn't do a GDR for the [MEDICATION NAME] because staff told her the resident was awake all night, and sleepy during the day. When asked about the resident's current physical condition, unable to walk, unable to self transfer, needed a hoyer lift for transfers, couldn't feed herself, all things she could do when she admitted to the facility, Staff GG stated the resident was very deconditioned right now. When asked about the ongoing pain management with all of the [MEDICATION NAME] for so long, Staff GG didn't have any information to offer. When asked if the resident was still having postoperative wrist pain, Staff GG stated she didn't know for sure, she stated she thought the resident's pain was all over. She stated the resident wasn't really talking much. Staff HH, physician/Medical Director, joined the interview. Staff HH was asked about the facility's adverse side effect monitoring program, he stated they relied heavily on self-report from the nurses. Staff HH said they go by what the nurses reported to them. In a phone interview on 02/18/2020 at 10:01 AM, Staff R, Consultant Pharmacist, and Staff S, Consultant Pharmacy Clinical Manager stated we were notified of the IJs related to [MEDICAL CONDITION] medications and opioids, we made a 300+ page report, there were many responses to pharmacy recommendations, a lot of recommendations that were not addressed or responded to appropriately, we sent some back to the facility for review, we met over the weekend with the facility and two providers. We had repeated recommendations that weren't addressed appropriately, so we spoke with the nursing director and a corporate representative, they did not know why the MRRs were not responded to. If MRRs were not responded to, we may make a repeat recommendation, or we may speak with facility staff. -Staff R stated that the first month he did MRRs, he met with the DNS, but he didn't get follow up until the next month, so he had no trends, especially with recommendations that were not followed up on. Staff R stated we are now implementing a percentage rate for what recommendations that were followed up on. When asked asked what was done if there was a recommendation for a GDR and the physician declined without documenting a rationale, Staff R stated that he reminded the nurse managers that rationales need to include some kind of concrete details, especially related to behaviors residents exhibited. When asked if it's an expectation that rationales were completed, Staff S stated in their meetings, they emphasized that just saying no to a GDR was not good enough, that they encouraged concrete details in the documentation. He stated they tried to draw the line without being too intrusive, but at the same time they did need information, and Risk vs Benefit should also be specific and customized. When asked what was the facility's system for monitoring for potential adverse side effects of medications, Staff R stated unfortunately, I am not familiar with their systems, I haven't gotten to the details of where they track side effects. When asked if the facility had notified them of concerns with this resident, the pharmacist staff answered Yes, I looked into it, I reviewed her my first month in December, then I sent a GDR letter because of the multiple [MEDICAL CONDITION] she was on. Then in 01/20 it looked like the [MEDICATION NAME] was being changed and monitored by the provider, I can't speak to going back, but the providers response in 12/19 was downtitrating. Staff stated multiple [MEDICAL CONDITION] can trigger hypersomnolence, so that could be an impact, I can't speak to hypersomnolence. When asked if this combination of [MEDICAL CONDITION] and opioids could have contributed to the multiple declines in her functional abilities, Staff S stated Thank you for that question, antipsychotic medications and the other drugs may see some additive effects on side effects, it is difficult unless there is a cause/effect relationship, unless there is a timeline, it is best to withdraw one medication at a time, if they withdraw one at a time and a side effect comes up, then there might be evidence the medication was causing harm. In a phone interview on 02/21/2020 at 8:22 AM, Staff CC, Registered Nurse/Mental Health Nurse Consultant (Behavioral Health), when asked about all of the potential side effects the resident was exhibiting like lethargy, somnolence, wheelchair-bound, etc .Staff CC stated that those side effects were not brought to my attention. Staff CC stated The facility did not notify me of any side effects, I would have of course looked into it. Is it the fault of the medications, I can't say that, I just don't know if that decline was related to medications. I have no way of knowing if her decline was related to medications. There were many concerns of putting her on medications and continuing to increase the doses. I was still coming to the building, but no one ever asked me to see her again. In an interview on 02/26/2020 at 9:26 AM, Staff N, RN/Minimum Data Set nurse, was asked about the significant change back in 09/19, Staff N stated we noticed she needed more care, because when she first admitted she was walking around more, but then she wasn't, she went from mostly continent to frequently incontinent, then to incontinent, she started sleeping more, and she needed more extensive assistance. In summary, this facility's medication management program failed Resident #32. When the resident admitted to the facility she was able to communicate effectively, walk, feed herself, to get herself in/out of bed, usuallly continent of urine, and always continent of bowels, she had no skin injuries, and she had no contractures. After about six months in the facility, of [MEDICAL CONDITION] medications and opioid pain medications, she was no longer able to walk or communicate, she required staff assistance with eating, she was incontinent of bowel and bladder, she had two skin injuries, she had a contracture in her hand/wrist, and she had significant weight loss. There was an extended period of time where the resident was somnolent and lethargic, but staff did not recognize and respond timely to potential side effects of medications. There were issues with: 1) [MEDICAL CONDITION] Medications Reviews not being accurate and comprehensive, 2) a lack of GDRs for [MEDICAL CONDITION] medications, 3) MRRs that failed to flag and identify issues/irregularities pertinent to medication management, 4) physician/nurse practitioner failures in addressing MRR irregularities and documenting rationales for declining pharmacist recommendations, 5) inadequate facility medication adverse side effect monitoring practices, 6) a lack of physician involvement in addressing medication-related adverse side effects. Overall, the resident exhibited many signs of adverse side effects that went unaddressed for months. These issues were not identified and timely addressed by the facility, nor was there documentation that the consultant pharmacists were fulfilling their roles as consultants in improving facility medication management systems. RESIDENT #29 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her quarterly MDS, dated [DATE] she was rarely/never understood, had delusions, got antipsychotic medications and opioids, and was on hospice care. CONSULTANT PHARMACIST MRR REPORTS REVIEWED: Multiple requests were made of staff for MRRs for this resident all the way back to 01/01/2019, the facility was unable to provide MRRs for 03/19, 04/19, 05/19, 06/19, and 09/19. If the resident's medication regimens were reviewed by a consultant pharmacist for those months, the reports were not made available to the survey team. -MRR dated 8/20/2019, the pharmacist notified the physician that the PRN [MEDICATION NAME] (antianxiety medication) order duration was limited by regulations to 14 days, the provider wrote a rationale the resident was very debilitated and near end of life care, and continued the order for an additional 90 days. -MRR dated 12/23/2019: the pharmacist notified the physician that the PRN [MEDICATION NAME] was limited to 14 days, the physician continued the order for 99 more days and wrote in hospice pt (patient). -MRR dated 12/26/2019, the pharmacist notified the physician the resident was on three [MEDICAL CONDITION] medications and was due for a GDR, the physician agreed with the [MEDICATION NAME] GDR and wrote for that, but did not address [MEDICATION NAME] or Quetiapine. A note on the form indicated the resident was averaging 10-12 hours of sleep a night. -MRR dated 02/14/2020, the pharmacist wrote the resident was on four [MEDICAL CONDITION] medications and required GDRs. The note indicated per behavior monitoring records: there has been no documented behaviors of anxiety (nervous agitation, excessive worry), being physically or verbally aggressive, or delusions and resistance to cares/meds, and that per IDT (interdisciplinary team) meeting on 02/17/2020 hospice resident, defer to hospice. Another form with the same date indicated: Please note, hospice may not be an adequate rationale for state survey purposes. Review of [MEDICAL CONDITION] Medication Review forms: -Dated 09/21/2019: revealed staff had documented the last GDR for [MEDICATION NAME] was 4/08/2019. Review of the April 2019 MARs for that date revealed the dose of [MEDICATION NAME] was actually increased on that date. On that same review, staff did not list any other potential contributing factors, like pain, or medication interactions, even though the resident was being treated with [MEDICATION NAME] and [MEDICATION NAME] (both opioid pain medications). The review had a note, under recommendations, that the pharmacist was going to write a letter requesting a decrease of [MEDICAL CONDITION] medications now that the resident was on hospice, the letter could not be located in the clinical record. Staff A was asked about the letter, she stated that would have gone to nursing, she stated she didn't know about the letter as it was pretty much out of my hands. In an interview on 02/21/2020 at 10:31 AM, Staff A confirmed there was not a [MEDICATION NAME] GDR on 04/08/2019, she stated I can fix that. Staff A reviewed the resident's clinical record and determined the last [MEDICATION NAME] GDR was 02/16/2019, so it had been over a year since the resident had a [MEDICATION NAME] GDR. Staff A stated we need to look at that again (the [MEDICATION NAME] for GDR). Staff A did not know if the resident's doctor had written an order that the [MEDICATION NAME] was at the Lowest Effective Dose. Staff A was asked about pain, and why was it not listed as a potential contributing factor, she stated I think I just need to slow down to make sure I do them right. We reviewed the 06/11/2019 [MEDICAL CONDITION] Medication Review, and it also did not have pain listed as a potential contributing factor. PROGRESS NOTE REVIEW -dated 12/24/2019, revealed on 09/25 pharmacist wrote a letter requesting decrease of [MEDICAL CONDITION] meds now that she was on hospice but it had yet to be initiated. Recommending decreasing [MEDICATION NAME] to 250mg twice daily. Review of this medication revealed [MEDICATION NAME] was not decreased until 01/08/2020. -06/11/2019 - [MEDICAL CONDITION] Med Review -IDT recommendation to continue to monitor and review next qtr. The quarterly review did not address adverse side effects of the medications, although it was identified that on two days the resident was leaning over in her wheelchair, tired PAIN EVALUATIONS REVIEWED Dated 03/18/2019: pain evaluation was incomplete, it did not list all of the pain medications Resident #29 was on, [MEDICATION NAME] (non-steroidal anti-[MEDICAL CONDITION] drug used to decrease pain and inflammation) was omitted. The evaluation did indicate the resident received scheduled [MEDICATION NAME] and [MEDICATION NAME], but it did not indicate whether they were effective or if there were side effects (per the form's instructions). The resident was also receiving PRN [MEDICATION NAME], but that medication was omitted from the pain evaluation. There were no comments regarding the overall pain evaluation and whether it was effective or not. On 06/13/2019: the pain evaluation was incomplete, it indicated she received scheduled [MEDICATION NAME], and [MEDICATION NAME], but it did not state if there were side effects. Summary: There was no documentation a consultant pharmacist had did MRRs for five months in 2019 for this resident. There was also a lack of consultant pharmacist documentation they had reviewed this resident's pain evaluations or [MEDICAL CONDITION] medication reviews done by nursing. The consultant pharmacist also failed to identify that the resident had not had a GDR for [MEDICATION NAME] for over one year. Additionally, the resident had potential medication related side effects, but this did not get identified on any monthly MRRs. RESIDENT #12 Review of the facility's pharmacy recommendations showed there were no recommendations for April 2019 through September 2019. A pharmacy recommendation, dated 10/21/2019, showed the pharmacist recommended decreasing [MEDICATION NAME] and [MEDICATION NAME]. On 12/10/2019, 50 days later, the recommendation was addressed. In an interview 02/25/2020 at 12:15 PM, the DNS confirmed there were missing reports and the 10/21/2019 recommendation was addressed late. RESIDENT #20 Review of the facility's pharmacy recommendations showed there were no recommendations for March 2019 through July 2019, October 2019 and November 2019. A pharmacy recommendation, dated 08/20/2019, showed the pharmacist recommended decreasing the [MEDICATION NAME]. The recommendation failed to include a rationale for no change, documenting stable only. RESIDENT #30 A pharmacy recommendation, dated 08/20/2019, showed the pharmacist recommended decreasing the Duloxetine. The recommendation failed to include a rationale for no change, documenting stable chronic condition only. In a similar 12/23/2019 recommendation to decrease the Duloxetine, the recommendation was not dated and did not include documentation as to why the recommedation was rejected. In an interview 02/25/2020 at 12:16 PM, the DNS confirmed there were missing reports and the 08/20/2019 recommendations did not include a rationale for no change and was addressed late. RESIDENT #3 Resident #3 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set assessment (MDS), dated [DATE], showed that Resident #3 was moderately cognitively impaired, suffered from delusions (misconceptions or beliefs that are firmly held, contrary to reality). During review of monthly pharmacy reviews for February 2019 through February 2020 revealed that there had not been monthly review completed for the months of September 2019 and November 2019. During a joint interview & record review on 02/27/2020, Staff BBB, Regional Director of Clinical Services verified that there were no pharmacy consults for September 2019 or November 2019 in the clinical record and was unable to provide any further information. RESIDENT #68 Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Pharmacy recommendation, dated 01/11/2019, showed a pharmacist recommended that the discontinuation of Memantine ([MEDICATION NAME]) medication, Resident #68 was receiving for dementia. The physician acknowledged this recommendation and confirmed order to discontinue on 01/11/2019. Review of Medication Administration Records (MAR's), dated January 2019, February 2019, March 2019, April 2019 and May 2019, showed that Resident #68 received the Memantine medication for approximately 5 months after the order was discontinued. Review of Pharmacy acknowledgment in the clinical record, dated 02/11/2019, showed no irregularities noted. The resident was still receiving a medication that should have been stopped in January 2019. Further review showed that there were no pharmacy acknowledgments completed in the clinical record for 03/2019, 04/2019, 05/2019, 06/2019, 07/2019, 08/2019 or 09/2019. During a joint interview & record review on 02/24/2020 at 3:08 PM, the DNS confirmed that Resident #68 had a pharmacy recommendation from January 2019 that was not followed up on until May 2019. The DNS verified that the medication memantine for d (TRUNCATED)

Based on observations, interviews and record review, the facility failed to 1) ensure there was sufficient numbers of nursing staff to provide care and services or provide adequate supervision to prevent accidents/elopements/wandering, 2) meet the needs or wants of the residents, 3) ensure all residents received showers, 4) answer call lights timely, 5) and to have enough staff to have consistent clinical systems in place to identify skin issues, bowel and bladder issues, restorative programs for two of two units reviewed for staffing. These failures caused harm for residents, placed residents at risk for unmet care needs and resulted in negative resident outcomes. Findings included . RESIDENT INTERVIEWS: RESIDENT #63 In an interview on 02/04/2020 at 12:13 PM, Resident #63's representative stated the resident had told her he had to wait a long time for staff to respond to his call light. RESIDENT #128 In an interview on 02/04/2020 at 2:02 PM, Resident #128 stated she had 45 minute wait times at times to get help, and stated it could be that long of a wait on any of the shifts. The resident stated she had only been at the facility for about two weeks. RESIDENT #45 In an interview on 02/05/2020 at 9:22 AM, Resident #45 stated there was not enough staff available, and sometimes there were only two people because the A wing gets most of the staff. The resident stated sometimes they get a light duty staff member and voiced concern for needing assistance with Hoyer lifts. The resident stated wait times were as long as 30 minutes, and voiced her roommate had negative outcomes due to waiting half an hour. In an interview on 02/07/2020 at 11:26 AM, Resident #45 stated she was supposed to receive assistance from female staff only, and on night shift there was only one male available. The resident stated males had been providing her care even though she was supposed to be assisted by female staff only. RESIDENT #59 In an interview on 02/05/2020 at 11:03 AM, Resident #59 stated it took a long time for someone to answer her call light when she turned it on for assistance. RESIDENT #18 In an interview on 02/05/2020 at 12:24 PM, Resident #18 stated there was not enough staff available to get the care and services he needed. RESIDENT #60 In an interview on 02/05/2020 at 2:03 PM, Resident #60 stated at times it took an hour to get his call light answered, and it happened on all shifts. RESIDENT #29 In an interview on 02/05/2020 at 2:23 PM, Resident #29's family stated they did not believe the facility had enough staff. The family member stated the nurses were constantly working double shifts, and the CNA's had to do double and triple shifts. The family member stated there was a long history of staffing concerns. The family member stated it was hard to find a staff member when they needed something. In an interview on 02/05/2020 at 3:08 PM, another family member of Resident #29 stated they did not think the staff knew the residents and stated they had be reminded of Resident #29's back fracture when turning her in bed. The family member stated they had to post a sign on the wall to remind staff of Resident#29's back fracture. The family member stated they were concerned because staff were coming to work coughing a lot and, did not feel ill staff should be around the resident's. RESIDENT #12 In an interview on 02/05/2020 at 2:33 PM, Resident #12 stated call light times ranged from five minutes to 30 minutes, depending on how many CNA's there were. The resident stated she did not think the facility had a handle on it with all the CNA's. RESIDENT #28 In an interview on 02/24/2020 at 3:22 PM, Resident #28 stated she had waited 30 minutes for assistance and resulted in her being incontinent and soaking her bed. In an interview on 02/26/2020 at 8:37 AM, Resident #28 stated that last night about 12:30 AM, she got sick and threw up in her bed. She stated she put her call light on and no one came for over half an hour. RESIDENT COUNCIL: In a resident council meeting, on 02/06/2020 at 11:32 AM, the group stated call lights being answered were an issue and that when they go down the hallways the call lights were lit up like a Christmas tree. The group stated getting showered was an issue. One member of the group stated she didn't get her shower yesterday, only on Sunday, and stated she complained and it did her no good. Another member of the group stated there were issues with getting timely assistance on and off the bedside commode. One group member stated there was a wandering resident that climbed into her roommate's bed and that staff would come and remove the wandering resident 20 minutes later. RECORD REVIEW: Review of the facility assessment, dated 06/30/2018 through 07/29/2019, showed the facility did not identify staffing needs related to resident population, care needs, and census. Review of daily staffing sheets, dated 10/09/2019-10/31/2019 showed the following: On 10/09/2019: Day shift B-wing showed four NACs (Nursing Assistant Certified) scheduled. Of the four scheduled, one was injured and one was light duty, leaving two fully capable NACs to care for residents on B wing. 10/11/2019: Day shift B-wing showed two NACs scheduled, whereas A-wing had four NACs. Night shift showed two NACs scheduled for A-wing, with one of the NACs listed as only working 11 PM- 4 AM. Leaving a total of three NAC'S for A and B wings. 10/12/2019: Night shift showed three NAC's scheduled for A wing, and two NAC's for B wing. One NAC called out on B wing, leaving one NAC scheduled for B wing. 10/16/2019: Day shift showed A and B wings to be scheduled with three NAC's each, totaling six. One NAC was moved from B wing to A wing, giving A wing four NAC's and leaving B wing with Two NAC's. 10/17/2019: Night shift showed two NAC's scheduled for A wing and one NAC scheduled for B wing. 10/18/2019: Night shift showed two NAC's scheduled for A wing and one NAC scheduled for B wing. 10/21/2019: Day shift showed 4 NAC'S scheduled for A wing, and three NAC's scheduled for B wing. A wing had a call out, and an NAC was pulled from B-wing to make four NAC's for A-wing, and leaving two NAC's for B-wing. 10/22/2019: Day shift showed 4 NAC'S scheduled for A wing. Two NAC's called out, leaving two NAC'S for A wing. 10/23/2019: Evening shift showed five NAC's scheduled. Of the five NAC's scheduled to work A and B wing, one called out, one was not to arrive till 5 AM, and one was scheduled to leave at 5 AM, leaving three NAC's for A and B Wings. 10/24/2019: Night shift showed five NAC's scheduled. Of the five NAC's scheduled, one was scheduled until only 2 AM, and one was scheduled to arrive at 5 AM, leaving three NAC's for A and B wings for the hours of 2 AM till 5 AM. 10/25/2019: Night shift showed four NAC's scheduled. Of the four NAC's scheduled, one was scheduled until only 2 AM, leaving three NAC's for A and B wings. 10/26/2019: Evening shift for B-wing showed two NAC's scheduled as a third scheduled person was crossed out. 10/27/2019: Day shift showed for B-Wing one NAC called out leaving two NAC's for the day shift for B wing. 10/31/2019: Night shift showed four NAC's scheduled for A and B wing. One NAC scheduled for A-wing showed the one NAC worked until 2 AM, leaving three NAC's for A and B wing. Review of the daily staffing sheets, dated 02/03/2020-02/08/2020 showed the following: 02/06/2020: Night shift showed one NAC scheduled for B wing. 02/07/2020: Night shift showed one NAC scheduled for B wing. RESIDENT #129 Resident #129 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident sustained [REDACTED]. The falls occurred on the following dates: 01/18/2020, 01/29/2020, with two falls on 02/02/2020. After every fall, the facility was unable to get the resident off the floor and called emergency medical services (EMS) to assist with getting the resident up from the floor. In an interview on 02/25/20 at 1:22 PM, the DNS stated, she called EMS to help get the resident off the floor because the resident was obese and the staff were not able to get her up. The resident required many people to lift her up and during that time there was not enough staff to help. GRIEVANCES/RESIDENT COUNCIL: Review of resident council notes, dated 08/07/2019 through 02/19/2020, showed the following: * 08/07/2019: Showed under old business- concerns for call lights not being answered while staff were on breaks. Under new business showed concerns for call lights being turned off and not addressing residents' concerns/needs. Under issues to follow up, it showed concern for call lights- waiting, turning off, and not being answered. * 09/04/2019: Showed under new business- concerns for staff turning off call lights without addressing resident's needs. Under issues to follow up, call lights was listed. * 09/18/2019: Showed under new business- concerns for call lights and staff not leaving the call light on if not able to answer it right away. * 10/02/2019: Showed under old business- concerns for call lights being turned off and needs not being met. Under new business- concern for call lights. * 10/16/2019: Showed under old business- concerns for call lights. Under new business concerns for answering call lights for both residents in room not just one, and showers not getting done on scheduled days. * 11/02/2019: Showed under old business- concerns for call lights and answering call light for both residents in a room, medication pass being slow on night shift, and concerns for showers. Under new business shower schedule was listed. * 11/06/2019: Showed under old business- concerns for call lights being answered. Under New business showed call light concerns related to answering both residents in the room and not turning off call light without answering needs. Other new business concerns were medication pass being slow, personal issues with call lights, and shower schedules. * 12/04/2019: Showed under announcements- shower schedule addressed. New Business showed concerns for call lights- reminding staff to put within reach for residents * 12/18/2019: Under old business it showed concerns for call lights being in reach of residents. Under New Business it showed personal issue with shower schedule. * 01/08/2020: Showed under addressed prior concerns- of fixed time on call lights and showers are being done .Under New Business for Nursing it showed a complaint about time length left on the commode. * 02/12/2020: Showed under new business for nursing- concern for average call light response was 20 minutes to an hour long. Residents requested that there were two CAN's (Certified Nursing Assistant) on the floor at all times for both wings, and more communication between residents and their care programs. *02/19/2020: Showed under Nursing- concerns for being short staffed, nurses running behind on their cares and passing out medications. Concerns for residents not getting enough showers, one resident stated, I've gone over a month without a shower. Showed residents are entitled to get two showers a week, and most residents stating they were only getting one a week. Review of the grievance log, dated 08/07/2019 through 01/30/2020, showed the following: 08/07/2019: concerns for not getting showered. 08/14/2019: concern for staffing. 09/10/2019: three concerns from three different residents for not getting showered. 09/13/2019: concern for not getting showered. 09/16/2019: concern for not getting showered. 09/18/2019: concern for not getting showered and wearing the same socks for three days. 09/23/2019: concern for long call light response. 09/24/2019: concern for long call light response. 09/25/2019: concern for a 3.5 hour long wait for pain medications. 09/27/2019: concerns for not getting showered regularly. 09/27/2019: concern for long call light response and not getting showered. 10/04/2019: concern for call light response. 10/04/2019: concern for call light response. 10/16/2019: concern for call light response. 10/17/2019: concern for not getting showered. 10/19/2019: concern for not getting showered. 10/21/2019: concern for call light response. 11/06/2019: concern for call light response. 11/14/2019: concern for not getting needed Activity of Daily (ADL) care related to oral care. 11/15/2019: concern for call light response. 11/16/2019: concern for not getting showered. 11/19/2019: concern for not getting showered. 11/20/2019: concern for not getting medication timely. 12/04/2019: concern for receiving insulin medication late. 12/06/2019: concern for call light response. 12/06/2019: concern for not getting showered. 12/12/2019: concern for not getting showered. 12/12/2019: concern for call light response. 12/26/2019: concern for call light response. 01/03/2020: concern for not getting ADL care related to oral care. 01/03/2020: concern for not getting showered. 01/17/2020: concern for not getting ADL care. 01/24/2020: concern for call light response and customer service. 01/20/2020: concern for call light response. CALL LIGHT OBSERVATIONS: The following call light observations were made: 02/07/2020 4:59 AM: room [ROOM NUMBER] call light on. Call light answered at 5:20 AM. 02/07/2020 5:33 AM: room [ROOM NUMBER] call light on. Call light answered at 5:53 AM. 02/07/2020 6:20 AM: room [ROOM NUMBER] call light on. Call light answered at 6:52 AM. 02/07/2020 6:50 AM: room [ROOM NUMBER] call light on. Call light answered at 7:05 AM. 02/07/2020 7:00 AM: room [ROOM NUMBER] and 123 call lights on. At 7:13 AM, rooms 123 & 160 were still on, unanswered. 02/10/2020 1:12 PM: room [ROOM NUMBER] call light on. Staff were observed in the area and not answering the call light. At 1:31 PM, the call light was answered. 02/12/2020 at 8:20 AM: room [ROOM NUMBER] call light on. At 8:35 AM the call light was answered. 02/13/2020 at 8:21 AM: room [ROOM NUMBER] bathroom light on. No staff were observed to be in the area. Call light answered at 8:30 AM. 02/18/2020 at 1:33 PM: room [ROOM NUMBER] and 161 call lights on. The call lights were answered at 1:52 PM. 02/18/2020 at 3:00 PM: room [ROOM NUMBER] call light on. At 3:23 PM, the call light was answered. 02/19/2020 at 10:09 AM: room [ROOM NUMBER] call light on. At 10:32 AM, the call light was answered. 02/19/2020 at 11:33 AM rooms [ROOM NUMBERS] call light on. room [ROOM NUMBER] call light was answered at 11:58 AM. room [ROOM NUMBER] call light was answered at 12:04 PM. Residents waited 20-30 minutes before their call lights were answered. STAFF INTERVIEWS: In an interview on 02/07/2020 at 6:01 AM, Staff OO, NAC, stated last night he had 30 residents on his assignment, and stated this happened a lot of time on A-wing. Staff OO stated managing fall risk patients and caring for residents was overwhelming. Staff OO stated it was frustrating with only 2-3 staff members for 60 residents. Staff OO stated he had worked alone as the only NAC on B wing with 37 residents. In an interview on 02/07/2020 at 6:30 AM, an anonymous staff member stated that night shift can be overwhelming if something goes wrong. The anonymous staff member stated that they had to often work late to get through the medication pass on A-wing for the long term care residents. The anonymous staff member stated night shift could use another staff member as the staff member stated they felt they were spread thin. Staff stated last night they had one aide on the hall. In an interview on 02/07/2020 at 6:46 AM, Staff PP, RN, stated staffing could be better in the evening as evening shift could be tightly staffed. Staff PP stated they had asked for another nursing staff but there had been turn over. Staff PP stated last night, they had up until 3:30 AM, 3 aides for A wing with 55-57 residents, two aides on the floor and one doing one to one. Staff PP stated after 3:30 AM the one to one staff left. Staff PP stated they did not know why the aide left at 3:30 AM as Staff PP stated they were busy dealing with a patient in acute respiratory distress. Staff PP stated they thought the 1:1 resident could be in line of sight and was not aware the resident continued to require 1:1 supervision. In an interview on 02/07/2020 at 7:12 AM, Staff QQ, Nursing Assistant Registered (NAR), stated on night shift staffing was sparse in the amount of nursing aides working. Staff QQ stated it was stressful working night shift with only two aides instead of three. Staff QQ stated it was hard when people called out and someone had called out last night. In an interview on 02/07/2020 at 7:25 AM, Staff FF, RN, stated for night shift after 10:30 PM, there was usually only one nurse scheduled. In an interview on 02/14/2020 at 6:08 AM, Staff T, Registered Nurse (RN), stated Resident #32 had a heel wound that was bleeding last night and the dressing came off, so Staff T changed the dressing. Staff T stated she had been rushing all night with 40 patients on A-wing, and stated she did not feel like she did good wound care because the dressing wasn't really fitting the wound at all. Staff T stated she failed to put the resident's sock back on after the wound care. When asked why Staff T did not put on the resident's sage boots after the wound care as reqired, Staff T stated she relied on the NAC's for that, and stated she didn't put on the sage boots because she didn't think about it. Staff T stated she felt she needed further training in wound care. Staff T stated there was just so much to do, and when one thing happens it throws everything off and she could not get everything done. Staff T stated she was supposed to change the resident's coccyx wound dressing last night but she did not get to it with everything going on. In an interview on 02/14/2020 at 11:00 AM, Staff RR, NAC, stated there were not enough staff to provide residents with needed care. Staff RR stated in the mornings they only have about 10 minutes to provide resident's care and it was not enough time as some residents can take longer such as 25-40 minutes. Staff RR stated managing 10-12 residents was hard, and stated they did not feel they could do a good job for the residents. In an interview on 02/14/2020 at 11:58 AM, Staff NN, Shower Aide, stated she worked Thursday, Friday, and Sunday. Staff NN stated she did come in and do extra shifts. Staff NN stated she was the only shower aide on A-wing. Staff NN stated she did 17 showers on Thursdays, 10 showers on Fridays, and 10 showers on Sundays. Staff NN stated she did not know if someone did showers on the days she was off work, and stated she did not think there was anyone else scheduled to give showers that she knew of. Staff NN stated she had snow days and missed work on 01/10/2020 and 01/17/2020, and stated she did not know who did showers for the residents in her absence. Staff NN stated she also had to help with meals. She stated she had only gotten to three showers for the day and it was slow going because she could not find staff help for Hoyer transfers that take two people. Staff NN stated she would likely have to stay late to try and get showers done. In an interview on 02/14/2020 at 12:23 PM, Staff SS, RN, stated often times the NAC's were stretched very thin. Staff SS stated the NAC's try very hard but was hard when there was 3-4 call lights on at once. Staff SS stated it was very frustrating. In an interview and observation on 02/18/2020 at 1:39 PM, Staff TT, NAC, was observed passing hall trays on A wing. Staff J, RN, stated hall trays were delivered at 1:15 PM. When asked about staffing, Staff J, stated he only had 3 aides when they try to have 5 aides and a shower aide. Staff J stated staffing was hard and it made him want to pull his hair out. In an interview and observation on 02/18/2020 at 1:52 PM, Staff UU, NAC, was observed to still be passing lunch trays. Staff J, asked Staff UU for assistance to lay down a resident, and Staff UU stated she was told she couldn't help until all the trays were passed and picked up. In an interview on 02/19/2020 at 10:08 AM, Staff J, RN, stated he only had four aides for today. Staff J stated he was not sure about a shower aide and stated his residents were itchy from not being showered. In an interview on 02/20/2020 at 1:59 PM, Staff K, NAC, stated he only had four aides today but had started with five aides and a shower aide. Staff K stated the fifth aide had to be sent home because they were a Nursing Assistant Registered (NAR) that was over the 120 days and the NAR did not have an active license yet. In an interview/observation on 02/21/2020 at 8:36 AM, Staff K, NAC, was the only staff present at the dining room table with five other residents in need of meal assistance. He said the restorative aide came on at 10 AM and helped at lunch but he just had to do his best to help at breakfast. In an interview on 02/21/2020 at 11:46 AM, Staff VV, NAC, stated there was not enough staff. Staff VV stated they often had three staff members split between the two halls instead of 5 due to call offs. Staff VV stated they get caught up in situations and it was difficult to provide equal care for each resident. Staff VV stated it was overwhelming then they were constantly pulled in all different directions. Staff VV stated it was overwhelming when on the floor to provide care for people who needed assistance. In an interview on 02/21/2020 at 12:55 PM, Staff NN, NAC, stated she did not think there was enough staff. Staff NN stated she sometimes comes in and pick up additional shifts. Staff NN stated shower aides absolutely needed another person on B-wing as the shower aide often was pulled to the floor and the aides were too busy to realistically get all showers done. In an interview on 02/21/2020 at 1:05 PM, Staff WW, Activity Assistant, stated there were not enough staff, and stated they would benefit from additional staff. Staff WW stated if during an activity a resident wanted to leave, they would have to stop the activity and assist the resident back to their room. In an interview on 02/24/2020 at 10:54 AM, Staff J, RN, stated that, Today, I have 4 aides and one training. No shower aides. In an interview on 02/24/2020 at 1:48 PM, Staff J stated there were not enough aides at times. Staff J stated he had to stop medication pass to go help a resident as they might fall. Staff J stated he knew the aides were tired. For further information regarding staffing Refer to F 600 Refer to F 677 Refer to F 684 Refer to F 686 Refer to F 688 Refer to F 689 Refer to F 692 Refer to F 838 This is a repeat citation from complaint survey on 08/14/2019 and Annual survey on 12/04/2018. Reference: (WAC) 388-97-1080 (1)

Based on observation, interview and record review, the facility failed to ensure four of eight residents (#38, #63, #30, and #59) received the necessary care and services to prevent a significant and severe weight loss. This failed practice caused harm for Resident #38 and #63 in the form of severe weight loss, signs of dehydration with dry lips and placed the residents at risk for adverse health, safety and diminished quality of life. Findings included . According to the State Operations Manual (SOM), with an implementation date of 11/22/2017, the Centers for Medicare and Medicaid Services defined the parameters for significance of unplanned and undesired weight loss for severe weight loss as greater than 5% in one month. Review of the facility's policy titled, Nutrition & Hydration: Nutrition at risk, dated March 2015 showed Nutrition at Risk (NAR) is aimed at recognizing the patient (s) at risk or already experiencing impaired nutrition, by improving, or maintaining acceptable parameters of nutritional status through integrated interdisciplinary interventions .Patient (s) are assessed and reviewed by the NAR committee when they meet the following criteria: * weight change of 5% (percent) in 30 days, 7.5 % in 90 days, or 10% in 180 days unless determined through assessment and documentation on nutritional progress note with evidence why this would not be required; * Consistent meal intake of less than 50% with impaired skin or weight decline; * Consistent meal intake of 0-25%; * Acute fluid balance alteration if unexpected i.e. resulting in a 5% or greater weight loss or gain: and significant change in condition confirmed by Interdisciplinary Team (IDT); *Patients being reviewed by NAR will continue to be seen weekly or bimonthly as designated by the IDT(interdisciplinary team) and discontinued once stable. RESIDENT #38 Resident #38 admitted on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], defined a clinically significant weight loss episode for nursing home residents as a loss equal to or greater than 5% within a 30-day period or 10% within a 180-day period. Review of the Admission Care Area Assessments (CAA's) on 06/08/2019 showed a risk of dehydration and recommended fluids pushed with 2,000 milliliters (ml) every day as the goal. The nutritional status showed staff were to proceed with the care plan interventions to minimize the risk of impaired nutrition and maintain a stable weight. Review of the care plan showed the resident had a potential for nutritional problems with the goal of no unanticipated weight loss and for the resident to be free of impaired hydration. The care plan directed staff to offer 180 ml of thickened fluids three times daily, conflicting with the CAA. Review of the weight summary showed on 12/31/2019, he weighed 152.8 pounds and on 02/11/2020 his weight was 138.6 pounds, a 14.2 pound weight loss, this reflected a 9.3% weight loss within 6 weeks. Review of the dietary notes showed Resident #38 had significant weight loss of 6% or 9.2 pounds beginning 01/15/2020. Review of a progress note dated 01/22/2020 at 7:50 AM revealed Resident declining, and deconditioned. Hospice consult for continuation of care and comfort measures. Review of the care plan showed Resident #38's nutrition care plan was not revised until 02/20/2020. Review of the dietary notes showed the following: 01/22/20 weight 138.0, loss of 12.5% or 19.8 pounds resident declining and deconditioned. Hospice consult placed for continuation of care and comfort measures; 02/06/20 weight 142.0 , loss of 6.9 % or 10.6 pounds in 30 days and 10% or 15.8 pounds; weight is stable at this time continue to monitor for significant changes; and 02/13/20 weight 138.6, loss of 9.2%/14.0 pounds in 30 days. Resident has [DIAGNOSES REDACTED]. Will monitor for significant changes Review of the physician orders [REDACTED]. Review of the clinical record showed multiple charting omissions for health shake intake and facility staff did not document the amount of health shake intake consumed. The resident received the honey thick liquids as ordered for hydration as follows: November 2019: received 5 of 90 shifts December 2019: received 14 of 93 shifts January 2020: 6 of 93 shifts February 2020: 2 of 78 shifts as of 02/27/2020 at 3:23 PM Review of the meal intake 01/15/2020 through 02/27/2020 showed: 0-25% of meal eaten=39 meals 26-50% of meal eaten=8 meals 51-75% of meal eaten=30 meals Meal replacement only offered once for his meal intake of less than 50%. In observations on 02/04/2020 at 1:03 PM and 3:10 PM Resident #38 was in bed asleep. There were no fluids at bedside. In observations on 02/05/2020 at 10:50 AM, 1:47 PM and 2:34 PM, Resident # 38 was in bed asleep with no fluids at bedside. In observations on 02/06/2020 at 8:17 AM, Resident #38 was in his recliner asleep. At 10:29 AM, he was in his recliner eating breakfast and stated I don't feel good. He was observed asleep at 11:44 AM and 1:17 PM with no fluids at bedside. In observations on 02/07/2020 at 4:50 AM, he was observed asleep in his recliner. At 6:00 AM, he was awake his lips were very dry and scabbed. He stated Thirsty, I am not good. There was no water or any fluids available. At 7:10 AM, 8:34 AM, and 11:21 AM, he was in his recliner asleep with no fluids available. His lips remained dry . In observations on 02/10/2020 at 8:33 AM, Resident # 38 was asleep in his recliner. At 9:42 AM he was in his recliner with his breakfast tray, trying to bring thickened juice with a fork up to his mouth. He ate 20% of his pureed entree. At 11:27 AM, 1:08 PM, 2:48 PM he was in bed asleep. There were no fluids at bedside. In observations on 02/11/2020 at 8:58 AM and 9:45 AM he was in bed asleep. There was no breakfast tray present. The meal monitor indicated he was unavailable. At 11:15 AM, he was in his recliner awake. His lips were dry. At 1:23 PM, he was in his recliner asleep. At 2:05 PM, he was standing up with unsteady gait. At 3:27 PM, he was asleep in his recliner with no fluids present on any observation. In observations on 02/12/2020 at 9:50 AM, he was awake in his recliner. At 11:27 AM and 12:10 PM he was in bed asleep, At 1:50 PM, he was in his recliner asleep. At 3:03 PM, was in his wheelchair facing the window asleep. There was a full ice cream on his overbed table. There was no water or other fluids present. In an observation on 02/13/2020 at 8:22 AM, he was in his recliner sleeping. At 10:02 AM, he was in his recliner eating. He stated, I do not feel well. I am sleepy. He ate 40% breakfast but only 90 ml juice. At 11:46 AM, 2:56 PM, and 3:25 PM, he was asleep in his recliner with no fluids present. In observations on 02/14/2020 at 6:22 AM, 7:38 AM he was asleep in his recliner. At 10:00 AM and 11:08 AM, he was observed asleep. His breakfast tray had been delivered and was untouched. His fluids were full and covered with Saran wrap. At 12:22 PM he was asleep in his recliner with no fluids available. In an interview on 02/18/2020 at 3:03 PM, Staff J, RN said he was not sure how much health shake the resident was supposed to get. Staff J said maybe Resident #38 had his own supply or the kitchen provided the shakes. Staff J confirmed the resident was to receive 240 ml of honey thick liquids every shift. In observations on 02/18/2020 at 9:26 AM and 11:05 AM, the resident was in bed asleep. At 1:53 PM Resident #38 was in his recliner with dry lips with thick mucous like strings on his upper and lower lips. The resident asked for water. At 3:02 PM and 3:33 PM Resident #38 was asleep in his recliner. There was no water or any fluids at bedside. In an interview on 02/19/2020 at 12:18 PM, Staff K, NAC said He sleeps a lot. He drinks coffee pretty well. This morning he did not drink anything. He does not always drink anything on his tray. Once he poured it on his lap. If I give it to him he may pour it and it is a catch 22. If we leave it, he dumps it on himself. In observations on 02/19/2020 at 8:45 AM, Resident #38 was asleep in bed. At 10:00 AM, the resident was sitting on the side of his bed. At 12:02 PM and 2:23 PM, Resident #38 was in bed asleep. There was no water or any fluids at bedside. In observations on 02/20/2020 at 8:18 AM, Resident #38 was in bed asleep. At 9:22 AM, the resident was sitting on the side of the bed and breakfast was delivered. At 10:45 AM, 11:37 AM, 2:20 PM and 3:20 PM, the same two half filled cups of juice remained at bedside In observations on 02/21/2020 at 8:40 AM, 9:47 AM, Resident #38 was asleep. At 11:18 AM, the resident was asleep and his breakfast tray remained untouched. At 1:06 PM, Resident 338 was observed asleep. In observations on 02/24/2020 at 10:02 AM, Resident #38 was in his recliner asleep with two glasses of juice covered with Saran wrap. At 11:19 AM and 12:29 PM, drinks remained untouched at bedside. At 2:23 PM, the resident was in bed asleep with no drinks at beside. In all observations on 02/25/2020 at 8:28 AM, 9:57 AM,10:27 AM, 1:10 PM and 2:33 PM, Resident #38 was asleep with untouched fluids at bedside. In an interview on 02/25/2020 at 12:16 PM, the Director of Nursing Services was informed of concerns of dry lips, lack of fluids available at bedside, excessive somnolence and untouched meal trays. The DNS said Resident #38 was on Hospice. An updated weight was requested but no additional information was provided. In observations on 02/26/2020 at 9:02 AM the resident was in his recliner with a glass of milk on his overbed table. At 3:07 PM no fluids were available. In an interview on 02/26/2020 at 11:32 AM, Staff Q, Registered Dietician was informed of concerns of dry lips, lack of fluids available at bedside, excessive somnolence and untouched meal trays. Staff Q stated, His weight fluctuates and goes up and down. I recommended a hydration pass 240 ml three times a day at a minimum and a nutrition shake three times a day between meals. In observations on 02/27/2020 at 9:00 AM, Resident #38 was in his recliner with one untouched glass of juice. His lips were dry. At 9:26 AM and 10:03 AM the resident had no breakfast tray. At 10:44 AM and 11:36 AM, the resident was asleep and no fluids were available. In observations on 02/28/2020 at 10:44 AM and 11:34 AM, Resident #38 was observed asleep in his recliner with dry lips and no fluids present. RESIDENT #63 Resident #63 admitted on [DATE] with [DIAGNOSES REDACTED]. He had left sided paralysis and required extensive assistance with ADL's (activities of daily living). Review of the Quarterly MDS dated [DATE], showed that the resident had a swallowing disorder and loss of liquids and solids from his mouth when eating or drinking. The assessment also indicated Resident #63 held food in his mouth or had residual food in his mouth after meals. He received his total calories and fluids via a feeding tube, and had no weight loss during the assessment period. Review of the care plan showed a revision on 01/02/2020 for progressive self feeding: Redirect patient towards food. Place individual items in patients field of vision and direct to eat. Hand under hand guidance or point to utensil and cups and provide cueing to eat and drink. Review of a progress note on 01/28/2020 showed that Resident #63 was sent to the hospital to replace his feeding tube but they were unable to replace it. Review of the care plan on 02/05/2020 showed no alteration in nutrition care plan present until 02/12/2020. The feeding tube had been discontinued off of the care plan on 02/04/2020 but there were no interventions to direct staff how to maintain his nutrition by mouth. The care plan showed Resident #63 was able to eat with supervision in the dining room. In a provider note dated 02/07/2020, Staff GG, Advanced Registered Nurse Practitioner (ARNP) documented the resident was at risk for depression,PEG (implanted feeding tube) tube was pulled out once again and patient was sent to ED (Emergency Department) for replacement. This is unable to be replaced he is now p.o. (by mouth) nutrition. Weight loss significant. RD following PEG tube pulled . Patient is fully P.O at this time. Makes this difficult to maintain weight and patient does have some dysphasia (difficulty swallowing). Will have to monitor closely. Review of a nurse progress note dated 02/09/2020, showed Dining aides report that resident sleepy during meals and not swallowing well. Needed cueing to swallow and some of his food dribbled out of the left side of his mouth. The nurse also had to remind him to swallow before drinking more of the med pass and he lets it dribble out of the L (left) side of his mouth. Resident has had a 12 pound wt loss in the last month. Will write a note to MD to follow up on this. Review of a nutrition note on 02/10/2020 revealed Resident #63's weight was down 7.5% or 13 pounds in 30 days. In an interview on 02/21/2020 at 10:50 AM, Staff K, NAC stated, He can feed himself but like today I had to help him. It was like he was distracted. Staff K confirmed the resident needed one person physical assistance for feeding and did not consistently feed himself. Review of a nutritional note on 02/25/2020 at 9:56 AM, showed the resident's weight was 161.2 pounds and he had lost 6.0 % or 10.2 pounds in 30 days. Review of the HS (bedtime) snack documentation 02/01/2020 to 02/26/2020 showed the resident refused the HS snack all but four nights. There was no follow up as to a possible different snack that Resident #63 would accept. Review of Resident #63's meal intake from 01/14/2020 through 02/27/2020 showed : 0-25%= 49 meals 26-50%=27 meals 51-75%=22 meals The nutritional supplement was offered only 4 of the 76 meals indicated times and the amount consumed was less than ordered on those occasions. In an interview on 02/05/2020 at 10:56 AM, Resident #63 stated he tried to eat on his own and did not want the tube feeding again. He said The first thing staff told me when I came here was not to pull on it or it would hurt and the first thing they do is pull it out. He also said he was interested in getting his teeth fixed. In observations on 02/06/2020 at 10:50 AM, 11:51 AM and 1:17 PM, the resident was observed with no food or fluids present. In observations on 02/07/2020 at 4:55 AM, 5:50 AM, 7:07 AM, Resident #63's lips were dry. He had no fluids at bedside. At 8:26 AM, the resident was in the dining room receiving meal assistance. At 11:13 AM, Resident #63 was in his room sliding down in his wheelchair. No fluids were available. In an observation on 02/12/2020 at 2:50 PM, the resident stated he thought he was losing weight and staff had to help him eat. He said he was not very hungry, his mouth was dry with long mucousy strings. In an observation on 02/21/2020 at 8:36 AM, the resident was in the dining room with his breakfast in front of him. No one was providing meal assistance. Staff K, NAC, was the only staff present at the table with five other residents in need of meal assistance. According to Staff K, the restorative aide came on at 10 AM and helped at lunch but that he just had to assist residents during breakfast. In an observation on 02/25/2020 at 8:20 AM, 1:10 PM and 2:27 PM, the resident was sitting in the hallway, with dry lips. During multiple observations on all days of survey, there were no fluids at bedside. In an interview on 02/25/2020 at 12:28 PM, the DNS was informed of nutrition concerns and weight loss with the need for more assistance in the dining room. Additionally, the nutrition care plan was not revised when Resident #63 was off tube feed and required meal intake to meet his nutritional needs. The DNS said he is was on NAR and we are looking at him. We are going to call the daughter as he is not able to meet his nutritional needs without the tube feeding. He does not want his peg tube. No additional information provided. In an interview on 02/26/2020 11:40 AM, Staff Q, RD was informed of concerns the resident had dry mouth, lack of fluids in between meals, lack of quiet environment and assistance in the dining room with subsequent weight loss. Staff Q stated, He does not want the tube feed he has told me that. As soon as his tube feed came out abruptly, we tried to do Cal Dense (nutritional shake) in between meals, tried to supplement like a tube feed and added vitamins. Staff were to push minimum 1500 ml in between meals and offer fluids in between meals. She said nursing was doing weekly NAR and she met with him again. She stated, Tube feed was providing 1800 calories a day and abruptly gone so he would lose weight. He likes ice cream but we cannot give him because of texture we offer a magic cup supplement. I really wanted them to push supplements for calorie and protein dense OJ too and fortified foods. She confirmed she did not revise care plans. RESIDENT #30 Resident #30 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of her Quarterly MDS, dated [DATE], revealed Resident #30 required extensive assistance of one for eating, and did not reject care. Review of the nutrition care plan last revised 01/04/2019 showed Resident #30 enjoyed comfort foods such as peanut butter flavored items and coffee, and her favorite meal was breakfast. The care plan directed staff to alternate bites/sips-small bites-slow rate-use small metal spoon when assisting resident with feeding presenting in midline-place cup in hand to encourage self feeding. Resident being followed by IDT in NAR, implement recommendations as she allows to encourage optimal PO intakes. Review of the 05/22/2019 Annual MDS Nutritional Status CAA showed Resident #30 was on a regular diet with drinkable puree texture and required encouragement and cueing. Review of the Medication Administration Records for 2019 and 2020 directed staff to provide House med pass 2.0 (nutritional supplement) 240 ml in a coffee cup three times daily. Review of the MAR indicated [REDACTED] November 2019: drank 240 cc on 20 of 90 offerings; December 2019: drank 240 cc on 24 of 93 offerings; January 2020: drank 240 cc on 19 of 93 offerings; and February 2020: drank 240 cc on 12 of 79 offerings Reviews of meal intake from 01/03/2020 through 02/28/2020 showed: 0-25% of meal eaten=76 meals 26-50% of meal eaten=4 meals 51-75% of meal eaten=2 meals Resident #30 was offered meal replacement on 22 of 80 indications for consuming less than 50 % of her meal. Review of the physician's orders [REDACTED]. On 03/01/2019, Resident #30 weighed 149 pounds. Her last previously recorded weight was on 02/04/2020 at 139.0 pounds. In observations on 02/06/2020 at 10:41 AM, Resident # 30 was up in her wheelchair in the Solarium requesting water. At 11:54 AM, she was in the dining room asleep. In observations on 02/07/2020 at 7:57 AM, she was in the hall drinking a health shake out of a disposable cup instead of a coffee cup. She tried to eat her disposable cup and the nurse intervened. At 8:22 AM, Resident #30 was in the dining room. Her food was served but she was not initiating eating. There were no staff present. At 11:16 AM, the resident was sitting in the he solarium and stated I love breakfast. I eat everything. In observations on 02/10/2020 at 8:27 AM, Resident #30 was in the dining room awaiting breakfast. At 1:06 PM, the resident was in the dining room. Her food and drinks were untouched. There was a chair by her but no one assisted. In observations on 02/11/2020 at 8:56 AM, the resident was in the dining room. Her drinks were 1/2 full and she ate 40% of her breakfast. In observations on 02/12/2020 at 8:20 AM and 12:12 PM, Resident #30 was in the dining room asleep in her wheelchair. In an observation on 02/13/2020 at 8:20 AM and 8:50 AM, Resident #30 was in the dining room asleep. There was no staff by her, and the resident's yogurt, cereal, health shake and 2 glasses of juice were untouched. In an observation on 02/19/2020 at 8:23 AM, the resident was in the dining room asleep, her liquids were completely untouched, and there was no staff by her. In an observation on 02/20/2020 at 8:18 AM, Resident #30 was in the dining room asleep. Her meal was untouched and no staff were around to assist her. In an observation on 02/21/2020 at 1:02 PM, the resident was in the dining room, her food and liquids were untouched. There was no staff offering assistance. In an observation on 02/24/2020 at 8:33 AM, Resident #30 was in the dining room with staff leaning over her who then left, and the resident's breakfast was untouched. In an observation on 02/28/2020 at 11:57 AM, Resident #30 was in the dining room with juice in front of her but she did not initiate to drink it, and no staff was present. In an interview on 02/19/2020 at 12:11 PM, Staff K, NAC stated All she does is drink health shakes. She does not eat food. She will drink apple juice, cranberry juice the vast majority is apple juice. She is on liquidized diet. You put fluids up to her lips and she will take it. In an interview on 02/25/2020 at 12:10 PM, The DNS was informed the resident had orders for Health shakes 240 ml three times daily but was not receiving this as ordered or consistently. She was also informed weekly weights were not being obtained. A recent weight was requested but not provided. In an interview on 02/26/2020 at 11:27 AM, Staff Q, RD was asked about Resident #30's weight loss and lack of adequate nutrition intake, including the need for more meal assistance. Staff Q stated, She seems to be stable. She has been stable, she fluctuates which is normal . RESIDENT #59 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was alert with some confusion. Review of the resident's clinical record, revealed the resident's weights to be as follows: On 12/19/2019, the resident weighed 165lbs On 01/06/2020, the resident weighed 153lbs On 01/24/2020, the resident weighed 138.6lbs On 02/06/2020, the resident weighed 138lbs On 02/07/2020, the resident weighed 138lbs On 02/21/2020, the resident weighed 134lbs Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], the MDS showed that the resident required supervision, oversight, encouragement or cueing for eating. Review of the resident's Kardex (care directives for the nursing assistants) documented: Modified independent after set up for eating. The Kardex erroneously documented the resident ate independently. In an observation on 02/05/2020 at 08:58 AM, the resident was observed in her room, with her breakfast tray in front of her. The resident had only eaten a few bites, there was no staff in the room supervising or encouraging the resident to eat. The resident was asked about her breakfast, the resident stated, oh, I think I am done. On 02/18/2020 at 1:50 PM, the resident was delivered her lunch food tray to her room and left on her bedside table, no assistance or encouragement was provided to the resident. The resident ate a few bites of her meal and then fell asleep. In an observation on 02/24/2020 at 10:27 AM, the resident was observed in bed, the resident had her breakfast tray in front of her, she had only eaten about 3 bites of toast. No staff was in the resident's room encouraging or cueing the resident to eat. On 02/24/2020 at 10:24 AM, in an interview with Staff Z, a nursing assistant, Staff Z stated that the resident was served her meals in her room, no assistance or encouragement was provided to the resident because the resident was independent with eating. Staff Z further stated that he used the information on the resident's Kardex to provide the resident care. On 02/24/2020 at 11:36 AM, in an interview with Staff C, the resident care manager, Staff C stated she was responsible for creating the resident's care plan, when asked about the resident's MDS information regarding eating, and the discrepancy of the care plan, Staff C stated she would look into it. Staff C was asked about the resident's weight loss and the lack of encouragement/cueing being a contributing factor, Staff C did not offer any more information. This is a repeat deficiency from SOD dated 02/13/19. Reference: (WAC) 388-97-1060 (3)(h)

Based on observation, interview and record review, the facility failed to provide care and services to prevent and heal pressure ulcers/pressure injuries for three of four residents (#32, #29, and #12) reviewed. The failure to float heels, to turn and reposition routinely, and to use standard resident handling practices, placed residents at risk for developing skin injuries. Resident #32 was harmed when she developed two pressure ulcers in the facility. The facility then failed to protect her heels by relieving pressure per the care plan, to put her back to bed between meals, to relieve pressure on her coccyx, and to use standard resident handling practices during incontinent care which resulted in delays in healing of her two skin pressure injuries. Findings included . RESIDENT #32 The resident admitted to the facility on [DATE] for rehabilitation after having a fall at home resulting in a left wrist fracture. On admission the resident had [DIAGNOSES REDACTED]. According to the resident's admission Minimum Data Set (MDS) assessment, dated 05/23/2019, she had severe cognitive impairment. The MDS indicated Resident #32 was not at risk of developing pressure ulcers and did not have any unhealed pressure ulcers. Review of the quarterly Minimium Data Set (MDS), dated [DATE], showed that Resident #32 required extensive assistance of 1-2 persons with bed mobility, transfers, and personal hygiene and was always incontinent of bowel and bladder. This MDS indicated the resident was at risk of developing pressure ulcers. Review of a wound consultant report, dated 02/11/2020, revealed the resident had two skin injuries; an unstageable pressure injury to the coccyx that measured 4.9 x 4.2 x 0 cm (centimeters), and a full-thickness left heel wound with necrotic/eschar tissue (necrotic is non-viable tissue due to reduced blood supply; eschar is dry, black, hard necrotic tissue) that measured 6 x 7 x 0 cm. Review of the care plan, print date 02/06/2020, revealed a focus area that the resident was at risk for skin impairment related to dementia, diabetes, and lack of self care. Interventions included: -resident to be up in wheelchair for all meals -ensure she is back in bed between meal times -ensure she is turned and repositioned when she is in bed -she was to have heel protectors on both feet at all times. In an observation on 02/10/2020 at 9:02 AM, the resident was being wheeled out of the dining room in her wheelchair, she had no heel protectors on. In an observation on 02/10/2020 at 10:14 AM, the resident was sitting in her wheelchair by the nursing station. The resident was not wearing heel protectors. The resident also was not wearing heel protectors this same day at 11:05 AM, 11:38 AM, 12:19 PM, 12:25 PM, and 1:58 PM (note: during all of these observations, the resident was sitting in her wheelchair, and not back in bed between meals). In observations on 02/11/2020 at 10:17 AM, 11:06 AM, and 2:12 PM, the resident was sitting in her wheelchair and not back in bed between meals, like her care plan directed. In an observation on 02/14/2020 at 5:57 AM, the resident was in bed, the sage boots (brand of heel protector) were in her wheelchair, and her heels were in contact with the bed without anything underneath to float them off of the bed. Also noted, the resident's left foot did not have sock on at this time. In an interview on 02/14/2020 at 6:08 AM, Staff T, Registered Nurse, was asked about the observation at 5:57 AM where the resident's left heel with bandage was observed sitting directly on the mattress. Staff T stated that the resident's heel wound started bleeding last night and Staff T and had not put the sock back on that left foot either, and that Staff T relied a lot on the nursing assistants for that. In an observation on 02/14/2020 at 8:48 AM, Staff ZZ, Nursing Assistant, was observed doing incontinent care on the resident. To turn the resident to her side, Staff ZZ grabbed the drawsheet and gave it a brisk tug, causing friction against the resident's wound. After removing the resident's briefs there was an unpleasant odor from her groin area even though she had not been incontinent of stool. In an observation on 02/19/2020 at 9:36 AM, the resident was observed sitting in her wheelchair between meals. In an observation/interview on 02/24/2020 at 10:42 AM, the resident was observed sitting in her wheelchair in the Solarium, the resident was asked if she wanted to be up in her wheelchair, she stated I'd rather be in bed. The resident was asked why she was up in her wheelchair, she stated she didn't know. In an interview on 02/24/2020 at 10:47 AM, Staff ZZ was asked about the resident being up in her wheelchair and not back in bed between meals per her care plan, Staff ZZ stated I just haven't gotten to it yet, I'll get to it. In an observation on 02/24/2020 at 1:26 PM, the resident was observed asleep in her wheelchair in the Solarium. In summary, this resident developed two skin injuries in the facility. The resident did not get her heels protected per her care plan, she did not get pressure relieved between meals per her care plan, staff did not use proper resident handling techniques during incontinent care, and staff did not ensure Resident #32's Sage boots were worn per her care plan, she developed a heel and a coccyx pressure injury. RESIDENT #29 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her quarterly MDS, dated [DATE], the resident was rarely/never understood, needed 2-person assist with bed mobility, transfers, dressing, toilet use, and personal hygiene, and was at risk of developing pressure ulcers. In an interview on 02/05/2020 at 3:17 PM, the residents' daughter stated she would come to visit, and no staff would come and reposition her mother for hours and hours. Review of the resident's Kardex (care directives for nursing assistants), print date 02/20/2020, revealed for bed mobility Resident #29 required two people to assist the resident. Review of the Braden Scale for Predicting Pressure Sore Risk, dated 12/05/2019, revealed the resident was at high risk for developing a pressure sore. Review of the care plan, print date 02/06/2020, revealed the resident required reposisitoning in bed for skin integrity. In observations on 02/07/2020, the resident was in bed on her back at 6:53 AM, 8:37 AM, and 10:42 AM. In observations on 02/10/2020, the resident was in bed on her back at 8:58 AM, 10:15 AM, 11:06 AM, 11:37 AM, and 12:20 PM. In an interview on 02/12/2020 at 12:28 PM, Staff C, RN, stated residents still needed to be repositioned even if they were on the APP mattress (pressure-relieving mattress). In an observation on 02/20/2020 at 3:24 PM, Staff ZZ was observed doing bed mobility by herself for the resident during incontinent cares. In an interview on 02/21/2020 at 2:26 PM, Staff D, Staff Development Coordinator, was asked about Staff ZZ doing incontinent care on the resident with only 1 person assist who was at high risk for skin injury, he looked in the electronic health record and stated the resident was supposed to be 2-person assist. He stated he would address it with Staff ZZ. RESIDENT #12 Resident #12 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. tissue), diabetes. She did not reject care. Review of the Admission MDS dated [DATE] showed the resident admitted with a stage I or greater pressure ulcer including one stage 3 pressure ulcer and one venous or arterial ulcer. In an interview on 02/05/2020 at 12:03 PM, Resident #12 said she had been in the hopital for five months for wounds prior to admit. She said currently she had wounds on her right leg and two blisters that had overloaded with fluid and opened up. She said she had wounds on her left stump and her right heel but they had healed. Review of a progress note from Staff GG, ARNP on 02/21/2020 showed the resident's right lower extremity positive for darkened, reddened, and warm skin with small open areas .improved but still draining. Review of the clincial record as of 02/27/2020, showed her skin and wound evaluations were last assessed on 01/27/2020 (four weeks earlier). Measurements were: distal 2.2 cm X 2.8 cm, mid 2.0 cm X 2.0 cm, proximal 1.0 cm X 1.7 cm The TAR (treatment administration records) directed staff to monitor open area to RLE (right lower extremety) until resolved beginning 01/05/2020 until 02/05/2020 when it was removed from monitoring although it was not resolved. Review of the care plan showed actual skin impairment including a stage III (stage 3) right heel pressure ulcer, and a left stump and left inner knee post surgical wound that had resolved. Staff were directed to complete a skin assessment weekly and place the SAGE boot to her right foot while the resident was in bed. Review of the Kardex directed staff to encourage the resident to wear a SAGE boot on her right foot while in bed. During multiple observations all days of survey, Resident #12 was not observed to wear the SAGE boot on her right foot when she was in bed. During an observation of wound care on 02/27/2020 at 12:16 PM, performed by Staff E, RN, Staff E stated that Resident #12's wound was greatly improved since admit and the resident's leg remained fragile and high risk. Staff E said she was unaware of how frequently staff do her dressing changes. No wound measurements were obtained at that time. In an interview on 02/25/2020 at 12:20 PM, the Director of Nursing was informed there were no weekly measurements for the resident's right leg and that Resident #12 had not had her SAGE boot on as careplanned. The DNS provided no additional information. In an interview on 02/28/2020 at 12:11 PM, Staff D, Staff Development Coordinator, was informed the resident's wounds were last measured on 01/27/2020. He confirmed that wounds were to be assessed daily, wounds measured weekly and documented. He said if there was no change in the wound within two weeks then another treatment was to be requested when the physician was updated. Reference: (WAC) 388-97-1060 (3)(b)

Based on observation, interview, and record review, the facility failed to ensure appropriate services were provided to maintain, increase and/or prevent a decrease in range of motion for three of five residents (#12, #32 and #59) reviewed for range of motion. This failure resulted in harm for two residents when Resident #12 developed foot drop (paralysis of muscles that lift the foot), and right knee contracture(shortening of muscles in a fixed position) and decline in function, and Resident #32 was harmed when she developed a contracture she did not have when she admitted to the facility, and the facility had not provided restorative services recommended by therapy services. When the facility did provide restorative services, there was a six week delay in starting them. The facility placed residents at risk for a decline in range of motion, developing pain, and contractures. Findings included . RESIDENT #12 Resident #12 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. tissue), and [MEDICAL CONDITION]. The resident required kidney [MEDICAL TREATMENT] three times a week for kidney failure, and did not reject care. Review of the Physical Therapy (PT) evaluation on 04/23/2019 revealed, RLE (right lower extremity) moves through full range against gravity and was within functional limits. Review of a PT evaluation on 05/28/2019 showed that Resident #12's right lower extremity ROM (range of motion) was within functional limits. Review of a PT evaluation on 09/28/2019 showed that Resident #12 experienced a decline in ROM related to a right knee flexion contracture, and included a short term goal: for the resident to increase her ankle range of motion using modalities and ROM to increase ankle ROM. Review of a physician order [REDACTED]. Review of the clinical record showed Resident #12 was not evaluated by PT at that time. Review of a progress note dated 12/29/2019, showed,Resident has a restorative nursing program to maintain/improve functional status related to amputation/prosthesis care, impaired physical mobility, risk/loss of ROM, Restorative Programs 1. AROM (active range of motion) to bilateral upper and lower to decrease risk of contractures 2. Exercise program to maintain strength. (Resident #12) refuses to do the RA (restorative) program. We will be dc'ing (discontinuing) the program as of today. The restorative care plan intervention was resolved on 12/29/2019. The care plan showed the resident had previously been on a restorative program to maintain/improve functional status related to amputation/prosthesis care, impaired mobility, risk of loss of ROM three to six times a week for fifteen minutes. Review of a PT evaluation on 01/14/2020 showed RLE ROM=impaired (knee 0-45, ankle lacks 25 degrees from neutral dorsiflexion). This showed Resident #12 experienced decline in her ROM. The Kardex (directs nursing assistants how to care for resident) did not include any restorative or range of motion directives. Review of the Minimum Data Set (MDS) assessment, dated 01/25/2020, documented the resident had impaired functional range of motion in her lower extremity and did not receive any restorative therapy in the lookback period. Review of a provider note from Staff GG, Advanced Registered Nurse Practitioner note dated 01/31/2020 showed on 12/11/2019 patient requested RA (restorative aid) to work with her. Review of restorative aide charting, between 01/01/20 and 02/26/2020, documented Resident #12 received nursing rehab AROM to Bilateral upper and lower (location of extremity was not specified) to decrease risk of contractures on five days of January 2020 and February 2020. There was no prior documentation of restorative care. Review of restorative program documentation showed the resident was to receive restorative three to six times a week. Resident #12 received restorative for a total of five days between January and February 2020. Review of behavior monitoring between 01/01/2020 and 02/26/2020 showed no refusals of care for Resident #12. In an interview and observation on 02/25/2020 at 8:19 AM, Resident #12 was in bed. The resident said she was concerned she did not get therapy or restorative and now her right foot had foot drop. Resident #12 attempted to move her right ankle but it barely moved. The resident said she had been on therapy upon admit and at one time was non weight bearing and had wounds. The resident said her insurance stopped therapy and she was supposed to get restorative. Resident #12 said she wasn't getting restorative and her doctor ordered it. Resident #12 said she complained to the Director of Nursing (DNS) and Staff G, Restorative Aide. The resident said the DNS and Staff G both came in later and said So are you going to do restorative or what? Resident #12 said she told them yes however, it needed to be scheduled around the [MEDICAL TREATMENT] appointments. Resident #12 said Staff G worked with her in the gym but mostly doing balloon toss which did not help or stop her foot drop. Resident #12 stated she tried to do the bands herself but it was better if someone else helped her. She said, I am concerned. I cannot stand on this. I am afraid. I cannot get a prosthesis now and need to get my electric wheelchair and go home. During observation of Restorative care performed by Staff LL, RA, on 02/26/2020 at 1:53 PM, Resident #12 was in bed. The resident stated, I am glad you are here or I was going to raise holy hell. Staff LL, RA began to perform heel stretches to the resident's right foot. The resident called out,Oh Lordy and Staff LL stopped. Staff LL was unable to do complete range of motion to Resident #12's right foot . Staff LL commented, Her heel cords are tight. The resident said it had been ten months since she walked and she was no longer able to stand because of the foot drop. In an interview on 02/25/2020 at 12:20 PM, the DNS was informed of the recently developed right foot drop and documentation showing Resident #12 was not consistently receiving restorative care. The DNS said the resident had an active restorative plan but the resident refused it. She provided no additional information. In an interview on 02/26/2020 at 3:00 PM, Staff G, RA, said the resident had come to the gym to do balloon toss. Staff G said Resident #12 did not do too much with her lower extremities. Staff G said it was hard to get to the resident's restorative with her [MEDICAL TREATMENT] schedule, and stated, Unfortunately, we were not documenting the refusals because there is no space to write that in or leave a note. According to Staff G, the DNS was overseeing the restorative program but was busy with the whole building, and could not recall when the last restorative meeting was to review the resident's programs. In an interview on 02/27/2020 at 9:58 AM, Staff DD, Rehab Manager/ Physical Therapy Assistant confirmed the resident had foot drop in her right foot. Staff DD said she worked with Resident #12 on four occasions, most recently for a wheelchair evaluation. Staff DD stated that the resident had not been seen for her right foot or was assessed for any devices. In an interview on 02/27/2020 at 10:03 AM, Staff EE, Physical Therapist stated the resident was currently on caseload for a power wheelchair evaluation. Staff EE said at one time she set the resident up for a restorative program for her ankle in June (2019). She said Resident #12 was on and off therapy a few times and was first seen in April 2019 until there was a change in payor source. Staff EE said in November of 2019 the resident was seen to increase her ankle dorsiflexion. Staff EE said Resident #12's baseline range was -(negative)25 degrees and the goal was for her to be at minus 15. According to Staff EE, the resident reached -20 degrees dorsiflexion at discharge. My recommendation would be she get restorative consistently. It does not take that much to have us come in and do RA even after [MEDICAL TREATMENT]. Staff EE said she did not take measurements but the resident's ankle was within functional limits upon admit and the foot drop was acquired in the facility since admission. Resident #12's resultant injury resulted in a physical impairment, decline in function and increased dependency on caregivers with a decreased ability to return to her prior living environment. RESIDENT #32 The resident admitted to the facility on [DATE] for rehabilitation after having a fall at home resulting in a left wrist fracture that required surgical repair. On admission the resident had [DIAGNOSES REDACTED]. According to the resident's Admission MDS assessment, dated 05/23/2019, she had severe cognitive impairment. In an interview on 02/19/2020 at 11:20 AM, Staff DD, Director of Rehabilitation, stated the resident now had a hand/wrist contracture that she didn't have when she admitted to the facility. In an interview on 02/21/2020 at 11:30 AM, Staff DD stated the resident had Occupational Therapy services twice while at the facility, the first time was after admission, and the second time was around 08/06/2019 because the resident had developed a contracture. Staff DD provided two Therapy RA referral forms, one was dated 06/17/2019 and the second was dated 09/03/2019. Review of a Therapy RA Referral form, dated 06/17/2019, revealed the resident had been referred to Restorative Nursing to get active ROM six times weekly to the left wrist, in order to maintain her current level of performance and in order to prevent a decline. Review of another Therapy RA Referral form, dated 09/03/2019, revealed the resident had a left hand contracture, and was referred for passive ROM and a splint/brace assistance, six times weekly. Review of the resident's clinical record revealed the first referral (dated 06/17/2019) did not result in the resident receiving restorative services. Review of the resident's care plan, print date 02/06/2020, revealed the second referral resulted in the resident being care planned to receive restorative, but not for 6x/weekly as recommended by therapy, the care plan reflected she was care planned for 3-6x weekly. The care plan indicated the restorative services were care planned as of 10/15/2019. Review of a Documentation Survey Report, dated October 2019, revealed the resident started restorative services on 10/15/2019, about six weeks after the referral from Occupational Therapy. The resident received restorative services as follows: -10/15/2019 - 10/31/2019 - 7 times -November 2019 - 5 times -December 2019 - 6 times -January 2019 - 4 times -02/02/2020 - 02/20/2020 - 5 times In an interview on 02/20/2020 at 10:53 AM, Staff G, Restorative Aide, was asked why the the resident did not receive restorative services as required per the care plan, Staff G stated, Obviously I should have tried to work with her more. In an interview on 02/21/2020 at 12:23 PM, the DNS was asked for documentation to show the resident got restorative services after the first Occupational Therapy referral, (06/17/2019), she was unable to provide any information. The DNS was asked about the delay in providing restorative services from 09/03/2019 - 10/14/2019, she stated it took time to process the referral. The DNS was asked why the resident wasn't care planned to receive restorative services 6x/weekly per the referral, the DNS stated that was therapy's preference, not nursing, and that restorative was a nursing function. The DNS was asked why the resident wasn't receiving restorative services even the 3-6x/weekly as she was care planned to receive, the DNS was unable to provide any information. The DNS was asked about the contracture, she was unable to provide any information. RESIDENT #59 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was alert and able to make her needs known. In an interview on 02/04/2020 at 11:36 AM, Resident #59 stated she had a hip injury that required surgery and was admitted to the facility to receive rehabilitation services. The resident stated, she was concerned about not getting exercises anymore. She stated she was getting therapy and then the aids were supposed to be trained to give her exercises but that has not happened, I am wondering what's going on, I can't just lay here in bed. Review of the resident's Physical therapy functional performance of encounter dated 01/20/2020 documented, discussed with resident upcoming discharge from therapy and transition to Restorative program, RA program established. Review of the physical therapy discharge summary dated 01/21/2020, documented, Skilled services discharge completed with resident. Therapist encouraged resident to get up in chair daily, participate with RA program. Review of the resident's progress notes, revealed no restorative notes were present. Review of the resident's task list showed no restorative task available for the resident. Review of the resident's Kardex did not include a restorative program. In an interview with Staff G, a restorative aid on 02/12/2020 at 1:52 PM, Staff G stated the resident was not on a restorative program. In an interview with Staff C, Resident Care Manager on 02/12/2020 at 2:19 PM, Staff C verified the resident was not on a restorative program but should have been and would now begin the program. This is a repeat deficiency from 02/13/2019. Reference: (WAC) 388-97-1060(3)(d)

Based on observation, interview and record review the facility failed to prevent an avoidable Stage III pressure injury for one of three residents (#1) reviewed for pressure injuries. This failed practice caused the resident harm due to the acquired Stage III pressure injury and a diminished quality of life. Findings included . Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown - Clinical Protocol, revised (MONTH) 2013, showed that the nurse should assess and document the full assessment of pressure sores including the location, stage, length, width and depth. According to the Centers for Medicare and Medicaid Services a Stage II pressure ulcer does not have granulation tissue, slough and/or eschar. A Stage III pressure ulcer was a full thickness loss of skin and granulation tissue was often present. Additionally, pressure ulcers/injuries are usually located over a bony prominence, such as the sacrum. According to the National Pressure Ulcer Advisory Panel (NPUAP) evidence based guidelines showed the following: - The description of a pressure ulcer (PU), also known as a pressure injury, should be supplemented with other findings. Indicating the exact location of the PU was important, making clear reference to bony prominence's if the PU was over a bony prominence. Historical information, such as the conditions under which the ulcer began, the history of prior treatment, and the trajectory of healing or non-healing of the ulcer (if known) should be communicated and documented. Such information helped health professionals to evaluate the effectiveness of later treatments; and - A category/Stage III PU was described as full thickness skin loss and full thickness tissue loss. Resident #1 was admitted to the facility on [DATE]. According to the hospital Discharge Summary dated 05/15/19, the resident had [DIAGNOSES REDACTED]. Review of the facility's Admission Nursing Data Base assessment dated [DATE], showed the resident had no indications of PUs, abrasions, bruised, soft heels or skin tears upon admission. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident did not have a pressure ulcer/injury but was at risk of development of a pressure ulcer/injury. The Care Area Assessment for the 05/22/19 MDS, showed the resident triggered due to risk of PUs related to [MEDICAL CONDITION], had a Braden (skin assessment indicating moderate risk of developing a pressure ulcer/injury) score of 13, was incontinent of bowel and had a indwelling catheter to the bladder. The resident was to be turned every two hours while in bed, to wear foam boots to protect her heels and the facility proceeded to care plan to minimize the risk of PUs. Review of the focus care plan titled, The resident has pressure/vascular ulcer potential for pressure ulcer development related to history of ulcers, - open lesion, with an initial date of 05/16/19 and a revision date of 08/02/19, showed a goal to maintain skin integrity and PU would show signs of healing, show reduction in size/stage of the PU and remain free from infection. Interventions included an Alternating Pressure Pad and Pump mattress overlay and applications of protective creams (which included zinc oxide), skin moisturizers, Sage boots (a type of heel protectors) while in bed, to reposition frequently, to apply TED hose (compression stockings) while up in the chair, and to notify physician of any new skin areas and obtain a treatment order. Review of a progress note dated 06/12/19, showed the resident had an open blister to her left leg near her achilles (the achilles tendon attaches the calf muscles to the heel bone) which was cleansed with normal saline and a dressing applied. There was another open area identified on the resident's coccyx (the tailbone). The coccyx wound measured 1.75 centimeters (cm), the length, by 1.75 cm (the width) and no depth was identified. The current treatment was to apply zinc cream. A referral to the wound team was made for further measurements. Review of Resident #1s medical record showed the first wound documentation was dated 06/13/19, which identified an open lesion measuring an area of 1.45 cm (centimeters), length of 1.91 cm, width of 1.07 cm, and no depth was identified. The body location was not indicated, not showing where this wound was located. Under Stable showed unknown minutes old, and under the Acquired information showed not set. The wound bed was noted to have 20% (percent) [MEDICATION NAME] (thin tissue that covers all exposed surfaces of the body) tissue and 80% granulation tissue (new connective tissue), with light sanguineous (blood)/bloody exudate (a fluid rich in protein and cellular elements that oozes out of blood vessels due to inflammation and was deposited in nearby tissues). No treatment was documented. On 06/29/19, the resident was admitted to the hospital. Review of the medical record showed no further documentation of the wound, that was identified on 06/13/19, from 06/13/19 to 06/29/19. Review of a hospital nursing note dated 06/29/19 at 3:41 PM, showed a skin check was completed which revealed two openings on the resident's buttock, one on her right groin and had a red area on her upper left thigh. A note was made to the physician for a wound care consult. Review of a hospital nursing note dated 06/30/19 at 4:56 AM, showed the resident was on every two hour check and turn, had a red buttock with an open area on the right groin and two open areas on her buttocks. Review of a hospital nursing note dated 06/30/19 at 3:51 PM, showed a wound care consult was ordered and the resident was on skin care, turning and butt paste (a type of cream that contained zinc oxide, [MEDICATION NAME] and [MEDICATION NAME]). Review of a hospital physician note dated 07/01/19 at 1:38 PM, showed the resident had a Stage III pressure ulceration which was present on admission (to the hospital) to the resident's sacrum. The resident had friction/moisture changes to her sacral area as well as gluteal cleft pressure break down and barrier cream was applied. Review of the hospital wound care progress note dated 07/01/19 at 4:10 PM, showed the resident had a pressure injury midline sacrum, which was a stage III PU, measuring 0.9 cm x 0.7 cm x 0.3 cm (depth). Review of the hospital discharge summary dated 07/03/19, showed the resident discharge [DIAGNOSES REDACTED]. The wound care recommendations included wound care for the gluteal cleft, sacrum and right and left buttocks. Staff were to cleanse the wounds four times daily and as needed, apply butt paste four times daily and as needed, leave skin open to air with no protective cover dressing to sacrum, continue the pressure injury prevention interventions, reposition side to sided off sacrum every two hours, keep the head of bed at 30 degrees or less and gatch (hospital bed with a frame in three movable sections equipped with mechanical spring parts that permit raising the head end, foot end, or middle as required) knees to prevent the resident from sliding down the mattress which caused friction/shearing. The resident re-admitted to the facility on [DATE]. Review of the facility's Admission Nursing Data Base assessment dated [DATE], showed the resident had a 1.0 cm by 1.0 cm by 0.0 depth pressure injury on the coccyx. The facility did not stage the pressure injury. The assessment stated further weekly documentation was indicated that included measurements and how the wound was progressing toward healing. Review of a physician nursing home visit note dated 07/08/19, showed [DIAGNOSES REDACTED]. The physician documented the hospital identified a stage III sacral PU, however nursing staff reports that it is already closed and they are applying the paste and closely monitoring the area. Review of a wound documentation dated 07/12/19, identified an open lesion area, not identified where on the resident's body, measuring of 0.69 cm. The open lesion measured 1.84 cm by 0.77 cm and no depth was identified. The assessment identified the wound was one month old. The wound bed was noted to have 50% [MEDICATION NAME] tissue and 50% granulation tissue. The treatment was to cleanse the wound with normal saline and apply a foam dressing as the secondary dressing. Review of the Admission MDS assessment dated [DATE], showed the resident had either a Stage I or greater PU, a scar over a bony prominence, or a non-removable dressing/device in place. The MDS assessment showed PU care was being provided, but did not identify the stage or measurements of the PU. Review of the wound documentation dated 08/02/19, identified an open lesion on the resident's coccyx which measured 1.17 cm by 0.93 and no depth was identified. The assessment identified the wound age as known and that the wound was acquired in the facility. The wound bed had 60% [MEDICATION NAME] tissue and 40% granulation tissue with light sanguineous/bloody exudates. It was noted the wound care consultant had not seen the resident's wound yet. In an interview on 08/02/19 at 10:00 AM, the Director of Nursing Services (DNS), stated she had spoken to the reporting hospital staff member who stated the wound had resolved in the hospital and the report was an oops report. In a telephone interview on 08/06/19 at 9:06 AM, the hospital wound care nurse stated that the resident's wound on 07/01/19 was a Stage III pressure injury with no necrotic (non-viable) tissue in the wound bed. The staff member stated the resident had pain when the wound was assessed. The staff member stated the resident had compromised skin and had an area of shearing as well. I recommended butt paste which is zinc oxide, [MEDICATION NAME] and [MEDICATION NAME] . when a resident is incontinent a dressing tends to hold the urine or stool onto the wound bed, it does not do any good to place a dressing on when urine and stool will hold against the wound we find we get better results with the use of butt paste. In an observation on 08/06/19 at 10:41 AM, Staff A, Registered Nurse (RN), and Staff B, Nursing Assisted (NA), were positioning the resident for wound care. Staff A and Staff B positioned the resident onto her left side exposing the resident's coccyx and sacrum. The resident was observed to have two wounds on her sacrum. The upper wound appeared to be the size of a dime with beefy red tissue, the lower wound appeared to be the size of a penny with a lighter pink tissue bed with a section of white tissue which extended from the bottom of the wound to approximately the middle of the wound bed. Staff A stated the wound bed tissue was granulating tissue. In a telephone interview on 08/06/19 at 11:19 AM, the hospital wound nurse stated she had not spoken with the facility's DNS (as the DNS stated in an interview on 08/02/19). She continued to state that she followed the hospital's policy to report any Stage III or higher pressure injuries upon admission to the hospital. She again confirmed she had never spoken to the facility's DNS. In a follow up interview on 08/06/19 at 2:22 PM, Staff A stated the wound care treatments were documented in the Treatment Administration Record. Staff A stated the managers and the wound doctor assessed the resident's wounds weekly. In an interview on 08/06/19 at 2:50 PM, Staff C, Licensed Practical Nurse/Resident Care Manager, stated the resident wounds were measured weekly through their electronic medical record. Staff C stated the Consultant Wound Physician Assistant (PA) would come into the facility weekly. Staff C stated the Consultant Wound PA would address the resident wounds and put the information into the facility's system. If the weekly pictures and information was not in the medical record either the PA did not come or a picture was not taken. Staff C stated that sometimes the documentation could be in the progress tab but regardless it should be in the medical record. Staff C confirmed there was no documentation of the resident's wound from 06/13/19 until the resident discharged to the hospital on [DATE]. In an interview on 08/06/19 at 3:10 PM, the DNS, stated the resident had admitted from an assisted living facility and had a pressure injury wound. The resident then went to the hospital and they asked us to take her. I know this because I met with her. She had to get a specialized wheelchair that was pressure relief, noted a sacral wound secondary to moisture and friction. The DNS review the medical record and confirmed the admission nursing assessment did not indicate the resident had an open lesion or a pressure injury. Review of the wound documentation dated 08/07/19 showed the resident had an open lesion on the coccyx. The wound measured 4.09 cm by 1.68 cm and no depth was identified (the wound had increased in size from the prior assessment). The wound documentation identified the resident had acquired the wound in house. Review of the consultant wound care documentation dated 08/07/19, showed the chief complaint was a sacral open area and rash. The wound consultant was asked as of 08/07/19 to provide a formal wound care consultation and treatment recommendations. The consultant the hospital discharge summary identified the resident had a sacral lesion, which was also identify by the facility upon admission. the consultant noted that the open area at the sacrum had come and gone per nursing. The sacral wound was noted to be an acute partial thickness abrasion. The abrasion measured 4.1 cm by 1.7 cm by 0.1 cm. The wound bed had 76-100% [MEDICATION NAME], no granulation and no slough (dead tissue, usually cream or yellow in color). The consultant documented that, We are uncertain what caused her initial sacral lesion described by (prior initial hospital) prior to her first admission to the facility . This could have been an old pressure ulcer that was in the closed final maturation phase of healing with fragile scar that comes and goes or just fragile skin that is effected by moisture and friction from time to time. The facility failed to prevent an avoidable pressure injury for Resident #1, the facility additionally failed to follow professional wound assessment and documentation of the resident's pressure injury, failed to code the MDS accurately and failed to prevent a Stage III pressure ulcer/injury resulting in harm for Resident #1. Reference: (WAC) 388-97-1060 (3)(b)

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and interventions to prevent accidents for two of three residents (#2 and #3) reviewed for falls and failed to provide adequate supervision for two to two residents (#6 and #7) to prevent potential unwanted sexual contact. Additionally, the facility failed to keep potential harmful chemicals securely stored. Failure to implement adequate supervision consistent with the residents' needs and care plan, and monitor the effectiveness of the interventions and modify the interventions to the residents' individualized needs resulted in harm for Resident #2 after having a fall which resulted in a [MEDICAL CONDITION] and Resident #3 who had multiple falls. Additionally, the failure to provide adequate supervision place residents at risk of unwanted touch, and failure to secure chemicals placed residents at risk of avoidable accidents. Findings included . FALLS RESIDENT #2 Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE], showed the resident was at risk for falls. Review of the resident's care plan with a focus problem of moderate risk for falls related to history of falls was initiated on 05/26/19. The goal was for the resident to be free of minor injury till the next review date. The initial interventions dated on 05/26/19, showed a front wheeled walker to be used when the resident walked, to notify family/responsible party of any falls, to notify the physician of any falls, Physical and Occupational therapy evaluation and/or treatment as needed and the resident was to wear non-skid footwear at all times. On 05/28/19, bilateral bed rails were added as a safety device. Review of the Physical Therapy (PT) Treatment Encounter notes showed the following: - On 05/29/19, showed the resident was found self-ambulating from the bathroom to bed. The resident was educated on use of the call light for safety; - On 06/01/19, showed the resident was asleep, and the resident's spouse was present and was very upset due to the resident's fall that morning; - On 06/11/19, showed the resident had a loss of balance which required assistance to prevent a fall (an intercepted fall occurs when the resident would have fallen if he or she had not caught him/herself or had not been intercepted by another person - this was still considered a fall); - On 07/06/19, showed the resident had increased confusion; - On 07/09/19, showed the resident had increased confusion from the prior week; and - On 07/08/19, showed the resident was having difficulty following verbal direction and was found attempting to self transfer out of the wheelchair to the bathroom. Review of the Occupational Therapy (OT) Treatment Encounter notes showed the following: - On 05/28/19, the resident reported difficulty remembering things and a SLUMS (Saint Louis University Mental Status Examination, a test to detect memory problems) score of 15 out of 30 which indicating cognitive impairment/dementia; - On 06/06/19, the resident required close supervision for a majority of the task for safety with bed mobility; - On 06/11/19, the resident required close supervision for majority of task for safety with toileting, bed mobility, transfers and mobility; - On 06/12/19, the SLUMS testing was re-administered and the score increased to 17, which indicated cognitive impairment/dementia; - On 07/06/19, the resident did not remember his spouses visit from the prior day; and - On 07/10/19, the resident's spouse complained the resident has had four falls when trying to get out of bed. The resident stated that he could not get to the bathroom in time and OT recommended for the resident to call ahead when possible and to use the urinal. Review of the Speech Therapy (ST) Treatment Encounter Notes showed the following: - On 05/30/19, a MoCA (Montreal Cognitive Assessment, a test that assesses for dementia) test was administered and the resident scored 8.2 (a score below 10 showed severe cognitive impairment); - On 06/05/19, ST attended a care plan conference and educated the resident, spouse and rest of interdisciplinary team regarding the residents cognitive status and results of the initial testing; - On 06/10/19, the resident demonstrated marked difficulty with cognitive and language work with money and writing and was consistently unaware of errors; - On 06/12/19 the resident was able to retain four details after auditory presentation for five minutes and only two details after 10 minutes; - On 06/18/19, the resident had noted moderate deficits in written expression skills, with lack of awareness of errors, activities of reorientation to recall numbers, address and date was completed; - On 06/21/19, the ST identified the resident had increasing cognitive errors and minimal awareness over the course of the interaction with written problem solving and attention task of unscrambling works; - On 06/25/19, the residentwas unable to recall the name of the facility after two minutes even with cues; - On 07/01/19, the resident was consistently unaware of cognitive errors during the session; - On 07/02/19, a M[NAME]A test was administered to determine current cognitive-linguistic status given the resident's report of reduction in ability to concentrate and PT reporting changes in his balance and gait pattern. The resident scored 8.3; - On 07/05/19, the resident demonstrated awareness of severity of memory impairment but continued to have limited insight regarding severity of problem solving deficits; - On 07/08/19, the resident demonstrated slowed processing and increased need for cues, visual cues to increase visual attention for improved response accuracy; - On 07/09/19, The resident was noted to have further changes in his cognitive status with noted moderate to severe deficits; and - On 07/12/19, a wall sign was provided to encourage increased use of the call light to help reduce fall risk (one and a half months after the start of speech therapy and five falls). Review of the Speech Therapy (ST) Evaluation and Plan of Treatment, Occupational Therapy had recommended ST due to observation of reduced memory, slowed processing and the results of a SLUMS testing on 05/28/19, which the resident scored 15 out of 30 indicating cognitive impairment/dementia. Further review of the resident's care plan showed no indication the facility had identified or care planned interventions for the resident's noted cognitive deficits. Review of the progress notes showed the resident's first fall at the facility was on 06/01/19 at 5:45 AM, the resident was found on the floor facing his bed. The resident could not remember if he hit his head. Review of the incident report dated 06/01/19, showed during the investigation the facility noted the resident had poor memory and lack of safety awareness. The facility's intervention to the fall was to re-educated on use of the call light and the need to wait for assistance, was re-educated on his transfer status and ambulation status. The resident's care plan was reviewed and updated about education, even though the resident had been identified as having poor memory and lack of safety awareness. Review of the progress note dated 06/05/19, showed the resident was forgetful at times and forgetful of safety precautions. Review of the progress note dated 06/11/19, showed no documentation addressing the fall the resident had with Physical Therapy. Review of a progress note dated 07/05/19, showed the resident had an unwitnessed fall. The resident had baseline confusion. Review of the incident report dated 07/05/19, showed the resident was noted to have impaired memory and confusion. The care plan was noted to have been updated with a note of the fall, but no additional interventions were put into place to prevent further falls. Review of the progress note dated 07/06/19, showed the resident was found on the bathroom floor. Review of the incident report dated 07/06/19, showed the resident was noted to be drowsy, weak, with gait imbalance and impaired memory. The care plan was noted to be in revision at that time but no additional interventions were initiated to prevent further falls. Review of the progress noted dated 07/08/19, showed the resident was found on the floor at the entrance of his bathroom. Review of the incident report dated 07/08/19, showed the resident was noted to be confused, weak, with gait imbalance, memory impairment and a recent change in cognition. Again, the care plan was noted to be in revision but no additional interventions were initiated to prevent further falls. Review of a progress note dated 07/13/19 at 9:19 AM, noted the resident was having frequent episodes of confusion and often forgot to use the call light appropriately for assistance as needed and had been seen self-transferring and walking independently without his walker despite the staff constantly reminding the resident to call for assistance and the call light being placed on the resident. There were no adjustments to the resident's care plan even though the facility identified the resident had continual indication of lack of safety awareness. Review of a progress note dated 07/13/19 at 4:10 PM, the resident was found on the floor (the sixth fall) in his doorway. The resident complained of severe pain to his left hip and was sent to the emergency room . Review of the hospital Admission History and Physical dated 07/13/19, showed the resident had a fracture of his left femur and pneumonia. Review of the hospital Discharge Summary dated 08/01/19, showed the resident had presented to the hospital with a left [MEDICAL CONDITION] and was found to have a large acute on chronic subdural hematoma. Subsequently the plan for hip surgery was deferred due to his multiple co-morbidities and little improvement in his mental status and a hospice evaluation was obtained. In an interview on 08/13/19 at 12:06 PM, the resident's spouse stated that the resident fell five times, out of bed and from his wheelchair. She continued to state that the last fall resulted in a [MEDICAL CONDITION] and they cannot do surgery due to the swelling in his head which had pushed his brain over. They (the facility staff) never would answer the call light, every time he fell he had to go to the bathroom. I battled every day for my husband, now he has no life because of (the facility). In an interview on 08/14/19 at 11:47 AM, Staff D, Nursing Assistant (NA), stated that she knew how to provide care to the resident from the resident's care plan in the electronic medical record. Staff D stated the care plan would be updated with resident changes. Staff D stated if a resident had a change in condition, the nurse and Resident Care Manger were notified. In an interview on 08/14/19 at 12:00 PM, Staff E, Licensed Practical Nurse (LPN), stated that the care plan would be updated with noted changes in a residents' condition. In an interview on 08/14/19 at 1:43 PM, the Director of Nursing Services (DNS) stated that every morning, in the clinical meeting, resident changes were reviewed. The DNS stated that the facility's fall assessment was used to review items and reviewed information in risk management as triggers to review which could trigger into a care plan that would be beneficial for the resident. The DNS was asked about the intervention to educate the resident who had memory deficits, about the incomplete neuro checks after Resident #2s first fall, about the lack of additional preventative interventions after the second, third and fourth fall the resident sustained [REDACTED]. The facility failed to initiate preventative interventions to prevent the resident's repeated falls. The only care plan intervention was made after the first fall which was to educate the resident, who had cognitive impaired and had limited memory recall. The lack of the facility to attempt interventions to prevent the resident from repeated falls resulted in harm for Resident #2 who sustained six falls within a seven week period of which the last fall resulted in an inoperable [MEDICAL CONDITION]. RESIDENT #3 Resident #3 was a long term resident of the facility with [DIAGNOSES REDACTED]. Review of the state reporting log, showed the resident had three falls in (MONTH) 2019. Review of an order dated 06/02/19 by the ARNP (advanced registered nurse practitioner), for PT eval and Tx (treatment) for w/c (wheelchair) positioning. (Tilt w/c is beneficial). Review of the incident report dated 06/09/19 at 8:20 PM (the incident report date was the day before the documented fall in the progress notes), showed on 06/10/19 the resident was propelling forward out of her wheelchair. The incident report noted that Physical Therapy to evaluate for a tilt-in-space wheelchair (allowed the whole chair to tilt up to 30 or 60 degrees while maintaining the hip and knee angles at 90 degrees) for comfort and position and the care plan was updated. Review of a progress note dated 06/10/19 at 8:30 PM, showed the resident was seen propelling forward out of her wheelchair onto the floor in the hallway. The resident sustained [REDACTED]. Review of the focus care plan of high risk for falls related to cognitive problems and history of falls showed the problem had a revision on 06/10/19. Review of the interventions for the high risk for falls care plan showed the facility added no new interventions due to the 06/10/19 fall. Review of the incident report dated 06/13/19 at 5:56 PM, showed the resident had slid down her chair in the residents lounge where the resident was seen sitting on her footrests and her feet were on the floor. The incident report further noted the care plan was revised and a new intervention put into place for preventative falling measures. Tilt N Space w/c (wheelchair) to be utilized for resident at this time to ensure resident does not slide out of her wheelchair. Staff education provided by Resident Care Manager due to facility protocol not followed effectively. Review of a progress note dated 06/13/19 at 7:25 PM, showed the resident was sitting upright on the foot rests of her w/c. Review of the focus care plan of high risk for falls related to cognitive problems and history of falls, with a revision date of 06/14/19, showed an intervention for a tilt-in-space w/c under safety device. Review of a PT evaluation and Plan of Treatment dated 06/14/19, showed, Nursing staff suggesting use of a tilt-in-space manual wheelchair to decrease risk of falling and promote improved body support/positioning. At this time PT would continue to be appropriate with use of manual upright 18 (inch) wide, 16 inch deep, hard seat with a 3 inch thick wheelchair cushion . PT in the process of finding of a facility manual wheelchair with recommended dimensions and parts. Review of a progress note dated 06/21/19 at 2:53 PM, noted the nurse was called for assistance because the resident had fallen. The resident was turned on her side and saw a small pool of blood was observed under her head, there was a bump on her forehead with an abrasion which was bleeding. The resident was transferred back to her w/c. The resident stated that she hurt all over. The resident's family wanted the resident sent to the emergency room (ER) but when the paramedics arrived they assessed the resident and felt she was stable and comfortable. The family was advised that the resident did not need to be sent to the ER. Review of the incident report dated 06/21/19 at 8:12 AM, showed the resident was sitting next to the nursing cart and had just received her morning medications. The nurse went to assist another resident and upon returning to the cart observed the resident face down on the floor beside her w/c. The incident report showed on 06/22/19, new interventions put in to place. Spoke with Physical Therapy about tilt-in-space w/c (which was mentioned after the 06/13/19 fall) and recommended placing Dycem (non-slip material) in the w/c to prevent the resident from sliding out of her w/c. Further review of the care plan focus problem of high risk for falls did not show any intervention for the use of Dycem or any other non-slip material in the resident's wheelchair. Review of the PT Treatment Encounter Note dated 06/21/19 at 10:44 AM, showed the resident had experienced another unwitnessed fall from her chair. The resident suffered a bruise to the middle of her forehead. PT assessed the current available in house tilt chairs and issued a Solera type tilt . It is too wide but she is well positioned and supported with addition of pillows on each side to help maintain midline positioning. Scheduling appointment with vendor to generate custom wheelchair prescription. Review of a progress note dated 08/03/19, showed that the resident's family had taken the resident to the ER due to the resident having a lot of pain. The family stated a CT scan was done and the resident had a compression fracture and gallstones. The ER physician also diagnosed the resident with an urinary tract infection. During an interview on 08/06/19 at 11:46 AM, a family care conference was held with the resident's two son's on the phone, and her daughter, granddaughter, and facility staff. The resident's family members stated that the resident had three falls in (MONTH) 2019, and the family had been advocating for a tilt-in-space w/c. One of the resident's family members asked if the resident had any falls since she was placed in a tilt-in-space w/c, and the IDT (interdisciplinary team) confirmed the resident had no further falls since the initiation of the tilt-in-space w/c. In an interview on 08/14/19 at 4:09 PM, Staff F, Physical Therapist, was asked to verify the date Resident #3 received a tilt-in-space w/c. Staff F stated that an order to evaluate for a w/c was written on 06/02/19. Staff F stated PT saw the resident on 06/14/19 and was not able to state why it took until 06/14/19, 12 days after the order was written, to see the resident. Staff F stated the PT note on 06/14/19, did not indicate they got the resident a tilt-in-space w/c. Staff F stated that she saw the resident on 06/21/19 and obtained a tilt-in-space w/c on that day. The therapist who worked on 06/14/19 was not from this building and probably did not know where to find one. The facility failed to implement the fall prevention intervention of a tilt in space wheelchair for the resident after the order for PT to evaluate for a wheelchair on 06/02/19. The therapy evaluation was delayed for 12 days and was not able to provide the resident with the requested intervention until 06/21/19 after which the resident sustained [REDACTED]. RESIDENT TO RESIDENT UNWANTED TOUCH Resident #6 was a long term resident of the facility with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], he required supervision and oversight with locomotion on and off the unit, had severe cognitive impairment and had no behaviors during the assessment period. Review of Resident #6s care plan showed a focus problem which was initiated on 02/24/16 and resided on 07/27/18, of problematic manner in which he acts characterized by inappropriate sexual behavior (verbal or physical) inappropriate touching of self or female staff. The resident also had a focus care plan dated 12/14/18, of problematic manner in which the resident acts characterized by inappropriate behavior, joking with other resident, acting like he was going to trip them, run into them, joking could be perceived as aggressive. The care plan showed he had a resident to resident altercation on 12/18/18. Resident #7 was a long term resident of the facility with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], showed the resident had severe cognitive impairment, had physical behavioral symptoms and wandering that occurred within one to three days of the assessment period. Review of Resident #7's care plan showed a focus problem with an initiated date of 08/10/18, of problematic manner characterized by inappropriate physical sexual behavior. Her interventions included to bring her to the nurses station or her room after meals and encourage visits in common areas, remind her that her behaviors were not appropriate, and remove her from public when behavior is disruptive or unacceptable. Review of an incident report dated 07/05/19, showed that the Activities Assistant had walked out of the activity room to take another resident to the bathroom and when she returned she observed Resident #6 grabbing and rubbing Resident #7s chest. Review of Staff S, Activities Assistant, written statement dated 07/05/19, showed at 11:55 AM, in the recreation center, Staff S observed Resident #6 grabbing and fondling Resident #7s breast. They were aware that they shouldn't be touching on another because ten minutes prior to this incident I observed them holding hands and asked them to stop because their behaviors were inappropriate, which they did. In a phone interview on 08/07/19 at 4:08 PM, Staff S stated that the incident happened on 07/05/19 and at the minute it she approached and redirected the residents. Staff S stated she took Resident 7 to the dining room and informed the nurse. Staff S confirmed that she had observed the residents holding hands, prior to the incident, and redirected them. Staff S stated she talked to the nurses extensively regarding Resident #6. Staff S stated Resident #6 had short term memory deficit, had behaviors common with someone who had dementia, and at times he did not realize his behaviors. Staff S stated that both residents were in the same position in the recreation center that they had been in when they had been holding hands. She stated she had walked out of the recreation room and came back and saw him fondling her. Staff S stated that no other staff were in the recreational room, she had went to take another resident to her room before lunch. Staff S stated that she was not aware of the residents' care plans prior to the incident but after the incident she became familiar with their care plans. The facility failed to supervise and implement the care plans for Resident #6 and Resident #7 to ensure each cognitively impaired resident did not receive potentially unwanted touch. HAZARDOUS CHEMICALS In an observation on 08/06/19 at 3:59 PM, the shower room across from the utility room and room [ROOM NUMBER] was unlocked with didecyl [MEDICATION NAME] ammonium chloride spray accessible in an unsecured open cabinet and there was a used razor lying in the sink. The Administrator and Director of Nursing were informed and confirmed the shower room was not to have been unlocked. Reference: (WAC) 388-97-1060 (3)(g) i

ation Text for Tag 0744, Regulation FF11 Based on interview and record review the facility failed to provide dementia care and develop a dementia care plan which promoted the resident's highest well-being for one of three Residents (4) reviewed. These failures resulted in verbal and physical altercations between residents. Findings Included: RESIDENT 4 Resident 4 was admitted [DATE] with [DIAGNOSES REDACTED]. Per the 10/15/18 Minimum Data Set Assessment (MDS) the Resident used a wheelchair for mobility. The Resident was also assessed as having no impairments to the upper or lower extremities. A review of the incident log revealed the Resident 4 was involved in Resident-to-Resident altercations on 01/01, 01/03, 01/09, and 01/13/19. The investigation dated 01/01/19, stated Resident 4 went into Resident 5's room. Resident 4 slapped resident 5 on the back three times, waking her up from her sleeping. Per the investigation, Resident 4 had been moved out of this same room recently. The investigation for Resident 4 stated intentional abuse was unsubstantiated related to cognitive issues. A STOP sign was placed on Resident 5's door. In an interview on 01/15/19 at 2:30 PM, Resident 5 stated Resident 4 came into my room several times, since I moved in here. She came in my room one night and hit me three times on the back, when you are woken up from a sound sleep by someone hitting you, it scares you! I see her as a danger. I am not sure of her mental state but I can tell you she takes advantage of things when no one is watching. Resident 5 went on to say, when Resident 4 came in my room I rang my bell and I had to push her wheel chair out of the room and no one was in the hallway. I don't want people in my room, they need to keep her out of here. She walked outside her room to show the STOP sign which was velcroed to the door and was not up. The Resident stated I guess I am supposed to put this up, having my door closed in not enough to keep her out, obviously. The investigation dated 01/03/19 stated, Resident 4 was attempting to enter the nurses' station. Staff redirected the Resident away from the nurses' station which increased the Resident's agitation. The Resident passed Resident 6, who was quietly talking to herself. At this point, the aggressor's (4) agitation was increased by the noise of her talking and she yelled shut up and hit the Residents left foot with her fist. Resident 6 was unable to be interviewed related to cognitive status. The investigation stated intentional abuse was ruled out related to cognition of the Resident. The Resident has a history of dementia, muscle weakness, and aggressive behaviors. The investigation dated 01/09/19 Resident 7 asked a nurse for help and reported that Resident 4 had hit her on the head. Abuse was substantiated related to the physical hitting. Care plan was reviewed, safety for both residents was to be separated. The investigation dated 01/13/19 noted a verbal altercation between Resident 4 and Resident 7. While in the dining room Resident 4 snuck up on Resident, grabbed her wheelchair, called her stupid, a dummy, and told her to get out of here. There was no physical contact between the Residents. The investigation determined verbal abuse was substantiated. In an interview on 01/15/19 at 1:55 PM, Resident 7 was asked if she knew Resident 4 and immediately she stated, yes. She stated I know from watching her that she has some mental disease, but when she is coming towards you, it is a scary feeling. She seems to enjoy hitting, pinching, and poking you, because she laughs when she does it. She has used her wheel chair to push me into the wall and when she is coming down the hallway, I am very aware of where I and what is near me. She has hit me and pinched me, just last week she hit me. When asked how does that make you feel, she stated, mad! A review of the care plan, noted no mention of the resident's behaviors towards other residents, nor was the care plan updated, to reflect the most recent incidents between Resident 4 and the three other Residents. The behaviors noted on the care plan state problematic behavior in which the resident acts paranoid, suspicious, self isolates, repetitiveness, and anxious related to the progressing cognitive impairment from dementia and [DIAGNOSES REDACTED]. Interventions included be mindful not to invade the resident's personal space. Encourage the resident to participate in out of room activities, establish daily routine, and remove the resident from public area when behavior is disruptive / unacceptable. Talk in a lower pitched tone. There was not a specific dementia care plan for Resident 4. In an interview on 01/15/19 at 3:00 PM, with Staff C, Staff Development Coordinator (SDC) and Staff D, Corporate Nurse Consultant who were asked what they would be doing with the behaviors of Resident 4. Staff D stated she would be on 15-minute checks and potentially when the behaviors increase, she would be on a 1:1. Staff D stated staff would be educated about the care plan updates and the importance in substantiating abuse in investigations. The care plan was not updated with the resident's current behavioral issues with other Residents. Nor was the care plan updated to state her past history of physical and verbal aggression with other Residents. The Resident did not have a dementia care plan which reflected her specific behaviors and it did not include specific interventions for the staff to use, to avoid altercations. Reference (WAC) 388-97-1040 (1)(a-c)

Based on interview and record review the facility failed to dispense medications per the physicians order and per appropriate medication period for two of three residents (1 and 2) reviewed. In addition, Resident 3 did not receive the appropriate dosage of a medication related to a transcription error. These failures resulted in harm to Resident 1 who received an extended release opioid medication twice within a one hour, which resulted in harm of a decrease in the resident's respirations and the resident's overall condition. These failures placed all residents at risk for medication errors. Findings included: The facility's policy titled, Medication Administration, stated during medication administration facility staff should take all measures required by facility policy and applicable law; to administer medications within time frames and to document the administration of controlled substances in accordance with applicable laws. The Nursing Drug Handbook (YEAR) stated extended release [MEDICATION NAME] capsules are not for use on an as-needed basis. The Black Box Warning stated life threatening respiratory depression may occur with [MEDICATION NAME] use. Signs and symptoms of an overdose would include respiratory depression, [MEDICAL CONDITION] (low heart rate), [MEDICAL CONDITION] (low blood pressure), [MEDICAL CONDITION] (heart stops), respiratory arrest (breathing stops), and death. RESIDENT 1 Resident 1 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The resident uses a wheelchair but is able to ambulate and usually does so by pushing her wheelchair in front of her. An incident investigation dated 01/03/19 stated the resident was observed by staff to be smoking off the property and did not sign out her cigarettes. The Director of Nursing Services (DNS) performed a search of the resident's items and removed four packs of cigarettes and fifteen tablets of [MEDICATION NAME]. The resident denied taking any of the tablets. As the resident did not have an order for [REDACTED]. -A physicians order dated 01/03/19 at 1:06 PM stated STAT draw of a CMP, CBC, [MEDICATION NAME] levels, and complete toxiocology screen including [MEDICATION NAME]. -A physicians order dated 01/03/19 at 3:00 PM stated to hold all narcotics until toxicology screen results are confirmed. -A physicians order dated 01/03/19 at 3:00 PM stated please check vital signs for 4 hours, then 15 minutes checks every hour for a day. In an interview on 01/04/18 at 1:50 PM, Staff B stated Staff A was present when the resident had a change in condition, a call to the physician for telephone orders, and the conversation with the DNS about the behaviors that could be expected from the resident while not receiving her medications. Staff B also stated that she monitored the resident and took her vital signs because she saw the resident ambulating with her wheelchair and crashing into things. The resident was also unsteady on her feet and slurring her words. When asked, both Staff B and the DNS stated the resident had an obvious change in her baseline. The physician was notified, both nurses were aware of the situation. The resident was being monitored, but then Staff A gave a narcotic medication seven hours prior to the scheduled time and without an order. Both Staff B and the DNS verified that was what happened. Staff B, RN also verified the residents respirations went to 10 respirations per minute (normal is 12 to 20 per minute). When asked how she knew this, Staff B stated, I was the one checking her vitals. I was watching her very closely. She stated the resident almost needed [MEDICATION NAME] (a drug used to treat opioid overdose) but she was arousable when we woke her. During an interview on 01/04/18 at 2:00 PM, the DNS stated that on 01/03/19, she spoke to both Staff A, LPN and Staff B, RN about holding the resident's narcotics until the toxicology screen could be obtained. The DNS stated she spoke with Staff A about the resident's potential behaviors related to her lack of narcotic medications. It was then, that Staff A told the DNS she had already given the resident her narcotic medication. The DNS asked Staff A if it was a routine medication or a PRN (as needed) medication. Staff A stated she gave the resident the 10:00 PM dose of medication at 3:30 PM. When asked why she did that, Staff A replied the resident yells at her, so she gave it to her so she would not get mad. The DNS asked if she had remembered being spoken to about holding the medication. Staff A said yes, but thought it was still fine. The DNS had the nurse count her medication cart with the day shift nurse, and Staff A was escorted out of the facility. Per the DNS, Staff A was suspended, escorted out of the facility, and later terminated related to her complete lack of nursing judgement. An incident investigation dated 01/04/19 regarding a medication error had an outcome of substantiated. The summary stated, on 01/03/19 a nurse did not follow MD orders or facility policy, as evidenced by the nurse's own admission. The nurse was immediately removed from the floor and suspended. A review of the Medication Administration Record [REDACTED]. The order indicated, give 15 mg by mouth three times a day for moderate pain. The MAR indicated [REDACTED]. On 01/04/19 the medication was checked at being given by Staff A, LPN 10:00 PM. A review of the electronic medical record revealed Staff A signed out the 10:00 PM medication at 3:30 PM. A review of the paper narcotic sign out book revealed Staff A wrote the medication was given at 10:00 PM. A review of Staff A's time card revealed the nurse clocked in at 2:19 PM and clocked out at 5:04 PM. Staff A, falsified of a medical document. A review of Staff A's employee file revealed there was no discipline for issues related to medication administration. On 10/11/18, Staff A was given an in-service on abuse, neglect, and a review of medication at the bedside. On 11/6/18, Staff A was in-serviced on Controlled medication, documentation and storage. On 12-11-18 in-serviced on licensed nurse (LN) scope of practice. A performance improvement dated 1/4/19 for Staff A, stated the employee showed inappropriate conduct, as the willful failure to perform job duties resulting in potential injury to a resident. On (MONTH) 3rd, Staff A was told by the DNS and RNC to hold the resident's pain medications. Staff A reported, even though she was told not to give any medications, Staff A had given the resident her 10 PM dose of [MEDICATION NAME] at 3:30 PM. Due to her failure to protect the resident and follow physician orders, the nurse's employment was terminated immediately. The complete lack of nursing judgement by Staff A in giving an extended-release narcotic medication to a resident who received the same narcotic medication an hour prior, was a deliberate act of harm towards the resident. Staff A was aware of the residents change in condition, she was present for the physician's telephone order to hold all narcotics, and she knew this was a scheduled medication not due until 10:00 PM. Staff A falsified the narcotic sign out sheet and she gave a medication without a physician's orders [REDACTED]. RESIDENT 2 Resident 2 was a long term care resident with [DIAGNOSES REDACTED]. Review of the (MONTH) monthly physician orders [REDACTED]. [MEDICATION NAME] was administered daily. The nurse was to hold the [MEDICATION NAME] if the resident's systolic blood pressure (SBP) was below 100 or if the heart rate was below 60 beats per minute. [MEDICATION NAME] was administered twice daily, and the nurse was to hold the medication if the SBP < (below) 100, HR (heart rate) < 60. Review of the (MONTH) MAR indicated [REDACTED]. Review of the medical record showed the medication errors had not been identified. Review of the state reporting log showed the medication errors had not been investigated. In a joint interview on 01/15/19 at 3:00 PM, with Staff C, Staff Development Coordinator, and Staff D, Corporate Nurse. Both staff members acknowledged the resident received the medications outside of the ordered parameters. RESIDENT 3 Resident 3 admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was able to ambulate with a walker. Review of a facility investigation dated 01/16/19 stated the resident had been given 10 mg [MEDICATION NAME](a medication to treat [MEDICAL CONDITION]). The investigation concluded the resident had been given the incorrect dose [MEDICATION NAME] times from 12/24/18 to 1/14/19. The resident returned to the facility on [DATE] [MEDICATION NAME] order, which had been decreased from her previous order of 10 mg dose. The investigation concluded a significant medication error had occurred. Per the investigation the resident did not feel any negative side effects from the higher dose. Three staff members (E, F, G) were identified as giving the incorrect dose to the resident. Staff E, LPN was identified as the licensed nurse who did not transcribe the medication when the resident brought a prescription back from an appointment. In an interview on 01/30/19 at 10:38 AM, Staff E, LPN stated, she remembered the resident coming back with an order but did not remember processing the order. In an interview 10:45 AM, Staff F, RN stated he worked the night shift and did not know the order had changed until he was told the medication had been given in error. In an interview at 1:23 PM, Staff G, LPN, who also worked nights, stated she never saw the order and usually night shift did not process medication orders. She did not know there was an error until she was notified by the DNS. All three staff members received written warnings and education regarding the incident. In an interview on 01/25/19 at 10:10 AM, resident 3 denied any negative effects from the medication error. In an interview at 10:30 AM, the DNS stated, the medication error occurred because the order was not transcribed properly. The DNS stated the three staff involved received written warnings. The DNS also stated all staff were educated by having the pharmacy do an in-service on medication administration and documentation. Reference (WAC) 388-97-1060 (3)(k)(iii)

Based on observation, interview, record review the facility failed to ensure 2 of 2 residents (1 and 2) who engaged in smoking were identified and assessed. This failed practice resulted in an Immediate Jeopardy, when Resident 1 was found smoking in her room while using oxygen therapy and placed residents at risk for a potential fire. An Immediate Jeopardy (IJ) occurred on 12/14/18 at 2:17 PM, when the facility failed to ensure all residents and the environment were as safe as practicable from injury [MEDICAL CONDITION] fire. The IJ was removed on 12/14/18 at 5:03 PM after the facility put measures into place to prevent the resident from smoking in her room. Findings include: Record review of the facility's policy titled, Smoking Policy Is a non- smoking facility, undated, showed the facility was a non-smoking facility. When a resident was admitted to the facility, the resident agreed to refrain from smoking throughout the duration of their stay. If the resident chose to smoke off premises, h/she agreed to relinquish all smoking materials to the facility staff for safekeeping upon return to the facility. If the resident chose to smoke in violation of the facility policy, an involuntary transfer (discharge) may be initiated. Smoking was not allowed at any time within 25 feet of when oxygen was in use or the oxygen storage locations. RESIDENT 1 Resident 1 admitted to the facility 01/20/18 with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident was on hospice services, was oxygen dependent and had no tobacco use. The resident was totally dependent with transfers and required extensive assistance with wheelchair mobility. The resident had no behaviors or refusal of cares. Review of a hospital History and Physical dated 01/16/18, showed Resident 1 had end-stage [MEDICAL CONDITION] and was oxygen dependent at 2-4 liters per minute. The resident was identified as having a long history of smoking and had not smoked in couple of weeks. Review of the hospital discharge orders dated 01/20/18, showed Resident 1 was prescribed a nicotine patch, one per day and nicotine gum every hour as needed for smoking cessation. Review of the medical record found no evidence, when the resident was admitted in January, of a smoking evaluation, the resident had been assessed for a history of smoking or an initial care plan identifying interventions regarding Resident 1's recent smoking history and recent smoking cessation. Review of a hospice note dated 05/08/18, documented that per the staff and the daughter, Resident 1 had been going outside and smoking. The resident confirmed this with the hospice nurse, stating she only had one cigarette a day and removed her oxygen while smoking. Review of a nursing progress note dated 05/13/18 at 2:29 PM, Staff O, Registered Nurse (RN), documented while performing cares in the resident's room, Staff O saw a pack of cigarettes in the resident's purse. Staff O asked the resident about the cigarettes and the resident denied having any. The resident was informed she could not keep the cigarettes in her room, and the resident refused to give them up. Staff O reported the incident to the RCM, who was able to remove all but one cigarette from the resident's room. Review of the Resident 1's self- care performance care plan, with revised interventions dated 05/13/18, directed staff to report to the Licensed Nurse/Resident Care Manager (RCM) if any pills, pill bottles or cigarettes were in the resident's possession or noted in her room. Review of the medical record, after the facility had knowledge the resident had cigarettes in her possession, did not show evidence of a smoking evaluation, a discussion regarding smoking, an assessment or conversation regarding where Resident 1 obtained the cigarettes, or interventions put into place regarding smoking or safety. Review of a hospice note dated 05/24/18, showed the resident requested a nicotine patch, but reported she went out of the facility daily and sneaked cigarettes. The resident was educated on the danger of having a nicotine patch on while smoking and the resident agreed to try nicotine gum because she enjoyed to smoke when she had an opportunity. The resident reported to the hospice nurse she turned off the oxygen source and removed the cannula from her face prior to igniting the flame. Review of a hospice note dated 06/01/18, showed the resident's SPO2 (blood saturations of O2 level) was 78 % on room air at rest and was nodding off and not able to finish sentences. Oxygen was placed on the resident and she perked up and was able to maintain a conversation. The resident requested a nicotine patch which was not an option because the resident went outside regularly for fresh air and smokes. The resident reported she had quit smoking last week, but the facility staff reported the resident's smoking was ongoing. The resident was not using the nicotine gum that was available. The note stated the resident had the nasal cannula hanging over her shoulder and did not realize she was not wearing her oxygen. Review of a nursing progress note dated 12/13/18 at 7:44 AM, showed a Nursing Assistant Certified (NAC) alerted the nurse the resident was smoking a cigarette in her room. The nurse documented upon entering the front hallway, there was apparent cigarette smoke. The resident was found in her room with a lit cigarette in her hand. The resident was asked to give the lit cigarette to the nurse, and the cigarette was then extinguished. The nurse documented she talked to Resident 1 at length related to safety issues to herself and others. The resident stated she would not smoke in her room again. The nurse removed the resident's smoking materials and checked the resident frequently. Review of a facility investigation dated 12/13/18, showed Resident 1 was found smoking in her room with her oxygen on. The cigarette was immediately extinguished and the smoking materials were secured. The resident had a history of [REDACTED]. The facility educated the resident and her family and the resident's room would be monitored every shift to ensure there were no smoking materials present. Review of a witness statement, showed Staff N, Licensed Practical Nurse (LPN), documented, I don't recall the exact time of this event. This nurse was at nurse's station working from cart 1 when NAC came stating this Res (resident) was sitting at the EOB (edge of bed) with a packet of cigarettes and a lighter. A few minutes later this NAC came stating Res had a lit the cigarette and would not give it up. This nurse ran into Res room, took the cigarette from her, put it out with water in the sink. Upon entering the room Res was sitting at the EOB facing the hallway, lit cigarette in her R (right) hand resting on her R thigh, lighter in her L (left) hand, pack of cigarettes on the bed to the right. Res O2 (oxygen) cannula laying in the middle of the bed approximately 12-14 inches from lit cigarette. Res did not have oxygen on at the time of incident. Res was found to be drowsy, unable to communicate appropriately. Pack of cigarettes and lighter removed from Res room and placed in the med room at nurse's station. In an observation on 12/14/18 at 10:05 AM, Resident 1 was lying on her back with oxygen (O2) in place via an O2 concentrator with her breakfast tray in front of her. In an observation and interview on 12/14/18 10:53 AM, Resident 1 was sitting in her wheelchair with her oxygen on and attached to a portable oxygen tank behind her wheelchair. Resident 1 stated she had late stage [MEDICAL CONDITION] (a lung disease) and was supposed to be on oxygen at all times. Resident 1 stated she was a smoker and that she had quit multiple times. Resident 1 stated I woke up out of a dead sleep with someone screaming at me that I was smoking, I didn't realize I was smoking. I think it was night time. I gave it to her (the cigarette). I believe I took it from the kids pack, I got matches too. I was told I had my O2 on. Resident 1 stated she goes out of the building and smoked with her husband and her kids all the time. At 11:15 AM, Staff B, Social Service Director (SSD), stated she heard about the smoking incident in the daily stand up meeting. Staff B stated she called Resident 1's husband for a conference about the incident. Staff B stated it was believed that Resident 1's family was bringing her cigarettes. Staff B stated her husband took her out of the facility, on the bus to a local grocery store, where Resident 1 could have gotten the cigarettes. Staff B thought Resident 1 had a nicotine patch present in July. At 11:38 AM, Staff A, Admissions Director, stated he was aware of a residents smoking history and physical condition by reading the residents history and physical. Staff A stated if the resident was a smoker, he asked the hospital discharge planner to notify the resident that the building was non-smoking and could the resident be placed on smoking cessation materials. All information about the resident was discussed at the facility's daily stand up meeting to see if the facility could meet the needs of the in-coming resident. Staff A stated an email was sent out to the Director of Nursing (DNS), the Resident Care Manager (RCM) and the Regional Director of Operations (RDO) of any upcoming admission, the resident's equipment needs and any other pertinent information regarding the resident's care needs. Staff A stated he was responsible to do the admission paperwork which included the resident's initials acknowledging to abide by the facility smoking policy. Review of the admission paperwork, with Staff A, showed Resident 1 had initialed the acknowledgement of the facility's smoking policy on 03/02/18. During an interview on 12/14/18 at 11:53 AM, Staff C, Licensed Practical Nurse (LPN), stated the night shift Nursing Assistant Certified (NAC) found Resident 1 in bed in the middle of the night with her O2 off lying beside her with a cigarette in her hand. The NAC alerted the night nurse. Staff C stated the night nurse was unable to open a risk management form to fill out the incident report, so Staff C told her to write a detailed nursing progress note. Staff C stated she thought she told the Staff Development Nurse. At 12:05 PM, Staff D, Restorative Aide, stated she knew Resident 1 was a smoker because Resident 1 had asked to go out to smoke daily. Staff D stated another NAC had seen cigarettes in the resident's purse. At 12:15 PM, Staff E, NAC, stated she did not know Resident 1 was a smoker but often saw her without her O2 and with her legs over the side of the bed and her head on the bedside table. Staff E stated she would have to remind the resident to put her oxygen back on. At 12:20 PM, Staff F, NAC, stated he knew Resident 1 smoked since she lived on the B-wing (the resident now lived on the A-Wing) which was around (MONTH) (YEAR). Staff F stated Resident 1's family brought her in cigarettes and had seen her smoking out front, across street in the parking lot, or across the road. Staff F stated, We all knew she was smoking, then hospice got involved and started the [MEDICATION NAME] gum. At 12:25 PM, Staff G, RN, stated when a resident was admitted , staff were notified via email of the resident's care provisions which included any history of smoking. Staff G stated a smoking assessment and a care plan should be initiated if there was a history. Staff G stated, I knew she was a smoker because when she was on B- wing she had an order for [REDACTED]. At 1:46 PM, Staff I, Corporate Consulting Nurse, stated smokers should be identified upon review of the hospital records by the admission nurse. Staff I stated a smoking assessment should have been completed for Resident 1 and quarterly thereafter. A care plan should have been initiated and inventions put into place. Staff I stated Resident 1's husband comes in often and took her out of the facility. Staff I was not aware Resident 1 smoked. Staff I acknowledged the facility failed to complete a smoking assessment, assess Resident 1's risk factors or develope a care plan. At 2:32 PM, Staff H, Hospice Consulting Nurse, stated she was aware Resident 1 smoked. Staff H stated look at my hospice notes. I was told by staff she lit up in the activity room at one time. Staff H stated Resident 1 had an order for [REDACTED]. At 4:07 PM, Resident 3 stated she knew Resident 1 smoked because the NACs were always talking about Resident 1 sneaking out to go smoke with her husband in front of her. Resident 3 stated she could see Resident 1 go outside along the sidewalk or across the road from her window to smoke. RESIDENT 2 Resident 2 was a long term care resident. According the quarterly MDS assessment, Resident 2 was alert and oriented with no tobacco use documented. Review of the medical record from 11/02/12 through 12/14/18, showed no smoking assessment completed. Review of medical record found a smoking assessment had been completed on 12/15/18. The assessment identified Resident 2 was safe to smoke independently. Review of the care plan, dated 12/15/18, identified Resident 2 was able to smoke safely, independently and without any adaptive equipment or supervision. There was no other care plan in place prior to 12/15/18, even though the resident stated she had gone outside to smoke while living at the facility. Review of a nursing progress noted dated 12/15/18, Staff L, Regional Director of Operations (RDO), documented she had met with resident as possible smoker. Resident smelled of smoke and RDO asked to meet with resident. Resident stated she only goes up [MEDICAL CONDITION] center and gets cigarettes from people outside smoking. RDO asked if she had cigarettes on her person. Resident state not. RDO asked if we could check and resident refused. RDO let her know this is her right to smoke; however it is not anyone right to endanger other residents and this is the challenge. Resident stated she does have a lighter and is willing to give this up as she does want to be compliant. Resident offer smoking cessation materials and declined. Will continue to monitor. Care plan updated. During an interview on 12/21/18 at 11:05 AM, Resident 2 stated she had smoked cigarettes on and off for years. Resident 2 stated she would go off the facility property on the trail to smoke. The resident stated just last week she had to retrieve and turn in her cigarettes and lighter to the nurse now. Prior to last week, she kept her smoking materials in her possession. At 12:07 PM, Staff M, LPN, stated Resident 2 comes to the cart and asked for her cigarettes and lighter, then would return the lighter when she came back. Staff M stated this procedure was new and had been implemented a couple of weeks ago. At 12:19 PM, Staff L stated when they were investigating Resident 1 smoking in her room, the facility management interviewed staff about residents who smoked. That was when the facility management found out Resident 2 smoked, a smoking assessment was completed and a care plan initiated. At 12:25 PM Staff C, LPN, was aware Resident 2 smoked. Staff C stated there was an incident last year, with the previous administration, where the resident was caught smoking out the facility's front door. At 12:27 PM, Staff E, NAC, stated she thought Resident 2 was a smoker, and thought she remembered hearing about that (smoking) but it was a long time ago. The facility failed to assess a resident who had a known history of smoking. The facility failed to address the resident who continued to smoke and created an immediate danger for herself and other residents by smoking inside the facility with oxygen in use. The facility identified Resident 2 was a smoker after the incident with Resident 1. The facility staff had knowledge of both residents smoking in a non-smoking facility and did not assess, prevent hazards, nor protect residents from the potential hazards involved with smoking. Reference WAC 388-97-1060 (1)(3)(g)

Based on interview and record review, the facility failed to implement their abuse prohibition policy and procedure including but not limited to prevention, identification, reporting, investigating and protection involving 15 of 17 residents (4, 17, 18, 24, 32, 33, 34, 42, 44, 52, 53, 58, 72, 81, and 190) reviewed for abuse and neglect. The facility failed to provide oversight and monitoring to ensure staff were screened, staff were educated and staff implemented their policy and procedures during the provision of care and services to each resident residing in the facility. The facility failed to immediately protect, report, and identify allegations of abuse and neglect. The facility failed to examine alleged residents for signs of injury including a physical examination and/or a psychosocial assessment. The facility failed to provide emotional support during and after an allegation of abuse and/or neglect and take all necessary actions as a result of investigations to include analyzing the occurrence and implementing changes to prevent further occurrence. This failed practice resulted in Immediate Jeopardy (IJ) on 11/20/18 at 3:30 PM, was identified related to implementation of the facility's abuse and neglect policy and procedure. After the IJ was implemented, the facility submitted a removal plan that included auditing abuse allegations, assessing current residents for similar issues, surveying staff regarding abuse, reviewing and revising facility policies, and educating staff on policies related to mandatory reporting, resident protection, police notification, abuse and neglect, immediate reporting to Administration and Director of Nursing Services (DNS), Administration/DNS immediate reporting to the Regional Director of Operations (RDO) and Regional Nurse Consultant (RNC). The Immediate Jeopardy was removed on 11/21/18 at 2:15 PM. Findings include: The facility's policy titled, Abuse Prevention Policy and Procedure, with a revision date of 08/11/17, stated each resident had the right to be free from abuse. All suspected, alleged, including injuries of unknown origin, should be thoroughly and completely investigated and reported according to State and Federal regulations. The policy described seven components of preventing and protecting residents from abuse, which included: screening, training, prevention, identification, investigation, protection and reporting/response. All staff members and agents of the facility were mandatory reporters. REPORTING AND INVESTIGATING ALLEGATIONS OF ABUSE AND/OR NEGLECT RESIDENT 52 The resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. During an interview on 11/14/18 at 2:44 PM, the resident's son stated he did not know what happened to the resident's right foot. The son stated the facility let him know that she had hurt her foot and needed a cast. The son stated this injury occurred when the resident admitted to the facility around August. Review of a nursing note dated 08/24/18, showed Staff P, Licensed Practical Nurse (LPN), noted a large area of bruising on the resident's right lower leg, around the ankle, was dark purple and reddish in color. Staff P did not report or begin an investigation to rule out abuse and/or neglect. Review of a nursing note dated 08/27/18, Staff P documented the resident had foot pain that was tender to touch and had facial grimaces. Staff P requested an order for [REDACTED]. Staff P was no longer employed by the facility and unavailable for interview to ascertain why this incident was not reported or promptly investigated. Review of a nursing note 08/28/18, showed per the x-ray results the resident had a non-displaced [MEDICAL CONDITION] foot. Review of a physician note dated 08/30/18, showed the resident was complaining of right ankle pain, it worsened significantly and an x-ray was obtained which showed a [MEDICAL CONDITION]. Nursing staff were not sure how resident broke her ankle given that she was mostly in her wheelchair and in bed. Review of the facility's state reporting log revealed no entry of this event occurring. During an interview on 11/20/18 at 9:38 AM, the Interim Director of Nursing Services (IDNS) stated, she did not know how the resident sustained [REDACTED]. The IDNS further verified there should have been an investigation to rule out abuse and/or neglect. RESIDENT 18 Resident 18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 11/13/18 at 10:16 AM, the resident stated there had been times where she did not receive care and reported it to the facility but they (management) always believed the staff. Review of a facility investigation dated 10/30/18, showed during peri-care Staff Z, Registered Nurse (RN) and Agency Staff 9, Nursing Assistant Certified (NAC), opened the resident's brief and found a one dollar bill tucked inside the resident's brief. When asked about the dollar bill, the resident stated, she put the dollar bill in her brief yesterday, to show that she had not been changed until now. The investigation did not address the dollar bill found in the resident's brief, it made no mention of it although it could have been a key component to the investigation. Agency Staff 9 did not report this incident, instead she encouraged the resident to report the incident to management. Agency Staff 9 failed to protect the resident and report the allegation of potential neglect to the state reporting hotline or facility management. During an interview on 11/20/18 at 10: 50 AM, Agency Staff 9 stated she did not report the allegation of potential neglect because assumed Staff Z, who was in the room, would take care of it. At 2:01 PM, Resident 18 stated the reason why she put the dollar bill in her brief was because the NAC's had been changing her and when I complained, they (facility management) always believe the aides because they document they do change me, they always believe them and I had to prove it to them and still they did not believe me. Review of a facility investigation dated 11/13/18, showed that on 11/10/18 an allegation of potential verbal abuse was witnessed by Staff GG, NAC. Review of Staff GG's witness statement stated she witnessed Staff HH, LPN, arguing with Resident 18 while they were providing the resident care. The resident asked Staff HH to stop arguing with her, but Staff HH did not stop. Staff GG asked Staff HH to leave the resident's room. The investigation showed that on 11/10/18, the resident reported the allegation of verbal abuse to Staff CC, RN. Staff CC did not immediately protect the resident and did not report this allegation. Staff GG and Staff CC failed to immediately protect the resident, failed to report this allegation to the state reporting hotline and to the facility. On Monday, 11/13/18, three days later, Resident 18 reported the potential verbal abuse to the IDNS and an investigation was initiated. Due to the lack of reporting from staff, Resident 18 and other residents were not protected during the weekend and were placed at risk for continued abuse. Review of the investigation dated 11/13/18, revealed no other residents where interviewed, no staff education was provided on protecting and reporting and not staff were interviewed regarding Staff GG's potential abusive behavior. During an interview on 12/03/18 at 11:56 AM, Resident 32 reported that last Friday Staff B, RN/Resident Care Manager (RCM), had reprimanded both Resident 32 and Resident 18. At 2:34 PM Resident 18 stated that the way Staff B had talked to her made her cry. It was the way she talked to me, her voice was harsh and she was abrupt. She should have spoken to us nicely. Resident 18 continued to state that she knew Resident 32 had reported Staff B to the Administrator and the Resident Council President (Resident 12). Resident 18 began to cry and stated, I do not want anyone to treat me like that, I was just trying to help, and they do not need to treat me like that. At 3:34 PM, the Resident Council President, Resident 12 stated that he knew at one point or another Resident 32 had come in and made it sound like they (Resident 32 and Resident 18) were scolded by Staff B. At 3:47 PM, the RDO stated, We use the Purple book and log (incidents) within five days. The RDO, IDNS and facility's Nurse Consultant both confirmed no recent allegation of verbal abuse was currently being investigated. The RDO was informed of the allegation of verbal abuse involving Resident 32 and Resident 18's which had been reported the incident to the Administrator on 12/01/18. In an interview on 12/04/18 at 12:05 PM, the RDO, stated that the Administrator had failed to report the incident. The Administrator failed to act on the allegation of verbal abuse, failed to initiate an investigation and failed to protect the involved residents. RESIDENT 53 Resident 53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an incident report revealed on 11/12/18, Agency Staff 1, NAC, felt Resident 53 had been neglected for the entire shift. Agency Staff 1 reported the allegation to Staff DD, RN, who stated she would write it up and take care of it. On 11/13/18, the next day, Agency Staff 1 found out the allegation had not been reported nor had an investigation been initiated. Agency Staff 1 called the state hotline and reported the potential allegation of neglect. Staff DD failed to protect the resident, begin an investigation, report the allegation of potential neglect to the state hotline or to the facility. Review of the facility investigation was not thorough. The investigation contained statements from staff, staff schedules and the resident's care plan but there was no other information provided to rule out abuse and/or neglect. The investigation did not address the lack of protection and reporting by Staff DD or what the facility was going to do to protect other residents. During an interview on 11/20/18 at 11:30, the IDNS and Administrator both stated, they identified the facility had reporting issues. They had been trying to educate the staff. When asked how the facility was ensuring residents were being protected, the IDNS stated, We are not doing enough apparently. The IDNS agreed the facility investigations were not complete. The IDNS stated she was overwhelmed and this was too much for one person. At 1:25 PM, Staff DD was not able to state why she had not protected the resident, reported the allegation or initiated an investigation when the allegation of potential neglect was reported to her. Staff DD stated she made sure the resident received care after hearing about the allegation. RESIDENT 44 Resident 44 was admitted [DATE] and had [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set (MDS) assessment, dated 10/03/18, the resident was totally dependent on staff for all activities of daily living. Review of a facility investigation dated 08/25/18, showed the resident had a bruise on the back of her right hand. The investigation was incomplete. The facility gathered only one staff interview/witness statement, which was from the NAC who discovered the bruise. There was a lack of investigation to determine the cause of the injury in an effort to prevent further incident and injury and to rule out abuse and/or neglect. On 11/16/18 at 10:30 AM, Staff Q and Agency Staff 5, NAC's, were observed providing morning care and transferring Resident 44 from her bed to her wheelchair, using a mechanical lift device. The resident's feet were observed during the provision of care. The second toe of the right foot had a heavy amount of dried, dark red drainage in the nail bed; some of which had drained down the bottom of her foot and dried on the skin. Staff Q or Agency Staff 5 did not report this observation to the nurse until they were both questioned about it. Staff Q stated, That's new. Review of documentation through 11/16/18 at 2:15 PM, revealed no documentation regarding an assessment or the initiation of an investigation into the potential injury to the resident's right foot. On 11/19/18, the resident's record contained no documentation regarding the potential right foot injury. There was no evidence the NAC's had reported the incident to the Licensed Nurse. At 10/30 AM, the observations were reported to the IDNS. RESIDENT 17 Resident 17 admitted on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], the resident was cognitively intact. Review of Resident 17's lab result on 10/29/18 revealed his potassium level was high at 5.9 (normal range is 3.50-5.50). On 10/30/18, the resident received a potassium supplement and [MEDICATION NAME] (a medication to lower the potassium level in the blood). Review of the (MONTH) 30th to (MONTH) 20th Medication Administration Record [REDACTED]. On 11/21/18 at 10:55 AM, Staff A RN/Resident Care Manager (RCM) was alerted the resident was receiving a daily potassium supplement even though he had a high potassium blood level. Review of the state reporting log showed the facility failed to investigate the medication error until 11/26/18, five days after the potential error was reported to Staff A. Review of a lab result dated 11/26/18, showed the resident's potassium blood level was 6.4. The ARNP ordered for [MEDICATION NAME] to lower the resident's potassium level. Review of the MAR indicated [REDACTED]. During a telephone interview at 1:11 PM, Staff A was notified of the medication error. During an interview on 11/30/18 at 8:45 AM, the IDNS stated she was not aware of the medication error. RESIDENT 58 Review of a quarterly MDS assessment dated [DATE], Resident 58 was cognitively impaired and had no evidence of hallucinations, delusions or refused care. The resident required extensive assistance for dressing. On 11/20/18, Resident 58 reported an allegation of abuse to Staff U, Maintenance Lead. Resident 58 stated They are going to take everything we have, and Staff told me they were going to hit me . small Asian lady and a tall buff guy. On 11/26/18, the allegation of abuse was not documented on the state reporting log and the investigation had not been completed timely (within five days). Review of the medical record showed the family had not been notified of the allegation and the resident was not monitored for potential psychosocial harm. During an interview on 11/26/18 at 12:23 PM, Staff U stated that during Quality Assurance rounds, Resident 58 reported the allegation of abuse. Staff U stated the allegation was reported to the state hotline, to the IDNS and the facility Administrator. At 12:47 PM, the IDNS stated all abuse allegations should be reported immediately. The IDNS stated she was unsure why the allegation was not logged on the state reporting log, but there were so many allegations coming in at once that some of them may have been missed being logged in a timely manner. The IDNS was not able to state why the investigation was not completed timely. On 11/26/18 at 12:40 PM, an allegation of abuse was reported. Staff E, NAC, was assisting Resident 58 get dressed. As Staff E placed on the resident's shirt, Resident 58 became upset, was striking out at Staff E and asked her to stop twice. Staff E continued to dress the resident and did not stop. Agency Staff 5, NAC, intervened, asked Staff E to leave the room and reported the allegation. Review of the medical record showed no evidence the allegation of abuse had occurred until 12/04/18 at 11:21 AM, eight days after the allegation. The resident had not been monitored for potential psychological harm. Review of the state reporting log, showed no evidence of the allegation. Review of the facility investigation showed no evidence of other residents being interviewed regarding care and services. The investigation did have resident interviews performed on 11/21/18, five days prior to this allegation. The investigation was not thorough. During an interview on 12/04/18 at 1:40 PM, the IDNS confirmed the investigation was not thorough and not completed within the required timeframe. RESIDENT 72 Review of the quarterly MDS assessment dated [DATE], the resident was cognitively intact, able to make her needs known and required extensive assistance of 2 or more staff members for bed mobility. On 11/27/18 at 12:15 PM, Resident 72 reported her call light was on for almost 45 minutes and no one was answering it. Review of the statement from Staff QQ, NAC showed, I was assigned this floor even after informing that I had no training on this floor side. I went to go look for another aide to help assist with the floor I was assigned to but I couldn't find anyone . nobody was available because we are short of aides today .I forgot to go back and let (Resident 72) know that I haven't found anyone and that I was still looking. I take responsibility on that. I have been pulled all over the floor to help with what I can. Review of the medical record showed no documentation the resident was assessed, placed on alert charting to rule out potential psychosocial distress or Social Service intervention. On 12/03/18, the facility completed the investigation and logged it into the state reporting log, which was a day late. Review of the investigation showed no evidence of any call light audits as a means to identify the root cause. During an interview on 12/04/18 at 1:40 PM, the IDNS confirmed the investigation was not thorough and not completed within the required timeframe. No additional information was provided. RESIDENT 81 Review of an MDS assessment dated [DATE], the resident was cognitively intact and required extensive assistance for all activities of daily living except eating. On 11/21/18 Agency Staff 10, NAC, wrote a grievance and placed it in the IDNS mail box. The grievance showed the resident informed him she was waiting for over an hour to get help. Attached to the grievance were the resident's documented call light wait times. Review of Resident 81's handwritten note dated 11/21/18, showed the resident asked for help at 5:00 PM. A staff member asked her to wait for a while. The resident stated she could. The resident documented after 6:00 PM, the resident did not receive her dinner meal, and the staff member went to get it. The dinner was brought to her . real cold so he heated it. The resident documented that at 7:00 PM she couldn't get help, at 8:00 PM she was still wanting help, at 8:00 PM she started to pull light switch finally got attention but it was from a guy different room, and it is just 9:10 (PM) still no help. Review of a progress note by Staff RR, LPN, dated 11/21/18 at 9:30 PM, showed Resident 81 complained that she had to wait too long for her dinner and cares this evening. Resident also complained that when she pulled her cord for her overhead light, that no staff member responded. The resident mistakenly thought she was activating her call light when she did so. The nurse reoriented the resident on correct use of the call light, obtained a written statement regarding her care and a statement from the aide. Staff RR updated the IDNS. Review of a witness statement dated 11/22/18, Staff SS, NAC, showed he helped the resident around 3:00 PM. Staff SS believed then a nurse had helped the resident and he did not need to do anything else. Review of the investigation showed no evidence the facility safeguarded the resident when the staff failed to recognize this was a potential allegation of neglect. There was no evidence any other residents were interviewed. The investigation failed to include the resident's statement in which they would have discovered she was using her overhead light to flash lights in an attempt to gain the staffs attention and get assistance. In an interview on 12/04/18 at 1:40 PM, the IDNS confirmed the investigation was incomplete. RESIDENT 42 Resident 42 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], showed the resident was cognitively intact, required two person extensive assistance for bed mobility and was totally dependent for transfers. Review of the care plan revealed a focus problem, dated 05/09/16, of risk for a decline and dependence in Activities of Daily Living and mobility with the goal to be a safe two person extensive assist with a Hoyer (mechanical device) lift. The interventions included two person extensive assist transfers with the Hoyer lift. In addition, the care plan listed interventions for Fall Risk Precautions which included a Hoyer safety check done before, during and after transfers. Review of the Kardex (nursing assistant care guide), showed the resident was a two person extensive assist with a Hoyer for transfers. Fall precautions included to do a safety check of the Hoyer lift before, during and after transfers. Review of a progress note dated 10/12/18, showed the resident had an incident with the Hoyer lift while being transferred back into the bed. The Hoyer lift frame started to tilt over towards the resident, was caught and brought back to the floor. The RCM and the Staff Development Coordinator were notified. The resident sustained [REDACTED]. Review of the (MONTH) (YEAR) state reporting log, showed the incident was not logged. During an interview on 11/16/18 at 10:50 AM, Staff Z, RN/Staff Development Coordinator, stated there had been a lot of education with the staff regarding using the Hoyer lift and there had been no further incidents since October. At 11:00, Resident 42 stated the Hoyer tipped over while she was about 6 inches above the bed, therefore she did not get hurt. Resident 42 stated there were two staff members present during the transfer and did not know how it happened. The resident stated nobody really asked me about what happened, but the other staff knew about it. During an interview on 11/20/18 at 10:29 AM, the IDNS stated she could not find any incidents regarding the Hoyer tipping over. The IDNS stated she was not sure why this incident was not investigated. During a joint interview at 11:29 AM, the Administrator and IDNS stated they were trying to get everyone educated on what should be reported. The incident with the Hoyer lift should have been looked at and reported to the Federal Food and Drug Administration (FDA) since equipment was involved. During an interview on 11/26/18 at 9:39 AM, Staff Z stated she did not know why the incident on 10/12/18 was not investigated at the time it occurred. RESIDENT 32 Resident 32 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the quarterly MDS assessment dated [DATE], documented the resident was cognitively intact and required extensive assistance of one person for bed mobility and supervision for transfers. Review of a progress note, dated 11/12/18, showed at approximately 9:00 PM the Licensed Nurse (LN) heard the resident shouting for help. The resident was found on the ground in a sitting position next to the bath chair with her walker in front of her. The resident was crying, wanted to get up and complained of pain on the back of her head. A golf ball sized bump was observed on the back of the resident's head, there were no other injuries noted. The bath chair's front wheels were locked but the back wheels were unlocked. The resident did not have non- skid socks on. The resident stated that she was trying to get up to go to bed and slipped. Review of a progress note dated 11/13/18 at 2:19 PM, the IDNS documented she had been informed of the fall and the resident's concern regarding being left alone. The note stated an investigation was pending. Review of the investigation report showed the investigation was not thorough or complete. The investigation did not contain an interview with the resident concerning the incident, any other residents who received care from the involved staff member or other NAC's who had worked with involved staff member. In an interview on 11/20/18 at 11:29 AM, the IDNS stated I'm sorry the investigations are incomplete. I'm just getting over-whelmed. During an interview on 11/20/18 at 2:39 PM, Resident 32 stated that on the day of the fall her aide had given her a shower and wheeled her back to her room on the shower chair. The resident stated the NAC had asked me how she transferred and she told them she used the walker to get into bed. The NAC then said, Oh, so you're ok then, and left the room shutting the door. Resident 32 continued to state, I tried to transfer myself and fell . I went to management I think a day or two after it happened because no one came and talked to me about it. No one ever came to see me or interview me about what happened. During an interview on 12/03/18 at 11:56 AM, Resident 32 stated that last Friday, Staff B, RN/ RCM came into my room while my friend, Resident 18 was in visiting and Staff B stated, I want to talk to you. She continued to state Staff B asked her roommate, Resident 34 if she was getting around okay, then she looked at me and my friend and said an aide had reported you had asked for help for your roommate. Staff B had stated that if she, (Resident 34) does not want help we cannot force her. Staff B reprimanded us both. We both started crying. We were just trying to help. At 3:31 PM, Resident 32's spouse stated that they had reported the incident to the Resident Council President and the Administrator during the Huskies game on Saturday and the Administrator had even stated they may have to suspend Staff B. In an interview on 12/04/18 at 12:05 PM, the RDO, stated that the Administrator had failed to report the incident. RESIDENT 24 Review of the quarterly MDS assessment dated [DATE], documented the resident was cognitively intact and required extensive assistance of two persons for bed mobility, toileting and transfers. Review of the facility's Incident Reporting Log revealed the resident had three falls since her admitted d 06/26/18, 07/04/18, and 07/20/18. Review of the investigations of these falls revealed the investigations were not thorough and complete. None of the investigations included an interview with the involved resident. The interviews were with the witnesses directly involved in the incident only. No additional staff members or residents were interviewed. Additionally, the care plan and Kardex were not updated after the 06/26/18 fall. In an interview on 11/20/18 at 11:29 AM, the IDNS confirmed the incident investigations were not thorough. Review of the state reporting log showed an allegation of abuse to Resident 24 on 11/21/18. The incident report showed during a skin check the resident had small patches of redness on her face. Resident 24 stated, Staff WW, NAC was giving me a shower and she started to shave my face. I have a couple of hairs on my chin that needed to be shaved. She kept shaving the rest of my face; between my eyebrows, my cheeks, above my lip. I told her to stop. She continued to shave my face. I am really upset about this. Review of the incident report showed the incident was not logged within the required 5 days, and not thoroughly investigated to include statements from the staff member who bathed her the day before the redness was documented (11/20/18) or a care plan revisions to notify NAC's regarding shaving. During an interview on 11/26/18 at 3:20 PM, Resident 24 stated No one ever came and talked to me about the falls that I can remember. During an interview on 11/28/18 at 12:30 PM. Resident 24 stated she was surprised when the NAC started shaving her whole face. RESIDENT 4 Review of the MDS assessment dated [DATE], revealed the resident had severe cognitive impairment and required extensive assistance of one person for all activities of daily living and transfers. Review of the clinical record revealed a progress note, dated 11/23/18 at 5:38 PM, documented the resident was sitting in his wheelchair, fell asleep while eating in the dining room, and fell straight out of the wheelchair onto his face. It was a witnessed fall. He was sent to emergency department (ED) and had a laceration to the bridge of his nose requiring sutures. Review of the hospital history and physical, dated 11/23/18, showed the resident had a critical blood sugar level of 27 when the medics arrived. On arrival to the ED he had a bloody nose, a nose deformity which later found to be a nose fracture. Review of the facility's incident reporting log on 11/26/18 and 11/27/18 showed the incident had not been logged. There was no evidence an investigation had been initiated. During an interview on 11/27/18 at 10:14 AM, Staff A stated she was aware the resident fallen on 11/23/18 and broke his nose. Staff A agreed that a broken nose was considered a significant injury. At 10:26 AM, the IDNS stated she had to manually update the state reporting log every couple of days and there were so many incidents occurring that they had not all been logged. RESIDENT 33 Resident 33 was admitted [DATE] with [DIAGNOSES REDACTED]. According the quarterly MDS assessment dated [DATE], the resident was alert and oriented and required physical help of one person for bathing. Review of the incident report dated 11/17/18, showed Staff F, NAC, abused the resident during a shower. The facility had substantiated the abuse. Staff F was terminated. The investigation showed a personnel action record dated 10/11/18, that Staff F was disciplined for failing to report suspicion of any abuse or neglect and it was her final notice as Staff F was verbally counseled before (no evidence of education was seen for this instance). The investigation showed no evidence of other residents being interviewed. Review of Resident 33's medical record showed no follow up documentation to rule out psychological harm. During an interview on 11/26/18 at 12:01 PM, Resident 33 stated Staff F was giving him a shower and he kept leaning over and Staff F kept yanking me up and it wasn't very nice. The resident further stated Staff F had given him a shower before but nothing like that happened before. He continued to state he didn't say anything when it happened because he thought she would get even meaner. Resident 33 stated Staff F said she would never give him a shower again. Resident 33 said he told someone about what happened but he did not remember who. RESIDENT 34 Review of the facility's incident report on 12/03/18 of an allegation of neglect for Resident 34 on 11/21/18 showed an incomplete investigation, 12 days after the allegation. RESIDENT 190 Review of the facility's incident report on 12/03/18 of an allegation of care for Resident 190 on 11/27/18 showed an incomplete investigation, six days after the allegation

Based on observation, interview and record review, the facility failed to consistently implement interventions for one of four residents (17) reviewed for nutrition. Failure to ensure individualized interventions were consistently implemented following a Registered Dietician (RD) recommendations after a significant weight loss was identified, caused harm to Resident 17 who had continued weight loss, dehydration, critical labs and a decreased quality of life. Findings include: Review of the facility's policy titled, Encouraging and Restricting Fluids Policy and Procedure, dated (MONTH) 2010, showed the purpose of this procedure was to provide the resident with the amount of fluids necessary to maintain optimum health. This may include encouraging fluids, being accurate when recording fluid intake and being supportive of the resident's fluid intake. The resident would be encouraged to follow specific instructions and encouraged to drink fluids. Fluid intake was recorded on the intake and output record and would be documented in milliliters (ml's). If the resident refused, this was reported to the supervisor. Review of the facility's policy titled, Hydration Clinical Protocol, revised (MONTH) 2013, showed for more severe or complicated fluid and electrolyte imbalances, subcutaneous re-hydration may be needed. Review of the facility's protocol titled, Nutrition (impaired)/unplanned weight loss-clinical, revised (MONTH) 2013, directed the physician and staff to closely monitor residents who had been identified as having impaired nutrition by evaluating the care plan and the resident's response to interventions. The protocol defined significant weight loss as: - 1 month-5% weight loss is significant; greater than 5 % is severe; - 3 months-7.5% weight loss is significant; greater than 7.5 % is severe; and - 6 months-10% weight loss is significant; greater than 10% is severe. Resident 17 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], the resident had moderately impaired cognition, did not exhibit behaviors or care refusals and required supervision including encouragement or cueing and assistance of one staff for eating. He was unable to move the left side of his body. Review of Resident 17's weight history revealed: - On 12/09/17, the resident weighed 227 pounds; - On 05/09/18, the resident weighed 203.1 pounds, a severe weight loss of 23.9 pounds or 10.5% in six months; - On 08/26/18, the resident weighed 188.4 pounds, a significant weight loss of 14.7 pounds or 7.2% in three months; and - On 11/27/18, the resident weighed 167.2 pounds, a severe weight loss of 21.2 pounds or 11.2% in three months. Review of Resident 17's care plan, last revised 08/23/18, showed the resident had a nutritional problem or a potential nutritional problem related to impaired swallow and decreased appetite. The goal was for no significant weight loss. Interventions included to explain/reinforce the importance of maintaining the diet as ordered, the resident liked to drink Snapple throughout the day, RD to evaluate, to request and provide speech therapy as appropriate, the interdisciplinary team (IDT) to follow in the Nutrition at Risk (NAR) meeting, to encourage optimal meal intake and to offer supplements as ordered. Review of the RD's assessment dated [DATE], showed Resident 17 was prescribed 120 ml house shake (a dietary supplement) three times a day, to provide 120 ml hydration pass three times a day between meals and to offer ice cream at lunch and dinner per the resident request. The RD estimated the resident's daily fluid needs to be 2,200 to 2,500 ml's. The RD documented the resident ate in his room independently 50% of the time, dined with supervision and/or cueing 50% of the time and would benefit from staff cueing 100% of the time. The RD recommended to continue to review the resident monthly in the NAR meeting secondary to significant weight loss. Review of the (MONTH) through (MONTH) 23, (YEAR) Medication Administration Record [REDACTED]. The resident consumed 120 ml on 13 of 74 times in (MONTH) and 24 of 67 times from (MONTH) 1st through (MONTH) 23rd. Further review of the MARs showed the resident consumed 0 to 100 ml's of the health shake on all other times it was offered. On 10/23/18, a new order was received to increase the health shake to four times daily. Review of the MAR from (MONTH) 23 to (MONTH) 28th, the resident consumed 120 ml of the health shake 70 of the 144 times it was offered. On 11/01/18, a review of the 30 day look back electronic health record (EHR) daily charting task for eating was done. The Nursing Assistants Certified (NAC's) documented Resident 17 did not receive any meal or fluid assistance and did not receive hydration pass nor any bedtime snacks on any shift. His average meal intake was primarily 0-25%. His fluid intake was documented as 280 to 1320 ml a day, which was less then the required 2200-2500 ml a day. Review of the Advanced Registered Nurse Practitioner (ARNP) visit dated 10/30/18, noted the resident exhibited signs of dehydration. The ARNP documented the resident appeared poorly hydrated, had poor skin tugor (a sign when the skin on the back of the hand is pulled up for a few seconds and does not return to its normal state which can indicate a late sign of dehydration) and the resident's BUN (Blood Urea Nitrogen, a kidney function blood test) level had increased. The ARNP recommended to hydrate the resident with 2 liters of half normal saline subcutaneous (into the skin tissue) infusion at 60 ml's per hour. Review of the (MONTH) and (MONTH) MAR indicated [REDACTED]. On 11/01/08, the night shift Staff W, Licensed Practical Nurse (LPN), initialed 9 (see progress notes) on the MAR. Review of the progress notes showed no documentation why Staff W did not administer the subcutaneous hydration per the physician order. Therefore, the hydration continued until 11/02/18 day shift. Review of the ARNP visit dated 11/13/18, showed the resident's chief complaint was a kidney injury, dehydration and [MEDICAL CONDITION] (high potassium level). The ARNP identified the resident had [MEDICAL CONDITION] and was currently experiencing an acute kidney injury. The ARNP stated the cause for the acute kidney injury could possibly be related to dehydration. The ARNP documented the resident looks slightly dehydrated. Review of a progress noted dated 11/13/18 at 3:08 PM, Staff ZZ, Registered Nurse (RN), documented Lab called to report a critical BUN (lab that reflects kidney function) of 99 (normal range is 7-25). NAC reports patient has not been voiding (urinating) much today and not drinking or eating much either. ARNP plans to write orders to address the labs and Nephrology (kidney specialist) consult tomorrow. Review of the (MONTH) MAR indicated [REDACTED]. The hydration began 11/13/18 on the PM shift and was completed on 11/15/18 evening shift. On 11/14/18 the day shift nurse did not document the hydration was given. There was no progress note detailing why SQ hydration was not administered as ordered. Review of the Nephrology consultation dated 11/14/18, showed the resident had acute kidney injury with long standing history of nephrolithiasis (kidney stones) and [MEDICAL CONDITION] ([MEDICAL CONDITION]/prostate enlargement). The Nephrologist documented treatment for [REDACTED]. In an observation on 11/15/18 at 2:30 PM, Resident 17 was in bed with no fluids at bedside. Review of the ARNP visit dated 11/16/18, showed the resident had a steady decline in his weight, had a decrease in his food intake and had not been eating per normal. The resident currently weighed 175.6 pounds and had lost 50 pounds. In an observation on 11/16/18 at 8:01 AM, Resident 17 was in bed. His urinal was located on his over bedside table and contained 250 ml of dark burgundy colored urine. There was a cup of water with approximately 50 ml in it on the over bedside table. At 9:03 AM, the resident was lying in bed with various drinks on his breakfast tray but only 50 ml of milk consumed. The resident's positioning was poor. He was leaning to the right and his head was bent awkwardly in a forward position. There was no staff observed assisting the resident. At 12:55 PM the resident was observed with the same amount of water in the water pitcher as observed at 8:01 AM. During an interview on 11/16/18 at 1:40 PM, Staff E, NAC, was asked why the resident did not consistently have fluids available. Staff E stated the resident was a good drinker and usually would drink anything that was placed in front of him. At 1:46 PM the same amount of fluids were observed on his over bedside table. In an observation on 11/19/18 at 8:30 AM, Resident 17 was in bed asleep. There was 20 ml of health shake in a cup and a water pitcher on the over bedside table without ice. At 8:51 AM, Resident 17 was observed trying to set up his breakfast tray. The resident asked Where is my milk. Where are my straws? The resident took the lid off his milk and spilled it all over his plate and tray in an attempt to pour it on his oatmeal. There was no observation of staff assistance. At 11:05 AM, the resident's water pitcher and health shake were observed to have the same amount of fluid as previously observed. At 2:02 PM, the resident was observed in his wheelchair just inside his room after returning from a doctor appointment. His covered lunch tray was on his over bedside table at least 4 feet away. There were no staff in the vicinity to set up the lunch tray for the resident. At 2:32 PM, the resident was observed in the same location with his lunch tray covered and untouched, which was across the room. Staff D, NAC, was then informed the resident had returned from his physician appointment over 30 minutes ago and he needed assistance in setting up his lunch tray. On 11/20/18 at 8:26 AM, Resident 17 was observed sleeping in his bed. The resident had poor bed positioning and leaning far over to the left hand side of the bed. There was an almost empty water pitcher and an empty urinal observed on the same over bedside table. At 8:43 AM the resident's breakfast tray was delivered. At 9:13 AM, thirty minutes later, Agency Staff 1, NAC, was observed starting to set up Resident 17's tray, but did not ensure he had the appropriate sippy cups or straws. In a joint interview on 11/20/18 at 11:57 PM, the Administrator and Interim Director of Nursing were informed of identified concerns of Resident 17's poor food and fluid intake, abnormal labs and [DIAGNOSES REDACTED]. No additional information was provided. At 2:13 PM, Resident 17 was observed in bed asleep. There were no fluids present and the over bedside table was approximately 3 feet from him. The resident's lips were dry. At 4:19 PM, the resident was in bed awake and the over bedside table remained in the same location, over 3 feet away from him. The resident had no access to fluids. At 4:34 PM, his over bedside table containing fluids was in the same location, over 3 feet away and was inaccessible to the resident. In a nursing care note dated 11/20/18 at 2:37 AM, Staff II, LPN, documented the ARNP was notified regarding the residents critical BUN. The ARNP ordered to continue to push fluids and to draw a weekly BMP (basic metabolic panel, a lab). In an interview on 11/20/18 at 4:35 PM, the Regional Director of Operations (RDO) was alerted Resident 17 was in his room with no access to fluids and he recently required subcutaneous hydration. The RDO directed Staff K, Medical Records, to go to Resident 17's room and ensure he had fresh water, to educate the staff and to tell them that is not cool. In an observation on 11/21/18 at 8:25 AM, Resident 17 was in bed with no fluids on his over bedside table. At 8:33 AM, an overhead page announced A-wing cart hall breakfast trays were ready. At 8:44 AM, Staff W was asked what measures were in place for Resident 17's nutrition and hydration. Staff W stated the resident did not have an IV any longer and staff were to push fluids. Staff W stated the resident enjoyed tea that his family and friends brought into the facility. Staff W stated each shift was responsible to document how much fluids the resident received every shift. Staff W was alerted that the resident currently had no fluids present at his bedside. No additional information was provided. At 9:07 AM, 34 minutes later after the breakfast trays were announced they were ready, Resident 17's breakfast tray was delivered to his room. The orange juice was delivered only 1/4 of the way filled and there was one sippy cup of milk. His breakfast tray was observed to not be set up. In an observation on 11/21/18 at 9:38 AM, the resident was observed lying flat in bed with hot cereal in his beard, on his chest and hospital gown. He said I need help .need straws. There were no straws in his juice and they were covered with plastic wrap. The resident's breakfast was largely uneaten. At 10:50 AM, the ARNP stated the resident had been prescribed 4 to 5 liters of IV fluids but it did not seem to do much. The ARNP stated it will do no good if nurses don't provide fluids. The ARNP was alerted nurses were documenting the resident received [PHONE NUMBER] ml a day and he had been observed without access to fluids on multiple occasions. The ARNP stated staff were to push fluids at least 2,000 cc (cubic centimeters) a day. At 12:12 PM, Staff A and I, RN/ Resident Care Managers (RCMs) were asked what interventions were in place for the resident's significant weight loss and dehydration. Staff A stated the resident's family would bring in foods and fluids the resident wanted, the resident loved Snapple and he was assessed in the NAR meeting. Staff A and I were informed there were no observations of Snapple in his room, or ice cream on his lunch tray on any observation and at times his fluids were out of reach or not there at all. Staff I confirmed he could use assistance. Both RCM's confirmed the plan was to encourage food and fluids. Staff A stated staff should check on the resident after they set him up for his meals and ensure that he had straws and any needed assistance. Staff A and I were not able to state what the facility was going to do to ensure the resident did not have further weight loss and dehydration. In an observation on 11/26/18 at 8:31 AM, Resident 17 was in bed asleep with his breakfast tray present. The lids were not removed and there were no straws present. At 11:32 AM he was in bed laying flat with the over bedside table pushed far away from him with no access to fluids. At 11:59 AM, Agency Staff 6, NAC, was in the room but did not move his bedside table so he could have access to his fluids. Reference WAC 388-97-1060(3)(h)

Based on observation, interview and record review the facility failed to prevent abuse for 3 of 7 residents (1, 2 and 11) reviewed. Theses failures resulted in physical pain for Resident 1 and psychosocial harm to Resident 2 and 11 related to the abuse they were subjected to by staff members. Findings include: The facility abuse policy stated the facility would not condone any form of resident abuse and would continually monitor the facility's policies, procedures, training program and systems to assist in preventing resident abuse. RESIDENT 1 Resident 1 was admitted [DATE] with [DIAGNOSES REDACTED]. On 09/19/18, Resident 1 went onto Hospice services. The care plan noted extensive three person assist for all bed mobility, position with pillows and blankets per request to offload pressure points. Review of a facility investigation dated 10/20/18, reported an incident which occurred on the evening of 10/19/18. The resident thought the Nursing Assistant's (NAs) were just going to change me, but the one (Staff A, NA) changed my wound dressing as well. They (Staff A and B, NAs) hurt me and made me cry. I told her (Staff A) to stop several times but she (Staff A) kept going. Afterward I hurt a lot because of all the wrinkles she (Staff A) left under me. It really made me mad so I am reporting her (Staff A). Per the facility's investigation, there were no new skin issues noted during the assessment. Staff A was not delegated to do any dressing change, clean the resident's open areas with normal saline, or apply a dressing. The staff did not follow the resident's care plan at the time of the incident due to the resident was a three person assist with bed mobility. The facility substantiated Staff A abused Resident 1. Staff A, who was a agency NA, was terminated from coming into the facility. Staff B received a final warning for non-reporting of a NA working outside of her scope of practice and for not reporting pain to the nurse. The facility educated all staff on mandatory reporting requirements and on abuse and neglect. In a personnel action form dated 10/24/18, Staff C, Licensed Practical Nurse (LPN), was disciplined for the incident on 10/19/18, due to failure to report the incident of Staff A working outside of her scope of practice, failure to assess the resident's wounds after Staff A performed the dressing change and the failure to report the incident to the Director of Nursing Services (DNS). In a second personnel action form dated 10/24/18, showed Staff B was disciplined for not reporting the resident's pain to the nurse and for not reporting Staff A performed wound care/dressing treatment on the resident, which was outside the NAs scope of practice. In an interview on 10/24/18 at 1:25 PM, Resident 1 reported Staff A and another aid were in the room changing her brief. The resident could not remember the name of the second aide. The second aide held me to one side. The resident stated Staff A, was being rough and scrubbing my skin harder than she had to. I asked her to stop several times. Staff A, then changed my dressings, when I told her the nurses do that, not the aides, she said well the aides do that at the hospital, so she changed it. Then Staff A put the linen underneath me but it was bunched up and she refused to fix it. The other aide never said anything to help me either. The resident reported she cried throughout the incident. The resident stated the bunched up linen made my butt sore. When asked how long she laid on the bunched up linen, the resident stated for a couple of hours and when the night shift came in they might have changed her brief, but she could not remember for sure. The resident stated there usually were three aides to help care for her and not just two. The resident stated she reported the incident to someone the next day. In an interview on 10/26/18 at 10:45 AM, the interim DNS stated the expectation for the NAs was they work within their scope of practice. Doing dressing changes was not in the NAs scope of practice. The DNS stated Staff A had told Staff C that she had changed Resident 1's dressing, which Staff C had failed to report. The DNS stated Staff A was an agency NA and would not be permitted back into the facility. The DNS confirmed the facility had substantiated abuse. RESIDENT 2 Resident 2 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE], showed the resident required two person assist for all transfers. The resident had an upper extremity impairment and used a wheelchair for mobility. Review of a facility investigation dated 10/11/18, the resident reported to staff on 10/10/18 about an incident which occurred on 10/08/18. The resident stated during a Hoyer transfer he told Staff D, agency NA, that he was slipping out of the sling. Staff D told the resident to quit yelling and do what I say. Per the resident Staff E, NA (who was in the room), attempted to tie the sling which was undone. Staff D then pushed the resident over the bed. When the resident was in the bed, he told the NAs he was not comfortable because the sling was pinching him in intimate places. The resident stated when the staff were done, Staff D told him he would never help him in the Hoyer lift again and not to even ask him and left the room. The resident stated about five minutes, Staff D did come back and apologized. Review of a witness statement, with an incident date of 10/08/18, Staff E stated he heard a little argument between Staff D and the Resident 2 during the Hoyer transfer. Staff E stated he intervened in the conflict by talking to the resident and empathizing with him. Staff E told the resident it was going to be ok and he would get more rest on his bed soon. Staff E stated he did not report the incident because he thought the conflict had been resolved. In an interview at 10/24/18 at 10:30 AM, Resident 3 (the roommate of Resident 2) stated he witnessed the incident on 10/08/18 between Staff D and Resident 2. Resident 3 stated he was in the room when Staff D was transferring his roommate using the Hoyer lift. Resident 3 stated the Hoyer straps were not applied properly and Staff D was just lifting him up, like he was just hurrying to get him up. That was when Resident 2 yelled and said he was falling, and Staff D at the resident and essentially told him to shut up- and to do what he told him to do. Resident 3 stated the other aid (Staff E) jumped in and grabbed the strap and pushed Resident 2 to the bed so he would fall onto the bed. Resident 3 heard Staff D tell the resident to never ask him to Hoyer him again because he would never Hoyer him again. Resident 3 stated a bit later the same aid (Staff D) came in and apologized for the actions and remarks. Per Resident 3 the aid acted a bit crazy, yelling one minute and then coming back and apologizing. Resident 3 then stated he had been offered several times to move rooms but he always requested to stay with his roommate. Resident 3 stated Resident 2 had [MEDICAL CONDITION] but he was still a highly intelligent man. I stay with him to advocate for him, he is hard to understand if you don't stop and listen. He needs someone to advocate for him. In an interview at 10:45 AM, Resident 3 stated Staff D was rude and almost made him fall. Resident 3 stated Staff D yelled at me and made me feel scared. During an interview on 10/26/18 at 3:45 PM, the interim DNS stated Staff D was no longer allowed to work in the facility as an agency NA. The DNS reported Staff D did not write a statement regarding the incident with Resident 2. The DNS stated that Staff E received a final written warning. The DNS stated when talking to Staff E, it was difficult for him to see that yelling at a resident was an abusive act. The surveyor attempted several times to interview Staff D and the agency he worked for. Both Staff D and the agency failed to return any phone calls. RESIDENT 11 In an investigation dated 10/30/18, there was a verbal altercation between a staff member and a resident. In a statement dated 10/30/18, the Administrator stated she was in her office and heard a loud voice say [***] and then another voice yelling you can't talk to me like that. As the administrator was leaving her office she heard someone yelling shut up and go to your room. When she arrived on A wing, she witnessed Staff G, LPN, yelling at Resident 11. Resident 11 had come outside of her room to the medication cart to ask Staff G for her medications. Staff G said she was too busy. Staff G told the Administrator that she can't give Resident 11 her medication when she asked for them. The Administrator told Staff G she was being inappropriate with the resident. Staff G then turned to the Administrator and said, she (the resident) isn't really deaf, she just pretends to be deaf. Staff G then walked away to finish another task. The Administrator then spoke with the resident who reported when she asked for her medications Staff G said she was too busy. When speaking to the Administrator she stated, I was wrong and you can do anything you want to me. The facility substantiated verbal abuse and terminated Staff G. In a telephone interview on 10/31/18 at 1:32 PM, the Administrator reported Staff G, who had also been involved with a case of misappropriation of resident property, verbally abused Resident 11. The Administrator stated she heard the abuse from her office and when she went in the direction of the yelling she could hear Staff G yelling at Resident 11. In an interview on 11/05/18 at 11:00 AM, Resident 11 (who required questions to be written out on a white board in large letters in which she read and then was able to answer or was able to lip read short statements), stated at 6:30 PM she asked Staff G for her routine medications. Resident 11 stated she could not hear what Staff G was saying to her, but Staff G had pointed her finger real close to my face like this (the resident demonstrated by pointing her finger and had it approximately four inches from the surveyors face). The resident reported that Staff G had pointed at her and then pointed at her room as if to tell me to get back to my room. I probably called her a name, I'll admit I am not perfect and I lose my temper with that one (Staff G). She has pointed her finger at me more than once, probably three or four times. Resident 11 again demonstrated how Staff G pointed her finger at her and then would point away. The resident stated when Staff G did this it meant for her to go back to her room. Resident 11 reported her recent losses of hearing and vision was difficult, because things she enjoyed she could no longer do. The resident reported that she could barely read her large print books any longer which she loved to read. The resident stated her hearing has failed as well, leaving her deaf. The resident continued to state that Staff G would also give her a hard time about her insulin. The resident reported she, herself was a nurse for several years so she understood her needs and her medications. The resident found Staff G difficult because she would say something and point for me to return to my room whenever I asked about my insulin. The resident went on to say if the Administrator had not heard the nurse yell at me, I would not have reported anything, like I never reported her before. I didn't see it as abusive, I thought I was encountering a mean person. That's life, there are mean people everywhere. Until it was witnessed by the Administrator, Staff G would have continued to treat me poorly. I just didn't put it together, I knew it felt wrong, and as a nurse, I never spoke to anyone or pointed my finger in their face. I just did know how wrong it was until now, I figured it was something I just had to deal with because of where I am. In three separate incidents staff did not follow facility policy and abused residents in their own home. These acts of abuse caused harm in the form of emotional responses during the incidents and the [MEDICATION NAME] memories on all the residents who were all able to recall the events, in detail, and state how it made them feel. Reference (WAC) 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure necessary care and services were provided to prevent avoidable pressure ulcers for two of four residents (1 and 5) reviewed for pressure ulcers. The facility failed to comprehensively assess the resident's clinical condition and provide pressure ulcer care which was consistent with the professional standards of care. These failures resulted in harm to Resident 1's skin which resulted in a lack of monitoring and a decline in a heel wound while in the facility. Findings included: Review of the facility's policy titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, revised (MONTH) 2014, showed the nursing staff and attending physician would assess and document a resident's significant risk for developing pressure ulcers. The nurse shall describe and document/report the following: a full assessment of the PU, a pain assessment, the resident's mobility status, current treatments (including support surfaces) and all active diagnoses. The Resident Assessment Instrument (RAI) Manual defined the stage of a pressure ulcer (PU) as followed: - A stage II PU (also known as a pressure injury) is a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. This may also present as an intact or open/ruptured blister; -A stage III PU was described a full thickness loss of the skin; - An unstageable PU was a full thickness skin and tissue loss was obscured by slough (non-viable yellow, tan, gray, green or brown tissue) or eschar (dead or devitalized tissue that was hard or soft in texture and was usually adherent to the base of the wound and often the sides/edges of the wound); and -A Deep Tissue Injury (DTI) was described as intact or non-intact skin with localized area of persistent non-blanchable deep red, marron, or purple discoloration. RESIDENT 1 Resident 1 was admitted on [DATE] after a hospitalization , was re-admitted on [DATE] with [DIAGNOSES REDACTED]. Per the Hospice Plan of Care dated 09/19/18 the resident was diagnosed with [REDACTED]. The resident was on Hospice services as of 09/19/18. Wound Rounds documentation dated 09/26/18 revealed a pressure injury to the left heel described as unstageable, boggy (soft) and a blood filled blister. The wound was facility acquired and was identified on 05/18/18. On 10/26/18 at 10:45 AM in an interview with the Director of Nursing (DNS) who stated the resident had been referred to a wound care service this week. The DNS also stated she would be working to re-vamp the wound care process. Per the DNS the resident refuses care from the staff frequently, including wound care. The DNS was made aware there was no documentation of refusals in the record, nor was there refusal monitoring in the treatment record. In a follow-up interview at 2:27 PM the DNS reported the licensed staff were not documenting as they should. There was one time dated 10/09/18 when the resident refused a dressing change. The DNS also stated when Hospice becomes a part of the resident care the facility staff seem to have taken a hands off approach. Hospice and the facility should talk about the expectations of the care and who is providing it. In an interview at 2:40 PM with Staff J, Resident Care Manager (RCM) who provided the most recent wound measurements, dated 09/26/18. Per the RCM since the resident was last hospitalized and came back on Hospice, they now take care of the wounds. When asked if staff were still changing the dressings twice a day, she hesitated and then said oh yeah, but we do not take the measurements. The RCM confirmed there were no wound measurements after 09/26/18 available from the facility. A review of the (MONTH) Medication Administration Record [REDACTED]. A Hospice visit note dated 10/10/18 noted a problem for the resident was impaired skin integrity related to immobility. Goals were the current wounds will be maintained without worsening or pain. There were no measurements of the wounds in the note. The Left heel had medpilex foam and gel booties for protection. A Hospice noted dated 10/18/18 noted staff had changed the dressings today and left heels open to air related to excessive moisture accumulation interrupting her otherwise stable Left heel scab. The order to leave the wound open to air is already in the facility orders. Review of the care plan showed the resident was to be offer/assist to reposition every 2 to 3 hours. Sage boot was to be on both feet at all times. On 10/26/18 at 8:45 AM, Resident 1 was observed to by lying on her back, with the head of bed elevated approximately 80 degrees and was eating breakfast. At 9:15 AM, Resident 1 was observed in the same position. At 9:48 AM, Resident 1 was observed in the same position, had completed her breakfast and was watching television. At 10:53 AM, Staff R, Licensed Practical Nurse (LPN), Staff Q, Registered Nurse (RN), and Staff P and T, Nursing Assistants (NAs), were observed to provide personal care and wound care to Resident 1. The resident was lying on her back in the same above observations and there were off-white heel socks in place on both feet. The resident was positioned on her left side, Staff Q assisted Staff R to clean an open wound to the back of the resident's left thigh. The wound bed was difficult to assess related to the resident's body structure and skin folds (the wound ran along a skin fold/crease on the thigh). At 11:22 AM, Staff R removed the off-white heel sock from the resident's left foot. There was a half dollar size dark brown drainage noted on the sock. Staff R asked the resident where she obtained the heels socks from and that there should be a Sage boot in place. The resident stated she did not like the Sage boot because it was too hot. The Sage boot was observed on a chair in the resident's room. Staff R and P lifted the resident's left leg. There was an approximately half dollar size black wound was observed on the bottom of the resident's left heel. On the bottom of the wound, the skin around the wound was lifting away from the resident's skin and the rest of the area was dry and intact. Staff R cleaned the wound and went to inform the Advanced Registered Nurse Practitioner (ARNP), who was in the facility, of the change of the resident's left heel wound. At 12:01 PM, Staff R stated the resident had just received the off-white heel socks the day prior when the Hospice nurse had visited the resident. Staff R stated the resident's care plan would be updated to reflect the new heel socks and to discontinue the Sage boot. A lack of coordination between the facility and Hospice Services regarding the resident's wound care allowed a wound to decline for Resident 1. The Licensed staff stopped monitoring the wound as soon as the resident went onto Hospice Services. RESIDENT 5 Resident 5 admitted [DATE] with [DIAGNOSES REDACTED]. Review of the annual MDS assessment dated [DATE], showed the resident had severe cognitive impairment, required extensive assist of two people for bed mobility, was dependent with the assist of two people for transfers and toileting and was always incontinent of bowel and bladder. The MDS assessment identified the resident had no current PU present, but was at risk for PU development. Review of the bowel and bladder incontinence care plan revised on 09/07/17, showed an intervention directing staff to notify the Licensed Nurse (LN) of any new skin issues. Review of the skin impairment care plan revised 09/07/17, identified the resident was at risk for skin breakdown related to her cognitive impairment, immobility and incontinence. The goal was to maintain her skin integrity. Interventions showed the resident was on a pressure relieving wheelchair (w/c) cushion, and low air loss mattress. There were no interventions on how often to reposition the resident. Review of the Kardex showed no direction to the NAs regarding repositioning the resident in bed or in her w/c. Review of a physician order [REDACTED]. This treatment was to be done until the small redness on the right buttock was resolved. Review of a nursing progress noted dated 10/13/18 at 11:43 PM, Staff Y, RN, documented the resident had a 1 cm open area on her coccyx. Staff Y placed the resident on alert charting, NAs to reposition the resident every two hours and reported the PU to the next shift. There was no evidence the physician or responsible party was notified of the PU. Review of the nursing progress notes showed only one entry on 10/14/18 at 7:14 AM, any documentation regarding the PU. Review of a Nutrition at Risk meeting note dated 10/15/17, identified the resident had a 1 cm PU on her coccyx. Review of a Braden score assessment dated [DATE], showed the resident was at high risk for skin breakdown. Review of a WoundRounds assessment dated [DATE], showed the resident had a 2.5 cm by 1.5 cm by 0 cm stage II PU on the resident's coccyx. The LN classified the PU as a blister, which meant the skin was closed and intact. This was inaccurate. On 10/24/18 at 9:05 AM, Resident 5 was observed sitting in a slightly tilted back w/c and leaning to the left in the A-wing dining room. The resident was sleeping. At 10:05 AM, Staff M, agency NA, and Staff K, NA, transferred Resident 5 into her bed. Staff K then assisted Staff M to remove the resident's pants and then left the room. Staff M provided incontinent care to the resident. As Staff M positioned the resident onto her right side a pink 4 centimeter (cm) by 4 cm foam dressing, which was coming off, was observed on the resident's coccyx. At 10:25 AM, Staff L, LPN, was notified that the resident's dressing needed to be changed. Review of the resident's record at 10:40 AM, showed no order for the above observed dressing. At 10:40 AM, Staff L, Staff M and Staff J, RN, were observed to provide wound care to Resident 5. Staff M and J positioned the resident onto her right side. Staff L removed the dressing. There was white ointment underneath the dressing. Staff L cleaned the PU. Staff L and J stated they were not aware Resident 5 had a PU. There was an open PU on the resident's coccyx. Staff J assessed the skin around the PU which was red and was approximately the size of the 4 cm by 4 cm dressing. The skin did not blanch very well. It was requested to have Staff J measure the wound. At 10:55 AM, the interim DNS was notified the facility failed to follow up on the resident's PU that was first observed on 10/13/18, the PU had not been adequately assessed or monitored since the PU was discovered and there was a dressing on the PU without a physician's orders [REDACTED].>At 1:30 PM, Resident 5 was observed in the A-wing dining room, tilted back in her w/c, leaning slightly to the left sleeping. At 1:50 PM, Staff M stated he knew how to care for a resident by reading the care plan or Kardex. Staff M stated he had not observed the PU on Resident 5 before. Staff M stated he had not noticed the dressing on the resident's coccyx until today. Staff M stated if a new PU was noted on a resident, this was reported to the LN. On 10/26/18 at 8:50 AM, a staff member was observed assisting Resident 5 with her breakfast in the main dining room. At 9:15 AM, Resident 5 was observed sleeping in a slightly tilted back w/c in the hall across from the A-wing LN station. At 9:46 AM, Resident 5 was observed in the same position. At 10:30 AM, Resident 5 was laid down in bed. At 10:43 AM, Resident 5 was heard calling out from her room. Upon entering, the resident was observed lying on her back, with a blue positioning device under her calves, to elevate her heels off of the bed. At 3:45 PM, the interim Administrator, Administrator in Training and interim DNS were notified the facitly failed to correctly assess and implement interventions for Resident 5 when a PU was first observed on 10/13/18, the facility failed to update the resident care plan, the facility failed to re-position the resident frequently and the facility failed to notify the physician and responsible party of the PU. STAFF INTERVIEWS During an interview on 10/24/18 at 10:00 AM, Staff L, LPN, stated if a PU was found on a resident, the physician was notified, a treatment was initiated, the resident was started on pressure relieving devices, and a referral would be made to the wound care team. Staff L stated every Tuesday an outside wound care provider came into the facility and did wound rounds with the Licensed Nurse. Staff L stated if the Licensed Nurse was not able to figure out how the PU developed, a facility investigation was initiated. At 1:40 PM, Staff P, NA, stated she knew how to care for a resident by reading the Kardex. Staff P stated if a PU was found on a resident, this was reported immediately to the LN. At 1:43 PM, Staff K stated she knew how to care for a resident by referring to each resident's care plan. Staff K stated if a PU was found on a resident, this was reported to the LN. During an interview on 10/26/18 at 9:37 AM, Staff S, RN/Resident Care Manager (RCM), stated if a PU was found on a resident, the LN would alert the RCM, the PU would be assessed, the physician would be notified, an appropriate treatment would be implemented and the resident would be referred to the outside wound care team. Staff S stated an incident would be initiated. Reference (WAC) 388-97-1060 (3)(b)

Based on interview, observation, and record review the facility failed to ensure all staff including agency staff, were trained in all aspects of abuse and neglect. This failure caused harm to 2 of 3 residents (1 & 2) by allowing agency staff to provide care in a physically aggressive manner and to be verbally threatening to cognitively impaired residents. Findings Include: Facility Abuse Policy and Procedure states, all staff members will receive a minimum of one-hour initial orientation training and one hour annually, regarding aspects of abuse. Staffing agencies that provide staff to the facility shall be subjected to the provisions of staff training that includes the same components of training. RESIDENT 1 Resident 1 admitted in November 2013 with [DIAGNOSES REDACTED]. The Minimum Data Assessment ((MDS) dated [DATE] noted the resident was severely cognitively impaired and required two staff members to transfer her into bed. In an investigation dated 01/09/18 which stated the resident was transferred by Staff B, Agency Nursing Assistant (NA) who used improper technique by lifting the resident up by her armpits and put the resident onto her bed roughly. The resident stated ouch. In an interview with Staff A, NA on 01/16/18 at 2:00 P.M., she reported Staff B, NA did not use proper technique. He literally cupped his fingers into her armpits and pulled her entire body weight up to get her into bed and then roughly put her down. No injuries were noted during a skin assessment and the resident was monitored for psychological harm. In an observation on 01/12/18 at 11:30 A.M., the resident was in her wheelchair with a blanket covering her. Attempts at conversation were unsuccessful. Resident 1 and resident 2 are roomates. After providing care to Resident 1, Staff A and B provided care to resident 2. RESIDENT 2 Resident 2 admitted in March of 2014 with [DIAGNOSES REDACTED]. The MDS dated [DATE] noted the resident was severely cognitively impaired and required two staff for transfers. In an investigation dated 01/09/18, which stated the resident was in her wheelchair and was going to be transferred to bed using a sit to stand. Staff A, NA asked the resident to lean forward to be able to buckle the sit to stand strap. The resident was not cooperating, so Staff B, NA, placed his hand behind the resident's neck and shoulder and pulled her forward. The resident stated, Ouch, you're hurting me. Staff A, stated it was fine she had the strap. Staff B then stated, no one explains that jobs go like this in America. The strap continued to be an issue and again Staff B grabbed the resident by the shoulders, yanking her downward. Staff A stated Staff B was being jerky, quick, and rough. The resident screamed and swatted Staff B with her hands. Staff B swatted the resident's hands away. The resident began to scream louder, Staff B then tapped the resident's face. The resident stated, don't hit me and Staff B replied, Stop screaming then. When cares were completed, Staff A reported her concerns to Staff C, Licensed Nurse (LN). Staff C, LN, explained to Staff B he was on suspension pending an allegation of abuse and immediately escorted him out of the facility. No injuries were noted during a skin assessment and the resident was monitored for psychological harm. The investigations for both residents substantiated abuse. Observations on 01/12/18 at 11:30 AM revealed the resident in her wheelchair next to her roommate. Resident 2 stated if ya wanna talk, then talk, and she repeated this phrase several times. In an interview with Staff A, NA on 01/16/18 at 2:00 P.M., she reported Staff B had been building up to this angry behavior. Staff B, NA had verbal arguments with two different LNs, prior to this incident. He did not seem to have good mechanics with the residents; he appeared to be rushed in his approach. Staff A stated she was too scared to leave the residents alone with him so she made sure she stayed in the room during care. She stated, he did not help the situation when he jerked the residents head forward several times in an attempt to get a strap, the resident screamed and swatted at Staff B. Staff A felt the resident was trying to defend herself. Staff B then swatted her hands away. The resident screamed again and Staff B tapped the resident on the cheek. The resident said don't hit me and Staff B said then don't scream. Staff A, stated I just knew the whole situation was wrong, I told the nurse as soon as we were done. On 01/12/18 at 12:15 P.M., an interview with Staff D, staff scheduler, stated she completed a second background check, license, OBRA, and [MEDICAL CONDITION] (TB) test. Staff sign off on an abuse and neglect prevention; they take two tests on Fraud, waste, abuse and another test on HIPPA. These have to be completed before they work in the building. The formal orientation is when they are here on the floor with the other NA's. They usually come in about 15 minutes early. Staff D also stated there were reports of Staff B, NA, had been acting as a dominate male and was rude to the LN's. She also stated the nurses did not write him up for his behaviors, it happened in the hallways, not in resident's rooms. No residents complained about his care. Staff D verified Staff B was contracted to work in the facility since September and received an increase in hours in December. Staff D explained the process if there is an issue with an agency nursing assistant. First, the agency was contacted and the incident was reported. If we have to give a written discipline then it goes in their employee file here. If we do not want to use the agency aide anymore, we write across the top of the file - not to come back. Unfortunately, Staff B was unable to be reached for his statement regarding the incident. His employer has not cooperated with several requests by Staff D for a statement. AGENCY NURSING ASSISTANTS In an interview on 01/12/18 at 2:25 P.M., with Staff E, Agency Nursing Assistant (ANA), reported she received no training for the unit she was working on. Staff E reported she did sign some paperwork but, she did not have any type of orientation and had been working in the building since September. At 2:30 P.M., Staff F, ANA, also reported she had worked in the facility for almost two months and did not receive any orientation, just paperwork. No shadowing other aides, we just work in pairs because most residents require two people. In an interview at 3:00 P.M., with the Director of Nursing Services (DNS) and the Administrator were asked about the process of using agency staff. They are background checked a second time; they receive paperwork about Abuse/Neglect, HIPPA, and evidence of TB testing. When asked about any training or orientation for agency nursing assistants the DNS stated it can be dependent upon experience. We give them the abuse neglect to review and sign. They are free to come to all staff meetings where we talk about abuse prevention frequently. The DNS stated it is not any different then what we do with our staff. They work in teams of two and they are oriented to the floor by the other NAC's. When asked about any discipline issues with Staff B, the DNS stated just verbal arguments with nurses, nothing that involved residents. The DNS and the Administrator reported that Staff B, NA would no longer be permitted in the facility. The facility failed to provide agency staff with adequate training to recognize and prevent abuse from occurring. In addition, the staff did not recognize burnout and did not prevent abuse from occuring which resulted in harm to residents. Refer to WAC 388-97-0640 (2)(a)(b)

Based on observation, interview and record review, the facility failed to ensure 1 of 3 residents (13) reviewed for urinary function received the appropriate care and services necessary to maintain and/or restore his bladder function. This failed practice resulted in harm to Resident 13 when his urinary function declined from being occasionally incontinent of urine, to frequently incontinent. Findings include: RESIDENT 13 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to his Minimum Data Set (MDS) assessment, dated 06/17/17, he had moderate cognitive impairment. Review of the admission MDS assessment, dated 03/17/17, revealed the facility had coded the resident's urinary function as occasionally incontinent of urine. The MDS also indicated he required extensive 2-person assist with toileting. The MDS also indicated the facility had not attempted a trial of a urinary toileting program such as scheduled toileting, prompted voiding, or bladder training since admission/reentry or since urinary incontinence was noted in the facility. Review of the quarterly MDS assessment, dated 06/17/17, revealed he was assessed as frequently incontinent of urine. The MDS also indicated he required extensive 2-person assist with toileting. The MDS also indicated the facility had not attempted a trial of a urinary toileting program such as scheduled toileting, prompted voiding, or bladder training since admission/reentry or since urinary incontinence was noted in the facility. Review of a Bowel and Bladder Evaluation, dated 03/10/17, revealed the resident Always voided appropriately without incontinence. It also indicated he was a Good candidate for retraining. Review of a Bowel and Bladder Evaluation, dated 06/17/17, revealed the resident Never voided appropriately without incontinence. It also indicated he was a Candidate for Schedule toileting (timed voiding). Review of a Bowel and Bladder Evaluation, dated 08/08/17, revealed the resident Never voided appropriately without incontinence. It also indicated he was a Candidate for Schedule toileting (timed voiding). Review of a Nurse Practitioner Nursing Home Visit note, dated 04/28/17, revealed he was continent of bowel and bladder. Review of a Nurse Practitioner Nursing Home Visit note, dated 06/28/17, revealed he was mixed continent of bowel and bladder. Review of a Care Area Assessment (CAA) worksheet, dated 03/22/17, revealed he was occasionally incontinent of bladder, he tried to manage using his urinal, but usually required assistance. Factors contributing to urinary incontinence included restricted mobility, urinary urgency and need for assistance in toileting. The form indicated urinary incontinence would be addressed in the care plan. It stated the goal was for the resident to be continent of bladder and be able to use his urinal successfully. Review of the resident's care plan, print date 09/01/17, revealed there was no focus of urinary incontinence care planned. The only care planning relating to toileting was an intervention Toilet Use: 2 person extensive assist. Review of the resident's KARDEX (Care Directive for Nursing Assistants), print date 09/01/17, revealed only 1 entry relating to toileting Toilet Use: 2 person extensive assist. Review of progress notes revealed the following: Note dated 03/10/17, Urinary continence is Always continent. Note dated 03/11/17, Continent of urine. Noted dated 03/12/17, Was continent of urine and used urinal with help. Review of shift Documentation Survey Reports for March through August 2017 reveal urinary continence status as follows: March: -Continent - 54% -Incontinent - 13% -Mixed continence- 32% April: -Continent - 37% -Incontinent - 25% -Mixed continence- 38% May: -Continent - 8% -Incontinent - 69% -Mixed continence- 23% June: -Continent - 1% -Incontinent - 73% -Mixed continence- 26% July: -Continent - 3% -Incontinent - 70% -Mixed continence- 27% August: -Continent - 4% -Incontinent - 76% -Mixed continence- 20% In an observation/interview on 09/01/17 at 1:19 PM, the resident stated he used his urinal as much as possible, and he wore briefs as a last resort if something didn't work out right. He stated he thought his urinary function could get better, but it may take him some time. He denied any staff had ever offered him any bladder retraining or scheduled voiding. He had 2 urinals sitting beside him in his room. In an interview at 1:24 PM, Staff O, Nursing Assistant, stated she did not know of any bladder retraining or scheduled voiding for the resident, and she thought he could be continent of urine if he wanted to. She stated she thought he was continent of urine less than ½ of the time and that he may just want to urinate in his briefs. In an interview at 1:34 PM, Staff P, Registered Nurse (RN)/Resident Care Manager, was unable to provide any care planning documentation related to urinary incontinence. She stated she could not find any information related to bladder retraining or scheduled voiding, and that it might be something they (the facility) should look at. In an interview at 1:40 PM, Staff Q, RN/MDS Coordinator, was unable to provide any documentation the facility had attempted to restore the resident's bladder function. Staff Q was unable to provide any documentation the facility had assessed the decline. Staff Q was unable to provide any documentation the facility had care planned urinary incontinence even though the CAA Worksheet (03/22/17) indicated it would be addressed in the care plan. In an interview at 2:37 PM, the Director of Nursing Services (DNS) stated the Bowel and Bladder Evaluation, dated 03/10/17, was based on a resident self-report, and they didn't always find them to be very accurate. The DNS was unable to provide any urinary incontinence care planning documentation. When asked what the facility did when Resident 13's urinary continence declined on the 03/17/17 MDS of occasionally incontinent to the 06/17/17 MDS of frequently incontinent, the DNS was unable to provide any information. Facility documentation reflected a decline in urinary function that was not addressed by the facility. Facility care planning did not address the urinary incontinence, even though facility documentation stated it would be addressed in the care plan. The facility did not implement any continence programs or provide any other related services to attempt to improve the resident's urinary continence. The resident was harmed when the facility took no efforts to maintain and/or restore urinary bladder function for Resident 13 when his urinary continence declined from 54% in March 2017 to 4% in August 2017. Reference: (WAC) 388-97-1060 (3)(c)

Based on observation, interview and record review the facility failed to ensure 1 of 4 residents (200) reviewed for falls received adequate supervision, assistance devices (tilt in space) and services (Physical Therapy) to prevent accidents. This failure led to Resident 200 falling 20 times to date resulting in harm related to the resident's functional decline, a head laceration with a hematoma, a shoulder injury and emergency room visit. Findings include: Physical Therapy (PT) is defined as therapy for the preservation, enhancement, or restoration of movement and physical function impaired or threatened by disease, injury, or disability that utilizes therapeutic exercise, physical modalities (such as massage and electrotherapy), assistive devices, and patient education and training. Resident 200 was admitted to the facility in the middle of June 2017 from the hospital after a syncopal (fainting) episode with a history of a stroke, with right sided weakness and dementia. The resident was discharged from the hospital with orders for skilled nursing, a general diet and for physical therapy (PT) to evaluate and treat the resident. PT was not started. The resident sustained [REDACTED]. The resident was discharged back to the facility on [DATE], again with orders for skilled nursing, a general diet and for physical therapy to evaluate and treat the resident. Review of the medical record revealed the resident did not receive physical therapy services. The resident proceeded to sustain an additional 8 falls. On 07/27/17, the facility failed to arrange staff to accompany the resident for an eye appointment. The resident fell while at the eye appointment, hitting his head, sustaining a laceration and a hematoma. The resident required an emergency room visit due to neck and head pain with a scalp contusion and laceration. On 08/04/17, the facility implemented an intervention for one to one services between the hours of 6:00 PM to 8:30 PM. Review of the times the resident had falls revealed this intervention only provided one to one supervision for 25% of the period the resident had falls. Review of the speech therapy recertification and update for the certification period of 08/21/17 through 11/12/17 revealed, Pt (patient) with decline in swallow function s/p (status [REDACTED]. Prior to this, Pt was tolerating mechanical soft diet with thin liquids . Review of the medical record from 07/27/17 to 08/09/17 revealed the resident sustained [REDACTED]. Review of the occupational therapy note dated 08/09/17 revealed, Skilled Services: Initial evaluation completed for w/c (wheelchair) positioning and fall prevention approaches due to Pt (patient) with multiple recent falls, some resulting in head laceration, contusions and bruising. Pt cooperated with evaluation, able to answer yes/no questions with aphasia (speech difficulty) present. (The resident) also presented with impaired trunk control . W/C management: OT unable to locate tilt-in-space w/c in equipment room or cleaning area. Provided with ROHO high-profile position for sitting comfort and request sent to maintenance for lowering rear wheels to provide 4 degree tilt to off load sitting surfaces as nsg (nursing) feels may be having . discomfort, until tilt-in-space w/c located. Further review of the resident's medical record form 08/09/17 to 08/31/17 revealed the resident sustained [REDACTED]. During all days of the survey, the resident was observed in a standard wheelchair. In an interview on 09/01/17 at 10:25 AM, the Director of Nursing Services stated, The staff should have thought to tell visitors the resident was not to be left alone. In an interview on 09/01/17 at 1:06 PM, Staff A, Physical Therapist was looking through the resident's electronic medical records and stated, The resident had an order for [REDACTED]. but I do not know why we did not receive them (the physical therapy orders). In an interview on 09/01/17 at 1:11 PM, Staff B, Speech Therapist stated, When therapy orders are generated, they are placed in PCC (electronic medical record), the orders are supposed to be printed out and placed on the therapy clip board, the therapy manger looks in PCC daily for any therapy orders and processes them. In an interview on 09/05/17 at 10:15 AM, Staff E, Therapy Director stated, No PT (physical therapy) eval was completed, not until this past Friday. An order was recently processed related to a recent fall. The facility failed to implement physical therapy twice for the resident as ordered upon hospital discharge on two separate occasions. The facility failed to provide services to accompany the resident on an eye appointment. The facility failed to implement the occupational therapy recommendation for a tilt in space wheelchair for fall prevention and the facility failed to provide enough adequate supervision so the resident was not to be left alone unsupervised. The resident endured harmed sustaining 20 falls with injury from admission. Reference: (WAC) 388-97-1060(3) (g)

Based on observation, interview and record review the facility failed to prevent an accident for 1 of 3 residents reviewed for accidents (Resident 1). Failure to develop a specific temperature-based policy for serving hot beverages resulted in harm of a second degree burn for Resident 1 and placed other residents at risk for injury. Findings Include: Resident 1 was admitted to the facility in August of 2012 with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was severely cognitively impaired. The resident's care plan stated the resident was able to feed herself and eat finger foods independently. The record showed that on 07/30/16 at 1:00 P.M., Resident 1 was served coffee and the resident spilled the coffee into her lap. Resident 1 sustained a second degree burn on both thighs and abdomen. In an incident investigation dated 08/03/16 showed that on 07/30/16, the resident had been served coffee which was tempted by staff at 160 degrees, so three table spoons of ice was placed in the coffee. The resident spilled the coffee on her abdomen and bilateral thighs. The coffee was wiped off the resident's pants and a shirt saver was placed down her pants to soak up the coffee. The resident was immediately taken to her room and assessed. Her skin was pink on her thighs and abdomen and ice was applied to areas. The Investigation also stated on 07/31/16 the Resident had blisters on the left inner thigh and abdomen that measured 3.5 centimeters (cm) x 0.5 cm. Progress notes dated 07/31/16 stated the Resident has a second degree burn to her left inner thigh near brief line, protected blisters approx. 3.5 inch long by 1/2 inch wide with abdominal blisters intact at this time. MD notified for treatment orders. The Hot Beverage Policy stated All hot beverage temperatures will be recorded on Hot Beverage Temperature Logs prior to service. Meal managers will monitor hot beverages and food temperatures on a regular basis at the point they are served. There was no specific temperature for documented for the hot beverages mentioned in the policy. In an interview on 08/03/15 at 10:10 A.M., Staff A, a Cook, stated kitchen staff checks the temperatures of the hot beverages and if they are too hot we add ice. The hot beverages are then placed in an insulated carafe and served during meal services to the residents. Staff A also stated we want temperatures for hot beverages below 160 degrees, we check before they go out to the dining room. We are responsible for checking temperatures. Staff A supplied a hot beverage policy and hand written on the bottom of the policy was #8 all liquids must temp below 160 degrees-before it goes out to the resident: -soup -coffee -hot water. In an observation on 08/03/16 at 11:55 A.M., of Staff B, a Dietary Aide who was preparing hot beverages explained, he checks the temperatures of the hot liquids, he poured coffee and hot water into a mug, the coffee temp was 161 and the water was 160. He filled the two carafes and set them on a tray for Staff C. In an observation at 12:00 P.M., Staff C, Dietary Aide, dispensed hot cocoa into a carafe and Staff A told Staff C to temp the cocoa, which was 159 degrees. The 160 degree hot liquids were placed in an insulated carafe and a lid was placed on the top. The third carafe had hot liquids with a plastic lid taped to it, which in itself, caused a safety hazard to the Residents. When asked, Staff C stated no further temperatures would be checked prior to the hot beverages being served to the Residents. She also stated every Resident gets a lid on their hot beverage and for those who ask for no lid are put on a list and we are to give it to management . In an observation of the main dining room at 12:30 P.M., the majority of the residents with coffee had taken their lids off. The hot beverage policy was hanging on the wall in the main dining room. Hand written on the side of the policy was the temperature of 160 degrees and highlighted. In an interview on 08/03/16 at 1:30 P.M., Staff D, a Licensed Nurse (LN), stated she had not witnessed the burn but had assessed the Resident when they brought her back to her room. She stated there was a pink area between her thighs and her skin was light pink on her abdomen. She reported the 2 blisters on her left thigh were intact yesterday. Attempts to see the resident's burn were refused by the resident. The LN's reported the resident was also refusing to allow them to see her burn and assess it. On 08/03/16 at 2:00 P.M., Staff E, a Certified Nursing Assistant (CNA), reported she had seen the blisters on the resident's left thigh yesterday there were two of them and they were intact, today when I dressed her, it appeared as if they had popped, because they were flat. Temperature logs were obtained from Staff A for the dates of May 29 to August 6, 2016. Temperatures for coffee ranged from as high as 185 degrees on June 17th, 180 degrees at Lunch on June 4th, 8th, & 18th. Temperatures for coffee were below 160 degrees on 40 recorded temperatures, hot water was below 160 degrees on 42 recorded temperatures out of a total of 189 recorded temperatures. Hot Cocoa is also served but there was not a space on the temperature records for a cocoa temperature to be recorded. On the date of the incident the coffee temperature was recorded on the log as 161. In an interview on 08/03/16 at 2:15P.M., with the Administrator, the Corporate Nurse and the Interim Director of Nursing Services (DNS), all were made aware of the three different versions of the hot beverage policy. They reported the hot beverage temperatures should be below 160 degrees. None could verify who wrote the temperatures on the policies in the kitchen. The policy provided by the DNS did not have any specific temperatures written on it. All were also made aware of the plastic lid used for the carafe with 160 degree water being poured by staff for the residents and the continued danger of burns. The Corporate Nurse reported the lid would be replaced immediately. The Facility failed to develop a policy which provided sufficient information for temperatures of hot beverages to lesson the likelihood of a burn.

Citation Text for Tag 0309, Regulation FF09 Based on observation, interview and record review, the facility failed to adequately assess or implement physician orders [REDACTED]. orders [REDACTED]. Failure to adequately assess and document resident's bruises and abrasions, adequately assess the resident's weight, placed the residents at risk of not reaching or maintaining their highest level of function. In addition, by not adequately assessing the resident's pain, notifying the physician and implementing interventions resulted in harm to Resident 136 due to inadequate pain relief as evidenced by the resident's verbal and non-verbal complaints of pain. Findings include: PAIN MANAGEMENT The facility's pain policy, dated 4/2013, directed staff to assess each resident for pain upon admission to the facility, quarterly or when there was an onset of new pain or worsening of existing pain. The nursing staff would identify any situation or interventions where an increase in pain may be anticipated and would evaluate how pain was impacting the resident's quality of life. Staff would discuss significant changes in level of comfort with the physician who would consider adjusting interventions accordingly. RESIDENT 136 Resident 136 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to the Minimum Data Set assessment (MDS), dated [DATE], the resident had cognitive impairment and was moderately impaired in decision making skills. Review of the pain assessment, dated 05/27/16, revealed the resident had pain present daily which impacted her day to day activities. The pain was described as severe. The resident used non-verbal indicators for pain (crying, moaning, groaning and whining). Review of the care plan included the following interventions: reposition for comfort, evaluate for new increased or decline characteristics of pain and to report complaints of pain to the Licensed Nurse (LN). The care plan did not address the resident's potential non-verbal indicators of pain. Review of the physician orders, dated 05/27/16, indicated the resident received as needed (PRN) [MEDICATION NAME] every three hours as follows: 2.5 milligrams (mg) for a pain level of 1-3, 5 mg for a pain level of 4-6, 10 mg for pain level of 6 - 8, and 15 mg for a pain level of 8-10. The physician's order [REDACTED]. There was no documentation of how the staff were assessing the resident ' s nonverbal pain. Review of an Advanced Registered Nurse Practitioner (ARNP) note, dated 05/31/16, stated Resident 136 had severe pain present in the left hip. The pain was manifested with movement. The ARNP encouraged the LN to use the as needed pain medication to control the resident's pain. Review of the May 27th through June 2nd, Medication Administration Record [REDACTED]. For example: On 05/31/16 at 7:50 AM, the LN documented the resident's pain level was a 7. The LN administered [MEDICATION NAME] 5 mg, when the resident should have received 10 mg. At 8:03 PM, the resident reported her pain was a level 7 so the LN administered 10 mg of [MEDICATION NAME]. At 10:21 PM, the LN documented the pain medication was minimally effective. At 11:30 PM, an hour later, the resident's pain level was 8. The LN administered 10 mg of [MEDICATION NAME]. On 06/01/16 at 4:26 AM, five hours later, the LN documented the pain medication was ineffective. At 5:01 AM, the resident's pain level was a 5. The LN administered 5 mg of [MEDICATION NAME]. At 8:33 AM the LN documented the pain medication was ineffective. At 8:35 AM, the LN documented the resident was shouting out in pain. The LN attempted to administer 5 mg of [MEDICATION NAME], but the resident spit the medications out. At 12:51 PM, the LN documented in the nursing progress notes the resident was not cooperative with care, shouting out in what appeared to be pain but spit out pain medication when offered. At 4:34 PM, the LN coded the residents pain level a 3 on the MAR but documented in the progress notes the resident was screaming. The LN administered 10 mg of [MEDICATION NAME]. At 5:25 PM, the LN documented the pain medication was minimally effective. There was no further pain medication offered until 06/02/16 at 2:02 AM, 7 ½ hours later. The resident had uncontrolled pain for over 24 hours with no further evidence the LN followed the physician orders [REDACTED]. Review of a physician note, dated 06/02/16, stated the resident may have post op [MEDICAL CONDITION] that may be manifested by her pain. The goal was to make Resident 136 comfortable which may help decrease her agitation and distress. On 06/02/16, the physician ordered liquid [MEDICATION NAME] (MS) 2.5 mg to 5 mg every two hours as needed for pain if the resident spit out her [MEDICATION NAME]. Review of the MAR from June 3rd through June 8th revealed the resident frequently received MS every two hours for pain. The MS was not given if the resident was sleeping. The LN frequently documented the residents pain was above a level 5. Review of the progress notes from June 3rd through June 8th revealed no further communication with the physician regarding the resident's pain level above a 5 or when the resident was screaming out in pain. On 06/06/16 at 8:23 AM, the resident was observed in bed. The resident was not interviewable. The resident was moaning out. At 9:10 AM, the resident was observed lying in bed. The resident was pulling at her night gown, had a worried expression on her face and moaning out. At 9:52 AM, the resident was observed lying in bed, had a worried facial expression and was moaning. At 1:01 PM, the resident was observed lying in bed and yelling/calling out. Resident 136 was asked if she needed anything, the resident looked up with a worried expression and cried out. On 06/08/16 at 7:30 AM, the resident was heard yelling out from down the hall. The resident was observed in bed lying on her back. At 9:35 AM, the resident was heard yelling out from down the hallway. The resident's door was slightly ajar. The room was dark. The resident did not respond to any verbal stimulation, but continued to yell out and move her arms. At 9:44 AM, the resident was heard yelling out. At 10:30 AM, 12:30 PM and 1:31 PM, the resident was observed to be sleeping. At 1:40 PM, the resident was screaming out. The resident was observed to be lying on her back, had a pained/worried expression on her face. The resident was not interviewable. Similar observations were present on 06/09/16, 06/10/16 and 06/11/16. Resident 136 was lying in bed and was moaning, yelling or screaming out. The resident could be heard from down the hall. The resident was observed to have a worried/pained facial expression and was not able to communicate her needs. On 06/09/16, the physician changed the MS order to: MS 0.25 ml (5 mg) to 0.5 ml (10 mg) every 30 minutes as needed for pain or shortness of breath. Review of the pain assessment, dated 06/10/16, revealed the resident had pain daily. The intensity of the resident's pain was very severe, horrible. The resident used non-verbal indicators of pain. In an interview on 06/10/16 at 8:24 AM, Staff P, LN, stated since the resident readmitted to the facility she had a lot of pain. The MS order had just been changed and they monitoring the resident closely. At 1:30 PM, Staff G, Nursing Assistant, stated the resident has had a significant decline in her function and required extensive to total assistance from staff. Staff G stated the resident does call out frequently. Staff G stated she reports this to the LN on duty. At 2:35 PM, Staff K, Resident Care Manager, stated the physician ordered Hospice and they should be coming on 06/11/16. Staff G was made aware of the above observations when Resident 136 would call or yell out and have a worried/pained expression on her face. Staff G felt when the resident yelled out mama this could be related to her life as an opera singer. Staff G was asked for documentation regarding communication to the physician regarding the resident's pain not being controlled. Staff G was not able to provide any further information. RESIDENT 213 Resident 213 was admitted to the facility 06/03/16 with [DIAGNOSES REDACTED]. The resident had no cognitive impairment and was able to make his needs known. Review of the pain care plan revealed the resident was at risk for uncontrolled pain. The goal was the resident would verbalize adequate pain relief. Interventions included administering pain medication per the physician order. Review of the admit physician orders [REDACTED]. In an interview on 06/07/16 at 8:02 AM, Resident 213 stated he had significant pain issues. The resident stated the LN directed him to request pain medication when he was starting to experience an increase in pain. When he did this, the LN would tell him that it was too soon or he was not due to receive any additional pain medication. He felt frustrated and that he was getting the run around. The resident stated he was keeping track of when he received a pain pill so he would know when the four hours were up and when he was due for the next dose. The resident stated it was impacting his ability to sleep and his ability to participate in his daily activities. The residents stated he had called 911 on 06/04/16 because the LN was not responding to his pain needs. At 12:03 PM, the resident's daughter confirmed the facility was not accurately treating his pain. Review of the MAR from June 3 through June 8th, revealed the LN did not effectively assess and monitor Resident 213's pain. For example: On 06/06/16 at 7:51 AM, the resident's pain level was a 10. The LN administered 10 mg of [MEDICATION NAME] instead of 15 mg. At 11:59 AM, the resident's pain level was an 8. The LN administered 10 mg of [MEDICATION NAME] even though the order directed the LN to administer 15 mg for pain level of 8-10. On 06/07/16 at 8:18 AM, the resident's pain level was a 7. The LN administered 10 mg of [MEDICATION NAME]. At 9:42 AM, the LN documented the pain medication was not effective. The LN did not assess for possible further interventions to help control the resident's pain. Review of the narcotic ledger revealed the resident received [MEDICATION NAME] 10 - 15 mg four to five times a day. Review of the progress notes revealed the LN did not notify the physician of the resident's uncontrolled pain. In an interview on 06/10/16, Staff L, RCM, was asked why the LN did not notify the physician regarding resident's complaints of frequent pain. Staff L stated the LN's were attempting non-pharmacological interventions along with administering the PRN pain medication to adequately control the resident's pain. No additional information was offered. Facility staff did not produce any documentation of non-pharmacologic interventions that were being used. NON-PRESSURE SKIN CONDITIONS RESIDENT 136 Resident 136 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the nursing admission assessment, dated 05/27/16, revealed the resident was admitted with no skin issues (it was blank). Review of the Treatment Administration Record (TAR) from May 27th through June 7th, revealed no documentation regarding any bruises observed. In an observation on 06/06/16 at 8:23 AM, the resident was lying in bed with her left hip exposed. There was a large bruise noted on the resident's inner left thigh. In an observation on 06/09/16 at 1:40 PM, the resident was lying in bed. The resident's gown was pulled up past her lower abdomen exposing her lower body. There was a large, dark purple bruise noted on the resident's lower abdomen and a lighter large bruise noted on the resident's left inner thigh. Review of the progress notes from May 27th through June 9th was done. The LN documented on 06/01/16 a large bruise around the left hip incision. On 06/08/16, the LN documented a bruise to the abdomen and left inner elbow was found. The LN documented the origin was unknown. There was no further documentation regarding how the resident obtained the bruises observed. Review of the state reporting log revealed no investigation regarding the resident's bruises. In an interview on 06/08/16 at 2:25 PM, Staff Q, LN, stated the LN performed weekly skin assessments on each resident. Established skin issues were monitored on the TAR. If a new skin issue was found, the LN would assess and try to establish how the resident obtained the new issue. This information was documented in the resident's medical record. If the LN was not able to establish the origin, then an incident report was initiated. At 3:18 PM, Staff V, LN, stated all current skin issues were monitored on the TAR. The LN performed a weekly skin assessment and documented the information in the progress notes. If a new issue was found, the LN would do an investigation. If the LN was unable to establish the origin, then they would initiate an incident report. If the LN was able to establish an origin, the information was documented in the progress notes. At 4:05 PM, Staff H, NA, stated if a new skin issues was found she would notify the LN immediately. In an interview on 06/10/16 at 8:24 AM, Staff P, LN, stated she thought the left inner thigh bruise and abdomen bruise were present upon admission. Staff P did not know how the bruise on the left inner elbow occurred. Staff P was not able to provide any additional information why the abdomen and left thigh bruise were not monitored on the TAR. At 1:30 PM, Staff G, NA, stated all skin issues were reported to the LN. This included bruises. At 2:35 PM, Staff K, LN, was asked about the bruising on the resident's left thigh, lower abdomen and left inner elbow. Staff K thought the bruise on the left thigh was present upon admission but was not aware of the bruise on the abdomen or left inner elbow. Staff K stated an incident report would be initiated. Review of the nursing admission assessment on 06/11/16 revealed documentation indicated the resident had a bruise to her left inner thigh. The admission assessment reflected the information was updated on 06/10/16, 13 days after the resident was admitted to the facility. In an interview on 06/11/16 at 9:45 AM, Staff K, LN, was asked about the admit nursing skin assessment being updated on 06/10/16. Staff K stated she was directed by the Director of Nursing Services (DNS) to update the assessment if she was positive the bruises were present upon admission. Staff K was asked how documentation could be updated 13 days later. Staff K was not able to provide any further information. At 9:55 AM, Staff R, LN stated the bruise on the resident's abdomen and inner left thigh had grown quite a bit. Staff R stated he was not aware how the bruise occurred but it was present upon admission. Staff R was made aware the bruises were not documented upon admission, monitored on the TAR or in the nursing progress notes. At 10:05 AM, the DNS, facility Administrator and Staff C was asked about the nursing admit skin assessment being updated 13 days after Resident 136 was admitted . The DNS stated Staff K was to document the left thigh bruise in the progress notes not change the admit assessment. The DNS and Staff C stated the nursing admit assessment should not have been updated 13 days later. RESIDENT 180 Resident 180 was admitted to the facility in April 2016 with [DIAGNOSES REDACTED]. Review of the June TAR revealed the LN monitored daily a 2 cm x 2 cm bruise on the back of the left hand and a 1 cm x 2 cm bruise on the left hand between the thumb and forefinger. In an observation on 06/08/16 at 10:15 AM, the resident was sitting in his wheelchair. There were varying bruises on the back of his right and left hands and his right arm. The resident was not able to state how the bruises occurred. Review of the progress notes from May 1 through June 8th, revealed no documentation regarding how the resident obtained the bruises to the back of the left hand and right forearm. The resident was admitted to the facility with a bruise on the back of his right hand. Review of the state reporting log revealed no investigation regarding the resident's bruises. In an interview on 6/10/16 at 10:39 AM, Staff Q, LN observed the bruises on the back of the resident's hands. Staff Q was asked if she was aware of the bruise on his right forearm. Staff Q stated she would assess his arm when she was able. At 2:23 PM, Staff Q confirmed there was a bruise on the resident's right forearm and would be filling out an incident report. RESIDENT 30 Resident was admitted to the facility in 2006 with [DIAGNOSES REDACTED]. In an observation on 06/06/16 at 3:34 PM, the resident was lying in his bed. There was a abrasion noted on his left neck. The resident was not able to state how the abrasions occurred. Review of the June TAR states monitor scratch on back of left posterior upper thigh daily. There was no documentation on the neck abrasion. Review of the progress notes from 05/01/16 to 06/08/16 did not reveal how the neck or thigh injuries occurred. Review of the state reporting log revealed no investigation regarding the resident's skin injuries. In an interview on 6/07/16 at 10:58 AM, Staff K, LN stated the resident scratches himself. Staff K was asked if she was aware of the abrasion on his left neck. Staff K stated she would assess his neck when she was able. On 06/10/16 at 4:04 PM, Staff K confirmed there was a scratch on the resident's left neck and she was investigating the scratch. Daily Weight RESIDENT 120 Resident 120 re-admitted [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. A physician's orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. On these dates, the nurses did not give additional [MEDICATION NAME] as there was no weight to evaluate the physician directed parameter. On 06/10/16 at 08:54 AM, Staff K stated that there were a couple missed weights. She stated that it was the nurses responsibility to ensure the weight was obtained before breakfast daily. She was unable to provide additional information. POSITIONING RESIDENT 30 Resident 30 was admitted to the facility in 2006 with [DIAGNOSES REDACTED]. In multiple observations on 06/06/16 through 06/10/16 the resident was observed lying in bed on his back. There were no observations of resident out of bed on any day of survey. Review of the skin care plan dated 02/03/16 stated potential impairment to skin integrity related to incontinence and altered mobility. Review of the Kardex (condensed care plan for NAC's) revealed no instructions for how often NAC's were to assist in repositioning the resident. The Kardex stated resident required extensive assist of 1 for bed mobility and occasionally 2 person assistance with bed mobility.

Based on observation, interview, and record review, the facility failed to implement preventative measures for 1 of 2 residents (134) after risks were identified for pressure ulcers. Failure to consistently assess and implement preventative interventions for Resident 134 who had a history of [REDACTED]. Findings include: Per the Resident Assessment Instrument (RAI) Manual, a stage 2 pressure ulcer was a partial thickness loss of the dermis presenting as a shallow open ulcer with a re-pink wound bed, without slough. According to the facility's policy Skin Program Guideline, dated 10/09, directed Licensed Nurses (LN) to maintain a weekly Wound/Pressure Ulcer log. Weekly documentation included measurements and how the wound was progressing towards healing. The record shows Resident 134 was admitted to the facility April 24, 2016 with two stage II pressure ulcers on the right buttock. The pressure ulcers measured: 0.4 centimeter (cm) by 0.4 cm and the second ulcer measured was 0.8 cm by 1.0 cm. According to the Minimum Data Set assessment (MDS), dated [DATE], Resident 134 required extensive assistance of two people for bed mobility and was dependent with transfers. On 04/24/16, 05/01/16 and 05/08/16 a Braden skin risk assessment was done. The resident was identified to be at mild risk for skin breakdown. Review of the care plan showed the resident was at risk for skin impairment related to his Foley catheter, immobility, and co morbidities. The goal was for him to Maintain Skin Integrity. The care plan directed staff to reposition the resident every 2 to 3 hours and to use pillows for pressure relief and repositioning. There was no aggressive interventions to prevent the resident from further breakdown. Review of a nursing progress note, dated 05/03/16 at 1:34 PM, the LN documented the open areas to the right buttock were resolved. Review of the medical record form April 24th through May 2nd, revealed no weekly measurements of the two stage II pressure ulcers indicating the wounds had healed. On 06/02/16 at 3:59 PM, a LN documented a new dime sized open area found on the resident's coccyx. The LN obtained an order for [REDACTED]. Review of the facility Wound Rounds documentation, dated 06/03/16, revealed the resident had a 3 cm by 2 cm stage II pressure ulcer on the right buttock. In an interview on 06/08/16 at 9:15 AM, Staff M, Resident Care Manager (RCM), stated the facility had started a new tracking system for pressure ulcers. The program was called WoundRounds. The new system was recorded on an electronic device and uploaded into the computer system. The RCM's were responsible to assesses and document to the pressure ulcers weekly. At 12:15 PM, the resident was sitting in his wheelchair (w/c) in his room. The resident stated he had a wound to his right buttock and it was to have a dressing in place. The resident stated he didn't think there was a dressing on right now because when he got up in the morning there was blood on his sheet. The resident stated he needed assistance from the staff to reposition in bed or in the w/c. At 2:15 PM, with Staff L, RCM, the resident's right buttock was observed. There was no dressing in place. A stage II pressure ulcer was present on the resident's right buttock. The surrounding skin was intact and blanchable. Staff L placed a new dressing on the pressure ulcer. In an interview on 06/09/16 at 2:49 PM, Staff L stated the nursing staff did not monitor the resident's pressure ulcers when he was first admitted . When the resident's pressure ulcer re-opened on 06/02/16, the area was measured and will be tracked weekly in Wound Rounds. The facility did not follow their own policy by analyzing all of the resident ' s risk factors and developing an aggressive plan to prevent the reopening of prior ulcers or the development of a new pressure ulcer.

Based on interview and record review, the facility failed to ensure prompt efforts were made to resolve a grievance, related to the behavior of another resident for 1 of 1 resident reviewed for grievances (210). This failure to assist the resident in a room change resulted in psychological harm due to loss of sleep, increased anxiety requiring additional medication, alteration in comfort and a diminished quality of life which resulted in the resident sleeping in other areas of the building. Findings include: RESIDENT 210 Resident 210 admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was cognitively intact and able to make his needs known. During a resident interview on [DATE] at 12:31 PM, when asked if he had any concerns or problems with a roommate or any other resident. Resident 210 replied Yes, on my first night, my roommate said Turn that damn thing off, while he was watching TV. He stated It wasn't even loud. The resident reported the best thing I can do is stay away from him When asked if he had reported the occurrence to staff, the resident replied yes, I have told everyone, it is no use. The resident was asked if staff had addressed the concerns to his satisfaction, and he replied no, that is why I have tried to sleep in the hallway, dining room and other rooms but they just bring me back to my room and tell me I have to sleep in here. There have been plenty of nights I didn't sleep period. I am done asking them, it is no use. They say there are no open rooms available. During an interview on [DATE] at 3:18 PM, Resident 210 stated He started in on me the first night so the best thing I can do is stay away from him. I quit asking the staff to move me because they say there is no room available. I have to hang in there until I go back to Orchard Park. In an interview with the Resident 210's roommate, Resident 120 on [DATE] at 2:22 PM stated I would really like my wife in my room. He denied any concerns with his roommate (Resident 210). During numerous observations on [DATE] to [DATE], Resident 210 and 120 were not in their room at the same time. Resident 210 was observed out of his room except while sleeping or eating in his room at which time his roommate was in the dining room. A progress note dated [DATE] at 6:13 AM stated pt. had a distressed night, claims to have slept very little .Pt. is very anxious and wants to be sent back to Orchard Park (Assisted Living Facility). In an Activity note dated [DATE] at 10:40 AM, the resident stated he was not going to spend one more night in this room. In a nursing note dated [DATE] at 9:42 PM, the resident reported that he had not gotten sleep last night. In a nursing note dated [DATE] at 10:00 AM, the on call MD, was called as resident assessed to have heart rates of 116, 115 and 110. The MD stated It could be related to anxiety order received for [MEDICATION NAME] (an anti-anxiety) every 8 hours, as needed for anxiety, for three days and Dr. Vanderbilt to reassess the patient. In review of physician nursing home visit notes dated [DATE], Resident 210's Physician noted He has been very anxious, this is a longstanding condition, but worse since he has been here because he is not happy here. He has [MEDICATION NAME] 0.5 MG (Anti-anxiety medication) at bedtime, which can be repeated if he cannot sleep. Over the weekend, the on-call MD ordered a trial of [MEDICATION NAME] 0.25 MG every 8 hours as needed for anxiety. This was used at least once a day for 4 days, but the order has expired, it was helpful when used. During physical exam he was insistent on being ready and able to leave here. In a nursing progress note date [DATE] at 12:57 PM, resident stated he needed to go back to Orchard Park and he can't stay in his room. The resident was requesting a private room and to call his daughter to get him out of here. He appeared anxious, was shaking and spoke adamantly. The resident had been having a difficult time adjusting to SNF from assisted living. In an eMar (electronic medical record) note [DATE] at 3:45 PM, the resident stated I think I am having an anxiety attack. Staff LL, LN had administered [MEDICATION NAME] 0.5 MG for the anxiety. On [DATE] at 2:07 PM, a mental health consultant (Registered Nurse), documented Resident is well known to me from previous SNF (skilled nursing facility) stays who has managed surprisingly well in his own home until recently. He has been unsuccessful at thriving in an institutional setting. Historically, resident can be doing fine and then will have a panic attack and perhaps look like he is having a [MEDICAL CONDITION]. Resident has a history of suicidal gestures which appear to be a way out of LTC and go to the hospital. He is begging me to leave here. The resident has poor coping skills. Talked with staff a bit about previous challenges. The resident threatens but has not seriously hurt himself in this type of setting. The resident manages his anxiety by getting much attention from staff. As this can't be done forever we will have to work together to come up with other interventions. If he is staying LTC would expect his behavior will worsen. Would be good to get his room set up here ASAP. I will review with psych MD and call you with thoughts Thursday. There is no follow up documentation from [DATE]. The above history was not transferred to the care plan to assist the staff in caring for the resident. A review of the facility grievance log revealed no documentation related to the occurrence involving Resident 210 and Resident 120. Additionally, a review of Resident 210's progress notes revealed no documentation of the concern involving Resident 120 on [DATE]. On [DATE] at 2:50 PM, Staff AA was asked about room availability. She reported There are lots. In an interview on [DATE] at 4:28 PM, Staff T stated I encourage you to read his mental health notes. He is in a room with is the nicest man in the facility (Resident 120). Staff T acknowledged she had not addressed the concern as a grievance, had not followed up with Resident 210 for a possible room change, or monitored him for psychosocial harm. She stated All he wants is to get a private room. In an interview with the Administrator on [DATE] at 5:48 PM, He stated We discuss room moves and requests every morning. The only thing I heard was that he wanted a private room. No specific information was provided. A review of the progress notes for Resident 210 revealed there were no social service notes discussing the residents' concerns with his roommate or psychosocial wellbeing. There were no interventions for anxiety, depression, and history of suicidal ideation with difficulty coping on the care plan. There was no care plan on admission to address the residents psychosocial needs. The resident was moved to a semi-private room (160) on [DATE] at 4:14 PM, 14 days after he initially requested a room change.

Based on interview and record review, the facility failed to prevent an accident for Resident 3. Failure to consistently follow the facility policy for cooling hot beverages resulted in harm of second degree burns for Resident 3 and placed other residents at risk of injury. Findings include: Resident 3 was admitted in July 2013 for rehabilitation after hospitalization for a recent stroke. Speech therapy identified she had difficulty swallowing and weakness that prevented her from holding her cup for drinking or utensils for eating. Resident 3 required "close supervision" while eating or drinking. Additionally, Resident 3 had some memory impairment contributing to poor safety awareness. On 07/12/13 about 6:45 p.m., Resident 3 was seated in her wheelchair in the dining room. She asked Staff 2 for a cup of coffee. Staff 2 took a cup from Resident 3's tray and filled it with hot coffee. Staff 2 gave Resident 3 the cup of coffee and transported her via wheelchair to the nursing station on the unit where she resided. Staff 2 did not cool the hot coffee with ice as stated in the facility policy for residents at safety risk. Staff 2 did not stay to supervise Resident 3 while she drank her coffee. About 07:15 p.m., Staff 3 heard Resident 3 yell and observed spilled coffee all over her lap. On 07/25/13 at 1:38 p.m., Staff 1 reported care plans are posted in each resident's room. The care plan for Resident 3, dated 07/01/13, identified interventions for nutrition. These interventions included positioning Resident 3 upright and sitting upright for 20-30 minutes after finishing a meal. It noted she used a lidded cup for all fluids and beverages. She was unable to hold onto her cup related to her weakness and confusion at times. Resident 3 required "close supervision" while eating or drinking for observation of any choking and/or coughing. Staff 1 reported Staff 3 failed to notify any other staff that Resident 3 was at the Nursing Station and needed close supervision while drinking. During the investigation, Staff 3 told Staff 1 she failed to cool the hot beverage as mandated by the facility hot beverage policy. Review of the facility investigation revealed they followed their policy and notified the physician and family of Resident 3 in a timely manner. Nursing assessment identified a second degree burn, 9 x2.5 centimeters (cm) with a fluid filled blister measuring 6 x 2 cm on the right inner thigh of Resident 3. The entire burn area was red. Resident 3 "screamed" and reported the pain as "hurts a whole lot" on the facial pain scale (5 of 6 faces, 6 being the worst pain). The physician ordered ice packs and a dry dressing to the affected area of the right thigh. The facility concluded Staff 2 failed to follow the policy for hotbeverage cooling for residents at safety risk and failed to closely supervise Resident 3 to prevent any accident(s).

Based on interview and record review the facility failed to ensure 1 of 4 sample residents was free from significant medication errors. The failure to ensure Resident 1 received medication prescribed to prevent recurrence of blood clots compromised the resident's health and resulted in harm. The resident developed decreased blood flow to lower extremities causing pain, swelling and frequent medical testing. Findings included: All interviews took place on 01/04/2013 unless otherwise indicated. Resident 1 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident was alert, confused and dependent on staff for her activities of daily living including medication management. Review of Resident 1's July 2012 physician orders [REDACTED]. The medication order directed staff to give the resident [MEDICATION NAME] 2.5 milligrams (mg) each evening for six days a week and [MEDICATION NAME] 5 mg was ordered for one day a week. On 7/29/12 a licensed nurse inadvertently discontinued the resident's 2.5 mg dose of [MEDICATION NAME] (ordered and administered 6 days a week). Staff continued the 5 mg of [MEDICATION NAME] as ordered one day a week. The resident missed 24 doses of her [MEDICATION NAME] 2.5 mg tablets from July 29, 2012 to the date the error was caught and the medication restarted on August 28, 2012. On August 30, 2012, a doppler ultrasound study confirmed the resident had developed a "very extensive deep vein thrombus" (a blood clot) to her left leg. On 8/19/12 the resident was noted to have "2+ swelling on her left leg from her foot to her knee". [MEDICAL CONDITION] is the build-up of fluid between the tissue and cells under the skin which causes swelling. The Director of Nursing Services (DNS) stated during interview on 01/16/2013 that the facility used the "standard [MEDICAL CONDITION] measurements." She went on to state that "2+" [MEDICAL CONDITION] meant after 5 seconds the indentation returned to the prior level. The [MEDICAL CONDITION] increased to "3+" on 8/21/12 and the resident was unable to wear her shoe. On 8/27/12 the resident had redness and weeping to the top of her left foot and the next day the resident was medicated for left leg pain and her left foot had an open area that was hot to touch. On the evening of 8/28/12 staff documented that the resident, " denies pain in calf but was very painful to touch at top of foot." The resident was started on antibiotics for left leg [MEDICAL CONDITION]. Staff notified the MD by fax of the medication error. On 8/29/12 the resident was seen by her medical provider. The resident had, "leg [MEDICAL CONDITION] from foot to thigh." The medical provider ordered labs to be drawn at that time and doppler studies to check the blood flow to the resident's leg. The resident was found to have a deep vein thrombus on doppler. Her treatment included daily blood test to monitor the effectiveness of the medication to dissolve the clot and return the blood flow to her leg. The DNS stated the facility switched to EMAR, an electronic Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]