Every finding on record at Ballard Center

Based on interview and record review the facility failed to ensure risks and benefits associated with a health care/treatment plan change was offered to a resident who had the capability to make that decision for 1 of 3 residents (Resident 1), reviewed for resident rights. This failure placed the resident at risk for emotional distress, not having health care coverage, unmet care needs, and a diminished quality of life.Findings included.A review of the admission Minimum Data Set (an assessment tool) dated 05/31/2026 showed a staff assessment was completed for Resident 1's Brief Interview for Mental Status (BIMS - a standard screening tool used to assess a resident's attention, orientation and memory), which revealed Resident 1 had difficulty with their short-term memory. A review of the primary payor status showed they were admitted to the facility on [DATE] on a Health Maintenance Organization (HMO) plan. Further review of the primary payer status showed the primary payor status changed on 06/01/2026 to a Federal Health Insurance Plan. A review of a form titled, Consent for Healthcare Insurance Enrollment & Disenrollment Form, dated 05/31/2026, showed Resident 1 requested assistance to disenroll from their HMO insurance and to enroll into the Federal Health Insurance Plan. Further review of the form showed Resident 1 understood that after disenrolling from their original [HMO] health plan, they may not be able to re-enroll in the plan when/if the Federal Health Insurance Plan ended. The form showed Resident 1 understood that the decision to change their health coverage was their choice. The form further showed An assessment of Resident 1's cognitive (thinking) function had been conducted, which supports the ability to understand the information contained in the information sheet. The Consent for Healthcare Insurance Enrollment & Disenrollment Form had Resident 1's name on it, dated 05/31/2026. A review of a form titled Brief Cognitive (relates to thinking, memory and learning) Assessment Tool Short Form (BCAT-SF) Report dated 06/03/2026 showed the BCAT-SF was a brief cognitive screening tool, with a possible score range of 0-21. Resident 1's score was 15, which was suggestive of dementia (a decline in mental ability severe enough to affect memory and thinking or severe cognitive impairment). The form further showed that residents with this score often had difficulty with management of activities of daily living and handling finances. In an interview on 07/07/2026 at 3:33 PM, Resident 1 could not respond to questions about their medical needs/care, which insurance plan they had or if they had a recent change in their health coverage/plan. In an interview on 07/21/2026 at 1:47 PM, Staff C, Business Office Manager, stated they did not know why Resident 1's payor status changed from their HMO plan to the Federal Health Insurance Plan. Staff C further stated that they thought Resident 1 would have to have requested the change, because the change should be requested by the residents and not by the facility staff. In an interview on 07/23/2026 at 2:25 PM, Staff D, Registered Nurse, stated Resident 1 was confused most of the time and only alert to their name. Staff D further stated they did not think Resident 1 would understand any information about their insurance plan.In an interview and joint record review on 07/23/2026 at 2:42 PM, Staff E, Speech/Language Pathologist, stated they were working with Resident 1 to assist with improvement of their cognition. Staff E further stated they did the assessment and completed the BCAT-SF form dated 06/03/2026 for Resident 1 and the score reflected severe difficulties with thinking/memory. In an interview on 07/23/2026 at 5:38 PM, Staff F, Regional Social Services Director, stated they assisted Resident 1 with the Consent for Healthcare Insurance Enrollment & Disenrollment Form dated 05/31/2026. Staff F stated Resident 1 requested assistance to disenroll from their HMO Health and to enroll in a Federal Health Insurance Plan. Staff F further stated that it would have to have been Resident 1's request to disenroll. Staff F was asked to find documentation to support it was Resident 1's request to change their health insurance plan, Staff F checked Resident 1's Electronic Health Record (EHR), and was not able to find or provide records that it was Resident 1 who requested it. In an interview on 07/23/2026 at 5:46 PM Staff A, Administrator, stated the request to change insurance plans should be initiated by the residents and not by the facility staff. Staff A further stated when Resident 1 requested to change health insurance plans it should have been documented in Resident 1's EHR. Reference (WAC): 388-97-0260 (1)(a)

Based on interview and record review, the facility failed to ensure physicians orders for referrals to audiology (healthcare focused on hearing and their related disorders) were followed for 2 of 3 residents (Resident 2 and Resident 3), reviewed for hearing devices. This failure placed the residents at risk for poor communication, low self-esteem, and unmet care needs.Findings included.RESIDENT 2Review of the quarterly Minimum Data Set assessment (MDS-a required tool) dated 07/03/2026 showed Resident 2 had moderate difficulty hearing.Review of the care plan with a review date of 07/10/2026 showed Resident 2 had impaired communication as evidenced by hard of hearing.Review of a physician's order in the Electronic Health Record (EHR) dated 04/03/2026 showed a referral to audiology further review of the EHR did not show that the referral was initiated/completed.RESIDENT 3Review of the quarterly MDS assessment dated [DATE] showed Resident 3 had intact thinking and memory.In an interview on 07/07/2026 at 12:30 PM, Collateral Contact 1 stated Resident 3 told them they would like to have a hearing test to see if they were hard of hearing and had already talked to their doctor about it, but nothing had happened to get them tested.Review of a physician's order in the EHR dated 04/03/2026 showed a referral to audiology. Further review of the EHR did not show that the referral was initiated/completed.In an interview on 07/23/2026 at 4:58 PM, Staff F, Regional Social Services Director, stated the facility would coordinate the referrals for residents to be seen by providers when they came to the facility or if the resident needed to go out of the facility to be seen by the provider when they were referred. Staff F stated if the residents were seen by providers when they were referred, the after-visit summary would be in the EHR.In an interview on 07/23/2026 at 5:34 PM, Staff B, Interim Director of Nursing Services, stated they could not find documentation in the EHR of Resident 2 or Resident 3 that the physicians orders dated 04/03/2026 for referrals to audiology were initiated/completed for Resident 2 and Resident 3.In an interview on 07/23/2026 at 5:48 PM, Staff A, Administrator, stated the referrals for Resident 2 and Resident 3 should have been completed.Reference: (WAC) 388-97-1060 (3)(a)

Based on interview and record review, the facility failed to provide a bed hold notice for 4 of 4 residents (Residents 1, 2, 3, & 4) and failed to provide a written transfer/discharge notice to the residents and/or their representative for 1 of 4 residents (Resident 4), reviewed for discharge process. These failures placed the residents at risk of not having opportunities to make informed decisions about transfer/discharge.Findings included.Review of the facility's policy titled, Bed-Holds and Returns, revised in October 2022, showed, All residents/representatives are provided written information regarding the facility and state bed-hold policies, which address holding or reserving a resident' bed during periods of absence (hospitalization or therapeutic leave). Residents, regardless of payer source, are provided written notice about these policies at least twice: a. notice 1: well in advance of any transfer (e.g. [for example], in the admission packet); and b. notice 2: at the time of transfer (or, if the transfer was an emergency, within 24 hours).Review of the facility's policy titled, Transfer or Discharge, dated in 2001, showed, Upon notice of transfer or discharge, the resident is provided with a statement of his or her right to appeal the transfer or discharge, including: a. the name, address, email, and telephone number of the entity which receives such requests; b. information about how to obtain, complete, and submit an appeal form; c. how to get assistance completing the appeal process; and d. the facility bed-hold policy.BED HOLD NOTICE<RESIDENT 1>Review of a progress note dated 04/13/2026, showed that Resident 1 was unresponsive and was transferred to the hospital.Review of Resident 1's discharge Minimum Data Set (MDS- an assessment tool) dated 04/13/2026 showed that they were discharged to a short-term general hospital. In an interview on 06/23/2026 at 1:10 PM, Resident 1 stated that they were not provided with a bed hold notice when they were transferred to the hospital on [DATE]. Review of Resident 1's Electronic Health Record (EHR- progress notes and miscellaneous files) showed no documentation that a bed hold notice was provided to Resident 1 and/or their representative. <RESIDENT 2>Review of a progress note dated 01/23/2026 showed that Resident 2 was transferred to the hospital. In an interview on 06/23/2026 at 3:19 PM, Resident 2 stated that they were not provided with a bed hold notice when they were transferred to the hospital on [DATE]. Review of Resident 2's EHR showed no documentation that a bed hold notice was provided to Resident 2 and/or their representative. <RESIDENT 3>Review of Resident 3's progress note dated 06/12/2026 documented, Send resident to [the] ER [Emergency Room] for evaluation and treatment. Review of Resident 3's discharge MDS dated [DATE] showed that they were discharged to a short-term general hospital. Review of Resident 3's EHR showed no documentation that a bed hold notice was provided to Resident 3 and/or their representative. <RESIDENT 4>Review of a progress note dated 06/03/2026 showed that Resident 4 was transferred to the hospital for evaluation. Review of Resident 4's discharge MDS dated [DATE] showed that they were discharged to a short-term general hospital. Review of Resident 4's EHR showed no documentation that a bed hold notice was provided to Resident 4 and/or their representative. In an interview on 06/24/2026 at 9:35 AM, Staff C, Registered Nurse, stated that when a resident was transferred to the hospital they would talk about the bed hold notice with the resident and that they had a form that they used. Staff D stated that they would document in the progress notes if the resident signed it or not. Staff D further stated that depending on the situation, if the resident was not able to sign the bed hold notice, the Social Worker or facility management would follow up with the resident and/or their representative. In an interview and joint record review on 06/24/2026 at 12:45 PM, Staff D, Licensed Practical Nurse, stated that they would provide the bed hold notice to the resident and that if they signed it, they would give the original copy to the resident, and a copy would be given to Medical Records to be scanned. Staff D stated that it should be documented in the progress notes that the bed hold notice was provided and if the resident had accepted or declined. A joint record review of Resident 1, Resident 2, and Resident 4's EHR showed no documentation that a bed hold notice was provided to them and/or their representative. Staff D stated that they were not able to find that a bed hold notice was provided to Resident 1, Resident 2 and Resident 4. Staff D further stated that they should have been provided with a bed hold notice. In a follow up joint record review of Resident 3's EHR and interview on 06/29/2026 at 1:15 PM with Staff D showed no documentation that Resident 3 was provided a bed hold notice when they discharged to the hospital on [DATE]. Staff D further stated that they could not find one and that they should have provided a bed hold notice to Resident 3. In an interview on 06/29/2026 at 1:28 PM, Staff B, Assistant Director of Nursing, stated that a bed hold notice was given when residents were leaving to go to the hospital and that it was part of the resident's discharge packet. If the resident was not in a position to sign or say anything, they would call the next of kin or emergency contact and offer them a bed hold. Staff B further stated that Residents 1, 2, 3, and 4 should have been provided with bed hold notices. TRANSFER/DISCHARGE NOTICE<RESIDENT 4>Review of Resident 4's EHR showed no documentation that a transfer/discharge notice was provided to Resident 4 and/or their representative when they discharged to the hospital on [DATE]. In an interview on 06/29/2026 at 12:30 PM, Staff E, Regional Social Services Support, stated that nurses who sent the resident out to the hospital provided the resident with the transfer/discharge notice. When Staff E was informed that Resident 4 was not provided with a transfer/discharge notice, Staff E stated that they would ask Medical Records for it. In an interview on 06/29/2026 at 1:41 PM, Staff F, Medical Records Coordinator, stated that they did not have a copy of the transfer/discharge notice form on file for Resident 4. Staff F stated that the Social Worker would complete the transfer/discharge notice form, scanned a copy to them and that they would upload it [to their computer system.]In a follow-up phone interview on 06/29/2026 at 2:27 PM, Staff E stated that if residents transferred to the hospital, staff should be completing a bed hold notice and a transfer/discharge notice and provided to the residents. In an interview on 6/29/2026 at 2:51 PM, Staff A, Administrator, stated that when residents were discharged to the hospital, they expected staff to provide documents required by their policy. Staff A stated that they would have expected staff to provide a bed hold notice to Resident 1, Resident 2, Resident 3 and Resident 4. Staff A further stated that Resident 4 should have been provided with a transfer/discharge notice. Reference: (WAC) 388-97-0120 (2)(a-d)(4).

Based on record review and interview, the facility failed to ensure annual Minimum Data Set (MDS - an assessment tool) were completed within 14 days of the ARD (Assessment Reference Date) for 3 of 26 residents (Residents 18, 100 & 2), reviewed for comprehensive assessments. This failure placed the residents at risk for delayed and/or unmet care needs, and a diminished quality of life.Findings included . Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents), Version 1.20.1, dated October 2025, showed that the completion date of the annual MDS assessment must be no later than 14 days after the ARD (ARD plus 14 calendar days). The MDS RAI manual further showed that the admission assessment must be completed by the end of day 14, counting the date of admission to the nursing home as day one. RESIDENT 18Review of Resident 18's annual MDS dated [DATE] showed that it was completed on 10/27/2025 (six days late). RESIDENT 100Review of Resident 100's annual MDS dated [DATE] showed that it was completed on 01/29/2026 (seven days late). In an interview and joint record review on 04/14/2026 at 12:31 PM, Staff D, MDS Coordinator, stated that the facility followed the RAI manual for MDS assessment completion. A joint record review of Resident 18's annual MDS dated [DATE] showed that it was completed on 10/27/2025. A joint record review of Resident 100's annual MDS dated [DATE] showed it was completed on 01/29/2026. Staff D stated that Resident 18's and Resident 100's annual MDS assessments were completed late, and it should have been completed within 14 days. In an interview on 04/15/2026 at 8:35 AM, Staff B, Director of Nursing, stated that the facility would follow the RAI manual as guidance for MDS completion, and stated they expected MDS assessments to be completed timely and accurately. RESIDENT 2Review of Resident 2's face sheet printed on 04/10/2026 showed that Resident 2 was admitted to the facility on [DATE]. Review of Resident 2's admission MDS dated [DATE], showed that it was completed on 01/05/2026 (11 days late). A joint record review and interview on 04/15/2026 at 6:03 PM with Staff D, showed the RAI manual revealed that an admission MDS was to be completed on day 14 of admission. A joint record review of Resident 2's admission MDS dated [DATE] showed that it was completed on 01/05/2026. Staff D stated that the MDS was not completed timely and that it should have been completed by 12/25/2025. In an interview on 04/16/2026 at 4:57 PM, Staff B stated that they expected MDS assessments to be completed accurately and timely. Reference: (WAC) 388-97-1000(1)(b)(3)(a) .

Based on interview and record review, the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS - an assessment tool) for 3 of 6 residents (Residents 10, 9 & 7), reviewed for SCSA. This failure placed the residents at risk for delayed care planning, unmet care needs, and a diminished quality of life.Findings included. Review of the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed that a SCSA is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. It further showed that a SCSA completion date (item Z0500B) must be no later than 14 days after the determination that the criteria for a SCSA were met. Review of the facility's policy titled, MDS Completion and Submission Timeframes, revised in October 2023, showed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. RESIDENT 10Review of Resident 10's progress note dated 10/03/2025 showed that the SCSA date of determination by the IDT was 10/03/2025. Review of Resident 10's SCSA MDS dated [DATE] showed a completion date (item Z0500B) of 11/18/2025 (32 days late). In an interview and joint record review on 04/14/2026 at 12:32 PM, Staff D, MDS Coordinator, stated that they followed the RAI manual for MDS assessment completion. A joint record review of Resident 10's progress note dated 10/03/2025 showed the SCSA date of determination by the IDT was 10/03/2025 and the SCSA MDS dated [DATE] showed that it was completed on 11/18/2025 (32 days late). Staff D stated that Resident 10's SCSA MDS was not completed timely. In an interview on 04/15/2026 at 8:25 AM, Staff B, Director of Nursing, stated that they expect Resident 10's SCSA MDS to be completed timely. RESIDENT 9Review of Resident 9's nursing progress notes dated 01/19/2026 showed the resident was readmitted to the facility on [DATE], and that a SCSA MDS was scheduled for 01/21/2026. Review of Resident 9's SCSA MDS dated [DATE] showed it was completed on 02/04/2026 (three days late). A joint record review and interview on 04/15/2026 at 5:56 PM with Staff D, showed the RAI manual revealed that a SCSA MDS should be completed no later than 14 days after determination that significant change in resident's status occurred. A joint record review of the nursing progress notes dated 01/19/2026 showed the IDT determined to do a SCSA MDS on 01/21/2026, and it showed it was completed on 02/04/2026. Staff D stated that Resident 9's MDS was not completed timely and that it should have been. In an interview on 04/16/2026 at 4:57 PM, Staff B stated that they expected MDS assessments to be completed accurately and timely. RESIDENT 7 Review of the nursing progress note dated 10/03/2025 showed Resident 7 had developed a pressure wound (bedsore) to their right heel and that Resident 7 would benefit from a significant change in condition MDS- ARD is set for 10/06/2025. Review of Resident 7's SCSA MDS dated [DATE] showed it was completed on 10/27/2025 (10 days late). A joint record review and interview on 04/15/2026 at 3:54 PM with Staff D, showed that Resident 7's SCSA MDS dated [DATE] was completed on 10/27/2025. Staff D stated that Resident 7's SCSA MDS was not completed timely. A joint record review and interview on 04/16/2026 at 10:41 AM with Staff B, showed Resident 7's SCSA MDS dated [DATE] was completed on 10/27/2025. Staff B stated that they expected Resident 7's SCSA MDS to be completed timely per regulation. Reference: (WAC) 388-97-1000 (3)(b)(5)(a) .

Based on interview and record review, the facility failed to complete quarterly Minimum Data Set (MDS- an assessment tool) timely within 14 days from the Assessment Reference Date (ARD) for 3 of 21 residents (Residents 14, 10 & 7), reviewed for resident assessments. This failure placed the residents at risk for delayed care planning, unmet care needs, and a diminished quality of life.Findings included. Review of the Resident Assessment Instrument (RAI) 3.0 User's Manual (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed a quarterly assessment was considered timely if the MDS completion date (Item Z0500B) must be no later than 14 days after the ARD (ARD + [plus] 14 days). Review of the facility's policy titled, MDS Completion and Submission Timeframes, revised in October 2023, showed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. RESIDENT 14Review of Resident 14's quarterly MDS dated [DATE], showed a completion date (item Z0500B) of 01/27/2026 (one day late). In an interview and joint record review on 04/14/2026 at 12:32 PM, Staff D, MDS Coordinator, stated that they followed the RAI manual for MDS assessment completion. A joint record review of Resident 14's quarterly MDS dated [DATE] showed that it was completed on 01/27/2026. Staff D stated that Resident 14's quarterly MDS was not completed timely. In an interview on 04/15/2026 at 8:25 AM, Staff B, Director of Nursing, stated that they expected Resident 14's quarterly MDS to have been completed timely. RESIDENT 10Review of Resident 10's quarterly MDS dated [DATE], showed a completion date of 01/27/2026 (eight days late). A joint record review and interview on 04/14/2026 at 12:32 PM with Staff D, showed that Resident 10's quarterly MDS dated [DATE] had a completion date of 01/27/2026. Staff D stated that Resident 10's quarterly MDS was not completed timely. In an interview on 04/15/2026 at 8:25 AM, Staff B stated that they expected Resident 10's quarterly MDS to have been completed timely. RESIDENT 7 Review of Resident 7's quarterly MDS dated [DATE] showed it was completed on 01/27/2026 (four days late). A joint record review and interview on 04/15/2026 at 3:54 PM with Staff D, showed that Resident 7's quarterly MDS dated [DATE] was completed on 01/27/2026. Staff D stated that Resident 7's quarterly MDS was not completed timely. In an interview on 04/16/2026 at 10:41 AM, Staff B stated that they expected MDS assessments to be completed on time per regulation. Reference: (WAC) 388-97-1000 (4)(a)(5)(a) .

Based on interview and record review, the facility failed to ensure resident assessments were completed accurately for 9 of 32 residents (Residents 49, 100, 14, 13, 66,19, 3, 10 & 71), reviewed for Minimum Data Set (MDS-an assessment tool). The failure to ensure accurate assessment was marked on the MDS regarding weights, PASRR [Preadmission Screen and Resident Review], insulin injections (medication used to manage blood sugar levels), Serious Mental Illness (SMI), diagnosis, weight loss, medication, and Bilevel Positive Airway Pressure (BiPAP - a noninvasive ventilator that helps people breathe easier by delivering pressurized air through a mask) placed the residents at risk for unidentified and/or unmet care needs, and a diminished quality of life.Findings included . According to the Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, (a guide directing staff on how to accurately assess the status of residents) Version 1.20.1, dated October 2025, showed, .an accurate assessment requires collecting information from multiple sources, some of which are mandated by regulations. Those sources must include the resident and direct care staff on all shifts, and should also include the resident's medical record, physician, and family, guardian and/or other legally authorized representative, or significant other as appropriate or acceptable. It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT [Interdisciplinary Team] completing the assessment. RESIDENT 49Review of the RAI manual showed, The measurement of weight is one guide for determining nutritional status. check the medical record and enter the weight taken within 30 days of the Assessment Reference Date (ARD or assessment period) of this assessment. If a resident cannot be weighed, for example because of extreme pain, immobility, or risk of pathological fractures, use the standard no-information code (- [dash]) and document rationale on the resident's medical record. Review of the annual MDS dated [DATE] showed that Resident 49's weight was recorded as 202.2 pounds (lbs. – a unit of measurement). Review of the Weight and Vitals Summary record printed on 04/09/2026 showed that Resident 49's last weight was taken 08/01/2024 and it was 202.2 Ibs. In an interview and joint record review on 04/14/2026 at 12:37 PM, Staff D, MDS Coordinator, stated that the facility used the RAI manual for MDS assessment completion. Staff D stated that they used Resident 49's last weight record to document weights in MDS. A joint record review of the annual MDS dated [DATE] showed Resident 49's weight was recorded as 202.2 Ibs. A joint record review of Resident 49's Electronic Health Record (EHR- under weights/vitals) showed their last weight was taken on 08/01/2024 and it was 202.2 Ibs. Staff D stated they used the weight taken on 08/01/2024 for the annual MDS dated [DATE]. Staff D further stated that the weight recorded on the MDS was not obtained within 30 days of the ARD. RESIDENT 100The RAI manual directed, Code 1, yes: if PASRR Level II [refers to the evaluation process conducted after a Level I screening indicates a possible serious mental illness or Intellectual Disability (ID) to ensure that individuals receive appropriate care and support based on their specific needs and conditions] screening determined that the resident has a serious mental illness and/or ID/DD [Developmental Disabilities] or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Review of the annual MDS dated [DATE] showed that Section A1500 (PASRR) showed Resident 100 was marked no for state Level II PASRR. Review of the Level II PASRR dated 02/03/2026 showed Resident 100 had a Level II PASRR determination (eligible for behavioral services). During a joint record review and interview on 04/14/2026 at 12:31 PM with Staff D showed Resident 100's annual MDS dated [DATE] was marked not considered by the state Level II PASRR. Staff D stated that the MDS was marked No for the Level II PASRR and it should have been marked, Yes. In an interview on 04/15/2026 at 8:35 AM, Staff B, Director of Nursing, stated that they expected MDS assessments to have been completed timely and accurately. RESIDENT 14Review of Resident 14's annual MDS dated [DATE], showed that Resident 14 was marked No, in Section A (A1500- PASRR). Review of Resident 14's PASRR level II dated 11/12/2020, showed that Resident 14 had a Level II PASRR determination. In a joint record review and interview on 04/14/2026 at 12:32 PM with Staff D, showed that Resident 14's annual MDS dated [DATE] was marked No, in Section A1500. A joint record review of Resident 14's PASRR level II dated 11/12/2020, showed that Resident 14 had a Level II PASRR determination. Staff D stated that Resident 14's annual MDS was not marked accurately. In an interview on 04/15/2026 at 8:25 AM, Staff B stated that they expected Resident 14's annual MDS to have been completed accurately. RESIDENT 13Review of the RAI Manual showed, .Count the number of days that the resident received any type of injection while a resident of the nursing home. Record the number of days that any type of injection. was received in Item N0300 [injections received during the seven [7] day look back period]. Enter in Item N0350A [insulin injections]. Review of Resident 13's quarterly MDS dated [DATE] showed it was marked for 7 injections in Section N0300 and 0 [zero] days for insulin injections in Section N0350A. Review of Resident 13's March 2026 Medication Administration Record (MAR) showed that Resident 13 was given insulin injections for 6 [six] days (03/19/2026, 03/20/2026, 03/22/2026, 03/23/2026, 03/24/2026 and 03/25/2026) during the look back period. A joint record review and interview on 04/15/2026 at 5:48 PM with Staff D, showed Resident 13's MDS dated [DATE] was marked for seven injections and zero insulin injections. A joint record review of March 2026 MAR showed that Resident 13 was given insulin injections for six days during the look back period. Staff D stated that Resident 13's MDS was not accurate and that it should have been marked for six injections and six insulin injections. In an interview on 04/16/2026 at 4:57 PM, Staff B stated that they expected MDS assessments to have been completed accurately and timely. RESIDENT 66 Review of the RAI manual coding instructions showed that if the resident had been diagnosed with SMI to code it in Section A1510A. Review of the admission record printed on 04/09/2026 showed Resident 66 had a diagnosis of Major Depressive Disorder (MDD-persistent feelings of sadness, loss of interest). Review of the annual MDS dated [DATE] showed Resident 66's MDS under Section A1510A was not marked for SMI. Review of a behavioral progress note dated 01/02/2026 showed Resident 66 had a diagnosis of MDD and had been undergoing mental health visits. A joint record review interview on 04/15/2026 at 3:59 PM with Staff D, showed Resident 66's annual MDS dated [DATE] showed Section A1510A was not marked for SMI. A joint record review of Resident 66's EHR (admission record and physician's order) showed a diagnosis of MDD. When asked if SMI should have been marked, Staff D stated that they would consult with Staff O, MDS Nurse. A joint record review and phone interview on 04/15/2026 at 5:02 PM with Staff O, showed Section A1510A on Resident 66's annual MDS dated [DATE] was not marked for SMI. Staff O stated that Resident 66 had MDD and had mental health visits. When asked if SMI should have been marked, Staff O stated, Yes. RESIDENT 19 Review of the RAI Manual coding instructions showed, Code diseases that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period. Review of the quarterly MDS dated [DATE] showed Resident 19's MDS under Section I (Active Diagnoses) was not marked for anxiety disorder (having intense, excessive and persistent worry and fear about everything). Review of the March 2026 MAR showed Resident 19 was receiving medication for anxiety during the observation period. Review of a physician progress note dated 03/23/2026 showed Resident 19 had a diagnosis of anxiety disorder. A joint record review and interview on 04/15/2026 at 4:42 PM with Staff D, showed Resident 19's quarterly MDS dated [DATE] was not marked for anxiety disorder. A joint record review of the March 2026 MAR showed Resident 19 was taking medication for anxiety. Staff D stated that Resident 19's quarterly MDS was not accurate and that anxiety disorder should have been coded. In an interview on 04/16/2026 at 1:19 PM, Staff B stated that they expected staff to follow MDS coding per regulation. Staff B further stated that Resident 66's SMI and Resident 19's anxiety disorder should have been marked in their MDS. RESIDENT 3The RAI showed, 10% [percent – standardized scale of 100] weight loss in 180 days.start with the resident's weight closest to 180 days ago and multiply it by 90 [or 90%]. The resulting figure represents a 10% loss from the weight 180 days ago. If the resident's current weight is equal to or less than the resulting figure, the resident has a lost 10% or more body weight. Review of Resident 3's quarterly MDS dated [DATE], showed that Resident 3 was marked, No or unknown, under Section K (K0300 - Loss of 5% or more in the last month or loss of 10% or more in the last 6 months). Review of Resident 3's September 2025 through March 2026 weights showed 147.4 lbs on 09/02/2025 and 132 lbs. on 03/01/2026. The weights further showed a 10.45% weight loss in the last 6 months. A joint record and interview on 04/14/2026 at 12:32 PM with Staff D, showed Resident 3's quarterly MDS dated [DATE], was marked, No or unknown, under Section K0300. A joint record review of Resident 3's September 2025 through March 2026 weights showed a weight of 147.4 lbs on 09/02/2025 and a weight of 132 lbs. on 03/01/2026. Staff D stated that Resident 3's quarterly MDS was not marked accurately and that it should have been marked, Yes [Loss of 5% or more in the last month or loss of 10% or more in the last 6 months]. In an interview on 04/15/2026 at 8:25 AM, Staff B stated that they expected Resident 3's quarterly MDS to have been completed accurately. RESIDENT 10The RAI showed, Check if an opioid [medication to treat moderate to severe pain] medication was taken by the resident at any time during the 7-day look-back period. Check if there is an indication noted for all opioid medications taken by the resident any time during the observation period. Review of Resident 10's significant change MDS dated [DATE], showed that Resident 10 was marked Is taking and Indication noted, under Section N (N0415H- Opioid). Review of Resident 10's October 2025 MAR showed that Resident 10 did not receive an opioid during the MDS look back period. In a joint record review and interview on 04/14/2026 at 12:32 PM with Staff D, showed that Resident 10's significant change MDS dated [DATE] was marked Is taking and Indication noted, under Section N (N0415H-Opioid). Staff D stated that Resident 10's significant change MDS was not marked accurately. In an interview on 04/15/2026 at 8:25 AM, Staff B stated that they expected Resident 10's significant change MDS to have been completed accurately. RESIDENT 71The RAI showed, Code any type of CPAP [Continuous Positive Airway Pressure – a device that treats sleep apnea [disorder where breathing repeatedly stops and starts while sleeping] by blowing a steady stream of air into a mask worn over the nose or mouth] or BiPAP use during the first three days of admission. Review of Resident 71's admission/5day MDS dated [DATE], showed that Resident 71 was marked CPAP under Section O0110G3. Review of Resident 71's March 2026 physician orders showed that Resident 71 was prescribed a BiPAP machine. Review of Resident 71's March 2026 Treatment Administration Record showed Resident 71 used a BiPAP during the look back period. In a joint record review and interview on 04/14/2026 at 12:32 PM with Staff D, showed Resident 71's admission/5day MDS dated [DATE] was marked CPAP in Section O0110G3. A joint record review of Resident 71's March 2026 physician orders showed that Resident 71 used a BiPAP. Staff D stated that Resident 71 used a BiPAP and that their admission/5day MDS was not marked accurately. In an interview on 04/15/2026 at 8:25 AM, Staff B stated that they expected Resident 71's admission/5day MDS to have been completed accurately. Reference: (WAC) 388-97-1000(1)(b) .

Based on observation, interview, and record review, the facility failed to ensure smoking materials were safely stored for 8 of 10 residents (Residents 66, 54, 63, 61, 75, 13, 2 & 85), reviewed for smoking. This failure placed the residents at risk for accidents, injury and a diminished quality of life.: Findings included. Review of the facility's policy titled, Smoking, dated 08/09/2022, showed, It is the policy of this facility to accommodate residents who desire to smoke by taking reasonable precautions, providing a safe environment for them. The policy further showed that the Interdisciplinary Team will develop an individualized plan for safe storage, use of smoking materials. RESIDENT 66 Review of the care plan for smoking printed on 04/10/2026 showed that Resident 66's smoking materials would be maintained with the smoking aide. In an interview on 04/08/2026 at 8:50 AM, Resident 66 stated that they smoked without supervision once a day and kept their cigarette and lighter in a bag inside their drawer. An observation and a follow-up interview at 11:47 AM showed Resident 66 had two lighters inside the open side pocket of their small black bag stored in their drawer. Resident 66 stated, I had everything [smoking materials] inside the bag. Another observation and interview on 04/10/2026 at 8:03 AM, showed Resident 66 had a small black bag inside their middle drawer. Further observation showed a lighter on the open side pocket of the small black bag. Resident 66 stated that they had been keeping the lighter all this time and that nobody told them that they could keep it. In an interview and joint observation on 04/14/2026 at 9:07 AM, Staff EE, Certified Nursing Assistant (CNA), stated that Resident 66 smoked independently outside the facility. Staff EE stated that Resident 66 kept their smoking materials in a small black bag. A joint observation with Staff EE showed a cigarette in the small black bag placed inside Resident 66's drawer and a lighter on top of Resident 66's bedside table. When asked about Resident 66's lighter, Staff EE stated, He is independent. They can keep it. RESIDENT 54 Review of the care plan for smoking printed on 04/14/2026 showed Resident 54's smoking materials are kept with [the] smoking aide. Observation and interview on 04/08/2026 at 11:30 AM, showed Resident 54 in their room sitting on the floor by their bedside. Resident 54's room smelled of cigarette smoke and an unlit half-smoked cigarette placed in a dark-purple cup with crumpled foil lining the inside of the cup. When asked if they had smoked in the room, Resident 54 stated, I do, sometimes, but I don't [do not] do it anymore. When asked if they kept lighter and cigarette in their room, Resident 54 mentioned they had a lockbox and that they had lost the key to their lockbox. Resident 54 showed the lighter they had placed on top of their pile and declined further questions. In an interview on 04/14/2026 at 8:59 AM, Staff EE stated that they had smelled cigarette smoke in Resident 54's room and did not see Resident 54 smoking inside their room. Staff EE stated that Resident 54 kept their smoking materials in their pocket. Staff EE further stated that they did not see a lockbox in Resident 54's room. RESIDENT 63 Review of Resident 63's smoking care plan printed on 04/15/2026 showed that their smoking materials are securely maintained in the smoking cart. The care plan further showed, Maintain [resident's] smoking materials at nurses' station. In an interview and observation on 04/08/2026 at 11:40 AM, Resident 63 stated that they smoked independently outside in the gazebo. When asked where they would keep their smoking materials, Resident 63 stated, I keep my lighter in my pocket and then showed their lighter and an empty pack of cigarette from their jacket. Resident 63 stated that they could not use the lockbox because it does not have a key and that they were informed by a facility staff about a new lockbox and [has] been waiting for it since Christmas. In an interview on 04/14/2026 at 9:03 AM, Staff EE, stated that Resident 63 kept their smoking materials in their pocket and that sometimes [their roommate, Resident 73] keeps it for Resident 63. In an interview and joint record review on 04/15/2026 at 2:52 PM, Staff C, Assistant Director of Nursing, stated that smoking materials for supervised smoking residents were kept in the smoking cart and that smoking materials for independent smoking residents were kept in the lockbox. Staff C stated that Resident 66, Resident 54 and Resident 63 were independent smoker. A joint record review of the smoking care plan for Resident 66, Resident 54 and Resident 63, showed that their smoking materials were to be maintained with the smoking aide and/or in the smoking cart. A joint record review of the care plan did not show use of a lockbox for their smoking materials. Staff C stated that it was not safe for the residents to keep their smoking materials with them. Staff C further stated that the smoking care plan for Resident 66, Resident 54 and Resident 63 were not implemented and/or updated to reflect their status. Resident 61 Review of Resident 61's smoking care plan printed on 04/15/2026 did not show how to safely store their smoking materials. On 04/08/2026 at 1:06 PM, Resident 61 was observed with an unlit cigarette on their mouth and a lighter on their hand, and an unknown staff wheeled Resident 61 to the smoking area. In an interview on 04/16/2026 at 7:41 AM, Resident 61 stated that they smoked independently outside in the gazebo. When asked where they kept their smoking materials, Resident 61 stated that they had their smoking materials in their pocket and that nobody has told me to use it [lockbox]. I have never used it. I think it is there somewhere. In an interview on 04/16/2026 at 8:09 AM, Staff C stated that Resident 61 was an independent smoker and that they were not aware that Resident 61 had not been using their lockbox. Staff C stated that they would educate Resident 61 to use their lockbox. In an interview on 04/16/2026 at 10:43 AM, Staff B, Director of Nursing, stated that they expected residents' smoking materials to be kept in a safe and a secured place and that the lockbox was considered a safe place for them to keep their smoking materials. Staff B further stated that the residents' [smoking] care plans should be implemented, reviewed and/or revised. RESIDENT 75Review of the unsigned smoking evaluation dated 03/13/2026 [printed on 04/08/2026], showed Resident 75 required supervision with smoking For safety. Review of the smoking care plan printed on 04/08/2026 showed, [Resident 75] may smoke with supervision per smoking assessment. Further review of the care plan showed an intervention to Inform family and significant others that the patient [resident] needs supervision while smoking. supervise patient with smoking in accordance with assessed needs. The care plan did not indicate where Resident 75 could safely keep their smoking materials. On 04/08/2026 at 11:31 AM, Resident 75 was observed in the designated smoking area sitting on their power wheelchair and removed a cigarette and a lighter from a brown leather-like bag hanging over their shoulder. Resident 75 lit their cigarette, placed their lighter back in their brown bag, and continued to smoke their cigarette. Resident 75 was observed smoking without staff supervision. In an interview on 04/15/2026 at 2:05 PM, Staff W, CNA, stated that Resident 75 smoked in the designated smoking area and they did not know if Resident 75 kept their cigarettes with them. On 04/16/2026 at 10:27 AM, Resident 75 stated that they smoked independently and kept their cigarettes and lighter in my purse pointing at their brown leather-like bag that was sitting on a chair in their room. In an interview joint record review on 04/16/2026 at 1:03 PM, Staff C stated they expected a smoking assessment to be done to determine if a resident was able to smoke independently or with assistance. Staff C stated that independent residents who smoke would keep their lighters and cigarettes with them and that they would be provided with a lockbox to store their smoking materials. A joint record review of the smoking care plan, and smoking evaluation dated 03/13/2026, revealed that Resident 75 required supervision with smoking. Staff C stated that staff should have followed Resident 75's smoking care plan to provide supervision with smoking. In an interview on 04/16/2026 3:48 PM, Staff B stated that residents who were evaluated to smoke independently would have a lockbox to store their smoking materials. Staff B stated that Resident 75's care plan should have been followed to provide for supervision when smoking. RESIDENT 13Review of the smoking evaluation dated 12/09/2025 showed Resident 13 was allowed to smoke independently. Review of the smoking care plan printed on 04/08/2026 indicated that Resident 13 smoked independently. Further review of the care plan showed an intervention to Maintain smoking materials with the smoking aid. Monitor [Resident 13] for compliance that was last revised on 03/25/2021. On 04/08/2026 at 11:29 AM, Resident 13 was observed sitting on their power wheelchair in the designated smoking area lighting their cigarette, smoked independently, and placed their lighter back in their pocket after they were done smoking. On 04/08/2026 at 12:24 PM, Resident 13 stated they smoked independently and kept their cigarettes and lighter with them in their pocket. Observations on 04/08/2026 at 1:31 PM and on 04/10/2026 at 11:59 AM, showed Resident 13 was smoking independently in the designated smoking area. In an interview on 04/15/2026 at 2:21 PM, Staff DD, CNA, stated that Resident 13 smokes independently and that they kept their cigarettes and lighter with them, usually under [Resident 13's] control]. In a joint record review and interview on 04/16/2026 at 1:22 PM with Staff C, revealed that Resident 13's smoking evaluation dated 12/09/2025, showed that Resident 13 was independent with smoking. A joint record review of Resident 13's smoking care plan showed to Maintain smoking materials with the smoking aid. Monitor [Resident 13] for compliance. Staff C stated that Resident 13 was independent with smoking and that it was okay for them to keep their smoking materials. Staff C further stated that Resident 13's smoking care plan should have been updated. In an interview on 04/16/2026 at 3:43 PM, Staff B stated that Resident 13 was independent with smoking and that they kept their smoking materials with them. Staff B further stated that Resident 13's smoking care plan should have been updated to keep their smoking materials in a lockbox. RESIDENT 2Review of the smoking evaluation dated 12/24/2025 showed Resident 2 was independent with smoking. Review of the comprehensive care plan printed on 04/08/2026 did not show Resident 2 had a care plan for smoking. On 04/08/2026 at 11:49 AM, Resident 2 stated they kept their lighter and cigarettes with them. Resident 2 was observed taking out their lighter and a pack of cigarettes from their zippered black bag. On 04/10/2026 at 12:37 PM, Resident 2 was observed smoking independently in the designated smoking area. A joint record review and interview on 04/16/2026 at 12:53 PM with Staff C, Resident 2's smoking evaluation dated 12/24/2025, showed they were independent with smoking. A joint record review of the comprehensive care plan did not show Resident 2 had a care plan for smoking. Staff C stated that Resident 2 should have had a care plan for smoking. A joint record review and interview on 04/16/2026 at 3:48 PM with Staff B, Resident 2's smoking evaluation showed they were independent with smoking. Staff B stated that Resident 2 smoked independently and kept their smoking materials with them. A joint record review of the comprehensive care plan showed that Resident 2 did not have a care plan for smoking. Staff B stated that Resident 2 did not have a care plan for smoking and should have had. RESIDENT 85Review of Resident 85's comprehensive care plan printed on 04/13/2026 showed an intervention to, Maintain patients smoking materials are securely maintained in the smoking cart. In an interview and observation on 04/08/2026 at 12:48 PM, Resident 85 stated that they smoked independently and that they kept their cigarettes and lighter with them. Observed Resident 85 took out one pack of cigarettes and a lighter out of their right leather jacket pocket. Resident 85 stated, I have to keep it in a lockbox. I'm waiting for a lockbox though. In an interview on 04/15/2026 at 1:14 PM, Staff W stated that some residents would keep their smoking materials in the smoking storage cart. Staff W further stated that they were unsure where Resident 85 kept their smoking materials. In an interview on 04/16/2026 at 10:58 AM, Staff C stated that they would expect residents to store their smoking materials in the smoking cart. A joint record review of Resident 85's care plan showed an intervention to, Maintain patients smoking materials are securely maintained in the smoking cart. Staff C stated that Resident 85 should not have kept their smoking materials in their pocket when not in use. In an interview on 04/16/2026 at 1:13 PM, Staff B stated that they would expect Resident 85 to have stored their smoking materials in the smoking cart. In an interview on 04/16/2026 at 1:22 PM, Staff A, Administrator, stated that independent residents should store their smoking materials in a lockbox in their room and for residents who need assistance should store their smoking materials in the smoking cart. Staff A further stated that they would expect Resident 85 to have stored their smoking materials in a lockbox. Reference: (WAC) 388-97-1060(3)(g) .

Based on observation, interview, and record review, the facility failed to comprehensively assess and evaluate the need for bed rails for 3 of 6 residents (Residents 9, 74 & 103), reviewed for bed rail use. This failure placed the residents at risk for entrapment, injury, and a diminished quality of life.Findings included .Review of the facility's policy titled, Bed Rails, dated 02/21/2025, showed, It is the policy of this facility to utilize a person-centered approach when determining the use of bed rails. Appropriate alternative approaches are attempted prior to installing or using bed rails. If bed rails are used, the facility ensures correct installation, use, and maintenance of the rails. As part of the residence comprehensive assessment, the IDT will review and determining [determine] the resident's needs, and whether or not the use of bed rails meets those needs. Once the IDT determines that the resident may benefit from a use of side rail, the licensed nurse will complete the bed rail assessment. Informed consent from the resident or resident representative must be obtained after appropriate alternatives have been attempted prior to installation and use of bed rails. Upon receiving informed consent, the facility will obtain a physician's order for the use of a specific bed rail.RESIDENT 9Review of a bed rail evaluation dated 01/26/2026 showed Resident 9's bed rail recommendations were, No to Rail/s.Mobility bars not indicated for this resident at this time.Review of the Electronic Health Records (EHR -miscellaneous/documents tab from 05/13/2025 to 04/01/2026) did not show that Resident 9 had a consent for their right-side bed rail.Review of the comprehensive care plan printed on 04/15/2026 did not show that Resident 9 had a care plan for the bed rail.During an observation and interview on 04/07/2026 at 11:42 AM and on 04/09/2026 at 1:37 PM, Resident 9 had a bed rail on their right side in the raised position. Resident 9 stated that they used their bed rail.A joint observation and interview on 04/15/2026 at 2:35 PM with Staff BB, Certified Nursing Assistant (CNA), showed Resident 9 had a right bed rail in the raised position. Staff BB stated that Resident 9 used their bed rail.In a joint observation and interview on 04/15/2026 at 2:59 PM with Staff CC, Registered Nurse, showed Resident 9 had a right bed rail in the raised position. Staff CC stated that Resident 9 had their bed rail since they were readmitted to the facility.In an interview and joint record review on 04/16/2026 at 1:28 PM, Staff C, Assistant Director of Nursing, stated that before a bed rail gets installed on the resident's bed, the facility would complete a bed rail assessment, obtain consent, and develop a care plan. A joint record review of Resident 9's bed rail assessment dated [DATE], showed no indication for bed rail use. A joint record review of Resident 9's EHR (miscellaneous/documents tab and care plan) did not show they had a consent and/or care plan for bed rail use. Staff C stated that Resident 9 should have had an evaluation for the right-side bed rail, consent, and a care plan.In an interview on 04/16/2026 at 4:00 PM, Staff B, Director of Nursing, stated that they expected residents to have a bed rail evaluation, consent, and a care plan for bed rail use. Staff B further stated that Resident 9 should have had an evaluation for their right-side bed rail, consent, and a care plan for bed rail use.RESIDENT 74Review of a bed rail evaluation dated 02/11/2026 showed Resident 74's bed rail indications for use and recommendation revealed, Bed rail/transfer bar is not indicated. No to Rail/s.Review of the EHR (miscellaneous/documents tab from 12/20/2025 to 04/13/2026) did not show Resident 74 had a consent for bed rail use.Review of the comprehensive care plan printed on 04/15/2026 did not show Resident 74 had a care plan for bed rail use.Observations on 04/07/2026 at 11:50 AM and on 04/09/2026 at 1:39 PM showed Resident 74 had bed rails attached on both sides of their bed in the raised position. Resident 74 stated they used their bed rails.A joint observation and interview on 04/15/2026 at 2:36 PM with Staff BB, showed Resident 74 had bed rails attached on both sides of their bed in the raised position. Staff BB stated that Resident 74 used their bed rails and that they had them since admission.A joint observation and interview on 04/15/2026 at 3:00 PM with Staff CC, showed Resident 74 was lying in bed, and had their bed rails in the raised position. Staff CC stated that Resident 74 used their bed rails and that they had had them for a while.A joint record review and interview on 04/16/2026 at 1:41 PM with Staff C, showed Resident 74's bed rail evaluation did not indicate use of bed rails. A joint record review of Resident 74's EHR (miscellaneous/documents tab and care plan) did not show Resident 74 had a consent and a care plan for bed rail use. Staff C stated that Resident 74 should have an evaluation, a consent, and a care plan for bed rail use.In an interview on 04/16/2026 at 4:07 PM, Staff B stated that Resident 74 should have had an evaluation, a consent, and a care plan for bed rail use.RESIDENT 103Review of a bed rail evaluation dated 02/22/2025 showed resident was evaluated for a left upper bed rail.Observation on 04/07/2026 at 8:41 AM, showed Resident 103 was in bed and had bed rails on both sides of their bed in the raised position. Resident 103 stated that they used their bed rails.A joint observation and interview on 04/15/2026 at 2:26 PM with Staff DD, CNA, showed Resident 103 had bed rails on both sides of their bed in the raised position. Staff DD stated that Resident 103 used their bed rails.A joint record review and interview on 04/16/2026 at 1:45 PM with Staff C, showed Resident 103's bed rail evaluation dated 02/22/2025 indicated that they were evaluated to use a left bed rail. Staff C stated that Resident 103 should have had a bed rail evaluation for both bed rails.In an interview on 04/16/2026 at 4:09 PM, Staff B stated that Resident 103 should have had an evaluation for both bed rails.Reference: (WAC) 388-97-1060 (3)(g).

Based on observation, interview, and record review, the facility failed to ensure the posted daily nurse staffing information included the actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift for 9 of 10 days (04/01/2026 to 04/08/2026 & 04/10/2026), reviewed for posted nurse staffing information. In addition, the facility failed to post the current nurse staffing information for 1 of 8 days (04/09/2026). The failure to post a complete and current nurse staffing form daily prevented the residents, family members, and visitors from exercising their rights to know the actual nursing staff hours worked in the facility.Findings included.Review of the facility's policy titled, Posting Direct Care Daily Staffing Numbers, revised in August 2022, showed Our facility will post on a daily basis for each shift nurse staffing data, including the number of nursing personnel responsible for providing direct care to residents. The policy showed that within two hours of the beginning of each shift, the number of licensed nurses including Registered Nurses, Licensed Practical Nurses and the number of unlicensed nursing personnel including Certified Nursing Assistants directly responsible for resident care is posted in a prominent location (accessible to residents and visitors) and in a clear and readable format. The policy further showed that the charge nurse completes the form and posts the staffing information in the location designated by the administrator.Observation on 04/07/2026 at 8:06 AM, showed a Daily Nurse Staffing Form, dated 04/07/2026 with the number of staff and scheduled hours filled out. The form further showed the hours worked column was blank.Observations on 04/09/2026 at 8:25 AM, at 10:30 AM, at 3:00 PM, and on 04/10/2026 at 8:00 AM, showed a Daily Nurse Staffing Form dated 04/08/2026 (not the current date or current nurse staffing information, what was posted was 04/08/2026).Observation on 04/10/2026 at 1:22 PM, showed the hours worked column on the Daily Nurse Staffing Form was blank.In an interview and joint record review on 04/10/2026 at 2:34 PM, Staff G, Scheduler, stated that they were responsible for the Daily Nurse Staffing Form and that it should be filled out completely for each nursing category with scheduled and actual hours [worked]. Staff G stated that the form should be current. Staff G stated that they filled out the hours worked column at the end of the shift and would know which staff showed up at the beginning of the shift. A joint record review of the Daily Nurse Staffing Form, dated 04/01/2026 to 04/08/2026 and 04/10/2026 showed the hours worked column was blank. Staff G stated that the forms should have been completed. Staff G stated that on the weekends they would leave the forms and update the hours worked on Monday when they returned. Staff G further stated that they were out of the facility on 04/09/2026 and did not update the form.In an interview on 04/15/2026 at 2:17 PM, Staff A, Administrator, stated that they expected the Daily Nurse Staffing Form to be complete, filled out including actual hours, be current and posted at the beginning of the shift.Reference: (WAC) 388-97-1620 (2)(b)(i).

Based on observation, interview, and record review, the facility failed to ensure a system was in place for tracking and accounting of controlled drugs, and failed to store controlled drugs in a locked, permanently affixed compartments in 1 of 2 medication rooms (Medication room [ROOM NUMBER]'s E-Kit [emergency medication box]), reviewed for controlled drugs management. This failure placed the facility at risk for potential loss and/or drug diversion of controlled drugs.Findings included.Review of the facility's policy titled, Controlled Substances, revised in November 2022, showed, Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substance record. Controlled substances are separately locked in permanently affixed compartment, except when using single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.During a joint observation and interview on 04/10/2026 at 1:37 PM with Staff H, Director of Staff Development, and Staff I, Licensed Practical Nurse, showed the Medication room [ROOM NUMBER]'s second medication refrigerator did not have a lock. Inside the unlocked refrigerator, a clear, removable emergency medication box (E-Kit) was stored. The E-Kit's security seal (a yellow zip tie) was found taped to the side of the box and was not applied to the E-Kit to secure the contents. Observation showed the following controlled drugs were stored in the E-kit: two 2 mg (milligram- a unit measurement) vials of Lorazepam (a controlled drug used to treat severe anxiety) injectable solution and two 30 ml (milliliter - a unit measurement) bottles of Lorazepam oral solution. Further observation showed there was no controlled drug logbook in the E-Kit. Staff H stated that the E-Kit was delivered by the facility's new pharmacy provider, and they had not seen the E-Kit's controlled drug logbook. Staff I stated that the refrigerator containing the E-Kit with controlled drugs should have been locked.In an interview on 04/15/2026 at 11:14 AM, Staff B, Director of Nursing, stated that controlled drugs must be counted, logged on the controlled drug book, and stored in a locked box. Staff B stated that they were unaware the E-Kit with controlled drugs were delivered by the new pharmacy. Staff B further stated that the medication room refrigerator used for storage of controlled drugs should have been locked and a controlled drug logbook should have been in place.Reference: (WAC) 388-97-1300 (3)(a).

Based on interview and record review, the facility failed to ensure adverse side effects and target behaviors were monitored for medication use and/or physician's orders were followed when administering medication for 3 of 6 residents (Residents 30, 13 & 7), reviewed for unnecessary medications. These failures placed residents at risk for adverse side effects, related complications, and a diminished quality of life.Findings included. Review of the facility's policy titled, Administering Medications, revised in April 2019, showed, Medications are administered in a safe and timely manner as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering the medication checks the label three times to verify the right result and right medication, right dosage, right time and right method (route) of administration before giving the medication. MONITORING OF SIDE EFFECTS AND TARGET BEHAVIORSRESIDENT 30Review of Resident 30's physician orders printed on 04/07/2026 showed an order for nortriptyline (antidepressant – medication for depression [a mood disorder that causes a persistent feeling of sadness and loss of interest]) to be given at bedtime. Review of Resident 30's January 2026 through April 2026 Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not show monitoring for adverse side effects and/or target behaviors related to antidepressant use. In an interview and record review on 04/16/2026 at 2:34 PM, Staff C, Assistant Director of Nursing, stated they expected residents on antidepressants to be monitored for adverse side effects and target behaviors. A joint record review of the January 2026 through April 2026 MAR and TAR did not show that Resident 30 was being monitored for adverse side effects and/or target behaviors. Staff C stated that Resident 30 should have been monitored for adverse side effects and target behaviors related to antidepressant use. In an interview and joint record review on 04/16/2026 at 4:22 PM, Staff B, Director of Nursing, stated that they expected residents to be monitored for adverse side effects and target behaviors due to antidepressant use. A joint record review of the January 2026 through April 2026 MAR did not show Resident 30 was being monitored for adverse side effects and target behaviors related to use of antidepressant. Staff B stated that Resident 30 was not monitored for adverse side effects and/or target behaviors and should have been. MEDICATION ORDERS WITH PARAMETERSRESIDENT 30Review of the physician orders printed on 04/07/2026 showed Resident 30 had orders for metoprolol (medication for high blood pressure [force of blood flowing through the blood vessels) to be given two times a day with an instruction to hold if systolic blood pressure (the top number in a blood pressure reading, representing the pressure in the arteries [blood vessels that carry blood to the organs] when the heart beats) was less than 100 and if pulse was less than 60. Review of the January 2026, February 2026, March 2026 and April 2026 MAR, showed Resident 30 had orders for metoprolol to be given at 8:00 AM and at 4:00 PM. Further review of the January 2026 through April 2026 MAR did not show that the blood pressure and pulse were recorded in the MAR. In an interview and joint record review on 04/16/2026 at 1:56 PM, Staff C stated that they expected staff to follow physician orders with parameters and to document them in the residents' MAR. A joint record review showed Resident 30's MAR from January 2026 through April 2026 had an order for metoprolol to be given at 8:00 AM and at 4:00 PM with instructions to hold the medication if systolic blood pressure was less 100 and if pulse was less than 60. Further review of the MARs showed the blood pressure and pulse were not recorded prior to giving Resident 30's metoprolol. Staff C stated that the metoprolol order did not include spaces to record Resident 30's blood pressure and pulse, and it should have been included in the MAR. In an interview on 04/16/2026 at 4:16 PM, Staff B stated they expected staff to follow doctor's orders with parameters for administration of medications. RESIDENT 13Review of the March 2026 MAR showed that Resident 13 had an order for insulin (medication/hormone that regulates blood sugar levels) Lispro (fast-acting insulin) to be given in the evening with an instruction to hold it if the blood sugar level was less than 150. Further review of the MAR showed insulin were administered when Resident 13's blood sugar was less than 150 on the following dates:- 03/07/2026: blood sugar level of 100- 03/28/2026: blood sugar level of 100- 03/31/2026: blood sugar level of 134 In an interview and joint record review on 04/16/2026 at 1:51 PM, Staff C stated that they expected staff to follow blood sugar parameters as ordered. A joint record review of the March 2026 MAR showed that insulin were given to Resident 13 when their blood sugar level were below 150. Staff C stated that insulin were given and should have been held when Resident 13's blood sugar were below 150. In an interview and joint record review on 04/16/2026 at 4:19 PM, Staff B stated they expected staff to follow physician orders. Staff B stated that a check mark in the MAR meant the medication was administered. A joint record review of the March 2026 MAR showed Resident 13 were given insulin when their blood sugar were below 150. Staff B stated that insulin should have been held. RESIDENT 7 Review of Resident 7's physician order dated 03/13/2026 showed an order for metoprolol two times a day (morning and at bedtime), with an instruction (parameter) to hold it if their systolic blood pressure was less than 110 and the diastolic pressure (the bottom number in a blood pressure reading indicating how much pressure is in the arteries when the heart is filling blood) was less than 60. Review of the March 2026 Electronic Health Record under vital signs for blood pressure and March 2026 MAR showed Resident 7's were administered metoprolol without their blood pressure monitoring at bedtime on the following dates: - 03/23/2026- 03/24/2026 - 03/25/2026 - 03/26/2026 - 03/29/2026 Further review of the March 2026 MAR showed metoprolol were given on the following dates when Resident 7's systolic blood pressure was below 110 and/or their diastolic blood pressure were below 60: - 03/22/2026: 108/69 at bedtime - 03/27/2026: 121/50 in the morning - 03/28/2026: 120/50 in the morning. Review of the April 2026 MAR showed that on 04/05/2026 Resident 7 was administered metoprolol in the morning when their blood pressure was 105/46 and it was given at bedtime when their blood pressure was 106/65. In an interview and joint record review on 04/13/2026 at 2:36 PM, Staff V, Registered Nurse, stated that they were expected to follow physician orders regarding parameters. A joint record review of Resident 7's physician order showed they had an order to take metoprolol twice a day and to hold it if their systolic pressure was less than 110 or their diastolic pressure was less than 60. A joint record review of the March 2026 Electronic Health Record under vital signs for blood pressure and March 2026 MAR showed Resident 7's were administered metoprolol without their blood pressure monitoring and/or when Resident 7's systolic blood pressure was below 110 and their diastolic blood pressure were below 60. Review of the April 2026 MAR showed that on 04/05/2026 Resident 7 was administered metoprolol in the morning when their blood pressure was 105/46 and it was given at bedtime when their blood pressure was 106/65. Staff V stated that Resident 7's blood pressure should have been checked twice or prior to medication administration and that their metoprolol should not have been administered when their blood pressure were low. In an interview and joint record review on 04/15/2026 at 1:44 PM, Staff C stated that staff were expected to follow parameters for blood pressure medication and checked the resident's blood pressure prior to administration of medication. A joint record review of the March 2026 Electronic Health Record under vital signs for blood pressure and March 2026 MAR showed Resident 7's were administered metoprolol without their blood pressure monitoring and/or when Resident 7's systolic blood pressure was below 110 and their diastolic blood pressure were below 60. Review of the April 2026 MAR showed that on 04/05/2026 Resident 7 was administered metoprolol in the morning when their blood pressure was 105/46 and it was given at bedtime when their blood pressure was 106/65. Staff C stated that staff should have checked Resident 7's blood pressure twice a day and should have held Resident 7's medication when their blood pressure readings were below the parameters. During a joint record review and interview on 04/16/2026 at 10:16 AM with Staff B, showed Resident 7's physician order for metoprolol was to be given twice a day and to hold if parameters were less than 110 for systolic and less than 60 for the diastolic. A joint record review of Resident 7's vital signs record, March 2026 and April 2026 MAR, showed the above orders/parameters were not followed. Staff B stated, [Staff] are supposed to check the BP [blood pressure] twice a day and they need to follow physician's order. Reference: (WAC) 388-97-1060 (3)(k)(i)

Based on observation, interview, and record review, the facility failed to ensure drugs were properly labeled and stored in accordance with current accepted professional standards for 3 of 3 medication carts (Medication Cart 3, Medication Cart 4 & Medication Cart 2), and for 1 of 2 medication rooms (Medication room [ROOM NUMBER]), reviewed for medication storage and labeling. These failures placed the residents at risk of receiving compromised and ineffective medications.Findings included .Review of the facility's policy titled, Medication Labeling and Storage, revised in February 2023, showed, Labeling of medications and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceutical practices.Multi-dose vials that have been opened or accessed (e.g. [example] needle punctured) are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial.MEDICATION CART 3 A joint observation and interview on 04/10/2026 at 1:31 PM with Staff I, Licensed Practical Nurse, showed an opened Albuterol Sulfate (used for breathing treatment) inhaler stored in Medication Cart 3. Observation showed the inhaler had a sticker attached Date Opened. Further observation showed the sticker's date opened field was blank and unlabeled. Staff I stated that the Albuterol inhaler should have been labeled when it was opened.MEDICATION CART 4 A joint observation and interview on 04/10/2026 at 3:14 PM with Staff K, Registered Nurse (RN), showed an opened Combivent Respimat (used for breathing treatment) inhaler stored in Medication Cart 4. Further observation showed the inhaler was not labeled with opened date. Staff K stated that the medication did not have an open date.MEDICATION CART 2A joint observation and interview on 04/10/2026 at 3:16 PM, with Staff J, RN, showed the following medications stored in the Medication Cart 2:- Resident 53's insulin (a hormone that helps regulate blood sugar levels) glargine (long-acting insulin) pen had a sticker that was blank/unlabeled (no pen date).- Two amantadine hydrochloride (used for movement disorders) oral solution bottles, the sticker attached to it was blank/unlabeled. - One opened Spiriva Respimat (used for breathing treatment) inhaler, the sticker attached to it was blank/unlabeled.Staff J stated that these medications should have been labeled with open date.MEDICATION room [ROOM NUMBER]A joint observation and interview on 04/10/2026 at 1:59 PM with Staff H, Director of Staff Development, showed there was an open Tuberculin (a solution used for tuberculosis [a contagious bacterial infection that primarily attacks the lungs] test) vial labeled with open date of 02/17/2026 stored in the refrigerator. Staff H stated that the vial was opened on 02/17/2026.Another joint observation and interview on 04/10/2026 at 3:28 PM with Staff J showed that there were two opened, unlabeled Tuberculin vials stored in the medication room [ROOM NUMBER]'s second refrigerator. Staff J stated that the vials were opened and had not been labeled.In an interview on 04/15/2026 at 11:14 AM, Staff B, Director of Nursing, stated that staff were expected to label medications with an open date. Staff B stated that any medication that had a sticker and required an open date must be labeled at the time of opening. Staff B further stated that Tuberculin vials should be labeled with the open date and be discarded within 30 days of opening. Reference: (WAC) 388-97-1300 (2).

Based on observation, interview, and record review, the facility failed to ensure Infection Prevention and Control Program (IPCP) policies and procedures were reviewed annually as required. In addition, the facility failed to ensure hand hygiene was performed after removal of Personal Protective Equipment (PPE - gloves and gown), disinfect shared medical equipment after resident use, ensure proper PPE and/or Enhanced Barrier Precautions [EBP-specialized infection control measures used to prevent the spread of specific infections) were followed for 3 of 8 staff (Staff P, Staff L & Staff M), reviewed for infection control. These failures placed residents, visitors, and staff at an increased risk for infection and related complications. Findings included. Review of the facility's policy titled, Infection Prevention and Control Program, dated 09/18/2023, showed, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. The policy showed, The program is reviewed annually and updated as necessary. The policy further showed that infection prevention included ensuring staff adherence to proper techniques and procedures and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC). IPCP ANNUAL REVIEW Review of the IPCP policies and procedures showed that they have not been reviewed at least annually. The Infection Prevention and Control Program and Antibiotic Stewardship were dated 09/18/2023 and the Water Management Program was dated 06/24/2021 and these policies did not show that they were reviewed annually. In an interview and joint record review on 04/16/2026 at 1:20 PM, Staff B, Director of Nursing, stated that they were not sure when the policies were reviewed. Staff B stated, The corporate does the review of the policies. A joint record review of the IPCP, antibiotic stewardship and the water management program showed they were not reviewed at least annually. Staff B stated that they would follow up with the corporate office, and informed Staff A, Administrator, during the interview. HAND HYGIENE STAFF P Review of the facility's policy titled, Handwashing/ Hand Hygiene, dated 09/18/2023, showed, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy further showed that hand hygiene would be performed after removing personal protective equipment. Observation on 04/15/2026 at 8:08 AM, showed Staff P, Certified Nursing Assistant (CNA), performed hand hygiene, put on a gown and a pair of clean gloves, carried a breakfast meal tray and entered room [ROOM NUMBER] (a TBP [specialized infection control measures used to prevent the spread of specific infections] room). At 8:11 AM, Staff P [already removed their gloves and gown] and exited room [ROOM NUMBER]'s room. Staff P did not perform hand hygiene after removing their PPE. In an interview on 04/15/2026 at 8:21 AM, Staff P stated that they delivered and set up the breakfast tray to the resident in room [ROOM NUMBER]. When asked if they were expected to perform hand hygiene after removing their PPE, Staff P stated, Yes. Staff P further stated, Oh, I missed that [hand hygiene]. No, I did not sanitize my hands. In an interview on 04/15/2026 at 8:27 AM, Staff I, Licensed Practical Nurse, stated that staff were expected to perform hand hygiene after removing their PPE. Staff I further stated, Staff should hand wash or use hand sanitizer. In an interview on 04/16/2026 at 2:57 PM, Staff B stated that they expected staff to perform hand hygiene after removing their PPE. MEDICAL EQUIPMENT CLEANINGSTAFF LReview of the facility's policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, revised in September 2022 showed, Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection and OSHA [Occupational Safety and Health Administration] Bloodborne Pathogens [germs in human blood that can cause disease in humans] Standard. Observation on 04/10/2026 at 7:40 AM, showed that Staff L, Registered Nurse, removed a digital blood pressure cuff from the medication cart and entered Resident 110's room to check the resident's blood pressure and heart rate (vital signs). After checking the resident's vital signs, Staff L left the room, performed hand hygiene, and placed the blood pressure cuff on the medication cart. Further observation showed Staff L stored the cuff in the medication cart drawer without cleaning or disinfecting it after use. In an interview on 04/10/2026 at 8:13 AM, Staff L stated that blood pressure cuffs should be cleaned between resident use. Staff L further stated that they did not clean the blood pressure cuff after using it on Resident 110 and stated that it should have been cleaned. EBPSTAFF MReview of the facility's policy titled, Enhanced Standard/Barrier Precaution, revised on 02/21/2025, showed, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant (to at least one drug in three or more different classes of antimicrobial agents, making infections harder to treat) organisms that employs targeted gown and glove use during high contact resident care activities. The policy showed the facility would make PPE available near or outside of the resident's room. The policy further showed that residents with indwelling urinary catheters (a flexible tube inserted into the bladder to drain urine) would benefit from EBP and changing linens and briefs were considered high contact resident care activities. Review of the order summary report printed on 04/14/2026 showed that Resident 110 had an order for indwelling urinary catheters with an order start date of 04/08/2026. Observation on 04/10/2026 at 9:16 AM, showed that there was no EBP signage or PPE cart available near or outside of Resident 110's room. Observation showed Staff M, CNA, entered Resident 110's room, performed hand hygiene and applied gloves. Further observation showed Staff M provided incontinence care for Resident 110 and changed the resident's bed linens. Staff M did not wear a gown during high contact resident care activity as required. In an interview on 04/10/2026 at 9:34 AM, Staff M stated that residents with indwelling catheters would require EBP, including the use of gown and gloves during incontinence care. Staff M stated that Resident 110 was a new admission, and there was no EBP signage or PPE cart outside the door. Staff M further stated that they should have worn a gown before providing incontinent care. In an interview on 04/15/2026 at 8:26 AM, Staff B stated that staff were expected to clean and sanitize blood pressure cuffs after each use before storing them. Staff B stated that for residents on EBP, an EBP sign would be posted on the door, and a PPE cart would be available. Staff B further stated that gloves and gowns should be worn during high-contact care activities of residents on EBP. Reference: (WAC) 388-97-1320 (1)(a)(c) (5)(c).

Based on observation, interview, and record review, the facility failed to ensure resident was evaluated, and a physician order was obtained for safe administration of medication for 1 of 1 resident (Resident 25), reviewed for self-administration of medication. This failure placed the resident at risk for inaccurate and unsafe medication administration, adverse side effects, and medical complications.Findings included.Review of the facility's policy titled, Self-Administration of Medications, revised in February 2021, showed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy showed that if the resident had been determined to be not safe to self-administer medication, the nursing staff would administer the resident's medications. The policy further showed, Any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party.Review of a face sheet printed on 04/09/2026 showed Resident 25 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure with hypoxia (a long-term condition where the lungs cannot supply enough oxygen to the blood).Review of the physician order printed on 04/10/2026 showed no documentation to indicate that Resident 25 had an order for self-administration of medication.Review of the Medication Self-Administration Evaluation dated 01/29/2026 showed Resident 25 was unable to administer inhalant (through nose and/or mouth) medications with proper procedure. It further showed, Resident is dependent on staff for all [their] cares and medication administration.Review of Resident 25's electronic health records (progress notes and care plans) did not show Resident 25 could keep medication at their bedside.An observation on 04/10/2026 at 7:59 AM showed Resident 25 was receiving nebulization (a process of converting liquid medication into a fine mist or aerosol, allowing it to be inhaled directly into the lungs). Further observation showed an albuterol (brand name-used to relieve breathing difficulties) inhaler with a red chamber (a tube-like device that attaches to a metered-dose inhaler [MDI]) at Resident 25's bedside table.An observation and interview on 04/13/2026 at 7:58 AM showed Resident 25 was using an inhaler with a blue chamber. When asked if they knew how much puff they should take, Resident 25 answered, I don't [do not] know. I just do it many times. Further observation showed an inhaler with a red chamber on Resident 25's bedside table. Both blue and red inhalers label showed, albuterol-sulfate HFA [or Hydrofluoroalkane, a propellant used in inhalers to deliver medication safely to the lungs] and did not show Resident 25's name on both inhalers. When asked, Resident 25 stated, that is my inhaler [red chamber] from home. While talking with Resident 25, Staff E, Registered Nurse, went inside the room and had a concurrent observation of two inhalers on Resident 25's bedside table. Staff E stated, [Resident 25] normally has inhaler at bedside and takes it by [themselves]. When asked about the red inhaler, Staff E stated, it is empty, and proceeded to throw the red inhaler in the garbage bin.During a follow-up interview on 04/13/2026 at 8:14 AM, Staff E stated that they were aware that Resident 25 brought inhalers when they were admitted to the facility. Staff E stated that they had told Resident 25 that they could not have inhalers at their bedside, but that Resident 25 insisted to have them at their bedside. When asked if Resident 25 was allowed to self-administer the inhaler, Staff E responded, I already told [Resident 25] that [they] cannot have it [inhaler] at bedside. Staff E stated that they had called and informed the provider. When asked if they had documented about it, Staff E stated, I don't [do not] remember. Staff E stated that Resident 25's inhaler with a red chamber was their rescue inhaler [fast-acting medication that quickly open airways to relieve sudden breathing difficulties] and that they did not know where the inhaler with a blue chamber came from. Staff E stated that Resident 25 was alert and oriented and that they would ask Resident 25 about the blue inhaler. A concurrent joint observation and interview showed Resident 25 had the blue inhaler at their bedside. When asked, Resident 25 stated that the blue inhaler came from my doctor in the ER [emergency room]. Resident 25 stated that the staff were aware that they keep the inhaler and that staff had seen them using the inhalers. Staff E then stated that they would conduct assessments for residents who self-administer medication and that there should be a doctor's order.In an interview on 04/14/2026 at 4:26 PM, Staff B, Director of Nursing, stated that residents should be assessed for self-medication administration before they were allowed to have medications at their bedside and that there should be a doctor's order. When asked if Resident 25 should have been allowed to keep and self-administer their inhalers, Staff B stated that Resident 25 should have been assessed, have had a doctor's order, provided education, and a care plan.Reference: (WAC) 388-97-0440,1060(3)(I).

Based on interview and record review, the facility failed to transmit the resident Minimum Data Set (MDS-an assessment tool) to the Centers for Medicare & Medicaid Service (CMS) within the required timeframe for 1 of 32 residents (Resident 94), reviewed for resident assessments. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included .Review of the Long-Term Care Facility Resident Assessment Instrument [RAI-instructional guidelines for MDS completion] 3.0 User's Manual Version 1.20.1, revised in October 2025, showed that a discharge (non-comprehensive) MDS must be completed no later than 14 days after the Assessment Reference Date (ARD-look back period), and it must be submitted/transmitted within 14 days of the MDS completion date to the database as required.Review of the facility's policy titled, MDS Completion and Submission Timeframes, revised in October 2023, showed, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes. Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual.Review of Resident 94's discharge MDS dated [DATE] showed that it was completed on 11/07/2025, however, it was not submitted/transmitted to CMS.In an interview and joint record review on 04/15/2026 at 5:45 PM, Staff D, MDS Coordinator, stated that they followed the RAI manual for completion of MDS. Staff D stated that the discharge assessment was to be submitted/transmitted 14 days from completion. A joint record review of Resident 94's discharge MDS dated [DATE] showed that it was completed on 11/07/2025 and was not submitted/transmitted. Staff D stated that Resident 94's discharge MDS should have been submitted/transmitted within 14 days from completion by 11/21/2025.In an interview on 04/16/2026 at 4:57 PM, Staff B, Director of Nursing, stated that they expected MDS assessments to be submitted/transmitted timely.Reference: (WAC) 388-97-1000(5)(e)(ii)(iii).

Based on interview and record review, the facility failed to ensure the Preadmission Screen and Resident Review (PASRR or PASARR) Level II (refers to the evaluation process conducted after a Level I screening indicates a possible serious mental illness or intellectual disability to ensure that individuals receive appropriate care and support based on their specific needs and conditions) was obtained for 2 of 10 residents (Residents 6 & 30), reviewed for PASRR coordination. This failure placed the residents at risk of not receiving the necessary behavioral health services and a diminished quality of life.Findings included .Review of the facility's policy titled, PASRR Completion, revised on 09/30/2024, showed, The Center will make sure that all admissions have the appropriate Patient [Preadmission] Screen and Resident Review (PASRR) completed. The facility will [follow] state-specific guidelines for completion.RESIDENT 6Review of an admission record printed on 04/08/2026 showed Resident 6 had diagnoses that included schizophrenia (a chronic mental disorder with symptoms such as hallucinations [experience involving the apparent perception of something not present], delusions [a false belief, judgment, or perception], cognitive challenges [affects the ability to think, learn, and process information], and anxiety [excessive, persistent and uncontrollable worry and fear about everyday situations] and Post-Traumatic Stress Disorder (PTSD - a mental health condition triggered by a terrifying event that was either experienced or witnessed).Review of a document titled, PASRR Notice of Determination, dated 05/13/2025, showed that Resident 6 had a mental health diagnosis, met the requirements for nursing facility level of care due to current mental health needs, and that Resident 6 may benefit from specialized behavioral health services. Further review of the document showed, The full PASRR [Level II] report will be sent to the nursing facility where you are staying and will become part of your medical record within 30 days.Review of the Electronic Health Record (EHR - miscellaneous/documents tab from 06/19/2024 to 03/28/2026) printed on 04/08/2026 did not show Resident 6's Level II PASRR full report.In an interview and joint record review on 04/15/2026 at 3:07 PM, Staff N, Social Services Director, stated they oversaw PASRRs and that if there were Level II PASRRs they would follow the Level II PASRR recommendations. A joint record review of the PASRR Notice of Determination dated 05/13/2025 showed Resident 6 met requirements for nursing facility level of care and may benefit from specialized services. A joint record review of the miscellaneous/documents tab did not show Resident 6's had a Level II PASRR report. Staff N stated that there was no Level II PASRR report for Resident 6 in their clinical record. Staff N further stated that they should have requested the Level II PASRR report after 30 days of receiving Resident 6's PASRR notice of determination.RESIDENT 30Review of a physicians' orders printed on 04/07/2026 showed Resident 30 had diagnoses that included depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) and anxiety disorder (having excessive/persistent worry and fear).Review of a document titled, PASRR Notice of Determination, dated 04/02/2025, showed that Resident 30 had a mental health diagnosis, met the requirements for nursing facility level of care due to current mental health needs, and that Resident 30 may benefit from specialized behavioral health services. Further review of the document showed, The full PASRR [Level II] report will be sent to the nursing facility where you are staying and will become part of your medical record within 30 days.Review of the EHR (miscellaneous/ documents tab from 04/05/2024 to 04/03/2026) printed on 04/07/2026 did not show Resident 30's Level II PASRR full report.A joint record review and interview on 04/15/2026 at 3:27 PM with Staff N, showed the PASRR Notice of Determination dated 04/02/2025 indicated that Resident 30 met requirements for nursing facility level of care and may benefit from specialized services. A joint record review of the miscellaneous/documents tab did not show Resident 30 had a Level II PASRR report. Staff N stated that there was no Level II PASRR for Resident 30 in their clinical record. Staff N further stated that they should have requested the Level II PASRR report after 30 days of receiving Resident 30's PASRR notice of determination.In an interview on 04/16/2026 at 11:19 AM, Staff A, Administrator, stated they expected staff to follow their PASRR policy and that they expected the facility to follow up/obtain the Level II PASRR reports for Residents 6 and 30.Reference: (WAC) 388-97-1975(8)(10).

Based on interview and record review, the facility failed to ensure a new Level I Preadmission Screening and Resident Review (PASARR or PASRR-an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities [ID]; or related conditions are not inappropriately placed in nursing homes for long-term care) was completed for an exempted hospital discharge resident who remained in the facility for more than 30 days and/or a Level I PASARR was completed accurately for 2 of 10 residents (Residents 99 &19), reviewed for PASARR screening. These failures placed residents at risk of not receiving the appropriate care, limited access to necessary specialized services, and a diminished quality of life.Findings included. Review of the facility's policy titled, PASRR Completion Policy, revised on 09/30/2024, showed, The Center will make sure that all admissions have the appropriate Patient [Preadmission] Assessment and Resident Review (PASRR) completed. The policy further showed that the facility would follow state-specific guidelines for completion. Review of a Level 1 PASRR form, revised in June 2025, showed, Exempted Hospital discharge: .a person may be admitted to a NF [nursing facility] directly from a hospital after receiving acute inpatient care at the hospital; the NF admission is to treat the condition for which the person was hospitalized ; and the person's attending physician, ARNP [Advanced Registered Nurse Practitioner], or physician's assistant certifies that the person requires fewer than 30 days of nursing facility services. RESIDENT 99Review of Resident 99's Level 1 PASARR dated 08/12/2025 showed that Section IA (SMI Indicators) was marked for Post Traumatic Stress Disorder (PTSD-a mental health condition that can develop after a traumatic event), mood disorders (conditions that significantly impact a person's emotional state, leading to prolonged periods of extreme sadness, hopelessness, or irritability), and anxiety. Further review showed that Section IV (Service Needs and Assessor Data), was marked, No level 2 evaluation indicated at this time due to exempted hospital discharge: Level 2 must be completed if scheduled discharge does not occur [after 30 days from admission]. Review of the Electronic Health Records (EHR-miscellaneous/documents tab) showed Resident 99 had no new Level 1 PASRR completed after 30 days of admission and no Level 1 PASARR was sent to the PASRR Coordinator. A joint record review and interview on 04/14/2026 at 11:12 AM with Staff N, Social Services Director, showed Resident 99's Level I PASARR dated 08/12/2025 was marked as exempted hospital discharge [for residents who were expected to be in the facility for less than 30 days]. Staff N stated, I supposed to send out a new PASARR Level I before they exceeded their [residents] 30 day. When asked if Resident 99 stayed in the facility for more than 30 days, Staff N stated, Yes. Staff N further stated that they did not complete a new Level I PASARR for Resident 99. RESIDENT 19Review of the admission record printed on 04/09/2026 showed Resident 19 had a diagnosis of PTSD. Review of Resident 19's Level I PASARRs dated 10/02/2025 and 02/18/2026 did not show PTSD were marked on both forms. Review of Resident 19's trauma questionnaire dated 10/10/2025 showed diagnosis of PTSD. Review of Resident 19's physician history and physical notes dated 11/26/2025 and 02/25/2026 showed diagnosis of PTSD. In an interview and joint record review on 04/14/2026 at 10:26 AM, Staff N stated that they would review Level I PASARR for SMI and need for a Level 2 referral for residents admitted to their facility as part of their process. A joint record review of Resident 19's Level I PASARRs dated 10/02/2025 and 02/18/2026 showed PTSD were not marked. Staff N stated that they were not sure if Resident 19 had PTSD. A joint record review of Resident 19's EHR (face sheet/admission record, trauma questionnaire and progress notes) showed diagnosis of PTSD. When asked if PTSD should have been marked and a new Level I PASARR completed for Resident 19, Staff N stated, Yes. In an interview and joint record review on 04/16/2026 at 8:42 AM, Staff A, Administrator, stated that their process would be to review residents' PASARR upon admission. Staff A stated that they expected staff to complete a Level I PASARR if required. A joint record review of Resident 99's Level I PASARR dated 08/12/2025 showed SMI and exempted hospital discharge were marked. Staff A stated that Resident 99 continued to stay in the facility past 30 days. A joint record review of Resident 19's admission record showed they had PTSD and was not marked in Resident 19's Level I PASARRs dated 10/02/2025 and 02/18/2026. When asked if a new Level I PASARR should have been completed for Resident 99 and Resident 19, Staff A stated, Yes. Reference: (WAC) 388-97-1915(1)(2)(a-c) .

Based on interview and record review, the facility failed to notify the State Pre-admission Screening and Resident Review (PASARR or PASRR-an assessment used to identify people [residents] referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions are not inappropriately placed in nursing facilities for long term care) Coordinator and complete a new Level I PASARR after a significant change in status occurred for 1 of 1 resident (Resident 7), reviewed for PASARR. This failure placed the resident at risk for unmet care needs and a diminished quality of life.Findings included. Review of the facility's policy titled, PASRR Completion Policy, revised on 09/30/2024, showed that the facility would follow state-specific guidelines for completion. Review of the Level I PASRR form revised in June 2025 showed, In the event the resident experiences a significant change in condition.the NF [Nursing Facility] must complete a new PASRR Level 1 and make referrals to the appropriate entities. Review of the admission record printed on 04/09/2026 showed Resident 7 had a diagnosis of major depressive disorder (a mental condition characterized by persistent feelings of sadness and loss of interest). Review of the MDS (Minimum Data Set-an assessment tool) look up page showed Resident 7 had a Significant Change Assessment (SCSA) dated 10/06/2025. Review of the nursing progress note dated 10/03/2025 showed Resident 7 had developed a pressure wound (bedsore) to their right heel and that Resident 7 would benefit from a significant change in condition MDS and was scheduled for 10/06/2025. In a joint record review and interview on 04/14/2026 at 10:59 AM with Staff N, Social Services Director, showed Resident 7 had a SCSA dated 10/06/2025. Staff N stated, I thought only when [residents] have a change in [their] mental condition, that a new Level I PASARR would be completed. When asked if the PASARR Coordinator was notified of Resident 7's significant change in condition through completion of a Level I PASARR, Staff N stated, No. In an interview on 04/16/2026 at 8:48 AM, Staff A, Administrator, stated that they expected staff to complete a new Level I PASARR for residents who had a significant change in condition and notify the PASARR Coordinator. Reference: (WAC) 388-97-1975(7).

Based on interview and record review, the facility failed to develop and/or implement a care plan for 2 of 26 residents (Residents 1 & 19), reviewed for comprehensive care plans. The failure to develop and/or implement care plans for psychotropic (medications that change how the brain works to affect mood, thoughts, feelings, or behavior) and Post Traumatic Stress Disorder (PTSD - a mental health condition that can develop after a traumatic event) placed the residents at risk for unmet care needs and a diminished quality of life.Findings included. Review of the facility's policy titled, Care Plans Comprehensive, dated 08/25/2021, showed, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, physical, mental and psychosocial needs shall be developed for each resident. RESIDENT 1Review of the admission Minimum Date Set (MDS-an assessment tool) dated 02/09/2026 showed Resident 1 was receiving an antidepressant (a psychotropic drug that relieves symptoms of depression) during the assessment period. Further review of the MDS's care area assessment showed that Resident 1's psychotropic drug use would be addressed in their care plan. Review of the February 2026, March 2026, and April 2026 Medication Administration Record showed Resident 1 was receiving Mirtazapine (an antidepressant) medication. Review of Resident 1's comprehensive care plan printed on 04/13/2026 showed that no care plan developed for Resident 1's psychotropic (Mirtazapine) use. In an interview and joint record review on 04/15/2026 at 1:43 PM, Staff C, Assistant Director of Nursing, stated that if a resident placed on an antidepressant medication, a comprehensive care plan would be developed. A joint record review of Resident 1's comprehensive care plan printed on 04/13/2026 showed there was no care plan developed for Resident 1's antidepressant medication. Staff C stated that there was no care plan initiated for Resident 1's antidepressant medication. In an interview on 04/16/2026 at 9:15 AM, Staff B, Director of Nursing, stated that they expected that care plan was initiated for psychotropic medication use. RESIDENT 19 Review of the admission record printed on 04/09/2026 showed Resident 19 was admitted to the facility on [DATE] with diagnosis that included PTSD. Review of Resident 19's quarterly MDS dated [DATE] showed PTSD was marked. Review of the progress note dated 03/23/2026 showed Resident 19 had diagnosis of PTSD. Review of Resident 19's comprehensive care plan printed on 04/10/2026 did not include plan of care for PTSD. In an interview on 04/14/2026 at 8:33 AM, Resident 19 stated that they were diagnosed with PTSD. Resident 19 stated that they got visits from doctors and taking medications related to their PTSD. A joint record review and interview on 04/15/2026 at 2:36 PM with Staff C did not show Resident 19 had a care plan to address their PTSD. Staff C stated, If [Resident 19] has PTSD, it should have been included in their [comprehensive] care plan. A joint record review and interview on 04/16/2026 at 10:03 AM with Staff B did not show Resident 19 had a care plan to address their PTSD. A joint record review of Resident 19's admission record showed diagnosis of PTSD. Staff B further stated that Resident 19 should have had a PTSD care plan. Reference: (WAC) 388-97-1020(1)

Based on observation, interview, and record review, the facility failed to ensure timely dental services was provided for 1 of 3 residents (Resident 1), reviewed for dental care and services. This failure caused harm to Resident 1 who experienced dental pain when food contacted their teeth or gums, and weight loss. The failure to provide timely dental services placed other residents at risk for dental pain, decline in nutritional status, and a diminished quality of life. Findings included . Review of the quarterly Minimum Data Set assessment (MDS - an assessment tool) dated 01/24/2024 showed the resident readmitted to the facility on [DATE]. The MDS assessment showed the resident had intact memory. On 02/06/2024 at 2:42 PM, Resident 1 stated, I don't have any teeth and when the food hits my gums it hurts, so I don't eat very much because I can't. I drink the milk shakes to keep from losing too much weight, it's not as bad as when I try to chew food. I just need some dentures, even soft foods hurt to chew. I was supposed to get dentures a long time ago. I don't know what happened. Observation on 02/06/2024 at 2:47 PM, showed Resident 1 had missing teeth in the front of their mouth and had dark brown teeth that were embedded in their gums in the back of their mouth. Observation on 02/28/2024 at 1: 41 PM, showed a meal tray that had a piece uncut meatloaf and white mashed potatoes. Resident 1 stated, I can't eat the meat loaf, but I tried to eat a little bit of the mashed potatoes. Review of a dental form dated 11/08/2023, showed Resident 1 was seen by a dentist in the facility. The form noted that Resident 1 had decayed (cavities) loose, missing, and broken teeth, and it documented that Resident 1 stated, their teeth hurt when they eat and would like dentures. Further review of the form showed a referral for x-rays (photographic images), evaluation, extraction of all upper and lower teeth, and for upper and lower dentures. Review of the weight record dated 11/02/2023, showed Resident 1's weight was 108.6 pounds; on 02/01/2024, the resident's weight was 100.4 pounds, and on 02/20/2024, the resident's weight was 99.6 pounds. Review of an Interdisciplinary Team (IDT) note dated 02/21/2024, showed Resident 1 had their food cut up at meals, usually consumed 25-50 percent of meals and received health shakes three times a day. The IDT note showed Resident 1 had a significant weight loss of 8.3 percent in the last two months, and usually drank 100 percent of supplements (health shakes). The IDT consisted of Staff B, Assistant Director of Nursing, Staff C, Resident Care Manager, and Staff D, Registered Dietician, when this note was documented in the electronic medical record on 02/21/2024. On 02/28/2024 at 4:26 PM, Staff B Registered Nurse, stated the dentist would give the completed referral form to nursing or to the social services department, and then the nursing or social services would follow-up on the referral, and make the necessary appointments. At that time, Staff B was not able to find documented follow-up or appointments for the referrals made by the dentist on 11/08/2023 for x-rays, evaluations, teeth extractions and/or dentures for Resident 1. On 02/28/2024 at 4:46 PM, Staff A, Administrator, stated the dentist would give the referral forms to the social services or the nursing department to follow up on, and the expectation was for the referrals to be followed up on and the information should be placed in the electronic medical record. Staff B further stated that the referral for Resident 1 should have been followed up on and placed in the electronic medical record. Reference: (WAC) 388-97-1060 (3)(vii)

Based on interview and record review, the facility failed to provide adequate supervision and implement the care plan for 1 of 3 residents (Resident 1) reviewed for avoidable accidents and supervision. Additionally, the facility failed to develop written policies and procedures related to the use of Motorized Wheelchairs (MW) and conduct a comprehensive assessment to ensure that residents were safe to operate a MW for 13 of 13 residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 & 14) reviewed for devices. These failures caused serious injury and serious harm to Resident 1 who sustained a [CONDITION(S)] and was hospitalized related to a MW incident with Resident 2. The facility's lack of policies and an effective system in ensuring that residents were assessed prior to the use of a MW increased the likelihood of serious injuries and serious harm to the residents of the facility. The facility also failed to provide adequate supervision and implement written policies and procedures related to elopement and initiate timely/appropriate interventions to minimize the risk of elopement incident for 3 of 4 residents (Residents 1, 15 & 16) reviewed for elopement. These failures resulted to an actual elopement incident of Resident 1 who was found at the facility's parking lot alone and unsupervised by staff for an unknown duration, placing the resident at risk for harm/injury. The facility's failure to provide adequate supervision to high-risk residents and the lack of an effective system to ensure that residents were safe prior to the use of a MW constituted a situation of an Immediate Jeopardy (IJ) on 09/09/2022. The facility was notified of the IJ on 09/09/2022 at 1:00 PM. An onsite survey was conducted on 09/12/2022 and verified the removal of the IJ related to CFR 483.25 - F689 - Free of Accident Hazards/Supervision/Devices. The remaining noncompliance was found to be an isolated deficiency that constitute actual harm to the resident [Resident 1] that was not an IJ. Findings included . FAILURE TO PROVIDE ADEQUATE SUPERVISION and RESIDENT TO RESIDENT INCIDENT Resident 1 was a long-term care resident of the facility. The resident's diagnoses list included dementia (memory problem), [CONDITION(S)] (extreme mood swings) and anxiety disorder. A review of Resident 1's annual Minimum Data Set (MDS) assessment dated [DATE] showed the resident had impaired cognition and required one person staff assistance with activities of daily living (ADL's). A review of Resident 1's care plan dated 08/25/2022 showed that Resident 1 was a high risk for elopement and unsafe wandering due to increase confusion and history of attempting to leave the facility without staff supervision. The care plan directed the facility staff to observe the resident frequently while ambulating in the hallway and to provide redirection when needed. A review of the facility's incident reporting log for September 2022 showed that on 09/06/2022 at 5:00 PM, Resident 1 was involved in a resident-to-resident altercation with Resident 2 that resulted to a fall incident with substantial injury ([CONDITION(S)]) to Resident 1. The incident log showed that Resident 1 required medical treatment and was admitted the hospital because of the incident. On 09/08/2022 at 11:30 AM, Staff A, Administrator, Staff B, Director of Nursing, and Staff C, Nurse Consultant, confirmed and stated that Resident 1 and Resident 2 had an altercation on 09/06/2022. Staff C stated that Resident 1 sustained a left [CONDITION(S)] from the incident that required surgery. Both Staff B and Staff C stated the resident had substantiated physical abuse due to Resident 2's intent to harm Resident 1 with the use of his MW. According to Staff A, Staff B, and Staff C, the incident between Resident 1 and Resident 2 was witnessed by a staff member [Staff D, Nursing Assistant Certified] who tried to separate the residents and had asked Resident 2 to move his MW backwards but instead run through Resident 1 that resulted in a fall. However, both Staff B and Staff C stated that there was no staff member present to supervise and provide redirection to Resident 1 prior to the altercation as directed by Resident 1's care plan. On 09/08/2022 at 2:00 PM, Staff D stated she witnessed the incident between Resident 1 and Resident 2. Staff D stated that she was on a resident room providing resident care when she heard a loud banging noise in the hallway. When she responded, she saw Resident 2 already screaming and telling Resident 1 to move out of his way, so she immediately intervened. Staff D stated she only saw Resident 1 hitting the wall with his walker but Resident 2 claimed that he was hit by Resident 1 using his walker and would not move out of his way. According to Staff D, she had asked Resident 2 to move his MW backward instead so he can maneuver and drive away from Resident 1 but instead, Resident 2 forced his way through towards Resident 1 causing Resident 1 to fall on to the ground. Staff D stated that there was no other staff member present when the incident happened, so she called for help, and that's when Staff E, Licensed Practical Nurse, and other staff members came to the scene to assist Resident 1 on the floor. Staff D further stated that the impact to Resident 1 was so strong that when he landed on the ground, he was not able to move and complained of severe pain to his hip and back area. On 09/08/2022 at 2:30 PM, Staff E stated during a phone interview that he was the nurse on duty on 09/06/2022 when the incident between Resident 1 and Resident 2 happened. Staff E stated they did not witness the incident and by the time he arrived, Resident 1 was already on the floor. Staff E stated he was busy providing care to other residents when the incident happened and did not notice either Resident 1 and/or Resident 2 prior to the incident. On 09/08/2022 at 2:45 PM, Resident 2 stated that Resident 1 was on his way and would not move even after telling him More than 5 times to get out of my way. Resident 2 also stated that Resident 1 would not only wander in the hallways and to other resident rooms but also was angry and agitated at times. According to Resident 2, Resident 1 was agitated at the time of the incident and when he asked for him to move, he started hitting him with his walker, so he had no choice but to defend himself. Resident 2 stated he was very angry, upset, and at the same time helpless and worried about his safety so he could have lost control of his MW and run through Resident 1. Resident 2 further stated that the incident could have been avoided if staff had intervened and redirected Resident 1 away from him because he was very confused and a very angry man. On 09/08/2022 at 3:10 PM, Staff A, Staff B, and Staff C stated that Resident 1 was care planned to be redirected frequently by staff while ambulating in the hallway but was not able to provide an explanation as to why no staff member was present to provide supervision and/or redirection to Resident 1 while he was ambulating in the hallway and prior to getting too close to Resident 2. According to Staff C, the other staff on duty could have been providing care to other residents at the facility and was not aware of Resident 1's whereabouts prior to the incident. A review of the hospital record dated 09/07/2022 showed that Resident 1 was admitted to the hospital with a left [CONDITION(S)] that required an operation to repair the fracture. LACK OF AN EFFECTIVE SYSTEM AND POLICY RELATED TO THE USE OF MW A review of Resident 2's clinical records including nursing progress notes, medical diagnoses and care plans dated 04/07/2022 with a revision date of 06/20/2022 showed that Resident 2 had always expressed frustrations towards others, was always irritable approximately 60% of the time and had history of physical aggressions towards other residents and/or staff. A review of Resident 2's most recent MW assessment dated [DATE] showed that the resident was physically able to operate the MW independently. However, the assessment only assessed Resident 2's physical ability and did not have any information whether the facility had assessed and/or considered Resident 2's safety use of MW related to aggressive behaviors towards others. On 09/08/2022 at 3:25 PM, Staff A stated that Resident 2's MW evaluation did not include an assessment regarding his mental health conditions and/or current behavioral concerns. According to Staff A, the facility did not have a policy regarding the use of MWs prior to the incident between Resident 1 and Resident 2. Staff A stated that the facility was currently working on re-assessing and re-evaluating current residents on MW's (including Resident 2) to ensure that each resident on MW were not just assessed physically but also mentally and that behaviors and other mental health conditions were reviewed and considered to ensure the safety of not just the resident operating the MW but also the residents around them. A review of the facility's list of current residents using MWs showed that all 13 of 13 residents (Residents 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 & 14) that were using MW's did not have a current comprehensive assessment that included information whether the resident's current mental health and/or behavioral issues/concerns were reviewed and/or considered to determine the residents safety to operate the MW and the safety of other residents around them. Three residents' (Residents 3, 4 & 5) clinical records including nursing progress notes, care plans and documented behaviors from 01/01/2021 to 09/09/2022 showed that each resident had a significant mental health condition and/or current behaviors that increased the risk of unsafe operation and use of MW's. Resident 3, Resident 4, and Resident 5 had documented history of behaviors and accidents/incidents involving the use of MW's. Resident 3's nursing progress notes and therapy evaluation dated 06/18/2021 showed that Resident 3 had a history of running over and hitting other residents using her MW on purpose. Resident 4's nursing progress notes and care plan dated 08/01/2021 showed that Resident 4 had a history of increased agitation towards others and had a documented behavior of traumatic attention seeking behavior that included driving his MW at a very high speed. Resident 5's clinical records including nursing progress notes and care plan dated 04/01/2022 and 05/01/2022 showed the resident had history of angry outburst and threatening behaviors towards other residents, poor impulse control, and history of several resident-to-resident altercations in the past. On 09/09/2022 at 10:45 AM, Staff A, Staff B, Staff C, and Staff G, Physical Therapy Consultant, they all stated that the facility did not have a system and policy for the use of MWs prior to the incident between Resident 1 and Resident 2. Staff C stated that the facility was working on completing comprehensive assessments for each resident on MWs including Resident 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 & 14. Both Staff A and Staff C stated and acknowledged the increased risk of accidents/incidents including the likelihood of serious harm and serious injury related to the use of MWs for those residents (and the residents around them) without a current MW assessment. ELOPEMENT INCIDENT A review of the facility's elopement policy dated 03/22/2022 showed that residents will be evaluated for elopement risk upon admission, re-admission, quarterly, and with a change in condition. The policy directed the facility staff to develop an interdisciplinary elopement prevention and person-centered care plan for those residents identified to be at high risk for elopement to minimize the risk of elopement incident. A review of the facility's incident reporting log for August 2022 showed that Resident 1 had an elopement incident on 08/25/2022. The incident log showed that Resident 1 was found outside the facility near the facility's parking lot. A review of the incident investigation report summary dated 08/25/2022 showed that on 08/25/2022 at 8:28 AM, Resident 1 was found by a staff member [Staff F, Registered Nurse] outside the facility in the parking lot heading towards the street. The incident report showed that Staff F immediately intervened and assisted the resident back to the facility. On 09/09/2022 at 11:30 AM, Staff F stated that the elopement incident of Resident 1 happened on 08/25/2022 at approximately 6:00 PM and not 8:28 AM. Staff F stated that she was on her way home when she saw Resident 1 in the parking lot alone. According to Staff F, she immediately helped and assessed the resident back to the facility and notified the nurse on duty, including the physician, Staff A, and Staff B. According to Staff F, she was not sure who was assigned to watch and supervise the resident at the time of the incident, and she was not sure why Resident 1 manage to leave the facility without any staff knowledge. Staff F further stated that Resident 1 was a high risk for elopement since admission to the facility due to his dementia, poor memory/cognition, and his ability to ambulate independently without staff assistance. A review of Resident 1's clinical records including nursing progress notes and care plans from 01/01/2022 to 09/09/2022 showed the facility did not initiate appropriate timely interventions to minimize the risk of elopement for Resident 1. Additionally, there was no elopement care plan developed prior to the elopement incident on 08/25/2022. On 09/09/2022 at 11:00 AM, Staff B and Staff C stated the facility did not consider Resident 1 to be at high risk for elopement prior to the incident on 08/25/2022 because Resident 1 had not attempted to leave the facility in the past. However, Staff C stated that Resident 1 had dementia and had been wandering throughout the facility [cognitively impaired and independently mobile] increasing his risk of elopement. Additionally, both Staff B and Staff C were not able to provide important details of the elopement incident, including who were the staff that were supposed to supervise and/or assigned to care for Resident 1 at the time of the incident. Both Staff B and Staff C stated they did not know when the last time was a staff person provided care to Resident 1 or had seen Resident 1 prior to the elopement incident. According to Staff B, she also made a mistake with the investigation because the elopement incident happened on 08/25/2022 at approximately 6:00 PM and not at 8:28 AM as listed on the investigation summary report. Staff B and Staff C were not able to provide an answer on how long Resident 1 was outside the facility without any staff supervision and what the resident was doing prior to the elopement incident. On 09/09/2022 at 11:30 AM, Staff A stated that Resident 1 was a high risk for elopement and should have been care planned with preventative measures including the need for increased supervision and/or the use of a wander guard alert system to minimize the risk of elopement. Staff A also stated that the incident investigation for Resident 1 would be re-investigated to ensure that all pertinent information was included and that the root cause of the elopement incident would be addressed with appropriate interventions. Similar findings were applicable to Resident 15 and 16. RESIDENT 15 Resident 15 was a long-term care resident of the facility. The resident's diagnoses list included [CONDITION(S)] disorder (mental and mood disorder). A review of Resident 15's quarterly MDS assessment dated [DATE] showed the resident had impaired cognition and needed supervision with ambulation. On 09/08/2022 at 10:30 AM, 09/09/2022 at 8:30 AM, and 09/09/2022 at 12:45 PM, Resident 15 was observed wandering at the nurse's station, activities area, unit's 200, 300 and 400 hallways, up to the front reception area close to the entrance/exit doors without staff supervision. A review of Resident 15's elopement assessment dated [DATE] showed the resident was a high risk for elopement due to his current medical conditions and prior history of elopement. The clinical records showed no recent elopement risk assessment completed for Resident 15 as directed by the facility' elopement policy. RESIDENT 16 Resident 16 was a long-term care resident at the facility. The resident's diagnoses list included Alzheimer's disease (memory problem). A review of Resident 16's quarterly MDS assessment dated [DATE] showed the resident had impaired cognition and needed supervision with locomotion (moving from one place to another) on and off the unit. On 09/08/2022 at 10:15 AM, 09/09/2022 at 8:25 AM, and 09/09/2022 at 12:50 PM, Resident 16 was observed wandering at the nurse's station, unit's 200, 300 (near exit doors) and 400 hallways, up to the front reception area without staff supervision. A review of Resident 16's elopement assessment dated [DATE] showed the resident was a high risk for elopement due to his current medical conditions and prior history of elopement. The clinical records showed no recent elopement risk assessment completed for Resident 16 as directed by the facility' elopement policy. On 09/09/2022 at 11:45 AM, Staff A, Staff B, and Staff C stated they were not aware that Resident 15 and Resident 16 did not have current elopement assessments and that both residents remained high risks for elopement due to their current conditions and history of elopement in the past. Reference: (WAC) 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to prevent physical abuse for 1 of 3 residents (Resident 1) reviewed for abuse and neglect. As a result of this failure, Resident 1 suffered physical injury, pain, and experienced psychosocial harm including refusal to take her medications, not wanting and/or refusing to eat, and it affected her sleep and mood. Findings included . The Code of Federal Regulations (CFR) define abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated October 2015, Abuse is the willful action or inaction that inflicts injury, unreasonable confinement, intimidation, or punishment on a vulnerable adult. Resident 1 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 1's quarterly Minimum Data Set (MDS) assessment dated [DATE] showed the resident had mild cognitive impairment and needed two-person extensive assistance for bed mobility and transfer. Review of the facility's August 2022 incident reporting log (IRL) showed Resident 1 was involved in a resident-to-resident altercation with another resident (Resident 2) on 08/01/2022. The IRL showed that the incident had resulted injuries to both Resident 1 and Resident 2. On 08/07/2022 at 10:30 AM, Resident 1 stated she was able to recall the physical altercation incident in detail. Resident 1 stated that Resident 2 rushed towards her at the smoking area and started hitting her and slapping her on the face. Resident 1 stated, this assault was witnessed by other residents who were also shocked why Resident 2 was being physical aggressive towards her. Resident 1 also stated she was hit on the face several times and her back area when she tried to leave the scene. According to Resident 1, she tried to defend herself and cover her face but was not able to because the left side of her body was paralyzed. Resident 1 stated she felt unsafe and did not feel comfortable around Resident 2. Resident 1 stated her face and back area were sore from the incident and that Resident 2's assault left red marks on her cheek. Resident 1 also stated that she was hurt and was treated badly and repeatedly by this resident (Resident 2) in the past. Resident 1 further stated that the incident affected her mood negatively, had affected her sleep and was not able to eat even days after the incident. Resident 1 stated, I am still mad and angry about the situation and wanted to get even with Resident 2. A review of Resident 1's clinical records including meal monitors and nursing/social services notes from 08/01/2022 to 08/03/2022 showed that Resident 1 sustained physical injuries (redness to the face/cheeks area) and exhibited probable signs of psychosocial harm related to the physical altercation incident in the form of refusal to take her medications and not wanting and/or refusal to eat. A review of the facility incident investigation report dated 08/01/2022 showed that the incident between Resident 1 and Resident 2 was witnessed by another resident (Resident 3). The incident report also showed that Resident 3 was trying to intervene and stop Resident 2 from hitting Resident 1, but Resident 2 also turned to Resident 3 and started hitting Resident 3 with a walker. A review of the written statement provided by Resident 3 dated 08/01/2022 showed Resident 2 came out with the intent to start a fight. She (Resident 2) started ramming Resident 1 with her walker. Resident 1 was being slapped in the face and the head area. Resident 1 tried to hold up arm in defense. Then she (Resident 2) rammed me with her walker when I tried to intervene. The statement went on and showed, She (Resident 2) continued to verbally abuse Resident 1 by calling her a fat w****. These even transpired over 20 minutes. On 08/17/2022 at 11:05 AM, Resident 2 stated she remembered having a physical altercation with Resident 1. Resident 2 stated Resident 1 and another resident (could not recall who) were taking a long time to smoke so she confronted them about it. According to Resident 2, she decided to take matters into her own hands when Resident 1 did not listen to her, so she hit and slapped her on the face. Resident 2 added, she deserves what she got and I'm not sorry. Resident 2 showed the scratch that she sustained on her face (left side) related to the incident. Resident 2 reported pain to the area when it was newer but denied any pain during the interview. A review of Resident 2's quarterly MDS assessment dated [DATE] showed that Resident 2 had intact cognition and was independent with locomotion (moving to one place to another) on and off the unit. A review of Resident 2's clinical records including nursing/social services notes from 08/01/2022 to 08/03/2022 showed that Resident 2 sustained physical injuries (scratch to the left side of the face/cheeks area) and exhibited probable signs of psychosocial harm related to the physical altercation incident in the form of withdrawal and attention seeking behaviors. On 08/17/202 at 11:35 AM, Resident 3 stated that Resident 2 came out to the smoking area to start a fight and assaulted Resident 1. Resident 3 stated that Resident 2 started slapping Resident 1 on the face and head, and even her when she tried to intervene. According to Resident 3, Resident 1 was defenseless because she could not use her arm and only tried to cover her face. Resident 1's face was so red because she was slapped and hit several times. When I tried to stop Resident 2, she then turned on me and started hitting me with her walker. Resident 3 further stated that there was a staff member that came right away to intervene but even after that, Resident 2 still called Resident 1 all kind of names, such as B**** and Fat w****. On 08/17/2022 at 1:00 PM, both Staff A, Administrator and Staff B, Interim Director of Nursing stated and confirmed the physical and verbal altercation between Resident 1 and Resident 2 that happened on 08/01/2022 at around 2:00 PM. Both Staff A and Staff B stated that both residents had sustained and documented injuries from the incident and acknowledged that they should have scheduled their smoking time differently to separate them and that the facility had revised both the resident's care plans (including smoking care plan) to minimize the risk of the reoccurrence of the incident. Reference: (WAC) 388-97-0640 (1)

Based on observation, interview and record review, the facility failed to provide adequate supervision for both residents and staff when staff did not implement the care plans for 3 of 4 residents (Residents 1, 2 and 3) reviewed for avoidable accidents and falls. Failure to provide adequate supervision of staff as determined by assessing the appropriate level and number of staff required, the competency and training of the staff, and the frequency of supervision as determined by the individual resident's assessed needs and identified hazards resulted in harm to Resident 1 and 2 and placed the other residents at risk for harm and injury. The facility's failure to provide the required supervision and care based on the residents' specific care plans and care directives, constituted a situation of an Immediate Jeopardy (IJ) and increased the likelihood of serious injury, impairment and/or death for Residents 1, 2 and 3. The facility was notifed of the IJ on [DATE] at 6:35 PM. An acceptable written removal plan related to the IJ was received from the facility on [DATE]. An onsite survey was conducted on [DATE] to verify the removal of the immediacy related to the Immediate Jeopardy (IJ) on to CFR 483.25 - F689 - Free of Accident Hazards/Supervision/Devices. However, the facility failed to remove the immediacy by not following and implementing the written removal plan. A second and updated removal plan was received form the facility on [DATE]. An onsite survey was conducted on [DATE] to verify the removal of the immediacy. The facility removed the immediacy on [DATE] by assessing the residents for safety, transfer status and falls and by re-educating and re-training staff about following the resident care plans. Findings included . RESIDENT 2 Resident 2 was a long-term resident of the facility. The resident's diagnoses list included stroke with right sided weakness and dementia (memory problem). A review of Resident 2's quarterly Minimum Data Set (MDS) assessment, dated [DATE], showed the resident had impaired cognition and needed two person staff assistance with bed mobility and transfers. A review of Resident 2's care plan, dated [DATE] and revised on [DATE], showed the resident required assistance with activities of daily living (ADLs) due to impaired mobility and stroke. The care plan directed facility staff to provide two-person extensive assistance with bed mobility and incontinent care. A review of the facility's incident investigation report, dated [DATE], showed Resident 2 had a fall on [DATE] at approximately 12:15 PM. The incident investigation report showed the incident happened during resident care when Staff I, Nursing Assistant Certified, NAC was providing incontinent care and brief change alone, without a second staff person as directed by the resident's care plan. On [DATE] at 4:30 PM, Staff B, Director of Nursing, DNS stated she had interviewed Staff I regarding the incident. Staff B said Staff I told her that she [Staff I] did not read or review Resident 2's care plan before providing the care and [Staff I] was not aware that Resident 2 required 2-person care for bed mobility or when providing incontinent care. Staff B requested that Staff I write a statement regarding the incident. A review of the written statement, dated [DATE], showed Staff I was changing Resident 2 and asked the resident to roll on his right side (which was the resident's weak side). Staff I documented, He [Resident 2] did, but kept rolling. He went off the edge of the bed landing on his knees facing his nightstand. He then rolled to his back [while on the floor]. On [DATE] at 10:30 AM, Staff I stated that she should have reviewed Resident 2's care plan before providing care to ensure the resident's safety. Staff I also stated that she usually worked with Resident 2 and had become familiar with his care, so she did not bother reading and looking at the care plan. According to Staff I, every time she worked and provided care to Resident 2, she always did it alone and independently for a while now. Staff I further stated, I should have not asked Resident 2 to roll on his right side because he kept rolling and fell out of bed. Staff I stated, We were lucky because he could have died and got seriously injured because of this incident. On [DATE] at 4:30 PM, Resident 2 stated his left knee was hurting and he was in pain. Resident 2 showed his left knee area that had two abrasions which both measured approximately 1 centimeter (cm) in length and 1 cm wide. Resident 2 reported soreness and pain to the area rated at 7 out of 10 pain scale (0 being no pain and 10 being the worst pain). Resident 2 was also trying to demonstrate using hand gestures how he rolled out of bed and how he hit the ground hard. Resident 2 was rubbing and massaging his left knee area during the interview. On [DATE] at 4:45 PM, Staff V, Registered Nurse stated he was the shift nurse on duty for Resident 2 and was not aware of the resident's injuries to the left knee area and pain concerns. A joint record review of Resident 2's clinical record showed no documented evidence that the facility had comprehensively assessed, monitored and treated Resident 2's knee abrasions and pain related to the fall incident on [DATE]. There was no documented evidence that the facility had notified the physician of these injuries and what actions were taken to address the resident's injuries and pain. On [DATE] at 5:00 PM, Staff V assessed Resident 2's left knee and identified 2 abrasions measured each at approximately 1 centimeter (cm) in length and 1 centimeter wide. Resident 2 also reported pain to the left knee upon palpation by Staff V. Staff V stated he was not aware of those injuries and that there was no report given to him when he started the shift this afternoon. On [DATE] at 5:15 PM, Staff B, DNS stated the incident involving Resident 2 was avoidable and could have been prevented if Staff I, NAC had read and followed the resident's care plan. Staff B also stated she was not aware of the injuries that Resident 2 had sustained as a result of the incident, but she was glad that the resident was not seriously injured because the incident was very serious and could have resulted in serious injury, impairment or even death. RESIDENT 3 Resident 3 was a long-term resident of the facility. The resident's diagnoses list included stroke with left sided weakness. A review of Resident 3's quarterly MDS assessment, dated [DATE], showed the resident had mild cognitive impairment and needed two person staff assistance with bed mobility and transfers. A review of Resident 3's care plan, dated [DATE] and revised on [DATE], showed the resident required assistance with ADLs due to impaired mobility, stroke and obesity. The care plan directed facility staff to provide two-person extensive assistance with transfers. A review of the facility's incident investigation report, dated [DATE], showed the resident had a fall on [DATE] at 10:35 PM. The incident report showed Staff K, NAC transferred Resident 3 from the wheelchair to the bed without the assistance of a second staff person as directed by the resident's care plan. The incident report documented, The resident [Resident 3] lost grip of her left leg and I slowly guided her to the floor. On [DATE] at 11:00 AM, Resident 3 stated she could recall the incident on [DATE] because she was frightened and scared during the transfer. Resident 3 stated she was transferred by a new NAC (Staff K) and she doesn't know what she was doing. According to Resident 3, she told Staff K that she needed a second person to transfer her for safety, but she did not listen and proceeded with the task. Resident 3 further stated she was scared, but at the same time she was glad that she did not hit her head hard or break any bone. On [DATE] at 2:30 PM, Staff K, NAC stated she was a new employee and did not know that Resident 3 required two staff people during care and transfers. Staff K stated she was not aware of the care plan or the kardex (care directives) and she does not know where to locate them. According to Staff K, she did not receive any training or education related to the care plan and was just observing what other NACs had done. On [DATE] at 5:15 PM, Staff B, DNS stated the incident involving Resident 3 was avoidable and could have been prevented if Staff K, NAC had read and followed the resident's care plan. However, Staff B also stated she was not aware that Staff K did not receive any training related to the care plan and the kardex. According to Staff B, Staff K should have been trained first on what the care plan and kardex were, where to locate and how to access them before she was allowed to work independently on the floor. Staff B stated she was glad that the resident was not seriously injured because the incident was serious and could have resulted in serious injury, impairment or even death. On [DATE] at 5:30 PM, Both Staff B, DNS and Staff N, Licensed Practical Nurse/Staff Development Coordinator (LPN/SDC) stated the facility had no current process or system to train new employees (including Staff K, NAC) about the importance of reading and understanding each resident's care plan, including how to locate and access them to ensure an effective and safe delivery of care. Both Staff B and Staff N stated that the facility's lack of an effective system to educate and train staff about care plans and kardex, including the lack of supervision that resulted to accidents does require immediate actions, had placed the residents at risk for the likelihood of serious injuries, serious impairments and/or potentially death from avoidable accidents like falls. RESIDENT 1 Resident 1 was a long-term resident of the facility. Resident 1's diagnoses list included left sided paralysis, [CONDITION(S)] (bone degeneration with pain and stiffness) of the hip, and muscle contractures. A review of Resident 1's quarterly Minimum Data Set (MDS) assessment, dated [DATE], showed Resident 1 had intact cognition and needed two-person physical assistance with bed mobility and transfer. A review of Resident 1's care plan, dated [DATE] and revised on [DATE], showed the resident required assistance with ADLs due to generalized weakness and impaired mobility. The care plan directed facility staff to provide two-person extensive assistance with bed mobility and transfers. The care plan also showed that Resident 1 preferred male caregivers when available. A review of the facility's incident investigation report, dated [DATE], showed Resident 1 had made an allegation of physical abuse against Staff T, NAC. The incident investigation showed Staff T did not follow Resident 1's care plan to have a second staff person when providing care. The incident report and supporting documentation, including staff witness statements and social services follow-up visits/notes, showed Resident 1 suffered psychosocial harm as the result of the incident. On [DATE] at 11:00 AM, Resident 1 stated that Staff T, NAC came into her room to provide personal hygiene care on [DATE]. Resident 1 stated she told Staff T that she needed two-person care due to her physical limitations and had informed Staff T about her left sided weakness, pain and to not turn her on the left side. According to Resident 1, Staff T ignored her and provided the care as she wishes and treated me like dead meat. According to Resident 1, Staff T scared the hell out of her as Staff T flipped her in bed,and shoved and pushed her on the left side while she was pleading and begging for mercy. Resident 1 further stated that she had serious pain during the care, and felt unsafe and felt fear, intimidation and abused by Staff T. During the interview, Resident 1 was tearful and asked please help me and do not let Staff T, NAC come back here. Resident 1 stated she did not feel safe to be around Staff T and she was concerned that Staff T will hurt her again if she came back to the facility. According to Resident 1, Staff T did not stop even after she asked and begged for mercy to please stop but Staff T did not stop until she was done. The resident stated she had feared for her safety because she almost fell out bed because of Staff T's action. On [DATE] at 12:30 PM, Staff B, DNS stated the incident investigation was completed for Resident 1 and that she was able to substantiate that Staff T, NAC had provided the personal care to Resident 1 alone and that Staff T was not aware of and did not know what was on Resident 1's care plan. Staff B also stated that Staff T told her that there were not enough staff at the time of the incident, and that she also had provided care to Resident 1 by herself at least 2 times in the past. Staff B stated Staff T was placed on suspension and that she was able to substantiate that Resident 1 had suffered psychosocial harm related to the incident. According to Staff B, Resident 1 could have fallen out of bed or got hurt physically, but also this entire incident could have been avoided if Staff T had read and followed Resident 1's care plan. Staff B offered no explanation as to why the resident's preference to have male caregiver be present was not followed even though there was a male caregiver/nurse present at the time of the incident. Reference: (WAC) [DATE] (1) and WAC [DATE](1)(3)(g)

Based on interview and record review, the facility failed to ensure residents were free from abuse or neglect for 8 of 10 residents (Residents 1, 4, 16, 3, 10, 11, 13 and 14) reviewed for abuse and neglect. This failure caused harm to Residents 1, 4, 16, 3, 10, 11, 13 and 14 and placed other residents at risk for harm and unmet care needs. Findings included . The Code of Federal Regulation (CFR) defined neglect as 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. RESIDENT 1 Resident 1 was a long-term resident of the facility. Resident 1's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's quarterly Minimum Data Set (MDS) assessment, dated 01/06/2022, showed Resident 1 had intact cognition and needed two-person physical assistance with bed mobility and transfer. A review of the facility's incident reporting log showed that on 01/25/2022, Resident 1 reported an allegation of physical abuse against Staff T, Nursing Assistant Certified (NAC). On 02/08/2022 at 11:00 AM, Resident 1 stated that she was physically abused by a staff member, [Staff T NAC]. Resident 1 stated Staff T came into her room to provide personal hygiene care. Resident 1 stated she told Staff T that she needed two-person care due to her physical limitations and had informed Staff T about her left sided weakness, pain, and to not turn her onto her left side. According to Resident 1, Staff T ignored her and provided the care as she wishes and treated me like dead meat. Resident 1 stated that Staff T scared the hell out of her as Staff T flipped her in bed, shoved and pushed her on the left side while she was pleading and begging for mercy. Resident 1 further stated, she felt unsafe and had serious pain during the care, and had felt fear, intimidation and abused by Staff T. During the interview, Resident 1 was tearful and asked please help me and do not let [Staff T NAC] come back here. Resident 1 stated she did not feel safe around Staff T and she was concerned that [Staff T] would hurt her again if she came back to the facility. According to Resident 1, Staff T did not stop even after she asked and begged for mercy to please stop, but Staff T did not stop until she was done. On 02/08/2022 at 11:30 AM, Staff R, Social Services (SS) stated that Resident 1 had reported the same experience to the facility and her daughter. Staff R stated she had interviewed and followed-up with Resident 1 on 01/28/2022 after receiving a call from the resident's daughter. According to Staff R, Resident 1 showed and verbalized psychosocial harm in the form of fear, emotional and mental anguish. Staff R further stated the facility administration was aware of the situation and the results of her visits. On 02/08/2022 at 12:30 PM, Staff B, Director of Nursing (DNS) stated the incident investigation was completed for Resident 1 and that she was able to substantiate that Staff T, NAC had provided the personal care to Resident 1 alone and was not aware of or did not know what was on Resident 1's care plan. Staff B also stated that Staff T told her that there were not enough staff at the time of the incident, and she had provided care to Resident 1 alone at least 2 times. Staff B stated Staff T was placed on suspension and that she was able to substantiate that Resident 1 had suffered psychosocial harm related to the incident. Staff B further stated that the incident could have been avoided if Staff T had read and followed Resident 1's care plan. RESIDENT 4 Resident 4 was a long-term resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 4's quarterly MDS assessment, dated 2/15/2022, showed the resident had intact cognition and needed two person staff assistance with bed mobility and transfers. On 02/01/2022 at 11:30 AM, Resident 4 stated she was neglected and felt abandoned by staff so many times. Resident 4 stated that on 01/23/2022 at around 2:00 PM, she called and asked for staff to bring her use a bedside commode. However, Resident 4 stated she had waited for at least 2-3 hours until any staff helped her, and she had peed and pooped herself while waiting. According to Resident 4, it was very humiliating and embarrassing, and this was not the first time that this had happened. Resident 4 stated she had reported these concerns of not getting staff assistance for at least 2-3 hours, and sometimes not at all almost every day and every month to the facility administration, but nothing had happened, They just ignore us and don't care about us. During the interview, the resident appeared visibly upset and stated that she was frustrated and angry about the situation and felt helpless because it wasn't just her who experienced these problems. Resident 4 further stated that she had developed skin breakdown and rash on her private areas and buttocks area because of this on-going neglect of care. A review of Resident 4's clinical records showed the resident had Moisture Associated Skin Damage on her buttock area and there was no documented evidence of any toileting or personal care provided on 01/23/2022 from 2:00 PM to 5:00 PM. A review of the facility's incident investigation report, dated 01/24/2022, showed the facility had investigated Resident 4's allegation and confirmed that the resident did not receive the care she needed on 01/23/2022 between 2:00 PM to 5:00 PM. On 02/01/2022 at 12:45 PM, Staff B, DNS stated that Resident 4 did not receive any care from any staff on 01/23/2022 from 2:00 PM to 5:00 PM. Staff B stated there were no NACs that were assigned to Resident 4 because NACs were late and did not arrive at the facility as scheduled. Staff B also stated that the nurse on duty failed to reassign and rearrange the unit assignments to cover resident care which resulted in Resident 4 not getting any help from the staff that were at the facility. RESIDENT 16 Resident 16 was a long-term resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 16's quarterly MDS assessment, dated 11/16/2021, showed the resident had intact cognition and needed two person staff assistance with bed mobility and transfers. On 02/01/2022 at 11:55 AM, Resident 16 stated that on 01/19/2022 and 01/20/2022 morning and afternoon shift (could not recall specific times) she had to wait for at least 1-2 hours to get staff to change her brief. Resident 16 stated she had urinated and had a bowel movement, so she had to call staff to change her. However, Resident 16 stated no staff person came for 1-2 hours and she was sitting in her own waste that made her itch and angry to a point where she had to file a complaint. According to Resident 16, the situation made her felt humiliated and neglected and was concerned because it happens all the time here. On 02/01/2022 at 12:55 PM, Staff B, DNS stated that Resident 16 did not receive timely assistance from staff on 01/19/2022 and 01/20/2022 because the assigned NAC was looking for a second staff person to help and assist with care. Staff B stated that she was not able to confirm how long the resident had to wait for care, but there was less staffing during those days (01/19/2022 and 01/20/2022) which could have lead to not finding another staff person to provide the needed care for the resident. Staff B further stated that when she interviewed Resident 16, the resident stated she had waited for at least 1 hour to get help and was consistent with her report. On 02/01/2022 at 1:30 PM, both Staff A, Administrator and Staff B DNS stated they were aware of the resident's concerns related to not getting timely assistance and care from staff which was the reason the facility developed a contingency plan related to staffing. However, both Staff A and Staff B stated that toileting, personal hygiene, and other basic needs should be provided within a reasonable time frame and not within hours as reported by the residents. RESIDENT 3 Resident 3 was a long-term resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 3's quarterly MDS assessment, dated 12/19/2021, showed the resident had mild cognitive impairment and needed two person staff assistance with bed mobility and transfers. On 02/01/2022 at 10:30 AM, Resident 3 stated, Residents here are being neglected including myself. According to Resident 3, she would ask and call for staff assistance with toileting and brief change, and simple requests for water, medicine and going to bed. The resident said that she had to wait hours to get help and sometimes staff would not return to the point where I've been sitting in my own waste for at least 2-3 hours and sometimes longer. Resident 3 also stated the Administrator and almost all the staff here knew about this and they have done nothing to address the problem. Resident 3 further stated this made her upset and angry because all her friends shared the same experience, and it has been happening for a long time. On 02/15/2022 at 10:30 AM, Resident 3 stated a similar incident of not getting assistance from staff happened again on 02/11/2022 in the morning shift (no specific time reported). Resident 3 stated she needed to have a brief change and get out of bed as usual, but no one came for almost 2-3 hours. According to Resident 3, she had her call light on and waited patiently, but when it was almost 2 hours, Resident 3 stated she had to scream and call staff attention by throwing things in her room hoping they could hear me. Resident 3 stated she was upset and angry about the situation and had reported her concerns to the facility administration. A review of the facility's incident investigation log, dated 02/11/2022, showed the facility was investigating Resident 3's allegation of neglect. On 02/15/2022 at 1:15 PM, Staff U, Regional Nurse Consultant (RNC) stated she was aware of the allegation made by Resident 3 and the facility had not yet finished the investigation. Similar findings were applicable to Residents 10, 11, 13 and 14: RESIDENT 10 and RESIDENT 11 Resident 10 was a long-term resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 10's quarterly MDS assessment, dated 12/24/2021 showed the resident had intact cognition and needed one person assistance with bed mobility and transfers. Resident 11 was a long-term resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/15/2022 at 11:00 AM, Resident 10 and Resident 11 (roommates) both stated that the facility had serious problems including neglect of care to the residents. Both residents stated they had to wait at least 2 hours to get staff help and sometimes longer than 4 hours. They also indicated there had been some instances in the past even overnight. Both residents stated they felt the facility staff just don't care and they both experienced neglect because most of the time, they just needed basic care such as to be cleaned and changed. Resident 11 stated, It was inhumane to experience such care, in that they just didn't have a choice and depended on the facility to care for them. Resident 11 became tearful during the interview and stated, they felt helpless at times because this has been the situation here for a very long time. RESIDENT 13 Resident 13 was a long-term resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 13's quarterly MDS assessment, dated 01/28/2022, showed the resident had intact cognition and needed one person staff assistance with bed mobility and transfers. On 02/15/2022 at 11:30 AM, Resident 13 stated she felt neglected by the facility a lot of times because she had to wait for at least 1-2 hours before she could get help or assistance from staff. Resident 13 stated this has been the situation at the facility for a very long time and she felt that the facility just wanted the residents to get used to this and not take any actions. According to Resident 13, the facility administration did not care and did not take any actions to help with the ongoing problem. Resident 13 further stated she was worried that if she had an emergency and needed immediate assistance from staff, she would be left alone in bed to die and the staff would just find her dead because of the amount of time needed for staff to respond to a call for assistance. Resident 13 was visibly upset and stated she was angry about the situation they were in because the administration seems to not care at all. RESIDENT 14 Resident 14 was a long-term resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the residents quarterly MDS assessment, dated 01/03/2022, showed the resident had intact cognition and needed one-to-two-person assistance with bed mobility and transfers. On 02/15/2022 at 11:45 AM, Resident 14 stated she was very upset and angry because she was not getting adequate care from the facility. Resident 14 stated she had to wait for at least 2-4 hours to get help and assistance from staff with basic care needs such as brief change. According to Resident 14, just recently (about 1-2 days ago with no specific date/time) she had to wait for at least 4 hours to get incontinent care. Resident 14 stated she was told by the NAC that there was only one NAC on duty and he can't help it. Resident 14 stated, this has been the situation here for a long time and I'm getting tired of it. The facility failed to provide oversight and monitor the provision of care and services that resulted in multiple residents reporting neglect of care. Additionally, the facility failed to provide the required and effective structures/processes to meet the needs of one or more residents. See also CFR 483.25 - F689 - Free of Accident Hazards/Supervision/Devices and CFR 483.35 F725 - Sufficient Nursing Staff for more information. Reference: (WAC) 388 - 97-0640 (1)(3)(a)(c)

Based on interview and record review, the facility failed to ensure sufficient nursing staff were consistently available to meet the needs of all residents of the facility. Failure to have a sufficient number of nursing staff with appropriate competencies and skills sets caused harm to Resident 4, 16, 3, 10, 11, 13 and 14 and placed all other residents at risk for harm and unmet care needs. Findings included . On 02/09/2022 at 5:30 PM, both Staff B, Director of Nursing and Staff N, Licensed Practical Nurse/Staff Development Coordinator (LPN/SDC) stated the facility had no current process or system to train new employees (including Staff K, NAC) about the importance of reading and understanding each resident's care plan, including how to locate and access them to ensure an effective and safe delivery of care. Both Staff B and Staff N stated that the facility's lack of an effective system to educate and train staff about care plans and kardex, including the lack of supervision that resulted to accidents does require immediate actions, had placed the residents at risk for the likelihood of serious injuries, serious impairments and/or potentially death from avoidable accidents like falls. FACILITY ASSESSMENT A review of the facility assessment, dated 01/21/2021 and revised/updated on 08/10/2021, showed the facility needed the following staff (s)/resources to provide competent support and care for its resident population at any given time: A. A full time Infection Preventionist (IP). B. At least 20 licensed nurses (11 nurses in the morning, 6 in the evening and 3 at night) per day. C. Direct care staff (Nursing Assistant Certified [NAC]) were determined based on care acuity and determined by the Minimum Data Set (MDS) Assessment acuity score/report. The Facility assessment showed the acuity report should be reviewed daily including the weekends. A review of the Staffing Pattern from 01/02/2022 to 02/01/2022 completed by Staff B, Director of Nursing (DNS) showed the facility did not meet the required number of staff needed to meet the needs of the residents for all the dates within that timeperiod, as determined by the facility assessment. On 02/09/2022 at 5:30 PM, Staff B stated the facility did not currently have a full time IP and that they were working on hiring more staff to meet the needs of the residents. Staff B also stated that she only had one unit manager currently, and sometimes that unit manager had to work on the medication cart due to staffing needs. According to Staff B, she was not sure when was the last time the facility had reviewed the MDS assessment acuity score, but there was none completed for a long time. Staff B further stated the facility was short of NACs and they had struggled on days where staff were sick and/or failed to show for work. On 02/18/2022 at 12:40 PM, Staff W, Registered Nurse/MDS coordinator stated she had not run and/or reviewed the MDS acuity score or report for a long time and that she had not met with the Administrator and/or the DNS to review the facility staffing based on this report. CONTINEGENCY STAFFING PLAN A review of the facility's undated Staffing Contingency Plan showed it was missing specific and detailed plan(s) on how the facility would operate and effectively utilize available resources and implement staffing management according to the facility's emergency plan. The contingency plan also lacked specific plans or interventions regarding which resident care and services would be affected and/or modified, including the duration, and how the facility would document and monitor the residents' response and potential negative implications to the residents' overall well-being. The facility's Staffing Contingency Plan did not address and specify which plan of action would be modified or implemented for basic care needs, including the prevention of abuse and neglect. On 02/09/2022 at 5:35 PM, Staff A, Administrator and Staff B, DNS stated they were not aware that the Contingency Staffing Plan should include such specific and detailed information, or that it should have been incorporated to their facility assessment and emergency plan. Both Staff A and Staff B stated that they were aware of the staffing concerns in the facility and were doing what they can to meet the needs of their residents. However, Staff A and Staff B stated the facility recently opened a COVID-19 unit with at least 10 residents with active COVID-19 infection. Both Staff A and Staff B did not provide an answer as to why the facility, who had urgent staffing needs and struggling to meet the needs of their current resident population, opened a COVID-19 unit that added more workload and pulled away more resources and available staff to be assigned and care for newly admitted residents. The facility failed to implement its own staffing plan to meet the needs of each resident, as detailed in the facility assessment. Additionally, the facility failed to update and incorporate the facility's Contingency Staffing Plan to its own Facility Assessment and Emergency Staffing Plan to ensure that the facility would adequately staffed based on self-assessment, identified risks, hazards and needs. RESIDENT INTERVIEWS RESIDENT 3 On 02/01/2022 at 10:30 AM, Resident 3 stated, Residents here are being neglected, including myself. According to Resident 3, she would ask and call for staff assistance with toileting and brief change and including simple requests for water, medicine and going to bed. Resident 3 said she had to wait hours to get help and sometimes staff would not return to the point where I've been sitting on my own waste for at least 2-3 hours and sometimes longer. On 02/15/2022 at 10:30 AM, Resident 3 stated that not getting assistance from staff happened again on 02/11/2022 in the morning shift (no specific time reported). Resident 3 stated she needed to have a brief change and get out of bed as usual, but no one came for almost 2-3 hours. According to Resident 3, she had her call light on and waited patiently but when It's almost 2 hours, Resident 3 stated she had to scream and call staff attention by throwing things in her room hoping they could hear me. Resident 3 stated that she was upset and angry about the situation and had reported her concerns to the facility administration. RESIDENT 4 On 02/01/2022 at 11:30 AM, Resident 4 stated she was neglected and felt abandoned by staff so many times. Resident 4 stated that on 01/23/2022 at around 2:00 PM, she called and asked for staff to bring her a bedside commode. However, Resident 4 stated she had waited for way too long, at least 2-3 hours until she got any staff to help her, and she had peed and pooped herself while waiting. According to Resident 4, what happened was very humiliating and embarrassing, and this was not the first time that this had happened. Resident 4 stated she had reported her concerns of not getting staff assistance for at least 2-3 hours and sometimes not at all, almost every day and every month to the facility administration, but nothing had happened, They just ignore us and don't care about us. RESIDENT 16 On 02/01/2022 at 11:55 AM, Resident 16 stated that on 01/19/2022 and 01/20/2022 morning and afternoon shift (could not recall specific time), she had to wait for at least 1-2 hours to get staff to change her brief. Resident 16 stated she had urinated and had a bowel movement, so she had to call staff to change her. However, Resident 16 stated no staff person came for at least 1-2 hours and she was sitting at her own waste that made her itch and angry to a point where she had to file a complaint. According to Resident 16, the situation made her felt humiliated and neglected and was concerning enough because it happens all the time here. RESIDENT 10 and RESIDENT 11 On 02/15/2022 at 11:00 AM, both Resident 10 and Resident 11 (roommates) stated the facility had serious problems, including neglect of care to the residents. Both residents stated they had to wait at least 2 hours to get staff help and sometimes longer than 4 hours with some instances in the past waited even overnight. Both residents stated they felt the facility staff just don't care and they both felt neglect because most of the time, they needed basic care, such as the need to be cleaned and changed. Resident 11 stated It was inhumane to experience such care but they just didn't have a choice and couldn't help, but to depend on the facility to care for them. Resident 11 became tearful during the interview and stated, they felt helpless at times because this has been the situation here for a very long time. RESIDENT 13 On 02/15/2022 at 11:30 AM, Resident 13 stated she felt neglected by the facility a lot of times because she had to wait for at least 1-2 hours before she could get help or assistance from staff. Resident 13 stated this has been the situation here for a very long time and she felt that the facility just wants the residents to get use to this and not take any actions. According to Resident 13, the facility administration did not care and did not take any actions to help with the on-going situation. Resident 13 further stated that she was worried that if she had an emergency and needed immediate assistance from staff, that she would be left alone in bed to die and the staff would just find her dead because of the amount of time needed for staff to respond when she called for assistance. Resident 13 was visibly upset and stated she was angry about the situation they were in because the administration seems to not care at all. RESIDENT 14 On 02/15/2022 at 11:45 AM, Resident 14 stated she was very upset and angry because she was not getting adequate care from the facility. Resident 14 stated she had to wait for at least 2-4 hours to get help and assistance from staff with basic care needs, such as brief change. According to Resident 14, just recently, about 1-2 days ago with no specific date/time, she had to wait for at least 4 hours to get incontinent care. Resident 14 stated she was told by the NAC that there was only one NAC on duty and he can't help it. Resident 14 stated that this has been the situation at the facility for a long time and, I'm getting tired of it. RESIDENT 7 and RESIDENT 8 On 02/15/2022 at 10:00 AM, both Resident 7 and Resident 8 stated that they had to wait a long time to get help and assistance from staff. Both residents stated they had to wait for at least 1-2 hours and sometimes longer to get help, especially during the night and the weekends. Resident 7 stated she had to sometimes call out for help, just to get somebody to her room. Resident 8 stated she had to file a complaint about the lack of assistance because she felt abandoned and neglected most of the time, and also because she had a heart condition that would require immediate action from staff if she developed symptoms of heart irregularities such as chest pain and changes in her vitals. RESIDENT 9 On 02/15/2022 at 10:15 AM, Resident 9 stated the facility had problems with staffing because she had to wait for at least 1-2 hours to get help and assistance from staff. Resident 9 was worried that if she had an emergency or needed immediate assistance, the facility staff would not be there fast enough for her to receive the care she needs. RESIDENT 6 On 02/15/2022 at 10:20 AM, Resident 6 stated she had to wait at least 2 hours most of the time to get help and assistance from staff. Resident 6 stated she would sometimes sit in her urine and own waste for a long time, usually hours before she could get a brief change. RESIDENT 12 On 02/15/2022 at 11:55 AM, Resident 12 stated he would have to wait at least 1-2 hours or longer and sometimes 4 hours even to get help and assistance from staff. Resident 12 stated he had gotten used to it and that waiting for long hours was just the normal at this place. STAFF INTERVIEWS On 02/01/2022 at 2:00 PM (joint interview), Staff F, NAC, Staff L, NAC, Staff P, NAC, Staff X, NAC, and Staff J, RN all stated they did not have enough time to provide the necessary care and services for each resident every shift due the short staffing. Each staff member stated they worked short-staffed most of the time and the residents would complain that they had to wait long hours to get assistance from staff. Each staff member stated if they work short, which happened all the time, tasks like bathing and showers were not done. On 02/09/2022 at 1:30 PM, Staff O, Licensed Practical Nurse stated she did not have enough time to care and complete her tasks and provide the necessary care and services for each resident during her shift. This would often result in the resident not getting timely assistance from her and delay in administering medications. On 02/09/2022 at 6:15 PM, Staff Y, Registered Nurse, stated he did not have enough time to provide the necessary care and services for each resident during his shift. Staff Y stated the residents would sometimes complain of not getting their medications on time or extended wait times for call lights. On 02/15/2022 at 10:00 AM, Staff H, NAC stated they mostly worked short-staffed which affected how they provide timely assistance with residents. Staff H stated it had been an on-going issue for a while and residents would mostly verbalize that they had waited a long time to get assistance from staff. On 12/15/2022 at 10:05 AM, Staff P stated the facility did not have enough staff to meet the needs and concerns of residents, such as answering call lights timely and providing quality care because they must rush and get to the next resident as quick as possible. Staff P stated that sometimes they were not able to provide showers because they worked short of NACs. On 02/15/2022 at 10:15 AM, Staff N, Staff Development Coordinator/Staffing Coordinator stated the facility needed more staff to meet the residents' needs in a manner that was safe and promoted each resident's rights and well-being. Reference: (WAC) 388-97-1660(1)(a)(c)(i)(ii)(iii)

Based on interview and record review, the facility Administration failed to effectively manage the facility in compliance with state and federal regulatory requirements. The facility Administration failed to ensure compliance and implementation of written policies and procedures and provide adequate oversight to facility staff related to Accident prevention/Supervision, Resident Rights, Sufficient Nursing Staff, Grievances, and Infection Prevention and Control. These failures caused harm to Residents 1, 2, 4, 16, 3, 10, 11, 13 and 14 and placed the other residents at risk for harm related to ongoing abuse and neglect. Findings included . On 02/09/2022 at 6:35 PM, an Immediate Jeopardy (IJ) situation was identified related to CFR 483.25 - F689 - Free of Accident Hazards/Supervision/Devices, including a substandard Quality of Care (SQC) related to CFR 483.12 F600 - Free from Abuse and Neglect. CFR 483.25 - F689 - Free of Accident Hazards/Supervision/Devices On 02/09/2022 at 6:45 PM, both Staff A Administrator and Staff B Director of Nursing stated the IJ situation related to F689 - Free of Accident Hazards/Supervision/Devices could have been avoided if staff were adequately trained and followed Residents 1, 2 and 3's care plan. Staff B also stated the facility's lack of an effective system in ensuring staff and new hires were educated and trained to access care plans/Kardex (care directives) had contributed to the accidents that could have seriously injured the residents. A review of Resident 1's incident on 01/25/2022, Resident 2's incident on 02/08/2022 and Resident 3's incident on 01/29/2022 showed each incident could have been avoided if the facility staff provided the required supervision and followed and implement each resident's care plan/care directives. The facility Administration's lack of oversight and ensuring staff were adequately trained in accessing, reading, and implementing each resident's care plan, caused harm to Resident 1 and 2 who suffered physical and psychosocial harm related to the incidents and placed all three residents (Residents 1, 2 and 3) at increased likelihood of serious harm, injury, impairment and/or death related to avoidable accidents and falls. CFR 483.35 - F725 - Sufficient Nursing Staff A review of the facility Staffing Pattern from 01/02/2022 to 02/01/2022 completed by Staff B showed the facility did not meet the required number of staff needed to meet the needs of the residents for that timeperiod as determined by the facility assessment. On 02/09/2022 at 5:30 PM, Staff B, DNS stated the facility had a Staffing Contingency Plan and were short of NACs. The facility's Staffing Contingency Plan showed it was missing specific and detailed plans on how the facility would operate and effectively utilize available resources and implement staffing management according to the facility's emergency plan. The contingency plan also lacked specific plans or interventions on which resident care and services would be affected and/or modified, including the duration and how the facility would document and monitor the resident's response and potential negative implications to the resident's overall well-being. The facility's Staffing Contingency Plan did not address and specify what plan of action would be modified or implemented for basic care needs, including the prevention of abuse and neglect. On 02/09/2022 at 5:35 PM, both Staff A, Administrator and Staff B, DNS stated they were not aware that the Contingency Staffing Plan should include specific and detailed information or that it should have been incorporated in the facility assessment and the facility's emergency procedure plan. Both Staff A and Staff B stated that they were aware of the staffing concerns in the facility and were doing what they could to meet the needs of their residents. However, Staff A and Staff B stated the facility recently opened a COVID-19 unit with at-least 10 residents with active COVID-19 infection. Both Staff A and Staff B did not provide an answer as to why the facility, who had urgent staffing needs, struggled to meet the needs of their current resident population, opened a COVID-19 unit which added more workload and pulled more resources and available staff to be assigned to care for newly admitted residents. The Administration's failure to have sufficient nursing staff caused harm to Residents 4, 16, 3, 10, 11, 13 and 14 who reported psychosocial harm and neglect of care by the facility staff by waiting long hours (1-2 hours or longer) before receiving basic care and services, including toileting needs and brief changes. Additionally, the Administration's lack of action and oversight related to the staffing needs of the facility placed all residents in the facility at risk for harm and unmet care needs. CFR 483.10 - F585 - Grievances On 02/09/2022 at 12:05 PM, Resident 5 (Resident Council President) stated she and the Resident Council group were aware and had reported an on-going concerns and complaints from residents about lack of staff. A review of the Resident Council minutes from November 2021 to January 2022 showed no evidence that the facility had documented and/or addressed the staffing complaints and grievances from the Resident Council Group. Additionally, a review of the facility's grievance log from November 2021 to February 01, 2022 showed no documented grievance and/or concerns related to staffing shared and reported by the Resident Council. On 02/09/2022 at 1:05 PM, both Staff A, Administrator and Staff B, DNS reviewed the Resident Council Minutes from November 2021 to January 2022, and stated there was no documentation and/or follow-up notes related to the staffing concerns and grievance reported by the Resident Council. Staff A stated she was responsible for providing oversight to the Resident Council process. However, Staff A stated she was not sure as to why the staffing concerns reported by the Resident Council group was not documented in the minutes and why there was no follow-up or resolution from the facility. Both Staff A and Staff B stated that any concerns or grievances by the Resident Council group should have been documented in the minutes and should have been addressed and followed-up on by the facility. The facility Administration's lack of oversight and actions on the Resident Council concerns and grievances, including the lack of an effective system in documenting and making sure follow-ups were made and grievances were reviewed and investigated as required placed all residents of the facility at risk for harm and unmet care needs. CFR F883.80 - F880 - Infection Prevention and Control A review of the facility's COVID-19 screening log for January 2022 showed that Health Care Personnel (HCPs), including staff and visitors, were not being screened properly for COVID-19 prior to entering the facility and providing care and services to the residents. Screening logs from 01/01/2022 to 02/01/2022 showed that employees, visitors, and other HCPs were not screened properly for signs and symptoms of COVID-19 but were allowed to enter the facility. The screening log was missing information, including whether the HCPs and visitors had COVID-19 signs and symptoms, most recent COVID-19 test/result, and COVID-19 vaccination status. On 02/01/2022 at 1:00 PM, both Staff A, Administrator and Staff B, DNS stated they were responsible in making sure that COVID-19 screening for all HCPs was done correctly based on CDC (Center for Disease Control) recommendation and their own policies and procedures. Both Staff A and Staff B stated that all HCPs and visitors should have been screened properly for COVID-19 prior to allowing entry to the facility to prevent and minimize the increased risk of COVID-19 transmission to residents and staff. The facility's Administration's failure to provide an adequate oversight to the facility's Infection Control COVID-19 prevention placed all residents of the facility at risk of acquiring COVID-19 infection. Reference: (WAC) 388-97-1620(1)

Based on interview and record review, the facility failed to ensure staff treat each resident with respect and dignity in a manner that promoted the maintenance or enhancement of quality of life and recognizing each resident's individuality, failed to ensure that each resident could exercise their rights without fear of intimidation and reprisal, and failed to protect each resident for exercising their rights for 2 of 4 residents (Residents 17 and 15) reviewed for dignity. This failure resulted in the residents expressing ongoing anger from violation(s) of their rights. Findings included . RESIDENT 17 Resident 17 was a long-term resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 17's quarterly Minimum Data Set (MDS) assessment, dated 12/17/2021, showed the resident had intact cognition and was independent with locomotion on and off the unit. On 02/09/2022 at 2:00 PM, Resident 17 reported an incident that happened between her and Staff B Director of Nursing (DNS) in May 2021 (could not recall specific date and time). Resident 17 stated she was forcibly dragged and that Staff B forced her to get inside the facility and falsely imprisoned her by not allowing her to leave the facility, not even to get some fresh air at the front desk area. Resident 17 stated she had gone on an outing with her daughter when this incident happened, and she had forgotten to sign out. Resident 17 said that it had not been explained to her that signing out was a requirement to leave the building. According to Resident 17, when she arrived at the bus stop, she saw Staff B, DNS smoking outside with her dog. Resident 17 stated she didn't know who Staff B was at that time and had not met her. Resident 17 also stated Staff B had no form of any identification that would identify her as an employee of the facility. Resident 17 stated when she got off the bus, Staff B immediately asked her If I wanted to talk to my daughter and that (Staff B) had her daughter on the phone. Resident 17 stated that Staff B told her that they had called the police and that they had been looking for her. According to Resident 17, she had asked Staff B who she was, but Staff B refused to give her name and responded it was not important. Resident 17 stated that Staff B told her she would be waiting for her until she got back into the facility, and that Staff B stood up with her dog and grabbed her wheelchair. Resident 17 stated she told Staff B to not grab her wheelchair and to not force her to move as she needed time to rest. Resident 17 stated that Staff B also directed her to a different way back to the facility (parking lot instead of the sidewalk area). This was when Staff B grabbed her wheelchair again and pushed her. This was when Resident 17 stood up to hold and push her wheelchair, so that Staff B would stop forcefully pushing her. Resident 17 stated Staff B continued to grab her even after being told to not push or touch me. According to Resident 17, she felt relieved that a staff person, who introduced himself as a therapist, came and assisted her. Resident 17 stated she felt fear and harassed by Staff B because she didn't know who she was, and that Staff B continued to be aggressive with touching her and pushing her wheelchair. Resident 17 stated as she got closer to the front door area, and it was just her and Staff B, she told Staff B that she wanted to catch her breath and sit on her wheelchair for a while. Resident 17 stated that Staff B started to push her wheelchair again and grabbed her arms to stop her from propelling/moving her wheelchair. Resident 17 stated she resisted and told her to please stop touching me, but Staff B dragged her to the front door. This was when a staff member (Staff N, Licensed Practical Nurse/Staff Development Coordinator [LPN/SDC]) intervened and told Staff B to let me go. Resident 17 stated that Staff B initially refused to listen to Staff N, but eventually followed him to his office. Resident 17 stated that Staff ZZ, a former employee of the facility, also witnessed when Staff B grabbed her wheelchair and blocked the front door so she could not leave the facility. Resident 17 stated she had reported abuse and false imprisonment to Staff A, Administrator, but she had not heard anything from the facility. Resident 17 stated there was no follow-up and no communication as to why I am being detained here at the facility. According to the resident, she felt like she was a prisoner, treated like a child, discriminated against and was physically hurt and abused by the Staff B, DNS. Resident 17 further stated she felt that her rights were violated, and the facility had tolerated Staff B's actions by not even talking to her [Resident 17] and letting her know that her concern were heard or investigated. Resident 17 was visibly upset, tearful and stated she was very angry about the situation. Resident 17 stated that Staff B, DNS and the facility had done so many bad things to her, including making false documentations into her record and for making her look insane with mental health issues. According to Resident 17, all she really wanted was for the facility to hear her concerns and give her an explanation as to why they did not acknowledge and listen to her and protect her from these on-going violations of her rights as a person. On 02/09/2022 at 4:30 PM, Staff ZZ, former employee, stated she remembered the incident that occurred last May 2021 (could not recall the specific date and time) between Resident 17 and Staff B, DNS. Staff ZZ stated she remembered seeing Staff B holding Resident 17's wheelchair to bring her back in the facility. Staff ZZ also stated that when Staff B managed to bring Resident 17 back inside the facility, she saw Staff B blocked the doors to prevent Resident 17 from leaving the facility. Staff ZZ stated Resident 17 was refusing to get inside the facility and wanted to stay outside. Staff ZZ further stated she was shocked and did not know what to do and whether she needed to do anything, but the facility Administration was aware of the incident, including Staff A, Administrator. On 02/09/2022 at 6:20 PM, Staff N LPN/SDC stated he remembered the incident between Resident 17 and Staff B, DNS last May 2021 (could not recall the specific date and time). Staff N stated he heard a loud commotion between Staff B and Resident 17, so he got out of his office to intervene. Staff N stated he asked Staff B to step away from the situation and took her in to his office. According to Staff N, he told Staff B that what she was doing was not right and that she could not block Resident 17 from going outside the facility. On 02/15/2022 at 1:30 PM, Staff R, Social Services (SS) stated she did a follow-up visit and interview with Resident 17 several times and stated Resident 17 was very consistent on what happened and the specific details of the incident and how Staff B had violated her rights as a resident of the facility and as a human being. Staff R also stated Resident 17 suffered psychosocial harm related to this incident in that it made Resident 17 very angry, felt like she was treated like a child, discriminated and physically hurt by Staff B and the facility. A review of Resident 17's clinical records and the facility's incident investigation report, dated 02/10/2022, showed Resident 17 was consistent with reporting the details of the incident to multiple staff members and had verbalized/documented evidence of psychosocial harm. RESIDENT 15 Resident 15 was a long-term resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 15's annual MDS assessment, dated 12/01/2021, showed the resident had intact cognition and needed two person staff assistance with bed mobility and transfers. On 02/09/2022 at 2:55 PM, Resident 15 stated she felt abused and violated by Staff B, DNS in the past. Resident 15 stated that there were at least two instances where she was very angry and upset with Staff B. One was when Staff B forcefully searched and touched me to find a lighter when I was not allowed to smoke (could not recall specific date or time). According to Resident 15, this specific incident happened at the front desk area close to the front office. Resident 15 stated this incident was witnessed by staff members including a receptionist. Resident 15 further stated, I also reported the incident to my aide and [Staff A, Administrator]. Resident 15 stated that the second incident was when Staff B entered her room and illegally searched her personal belongings and closets (could not recall specific date and time) apparently looking for a lighter and cigarettes. Resident also stated, that during both incidents, she refused and told Staff B to not touch her and search her personal belongings but she did it anyway. According to Resident 15, she felt that Staff B harassed me and treated me like a child. Resident 15 further stated she was angry about the situation and she had lost sleep for days after the incident happened. On 02/10/2022 at 11:30 AM, Staff ZZ,former employee, stated she remembered the incident that she witnessed (could not recall the specific date and time) between Resident 15 and Staff B, DNS at the front office (Infection Preventionist office). Staff ZZ stated Staff B searched and reached for Resident 15's pockets and clothing searching for smoking materials. Staff ZZ also stated that Resident 15 was screaming and shouting at Staff B to not touch her, but Staff B proceeded and searched Resident 15 against her will. According to Staff ZZ, Resident 15 was very upset and angry after the incident. A review of the facility's incident investigation report, dated 02/10/2022, showed that Resident 15 had reported a similar incident to Staff YY, NAC (unknown date and time). The witness statement signed by Staff YY on 02/14/2022 showed Resident 15 had reported that Staff B searched her room and drawers without permission and confiscated a cigarette lighter, Resident 15 was mad about it. It indicated that Staff A, Administrator was aware of the incident and had Resident 15's lighter. On 02/15/2022 at 1:30 PM, Staff XX, Chief Operating Officer (COO) stated the facility had investigated both the allegations made by Resident 15 and by Resident 17 against Staff B. Staff XX stated that the facility was not able to substantiate abuse and/or neglect regarding Resident 15's allegations, but they were able to verify that Staff B took a cigarette lighter from Resident 15. However, Staff XX stated that the circumstances and the details of the incident were not clear because it had been quite a while since the incident happened, and there were some discrepancies with the possible location and the timing of the incident. Staff XX stated that Staff B had confirmed and told the facility investigator that she took a lighter from Resident 15. Staff XX stated that regarding Resident 17's allegation against Staff B, the facility was not able to substantiate abuse and/or neglect. According to Staff XX, the incident showed that there could have been a situation where Staff B attempted to help Resident 17 when she was outside the facility and prevent her from leaving the facility due to safety concerns, but he believes that the intention was to help the resident and not to cause any harm. Staff XX also stated that regardless of what Staff B's intent was, Resident 17's perception was that Staff B had violated her rights and that she should have allowed her [Resident 17] to do what she wanted without blocking the exit doors and while providing a safe environment (as possible), but also promoting the resident's independence. Reference: (WAC) 388-97-0180 (1-4)

Based on observation, interview, and record review, the facility failed to ensure systems were in place for staff following and implementing abuse and neglect policies & procedures for reporting, investigation, and protection for 16 of 16 residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) reviewed for abuse and neglect. These failures caused harm to Resident 1, 2, 3, 4, 5, 6 and 10 and placed other residents in the likelihood of serious harm and injury from abuse and neglect. The facility's failure to act and initiate immediate interventions to protect residents from further harm related to potential abuse and neglect and the failure to timely investigate abuse and neglect allegations constituted a situation of an immediate jeopardy (IJ) related to CFR 483.12 - F607 - Develop/Implement Abuse/Neglect Policies. The IJ was identified and communicated to the facility on [DATE]. Findings included . A review of the facility's policy titled, Abuse Prohibition Policy and Procedure dated 02/23/2021, showed the facility prohibited abuse and neglect. The policy also showed that the facility would implement abuse prohibition through the following: Prevention of occurrences, Identification of possible incidents or allegations which need investigation, Investigation of incidents and allegation, Protection of residents during the investigations, and Reporting of incidents, investigations and the facility's response to the results of their investigations. The policy directed facility staff to: A. Identifying, correcting, and intervening in situations in which abuse, neglect and/or misappropriation of patient property is more likely to occur. B. The notified supervisor will report the suspected abuse immediately to the Center Executive Director (Administrator) or designee and other officials in accordance with state law. If the resident sustains serious bodily injury, the employee who forms the suspicion or witnesses the incident must report no later than two (2) hours after forming the suspicion. C. The employee alleged to have committed the act of abuse will be immediately removed from duty, pending the investigation. D. If the suspected abuse is resident to resident, the resident who has in any way threatened or attacked another will be removed from setting or situation and an investigation will be completed. E. Report allegations of abuse and neglect no later than 2 hours after the allegation was made if the event results in serious bodily injury. Serious bodily injury is reportable. Only an investigation can rule out abuse, neglect or mistreatment. F. Notify local law enforcement, Ombudsman, Licensing District Office, Licensing Boards, Registries and other agencies as required. G. Initiate an investigation within 2 hours of an allegation of abuse that focuses on whether abuse or neglect occurred and to what extent; clinical examination for signs of injuries, if indicated, causative factors, Interventions to prevent further injury. H. The Center will protect patients from further harm during an investigation. Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. I. The Administrator or designee will take all necessary corrective action depending on the result of the investigation and Report findings of all completed investigation within (5) working days to the licensing District office. PHYSICAL ABUSE ALLEGATION Resident 1 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's 5 Day Minimum Data Set (MDS) assessment, dated 09/04/2021, showed the resident had intact cognition and needed 2-person extensive assistance with bed mobility and dressing. On 09/28/2021 at 12:50 PM, Resident 1 stated she was physically abused and feared a particular staff member, Staff C, Nursing Assistant Certified (NAC). Resident 1 stated that about 1-2 weeks ago (could not recall the exact date), Staff C forcefully yanked and manhandled her in bed while she was receiving personal care. Resident 1 also stated that Staff C grabbed her right arm/wrist area so hard that it caused her severe pain and had left bruising to the area. According to Resident 1, she told Staff C that she was terrified by her [Staff C] and that she did not want her [Staff C] to care for me anymore. Resident 1 further stated that Staff C had continued to come into her room and provide her meal trays after the incident. Resident 1 stated that this continued to occur even after she reported the incident of abuse to several staff members and told the facility's administration that she no longer feels safe to be around Staff C. Observation showed that Resident 1 had 2 or 3 fading/scattered light purple bruises (approximately) on her right wrist. Resident 1 stated she had lost sleep and appetite because of her fear that Staff C would just enter her room and hurt her again, especially when she's asleep. Resident 1 stated that Staff C neglected her and had retaliated against her by removing her dinner tray even before she started eating, and by not placing her call button where she could easily reach it and call for help. Resident 1 stated that these incidents of removing her meals and call light out of her reach occurred almost every day after she had reported the allegation of physical abuse to the facility. On 09/28/2021 at 1:15 PM, Staff B Director of Nursing (DNS) stated she was aware of the allegation of physical abuse involving Resident 1 dated 09/17/2021. Staff B also stated that Resident 1's description of the alleged perpetrator matched a staff member (Staff C, NAC) but Resident 1 was not able to identify the name of the alleged staff member. However, Staff B stated that the investigation was not completed at this time and that the facility had not suspended (removed from duty) any staff member, including Staff C, related to the allegation of physical abuse reported by Resident 1. On 09/28/2021 at 1:25 PM, Staff D, Social Services Director (SSD) stated she was aware of the allegation of physical abuse reported by Resident 1. Staff D stated that Resident 1 reported the allegation on 09/17/2021 early afternoon (not sure of the exact time) and provided a description of the alleged staff member. Staff D also stated that Resident 1's description of the alleged staff member matched the description of a particular staff member, Staff C, who was scheduled to work that afternoon shift immediately after the allegation was made (on 09/17/2021). According to Staff D, they immediately interviewed other residents in the unit on the same day to see whether other residents had any issues or concerns with Staff C. Staff D said they also reported the allegation to the state agency, and the facility Administration (Staff A, Administrator and Staff B, DNS). However, Staff D stated that the facility did not suspend any staff member related to the allegation, and that Staff C continued to work with residents, including Resident 1, without the facility completing the investigation and ruling out abuse and or neglect. Review of the daily staffing schedule from 9/17/2021 through 9/28/21? showed that Staff C was remained on the resident care schedule. Additionally, a review of Staff and personnel files showed no staff was suspended related to the allegation until the incident was investigated by the surveyor on 09/28/21. On 09/28/2021 at 1:30 PM, both Staff A, Administrator, and Staff B, DNS, stated they were not aware of the specific details of the incident. Staff A stated she was out of the facility when the incident happened and Staff B also stated that she was working as a nurse on the cart (medication/treatment nurse) when the incident happened, and that neither of them followed-up with the investigation. Both Staff A and Staff B stated that residents should have been protected from potential abuse (or on-going abuse), investigations should have been completed timely within 5 days of the incident and that the alleged staff member (Staff C NAC) should have been suspended pending the result of the investigation. Both Staff A and Staff B stated they knew that the investigation was not complete and offered no explanation as to why the facility's abuse and neglect policies and procedures were not followed to ensure Resident 1 and other residents of the facility received immediate protection from abuse so as to not be subjected to on-going abuse or neglect after the allegation was made and during an investigation. A review of the facility's daily staff schedule and Resident 1's clinical records for September 2021 showed Staff C continued to work with Resident 1 as her primary caregiver and worked with other residents after the allegation of physical abuse was reported to the facility. On 09/28/2021 at 1:45 PM during a meeting with Staff A and Staff B, Resident 1 stated and reiterated the allegation of physical abuse that she said she experienced from Staff C, NAC. Resident 1 stated that she was fearful and did not feel safe around Staff C, especially when Staff C came to her room every evening to deliver her meal and food tray. Both Staff A and Staff B were not able to state or provide evidence on what action(s) (if any) was taken by the facility to protect Resident 1 and other residents from a similar situation. Additionally, both Staff A and Staff B were not able to provide evidence that the facility had thoroughly investigated the incident for abuse and/or neglect, and whether the incident was reported to law enforcement agency as needed and required. On 09/28/2021 at 3:15 PM, Staff C stated that Resident 1 told her about 1-2 weeks ago that Resident 1 did not want Staff C to take care of her anymore for something that Staff C did. Staff C stated she continued working with residents, including Resident 1, but mostly just served meal trays to Resident 1 because the resident would refuse care from her, even if Staff C offered to provide care. Staff C further stated the facility was aware of the allegation made against her by Resident 1, but Staff C did not receive any instructions on what to do or whether she was to totally avoid and remove herself from providing any care to Resident 1 or not. The facility's lack of action and the failure to protect Resident 1 after the allegation of physical abuse caused harm to Resident 1 in the form of fear and psychosocial harm. Additionally, Resident 1 said she continued to experience on-going abuse, neglect and/or retaliation from Staff C. These failures caused serious harm to Resident 1 and placed other residents in the likelihood of serious harm and injury from ongoing abuse and neglect. NEGLECT ALLEGATION RESIDENT 2 Resident 2 was a long long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Quarterly MDS assessment, dated 09/24/2021, showed the resident had intact cognition and needed 2-person assistance with bed mobility and transfers. A review of Resident 2's care plan, dated 04/06/2021, showed the resident required a mechanical lift device (Hoyer Lift) with 2 staff person assistance for transfers. A review of a nursing progress note completed by Staff E, Licensed Practical Nurse (LPN), dated 09/19/2021, showed that on 09/18/2021 at 3:40 PM, Resident 2's caregiver Staff F, NAC reported that Resident 2 had a fall while being transferred from the wheelchair to bed. Staff E completed an assessment immediately after the incident and noted the following injuries: A. Purple bruise on the left lower back area, 40 centimeter (cm) in length by 12 cm wide. B. Left lower back abrasion, 11cm in length by 0.5cm wide. C. Abrasion on the left buttocks area, 3cm in length x 0.5cm wide. On 09/28/2021 at 2:30 PM, Resident 2 stated that he remembered the incident occurred about 1 week ago when he fell out of the mechanical lift device while being transferred from the wheelchair to bed. Resident 2 stated Staff F, NAC, transferred him by herself using the mechanical lift device when he [Resident 2] suddenly slid off the sling. Resident 2 stated that Staff F attempted to hold him up while she lowered him to the floor. According to Resident 2, the resident landed on his back, but did not hit his head, Luckily, I just bruised myself and bled a little. Resident 2 further stated that staff usually transferred him by only 1 person, instead of 2 persons, because there was not enough staff available when the resident needed to be transferred to and from the bed. On 09/28/2021 at 1:15 PM, Staff B, DNS, stated that the incident occurred because Staff F, NAC used the mechanical lift device alone and attempted to self-transfer Resident 2 without the second person for safety and as directed by the resident's care plan. However, Staff B stated that the incident investigation was not completed at this time, and that the facility was still investigating the incident. Staff B was not able to state and provide evidence on what action(s) (if any) was taken by the facility to protect Resident 2 and other residents from a similar situation. Additionally, Staff B was not able to provide evidence that the facility had thoroughly investigated the incident for abuse and/or neglect, or whether the incident was reported to the state agency as required. A review of the state agency's hotline reports from 09/01/2021 to 09/28/2021 showed this incident was not called in and/or reported to the state hotline. On 10/01/2021 at 1:10 PM, Staff F, NAC, stated she knew Resident 2 required 2 staff person for safe transfers and when using a mechanical lift, but she was not able to locate and/or get any help from other staff to assist her with transfer, so she attempted to transfer Resident 2 from wheelchair to bed by herself. Staff F stated that during the transfer, Resident 2 slid off the sling, so she lowered the resident to the ground immediately. According to Staff F, she immediately called in the nurse to help assist with the situation and to check on Resident 2. Staff F further stated that Resident 2 was assessed by Staff E, LPN after the incident and the resident was found with a huge bruise on his back, skin tear and abrasions on his back after the incident. The facility's failure to ensure staff followed and implemented Resident 2's care plan directives caused harm and injury to Resident 2. Additionally, the facility's failure to timely investigate and implement timely interventions based on the root cause of the incident placed Resident 2 and other residents of the facility in the likelihood of serious injury, harm and serious impairment related to ongoing staff neglect. RESIDENT 10 Resident 10 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Quarterly MDS assessment, dated 09/18/2021, showed the resident had intact cognition and needed one person assistance with bed mobility and transfers. On 09/28/2021 at 1:20 PM, Staff B, DNS, stated Resident 10 made an allegation of neglect about a staff member (Staff I, NAC) on 09/15/2021. Staff B said Resident 10 reported on 09/17/2021 that on 09/15/2021, day shift - no specified time, Resident 10 did not receive peri-care, her brief was not changed, and she had stayed in bed all day because Staff I did not provide the care and refused to get her up in bed. Staff B also stated that the investigation of the allegeation was not complete at this time, and that Staff I was not suspended during the investigation. Staff B offered no explanation as to why the facility's abuse and neglect policy was not implemented or why Staff I was not suspended pending the result of the investigation. On 09/28/2021 at 3:05 PM, Resident 10 stated Staff I, NAC refused to clean her and get her up from bed few weeks ago. The resident was not able to recall exact date and time. Resident 10 stated that she ended up staying in bed the entire day and did not receive peri-care from 6:00 AM till about 3:00 PM. According to Resident 10, she had a bowel movement and was sitting in her own urine for hours. Resident 10 stated, I was very angry and upset because I have bad rash and open sores on my bottom and private area. Resident 10 also stated that she reported her concern to the nurses and the social worker, but they didn't care. Resident 10 stated that Staff I was back to working with her and was never sorry for what she did. Resident 10 added that Staff I was blaming me instead because she said that I refused. Resident 10 stated, I never refuse. I always want to get up from bed. Resident also stated, I felt attacked because I was being blamed for what happened. Resident 10 stated the facility was shorthanded and she would always wait for hours to be changed or be transferred from wheelchair to bed. You wonder why most residents here complain about not getting help? Go figure. Resident 10 stated, It was embarrassing and humiliating to be in your own waste for hours. A review of Resident 10's clinical records and skin assessment, dated 09/20/2021, showed the following new skin injury/wound(s) were identified: Rash to bilateral groin area and left buttocks/left upper rear thigh Moisture associated skin damage (MASD). The facility's failure and lack of action to protect Resident 10 and other residents of the facility, and the failure to timely investigate the allegation of abuse/neglect caused harm to Resident 10 in the form of anger/psychosocial harm and contributed to the development of new skin breakdown/conditions. A reasonable person would feel humiliated and embarrassed when left sitting in their own urine and waste as described by Resident 10. RESIDENT 11 Resident 11 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Quarterly MDS assessment, dated 08/09/2021, showed the resident had impaired cognition and needed 1 person assistance with transfers and personal hygiene. On 09/28/2021 at 1:20 PM, Staff B, DNS stated that Resident 11 made an allegation of abuse and rough handling on 09/17/2021 against Staff J, NAC. Staff B stated Resident 11 was not sure about the specific date and time, but she said it was few weeks ago around 09/17/2021. Staff B stated that Staff J came to the resident's room to give her a shower, but during the transfer, Staff J pushed her hard into the shower chair causing the resident pain and soreness on the back. Staff B stated Resident 11 ended up refusing the shower because of what happened. Staff B also stated that the investigation was not complete at this time, and that Staff J was not suspended during the investigation. Staff B offered no explanation as to why the facility's abuse and neglect policy was not implemented and why Staff J was not suspended pending the result of the investigation. On 09/29/2021 at 10:30 AM, Resident 11 stated she remembered what happened between her and Staff J, NAC. Resident 11 stated that few weeks ago (was not able to recall the date and time), Staff J offered to give her a shower. However, Resident 11 stated that when she transferred from the bed to the shower chair, Staff J shoved her and pushed her hard enough to cause her severe back pain. Resident 11 stated that she asked Staff J why was he so rough? and told Staff J that she will be filing a complaint against him. According to Resident 11, Staff J responded by saying go ahead, so she decided to not let Staff J give her a shower because of the incident. Resident 11 stated she reported the incident to several facility staff including nurses and social workers. However, Resident 11 stated Staff J continued to come into her room and from time to time, asked her if she would like a bath or shower. According to Resident 11, she does not feel comfortable around Staff J and that she would always refuse to have Staff J give her a shower because of the incident. On 09/29/2021 at 11:00 AM, both Staff A, Administrator and Staff B, DNS stated they were not aware of Resident 11's preference of not wanting Staff J, NAC to offer and provide her a shower and/or bath due to the allegation of abuse reported on 09/17/2021. RESIDENT 12 Resident 12 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/28/2021 at 1:20 PM, Staff B, DNS stated that Resident 12 made an allegation of neglect on 09/14/2021 about Staff H, NAC. Staff B stated that Resident 12 reported that there was a delay in care and with the amount of time it took staff to respond to his call light, but Resident 12 was not able to provide a specific date and time. Staff B was not able to provide additional information related to the investigation, such as the specific details of the incident, witness statements and/or interview including any supporting documents on what action was taken (if any) to protect the resident and other residents of the facility. Staff B stated the incident investigation was not complete at this time. AVOIDABLE ACCIDENTS (FALLS) RESIDENT 3 Resident 3 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Quarterly MDS assessment, dated 09/14/2021, showed the resident had impaired cognition and needed 2 person staff assistance with bed mobility and transfers. A review of Resident 3's care plan, dated 10/08/2019 and revised on 09/30/2021, showed the resident was at risk for falls due to cognitive loss, lack of safety awareness, impaired mobility and current medical diagnoses. A review of a report submitted to the state agency on 09/27/2021 showed that Resident 3 had fallen at least 3 times within the last month. The concern report also showed that Resident 3 told this family member that He hit his head very hard on the floor and his hip. He said he laid on the hard cold floor and waited for someone to come find him. It took so long that he fell back to sleep. The report showed the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . On 09/28/2021 at 1:20 PM, Staff B, DNS, stated that Resident 3 had fallen out of bed on 09/15/2021 and 09/24/2021. Staff B stated that both fall incidents were unwitnessed, but the resident and staff reported that Resident 3 had rolled out of bed on both occasions resulting in injury. Staff B stated that on 09/15/2021 fall, Resident 3 sustained a head laceration with abrasions to the right side of the head, and bruised right elbow measured at 3cm long by 3cm wide. During the fall on 09/24/2021, Resident 3 sustained a skin tear on his right elbow measured at 6cm long by 5cm wide. Staff B stated that the incident investigation for Resident 3 on both falls were not completed at this time, and that the facility was still investigating the incident. Staff B was not able to state and provide evidence on what action(s) (if any) was taken by the facility to protect Resident 3 and other residents from a similar situation. Additionally, Staff B was not able to provide evidence that the facility had thoroughly investigated the incident for abuse and/or neglect, and whether the incident was reported to the state agency as required. On 09/29/2021 at 12:30 PM, Resident 3 stated he had recently fallen out of bed at least 2 times that he could remember. Resident 3 stated that he rolled out off bed on both occasions because the bed was too small and slippery. According to Resident 3, he always slides to either side of the bed a lot and also it was impossible to get any staff member here to help you. Resident 3 further stated he had waited hours, maybe 1-3 hours before somebody found him on the floor on both occasions. Resident 3 stated he hit his head hard that he had lost consciousness and suffered several lacerations on his head and elbows. Resident 3 stated he had requested to get something done to his bed or mattress but there has been no follow-up made to his request and he was afraid that he would fall out of bed again soon. Resident 3 was observed on a regular size bed with a low air loss mattress. Resident 3 was positioned close to the edge of the bed with his head leaning on the right side. There was no safety device to keep the resident at the center of the bed and minimize risk of him sliding on the side. Resident 3 stated he was not able to reposition himself in bed independently. RESIDENT 4 Resident 4 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Significant Change MDS assessment, dated 09/14/2021, showed the resident had impaired cognition and needed one person assistance with bed mobility and toilet use. A review of Resident 4's care plan, dated 04/10/2021 and revised on 09/21/2021, showed Resident 4 was at risk for falls due to cognitive loss and lack of safety awareness. The care plan directed facility staff to: ensure left side fall mat is in place at all times while resident lying/resting in bed. On 09/28/2021 at 1:20 PM, Staff B, DNS, stated Resident 4 fell on [DATE] and sustained injuries including a bruise on the face (left cheek area), multiple lacerations to the left lower extremities, and skin tears to the left elbow and left foot. Staff B stated the incident was not witnessed, but the resident reported that she was trying to use the bathroom when the incident happened. Staff B stated that the incident investigation for Resident 4 was not complete at this time, and that the facility was still investigating the incident. Staff B was not able to state and provide evidence on what action(s) (if any) was taken by the facility to protect Resident 4 and other residents from a similar situation. Additionally, Staff B was not able to provide evidence that the facility had thoroughly investigated the incident for abuse and/or neglect, and whether the incident was reported to the state agency as required. On 09/29/2021 at 12:35 PM, Resident 4 stated that she fell and rolled out of bed last week, but could not recall the exact date and time, and hit her head and face hard. Resident 4 stated she also injured her left arm and blood was all over. According to the Resident 4, she needed to use the bathroom at the time of the incident, and she called for help, but no one came for hours so she decided to get up by herself. Resident 4 further stated, she had waited for a very long time on the floor calling for help before she received help from any staff member. Observation showed the resident lying on a regular/standard size bed and mattress with no other safety device in place. There was no fall matt on the floor, as directed by the plan of care. The facility's failure to act and protect Resident 3 and Resident 4 from further injuries from falls, the failure to timely investigate and identify the root cause, and implement timely interventions caused harm and injury to Resident 3 and 4. Additionally, these failures placed Resident 3 and Resident 4 in the likelihood of serious harm and injury, impairment and/or death related to avoidable accidents. RESIDENT 9 Resident 9 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Quarterly MDS assessment, dated 08/19/2021, showed the resident had impaired cognition and needed 2-person extensive assistance with bed mobility and transfer. A review of Resident 9's care plan, dated 03/01/2016 and revised on 04/13/2020, showed the resident was at risk for falls due to her current medical conditions. On 09/28/2021 at 1:20 PM, Staff B, DNS, stated Resident 9 fell on [DATE] at approximately 5:00 PM. Staff B stated the incident was not witnessed and the resident did not suffer any injury. However, Staff B stated that she does not have the specific details of the incident including what action was taken (if any) to minimize the risk of the incident because the investigation was not complete at this time. A review of a nursing progress note, dated 09/16/2021, showed that at 5:00 PM, Resident 9 was found lying face down, right next to her bed. The note documented, Res (resident) apparently slid down from her wheelchair onto floor. Prior to incident res was offered by CNA to be put in bed as she looked sleepy but refused . PRN (as needed) Tylenol (pain/fever medication) and routine [MEDICATION(S)] (narcotic pain medication) given for discomfort from fall. On 09/28/2021 at 3:00 PM, Resident 9 stated that a few days ago (did not know the exact date and time) she fell asleep while in the wheelchair and fell forward. Resident 9 stated she wanted to go back to bed, but there was no staff member around to put her back to bed. The resident stated she hit her head hard on the floor and had waited a long time for any staff to found her and assist her. Observation of Resident 9 did not show any injury related to the fall. The facility's failure to address the root cause of the incident and the failure to timely investigate and implement interventions to minimize the risk of reoccurrence of the incident placed Resident 9 at increased risk of harm and injury related to fall. RESIDENT 15 Resident 15 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Admission MDS assessment, dated 08/27/2021, showed the resident had intact cognition and needed 1 person assistance with bed mobility and transfers. On 09/28/2021 at 1:20 PM, Staff B, DNS, stated that Resident 15 had a fall on 09/21/2021. However, Staff B was not able to provide additional information about the incident and stated that the investigation was not complete at this time. On 09/28/2021 at 3:30 PM, Resident 15 stated he had a fall on 09/21/21, but could not recall the time. Resident 15 stated he tried to get some clothes from his drawer, but he became dizzy and lightheaded. Resident 15 also stated that he landed on his right side, and hit the wall before hitting the ground. According to Resident 15, there was no staff member present and/or around when the incident happened, but he was able to crawl back in bed. Resident 15 further stated that he had an on-going problem with being lightheaded and dizzy, so he would appreciate if somebody from the facility could help him figure out a way to how to minimize the risk of falling and possibly getting injured. RESIDENT 16 Resident 16 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the resident's Annual MDS assessment, dated 07/01/2021, showed the resident had impaired cognition and needed two staff person with bed mobility and toileting needs. On 09/28/2021 at 1:20 PM, Staff B, DNS, stated that Resident 16 had a fall on 09/21/2021. Staff B stated that the incident was unwitnessed, and the resident was found on his knees in the room leaning on his bed. However, Staff B was not able to provide additional information about the incident and stated that the investigation was not complete at this time. On 09/29/2021 at 9:30 AM, Staff B, DNS, stated she was still gathering information about Resident 16's fall, but said the resident was found to have incontinent (lack of voluntary control) episodes of bowel and bladder at the time of the incident. However, Staff B was not able to provide any additional information regarding when the resident last received incontinent care and who assisted, and whether the resident's care plan was followed, and/or if the [TRUNCATED]

Based on interview and record review, the facility Administration failed to effectively manage the facility in compliance with state and federal regulatory requirements. The facility Administration failed to ensure compliance related to the development and implementation of effective policies and procedures on timely investigation and immediate protection of residents from abuse and neglect. The facility Administration also failed to timely investigate incidents and accidents to immediately protect the resident(s) from harm and to minimize the risk of reoccurrence of the same incident/accident. These failures caused harm to Resident 1, 2, 3, 4, 5, 6 and 10 and placed the other residents at risk for harm related to ongoing abuse and neglect. An immediate Jeopardy (IJ) related to CFR 483.12 - F607 - Develop/Implement Abuse/Neglect Policies was identified and communicated to the facility on [DATE]. Findings included . A review of the facility's accident and incident reporting log for the month of September 2021 showed 17 incomplete investigation that were not investigated timely to ensure that residents involved with each incident and accidents were protected and received timely and effective interventions to minimize the risk of serious harm, injury, and further reoccurrence of the accidents/incidents. The facility failed to implement written abuse and neglect policies and procedures related to the required and timely investigation, resident protection, and/or reporting to the state agency/other agency as required for the following incidents and accidents: A. Resident 1 - Physical Abuse allegation dated 09/17/2021. B. Resident 2 - Neglect (substantiated) dated 09/18/2021. C. Resident 10 - Neglect allegation dated 09/15/2021. D. Resident 11 - Physical Abuse allegation/rough handling dated 09/17/2021. E. Resident 12 - Neglect allegation dated 09/14/2021. F. Resident 7 - Unexpected death at the facility on 09/16/2021. G. Resident 3 - Fall with injuries dated 09/15/2021 and 09/24/2021. H. Resident 4 - Fall with injuries dated 09/15/2021. I. Resident 5 - In-house acquired (developed in the facility) stage IV pressure ulcer/injury. J. Resident 6 - In-house acquired stage IV pressure ulcer/injury. K. Resident 8 - Elopement on 09/10/2021 and 09/12/2021. L. Resident 13 and Resident 14 - Resident-to-Resident altercation on 09/16/2021. M. Resident 9 - Fall dated 09/16/2021. N. Resident 15 - Fall on 09/21/2021. O. Resident 16 - Fall on 09/21/2021. On 09/29/2021 at 12:50 PM, both Staff A, Administrator and Staff B, Director of Nursing (DNS) stated those sixteen investigations were not followed-up on and completed timely so as to ensure those residents were safe, and that timely and effective interventions were put in place to minimize the risk of recurring abuse and neglect incidents. Both Staff A and Staff B offered no explanation as to why the facility's written policies and procedures were not followed to ensure resident safety and protection from abuse and neglect. Reference: (WAC) 388-97-1620(1)

Based on interview and record review, the governing body failed to provide adequate oversight and monitoring of the facility's administration and operation. The governing body failed to ensure the facility implemented abuse and neglect policies and procedures related to resident protection, reporting and investigation of allegations of abuse, neglect, and accidents/incidents for 16 of 16 residents (Resident 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 and 16) reviewed for abuse and neglect. Additionally, the facility failed to effectively implement corrective actions for the deficiencies cited on previous abbreviated surveys' Statement of Deficiencies, dated 07/12/2021, 08/17/2021, and 09/15/2021. These failures caused harm to Resident 1, 2, 3, 4, 5, 6 and 10 and placed other residents at risk of harm and injury from abuse and neglect. Findings Included . A review of an undated policy titled, Governing Body, showed the governing body was legally responsible for establishing and implementing policies regarding the management and operation of the facility. The facility showed continued noncompliance for the following Federal Regulatory requirements after the facility alleged to be back in substantial compliance prior to the start of the current abbreviated survey. The Governing Body failed to ensure the facility administration implemented their plan of corrections and sustained compliance as alleged on the written plan of correction submitted on 07/27/2021, 09/09/2021, and 10/08/2021. The continued noncompliance resulted to an Immediate Jeopardy (IJ) situation related to CFR 483.12 - F607 - Develop/Implement Abuse/Neglect Policies, a repeat citation from 08/17/2021. 1. CFR 483.25 - F689 - Free of Accident Hazards/Supervision/Devices. - Scope and Severity of pattern Immediate Jeopardy to resident health and safety (K). 2. CFR 483.25 - F684 - Quality of Care - Scope and Severity of isolated actual harm that is not immediate jeopardy (G). 3. CFR 483.25 - F686 - Treatment/Services to Prevent/Heal Pressure Ulcers - Scope and Severity of isolated actual harm that is not immediate jeopardy (G). 4. CFR 483.70 - F835 - Administration - Scope and Severity of isolated actual harm that is not immediate jeopardy (G). 5. CFR 483.70 - F837 - Governing Body - Scope and Severity of isolated actual harm that is not immediate jeopardy (G). 6. CFR 483.12 - F600 - Free from Abuse and Neglect - Scope and Severity of isolated no actual harm, with potential for more than minimal harm. 7. CFR 483.12 - F607 - Develop/Implement Abuse/Neglect Policies - Scope and Severity of isolated no actual harm, with potential for more than minimal harm. 8. CFR 483.12 - F609 - Reporting of Alleged Violations - Scope and Severity of isolated no actual harm, with potential for more than minimal harm. 9. CFR 483.12 - F610 Investigate/Prevent/Correct Alleged Violation - Scope and Severity of isolated no actual harm, with potential for more than minimal harm. The following accidents, incidents, and allegations of abuse and neglect were not reviewed and investigated timely to ensure residents were protected during an on-going investigation as directed by the facility's abuse and neglect policy: A. Resident 1 - Physical Abuse allegation dated 09/17/2021. B. Resident 2 - Neglect (substantiated) dated 09/18/2021. C. Resident 10 - Neglect allegation dated 09/15/2021. D. Resident 11 - Physical Abuse allegation/rough handling dated 09/17/2021. E. Resident 12 - Neglect allegation dated 09/14/2021. F. Resident 7 - Unexpected death at the facility on 09/16/2021. G. Resident 3 - Fall with injuries dated 09/15/2021 and 09/24/2021. H. Resident 4 - Fall with injuries dated 09/15/2021. I. Resident 5 - In-house acquired (developed in the facility) stage IV pressure ulcer/injury. J. Resident 6 - In-house acquired stage IV pressure ulcer/injury. K. Resident 8 - Elopement on 09/10/2021 and 09/12/2021. L. Resident 13 and Resident 14 - Resident-to-Resident altercation on 09/16/2021. M. Resident 9 - Fall dated 09/16/2021. N. Resident 15 - Fall on 09/21/2021. O. Resident 16 - Fall on 09/21/2021. On 10/04/2021 at 11:25 AM, Staff Z, Vice President of Operations (VPO) stated he was not aware that the facility was behind in completing the required and timely investigations of allegations of abuse and neglect, including other accidents and incidents as required by the state and federal regulations. Staff Z also stated that during his visits to the facility, he did not review the facility's record/incident and accident logs to ensure that the facility administration was up to date in conducting investigations and ensuring residents were protected during the investigation process as directed by the facility's abuse and neglect policy. According to Staff A, he also reviewed the facility's written plan of correction for the recent citations (as detailed above). However, Staff Z stated he did not review specific records (including open and current accidents, incidents, allegations of abuse and neglect) and would only review what he thought would be appropriate for him to check based on his credentials/qualifications. Staff Z further stated the facility Administration did not communicate and reach out to the Governing Body about the need for help in making sure that the facility was up to date with investigations and were implementing the plan of corrections as required. Reference: WAC 388-97-1620 (2)(c)

Based on observation, interview and record review, the facility failed to develop and implement an effective policy and procedure(s) related to serving hot beverages, failed to provide adequate supervision, and failed to implement the plan of care for 1 of 3 residents (Resident 1) reviewed for avoidable accidents and supervision. These failures caused serious harm and injury to Resident 1 who sustained a second-degree burn and experienced pain and placed other residents of the facility in the likelihood of serious harm and injury related to the unsafe temperature of hot beverages served. The facility's failure to ensure an effective policy and procedures related to serving hot beverages were in place to minimize risks and protect residents from avoidable accidents and the failure to provide adequate supervision to Resident 1, caused serious injury/harm and constituted a situation of an Immediate Jeopardy (IJ) related to CFR 483.25 - F689 - Free of Accident Hazards/Supervision/Devices. The IJ was identified and communicated to the facility on [DATE]. Additionally, the facility failed to provide adequate supervision and implement the plan of care to minimize the risk of avoidable accidents (falls) for 2 of 3 residents (Residents 3 and 4) reviewed for falls. These failures caused harm to Resident 3 and Resident 4 who sustained multiple bone fractures, pain, and diminished quality of life. Findings included . Resident 1 was a long-term resident in the facility. The resident's diagnoses list included generalized muscle weakness and lower body [CONDITION(S)] (loss of the ability to move the lower body). A review of the resident's quarterly Minimum Data Set (MDS) assessment, dated 08/10/2021, showed the resident required extensive staff assistance with bed mobility and supervision (oversight, encouragement or cuing) and set-up with eating. A review of the resident's care plan, dated 06/19/2020 and revised on 04/01/2021, showed Resident 1 was at risk for decreased ability to perform activities of daily living (ADL) including bed mobility and eating. The care plan directed the facility staff to: A. Provide cuing for safety and sequencing to maximize current level of function. B. Eating - Set up assistance, then indirect supervision. HOT WATER TEMPERATURE/UNSAFE HOT BEVERAGES A review of a facility incident report, dated 08/29/2021, showed that on 08/29/2021 at 7:30 AM, Resident 1 had an unwitnessed incident that resulted in an injury (burn). The incident investigation showed that Resident 1 reported to the nurse aide [Staff Y, Nursing Assistant Certified (NAC)] that she had spilled hot tea on herself while attempting to drink it. The incident report also showed that no staff member was present when the incident had occurred. The incident investigation report concluded that the root cause of the incident was that the facility did not implement policies and procedures related to safe delivery of hot beverages to the resident. The conclusion also indicated that a contributing factor to the incident was that Resident 1's care plan directed staff to provide indirect supervision which was not clear to staff. The incident investigation report showed that Resident 1 sustained a second-degree burn (a burn injury involving the first 2 layers of the skin) related to the incident, and the facility had implemented corrective actions immediately after the incident to ensure hot beverages were not delivered to residents at a temperature greater than 150 degrees Fahrenheit (F). On 08/31/2021 at 10:20 AM, Staff W, Dietary Manager (DM) and Staff X, Dietary Aide (DA) both stated that the facility had no written policies and procedures in place related to the safe delivery of hot beverages to the residents. Staff W and Staff X stated that there was no hot water temperature testing or screening being done prior to the incident, and that there was no system as to how to make sure that hot beverages were served at a safe temperature to the residents. Both Staff W and Staff X stated that Staff A, Administrator, and Staff C, Regional Dietary Manager (RDM), had recently provided staff education (08/30/2021) to make sure that hot beverages leaving the kitchen and being served to the residents did not exceed 150 F. On 08/31/2021 at 10:30 AM, Staff A, Administrator and Staff B, Director of Nursing (DNS) both stated the facility had no written policies and procedures in place related to the safe delivery of hot beverages to the residents. Both Staff A and Staff B stated that the facility had just started checking hot beverage temperatures yesterday (08/30/2021) at lunch time and that dietary staff had been educated to ensure that hot beverages leaving the kitchen and served to the residents did not exceed 150 F. Observation on 08/31/2021 at 10:55 AM showed Resident 1 had a partial thickness burn (a burn injury involving the first 2 layers of the skin) on her left upper arm extending to the left shoulder. The wound was measured at approximately 10 centimeters (cm) in length and 10 cm wide. The burn site was red with open areas and the surrounding skin was swollen. According to the resident, the burn area was painful to touch. On 08/31/2021 at 11:00 AM, Resident 1 stated that she was having breakfast when the incident happened. The resident stated the hot tea might have spilled because she was not sitting upright, and the head of the bed was not high enough when she was drinking. The resident also stated she tended to lean on her left side because of her weakness and contractures (permanent tightening of the muscles), and that there was no staff member near her to cue or supervise her when the incident happened. The resident further stated the facility served hot water and her tea was very hot on a daily basis, and she was not sure as to why the hot drinks had to be extremely hot. Observation on 08/31/2021 at 12:40 PM showed two residents in the dining room (Resident 5 and Resident 6), having lunch with hot beverages served at the table. Both residents stated their hot water, and the coffee were too hot to drink, and they were letting it cool down before they can drink the beverages. A joint observation on 08/31/2021 at 12:45 PM with Staff C, Regional Dietary Manager (RDM) showed the temperatures of the hot water and hot coffee served in the main dining room were recorded as 166.0 F. Additionally, 5 of 6 beverage carts that had come out of the kitchen with beverages for residents to drink (located close to the nurse station and clean utility room) showed the recorded temperatures of the hot water was 162.0 to 173.1 degrees F, and the recorded temperatures of the coffee was 147.3 to 163.0 degrees F. On 08/31/2021 at 1:00 PM, Staff C, RDM, stated that kitchen and dietary staff had received education and training on 08/30/2021 regarding this issue and she was not sure why the kitchen and dietary staff had continued to serve hot beverages at unsafe temperature level of more than 150 F. Staff C stated the hot water and coffee temperatures should have been taken in the kitchen and brought down to a safe level [120 F to 150 F] if necessary before leaving the kitchen for residents to drink. Although the facility took steps to train and educate staff related to the safe delivery of and serving hot beverages to the residents, the facility failed to ensure staff continued to implement the steps of checking the temperatures of hot beverages and serving the hot beverages at a safe temperature level. This failure increased the likelihood of serious harm and injury related to the unsafe temperature of hot beverages served to the residents. On 08/31/2021 at 1:45 PM, both Staff A, Administrator, and Staff B, DNS, stated that kitchen and dietary staff had received education and training on 08/30/2021 regarding safe delivery of hot beverages to the residents and they were not sure why the kitchen and dietary staff had continued to serve hot beverages at unsafe level of more than 150 F to the residents. Staff A and Staff B both stated that they would immediately re-educate and re-train dietary staff to ensure the safe delivery of hot beverages to the residents. FAILURE TO PROVIDE ADEQUATE SUPERVISION On 08/31/2021 at 11:00 AM, Resident 1 stated that there was no staff member present when the burn incident occurred. The resident also stated that she did not receive any additional staff assistance or supervision during meals, other than delivering her food. The resident further stated that staff did not provide any kind of cuing during meals. On 08/31/2021 at 11:05 AM, Resident 1's roommate stated that she was in the room when the incident happened. The roommate said that Resident 1 often leaned on her left side when she ate and drank, and that Resident 1 would often call for help, but no one will come. The roommate further stated that staff do not check on either her or Resident 1 during meals because the staff were busy, and the facility was mostly understaffed almost everyday. On 08/31/2021 at 11:30 AM, Staff Y, Nursing Assistant Certified (NAC), stated that he did not witness Resident 1's incident and he was not in the room when the incident happened. Staff Y stated that Resident 1 was independent with eating and only needed set-up assistance with eating and drinking. Staff Y was not aware of the care-planned direction for indirect supervision while eating for Resident 1. On 08/31/2021 at 11:36 AM, during a joint interview with Staff J (NAC), Staff K (NAC), Staff L (NAC), and Staff M (NAC), the staff gave different responses as to what indirect supervision meant, either that indirect supervision meant Resident 1 should have been supervised within line of sight or that it meant that Resident 1 should not be left alone in the room due to the need for supervision. On 08/31/2021 at 11:45 AM, Staff B, DNS, stated that Resident 1's care plan showed the resident needed cuing for safety, set-up assistance with eating, and indirect supervision from staff. Staff B also stated that staff were not clear as to what indirect supervision meant, and that she had to update Resident 1's care plan to clarify this intervention. FALLS WITH MAJOR INJURY RESIDENT 3 Resident 3 was a long-term resident of the facility. The resident's diagnoses list included respiratory/breathing problems and [CONDITION(S)]. A review of Resident 3's annual MDS assessment, dated 06/24/2021, showed the resident had intact cognition and needed 1 person staff assistance with transfers and toilet use. A review of Resident 3's care plan, dated 06/2018, showed Resident 3 was at risk for falls related to impaired mobility, generalized weakness, lack of safety awareness and current use of high-risk medications. The care plan directed facility staff to anticipate needs and frequently check on the resident. The Activities of Daily Living (ADL) care plan, dated 06/2018 and recently revised on 06/24/21, showed the resident requires 1-person limited assistance when the resident allows, for oxygen tubing management. Review of an incident investigation report, dated 08/02/2021, showed Resident 3 had a non-witnessed fall on the night of 07/31/2021, when the resident had rushed to the bathroom and fell . The incident report showed Resident 3 reported the incident to Staff N, NAC on the morning of 08/01/2021. Staff N immediately reported the incident to the nurse on duty, Staff D, Licensed Practical Nurse (LPN). However, no follow-up or action(s) were taken to address the fall until 08/02/2021, when another nurse noticed a bruise on Resident 3's left back. The incident investigation report also indicated that Resident 3 also had changes in his medical condition between 08/02/2021 to 08/08/2021. The resident received antibiotic treatment, fluids therapy and several medication changes related to the worsening of his chronic respiratory disease. On 08/09/2021, a chest x-ray was ordered and showed a left lower lung collapse with numerous posterior (back) left rib fractures, 5th rib fracture in at least 2 places. Cannot exclude flail chest [a serious condition that results from having two or three ribs that are broken in two or more places mostly due to a crushing injury]. On 09/08/2021 at 9:15 AM, Resident 3 stated that he remembered what happened when he fell and broke his ribs. The resident stated he needed to use the bathroom to urinate and have a bowel movement. Resident stated he felt dizzy and lightheaded at the time, so he called for staff assistance and pressed his call light. However, Resident 3 stated he had waited for a long time (at least 45 to 60 minutes according to the resident) but no staff member came. Resident 3 stated that he tried shouting for help, which was very difficult due to his lung problems. Resident 3 stated that after waiting for almost an hour, he decided to go to the bathroom because he did not want to have a bowel movement in bed. According to Resident 3, he fell and landed on one of the bedside tables or a trash bin, directly hitting his back and rib cage. Resident 3 added, That is why I called for assistance, but nobody came. Resident 3 also stated he reported the incident the following morning (08/01/2021) to an aide (Staff N, NAC). However, Resident 3 stated that he did not get any help or attention related to his fall until 08/02/2021. Resident 3 stated that he felt sharp pain immediately after the fall and he knew he may have fractured his ribs, but no one seems to believe me. Resident 3 stated it was harder to breath and the rib fractures caused him more pain and discomfort than usual. Resident 3 said that staff did not check on him frequently or on a regular basis. According to Resident 3, the only time he would see a staff member was when they delivered his meals and medications, Staff don't come even if you call them. The resident further stated that the incident could have been avoided if a staff member had come to help and assist him to the bathroom. On 09/08/2021 at 10:00 AM, Staff B, DNS, stated there was a delay in communication to the physician that Resident 3 had a fall and a delay in the management of the fall injury for at least 24 hours. Staff B stated that Resident 3's care plan intervention showed frequent checks, which meant staff should check the resident more than every 2 hours, but this instruction was not clear to staff. Staff B further stated that it was not clear as to when the resident was last seen by a staff member and whether he received any care or services from a staff member before the incident. On 09/08/2021 at 10:30 AM to 11:30 AM, interviews with Staff N NAC, Staff L NAC, Staff M NAC, and Staff D LPN showed the staff had different understanding of what frequent checks meant related to resident supervision. Staff L and Staff M stated that frequent checks meant to check the resident at least every 30 minutes or sometimes every 15-30 minutes. Staff N and Staff D stated that the meaning of frequent checks varied and could be interpreted as to check the resident often or at least every 30 minutes and/or every time staff walked by the resident's room. RESIDENT 4 Resident 4 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses list included history of repeated falls and [CONDITION(S)] (sudden drop in blood pressure). A review of Resident 4's MDS assessment, dated 07/14/2021, showed the resident had intact cognition, needed one person assistance with bed mobility, and two person staff assistance with transfers and toileting needs. A review of Resident 4's care plan, dated 07/08/2021, showed the resident required staff assistance with ADLs including bed mobility, transfers, ambulation and toileting. The care plan also showed Resident 4 had several fall incidents in the facility. The care plan directed facility staff to do frequent visual checks while in bed d/t (due to) impulsiveness. A review of Resident 4's clinical records and the facility's incident reporting log from 07/2021 to 09/05/2021 showed Resident 4 had 5 falls (07/21/2021, 08/02/2021, 08/07/2021, 08/10/2021 and 08/24/2021) while at the facility. During the fall that occurred on 08/24/2021 at 8:00 AM, Resident 4 sustained a laceration (deep cut) on his left elbow and was sent out to the hospital for further evaluation and treatment. On 09/08/2021 at 10:30 AM, Resident 4 stated that he remembered what happened on his last fall on 08/24/2021. Resident 4 stated he wanted to use the bathroom to urinate, so he called for help using the call light. Resident 4 stated, I waited and waited, but no one came. According to Resident 4, he waited an hour, but he couldn't hold it anymore, so he decided to use the bathroom on his own. Resident 4 added that he knew he was supposed to have a staff member when he got up to use the toilet, but he felt he had no choice. Resident 4 said to ask his roommate about it, as his roommate also knew what happened. Resident 4 stated that the fall could have been avoided if staff had been present to help him and supervise him when he got up from bed to use the bathroom. On 09/08/2021 at 10:40 AM, Resident 4's roommate stated that Resident 4 had waited patiently for staff to came and help him, but there was no staff around to help him. Resident 4's roommate stated he also had experienced an hour wait (sometimes longer) to get help from staff. On 09/08/2021 at 10:45 AM, Staff L, NAC, stated that he was familiar with Resident 4's care and care plan. Staff L stated Resident 4 required assistance and increased supervision from staff, at least every 15 minutes. However, Staff L stated that most of the time it was not possible to provide that amount of supervision, especially in the early morning get-up times and during mealtimes (6:00 AM to 9:00 AM and 11:30 AM to 1:00 PM). A review of the fall incident investigation report, dated 08/24/2021, showed Resident 4 had a history of multiple falls in the past and his care plan required him to have 1 person staff assistance with transfers, ambulation, and dressing. The incident report also showed the resident was last toileted and received care from staff at around 7:00 AM (1 hour before the incident). However, the incident investigation was missing key information as to what was the root cause of the incident and whether staff had followed the resident's care plan and provided the necessary care and services to minimize risk of the incident. On 09/08/2021 at 11:00 AM, Staff B, DNS, stated that Resident 4's fall on 08/24/21 was not witnessed by staff. Staff B also stated Resident 4's care plan showed he required extensive assistance from staff and frequent visual checks, which meant staff should be providing increased supervision of at least every 30 minutes to every one to two hours. However, Staff B also stated that the phrase frequent checks was not clear to staff as to how often they should be checking and providing supervision to the resident. Staff B further stated the incident investigation did not contain information as to whether the incident was avoidable or not because the incident report submitted to her was missing information about the details of the incident, including lack of witness statements and interviews from the resident and his roommate. On 08/31/2021 at 11:36 AM and again on 09/08/21 at 11:30 AM, during joint interviews with Staff J NAC, Staff K NAC, Staff L NAC, and Staff M NAC, the staff gave different responses as to what frequent visual checks meant in terms of resident supervision, such as frequent checks meant staff were to check residents every 30 minutes, frequent checks meant check every time they passed the resident's room, or that frequent checks meant staff were to check the resident at least every 2 hours. A review of Resident 4's clinical records showed the resident's fall on 08/24/2021 resulted in multiple injuries, including fracture of multiple ribs of the right side and a closed traumatic Pneumothorax (a collapsed lung). On 09/08/2021 at 11:45 AM, Resident 4 stated his injury from the fall caused him increased pain, affected his ability to breath normally, and affected his ability to enjoy his day and have quality sleep at night. Reference: (WAC) 388-97-1060(3)(g)

Based on interview and record review, the Administration failed to effectively manage the facility in compliance with state and federal regulatory requirements. The administration failed to ensure compliance related to the development and implementation of an effective policy and procedures related to the safe delivery of hot beverages to the residents, and failed to ensure staff provided adequate supervision for 3 of 4 residents (Residents 1, 3 and 4) reviewed for accident hazards, supervision, and devices. These failures caused serious harm to Resident 1, 3 and 4 and resulted in an Immediate Jeopardy (IJ) situation on 08/31/2021. Additionally, the facility administration failed to ensure staff followed and implemented an effective, on-going system to safeguard resident's property from misappropriation and potential drug misuse/diversion for Resident 3. These failures placed residents of the facility at risk for harm, injury, and abuse and/or neglect. Findings included . On 08/31/2021, an IJ situation was identified related to CFR 483.25 - F689 - Free of Accident Hazards/Supervision/Devices. RESIDENT 1 (BURN) The facility failed to develop and implement an effective policy and procedure related to the safe delivery and serving of hot beverages to the residents that resulted in serious injury and harm to Resident 1 who sustained a second-degree burn (a burn injury involving the first 2 layers of the skin) on 08/29/2021. A review of the facility incident report dated 08/29/2021 showed that Resident 1 had spilled hot tea on herself while attempting to drink it. The incident report also showed that no staff member was present to supervise the resident when the incident had occurred. The incident investigation report concluded that the root cause of the incident was due to the facility's failure to implement policies and procedures related to safe delivery of hot beverages to the resident. The conclusion also included information that a contributing factor to the incident was related to Resident 1's care plan that was directing staff to provide indirect supervision which was not a clear direction to staff. On 08/31/2021 at 1:45 PM, Staff A, Administrator, and Staff B, Director of Nursing (DNS) both stated that it was the facility's administration's responsibility to ensure that an effective policy and procedure was in place related to the safe delivery of hot beverages to the residents. Staff A stated she was not sure as to why the kitchen staff did not have a policy in place at the time of the incident that resulted in a serious burn injury for Resident 1 by accidentally spilling hot beverage to herself at unknown temperature. RESIDENT 3 and RESIDENT 4 (FALL WITH MAJOR INJURIES) The facility failed to provide adequate supervision and implement the resident's plan of care to minimize the risk of avoidable accidents (falls) for Resident 3 and Resident 4. These failures caused harm to Resident 3 and Resident 4 who sustained multiple bone fractures, pain, and diminished quality of life. Resident 3 had a non-witnessed fall on 07/31/2021 and sustained a left lower lung collapse with multiple rib fractures and potentially a flail chest (a serious and life-threatening condition resulting from having two or three ribs that were broken in two or more places mostly due to a crushing injury). On 09/08/2021 at 9:15 AM, Resident 3 stated that the incident could have been avoided if a staff member had come to help and assist him to the bathroom. Resident 4 had a non-witnessed fall on 08/24/2021 and sustained multiple injuries including fracture of multiple ribs of the right side and a closed traumatic Pneumothorax (a collapsed lung). On 09/08/2021 at 10:30 AM, Resident 4 stated the incident could have been avoided if staff were present to assist and supervise him when he got up from the bed to use the bathroom. On 09/08/2021 at 11:00 AM, Staff B, DNS stated that both Resident 3 and Resident 4's fall incidents were not witnessed. Staff B stated she was not aware of the specific circumstances of the incidents, in that both Resident 3 and Resident 4 reported that they did not receive timely assistance and supervision from staff. ABUSE ALLEGATION (MISAAPROPRIATION - NARCOTIC PAIN MEDICATION) A review of the incident report for Resident 3 dated 08/29/2021 showed that an entire medication card (bingo card) of Oxycodone (a narcotic pain medication) 10 milligram (mg) tablet went missing on 08/28/2021. The incident investigation report concluded that the root cause of the incident was due to the facility staff's failure to follow and implement the facility's written policy and procedures related to the proper accounting of controlled narcotic medications. The incident report showed that staff did not conduct an end of shift narcotic count for an unknown period of time. On 09/08/2021 at 12:05 PM, Staff B, DNS stated she was not aware and not sure as to why some nurses were not counting narcotics at the end of each shift. Staff B, DNS stated that she was responsible for ensuring that nurses followed and implement written policies and procedures in safeguarding residents' medications, including controlled substances. Reference: (WAC) 388-97-1620(1)

Based on interview and record review, the governing body failed to provide adequate oversight and monitoring of the facility's administration and its operation. The governing body failed to ensure the facility had a policy in place to ensure compliance related to a safe delivery of hot beverages and minimize the risk/hazards to residents. These failures caused serious harm and injury to Resident 1 and resulted in an Immediate Jeopardy (IJ) situation on 08/31/2021. Additionally, these failures also placed residents of the facility at risk for harm and injuries. Findings Included . A review of an undated policy titled, Governing Body, showed the governing body was legally responsible for establishing and implementing policies regarding the management and operation of the facility. A review of the facility incident report, dated 08/29/2021 showed that Resident 1 had spilled hot tea on herself while attempting to drink it. The incident investigation report concluded that the root cause of the incident was due to the facility's failure to implement policies and procedures related to safe delivery of hot beverages to the resident. On 08/31/2021 at 1:45 PM, both Staff A Administrator and Staff B Director of Nursing (DNS) stated that it was the facility administration's responsibility to ensure that an effective policy and procedure was in place related to the safe delivery of hot beverages to the residents. Staff A stated she was not sure as to why the kitchen staff did not have a policy in place at the time of the incident that resulted to Resident 1 getting burned by accidentally spilling hot beverage on herself at unknown temperature. On 09/01/2021 at 4:40 PM, Staff AA, Vice President of Operations, stated that he was not sure as to why there was no policy being implemented at the facility related to the safe delivery of hot beverages to the residents. Staff AA also stated that there could have been a policy, but he was not sure what could have happened as to why there was none in place at the time of the incident. According to Staff AA, the lack of policy and procedure related to the safe delivery of hot beverages could have been the result of the management turnover in the kitchen and dietary staff, but the issue should have been identified. Reference: WAC 388-97-1620(2)(c)

Based on observation, interview and record review, the facility failed to provide adequate pain management to meet the needs of each resident for 1 of 3 residents (Resident 1) reviewed for pain. This failure caused harm to Resident 1 who experienced severe pain and discomfort. Findings included . Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted to the facility with an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 07/23/2021 at 11:30 AM, Staff B, Director of Nursing (DNS) stated that Resident 1 was admitted to the facility around 3:00 PM on 07/20/2021. Staff B stated that the resident had reported to facility staff that she had not received her [MEDICATION(S)] for at least 12 hours after admission, which caused severe pain and poor pain management for Resident 1. Staff B stated that the facility had initiated an investigation as to what could have happened and why the resident did not receive her narcotic pain medication as ordered. A review of the resident's clinical records, including Medication Administration Records (MAR), Nursing Progress notes and Narcotic Pain Medication Log from 07/20/2021 to 07/23/2021, showed Resident 1 did not receive any [MEDICATION(S)] until 07/21/2021 at 4:00 AM. The nursing progress note, dated 07/21/2021 at 5:09 AM, showed the resident requested [MEDICATION(S)] on 07/20/2021 at 5:00 PM (approximately 2 hours after admission). The progress notes also showed Staff C, Licensed Practical Nurse (LPN) started communication with the (offsite) pharmacy regarding the need for the resident's narcotic medication. Staff C's initial communication to the pharmacy requested an authorization number/code to access and remove a dose(s) of [MEDICATION(S)] medication for Resident 1 out of the facility's emergency kit (e-kit/Pyxis machine) to tide her over until her prescription arrived from the pharmacy. However, Staff C did not hear back/receive any communication from the pharmacy until 07/21/2021 at 4:00 AM when the medication [resident's [MEDICATION(S)]] was delivered. On 07/23/2021 at 11:50 AM, Resident 1 stated that she was in severe, excruciating, agonizing pain on 07/20/2021 from around 4:00 PM until the following morning (07/21/2021) at 4:00 AM. Resident 1 also stated that her pain was so severe that she wanted to call 911 to get her back to the hospital because she can't take it anymore being in so much pain. According to the resident, she could not understand why the facility did not give her the pain medication. Resident 1 stated that the hospital made it clear to her that due to her recent surgery and type of procedure that she undergone, it was very important for her to take the medication at least every 3 hours until her pain got under control. The resident further stated that she was afraid that she would develop withdrawal symptoms from narcotics (she received while at the hospital) because she then did not receive any of the pain medication for at least 12 hours at the facility. The resident became tearful and stated that she was upset with what happened and certainly would not like to experience the same situation. Observation showed the resident's abdomen had a large abdominal wound dressing and a drainage bag from a [CONDITION(S)] (an artificial opening in the abdomen). The resident stated, These are the reasons why I am in severe pain (pointing at the abdominal wounds area), and that her pain could not be relieved by simply taking Tylenol (an over-the-counter pain medication/fever reducer). The resident stated that she finally fell asleep while waiting for the pain medication because she was extremely exhausted from being in so much pain. Both the MAR and the Narcotic Pain Medication log showed the resident complained of severe pain and received the highest dose ordered, [MEDICATION(S)] (6mg), thirteen times since the medication became available on 07/21/2021. On 07/23/2021 at 12:20 PM, Staff D, Registered Nurse (RN) stated she was the day shift nurse who came on duty soon after Resident 1 had received her first dose of [MEDICATION(S)] at 4:00 AM. Staff D stated that the resident reported severe agonizing pain during her shift and requested [MEDICATION(S)] almost every 3 hours to ease and manage her pain to the abdomen and lower back area. According to Staff D, Resident 1 reported she was not feeling good and was hurting so bad the entire night without pain medication. On 07/23/2021 at 3:00 PM, Staff C, Licensed Practical Nurse (LPN) stated that Resident 1 was admitted to the facility on [DATE] at 3:00 PM. Staff C stated Resident 1 arrived to the facility with a valid prescription for the [MEDICATION(S)] which was immediately sent to the pharmacy to be processed. Staff C also stated that he spoke to a pharmacy staff who acknowledged the receipt of the prescription for [MEDICATION(S)], but the pharmacy staff refused to provide him with an authorization number to remove the medication from the facility e-kit and told him that they would fax him the authorization number. According to Staff C, Resident 1 complained of severe pain and had requested [MEDICATION(S)] at around 5:00 PM on 07/20/2021. Staff C stated that he attempted to call the pharmacy at least 5 times and left messages, but he did not hear back from the pharmacy until the medication arrived at the facility on 07/21/2021 at 4:00 AM. Staff C further stated that he attempted to offer the resident Tylenol while waiting for the [MEDICATION(S)], but the resident had refused. Staff C also stated that he did not notify the doctor or the Director of Nursing/facility administration about the delay in access issue with Resident 1's narcotic medication. Staff C stated that he should have called the doctor and the Director of Nursing, as both could have helped him with the situation in getting the authorization number and ensuring timely administration of the medication. On 08/02/2021 at 11:00 AM, Staff B, DNS, stated the pharmacy had reviewed and revised its process in providing authorization number to the facility. Staff B stated that the root cause of this incident was due to the pharmacy's procedure of not providing authorization code timely to access the facility's emergency kit. Staff B also stated that Staff C LPN should have called her when he had trouble contacting the pharmacy in obtaining authorization, so she could have intervened and call the pharmacy herself to assist in the process. Staff B further stated that no resident should experience what Resident 1 had experienced, to be in so much pain and not able to receive the medication timely as ordered after a major surgery. Staff B added that the incident was clearly avoidable and the process in acquiring an authorization number from the pharmacy should have been better than this to meet the needs of the residents. Reference WAC: 388-97-1060 (1)

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate and timely acquiring, receiving, dispensing, and administering of all drugs, to meet the needs of each resident for 1 of 3 residents (Resident 1) reviewed for pharmacy services. Failure to ensure timely administration of a narcotic pain medication caused harm to Resident 1 who experienced severe pain and discomfort. Findings included . Resident 1 was admitted to the facility on [DATE] for rehabilitation therapy. The resident's diagnoses list included a complicated major abdominal surgery. The resident was admitted to the facility with an order for [MEDICATION(S)] ( a narcotic pain medication) 2 milligram (mg) to 6mg every 3 hours as needed for moderate to severe pain. A review of the resident's clinical records, including Medication Administration Records (MAR), Nursing Progress notes and Narcotic Pain Medication Log from 07/20/2021 to 07/23/2021, showed Resident 1 did not receive any [MEDICATION(S)] until 07/21/2021 at 4:00 AM. The nursing progress note, dated 07/21/2021 at 5:09 AM, showed the resident requested [MEDICATION(S)] on 07/20/2021 at 5 PM (approximately 2 hours after admission). The progress note also showed Staff C, Licensed Practical Nurse (LPN) started communication with the (offsite) pharmacy regarding the need for the resident's narcotic medication. Staff C's initial communication to the pharmacy requested an authorization number/code to access and remove a dose(s) of [MEDICATION(S)] medication for Resident 1 out of the facility's emergency kit (e-kit/Pyxis machine) to tide her over until her prescription arrived from the pharmacy. However, Staff C did not hear back/receive any communication from the pharmacy until 07/21/2021 at 4:00 AM when the medication [resident's [MEDICATION(S)]] was delivered. On 07/23/2021 at 11:50 AM, Resident 1 stated that she was in severe, excruciating, agonizing pain on 07/20/2021 from around 4:00 PM until the following morning (07/21/2021) at 4:00 AM. Resident 1 also stated that her pain was so severe that she wanted to call 911 to get her back to the hospital because she can't take it anymore being in so much pain. According to the resident, she could not understand why the facility did not give her the pain medication. Resident 1 stated that the hospital made it clear to her that due to her recent surgery and type of procedure that she undergone, it was very important for her to take the medication at least every 3 hours until her pain got under control. The resident further stated that she was afraid that she would develop withdrawal symptoms from narcotics (she received while at the hospital) because she then did not receive any of the pain medication for at least 12 hours at the facility. Both the MAR and the Narcotic Pain Medication log showed the resident complained of severe pain and received the highest dose ordered, [MEDICATION(S)] (6mg), thirteen times since the medication became available on 07/21/2021. On 07/23/2021 at 3:00 PM, Staff C, Licensed Practical Nurse (LPN) stated that Resident 1 was admitted to the facility on [DATE] at 3:00 PM. Staff C stated Resident 1 arrived to the facility with a valid prescription for the [MEDICATION(S)] which was immediately sent to the pharmacy to be processed. Staff C also stated that he spoke to a pharmacy staff who acknowledged the receipt of the prescription for [MEDICATION(S)], but the pharmacy staff refused to provide him with an authorization number to remove the medication from the facility e-kit and told him that they will fax him with the authorization number. According to Staff C, Resident 1 complained of severe pain and had requested [MEDICATION(S)] at around 5:00 PM on 07/20/2021. Staff C stated that he attempted to call the pharmacy at least 5 times and left messages, but he did not hear back from the pharmacy until the medication arrived at the facility on 07/21/2021 at 4:00 AM. Staff C further stated that he attempted to offer the resident Tylenol while waiting for the [MEDICATION(S)], but the resident had refused. On 08/02/2021 at 11:00 AM, Staff B, DNS, stated the pharmacy had reviewed and revised its process in providing authorization number to the facility. Staff B stated that the root cause of this incident was due to the pharmacy's procedure of not providing authorization code timely to access the facility's emergency kit. Staff B also stated that Staff C LPN should have called her when he had trouble contacting the pharmacy in obtaining authorization, so she could have intervened and call the pharmacy herself to assist in the process. Staff B further stated that no resident should experience what Resident 1 had experienced, to be in so much pain and not able to recieve the medication timely as ordered after a major surgery. Staff B added that the incident was clearly avoidable and the process in acquiring an authorization number from the pharmacy should have been better than this to meet the needs of the residents. Reference WAC: 388-97-1300(1)(a)(b)(i)(ii)

Based on observation, interview and record review, the facility failed to prevent and timely identify, monitor, and treat a change in condition/skin breakdown for 1 of 3 residents (Resident 1) reviewed for change in condition and skin care. These failures caused harm to Resident 1 who was hospitalized and developed a severe form of skin breakdown and pain while at the facility. Findings included . [CONDITION(S)] (or [CONDITION(S)] [CONDITION(S)]) is defined as an [CONDITION(S)] condition of skin folds, induced or aggravated by heat, moisture, maceration, friction and lack of air circulation. Moisture Associate Skin Damage or MASD is defined as an inflammation and erosion of skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate (discharge), [MEDICATION(S)] or saliva. Resident 1 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's skin care plan, dated 01/20/2021, showed the resident was at risk for skin breakdown related to obesity and diabetes. The care plan directed facility staff to monitor and observe the resident's skin every shift for signs and symptoms of skin breakdown. A review of nursing progress notes, dated 06/15/2021, showed the resident complained of feeling weak and that he felt a shock twice in the morning. Resident 1 was found to have a burn wound on his left lower back area. The resident was transported to the hospital for further evaluation. A review of the hospital records from 06/16/2021 to 06/29/2021 showed Resident 1 arrived at the hospital's emergency department on 06/16/2021 at 12:34 AM. The hospital records showed the resident was found to have a large purulent [consisting of, containing, or discharging pus] Skin and soft tissue infections [SSTI] on his left flank and groin [CONDITION(S)]. The hospital records, inpatient wound consultation reports, and assessments showed the resident arrived at the hospital with several skin issues, which included the following two non-pressure related wounds present on admission (POA): A. Left lower back full thickness wound (the skin damage extends below all layers of skin into the fat and/or beyond muscle, bones or tendon). The wound measured 2.5 centimeter (cm) in length and 1.5 cm wide with the depth unable to be assessed or measured due to the presence of 100% purulent slough (dead tissue). The surrounding skin was described as erythematous (skin redness), indurated (hardened/firm skin), denuded (loss of the outer layer of the skin caused by moisture and friction) and painful. B. Bilateral (both sides) groin and inner thighs MASD. The skin breakdown extends from the bilateral groin area, to the supra pubic (top/above the groin), and to the bilateral inner thighs area. The skin was described as erythematous with [CONDITION(S)] (abnormal growth or appearance), fragile, denuded and painful. C. Coccyx (tailbone) unstageable pressure ulcer/injury (PU/PI). The wound measured 6cm in length and 1cm wide with the depth unable to be assessed or measured due to the presence of 100% slough. The surrounding skin was noted to have blanchable redness that measured 10 cm in length and 6 cm wide and was painful with wound palpation. The hospital records documented that the facility reported and noted a gradual change in Resident 1's mental status over the last 5 days and suspected the resident developed a burn on his L [left] flank, but are unsure where the skin changes there came from, which has been present for a few days per their report. The hospital records also showed that the hospital staff were concerned about the care and services the resident received from the facility, particularly the delay in recognition of the wounds and inadequate help with hygiene. A review of Resident 1's clinical records from 06/10/2021 to 06/16/2021 showed the facility had no documented assessment and/or record of a change in mental status or condition or MASD in the groin area or any documented pressure ulcer. The only documented wound assessment was dated 06/15/2021, prior to the resident's transport to the hospital. On 06/17/2021 at 2:30 PM, Staff B, Director of Nursing (DNS) stated, the facility had no record of Resident 1 having a change in mental status, or MASD or pressure ulcer. The DNS stated that the facility had identified the back wound on 06/15/2021, which was one of the main reasons Resident 1 was sent to the hospital for evaluation. The DNS stated that the nursing staff who sent the resident to the hospital did not conduct a head-to-toe skin assessment to check whether the resident had any other skin issues or breakdown prior to the hospital transport. The DNS further stated, Resident 1 was independent with toileting task and personal hygiene and that she was not aware of any other change in condition or skin issues on Resident 1. A review of the eINTERACT Transfer Form (hospital transfer form), dated 06/16/2021, completed by Staff C, Registered Nurse (RN) showed the resident had no other skin issues except the left lower back wound. On 06/21/2021 at 4:25 PM, Staff C, RN, stated that she completed the eINTERACT Transfer Form and wound assessment for Resident 1. Staff C stated she only assessed the left lower back wound of Resident 1 and she did not perform a head-to-toe skin assessment. Staff C stated she was not aware of any recent change in condition and any other skin breakdown on Resident 1. Staff C further stated, Resident 1 was independent with activities of daily living (ADL's) and staff were not providing any type of assistance including personal hygiene. On 06/21/2021 at 4:35 PM, Staff D, RN, stated that she was the nurse on duty when Resident 1 was transferred to the hospital on 06/15/2021. Staff D stated that she did not conduct a skin assessment at the time of Resident 1's transfer and was not aware of any other skin issues. On 06/21/2021 at 4:45 PM, Staff E, RN, stated that he recently conducted a head-to-toe skin assessment of Resident 1 on 06/14/21 at around 8:30 PM, but did not notice any skin problems. Staff E stated he was not sure why Resident 1 was then found to have significant wounds the following morning, less than 24 hours after he conducted a skin check. Staff E stated he was not aware of any changes in Resident 1's condition prior to this recent hospitalization . Staff E further stated, Resident 1 was independent with activities of daily living (ADL's) and staff were not providing any type of assistance including personal hygiene. On 06/24/2021 at 8:10 AM, Hospital Staff #1 (HS1) stated the doctors and hospital staff were concerned about Resident 1's condition when he arrived at the emergency room (ER) on 06/16/2021. HS1 stated that Resident 1's wounds should have been identified and cared for sooner. HS1 stated that the resident was disheveled with serious wounds on his back, coccyx, and groin area that were infected. During an observation and interview on 06/24/21 at 1:30 PM, Resident 1 stated he developed the wounds on his back, groin and tailbone area while at the nursing facility. The resident stated that he had not been feeling good approximately 3 to 5 days before he was hospitalized , and the wounds had developed because he had not been getting out of bed and moving around as he used to. The resident further stated that he could not recall any staff member or any nurse at the facility checking his skin except maybe before he left the faciity on a gurney. The resident said, They don't check my skin regularly and I don't get help [from staff] in cleaning myself. The resident also stated he had diarrhea and urine leak days before he was hospitalized . Resident 1 then showed his groin wounds for observation. The wound was treated with powder and the skin remained open with redness and minimal drainage. The resident also tried to show his back wounds, but the wounds had a wound dressing in place. According to the resident, his wounds were healing but were still very painful and All of it hurts. The resident stated the pain on his wounds was bad enough for him not to be able to sleep, and for him to lose his appetite and his ability to enjoy his day. On 06/24/2021 at 2:00 PM, Hospital Nurse #1 (HN1) stated that Resident 1 was admitted to the hospital with the wounds on his back, coccyx and groin area. HN1 also stated that Resident 1's wounds were infected and was treated with antibiotics. HN1 further stated that Resident 1 had complained of severe pain to his back and groin area, especially during care and/or even at rest. On 06/24/2021 at 2:15 PM, Hospital Nurse, HN2, stated that she was one of the ER nurses who admitted Resident 1. HN2 stated that Resident 1 was admitted to the hospital with a large purulent soft tissue injury on his back, groin MASD and pressure ulcer on his coccyx. HN2 also stated that the doctors who evaluated Resident 1 were concerned that these wounds did not appear to have been receiving care from the nursing facility. During a follow-up interview and record review on 06/30/2021 at 8:15 AM, Staff B, DNS, stated that the facility conducted an investigation related to Resident 1's wounds. Staff B stated that the facility first identified the wound on Resident 1's left lower back on 06/15/2021 and they had no record of any recent change in condition and/or any other skin breakdown. On 07/09/2021 at 11:30 AM, the resident stated that his wounds continued to cause pain and discomfort, but he was feeling a little bit better now because it wasn't as painful as before. Reference: (WAC) 388-97-1060 (1)(3)(b)

Based on interview and record review, the facility failed to timely identify, monitor and treat a pressure ulcer for 1 of 3 residents (Resident 1) reviewed for pressure ulcers/pressure injury (PU/PI). Additionally, the facility failed to implement Resident 1's directed plan of care to minimize the risk of the development of an avoidable pressure ulcer. These failures caused harm to Resident 1 who developed an untreated pressure ulcer while at the facility. 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 nutrition, co-morbidities and condition of the soft tissue. 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 (dead tissue). If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Resident 1 was a long-term care resident of the facility. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of Resident 1's quarterly Minimum Data Set (MDS) assessment, dated 04/28/2021, showed the resident had impaired cognition and required staff supervision with bed mobility and transfers. A review of Resident 1's skin care plan, dated 01/20/2021, showed the resident was at risk for skin breakdown related to obesity and diabetes. The care plan directed facility staff to monitor and to observe the resident's skin every shift for signs and symptoms of skin breakdown. A review of Resident 1's nursing progress notes, dated 06/15/2021, showed Resident 1 was transported to the hospital for further evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the hospital records from 06/16/2021 to 06/29/2021 showed Resident 1 arrived at the hospital's emergency department on 06/16/2021 at 12:34 AM. The hospital records showed the resident had several wounds, including a large purulent (consisting of, containing, or discharging pus) skin and soft tissue infection (SSTI) on his left flank (side of the body between ribs & hip) area and an unstageable pressure ulcer at the coccyx (tailbone) area. The hospital records showed the pressure ulcer wound on the coccyx measured 6 centimeter (cm) in length and 1 cm wide with the depth unable to be assessed or measured due to the presence of 100% slough. The surrounding skin was noted to have blanchable redness that measured 10 cm in length and 6 cm wide and was painful with wound palpation. Per the hospital records, the left lower back (flank) wound was described as a full thickness wound (the skin damage extends below all layers of skin into the fat and/or beyond muscle, bones or tendon). The wound measured 2.5 cm in length and 1.5 cm wide with the depth unable to be assessed or measured due to the presence of 100% purulent slough (dead tissue). The surrounding skin was described as erythematous (skin redness), indurated (hardened/firm skin), denuded (loss of the outer layer of the skin caused by moisture and friction) and painful. A review of the hospital's abdominal and pelvic CT scan (an x-ray image scan) report, dated 06/16/2021 at 5:04 AM, showed that the findings of the CT scan could be consistent with evolving chronic pressure injury/trauma. The hospital records also showed that the hospital staff were concerned about the care and services the resident received from the facility, particularly the delay in recognition of the wounds and inadequate help with hygiene. A review of Resident 1's clinical records from 06/01/2021 to 06/16/2021 showed the facility had no documented assessment and/or record of any pressure ulcer. The clinical records also showed no documented evidence the facility staff monitored and observed the resident's skin every shift for signs and symptoms of skin breakdown as directed by the resident's plan of care. On 06/17/2021 at 2:30 PM, Staff B, Director of Nursing (DNS) stated the facility had no record of Resident 1 having a pressure ulcer prior to his recent hospitalization . A review of the eINTERACT Transfer Form (hospital transfer form), dated 06/16/2021, completed by Staff C, Registered Nurse (RN) showed the resident had no pressure ulcer on 06/15/2021 prior to the hospital transfer. On 06/21/21 at 4:25 PM, Staff C, RN, stated that she completed the 06/15/2021 eINTERACT Transfer Form and wound assessment for Resident 1. Staff C stated that she only assessed the left lower back wound of Resident 1, and she did not perform a head-to-toe skin assessment. When asked why she documented None on the eINTERACT Transfer Form without fully assessing the resident's skin, Staff C was not able to provide an answer. Staff C stated she was not aware of any other skin breakdown on Resident 1. Staff C further stated, Resident 1 was independent with bed mobility and transfer, and was not on any turning or repositioning schedule to prevent and/or minimize the risk of pressure ulcer. On 06/21/2021 at 4:35 PM, Staff D, RN, stated that she was the nurse on duty when Resident 1 was transferred to the hospital on 06/15/2021. Staff D stated that she did not conduct a skin assessment of Resident 1 and was not aware of any pressure ulcer prior to and at the time of the hospital transfer. On 06/21/2021 at 4:45 PM, Staff E, RN, stated that he recently conducted a head-to-toe skin assessment of Resident 1 on 06/14/2021 at around 8:30 PM, but did not notice any skin problems. Staff E stated he was not sure why Resident 1 was observed at the hospital with significant wounds the following morning, less than 24 hours after his documention that he conducted a skin check. Staff E further stated, Resident 1 was independent with bed mobility and transfer, and was not on any turning or repositioning schedule to prevent and/or minimize the risk of pressure ulcer. On 06/24/2021 at 8:10 AM, Hospital Staff #1 (HS1) stated that the doctors and hospital staff were concerned about Resident 1's condition when he arrived at the emergency room (ER) on 06/16/2021. HS1 stated that Resident 1's wounds should have been identified and cared for sooner. HS1 stated that the resident was disheveled with serious wounds on his back, coccyx, and groin area that were infected. During an observation and interview on 06/24/2021 at 1:30 PM, Resident 1 stated that he acquired the wounds on his back, groin and tailbone area at the nursing facility. The resident stated he had not been feeling good approximately 3 to 5 days before he was hospitalized , and the wounds he had developed on or about the same time because he had not been getting out of bed and moving around as he used to. The resident further stated, he could not recall any staff member or any nurse at the facility checking his skin except maybe before he left the faciity on a gurney. The resident added, they don't check my skin regularly and I don't get help in cleaning myself from staff. The resident also stated he had diarrhea and urine leak days before he was hospitalized . Resident 1 then tried to show his wounds, including the coccyx wound, however it had a wound dressing in place. The resident stated his wounds on his back and coccyx area caused so much pain that he could not lay flat and rest comfortably on his back. According to the resident, his wounds were healing, but were still very painful. All of it hurts. The resident stated that the pain on his wounds was bad enough for him not to be able to sleep, and for him to lose his appetite and his ability to enjoy his day. On 06/24/2021 at 2:00 PM, Hospital Nurse #1 (HN1) stated that Resident 1 was admitted to the hospital with the wounds on his back, coccyx and groin area. HN1 also stated, Resident 1's wounds were infected and was treated with antibiotics. HN1 further stated that Resident 1 had complained of severe pain to his back and groin area, especially during care and/or even at rest. On 06/24/2021 at 2:15 PM, Hospital Staff #2 (HN2) stated that she was one of the ER nurses who admitted Resident 1. HN2 confirmed that Resident 1 was admitted to the hospital with a large purulent soft tissue injury on his back, groin MASD and pressure ulcer on his coccyx. HN2 also stated that the doctors who evaluated Resident 1 were concerned that these wounds did not appear to have been receiving care from the nursing facility. During a follow-up interview and record review on 06/30/2021 at 8:15 AM, Staff B, DNS, stated that the facility conducted an investigation related to Resident 1. The DNS stated the facility first identified the wound on Resident 1's left lower back on 06/15/2021, and they had no record of a change in condition or any other skin breakdown. On 07/09/2021 at 11:30 AM, the resident stated that his wounds continued to cause pain and discomfort, but he was feeling a little bit better and it wasn't as bad as before. The resident stated he could not sleep and lay on his back because of his sore which makes it very uncomfortable. On 07/09/2021 at 12:05 PM, Staff B, DNS, stated that the resident now required more staff assistance with his activities including bed mobility, transfers, toileting and personal hygiene. Staff B stated the resident continued to require skin and wound care after his recent hospitalization . Reference: (WAC) 399-97-1060 (3)(b)

Based on interview and record review, the facility failed to prevent an accident for one of three residents sampled for falls (Resident #1). The facility failed to implement the care plan for two staff to assist the resident with bed mobility and the resident fell out of bed during care. This fall caused significant pain and a transfer to the emergency room for Resident #1. Findings included . Review of facility records showed Resident #1 admitted to the facility in September 2020 for rehabilitation and had general arthritis. According to the facility Minimum Data Set assessment (MDS), dated [DATE], Resident #1 was alert and oriented and needed two people to assist him with bed mobility. The facility record showed Resident #1 weighed 455.2 pounds on 10/05/2020. The facility admission Pain Evaluation, dated 09/11/2020, showed Resident #1 had a pain level of zero with some soreness and aches. The facility care plan, dated 09/12/2020, showed Resident #1 was to have two persons assist him with his bed mobility. Review of the facility progress note, dated 10/28/2020, showed Resident #1 experienced a fall out of bed resulting in injury to knees, reported significant pain to the nurse and could not move on his own. According to the facility investigation, dated 10/28/2020, Resident #1 fell from the bed to the floor in his room during care while a nurse aide, Staff A, was changing the bed linens with Resident #1 in the bed. According to the facility investigation, Staff A was moving Resident #1 in the bed without help from other staff and was the only staff present in the room. During an interview on 11/11/2020 at 4:40 p.m., Resident #1 stated at the beginning when he was first admitted to the facility during the month before the fall, two staff always helped him with mobility in bed, but lately it was often only one person assisting him. Resident #1 also stated on the day of the fall from bed on 10/28/2020, Staff A was changing the bed sheets and leaned Resident #1 to one side, with no rail to grab on the bed. Resident #1 fell from the bed when Staff A tugged on the (underlying) bed sheet. Resident #1 stated he fell face down on the floor and onto his knees and elbows. The facility investigation also showed that after Staff A rolled Resident #1 to one side of the bed to change the bed sheet, Resident #1 slipped out of bed and fell to the floor. The investigation showed there were no enablers on the bed for Resident #1 to hold onto at the time of the fall. And that the fall resulted from Resident #1 being moved in the bed by only one staff when two staff were needed per facility care plan. Further review of the facility investigation showed preventative measures for this fall would have been to follow the plan of care and have two staff assisting Resident #1 with bed mobility as the resident was a larger person, 441.6 pounds, 6 feet tall, and used a bariatric bed (bed sized for large person). The facility investigation report that other staff who entered Resident#1's room after the fall found the resident lying face down on the floor screaming due to pain in both knees and arm. Pain medication was given and Resident #1 was transferred via 911 to the hospital due to significant pain and possible injury. Staff A was educated to follow the care plan. A facility Skin Check, dated 11/12/2020, showed Resident #1 had bruising and abrasion on the right knee, bruise on left shin, and bruise on left shoulder. Review of the facility Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED]. During the following days after the fall into November 2020, Resident #1 received as needed narcotic pain medication three times per day on November 1 and 2, 2020, and three to four times per day on November 5 through November 12, 2020. During an interview on 11/13/2020 at 1:50 p.m., Resident #1 stated that before the fall his knee pain was around 7 out of 10, and after the fall it was 25 out of 10, worse than ever. Resident #1 stated that now, 15 days later, the pain was still 10 out of 10 if it has been awhile since pain medication (narcotics) was given (Resident #1 specified if without narcotic for 12 hours the pain is at 10 level). Review of the facility post-fall nursing documentation, dated 10/28/2020, showed Resident #1 returned from the emergency roiagnom on [DATE] at 7:20 p.m., with a [DIAGNOSES REDACTED]. In addition, Resident #1 had new narcotic MEDICATION ORDERS FOR [REDACTED] An additional nursing note, dated 10/29/2020, showed Resident #1 had bilateral knee pain the following day after the fall and narcotics were given. Review of the facility progress note, dated 10/29/2020 the day after the fall, showed Resident #1 had a new order for a narcotic for acute severe pain bilateral knees for seven days. The 10/29/2020 nurse note also showed Resident #1 had pain due to the fall that was difficult to manage and ice packs were also being implemented. In addition, the nurse note, dated 10/29/2020, showed a new order was also obtained for another medication for the knee inflammation for ten days, and a one-time injection for the acute knee pain experienced by Resident #1. During an interview on 11/16/2020 at 12:20 p.m., Staff A, the nurse aide present at the time of the fall from bed, stated that she did not know until after the fall that there was supposed to be two staff to assist Resident #1 with care in bed. Staff A stated that this was the second time she took care of Resident #1. Staff A stated she was alone when she was changing the bed sheet for Resident #1, and when she tugged on the sheet to tuck it, Resident #1 fell out of bed onto the floor. Staff A stated that Resident #1 yelled in pain when he was on the floor. During an interview on 11/16/2020 at 12:30 p.m., Staff B, the licensed nurse on duty at the time of Resident #1's fall, stated that he found Resident #1 on the floor after the fall and the resident was screaming in pain. Staff B stated that it was not normal for Resident #1 to scream in pain. Staff B also stated Resident #1 was screaming about pain in his knee and shoulders. Staff B further stated that Resident #1 had discomfort in his knee before the fall, but the pain was worse after the fall which was treated with new narcotic medication. Staff B also stated that Resident #1 was supposed to have at least two people help him for care, but only had one staff there at the time of the fall. Reference (WAC) 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to immediately notify a medical provider of and follow-up on early signs and symptoms of a urinary tract infection [MEDICAL CONDITION] and failed to promptly implement a medical provider's order that led to a delay in care for one of two residents (#6). This failure resulted in harm for Resident #6 who developed [MEDICAL CONDITION] (in response to severe a infection) with hospitalization that lead to the resident's death. Findings included . A journal supported by the National Institute on Aging (www.nia.nih.gov.) showed that older adults with Urinary Tract Infections (UTI's) may not always exhibit any of the hallmark signs and symptoms of a UTI, such as cloudy, dark, bloody, strong or foul smelling urine, or low grade fever. This is because their immune systems are unable to mount a significant response to the infection. A marked change in mental state (Confusion) is often a symptom of a UTI in the elderly. Indicators of infection in older adults include the following symptoms, especially if the onset is sudden: *Confusion or [MEDICAL CONDITION] *Agitation *Hallucinations *Other unusual behavioral changes *Poor motor skills or loss of coordination The National Institute of Heath (www.NIH.gov) also issued a UTI algorithm to identify major symptoms of a UTI; and how to proceed if at least 1 major symptoms of UTI is present, such as fever, pain on urination, mental status changes, blood in urine, flank pain: A urinalysis/urine culture should be obtained, the designated provider Notified, and provider orders followed. Review of the facility policy revised on 11/19/19, titled, Change in Condition, Notification of, showed the following: 1. A center must immediately inform the patient, consult with the patient's physician and notify, consistent with his/her authority, the patient's Health Care decision maker (HCDM) where there is: - A significant change in the patients's physical, mental or psychosocial status (a deterioration in health, mental or psychosocial status in either life threatening conditions or clinical complications) 2. Immediate notification- Acute or sudden in onset. A marked change, unrelieved by measures already prescribed. 3. Report immediately- Altered Mental Status (significant change in cognitive function from usual with or without altered level of conciousness). Confusion follows the same criteria for Altered Mental Status. Resident #6 The resident was admitted to the facility on [DATE] for rehabilitation services including Physical Therapy (PT) with a discharge plan to go back to her prior living situation. According to the resident's admission Minimum Data Set assessment (MDS), dated [DATE] as per a hardcopy printed from the facility's electronic medical record system (EMR) on 08/06/2020, the Brief Interview for Mental Status (BIMS) Assessment showed the resident was alert, oriented, and able to communicate her needs. Review of the nursing progress notes, dated from 02/25/2020 to 03/01/2020, showed the resident was alert, oriented, and able to communicate her needs during this period. A progress note written by Staff E, Physical Therapy Assistant (PTA), dated 03/02/2020 at 4:35 PM, showed that during a physical therapy session, the resident demonstrated increased confusion and impulsiveness compared to a previous session. Staff E also noted that the resident was not able to state the correct month which was a change in the resident's cognition. Staff E's progress note showed, Informed nursing of the patient's recent confusion. Four hours later at 9:00 PM, a nursing progress note showed no mention of any specific follow-up interventions to the PTA's report of resident confusion, assessment of the resident r/t altered mental status, nor notification of the medical provider related to the resident's earlier episode of confusion. The next nursing progress note, dated 03/03/2020 at 12:00 AM (but was a Late entry note entered into the EMR on 03/5/2020 at 5:48 PM) showed there was a significant change in Resident #6's mood/behavior (restlessness, constant shifting in chair and tiredness) which was reported to the Nurse Practitioner (NP). The note showed that the NP ordered a UA urinalysis (A urine test to detect disorders, such as urinary tract infections) and STAT blood tests (Immediate blood draw). The note did not show the resident's earlier episode of confusion was reported to he NP. This note also showed the resident's legal representative was not notified of these events until 4 PM on 03/03/2020 (16 hours later). Review of the EMR Physicians orders for Resident #6 showed an order to obtain a UA and Stat Labs (blood tests) which was to start at 10:31 AM on 03/03/2020 and ended at 23:59 PM on the same day. Review of the March 2020 Medication Administration Record [REDACTED]. However there was no indication that the order was completed as it was left blank without a check mark or nurses initials. Further review of the EMR for Resident #6 did not show any documented attempts by nursing staff to collect a urine sample for the urinalysis or STAT blood tests from 03/03/2020 at 12 AM until 03/04/20 at 1:27 AM (over 24 hours later). The next nursing progress note, dated 03/04/2020 at 01:27 AM, showed Resident #6 had increasing confusion that worsened throughout the day and evening (of 03/03/2020). The note showed the resident was more confused, less cooperative, refused to give urine sample by catheterization, clean catch and refused blood draw. The note did not show the medical provider was immediately notified of failed attempt(s) to obtain the urine sample and blood draw and/or the increasing confusion. Review of the NP's progress notes, dated 03/04/20 at 3:46 PM (written after the resident's transfer to a hospital), showed she was notified of a failed blood draw (however it did not indicate when the NP was notified). There was no documentation regarding notification of a refused urine sample collection). There were no further nursing progress notes that showed any documented attempts to collect the urine and blood samples (since the verbal order was obtained over 24 hours prior) nor were there any more nursing notes describing the resident's condition after the NP was notified of the significant change to the failed urine and blood draw attempt over 24 hours later. A nursing note, dated 03/04/2020 created at 12:27 PM, showed Resident #6 had an unplanned transfer. Review of a hospital note showed that on 03/04/2020 at 3:13 PM, the resident was brought into the emergency room (ER) to be evaluated. Upon arrival, the ER note showed the resident was confused with slurred and mumbling speech. The note showed the resident was hallucinating and seeing bugs on the wall. A urinalysis and chest x-ray showed the resident had a UTI and pneumonia, and was admitted to the hospital. The hospital note showed that upon admission to the hospital, the resident was already presenting with signs of organ failure and the resident was immediately treated for [REDACTED].#6 passed away on 03/06/2020. The hospital record documented the cause of death [MEDICAL CONDITION] secondary to UTI and Pneumonia. During an interview on 04/16/2020 at 4:30 PM, the resident's legal representative stated that she had told the facility nursing staff on 03/01/2020 that her mother was having confused episodes with hallucinations of seeing bugs on the wall. The family representative also stated that the next day, during a PT session on 03/02/2020 with Staff E, PTA, the resident was too confused to complete the therapy session and that Staff E had told the representative that the resident probably had a UTI. During staff interviews conducted from 08/05/2020 to 08/11/2020 included the following: Interview on 08/05/2020 at 11:02 AM, Staff I, Registered Nurse (RN) stated that she would report mentation changes to a provider. She stated if another clinician reported mentation changes, she would further investigate and pass the information on to the oncoming shift. Interview on 08/06/2020 at 2:16 PM, Staff J, RN stated that early signs and symptoms [MEDICAL CONDITION] included vital sign changes, but most importantly any changes to the resident's mentation away from the resident s baseline such as confusion. She stated that if she saw or received report of such a change, she would immediately report it to a provider. Interview on 08/10/2020 at 6:37 AM, Staff K stated that a change of condition such as confusion could mean infection such as UTI. Staff K stated that sometimes a resident's temperature might be okay, but he would report to a provider immediately to cover all bases. During an interview on 08/10/2020 at 9:37 AM, Staff F, NP, stated that in any resident situation early reporting to a provider, related to significant changes such as confusion that were away from the resident's baseline, should be reported immediately to prevent irreversible damage. Staff F stated she had no knowledge of Resident #6's initial onset of confusion, she also stated that the resident's episode of confusion should have been reported to a provider to allow for further investigation and early intervention. During an interview on 08/10/20 at 4:53 PM, corporate nurses Staff G and Staff H, stated nursing staff did a shift neurological assessment and because they did not see any evidence of confusion, did not see any reason to notify a provider of the resident's initial onset of confusion. Both staff members were then asked regarding the apparent 24 hour delay in collection of the urine sample and blood draw ordered. Staff G stated that was a more of a documentation issue and how the nurses documented. Reference (WAC) 399-97-1060 (1)

Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19. COVID-19 is an infectious disease from by a new virus causing a respiratory illness with symptoms of a cough, fever, and in severe cases difficulty breathing. Specifically, 1. Facility staff failed to follow droplet transmission based precautions and wear personal protective equipment (PPE) goggles during care of presumed COVID-19 positive resident (R) (R1) and then proceeded to care for other residents during four of six observations when entering/exit droplet precaution rooms on Unit 600. Unit 600 is a separate area from other parts of the facility which housed positive COVID-19 residents as well as presumed and unknown COVID-19 residents. This failure increased the likelihood for serious injury, serious harm, or death and required immediate action to prevent transmission of COVID-19 from positive and/or presumptive COVID-19 residents to negative COVID-19 residents and staff. These failures failure increased the likelihood for serious injury, serious harm, or death and required immediate action to prevent transmission of COVID-19 from positive and/or presumptive COVID-19 residents to negative COVID-19 residents and staff. On 4/8/20 at 3:30 PM the Center Executive Director/Administrator was informed of Immediate Jeopardy (IJ) determination for 42 CFR §483.80 (F880) and the IJ template was emailed on 4/8/20 at 4:18 PM. On 4/10/20 at 11:00 AM the Administrator was informed it was determined the immediacy was removed based on onsite verification that IJ removal plan was implemented. Additionally, 2. Staff did not clean and disinfect high-touch items in resident rooms (room [ROOM NUMBER], 606, 609 and 612) on Unit 600 during 4 of 4 observations of daily room cleaning. 3. Staff did not perform hand hygiene after removing dirty gloves between cleaning different resident rooms (room [ROOM NUMBER], 606, 609 and 612) on Unit 600 during 4 of 4 observations of daily room cleaning. Findings include: Record review of the facility's policy titled, Interim Policy for Suspected or Confirmed Coronavirus (COVID-19), dated March 11, 2020, showed this facility follows current guidelines and recommendations to minimize exposure to respiratory pathogens including [MEDICAL CONDITION] that causes COVID-19. Coronavirus is thought to spread from person to person primarily via respiratory droplet transmission among close contacts. (e.g., when an infected person coughs or sneezes near a susceptible person) . Droplets generally travel only short distances (approximately six (6) feet or less) through the air. Indirect contact transmission via hand transfer of COVID-19 virus [MEDICAL CONDITION]-contaminated surfaces or objects to mucosal surfaces of the face (e.g., nose, mouth) may also occur. Residents with suspected COVID-19 will be placed on droplet precautions. Personnel entering the room will use PPE including gloves, gowns, mask and eye protection. Record review of the facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities, fax dates of 4/4/20, 4/7/20, showed the earliest COVID symptom onset date of 3/6/20 with four current COVID-19 positive residents and three discharged COVID-19 positive residents, four staff were COVID-19 positive, 27 additional residents with fever, respiratory signs and symptoms or other signs and symptoms related to COVID-19, 14 additional staff with fever, respiratory signs and symptoms or other signs and symptoms related to COVID-19, 20 active and discharged /transferred residents were tested for COVID-19 and 14 staff were tested for COVID-19. Unit 600 housed four residents that were positive for COVID-19 and three residents with symptoms related to COVID-19. During interview on 4/8/20 at 8:15 AM during Entrance Conference, Clinical Vice President and Administrator stated that all COVID-19 positive residents were housed on Unit 600 which was on first floor and separate from other areas of the facility by an elevator/stairs. *Failed to wear goggles Record review of the facility's Line List for COVID-19 Outbreaks in Long Term Care Facilities, fax dates of 4/4/20, 4/7/20, showed R1 had COVID-19 symptoms on 4/1/20 with temperature of 101.1 degrees Fahrenheit. R2 had COVID-19 symptoms on 4/1/20 when he had a temperature of 99.1 degrees Fahrenheit and was positive for the coronavirus. R1 Review of R1's record showed the facility admitted the resident on 3/23/20 with [DIAGNOSES REDACTED]. *Medication Administration Record [REDACTED] COVID 19 with start date of 4/3/20. *Progress notes, dated 4/9/20, showed reason for stay was after care for fracture, pain management, elevated temperature yesterday evening, and exposure to COVID-19 patient. *Progress notes, dated 4/8/20, showed appointment for today rescheduled due to awaiting results of COVID-19 test. Will reschedule once results are obtained. *Progress notes for time period of 3/26/2020 08:40 to 4/9/2020 06:59 showed R1 resided in 602B with R2. No room change during this time period. *Progress notes, dated 4/8/20, documented by Licensed Nurse (LN) 1 showed dressing changed to RLE (right lower extremity) and R (right) upper thigh. No s/s (signs and symptoms) of infection at the site, skin graft healing well. T(emperature) today 100.8, reported to (name of ARNP), will monitor at this time. *Current physician orders [REDACTED]. R2 Review of R2's record showed the facility admitted the resident on 2/5/20 with [DIAGNOSES REDACTED]. *Progress notes, dated 4/9/20, showed reason for stay was exacerbation of respiratory condition, positive COVID-19, used four liters of oxygen continuously via nasal cannula, and walked to the bathroom with assistance. *Progress notes, dated 4/5/20, showed a change in condition with resident tested positive for COVID-19 on 4/3/20. *Care plan, initiation date of 4/6/20, showed Patient is positive for COVID-19 on 4/2/20 and at risk of respiratory complications and interventions included Droplet Precautions. During concurrent observation and interview on 4/8/20 at 9:20 AM showed Standard plus Droplet Precautions sign on room [ROOM NUMBER]. The sign showed wear a mask and gloves upon entering this room; and if necessary, eye protection. Wear gowns. R1 and R2's names were shown on 602 door. R1 was in the window bed and R2 was in the door bed. Licensed Nurse (LN) 1 was observed in 602 and stood within six feet of R1. R1 asked in a loud voice why his appointment scheduled for 10am today was cancelled and why he was not informed about it earlier. LN1 left room [ROOM NUMBER] and went to the nursing station to speak with Admissions staff. LN1 returned to room [ROOM NUMBER] and stood within six feet of R1 and stated that R1's coronavirus test results had not come back yet and therefore appointment will be rescheduled until test results are known. LN1 exited room and returned within a few minutes and again stood within 6 feet of R1 and handed R1 a piece of paper. During the above interactions with R1, LN1 wore a gown and face mask but did not wear goggles or face shield. During interview, LN1 stated that R1 was supposed to go to a skin graft appointment but it was cancelled as COVID-19 results were not back yet. LN1 stated that R1's roommate, R2, was COVID-19 positive. When asked if LN1 was supposed to be wearing goggles due to Droplet Precautions, LN1 stated that she should be wearing goggles but she forgot to wear it. LN1 immediately went to nursing station and later was observed wearing goggles. During a concurrent record review and interview on 4/8/20 at approximately 9:40 AM Infection Preventionist (IP) reviewed Standard plus Droplet Precautions sign on room [ROOM NUMBER] and stated that goggles should be worn as it was necessary. Observation on 4/8/20 at 12:30 PM showed LN1 standing within 6 feet of R1 in R1's room. LN1 exited room and went to the nursing station (about 50 feet away) and then immediately returned to R1's room. LN1 stayed in R1's room for several minutes and was observed standing within 6 feet of R1 and then exited the room. LN1 wore a gown and face mask while in R1's room but was not wearing goggles. During an interview on 4/8/20 at approximately 12:45, immediately after above observation, LN1 stated that she had completed R1's dressing/wound care and was going to see what else needed to be done. LN1 stated that she exited R1's room because she forgot A&D ointment for the wound care and got it from the medication cart near the nursing station. When asked if LN1 was supposed to be wearing goggles due to Droplet Precautions, LN1 stated that she wasn't wearing goggles during the dressing change because the goggles fall off during dressing change and motioned by bending her head towards her chest. LN1 stated that the Droplet Precautions sign for room [ROOM NUMBER] was for the roommate, R2, who was COVID-19 positive and not for R1. During an interview on 4/8/20 at 1:30 PM IP stated that both R1 and R2 in room [ROOM NUMBER] were on Droplet Precautions and gloves, gown, mask, and goggles should be worn for any interactions with either resident. IP stated that R2 was COVID-19 positive and R1 was presumed COVID-19 positive until R1's coronavirus test results came back negative. During an interview on 4/9/20 at 10:30 AM IP stated that both Unit 600 and the entire facility was considered on COVID-19 quarantine but only Unit 600 had COVID-19 positive residents. Record review of nursing assignment sheet, dated 4/8/20, showed Unit 600 had two nurses and two certified nurse aides assigned. LN1 was assigned Rooms 600 to 611; which included residents who a) tested positive for the coronavirus (COVID-19 positive), b) coronavirus test results were pending but with symptoms of coronavirus, and c) residents who had not yet been tested for the coronavirus. During an interview on 4/8/20 at 3:47 PM IP stated that the Infection Prevention and Control Program Description outlines the role of IP is to initiate specific precautions to prevent transmission of infections and therefore a nurse is able to put someone of transmission based precautions (TBP) and a physician's orders [REDACTED]. During an interview on 4/10/10 at 10:20 AM LN2 stated that Unit 600 census was 14 residents. During Exit Conference interview on 4/10/20 at 11:00 AM with Administrator, Clinical Vice President, and Director of Nursing immediate jeopardy for two observations of staff not wearing PPE goggles for COVID-19 presumed positive resident with potential to spread COVID-19 to negative COVID-19 residents was stated again, no further information was provided. During interview on 4/10/20 at 11:00 AM the Administrator was informed it was determined the immediacy was removed based on onsite verification that IJ removal plan was implemented. Record review of In-Service Sign-in sheet for Droplet Precautions for COVID-19, dated 4/8/20, showed use gown, mask, eye protection (goggles/face shield) when going into a COVID positive room even if roommate is negative, you need to gown and mask and eye protection. Treat roommate as positive COVID also. IJ removal plan included: *LN1 was terminated for not following policy and procedures of facility related to transmission of COVID-19 after training was received. *The facility investigated where LN1 traveled after the exposure and concluded that she remained in Unit 600 where she was working that day. Unit 600 is an area of the facility on the first floor, isolated from other parts of the facility. The facility took the following steps to further protect and monitor the residents of Unit 600: a) All residents are being monitored every shift for changes in condition including cough, shortness of breath and elevated temperature ongoing through the pandemic as mandated by the CDC, DOH and other regulatory agencies. b) The Primary Physician and Medical Director have been notified of incident. In addition, the facility is re-educating Licensed and Non-licensed staff. The re-education will be completed by the Infection Control Preventionist/designee and will be provided to staff working currently and prior to staff working their next scheduled shift. *Re-Education will include contact/droplet precautions and the use of PPE to include the use of goggles. No Employee will be allowed to work until they complete the re-education. *Infection Control Preventionist, Director of Nurses, Nursing Management and/or designee will complete rounds of all units to observe the proper use of PPE by staff. Rounds will occur on all 3 shifts at random times and days of the week. Adverse findings, if any, will be immediately corrected and re-education of staff will occur. Any non-compliance with procedures will result in disciplinary action. Findings will be reported to the Administrator, Director of Nursing and Infection Control Preventionist for additional follow up. *Results of the audits will be reviewed by the QAPI committee monthly. *Failed to clean/disinfect high-touch items and perform hand hygiene between glove changes Record review of Healthcare Services Group, facility contractor for housekeeping services, document titled Coronavirus in Long-Term Care Facilities, undated, showed under Environmental Services and Laundry Employees, five step daily room cleaning procedure: proper way to sanitize patient rooms, etc., focusing on high-touch areas such as door knobs, light switches and hand rails, etc. Record review of Healthcare Services Group Handwashing Procedure, dated 10/25/16, showed employees must wash their hands immediately (or as soon as feasible) after they remove gloves. Observation on 4/8/20 at 9:20 AM to 10:00 AM showed Housekeeper (HSKP) 1 in room [ROOM NUMBER] wearing gown, gloves, mask and face shield sweeping the floor, HSKP1 then mopped floor, entered bathroom, gathered plastic bags filled with trash and exited room and walked down the hallway and placed plastic bags into a bin and wheeled bin down the hall. HSKP1 removed gloves and put on new gloves, without performing hand hygiene and entered room [ROOM NUMBER] and proceeded to complete the same tasks above. After exiting room [ROOM NUMBER], HSKP1 removed gloves and entered room [ROOM NUMBER]. HSKP1 donned gloves, but did not perform hand hygiene in between glove changes. Observed HSKP1 sweep and mop floor, bag and remove trash and clean bathroom. HSKP1 exited room [ROOM NUMBER] and removed gloves. No hand hygiene was performed. HSKP1 then entered room [ROOM NUMBER] after donning gloves. HSKP1 again removed trash, swept and mopped and entered bathroom. HSKP1 exited room [ROOM NUMBER] and removed gloves and walked to the exit door at the end of the hall and was entering code in wall mounted key pad to exit unit. During interview on 4/8/20 at approximately 10:00 AM HSKP1 stated that she worked in Laundry and does housekeeping on units a couple days a week. When asked to describe housekeeping tasks for daily room cleaning, for both isolation and non-isolation rooms, HSKP1 stated that daily room cleaning includes sweeping and mopping floors, emptying trash cans, and cleaning bathrooms. When asked about cleaning bedside table in the resident's room, HSKP1 stated that she doesn't touch the bedside table because resident's don't like their things touched and she cleans the bedside table when residents go to the hospital or at the end of their stay. When asked if HSKP1 cleaned the bedside table in any of the rooms she cleaned today including room [ROOM NUMBER], 606, 609 or 612, HSKP1 stated, no. When asked if HSKP1 offered to clean bedside table in these rooms, HSKP1 stated that she did not. When asked if HSKP1 cleaned other high-touch items in the rooms such as door knobs, light switches, tv remote control, side rails, or bed controls and don't involve touching resident's belongings, HSKP1 stated that she did not but should have as that is what she was taught to do. When asked if hand hygiene was performed between glove changes, HSKP1 stated that she did not use hand sanitizer between glove changes between resident rooms because it's hard to put on gloves after her hands are wet. During an interview on 4/9/20 at 11:29 AM with Healthcare Services Group district manager, (DM) facility contractor who provides housekeeping services, DM stated that daily room cleaning includes cleaning and disinfection of high-touch items such as door knobs, door handles, bedside table/desk, hand rails in bathroom, pull cords, toilet flusher, tv remote control, bed control and side rails. DM stated that the daily room cleaning was for all resident rooms; both isolation and non-isolation rooms. DM also stated that housekeeping staff are provided a four-hour in-service as new employees and sign off. DM stated that HSKP1 has worked for facility for the past 3-4 months but previous worked for another facility as a housekeeper. DM stated that the expectation is hand washing or use of hand sanitizer should be done between glove changes and between cleaning resident rooms. Email communications with Healthcare Services Group account manager, dated 4/9/20 at 12:53 PM showed high touch area sign off sheet had been in use since March 2020 and should be done by housekeepers. During an interview on 4/10/20 at 10:25 AM IP stated that hand hygiene audits were done via observation on a weekly basis and included housekeeping staff.

Based on observation, interview, and record review, the facility failed to assess and implement effective interventions to reduce accidents for one of eight (#102) residents reviewed for fall hazards, four of five residents (#39, #66, #84 and #104) reviewed for smoking, and one of three residents (#64) for oxygen use hazards. These failures caused harm for Resident #102 due to fracture re-injury related to a fall, and placed the other residents at risk for serious injury and diminished quality of life. Findings included . Review of the facility policy titled Falls Management initiated on 09/15/01 and revised on 02/18/20, stated, Patients will be assessed for falls risk as part of the nursing assessment process. Those determined to be at risk will recieve appropriate interventions to reduces risk and minimize injury. The purpose of the policy was to reduce risk for falls and minimize the actual occurance of falls. Practice standards stated in the policy included communicating patient's fall risk status to caregivers. RESIDENT #102 The resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Prior to admission, the resident ambulated using an assistive device related to weakness to her legs and impaired imbalance. Review of the a Nurse Practitioner progress note, dated 01/20/2020, showed the resident was admitted to the facility for rehabilitation after a right arm fracture she sustained from a fall at home on 01/11/2020. The note showed the resident had sustained re-injury to her fracture from a second fall that occurred few hours after admission (01/18/2020) while trying to ambulate without an assistive device to the bathroom. The documentation showed the resident sustained [REDACTED]. Review of the Admission Nurse to Nurse Report that was done before a resident was admitted to the facility, dated 01/18/20, showed the resident had a right arm fracture with pain, and was non-weight bearing to the right arm (not to exceed the weight of a coffee cup). The report also showed the resident was a one person assist, walked with a cane, had a history of [REDACTED]. The report showed the facility had knowledge that the resident used an assistive device and was at risk for falls and fractures. Review of the facility admission assessment, completed on 01/18/2020 at 11:12 AM, by Staff K, showed the resident had a fall with a fracture in the last month prior to admission. The assessment showed the resident's mental status was alert with no change in mental status. It also showed the resident had limited/non weight bearing to the right upper extremity, and that the current toileting method assessed for bowel and bladder was bathroom. However, the assessment section for mobility devices needed was left unchecked for cane, crutch, wheelchair and walker. The assessment did not show that the resident's ability to ambulate was assessed nor showed whether there was the need for any assistive devices such as cane, wheelchair or bedside commode were assessed for fall safety. The assessment showed the facility had knowledge of the resident's cognitive status to know her preference of toileting was to use the bathroom, was a 1 person assist, and that the resident used an assistive device. The assessment showed the resident walked every 2 hours while awake, even though her ambulation status at that point of admission had not been assessed and was not mentioned on the nurse to nurse report. Review of the nursing progress notes from 01/18/2020 to 01/19/2020 showed the resident's ambulation needs were never assessed or communicated to direct care staff for safety. The progress notes also did not show that any education was given to the resident or staff regarding fall safety precautions and prevention. Review of the resident's care plan, initiated and revised on 01/20/2020 (2 days after the resident's fall with reinjury), showed the resident was identified as fall risk related to impaired mobility, balance and history of falls. The care plan showed the resident's fall occurred on the day of admission 01/18/20. The care plan included the following interventions: 1. Provide resident extensive assist of 1 person for toileting, 2. Provide resident, limited assist of 1 person for ambulation using a FWW (Front wheel walker) 2. Assist the resident getting in and out of bed with I person extensive assistance. 3. Provide verbal cues for safety and sequencing when needed 4. Monitor for and assist toileting needs. Review of the Kardex (Care plan for nursing assistants(NAC) that was derived from the care plan) dated 02/12/20, showed the same interventions. No baseline care plan was developed upon admission or provided by the facility. Review of the PT (Physical Therapy) Evaluation, completed from 01/20/2020 to 02/18/2020, showed the resident needed contact guard assist (hand contact to help steady or help with balance) and a cane for ambulation. The resident was assessed to be independent with wheel chair use. There was no documentation that showed a wheelchair, cane or contact guard assist were provided upon admission, prior to her fall that reinjured her fracture. Review of the facility investigation, dated 01/19/20, showed the only fall preventative measures that were in place prior to the fall was the call light. The investigation showed the resident was attempting to transfer self to bathroom when she fell without use of any assistive devices. The investigation showed the resident tried to use a bedside (wheeled) table to assist herself with ambulation to the bathroom. It also showed the resident had a history of [REDACTED]. The investigation showed the fall was reasonably related to and resulted from poor safety awareness, use of bedside table to assist with ambulation to the bathroom, impulsive behavior and general weakness. During an interview on 02/07/2020 at 9:22 AM, Resident #102 stated that she initially came into the facility for rehabilitation therapy on her fractured right arm that she sustained after a fall at home. Resident #102 stated that she had a neuro-muscular problem and stated that she had asked the facility for a walker on the day of admission and was told by Staff KK, Nursing Assistant Certified (NAC) that the facility did not have one. The resident then tried to get to the bathroom without a walker, fell , and re-fractured her right arm. The resident stated that she did not have any assistive devices to help her with ambulation. She stated that she had told Staff KK about the fall, and when a nurse looked at her arm two days later, the arm to be fractured with the bone sticking out. The resident stated that she was sent out to the hospital which prolonged her recovery and her stay in the facility. An observation showed the resident's right arm was bluish-black in color. Resident #102 stated that the fall in the facility occurred before she had been assessed by PT, and she did not have any assistive devices or assistance to help with toileting. The resident stated that a cane was given to her after she was assessed by PT on 1/20/2020. The resident stated that the walker that was currently observed in her room was brought in by her family after she got back from the hospital from reinjuring her arm from the fall. During an interview on 02/12/2020 at 3:50 PM, Staff LL, PT Director stated that when a resident was admitted on the weekend, the therapy assessment was usually done 3 days after admission and the initial nursing assessment was done at a lower level. He stated that he would expect to see maximum precautions in place. He stated that the mobility assessments done by PT would have determined what functional interventions or assistive devices would have been appropriate for the resident. During a follow-up interview on 02/13/2020 at 9:59 AM, Resident #102 stated that she was scheduled to have surgery the following week due to the re-injury that occurred in the facility. During an interview on 02/13/2020 at 11:10 AM, Staff MM PT stated that she was involved with the resident's initial assessment after she admitted . She stated that the facility had enough information from the hospital to determine the resident's mobility needs. She stated that the resident had a spinal injury that compromised her lower extremity mobility which placed her at high risk for falls and was the reason the resident sustained [REDACTED]. She stated this could have been prevented if staff had responded to the resident's call light or properly assessed the resident's mobility needs after admission. During a telephone interview on 02/28/2020 at 10:29 AM, the Director of Nursing (DNS) stated that she understood that the resident's fall and reinjury could probably have been avoided if there was better safety precautions in place, better mobility assessment upon admission, and placement of an assistive device such as a wheel chair or bedside commode for safety until a more thorough assessment was done by PT. The DNS stated that to prevent this from happening again, she would work on including better mobility assessments upon resident admission. SMOKING RESIDENT #39 Resident #39 was readmitted to the facility on [DATE]. The primary [DIAGNOSES REDACTED]. According to the quarterly MDS assessment, dated 11/19/2019, the resident was cognitively intact. Record review of the quarterly smoking evaluation, dated 11/08/2019, showed all residents that wanted to smoke required staff to observe them while they smoked prior to the evaluation decision. The evaluation showed that when staff observed the resident smoke, the resident did not properly dispose of ashes/butts and did not safely smoke without use of a smoking apron. The evaluation decision showed supervised smoking was required. Record review of the care plan, with a review date of 01/02/20 showed, Patient (Resident) may smoke with supervision per smoking assessment due to history of non-compliance with safer smoking policies. Refuses to wear smoking apron. Interventions included: Supervise patient with smoking in accordance with assessed needs; maintain patients smoking materials at nurse's station. During an observation and interview on 02/10/20 at 12:08 PM, the resident was returning to the building from the designated smoking area. She had an open package of cigarettes and a lighter. The resident stated, I am not supervised, I can smoke anytime I want to smoke, and she also said there was no staff member with me, I just finished smoking. A staff member was not observed in the designated smoking area at this time nor was a staff member observed to return to the building with the resident. During an observation on 02/13/2020 at 10:53 AM, the resident was in her wheelchair in the hallway. She had an open package of cigarettes and a lighter. Observation on 02/19/2020 at 2:55 PM showed the resident was in her wheelchair in her room with an open package of cigarettes and a lighter. During an interview on 02/25/2020 at 9:52 AM, the resident stated, I keep my cigarettes with me all the time. During an interview on 02/25/20 at 10:33 AM, Staff U, nurse assistant, stated, She (the resident) is a supervised smoker, she keeps he own cigarettes and lighter, we never keep her cigarettes or lighter. We should keep the cigarettes and lighter for the supervised smokers. During an interview on 02/26/2020 at 1:23 PM, the facility Admininstrator stated, We need to be more careful and consistent with our smokers. RESIDENT #84 Resident 84 admitted to the facility on [DATE], the primary [DIAGNOSES REDACTED]. A review of the quarterly MDS assessment, dated 10/10/2019, showed the resident was cognitively intact. A review of the resident's quarterly smoking evaluation, dated 12/13/2019, showed the resident required staff supervision when smoking. In addition, the resident acknowledged the facility's smoking policy and acknowledged that not following the smoking policy may result in the loss of privileges to smoke. A review of the resident's care plan, dated 01/06/2020, related to smoking stated, Monitor patients compliance to smoking policy. A review of the facility's policy on Smoking, revision date 07/24/2018, showed If the patient is cognitively and physically able to secure all smoking materials, the Center may allow him/her to maintain his/her own tobacco or electronic cigarette products in a locked compartment. During an observation and interview on 02/14/2020 at 9:55 AM with Resident #84, the resident was in the hallway with her cigarettes and a lighter. The resident stated that she kept her cigarettes and lighters in her room on top of her dresser. Resident #84 further stated that she did not have a lock box in her room. Observation on 02/14/2020 at 9:58 AM in the resident's room showed there were packs of cigarettes and lighters on top of the night stand. During an interview and observation on 02/14/2020 at 10:02 AM with the DNS showed that in the resident's room on top of the dresser, there were six lighters and several cigarette packs. The DNS stated, Smoking materials, if kept by residents must be locked up. There was no lock box in the resident's room. The DNS stated that she will keep the resident's smoking materials until there is a lock box in her room. SMOKING RESIDENT #30 Resident #30 was a long-term care resident who re-admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A review of his significant change of condition MDS, dated [DATE], showed the resident had intact cognition and needed two people assistance for activities of daily living, except for eating and locomotion. He was also coded a yes for tobacco use. Review of the resident's most recent smoking care plan, initiated on 10/27/2019 and revised on 12/03/19, showed the resident was a supervised smoker per smoking assessment. The interventions showed that the resident required supervision during smoking and staff were to offer smoking apron, however resident refused at this time and will keep offering. Review of the smoking evaluation, dated11/06/2019, showed for smoking decision: supervised smoking is required for resident exhibits times of poor safety awareness and non-smoking areas. Observation on 02/11/2020 at 01:16 PM showed Resident #30 was smoking by himself in the gazebo. He was using a smoking apron, but there were no staff present. Observation on 02/14/2020 at 05:29 AM showed the resident was in bed and observed a lighter at the bedside table. During an interview on 02/14/2020 at 07:19 AM, Resident #30 stated smoking staff keeps his cigarettes and lighter but observed a lighter at his bedside table. During this same time, observed a lighter at the bedside table and Staff Q, Nursing Assistant Certified (NAC) who was in the room stated that sometimes resident did not listen. Resident #30 then agreed that sometimes he kept the lighter with him. Staff Q then removed the lighter and brought it to designated smoking staff for safekeeping. Resident #30 stated that he was told that it was ok for him to keep the lighter, but not the cigarettes. Observation on 02/14/2020 at 10:04 AM showed the resident had a new pack of cigarettes. He stated that he could keep his cigarettes. During an interview on 02/20/2020 at 09:28 AM, Staff U, nurse aide, stated that smoking staff kept the smoking materials for the residents. She further stated that Resident#30 would go out to community during outings and would buy his cigarettes/lighter and would give it to the smoking technician (tech). Record review of the smoking list on 02/20/20 at 09:30 AM showed Resident #30 listed under residents that required supervision. In addition, facility practice for supervision was that the smoking staff/tech kept the smoking materials. During an interview on 02/26/2020 at 11:57 AM with Staff D, Registered Nurse (RN)/Resident Care Manager (RCM), Staff D stated that the resident was supervision with smoking per smoking assessment. In addition, she stated that the smoking tech should be keeping the smoking materials. She further added that for Resident #30, it was difficult to do as the resident would go out and buy his smoking materials. UNSAFE ENVIRONMENT - RAZORS AT BEDSIDE RESIDENT #30 Resident #30 was a long-term care resident who re-admitted to the facility on [DATE]. A review of his significant change of condition MDS, dated [DATE], showed the resident had intact cognition and needed two people assistance for activities of daily living, except for eating and locomotion. A review of the resident's care plan for Activities of Daily Living (ADL), created on 01/03/2019 and revised on 12/20/2019, showed the resident required extensive assist with hygiene. Observation on 02/07/2020 at 09:51 AM showed Resident #30's nightstand had personal items for grooming on it, including four razors with caps. Observation on 02/14/2020 at 05:29 AM showed there were four disposable razors (capped) on the nightstand. During observation and interview on 02/14/2020 at 10:22 AM with Resident #30, the resident had facial hair. When asked who shaved him, the resident stated that he shaved himself, but staff watched him do it. During an interview on 02/14/2020 at 11:39 AM, Staff Q, Nurse Assistant Certified (NAC) stated that the resident usually shaved in the shower, but sometimes, the resident would ask to be shaved and staff would help. During this time, observation with Staff Q showed three razors in the night stand, two were capped/covered and one was without cover. There was one razor that was a facility stock, and the two other razors that were not the facility type razor. Staff Q stated that their practice was to discard used razors in the sharps container. Staff Q discarded the razors in the sharps container located in the nurse's medication cart. Staff Q was told that the razors had been observed in the room since last week. Also during this time, the DNS was informed that razors were found at the bedside and that Staff Q had disposed them in the sharps containers. During an interview on 02/26/2020 at 11:57 AM with Staff D, Registered Nurse (RN)/Resident Care manager (RCM), Staff D was notified that razors were found at the bedside. She stated that it was hard to monitor for this, as the resident would go out to the community and buy his supplies (such as razors, smoking materials). There were no resident observed wandering in the unit. Resident #30 was not using a lock box. Failure to store oxygen tank safely. Resident #64 The resident was admitted to the facility with multiple medical diagnoses, including [MEDICAL CONDITION] and mental illness. The last quarterly MDS assessment, dated 12/27/2019, showed the resident needed supervision from staff for activities of daily living and used a wheelchair for locomotion. Observation on 02/05/2020 at 2:30 PM showed Resident #64 lying on the top of the bed with a nasal cannula in place that was attached to a oxygen cylinder (an aluminum tank of compressed oxygen) which was also lying on top of the bed surface. The top of the tank, the neck and gauge, was pointed toward the foot board of the bed and the resident's legs were positioned next to the tank. The resident stated he had been on oxygen for the last four years and stated that he always kept the cylinder on the bed surface. During an interview on 02/05/2020 at 3:00 PM, the Administrator and the Director of Nursing (DNS) were asked about the cylinder. They stated that the resident refused to allow the staff to remove it or secure it. During an interview on 02/05/2020 at 3:05 PM, Staff B, a Registered Nurse was asked if any alternative to the oxygen tank had been discussed with the resident. Staff B stated that the resident had refused to use an oxygen concentrator because it was too noisy. When asked if they offered the resident a stand (or cart) to secure the oxygen cylinder, she stated no. Observation on 02/05/2020 at 3:07 PM showed both the Administrator and the DNS entered the resident's room, and observed the oxygen cylinder lying on top of the bed surface. After a few minutes of discussion, Resident #64 agreed to place the cylinder in a stand (or cart) next to the bed. Not ensuring the oxygen tank was secured in a stand placed this resident and other residents at risk for traumatic injury if the tank were to fall off the bed surface. Reference: WAC 388-97-1060 (3) (g)

Based on observation, interview and record review, the facility failed to ensure adequate pain management was provided for two of three residents (#63, #105) who were reviewed for pain management. Failure to ensure that Resident #63, who displayed symptoms of pain, consistently received care and treatment for [REDACTED]. In addition, failure to complete a comprehensive pain assessment and include non-pharmacologic interventions in Resident #105's plan of care increased the risk of unnecessary medications. Findings included . The policy for Pain Management, revised on 11/01/2019, showed the goal was to maintain the highest possible level of comfort for patients by providing a system to identify, assess, treat, and evaluate pain. The policy showed that if the assessment triggered pain, a pain evaluation would be completed. The nurse would notify the physician, obtain orders for treatment, and develop an individualized care plan to address and/or treat the underlying cause of pain to the extent possible; with non-pharmacological and pharmacological interventions; using specific strategies for preventing or minimizing pain. RESIDENT #63 Resident #63 was admitted to the facility in 2014, with multiple [DIAGNOSES REDACTED]. The MDS section for assessment of pain showed no pain medications were administered routinely or as needed, and showed that the resident reported no issues with pain. The most recent annual MDS, completed 09/25/2019, showed the same information, and a Care Area Assessment (CAA) for pain was not completed. The resident's care plan, initiated in 2014 and updated 01/08/2020, showed the resident exhibits or is at risk for alteration in comfort related to chronic pain and DJD ([MEDICAL CONDITION] Joint Disease). The interventions directed staff to Monitor for non-verbal signs/ symptoms of pain and medicate as ordered. The care plan also contained directives for staff to monitor and treat pain. Observation on 12/12/2020, at 1:20 PM, found Resident #63 was in the common area seated in the wheelchair. When greeted, the resident responded in non sensical manner (work salad), and responded, in the same way to basic questions., when asked. On 02/13/2020 at 1:30 PM , 02/14/2020 at 1:50 PM, and 02/18/20 at 2:30 PM, the resident was greeted and asked basic questions, a similar response was obtained. Observation on 02/19/2020 at 10:43 AM, during a transfer from the bed to the wheel chair, by two Nursing Assistants (NA's) via a mechanical lift device, Resident #63 was grimacing and moaning during the transfer and when repositioned in the chair. Staff R, one of the NA's present attempted to place a hand splint on the resident's left hand. However, when Staff R attempted to open the resident's partially closed fist to place the splint, Resident #63 cried out in pain and refused to wear the splint device. Observation on 02/20/2020 at 10:45 AM showed Staff C, Licensed Practical Nurse, preparing to do a wound dressing change. Staff C, removed a leg protector from the resident's leg, and then removed an adhesive bandage and dressing. Resident #63 cried out in pain and retracted his leg when the bandage was removed. The leg wound was a shallow crater in which the wound base had white colored slough adhered to it. When asked if the wound bed was visible, Staff C repeatedly attempted to wipe the slough from the wound bed while Resident #63 called out in pain, despite the non verbal and verbal symptoms of pain displayed. After applying the dressing, Staff C, then applied lotion to the resident lower legs feet and toes. The resident also called out in pain as the lotion was applied to the lower legs and toes. When asked about the resident's symptoms of pain, Staff C stated the resident did not need to be medicated for pain. Review of the Medication Administration Records (MAR) for 01/01/2020 through 02/20/2020, showed an order for [REDACTED]. On 02/19/2020 and 02/20/2020, the licensed staff documented the resident was repositioned, for pain relief which was documented consistently for each shift through out the month of February. Despite the pain symptoms displayed while providing care, the [MEDICATION NAME] medication was not administered. Review of the Treatment Administration Record (TAR) between 01/01/2020 and 02/20/2020 showed a directive to ask the resident each shift, Are you free of pain or hurting? It directed staff to document Yes or No. The staff consistently documented Yes, indicating the resident was free of pain, despite the resident having severely impaired cognition. The facility staff did not assess and/or identify pain and did not treat the resident's pain. This resulted in the Resident # 63 experiencing unrelieved pain while care was provided. RESIDENT #105 Resident #105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission/5 day Minimum Data Set (MDS) assessment, dated 01/29/2020, showed the resident was cognitively intact. Review of the (MONTH) 2020 Medication Administration Record (MAR) and Treatment Administration Record (TAR) showed the resident received the following routine and PRN (as needed) medications for pain: 1. [MEDICATION NAME]-Menthol lotion 0.5-0.5% apply to bilateral (both) legs topically two times a day for muscle pain. 2. [MEDICATION NAME] 4% apply to site patient requests topically one time a day for pain. 3. [MEDICATION NAME] HCl tablet 10 mg (milligram) give one tablet by mouth every 8 hours as needed for pain management. 4. [MEDICATION NAME] HCl tablet 2 mg give 0.5 mg tablet by mouth every 4 hours as needed for pain. Further review of the (MONTH) 2020 MAR and TAR showed no documentation that non-pharmacological pain management interventions were developed and implemented for Resident #105. Review of the history and physical conducted by the resident's nurse practitioner, dated 01/26/2020, showed Patient reports increased pain to the area (lower back) does have history of this in the past, during admission was managed for ongoing pain. This is what largely causes agitation and reluctance to care and examination. Review of the care plan, initiated on 02/12/2020 for alteration in comfort related to acute and chronic pain due to osteo[DIAGNOSES REDACTED], intra-spinal abscess, and multiple chronic conditions directed the nursing staff to complete pain assessment per protocol. The care plan also directed nursing staff to evaluate pain characteristics, quality, severity, location, precipitating/relieving factors and to evaluate pain characteristics: such as precipitating/relieving factors. Further review of the resident's clinical records showed no comprehensive pain evaluation or assessment in the resident's assessment list. Factors such as activities, care, or treatment that precipitate or exacerbate pain as well as those that reduce or eliminate pain was not assessed and documented by nursing. During an interview on 02/18/2020 at 1:09 PM, Staff F, Registered Nurse (RN), stated that non-pharmacological intervention for pain were not offered to the resident, and were not identified and documented in the current MAR or TAR. During an interview on 02/20/2020 at 1:58 PM, Staff K, Resident Care Manager, RN, reviewed the completed assessments in the resident's clinical health records, and stated that there was no pain evaluation or assessment, and there was non-pharmacological interventions in the current MAR or TAR. During an interview on 02/26/2020 at 11:26 AM, the Director of Nursing Services stated that nursing staff should have offered a non-pharmacological intervention prior to giving the resident's PRN medications, and should have done a comprehensive pain assessment that included pain threshold. See also F600 regarding the resident's complaints for not getting his pain medications timely. Reference: (WAC) 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to ensure staff followed and implemented abuse and neglect policies and procedures for reporting, investigation and protection for 3 of 5 residents (60, 115, 104) reviewed for abuse and neglect. Additionally, the facility failed to investigate and protect residents from retaliation and further abuse/neglect after reporting concerns to the resident council. The facility's failure to immediately report allegations of abuse and neglect to state agency as required, failure to initiate immediate investigations and failure to protect residents after an allegation of abuse/neglect were made constituted a situation of immediate jeopardy (IJ) on 10/25/18. Resident 60 and Resident 104 suffered psychosocial harm in the form of fear, feeling of abandonment/neglected and experienced retaliation from staff. Findings Included: According to the Washington State Reporting Guidelines for Nursing Homes (Purple Book) dated (MONTH) (YEAR), stated, PROTECTION: Implement facility administrative decisions to ensure the suspected or accused staff person does not have unsupervised access to any resident; INVESTIGATION: Protect the resident and other residents during the course of the investigation. The Elder Justice Act of 2009 added the requirement for the reporting of possible crimes to law enforcement. A review of the facility policy titled Abuse Prohibition dated 08/01/16, stated, the corporation and residential care facilities shall prohibit abuse, neglect, exploitation, involuntary seclusion, and misappropriation of property for all residents through the following: Investigation of incidents and allegations, protection of residents during investigations, and reporting of incidents, investigations, and facility response to the result of their investigations. The Policy directed facility staff to: 1. The Center Executive Director (administrator) or designee is responsible for operationalizing policies and procedures that prohibit abuse, neglect, exploitation, involuntary seclusion and misappropriation of property. 2. The employee alleged to have committed the act of abuse shall be immediately removed from duty, pending investigation. 3. All reports of suspected abuse must be reported to the resident's family and physician. 4. All cases of suspected abuse, neglect, or exploitation require mandatory reporting within one working day to the department of Health and Human Services and to one or more of the following: Disability Rights Center, Long Term Care Ombudsman Program, Office of Advocacy for incidents involving person with mental [MEDICAL CONDITION] or Adult Protective Services. 5. Conduct an immediate and thorough investigation which shall focus on: if abuse or neglect occurred and to what extent; a clinical examination for signs of injuries if indicated; causative factors; Interventions to prevent further injury. 6. The Investigation shall be thoroughly documented on any state required form, and on the incident/accident investigation. Ensure that documentation of witnessed interviews are included. 7. The facility shall protect residents from further harm during an investigation. Findings Included: RESIDENT 104 Resident 104 admitted to the facility on [DATE]. A review of the most recent quarterly Minimum Data Set Assessment MDS dated [DATE] reflected the resident as alert and oriented and able to make needs known. The assessment listed the Resident as dependent on staff for care, requiring two person extensive assist for transfers, and toileting. During an observation and interview on 10/25/18 at 11:25 AM, Resident 104 stated Staff X, Certified Nursing Assistant, CNA, would turn off her call light and did not provide care to her when requested. Staff X would sometimes provide care to her roommate, but not for me when requested. Resident 104 stated there were other staff members that also ignored her requests for care. Throughout the interview, Resident 104 was visibly upset and crying while she recounted an event that occurred on (MONTH) 22, (YEAR): The resident stated she used the call light to request assistance to have her incontinence brief changed. Staff X turned off the call light and proceeded to put her roommate to bed. Resident 104 said she asked Staff X to change her and was told he needed to put the roommate to bed first. Staff X left the room without providing incontinence care for Resident 104. Resident 104 said, I needed to get changed and sat in my wet brief for at least an hour to an hour and 15 minutes. The resident stated she told the next shift about what occurred, but there was no follow-up by the facility about her allegation of not receiving needed incontinence care. Resident 104 said, They never came and said anything to me. Review of the facility grievance/concern log revealed no entries to indicate staff reporting of the resident's concerns of neglect on 06/22/18. Further review of the facility grievance/concern log reflected an entry dated 08/02/18, (Resident 104) states that grievances given to CNAs result in retaliation; she states that she is forced to wait more than 2 hours and feels punished. She also states that resident (Staff QQ, CNA) that is not supposed to care for her still comes in her room to care for her roommate. Additionally, she states that she is forced to lie in bed for six hours without help and feels left behind. The form did not include documented evidence of an immediate and thorough investigation into the resident's grievance as to rule out abuse/neglect and protect the resident. The record failed to include indication that the resident's allegations of abuse/neglect had been reported to the state complaint line. Review of the facility record did not include any documentation in the medical record/progress notes regarding staff report of the 06/22/18 alleged incident or the 08/02/18 grievance. There was no documented evidence of immediate follow-up to the resident's care concerns, protection of the resident, and/or monitoring of the resident for possible psychosocial harm. Review of the incident reporting log failed to reflect any entries or indication of immediate and thorough investigations related to the alleged incident on 06/22/18 or for Resident 104's 08/02/18 grievance regarding abuse/neglect/retaliation. On 10/25/18, the facility was informed of Resident 104's allegations made during the interview with state surveyor. A review of the facility's 10/25/18 investigation into the alleged incident of 06/22/18 reflected Resident 104 had teared up when meeting with facility staff as her telling the story reminded her of what happened in June. Additional review of the record from 06/22/18 to 10/25/18 failed to include monitoring for psychosocial harm related to allegations of abuse/neglect. Additional review failed to include any reporting of abuse to state agencies, law enforcement, or documentation on the facility incident log. RESIDENT COUNCIL In review the resident council minutes dated 07/18/18 reflected multiple concerns. 3. Residents reported that they are afraid/not comfortable reporting individual staff members, when staff does/says something inappropriate to them, due to the retaliation they have experienced, have witnessed, or their peers have stated, when they have asked for their preferences to be met, or assistance they need. They feel strongly that staff should be expected to be aware of, and follow the Resident's Rights, and feel that the majority of staff responds to them as if they have no awareness of the Resident's Rights. Residents reported that when they have reminded staff of Resident's Rights, staff responds that they did not know this information. 4. Resident are upset that their call lights are not being answered in a timely manner, mostly on the evening and night shifts, and are afraid to say anything about the staff, due to #3 above. They report that staff is rude to them, ignore them, laughs at them, do not take them seriously, accuse them of asking from too much from staff, and that even co-worker friends treat them badly when they have spoken up for themselves. 9. Overall, the residents do not feel heard, and supported in their numerous attempts to have their needs and preferences met, as described above. They stated they were asked what their preferences are in the assessment process, and have these preferences met by some departments, but not others. 10. Residents have stated they feel that Genesis (corporation) does not care about them. The facility written response to the 07/18/18 meeting minutes addressed on 08/14/18 reflected no response to concerns addressed under item numbers 3, 4, and 10. There was a written response to number 9 that addressed dietary items, but failed to address the concern of the residents' feelings of not being heard by the facility. Additional review of the facility documentation did not reflect any other facility follow-up to the concerns raised in the 07/18/18 meeting. The record failed to show evidence of immediate and thorough investigation into all of the allegations made on 7/18/18. A review of the facility incident log between 05/01/18 through 10/25/18 failed to show any entries reporting the group concerns raised at the Resident Council 07/18/18 meeting or of any entries reporting individual resident's concerns about staff retaliation. In interview on 10/25/18 at 08:55 AM Staff E, Activities Director, Staff E stated the notes from 07/18/18 reflected the facility response under the minutes. The grievance log would include allegations for people afraid of retaliation. Staff E, Activities Director stated the Resident Council minutes, once completed, were sent to the administrator for review. Staff E said, I brought it to the administrator's attention at a weekly meeting, there was no follow up. A joint interview on 10/25/18 at 11:59 AM included Staff A, Administrator, and Staff B, Director of Nursing Services, DNS. Staff A stated the facility abuse policy included zero tolerance for abuse as staff received abuse/neglect training. Staff A said the facility expectation included separation of individuals involved, and reporting right away to the management team. Staff A said abuse should be reported to the state as soon as possible, and law enforcement notification depends on the situation. Staff B, DNS stated the facility expectation for staff included documentation in the clinical record, and residents should receive assessment for psychosocial and physical harm. At 12:11 PM, Staff A stated the incident with Resident 104, and Resident Council concerns had not been reported to the state. Staff A said, There was a fall through where it was not reported to the state. Staff B, DNS stated there was no documentation to reflect follow-up to the reported incidents for Resident 104 and Resident Council. The facility initiated an investigation of the allegations on 10/25/18, however, a follow-up review of the incident reporting log for dates 10/25/18 through 11/05/18 failed to include any entries to report the residents' group concerns or any individual resident concerns related to staff retaliation. RESIDENT 115 Resident 115 admitted to the facility on [DATE]. A review of the admission MDS assessment dated [DATE] reflected the resident as able to make needs known. The assessment reflected the resident presented with minimal to mild depressive symptoms. In interview on 10/24/18 at 09:23 AM, Resident 115 stated Staff Y, CNA, throws blankets on the bed and also threw wet sheets on the chair. The resident said Staff Y attempted to cover me with a blanket but it makes it too warm. When I alert (Staff Y) that the blanket is too warm, (Staff Y) throws the blanket on the table. Resident 115 said, She gets mad when I complain. Last night she put(took) my blanket and threw it on the table. The other aide folds it and puts it on the chair. I don't feel safe with the night aide. Resident 115 stated both herself and her daughter spoke to someone that worked at the facility about the concern with Staff Y, but there had been no follow-up on her allegation by the facility. During a follow-up interview on 10/31/18 at 09:34 AM, Resident 115 said, I was feeling lonely for a while because I feel they didn't want me here. I no longer feel that way since they have followed up. In review of facility Incident log dated 05/01/18 through 10/23/18, there were no entries in the log to report any incidents or allegations related to safety concern for Resident 115. Review of the record grievance log did not include any entries indicating a grievance for Resident 115. RESIDENT 60 Resident 60 was admitted to the facility on [DATE] for rehabilitation therapy. The resident [DIAGNOSES REDACTED]. A review of the resident's admission MDS assessment dated [DATE], showed the resident had an intact cognition and needed two person assistance with activities of daily living. During a joint interview on 10/26/18 at approximately 1:00 PM with the resident and another surveyor, the resident reported an allegation of neglect against Staff N, NAC. The resident stated, one Sunday ago (unable to recall exact date) at approximately 1:00 PM to 2:00 PM, she called for help and Staff N answered her light. The resident stated she needed to be changed because she had a loose bowel movement. The resident stated Staff N told her he would be back but never returned. The resident added, she did not received any care or changed until about 8:00 PM that day. The resident further stated, I felt neglected. I was crying the whole time I was waiting. I said to myself, please God help me and have somebody come. During a meeting on 10/26/18 at 1:05 PM, the Director of Nursing and Staff J, Regional Resource Nurse were immediately notified of the concerns and allegation of neglect reported by Resident 60 against Staff N. During a joint interview on 10/26/18 at 2:00 PM with the resident and two other surveyors, Staff N was observed leaving Resident 60's room. The resident stated, Yes, it was him who just left my room. The facility was immediately notified of the allegation of neglect against Staff N. However, the facility failed to protect the resident, failed to immediately suspend the alleged staff /perpetrator, and failed to implement the facility's written abuse and neglect policy. During a follow up meeting on 10/26/18 at approximately 2:15 PM with the Director of Nursing and Staff J, both staff members stated they failed to immediately suspend the alleged staff member, and failed to immediately protect the resident after having knowledge of the allegation of neglect. During a joint interview and skin inspection on the same day at 3:00 PM, the resident was observed with a skin breakdown/rash on the left groin area extending to the buttocks, sacrum and coccyx region (tailbone) was observed. The resident reported severe pain to the area. The resident further stated, her skin breakdown started because she would lay on her back for 10-12 hours and she would be sitting on her own urine and bowel movement for a long time. (Refer to F690 - Bowel and Bladder Incontinence for more information.) Reference: (WAC) 388-97-0640 (2)(b), (6)(a-c)

Based on observation, interview and record review, the facility failed to comprehensively assess, initiate appropriate and timely fall interventions, failed to provide adequate supervision and followed the plan of care for 4 of 4 residents (78, 92, 477, 35) reviewed for accidents hazards and fall. The facility's failure to provide adequate supervision, failure to initiate timely and appropriate fall interventions and the failure to follow written policy and plan of care for Resident 78, 92 and 477 constituted an Immediate Jeopardy (IJ) on 10/25/18 and placed other residents at significant risk for serious harm and injury. Resident 78 suffered falls with major injury including head injury, [MEDICAL CONDITION] and hematoma (collection of blood caused by an injury/trauma to the wall of a blood vessel) that required hospitalization . Resident 92 and Resident 477 had multiple falls and no safety plan or timely interventions were put in place to keep the resident safe to minimize the risk of serious injury and harm related to falls. Findings included: According to the Center for Disease Control, (CDC), a fall can cause an injury such as a broken bone or a head injury. These can be very serious, especially if the person is taking certain medicines like blood thinners. Such injuries can make it hard for a person to get around and do everyday activities. A review of the facility fall policy dated 03/15/16, documented, residents will be assessed for fall risk as part of the nursing assessment process. Residents experiencing a fall will receive appropriate care and investigation of the cause. The policy directed facility staff to: A. Identify the resident's fall risk by reviewing and completing nursing assessment and fall risk evaluation. B. Communicate the resident's fall risk status to caregivers. C. Develop individualized plan of care. D. Review and revise care plan regularly. E. If the resident falls, document accident/incident, update care plan to reflect new interventions, conduct interdisciplinary team meeting within 72 hours of fall, and the Center Executive Director and Center Nurse Executive will conduct a post fall review. RESIDENT 78 Resident 78 was admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. A review of the resident's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had intact cognition and needed one person assist with activities of daily living (ADL) including dressing, toilet use and personal hygiene. The MDS also showed the resident balance was not steady and only able to stabilize his balance with assistance from staff/caregivers. Review of the resident's most recent fall care plan initiated on 12/06/16 with review and revision date of 06/20/18, showed the resident was at risk for falls related to stroke. The resident care plan was due for a review, not person centered and individualized. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) During an interview and observation on 10/24/18 at 2:49 PM, the resident stated he had multiple falls in the past. I fell recently with my head bleeding. The resident stated, he suffered a head injury and his head was bleeding pretty good when the staff member found him on the floor. The resident added, I am surprised they found me alive. The resident also stated, his falls always happened at night and he does not know why he is falling. The resident further stated, By midnight, you're on your own here. I pray to God I will not need any help because no one would come to help you until about 6am to 7am. (Refer to F725 - Sufficient Nursing Staff for more information.) The resident stated, he does not feel safe in the facility and nobody had talked to him about his falls and how to keep him safe since he returned from the hospital. The resident was observed with a head injury (a huge hematoma on his head measured at approximately 4 centimeter (cm) in length and 4cm wide with a closed and healing [MEDICAL CONDITION].) Review of the hospital emergency room report and discharge summary dated 10/21/18, showed the resident had a fall and was sent to a local hospital on [DATE] with a [MEDICAL CONDITION], frontal contusion (bleeding under the skin) and head hematoma. The resident was readmitted back to the facility on [DATE]. Review of the facility's incident reporting log dated 05/01/18 to 10/24/18, showed the resident had 3 recent falls (10/16/18, 10/18/18 and 10/19/18). The log showed these incident investigations were not completed and no root cause analysis was conducted to determine appropriate actions and/or interventions to prevent and minimize the risk of falls and injury to the resident. Review of the resident's clinical records from 10/16/18 to 10/25/18 showed no evidence that the resident plan of care was reviewed or revised to reflect the resident's fall risk and root cause of the accidents and falls from the above date. There was no evidence of a timely and appropriate interventions, no interdisciplinary team meeting and a post fall review in the clinical records as directed by the facility's policy. In a follow-up interview on 10/25/18 at approximately 8:30 AM, the resident reiterated and stated, I do not feel safe here. I keep falling at night and I don't know why. The resident further stated, no facility staff had talked to him about his falls and how to keep him safe especially at night. Review of the unfinished Risk Management Summary Report (RMS) incident report dated 10/19/18, showed the resident was found in his room face down at approximately 2:15 AM. Interventions included: frequent checks while asleep in chair. During a record review and interview on 10/25/18 at 9:09 AM, the Director of Nursing (DNS) stated, she had not reviewed the falls for Resident 78 and she was behind in completing these investigations. The DNS stated, the incident reports for 10/16/18, 10/18/18 and 10/19/18 hasn't been looked at by the interdisciplinary team and there were no care plan revisions and new appropriate interventions initiated to prevent and minimize the risk of future falls and injury to Resident 78. This increased the likelihood of having another fall with serious injury/harm. The DNS further stated, she was not aware of the circumstances of the fall and the current interventions for the resident needed to be more specific to effectively monitor and evaluate the effectiveness of the intervention. During a meeting on 10/25/18 at 12:18 PM with the Administrator, DNS and Staff I, Regional Nurse Consultant, the DNS stated, incident investigations should have been completed within 5 days of the incident and the interventions and care plan should have been updated immediately. The DNS stated, she takes full responsibility for not having the investigations reviewed and completed on a timely manner. The Administrator stated, he was not aware of the incident and he was not sure why the investigations was not completed timely as required. Each staff member stated, the facility failed to follow their written policy related to falls. RESIDENT 92 Resident 92 was admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. A review of the resident's admission MDS assessment dated [DATE], showed the resident had impaired cognition and needed one to two person assistance with activities of daily living. Review of the resident's most recent fall care plan initiated on 10/04/18 (6 days after admission), showed the resident was at risk for falls related to his current medical conditions. The resident care plan was due for a review, not person centered and individualized. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) Review of the facility's incident reporting log dated 05/01/18 to 10/24/18, showed the resident had 3 recent falls (10/11/18, 10/16/18 and 10/20/18). The log showed these incident investigations were not completed and no root cause analysis was conducted to determine appropriate actions and/or interventions to prevent and minimize the risk of falls and injury to the resident. During an observation on 10/25/18 at 9:06 AM, the resident was observed with bilateral bedrails (side rails) used and installed in bed. The right side rail was loose and jiggled when grabbed onto or moved. Review of Resident 92's clinical records showed no evidence of any assessment, consents, physician orders [REDACTED]. (Refer to F700 - Bed rails for more information.) During a record review and interview on 10/25/18 at 9:09 AM, the Director of Nursing (DNS) stated, she had not reviewed the falls for Resident 92 and she was behind in completing these investigations. The DNS stated, she was not aware of the circumstances of the falls and the incident reports for 10/11/18, 10/16/18 and 10/20/18 hasn't been looked at by the interdisciplinary team and there were no care plan revisions and new appropriate interventions initiated to prevent and minimize the risk of future falls and injury to Resident 92. RESIDENT 477 Resident 477 was admitted to the facility on [DATE] for rehabilitation therapy. The resident [DIAGNOSES REDACTED]. A review of the resident's admission MDS assessment dated [DATE], showed the resident had an intact cognition and needed one to two person assistance with activities of daily living. Review of the resident's most recent fall care plan initiated on 10/19/18 (9 days after admission), showed the resident was at risk for falls related to cognitive loss, impaired mobility and lack of safety awareness. Review of the facility's incident reporting log dated 05/01/18 to 10/24/18, showed the resident had multiple falls (10/15/18, 10/20/18, 10/23/18 and 10/24/18). The log showed these incident investigations were not completed and no root cause analysis was conducted to determine appropriate actions and/or interventions to prevent and minimize the risk of falls and injury to the resident. The resident suffered a facial injury (abrasion) on 10/15/18. During a record review and interview on 10/25/18 at 9:09 AM, the Director of Nursing (DNS) stated, she had not reviewed the falls for Resident 477 and she was behind in completing these investigations. The DNS stated, she was not aware of the circumstances of the falls and the incident reports for 10/15/18, 10/20/18, 10/23/18 and 10/24/18 hasn't been looked at by the interdisciplinary team and there were no care plan revisions and new appropriate interventions initiated to prevent and minimize the risk of future falls and injury to Resident 477. Additional review of the resident's clinical records, showed the resident continued to have falls on 10/25/18 at 12:30 AM, 10/25/18 at 4:15 AM, 10/25/18 at 8:30 PM and 10/28/18 at 12:50 AM. RESIDENT 35 Resident 35 was admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment dated [DATE], showed the resident had an intact cognition and needed one person assistance with activities of daily living. Review of the facility's incident reporting log dated 05/01/18 to 10/24/18, showed the resident had a fall on 10/14/18. The log showed the incident investigation was not completed and no root cause analysis was conducted to determine appropriate actions and/or interventions to prevent and minimize the risk of falls and injury to the resident. During a record review and interview on 10/25/18 at 9:09 AM, the Director of Nursing (DNS) stated, she had not reviewed the fall for Resident 35 and she was behind in completing the investigation. The DNS stated, she was not aware of the circumstances of the fall and the incident report hasn't been looked at by the interdisciplinary team and there were no care plan revisions and new appropriate interventions initiated to prevent and minimize the risk of future falls and injury to Resident 35. SUMMARY The facility's failure to provide adequate supervision, failure to follow written policy and procedures related to falls, failure to ensure incident investigations were accurate and followed-up on timely, failure to initiate timely and appropriate interventions to minimize risk of avoidable accidents and the failure to update and follow the plan of care caused serious harm and bodily injury to Resident 78 and placed Resident 92, Resident 477, Resident 35 and other residents in the likelihood of having serious injuries from avoidable accidents and falls. Reference: (WAC) 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to comprehensively assess and ensure 7 of 9 residents (78, 111, 119, 60, 36, 75 and 89) received appropriate care and services necessary to maintain and avoid loss of bowel and bladder functions. These failed practices caused harm to Resident 78, 60, 111, 119 and 36 who suffered harm in the form of self-humiliation, diminished quality of life and contributed to the development of skin breakdowns, Moisture Associated Skin Damage (MASD), pain and placed other residents at risk for harm and related complications. Findings included: RESIDENT 78 Resident 78 was admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. A review of the resident's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had intact cognition and needed one person assist with activities of daily living (ADL) including dressing, toilet use and personal hygiene. The MDS also identified the resident as incontinent of bowel and bladder, was not on a toileting program, and no trial of a toileting program had been attempted since admission or since urinary/bowel incontinence was noted in the facility. Review of the resident's most recent bowel and bladder care plan, initiated on 12/06/16, showed the resident was continent of bowel and bladder. The resident care plan was due for a review, not person centered and individualized. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) Review of the most recent Nursing assessment dated [DATE], showed the resident was continent of bowel and bladder and was not on a scheduled toileting program. During an observation and interview on 10/24/18 at 2:30 PM, the resident stated, he had issues going to the bathroom. If I go to the bathroom, I need to have help. Sometimes they don't even want to do that so they gave me a commode. It is not my choice. The resident added, At night, you can hardly see anyone. I just hope I don't have to use the toilet at night because if I do, I don't have anybody to help me. The resident stated, It makes me scared specifically at night. I feel unsecured. The resident further stated, I still feel the urge to go to the bathroom if I get the help I need, I'll be ok. During an interview and observation on 10/25/18 at 9:20 AM, the resident stated he had not received any incontinent care for today. The resident was observed in a night gown with a strong urine and body odor present. During an interview and observation on 10/26/18 at 9:04 AM, the resident stated he had not received any incontinent care for today. The resident was observed with a strong urine and body odor present. Review of the resident's bowel and bladder pattern from 10/02/18 to 10/31/18, showed the resident was incontinent of bowel and bladder. In a follow-up interview on 10/31/18 at 9:34 AM, the resident stated he could still feel the urge of when to use the toilet but he couldn't get the help he needed from the staff. The resident added, the facility staff had given him an artificial toilet instead of talking to him about his concerns. The resident reiterated that if he had a choice, he would rather use the toilet. The resident stated, Sometimes he had to sit in his own urine or bowel movement because he cannot get the help from staff. The resident added, he has to wait for a long time sitting in the commode to get help. The resident further stated, I don't feel safe here. It is inhuman to have accidents. It is embarrassing and humiliating. In an interview on 10/31/18 at 9:40 AM, Staff P, Certified Nursing Assistant, (CNA), stated, the resident was incontinent of bowel and bladder and currently not on a scheduled toileting program. In an interview on 10/31/18 at 9:42 AM, Staff V, Registered Nurse, (RN), stated, the resident was incontinent of bowel and bladder and currently not on a scheduled toileting program. During a joint skin inspection and interview on 10/31/18 at 1:56 PM with Staff V, RN, and Staff M, RN, the resident was observed with severe excoriation with skin peeling off the buttocks, coccyx, and sacrum area extending to the groin. Both Staff V and Staff M stated, they would call the skin breakdown MASD and they were not aware of any treatment specific to the skin breakdown. The resident reported pain to the area throughout the skin inspection. (Refer to F684 - Quality of Care for more information.) During a meeting on 11/01/18 at 10:37 AM with the Director of Nursing, (DNS), Staff J, Regional Resource Nurse and another surveyor, the resident stated, he doesn't feel safe at night and still worried that if he had to use the bathroom, no one would come to help him. (Refer to F689 - Free of Accident/Hazards/Supervision and Devices and F725 - Sufficient Nursing Staff for more information.) During a joint record review and interview on 11/02/18 at 2:23 PM, the DNS stated, the resident was incontinent of bowel and bladder and currently not on a scheduled toileting program. The DNS further, there was no trial of a toileting program attempted or initiated to either maintain, restore/improve the resident's bowel and bladder continence. In an interview on 11/05/18 at 1:04 PM, Staff HH, Advanced Registered Nurse Practitioner, stated she wasn't aware and was not notified of the resident's bowel and bladder incontinence and skin breakdown until 11/02/18. RESIDENT 111 Resident 111 was re-admitted to the facility on [DATE] for rehabilitation therapy. The resident [DIAGNOSES REDACTED]. A review of the resident's quarterly MDS assessment dated [DATE], showed the resident needed 1 person assist with bed mobility, transfers, toileting and personal hygiene. The MDS identified the resident as incontinent of bladder, continent of bowel and was not on a toileting program, and/or no trial of a toileting program had been attempted since admission or since urinary incontinence was noted in the facility. Review of the resident's most recent care plan dated 05/18/18, showed the resident was at risk for decreased ability to perform activities of daily living (including toileting needs). The resident care plan was missing specific information related to the resident's incontinence, not person centered and individualized. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) Review of the most recent nursing assessment completed on 06/18/18, showed the resident was continent of bowel and bladder and was not on a scheduled toileting program. During an observation and interview on 10/24/18 at 9:00 AM, the resident was observed in bed wearing a hospital gown with strong body odor and urine present. The resident stated, nobody helps him to go to the bathroom and he could still feel the urge when to urinate or use the toilet. The resident added, Not good. I am peeing and[***]ing in my bed. Review of the resident's bowel and bladder pattern from 09/30/18 to 10/28/18, showed the resident was incontinent of bowel and bladder. In an interview on 10/31/18 at 9:40 AM, Staff P, CNA, stated, the resident was incontinent of bowel and bladder and currently not on a scheduled toileting program. In an interview on 10/31/18 at 9:42 AM, Staff V, RN, stated, the resident was incontinent of bowel and bladder and currently not on a scheduled toileting program. During a joint observation at the time of the interview, the resident was observed to be incontinent of urine and a strong urine odor was present. During a joint interview on 11/01/18 at 2:21 PM with Staff R, CNA and Staff T, CNA, both staff members stated the resident was incontinent of bowel and bladder and currently not on a scheduled toileting program. In an interview on 11/05/18 at 1:04 PM, Staff HH, Advanced Registered Nurse Practitioner, stated she wasn't aware and was not notified of the resident's bowel and bladder incontinence. In a follow-up interview on 11/06/18 at 9:03 AM, the resident stated, It is not ok to urinate and toilet in bed if you can go to the bathroom. The resident added, It is depressing, humiliating and embarrassing. During a record review and interview on 11/06/18 at 9:49 AM, the DNS stated, the facility's bowel and bladder process was not followed for Resident 111. The resident had a change in his bowel and bladder continence and no interventions and/or trial of a toileting program was initiated or attempted to either maintain, restore/improve the resident's bowel and bladder continence. RESIDENT 119 Resident 119 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the resident's MDS assessment dated [DATE], showed the resident needed two person assistance with bed mobility, transfers and toileting needs. The MDS identified the resident as incontinent of bowel and bladder, was not on a toileting program, and/or no trial of a toileting program had been attempted since admission or since urinary/bowel incontinence was noted in the facility. Review of the most recent nursing assessment completed on 06/18/18, showed the resident was continent of bowel and bladder and currently not on a scheduled toileting program. The assessment also showed that a new nursing assessment was overdue (18 days overdue) and should have been completed on 10/11/18. Review of the resident's care plan initiated on 11/02/15 and revised on 03/27/18, showed the resident was incontinent of bladder. The care plan was missing information related to the resident's bowel incontinence, due for a review, not person centered and individualized. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) During an observation and interview on 10/26/18 at 12:54 PM, the resident was observed in bed wearing a hospital gown with strong urine odor present. The resident stated, she needed a brief change and she could still feel the urge when to urinate and use the bathroom, (I) just don't get the help on time. The resident further stated, well, it is inhuman and embarrassing to urinate and have a bowel movement in your brief. Review of the resident's bowel and bladder pattern from 09/30/18 to 10/28/18, showed the resident was incontinent of bowel and bladder. In an interview on 11/01/18 at 2:10 PM, Staff V, RN, stated, the resident was incontinent of bowel and bladder and currently not on a scheduled toileting program. During a joint interview on 11/01/18 at 2:20 PM with Staff R, CNA and Staff T, CNA, both staff member stated the resident was incontinent of bowel and bladder and currently not on a scheduled toileting program. During an observation and interview on 11/01/18 at 2:57 PM, the resident stated, no staff member had offered or asked her to use the toilet. A strong urine odor was present during the interview. During a joint record review and interview on 11/02/18 at 2:14 PM, the DNS stated, the resident was incontinent of bowel and bladder and currently not on a scheduled toileting program. The DNS added, the resident's assessment was overdue and the care plan needed to be revised. The DNS also stated, there was no trial of a toileting program attempted or initiated to either maintain, restore/improve the resident's bowel and bladder continence. The DNS further stated, that currently, the facility's bowel and bladder system needed to be worked on because the assessments were only completed on a quarterly basis and staff needed more education to have an effective system. In an interview on 11/05/18 at 12:41 PM, Staff HH, Advanced Registered Nurse Practitioner, stated she wasn't aware and was not notified of the resident's bowel and bladder incontinence. RESIDENT 60 Resident 60 admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the Admission MDS, dated [DATE] revealed the resident was cognitively intact, had the ability to hear adequately, was able to understand others and make self- understood with clear speech. The MDS also showed the resident required extensive two person assist for transfers and toileting. Further review of the MDS dated [DATE] revealed the resident was occasionally incontinent (less than 7 episodes of incontinence in a week) of bladder and occasionally incontinent of bowel (less than 1 episode of incontinence in a week). The MDS also showed; no toileting program (e.g. scheduled toileting, prompted voiding, or bladder and bowel training) had not been attempted while in the facility. A review of the initial nursing assessment dated [DATE] indicated the resident was continent of both bowel and bladder, the toileting method was bedpan and no current toileting program or trial is used. A review of the resident's bowel and bladder patterns documented in the electronic record from 10/07/18 thru 11/05/18 showed the resident was incontinent. A review of skin check done on 10/19/18 by Staff B, DNS, showed no skin issues. In an interview on 10/26/18 at 12:12 PM Resident 60 stated, I ring and ask for someone to help me get on the bedside commode or toilet and staff will tell me they are busy and they don't have time to get me out of bed and onto the commode. Staff will say to use a bedpan but then they don't come back. I am able to tell when I need to use the bathroom but no one gets me there and I have to go in my brief most of the time. I had a stroke that affected my bowels, but if I have enough time to just sit and relax on the commode I can go there. I feel so happy when I get to do this. Resident reported pain on her backside from the skin breakdown as a 9 on a scale of 1 thru 10. In an observation and interview on 10/26/18 at 4:08 PM in resident's room with Staff J, RN and Staff Q, RN/RCM, a joint skin check was conducted and the State surveyor Nurses observed the following: Left side of the groin pink/red and moist with white substance (cream) in groin area; and a red area at sacrum/tailbone and pink/red areas on both buttocks. The resident reported the area to be sore and itchy like a yeast infection, and that her pain was a 9 out of 10. She said the cream helped and ignoring it makes it worse. Staff J, stated, the aides should have reported the change in skin integrity to a nurse, and nursing would then assess to see if it was a fungal rash. The aides should not have used cream for the rash. The resident further stated, when I feel the urge, I tell the aides right away. They say I will be right back and poof they are off to do something else. I feel like I have no control of when and where I go to the bathroom. They do not come back. The resident further stated, the skin breakdown was caused because she sat in her own urine and bowel movement for a long time, hours. It is embarrassing and you feel neglected. A review of skin check done on 10/26/18 by Staff Q, RCM showed, new skin injury, blanchable red area of bottom and groin. In an interview on 11/06/18 at 10:11 AM with the resident, she stated she was continent of bowel and bladder, but does have urgency, with some occasional incontinence, mostly due to urgency. She wanted to use the commode, but the staff needed her to use her brief because they were not able to get her to the commode. The resident said no one has asked her about a toileting program. She stated, It is upsetting and demoralizing to go in a brief. In an interview with Staff Q at 10:18 AM, stated I have had a conversation with the resident about toileting and she does know when she needs to go to the bathroom, but she does have urgency and there is not enough time for the CNA's to help her. I have not discussed a toileting program for her and I have not had a discussion with her about her preferences. The interview continued in the resident's room in where the resident stated the aides did not ask her if she wanted to transfer to the commode. The resident further stated, I do know when I need to go to the bathroom, but it takes too long to get anybody to come help me. Most of the CNA's tell me 'I am not cleared' to use the commode, so they ask me to go in my brief and then they will change me. In an interview on 11/06/18 at 02:45 PM with Staff WW, CNA, stated the resident was incontinent of bowel and bladder and used a hoyer lift. In an interview at 2:46 PM with Staff RR, CNA, who stated that the resident was incontinent of bowel and bladder, and she changed her brief when resident used the call light. In an interview at 3:02 PM with Staff VV, CNA, Staff VV stated the resident wore a brief, and was incontinent of bowel and bladder, I don't know of any toileting program for this resident. RESIDENT 36 Resident 36 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. He also had muscle weakness. Record review of the annual MDS assessment dated [DATE] revealed the resident was cognitively intact, had the ability to hear adequately, was able to understand others and make self-understood with clear speech. The MDS also showed the resident required extensive assist for transfers and toilet use. Further review of the MDS dated [DATE] revealed the resident was frequently incontinent of urine (7 or more episodes of urinary incontinence, but at least 1 episode of continent voiding) and always incontinent of bowel (no episodes of continent bowel movements). The MDS also indicated a trial of a toileting program (e.g. scheduled toileting, prompted voiding or bladder training) had not been attempted on admission or since urinary incontinence was noted in this facility. It also showed a toileting program was not used to manage the resident's bowel incontinence. The most recent documented nursing assessment dated [DATE] of urinary continence indicated the resident was always continent of urine and bowel. In an interview on 10/24/18 at 9:32 AM with the resident he said: I have to lay in my bed and have a bowel movement (BM), I know when I have to go, I don't use the toilet or a bedpan, and no one ever offers it to me. They all want me to use my brief and then they will come and change me. I use my brief, turn on my call light and wait for someone to come and change me. Sometimes I scratch holes in my skin because it itches so bad from sitting in it for so long and waiting for someone to come and help me. It happens when I am up in my wheelchair too, if I am up in my wheelchair and I go, like have a BM or something, I have to do it in my brief. Then they will put me back to bed and change me, it makes me feel less than human. In observation and interview on 11/02/18 at 9:14 AM the resident was observed in his room, in bed. Resident 36 stated: I wear these all the time (pointed to a white disposable brief fastened around his waist) it makes me feel like a baby to wear this. I am waiting for them to come and get me out of bed. In an interview on 11/01/18 at 2:26 PM with Staff RR (CNA) said, I have worked with him(Resident 36) a lot, we put him back to bed and change him. He tell us when he had a BM or if he was wet, he knows when he had to have a BM or needed to urinate. I have never put him on the toilet or on a commode, just to bed to change him after he had a BM of if he was wet. In interview on 11/02/18 at 12:28 PM with Staff UU (CNA) who said, He(Resident 36) would tell us when he needed to have his brief changed and we would put him back to bed and change him there. We will put him to bed and change him, he knows when he needs it. He will use a urinal, but that is about it. In interview on 11/05/18 at 10:15 AM with Staff Z (CNA) said: He was up in his chair and he called me to change him, I put him back to bed. He knows when he has to go to the bathroom, he will tell you. He wears a brief all the time. In an interview on 11/07/18 at 8:32 AM with Staff SS (RN) said, He is incontinent, he will turn on his light to be changed, and he knows when he needs to be changed. He will tell you. In an interview on 11/07/18 at 9:15 AM with Staff B, Director of Nursing Servicies (DNS), the DNS said the bowel and bladder assessments are completed with the nursing assessments at least every quarter. The last assessment was completed in (MONTH) of this year. He was continent of bowel and bladder at that time. We missed a nursing assessment in August, which would have included the bowel and bladder assessment. There was a decline, the quarterly MDS assessment done on 08/15/18 showed he was incontinent of bowel and bladder. We should have offered him the toilet every few hours. We needed to address his toileting needs. RESIDENT 75 Resident 75 admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] showed the resident was cognitively intact. The MDS also showed the resident had an indwelling catheter (a tube that is inserted in the bladder and left to drain urine from the bladder into a collection bag). Record review of the treatment administration record dated 10/17/18 showed: discontinue catheter per patient's request and watch for retention. Record review of the treatment administration record dated 10/19/18 documented: straight catheterization (a tube used for one time emptying of the bladder and removed) until urology appointment every shift. Record review of the physicians order dated 10/19/18 documented: referral to urology (focuses on diseases of the urinary system) for catheter placement. Record review of the Advanced Registered Nurse Practitioner note dated 10/29/18 documented: Seen today for evaluation of [MEDICAL CONDITION] (difficulty urinating and completely emptying the bladder) per patient's request. He requests evaluation by urology to see if he has any problems. Referral to urology. Record review of the nursing progress note dated 11/06/18 documented, blood noted on his brief and penis tip, hematuria (blood in the urine) also noted after catheterization. Record review of the clinical record showed no documentation of a referral to urology and/or a scheduled appointment. In interview on 10/24/18 at 2:32 PM the resident stated: I will not let them put another catheter inside me here at this place and leave it there, they are straight cathing me now. I need to see a specialist, I think I have some kind of problems with my bladder. In interview on 11/07/18 at 8:36 AM with Staff SS (RN) said, He has not had a urology appointment, the Resident Care Manager (RCM) makes the appointments for the residents. In interview on 11/07/18 at 9:02 AM with Staff B (DNS) stated: The RCM's make the appointments for the residents. I will follow up and let you know if an appointment was made. No further information was provided. RESIDENT 89 Resident 89 admitted to the facility on [DATE]. A Review of the most recent admission Minimum Data Set Assessment ((MDS) dated [DATE] revealed Resident 89 as able to make needs known. Additional review of the admission MDS reflected resident as frequently incontinent of bowel and bladder. In an interview on 10/24/18 at 12:36 PM Resident 89 said I have sat in poop. I was hot about that. I sat in that in almost an hour. The resident stated the incident occurred a couple of days ago. I felt angry and helpless. In an interview on 10/30/18 at 10:00 AM Resident 89 said, I can tell when I need to go. In an interview on 10/30/18 at 10:35 AM Staff Z, Certified Nursing Assistant, CNA, Staff Z stated Resident 89 was demanding when the call light was used. Resident 89 can call for peri care and can verbalize if she needs to go to the bathroom. Then in an interview and record review at 11:01 AM Staff AA, Licensed Practical Nurse, LPN, stated Resident 89's care does not include a toileting program. The record reflected no assessment for bowel and bladder and retraining, and no record of an incontinence evaluation. Then in an interview at 02:02 PM Staff BB, LPN, stated Resident 89 was alert and oriented and able to let staff know when she needed to go to the restroom. Additional review of the record reflected no assessment for bowel and bladder retraining and no record of an incontinence evaluation. SUMMARY In summary, the facility's lack of accurate and comprehensive assessment, lack of effective and person centered plan of care, lack of effective monitoring and system for bowel and bladder caused physical and psychosocial harm to Resident's 60, 78, 111, 119 and 36. A reasonable person would experience embarrassment, humiliation, anxiety, low self-esteem, decrease self-confidence and sense of well-being related to having incontinent accidents/episodes of urine and bowel. This is a repeat citation from 11/03/17 survey related to F241 - Dignity and Respect of Individuality and F315 - No Catheter, Prevent UTI, Restore Bladder. Reference (WAC) 388-97-1060 (3)(c)

Based on observation, interview and record review, the facility failed to prevent, assess, monitor and treat skin breakdown, failed to initiate timely/appropriate interventions, and failed to notify the physician of a change of condition for 4 of 5 residents (42, 78, 113, and 6) reviewed for non-pressure skin conditions. These failures caused harm to Resident 42 and Resident 78 who developed severe Moisture Associated Skin Damage (MASD), experienced pain, and placed other residents at significant risk for harm and related complications. Findings Included: Moisture Associate Skin Damage or MASD is defined as an inflammation and erosion of skin caused by prolonged exposure to various sources of moisture, including urine or stool, perspiration, wound exudate (discharge), mucus or saliva. A review of the Skin Integrity Management Policy dated 11/28/16, stated, Staff continually observes and monitors patients for changes and implements revisions to the plan of care as needed. Practice Standards, 3: Identify patient's skin integrity status and need for prevention intervention or treatment modalities. 3.2: Perform skin inspection weekly. Document on treatment administration record or in computer system. RESIDENT 42 Resident 42 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. The resident was receiving artificial nutrition by tube ([DEVICE]/Gastrostomy tube). A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident required 2 person assistance from staff for bed mobility, transfers, toileting and personal hygiene. The resident was identified to be incontinent of bowel and bladder. Review of the resident's care plan dated 05/15/18, showed the resident was at risk for skin breakdown related to limited mobility and current medical conditions. The resident care plan was due for a review, not person centered and individualized. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) Review of the weekly skin check documentation dated 10/10/18 and 10/24/18, showed the resident was identified to have a MASD to the buttock area. The skin assessment was missing any detailed information related to the skin breakdown, no measurements and/or description documented. During an observation and interview on 11/02/18 at 9:01 AM, the resident was observed moving and shaking his back and neck area. The resident reported he had a bowel movement at 6:00 AM that morning. The resident stated, he has been sitting on his bowel movement for a while but unable to state a specific time. The resident was observed with dried bowel movement that had leaked to the bed sheets, blanket and mattress. During a joint inspection on 11/02/18 at 10:37 AM, Staff I, Regional Nurse Consultant, the resident was observed to be in the same situation as stated above. Staff I stated she would immediately get someone to clean the resident. During a joint skin inspection on 11/02/18 at 11:15 AM with Staff J, Regional Resource Nurse, Staff V, Registered Nurse, (RN), and Staff R, Certified Nursing Assistant, (CNA), the resident was observed with severe redness and rash (superficial layer of the skin was open) to the scrotum area extending to the groin and buttocks area. Staff J and Staff V stated, they would identify the skin breakdown as excoriation and MASD. The resident was screaming and verbalized pain throughout the observation specifically during turning and repositioning. During a joint record review and interview on 11/02/18 at approximately 11:20 AM, Staff V, stated, there was no specific treatment in place in the clinical record for the resident's skin breakdown. Staff V stated, the MASD wasn't new and the resident had it for a while. Staff V further stated, the resident had no specific plan of care and treatment for [REDACTED]. (Refer to F697 - Pain Management for more information.) During a joint record review and interview on 11/02/18 at 2:50 PM, the Director of Nursing, (DNS), stated, there was no specific treatment order in place to the address the resident's skin breakdown and pain related to MASD and the resident's plan of care was overdue and needed to be revised. The DNS further stated, there was no documentation in the resident's clinical record that a physician was notified/contacted related to the skin breakdown and pain concerns for Resident 42. Additional record review of the resident's Physician order [REDACTED]. condition/breakdown. In an interview on 11/05/18 at 1:04 PM, Staff HH, Advanced Registered Nurse Practitioner, stated she wasn't aware and was not notified of the resident's skin breakdown prior to 11/02/18. RESIDENT 78 Resident 78 was admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. The resident had a recent hospital stay and was readmitted to the facility on [DATE]. A review of the resident's most recent quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident had intact cognition and needed one person assist with activities of daily living (ADL) including dressing, toilet use and personal hygiene. Review of the resident's most recent skin care plan initiated on 12/06/16 with review and revision date of 08/08/18, showed the resident was at risk for skin breakdown related to impaired mobility, stroke and groin redness. The resident care plan was due for a review, not person centered and individualized. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) In an interview on 10/24/18 at 2:56 PM, the resident stated he had rash on his groin area from sweat and incontinence. The resident added, the hospital staff told him he have(has) a serious skin breakdown on his buttock area that needed to be looked at by the facility but no one had looked at or followed up on him since he returned from the hospital. A review of the hospital discharge summary report dated 10/21/18, showed the resident discharge [DIAGNOSES REDACTED]. Hospital course his sacral [DIAGNOSES REDACTED] was treated with pressure reduction and barrier cream. Review of the resident's most recent skin assessment dated [DATE], showed the resident had an abrasion to the nose and forehead area and scab on the right shin. The skin check showed no documented skin breakdown/impairment to the resident's groin or buttock area. In an interview on 10/31/18 at 9:44 AM, Staff P, Certified Nursing Assistant (CNA), stated, he was not aware of any skin breakdown/treatment for [REDACTED]. In an interview on 10/31/18 at 9:48 AM, Staff U, shower aide, stated, she was not aware of any skin breakdown/treatment for [REDACTED]. During a joint skin inspection and interview on 10/31/18 at 1:56 PM with Staff V, RN, and Staff M, RN, the resident was observed with severe excoriation with skin peeling off the buttocks, coccyx, and sacrum area extending to the groin. Both Staff V and Staff M stated, they would call the skin breakdown MASD and they were not aware of any treatment specific to the skin breakdown. The resident reported pain to the area throughout the skin inspection. The resident added, the cream only gets applied sometimes and only during the evening. It was a hit and miss situation. During a joint record review and interview on 10/31/18 at 2:04 PM, Staff V reviewed the resident's clinical records including the Medication Administration Record, [REDACTED]. Staff V reiterated there was no specific treatment order for her shift to administer/give to the resident specific for the skin breakdown observed. Staff V stated, there was an order for [REDACTED]. Additional record review of the resident's Physician order [REDACTED]. condition/breakdown. During a joint record review and interview on 11/02/18 at 2:50 PM, the Director of Nursing, (DNS), stated, there was no specific treatment order in place to address the resident's skin breakdown and pain related to MASD and the resident's plan of care was overdue and needed to be revised. The DNS added, there was no documentation in the resident's clinical record that a physician was notified/contacted related to the skin breakdown and pain concerns for Resident 78. The DNS stated she was not aware of the hospital records, specifically the documented skin breakdown identified and listed in the hospital discharge summary report. The DNS further stated, the physician orders [REDACTED]. being marked as applied or checked in PCC (electronic medical record) but truly wasn't being implemented or administered. In an interview on 11/05/18 at 1:04 PM, Staff HH, Advanced Registered Nurse Practitioner, stated she wasn't aware and was not notified of the resident's skin breakdown before and after re-hospitalization and prior to 11/02/18. RESIDENT 6 Resident 6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review of the most recent completed quarterly MDS assessment dated [DATE] revealed the resident required physical assist of two or more persons for bed mobility and transfers. The MDS also showed the resident had physical limitations of movement on one upper extremity (shoulder, elbow, wrist, hand) and both lower extremities (hip, knee, ankle, foot). Record review of the skin check dated 10/03/18 showed documentation of multiple abrasions (a wound caused by superficial damage to the skin) that measured less than 0.5 centimeters (cm) identified on the left lower extremity. The skin check documented the abrasions/scratches were self-inflicted and nails were trimmed. Record review of the skin check dated 10/10/18 showed documentation of left lower extremity scratches, self-inflicted and nails were trimmed. Record review of the skin checks dated 10/14/18 and 10/21/18 showed documentation of a rash on the groin area and left lower extremity scratches. Further review of the clinical record revealed the last documented skin check was completed 10/30/18, nine days after the previous skin check dated 10/21/18. In observations on 10/24/18 at 9:34 AM and on 10/25/18 at 3:22 PM, the resident was observed with multiple (too numerous to count) open skin areas and dried areas on both upper and lower legs. The open and dried areas varied in size from superficial to approximately 1.0 cm in size and depth. The color of the open areas varied from pink to red and the closed areas from light brown to dark brown. In interview on 10/31/18 at 11:01 AM with Staff UU (CNA) who said, the resident had those scabs on both his legs for over a month now, I have no idea how he got them. The nurses know about it. In interview on 11/05/18 at 11:45 AM with Staff Z (CNA) who stated: I don't know how he got all the scratches, he can't reach them. In interview on 11/05/18 at 2:34 PM with Staff M (RN) who said, I don't know how he got the scratches on his legs, I don't think he can do it himself. Some staff say he can do it himself, but I don't think so. In interview on 11/05/18 at 3:40 PM with Staff TT (RN) who said, skin checks are done weekly and documented in the computer. I would call the doctor and get a treatment if I found a skin problem. In interview on 11/06/18 at 2:55 PM with Staff B who (DNS) said the skin assessments should be done weekly. The CNA should report to the nurse, the nurse should check the skin, call the doctor and the doctor would order treatments if necessary. The treatments, the causes for the skin problem and how the skin is healing should be assessed with [REDACTED]. If abrasions and scratches were not healing and he kept scratching himself we should have tried something more than just to trim his nails. We don't know what could have caused him to itch and scratch his skin so much. RESIDENT 113 Resident 113 admitted to the facility on [DATE] for long term care following a stroke that affected his ability to use the left side of his body. A review of the Admission MDS assessment dated [DATE], showed the resident had no cognitive impairment. He required 2 person assistance from staff for: bed mobility, transfers, toileting and personal hygiene. The resident was identified to be occasionally incontinent of bladder and frequently incontinent of bowel. A review of the Initial Nursing assessment dated [DATE] showed, Integumentary (skin) Occasionally Moist-incontinent daily, but infrequent exposure (e.g.,night incontinence, but use of padding system). A review of the resident's skin care plan initiated on 10/16/18 showed, the resident was at risk for skin breakdown as evidenced by incontinence, limited mobility, shear/friction risks, hx of fungal infection on back and sacral/groin area. Monitor skin for signs/symptoms of skin breakdown: redness, cracking, blistering, decrease sensation, and skin that does not blanche easily. Nursing to observe skin condition with ADL (activities of daily living) care daily. A review of the skin check dated 10/24/18 showed no skin issue identified. In an interview on 10/31/18 at 1:42 PM with Staff FFF, Licensed Nurse (LN) stated, resident does not have any skin conditions, nothing on his back side and was not aware he has had any skin issues in the past. In an interview on 10/31/18 PM at 1:54 PM with Staff GGG, CNA, stated, resident does not have any skin issues. I just gave him a bed bath on Saturday (10/27/18) and his skin was clean. In a joint skin inspection and interview on 10/31/18 at 2:10 PM with Staff Q, Registered Nurse (RN) Resident Care Manager (RCM), Staff FFF, LN, and Staff WW, CNA, the resident reported a rash on his groin/scrotal area. Upon inspection the area was moist with MASD to the right and left groin area, extending to both of his scrotum. Also, observed a 0.5 cm x 0.5 cm blister on the mid back area. The resident reported it was sore and burning when rubbed. He further stated, sometimes staff put cream on it and sometimes they don't, it is hit and miss, maybe once or twice a week. Staff LN and Staff WW, stated they were not sure how long the rash or MASD has been there but it did not look new. Staff FFF, stated, she had not applied any treatment to the area. In a follow-up interview and record review at 2:35 PM with Staff Q RN/RCM and Staff FFF, LN, stated, there was no documentation of the rash in the medical record, and no treatment ordered. Staff Q, stated, I will let the doctor know about the redness and ask for some treatment. Reference (WAC) 388-97-1060

Based on observation, interview and record review, the facility failed to prevent the development of avoidable pressure ulcers for 2 of 7 residents (6, 92) reviewed for pressure ulcers. The failure to conduct timely skin checks, provide frequent changes in position and ensure an air mattress on the bed functioned properly and provided adequate pressure relief caused harm to Resident 6 who developed pressure ulcers with partial thickness skin loss and exposed skin, full thickness skin loss and pain. Additionally, the facility failed to develop and implement a timely care plan and to ensure accurate, consistent descriptions and measurements of skin wounds were completed for Resident 92. These failures placed residents at risk for pressure ulcers, pain and diminished quality of life. 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 2 Pressure Injury: Partial-thickness skin loss with exposed dermis Partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. Adipose (fat) is not visible and deeper tissues are not visible. Granulation tissue, slough and eschar are not present. These injuries commonly result from adverse microclimate and shear in the skin over the pelvis and shear in the heel. This stage should not be used to describe moisture associated skin damage (MASD) including incontinence associated [MEDICAL CONDITION] (IAD), intertriginous [MEDICAL CONDITION] (ITD), medical adhesive related skin injury (MARSI), or traumatic wounds (skin tears, burns, abrasions). 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 [DIAGNOSES REDACTED] or fluctuance) on the heel or ischemic limb should not be softened or removed. RESIDENT 6 Resident 6 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. It also resulted in the resident's inability to speak. Record review of the most recent completed quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident required physical assist of two or more persons for bed mobility, transfers and was always incontinent of bladder and bowel. Further record review of the MDS showed the resident was at risk of developing pressure ulcers, and had no pressure ulcers at the time of the assessment. Record review of the clinical record revealed a care plan with the revision date of 10/10/18 showed: Resident at risk for skin breakdown as evidenced by limited mobility, incontinence and weakness. Goal: The resident will not show signs of skin breakdown, with a target date of 01/07/19. Interventions included: apply barrier cream with each cleansing, evaluate for skin risk factors per protocol, weekly skin assessments by licensed nurse, skin risk assessments per policy, observe skin condition with care daily and report abnormalities to nurse. Record review of the Braden Scale (scale used to predict pressure injury risk) dated 10/10/18 showed the resident was at mild risk of pressure injury development. Record review of the (undated) Kardex (directs how the nursing assistants care for the resident) revealed: assist resident in turning and reposition as need for comfort, pressure redistribution surfaces to bed as per protocol, float (elevate) heels while in bed and support feet to prevent foot drop and use Prevalon (pressure relieving) boots on both feet when in bed. Record review of the skin check dated 10/21/18 indicated no pressure ulcers. Further record review of the skin check dated 10/30/18, more than a week later showed deep tissue injury to the tailbone, pressure injury to the fourth toe on the left foot, and a Stage 2 pressure injury to the side of the right foot. In observations on 10/24/18, 11/01/18, 11/02/18 and 11/05/18 the resident was in his room in bed, positioned on his back. A pressure distribution mattress was on the bed. The head of the bed was elevated to an upright position. The resident had pressure relieving boots on both feet, both boots were in contact with the mattress and the toes on both feet was positioned against the foot board of the bed. In a joint observation of wound care on 10/31/18 at 11:01 AM with Staff M, Registered Nurse (RN) and Staff V, RN: the tail bone and the fourth toe on the left foot had a pressure injury covered with dark eschar and the pressure injuries had no drainage. The base of the wounds could not be visualized. Staff M (RN) confirmed the base of the wound was covered with dark, dry eschar and were unstageable pressure injuries. The right foot on the outer side, on the boney prominence had a Stage 2 pressure injury. This was also confirmed by Staff M (RN). In interview on 11/02/18 at 11:16 AM with Staff UU, Certified Nursing Assistant (CNA) said: I only change his position one time in my shift, when he is incontinent, he is only incontinent one time during my shift. One time, I do everything for him, he can't do anything for himself. I get him up in his wheelchair if he wants to get up, but most of the time he wants to stay in bed. I turn him from side to side if he is incontinent, that is just maybe one time in my shift. I don't do anything with his heels, he wears those boots. They support his heels. The resident spent prolonged periods of time in bed, in an upright position on his back, with both feet positioned on the mattress and the toes on both feet positioned against the footboard of the bed, which lead to prolonged pressure on the tailbone and toes/feet that resulted in unstageable pressure injuries to the tailbone and left foot (fourth toe) and an Stage 2 pressure injury to side of the right foot. The proper functioning of the pressure relieving mattress on the bed was questionable. In interview on 11/05/18 at 10:15 AM with Staff Z (CNA) stated: I have not gotten to him yet, I did not do anything for him yet, I have been busy. I will try to get to him next. I will get him up in his chair and change him. I can probably only get to him every 2 or 3 hours that is it. In an interview on 11/05/18 at 2:34 PM with Staff M, Registered Nurse (RN) said, for residents at risk of pressure injury development, we would turn them frequently if they cannot turn themselves, even if they have a pressure relieving mattress. He wears the boots, but we should still keep his heels up and off the bed. In an interview on 11/06/18 at 9:37 AM with Staff UU (CNA), stated: the Kardex tells us how to take care of the residents. That is how we know how to transfer them, if they can move on their own in bed and things that we need to do for them. In a joint observation on 11/06/18 at 10:06 AM with Staff J, (RN, Regional Nurse Consultant) the resident was observed in his room, in bed on his back with the head of the bed elevated. The pressure relieving boot was on his right foot, the left boot was off and positioned next to him in bed. Both feet were positioned on the mattress. The top of both feet were pressed against the footboard of the bed. In an interview on 11/06/18 at 10:19 AM with Staff J, (RN, Regional Nurse Consultant) stated: I am going to get them to come check the settings on the bed, I think that may have caused the skin problems. I think the bed is too firm and the pump is not working properly. I am going to get a new pump to make the bed softer. He is too tall for this bed, his feet touch the bottom footboard. I am going to call and get a longer bed for him. That is how he got the unstageable wounds on his coccyx (tailbone) and feet, the bed needs to be longer, the mattress has to be softer and the pump on the mattress has to work. In an interview on11/06/18 at 2:55 PM with Staff B, Director of Nursing Services (DNS) said, the skin checks should be done weekly, and in between that the CNA's should report skin problems to the nurse so the nurse could go and assess the problem. The CNA'S should always follow the Kardex for the residents. Yes, the pressure ulcers were avoidable for Resident 6. RESIDENT 92 Resident 92 was re-admitted to the facility on [DATE]. The resident [DIAGNOSES REDACTED]. A review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident required 2 person assistance with bed mobility and transfer. The MDS showed the resident was at high risk for developing skin breakdown and was admitted with a stage 2 pressure ulcer. Review of the resident's care plan dated 10/04/18 (14 days after admission), showed the resident was at high risk for developing skin breakdown. The care plan was missing specific information, goals and interventions to prevent and minimize the risk of skin breakdown, was not person centered and individualized. During multiple observations on 10/25/18 at 09:15 AM, 10/25/18 at 02:34 PM and 10/26/18 at 10:14 AM the resident was observed on a specialized mattress (air mattress) which was not properly inflated. A review of the nursing progress note dated 09/21/18, showed the resident was observed with a stage 2 pressure ulcer on her lower back. The note was missing specific information about the wound such as specific measurements and the description of the wound. Review of the subsequent progress notes documented the following: 09/21/18 Skin check: wounds Stage 2 (2), lower back. There were no interventions listed in the skin check. 09/24/18 Advanced Registered Nurse practitioner (ARNP) note included: Pressure ulcer on R (right) ischium (hip)-covered with dressing. 09/30/18 Skin check shows: No new skin injury/wounds, previous skin injury/wound Yes 10/09/18 Physician order [REDACTED]. 10/11/18 and 10/15/18 physician notes include: Skin Pressure ulcer on right ischium - covered with dressing. 10/28/18 Skin check shows: no new skin injury/wounds identified 11/04/18 Skin check shows: no skin injury/wounds identified . The nursing progress notes and skin check documentations were missing specific information about the wound such as specific measurements and the description of the wound. During a joint skin observation and interview on 11/02/18 at 11:41 AM, with Staff M, Registered Nurse (RN), and Staff U, Certified Nursing Assistant (CNA). Resident 92 was observed to have multiple reddened areas over boney prominences on her spine and lower back. The areas were red with open skin approximately 1 to 2 centimeters (cm) in length and 1 to 2 cm wide. The resident reported pain to the area throughout the observation and stated those areas had been there for a while. Staff M, RN, said he had worked with the resident previously but did not recall how long the areas had been there. Staff U, CNA, said she had not worked with Resident 92 for a few days, but said Those areas have been there for a while. During a joint interview and record review on 11/02/18 at 2:55 PM, the Director of Nursing, (DNS), stated, the resident's clinical records only showed skin tears and not pressure ulcer. The DNS further stated, the resident's clinical records were inaccurate as it does not accurately reflect the resident's current skin condition. Reference (WAC) 388-97-1060 (3)(b)

Based on interview and record review, the facility failed to follow written physician orders [REDACTED]. This failure caused harm to Resident 42 who developed contractures and decreased ROM and placed other residents at risk for developing new contractures and/or worsening of existing contractures. Findings included: The National Stroke Association defines [MEDICAL CONDITION] or one-sided (hemi) weakness (paresis) as weakness or the inability to move one side of the body. Side effects of [MEDICAL CONDITION] include: Muscle [DIAGNOSES REDACTED] (weakness in the muscles), [MEDICAL CONDITION] (loss of muscle strength) and pain. Rehabilitation treatments, ROM exercises and assistive devices can help improve mobility and recovery. RESIDENT 42 Resident 42 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident required 2 person assistance from staff for bed mobility, transfers, toileting and personal hygiene. Review of the resident's care plan dated 05/15/18, showed the resident demonstrates loss of range of motion in cognitive loss/dementia and functional deterioration. The resident care plan was due for a review, not person centered and individualized. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) Review of the physician order [REDACTED]. During multiple observations on 10/24/18 at 9:21 AM, 10/25/18 at 10:45 AM and 11:36 AM, 10/26/18 at 11:46 AM, 10/29/18 at 4:32 AM and 5:38 AM, 11/01/18 at 2:20 PM, 11/02/18 at 9:02 AM, 10:31 AM, and 11:30 AM, the resident was not wearing any type of splint to his left hand. The resident's hand was observed with limited ROM and was bent inwards (towards the resident's mid-section.) In an interview on 10/29/18 at approximately 6:00 AM with Staff P, Certified Nursing Assistant, (CNA), stated, the resident had a stroke and he had not seen the resident wear a splint during his shift. Staff P stated he worked 2-3 times per week with the resident and the nurses or CNAs do not put on splints for this resident. During a joint interview with Staff T, CNA, and Staff R, CNA, on 11/01/18 at 2:20 PM, both staff members stated, the resident had not worn a splint to his left hand during their shift and they were the regular CNA's who cared for Resident 42. Both staff members stated CNA's and nurses don't put splints on, only restorative aides and therapy staff. During a joint observation and interview on 11/02/18 at 10:32 AM with Staff P, CNA, and Staff V, Registered Nurse, (RN), both staff member stated, the resident had not worn a splint now for weeks and maybe months. Both the staff members stated, they have not applied it themselves and the last time they heard about the splint was when it was broken. Both staff members stated, the resident left hand had gone worse since. Both Staff P and Staff V were not able to find the splint in the resident's room. During a joint observation and interview on 11/02/18 at 10:37 AM with Staff I, Regional Nurse Consultant, stated, the resident had an order for [REDACTED]. Review of the resident's clinical records, therapy screen and evaluations, showed an occupational therapy screen completed on 10/11/18 that stated, the resident left hand clenched resulting in skin integrity compromise. Able to open hand. Recommended OT (occupational therapy) eval (evaluation) and order present in chart. In an interview on 11/02/18 at 10:57 AM, Staff C, Rehabilitation Therapy Director, stated, he was aware of the recommendations and order for an OT evaluation on 10/11/18. However, at this time, he was still in the process of identifying the payer source for the resident and still obtaining authorizations. Staff C stated, at this time there was no therapy evaluation or assessment completed. Staff C added, he would obtain and complete the therapy evaluation as soon as possible. During a joint record review and interview on 11/02/18 at 12:31 PM with Staff V, the resident's TAR for (MONTH) and (MONTH) (YEAR) were reviewed. Staff V stated, she does not physically put on the splint and was just checking and clicking it in the computer. Staff V stated, she had not put on the resident splint in the past weeks. During a record review and interview on 11/02/18 at 2:35 PM, the Director of Nursing, (DNS), stated, she was aware of the therapy recommendation and order from 10/11/18, but at this time there was no therapy evaluation completed. The DNS stated, there should be no reason for the delay and the evaluation should have been completed within 3 days of the order. The DNS further stated, she would immediately address the therapy order and the documentation issues with the nurses when it comes to the resident's splint being marked as applied or checked in PCC (electronic medical record) but actually wasn't being implemented or administered. The facility received an order and recommendation for a Therapy Evaluation and Treatment on 10/11/18. The facility failed to timely follow-up and follow written physician's orders [REDACTED].>In an interview on 11/05/18 at 8:07 AM, Staff JJ, Restorative Aide, RA, stated, she had not worked with the resident and nurses do not put on splints, only RA's. In an interview on 11/05/18 at 1:04 PM, Staff HH, Advanced Registered Nurse Practitioner, stated, she was not aware of the resident's worsening contractures and she wasn't aware that there was a delay in implementing the OT evaluation order on 10/11/18. Review of the OT evaluation dated 04/07/18, showed the resident's ROM to Left Upper Extremity ROM = WFL (within functional limits); left hand ROM = WNL (within normal limits.) During a joint record review and interview on 11/05/18 at approximately 1:30 PM with Staff C, stated, the resident's left hand and arm had deteriorated compared to the previous OT evaluation. The OT evaluation dated 11/02/18, showed the resident's Left upper Extremity ROM = impaired; Left Wrist ROM = Impaired; Left Hand ROM = Impaired (minimally impaired extension . roughly -10 to -15 degrees. Staff C stated, the worsening contractures could have been a result of the resident's medical condition and for not receiving the splint/ROM exercises as ordered. During a joint record review and interview on 11/07/18 at 9:20 AM with Staff KK, RA, stated, the resident's restorative program should be happening everyday but he only worked 4-5 days a week. Staff KK stated, the resident was not receiving the restorative exercises, including ROM exercises and splint application as ordered especially when he was off and not working. Nurses and CNA's on the floor don't put the splints, only RA's. Staff KK stated, I don't even see the splint in my task and he noticed that the resident's left hand was harder and tough to stretch especially his fingers. Staff KK showed the surveyor his restorative log and revealed documentations that the resident only received ROM exercises 4 times per week instead of daily. There was no documentation for splint applications and no restorative services were provided for the remainder of the week. Reference (WAC): 388-97-1060 (3) (d)

Based on interview and record review, the facility failed to provide adequate pain treatment and management, failed to ensure pain management was provided consistent to professional standards of practice, facility policy and resident directed plan of care for 3 of 7 residents (2, 42, and 23) reviewed for pain management. These failures caused harm to Resident 2 and Resident 42 who experienced uncontrolled pain, severe discomfort and diminished quality of life. Findings included: According to the United States Library of Medicine National Institute of Health and National Center for Biotechnology Information (NCBI), Chronic geriatric pain may be defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage, for persons who are either aged (65 to [AGE] years old) or very aged (80 and over) and who have had pain for greater than 3 months. The consequences of this pain include impaired activities of daily living (ADLs) ambulation, and depression. Pain may also be related to complications associated with deconditioning, gait abnormalities, accidents, polypharmacy, and cognitive decline. The treatment of [REDACTED]. Without a thorough assessment, pain that is causing severe impairment may not be revealed for an array of personal, cultural, or psychological reasons. Evaluation of the patient's level of function is important as it affects the degree of independence, level of need for caregivers, as well as overall quality of life. Review of the facility's Pain Management policy dated 03/01/18, stated, residents will be evaluated as part of the nursing assessment process for the presence of pain upon admission,/re-admission, quarterly, with change of condition or change in pain status, and as required by the state thereafter. The policy directed facility staff to: An individualized, interdisciplinary care plan will be developed and include: Addressing/treating underlying causes of pain to the extent possible; non-pharmacological and pharmacological approaches; using specific strategies for preventing or minimizing different levels or sources of pain or pain related symptoms. 2. At a minimum of daily, patients will be evaluated for the presence of pain by making an inquiry of the patient or by observing for signs of pain. 7. If a patient has a change in pain status, complete a pain evaluation. 8. Patient receiving interventions for pain will be monitored for effectiveness and side effects in providing pain relief. Document: 8.1 Non-pharmacological interventions and effectiveness, 8.2 effectiveness of PRN medications, 8.3 Ineffectiveness of routine or PRN (as needed) medications including interventions, follow-up and physician/APP (advance practitioner) notification. 9. Patient who have unstable pain management will be indicated on the 24-hour summary report. 10. The care plan will be evaluated for effectiveness until satisfactory pain management is achieved. 10.2 Review the non-pharmacological approaches for effectiveness, 10.3 revise the care plan as indicated. RESIDENT 2 Resident 2 was a long term resident of the facility. The resident's [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident needed two person assistance with bed mobility and transfers. The MDS also documented, the resident reported pain presence of moderate pain occasionally. Review of the resident's care plan dated 09/22/14 with revision date of 01/20/16, showed the resident was at risk for alteration in comfort related to chronic pain, muscle pain to back and neck, and left shoulder. The resident care plan was missing the resident's specific goal for pain management, due for a review, not person centered and individualized. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) The resident's care plan directed the facility staff to: 1. Apply muscle rub cream to left shoulder, back of neck 3 times a day and every 2 hours as needed for 1 minute each area. 2. Manage pain by providing ice packs or cold compresses to applicable area. 3. Manage pain by applying warm soaks to applicable area. During an observation and interview on 10/29/18 at 5:03 AM, the resident was observed crying, screaming and moaning in pain. The resident legs were both shaking uncontrollably, his skin was observed to be pale in color and was sweating. The resident stated, his pain medication does not work and sometimes, all he wanted was to be repositioned in bed and have his legs moved but staff would just ignore him and will tell him I just got my medicine and I am ok. The resident added, the staff just give him medication. The resident continued to scream and yelled for help but no staff was around and available in the unit. During an observation on 10/29/18 at 5:30 AM, (27 minutes later) Staff O, Certified Nursing Assistant (CNA), responded to the resident. Staff O did not enter the resident room nor visualize the resident and just stood by the door. The resident told Staff O about his excruciating pain but Staff O simply responded, she would notify the nurse. During an observation on 10/29/18 at 5:40 AM, 2 different surveyors followed-up with the resident. The resident continued to scream and moan related to pain. The resident stated, he has been in pain since midnight. The resident further stated, he has pain every night and it wakes him up at night. They give me pain medication but it doesn't help. I just need my leg to be moved. Pain medication does not help. During an observation on 10/29/18 at 5:42 AM, (39 minutes later), Staff ZZ, Registered Nurse, (RN), came and administer the resident's as needed narcotic pain medication. In an interview on 10/29/18 at 5:44 AM with Staff ZZ, stated, the resident always moan and cry about pain every night that she worked with the resident. Staff ZZ confirmed that she only gave the pain medication as ordered and no non-drug interventions or pain assessment/evaluation was completed. In an interview on 10/29/18 at 5:45 AM with Staff O, stated, the resident moan and cry like this all the time. Staff O further stated, every night he would scream in pain. That is him. Review of the Physician order [REDACTED]. A. Pain Monitor Daily. B. [MEDICATION NAME] 325 milligram (mg) tablet - give 2 tablets by mouth every 4 hours as needed for general discomfort. C. [MEDICATION NAME] 5mg tablet (a narcotic pain medication) by mouth 2 times a day for chronic pain. D. [MEDICATION NAME]-[MEDICATION NAME] 5/325mg tablet (a narcotic pain medication) - give 1 tablet by mouth every 4 hours as needed for chronic pain. E. [MEDICATION NAME] 900mg 4 times a day for neuropathic pain. The resident was receiving the scheduled pain medications as ordered. However, the record did not reflect/no evidence of documentations that the facility had consistently evaluated the effectiveness of the regularly scheduled pain medication on a routine basis. The pain medication orders were not clear and specific on when the staff should be giving the as needed [MEDICATION NAME] tablets instead of the narcotic pain medication ([MEDICATION NAME]-[MEDICATION NAME]). The MAR indicated [REDACTED]. However, the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. During an observation and interview on 11/01/18 at 10:20 AM, the resident was observed on his wheelchair across the 200 hall nurses station. The resident was tearful and grabbed the surveyor and stated, Call the hospital. I need to go. Pain in my leg. The resident complained of severe pain to his legs. At the same time, there were several staff members who observed the resident in severe pain, had walked passed by and ignored the resident. In an interview on 11/01/18 at 10:23 AM with Staff V, RN, stated she just gave the resident his pain medication and not sure what else to do and left the resident. In an interview on 11/01/18 at 10:25 AM with the facility' Medical Director, (MD), stated, he was aware of the resident's history of pain problems. However, he was not aware of the resident's uncontrolled pain problem at night but he would immediately look at the circumstances and order alternative treatments as necessary. During an interview and record review on 11/05/18 at 12:43 PM with Staff HH, Advanced Registered Nurse Practitioner, (ARNP), stated, she was aware of the resident's pain problems. Staff HH stated, every time he comes to the facility the resident would complain of pain. Staff HH added, she asked the facility before to seek pain consultation and have the resident see rehabilitation medicine to help manage the resident's pain and she even wrote a written order on 10/26/18 but she has not heard any updates from the facility. Staff HH further stated, there was a discrepancy with the resident's as needed medication order for [MEDICATION NAME] (an anti-anxiety/anti-spasmodic medication). Staff HH stated, she specifically wrote and prescribed this medication for spasm and not for anxiety but the orders and MAR indicated [REDACTED]. During a joint interview and record review on 11/05/18 at 12:56 PM with the Director of Nursing (DNS), stated, she was aware of the resident's uncontrolled pain and would immediately review the resident's pain medication regimen including both drug and non-drug interventions to effectively manage the resident pain. The DNS further stated, she was not aware of the discrepancy on the resident's medication and confirmed, no evidence in the resident's clinical records that showed documentations that the facility had comprehensively assessed the resident pain, no interdisciplinary team approach/interventions and no person centered plan of care to effectively manage the resident pain. RESIDENT 42 Resident 42 was a long term resident of the facility. The resident [DIAGNOSES REDACTED]. A review of the resident's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed the resident required 2 person assistance from staff for bed mobility and transfers. Review of the resident's care plan dated 05/15/18, showed the resident was at risk for alteration in comfort related to phantom and chronic pain. The resident care plan was due for a review, not person centered and individualized. (Refer to F656 - Develop/Implement Comprehensive Care Plan for more information.) The resident's care plan directed the facility staff to: 1. Evaluate pain characteristics such as the quality, severity, location and precipitating/relieving factors. 2. Monitor the resident for non-verbal signs/symptoms of pain such as increase in agitation, grimace and resistance to care. 3. Utilize pain scale. During an observation and interview on 10/24/18 at 9:24 AM, the resident was observed in bed screaming, shaking and moving his upper body and head. The resident stated, he was in pain and itching to his back. During an observation and interview on 10/25/18 at 11:24 AM, the resident was heard screaming and calling out in his room. The resident stated, Pain to the surveyor. During an observation and interview on 10/26/18 at 6:04 AM, the resident was screaming and verbalized pain to the surveyor. The resident stated that the pain was on his back and groin area. The resident was shaking and tearful during the observation. During an observation and interview on 10/26/18 at 11:27 AM, the resident was observed screaming in pain during care. Staff P, CNA, and Staff R, CNA, stated the resident would scream and complain of pain all the time when they care and turn the resident. The resident was tearful during the observation and complained of generalized pain to the staff and to the surveyor. During a joint record review and interview on 10/26/18 at 11:30 AM, Staff V, RN, stated the resident was on routine Tylenol for pain but nothing stronger. Staff V stated, the resident would always scream in pain during care. The MAR indicated [REDACTED]. However, there was no evidence that any interventions were provided/documented and was missing information regarding the characteristic, severity and location of the pain as directed by the resident's plan of care. Review of the resident's clinical progress notes from 10/01/18 to 10/26/18, showed no follow-up assessments, no physician notification and no documentation that a thorough pain assessment and evaluation was completed. During an observation and interview on 11/01/18 at 1:24 PM, the resident was screaming and verbalized pain to the surveyor. During a joint skin inspection on 11/02/18 at 11:15 AM with Staff J, Regional Resource Nurse, Staff V, Registered Nurse, (RN), and Staff R, Certified Nursing Assistant, (CNA), the resident was observed with severe redness and rash (superficial layer of the skin was open) to the scrotum area extending to the groin and buttocks area. Staff J and Staff V stated, they would identify the skin breakdown as excoriation and MASD. The resident was screaming and verbalized pain throughout the observation specifically during turning and repositioning. (Refer to F684 - Quality of Care for more information.) Review of the Physician order [REDACTED]. A. [MEDICATION NAME] 650mg via [DEVICE] (gastrostomy tube) 4 times a day for chronic pain. B. [MEDICATION NAME] 325 milligram (mg) tablet - give 2 tablets via [DEVICE] every 4 hours as needed for mild pain. C. [MEDICATION NAME] 600mg via [DEVICE] 3 times a day for pain. The resident was receiving the scheduled pain medications as ordered. However, the record did not reflect/no evidence of documentations that the facility had consistently evaluated the effectiveness of the regularly scheduled pain medication on a routine basis. During a joint interview on 11/02/18 at 1:32 PM with Staff V, RN, Staff P, CNA, Staff R, CNA, and Staff U, shower aide, each staff member stated, the resident would always scream and yell during care, specifically when turning and repositioning in bed. During an interview and record review on 11/02/18 at 2:59 PM, the DNS stated the most recent pain assessments for the resident was completed on 03/29/18 and 05/15/18, (5 months ago). The DNS stated there should be an up to date/recent pain assessment for the resident to accurately assess and identify the characteristic of the pain such as the quality, severity, location and precipitating/relieving factors. The DNS further stated, she would immediately address the documentation issues with the nurses when it comes to the resident's daily pain monitoring being marked as N (no) pain and 0 (0 pain) in PCC (electronic medical record) but did not accurately reflect the resident's pain condition. During an interview and record review on 11/05/18 at 12:43 PM with Staff HH, ARNP, stated, she was not aware of the resident's pain problems but would immediately review the resident's current condition. RESIDENT 23 Resident 23 was a long term resident of the facility. The [DIAGNOSES REDACTED]. Record review of the quarterly MDS dated [DATE] showed the resident had clear speech and was able to be understood and usually understood others. Record review of the physicians progress note dated 08/07/18 revealed he resident continued to complain of recurrent left upper chest/shoulder pain that gets worse with movement. The progress note also indicated the resident had occasional headaches and chronic pain in the back and feet. Record review of the physicians progress note dated 09/24/18 and 10/25/18 documented the same findings, recurrent left upper chest/shoulder pain that gets worse with movement; occasional headaches and chronic pain in the back and feet. Record review of the clinical record revealed a pain assessment interview conducted with the resident on 08/03/18. There was no further documented pain assessment available in the clinical record. Further record review of the MAR indicated [REDACTED]? Y or N every shift. Start date 10/07/18. In an interview with on 10/25/18 at 8:41 AM with the resident, stated: I have pain in my head, both sides of my head hurt sometimes. It can get pretty bad. In an interview on 11/07/18 at 8:22 AM with Staff V (RN) stated: I assess for pain on my shift. I generally just ask them how they are doing. I would document it on the MAR indicated [REDACTED] In an interview on 11/07/18 at 8:30 AM with Staff SS (RN) said, we do the pain assessment if we see them in pain, if there was a change of condition or if they complained of pain. We would document that on the MAR, then call the doctor. In an interview on 11/07/18 at 8:54 AM with Staff B (DNS) said, The pain assessments should be done at least quarterly or with the MDS. The nurses should also routinely assess for pain every shift. Resident 23's routine pain assessment's just started in October, (YEAR). It did not mention location of the pain, type of pain, how long it last or anything. We will work on that. Reference WAC: 388-97-1060 (1)

Based on interview and record review, the Administration failed to effectively manage the facility in compliance with state and federal regulatory requirements. The administrator failed to ensure compliance related to the implementation of abuse and neglect policy for reporting, investigation and resident's protection for Resident 104 and Resident 60 and failed to ensure staff provided adequate supervision, and ensure timely/appropriate fall interventions and follow the written plan of care for Resident 78, 92 and 477. These failures caused serious harm and resulted in an Immediate Jeopardy (IJ) situation on 10/25/18. Additionally, the facility administration failed to ensure effective and on-going systems (administrative and clinical) were in place and failed to effectively use its resources to attain or maintain the highest practicable physical, mental and psychosocial well-being of the residents. These failures caused harm and residents lived a diminished quality of life. See also F867 - QAPI/QAA Improvement Activities. See also F837 - Governing Body. Findings included: 1. The Administration failed to provide adequate supervision, failed to ensure incident investigations were accurate and followed-up on, failed to initiate timely and appropriate interventions to minimize risk of avoidable accidents, and failure to update and follow the plan of care caused serious harm and bodily injury to Resident 78. During a meeting on 10/25/18 at 12:18 PM, the Administrator and the DNS concurred and stated, the incident report hasn't been looked at by the Interdisciplinary team. Both staff member stated, there were no care plan revisions and interventions made to prevent and minimize the risk of future falls and injury to Resident 78 increasing the likelihood of having another fall with serious injury/harm. The Administrator stated, he was not aware of the incident and he was not sure why the investigation was not completed timely as required. Each staff member stated the facility failed to follow their written policy related to falls. (Refer to F689 - Free of Accident Hazards/supervision/devices for more information.) 2. The Administration failed to immediately call and notify law enforcement and the state agency as required for an allegation of abuse/neglect and staff retaliation to residents, failed to immediately suspend Staff N and failed to protect Resident 104, 60 and other residents of the facility for potential abuse. These failures placed Resident 104, 60 and other residents of the facility in serious harm and jeopardy related to abuse. During a meeting on 10/25/18 at 11:59 AM with the Administrator, DNS and Staff I, Regional Nurse Consultant, the administrator stated, the facility failed to follow their written abuse and neglect policy regarding the concerns reported by Resident 104 and the Resident council. The Administrator stated, the incident involving Resident 104 and the documented concerns in the Resident Council minutes were not reported to the state agency as required, no abuse/neglect investigation was completed and no resident protection was provided when the incident was initially reported to the facility. During a follow up meeting on 10/26/18 at approximately 2:15 PM with the Director of Nursing and Staff J, Regional Resource Nurse, both staff members stated they failed to immediately suspend the alleged staff member, and failed to immediately protect the resident after having knowledge of the allegation of neglect. (Refer to F607- Develop/Implement Abuse/Neglect Policies for more information.) 3. The Administration failed to comprehensively assess and ensure 7 of 9 residents (78, 111, 119, 60, 36, 75 and 89) received appropriate care and services necessary to maintain and avoid loss of bowel and bladder functions. These failures caused harm to Resident 78, 60, 111, 119 and 36 who suffered harm in the form of self-humiliation and diminished quality of life. During a joint interview and record review on 11/06/18 at 1:31 PM with the DNS and interim administrator, both staff member stated the facility had not identified these concerns and the facility had failed to follow their written plan of correction and ensure on-going compliance for the deficiency cited on the last standard survey dated 11/03/17. (Refer to F690 - Bowel/Bladder Incontinence, Catheter, and UTI for more information.) 4. The Administration failed to prevent, assess, monitor and treat skin breakdown, failed to initiate timely/appropriate interventions, and failed to notify the physician of a change of condition for Residents 42, 78, 113, and 6. These failures caused harm to Resident 42 and Resident 78 who developed severe Moisture Associated Skin Damage (MASD), experienced pain, and placed other residents at significant risk for harm and related complications. During a joint interview and record review on 11/06/18 at 1:31 PM with the DNS and interim administrator, both staff member stated the facility had not identified these concerns thru internal process and quality assurance program. (Refer to F690 - Bowel/Bladder Incontinence, Catheter, and UTI for more information.) 5. The Administration failed to prevent the development of avoidable pressure ulcers for Resident 6. The failure to conduct timely skin checks, provide frequent changes in position and ensure an air mattress on the bed functioned properly and provided adequate pressure relief caused harm to Resident 6 who developed pressure ulcers with partial and full thickness skin loss and pain. (Refer to F686 - Treatment Services to Prevent/Heal Pressure Ulcers for more information.) 6. The Administration failed to ensure staff followed written physician orders [REDACTED]. This failure caused harm to Resident 42 who developed contractures and decreased ROM and placed other residents at risk for developing new contractures and/or worsening of existing contractures. (Refer to F688 - Increase/Prevent Decrease in ROM/Mobility for more information.) 7. The Administration failed to provide adequate pain treatment and management, failed to ensure pain management was provided consistent to professional standards of practice, facility policy and resident directed plan of care for Resident 2, 42, and 23. These failures caused harm to Resident 2 and Resident 42 who experienced uncontrolled pain, severe discomfort and diminished quality of life. (Refer to F697 - Pain Management for more information.) 8. The Administration failed to promote self-determination for resident preferences/choices placing 127 of 127 residents at risk for psychosocial harm and diminished quality of life. (Refer to F561 - Self Determination for more information.) 9. The Facility failed to ensure sufficient nursing staff to provide nursing and related services to 127 of 127 residents of the facility. These failures cause harm and placed residents for unmet care needs. (See F725 - Sufficient Nursing Staff for more information.) 10. The Administration failed to ensure sufficient dietary staff were available to provide and meet the resident's needs and facility's scheduled meal service. This failure placed residents at risk for not receiving their meals as scheduled, potential medical complications [REDACTED]. (See F802 - Sufficient Dietary Support Personnel for more information.) 11. The Administration failed to ensure an effective infection control practices to minimize the risk/prevent the spread of infection when washing linens and resident's personal laundry. These failures placed all 127 of 127 residents at risk for acquiring infection and diminished quality of life. (See F880 - Infection Prevention and Control for more information.) 12. The Administration failed to ensure an effective and ongoing QA and QAPI (Quality Assurance and Performance Improvement) programs. Additionally, the facility failed to put forth effort of Good Faith attempts to identify and correct own identified deficiency, failed to develop and measure systems and performance improvement to ensure compliance with state/federal regulations and previous deficiencies. These failures placed all 127 of 127 residents at risk for harm and unmet care needs. (See F867 - QAPI/QAA Improvement Activities for more information.) The facility Administrator was not available from 10/26/18 to 11/07/18 for an interview. In an interview on 11/06/18 at 1:32 PM, the interim Admnistrator and DNS stated, there would be changes in the facility's administration/management. Reference: (WAC) 388-97-1620 (1)

Based on interview and record review the governing body failed to provide adequate oversight and monitoring of the appointed Administrator. The governing body failed to ensure the facility's abuse/neglect policy was followed and implemented by the Administrator, which caused harm to residents (104, 60) who suffered retaliation after reporting abuse/neglect. The governing body failed to provide adequate oversight to ensure fall policies and procedures were followed by administration for immediate investigation and implementation of appropriate interventions, which resulted in an Immediate Jeopardy/causing bodily injury to Resident 78 and placing residents (92, 477, and 35) the likelihood of acquiring serious injuries from falls and avoidable accidents. The governing body had knowledge of these concerns and failed to act and provide remedy to these issues. These failures caused/placed all residents for continued abuse/neglect, continued to experience falls, and an overall decline in health status. Findings Included: The governing body was responsible for establishing and implementing policies regarding the management and operation of the facility. A review of a policy titled, Governing Body: Centers, dated 06/01/17, showed the corporation have a governing body that consists of the Center Executive Director (Administrator), Center Nurse Executive (DNS), and the Regional Vice President or Operations of the Center's administrative services provider (corporate resources). The governing body is legally responsible for: Establishing and implementing policies regarding the management and operation of the centers; appointing a licensed administrator for the management of the center; and Maintenance of the QAPI program. During a joint interview and record review on 10/25/18 at 8:35 AM, the Director of Nursing, (DNS), and Staff J, Regional Resource Nurse, Staff J stated, the DNS was new to her position and just started in the DNS role for about 2 months. Both staff members stated, they were aware of the incomplete investigations (including falls and allegations of abuse/neglect) from residents and the facility was behind in completing the investigations. During a meeting on 10/25/18 at 11:59 AM, the Administrator, DNS and Regional Nurse Consultant, (RNC), the RNC stated, she was aware and notified of the allegations of abuse/neglect including unresolved grievances since 08/02/18. However, the facility had failed to implement written abuse and neglect policy and failed to immediately report allegations of abuse/neglect to state agency and law enforcement as required, failed to immediately protect residents from abuse and on-going abuse/retaliation from staff, and failed to complete the investigation/develop appropriate plan and interventions to prevent reoccurrence and future abuse/neglect. (See F689 - Free of Accident Hazards/Supervision/Devices and F607 - Develop/Implement Abuse/Neglect Policies for more information.) The governing body failed in its duties to recognize patterns of potential abuse and neglect by staff members as documented and reported in the resident council group meetings which resulted in harm to residents in the form of fear, feeling of abandonment and neglected. During a joint interview and record review on 11/06/18 at 1:31 PM with the DNS and interim administrator, both staff member stated the facility's QAPI committee meeting was last held on 06/28/18. Both the staff member stated, the facility had no active project or performance improvement plans and had failed to follow their written plan of corrections to ensure on-going compliance for the deficiency cited on the last standard survey dated 11/03/17. The governing body failed to provide adequate oversight and ensure the Administrator followed and implement written policies for Quality Assurance/Performance Improvement (QAPI) program, failed to put forth effort of Good Faith attempts to identify and correct own identified deficiency, failed to develop and measure systems and performance improvement to ensure compliance with state/federal regulations and previous deficiencies. These failures placed all 127 of 127 residents at risk for harm and unmet care needs. REPEAT CITATIONS AS FOLLOWS; F561 - Self Determination. A repeat citation from 11/03/17 survey. F584 - Safe/Clean/Comfortable/Homelike Environment. A repeat citation from 11/03/17 survey. F689 - Free of Accident Hazards/Supervision/Devices. A repeat citation from 06/18/18 survey. F690 - Bowel/Bladder Incontinence, Catheter, UTI. A repeat citation from 11/03/17 survey. F692 - Nutrition/Hydration Status Maintenance. A repeat citation from 11/03/17 survey F835 - Administration. A repeat citation from 11/03/17 survey. Reference: WAC 388-97-1620 (2)(c)

Based on observation, interview and record review, the facility failed to maintain the kitchen in a clean and sanitary manner with observations of mold in the kitchen, water damage in the ceiling directly over food prep area, dust in kitchen vents, dried grease and dirt under food prep area and stagnant water. Facility awareness of the ceiling damage for around one month without a fix for residents at risk for food borne infection pertaining to unsanitary storing, preparing, distributing and serving food for 2 of 2 kitchens in the facility (food preparation kitchen and serving kitchen), in accordance with the professional standard for food service resulted in the likelihood of serious harm or death. Failure to ensure the ceiling over the food preparation table in the food preparation kitchen was free from leaks, cracks and peeling paint; and the window in the ceiling (skylight) over the food preparation table was free from a dark substance that covered the glass portion of the window, surrounded the window seal and descended down the wall. Also to ensure the tiled floor under the food preparation table was free from a dark pooled liquid substance that included areas of tiles stained with a dark substance and the floor tile next to the refrigerator was free from green, gray and black spots too numerous to count that varied in size from approximately nickel size to quarter size. Additionally, failure to ensure the ceiling vents in the serving kitchen, located above uncovered coffee urns with uncovered coffee filters was free from debris, the tiled kitchen floor between the ice machine and the steam table was free from a layers of dark colored substances and broken, cracked floor tiles, the ice machine door was in working order and free from gray tape on the inside of the door where ice was stored for use, packets of both opened and unopened packets of jam, salt, pepper and saltine crackers was stored in the same basket. In interview on 10/23/17 at 8:52 AM, Staff N, DM stated the ceiling leaked and the cracks and brown stains on the ceiling came from water damage when the ceiling leaked. He then stated Administration and the Maintenance Department were aware of the leaks in the kitchen ceiling for at least a month and that it needed to be replaced. In an interview on 10/23/17 at approximately 9:00 AM with Staff S, Dietary Aide, she stated when it rained outside they had to move the food on the preparation table to a different location in the kitchen, because the ceiling leaked and it would get on the food. In interview on 10/23/17 at 11:13 AM with Staff Z, the facility administrator, stated he visited the kitchen daily. Staff Z, also said he had no reports that the kitchen ceiling leaked. These failures resulted in an Immediate Jeopardy (IJ) on 10/23/17 after dietary staff was observed to prepare food and coffee in the kitchens for lunch distribution to the residents. Findings include: In a joint observation of the food preparation kitchen on 10/23/17 at 8:45 AM with Staff N, Dietary Manager (DM), the ceiling above the food preparation table was observed to be cracked with paint that peeled away from the crack, there were also brown spots on the ceiling and a skylight window that had multiple areas of a dark substance that descended down the wall from the window. The food preparation table was lined with uncovered pot pies placed there by the cook in preparation for the lunch meal service. In a joint observation on 10/23/17 at 9:17 AM of the tiled floor underneath the food preparation table, and in an interview at this same time with Staff N, DM, he stated the dark substance under the food preparation table was grease and dirt and the pooled liquid was from the rain that came in when the ceiling leaked and caused some of the tiles to mold. He then stated the the green, gray and black spots on the tiles next to the refrigerator looked like mold. In an observation of the serving kitchen on 10/23/17 at approximately 9:52 AM with Staff N, DM, present for the duration of the observation, the cart that held the hot food plates was soiled with dried debris on the inside of the cart where clean food plates were placed to hold the food temperatures and on the outside of the cart. In an interview with Staff N, DM, at this time, stated they needed to deep clean the carts. The tiled floor surface under the steam table had a dark colored substance on the surface, the floor tile between the steam table and the ice machine also had a dark colored substance on the surface and was cracked with gaps between the tiles. There was a towel underneath the ice machine. In an interview with Staff N, DM, at this time, he stated the towel was placed to absorb water from the floor when the ice machine leaked. RESIDENT FOOD AND NOURISHMENTS REFRIGERATOR In an observation on 10/23/17 at approximately 10:20 AM with Staff N, DM, present the nourishment refrigerator had one yogurt cup with the expiration date of 08/09/17 and another yogurt cup with the expiration date of 09/06/17. In an interview at this time with Staff N, DM, he stated the nursing department was responsible to maintain the resident refrigerators. DRY FOOD STORAGE In an observation of the dry food storage room on 11/01/17 at 1:04 PM with Staff N, DM, present for the duration of the observation a can of diced tomatoes was noted with a large dent on the side of the can. In an interview at that time with Staff N, DM, he stated he would throw the can away, since it had a dent in it, he should not use it. Further observations at this time, revealed 2 large gallon sized bottles with stuck on debris and dust on the outer surface of the bottles. The bottles had a handwritten date of 09/30, there was no year documented on the bottles. Staff N, DM, stated the contents of the bottles was used by the Activity Department to make snow cones. He was unable to state the expiration year for the bottles. Staff N, stated he would throw them away, and was unable to state how long the bottles had been stored in the storage area. A large bin of popcorn kernels was observed with a use by date of 06/26/17. Additionally a large bag of salad croutons was observed with a label that had faded and had a use by date of 07/17/17. Staff N, DM, stated he would check the storage room and dispose of all the expired food. There was a box on the bare floor that contained loaves of bread and other boxes on the floor that contained plastic cutlery, paper napkins, and disposable cups and plates. In an interview with Staff N, DM, at that time, he stated he was unaware that boxes that contained food or supplies could not be placed on the floor. HAND WASHING In an observation on 11/01/17 at 12:15 PM of the tray line, Staff CC, Dietary Aide, was observed to open the garbage can with his gloved hand, use the same gloved hand to pick up a tray of food, place the tray in the refrigerator then return to the tray line. There was no observation of glove removal and/or handwashing at this time. In an interview with Staff N, DM, on 11/01/17 at approximately 12:30 PM he stated he would inservice the dietary staff on proper handwashing and glove use. In an observation on 11/02/17 at 11:10 AM of the food preparation for lunch distribution, Staff DD, Dietary Aide, was observe to touch her mouth with a gloved hand and then returned to the tray line for food preparation. There was no observation of changed gloves or hand washing. In an interview with Staff N, DM, on 11/02/17 at 11:30 AM he stated: they still are not washing their hands as they should. Record review of a report from an outside mold inspection agency dated 10/25/17 revealed there was light mold growth from a sample of the ceiling that was taken for analysis. On 10/24/17 at 12:10 PM the hall trays were observed being passed to residents in the 600 hallway. During the hall tray delivery and meal set up the following were observed: Staff L, Nurses Aide (NA), was observed touching his hair and beard between tray deliveries. Staff L was also observed touching doorknobs, food carts, and resident's bedside tables as he passed the trays and set up the resident's meals. He was not observed performing hand hygiene prior to passing trays, in between residents, or after touching contaminated objects. Additionally, he was observed to touch the rim of a cup with his bare hand prior to pouring coffee. Staff O, NA was observed passing hall trays and setting up residents with their meals. She was observed touching the food carts, doorknobs, resident bedside tables and her clothing while she passed the trays. She was not observed dong hand hygiene during the tray pass. In and interview on 10/24/17 at 12:53 PM, Staff O stated she did hand hygiene before meal service and during if she needs to. I wash my hands really well before starting then I wash again if I touch a resident or furniture. I like to wash my hands instead of using the gel. I didn't realize I was touching other objects. In an interview on 10/25/17 at 10:59 AM, Staff L stated he normally washed his hands before and after passing trays and I use hand gel in between if I touch something. I didn't know I was touching my hair and other things, guess I did it without realizing. In review of the facility's hand hygiene policy it is documented that hand hygiene (either hand washing with soap and water or alcohol based hand sanitizers) should be performed after contact with the patient's environment. Reference WAC 388-97-1100(3)

Based on interview and record review the facility failed to assist a resident with toileting in a manner that maintained dignity and individuality for 1 of 1 resident (40), when staff instructed the resident to toilet in his brief for the convenience of staff. This failure resulted in psychological harm related to care and services that did not promote an environment which, humanized and individualized the resident, as evidenced by the resident's verbalization of anger. Findings include: RESIDENT 40 Resident 40 was admitted to the facility in August 2017 with [DIAGNOSES REDACTED]. He also had muscle weakness. Record review of the admission Minimum Data Set (MDS) (admission assessment) dated 08/12/17, indicated the resident was cognitively intact and required extensive assist of two or more persons for transfers to or from bed or wheelchair, and for toilet use. In an interview on 10/26/17 at 9:08 AM with the resident, he was asked: do the staff treat you with respect and dignity? He responded no, and then stated: when I ask her (Staff HH, nursing assistant) to take me to the bathroom, she says to just do it in bed and she will clean me because I am too big for her to put on the toilet. It makes me feel mad and angry because it never happened to me in the past. I feel a burning sensation on my bottom from sitting too long in my stool in my bed or my wheelchair while waiting to be changed. In an interview on 10/30/17 at 8:26 AM with Staff HH, nursing assistant (NA) she stated she was routinely assigned to provide care for the resident when she worked. She also stated she gave the resident a urinal or put him back to bed and changed him when he needed to use the toilet because he was too big for her to transfer. She then stated she had never assisted the resident on or off the toilet. In another interview with the resident on 10/30/17 at 1:06 PM he stated he had never used a toilet since he was admitted to the facility. He also stated he could feel when he needed to use the toilet, he stated: I tell them, but nobody will take me. They all tell me to use my urinal or they just put me in bed and change me after I have a bowel movement in my wheelchair. In an interview on 10/31/17 at 12:21 PM with Staff C, he stated he was unaware the resident was incontinent. He was unable to provide intervention's on the resident's care plan or Kardex (document that directs the nursing assistants on care of the resident), related to toileting. He then stated he would update the resident's care plan and Kardex to reflect his toilet needs. In an interview on 11/03/17 at 9:15 AM with Staff Y, Director of Nursing Services, was unable to provide information. Reference WAC: 388-97-0860(1)(a)

Based on interview and record review the facility failed to assess and revise implemented interventions as needed to prevent severe, unplanned weight loss for 1 of 3 (16) residents reviewed for nutritional status and weight loss. This failure resulted in harm for the resident as evidence by a 16 percent weight loss in 10 months. Findings include: Resident 16 was a long term resident of the facility. [DIAGNOSES REDACTED]. Record review of the annual Minimum Data Set assessment dated [DATE] revealed the resident was able to eat independently with staff supervision and set up of his meal tray up. Review of the resident's Weight Summary showed the following weights: 01/17: 202.1 pounds (lbs) 02/07/17: 201.7 lbs. 03/07/17: 202.3 lbs. 04/07/17: 199.1 lbs. 05/07/17: 174.2 lbs. 06/25/17: 173.5 lbs. 07/05/17: 170.0 lbs. 08/07/17: 168.2 lbs. 09/07/17: 169 lbs. 10/07/17: 167.2 lbs. The weight on 04/07/17 was 199 lbs. the resident's weight on 05/07/17 was 174 lbs. thus, a loss of 25 lbs. in 4 weeks, a 13% loss of body weight. The resident's weight continued to decline. The weight of 10/07/17 totaled a significant weight loss of 32 lbs. from 04/07/17 to 10/07/17, a 16% loss of body weight. Record review of the Nutritional assessment dated [DATE], completed by Staff JJ, Dietician, revealed the resident was consuming 75-100% of meals and that the weight was stable. It was also documented that the resident had a 15.8% weight loss in 4 months. The reason documented for the weight loss was intake not meeting estimated needs as evidenced by unintentional weight loss. The nutrition intervention listed was scheduled snacks. The summary of the nutritional assessment was: wt (weight) is trending down since March, only significant change since last assessment is weight loss. Will follow prn (as needed or quarterly). There was no further documentation noted in the clinical record of follow up on the weight loss until the routine, scheduled quarterly Nutritional assessment dated [DATE], the assessment was completed by Staff JJ. Record review of the Nutritional Assessment documentation dated 10/12/17 revealed: will recommend addition of scheduled snacks. Will continue to follow. Intake at 75-100% of meals. Scheduled non peanut snacks added to promote weight stabilization. The last documented weight in the clinical record dated 10/07/17 was 167.2, there was no interventions or further follow up documentation in the clinical record. In an interview on 10/31/17 at 12:21 PM with Staff C, Resident Care Manager (RCM), he stated he reviewed the weights weekly and referred the residents with weight lose to the dietician. He also said weights were done monthly if the resident was stable, and a reweight was done within 24 hours if there was a significant change from the resident's baseline weight. He also said residents with unplanned weight lose were discussed weekly in the nutrition meeting with the Dietician, he then indicated the Dietician had access to the weights and reviewed them weekly and implemented intrerventions to help stop the weight lose. In an interview on 10/31/17 at 1:50 AM with Staff JJ, she stated she should have assessed and documented more on the interventions. She said she followed up on the weight loss weekly when she came to the facility, but did not document. In an interview on 11/03/17 at 9:11 AM with Staff Y, Director of Nursing Services, she stated she was unaware of Resident 16's weight loss. Reference WAC: [PHONE NUMBER]

Based on interview and record review, the facility failed to ensure continuity of care for 1 of 1 resident (#1) sampled for discharging to home. Failure to ensure [MEDICAL TREATMENT] treatment and home health services were coordinated, resulted in the resident's decline in medical condition and subsequent hospitalization . Findings Include: The facility discharge planning process policy and procedure with a revision date of 2/13/17 included: The center must develop and implement an effective discharge planning process that includes effectively transitioning the residents to post-discharge care and the reduction of factors leading to preventable re-admissions. Review of the resident's annual MDS dated [DATE], documented Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident received [MEDICAL TREATMENT] treatment three times a week. The resident's discharge care planning meeting dated 8/18/17, documented the resident would be set up with a [MEDICAL TREATMENT] clinic close to his home prior to discharge in order to continue [MEDICAL TREATMENT] treatment and home health services. The facility discharged the resident to his brother's home on 8/28/17, without ensuring the new [MEDICAL TREATMENT] clinic close to the resident's home had all the necessary documentation to provide the resident [MEDICAL TREATMENT] treatment and without ensuring home health services were coordinated. In an interview with collateral contact (CC) on 9/11/18 at 9:15 a.m., the CC stated, due to the lack of service coordination, the resident did not receive his required [MEDICAL TREATMENT] treatment. Not having a [MEDICAL TREATMENT] center to provide services, the resident's family member took the resident to the hospital where the resident was admitted and is currenlty still residing. In an interview with the Director of Nursing Services (DNS) on 9/11/17 at 12:00 p.m., the DNS stated, the resident wanted to leave on Monday, September 28, 2017 and it was a scramble to get him set up with [MEDICAL TREATMENT]. Transfer of services did not go through on Friday, September 25, 2017 as expected because the facility that would be taking over the resident's [MEDICAL TREATMENT] treatment required more information prior to initiating services. She further acknowledged home health services had also not been initiated as they should have. WAC 388-97-0080(6)(7)(c)

Based on observation interview and record review, the facility failed to implement social service interventions to sufficiently to prepare 1 of 2 residents (Resident #1) for discharge to an Adult Family Home (AFH). This failure resulted in Resident #1's unnecessary hospital ER admission, a failed discharge to a lower level of care, and a decreased quality of life experience. According to the admission records, Resident #1 had lived in the facility for over 2 years. Upon review of his records, he had multiple [DIAGNOSES REDACTED]. According to record review of discharge documentation, the resident was scheduled for discharge to an AFH on 3/28/2017. The resident was looking forward to the discharge to the AFH, lower level of care which he visited six months prior. According to the facility's document Discharge Transition Plan, dated 3/28/17, the section under Health Care/Community Services was blank and the resident's equipment need listed was a wheelchair. The facility SS did not ensure the SS component of the document was completed with equipment such as glucomoter, colostomy bag and equipment for colostomy care, and insulin syringes for insulin administration. The facility SS did not sufficiently coordinate the resident's discharge with home and community services (HCS) case manager. In interview, the HCS case manager said she was not informed of any other equipment needs besides the wheelchair for discharge, as that was the only equipment listed on the form. There were special care instruction for a follow up doctor's appointment for the next day 3/29/2017 with the resident's Primary Care Doctor. There was no transportation arrangement made for the resident to attend this appointment one day after his discharge. The resident was discharged to the AFH of his choice on 3/28/2017. According to an outside source and resident interview on 4/6/17 at 1:30 p.m., Resident #1 did not have syringes for staff to administer his insulin; which he had an order for [REDACTED]. After Resident #1 arrived to the AFH, his colostomy bag required changing. According to an interview with an outside medical professional and Resident interview on 4/6/2017 at 1:30 p.m., the provider at the AFH was not aware of how to change or empty Resident's #1's colostomy bag. According to an outside professional source, Resident #1's colostomy bag became so full that it burst and resulted in feces all over the resident's clothing, causing anxiety and frustration for the resident and the AFH provider. The AFH Provider called 911 and the resident was transported to the hospital emergency room due to the provider's lack of knowledge of how to care for the resident's colostomy. Resident #1's blood sugar was not checked that evening in the AFH and his insulin was not given because the resident's glucometer or insulin syringes were not sent with the resident to the AFH. The resident missed his opportunity to remain in a lower level of care in the AFH that he had chosen. Resident #1 had to be transported back to the same Nursing Home from the hospital. During an interview on 4/6/2017 at 1:00 p.m. with the Director of Nursing, Adminstrator and the Social Worker (SW) at the facility about why the resident did not have the appropriate supplies and preparation to meet his care needs after he was discharged , The SW stated, I spoke to the provider over the phone, she said she had everything. When asked how she ensured the resident had the supplies and preparation he needed to meet his care needs, the SW replied, what do you want me to do, use my own gas and drive all the way out there to make sure he has the supplies? Observation on 4/06/17 at 1:45 p.m, found Resident #1 at the facility in his bed. When asked about the experience of his discharge to the AFH, Resident #1 replied they did not send the right supplies, she (the provider) did not know how to care for me, and they (the facility staff) did not show her how to care for me. It made me feel, frustrated, angry, embarrassed and disappointed; now I am back where I started. According to the facility policy on the discharge planning process: the facility should provide ongoing support, encouragement and education to patient families from admission through discharge, to ensure patient transition successfully from one level of care to another. As of 4/13/2017 at 2 p.m., an observation confirmed Resident #1 remained in the facility awaiting a discharge to the AFH. Reference: (WAC) 388-97-0960 and WAC 388-97-0080(6).

Based on interview and record review the facility failed to ensure 1 of 5 residents (#1) reviewed for care from a census of 124 residents received necessary care and services for insulin dependent diabetes management (meal monitoring, anticipation of low blood sugar when not eating, checking for low blood sugar when the resident was found unresponsive). This resulted in the resident being found with a critically low blood sugar requiring emergency intervention. Findings include: Record review found Resident #1 was last admitted to the facility 2/7/15 with medically disabling conditions related to liver and kidney failure and diabetes. [DIAGNOSES REDACTED]. Progress notes documented on 2/23/15 at 11:30 p.m. Resident #1 was found with abnormal breathing and lots of saliva inside his throat. The resident was unresponsive, unable to swallow. Blood pressure, pulse and oxygenation was within normal limits. Staff did not check Resident #1's blood glucose level. Instead, staff called 911 who checked Resident #1's blood glucose and found is was extremely low. Facility protocol for Hypoglycemic (abnormally low blood sugar) dated 1/2/14 identified if a resident was extremely drowsy or unconscious, staff would perform fingerstick blood glucose measurement. If blood glucose is less that 70 immediately administer [MEDICATION NAME] 1 mg intramuscularly or subcutaneously and notify physician immediately. Staff documented in February 2015 Resident #1 received twice daily blood sugar monitoring and [MEDICATION NAME]10 units given at 8:00 a.m. and 8:00 p.m. Twice daily blood glucose readings between 2/17 and 2/24/15 ranged from 88 to 200. Resident #1's 8:00 p.m. blood sugar reading on 2/23/15 was 121. Normal blood glucose range is 70-130. Emergency medical services (EMS) called to the facility on [DATE] found Resident #1's blood glucose was below 16. "On scene we had at least 4 nurses stating patient has been decreasing neurologically for the last couple days with many falls." and "Spoke with at least 3-4 nurses who had very little info in (sic) patient." Resident #1 was transported to the hospital. Review of Resident #1's meal record between 2/17 and 2/23/15 documented Resident #1 took in 75-100 percent of all meals on 2/17/15 and 2/20/15. The other 4 days (2/18, 2/19, 2/21, 2/22) were blank, meal refused or intake was 50-75 percent of one meal for the entire day. On 2/23/15 staff documented Resident #1 took in 50 percent at each meal (breakfast, lunch, dinner). On interview 3/5/15 at 3:40 p.m. Staff A stated if an insulin dependent resident does not eat well, staff check blood glucose readings, give a snack or supplement. Every resident with diabetes receives a bedtime snack such as a sandwich or yogurt. If resident does not eat (different from baseline), staff notify the doctor. If not eating is the resident's baseline, then staff monitors signs and symptoms so the resident does not have [DIAGNOSES REDACTED]. Staff A said Resident #1 at his "baseline" did not eat well. Staff A said he offered a bedtime snack to Resident #1 but the resident refused. Staff A stated he or Staff B (resident care manager) were responsible to notify the doctor of a resident was not eating. Staff A said he was not sure the doctor was aware Resident #1 was not eating but knew the doctor was aware of falls and Resident #1's other conditions. Staff A stated he last saw Resident #1 at 10:00 p.m. on 2/23/15 and observed nothing unusual and no signs of low blood sugar. The facility failed to monitor the resident's food intake in relationship to receiving evening insulin and although a known diabetic, facility staff failed to use the facility protocol for unconscious residents who might have hypoglycemic episodes.

Based on observation, interview and record review the facility failed to provide medically-related social services to 1 of 4 sample residents (Resident #1) from a census of 119 by failing to adequately intervene for clear symptoms of depression (hopelessness, helplessness, suicidal thoughts, decreased appetite and significant weight loss). This resulted in harm from inadequate mental health support and attention. Findings include: Observation at 10/30/14 at 1:55 p.m. found Resident #1 lying in bed awake and alert. On interview, Resident #1 stated "I can't walk" and "I can't eat the food here." and "They just try to keep you here." According to Resident #1 he could not go home because he couldn't walk or drive his car and had no one to watch out for him at his house. Resident #1 said he did not get out of bed because "What is the point of getting up?" On interview 11/04/14 Resident #1's family member stated Resident #1 went from being completely independent and ambulatory in the community to completely dependent and unable to walk after surgery. The family member said Resident #1 developed incontinence of bowel and bladder while in the facility. According to the family member "The experience is traumatic for him, he refuses to eat and has lost significant weight." and "He is a very different person." The family member said no one at the facility talked to her about Resident #1's mental condition or emotional adjustment to change in life circumstances. Record review found Resident #1 was admitted to the facility 8/18/14 after surgery for [REDACTED]. The resident's admission minimum data set (MDS) assessment dated [DATE] scored the resident's brief interview for mental status (BIMS) at 9, indicating moderate cognitive impairment. The MDS identified a baseline of no depression and no behavior problems. Resident #1 required extensive assistance of 1-2 persons for activities of daily living. According to the admission MDS, Resident #1 was always continent of bowel and bladder. Nutrition notes documented from admit on 8/18/14 to 10/25/14 Resident #1 lost 41.9 pounds in 2 months due to food refusal and not eating (186 to 144 pounds). Facility records documented standard nutritional interventions: family bringing in food, health shakes, snacks, fortified food, meeting food preferences. Nutrition notes documented there could be a psychological or depressive component to the resident's condition. On 9/18/14 Resident #1 said "I don't want to live like this anymore." On 10/16/14 Resident #1 was asked to eat in the dining room. Resident #1 responded "It would be depressing, most of there (sic) people are never going to leave this place." Nursing notes and Social Service notes documented on 9/5/14 Resident #1 had suicidal thoughts. Nursing notes documented "Upon interview, resident stated that he had wished to be dead because he was tired of having people take care of him." Social services notes documented Resident #1 had suicidal thoughts 4 days in the last two weeks. Social Service interventions for Resident #1's suicidal thoughts on 9/5/14 included completing a suicide risk form, informing nursing staff so the resident could be monitored every 15 minutes. Social service staff offered Resident #1 a care conference, which was declined. There was no documentation or indication that social services checked back in or talked to Resident #1 about his feelings or concerns. There was no documentation the doctor was notified of Resident #1's suicidal thoughts. There was no mental health referral. There was no update to the plan of care related to Resident #1's suicidal thoughts or statements of not wanting to "live like this". A care conference was held on 9/26/14. Care conference notes documented Resident #1 had a decline in function, had very poor eating and wanted to discharge home. There was no reference to suicidal thoughts, depression or determination of why the resident was eating so poorly other than "Resident will not eat food at facility." The plan was "will eat cream of wheat from facility." There was no plan to talk to the resident about his loss of function or factors contributing to his food refusal. On interview 10/30/14 at 4:20 p.m. Staff F (social service director) stated she and Staff G shared social service duties and communicated verbally about resident care needs. According to Staff F when residents make suicidal statements, staff makes sure the resident is safe, nurses check every the resident every 15 minutes and the resident is offered mental health services. After reviewing Resident #1's record, Staff F said "I don't know what happened to the follow up." On interview 11/05/14 at 12:10 p.m. Staff G stated she did not talk with Resident #1 after 9/5/14 about his suicidal thoughts or feelings or discuss the resident's statements of suicidal feelings at the 9/26/14 care conference because the resident's suicidal thoughts were not brought up again. Staff G stated she was not aware that Resident #1 had continuing significant weight loss. On interview 11/05/14 at 10:25 a.m. Resident #1's doctor stated 10 - 15 pounds of the resident's 40 pound weight loss could have been related to eliminating excess bodily fluid built up during surgery. According to the doctor, overall Resident #1's weight loss was related to his medical condition (causes breakdown of body tissue), depression and lack of eating. According to the resident's doctor, no one told her about Resident #1's suicidal statements on 9/5/14. The doctor stated the first she heard of Resident #1's expression of suicidal thoughts was 10/31/14 (the day after the department investigation visit). .

Based on observation, interview and record review the facility failed recognize and provide timely intervention for signs of injury after a fall and failed to provide adequate pain monitoring and medication after return from surgery for [REDACTED].#3) from a census of 119 . This resulted in a 4 day delay in care for a broken hip and inadequate pain relief. Findings include: Observation on 10/30/14 at 3:35 found Resident #3 lying in bed. The resident was unable to answer questions about recent history or care at the facility. Record review found Resident #3 was admitted to the facility 06/11/12 with medically disabling conditions and dementia. Resident #3's annual minimum data set (MDS) assessment dated [DATE] identified the resident had moderately impaired decision making. The MDS identified Resident #3 required extensive assistance of 1 person for activities of daily living including transfer, toileting and hygiene. Resident #3 was always incontinent of bowel and bladder. Resident #3's care plan identified Resident #3 was to have physical assistance of 1 person getting in and out of bed. Resident #3 used a wheelchair for mobility. Alarms were used to alert staff when the Resident tried to get up without staff assistance. Progress notes document at 1:00 p.m. 10/11/14 Resident #3 was found on the floor in his room, holding onto his bed. The alarm was sounding. On assessment, staff documented there was a small scratch on the right knee on the lateral side down to the shin. A pain assessment done after the fall noted the Resident ' s pain level was 3/10 (on a scale of 1-10 with ten being the worst pain possible). The pain assessment identified soreness was worse with activity. The pain was better (0/10) with rest. The doctor was notified of the fall. Review of progress notes, staff statements and pain monitor found staff did not identify any physical signs of fracture (swelling, internal rotation or obvious dislocation). Staff did document Resident #3 had pain (especially with movement or repositioning) and change in mobility status over the next 4 days: -10/12/14 (day shift) complained of mild pain. (There was less pain on his right thigh after Tylenol was given) -10/12/14 (11:30 p.m. to 10/13/14 12:00 a.m.) suddenly shouted when an aid tried to change his position. -10/13/14 (day shift) had difficulty transferring from wheelchair to bed. Complained of "Pain all over". Bruising was noted on right knee. Complained of pain when being turned to side during peri-care with 2 person assist. Complained of pain when in bed and head of bed was being raised to 90 degrees. On assisting with peri-care Staff H noted Resident #3 grimace and say "ouch" on turning to his side. -10/14/14 (day shift) needed increased assistance when transferring out of bed to the wheelchair and back. Resident now needed two people to assist from sit to stand and pull up his pants. Had decreased mobility compared to baseline. -10/14/14 (evening shift) complained of pain with movement of the body and repositioning. Medication record review identified staff treated Resident #3's pain with a standing order for Tylenol 325 mg (2 tabs) every 6 hours as needed for pain. No Tylenol was given from October 1-11 but was given once daily October 12, 13, 14, 15. Progress notes document 10/14/14 at the request of the POA (power-of-attorney) day shift staff Faxed the doctor and requested an X-ray order. X-ray done on 10/15/14 showed " impacted (pieces of bone break into multiple fragments which push into each other) right femoral neck fracture. " According to <http://www.wisegeekhealth.com/what-is-an-impacted-fracture.htm> " Impacted fractures are usually very painful and also very noticeable; the fracture will not be confused with a lesser sprain. " Resident #3 was transported to the hospital for surgical repair of the fracture on 10/15/14 - 4 days after the fall. On interview 11/05/14 at 4:30 p.m. Resident #3 ' s POA stated the resident fell on Saturday 10/11/14 after she left from her daily visit. The POA stated when she came for her daily visit on Sunday 10/12/14 she found Resident #3 " Sitting in a wheelchair bent over like in misery. Something was wrong. He was just different ...just pitiful! " The POA stated she talked to staff to try to figure out what happened but there was not good documentation. The POA stated when she came in Monday 10/13/14 she could see Resident #3 was still in pain by the way he looked " His face was screwed up, he was tense. I said he needs and X-ray. " The POA said she talked to the director of nursing who said an X-ray would be ordered. (This was ordered 10/14, done 10/15/14). The POA stated that a few days after return from the hospital 10/19/14 after surgery, staff told her they were starting pain medication because they heard Resident #3 cry out in pain. review of medication records [REDACTED]. Pain monitoring flow sheet documented on 10/21/14 at 12:00 Resident #3 had pain level of 6/10. On 10/22/14 the resident ' s pain level was 5/10. The resident was given Tylenol 650 mg on both days. Records show Resident #3 did not receive any other pain evaluation or medication until a new order was written 10/23/14 for [MEDICATION NAME] 5 mg four times daily for 30 days. .

Based on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible by not posting appropriate signage when cleaning carpets and providing supervision to prevent accidents. Facility carpet extraction procedure left carpet wet enough to cause a resident to slide on vinyl flooring after walking on wet carpet. This resulted in a fall and injury to 1 of 2 residents (Resident #1) reviewed for accidents from a sample of 6 residents reviewed for care from a census of 127. Findings include: Observation 9/26/14 at 12:45 p.m. noted resident rooms were vinyl or linoleum tile, while the hallway was carpeted. Previous visits to the building noted carpet extraction (cleaning with wet solution using a machine) was regularly done. Observation 9/26/14 at 4:00 p.m. noted Resident #1 seated on her bed in her room. A right wrist brace was in place. Resident #1 stated she broke her wrist in a fall. "I was in the hall, the floor was wet, I walked in the room, I slipped and fell .... They usually put signs wet floor but here were no signs up. I yelled and screamed, they came running." Record review found Resident #1 was admitted to the facility 7/8/14 with medically disabling conditions. Resident #1's minimum data set (MDS) assessment dated [DATE] identified the resident had brief interview for mental status (BIMS) score of 15, indicating she was cognitively intact. The assessment identified the resident required supervision for activities of daily living. Resident #1's care plan identified the resident was independent in walking, transfers, dressing and bathing. Facility incident report documented on 9/9/14 staff responded to Resident #1's cries for help. The resident was noted on the floor of her room and complained of right shoulder and right knee pain. X-ray determined right forearm bone fracture. Resident #1 told staff she stepped off the wet carpet and slid on the vinyl flooring in her room. Facility incident report identified a wet floor sign was near but not directly in the path of the doorway to warn the resident of wet carpet. Facility incident report documented housekeeping was re-educated on placement of wet floor signs on 9/11/14 and more signs were ordered. As correction to prevent future incidents, signs were to be placed in every doorway affected during carpet extraction. The incident report did not identify why the carpet was wet enough to result in the resident sliding on her vinyl floor or other means to provide supervision to protect residents. The incident report did not determine if staff used the carpet extractor correctly on the day of Resident #1's fall and injury.

Based on observation, interview and record review the facility failed to ensure food service practice systems prevented 1 of 13 residents with identified food allergy (Resident #1) from being served food containing the known allergen. This resulted in the resident receiving emergency treatment for [REDACTED]. Findings include: Record review found Resident #1 was admitted to the facility 11/20/13 with multiple medically disabling conditions. Resident #1's face sheet, medical record and admission orders [REDACTED]. Resident #1's minimum data set (MDS) assessment dated [DATE] identified the resident had no cognitive impairment. The resident required supervision and set up assistance for eating. Resident #1's care plan dated 11/22/13 focused on weight monitoring, hydration and nutrition "diet as ordered." The care plan did not mention about that the resident had an allergy to peanuts, it was updated after the incident. Progress notes dated 12/20/13 identified that shortly after the evening meal, Resident #1 approached the nursing desk and reported tightening of the throat after eating what he thought was pecan pie. The resident told staff he had a peanut allergy. Staff called 911 and Resident #1 was transported to the hospital. Facility records documented Resident #1 was given and took a bite of peanut butter (not pecan) pie. Medical records documented on 12/20/13 Resident #1 was treated in the emergency room for anaphylaxis, swelling of the lips, throat and tongue related to allergic reaction. Resident #1 returned to the facility the same day with orders for 3 days of daily medications to treat swelling an inflammation related to allergic reaction: Prednisone 60 mg, Pepcid 20 mg, Benadryl 50 mg every 6 hours as needed for itchiness. Facility incident report documented three kitchen staff (B, C, D) were involved in preparing the evening meal trays on 12/20/13. Staff C (cook) expedited by calling out meal choice and allergies. Staff B (dietary aide) plated the food. Staff D (dishwasher) checked the tray. Facility incident investigation identified Staff C did not call out allergies loud enough for Staff B or D to hear. The report also identified the peanut butter pie had no topping or other appearance to indicate that it contained peanuts. On interview 1/2/14 at 11:10 a.m., Staff A (interim dietary director) stated he discovered that the meal card filled out for Resident #1 on 12/20/13 did not list Resident #1's allergy as "Peanuts." The meal card listed the Resident #1's allergy as "PB" for peanut butter. According to Staff A, Staff D did not know what "PB" meant. Observation of meal service procedures on 1/2/14 from 11:20 to 11:30 a.m. found resident allergies and diet orders were printed on individual meal cards. Staff E called out the resident's name, meal choice, diet and allergy. Staff C plated the food. Staff F covered the food, checked the tray and added dessert. The room was noisy. The cycle for service was ongoing, so one tray was not fully completed before the next tray was called out and prepared. This meant that one person was checking and completing a tray while listening to additional diet orders being called. On interview 1/2/14 at 12:10 p.m. Resident #1 stated he was very aware of his peanut allergy and tried to be suspicious of food. The resident said the day of his allergic reaction he thought he was eating pecan pie. "I took a bite and knew it did not taste right. I spit it out and walked to the nurses' desk. My throat started to close and mouth started to swell." Resident #1 said staff called 911 and emergency personnel gave him epinephrine and cortisone before taking him to the emergency room . The facility food service delivery system (including use of an abbreviation instead of the actual word on a meal card) resulted in Resident #1's accidental ingestion and allergic reaction to food containing peanuts.

Based on observation, interview and record review the facility failed to ensure 3 of 3 sample residents (#1, #2, #3) reviewed for medication errors from a census of 130 was free of significant medication errors related to unsecured medication, improper transcription of medication orders and/or inadequate follow up to ensure the error did not occur again. This resulted in harm to Resident #1 and potential harm to Residents #2 and #3. Findings include: RESIDENT #1: Record review found Resident #1 lived at the facility from [DATE] to present. The resident had mentally and medically disabling conditions. The resident received continuous oxygen by nasal cannula. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] documented a brief interview for mental status (BIMS) score 15 of 15 possible points, indicating the resident had no cognitive impairment. The MDS identified no behaviors of concern. Resident #1's care plan identified a history of refusing to go to bed and put his legs up or refusing blood draws. The care plan identified the resident had regular visual and auditory hallucinations due to his mentally disabling condition. Behavior monitoring documentation for October and [DATE] noted only auditory hallucinations. There was no refusal behavior or visual hallucinations noted by staff. Medication record review found the resident received multiple [MEDICAL CONDITION] medications but no narcotics. Resident #1 received Tylenol 650 mg 4 times daily and ,[DATE] mg Tylenol at bedtime as needed for headache. Observation [DATE] at 10:35 found the resident propelling himself in his wheelchair down the hall. The resident's demeanor and behavior was calm and pleasant. During private conversation Resident #1 stated it was OK living at the facility but a week ago he was given the wrong medication. "They gave me [MEDICATION NAME] (synthetic narcotic) - they say I almost died ." Resident #1 said a nurse gave him the [MEDICATION NAME]. "They say I took it from the cart - I never tried. The nurse gave me pain in a small plastic cup. I put it in my hand then I take it. They say I did - I'm sure I didn't (take medication off the cart) never!" Facility incident report and progress note review found on [DATE] at 7:00 p.m. Resident #1 accidentally ingested 70 mg of [MEDICATION NAME] prepared/intended for a different resident. The incident report identified Staff E left [MEDICATION NAME] unsecured on top of the medication cart while responding to an emergency. Staff E documented seeing Resident #1 ingest the medication on returning to the medication cart. Facility records documented over the course of the evening [DATE] Resident #1 became more sedated and at around 10:00 p.m. Staff E called 911 to transport Resident #1 to the hospital. Medical records document while at the facility Resident #1 experienced oxygen desaturation (inability to maintain adequate oxygen concentration) into the 80's while on his usual 2 liters/minute oxygen. Normal oxygen saturation ranges is ,[DATE]%. Staff called 911 and Resident #1 was transported to the hospital. Medical records document Resident #1 was given [MEDICATION NAME] (medication to counteract narcotic) by emergency personnel at the facility, again in the emergency room and then the resident required a continuous [MEDICATION NAME] drip overnight to counteract the sedating effects of the accidentally ingested [MEDICATION NAME]. Resident #1 returned to the facility [DATE] after being treated at the hospital with [MEDICATION NAME]. On interview [DATE] at 10:30 a.m. Administrative Staff #2 acknowledged the [MEDICATION NAME] should not have been left unsecured on top of the medication cart per facility policy. RESIDENT #2: Record review found Resident #2 admitted to the facility [DATE] with medically disabling conditions including insulin dependent diabetes. Resident #1's Minimum Data Set (MDS) assessment dated [DATE] identified no cognitive impairment. The resident required extensive one to two person assistance for most activities of daily living. Medication review found on admit Resident #2 was prescribed both insulin and [MEDICATION NAME] 1000 mg (oral medication the lowers blood sugar) twice daily every day. Both of these medications were listed on the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Doctor's order review found on [DATE], the bedtime insulin dose was decreased from 60 unit injection to 55 unit insulin injection. Review of the MAR found on [DATE] Staff D wrote D/C (discontinue) with a large arrow encompassing both insulin and [MEDICATION NAME], indicating that both medications were discontinued. Resident #2 did not receive his ordered medication for 17 days. Blood sugar record review found that from ,[DATE] to [DATE] Resident #2 was given 22 doses of additional insulin for blood sugar reading over 175 according to a standing sliding scale. Facility incident report documented the error was found at month end review of medications. See findings under F514 Res Records Complete/Accurate/Accessible. On interview [DATE] at 2:05 p.m. Staff D stated he works part time on call and was not aware of the error until told by the surveyor. RESIDENT #3: Record review found Resident #3 admitted to the facility [DATE] with medically disabling conditions. Resident #3's Minimum Data Set (MDS) assessment dated [DATE] identified no cognitive impairment. The resident required extensive two person assistance for most activities of daily living. Medication review found on admit Resident #3 was prescribed [MEDICATION NAME] (reduces stomach acid) 40 mg daily to treat [MEDICAL CONDITION] reflux. Medical record review found that on [DATE] Resident #3 was transported to the hospital for a scheduled gastro-intestinal procedure. The resident returned [DATE] with an order for [REDACTED]. Review of Resident #3's MAR found the facility gave [MEDICATION NAME] 40 mg daily (not 20 mg as ordered) from [DATE] until [DATE] (17 days). The medication error was found when a nurse called the pharmacy for a refill of [MEDICATION NAME] 40 mg and was told the correct dose was 20 mg. The discrepancy in doses was not picked up on monthly MAR indicated [REDACTED] Facility incident report documented that Staff A transcribed medication orders into the facility system using the medications listed on hospital records, not the actual discharge order. On interview [DATE] at 12:30 p.m. Administrative Staff #2 stated the nurse who did not check the discharge orders is getting a write up. Staff gave a dose of medication for 17 days which was not listed on the doctor's orders. .

Based on observation, interview, and record review, the facility did not appropriately supervise Resident #1 when assisting the resident on a bedpan in bed. The resident was 1 of 2 sampled residents (#1) reviewed for appropriate supervision during the provision of care and services. This failure resulted in actual harm to the resident who rolled off the bed and sustained bilateral femur fractures. Findings Include: Record review found Resident #1 was initially admitted to the facility 6/14/10 and readmitted to the facility 11/15/12 with multiple medically disabling conditions including muscle weakness, pain, left lower limb amputation, diabetes, respiratory compromise and obesity. Resident #1's Minimum Data Set (MDS - an assessment tool) quarterly assessment dated [DATE] identified that the resident required extensive one person assistance with dressing, toileting and personal hygiene and extensive two person assist with bed mobility and transfers. The assessment showed no cognitive impairment. Resident #1's care plan had multiple different updates. On 8/23/12 directions were for 2 to assist bed mobility "can roll side/side with cue." Review of facility incident reports found that on 1/25/12 at 10:45 a.m. Staff C was completing routine care for Resident #1 after toileting on the bed pan. Staff C cued the resident to turn away from her and Resident #1 fell from the bed onto the floor face down. On evaluation at the Emergency Department the resident was found to have broken both femurs (long thigh bones). The resident's bed did not have rails and Staff C did not have another person stand next to the other side of the bed to prevent the resident from rolling out of the bed. Not having another staff to help resulted in the resident not being appropriately supervised and assisted during placement and removal of the bedpan. Without this appropriate supervision, the resident rolled off the bed.

Based on observation, interview and record review the facility failed to ensure that 2 of 3 sample (#1, #2) residents received adequate supervision to prevent elopement from the facility. Failure to adequately evaluate elopement risk and implement timely, appropriate prevention measures: resulted in harm to Resident #1 who was hospitalized with hypothermia after being found on the ground 2 days after eloping from the facility; placed Resident #2 at risk of harm when she was found unsupervised outside the facility and placed current and future residents at risk for harm from inadequate supervision to prevent elopement. Findings include: RESIDENT #1: Facility records document that Resident #1 was admitted [DATE] after being found unresponsive at home. [DIAGNOSES REDACTED]. According to the resident's 09/27/12 Minimum Data Set (MDS - a standardized assessment tool), Resident #1 had a score of 9 on the Brief Interview for Mental Status tool, indicating moderate cognitive impairment. The resident was continent of bowel and bladder and required minimal supervision for activities of daily living. No wandering behavior was identified. Review of Resident #1's Elopement/Wander Risk Evaluation dated 10/15/12 found that the resident had short term memory problems related to his medical condition, goal directed wandering (smoking), observable situational frustration, and was independent in walking off the unit. Resident #1 was determined by facility staff to have no elopement potential. No approaches addressing elopement potential were listed on the plan of care. Facility progress notes dated 11/29/12 to 12/15/12 document Resident #1 was very confused, forgetful, and had significant cognitive deficits. Staff documented Resident #1 frequently asked for cigarettes and at times become very agitated. On 12/03/12 Resident #1's agitation escalated after he temporarily ran out of cigarettes. Staff obtained a doctors order for Ativan (anti-anxiety medication) and a nicotine patch. No care changes were made recognizing the resident's behavior as elopement risk and alerting staff of the need for increased supervison. Facility progress notes dated 12/15/12 document at 7:30 a.m. after smoking a cigarette Resident #1 said his car was not in the parking lot and then paced up and down the hallway becoming increasingly agitated. At 9:00 a.m. the resident was given Ativan for his agitation and appeared to calm down. No additional or increased supervision was implemented after Resident #1 exhibited clear agitation, ambulation and statements about his car. Staff saw the Resident at the nurses' station at 11:30 a.m. At 1:00 p.m. staff could not find Resident #1 on the premises and implemented the missing resident protocol. Medical records document on 12/17/12 Resident #1 was found by a passersby unresponsive lying in a school field, cold and shivering. On admission to the hospital Resident #1 had wounds to his right arm and left hand. Resident #1 was placed in the intensive care unit. Doctors determined Resident #1 had life threatening failure of circulatory, neurologic, kidney systems, sepsis (total body infection), dehydration and severe hypothermia due to exposure. Medical records show that Resident #1 was readmitted to the facility 12/22/12. Observation 12/27/12 at 1:00 p.m. found Resident #1 lying in bed. On interview the resident did not know where he was, saying that it was hard to remember things because he wakes up for a day or two and then slips into a coma. On interview 12/27/12 at 11:50 a.m. Staff C (Staff RN) described Resident #1 as pleasant, occasionally confused but easily redirectable. The resident mostly talks about his car/keys "where is the car" and looks for cigarettes. On interview 12/27/12 at 3:50 p.m. Staff A (Resident Care Manager) stated Resident #1 came to the nurses desk every morning asking why he is here, saying "I'm ready to go" and asking about his suitcase. Staff A stated he did not identify Resident #1 as an elopement risk because the resident was easily redirectable and had made no attempt to elope. On interview 12/27/12 at 4:30 p.m. administrator and Director of Nursing (DON) stated that the Elopement/Wander Risk Evaluation tool used by the facility only identified potential risk of elopement. The DON said that elopement risk or determination of the need for electronic alert systems (like Wanderguard) was based on professional opinion of staff. According to the administrator, someone wandered (Resident #1) so clearly the assessment needed to be different and perhaps the facility could broaden their perspective/evaluation to identify more clearly elopement risk. RESIDENT #2: Facility records document Resident #2 was admitted to the facility 05/30/12 with medical conditions and mild cognitive impairment. Medical records document that 10 days prior to admission on 05/20/12 Resident #2 was found down on a sidewalk by a bystander, unable to supply any history. The resident was admitted to the hospital as Jane Doe and then transferred to the facility on ce her identity was established. According to the resident's 06/06/12; 09/02/12; 12/02/12 MDS assessments, Resident #2 had no identified wandering behavior. Resident #2's Elopement/Wander Risk Evaluation dated 05/30/12 identified elopement potential as the resident was very confused and had poor judgment. The plan of care was to "evaluate for wandering" and provide a supportive environment. Resident #2's 09/05/12 Elopement/Wander Risk Evaluation identified concerns in cognition, behavior/mood and mobility but no elopement potential as there was no history of elopement. Facility records show that on 09/20/12 Resident #2 eloped to a local grocery store. The Elopement/Wander Risk Evaluation for 09/20/12 and 10/15/12 identified that there was elopement potential but the resident refused to wear a Wanderguard. A wander risk care plan was implemented 09/20/12. Progress notes document 12/23/12 around 2:00 p.m. Resident #2 was found by Staff D standing outside, unsupervised. Staff D opened the door to let Resident #2 inside. The facility treated the incident as an elopement and implemented 1:1 monitoring after Resident #2 again adamantly refused to wear the Wanderguard. Observation 12/27/12 at 11:00 a.m. found Resident #2 standing in the hallway at the medication cart fully clothed and groomed. On interview the resident spoke in partial or incomplete sentences saying that she was going back to to where she lived before in the city "sometimes I stay, sometimes not." On interview 12/27/12 at 3:50 p.m. Staff A stated that the 09/20/12 elopement was thought to be related to a recent re-connection with family and a family outing. Staff A said that he thought the 12/23/12 elopement occurred when a temporary outside smoking area was implemented during an infectious gastrointestinal outbreak and Resident #2 followed other residents outside. Staff A stated that social services are working on getting a place where the resident can be safe. Increased supervision was not implemented when the facility practice changed (temporary outside smoking area) increasing the resident's elopement risk. On interview 12/27/12 at 4:30 p.m. the administrator stated that Resident #2's photo was in the "wander alert" notebook at the front desk and she was sure there were other wander prevention measures in place even though the resident refused the Wanderguard. FACILITY PRACTICE: Observation 12/27/12 at 9:00 a.m. noted that Ballard Care and Rehabilitation Center is located in the city of Seattle in a residential neighborhood 4 blocks from a busy thoroughfare. The building has a Wanderguard departure alert system (electronic alarm that sounds when a resident with a Wanderguard bracelet attempts to exit). The facility Elopement/Wander Risk Evaluation tool directed that if a resident had a single factor related to mobility, behavior/mood, cognition or factors in all 3 areas (mobility, behavior/mood or cognition) it "raises the potential for elopement." If any factors were present (regardless of area or amount) staff was directed to complete the Evaluation Risk Identification Form. Nowhere on the form or in the facility policy was staff given direction about how to assess the level of elopement risk in light of identified risk factors or when/if to use a Wanderguard or implement increased supervision. The form did not include and staff did not identify that Resident #1 making statements about being ready to go, or looking for suitcases/car indicated a desire or possible intent to leave. Previous department investigation in September 2012 related to elopement events identified the facility Elopement/Wander Risk Evaluation tool did not assist staff to analyze information in order to determine elopement risk. On 12/27/12, Staff B identified 11 residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11) as wearing Wanderguard devices due to risk of elopement from a census of 134. Review of current facility practice found the same Elopement/Wander Risk Evaluation Form from September 2012 was in use without modification.