Every finding on record at Belmont Terrace

Based on interview and record review, the facility failed to ensure that Skilled Nursing Facility (SNF) Advanced Beneficiary Notices (ABN: a notification that provides an estimated cost of continuing services which may no longer be covered by Medicare. Beneficiaries may choose to continue the services but may be financially liable) were provided, as required, for 2 of 2 residents (Residents 18 & 56) reviewed for provision of SNF ABN. This failure placed residents at risk of not having adequate information to make care and financial decisions during their continued stay.Findings included . Resident 56Record review showed Resident 56's Medicare Part A stay started on 11/07/2025 and had a last covered day of 01/21/2026. Resident 56 remained in the facility after the services ended. No SNF ABN was found in Resident 56's record. On 02/26/2026 at 4:13 PM, when asked if a SNF ABN was provided to Resident 56 Staff P, Social Services Director (SSD), stated, No. Resident 18Record review showed Resident 18's Medicare Part A stay started on 12/24/2025 and had a last covered day of 01/29/2026. Resident 18 remained in the facility after the services ended. No SNF ABN was found in Resident 18's record. During an interview on 2/26/2026 at 4:13 PM, Staff P, SSD, said a SNF ABN was not provided to Resident 18 and explained they were informed SNF ABNs were only provided to residents whose Medicare Part A services ended, remained in the facility, and were private pay. Reference WAC 388-97-0300 (1)(e), (5), (6)

Based on observation, interview and record review the facility failed to maintain a homelike environment regarding noise levels for 1 of 4 halls (Mountain View Hall) reviewed for a homelike environment. The failure to ensure appropriate noise levels placed residents at risk for not having a homelike environment, a decreased quality of life, and potential health concerns. Findings included .On 02/23/2026 at 10:33 AM, Resident 30 said the kitchen door was always slamming and the kitchen staff were very loud and she could hear the conversation from across the hall. Resident 30 said the facility was always telling us this is our home, but this does not feel like my home, because there would not be all the yelling and slamming of the doors in my home. Resident 30 said there was a resident on the hall that yelled all day and all night long and staff could not stop them. Resident 30 said they would keep the door shut due to the noise level. Resident 30 said they had written grievances and brought the concern to Resident Council, but they had stopped doing that, because nothing ever happened with their concerns. On 02/23/2026 at 11:20 AM, Resident 44 said the doors in the hall were always slamming shut, including the kitchen door and the housekeeping door. Resident 44 said they often kept the door shut because of the noise level in the hall.On 02/23/2026 at 2:08 PM, Resident 35 said there was a resident on the hall that continued to scream all day and night, to the point Resident 35 had yelled back at them to stop.Observations of Kitchen door (across from room [ROOM NUMBER]), Housekeeping door (across from room [ROOM NUMBER]) and Social Services (SS) door (next to room [ROOM NUMBER]) slamming shut on Mountain View Hall:02/24/2026 8:26 AM, Kitchen door (x2 Maintenance walked in and then out).02/24/2026 8:26 AM, Housekeeping door (staff member put away vacuum cleaner).02/24/2026 8:29 AM, Kitchen door. Resident 30 pointed out slamming kitchen door.02/24/2026 8:32 AM, Kitchen door, staff member entered.02/24/2026 8:33 AM, Kitchen door.02/24/2026 8:34 AM, staff member walked out the Kitchen door. 02/24/2026 8:34 AM, Kitchen door, staff member entered. 02/24/2026 8:37 AM, Kitchen door, staff member exited with meal cart.02/24/2026 8:41 AM, Social Service door, Staff C, Licensed Practical Nurse/Resident Care Manager entered. 02/24/2026 11:23 AM, Kitchen door, staffed member entered. 02/24/2026 11:25 AM, SS door, staff member exited.02/24/2026 11:28 AM, Kitchen door, staff member entered.02/24/2026 11:31 AM, Housekeeping door, staff member exited. 02/24/2026 11:35 AM, Housekeeping door, staff member exited.02/25/2026 11:45 AM, SS door, Staff B, Director of Nursing Services (DNS) entered.02/25/2026 11:53 AM, Kitchen door, two staff entered in the same minute, both slamming the door.02/25/2026 12:00 PM, Resident room [ROOM NUMBER] door slammed shut by Staff H, Certified Nursing Assistant, entered room.02/25/2026 12:04 PM, Kitchen door, staff member entered. 02/25/2026 12:08 PM, Kitchen door, staff member exited.02/25/2026 12:12 PM, SS Door. Staff B, DNS exited.On 02/26/2026 at 12:46 PM, when asked about the noise level related to residents' yelling, Staff EE, Licensed Practical Nurse, said there was a particular resident that constantly hollers out all the time including during the day and night. Staff EE said other residents have complained of the constant hollering, especially rooms next to the hollering residents'. On 02/26/2026, the previous six months (September 2025-February 2026) of Grievances were reviewed and documented the following:09/23/2025 grievance filed by Resident 30 & Resident 52, Noisy outside the kitchen which is right opposite resident's room.10/15/2025 grievance filed by Resident 44, Resident reports concern about neighbor yelling.02/03/2026 grievance filed Resident 35, Resident reports noise concerns about her next-door neighbor.On 02/26/2026, the Resident Council Meeting Minutes were reviewed and showed in February 2026 there was a noise complaint from residents about the kitchen, There is too much noise coming from the kitchen! Voices are too loud, banging, dishes, etc. that echoes throughout the hall.On 02/27/2026 at 10:50 AM, when asked about the complaints regarding noise levels on Mountain View Hall, Staff B, DNS, said they were not aware of any complaints about the noise levels. When asked about the doors on Mountain View Hall, Staff B said there had been complaints about the doors slamming but said they did not know how to fix the issue. When asked about residents hollering out, Staff B said they thought they had fixed it. Staff B was asked what was fixed. Staff B explained there had been a resident always hollering out day and night and they had implemented interventions to address the concern. When it was explained that other residents have continued to experience side effects from the residents' hollering out including not sleeping, frustration and yelling back at the specific resident, Staff B said they were not aware this had started up again and it needed to be addressed.Reference WAC 388-97-0880

Based on interview and record review, the facility failed to offer a bed hold upon transfer to the hospital for 1 of 2 residents (Resident 7 ), and to communicate required/necessary information to the receiving hospital to ensure continuity of care for 2 of 2 residents (Resident 7 & 80) and 4 of 4 discharges reviewed for hospitalization. Failure to offer bed holds placed residents and their representatives at risk of not being informed of their right to, and the cost of holding the resident's bed while hospitalized . The failure to ensure necessary information was communicated to the receiving hospital detracted from continuity of care and placed residents at risk of receiving incoherent, fragmented, or redundant care.Findings included.BED HOLDResident 7Review of the 01/20/2026 Discharge Minimum Data Set (MDS - an assessment tool) showed Resident 7 was transferred to an acute care hospital on [DATE] with their return anticipated. Review of the electronic health record (EHR) showed there was no documentation Resident 7 was offered a bed hold.On 03/02/2026 at 9:23 AM, when asked if there was documentation to show Resident 7 was offered a bed hold Staff B, Director of Nursing Services (DNS) and Registered Nurse (RN), stated, No. COMMUNICATON WITH RECEIVING FACILITYResident 7 was admitted to the facility 09/19/2025. Record review showed Resident 7 was transferred to the hospital on three separate occasions.a) Review of the 11/19/2025 Discharge MDS showed Resident 7 was transferred to an acute care hospital on [DATE] with their return anticipated. Review of the EHR showed no documentation that facility staff called report to the receiving hospital, and no e-interact transfer form (a document completed by staff that includes documentation on who staff called report to and what documents were sent with the resident at discharge) was completed. b) Review of the 12/24/2025 Discharge MDS showed Resident 7 was transferred to an acute care hospital on [DATE] with their return anticipated. Review of the EHR showed no documentation that facility staff called report to the receiving hospital, and no e-interact transfer form (a document completed by staff that includes documentation on who staff called report to and what documents were sent with the resident at discharge) was completed. c) Review of the 01/20/2026 Discharge MDS showed Resident 7 was transferred to an acute care hospital on [DATE] with their return anticipated. Review of the EHR showed no documentation of what documents, if any, were sent with the resident, that staff called report to the receiving hospital, or that an e-interact transfer form (a document completed by staff that includes documentation on who staff called report to and what documents were sent with the resident at discharge) was completed. On 03/02/2026 at 9:23 AM, when asked if there documentation to show staff called report to the hospital, or otherwise communicated the resident condition to the receiving facility and that identified what documents, if any, were sent with Resident 7 at the time of the above referenced discharges, Staff B, DNS, said no. Resident 80.Review of the 11/25/2025 Discharge MDS showed Resident 80 was transferred to an acute care hospital on [DATE] with their return anticipated. Review of the EHR showed an e-interact transfer form, dated 11/25/2025, that documented report was called to 911 not the receiving facility. The document had a section at the bottom for nurses to check-off the documents that were sent with Resident 80 and for the transporting EMTs to sign that the documents were received, but the section was not completed. On 03/02/2026 at 9:12 AM, Staff B, DNS, said they could not find documentation that staff called report to the receiving hospital, or what documents, if any, were sent with the resident.Reference WAC 388-97-0120 (2)(a-d), -0140 (1)(a)(b)(c)(i-iii)

Based on observation, interview, and record review, the facility failed to ensure quality of care was provided for insulin administration for 1 of 1 resident (Resident 44), bowel management for 2 of 5 residents (Resident 36 & 85), physical therapy evaluation for 1 of 1 resident (Resident 23) reviewed to Activities of Daily Living (ADLs), oxygen administration for 1 of 1 residents (Resident 85) and edema and weight monitoring for 1 of 1 resident (Resident 80). These failures placed residents at risk of medical complications, unmet care needs and a diminished quality of life. Findings included .Resident 44 Resident 44 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, (MDS, an assessment tool) dated 12/17/2025, documented Resident 44 was cognitively intact. On 02/23/2026 at 11:15 AM, Resident 44 said they had missed 3 days of their insulin, due to the facility not having it in supply. Review of Resident 44's February 2026 Medication Administration Record (MAR) documented the following: 02/05/2026- code 2 (meant medication was held) 02/06/2026- medication was given 02/07/2026- code 7 (meant see progress note for details) 02/08/2029- medication given 02/09/2026- medication given 02/10/2026- medication given 02/11/2026- medication given A progress note dated 02/05/2026 at 8:00 PM, documented Tresiba (a long acting insulin used to help control blood sugar) was not given due to not being available, instead another long-acting insulin was provided. No progress notes from 02/06/2026 were found indicating whether the Tresiba had been given or was out of stock. A progress note dated 02/07/2026 at 1:34 PM, documented Tresiba was not given due to being not available. No progress notes from 02/08/2026 were found indicating whether the Tresiba had been given or was out of stock. A progress note, dated 02/09/2026 documented the pharmacy was sending the medication that day. Resident 44 was given the Tresiba at 8:02 PM on 02/09/2026. On 02/26/2026 at 2:40 PM, in a joint interview with Staff B, Director of Nursing Services (DNS) and Staff C, Licensed Practical Nurse (LNP)/Resident Care Manager (RCM), Staff C pulled up Resident 44's MAR and confirmed the documentation showed Tresiba had been given per the dates listed. Staff B and Staff C then reviewed the progress notes from 02/05/2026 - 02/10/2026. Staff C confirmed the progress notes documented Tresiba had not being given and was unable to determine if on 02/06/2026 and 02/08/2026 the Tresiba had been given (due to previous notes stating it was unavailable). When shown the contradictory documentation about the medication (MAR documented it was given and progress notes documented it was not given), Staff B said there was not way to confirm if the resident received the medication or not. Staff B said the expectation for unavailable medication was for staff to contact the provider for further instruction. Resident 36 Resident 36 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], documented Resident 36 was cognitively intact and on continuous oxygen therapy. On 02/23/2026 at 3:07 PM, Resident 36 was observed receiving oxygen by nasal cannula (NC - flexible tube with two prongs inserted into the nostrils to deliver supplemental oxygen) at 2 liters (L -a metric unit) per minute and there was no humidifier. On 02/24/2026 at 1:30 PM, Resident 36 was observed receiving oxygen by NC at 2L and there was no humidifier. An order, dated 01/23/2026, said to change Resident 36's oxygen humidifier every Sunday on night shift. A review of Resident 36's MAR documented that the humidifier was changed 02/22/2026. On 02/24/2026 at 2:27 PM, Staff AA, Licensed Practical Nurse(LPN), said Resident 36 did not have a oxygen humidifier while looking at the oxygen concentrator at Resident 36's bedside. Staff AA reviewed Resident 36's order and said they should have had a humidifier. On 02/24/2026 at 2:31 PM, Staff B, DNS, said Resident 36 does not need a humidifier because their oxygen was at 2L. Staff B said Resident 36's order did not indicate this, but he would have the order changed. On 02/24/2026 at 3:09 PM, Staff AA, LPN, said they had called the doctor and had the oxygen order for Resident 36 changed to add humidifier if oxygen was above 4L. Resident 85 Resident 85 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact and was constipated during the assessment period. Review of the electronic health record showed Resident 85 had the following as needed bowel orders: - MiraLax (a laxative) as needed, If no bowel movement after 3 days. - Bisacodyl suppository rectally as needed, if no or small results 12 hours after Miralax was administered. - Fleet Enema rectally as needed, If no results 12 hours after Bisacodyl suppository was administered; notify the provider if no results after 8 hours after enema. On 02/24/2026 at 10:02 AM, Resident 85 indicated they periodically still struggled with constipation. Review of the bowel record showed Resident 85 went from 02/20/2026- 02/25/2026 (6 days), without a bowel movement. Review of the February 2025 MAR showed Resident 85 was not administered as needed bowel medication until 02/25/2026, the sixth day without a bowel movement. On 03/02/2026 at 9:45 AM, when asked if facility nurses administered Resident 85's Miralax after three days without a bowel movement, as ordered Staff B, DNS, stated, No. Resident 80 Resident 80 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact, had a diagnosis of renal disease and received diuretic medication during the assessment period. Record review showed Resident 80 had the following 11/14/2025 orders: Furosemide (a diuretic) daily for edema (swelling caused by excess fluid trapped in the body's tissues), Daily weights, for three days, weekly for four weeks. Review of the comprehensive care plan, initiated 11/14/2025, showed no care plan was developed/implemented that addressed the resident's diuretic use or edema. On 02/27/2025 at 12:52 PM, the facility's edema monitoring policy was requested. Staff B, DNS, said he was not sure the facility had a policy, but explained they used the 0-4+ pitting edema scale, unless the provider specifically ordered daily weights or circumference measurements. The November 2025 Treatment Administration Record (TAR) showed Resident 80's daily weights for three days were scheduled to be obtained on 11/15/2025, 11/16/2025 and 11/17/2025. Review of the TAR showed facility nurses failed to obtain the weights as ordered, all three days were blank. Further review of the MAR and TAR showed there was no direction to staff to monitor Resident 80's edema. On 03/02/2026 at 09:12 AM, Staff B, DNS, confirmed facility nurses failed to obtain daily weights for three days as ordered and indicated instruction to monitor Resident 80's edema and a place to record it should have been included. Review of the electronic health record (EHR) showed provider notes dated 11/20/2025 and 11/21/2025, documented Resident 80 had no peripheral edema. Review of Resident 80's weight record showed on 11/14/2025 the resident weighed 275 Lbs. and on 11/24/2025 weighed 285.4 Lbs., a weight gain of 10.4 Lbs. in 10 days. Review of the EHR showed there was no documentation present that showed the provider was notified. A provider note, dated 11/25/2025, documented Resident 80 was significantly short of breath at rest and with speaking. During the evaluation, she reported she needed to use the bathroom and was assisted by the provider and a Certified Nursing Assistant. Physical exam revealed plus four pitting edema of the lower extremities and course breath sounds bilaterally. Nursing and the patient deny recent fever, chills, or upper respiratory symptoms. Assessment is significant breathing issues concerning for acute pulmonary edema or pneumonia. Resident 80 required artificial respirations and oxygen support and was subsequently transferred to the hospital. On 03/02/2026 at 9:15 AM, when asked if staff should have notified the provider of the 10.4 Lbs. weight gain in 10 days Staff B, DNS, stated, yes. When asked if there was any documentation to show the provider was notified Staff B, DNS said no. Resident 23 Resident 23 was admitted to the facility 05/06/2024. The Quarterly MDS, dated [DATE], documented Resident 23 used a manual wheelchair. On 02/23/2026 at 11:44 AM, Resident 23 said they got out of bed very little, saying they needed a lift to get out of bed and their wheelchair did not fit them, it was too small and they were long and their wheelchair did not fit long people. Resident 23 said if they got a new wheelchair they would get up more, and they had been waiting for a year for a new wheelchair. On 02/26/2026 at 8:53 AM, Resident 23 was in bed eating breakfast. Observed next to the bed was a wheelchair with pillows and towels stacked on it. Resident 23 said the wheelchair did not fit them, it was too small and they brought this up to people all the time, but they were not sure who they had talked to. Resident 23 had a provider order, dated 08/29/2025, addressed to the physical therapy department. The order read: the patient stated that his chair is too small and wants a different one. Kindly evaluate if his chair is appropriate or not and respond as warranted. On 02/26/2026 at 9:15 AM, Staff L, Rehabilitation Director, was told Resident 23 reported his wheelchair did not fit him well and that he had been waiting for a year for a new wheelchair. Staff L said they had swapped out Resident 23's wheelchair a few times within house wheelchairs. When asked when the swaps happened, Staff L said when in house swaps were done they would swap out the wheelchair but did not document this and she did not have documentation of when Resident 23's wheelchair had been swapped. On 02/26/2026 at 12:13 PM, Staff L confirmed the order, dated 08/29/2025, for physical therapy to evaluate Resident 23's wheelchair fit. When asked if an evaluation or screen was completed at that time, Staff L looked in the electronic health record and said, no, Resident 23 had not been seen and there was no documentation. When asked if this met her expectations, Staff L said it did not. When asked if an order for physical therapy to evaluate was in place there should have been a formal evaluation done and documented in the electronic health record. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure restorative nursing programs were provided at the frequency residents were assessed to require, for 6 of 7 residents (Resident 15, 26, 30, 32, 9 & 24) reviewed for restorative services. This failure placed residents at risk for decline in functional mobility, range of motion (ROM), contracture (a permanent tightening or shortening of muscles, tendons, skin, or other tissues that causes joints to become stiff) formation and diminished quality of life.Findings included . Resident 15 Resident 15 was admitted to the facility on [DATE]. A restorative nursing program care plan, initiated 08/15/2024, showed the resident had the following restorative program(s): Restorative walking program with front wheeled walker for 15 minutes as tolerated, up to three times per week. Active ROM program to bilateral upper and lower extremities using the Omni cycle for 15 minutes as tolerated, up to three times per week. Review of the restorative documentation from 02/02/2026 - 03/02/2026 (28 days) showed Resident 15 was offered/provided the restorative walking program two times with one refusal, and the active ROM program six times with no refusals. Resident 26 Resident 26 was admitted to the facility on [DATE]. A restorative nursing program care plan, initiated 08/15/2024, showed the resident had the following restorative program(s): Restorative gait training program using the parallel bars or front wheeled walker up to 20 feet, follow with wheelchair for 15 minutes as tolerated, up to three times per week. Active ROM program to bilateral upper and lower extremities using the Omni cycle on level 1 for 15 minutes as tolerated, up to three times per week. Review of the restorative documentation from 02/02/2026 - 03/02/2026 (28 days) showed Resident 26 was offered the restorative gait training program three times with one refusal, and the active ROM program six times with one refusal. Resident 30 Resident 30 was admitted to the facility on [DATE]. A restorative nursing care plan, initiated 08/20/2024, showed the resident had the following restorative program(s): Restorative walking program with front wheeled walker, 50 feet, as tolerated, up to three times per week. Active ROM program to bilateral upper and lower extremities using the Omni cycle for 15 minutes as tolerated, up to three times per week. Review of the restorative documentation from 02/02/2026 - 03/02/2026 (28 days) showed Resident 30 was offered the restorative walking program six times, and the active ROM program seven times with one refusal. Resident 32 Resident 32 was admitted to the facility on [DATE]. A restorative nursing care plan, initiated 08/20/2024, showed the resident had the following restorative program(s): Active ROM program using the Nu-step for 15 minutes as tolerated, up to three times per week. Review of the restorative documentation from 02/02/2026 - 03/02/2026 (28 days) showed Resident 32 was offered the active ROM program eight times with two refusals. Resident 9 Resident 9 was admitted to the facility on [DATE]. A restorative nursing care plan, initiated 08/20/2024, showed the resident had the following restorative program(s): Active ROM program to bilateral upper and lower extremities using the Nu-step or Omni cycle for 15 minutes as tolerated, up to three times per week. Review of the restorative documentation from 02/02/2026 - 03/02/2026 (28 days) showed Resident 9 was offered the active ROM program three times with one refusal. Resident 24 Resident 24 was admitted to the facility on [DATE]. The Annual Minimum Data Set, an assessment tool, dated 01/14/2026, documented Resident 24 was moderately cognitively impaired and needed partial to moderate assist with showers and bathing, and independent with dressing and personal hygiene. Resident 24's restorative nursing care plan, revised on 10/01/2024, said they had limited physical mobility related to impaired balance, impaired mobility, weakness. The nursing rehab interventions, revised on 12/13/2024, said omnicycle for up to 15 minutes up to 3 times a week and a walking program for up to 15 minutes ambulation up to 100 feet up to 3 days a week. A 30-day review of walking up to 100 ft. up to 3 times a week from 01/28/2026 - 02/25/2026 documented Resident 24 walked for 15 minutes on 02/02/2026 02/03/2026, 02/08/2026, and 02/25/2026. It documented Resident 24 walked for 10 minutes on 02/14/2026. Resident 24 refused on 02/12/2026. A 30-day review of active ROM with Omni-cycle up to 15 min up to 3 days per week from 01/28/2026 - 02/25/2026 documented Resident 24 participated for 15 minutes on 02/12/2026, for 5 minutes on 02/14/2026, and for 3 minutes 02/21/2026. No refusals were documented. A review of the Restorative Nursing Summary, dated 09/16/2025, said continued active ROM and ambulation program to maintain strength and functional mobility. On 02/26/2026 at 9:40 AM, Staff T, Driver/ Restorative Aide said Resident 24 was scheduled for restorative therapy three times a week. Staff T said Resident 24 did not receive restorative therapy three times a week because they had other duties. Staff T said they were the facility's transportation driver for resident appointments and they would get pulled to the floor to cover direct nursing care. Staff T said Resident 24 did not refuse restorative therapy. On 02/26/2026 at 9:59 AM, Staff B, Director of Nursing Services (DNS), said Resident 24 was not receiving restorative therapy three times a week and Resident 24 was not refusing. Staff B said restorative therapy was not being offered three times a week and this was not optimal to maintain Resident 24's functions. Refer to F-725 Reference WAC 388-97-1060 (3)(d), (j)(ix)

Based on observation, interviews and record review, the facility failed to have sufficient staff to provide and supervise care as evidenced by information provided by 6 resident interviews (Resident 30, 44, 23, 3, 13 & 66), Staff interviews (Staff Q & T) and Resident Council interviews. Additionally, the aid from the Restorative Nursing Program (RNP) was removed from restorative duties to cover direct care staff absences and resident transportation resulting in the RNPs not being completed for residents. The shower aides were also removed from assigned duties to cover direct care staff shortages. The facility had insufficient staff to ensure residents received assistance with Activities of Daily Living (ADL) including showers, restorative services, dining services and basic resident care. These failures placed residents at risk for unmet care needs, negative outcomes and a diminished quality of life. Findings included .On 02/23/2026 at 10:52 AM, Resident 30 said their shower days were changed without notice by Staff B, Director of Nursing Services (DNS) and they were never informed about the shower changes. On 02/23/2026 at 11:32 AM, Resident 44 said they would use the call light, and no one would respond for up to 45 minutes, and on night shift sometimes no one would respond at all, they would have to get out of bed and go into the hall to get staff. Resident 44 said they have filed grievances in the past, but it did no good, because nothing had changed. Resident 44 said when staff would call out, restorative and shower aids would be pulled from their assigned duties to cover the other staff. Resident 44 said the previous weekend two aids called out from work and they did not get care until 10 AM. On 02/23/2026 at 11:38 AM, Resident 23 said sometimes they would wait up to an hour to get care. On 02/23/2026 at 12:31 PM, during a dining room observation, the meal cart had been delivered/dropped off, and no staff were observed in the Garden dining room. Resident 38's relative had begun to pass meal trays to the residents sitting in the Garden dining room. The relative was passing one to a resident, and 4 other residents already had their trays in front of them, with no staff present. Resident 38's relative said they did not want the resident's food to get cold. On 02/23/2026 at 12:45 PM, Staff Q, Central Supply Staff, said the Garden dining room was a supervised eating area. Staff Q said they had been passing trays on another hall and could not get to the dining room by the time the meal cart had arrived. Staff Q said there was usually a shower aide in the dining room to pass trays, but there was no shower aide this day. Staff Q said the relative should not have been passing meal trays to the residents. On 02/23/2026 at 2:09 PM, Resident 3 said they had had one shower since being admitted . On 02/23/2026 at 2:14 PM, Resident 3 said they had to wait up to 45 minutes to get care. On 02/24/2026 at 8:00 AM, Resident 13 said on the night shift, it would take 30-40 minutes to obtain pain medication, due to not having enough staff. On 02/24/2026 at 9:45 AM, Resident 66 said they had waited anywhere between 45 minutes to an hour for staff to provide care, mealtimes and evening shift seem to be the worst. There were not enough staff to help pass meal trays. Resident 66 said due to staffing shortage, showers aids would be pulled from their assignments to cover other staff duties. On 02/26/2026 at 9:40 AM, Staff T, Driver/ Restorative Aide said Resident 24 was scheduled for restorative therapy three times a week. Staff T said Resident 24 did not receive restorative therapy three times a week because they had other duties. Staff T said they were the facility's transportation driver for resident appointments and they would get pulled to the floor to cover direct nursing care. Grievances:On 09/17/2025 a grievances documented Resident reports concerns about his Bi-pap face mask being cleaned. On 09/26/2025 a grievances documented Resident's sister had concern about resident needing more therapy. On 10/25/2025 a grievances documented Resident and wife requesting scheduled therapy sessions. On 11/03/2025 a grievance documented Resident reports concerns about her room not getting cleaned over the weekend. On 11/04/2025 a grievance documented Resident reports missing her shower. On 01/28/2026 a grievances documented Reports concerns about need for extra clothing for residents, need to review shower schedule for new admission and customer care concerns with staff. On 01/29/2026 a grievances documented Resident raised concerns about bathroom assistance from staff. On 01/31/2026 a grievances documented Received reports concerning resident/nurse interaction on pain meds. On 01/31/2026 a grievance documented Resident's family reports concerns about bed mobility and oral care. Resident Council Meeting Minutes:September 2026 minutes documented:- Back up plan for when the shower aid is not available.- Cold food being warmed up. October 2025 minutes documented:- When shower aids go to the floor residents would like to be notified so they are not waiting for them to come November 2025 minutes documented:- Showers- not getting showers at times especially Saturday- Restorative aid-trying to tweak the program, maybe 3 days a week with a new and improved program. December 2025 minutes documented:- Nursing/aides- meal times in dining room aides are short with several residents. On the weekend no aide comes to the dining room. Residents are reporting long call tight times and on occasion resident has gone into hallway to see aides standing. Residents state that these have been already been submitted in grievances.- Complaints of Saturday missed showers and grievance has been filed. January 2026 minutes documented:- Residents talked with the new chef last month. Dinner is scheduled for 5:15 p.m. but served at 6:00 p.m.- Concerns: food is late, servers are rude, food is cold, raw food is served, food looks sloppy, there is only one choice.- The food is getting worse and less edible, the menu shows 6 choices, there is only one choice.- Call lights are not being answered in a timely manner.- Some residents are keeping track of response times. Residents are missing their showers and are not being notified.- One resident stated that he had not had a shower in two weeks. February 2026 minutes documented:- There is too much noise coming from the kitchen! Voices are too loud, banging dishes, etc. that echoes throughout the hall.- Food issues: most attendees had food complaints saying: The food is not good.- There doesn't seem to be staff oversite. Portion sizes are inadequate, either too large or too small, presentation is not appealing. Meat is tough or undercooked. Dietary restrictions are not being followed. A resident on a soft diet is not being accommodated.- A resident talked with [Dietary Manager] saying she wanted to show him pictures of her plates, he was rude, the resident filed a complaint.- Nursing Services/Aides: Aides are not assisting residents who need help eating.- Residents were ill with no follow through from Staff.- Showers - residents do not know the day(s) or time of their showers. Can there be a consistent shower schedule? Resident Council meeting:On 02/25/2026 at 1:35 PM, during the Resident Council Meeting interview, residents reported the following concerns:-stopped filing grievances because nothing ever happens or changes.-staff have been snappy towards residents when they were mad. Residents felt like they have to walk on eggshells around certain staff.-showers aides often pulled from showers to cover other duties.-environmental noise including slamming doors and other residents yelling during the day and night.-food concerns over the past few months. Record reviewed on 02/27/2026 showed dates shower aides were pulled to cover floor/no shower aide available in February 2026: 02/01/2026: Staff R, shower aide, pulled to cover Mtn View Odd02/10/2026: No NAC on Med202/12/2026: No NAC on MedA202/15/2026: Staff R pulled to cover Mt View Odd02/20/2026: Staff S, shower aide, pulled to cover Mtn View Even02/22/2026: Staff R pulled to cover MedB102/26/2026: Staff R pulled to cover Mtn View Odd Record review on 02/27/2026 showed dates in February 2026 where Staff T, Driver/Restorative Aide completed resident transport, not able/limited time to completed restorative duties:02/02/2026 (2 appts), 02/03/2026 (3 appts), 02/04/2026 (1 appt), 02/06/2026 (1 appt), 02/09/2026 (2 appts), 02/10/2026 (2 appts), 02/11/2026 (5 appts), 02/12/2026 (1 appt), 02/13/2026 (2 appts), 02/16/2026 (1 appt), 02/17/2026 (1 appt), 02/18/2026 (3 appts), 02/20/2026 (1 appt), 02/23/2026 (1 appt), 02/24/2026 (2 appts), 02/25/2026 (1 appt) & 02/27/2026 (2 appts). Seventeen out of 20 days the Restorative aide had transportation duties. On 02/27/2026 at 10:46 AM, Staff B, DNS, said both restorative services and showers were an issue, not enough staff and the facility currently had a Performance Improvement Plan for showers. Staff B said they thought the showers had gotten better but confirmed shower aides were pulled to cover other duties on the floor. When asked about the meals being delivered to residents without staff present, Staff B said they were made aware of the situation, confirmed there was no shower aide available that day and said the relative should not have served residents their meal trays. Staff B said they were not aware of residents being left on the toilet for extended periods of time during meal tray pass. Reference F677, F688 & F804.Reference WAC 388-97 -1080 (1), 1090 (1)

Based on interview and record review the facility failed to routinely complete Certified Nursing Assistant's (CNA) annual performance reviews as required for 3 of 5 sampled nursing assistants (Staff I, J, & K) reviewed for performance reviews. This failure placed residents at risk of receiving care from inadequately trained and/or under-qualified care staff, and a diminished quality of life. Findings included .Staff I, CNA, was hired 12/27/2024. Staff I had no annual performance review completed from 12/2024-12/2025. Staff J, CNA, was hired 08/07/2024. Staff J had no annual performance review completed from 08/2024-08/2025. Staff K, CNA, was hired 07/29/2024. Staff K had no annual performance review completed from 07/2024-07/2025. On 02/27/2026 at10:50 AM, Staff B, Director of Nursing Services, said none of the CNA annual performance reviews were completed for their review periods and they should have been. Reference WAC 388-97-1680 (1), (2)(a-c)

Based on observation, interview and review of recorded food temperatures, the facility to prepare food in a manner that conserved nutritive value, palatability and that ensured meals served were appetizing and at appropriate temperatures. The facility's failure to follow written recipes for preparation of pureed food, to ensure cold beverages were maintained at or below 40 degrees, and hot food at or greater than 135 degrees during meal service, resulted in residents being served unpalatable food and beverages at unappetizing temperatures. These failures placed the residents at risk for decreased intake, weight loss and dissatisfaction with meals.Findings included . <Meal Preparation>Observation of meal preparation on 02/26/2026 at 10:59 AM, showed Staff BB, Cook, preparing pureed carrots. Staff BB grabbed a large metal container of cooked carrots and used a spatula to push an unmeasured amount into a smaller 6 x 6 metal container. Staff BB then used a handheld immersion blender to blend the carrots for 45 seconds. Staff BB then left to fill a plastic container with an unmeasured amount of water and returned to the carrots. An unmeasured amount of water was added to the carrots and Staff BB blended the mixture for another 30 seconds. Staff BB then covered the carrots and placed them on the steam table. On 02/26/2026 11:08 AM, Staff BB obtained a large metal tub of pork and used a spoon to scoop an unmeasured amount into a 6 x 6 metal bin and added an unmeasured amount of water and blended the mixture. Staff BB then observed the mixture and added more water indicating it was a little bit dry and then blended another 30 seconds, covered the bin and placed it on the steam table. On 02/26/2026 11:17 AM, Staff DD, Dietary Aide, was placing beverages and deserts on resident trays on the tray carts. <Beverage Temperatures>On 02/26/2026 12:03 PM, Staff DD was asked to check the temperature of a cup of milk that was previously placed on a resident tray in the tray cart. The milk was 56.5 degrees. Staff DD then placed the milk back on the tray in the tray cart to be delivered. During an interview on 03/02/2026 at 12:48 PM, Staff CC, Dietary Supervisor, said Staff BB, Cook, should follow a recipe when preparing pureed food to ensure consistency and palatability. When asked about dietary staff s' practice of placing resident beverages and deserts on their trays 45 minutes before tray line began Staff CC, Dietary Supervisor said they had identified that as an issue and educated the dietary staff. Staff CC motioned to signage on the outside of the beverage refrigerator that directed staff not to put any beverages on trays until 11:40 AM at the earliest. Staff CC said putting beverages out earlier is what caused the milk to be 56.5 degrees. Staff CC said the milk should have been removed and the other beverages already on the cart checked to ensure they were less than 40 degrees. Resident 30 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set (MDS, an assessment tool) dated 01/09/2026, documented Resident 30 was cognitively intact. On 02/25/2026 at 8:15 AM, observation of Resident 30 sitting in their wheelchair with breakfast meal tray on bedside table. On 02/25/2026 at 8:37 AM, when asked how their breakfast meal was, Resident 30 said they had not eaten it yet, due to Staff W, Certified Nursing Assistant (CNA), had told them, they needed to obtain the residents' weight prior to them eating. Staff W told Resident 30 they would be right back to get the residents' weekly weight and never returned. Resident 30 said the breakfast meal was cold, but they were used to eating a cold breakfast, due to things like this always happening and they never got their morning coffee. On 02/25/2026 at 8:52 AM, Staff C, Licensed Practical Nurse (LPN)/Resident Care Manger was stopped in the hall and asked when staff should be obtaining resident weights. Staff C said weights were done monthly unless otherwise directed, like weekly or daily if weight loss concerns were identified. Resident 30 told Staff C the event that had taken place with the breakfast meal. Staff C immediately found Staff W, had them obtain Resident 30's weight and obtain a hot meal for Resident 30. When asked if it was acceptable to tell a resident to not eat, say they would be back and then not return for over 45 minutes, Staff C said that was not acceptable and it should have never happened. On 02/26/2026 at 2:40 PM, in a joint interview with Staff B, Director of Nursing Services and Staff C, LPN/RCM, the situation with Resident 30's breakfast meal was explained. Staff B said the expectation was a grievance should have been written, the staff member needed more training, and it was not acceptable to tell a resident not to eat or for a resident to have to wait over 45 minutes for their breakfast meal. Reference WAC 388-97-1100 (1), (2)

Based on observation, interview and record review the facility failed to follow and/or implement transmission-based precautions (TBP, infection-prevention measures for known or suspected infections used in addition to Standard Precautions) for 4 of 4 residents (Residents 52, 40, 58, and 17) reviewed for transmission-based precautions. The facility did not ensure staff used appropriate personal protective equipment (PPE) and implemented TBP for symptomatic residents. This failure placed residents and staff at risk for cross-transmission with infectious pathogens. Findings included.Review of the facility policy, titled IPCP [Infection Prevention and Control Program] Standard and Transmission-Based Precautions, revised 08/2025, documented for Contact Precautions PPE use would include wearing a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Staff were to don (put on) PPE upon room entry, then doff (take off) and properly discard PPE and perform hand hygiene before exiting the patient room to contain pathogens (microorganisms that can cause disease).Additional review of this policy documented Droplet Precautions (TBP) were to be used for patients known or suspected of being infected with pathogens transmitted by respiratory droplets that are generated by a patient who is coughing, sneezing, or talking. The policy referenced Center for Disease Control Appendix A: Type and duration of precautions recommended for selected infections and conditions. Droplet precautions as outlined in the policy included the following:Implement source control by placing a mask on the patient.Ensure appropriate patient placement in a single room if possible. In long-term care and other residential settings, make decisions regarding patient placement on a case-by-case basis considering infection risks to other patients in the room and available alternatives.Use personal protective equipment (PPE) appropriately. [NAME] mask (and eye protection if indicated) upon entry into the patient room or patient space.Limit transport and movement of patients outside of the room to medically-necessary purposes. If transport or movement outside of the room is necessary instruct patient to wear a mask and follow respiratory hygiene/cough etiquette.FAILURE TO FOLLOW TBPResident 52 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident 52 had an order, dated 02/13/2026, for contact precautions and had signage outside of their door indicating they were on contact precautions.On 02/25/2026 at 9:30 AM, Staff E, Activities, was observed in Resident 52's room with no PPE on. Staff E was observed adjusting Resident 52's shirt, pushing the call light button, holding Resident 52's hand, and squatting down and leaning their arm on Resident 52's blankets.On 02/25/2026 at 9:37 AM, Staff E, was asked about observations of not wearing PPE while interacting with Resident 52. Staff E said she was supposed to have worn a gown and gloves. On 02/25/2026 at 10:23 AM, Staff D, Infection Preventionist, Registered Nurse (RN), said her expectation of staff interacting with a resident on contact precautions was for staff to follow the signage instructions for contact precautions. Regarding the observations of staff interacting with Resident 52 without wearing PPE, Staff D said this did not meet her expectations.FAILURE TO IMPLEMENT TBPResident 40Resident 40 was admitted to the facility on [DATE]. Review of a Nursing progress note, written by Staff F, Licensed Practical Nurse (LPN), dated 02/14/2026, documented Resident 40 was noted to have a moist productive cough.An Alert Charting (charting done when a resident is being monitored) progress note, written by Staff F, dated 02/15/2026, documented Resident 40 had a moist productive cough. Review of Resident 40's electronic health record (EHR) showed no documentation that Resident 40 was placed on TBP for their symptoms that could indicate a potentially transmittable infectious process. Resident 58Resident 58 was admitted to the facility on [DATE].Review of a Nursing progress note, written by Staff F, LPN, dated 02/24/2026, documented Resident 58 had a moist productive cough. An Alert Charting progress note, written by Staff F, dated 02/25/2026, documented Resident 58 continued with upper lung congestion, cleared with cough, sputum (thick mucus that is coughed up) noted to be thick, yellowish and brown in color. Review of Resident 58's EHR showed no documentation that Resident 58 was placed on TBP for their symptoms that could indicate a potentially transmittable infectious process.Resident 17Resident 17 was admitted to the facility on [DATE]Review of a 02/25/2026 Nursing progress note, written by Staff F, LPN, dated 02/25/2026, documented resident 17 complained of a cough and was noted to have chest congestion. An Alert Charting progress note, written by Staff G, LPN, documented Resident 17 had respiratory symptoms with mild non-productive, congested cough.Review of Resident 17's EHR showed no documentation that Resident 17 was placed on TBP for their symptoms that could indicate a potentially transmittable infectious process.On 02/27/2026 at 3:01 PM, observations of Resident 40, 58, and 17's room doors showed no signage to indicate TBP was in place.On 02/27/2026 at 3:03 PM, Resident 17 was observed in the hallway with no mask on.On 03/02/2026 at 8:31 AM, Staff D, Infection Preventionist, RN, said for residents showing symptoms of a potentially infectious process such as respiratory symptoms staff should assess the resident, notify the physician, place residents on alert monitoring (a temporary, documented observation plan used to monitor and track a resident's condition), implement standing orders such as rapid testing (tests to rule out an infectious process). When asked the expectations of when TBP would be initiated for a resident who was symptomatic with what could be a transmittable infectious process, Staff D said when there was a positive test, TBP should be initiated. Staff D said the nursing staff had been educated and encouraged to take preventative steps and she was encouraging mask use, but it was not mandatory. Regarding Resident 40 having moist productive cough with nasal drainage and placed on alert monitoring Staff D was asked if the facility had been ruling out an infectious process, Staff D said with moist wet cough, yes. When asked if TBP had been initiated, Staff D looked in the EHR and said she did not see that it had been initiated and until suspicions had been ruled out, TBP should have been initiated.Regarding Resident 58 noted in documentation to have a moist productive cough, with alert monitoring in place, Staff D said both Resident 58 and Resident 40 were COVID-19 tested every 48 hours until 3 negative tests were obtained. When asked if TBP should have been initiated while ruling out infectious process, Staff D said if suspected and until ruled out, TBP should have been initiated, and it was not.Regarding Resident 17 noted to have cough with chest congestion, and alert monitoring in place, Staff D said Resident 17 had not been placed on TBP. Staff D said it did not meet her expectations that while ruling out potentially transmissible infections residents were not placed on TBP.Reference WAC 388-97-1320(1)(a)(2)(a)

Based on interview and record review the facility failed to ensure residents and/or resident representatives were informed and provided consent before administering psychotropic (medications that alter moods, behaviors, thoughts or perceptions, and affects the brain) medication for 1 of 5 sampled residents (Resident 2) reviewed for right to be informed about treatment decisions. This failure placed residents and/or resident representatives at risk of not being fully informed of the risks and benefits before making decisions about medications and a diminished quality of life. Findings included .Resident 2 Resident 2 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder, vascular dementia (a type of cognitive impairment caused by reduced blood flow to areas of the brain), and depression (mood disorder that causes a persistent feeling of sadness or loss of interest). Resident 2's Quarterly Minimum Data Set (MDS), an assessment tool, dated 02/04/2026, indicated severe cognitive impairment with inattention and disorganized thinking was continuously present. Resident 2's care plan, initiated 10/31/2025, documented risk for impaired cognitive function and impaired thought processes related to altered mental status change. This care plan listed as an intervention, needs supervision/assistance with all decision making. Resident 2 had an order, dated 10/31/2025, for Olanzapine (an antipsychotic medication used to treat psychiatric conditions that involve disturbances in thinking, perception, mood, or behavior) to be given daily at bedtime for vascular dementia with hallucinations (sensory perceptions in which a person sees, hears, smells, tastes, or feels something that is not actually present in the environment). Review of Resident 2's EHR showed a document titled, Consent for Treatment: Use of Anti-Psychotic Medication. dated 10/31/2025, for the Olanzapine medication. The consent listed common side effects, which included sedation, constipation, blurred vision, weight gain, swelling, loss of appetite, urinary retention, irregular heart rhythm, dizziness and more with a black box warning which indicated Olanzapine was not approved to treat mental problems caused by dementia. The consent had an area for the resident's legal representative/surrogate decision-maker to consent or decline treatment; this area was left blank. The consent indicated that Resident 2 was able to understand and consent to the treatment and was signed by Resident 2. On 02/26/2026 at 12:00 PM, Staff B, DNS, when asked about Resident 2's mentation Staff B said that it was difficult to characterize Resident 2's brand of confusion, they could talk well but were confused about their capabilities, situation, ability to care for self and safety awareness. When asked what the expectation of a resident's mentation to be before signing for psychoactive (any medication that affects brain function, mood, behavior, perception, or cognition) medications, Staff B said they would like to get family, Power of Attorney and resident involved. Staff B reviewed the antipsychotic consent for Olanzapine and confirmed Resident 2 had signed it themselves. When it was pointed out that documentation indicated Resident 2 had severe cognitive impairment and required assistance with all decision making and asked if it met expectations for them to sign their own consent, Staff B said they would have expected someone else to have been contacted. Staff B looked in the EHR and said he did not see a progress note that Resident 2's family had been contacted. When asked if this met his expectations, Staff B said no. Reference WAC 388-97-0260

Based on interview and record review, the facility failed to ensure resident assessments accurately reflected the health status and/or care needs for 4 of 20 residents (Residents 43, 80, 7 & 24) whose Minimum Data Sets (MDS, an assessment tool) were reviewed. The failure to ensure active diagnoses, oral assessments, Level II Pre-admission Screening and Resident Review (PASRR) status, and restorative services accurately reflected residents' health status and care provided, placed residents at risk for unidentified and/or unmet care needs. Findings included .Resident 43Resident 43 was admitted to the facility on [DATE]. Review of the 03/23/2025 Annual and 12/02/2025 Significant Change MDS showed the resident was edentulous (no natural teeth or tooth fragments) and had no abnormal mouth tissue, ulcers, masses, or lesions. Oral Assessment Review of Resident 43's dental consultations showed the following: A dental consult, dated 09/09/2025, instructed staff to assist Resident 43 with cleaning their oral tissues and to See all previous notes related to osteonecrosis (a rare but serious condition that causes bone cells in your jawbone to die and your jawbone to poke through an opening in your gums, characterized as a lesion or exposed and necrotic bone that has been present for more than 8 weeks) to the lower right posterior jaw, which was noted previously. The consultation documented the family was aware and directed staff to schedule an oral surgery appointment if the family desired. A dental consultation, dated 02/29/2025, documented Resident 43 had exposed bone to the lower right jaw with possible osteonecrosis noted. The consultant instructed staff to See previous notes/referral to oral surgeon. A dental consultation, dated 07/12/2023, documented that lower right buccal retromolar ulcers were identified. On 03/02/2026 at 8:43 AM, Staff U, MDS Coordinator, said the 03/23/2025 Annual and 12/02/2025 Significant Change MDSs inaccurately coded Resident 43's oral status and needed to be modified. PASRR The Quarterly MDS, dated [DATE], and Significant Change MDS, dated [DATE], showed Resident 43 had an active diagnosis of anxiety disorder (characterized by feeling nervous, restless, tense or having a sense of impending danger, panic or doom.) A [NAME] I PASRR showed Resident 43 had a diagnosis of mood disorder and did not have a diagnosis of anxiety disorder. The electronic medical record (EMR) showed no documentation was present to show the resident was treated and/or monitored for anxiety disorder. On 02/27/2026 at 1:56 PM, when asked if there was documentation to support Resident 43 had a diagnosis of anxiety disorder and that documented what facility staff were doing to treat and monitor it, Staff U, MDS Coordinator, said they could not immediately find documentation to support Resident 43 had an active diagnosis of anxiety disorder but requested more time to fully review Resident 43's EMR. During an interview on 03/02/2026 at 8:43 AM, Staff U, MDS Coordinator, indicated they were unable to find documentation to support an active diagnosis of anxiety and said the 06/23/2025 Quarterly MDS, and 12/02/2025 Significant Change MDS, needed to be modified. Resident 80Resident 80 was admitted to the facility on [DATE]. Review of the hospital history and physical, dated 11/09/2025, documented that Resident 80 was admitted to the hospital for acute hypoxemic respiratory failure (occurs when the lungs fail to adequately oxygenate the blood) in the setting of influenza A, pneumonia and concomitant (occurring at the same time) chronic obstructive pulmonary disease (COPD). Dyspnea (difficulty breathing) was further worsened by obesity and rib fractures causing poor chest excursion (refers to the expansion and contraction of the chest during breathing). The admission MDS, dated [DATE], showed respiratory failure and COPD were not coded as active diagnoses for Resident 80. In an interview on 03/02/2026 at 8:31 AM, Staff U, MDS Coordinator, said respiratory failure and COPD should have been coded as active diagnoses for Resident 80 and the MDS needed to be modified. Resident 7Resident 7 was admitted to the facility on [DATE]. Review of the admission MDSs, dated 12/08/2025 and 12/31/2025, showed the resident had a diagnosis of Autism, but was not considered by the state Level II PASRR process to have a serious mental illness, intellectual disability or related condition. Record review showed a Level II PASRR, dated 09/18/2025, which was scanned into the EMR on 03/02/2026 under the title PASRR Invalidation, which recommended specialized services for Resident 7. On 03/04/2026 at 1:37 PM, Staff U, MDS Coordinator, said the 12/08/2025 and 12/31/2025 admission MDSs were incorrect and needed to be modified. Resident 24 - Restorative Resident 24 was admitted to the facility on [DATE]. The Annual MDS, dated [DATE], documented Resident 24 received restorative nursing programs as follows: two days of active range of motion (ROM) and two days of transfer for at least 15 minutes a day in the previous seven calendar days. A review of the Restorative Nursing Summary, dated 09/16/2025, said continued active ROM and ambulation program were needed to maintain strength and functional mobility. On 02/26/2026 at 2:18 PM, Staff U, MDS Coordinator said the restorative nursing summary was not completed quarterly and should have been completed in December 2025. On 02/26/2026 at 2:44 PM, Staff U said she had decided to modify the MDS for January 2026 and the plan moving forward was to have the restorative nursing summary completed when entering the MDS data for residents on restorative therapy. On 02/27/2026 at 9:59 AM, Staff B, Director of Nursing and Registered Nurse, said the most recent Restorative Nursing Assessment was [DATE] and it should have been completed quarterly. Staff B said his expectation was for the Restorative Nursing Assessment to be completed around the MDS assessment. Reference WAC 388-97- 1000 (1)(b)

Based on record review and interview, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) was completed and/or reflected accurate mental health diagnosis for 2 of 5 sampled residents (Residents 2 and 7) reviewed for PASRR. This failure placed residents at risk of not receiving mental health services and a diminished quality of life.Findings included. Resident 2 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (recurring intrusive thoughts or concerns), vascular dementia (a type of cognitive impairment caused by reduced blood flow to areas of the brain), and depression (mood disorder that causes a persistent feeling of sadness or loss of interest). Resident 2's Quarterly Minimum Data Set (MDS, an assessment tool), dated 02/04/2026, indicated severe cognitive impairment with inattention and disorganized thinking continuously present. Resident 2 was admitted to the facility with a Level 1 PASRR, dated 10/20/2025, received from the transferring hospital. The Level 1 PASRR indicated Resident 2 had an anxiety disorder, requiring a Level 2 evaluation referral for serious mental illness. The Level 1 PASRR did not include Resident 2's depression diagnosis under the section for mood disorders. On 02/26/2026 at 11:43 AM, Staff P, Social Services Director, said when a resident was admitted with a PASRR it was herself and the Admissions Director who reviewed the PASRR to make sure it was accurate. Regarding Resident 2's PASRR only reflecting their anxiety disorder when Resident 2 also had a diagnosis of depression, Staff P said she believed it was one they needed to correct. When asked if a new Level 1 PASRR should have been completed that included depression, Staff P said, yes. On 02/26/2026 at 1:50 PM, Staff P confirmed that the PASRR Level 1 had not reflected Resident 2's depression diagnosis which had been present when they transferred to the facility and said a new corrected Level 1 would be sent. Resident 7Resident 7 was initially admitted to the facility on [DATE]. A Level I Pre-admission Screening and Resident Review (PASRR), dated 12/02/2024, showed the resident had an intellectual disability or related condition. The PASRR instructions indicated the PASRR should be forwarded to the regional DDA (Developmental Disabilities Administration) PASRR Coordinator, but the resident met the criteria for an exempted hospital discharge due to requiring nursing facility care for the same condition they received acute inpatient hospital care for, and the physician certified they likely require less than 30 days of nursing facility services. Thus, Resident 7 could admit to facility without a PASRR Level II. For resident with an intellectual disability, the PASRR Level I was required to be forwarded to the DDA PASRR Coordinator upon admission to the nursing facility. The level I PASRR showed no Level II PASRR was required at that time due to the exempted hospital discharge but showed that a Level II evaluation would have to be completed if scheduled discharge (within 30 days) did not occur. Record review revealed Resident 7 was not discharged from the facility until 03/14/2025. Review of the electronic medical record (EMR) showed there was no documentation that the Level I PASRR was forwarded to the DDA Coordinator upon admission as required, or that the facility referred Resident 7 for a Level II evaluation when they did not discharge within 30 days. On 02/27/2026 at 2:05 PM, when asked if they had documentation to show Resident 7's Level I PASRR was forwarded to the DDA Coordinator upon admission to the facility as required and that Resident 7 was referred for a Level II evaluation when they did not discharge from the facility within 30 days as required, Staff P, Social Services Director, stated, No. Reference WAC 388-97-1915 (1)(2)(a-c)

Based on observation, interview and record review, the facility failed to implement a comprehensive care plan for 5 of 20 sampled residents (36, 2, 80, 7 & 43) reviewed for care plans. The failure to establish care plans that were individualized placed residents at risk for receiving inconsistent and/or inadequate care.Findings included. Resident 36 Resident 36 was admitted to the facility on [DATE]. The admission Minimum Data Set, MDS-an assessment tool, dated 01/26/2026 documented Resident 36 was cognitively intact and on continuous oxygen therapy. On 02/23/2026 at 3:07 PM, Resident 36 was observed wearing a nasal cannula that was administering oxygen. A review of Resident 36's care plan, on 02/24/2026, did not show oxygen therapy listed as a focus, goal, or intervention/task. On 02/26/2026 at 11:32 AM, Staff X, Licensed Practical Nurse / Resident Care Manager said while looking at Resident 36's care plan that they did not have an oxygen care plan and they should. Staff X said her expectation was for oxygen to have been added to the care plan. On 02/27/2026 at 9:59 AM, Staff B, Director of Nursing Services (DNS) and Registered Nurse (RN) said there should have been something in the care plan about Resident 36's oxygen. Resident 2 Resident 2 was admitted to the facility on [DATE] with a diagnosis of vascular dementia (a type of cognitive impairment caused by reduced blood flow to areas of the brain). The Quarterly MDS, dated [DATE], documented Resident 2 required supervision or touching assistance with upper and lower body dressing. On 02/26/2026 at 10:53 AM, Resident 2 was observed to have an open zippered red sweatshirt on and was otherwise nude. As Resident 2 sat up from a laying position their body was exposed. When asked if anyone had offered to get them dressed for the day, Resident 2 said no. When asked if they usually got dressed in the morning, Resident 2 said yes. When asked if they received regular bathing, Resident 2 said they were showered on Wednesdays and everyday staff would come in and say, let's get dressed, Resident 2 added, I sort of don't care. On 02/26/2026 at 12:30 PM, Resident 2 was observed laying on bed with same red sweatshirt on, bare buttocks showing. When asked if anybody had offered to assist them with dressing, Resident 2 said, no, it didn't matter to them unless it was Wednesday shower day. When asked if it bothered them that their buttocks were observable, Resident 2 said no. On 02/26/2026 at 2:41 PM, Resident 2 was observed to have the same red sweatshirt on, now with a blanket covering their lower body. On 02/26/2026 at 2:43 PM, Staff V, Certified Nursing Assistant (CNA), was asked if they had provided morning care to Resident 2 that day, Staff V said, no that Resident 2 did not allow it and added Resident 2 would often yell at staff to get out of their room. Regarding Resident 2 being in nothing but a sweatshirt all day, Staff V said Resident 2 was usually barely dressed and that was Resident 2's preference. Regarding Resident 2's body being exposed, Staff V said that was usual for most days, staff would attempt to help Resident 2 to get dressed but they often refused and she had offered that morning to get them dressed. Staff V said she would document in the electronic health record when Resident 2 refused care. Review of the electronic health record for Resident 2 did not show an area for CNA's to document morning care refusals and/or refusals to get dressed. Review of Resident 2's progress notes did not show a note about the reported morning care refusal. Resident 2 had a care plan for Activities of Daily Living performance deficit related to cognitive deficit, memory loss, confusion, decreased awareness, revised on 11/19/2025, that documented they were refusing showers. The care plan for dressing lower and upper body, initiated 10/31/2025, documented Resident 2 required 1 staff member to participate with dressing. The care plan did not address or offer interventions for Resident 2's reported frequent refusals of care or reported preference not to be fully clothed. On 02/27/2026 at 1:49 PM, Staff B, DNS, was made aware of CNA reporting that Resident 2 was refusing care on the morning of 02/26/2026, and of the observations of Resident 2 wearing nothing but an open sweatshirt with their body exposed. Staff B was informed that staff also reported Resident 2 frequently refused care and at times would yell at staff to leave and they were unable to complete care. When asked the expectation of documentation of the refusal of morning care Staff B said it should have been somewhere in the progress notes, and for a CNA the documentation would be in the tasks. Staff B said he would expect the CNA to report this to the nurse who would then put in a progress note. Staff B looked in the electronic health record and was unable to find documentation for Resident 2's refusal of morning care on 02/26/2026 and said there should have been some documentation of this. When asked if the care plan should reflect if Resident 2 frequently refused care and list interventions for staff to attempt, Staff B said yes. Staff B reviewed Resident 2's care plan and said Resident 2 did have an Activates of Daily Living care plan regarding preference not to be fully clothed. A second review of the care plan for Activities of Daily Living, showed there had been a revision, dated 02/27/2026, (after interview with Staff V) which documented Resident 2 Required 1 staff participation to dress, dressed and undressed self independently from time to time and often likes to lay in bed and sit in chair without fully clothed. On 02/27/2026 at 2:17 PM, when made aware that the care plan reviewed previously had not included Resident 2's preference to be without full clothing and asked when it had been updated, Staff B said the update may have gone in later. When asked if there was a place for CNA's to document refusals of morning care, Staff B said, not really, the expectation was for staff to get the nurse involved unless it was care planned. Resident 80Resident 80 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact and required supplemental oxygen during the assessment period. Review of the hospital history and physical, dated 11/09/2025, documented that Resident 80 was admitted to the hospital for acute hypoxemic respiratory failure (occurs when the lungs fail to adequately oxygenate the blood) in the setting of influenza A, pneumonia and concomitant (occurring at the same time) chronic obstructive pulmonary disease (COPD). Dyspnea (difficulty breathing) was further worsened by obesity and rib fractures causing poor chest excursion (refers to the expansion and contraction of the chest during breathing.) Resident 80 had an 11/14/2025 order for oxygen 0-2 liter via nasal canula as needed to maintain oxygen saturation greater than 90%. The November 2025 Treatment Administration Record showed the resident was administered oxygen daily. A respiratory infection secondary to Influenza and pneumonia care plan, initiated 11/14/2025, directed staff to provide antibiotic therapy as ordered, encourage resident to change positions as needed, especially if in bed, and to monitor and document any changes to level of consciousness. Care plans addressing Resident 80's COPD exacerbation, acute hypoxemic respiratory failure and use of supplemental oxygen were not developed or implemented. On 03/02/2026 9:34 AM, Staff B, DNS, said comprehensive care plan should have identified and addressed Resident 80's COPD, acute hypoxemic respiratory failure and oxygen therapy and included identified goals and interventions. Resident 7Resident 7 was admitted to the facility on [DATE]. Review of the admission MDS, dated [DATE], showed the resident was cognitively intact, and had a diagnosis of autism, neurogenic bladder (bladder does not function normally because of a problem with the nerves) and obstructive uropathy (urine flow is blocked somewhere in the urine tract). Record review showed a Level II Pre-admission Screening and Resident Review (PASRR), dated 09/18/2025, which determined the resident had a serious mental illness, intellectual disability or related condition and would benefit from specialized services. Review of the comprehensive care plan, initiated on 09/24/2025, showed Resident 7's diagnosis of autism and status as a Level II PASRR were not identified or addressed in the resident's plan of care. On 03/04/2026 at 1:37 PM, Staff U, MDS Coordinator, said care plans addressing Resident 7's autism and Level II PASRR status should have been included in the resident's plan of care. A urinary catheter care plan, initiated 09/24/2025, identified Resident 7 had a diagnosis of neurogenic bladder, but did not address the residents obstructive uropathy. On 02/27/2026 at 12:59 PM, Staff B, DNS, said Resident 7's diagnosis of obstructive uropathy should have been addressed on their urinary catheter care plan. Resident 43Resident 43 was admitted to the facility on [DATE]. Review of the Significant Change MDS, dated [DATE], showed the resident had a diagnosis of dementia with behaviors, and received antipsychotic (medications primarily used to manage psychosis symptoms like hallucinations, delusions, and severe agitation in schizophrenia, bipolar disorder, and severe depression) and antidepressant medication during the assessment period. Record review showed Resident 43 had the following psychotropic (prescription drugs that alter brain chemistry to modify a person's thoughts, feelings, moods, perceptions, and behaviors) medication orders: A 12/19/2025 order for quetiapine (an antipsychotic) for vascular dementia with moderate mood disturbance. A 07/01/2025 order for fluoxetine (an antidepressant) for major depression. An antidepressant medication use related to depression and low meal intake care plan, revised 05/03/2025, identified the goal of therapy as, will be free from discomfort or adverse reactions related to antidepressant therapy. The care plan did not identify what the goal of the antidepressant therapy was (e.g. decreased self-isolation, negative self-statements etc.). Additionally, fluoxetine is not known to have appetite stimulant effects. On 02/27/2026 at 12:59 PM, Staff B, DNS, said a goal for Resident 43's antidepressant therapy should have been identified. Staff B said the antidepressant for low meal intake was related to the mirtazapine (an antidepressant frequently used as an appetite stimulant) that had been discontinued. An antipsychotic medication use care plan, initiated 11/24/2025, documented Resident 43 had a diagnosis of dementia with psychosis. Review of the electronic health record showed there was no documentation of a diagnosis of dementia with psychosis. On 02/27/2026 at 12:59 PM, when asked if there was documentation to support Resident 43 had a diagnosis of dementia with psychosis, Staff B, DNS, said no and indicated the care plan needed to be corrected. Review of Resident 43's electronic health record showed a dental consult, dated 09/09/2025, instructed staff to assist Resident 43 with cleaning their oral tissues and to See all previous notes related to osteonecrosis (a rare but serious condition that causes bone cells in your jawbone to die and your jawbone to poke through an opening in your gums, characterized as a lesion or exposed and necrotic bone that has been present for more than 8 weeks) to the lower right posterior jaw, which was noted previously. The consultation documented the family was aware and directed staff to schedule an oral surgery appointment if the family desired. The Significant Change MDS, dated [DATE], documented Resident 43 was edentulous (had no natural teeth or tooth fragments). An oral dental health care plan, revised 05/03/2025, directed staff to monitor for pain related to exposed tooth fragment to right lower jaw. Resident 43's diagnosis of osteonecrosis to the right lower posterior jaw was not identified or addressed. On 03/02/2026 at 9:23 AM, Staff B, DNS, indicated the care plan was inaccurate and needed to be updated/revised. Reference WAC 388-97 -1020(1), (2)(a)(b)

Based on interview and record review, the facility failed to provide necessary care and services to ensure that residents received weekly showers for 1 of 2 residents (3) reviewed for activities of daily living (ADLs). This failure placed the residents at risk of poor hygiene and a diminished quality of life.Findings included .Resident 3 was admitted to the facility on [DATE]. The admission Minimum Data Set, an assessment tool, dated 01/26/2026, documented Resident 3 was cognitively intact and was dependent to substantial/moderate assist with ADLs. On 02/23/2026 at 2:09 PM, Resident 3 said they had one shower since they had been in the facility. Resident 3 said things keep happening that delayed the shower, like physical therapy. Resident 3 said the nurse believed they were refusing showers. Resident 3 said they were not refusing and they would like a shower. A review of Resident 3's care plan on activities of daily living self-care performance deficit related to weakness, immobility, surgery on the nervous system, spinal fusion aftercare, was revised on 02/12/2026, and had an intervention, initiated on 01/22/2026, as bathing (shower/bathe self): one person with bathing/showering one time weekly and as necessary. A review of Resident 3's 30-day bathing record for 01/26/2026 - 02/22/2026 documented a shower on 02/06/2026 and 02/07/2026, a full body bath on 02/12/2026, a sponge bath on 02/22/2026, and a resident refusal on 01/31/2026. A review of Resident 3's progress note, dated 01/31/2026 at 3:00 PM, by Staff Y, Registered Nurse (RN), documented Resident 3 declined their scheduled bath that day because they had family/visitors and requested to have it the following day instead. A review of Resident 3's progress note, dated 02/01/2026 at 9:46 AM, by Staff Y RN, documented the assigned shower aide was made aware of Resident 3's request for bed bath that day.A review of Resident 3's progress note, dated 02/11/2026 at 11:07 PM, by Staff Z, RN, documented Resident 3 did not receive their shower on that shift due to Certified Nursing Assistant (CNA) time constraints. On 02/26/2026 at 11:22 AM, Staff X, Licensed Practical Nurse / Resident Care Manager said Resident 3 was not getting a shower once a week and they were care planned to receive a shower once weekly and as necessary. Staff X said there was a progress note on 01/31/2026 that Resident 3 declined a shower and was supposed to get one on 02/01/2026 but there was not a shower documented that day. Staff X said they were not sure what happened on 02/11/2026 to prevent a shower due to CNA time constraints. On 02/27/2026 at 9:59 AM, while looking at Resident 3's bathing record, Staff B, Director of Nursing Services, said they were not getting a shower once a week. Staff B reviewed the progress note from 01/31/2026 and said Resident 3 should have received a shower the next day as planned. Staff B said his expectation was for Resident 3 to get a shower once a week. Reference WAC 388-97-1060 (2)(c)

Based on observation, interview, and record review, the facility failed to ensure the daily nurse staffing was consistently posted to include the actual nursing staff hours worked for 3 out of 6 days (02/22/2026, 02/23/2026 and 02/27/2026). This failure caused the facility's staffing information not to be readily available to residents and visitors who may wish to review it. Findings included .On 02/23/2026 at 9:53 AM, upon entrance to the facility, the daily nurse staffing was posted on the wall outside of the therapy room, it showed the dates for 02/19/2026, 02/20/2026 and 02/21/2026. No daily nurse staffing was posted for 02/22/2026 or 02/23/2026. On 02/27/2026 at 8:56 AM, the daily nurse staffing was from 02/26/2026. Staff B, Director of Nursing Services was walking past, was stopped and asked to confirm the daily nurse staffing posted on the wall. Staff B confirmed the daily nurse staff posting was dated 02/26/2026. Staff B said the daily nurse staffing should have been updated. When observation from 02/23/2026 were explained, Staff B said the daily nurse staffing should be updated daily. No Associated WAC.

Based on observation, interview and record review, the facility failed to ensure written menus were followed, planned menu items were served at the appropriate serving size, substitutions only occurred when necessary and were approved by the Registered Dietician and communicated to the facility residents, and appropriate serving sizes were provided. These failures detracted from residents' ability to determine if they wanted the main meal or the alternative meal when filling out their menus for the week, due to uncertainty if the listed meal would actually be served. This placed residents at risk of receiving food they did not request, therapeutic diet not being followed, and dissatisfaction with meals. Findings included Review of the posted menu showed on 02/26/2026 the lunch meal would be country fried steak, garlic mashed potatoes, garden blend vegetables with banana pudding. Residents on renal diets, two-gram sodium diets, or low fat/low cholesterol diets would be served a baked beef patty, garlic mashed potatoes, garden blend vegetables with banana pudding or oranges with whipped topping (diet specific). The alternative lunch meal was cheese tortellini/no sauce and spinach with garlic butter. Observation of the steam table on 02/26/2026 at 12:04 PM showed Staff BB, Cook, had prepared pureed pork and carrots, instead of pureed country style steak, beef patties and garden blend vegetables. For regular texture meals Staff BB, prepared country style steak and pork and rice. On 02/26/2026 at 12:06 AM, when asked why Pureed pork and carrots was prepared instead of pureed country fried steak/beef patties and garden blend vegetables as directed on the menu Staff CC said because pork was easier to puree. Staff CC indicated she also made pork and rice instead of beef patties because it was already cooked (left over from the sweet and sour pork the facility served for lunch on 02/25/2026). Observation of the deserts available showed there was banana pudding and instead of oranges with whipped topping for renal diets, a canned fruit cocktail made of blend of pineapple, papaya, guava, passion fruit was provided.Review of an undated facility document titled Fruits to avoid on Renal Diet listed papaya as fruit to be avoided. <Serving Sizes>Tray line was observed on 02/26/2026 from 12:06 PM- 12:37 PM and showed the following:Resident 77's tray card showed they were to receive small portions (1/2 serving size). Staff BB provided a full portion of country style steak.Resident 41's tray card showed they were to receive small portions. Staff BB provided a full portion of country style steak.Resident 30's tray card showed they were to receive large portions (1.5 serving size). Staff BB provided double portions of country style steak.Resident 51's tray card showed they were to receive large portions. Staff BB provided double portions of country style steak. On 02/26/2026 at 12:54 PM, Staff CC, Dietary Supervisor, confirmed Staff BB failed to follow the planned menu and made substitutions without approval of the Registered Dietician and without notifying the residents or posting the changes. Staff CC, Dietary Supervisor, confirmed Staff BB provided the incorrect portion size for small and large portion diets. Staff CC said Staff BB knew the residents very well and what they wanted. Staff BB reported that he trusted Staff BBs judgment.On 03/02/2026 at 7:48 AM, Staff CC, Dietary Supervisor, said Staff BB should have provided the correct portion sizes as directed by the residents' tray card. Staff CC also confirmed changes to the menu needed to be approved by the Registered Dietician and posted. Reference WAC 388-97-1160 (1)(a)(b)

Based on observation, interview and record review, the facility failed to ensure recommendations of gradual dose reductions were followed for 3 of 4 sampled residents (1, 2, & 3) reviewed for gradual dose reductions. These failures placed residents at risk of taking unnecessary medications, avoidable medication side effects, and a diminished quality of life. Findings included.Resident 1Resident 1 was admitted to the facility on [DATE] with diagnoses of vascular dementia and anxiety disorder. The quarterly minimum data set (MDS), an assessment tool, dated 08/19/2025, documented Resident 1 has severe cognitive impairment and required substantial to maximal assistance with activities of daily living (ADL).The care plan, dated 11/22/2024, documented staff would monitor target behaviors and monitor for side effects. The care plan, dated 05/15/2025, documented Resident 1 would receive hospice services and staff will assess the resident's coping strategies and respect their wishes.On 09/15/2025 at 12:39 pm, Resident 1 was observed sitting in their wheelchair in the hallway. The resident was twisting and pulling at their clothing. The resident had a grimace on their face.Consultation Report, dated 06/16/2025, documented the Consulting Pharmacist recommended Resident 1's medication, escitalopram (a antidepressant used to treat anxiety and depression), for a gradual dose reduction (a reduction or discontinuation of a medication to see if symptoms can be managed at a lower dose).On 06/26/2025, the medical provider checked that they accept these recommendations.Progress notes, dated 06/30/2025, documented Resident 1's Guardian was informed of the intent to discontinue the escitalopram. The Guardian did not want the reduction in medication because they felt the resident was stable, not wanting symptoms to reappear. The Guardian said this would be distressing to Resident 1. If the provider had questions, they could contact the Guardian.The Medication Administration Record (MAR), dated July 2025, documented Resident 1's escitalopram was discontinued on 07/15/2025. The MAR documented Resident 1 needed Ativan (an anxiety reducing medication) one time during the period when Resident 1 was not taking the medication.The MAR, dated August 2025, documented Resident 1 required Ativan three times until restarting the medication on 08/08/2025.Progress notes, dated 07/17/2025, showed the resident had a fall to the floor, trying to go outside. There was no injury to the resident. The resident was combative with staff who were trying to assist the resident.Progress notes, dated 07/24/2025, documented Resident 1 was different and was not smiling doesn't want to do things the resident did before. The change occurred after the discontinuation of escitalopram.Progress notes, dated 07/25/2025, documented the resident was different doesn't interact like [they] did before. just sits there doesn't smile.Progress notes, dated 08/03/2025, documented Resident 1 had shown worsening behaviors since discontinuation of escitalopram. Resident 1 had been hitting, calling names, pinching, punching and scratching staff. The resident was medicated with Ativan, and the resident did calm down. Hospice was consulted.Progress notes, dated 08/04/2025, documented Resident 1 was upset and crying unrelated to pain. Resident spoke of upsetting past experiences. One on one time given.Progress notes, dated 08/05/2025, documented Resident 1 had episodes of being terribly upset and crying. As needed medications given.Progress notes, dated 08/08/2025, documented Resident 1 was given orders to restart escitalopram. When staff called Resident 1's Guardian for consent to restart escitalopram, the Guardian voiced they were upset the medication was ever stopped and to not stop it again and said the resident was on hospice and should be happy and comfortable.On 10/07/2025 at 4:07 pm, Staff B, Registered Nurse and Director of Nursing, said he could not explain why they discontinued the escitalopram. Staff B said they should have made sure the provider had a discussion with the Guardian to discuss the GDR or discussed keeping the resident on the medication. Either way there should have been a discussion.Resident 2Resident 2 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease and Alzheimer's disease. The quarterly MDS, dated [DATE], documented Resident 2 has no cognitive impairment and was dependent on staff with assistance with ADL.The care plan, dated 09/03/2025, document Resident 2 had a history of anxiety and depression. Staff would monitor the residents' target behaviors of no appetite or refusing food and negative verbalizations.The Consultation Report, dated 06/13/2025, documented Resident 2 was due for a GDR on aripiprazole (an anti-psychotic used to treat bipolar disease and Schizophrenia). The recommendation included reducing the amount of aripiprazole to 2 mg daily. The Physician's Response was checked I accept the recommendations above, please implement as written. No directions on the medication were written by the medical provider. The provider signed the document on 06/26/2025.Order summary reported, dated 09/16/2025, showed aripiprazole 10 mg daily had been ordered since 08/15/2024.The MAR, dated July, August, and September 2025, documented Resident 1 was administered aripiprazole 10 mg daily.At 4:07 pm, Staff B, verified the medication was not reduced as recommended by the Consulting Pharmacist. Staff B said this GDR should have been acted on per the recommendations.Resident 3Resident 3 was admitted to the facility on [DATE] with diagnoses of congestive heart failure and morbid obesity. The annual MDS dated [DATE], documented Resident 3 has no cognitive impairment and required supervision with ADL.The care plan, dated 09/09/2025, documented Resident 3 required the use of bupropion for depression and insomnia. Staff would monitor social isolation, tearfulness, and heightened awareness.The Consultation Report, dated 06/16/2025, documented Resident 3 was due for a GDR on bupropion (an antidepressant used to treat major depressive disorder) with a trial to discontinue the medication. Under physician's response, the provider noted I accept the recommendations above, please implement as written of bupropion. No instructions for staff to discontinue the medication were noted. The document was signed 06/27/2025.Order summary reported, dated 10/08/2025, showed Resident 3 had been receiving bupropion 75 mg daily since 08/31/2024.The MAR, dated July and August 2025, documented Resident 3 was administered bupropion daily by staff.At 4:07 pm, Staff B, said the order should have been clarified and acted on. Staff B said this should have been followed up on.Reference: (WAC) 388-97-1060 (3)(k)(i)

Based on observation, interview and record review, the facility failed to develop a personalized discharge plan based on each residents' identified needs, goals, and preferences and implement it timely for 2 of 3 residents (6 & 8) reviewed for discharge planning. This failure placed residents at risk for delayed discharge, unmet care needs after discharge and a diminished quality of life. Findings included . <Resident 6> Resident 6 was admitted to the facility on [DATE] with diagnoses including a cognitive communication deficit. The quarterly Minimum Data Set (MDS/An assessment tool), dated 02/06/2025, documented Resident 6 had no cognitive impairment Care Plan, dated 07/31/2024, documented Resident 6 wished to return home with their son. Care Plan, dated 12/20/2024, document Resident 6 was waiting to discharge with their son until the Medicaid application was complete. Progress notes, dated 02/03/2025, showed Resident 6 was wanting to know discharge plans. The resident was told the Medicaid application was approved. No mention was made of discharge plans. Progress notes, dated 02/10/2025, documented Resident 6 wanted to go to an assisted living facility. The plan to go home with their son was not in their best interest, as their son had many health issues himself. The note showed social services would work with the State Agency to finding a location. On 04/01/2025 at 3:10 PM, Resident 6 said they did not know what their discharge plan was and wished staff would communicate the status of a community discharge location. Resident 6 was aware the State Agency was working to help find a location, but there had not been updates on when Resident 6 could discharge. Resident 6 said they did need some assistance but could do many things for themselves. At 4:22 PM, Staff C, Social Services, said they were working with the State Agency and the resident's Medicaid application had been approved. Staff C said they probably needed to update the resident more often and they would do this. Staff C said Resident 6's care plan should have been updated with the current discharge plans. At 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), said discharge care plans should have been updated. <Resident 8> Resident 8 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a lung disease with limits air flow and breathing) and respiratory failure. The significant change MDS, dated [DATE], documented Resident 8 has no continued impairment and required set up or was independent with activities of daily living (ADLs). Care plan, dated 01/29/2025, documented Resident 8 planned to stay long-term at the facility. On 02/28/2025 at 9:30 AM, Resident 8 said they wished to discharge home. Resident 8 feelt urgent about this as they were on hospice and did not want to die at the facility. Resident 8 appeared anxious and worried. Resident 8 said they would like to go home with their daughter. The resident had spoken with their daughter but needed help coordinating the discharge. Resident 8 said they would like staff at the facility to help them with the discharge. At 10:00 AM, Staff B, was informed of Resident 8's wishes to discharge home. At 10:30 AM, Staff A, Administrator, was informed of Resident 8's wishes to discharge home. No progress notes regarding Resident 8's wishes to discharge home were found. No discharge planning notes were made since the resident's statements. On 04/01/2025 at 4:22 PM, Staff C, social services, said she was not made aware of statements made by the resident. Staff C said she would have followed up had she known. Staff C said Resident 8's care plan and discharge plan should have been updated with the resident's current wishes. At 4:35 PM, Staff B, said he should have put a note in the record regarding Resident 8's discharge wishes. The resident should have discharge notes in the medical record and the care plan should have been updated. Reference WAC 388-97-0080 .

Based on interview and record review, the facility failed to accurately assess and identify a change in urinary incontinence, ensure a plan for treatment and services to restore as much normal bladder and/or bowel function as possible for 2 of 3 residents (5 & 6) reviewed for urinary incontinence. Failure to identify and assess/determine causative factors of urinary incontinence placed residents at risk for unmet care needs and decreased quality of life. Findings included . <Resident 5> Resident 5 was admitted to the facility on [DATE] with diagnoses including a fracture of the arm. The admission Minimum Data Set (MDS/an assessment tool), dated 01/28/2025, documented Resident 5 had no cognitive impairment and was frequently incontinent of urine. The Bowel and Bladder Evaluation, dated 01/31/2025, documented Resident 5 was continent of urine. No further assessment or interventions were implemented. Care Plan, dated 02/25/2025, documented Resident 5 was occasionally incontinent of bladder related to diuretic (medication that draws excess fluid from the body via urine) use, muscle weakness, urgency, and frequency. Staff will provide briefs for the resident and check the resident for incontinence. Progress notes, dated 01/31/2025, documented Resident 5 voiced concerns about staff assisting them to the toilet. The resident was able to maintain continence and brought themselves to the toilet. Progress note, dated 02/03/2025, documented Resident 5 was started on oxybutynin (a medication used to treat an overactive bladder) for frequent urination and bladder spasms. Progress notes, dated 02/04/2025, documented the resident was voiding nine times a shift. Progress notes, dated 02/19/2025, documented Resident 5 asked to discontinue the oxybutynin. During the resident's stay, no new reassessment or monitoring was implemented nor were appropriate interventions initaited for the resident. On 04/01/2025 at 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), could not indicate Resident 5's type of incontinence. Staff B said the facility did not reassess the resident or address the inconsistencies in Resident 5's bladder incontinence. <Resident 6> Resident 6 was admitted to the facility on [DATE] with diagnoses including a cognitive communication deficit. The quarterly MDS, dated [DATE], documented Resident 6 had no cognitive impairment and was frequently incontinent of urine. The Bowel and Bladder Evaluation, dated 02/06/2025, documented Resident 6 was continent of urine. No further assessment or interventions were implemented. Care Plan, dated 01/24/2025, lacked documentation related to Resident 6's bladder status. Progress notes, dated 02/10/2025, documented Resident 6 had a urinary tract infection requiring treatment. On 04/01/2025 at 3:50 PM, Staff D, Nursing Assistant, said Resident 6 was incontinent of urine. Sometimes the resident dribbled a small amount of urine and other times it was large amounts. The resident could bring themselves to the bathroom, but staff checked on Resident 6 due to incontinence. At 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), could not indicate Resident 6's type of incontinence. Staff B said the care plan was not updated. The facility did not reassess the resident nor address the inconsistencies in Resident 6's bladder incontinence. Reference WAC 388-97-1060 (3)(c)

Based on interview and record review, the facility failed to provide pain management to adequately control residents pain for 1 of 3 sampled residents (1) when reviewed for pain management. This failure put residents at risk of uncontrolled pain and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with respiratory failure and chronic obstructive pulmonary disease (a lung disease with limits air flow and breathing). On 02/27/2025 at 3:46 PM, Resident 1 said when they were discharged , the facility sent them with a large bag full of medication. It was very overwhelming for Resident 1 to be given a bag with many different medications. Because Resident 1 was so overwhelmed, they did not notice any concerns with their pain medication. Resident 1 discovered once home they were sent home with only three oxycodone (a narcotic pain medication). Resident 1 experienced pain until they could get to the appointment with their community provider. No prescription was sent with the resident, and they were not told they would only have three tablets of oxycodone. Physician orders, dated 01/15/2025, documented Resident 1 could take oxycodone every eight hours as needed. Progress notes, dated 01/16/2025, documented Resident 1 received oxycodone for back and abdominal pain. Provider notes, dated 01/17/2025, documented Resident 1 reported abdominal pains with some relief from oxycodone. Tenderness was found upon abdominal exam. The provider increased administration of oxycodone to every six hours as needed. Progress notes, dated 01/17/2025, documented Resident 1's pain originated in the chest from coughing. Provider notes, dated 01/20/2025, documented Resident 1 continued to complain of abdominal pain. Oxycodone was continued every six hours as needed. Progress notes, dated 01/20/2025, documented Resident 1's pain originated from osteoporosis. Doing art projects in room eased pain. The care plan, dated 01/25/2025, documented Resident 1 had acute pain from osteoporosis. Staff wwere to assess pain each shift, monitor pain quality and severity of pain, and document side effects from pain medication. The January 2025 Medication Administration Record (MAR), documented Resident 1 received one tablet of oxycodone two to three times a day during their stay the facility. The resident's pain ranged from a 4-7 on a scale of 1-10 (1 is mild pain and 10 is severe pain). The Discharge Resident Medication Transfer Record, dated 01/22/2025, documented Resident 1 was sent home with three oxycodone. No prescription was provided to the resident to ensure they had sufficient oxycodone until Resident 1 was assessed by their community provider. On 04/01/2025 at 4:35 PM, Staff B, Registered Nurse (RN) and Director of Nursing (DNS), said the resident did not get sufficient oxycodone upon discharge. Staff B said a prescription should have been sent with the resident, but Staff B was unable to locate a prescription. Staff B said a new staff member discharged Resident 1 and may have missed this. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to provide the amount of supervision 1 of 3 (Resident 1) sampled residents who was at risk for falls was care planned to require. This failure resulted in harm when Resident 1 was left unattended in the bathroom, fell , and sustained a hip fracture. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses to include stroke and left sided weakness. Review of the Minimum Data Set assessment, dated 01/03/2023, showed the resident was cognitively impaired and required extensive assistance with toileting. Resident 1's care plan, revised on 02/03/2022, showed that Resident 1 was not to be left unattended on the toilet due to impulsiveness. Resident 1's Fall Risk Assessment, dated 03/30/2023, showed the resident was a high risk for falls. On 05/03/2023 at 1:26 PM, Resident 1 stated that they had fallen, and it hurt bad. On 05/03/2023 at 1:32 PM, Staff B, Certified Nursing Assistant (CNA), stated that they had cared for Resident 1 often and knew the resident well. Staff B stated that the resident was impulsive and always tried to stand up without assistance. Staff B stated the resident was not aware of their limitations and had always been that way. Review of Resident 1's progress notes, dated 04/05/2023, showed that Resident 1 was found on the floor next to the toilet. The progress notes further showed that that the resident was complaining of left hip pain and was sent to the hospital for evaluation of a hip fracture. Review of the Hospital Records, dated 04/06/2023, showed Resident 1 had a left acetabulum (socket portion of the ball and socket hip joint) fracture. The Facility's Investigation, dated 04/07/2023, showed that Staff C, CNA, on 04/05/2023, had transferred Resident 1 onto the toilet and left the bathroom. The investigation showed that Staff C was at the nursing station when they heard the resident scream, returned to the bathroom, and found the resident on the floor. The investigation further showed that Staff C was unaware the care plan directed staff not to leave the resident unattended on the toilet. On 05/09/2023 at 12:20 PM, Staff A, Director of Nursing Services, stated staff were expected to provide care based on a resident's care plan. Staff A stated that Resident 1's care plan showed not to leave the resident unattended in the bathroom prior to the fall on 04/05/2023. Staff A stated that the expectation was for staff to have followed the resident's care plan and remained with the resident in the bathroom during toileting. Staff A stated that staff did not follow the care plan when they toileted the resident prior to the fall. Reference WAC 388-97-1060 (3)(g)

Based on observation, interview, and record review, the facility failed to identify potential hazards, root cause analysis of falls, or to adequately supervise staff and residents, to prevent falls for 6 of 8 Sampled Residents (#7, 8, 9, 10, 11, and 15). In addition, the facility failed to implement a fall prevention program that included a systematic, comprehensive assessment and interdisciplinary care planning process for use of assistive devices or environmental modifications as part of a fall and injury prevention program. These failures resulted in multiple falls for Residents #7, #10, and #15, and subsequent serious injury to Residents #7 and #15. Findings include: FALLS RESIDENT #7 Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was on a hospice program. According to the resident's Minimum Data Set (MDS), a nursing assessment tool, dated 1/22/16, the resident had moderate cognition problems and required extensive (weight bearing) assist when using the toilet or transferring from one surface to another. The MDS revealed Resident #7 was not steady moving on and off the toilet, and was only able to stabilize with human assistance. During an observation on 2/26/16 at 3:42 p.m., Resident #7 was lying in a bed which was against the wall, there was a mat to the floor and the call light was accessible. During a record review of the facility state log, it was noted Resident #7 had multiple falls, and upon further review of of the documentation regarding the resident's falls, Resident #7 was noted to have had 7 non injury falls on the following dates: 11/23/15, 12/7/15, 12/9/15, 12/23/15, 12/30/15, 1/18/16, 1/19/16 and one fall with significant injury 2/15/16. According to the resident's MDS Kardex report printed on 2/3/16, which the Certified Nurses Aid (CNA) used as a guide for resident care, safety interventions included hip pads, personal alarm while in bed and on wheel chair, dysem non-skid on wheelchair, and the resident was not steady during transfers and walking, moving from a seated to a standing position and moving on and off the toilet. An intervention from a previous fall on 12/3/15 was avoid res. sitting in wheelchair alone in room (poor safety awareness). The facility did not educate the CNA's regarding the resident's ability to be left alone in the bathroom. During a record review of the facility investigation dated 2/16/16, it was noted the resident was taken to the toilet at 6:55 p.m. and was left alone by Staff Q with a personal alarm attached to the resident and the wheelchair. The resident fell trying to get back to the bed, and sustained a left hip fracture and fractures of the 3rd, 4th, and 5th ribs. Resident #7 stated he/she deliberately took the personal alarm device off the resident's body. Staff Q left Resident #7 unsupervised in a bathroom (refer to F 498 for further information regarding the orientation and training of facility CNA's) According to Resident #7's Morse fall risk assessment dated [DATE], the resident's fall score was 65 and considered a high risk. On 10/19/15, the care plan was updated to include a personal alarm. Staff provided the following responses when asked if the care plan instructed to not leave a resident alone in their room and they had a personal alarm what supervision should the resident get during toileting: During an inteview on 2/26/16 at 4:15 p.m., Staff A stated You never leave a person with an alarm alone in the bathroom. During an interview on 3/2/16 at 9:50 a.m., when asked how a CNA would know wheter a resident with a personal alarm could be left alone unattended in the bathroom, Staff D reported CNA's usually have to stay with the resident. Staff D explained when a resident's mentation was decreased, the CNA would stay with the resident in the bathroom and Aides are told in meetings what they need to do and most residents should be attended one to one. Staff X stated in an interview on 3/2/16 at 3:30 p.m., residents should not be left unattended in the bathroom, and said there was nowhere to hook the personal alarm to. On 3/11/16 at 1:17 p.m., Staff FF reported I think leaving them in the bathroom would be the worst place to leave them unattended. At 2:32 p.m. Staff GG reported it meant to not leave the resident alone anywhere where they cannot be seen. At 2:44 p.m. Staff T reported if they are a fall risk the bathroom could be one of the most dangerous places. At 3 p.m., Staff Q reported the resident should be in line of vision, and the staff should know if a resident is not to be alone in a specific room, then the resident should not be left alone in any room. Failure to adequately supervise staff and individualize the resident's falls interventions to ensure staff did not leave Resident #7 in the bathroom unattended, resulted in serious harm from a fall, when the resident sustained [REDACTED]. RESIDENT #15 Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to Resident #15's Minimum Data Set (MDS), a nursing assessment, the resident had long and short term memory problems, made poor decisions, required cues and supervision with decision making, had signs and symptoms of delerium, required weight bearing assistance with toileting and transfers, and had a loss of balance during transitions and walking. Review of the state log revealed Resident #15 had 4 falls since admission to the facility. The resident falls were dated 3/7/16, 3/8/16, 3/16/16, and 3/19/16. Fall 2, 3, and 4's root cause was due to the resident wanting to use the bathroom. Increased toileting was not offered as an intervention. The first fall on 3/7/16, the resident was left on the toilet alone and not given the call light cord to call when she was finished. During an observation on 3/29/16 at 4:40 p.m., the resident's former bathroom room call light was readily available to the left while sitting on the commode. However, the resident could not see out of the left eye, due to paralytic diagnosis. Resident #15 reached for the call light, and fell off the commode. The facility did not individualize the resident's intervention to assist the resident with limited ability to find the call light. The second fall on 3/8/16, Resident #15 was found in the bathroom on the floor at 9:10 a.m. The last time the resident was toileted was at 8 a.m., and was offered toileting 10 minutes previous to the fall. An intervention placed on the Kardex in the residents room to prevent additional falls was to not leave Resident #1 in her wheel chair when she is in her room. Encourage to stay in the lobby. Encourage resident to use the toilet every 2 hours. Root cause anaylsis was medications could not be ruled out as a cause, although the resident was left alone in the wheellchair in her room. The third fall resulted the resident sustaining a rigtht temple hematoma and extensive facial bruisin, on 3/16/16 at 6:30 a.m., when the resident was found on the floor next to the bed and stated I was trying to go to the bathroom. Resident #15 was toileted at 5:30 a.m. An intervention was to place the bed against the wall to provide a boundry. The resident was also not to be left alone in the bathroom, not to push fluids after dinner and if Resident #15 chose to be in the room the resident was to be transferred to bed. The fourth fall with significant injury, occurred on 3/19/16 at 6:40 a.m. The resident was in the commons area and the fall was witnessed. Again, the resident stood up and fell while trying to get to the bathroom. The resident was assessed, monitored and sent to the hospital on [DATE] at 1 p.m. Resident #15 was diagnosed with [REDACTED]. According to the 3/19/16 facility incident report, Resident #15 said she was trying to get to the bathroom, and staff took the resident to the bathroom after the fall in the commons area. The facility investigation conclusion related to what may have contributed to the fall, was that the resident had poor safety awareness, and the behavior of not making her needs known. In an interview with Staff A, on 3/29/16, beginning at 4:38, he/she stated an individualized toileting plan to increase toileting was not considered as an intervention for Resident #15. The facility failed to prevent falls for Resident #15, as the facility did not find root cause anaylsis to determine why the resident had repeated falls, or did not revise the interventions to address individualized toileting needs, and anticipating the needs of the resident. As a result, Resident #15 had a significant injury. RESIDENT #10 On 3/11/16 at 2:10 p.m. Resident #10 lay in bed with a bed alarm attached to the back of the wheelchair. The resident did not articulate words that could be understood when asked simple questions. Resident #10 was admitted to facility on 1/6/16. Admission records identified the resident's [DIAGNOSES REDACTED]. Current physician orders [REDACTED]. On 2/11/16 the physician prescribed an antidepressant medication given to stimulate appetite. Potential adverse reactions for these medications included dizziness or drop in blood pressure during sudden change in body position. An Admission Minimum Data Set (MDS, an assessment tool) dated 1/13/16 identified the resident had short and long term memory impairment, impaired decision making. The facility could not complete a brief interview for mental status. The assessment noted the resident experienced two falls since admission. A Morse Fall Assessment (fall assessment tool) dated 1/6/16, identified Resident #10 had a moderate risk for falls with a score of 35. The Morse Fall Assessment documented the resident did not have history of falls, which was not consistent with the MDS assessment. Additional risk factors noted on the fall assessment included resident diagnoses; bed rest and use of wheelchair; impaired gait and mental status. Resident #10 experienced four falls between 1/6/16 and 2/1/16. 1/6/16 A progress note dated 1/6/16 noted the Resident #10 had a non-injury fall out of bed at 11:10 p.m. with the call light still in hand. An incident investigation noted it appeared the resident tried to get out of bed and may have become twisted in blankets, but unsure. Following an investigation after staff found Resident #10 on the floor in room on 1/6/16, staff identified to ensure the resident's bed was placed in the lowest position to increase resident safety. The resident's plan of care for falls did not include the intervention to place the bed in the lowest possible position to determine if this was implemented or discontinued. During an interview on 3/29/16 beginning 2:35 p.m., Staff A reported placing the bed in the lowest possible position was part of the standard of care. Staff A provided a copy of the standard of care document, it did not contain placing beds in the lowest possible position. 1/7/16 A facility investigation identified on 1/7/16 at 5:50 p.m. staff found Resident #10 on the hallway floor outside the dining room just before dinner. The resident's personal alarm did not sound. The investigation noted interventions to increase resident safety included to ensure the personal alarm was attached to the resident and to supervise the resident in the dining room at all times. The aide Kardex located in Resident #10's room signed 2/18/16, did not include the updated interventions for staff to ensure the alarm clip was attached to the resident and to supervise the resident in the dining room at all times following the fall on 1/7/16. 1/8/16 On 1/8/16 Resident #10 fell for the second time when left unattended and unsupervised in a wheelchair. A facility investigation identified on 1/8/16 at 12:00 p.m., staff found Resident #10 lying on the floor on his/her right side with right shoulder resting on the left wheelchair footrest. The investigation identified a roommate saw the resident attempt to pick something up off the floor and the wheelchair tipped. Staff interventions to increase resident safety included to not leave the resident in room unattended, put the resident in bed and to train the resident on use of a reaching tool. The current Kardex Report located in Resident #10's room signed 2/18/16, did not contain the updated intervention instructing staff to not leave the resident unattended in resident room. During an interview on 3/29/16 beginning 2:35 p.m., Staff A reviewed the resident's aide Kardex and stated he/she did not see the intervention to not leave the resident alone in the room on the directive. Staff A identified not all care plan changes were made and the problems were being addressed. It was unclear since staff determined the resident should not be left unattended in the wheelchair in the dining room after the fall on 1/7/16, why staff did not care plan the need to supervise Resident #10 in all locations, and to not leave unattended in the wheelchair in any location. (See string monitors related to staff training for personal alarm use). 2/1/16 FALL On 2/1/16 Resident #10 fell for the third time when staff failed to supervise the resident and left him unattended in room in a shower chair. A facility investigation identified on 2/1/16 at 7:45 a.m., staff assisted to dress Resident #10 following a shower and walked five feet away from the resident and poked head out of the doorway of the room to ask for assistance. Staff heard a loud bang and found the resident on the bedroom floor. The investigation noted the resident did not remember own limitations and to constantly watch the resident when in chair. The investigation documentation noted the directive on the Kardex in the resident's room for nursing aides to see, indicating it would advise aides do not leave unattended in shower chair. Following this fall, the resident's current aide Kardex in the room only indicated to not leave unattended in a shower chair and still did not contain updates to reflect to not leave unattended at any time when seated in a wheelchair following two previous falls. Failure to modify interventions to reflect level of supervision Resident #10 required from staff to not leave unattended while in the wheelchai,r increased the resident's risk for continued falls from the wheelchair. Resident #10's aide and fall care plans did not reflect the need to not leave the resident unattended in the wheelchair in any location. The aide care plan indicated to not leave unattended specifically in a shower chair after the resident fell out of the wheelchair on 2/16/16 when left unattended for the third time. On 3/29/16 at 12:50 p.m., Staff RR reported nursing staff updated the Kardex in the room after fall investigations when new interventions were started. Staff RR stated he/she was not familiar with resident computerized care plans. When asked how he/she knew what care a resident needed, Staff RR stated, by looking at the Kardex in the room and medication and treatment records. On 3/29/16 beginning 2:35 p.m., Staff A reported sometimes there was a problem getting changes onto the care plans. RESIDENT #11 During observation on 3/2/16 at 11:10 a.m., Resident #11 lay in bed asleep on right side with the left side of the bed placed against a wall. At 11:15 a.m., Staff MM lifted the resident's covers which revealed a personal alarm attached by a clip to the back of the resident's shirt and the alarm box attached to an incontinent pad behind the resident's back. Resident #11 admitted to the facility on [DATE]. Medical [DIAGNOSES REDACTED]. An MDS dated [DATE] identified the resident had severe impairment for daily decision making skills, long and short term memory impairment; impaired vision and unclear speech. A current Medication Review Report indicated on 11/26/14 the physician ordered for the resident to receive a medication to treat epilepsy and a psychoactive medication to treat a mental health condition. Resident #11 experienced multiple falls on 12/27/15, 12/28/15, 1/9/16, 1/10/16, 1/15/16, and 1/29/16. Investigations did not contain evidence of potential root cause analysis of what the resident attempted to do or needed at the time of the falls when found on the floor following the first four falls. Investigations following the first five falls noted either staff did not identify the resident's mental status at the time of the fall or if the resident had confusion, and did not provide an answer to what he tried to do at the time of the fall. Resident #11's medical record did not contain evidence staff assessed the resident at the time of falls for potential impact of medications taken that may have contributed to falls, such as a sudden drop in blood pressure. During an interview on 3/29/16 beginning 2:35 p.m., Staff A said the resident could answer correctly if asked if he hit his head if asked at the time it happened. Staff A also stated it depended on the day you catch him. Staff A said she/he reviewed medications at the time of falls and was lax about documenting it. Resident #11's record did not contain evidence the facility identified timely steps to prevent further falls. The facility referred Resident #11 for a Physical Therapy (PT) evaluation after the fifth fall on 1/15/16. During an interview on 3/29/16 beginning 2:35 p.m., Staff A reported Resident #11 became weaker after the fall by the beauty shop on 12/28/15 (second fall) and began to use a wheelchair and could not walk anymore. Physical Therapy (PT) Evaluation and Plan of Treatment notes dated 1/18/16, identified The resident lacked insight to his/her own functional limitations and had decreased safety awareness. Therapy notes identified the facility did not evaluate Resident #11 for assistance with fall reduction until 1/18/16, three weeks after the second fall and after the resident fell three more times on 1/9/16; 1/10/16 and 1/15/16. When asked why it took so long for therapy to assess the resident, Staff A reported it took awhile for the outside provider to assess the resident. SAFETY ISSUES/MEDICAL DEVICES RESIDENT #9 An Investigative Summary signed 9/6/14, identified Resident #9 fell on the floor next to the bed during an attempt to self-transfer. The facility implemented the fall matt on the floor next to the bed. A physician order [REDACTED]. An MDS quarterly assessment dated [DATE] identified the resident did not have any falls during the past six months. A Morse Fall Risk assessment dated [DATE] identified the resident as a high fall risk with a score of 75. Resident #9's Care Plans and aide directives (Kardex) inconsistently identified what interventions staff followed and did not match observations of care currently provided. Resident #9's plan of care for Falls, Unaware of Safety Needs contained interventions revised on 9/25/14 that included bed against wall and mat on floor. The care plan contained an intervention revised 10/21/13 for a personal alarm. An intervention revised 8/30/13 indicated to place the bed in the lowest position against a wall. During observations on 3/2/16 at 10:29 a.m. at approximately 12:48 p.m., Resident #9's bed was elevated high with right side placed directly next to a wall with a window. An electric baseboard heater was located on the same wall above the floor and extended the length of the bed. A trapeze placed above the bed was within reach of the resident and the head of bed was elevated. No other assistive devices were observed. At 12:48 p.m., when asked why the resident's bed was placed directly next to the wall, the resident stated he/she did not know why but liked to look out the window. An Admission Record form identified Resident #9 admitted to the facility in 2013. [DIAGNOSES REDACTED]. The admission form identified the resident as his/her own responsible party for decision making. A Mobility Assistive Device and Personal Safety Assessment form recently reviewed and dated 12/22/15, contained names of multiple devices implemented for Resident #9 that included trapeze, personal alarm, bed side mat and bed against wall. Observation on 3/2/16 at 10:29 a.m. and 12:48 p.m., revealed the resident did not have a personal alarm or bed side mat. The form indicated the resident was not totally dependent for positioning and contained a section to describe how the resident would benefit from the devices/modifications. Documentation indicated the trapeze allowed the resident to assist with repositioning in bed; the alarm reminded the resident to request assistance with care and transfers and other interventions decreased risk of injury related to falls. The form and the resident's record did not contain an analysis of impact of mobility and physical limitations related to the resident's amputation and ability to use the devices, and safety consideration. The assessment did not identify how the benefit of use for each individual device/modification exceeded their risks. The record did not identify the potential safety risk of placing a bed next to a wall with an electric heating unit. An Investigative Summary signed 9/6/14, identified staff implemented the fall matt on the floor next to the bed. During an interview on 3/2/16 at 2:45 p.m., when asked what devices the resident used and their purpose, Staff G reviewed Resident #9's record and stated the resident had a personal alarm and fall mat, trapeze and bed against wall. Staff G could not locate individualized assessments for use of each device. Staff G and the investigator went to the resident's room at this time to observe what devices were in place. Staff G reported Resident #9 had the bed against the wall and a trapeze, and stated the personal alarm and fall mat must have been discontinued. On 3/2/16 at 3:50 p.m. Staff B reported the facility discussed fall risks for residents and types of device needed. When asked where staff documented the assessment for each device, Staff B reported, the facility used the assessment on the consent/risk benefit form. The facility did not provide further evidence for completion of a comprehensive assessment for the trapeze and bed against wall that assessed potential safety considerations for Resident #9, such as the resident's current risk for falls, current physical limitations and effect of medication administered to assist with sleep. During an interview on 3/2/16 at 12:58 p.m., when asked if it was safe to place a bed next to a wall with a heater, Staff G reported I don't know. On 3/2/16 at 1:05 p.m., Maintenance Staff F observed Resident #9's bed next to the wall with a heater and reported by rule the bed should be one foot away from a heater. Staff F reported if the resident could lower the bed down to the heater it shouldn't be that close. Staff F read a warning label on top of the heater and stated it read danger; fire hazard; do not block heater and keep items a minimum of 12 inches above or in front of the heater. Staff F stated normally we don't put beds by a window and nurses know not to put a bed next to a heater. We've been over this. During a meeting on 3/2/16 beginning 3:45 p.m., Staff E reported we don't normally place a bed next to a heater and place it 12 inches away from it. Staff B stated she did not know how the bed got next to the heater. A Bedside Kardex Report for Safety used as directives for nurses aides printed 12/23/15 instructed to place the bed against the wall in lowest position, personal alarm for safety and an air overlay mattress. Resident #9 no longer had an overlay air mattress, bed in lowest position or personal alarm. The care plan did not identify Resident #9 currently had a trapeze above the bed. During a meeting on 3/2/16 beginning 3:45 p.m., Staff E reported Resident #9 no longer used a mat on the floor and personal alarm. Resident #9's record did not contain evidence of an individualized assessment for each device that included trapeze, personal alarm and floor mat that identified risks and benefits for each device to ensure they were safe to use. The record and staff could not readily identify when each device was discontinued. Staff did not recognize or assess the potential safety risk for burns or fire associated with placing a bed on a wall that contained an electric baseboard heater FALLING STAR PROGRAM On 3/2/16 at 11:10 a.m., Resident #11's nameplate outside the room door contained two red stars, one gold star and one green star, for a total of four stars. During an interview on 3/2/16 at 11:15 a.m., Staff MM reported one star meant the resident was a fall risk; two stars meant the bed was placed against the wall and three stars meant a mat on the floor was used. Staff MM did not know what the fourth star meant. When asked if the resident needed a fall matt, Staff MM stated she thought it would be more dangerous since the resident could move and sit up in bed. Staff MM confirmed Resident #11 did not have a fall mat on the floor at this time. During further interviews on 3/2/16 at 11:20 a.m., both Staff K and Staff Z did not know what the fourth star meant or what specific colors of stars meant. The Falling Star Program protocol provided by the facility confirmed three stars meant mat on the floor. Resident #11's nursing aide Kardex Report, review date 12/11/15, identified placement of bed against wall and use of a personal alarm. It was not clear why the nameplate outside the resident's door contained the third and fourth star and did not identify interventions listed in the resident's plan of care. The facility did not ensure staff were trained or educated in using the falling star program for the prevention of resident falls in the facility. FAILURE TO MONITOR RESIDENT RESPONSES TO DEVICES FOLLOWING IMPLEMENTATION Records for Resident #7, Resident #9 and Resident #11 did not contain evidence the facility monitored resident response to personal alarms following implementation or beds placed against walls for Resident #9 and Resident #11. During an interview on 3/11/16 beginning 3:15 p.m., Staff C reported after residents were given assistive devices, the facility did not place the residents on alert charting to monitor their response to the device. FAILURE TO FOLLOW MANUFACTURERS INSTRUCTIONS FOR EFFECTIVE USE OF STRING MONITORS Resident #1 was admitted to the facility from the hospital on [DATE] with [DIAGNOSES REDACTED]. During a review of a facility investigation regarding a fall on Resident #1 on 5/1/16 at 0510 a.m., the String Monitor was in the resident's hand while walking to the bathroom. The resident had dropped the device and in the process of picking it up, Resident #1 fell . During an interview on 1/29/16 at 3:45 p.m., Staff A stated, You cannot put a person in bubble wrap. According to Staff A, the facility attached the String Monitor to something solid like a call light cord, while residents were in bed. During an observation on 1/29/16 at 3:55 p.m., Staff B demonstrated how the alarm could be fastened to the sheet under the pillow, then clipped to the resident's gown. During an observation, on 1/29/16 at 4 p.m., Resident #2 had a String Monitor tucked under the pillow unattached with a clip to the residents gown. During an interview on 1/29/16 at 4 p.m., Staff C stated, I can't bubble wrap or restrain residents. People have rights. During an observation on 1/29/16 at 4:10 p.m., Resident #3 was noted to have a String Monitor tucked under the pillow with the resident's hand on the monitor. During an observation on 1/29/16 at 4:20 p.m., Resident #4 had the String Monitor tucked under the pillow, but not attached to anything. In an interview with Staff C, on 1/29/16 at 4:45 p.m., he/she stated, the magnetic disk should alarm when the weight of the monitor dangled from the alligator clip, usually attached to a resident's clothing. Staff C then picked up the monitor by the string to demonstrate how the monitor should detach, which it did not. Staff C added the monitors were placed under the pillows or attached to the sheet, depending on the resident. In an interview on 1/29/16 at 4:55 p.m., Staff D stated no one had shown the Nursing Assistant Certified (NAC) how to use the String Monitor. In an interview on 2/2/16 at 10:05 a.m., with the manufacture representative of the String Monitor, he stated the String Monitors were tricky to use in bed, and recommended the use of a sensor pad. During an interview on 2/17/16 at 12:30 a.m., Staff E sent a fax regarding the policies and procedures about falls, and stated there was not a procedure specific to the String Monitor use. During an observation on 3/2/16 at approximately 10:50 a.m., Resident #11 lay in bed asleep on the right side. The resident's personal alarm was resting on the edge of the incontinent pad behind the resident's lower back. In an interview at 12:46 p.m., Staff NN reported staff typically attach personal alarms near the head of the bed. Staff do not attach them to an incontinent pad since a resident could roll on to it. During record review of the String Monitor's Patient Set-up and Use, undated, revealed to follow the procedure before each use: 1) Securely mount the pull string monitor to a wheelchair using the clip of the monitor. If using on a bed, clip the monitor to the optional bed mounting bracket .make sure the string assembly is always free of interference from environmental factors such as sweaters, blankets and pillows. In summary, the facility did not have a procedure to use the monitor, and staff were not using the String Monitor as per manufacturer specifications. This failure to properly use the monitor had a potential to increase fall risks of residents in the facility. Failure to attach personal alarms according to manufacturer instructions had the potential for them to not alarm when needed to alert staff. FAILURE TO IDENTIFY TRIPPING HAZARD On 3/22/16 at 10:15 a.m. a long opaque colored, thin plastic sheet approximately 25 feet long and three feet wide covered the length of the carpeted hallway to the left of the front entrance reception desk. The plastic runner extended between two doors that exited the building. Blue tape intermittently attached the sides of the runner to carpet and were spaced approximately three feet apart. The side edges of plastic runner between pieces of taped sections did not lay flat or secure and moved easily across the surface of the carpet. Hazard cones did not significantly block access to the hallway. At approximately 10:55 a.m., Resident #14 walked into the hallway from the resident care area using a front wheeled walker. The resident walked very slowly and carefully raised her feet to cross from the carpeted area onto the plastic sheet and maneuver the wal

Based on observation, interview, and record review the facility failed to effectively and efficiently manage its resources to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident in the area of fall prevention that included adequate supervision to prevent accidents; conduct comprehensive investigations following falls; comprehensively assess and obtain consents for each assistive device and environmental modification implemented for residents and conduct competency reviews of newly hired staff for 6 of 6 Sampled Residents (# 7, 8, 9, 10,11and 15) who were reviewed for accident prevention. These failures resulted in harm related to significant injuries for Resident #7 from a fall resulting in multiple fractures, and Resident #15 from a fall that resulted in a cranial bleed. Findings include: The administrator is responsible for overall operations to ensure the facility meets and maintains compliance with regulations at all times and nursing services provide care and services that meet resident needs. HARM LEVEL CITATION: F 323: failure to supervise and prevent a fall resulting in a fracture for Resident #7 and an intracrainial bleed for Resident #15; significant injuries which required hospitalization . ADDITIONAL CITATIONS: The facility did not develop a system to implement an effective accident prevention program to ensure resident safety to prevent falls and to ensure appropriate and safe use of assistive devices and modification of resident environments. F 225: failure to conduct comprehensive investigations following resident falls to rule out abuse and neglect and identify potential root causes. 498: failure to conduct competency skill reviews of newly hired nursing aides. F 501: failure to ensure collaboration with the Medical Director to evaluate resident care policies and procedures related to accident prevention. F 520: failure to timely self- identify deficiencies and develop action plans and initiate and monitor effectiveness of corrective actions. On 3/11/16 at 4:40 p.m. Staff E reported the facility discussed evaluating the fall prevention program in January (2016).

Based on observation, interview and record review, the facility failed to comprehensively assess, recognize and address the concerns or resident care needs, monitor, and reassess effectiveness of interventions to provide necessary care and services for 1 of 3 Residents (#114) following an allegation of inappropriate touch by a staff member when investigated for abuse prohibition. Failure to assess, identify and provide effective interventions resulted in psychological harm for Resident #114 and potential for all residents to be at risk of unrecognized and untreated psychological harm. Findings include: Review of Resident #114's record revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Short and long term memory was adequate. The resident required a lift for transfers, assistance for dressing and toileting, and used a power chair for mobility. In interview on 10/6/15 at 11:24 a.m., the surveyor asked Resident #114 if s/he was abused by a resident or anyone else in the facility. At that time, the resident became tearful and did not want to talk about it. When offered, the resident was in agreement with attempting the conversation at a later time. In a follow-up interview on 10/6/15 at 3:20 p.m., Resident #114 reported in August 2015, a staff member had slapped his/her buttocks when in the sit-to-stand lift and said, I couldn't resist it. The resident reported the allegation, and the staff member was removed from the hall. The resident stated s/he was not supposed to see that staff member, but still sees him/her frequently. The resident reported I can't stop thinking about it each time the resident saw the staff member. It made me feel upset, and stated s/he told two nursing assistants. The resident stated s/he has not interacted with the staff member since the incident occurred. In addition, the resident reported s/he asked for a copy of the investigation, but never received one. Record review of the investigation dated 8/17/15 revealed the allegation was reported and investigated. The staff member identified was removed from the resident ' s hall. Resident #114 was placed on alert charting to monitor for possible psychosocial harm. Record review of August 2015 Medication Administration Record [REDACTED]. The resident exhibited positive indicators on evening and night shift on 8/18/15. Target behaviors included [MEDICAL CONDITION], nightmare, change in mood/behavior, flashbacks, and difficulty concentrating. Tearful episodes were not listed. Monitoring of target behaviors was discontinued after 8/21/15. [MEDICAL CONDITION] was the documented target behavior for the evening and night shift on 8/18/15. Nursing progress notes dated 8/19/15 at 2:19 p.m. revealed Resident #114 reported to Staff D that s/he wished people would stop focusing on the incident. The resident felt bad about reporting it and considered it a bad taste of a joke. Record review of nursing progress notes dated 8/20/15 at 12:29 p.m., nursing discussed conclusions of the investigation with the resident. Mental health services were offered and the resident accepted. Nursing progress note dated 8/20/15 at 1:36 p.m., Resident #114 exhibited tearfulness and refused to discuss the matter with nursing. Record review of care plan dated 5/15/14 revealed, the incident on 8/17/15 was not addressed to include target behaviors, interventions or goals identified. No ongoing monitoring or reassessment was put in place to manage the resident's unresolved [MEDICAL CONDITION], nightmares, and tearful episodes. Record review of document titled Intake Evaluation and Initial Treatment Plan dated 8/28/15 revealed Resident #114 was seen by a mental health (MH) specialist. Staff reported the resident had been tearful following the incident on 8/17/15. The resident's thought process was assessed as logical; concentration was variable, speech within normal limits, and appeared somewhat depressed. Resident reported the incident was disturbing, and was not completely satisfied with the outcome because the facility did not provide a copy of the report. In addition, the resident reported that s/he is not supposed to be able to see the staff involved and not certain that the facility followed up. The assessment revealed the resident appeared to be experiencing adjustment disorder, and recommended something in writing as s/he requested, to help him/her cognitively process. The services were recommended to continue until the resident rescinded. No additional MH consults were located. Record review of care plan dated 5/15/14 revealed recommendations from the mental health specialist were not addressed. There were no Social Service progress notes after 8/17/15. No interdisciplinary team notes or nursing notes specifically addressed the mental health evaluation recommendations or followed up with the resident's status in regards to the incident on 8/17/15. In interview on 10/9/15 at 9:56 a.m., Staff FF had heard that Resident #114 had been tearful in the last month. In interview on 10/9/15 at 12:29 p.m., Resident #114's family member reported the alleged incident still bothered him/her, was still tearful at times. The family member also stated s/he did not know what was being done about it and that no one had received a report yet. In interview on 10/9/15 at 12:32 p.m., Staff GG reported when a resident is placed on alert charting for possible psychosocial harm, it is only done by nursing. A progress note is documented regarding the nature of the circumstances and the alert charting is documented in the MAR. The doctor is notified for recommendations and a possible mental health evaluation. Social services makes the appointment for the mental health evaluation and follows up with the resident and /or family. Staff GG recalled when Resident #114 was recently tearful. Staff GG indicated a progress note was documented, the doctor was notified and a mental health evaluation was recommended and performed. Staff GG was uncertain if Social Services followed up with the resident. In interview on 10/9/15 at 1:15 p.m., Staff E was not aware that Resident #114 exhibited any tearful episodes following the alleged incident on 8/17/15. Staff E acknowledged the last progress note for the resident was 8/17/15 and the resident reported s/he was fine. Staff E was not aware the family was still concerned with the resident. Staff E was aware of the mental health evaluation and documented adjustment issues. Staff E reported the resident sounded like s/he had post-traumatic stress disorder ([MEDICAL CONDITION]) from something in the past. The resident was not identified or monitored for any target behaviors because s/he was not prescribed any [MEDICAL CONDITION] medications. Staff E stated Resident #114 was offered an antidepressant in the past, but because he was religious, s/he refused. In interview on 10/14/15 at 11:42 a.m., Staff C reported having followed up with Resident #114 and said the incident had brought back trauma to him/her. According to Staff C, in the last few days, the resident appeared to have been traumatized when bringing the subject up, and it comes and goes. Staff C explained the resident reportedly just wants it to go away. Staff C had not heard of any negative reports about Resident #114 in the last few weeks. Staff C said, the facility sent mental health professionals to address those issues. The facility failed to comprehensively assess, address psychosocial well-being needs, assure effective interventions and provide acceptable standards of practice to a resident identified with psychosocial harm.

Based on interview and record review, the facility failed to implement written policies and procedures to prohibit mistreatment and abuse for 2 of 4 current sampled residents (#110 & 70) reviewed for abuse when the facility failed to identify a physical resident to resident altercation as abuse, protect the residents and immediately report and investigate the incident. The facility also failed to implement the facility's policy when 4 of 8 staff (LN F, PTA, SSD A & HK A) interviewed failed to acknowledge their mandatory reporting responsibility. This failure to identify abuse and thoroughly investigate the incident caused harm to Resident #110 when a subsequent incident occurred. The facility was asked for an immediate safety plan to protect the residents from abuse, mistreatment and retaliation. Findings include: The facility's policy for documenting resident to resident abuse stated, the nurse will: 1. Immediately separate the residents involved. 2. If the predator still poses a threat to themselves or others, call 911, the physician and the individual ' s family guardian or legal representative. 3. Maintain visual surveillance of the predator until she had calmed or until the police or a mental health professional has arrived. 4. If the victim has sustains a physical injury or has pain, notify the physician, the resident ' s family, guardian, or legal representative. 5. If possible, interview the victim and obtain a statement. Interview the predator. 6. Take actions to ensure the predator will not have access to the victim. 7. Interview other residents in the vicinity to identify any other possible victims. 8. Document all actions taken in completed accident. A separate incident report is made for each resident involved, including the predator. 9. Document all actions taken to protect the victim and other possible residents. 10. If the victim sustained a substantial injury, or if psychological harm is or becomes apparent, notify the Department of Social and Health Services. Resident #110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #110 was assessed as needing supervision related to wandering. Resident #110 had a care plan (instructions for caregiving) documenting the facility's knowledge she wandered in the facility. Interventions to ensure her safety included wearing "a smart bracelet" (an alarm would sound if resident were close to an exit door) and involving her in activities. "Resident gets restless provide her with magazines. She likes music." There were no care plan interventions to address her wandering into other resident rooms. On 7/24/12 at 12:20 p.m., Resident #110's daughter reported, "Two weeks ago my mom was in the facility hallway, and another resident started to hit her. "Resident #110's daughter stated she was concerned about her mother and was upset by the treatment she had received. She stated her mother was "frightened" by the incident. During the survey time from 7/23/12 - 7/27/12 intermittently during the day Resident #110 was observed self-propelling her wheel chair with her feet. She was observed propelling in and out of the dining room, activities and up and down the facility hallway where she lived. Resident #110 was not able to be interviewed; she did not understand questions asked. On 7/25/12 at 2:30 p.m., Licensed Nurse (LN) E stated she did not know the specifics of an incident, however, recalled Resident #70 and Resident #110 "had an altercation two weeks ago." LN E provided a facility form titled "24 Hour Nursing Report " dated 7/13/12 documentation stated, (Resident #70) hit (Resident #110.) The form was signed by LN F. At 2:45 p.m., via telephone call LN F stated, "What happened was one of the physical therapy assistants (PTA), who works here witnessed Resident #70 walk up to Resident #110 and start "punching her in the shoulder, face and chest." LN F reported Resident #110 "was crying she was really upset about it. It was devastating to her." LN F stated she filled out an incident report and gave it to the Director of Nursing Services (DNS.) At 3:20 p.m., the DNS stated she recalled getting the incident report from LN F regarding the resident to resident altercation. The DNS stated on that day she had to leave the facility on an unrelated matter and gave the incident report to the Administrator (ADM.) The DNS did not initiate an investigation. At 3:30 p.m., PTA stated on 7/13/12, as he walked around the corner of the facility hallway he witnessed Resident #70 "punching (Resident #110) in the arm and pinching and twisting her arm. I jumped in and said stop, stop and I tried to stop her and she continued to try and hit her. I called for the nurse, and held her until the nurse got there. She (Resident #110) was red faced and crying, the other resident was really punching and grabbing and pinching her. I could not understand either resident as to why the situation occurred." Review of the incident and accident log revealed no documentation a resident to resident altercation occurred. Review of the Resident #110's and #70's medical record revealed, no progress notes, no alert charting, no assessment and no changes made to the care plan reflective of an incident of this nature happening. There was no documentation any action had been taken to protect the residents. At 4:15 p.m., review of record showed no evidence either Resident had been assessed after injury and/or possible psychological harm following the incident. Resident #70 was admitted to the facility 11/7/07 with [DIAGNOSES REDACTED]. According to her MDS dated [DATE], the resident was cognitively able to make her care needs known. Resident #70 was assessed as independent with mobility inside and out of the facility. Resident #70 had a care plan reflecting her inability to communicate in English as Japanese was her native language. Interventions included "provide reassurance and be patient when she is attempting to communicate or doesn't understand. She has friends that visit who are able to assist with interpretation if needed." At 4:30 p.m., during interview with Resident #70 she was agitated as evidenced by her starting to pick up quickly and put down items on her bedside table demonstrating what Resident #110 did to her. She was pointing to Resident #110's room approximately 15 feet down the hallway from her room. Her English was not understandable, however, she was breathless and her expression revealed concern as she tried explaining this situation to the surveyor. There was no documentation in Resident #70's medical record any attempt had been made to talk with her about the situation, as to why it occurred and/or any interventions put in place to mitigate the opportunity for the situation to occur again. At 4:45 interview with the Social Service Designee (SSD) B, the Administrator (ADM) and the DNS, all stated an incident report had been filled out, but it was not completed. SSD B stated, "there is an ongoing bad feeling (Resident #70) has regarding (Resident #110) because she wanders into her room and takes her things, she (Resident #110) wanders in the facility and doesn't seem to bother anyone, her dementia is pretty severe, so you really can't tell her not to do that. (Resident #70) understands more than she lets on, I think she understands more English than she can speak. She has a friend who is a friend of her husbands because I called to tell her what our expectations are for her behavior. I am not aware of what I need to do in an instance like this. I saw (Resident #70) pinky swear to not hurt other residents, she was crying and was very upset about the situation too when we had her friend talk to her about her behavior. The DNS stated, "Her behavior (Resident #70) has escalated over the past several months, maybe she has less tolerance in the past couple of weeks. She is Japanese, the culture is mild mannered. I don't know what is happening." When asked about what action had been taken related to this change in behavior of Resident #70, the DNS shook her head to indicate nothing. The Administrator stated, "Our policy is good, I did not follow it. The abuse hotline should have been called and it should have been logged and should have been responded to. I'm not disagreeing." At 6:30 p.m., the administrator stated the facility placed a 1:1 caregiver to protect Resident #110. On 7/26/12 an updated Incident and Accident log was requested. Documentation revealed an incident on 7/23/12 (three days prior) which documented, "Resident #70 threw water in the face of Resident #110." A safety plan was requested 7/26/12 at 9:24 a.m., on 7/26/12 and accepted at 5:03 p.m., to ensure protection of Resident #s 70 and 110. The facility's policy for reporting abuse and neglect documented, "... all staff in nursing homes are mandatory reporters. Immediately report suspected abuse to your supervisor and they will assist you in calling the hotline. The hotline numbers are located on all the phones and at the nurses' station. Reporting abuse to the supervisor does not relieve you of the responsibility of reporting incidence to the hotline..." On 7/25/12 at 3:30 p.m., when asked what is a mandatory reporter, the PTA stated, "if he witnessed abuse he would report it immediately to the nurse." On 7/26/12 at 1:44 p.m., when asked what is a mandatory reporter, the SSD A stated, " I would have to check into that." When asked when do you report abuse and to whom, the SSD A stated, "I think I know the answer, but I would have to check that too." At 2:04 p.m., when asked what is a mandatory reporter, housekeeper (HK) A stated, "I could be considered one; I would report abuse to my supervisor." At 2:30 p.m., Licensed Nurse (LN) F stated she would report allegations or knowledge of abuse or neglect directly to the Director of Nursing (DON). Two of the four staff members who failed to acknowledge the mandatory reporting requirements to the State agency complaint hotline as outlined in the facility's policy were responsible for supervising and/or training various facility staff. Their lack of knowledge of reporting procedures placed other staff at risk of not receiving correct information. Federal and State statues and regulations mandate all allegations of abuse must be reported immediately to the appropriate State agency if there were reasonable cause to believe abuse occurred.

Based on observation, interviews and record reviews, the facility failed to provide necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial needs for 3 of 19 (#s 6, 89 and 103) Sample Residents. The services not provided were in the following areas: positioning, comfortable transfers, assessing a significant bruise and pain. Because of the lack of on going assessment and evaluation of pain related to a significant bruise from 8/4/11 through 8/6/11, Resident #6 was determined to have suffered harm. Findings include: RESIDENT #6 ONGOING EVALUATION The Resident was admitted to the facility in December of 2004 and had the following Diagnoses: [REDACTED]. The Resident was observed from 9/6/11 through 9/13/11 as being dependent on staff for all activities of daily living. The Resident was observed on 9/6/11 at 1 p.m.asleep in her recliner chair. The Resident moved her right arm and cringed in her sleep. She awoke for a moment and went back to sleep. On 8/4/11 at 11 p.m., the Resident's progress notes indicated the following: "Bruise to (R) upper arm 12 by 7 centimeters; slight swelling, warm to touch, frowned/grimaced when moved ..... MD (physician) made aware and daughter. Will elevate (R) arm with pillow and applied ice. Addendum: Placed on alert charting to monitor." No other assessment of the bruise or assessment of pain from bruised area (size of bruise, swelling of bruise, color of bruise, temperature of bruise, grimacing/cringing when moved the arm, or change in behaviors) was made until 14 hours later. On 8/5/11 at 1:45 p.m. the Resident's progress notes included: "Resident had a shower and continues routine as usual without any problem noted. The bruise is still very visible." No other assessment of the bruise or assessment of pain was made for another 26 hours. On 8/6/11 at 6 p.m. the Resident's notes included: "Resident family member came around 5 p.m. and was upset! Right upper arm with big bruise ... Resident's family member wants full x-ray to rule out any further problem. ... Received telephone order to do x-ray of right elbow, right humerus and right shoulder. To be done by mobile and scheduled for tomorrow at 8/7/11 between 9AM and 12 noon. "There was no evidence the facility assessed the Resident's bruise or pain when the family member expressed her concern. During a 9/7/11 interview, the same family member stated the Resident's bruise was "large and swollen on 8/6/11". The family member indicated she was "shocked that it was so large". The family member indicated she asked for a "full X-ray to be done". The family member further commented on the Resident's pain from the bruise. She indicated every time the resident moved she "cringed and drew her legs up in pain". The 8/7/11 X-ray indicated the resident's right upper arm was fractured. The facility failed to provide the service of ongoing monitoring and documentation of a significant bruise 12 cm by 7 cm on the resident's right upper arm and failed to monitor consistently for any behaviors related to pain for a Resident with dementia from 8/4/11at 11p.m. to 8/6/11 at 4:45 p.m. On 8/8/11 after the Resident was diagnosed with [REDACTED]./9/11 for "splinting or bracing her body". RESIDENT #6 UNCOMFORTABLE TRANSFER The Resident has the [DIAGNOSES REDACTED]. On 9/8/11 at 12:30 p.m., three nursing assistants (Staff O, P & Q) transferred the Resident from her recliner to her bed. Licensed Nurse Staff D was in the room to observe the transfer. The Resident was sitting in her recliner with the sling for the lift bunched up around her shoulders. The nursing assistants told the Resident that they were going to move her. The recliner chair was close to the bed. The nursing assistants put the Resident'a hands and arms within the sling. They draped and connected the chain between her legs to secure her in the sling. The nursing assistants talked softly to the Resident as they began to pump the hoyer lift up from the chair. The sling wrapped around the Resident's arms and shoulders like a tight cocoon and the top of the sling lightly fell over the Resident's face and eyes. One nursing assistant saw the sling fall over the Resident's eyes and quickly folded the material back so the Resident could see. The Resident's bottom was wedged between the sling and the chains. There was no chance of the Resident falling but the tightness of the sling around her bottom and the tightness of the sling cocooned against her arms and shoulders (right fracture upper arm) made the transfer not a comfortable transfer. Staff D said nothing and did not assist during the transfer. On 9/9/11 at 1:30 p.m, Staff E was made aware of the transfer. After the notification, the facility updated the nursing assistant's directives for the Resident to include "use correct size sling when transferring Resident and assure the Resident is positioned correctly with head 2-3 inches from the top of the sling and the bottom so the lower body is supported by the sling. LACK OF POSITIONING OF THREE RESIDENTS FROM THE SAME UNIT RESIDENT #89 POSITIONING Resident #89 was admitted to the facility 5/5/2008 with [DIAGNOSES REDACTED]. Review of Resident #89's most recent minimum data set assessment dated [DATE] revealed he was coded as needing extensive assistance to change positions while in bed. The quarterly assessment notes also dated 6/10/11 indicated Resident #89 required extensive assistance assist with bed mobility and two person assist to scoot him up in bed. Review of Resident #89's care directive indicated he was on an every 2 hour turn schedule (meaning staff should change his position every two hours) and to float heels (heels elevated off of the mattress to relieve pressure to skin and tissues over the heel bone). During an interview on 9/6/11 at 10:31 a.m. Staff G confirmed Resident #89 was to be turned and repositioned every 2 hours. Observations of Resident #89 on 9/6/11 revealed: 11:30 a.m. Resident was lying in bed on his back with his heels resting on the mattress. 12:37 p.m. Resident remained in bed lying on his back with his heels on the mattress and the bottom of his feet against footboard of the bed. 2:00 p.m. Resident remained in bed on his back with his heels on the mattress and the bottoms of his feet against the footboard. Further observations of Resident #89 on 9/7/11 revealed: 9:00 a.m. Resident in bed sitting up in bed eating breakfast.. 10:08 a.m. Resident was asleep in bed lying on his back. 10:54 a.m. Resident remained asleep in the same position. 12:35 p.m. Resident was awake watching television in bed, remained in the same position. 1:51 p.m. resident in bed in hospital gown on back with the head of bed elevated 80% lunch tray on bedside table Further observations on 9/8/11 revealed: 8:49 a.m. resident sitting up in bed, asleep with head of bed elevated approximately 80 degrees. 10:04 a.m. Resident remained in bed, head of bed remained at same elevation. 12:17 p.m. Resident remained in bed, lying on his back with head of bed lowered to approx 25 degrees. 1:47 p.m. Resident remained in bed on his back, heels resting on the mattress. 2:23 p.m. Resident remained in the same position. Further observations on 9/9/11 revealed: 8:52 a.m. Resident was in bed sitting up in bed eating breakfast with his heels against mattress. 9:58 a.m. Resident lying in bed with head of bed elevated approximately 45 degrees watching television. 11:04 a.m. Resident remained in same position in bed with a pillow between the bottom of his feet and the footboard, heels remained resting on the mattress. 11:25 a.m. Resident remained in the same position. 12:24 p.m. Resident remained on back lying in bed with his heels resting on the mattress. Observations of resident #89 on 9/12/11 at 2:00 p.m. revealed resident was sitting up in bed with his feet on a pillow however heels were resting on the mattress. During an interview on 9/13/11 9:14 a.m. Staff S reported resident frequently refuses care and can reposition himself off of the pillows used for positioning to relieve pressure to his coccyx. Observations made on 9/13/11 of Staff S postioning revealed Resident #89 had thin pillow placed behind his left hip which did elevate the hip, however, did not relieve pressure from the coccyx area. Staff S then confirmed Resident #89's heels were not being floated, as he had a pillow under his calves but heels were still resting on the mattress. Staff G then moved the pillow down so that Resident #89's heels were resting on the pillow. When asked if his heels were floated in that position Staff S confirmed the pillow was flat and did not lift the heels off of the mattress. During an interview on 9/12/11 Staff E confirmed when a resident's heels were on a pillow they were not considered to be floated. During an interview on 9/13/11 Staff F reported staff should only consider heels to be floated when they are not in contact with the surface of the mattress. During an interview on 9/14/11 at approximately 12:35 p.m. Staff P reported Resident #89 has been refusing his care. Review of Resident #89's Nursing assistant documentation record revealed no documentation to evidence refusal of repositioning. Staff P confirmed there was not documentation of refusals of care during an interview on 9/14/11 at 12:35 p.m. Failure of the facility to provide the necessary services to ensure he was being repositioned adequately to relieve pressure from his coccyx in accordance with his plan of care place him at risk for prolonged pressure to his skin and underlying tissues. RESIDENT #103 POSITIONING The Resident was admitted to the facility on [DATE] with dementia and chronic back pain. Facility written communication to the physician on 8/25/11 included the resident had lost weight, was only eating 50% of his meals, and was sleeping more. The Resident's care directives related to positioning the Resident included the following: "turn every two hours, keep off back, avoid pressure on the coccyx, and float heels". The Resident was observed every one to two hours on the following days and times: On 9/6/11 from 10:30a.m. to 3 p.m., on 9/7/11 from 9 a.m. to 3 p.m., on 9/8/11 from 11 a.m. to 3 p.m. and on 9/9/11 from 9 a.m. to 1 p.m. The Resident was observed to be on his back with no pillows in his bed except under his head on 9/6/11, 9/7/11 and 9/9/11. On 9/8/11, the resident was observed on his back in bed except from 11:30 a.m. to 1:30 p.m. He was observed sitting in his bed at an approximate 80 degree angle. He had a pillow under his knees. During the two hours, the Resident was observed to slowly move down toward the foot of the bed, the pillow under his knees was pushed to the side and his head leaned over his right shoulder. Staff D was notified and the Resident position was changed. At 2:30 p.m., the Resident was observed on his back with no pillows floating his heels. On 9/9/11 at 1:30 p.m., Staff E was notified the Resident's care directives were not being followed. Without the directives being consistently followed the Resident would potentially have an increase in back pain and/or a higher potential for skin break down. RESIDENT #6 POSITIONING The Resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident was diagnosed with [REDACTED]. The Resident's care directives for positioning included the following: "Turn every 2 hours when in bed, float heels, and keep head of bed elevated above 30 degrees" The Resident's care directives also included, "Family prefers the resident stay in her room most of the time. The Resident likes to sit in her recliner during the day". The family had posted signs in the Resident's room reguarding how they wanted her care to be given. They did not want the Resident to be laid down in bed before 7 p.m. each night and when the Resident was in her recliner chair they posted: "please put a pillow under her legs, pillow under her left shoulder and left side because she falls to the left side." Resident observations were made every 1 to 2 hours on the following dates and times: on 9/6/11 from 10:45 a.m. through 3 p.m., on 9/7/11 from 9:30 a.m. through 3 p.m., and on 9/9/11 p.m. from 9 a.m. through 1 p.m. The Resident was observed in her recliner chair on 9/6, 9/7 and 9/9/11. The Resident had a pillow under her knees, left shoulder and left elbow. The Resident and the pillow positions only changed as the resident slumped more to the left as the day moved on. The Resident wore a sling on her right arm. The Resident sat this way for hours at a time. On 9/9/11 at 1:35 p.m., Staff E was notified the care directives were not being followed. Without the directives being consistently followed the Resident would be more at risk for skin breakdown and lack of comfort. After the facility notification on 9/9/11, the Resident's care directives were revised to include repositioning every two hours in the recliner chair and to lay the Resident down between 11 a.m. and 12 noon and transfer back to the recliner by 3 p.m. .

Based on interview and record review the facility failed to provide services to address pain management for 1 of 1 Sampled Residents (#1) using [MEDICATION NAME] pain pump. This failure constituted harm due to the resident suffering from unrelieved pain overnight. Findings include: Record review revealed Resident #1 was diagnosed with [REDACTED]. Interview with Resident #1 revealed his pain pump became disconnected the night of 11/18/10 around 10:30 at night. The resident reported the pain was excruciating and it took the facility more than 8 hours to get the pump working again. The resident said he was scheduled for an appointment with his physician the next day but he was unable to attend it because he was so exhausted from being awake due to pain all night. The appointment was rescheduled for a week later. Record review of Daily Skilled Nurses Notes dated 11/18/10 revealed the facility spoke with the physician at 6:00 a.m. although Resident #1 was off the [MEDICATION NAME] pain pump since 11:00 p.m. The resident complained of pain at a level of 10 out of 10 (10 is the most severe pain, 0 is no pain). The same progress note indicated the resident experienced pain relief at 9:00 a.m. Review of progress notes and physician orders [REDACTED]. No call to pharmacy regarding the equipment not functioning correctly. Interview with Staff A on 12/3/10 at 4:15 p.m. revealed the nurse on duty assumed the pain pump was an [MEDICATION NAME] pump the nurse was not allowed to access. Staff A stated the facility policy was to send residents with [MEDICATION NAME] pumps to the hospital when complications arise. However, the resident's [MEDICATION NAME] pump used a Huber Needle which could be replaced by the facility RN's. Staff A reported the nurse on duty did not know to replace the needle so the pump could be used. There was no evidence of any attempt to send the resident to the hospital for assessment of the [MEDICATION NAME] pump. There was no documentation of any attempt to change the Huber Needle prior to the transferring care to the day shift. The facility investigation dated 11/19/10 indicated the night shift nurse contacted the physician and received orders for an oral pain medication and instructions to contact another named physician in the morning. There was no documentation of notifying the physician or a TO (telephone order) indicating the physician instructions. The order for the oral pain medication was acquired on 11/17/10, the day before the pain pump was disconnected. A follow-up call with the physician revealed he was not able to recall providing the order. The same investigation summary indicated the resident's pain decreased to a level "2" after receipt of medication. However, review of pain management flowsheet entry dated 11/19/10 at 3:50 a.m. indicated decreased pain; no number was entered to indicate the severity of the resident's pain. A "2" was entered as a non-verbal intervention indicating the resident was repositioned; however the resident was independent with repositioning. The order indicated the resident could receive the medication every two hours. The resident only received the medication once. The Daily Skilled Nurses Notes entry dated 11/19/10 at 9:00 a.m. the Resident #1 refused to go to his physician appointment due to the resident being tired and in pain. The investigation also revealed the dayshift nurse contacted the physician at 6:00 a.m. on 11/19/10 and received an order to replace the needle which was available in the facility. The pain pump was functioning by 6:30 a.m. after replacing the needle. Staff A mentioned during interview on 12/03/10 at 4:15 p.m. that all RNs were trained on the Huber Needle replacement. However; the chart contained no documentation of any attempt to change the Huber Needle. The facility provided in-service records for training nurse on the CADD (continuous ambulatory delivery device) pump and the Baxter (name brand) IV (intravenous) pump in 2007. There was no evidence of the staff being trained on the use of the Huber Needle only the pumps. Resident #1's experienced severe pain requiring an [MEDICATION NAME] pain pump to lessen the severity of the pain. The pain pump became disconnected on the evening of 11/18/10, leaving the resident without adequate pain relief all night. The resident missed a physician appointment due to exhaustion form being awake all night from pain.