Every finding on record at Benson Heights Rehabilitation Center

Based on observation, interview and record review, the facility failed to provide appropriate treatment, services and interventions to prevent an avoidable reduction of Range of Motion (ROM) for 1 of 5 sampled residents (Resident 4) reviewed for limited ROM. Resident 4 experienced harm as evidenced by after discharge from specialized rehab services the resident was able to open/close their right hand and perform Active ROM (AROM) and now Resident 4's right hand developed a contracture due not implementing therapy gloves, staff not consistently assisting resident with AROM as assessed and care planned. Resident 4 was also at risk for decreased ROM/worsening of left-hand contracture due to staff not implementing rehab training gloves, consistently applying splint, and consistently assisting the resident with Passive ROM (PROM). The failure to not provide appropriate services/interventions for ROM placed other residents at risk of developing new contractures and/or worsening of existing contractures.Findings included. <Facility Policy>Review of the facility policy titled, Restorative Nursing Programs (RNP), dated 11/2017, documented the facility would provide services, care, and equipment to assure residents maintained and/or improved their ROM. The policy showed RNP's would be developed and/or formulized by a supervising nurse and be included in the patients Care Plan (CP), The policy showed the RNP could include splint or brace assistance, and passive and/or active ROM.<Resident 4>According to a 02/23/2026 Quarterly Minimum Data Set (MDS- an assessment tool) assessment, Resident 4 readmitted to the facility on [DATE]. The MDS showed Resident 4 had no memory impairment. The MDS showed Resident 4 was able to make themselves understood and understood others. The MDS showed Resident 4 had a PROM and an AROM RNP. The MDS showed no splint or brace assistance was provided to Resident 4 during the assessment period. The MDS showed Resident 4 had diagnoses of paralysis of left side of the body and paralysis of the lower half of the body both legs, and a neurological disorder that affected movement, balance, and posture.Review of an active at risk for pain CP initiated on 08/26/2024 showed an intervention for staff to perform both upper and lower ROM/stretching for Resident 4.Review of a 05/03/2025 left upper extremity splint CP showed Resident 4 was to wear a splint to their left hand at all times. Resident 4's CP did not include a brace/splint to their right-hand contracture.Review of Resident 4's 07/22/2025 functional maintenance plan/RNP showed that staff were instructed to provide PROM to left hand, arm, shoulder, and AROM to right hand, arm and shoulder daily.Review of Resident 4's 07/31/2025 Activities of Daily Living (ADL) CP showed an intervention for a functional maintenance program that instructed staff to provide PROM of left hand, arm, shoulder, and AROM to right hand, arm, and shoulder.Review of Resident 4's behaviors related to loss of ADLs CP showed Resident 4 appreciated staff to do ROM/stretching exercises to alleviate their distress.Review of Resident 4's limited physical mobility CP showed a 02/27/2026 intervention for staff to provide AROM of right hand, arm, shoulder, and PROM of left hand, arm, and shoulder.In an observation and interview on 04/29/2026 at 1:52 PM Resident 4 stated they were concerned about their hands being stuck closed. Observation showed Resident 4's bilateral hands were contracted closed, and Resident 4 was unable to open either hand. Resident 4 stated staff did not assist them with ROM services. Resident 4 stated the guy from therapy instructed staff on how to use rehab training gloves for both hands but staff did not provide the treatment since instruction. A box with rehab trainings gloves with the gloves in it was on Resident 4's nightstand. Resident 4 stated the gloves had sat on their nightstand since last year when therapy placed them there, but staff had not assisted them with using the gloves. Resident 4 stated they really wanted to use the rehab training gloves to keep their ROM to both hands and had expressed this to many unidentified staff but still did not receive the rehab training gloves treatment.Observations and interviews on 04/30/2026 at 10:17 AM, 05/01/2026 at 8:14 AM, and 05/04/2026 at 10:55 AM showed Resident 4 with bilaterally contracted hands and no splint. Resident 4 stated staff did not offer or provide rehab training gloves, splint, or any ROM services on any of these days.In an observation and interview on 05/04/2026 at 12:04 PM Resident 4 was up in their wheelchair in the day room with both hands contracted and resting in lap without a splint on either contracted hand. Staff O (Certified Nursing Assistant - CNA) stated Resident 4 was supposed to have a splint to their left hand per CNA tasks. Staff O searched Resident 4's room and stated they did not have a splint in their room, but a palm protector was in their drawer. Staff O stated they should have applied a splint to Resident 4's left hand in the AM to wear during the day, but they did not. Staff O stated they were also supposed to sometimes assist with ROM to resident 4's hands. Staff O stated the splint and ROM treatments were important to prevent decreased ROM.Observation and interview on 05/05/2026 at 9:27 AM showed Resident 4 wearing a splint to their left-hand contracture but no splint to their right hand. Resident 4 stated staff still did not offer or provide the rehab training gloves.Interview on 05/05/2026 at 9:38 AM Staff F (Unit Manager) stated they expected staff to ensure Resident 4 always wore the splint to their left hand per CP and offer and provide ROM services to both hands daily. Staff F stated it was important to provide splint and ROM treatments to prevent decrease in ROM. Staff F reviewed Resident 4's ADL self-care deficit CP and stated staff were expected to offer and provide PROM to Resident 4's left hand, arm, shoulder, and AROM to their right hand, arm, and shoulder. Staff F stated they were notified last year sometime about Resident 4's rehab training gloves and was instructed by Staff K (Therapy Coordinator) that Resident 4 needed to use them daily for a certain number of minutes. Staff F stated Staff K had instructed the CNAs that worked with Resident 4 routinely on how to use them and about the addition of the rehab training gloves to Resident 4's RNP. Staff F stated they forgot to add the rehab training gloves to Resident 4's CP or physician orders but should have. Staff F stated it was important to add the rehab training gloves to Resident 4's CP so staff would offer and provide the rehab training gloves per therapy recommendations. Staff F stated the rehab training gloves were important to assist in prevention of decreased ROM.In an interview on 05/05/2026 at 9:49 AM Staff K stated when Resident 4 discharged from specialized rehab services they instructed staff how to use the rehab training gloves and to provide them to Resident 4 daily. Staff K stated they wrote a Functional Maintenance Program/RNP which included the rehab training gloves to be offered and provided daily. Staff K stated the gloves were an important part of Resident 4's ROM services to prevent a decrease in ROM to both of their hands.In record review and interview on 05/05/2026 at 11:03 AM staff K provided a copy of the Occupational Therapy (OT) discharge plan created by Staff P (OT) on 11/17/2025 which showed Resident 4 was able to tolerate the rehab training gloves to both hands to perform table top tasks for 20 minutes and all Resident 4's caregivers were trained on and to continue the rehab training gloves twice daily for 20 minutes and that a Functional Maintenance Plan/RNP was not indicated for Resident 4 at that time. Staff K assessed Resident 4's contractures and stated they were worse than when Resident 4 discharged from therapy to the RNP. Staff K asked Resident 4 to open their right hand and Resident 4 attempted but was unable to move their right hand at all. Staff K stated Resident 4 was able to fully open and close right hand on their own when they discharged from specialized rehab services and transitioned to the RNP but now was unable. Staff K attempted to perform PROM to both hands and stated they would get a splint for Resident 4's right hand, apply warm packs for ROM, and would get Resident 4 back on specialized rehab services.Review of a 05/05/2026 revision to Resident 4's CP showed staff would apply a splint to Resident 4's right hand.Observation and interview on 05/06/2026 at 8:13 AM showed Resident 4 in bed without a splint to either hand. Resident 4 stated staff still did not offer or provide the rehab training gloves and only put the splints to both hands on 05/05/2026.In an interview on 05/06/2026 at 8:28 AM Staff N (CNA) stated they worked with Resident 4 yesterday but did not do PROM or AROM with the resident because they were wearing splints to both of their hands. Staff N stated they had signed the CNA task to perform ROM services to bilateral hands as if they had assisted Resident 4 with the treatments because they thought the splints did that since they stretched the residents' hands out and did not understand what it meant to offer/provide PROM/AROM treatments. Staff N stated they remembered being trained last year on the rehab training gloves by Staff K but had not seen them listed on Resident 4's CNA tasks to provide since the training occurred. Staff N stated Resident 4 could not perform AROM to their right hand because Resident 4 was now unable to move either hand on their own. Staff N stated it was important to provide splints and ROM treatments to prevent decreased ROM.In an interview on 05/06/2026 at 9:15 AM with Staff A (Administrator) and Staff B (Director of Nursing) stated they expected staff to follow CPs, offer and provide ROM treatments, and apply splints for contractures. Staff B stated they expected staff to add the rehab training gloves to Resident 4's Functional Maintenance Program/RNP, obtain a physician order and add the gloves to Resident 4's CP but they did not. Staff B stated it was important to prevent decreased ROM.Reference WAC 388-97-1060 (3)(d).

Based on interview and record review, the facility failed to ensure Staff H (Dining Services Manager) met the minimum qualifications to serve as the director of food and nutrition services when the facility had no qualified dietitian or other clinically qualified nutrition professional employed full-time. This failure placed residents at risk for unmet nutritional needs and for receiving unsafe dietary services from staff without the required competencies and skills to carry out food and nutrition services management.Findings included. <Facility Policy>According to the facility's Food and Nutrition Services Qualified Dietary Staff policy, dated July 2018, if a dietician or qualified nutrition professional was not employed full-time, the facility would designate a director of food and nutrition services who was a Certified Dietary Manager (CDM), or a certified food service manager, or have similar national certification of food service management and safety, or had an associates or higher degree in food service management or hospitality. In an interview on 04/29/2026 at 8:27 AM, Staff H stated they had served as the facility's dietary manager since September 2025.Review of a staff list provided on 05/01/2026 showed the facility hired Staff H on 08/21/2025.In an interview on 05/04/2026 at 8:38 AM, Staff H stated they were working to complete an on-line course to obtain their CDM credential and were hoping to complete it in June 2026 or July 2026. Staff H stated they started the course in March 2026 and had until the beginning of 2027 to complete it. Staff H stated the facility had a Registered Dietician (RD) that came to the facility once a month to see residents and held weekly meetings with Staff H and the nursing unit managers to discuss resident-specific nutritional concerns.In an interview on 05/05/2026 at 2:45 PM, Staff I (RD) stated they routinely came to the facility once a month to see residents and to do a walk-through in the kitchen, and they had weekly virtual meetings with unit managers. Staff I stated they were not aware that Staff H did not meet the minimum qualifications to serve as the dietary manager.Review of a 01/08/2026 e-mail correspondence showed Staff H enrolled in a Dietary Manager Training course that started on 01/14/2026 and was scheduled to end on 01/14/2027.In an interview on 05/05/2026 at 1:24 PM, Staff A (Administrator) reviewed Staff H's employee file and stated Staff H was taking a course to obtain their CDM, and they currently did not meet the federal criteria to work as the dietary manager. Staff A stated Staff H had over two years of experience working as a dietary manager at an assisted living facility but did not meet the federal requirement to complete a course of study in food safety and management by no later than 10/01/2023. Staff A stated that they thought dietary managers had a certain amount of time allowed to work on obtaining a CDM, but they were mistaken. No documentation was provided regarding Staff H's qualifications to serve as a dietary manager.Refer to F803- Menus Meet Resident Needs/Prep in Advance/Followed.Refer to F812- Food Procurement, Store/Prepare/Serve - Sanitary.Reference WAC 388-97-1160 (1)(2)(3)(a)(b)(i)(ii).

Based on observation, interview and record review, the facility failed to ensure the menu was followed for 1 of 1 sample residents (Resident 15) reviewed for food concerns, and failed to implement a system to ensure residents were provided with the correct food portion sizes according to their assessed nutritional needs for 1 of 1 kitchen tray line observations. These failures placed residents at risk for unmet nutritional needs and a diminished quality of life.Findings included. <Facility Policy>According to the July 2018 facility's Food and Nutrition Services Menus and Therapeutic Diets policy, the facility would have and follow menus that met the nutritional and personal needs of the residents. <Menu Items><Resident 15>According to the 02/24/2026 annual Minimum Data Set (MDS - an assessment tool), Resident 15 was usually able to understand and to be understood, had no natural teeth, and was on a mechanically altered diet.In an interview on 04/29/2026 at 1:25 PM, Resident 15 stated they were on a pureed (blended, whipped, or mashed into a smooth consistency, requiring no chewing) diet because they did not have any teeth. Resident 15 stated they were served mashed potatoes for every lunch and dinner, they were tired of it, and they felt it was too much starch for their nutritional needs.In an interview on 05/04/2026 at 8:54 AM, Staff H (Dining Services Manager) stated residents on a pureed diet received the same menu items as other residents. If the menu item was pasta, residents on a pureed diet would receive pureed pasta.Review of a Spring/Summer 2026 - Week 4 menu showed the lunch menu for 05/04/2026, included chicken alfredo with noodles and cauliflower.In an observation of the kitchen tray line on 05/04/2026 at 11:34 AM, Staff J (Cook) prepared a lunch plate for Resident 15 that included mashed potatoes with sauce, pureed chicken, and pureed cauliflower. Similar findings were observed with lunch plates for other residents on pureed diets. Residents with regular texture diets received noodles and chicken with sauce and cauliflower.In an interview on 05/04/2026 at 12:53 PM, Staff J stated they served mashed potatoes for lunch for residents on pureed diets. Staff J stated they were able to puree noodles as indicated on the menu, but they did not.In an interview on 05/05/2026 at 2:45 PM, Staff I (Registered Dietician - Regional) stated residents on a pureed diet should receive the same menu items as other residents. Staff I stated they were concerned that residents' nutritional requirements may not be met if staff did not follow the menu.<Kitchen Tray Line Observation>In an interview on 05/04/2026 at 8:54 AM, Staff H stated they received their menus through a food supplier, and a corporate Registered Dietician adjusted the menus to meet the needs of the facility. Staff H stated they did not have access to a break-out menu (a spreadsheet showing portion sizes for each menu item according to the various prescribed diets), and staff used each resident's tray card to determine the portion size to serve them. Staff H stated they reviewed the correct portion-size scoops to use with staff before serving each meal.Review of a Spring/Summer 2026 - Week 4 menu showed the lunch menu and portion sizes for 05/04/2026, included two #8 scoops of chicken alfredo with noodles and 1/2 cup cauliflower. The menu did not break down the portion size for chicken, noodles, or alfredo sauce.Review of an undated Portion Control Scoops Color Guide included the following scoops:#8 Gray, 1/2 cup#12 Green, 1/3 cup#16 Blue, 1/4 cup#20 Yellow, 1/5 cup#30 Black, 2 tbsp.Observations on 05/04/2026 from 11:17 AM to 11:31 AM showed Staff J prepared to begin lunch service. Staff J chose colored scoops from a bin and placed a scoop in each food container on the tray line. At that time, Staff H was in their office and was not observed participating in scoop selection.Observation on 05/04/2026 at 11:34 AM showed Staff J prepared Resident 15's lunch plate. The tray card showed no portion size for the entree, and 1/2 cup of cauliflower. Staff J used a green scoop (1/3 cup) for mashed potatoes, a yellow scoop (1/5 cup) for pureed chicken, and a yellow scoop (1/5 cup) for pureed cauliflower. Staff J stated they used yellow scoops for the pureed foods at every meal.Observation on 05/04/2026 at 11:57 AM showed Staff J prepared a lunch plate for a resident whose tray card indicated a minced and moist diet (consists of soft, finely minced, or ground foods that are moist and easy to swallow). Staff J used a green scoop (1/3 cup) for mashed potatoes, a yellow scoop (1/5 cup) for minced chicken, and a blue scoop (1/4 cup) for minced cauliflower.Observations on 05/04/2026 from 11:35 AM to 12:51 PM showed Staff J prepared lunch plates for residents on regular texture diets using a large black scoop (not listed on the scoop color guide) for noodles, a green scoop (1/3 cup) for chicken, a blue scoop (1/4) cup for sauce, and a gray scoop (1/2 cup) for cauliflower. Staff J frequently used heaping scoops and/or added extra partial scoops of food to the plates. For residents whose tray card indicated large portions or double portions, Staff J used two scoops of each item and frequently added extra amounts.In an interview on 05/04/2026 at 12:53 PM, Staff J was asked how they determined which scoops to use for each food item. Staff J stated they used the scoops they usually used and sometimes added a little more food on the plates.In an interview on 05/04/2026 at 12:55 PM, Staff H stated that residents on altered texture diets should get the same size portions as residents on regular texture diets. Staff H stated it was a problem that the menu did not break down the portion sizes for the chicken, noodles, and alfredo sauce.In an interview on 05/05/2026 at 2:45 PM, Staff I stated Staff H should have access to a more detailed break-out menu through their computer application that showed portion sizes for each food item according to each diet type. Staff I stated staff should use the appropriate scoop sizes according to the break-out menu. Staff I stated residents on pureed diet should receive the same portion sizes as residents on regular diets.REFERENCE: WAC 388-97-1100 (1).

Based on observation, interview, and record review, the facility failed to ensure food was stored and prepared under sanitary conditions for 1 of 1 kitchens and 1 of 1 unit refrigerators designated for resident use. The failure to ensure food was not expired, ensure proper food labeling, and ensure staff performed hand hygiene during food preparation placed residents at risk for foodborne illness and the spread of infection.Findings included. <Facility Policy>According to the facility's July 2018 Food and Nutrition Services Food Safety policy, food items would be stored, prepared, distributed and served in accordance with professional standards for food service safety. Food in the refrigerator would be labeled and dated. Staff would practice good hygienic practices and techniques. <Food Storage><Kitchen>Observation with Staff H (Dining Services Manager) on 04/29/2026 at 8:27 AM showed the following items found in kitchen storage areas and kitchen refrigerators:Large plastic bag of sliced pepperoni with a handwritten date of 09/02/2025, eight months prior, and no other labeling.Three crates of eggs with no labeling, no expiration date.In an interview on 04/29/2026 at 8:27 AM, Staff H stated they pulled the pepperoni from the freezer the previous night. Staff H stated they should label the bag to show when it was refrigerated, but did not.In an interview on 05/04/2026 at 8:51 AM, Staff H stated they got the eggs from their food supplier about two weeks ago. Staff H stated the egg crates came from the supplier in a labeled box and staff took them out of the box.Observation on 05/04/2026 at 8:52 AM showed a kitchen refrigerator contained 3 undated containers of individually wrapped sandwiches.In an interview on 05/04/2026 at 8:56 AM, Staff T (Dietary Aide) stated they were busy with the tray line and forgot to date the sandwiches. STaff T stated they should date the sandwiches.<Unit Refrigerator>Observation with Staff S (Behavioral Tech) on 05/04/2026 at 2:31 PM showed a unit refrigerator located outdoors on the resident's porch that contained the following:A plastic bag containing grapes, expiration date 04/15/2026.A plastic bag containing grapes, expiration date 04/24/2026.A plastic bag containing sliced meat with no open date or expiration date.A plastic container of sliced roast beef, expiration date 05/02/2026.In an interview on 05/04/2026 at 2:31 PM, Staff S stated the listed food items were expired or unlabeled and should have been discarded, but were not.In an interview on 05/05/2026 at 2:45 AM, Staff I (Registered Dietician - Regional) stated they had concerns about food storage practices at the facility. Staff I stated it was not acceptable to still store pepperoni dated 09/02/2025, eggs should have labeling to show where they came from and an expiration date, each sandwich should be labeled with a use by date, and food storage areas should be checked regularly for expired foods, but they did not.<Hand Hygiene (HH)>Observation on 05/04/2026 at 9:27 AM showed Staff J (Cook) used gloved hands to separate thawed chicken filets and place them on a baking tray. Staff J used a brush to apply sauce to the chicken filets. With the same gloved hands, Staff J opened the oven door, placed the tray in the oven, and adjusted the oven temperature dial. Staff J removed their gloves and did not perform HH. Staff J used a cloth to wipe off the countertops, opened the outside door and brought a garbage bag outside. Staff J returned to the kitchen, rinsed their hands for less than five seconds without using soap, and turned off the faucets without using a barrier. With bare hands, Staff J used a pitcher to add sauce to a pot of boiling water on the stove, added pasta from a bag to the pot, and used a ladle to stir the pot.Observations on 05/04/2026 at 9:43 AM, 05/04/2026 at 9:47 AM, 05/04/2026 at 9:51 AM, and 05/04/2026 at 11:21 AM showed Staff J went outside of the kitchen, came back to the kitchen, washed their hands for less than five seconds without using soap, turned off the faucets without using a barrier, and resumed food preparation activities. Observation on 05/04/2026 at 11:23 AM showed Staff V (Dietary Aide) washed their hands with soap and water, then turned off the faucets without using a barrier. Staff V then assisted Staff J to prepare trays for meal service.In an interview on 05/04/2026 at 1:06 PM, Staff H stated they expected kitchen staff to perform HH every time they changed gloves, touched something dirty, went outside the kitchen, smoked, or used the bathroom. Staff H stated HH included using warm water and soap, washing for 20 seconds, rinsing, drying with a paper towel, then using a paper towel to turn off faucets.In an interview on 05/05/2026 at 2:45 PM, Staff I stated staff should perform HH every time they put gloves on, and every time they are touching something different to prevent cross-contamination. HH included washing hands with soap and warm water, scrubbing for 20 seconds including between fingers, rinsing, drying hands with a paper towel and using a paper towel to turn off faucets.Reference WAC 388-97-1100(3).

Based on observation, interview, and record review, the facility failed to provide respiratory care and services consistent with professional standards and deliver oxygen therapy according to physician orders (POs) for 1 of 2 residents (Resident 2) and 1 supplemental resident (Resident 60) reviewed for respiratory care. These failures placed residents at risk for potential negative outcomes such as under oxygenation, respiratory discomfort, and a decreased quality of life.Findings included . <Facility Policy> According to the facility's July 2018 Respiratory Care/Tracheostomy Care & Suctioning policy, the facility would ensure respiratory care and services were provided in accordance with professional standards of practice, resident Care Plans (CPs), and resident goals. Staff would assess and monitor resident respiratory status, including signs of shortness of breath and respiratory distress (unusual breathing patterns) and notify the physician of changes in condition. <Resident 2> According to the 03/20/2026 Significant Change Minimum Data Set (MDS - an assessment tool), Resident 2 had multiple diagnoses including kidney failure, depression, and dysphonia (voice disorder/impairment). This MDS showed Resident 2 had memory impairment and required no oxygen during the assessment period. Review of a 04/02/2026 PO showed an order directing staff to administer oxygen at one-to-four Liters Per Minute (LPM) via nasal cannula (NC - tubing with two short prongs placed in nostrils to deliver oxygen therapy) continuously to maintain oxygen saturation (a measurement of oxygen levels in the blood) more than 90% every shift for shortness of breath. Review of the 05/01/2026 Breathing difficulty related to intermittent dyspnea Care Plan (CP) showed instructions to the nursing staff to administer oxygen to Resident 2 via NC per PO. Observations on 04/30/2025 at 1:36 PM showed Resident 2 was lying in their bed and the NC was not in their nose. The oxygen concentrator (a device used to increase the concentration of oxygen inhaled) was turned on and set at two LPM. Observation and interview on 04/30/2026 at 1:54 PM showed Resident 2 lying in their bed and oxygen via NC was not in their nose. Resident 2 stated they were feeling short of breath and having hard time breathing. Observation on 04/30/2026 at 1:56 PM showed Resident 2's call light was turned on, and Staff U (Certified Nurse Assistant-CNA) came to the room to answer the call light. Staff U assessed Resident 2's oxygen saturation was 86%. Staff U raised Resident 2's head of bed up and oxygen saturation went up to 87-88%. Staff U noticed Resident 2's NC was not placed in their nostrils. Staff U then placed NC in Resident 2's nostrils. In an interview on 04/30/2026 at 2:00 PM, Staff X (Registered Nurse) stated staff assisted Resident 2 with feeding at lunch time and Resident 2 might have removed the NC from their nostrils. Staff X stated staff should check Resident 2 to make sure the NC was in their nostrils. In an interview on 05/06/2026 at 10:30 AM, Staff B (Director of Nursing) stated they expected nursing staff to follow the POs and check at least hourly to make sure resident's oxygen was on and in their nose, but they did not. <Resident 60> According to the 03/17/2026 Quarterly MDS, Resident 60 had diagnoses of medically complex conditions including respiratory problems, memory impairment, and altered level of consciousness with behavior fluctuations. Resident 60 required oxygen therapy. Review of a 04/29/2026 end stage respiratory disease CP showed staff were instructed to keep Resident 60's oxygen settings at two-to-four LPM via NC to keep oxygen saturation greater than 90%. Staff were instructed to monitor Resident 60 and report to the physician signs and symptoms of shortness of breath, increased breathing, accessory muscle use (neck and chest muscles) and decreased oxygen saturation. Observation and interview on 05/01/2026 at 9:11 AM showed Resident 60 self-propelled in their wheelchair from their room to the hallway, and approached this surveyor calling, Help! Help! Resident 60 was using their accessory muscles with forceful rise and fall of the chest to breathe. Resident 60 stated they were having shortness of breath. A portable oxygen tank hung on the back of Resident 60's wheelchair had no oxygen tubing connected. Staff M (Licensed Practical Nurse) assessed Resident 60's oxygen saturation and showed their oxygen saturation was 53%. Staff M left, and then brought a NC, connected it to the oxygen tank, and placed the NC in Resident 60's nostrils. Staff M reassessed Resident 60 and their oxygen saturation showed 53%. Staff F (Unit Manager) walked by and Resident 60 called out, Help! Help!. Staff F stated that Resident 60 was always low in oxygen saturation, was on hospice and had COPD. Staff F continued walking away from Resident 60. This surveyor stated to Staff F that Resident 60 oxygen saturation was 53% on oxygen, and they were still using their accessory muscles. Staff F then turned and walked toward Resident 60 and stated, How can I help you? Staff F and Staff M assisted Resident 60 back to their room and provided a respiratory treatment. Staff F reported to Staff M that Resident 60's oxygen saturation was 87%, and Resident 60 was back in the hallway. Observation showed Resident 60 sat in the hallway without the NC in their nostrils. Staff M reassessed Resident 60's oxygen saturation and showed it was 87%. Review of a PO summary on 05/01/2026 showed a 04/29/2026 order directing staff to maintain Resident 60's oxygen saturation above 90% by administering oxygen at two-to-four LPM via NC while sleeping and as needed, and Resident 60 may decline use. Review of Resident 60's documented vital signs showed the following: 04/04/2026 oxygen saturation 65% on room air (RA- without supplemental oxygen) 04/05/2026 oxygen saturation at 69% on RA, 04/11/2026 oxygen saturation at 55% on oxygen via mask, 04/15/2026 oxygen saturation at 66% on RA, 04/19/2026 oxygen saturation at 47% on oxygen via Mask, 04/28/2026 oxygen saturation at 77% on oxygen via NC, 04/29/2026 oxygen saturation at 88% on oxygen via NC, 04/30/2026 oxygen saturation at 79% on oxygen via NC. Review of Resident 60's April 2026 Medication Administration Record showed staff did not document the LPM of the oxygen administered to Resident 60 when oxygen was given, per PO. Review of Resident 60's progress notes from 04/01/2026 through 04/30/2026 showed staff did not document notification to the physician when Resident 60's oxygen fell below parameters, per PO. In an interview on 05/01/2026 at 11:25 AM with Staff A and Staff B, Staff B stated they expected staff to offer oxygen and care to Resident 60 according to the PO, and expected staff to document the LPM of oxygen administered. Staff B stated they expected staff to notify the physician when Resident 60's oxygen saturation fell below parameters as ordered. Reference WAC 388-97-1060 (3)(j)(vi)

Based on interview and record review, the facility failed to provide a copy of a written discharge or transfer notice to the Office of the State Long-Term Care Ombudsman (LTCO - resident advocates) for 1 of 3 residents (Resident 89) reviewed for closed records and 2 of 2 supplemental residents (Residents 24 & 95) reviewed for discharge notifications. Failure to notify the LTCO of all resident discharges placed residents at risk of a lack of advocacy in the event of an inappropriate discharge.Findings included. <Facility Policy>According to the facility's Admission, Transfer and Discharge - Transfer and Discharge Process policy, dated 04/28/2025, the facility would provide written notification to a resident and their representative before a transfer or discharge. Notifications to the LTCO would occur before or as close as possible to the actual time of transfer or discharge. The medical record would contain evidence of the notification sent to the LTCO. <Resident 89>Review of a Social Services Note, dated 03/02/2026, showed Resident 89 and their family member requested that Resident 89 be discharged home.Review of an IDT (Inter-Disciplinary Team) Discharge Planning and Summary, dated 03/02/2026, showed the facility discharged Resident 89 to their home in a family-directed discharge on [DATE]Review of Resident 89's Electronic Health Record (EHR) showed no evidence that a copy of a written discharge notice was provided to the LTCO.In an interview on 05/06/2026 at 8:17 AM, Staff D (Social Service Director) stated they did not notify the LTCO of Resident 89's discharge because Resident 89 and their family initiated the discharge. Staff D stated that they sent a list to the LTCO every month of residents who had facility-initiated discharges or transfers but did not inform the LTCO of residents who had resident-initiated discharges.<Resident 24>Review of an IDT Discharge Planning and Summary, dated 04/23/2026, showed the facility discharged Resident 24 to an adult family home in the community in a resident-driven discharge.Review of Resident 24's Electronic Health Record (EHR) showed no evidence that a copy of a written discharge notice was provided to the LTCO.<Resident 95>Review of a progress note, dated 03/06/2026, showed the facility discharged Resident 95 to an adult family home in the community.Review of Resident 95's EHR showed no evidence that a copy of a written discharge notice was provided to the LTCO.In an interview on 05/06/2026 at 9:24 AM, Staff D stated they did not notify the LTCO of Resident 24's or 95's discharges.Reference: WAC 388-97-0120 (2)(5).

Based on observation and interview, the facility failed to ensure residents were provided with a homelike environment for resident areas in 2 of 3 units (North & Middle hallways) and the main dining room. These failures put residents at risk for skin injuries and a less-than-homelike environment. Findings included . <Facility Policy>The facility's 07/2018 Safe, Clean, and Comfortable Environment Policy showed residents would be provided a safe, clean, comfortable, and homelike environment. The policy showed the facility environment should be clean and sanitary. <Resident Areas>Observation on 04/29/2026 at 9:33 AM showed room [ROOM NUMBER]'s door panel/kick plate was broken with sharp edges, putting residents at risk for skin injuries. Observation showed room [ROOM NUMBER]'s door frame had dents and areas of paint were scratched off. Observation on 04/29/2026 at 10:55 AM showed room [ROOM NUMBER]'s door panel/kick plate was broken and the door frame had dents.Observation on 04/29/2026 at 11:05 AM showed room [ROOM NUMBER]'s door panel/kick plate was broken and the door frame had dents and paint chipped off. Observation on 04/29/2026 at 11:27 AM showed the North hallway wall base board was broken.Observation on 04/29/2026 at 11:42 AM showed room [ROOM NUMBER]-Bed 2 had a broken overhead bed light cover. The resident in room [ROOM NUMBER]-Bed 2 stated their overhead bed light cover had been broken for a while.Observation on 04/30/2026 at 8:47 AM showed residents in room [ROOM NUMBER] - Bed 1 and Bed 2 both had televisions (TVs) and were watching the same TV program. Both residents stated they could not watch the programs they each wanted to because both TVs played the same channels.In an observation and interview on 05/06/2026 at 9:23 AM, Staff R (Maintenance Director) confirmed the door panels/kick plates and door frames for rooms [ROOM NUMBER] and the baseboard in the North hallway were damaged and should be repaired. Staff R confirmed the overhead bed light cover in room [ROOM NUMBER] - Bed 2 was broken and should be fixed, and stated floor staff should have notified them of the broken light cover but did not. Staff R stated they should change room [ROOM NUMBER] - Bed 2's TV because both residents in room [ROOM NUMBER] had the same brand of TV, causing them to play the same programs at the same time.<Main Dining Room>Observation and interview on 05/06/2026 at 9:52 AM showed the main dining room in the South hallway by the kitchen had multiple floor tiles broken. Staff R confirmed the broken floor tiles and stated they needed to be fixed.In an interview on 05/06/2026 at 10:15 AM, Staff A (Administrator) stated their expectation was for residents to have a home-like environment. Staff A stated the door panels/kick plates, door frames, base boards, overhead bed light and floor tiles should be fixed and should be free from risk of injuries. Reference: WAC 388-97-0880.

Based on observation, interview, and record review, the facility failed to provide care in a manner that promoted dignity for 2 of 4 sampled residents (Residents 91 and 8) reviewed for dignity. The facility staff failed to provide Resident 91 with a privacy bag for their catheter, provide privacy while providing feeding tube care and put abdominal binder to protect feeding tube under their shirt for Resident 8. These failures placed residents at risk for feelings of diminished self-worth and embarrassment.Findings included . <Facility Policy> According to the facility's 09/20/2022 Respect and Dignity policy, residents had the right to be treated with respect and dignity. According to the facility's 04/2021 Urinary Catheterization, policy, the facility would provide care and services to support residents in the management of urinary catheters. <Resident 91> According to the 04/21/2026 admission Minimum Data Set (MDS-an assessment tool), Resident 91 admitted to the facility on [DATE] with diagnosis of Cancer and loss of bladder control. Record review of a 04/16/2026 urinary catheter Care Plan (CP) related to bladder cancer and urinary retention showed interventions included monitoring catheter function and providing catheter care every shift and as needed for Resident 91. In an observation on 04/29/2026 at 1:02 PM, Resident 91 was sitting in a wheelchair with the urinary drainage bag uncovered. In an observation on 04/30/2026 at 8:39 AM, Resident 91 was seen in the hallway with the urinary drainage bag exposed, and hanging on the wheelchair. In an observation on 04/30/2026 at 9:46 AM, Resident 91 returned to the facility in a wheelchair with their urinary bag attached to the wheelchair and uncovered. In an observation on 04/30/2026 at 1:55 PM, Resident 91 was sitting in their wheelchair in the hallway with the urinary bag uncovered and urine exposed. In an interview on 05/05/2026 at 10:01 AM, Staff E (Unit Manager) stated urinary drainage bags should be covered as it ensured the dignity of residents. In an interview on 05/06/2026 at 10:37 AM, Staff B (Director of Nursing) stated they expected staff to ensure residents urinary drainage bags were covered to provide resident privacy and dignity. <Resident 8> According to the 03/12/2026 Quarterly MDS, Resident 8 had some cognitive impairment and required extensive assistance from staff to meet their daily needs. The MDS showed Resident 8 required a feeding tube (artificial nutrition through a surgically implanted tube directly into their stomach) to receive their medications and food. Review of the revised 04/21/2025 Nutritional Problem CP showed Resident 8 had pulled at their feeding tube and interventions directed staff to put an abdominal binder on Resident 8 when feeding tube was off during the daytime. In an observation on 04/29/2026 at 1:03 PM Resident 8 was up in their wheelchair with the abdominal binder on top of their shirt. In an observation on 05/04/2026 at 7:57 AM, Resident 8 was lying in their bed and had the abdominal binder on top of their shirt. In an observation and interview on 05/04/2026 at 11:43 AM, Resident 8 was sitting up in their wheelchair with the abdominal binder on top of their shirt. Resident 8 stated they did not know why they had the abdominal binder on top of their shirt. In an observation on 05/04/2026 at 11:47 AM Resident 8 was sitting up in their wheelchair in their room, privacy curtain and door was open, and Resident 8 was visible from the hallway. Staff Q (Registered Nurse) pulled Resident 8's shirt up and administered medication via feeding tube with no privacy. In an interview on 05/04/2026 at 2:20 PM, Staff Q stated they should have pulled the privacy curtain while providing medications via feeding tube to Resident 8, but they did not. When asked Staff Q about Resident 8 wearing abdominal binder on top of their shirt, Staff Q stated that it was to protect the feeding tube. In an interview on 05/06/2026 at 10:03 AM, Staff B stated their expectations from staff were to provide privacy while providing care including feeding tube care. Staff B stated they were aware of Resident 8 pulling at their feeding tube, but the abdominal binder should be under their shirt for dignity issues. Reference: WAC 388-97-0180 (1-4).

Based on observation, interview and record review, the facility failed to ensure physician's orders (PO's) were followed for 2 of 5 residents (Residents 23 and 43) reviewed for unnecessary medications and 2 supplemental residents (Residents 91 and 11). The failure to follow orders for bowel protocols, to check ordered parameters for blood pressure (BP) medications, and to ensure topical medications were only given with a PO by qualified staff placed residents at risk for inappropriate treatment, unmet care needs, and other negative health outcomes.Findings included . <Facility Policy> Review of the undated Bowel Protocol and Bowel Tracking facility policy showed Bowel Movement (BM) frequency would be assessed by the nurse daily. Residents identified as having no bowel movement more than three days would be assessed by the nurse. The nurse would follow the bowel protocol by administering physician ordered stool softeners, laxatives and enemas (fluid administered rectally to treat constipation). <Bowel Protocol> <Resident 23> Review of the 03/10/2026 Annual Minimum Data Set (MDS - an assessment tool) showed Resident 23 had multiple diagnoses including constipation, was incontinent of bowel and dependent on staff for toileting hygiene. Review of a revised 07/29/2024 constipation Care Plan (CP) showed Resident 23 was at risk for constipation and staff were to follow the bowel protocol and keep the physician informed of any problems. Review of Resident 23's PO summary showed the following 04/12/2024 PO's: An oral laxative as needed for constipation, with no frequency indicated A different oral laxative if Resident 23 did not have BM for three days A suppository (medication administered rectally) to be given if no BM for four days An enema if the suppository was ineffective. Review of Resident's 23's April 2026 task documentation showed Resident 23 did not have a BM for five days, from 04/19/2026 through 04/23/2026, then had a BM on 04/24/2026. Review of Resident 23's April 2026 Medication Administration Record (MAR) showed staff did not administered the oral laxatives, suppository, or enema per PO. Review of Resident 23's progress notes showed no documentation that staff offered Resident 23 the bowel protocol medications or that they informed the physician of constipation concerns. <Resident 91> Review of the 04/21/2026 admission MDS showed Resident 91 had multiple diagnoses, including constipation and impaired mobility of a lower extremity, was continent of bowel and dependent on staff for toileting hygiene. Review of a 04/16/2026 constipation CP showed Resident 91 had episodic constipation and staff were to follow the bowel protocol and keep the physician informed of any problems. Review of Resident 91's PO summary showed the following 04/15/2026 PO's: An oral laxative every 24 hours as needed for bowel care if no BM in three days A suppository if no BM for four days and if not relieved by oral laxative An enema to be given as needed for constipation if the suppository was ineffective Review of Resident's 91's April 2026 task documentation showed staff documented Resident 91 did not have a BM for five days, from 04/24/2026 through 04/28/2026, then had a BM on 04/29/2026. Review of Resident 91's April 2026 MAR showed staff did not administer the oral laxatives, suppository or enema per PO. Review of Resident 91's April 2026 progress notes showed no documentation that staff offered Resident 91 the bowel protocol medications or that they informed the physician of constipation concerns. In an interview and record review on 05/06/2026 at 10:37 AM, Staff B stated they expected staff to follow the bowel protocols and inform the physician of any problem relating to constipation. Staff B stated it was important to monitor residents for constipation and provide interventions as ordered to prevent bowel complications. Staff B reviewed Resident 23's and Resident 91's medical records and stated they did not see that any of the bowel protocols or interventions were followed. <BP Medication Parameters> <Resident 43> According to a 04/09/2026 admission MDS, Resident 43 had medically complex conditions including high BP, was usually understood, and sometimes understood others. Review of Resident 43's April 2026 MAR showed a 04/04/2026 PO for a BP medication to be given once daily between 6:00 AM and 10:00AM, and to hold (do not give) the medication for a systolic blood pressure (SBP – the top number in a BP reading) less than 100 or for a heart rate (HR) of less than 60. The MAR showed the medication was administered to Resident 43 daily from 04/04/2026 through 04/30/2026, with no documentation of Resident 43's SBP or HR. Review of Resident 43's April 2026 vital signs records and progress notes showed no documentation of SBP or HR results obtained at the scheduled time of the BP medication administration on the following days: 04/06/2026, 04/07/2026, 04/09/2026 through 04/14/2026, 04/16/2026 through 04/21/2026, and 04/23/2026 through 04/29/2026. In an interview on 05/05/2026 at 11:12 AM, Staff G (Unit Manager) confirmed that Resident 43 had a PO for daily blood pressure medication with parameters to hold the medication based on SBP and HR results. Staff G stated staff should check and document the SBP and HR each time prior to giving the medication to determine whether to hold the medication, but they did not. In an interview on 05/06/2026 at 9:38 AM, Staff B said they expected staff to check residents' SBP and HR before administering medications when there were SBP and HR parameters. <Topical Medications with No PO, Unqualified Staff> <Resident 11> According to a 04/09/2026 annual MDS, Resident 11 had a progressive condition affecting the brain, had no speech, was sometimes understood and usually understood others. Resident 11 was dependent on staff for mobility, transfers, and hygiene, and had no existing skin conditions. Observation on 05/01/2026 at 8:48 AM showed Staff Z (CNA) provided a bed bath for Resident 11. Staff Z brought a basin of supplies to Resident 11's room, including a medicated topical cream and a medicated topical powder. Staff Z applied the cream to Resident 11's buttocks and applied the powder to Resident 11's groin area, chest, and under arms. Observation showed no redness or obvious skin issues in those areas. In an interview on 05/01/2026 at 9:25 AM, Staff Z stated that nurses told CNAs which cream or powder residents needed to prevent redness, and CNAs applied them. Staff Z stated CNAs obtained the needed supplies from the supply room. Review of Weekly Skin Checks completed on 04/24/2026 and 05/01/2026 showed Resident 11's skin was dry, warm, and intact with no skin concerns noted. Review of an 05/01/2026 Order Summary Report and an April 2026 MAR showed Resident 11 had no POs for the medicated topical cream or the medicated topical powder. In an interview on 05/05/2026 at 10:49 AM, Staff M (Licensed Practical Nurse) stated that CNAs were not supposed to apply topical medications. Staff M stated CNA's usually called the nurse to apply them while they cleaned the resident if topical medications were ordered. Staff M stated that staff needed to have a PO to apply topical medications, and they could not just decide what to apply on their own. In an interview on 05/05/2026 at 11:12 AM, Staff G stated that Resident 11 did not have a PO for the medicated cream or the medicated powder and staff should not have applied them. Staff G stated that if a resident needed a medicated topical treatment, a nurse would notify the doctor and obtain a PO. A nurse would then apply them as ordered. In an interview on 05/06/2026 at 9:38 AM, Staff B stated that medicated skin treatments required a PO, and nurses, not CNAs, should apply them. Reference: WAC 388-97-1620 (2)(b)(i)(ii)

Based on observation, interview, and record review, the facility failed to ensure staff used appropriate hand hygiene (HH) during incontinence for 1 supplemental resident (Resident 11) reviewed for incontinence care, and failed to ensure staff used Personal Protective Equipment (PPE) in accordance with Enhanced Barrier Precautions (EBP - infection control measure used to reduce the spread of multidrug-resistant organisms) for 1 of 3 sample residents (Residents 48) reviewed for skin conditions, 1 of 3 sample residents (Resident 71) reviewed for urinary catheters (flexible tube inserted into the bladder to drain urine) and 1 of 1 sample resident (Resident 8) reviewed for tube feeding (surgically implanted tube directly into the stomach to deliver nutrition, fluid and/or medications). These failures placed residents at risk for the development and transmission of communicable diseases and an unsanitary environment.Findings included <Facility Policy> According to the facility's reversed 06/08/2022 Infection Prevention and Control Program (IPCP) policy, staff were expected to followed standard and transmission-based precautions, utilize PPE appropriately, and monitor compliance with infection prevention practices. EBP was indicated for residents with wounds and indwelling medical devices, including urinary catheters and feeding tubes, and required staff to wear a gown and gloves during high-contact resident care. Staff were to perform HH, even if gloves were used, before and after contact with a resident, after contact with body fluids or visibly contaminated surfaces, and after removing PPE. <Hand Hygiene> <Resident 11> According to the 04/09/2026 annual Minimum Data Set (MDS - an assessment tool), Resident 11 had a progressive condition affecting the brain, was dependent on staff for mobility, transfers, and hygiene, and was always incontinent of bladder and bowel. Observation on 04/29/2026 at 12:37 PM showed Staff AA (Certified Nursing Assistant - CNA) provided incontinence care for Resident 11. While wearing gloves, Staff AA unfastened Resident 11's briefs (disposable incontinence product) and used a moistened wipe to clean urine and feces from Resident 11's peri area (genitals and buttocks). Using the same gloves and without performing HH, Staff AA applied a clean brief, adjusted Resident 11's clothing and bedding linens, used the bed controller to adjust the bed position, placed a mat on the floor by the bed, and moved Resident 11's wheelchair by holding onto the wheelchair handles. Staff AA removed their gloves, left the room to take a garbage bag to the soiled utility room, exited the soiled utility room, then performed HH. Observation on 05/01/2026 at 8:48 AM showed Staff Z (CNA) prepared to give Resident 11 a bed bath. Staff Z entered the room and put on gloves without performing HH. Staff Z used a towel, soap, and water to bathe Resident 11's body and their peri area, which was soiled with urine and feces. Without changing gloves or performing HH, Staff Z placed a clean brief under Resident 11, then applied a medicated cream to their buttocks, a medicated powder to their groin and upper body, and moisturizing lotion to arms and legs. Staff Z used a moistened wipe to clean off their gloves. Without changing gloves or performing HH, Staff Z fastened Resident 11's clean brief, dressed them in clothing, used the bed controller to adjust the bed position, and placed a fall mat on the floor. Staff Z removed their gloves and left the room without performing HH. In an interview on 05/01/2026 at 9:25 AM, Staff Z stated they were trained to perform HH before they enter a resident room, when they leave the room, after giving care, and when passing food trays. In an interview on 05/04/2026 at 12:55 PM, Staff C (Infection Preventionist) stated that there was an ongoing issue at the facility with staff not performing HH. Staff C stated staff should perform HH before and after contact with residents and before and after they go into resident rooms. Staff C stated when staff performed incontinence care, they should change gloves and perform HH when moving from a dirty area to a clean area. <EBP> <Resident 71> According to the 04/14/2026 Medicare - 5 Day MDS, Resident 71 readmitted to the facility on [DATE] and had Medically complex conditions including left side of the body weakness, kidney failure, and urinary retention. The MDS showed Resident 71 had an indwelling urinary catheter and required extensive assistance from staff to meet their daily needs. Review of the revised 04/28/2026 Enhanced Barrier Precautions related to indwelling catheter Care Plan (CP) showed directions for staff to use a gown and gloves during high contact resident care activities including dressing, bathing, transferring, changing linens, and changing briefs or assisting with toileting and/or indwelling catheter care. Observation on 04/29/2026 at 9:02 AM showed an EBP sign posted outside Resident 71's door. Observation on 05/04/2026 at 8:54 AM showed a privacy curtain was closed in Resident 71's room. This observation showed Staff Y (CNA) assisted Resident 71 with dressing, including to put their pants on while in their bed. Staff Y wore gloves, but did not wear a gown as directed in the CP. In an interview on 05/04/2026 at 9:00 AM, Staff C stated staff should wear a gown and gloves while providing direct care to Resident 71. Staff C stated staff should follow the directions related to EBP, but they did not. <Resident 8> According to the 03/12/2026 Quarterly MDS, Resident 8 had some cognitive impairment and required extensive assistance from staff to meet their daily needs. The MDS showed Resident 8 required a feeding tube. Review of the 03/31/2025 Enhanced Barrier Precautions related to feeding tube CP showed directions for staff to use a gown and gloves during high contact resident care activities included dressing, bathing, transferring, providing hygiene care, and using and/or providing feeding tube care. Observation on 04/30/2026 at 8:17 AM, showed Resident 8 was lying in bed and their feeding tube was disconnected from the tube feeding pump. Resident 8 had an EBP sign posted outside their door. Observation on 05/04/2026 at 11:47 AM showed Resident 8 sat in a wheelchair in their room while Staff Q (Registered Nurse) administered medication via their feeding tube. Staff Q did not wear gown. In an interview on 05/04/2026 at 12:37 PM, Staff Q stated EBP was indicated for residents at high risk for infection. Staff Q stated they should have worn a gown while providing feeding tube care, but they did not. In an interview on 05/06/2026 at 9:00 AM, Staff C stated staff should follow the care plans to wear PPE related to EBP. Staff C stated staff they expected staff to wear a gown and gloves while providing care to residents with feeding tube. <Resident 48> According to the 04/20/2026 annual MDS, with multiple diagnoses including a skin picking disorder, was dependent on staff to meet their daily needs, and was always incontinent of bladder and frequently incontinent of bowel. Review of a revised 03/31/2025 Enhanced Barrier Precautions related to chronic wounds CP showed Resident 48 was on EBP and caregivers should use a gown and gloves for high contact resident care activities including dressing, bathing, transferring, providing hygiene, changing linens, changing briefs and assisting with toileting, and wound care. Observation on 05/05/2026 at 11:19 AM showed no EBP signage posted at the resident's room door. Observation and interview on 05/05/2026 at 11:36 AM showed Staff L (CNA) completed incontinence care for Resident 48 without wearing a gown. Staff L stated they were not aware Resident 48 was on EBP as there was no EBP signage posted on their door. Staff L acknowledged Resident 48 had wounds and should be on EBP. In an interview on 05/05/2026 at 11:38 AM, Staff E (Unit Manager) stated staff were supposed to wear a gown and gloves when performing incontinence care for Resident 48. Staff E stated it was important for infection prevention and staff protection. In an interview and observation on 05/05/2026 at 11:46 AM, Staff C stated they expected staff to follow proper EBP practices, including wearing a gown and gloves, to prevent the spread of infection. Staff C stated staff had been trained on EBP precautions. Staff C stated EBP signage was to be placed on residents' doors for staff awareness. Staff C confirmed there was no signage on Resident's 48's door. In an interview on 05/06/2026 at 10:37 AM, Staff B (Director of Nursing) stated they expected staff to follow the policy for residents on EBP to ensure residents safety and prevent the spread of infection. Reference WAC 388-97-1320 (1)(2)(b)(5) .

Based on observation, interview, and record review the facility failed to ensure one (Resident 1) of 3 residents reviewed received the necessary care and services in accordance with professional standards of practice and the resident's choice. The facility failed to ensure Resident 1 had pain medications available, new staff was aware of facility protocols when a resident requested hospitalization, and failed to honor Resident 1's request to go to the hospital. These failures placed all residents at risk for unmet care needs and left Resident 1 feeling helpless, anxious, and fearful.Findings included. <Resident 1>Review of the Annual Minimum Data Set (MDS, an assessment tool), dated 05/21/2025, showed Resident 1 was able to make their own decisions, to understand others and to make themselves understood. The MDS showed Resident 1 had medically complex conditions including, post-traumatic stress disorder, inability to use lower body/legs, anxiety, depression, delusional disorder, adult failure to thrive, and chronic pain syndrome. The MDS showed Resident 1had frequent pain that occasionally disrupted their day-to-day activities and used pain medication to manage their pain.Review of a pain assessment dated [DATE] showed Resident 1 was able to verbalize pain, experienced pain in their lower extremities, including their hips and back. The pain assessment showed taking the pain medication made the pain better, the pain was worse when the resident did not have their pain medications available, and the negative effects made Resident 1 aggressive and emotional leading to anxiety when they are not sure when the pain medication would arrive to the facility.Review of pain Care Plan (CP), revised on 06/17/2024, showed Resident 1 had chronic pain and directed staff to administer pain medications as ordered. The CP showed Resident 1 was able to call for assistance when in pain, reposition self, ask for medication, express how much pain was experienced and what increased or alleviated the pain.Review of the June 2025 Medication Administration Record (MAR) showed Resident 1 had a physician's order, dated 12/02/2024 for a pain medication 5 milligrams (mg) two tabs every 4 hours as needed for pain. The MAR showed on 06/24/2025, Resident 1 received pain medications at 5:41 PM. The MAR showed on 06/25/2025, Resident 1 received pain medications at 12:10 AM.In an interview on 07/08/2025 at 3:56 PM, Staff C (Registered Nurse, RN) stated when a resident requested to go to the hospital staff should assess the resident, talk with the nurse, and send the resident to the hospital when indicated. On 07/08/2025 at 4:52 PM, Staff C stated at 9:50 PM, Resident 1 requested pain medications, that were not available and wanted to go to the hospital. Staff C stated it was their second day working at the facility, they did not know the facility protocol to send a resident to the hospital, and informed Staff D (RN, Charge Nurse) of Resident 1's request. Staff C stated they were busy passing medications, would answer Resident 1's call light every time they called, and was not sure if Staff D went to assess Resident 1.During an observation and interview on 07/08/2025 at 4:00 PM, Resident 1 was observed in bed on their back, and stated on 06/24/2025 at 9:45 PM they requested pain medication from Staff C, Resident 1 stated Staff C informed them their pain medication was not available in the emergency supply and Resident 1 requested to be sent to the hospital. Resident 1 stated Staff C told them they would talk with Staff D for directions. Resident 1 stated Staff D did not come and talk with them after requesting to go to the hospital five times. Resident 1 stated Staff C returned to their room and told Resident 1 that Staff D stated a resident could call 911 themselves. Resident 1 stated Staff E (RN) arrived for the night shift, came to their room and spoke with them about the pain medications. Staff E informed Resident 1 that their pain medications were on the next pharmacy delivery, should arrive within an hour. Resident 1 stated they agreed to wait an hour for the pain medications to arrive, and if they did not arrive wanted to go to the hospital. Resident 1 stated they felt helpless, captive, and stressed not knowing when the medication would arrive and staff were not honoring their choice to go to the hospital. Resident 1 stated they had to start taking antidepressant medication again due to the incident.Review of a provider note, dated 07/01/2025, showed Resident 1 was seen by the provider for worsening depression, anxiety, paranoia, and requested to start medications to help with their symptoms. The note showed Resident 1's worsening symptoms were linked to challenges in managing physical pain, denial of requests for further medical intervention, and re-emerging distressing delusions. The note showed Resident 1 was re-started on medications to manage their symptoms of depression and anxiety.During an interview on 07/08/2025 at 5:15 PM, Staff D stated they did not go and see Resident 1 because they were busy on another hallway. Staff D stated they directed Staff C to offer Resident 1 a different pain medication and call the pharmacy to see when the pain medications would be delivered. Staff D stated the pharmacy was called time, staff were waiting for an authorization code to get pain medication from the emergency supply when the pain medication arrived at the facility. Staff D stated staff should assess the resident and the resident had the right to go to the hospital.In an interview on 07/08/2025 at 5:30 PM, with Staff A and Staff B, Staff B stated the facility had the pain medication Resident 1 was prescribed in the emergency supply in a different dose. Resident 1's pain medication prescription was 5mg two tabs to equal 10 mg and the facility emergency supply contained 10 mg tabs of Resident 1's prescribed pain medication. Staff A stated facility staff offered Resident 1 a different pain medication, Resident 1 refused that medication, and agreed to wait until the pharmacy delivered the pain medication. The pain medications arrived at the facility at midnight; Resident 1 was medicated and did not go to the hospital. Staff B stated they would expect staff to call the physician to have the order changed and when a resident requested to go to the hospital to send them as that was their right.During an interview on 07/22/2025 at 1:20 PM, Staff A stated they would expect staff to call the physician to obtain further instructions, and call emergency services when a resident requested to be hospitalized . REFERENCE: WAC 388-97-1060(1)(3)(k).

Based on observation, interview, and record review the facility failed to ensure food and drinks served to residents were prepared and distributed under sanitary conditions for 1 of 1 facility kitchens. The failure to maintain an effective system for sanitizing counters and monitor refrigerator temperatures placed residents at risk for contaminated/spoiled food, foodborne illness, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 07/2018 Food and Nutrition Services - Food and Drink policy, the facility would be provided food and drink prepared using methods to preserve the nutritive value, flavor, and appearance of the food. <Facility Kitchen> During initial rounds of the facility kitchen on 02/18/2025 from 8:54 AM to 9:08 AM no log documenting facility staff monitored the kitchen's sanitizing solution was at an effective concentration was found. Staff S (Dining Services Director) asked the kitchen staff if anyone knew where the log was, and no staff could provide an answer. At that time Staff S stated the daytime dietary staff started their shift at 6 AM and therefore the sanitizer was not checked for being at an effective concentration since shift change over three hours prior. Review of the refrigerator logs on 02/18/2025 at 9:03 AM showed no temperatures were logged for the kitchen refrigerators since 02/15/2025, meaning the temperature of the refrigerators were not checked on 02/16/2025 and 02/17/2025. Staff S stated they expected the logs to be maintained daily but they were not. During observations of lunch preparations on 02/21/2025 Staff S stated they were no paper towels. Observation at that time showed the paper towel dispenser was empty. On the nearest counter to the left, a roll of paper towels was placed where the loose part of the paper towel roll was resting against a can opener. The top of the paper towel roll was dotted with drips of water from staff using the roll from the counter to wash their hands. At that time with gloved hands, Staff U (Dietary Aide) took a large piece of paper towel from the roll on the counter and wiped down a cart. Staff U did not use any sanitizer or wash their hands before or after wiping the cart with paper towels and returned to food preparation. In an interview on 02/25/2025 at 8:55 AM, Staff S stated the paper towel dispenser should have been refilled when emptied instead of dietary staff placing it on the counter. Staff S stated they expected staff to check the sanitizer concentration as scheduled and only use sanitizer solution to clean surfaces. Staff S stated dietary staff should only use gloves when handling ready-to-eat foods. REFERENCE: WAC 388-97-1100 (3).

Based on record review and interview the facility failed to ensure residents received required written notices at the time of transfer/discharge, or as soon as practicable for 3 of 3 residents (Residents 22, 63, & 82) reviewed for hospitalization s and 1 supplemental resident (Resident 20) reviewed. The failure to ensure written transfer notifications were provided to residents and/or their representatives, in a language and manner they understood, placed residents at risk for not having an opportunity to make an informed decision about the transfer/discharge. Findings included . <Policy> According to the facility policy titled, Notice Requirements Before Transfer/Discharge, dated 07/2018, the facility would provide the resident and/or their representative, in writing, the reasons for the move in a language and manner they understood prior to the transfer/discharge. The policy showed the written notice would include the reason for transfer/discharge, the effective date, the location, a statement of the resident's rights to appeal, contact information for the office of the state long term ombudsman, contact information for the agency responsible for the protection and advocacy of individuals with developmental disabilities, and contact information for the agency responsible for the protection and advocacy of individual with a mental disorder. <Resident 22> Review of a 03/16/2024 Discharge Return Anticipated Minimum Data Set (MDS- an assessment tool) showed Resident 22 was discharged to an acute care hospital on 03/16/2024. The MDS showed Resident 22 had no memory impairment. Review of Resident 22's health records showed a 03/16/2024 written transfer notification form with only Staff M's (Registered Nurse) signature, no witness signature, and Resident 22's name written in, not signed by the resident. In an interview on 02/19/2025 at 9:22 AM Resident 22 stated they went to the hospital on 03/16/2024 for a fall. In an interview on 02/24/2025 at 1:45 PM Staff E (Unit Manager) stated Resident 22's written transfer notification should have been witnessed since the resident was unable to sign. Staff E stated the written transfer notification should be provided to Resident 22 or their representative, to ensure the resident/representative understood their rights. <Resident 63> Review of a 12/31/2024 Discharge Return Anticipated MDS showed Resident 63 was discharged to an acute care hospital on 12/31/2024. The MDS showed Resident 63 had no memory impairment. Review of Resident 63's health records showed a 12/31/2024 written transfer notification form with only Staff E's signature, no witness signature, and Resident 63's representative name written in, not signed by the resident or representative. In an interview on 02/18/2025 at 10:02 AM Resident 63 stated they went to the hospital on 12/31/202. In an interview on 02/24/2025 at 1:37 PM Staff E stated they complete the written transfer notification and gave the notice to the social service staff to send to the representative. Staff E stated they were not informed they were responsible for giving a physical copy to the residents or their representatives. Staff E stated it was important to provide a copy, so the resident or resident representative had instructions about their rights to appeal the transfer/discharge if they wished to do so. <Resident 82> Review of a 02/07/2025 Discharge Return Anticipated MDS showed Resident 82 was discharged to an acute care hospital on 02/07/2025. The MDS showed Resident 82 had no memory impairment. Review of Resident 82's health records showed a 02/07/2025 written transfer notification form with only Staff E's signature, no witness signature, and Resident 63's representative name written in, not signed by the resident or representative. In an interview on 02/24/2025 at 11:26 AM Staff D (Social Service Director) stated there wasn't a written transfer notification in Resident 82's health records for the transfer on 02/07/2025 but should be. Staff D went to medical records department and Staff N (Medical Records) stated they did not have a written transfer notification for Resident 82's transfer to hospital on 02/07/2025. Staff stated the only other place it could be, if one was done, would be in the scanning bin at the nurse's station. Staff D checked the scanning bin and Resident 82's written transfer notification form was not in there. Staff D stated the nurses were responsible for ensuring the resident or representative received the physical copy in writing. Staff D stated it was important to make sure the resident or representative received a copy in writing because the form had instructions on what to do and how to appeal the transfer/discharge. In an interview on 02/24/2025 at 1:37 PM Staff E stated they were unaware it was their responsibility to mail a written transfer notification and thought the social service department mailed the representative a copy. Staff E stated it was important to provide a written transfer notification for resident rights to be informed about the transfer and to provide them the instructions on how to appeal. 50511 <Resident 20> According to a 02/05/2025 Admission MDS Resident 20 had no memory impairment. The MDS showed Resident 20 had an indwelling urinary catheter, history of urinary tract infections, was partially paralyzed, and had a behavior disorder. Review of a Nursing Home Transfer or Discharge Notice dated 02/08/2025 showed Resident 20 was transferred to the hospital due to a higher level of care needed, low blood pressure, high heart rate and a fever. Review of Resident 20's health records showed the 02/08/2025 written transfer notification form with only Staff Q's (Licensed Practical Nurse) signature, no witness signature, and Resident 20's name written in, not signed by the resident. Resident 20's records also showed a transfer to an acute care hospital on 02/20/2025 for a stomachache with a written transfer notification with Staff R (Registered Nurse) signature, no witness signature, and Resident 20's name written in, not signed by the resident. In an interview on 02/25/2025 at 1:17 PM Staff A (Administrator) stated whenever a resident was transferred to the hospital the nurse transferring the resident would complete a notification of transfer/discharge form. Staff A stated staff should get the resident to sign the form, if a resident was not alert, the facility would provide follow up and notify the family. Staff A stated nurses were responsible for filling out the form and social services would be responsible for follow up right away to make sure the form was provided to the resident and/or their representative. REFERENCE: WAC 388-97-0120(2)(a-d).

Based on observation, record review, and interview, the facility failed to ensure safety assessments were completed for 3 of 6 residents (Residents 4, 63, & 70) reviewed for bed against the wall/bed rails, failed to store chemicals and razors for 1 of 2 utility rooms (North Utility Room) and failed to supervise the leave of absence for 1 of 2 residents (Resident 90) reviewed for leave from the facility. Failure to complete safety assessments for the beds against the wall, store chemicals and razors safely, and supervise a resident at risk for safety while on a leave of absence placed residents at risk of entrapment and injury. Findings included . <Policy> According to a facility policy titled, Accident Hazards/Supervision/Devices, dated 07/2018, the facility would implement systems that addressed residents risk and environmental hazards to minimize the likelihood of accidents. The policy showed a potentially hazardous item or situations that was accessible to vulnerable residents would be considered hazardous. The policy showed hazardous materials would be contained to protect residents from exposure. The policy showed risks and benefits of devices which may pose an entrapment risk would be assessed prior to implementation of such devices. The policy showed the facility would use supervision as an intervention to mitigate accident risks. The facility would work with resident vulnerabilities to understand the reasons for their choices and discuss possible options and the Care Plan (CP) would be updated to honor the resident's choices while mitigating risks. According to a facility policy titled, Bed Rails, dated 02/2018, showed the facility would inform the resident or resident representative of the risks and benefits of bed rails prior to installation of the rails and obtain consent from the resident or the resident representative. <Resident 4> Review of a 01/17/2025 Admission Minimum Data Set (MDS - an assessment tool) showed Resident 4 had no restraints used on their bed. The MDS showed Resident 4 had no memory impairment. The MDS showed Resident 4 had diagnoses of, but not limited to, morbid obesity and a history of a stroke. Review on 02/19/2025 of Resident 4's health records showed no safety assessment for their right side of bed against the wall. Observation on 02/19/2025 at 10:19 AM showed Resident 4's right side of their bed against the wall. In an interview on 02/24/2025 at 1:59 PM Staff E (Unit Manager) stated the facility did not complete Resident 4's safety assessment prior to placing their bed against the wall but should have. Staff E stated it was important to complete the assessment prior to placing the resident's bed against the wall to ensure their safety. <Resident 63> Review of a 01/10/2025 Admission MDS Resident 63 had restraints to their bed. The MDS showed Resident 63 had no memory impairment. The MDS showed Resident 63 had diagnoses of, but not limited to, general muscle weakness, unsteadiness on feet, and other abnormalities of gait and mobility. Review on 02/18/2025 of Resident 63's health records showed no safety assessment for their left side of bed against the wall. Observation on 02/18/2025 at 10:08 AM showed Resident 63's left side of bed against the wall. In an interview on 02/24/2025 at 1:59 PM Staff E stated they did not complete a safety assessment for Resident 63's left side of bed against the wall but should have. Staff E stated it was important to complete the assessment prior to placing the resident's bed against the wall to ensure their safety. <Resident 70> Review of a 10/01/2024 Admission MDS Resident 70 had no restraints used to their bed. The MDS showed Resident 70 had no memory impairment. The MDS showed Resident 70 had diagnoses of, but not limited to, lack of coordination, general muscle weakness, and need for assistance with personal care. Review on 02/19/2025 of Resident 70's health records showed no safety assessment for their left side of bed against the wall. Observation on 02/19/2025 at 7:39 AM showed Resident 70's left side of bed against the wall. In an interview on 02/24/2025 at 1:45 PM Staff E stated they did not complete a safety assessment for Resident 70's left side of bed against the wall but should have. Staff E stated it was important to complete the assessment prior to placing the resident's bed against the wall to ensure their safety. <North Utility Room> Observation on and interview on 02/21/2025 at 8:30 AM showed the north utility room door unlocked. The north utility room had razors, hygiene supplies, and disinfectant cleaners stored in open cabinets. Staff E stated it should be kept locked but was not. Staff E stated the utility rooms should be kept locked for resident safety because they had chemicals and razors stored inside them that residents should not have open access to. 50511 <Resident 90> According to a 01/31/2025 Admission MDS Resident 90 had some memory impairment, history of a post-traumatic stress disorder, had a bone infection of the lower back and spine and a skin infection to the right lower leg. According to the 01/25/2025 Behavior CP, Resident 90 could exhibit a behavior concern related to post traumatic stress order and a history of substance abuse. The CP did not show interventions for Resident 90 leaving the facility unaccompanied. Review of a physician order 01/24/2025 showed Resident 90 could leave the facility with a responsible person with them. Interview on 02/21/2025 at 08:55 AM, Resident 90 stated that they left the facility at 4:30 PM and returned to the facility at 8:15 PM. Resident 90 stated they were told according to the facility policy they should be accompanied by a person when they left the facility. Resident 90 stated they did not have anybody with them when they left the facility and called a cab for a ride and wondered if the cab driver counted as a responsible person. Resident 90 stated they went out to go shopping and then went to another city to have a drink with a friend and then went to their apartment to check their mail. Resident 90 stated they told the staff that they got permission to leave without anyone accompanying them when they signed out of the facility and admitted that was not the truth. In an interview on 02/25/2025 at 11:25 AM, Staff F (Unit Manager) stated Resident 90 had the right to leave the facility and the facility had a sign in and sign out book they used to monitor residents. Staff F stated the physician order that showed Resident 90 needed to be accompanied out of the facility could have been incorrect and the facility should have had the order verified but did not. In an interview on 02/24/2025 at 01:48 PM Staff A (Administrator) stated the facility was aware that Resident 90 left the facility unaccompanied and stated Resident 90 told the facility they wanted to go alone and did not need an escort. Staff A stated they were not aware of the physician order showing Resident 90 needed to be accompanied and the doctor may have ordered that because Resident 90 had a Percutaneous Intravenous Central Catheter line (PICC, an inserted tube placed within a vein to deliver fluids and medication into the bloodstream) used to receive antibiotics for their infection. Staff A stated the CP should have been revised to show Resident 90 could leave the facility on their own but was not currently updated with this information. Refer to F552 - right to be informed Refer to F656 - develop/implement comprehensive care plan Refer to F658 - services provided meet professional standards REFERENCE: WAC 388-97-1060 (3)(g).

Based on observation, interview, and record review the facility failed to ensure 2 of 5 sampled residents (Residents 38 & 22) reviewed for Oxygen (O2) administration were provided care consistent with professional standards of practice. Failure to provide oxygen monitoring and maintain oxygen equipment left residents at risk for respiratory discomfort, oxygen-related accidents, infection, and a decreased quality of life. Findings included . <Facility Policy> According to the facility's July 2018, Quality of Care Respiratory Care Policy, the facility would assure respiratory care was provided to residents in need of such care. The care would be consistent with professional stands standards of practice, the comprehensive person-centered care plan and resident's goals. The facility would have procedures for response to adverse reactions to respiratory interventions, for respiratory assessments and should include when and how the assessment would be conducted and the type of documentation required. <Providing Oygen Level Monitoring> <Resident 38> According to the 01/07/2025 Annual Minimum Data Set (MDS - an assessment tool) Resident 38 had respiratory failure with low blood (O2) levels. Review of the revised 07/22/2024 Respiratory Failure Care Plan (CP) showed staff were to monitor for signs and symptoms of respiratory distress and report these findings to the provider. The CP showed the symptoms staff were to report to the provider included increased respirations and decreased blood oxygen levels. Review of a physician order dated 05/31/2024 showed staff were to monitor Resident 38's blood O2 levels every shift and to notify the provider of low O2 levels when Resident 38 was using supplemental O2. Review of a February 2025 Treatment Administration Record (TAR) showed an order dated 02/05/2025 to provide O2 at a rate of 1 to 4 liters per minute every shift and to maintain O2 blood levels greater than 90%. The February TAR showed on 02/01/2025, 02/02/2025, 02/03/2025, 02/04/2025, 02/05/2025, 02/10/2025, 02/11/2025 and 02/15/2025 O2 blood levels were at 90% or lower. Review of progress notes in Resident 38's health record from 01/31/2025 through 02/18/2025 did not show documentation that the provider was notified of low O2 levels and did not show further documentation by the nurse practitioner regarding adjusting O2 level orders. Interview on 02/21/2025 at 8:44 AM, Staff O (Certified Nursing Assistant) stated Resident 38 was not as responsive today and was coughing. Observation on 02/21/2025 at 11:35 AM showed Staff F (Unit Manager) inform care staff they were to get Resident 38 up from bed because people with respiratory illness need to be up in the wheel chair and Resident 38 also needed to be monitored. In an interview on 02/25/2025 at 11:12 AM Staff F stated low O2 levels should be documented in Resident 38's progress notes and the provider should have been notified. In an interview on 02/25/2025 at 2:19 PM Staff B (Director of Nursing) stated staff should have notified the provider of Resident 38's low O2 levels and should have documented this in the progress notes. Staff B stated this was important to notify the provider of Resident 38's care and to document providers orders if a change in plan of care was needed. 47836 <O2 Equipment Maintenance> <Resident 22> Review of a 07/19/2024 Annual MDS Resident 22 had respiratory failure, chronic obstructive pulmonary disease, and dependence on supplemental O2. The MDS showed Resident 22 received O2 during the assessment period. Review on 02/19/2025 of Resident 22's physician orders showed no order to change O2 tubing. Observation on 02/19/2025 at 9:38 AM showed Resident 22 with O2 being administered via nasal canula. Resident 22's nasal canula was dated 02/13/2025. Observation and interview on 02/21/2025 at 9:03 AM showed Resident 22's O2 tubing dated 02/13/2025. Staff F stated it was the facility's policy to change O2 tubing weekly. Staff F stated Resident 22's tubing was not changed according to facility policy but should have been. Staff F stated it was important to change O2 tubing weekly to prevent respiratory infections. REFERENCE: WAC 388-97-1060(3)(j)(vi).

Based on interview and record review, the facility failed to ensure a level II Preadmission Screening and Resident Review (PASRR- a mental health screening required prior to nursing home admission) evaluation was completed and/or incorporated into the Care Plan (CP) for 4 of 6 residents (Residents 61, 22, 82, & 20) reviewed for PASRR. This failure placed residents at risk for unmet mental health care needs. Findings included: <Facility Policy> According to the facility's 11/2017 PASRR policy, a PASRR screening must be completed prior to admission. The policy showed for residents assessed to need Level II services, the facility would incorporate the recommendations into the resident's CP. <Resident 61> According to the 11/14/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 61 admitted to the facility from the hospital on 07/16/2022 and was assessed with a severe memory impairment. The MDS showed Resident 61 had diagnoses including dementia and three mental health diagnoses, and needed to use antipsychotic and anti-anxiety medications. Record review showed three Level I PASRR screenings on file for Resident 61: a 07/18/2022 Level I screening showing Level II services were not required, an 08/24/2022 Level I PASRR showing a Level II referral was necessary, and an 08/18/2023 Level I PASRR also showing Level II services were required. Record review showed there was no Level II PASRR evaluation on file for Resident 61. Resident 61's record included a 02/05/2018 Level II PASRR invalidation from a previous unaffiliated nursing home admission. In an interview on 02/24/2025 at 2:07 PM Staff D (Social Services Director) stated if the Level I PASRR showed a resident required further screening for Level II services, it was social services responsibility to follow as needed. Staff D stated they believed there was a Level II invalidation on file but upon review of the document acknowledged it did not address Resident 61's stay at this facility. Staff D stated there was no Level II determination on file for the 08/18/2023 Level I PASRR screening. Staff D checked their email and stated the last time they reached out to the PASRR office for follow up was on 02/27/2024. 47836 <Resident 22> Review of a 07/19/2024 Admission MDS Resident 22 had no memory impairment. The MDS showed Resident 22 had diagnoses of, but not limited to, depression and schizophrenia (chronic mental health condition with disruption in thought processes, perceptions and behavior). Review of Resident 22's CP showed a PASRR level I with Serious Mental Illness (SMI). The CP showed an intervention for social service to review the PASRR quarterly and as needed. Review of Resident 22's health records showed a 08/18/2023 PASRR level I stating a level 2 PASRR was required for SMI. Resident 22's health records had no documentation of a level II PASRR being done. In an interview on 02/24/2025 at 10:54 AM Staff D stated there was no evidence of the level II PASRR in Resident 22's health records for the 08/18/2023 PASRR level I with SMI. Staff D stated it was important to complete the PASRR level II to obtain the consultants recommendations for the resident's mental health care. <Resident 82> Review of a 12/16/2024 Significant Change MDS Resident 82 had no memory impairment. The MDS showed Resident 82 had diagnoses of, but not limited to, depression, Post Traumatic Stress Disorder (PTSD), and psychotic disorder. Review of a 10/24/2024 PASRR CP showed Resident 82 had a PASRR level II. The CP showed staff were to follow the recommendations of the level II PASRR. Review of Resident 82's health records showed a 08/29/2024 PASRR level I documenting a level II PASRR was required for SMI. Resident 82's health records had no documentation of a level II PASRR being done. Resident 82's level I PASRR showed they had a new diagnosis of PTSD. In an interview on 02/24/2025 at 10:54 AM Staff D stated there was no evidence of the level II PASRR in Resident 82's health records for the 08/29/2024 PASRR level I with SMI and new diagnosis of PTSD. Staff D stated it was important to complete the PASRR level II to obtain the consultants recommendations for the resident's mental health care. 50511 <Resident 20> According to the 02/05/2025 Admission MDS, Resident 20 admitted to the facility on [DATE]. The MDS showed Resident 20 diagnoses of a chronic mental health condition, hallucinations, delusions, verbal behavior towards others and Resident 20's behavior significantly interfered with care. Review of the 01/29/2025 level I PASRR showed Resident 20 had SMI indicators for personality and anxiety disorders. A level II evaluation referral was indicated on the PASSR form due to SMI. Review of Resident 20's medical records did not show a level II PASRR with recommendations for the resident's behaviors was completed. In an interview on 02/25/2025 at 2:50 PM, Staff D stated the level II PASRR referral should have been completed by the hospital before Resident 20 was admitted to the facility. Staff D stated they follow up to make sure the referral was made to the correct authority. Staff D stated since Resident 20 discharged in and out of the facility on two occasions they were not able to follow up to determine if a level II PASRR referral was made. Staff D stated that a PASSR level II referral was important to determine the level of care needed for the resident. REFERENCE: WAC 388-97-1915(4).

Based on record review and interview the facility failed to ensure physician orders for 3 of 3 residents (Residents 4, 22, & 71) reviewed for accident hazards, 1 of 2 residents (Resident 63) reviewed for physical restraints, a physician order for 1 of 4 residents (Resident 22) reviewed for respiratory care, and 1 of 5 residents reviewed for nutrition (Resident 38) were obtained, clarified, and/or implemented. These failures placed residents at risk for potential adverse effects, unmet needs, complications, and diminished quality of life. Findings included . <Policy> According to a facility policy titled, Respiratory Care/Tracheostomy Care & Suctioning, dated 07/2018, the facility would provide residents with necessary respiratory care and services that were in accordance with professional standards of practice. <Resident 4> Review of the 01/17/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 4 had no memory impairment. The MDS showed Resident 4 had no restraints used on their bed. The MDS showed Resident 4 had a history of a stroke. Observation on 02/19/2025 at 10:19 AM showed Resident 4's right side of bed against the wall. Review of Resident 4's health records on 02/23/2025 showed no physician order for the right side of their bed against the wall. In an interview on 02/24/2025 at 1:59 PM Staff E (Unit Manager) stated Resident 4's right side of bed was against the wall but there wasn't a physician order for this. Staff E stated it was important to have a physician order for the bed against the wall to ensure this was an appropriate plan of care for the resident. <Resident 22> Review of the 07/19/2024 Annual MDS Resident 22 had no memory impairment. The MDS showed Resident 22 had no restraints used on their bed. The MDS showed Resident 22 had diagnoses of, but not limited to, general muscle weakness, restless leg syndrome, and difficulty walking. Observation on 02/20/2025 at 1:26 PM showed Resident 22's left side of bed against the wall. In an interview and observations on 02/21/2025 at 9:03 AM Resident 22's oxygen tubing showed a date of 02/13/2025. Staff F (Unit Manager) stated oxygen tubing should be changed weekly. Staff F reviewed Resident 22's health records and stated they did not have a physician order to change the oxygen tubing weekly per facility policy but should have. Staff F stated it was important to change the oxygen tubing weekly for infection prevention. Review of Resident 22's health records on 02/23/2025 showed no physician order for the left side of their bed against the wall. In an interview on 02/25/2025 at 8:45 AM Staff F stated Resident 22's left side of bed was against the wall but there wasn't a physician order for this. Staff F stated it was important to have a physician order for the bed against the wall to ensure a physician guided plan of care for the resident. <Resident 63> Review of the 01/10/2025 Admission MDS Resident 63 had no memory impairment. The MDS showed Resident 63 had no restraints used on their bed. The MDS showed Resident 63 had diagnoses of, but not limited to, general muscle weakness and unsteadiness on feet. Observation on 02/18/2025 at 10:08 AM showed Resident 63's left side of bed against the wall. Review of Resident 63's health records on 02/23/2025 showed no physician order for the left side of their bed against the wall. In an interview on 02/24/2025 at 1:59 PM Staff E stated Resident 63's left side of bed was against the wall but there wasn't a physician order for this. Staff E stated it was important to have a physician order for the bed against the wall to ensure this was an appropriate plan of care for the resident. <Resident 71> Review of the 07/29/2024 Annual MDS Resident 71 had no memory impairment. The MDS showed Resident 71 had no restraints used on their bed. The MDS showed Resident 71 had diagnosis of, but not limited to, a right leg displaced fracture. Observation on 02/18/2025 at 10:08 AM showed Resident 71's right side of bed against the wall. Review of Resident 71's health records on 02/23/2025 showed no physician order for the right side of their bed against the wall. In an interview on 02/24/2025 at 2:08 PM Staff E stated Resident 71's left side of bed was against the wall but there wasn't a physician order for this. Staff E stated it was important to have a physician order for the bed against the wall to ensure this was an appropriate plan of care for the resident. 42203 <Resident 34> According to the 11/20/2024 Admission MDS, Resident 34 had medically complex diagnoses including a spinal fracture and a history of falling. The MDS showed Resident 34 had frequent pain that affected their sleep and ability to participate in activities and therapy. Record review showed two physician orders for a pain medication patch: a 02/18/2025 physician's order for a pain medication patch to be placed on Resident 34's lower back in the evening and removed at bedtime for pain, and a 02/19/2025 physician's order for the same pain medication patch to be applied in the morning and removed in the afternoon. The orders did not include the strength of the painkiller required. In an interview on 02/25/2025 at 9:32 AM, Staff B (Director of Nursing) stated they expected orders to be clarified when unclear. In the same interview at 9:45 AM, Staff B reviewed the pain medication patch orders and stated they should include the strength of the medication but did not. 50511 Resident <38> According to the revised 10/7/2024 Quarterly MDS, Resident 38 had a history of a stroke, respiratory failure, and difficulty swallowing. The MDS showed Resident 38 needed substantial assistance with eating and needed a pureed food and thickened liquid diet. Review of a revised 10/14/2024 Nutritional Problem Care Plan (CP) showed Resident 38 needed one on one supervision with meals to prevent choking and aspiration and to promote a consistent intake. Review of Resident 38's health record showed a physician order dated 02/20/2025 for a swallow evaluation with treatment related to possible aspiration. Health record did show a swallow evaluation had been completed. Observation on 2/20/2025 at 11:32 AM showed Resident 38 sitting in wheelchair in the dining room. Observed Resident 38 had a food tray of pureed foods and thickened juice, coffee and water. An Unidentified Certified Nursing Aid (CNA) assisted Resident 38 with feeding, resident 38 began coughing while eating. In an interview on 2/21/2025 at 8:44 AM Staff O (Certified Nursing Aid) stated while Resident 38 was being fed they began to cough. In an interview on 02/25/2025 at 11:06 AM Staff F (Unit Manager) stated the swallow evaluation ordered on 02/20/2025 did not occur. Staff F stated they expected the swallow evaluation to be done as soon as possible. Staff F stated the CP should also provide specific instructions on how to feed Resident 38 to avoid choking, but feeding details needed to be added after a swallow evaluation occurred. In an interview on 02/25/2025 at 2:19 PM Staff B (Director of Nursing) stated Resident 38 was at risk for aspiration while eating and a swallow evaluation was ordered on 2/20/2025, five days ago. Staff B stated a swallow evaluation should be set up within 48 to 72 hours of the order being received but was not. Refer to F552 - right to be informed Refer to F656 - develop/implement comprehensive care plan Refer to F689 - free of accident hazards REFERENCE: WAC 388-97-1620(2)(b)(i)(ii).

Based on observation, interview, and record review the facility failed to implement skin breakdown interventions for 1 of 6 residents (Resident 61) reviewed for positioning/mobility and failed to provide weight monitoring for 1 of 1 resident (Resident 82) reviewed for edema. The failure to ensure palm protectors were used as ordered (Resident 61) and weights monitored as required (Resident 82) placed residents at risk for skin breakdown, weight loss, weight gain, and other negative health outcomes. Findings included . <Facility Policy> According to the facility's 11/2017 Quality of Care -policy, for residents with non-pressure-related skin impairments, the facility would provide care and services consistent with professional standards to prevent skin breakdown. The policy showed the facility would provide preventative measures as needed to maintain skin integrity. According to an undated facility policy titled, Edema Management, interventions for heart failure may include monitoring weights. <Resident 61> According to the 11/14/2024 Quarterly Minimum Data Set (MDS - an assessment tool) Resident 61 had a severe memory impairment and required total assistance with all daily routines. The MDS showed Resident 61 had diagnoses including dementia, seizures, malnutrition, and an altered mental state. The MDS showed Resident 61 required total assistance with all daily care and had open lesions. Review of the physician's orders showed a 12/18/2024 order to apply Therapy Carrot [a carrot-shaped, fabric, therapy tool used to create space in a hand that no longer opens freely] for 4 hours in each hand then switch to the other hand. Therapy carrots can be placed in one hand at a time as tolerated. every shift . According to the 12/18/2024 Potential for skin breakdown Care Plan (CP) nursing staff should place the Therapy Carrot in each hand for 4 hours per hand or as tolerated. The CP showed staff should place a Therapy Carrot in one hand at a time. Record review showed there was nowhere for nursing staff to document they placed the Therapy Carrot in either hand, how long Resident 61 tolerated the Therapy Carrot, or when the Therapy Carrot was removed. Observation on 02/18/2025 at 1:43 PM showed a sign above Resident 61's bed informing staff that the resident's previous sheepskin palm protector was discontinued and to now use the Therapy Carrot. There was no Therapy Carrot observed in place. Observation on 02/24/2025 at 12:13 PM, 12:35 PM, and 01:17 PM showed no Therapy Carrot in either hand. In an interview on 02/25/2025 at 10:03 AM, Staff B (Director of Nursing) stated if a resident had a physician-ordered intervention to prevent skin break down, they expected the provision of the care to be documented. Staff B reviewed Resident 61's chart and stated there was not but should be a place for the nursing staff to document when they provided the Therapy Carrot. Staff B stated given how the order was written, Resident 61 should have the Therapy carrot in the middle of the day. Staff B then went over to Resident 61 and asked the resident if they could look at their hands. Staff B then examined Resident 61's hands and stated the Therapy Carrot should be but was not placed in one of Resident 61's hands. 47836 <Resident 82> Review of a 12/16/2024 Quarterly MDS Resident 82 had no memory impairment. The MDS showed Resident 82 received diuretic medication during the assessment period. The MDS showed Resident 82 had diagnoses of, but not limited to, heart failure and edema. Review of a 06/10/2024 heart failure CP showed the facility would monitor Resident 82's weight daily and monitor for lower extremity edema. Observation on 02/20/2025 at 1:57 PM showed Resident 82 had pitting edema (fluid in tissues that shows an indentation when pressed with a finger) to bilateral lower extremities. In an interview on 02/24/2025 at 9:12 AM Staff E (Unit Manager) stated Resident 82 had bilateral lower extremity edema. Staff E stated they were only obtaining Resident 82's weight weekly and should be monitoring it daily. Staff E stated it was important to monitor Resident 82's weight daily because excessive fluid retention could cause cardiac overload and fluid in the lungs. REFERENCE: WAC 388-97-1060(1).

Based on observation, interview, and record review the facility failed to develop and/or implement a comprehensive Care Plan (CP) for 6 of 18 residents (Residents 34, 10, 4, 63, 70 & 38). This failure placed residents at risk for unmet care needs, frustration, and other negative health outcomes. Findings included . <Resident 34> According to the 11/20/2024 Admission Minimum Data Set (MDS - an assessment tool) Resident 34 had intact memory and medically complex diagnoses including a history of stroke, but no seizure/epilepsy diagnosis. The MDS showed Resident 34 used an anticonvulsant (anti-seizure) medication. According to a 12/02/2024 physician's progress note, Resident 34 had metabolic encephalopathy (a change in how the brain works due to an underlying condition) in part due to a seizure disorder. Record review showed a 02/15/2025 physician's order for an anticonvulsant medication at 750 Milligrams (MG) twice a day for a seizure disorder, and a prior 11/13/2024 order for the same medication with the same schedule for spinal injuries. Review of Resident 34's comprehensive CP showed no CP developed addressing the resident's anticonvulsant use. In an interview on 02/25/2025 at 9:45 AM, Staff B (Director of Nursing) stated the anticonvulsant medication was ordered to treat a seizure disorder. Staff B stated the facility should have but did not develop a CP to address the use of the anticonvulsant medication. <Resident 10> According to the 12/20/2024 Quarterly MDS, Resident 10 had diagnoses including difficulty voiding urine and dementia. The MDS showed Resident 10 used a urinary catheter (tubing to help with voiding urine) and had two Stage-3 Pressure Ulcers (PU) and one Stage-4 PU. Observation on 02/19/2025 at 8:52 AM showed a sign outside Resident 10's room indicating staff were required to use Enhanced Barrier Precautions (EBP - precautions such as gloves, gowns, eye protection etc. required when providing certain types of close contact care such as changing a resident.) Record review showed a 02/05/2025 physician's order showing Resident 10 required a urinary catheter related to their difficulty urinating. Resident 10 also had a 10/04/2023 order for wound care for a PU on their left buttock, and a 02/17/2025 order for wound care to their right thigh. According to the 12/20/2024 EBP CP staff should use EBP when providing high-contact care including ostomy (an artificial opening into the body) care and for device care/use including a central line (a type of intravenous access), feeding tube, trachesotomy (a whole in the throat to open airways), and ventilator (a large breathing apparatus) care/use. In an interview on 02/25/2025 at 11:12 AM Staff B (Director of Nursing) stated Resident 10 did not have any kind of ostomy including a tracheotomy, a central line, feeding tube, or a ventilator. Staff B stated the CP needed to be individualized to reflect Resident 10's PU and catheter status as the reason for EBP. 47836 <Resident 4> Review of the 01/17/2025 Admission MDS Resident 4 had no memory impairment. The MDS showed Resident 4 had no restraints used on their bed. The MDS showed Resident 4 had a history of a stroke. Observation on 02/19/2025 at 10:19 AM showed Resident 4's right side of bed against the wall. Review of Resident 4's health records on 02/23/2025 showed no CP for the right side of their bed against the wall. In an interview on 02/24/2025 at 1:59 PM Staff E (Unit Manager) stated Resident 4's right side of bed was against the wall but there was not a CP for it. Staff E stated it was important to CP the bed against the wall for resident safety, to ensure staff were aware and monitoring the resident's safety. <Resident 63> Review of the 01/10/2025 Admission MDS Resident 63 had no memory impairment. The MDS showed Resident 63 had no restraints used on their bed. The MDS showed Resident 63 had diagnoses of, but not limited to, general muscle weakness and unsteadiness on feet. Observation on 02/18/2025 at 10:08 AM showed Resident 63's left side of bed against the wall. Review of Resident 63's health records on 02/23/2025 showed no CP for the left side of their bed against the wall. In an interview on 02/24/2025 at 1:59 PM Staff E (Unit Manager) stated Resident 63's left side of bed was against the wall but there was not a CP for the bed against the wall. Staff E stated it was important to CP the bed against the wall for resident safety, to ensure staff were aware and monitoring the resident's safety. <Resident 70> Review of the 10/01/2024 Admission MDS Resident 70 had no memory impairment. The MDS showed Resident 70 had no restraints used on their bed. The MDS showed Resident 70 had difficulty hearing. The MDS showed Resident 70 had diagnoses of, but not limited to, general muscle weakness, difficulty walking, and lack of coordination. During an observation and interview on 02/19/2025 at 7:32 AM showed Resident 70's left side of bed against the wall. Resident 70 showed symptoms of difficulty hearing and stated they could not hear out of their left ear. Review of Resident 70's health records on 02/23/2025 showed no CP for the left side of their bed against the wall or the inability to hear with their left ear. In an interview on 02/24/2025 at 1:59 PM Staff E (Unit Manager) stated Resident 70's left side of bed was against the wall but there was not a CP for it. Staff E stated it was important to CP the bed against the wall for resident safety, to ensure staff were aware and monitoring the resident's safety. Staff E reviewed the MDS showing Resident 70's difficulty hearing and stated they did not have a hard of hearing CP but should, so staff knew how to best communicate with them and ensure they heard what staff was saying. 50511 <Resident 38> <Seizure Medication> According to the 01/02/2025 Quarterly MDS, Resident 38 medical conditions included respiratory failure, history of falls and a seizure disorder. Review of Resident 38's revised 07/22/2024 Seizure Disorder CP showed staff were to give seizure medications as ordered and to monitor for side effects. The CP did not identify what side effects staff were to monitor and did not show drug toxicity side effects for one of Resident 38's seizure medications that required lab monitoring. Review of the February Medication Administration Record (MAR) and February monitors record did not identify side effects or drug toxicity symptoms staff were to observe for their seizure medication. <Antibiotic Medication> Review of Resident 38's revised 07/22/2024 history of Pneumonia (lung infection) related to aspiration (food or liquid accidentally enters the lungs) CP showed staff were to give medications as ordered and to monitor side effects and effectiveness. The CP did not indicate Resident 38 had taken antibiotics due to acute respiratory illness and did not indicate symptoms or dietary adjustments to observe for while taking an antibiotic. Review of February 2025 MAR showed an order dated 02/20/2025 for an antibiotic medication, 500 Milligrams (mg) once a day for acute respiratory illness for 7 days. The MAR did not indicate what signs and symptoms to observe while Resident 38 was on the antibiotic medication. Review of June 2024 MAR showed an order dated 06/08/2024 to give an antibiotic medication, 600 mg twice a day for a respiratory illness for 5 days. The MAR did not indicate what signs and symptoms to observe while Resident 38 was on the antibiotic medication. In an interview on 02/25/2025 at 11:12 AM, Staff F (Unit Manager) stated antibiotic medication and side effects and side effects of the seizure medication should be listed on the CP but was not. Staff F stated this was important for tracking purposes and to make sure Resident 38 was on the right treatment for their illness and care. In an interview on 02/25/2025 at 2:23 PM, Staff B (Director of Nursing) stated antibiotic monitoring should be on the CP but was not. Staff B stated seizure medication should be on the CP because of risk of drug toxicity but was not. Refer to F552 - right to be informed Refer to F658 - services provided meet professional standards Refer to F689 - free of accident hazards REFERENCE: WAC 388-97-1020(1),(2)(a).

Based on observation, record review, and interview, the facility failed to ensure residents were provided informed consent (ensuring an explanation of the risks and benefits were provided) for the use of bed rails and/or the bed against a wall for 3 of 6 residents (Residents 63, 4, & 70) reviewed for bed rails/bed against the wall. This failure placed residents at risk for loss of autonomy, entrapment, injury, and loss of the opportunity for alternative treatment options. Findings included . <Policy> According to a facility policy titled, Bed Rails, dated 02/2018, showed the facility would inform the resident or resident representative of the risks and benefits of bed rails prior to installation of the rails and obtain consent from the resident or the resident representative. <Resident 63> Review of a 01/10/2025 Admission Minimum Data Set (MDS - an assessment tool) Resident 63 had no bed rails installed on their bed. The MDS showed Resident 63 had no memory impairment. The MDS showed Resident 63 had diagnoses of, but not limited to, general muscle weakness, unsteadiness on feet, and other abnormalities of gait and mobility. Review of Resident 63's at risk for activity of daily living self-care performance deficit Care Plan (CP) showed an intervention of assist rail for bed mobility dated 07/17/2024. Observation on 02/18/2025 at 10:08 AM showed a bed rail on the right side of Resident 63's bed. In an interview on 02/24/2025 at 1:59 PM Staff E (Unit Manager) stated they did not obtain consent from Resident 63 for the quarter rail to the right side of their bed but should have. Staff E stated it was important to obtain consent prior to installation of bed rails to ensure the resident can use them safely and wants them. <Resident 4> Review of a 01/17/2025 Admission MDS Resident 4 had no restraints used to their bed. The MDS showed Resident 4 had no memory impairment. The MDS showed Resident 4 had diagnoses of, but not limited to, morbid obesity and a history of a stroke. Review of Resident 4's CP showed the bed against the wall was not identified as of 02/18/2025. Observation on 02/19/2025 at 10:19 AM showed Resident 4's right side of their bed against the wall. In an interview on 02/24/2025 at 1:59 PM Staff E stated the facility did not obtain Resident 4's consent to have their bed against the wall but should have. Staff E stated it was important to obtain consent prior to placing the bed against the wall to ensure the resident was informed and had a say in their care. <Resident 70> Review of a 10/01/2024 Admission MDS Resident 70 had no restraints used to their bed. The MDS showed Resident 4 had no memory impairment. The MDS showed Resident 70 had diagnoses of, but not limited to, lack of coordination, general muscle weakness, and need for assistance with personal care. Review of Resident 70's CP showed the bed against the wall was not identified as of 02/18/2025. Observation on 02/19/2025 at 7:39 AM showed Resident 70's left side of bed against the wall. In an interview on 02/24/2025 at 1:45 PM Staff E stated the facility did not obtain consent from Resident 70 for the bed against the wall but should have. Staff E stated it was important to obtain consent prior to placing the bed against the wall to ensure the resident was informed and had a say in their care. Refer to F656 - develop/implement comprehensive care plan Refer to F658 - services provided meet professional standards Refer to F689 - free of accident hazards REFERENCE: WAC 388-97-0260.

Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from abuse for 1 of 3 residents (Resident 1) reviewed for resident to resident incidents. This failed practice resulted in psychological harm, applying the reasonable person approach, for Resident 1 who experienced an attempted sexual act by another resident who removed their brief (undergarment) and was found with their pants down on top of Resident 1 by facility staff, and resulted in Resident 1 being transferred to a hospital emergency room (ER) to undergo a sexual abuse examination. This failed practice placed all residents at risk for the potential of sexual abuse, psychological harm, and diminished quality of life. Findings included . Review of a facility policy, Freedom from Abuse, Neglect and Exploitation, dated 11/2017, showed the facility would provide a safe resident environment and protect residents from abuse. The facility would keep residents free from abuse, neglect, misappropriation of resident property, and exploitation. This included freedom from verbal, mental, sexual, or physical abuse, corporal punishment, and involuntary seclusion. Sexual abuse, defined as non-consensual sexual contact of any type with a resident who appears to want the contact to occur, but lacks the cognitive ability to consent or a resident who does not want the contact to occur. <Resident 1> Review of a 07/31/2023 Quarterly Minimum Data Set (MDS, an assessment tool) showed Resident 1 was not able to make their own decisions and had unclear speech. Resident 1 had diagnoses that included a history of a stroke (brain bleed), seizure disorder, schizophrenia (mental disorder that include symptoms of auditory hallucinations (hearing voices) and delusions (misconceptions or beliefs that are firmly held, contrary to reality), disorganized thinking, and a catatonic disorder (associated with mental disorders, a behavioral syndrome marked by an inability to move normally). Review of Resident 1's Care Plan (CP), revised on 09/23/2023, showed Resident 1 was dependent on facility staff to meet their emotional, intellectual, physical, and social needs. The CP showed Resident 1 had difficulty making their needs known. Review of a Psychotropic (affects behavior, mood, thoughts, or perception) Medication CP, revised on 02/22/2022 showed Resident 1 was monitored for behaviors of afraid/pain, angry, screaming/yelling, sadness/crying, hallucinations, delusions, and catatonia. The CP directed staff to provide a calm quiet environment, reassurance, validation of feelings, and redirection as needed. Review of a 10/17/2023 Nursing Progress Note (NPN) showed at 1:39 PM facility staff documented that Resident 1 had an alleged resident to resident incident. Resident 1 was not able to tell facility staff what happened and was observed by staff rubbing their legs. Resident 1 was sent to the local hospital for an assessment. Review of the October 2023 behavior monitoring (documentation that used a number to show what behavior was observed by facility staff), showed on 10/17/2023 day shift staff documented a 2, indicating Resident 1 was angry. Observations on 10/17/2023 at 2:00 PM, showed Resident 1 being transported out of the facility on a gurney by the local fire department and paramedics. During an interview on 10/17/2023 at 2:30 PM Staff A (Administrator) stated Staff C (Case Manager) was passing afternoon snacks, approached Resident 1's room and the door was closed. Upon entering the room Staff C observed Resident 2 with their pants down past their knees and on top of Resident 1. Resident 1 was observed by staff to be naked from the waist down. Staff C immediately asked Resident 2 to get off of Resident 1, which Resident 2 complied and removed Resident 2 from Resident 1's room. Staff C requested immediate assistance from other staff members. Resident 2 was placed on a one on one caregiver (one caregiver assigned to one resident to provide constant supervision) until being sent to the hospital for an assessment. Resident 1 was assessed by a nurse; no bruising or abnormalities were observed to the genital area. The facility informed the physician who gave orders for Resident 1 to be assessed at the hospital. Review of an ER Encounter note, dated 10/17/2023, showed the facility staff called 911 due to a report of alleged sexual assault. A Sexual Assault Nurse Examiner (SANE) performed an examination on Resident 1 that showed no signs of severe trauma to the genital area. Resident 1 was later sent back to the facility. <Resident 2> Review of a 10/17/2023 Medicare 5-day MDS showed Resident 2 admitted to the facility on [DATE], was not able to make their own decisions, and had short and long term memory loss. Resident 2 had medically complex conditions that included Alzheimer's dementia, anxiety, and insomnia. The MDS showed Resident 2 had behaviors that included hallucinations (perceptual experiences in the absence of real external sensory stimuli), delusions, physical behaviors directed towards others (such as hitting or throwing objects), and other behavioral symptoms not directed at others. Review of a Behavior CP, dated 10/11/2023, showed Resident 2 had exhibited physical aggression towards others when they felt threatened. The CP directed staff to analyze and document the time of day, place, circumstances, triggers, and what deescalated Resident 2's behaviors. The staff were supposed to assess and address any contributing factors and assess and anticipate the resident's needs, such as food, thirst, toileting, comfort level, positioning, and pain. When Resident 2 was observed as agitated, staff were directed to intervene before agitation escalated, guide the resident away from the source of distress, and engage calmly in conversation. Review of a Psychiatric Provider note, dated 10/16/2023, showed Resident 2 was referred to the Psychiatric Provider for mood evaluation and medication review. The provider documented that Resident 2 was impulsive at times when not assisted immediately by staff, and yelled and cussed at staff because no one assisted them [Resident 2] with the telephone. Resident 2 told the Psychiatric Provider that they were in the Indian Army for a long time, the shrapnel hit my forehead, and since then I have been like this ., I can't control it, I get upset. The Psychiatric Provider recommended increasing a mood stabilizer medication for Resident 2's dementia with behavioral disturbances and agitation. Observations on 10/17/2023 at 2:32 PM showed Resident 2 sitting in a chair in the hallway with a one on one staff member present. Resident 2 was observed smiling and drinking a cup of coffee. In an attempted interview at the same time showed Resident 2 was not able to answer complex questions due to their dementia and English as a second language. During an interview on 10/17/2023 at 2:35 PM Staff B (Director of Nursing) stated Resident 2 was new to the facility and admitted seven days prior. Staff B stated Resident 2 had a known history of being verbally aggressive towards staff and throwing items, but the facility was not aware of any history of sexual inappropriateness. Staff B stated Resident 2 spoke another language and usually did not talk with other residents. Review of a 10/17/2023 facility investigation showed based off staff timelines and the SANE nurse examination, the facility was not able to substantiate sexual penetration but based on the fact that Resident 2 touched Resident 1 without their consent, abuse could not be ruled out. In an interview on 10/30/2023 at 2:56 PM with Staff A and Staff B, Staff A stated it was unfortunate that this occurred and if the facility knew of this type of behavior with Resident 2, preventative measures would be in place. Staff B stated Resident 2 would not be returning to the facility to ensure the safety of all residents in the facility. REFERENCE: WAC 388-97-0640(1)

Based on observation, interview and record review, the facility failed to identify, protect, assess, report and prevent a pattern of resident to resident abuse. This included identifying a known pattern of aggressive behaviors by Residents #42, #49 and #77, three of 19 sample residents. Abusive behaviors identified by staff included hitting, punching, kicking, ramming into other residents with a wheelchair (w/c), verbal abuse, threats and intimidation of other residents. The facility failed to recognize these incidents as abuse, even though staff identified immediate responses to instances of abuse. The facility did not analyze the circumstances of these abusive behaviors or implement plans for prevention or recurrence. Failure to recognize multiple incidents of resident to resident altercations as abuse placed residents at risk of serious injury or harm. This failure resulted in an Immediate Jeopardy (IJ) related to abuse on 02/28/2020. The facility reassessed residents #42, #49 and #77 and provided training for all staff regarding recognizing and reporting abuse, which led to the removal of the IJ on 03/03/2020. Findings included . A July 2018 facility policy titled, Accidents/Hazards/Devices, showed the facility recognized that resident to resident altercations could be a situation of abuse, and that reasonable precautions would be taken when the risk of resident to resident altercations was present. In addition, interventions would be implemented to minimize or control incidents of disruptive or intrusive behavior to minimize altercations. RESIDENT #42 Resident #42 admitted on [DATE] with care needs related to depression, dementia and other chronic illnesses. According to the resident's Care Plan (CP), revised on 01/30/2020, he had the potential to be verbally and physically aggressive towards others. On 02/27/2020 at 10:25 AM, four staff were observed in Resident #42's room. He was seated on his bed, while a staff member told him he would need to take some time in his room and calm down, and she would check back with him when he was calmer. At 10:30 AM, Staff J, Social Service Assistant (SSA), was asked why Resident #42 was needing time to calm down. According to Staff J, as she exited a room on the South Hall, she observed two staff in the hallways attempting to separate Residents #42 and #49 who were both agitated. Staff J stated Resident #42 was making threatening comments to (Resident #49). Three staff who were present separated the residents. Resident #42 was escorted back to his room by staff. A 02/27/2020 progress note by Staff J after this incident described Resident #42 as agitated and striking Staff J's arm. The note did not identify any threatening behavior towards Resident #49. Threats or intimidation are included in the definition of mental abuse, which staff have a responsibility to recognize and report to the Administrator and the State Agency (SA). On 02/28/2020 at 10:22 AM, Staff J was interviewed about her response to the resident to resident altercation on 02/27/2020. When asked to clarify what type of threats Resident #42 made to Resident #49, Staff J said she recalled Resident #42 saying I'm gonna kick your a** as the two residents moved towards each other in their wheelchairs. At this point, staff separated the residents. When asked who was notified of this incident after the residents were separated, Staff J said she talked to Staff B, Director of Nursing (DON). When Staff J was asked if she had notified the Administrator, she said she did not remember. When asked if she considered the altercation between Residents #42 and #49 as abuse, she said it was not. When asked to clarify why it was not abuse, Staff J replied, Because there was no resident to resident contact and (Resident #49) said he was okay. When Staff J was asked if it was acceptable for one resident to threaten another resident, she replied, No. As the current definitions of mental abuse, mistreatment, threats and intimidation were reviewed, Staff J acknowledged the behavior she observed on 02/27/2020 met the definition of mental abuse. The incident was not reported to the Administrator. ADDITIONAL INTERVIEW: On 03/03/2020 at 9:35 AM, Staff C, Social Service Director, was interviewed regarding her recent training about abuse and resident to resident altercations. When asked about her understanding of when abuse occurred, she replied, When there is physical or emotional harm. Her response failed to identify the occurrence of abuse as one or more defined behaviors, whether or not a resident reported or sustained some type of harm. After further discussion to clarify this definition, Staff C said she did see the difference and the need to focus on the resident's behavior at the time of an incident to determine abuse, with efforts to later determine if harm had occurred after the incident. RESIDENT #49 Resident #49's 01/03/2020 Annual MDS (Minimum Data Set-an assessment tool) showed the resident admitted on [DATE] with multiple complex medical and cognitive conditions. The assessment showed the resident had verbal behaviors directed toward others for one to three days in the look-back period. The resident's care plan, last revised 02/24/2020, showed the resident could be .verbally and physically aggressive . and had .Potential for injury to self or others . Review of progress notes for Resident #49 showed that on 10/20/2019 the resident exhibited .many inappropriate behaviors, one resulting in a (sic) aggressive confronting with another resident. A note, dated 10/22/2019, showed, Resident blocked another resident in the hallway and grabbed her hand and arm, then hit her. A note of 11/23/2019 showed the resident attempted .to run into ambulating resident with his w/c and grabbed a hold of another resident's w/c and pulled her backwards. The note also said the resident .attempted to kick another resident in her w/c as she was passing by. A note of 11/24/2019 showed the resident was noted to be hitting (unidentified person's initials). The note also showed staff tried to move Resident #49 away from the other unidentified person when Resident #49 .grabbed a hold of (unidentified person's initials) w/c. A note of 01/08/2020 showed Resident #49 was witnessed .yanking on (unidentified person's initials) arm in entryway . A note of 02/16/2020 showed Resident #49 was .heard cussing at his roommate. On 02/28/2020 at 12:05 PM, the above findings involving Resident #49 were discussed with Staff B. No further information to show the facility developed and implemented interventions to prevent future altercations or abuse between Resident #49 and other residents was received. RESIDENT #77 Review of the medical record showed Resident #77 was admitted to the facility on [DATE] with multiple medical and psychiatric diagnoses. Review of a CP, initiated and revised on 01/25/2020, showed, (Resident) is/has potential to be physically aggressive r/t (related to) Poor impulse control, with the goal of, (Resident will not harm self or others, and (Resident) will verbalize understanding of need to control physically aggressive behavior through the review date. Interventions, also initiated 01/25/2020, identified triggers for physical aggression and what to do when the resident became agitated, such as intervening before agitation escalated, guiding away from source of distress, engaging calmly in conversation, and to re-approach later. Additionally, the resident's CP showed an intervention dated 02/23/2020 to get a case manager or charge nurse to assist if the resident is continuously yelling and is bothering others. Review of a progress note dated 12/06/2019 at 1:33 AM, showed, Res (Resident) has been up and about in the facility. He has been loud . He has been coming to the NS (Nursing Station) making verbal threats, fire-ring (sic) staff, then wheels away quickly . has been out in the smoking patio with another male res (Resident #13) making threats, which are becoming more explosive, more difficult to redirect. Call placed to MD for a PRN (as needed medication) or to review his current meds (medications), for possible med change. Awaiting C/B (call back). A subsequent 12/06/2019 progress note showed, At ~(approximately) 0200 (2:00 AM) (Resident) is seen talking to himself loudly outside the porch near another res (Resident #13), who told him to shut the f*** (expletive) up: (Resident #77) retorted You have no right to tell me what to do which enraged Resident #13; the two engaged in a shouting match, got closer to each other and almost engaged in a physical fight; we broke them up in time. (Resident #77) then made provoking statements such as 'Let me go say one last word to him' 'I'll make sure he's in jail'. A subsequent progress note of 12/06/2019 and timed at 2:37 PM showed, Once outside could hear both (Resident #13) and (Resident #77) yelling at each other, (Resident #77) yelling at (Resident #13) 'I'm going to kill you!' As staff separated the two . A) (Assessment) (Resident #77) had several verbal altercations with others this shift, easily agitated P) (Plan) Will place on alert for increased agitation. The above findings were shared with Staff J on 02/28/2020 at 8:41 AM. When asked how the interventions were changed or what precautions were taken to prevent future altercations between Residents #77 and #13, or other residents, Staff J stated, I will find out. When asked if the record showed who were the others Resident #77 had verbal altercations with, Staff J stated, I honestly don't know the answer to that. I can try to dig some information for this. When asked if it was relevant that Resident #77's CP showed he had altercations with Resident #13, Staff J stated, Absolutely, so we can all protect. When asked if the above resident to resident altercations represented abuse, Staff J stated, That would depend on how the other person responded. When asked what kind of abuse yelling was, Staff J stated, It can be verbal and can cause psychological harm and how the other person perceives it. When asked what kind of abuse the words, I'm going to kill you! represented, Staff J stated, That is a threat and is verbal abuse. No further information was provided to show the facility developed and implemented interventions to prevent future altercations or abuse between Residents #77 and #13, or other residents. Review of a progress note dated 12/07/2019 showed, At approximately 0615 (6:15 AM), resident was propelling w/c from outside through day room. Resident #13 was blocking (Resident #77) way out of day room and refused to move. (Resident #77) pushed Resident #13 w/c to move him. (Resident #13) reached around and punched (Resident #77). (Resident #77) started to punch back. LN (Licensed Nurse) got in between the two residents and moved (Resident #77) to south end of building. This LN held (Resident #13's) w/c to prevent him from following (Resident #77). All other residents removed from the area. (Resident #13) continued to yell and scream profanities at (Resident #77) and staff, using threatening language. (Resident #77) responded with threatening language when being escorted to south. Another 12/07/2019 note showed, Resident will be monitored very closely. In this continued interview with Staff J, when asked what kind of abuse punching represented, Staff J stated, Physical. When asked if interventions changed to show how staff would monitor Resident #77 closely, Staff J stated, I will find out. No further information was provided to show the facility developed and implemented interventions to prevent future altercations or abuse between Residents #77 and #13, or other residents. Review of a progress note dated 12/07/2019 at 2:41 PM, showed Resident has been quite labile throughout the day. Had another minor verbal altercation with another resident today. In this continued interview, when asked if the record showed who the other resident involved in the verbal altercation was, Staff J stated, I don't know. I think it would be important to pass on (that information). No further information was provided to show the facility developed and implemented interventions to prevent future altercations or abuse between Residents #77 and the other resident. Review of a progress note dated, 12/08/2019 at 4:25 PM showed, .this afternoon, kicked at another resident's wheelchair that was in front of him. The med (medication) nurse was right there when this occurred and she states that the other resident had been quietly sitting there when he kicked out at the chair with his foot will remain on alert for behavior towards others. Additionally, a 12/08/19 progress note timed at 5:21 PM showed, (Resident #77) has had behaviors in the facility that are aggressive, disorganized and seemingly out of control . his grabbing at other residents the last two days is unclear. Review of a progress note dated 12/08/2019 and timed at 7:51 PM showed, Res has had aggressive behavior during this shift, and kicked at another residents wheel chair (Resident #46) when (Resident #46) came to this writer for meds. NO visible injury noted. Kept away from each other . will cont to monitor. In this continued interview, when asked if the record showed the facility identified who the other residents were that Resident #77 was grabbing at, Staff J stated, Not in this note. When asked if Resident #46's record showed he was involved in a resident to resident altercation with Resident #77, Staff J stated, No. When asked what she expected to happen for the alleged victim in a resident to resident altercation, Staff J stated, A note reflecting whether he felt safe or ruling out psychological harm. When asked what kind of abuse kicking represented, Staff J stated, Kicking can also be considered physical abuse. When asked if the facility developed and implemented interventions to prevent future altercations or abuse between Residents #77 and #46, or other residents, Staff J stated, I will find out. No further information was provided. Review of a 12/13/2019 progress note for Resident #77 showed, He continues to exhibit unpredictable behavior exacerbated by mood lability, and During this shift he was hitting and ramming people with his wheel chair. He mentioned that I should call the police. I told him if he continued with this bx (behavior) I might. Since he was all for me calling the police I changed the direction of the conversation and nurse gave him a prn. He kept going in and out of his room as in defiance. I told him it was okay to come out of his room if he was calmer and stopped threatening both residents and staff. In this continued interview, when asked if the record showed who the people were Resident #77 was hitting and ramming, Staff J stated, It does not say. When asked what kind of abuse ramming and hitting people represented, Staff J stated, Physical abuse. When asked what kind of abuse threatening residents represented, Staff J stated, It can be psychological harm. When asked what the facility did to protect the residents from recurrence of resident to resident physical or mental abuse, Staff J stated, I'll try to find out what I can. When asked if interventions changed to prevent future resident to resident altercations, Staff J stated, I will find out. No further information was provided. A 12/14/2019 progress note showed, It was reported to this writer that the resident was up most of the night. When this writer arrived, resident was yelling at everyone around . Social service team will continue to monitor this resident. A 12/15/2019 progress note showed, (Resident) tried to ram into me with his wheel chair but instead he hit another resident's wheel chair. This writer then stopped him from ramming into us again and took him to his room . I asked him if he planned to hit anyone else and he said maybe . is impulsive and aggressive. He focuses on staff but is unaware when other residents are near. He stated he feels he cannot control his anger. A subsequent 12/15/2019 progress note showed, Resident has been on alert for agitation, also for hitting staff, and other residents . In this continued interview, when asked who everyone Resident #77 yelled at on 12/14/2019 was, and if the staff followed up on the potential effects of the yelling on other residents, Staff J stated, I will find out. I think again it's a matter of investigating and doing our work. When asked if staff re-evaluated interventions to prevent future resident to resident altercations or abuse, Staff J stated, I will find out. No further information was provided. A 01/25/2020 progress note showed, I have intervened a few times this shift with (Resident #77) and (Resident # 71). The first being outside where Resident #71 was screaming at her (sic) and he was yelling at her to Stay away from me or I'll hit you! That incident I was able to separate w/o (without) any contact. Then later during dinner (Resident #71) had sat near the dining room and as (Resident #77) was rolling by she began yelling at him to not steal from her and raised her fist, he then struck her on the right shoulder. The two were separated before any further incidents happened . appears to be responding to other residents agitation . will place on alert for increased agitation. In this continued interview, when asked if the record showed what interventions were put in place to prevent recurrences of resident to resident altercations or abuse between Resident #77 and Resident #71, Staff J stated, No. When asked why it took 51 days to develop interventions to manage recurring resident to resident altercations and abusive behaviors identified since 12/06/2019, Staff J stated, I would have to look and see what we have. When asked if the record showed the facility put measures in place to protect Resident #77 and other residents from recurring verbal and physical abuse, Staff J stated, I will look for that. No further information was provided. The above findings were shared with Staff B on 02/28/2020 at 11:39 AM. Staff B stated, Resident to resident altercations are interesting here. It depends. If there's any indication the residents physically harm one another or psychological harm happened then we follow the abuse protocol. When asked if she recognized Resident #77's behaviors as abuse, Staff B stated, Sure, and I would only know about them if I had received an incident report. The above findings were shared with Staff A, Administrator, on 02/28/2020 at 10:30 AM. Staff A stated he was unaware of the resident to resident altercations and recurring abusive behaviors and stated, I don't dispute, it's resident to resident altercations. Staff A identified punching, kicking, ramming into others with a wheel chair, hitting, and threatening others as abuse, and stated, There definitely is some retraining needing to be done right here. Do they (staff) really know abuse and neglect? These were examples of abuse and of not investigating it properly which we should be. Our system needs to be worked on. REFERENCE: WAC 388-97-0640.

Based on observation, interview and record review, the facility failed to use other alternatives to side rails, recognize or protect one resident (#74) of six, a dependent resident for bed mobility, from the dangers of entrapment after gathering information and completing assessments; failed to have a system in place to monitor and or maintain bedrails; failed to assess and provided risk information for side rail use, for two residents (#8 and #22) of six residents. These failures placed the other residents at risk for harm, such as entrapment. This failure resulted in an Immediate Jeopardy (IJ) related to side rails on 02/23/2020. The facility re-evaluated and modified Resident #74's side rails and provided training for all licensed staff, which led to the removal of this IJ on 02/25/20. Findings included . Review of a February 2018 facility policy titled Quality of Care Bed Rails showed the facility would attempt to use alternatives prior to installing a bed rail. It also stated, prior to implementation, the facility would assess each resident for risk of entrapment. The policy showed that if a bed rail was implemented, the resident would be re-assessed at routine intervals to verify its need. RESIDENT #74 A 02/07/2020 quarterly MDS (Minimum Data Set-an assessment tool) showed Resident #74 was admitted to the facility on [DATE] with multiple complex conditions including a neurological condition with symptoms of muscle spasms affecting movement and posture, a [MEDICAL CONDITION] disorder, muscle weakness and severe intellectual disability. The assessment showed the resident did not speak, rarely/never understood others, and had short term and long term memory problems. The assessment also showed the resident had severely impaired cognitive skills for daily decision making and had physical behaviors directed toward others. The assessment showed the resident was totally dependent on two persons for bed mobility, did not walk, and had range of motion (ROM) impairments of all extremities. The assessment endorsed the use of bed rails daily. Resident #74's 11/11/2019 admission MDS also showed daily bed rail use, and stated, .two side rails due to frequent [MEDICAL CONDITION], and He is always placed in the middle of the bed but he can occ (occasionally) scoot. The MDS said the resident could not sit up on his own, stand or bear weight. The MDS also showed the resident .may be appropriate for a low bed and mat next to bed, may approach family with this later. Review of an 11/07/2020 interdisciplinary care plan conference note showed Resident #74's parents indicated the resident, .has the capacity of a 7-9 month old. Resident #74's care plan (CP), last revised 02/20/2020, showed the resident had two assist rails for bed mobility. In another entry the CP said the resident had a half rail to allow the resident to, .move freely while in bed r/t (related to) [MEDICAL CONDITION] activity and (Resident #74's neurological diagnosis). The care plan said the resident had a behavior of hitting or biting himself if in pain, was at risk for falls, and was Unaware of safety needs. The care plan stated, The resident uses physical restraints r/t bilat (bilateral) ½ rails. The plan instructed to Evaluate the resident's restraint at least quarterly. Review of a Medication Administration Record [REDACTED]. Review of a Physical Therapy (PT) evaluation dated 11/06/2020 for Resident #74 showed the resident had impaired ROM of all extremities, impaired strength in the lower extremities, and contractions in the right hand, both ankles and the right knee. The evaluation did not include a side rail evaluation. Review of a Fall Risk Evaluation dated 02/03/2020 showed the resident was not at risk for falls, and had decreased muscular coordination. Review of provider orders showed on 11/04/2019 a physician wrote an order, May have bedrails to assist with bed mobility and for [MEDICAL CONDITION]. Review of a Bed Rail Screen dated 11/04/2019 showed the rationale for bed rail use was Medical Condition, specified as [MEDICAL CONDITION] and a neurological disease, and the resident displayed impaired safety awareness. The question, Have alternatives to bed rails been attempted? was answered, NA (not applicable)-Resident/Family refuse (sic) alternatives to bed rails. The screen showed the document included comments by staff, Family very concerned of resident not having rails as he uses also for bed positioning and due to [MEDICAL CONDITION] activity and .no ability to understand safe or unsafe instructions. The screen showed the resident had spontaneous body movement and instability when sitting. The question, Is the resident able to move self in bed? was answered Yes. It also said the resident could move himself side to side, up and down in the bed, and could pull himself to a seated position. Progress notes dated 11/07/2019 showed Resident #74 was .restless throughout the night . On 11/08/2019 the resident had increased agitation. A note of 11/11/2019 showed the resident was .easily agitated . Review of [MEDICAL CONDITION] Episode forms showed Resident #74 had a three second [MEDICAL CONDITION] on 11/29/2019 which included jerking of his left arm and left leg. Another [MEDICAL CONDITION] Episode form showed on the same day the resident had a 30 second [MEDICAL CONDITION] which included jerking of his left arm and both legs. SURVEY OBSERVATIONS Initial observation on 02/23/2020 at 8:53 AM showed Resident #74 in a bed with side rails raised on both sides of the bed. The side rails were located along the middle two thirds of the bed. Both rails were uncovered metal about an inch and a half in diameter, and consisted of a top, middle and lower bar. On the same day at 12:54 PM, the resident was observed in bed with both side rails raised. The head of the bed was elevated, and the resident's head leaning to his left. On 02/23/2020 at 1:38 PM, the resident's right side rail was observed to have a four and a half inch space between the top and middle rail. The space between the middle and bottom rails was five inches. No padding or pillows were on or near the rails. At this time, Resident #74 was observed to be repeatedly lifting up and banging down his left arm on the mattress. INTERVIEWS On 02/23/2020 at 9:00 AM, Resident #74's representative was asked why the resident had side rails. The representative replied the resident had [MEDICAL CONDITION] at night, and the rails were there so the resident would not fall on the floor during a [MEDICAL CONDITION]. He was asked how long the resident had had the rails. He said since the resident's admission three to four months prior. The representative was asked if Resident #74 could use the rails to reposition himself, and he replied the resident could not. On 02/23/2020 at 11:58 AM, Staff H, Certified Nursing Assistant (CNA) was asked why Resident #74 had side rails on his bed. Staff H replied it was because the resident got excited and it helped him not to fall. Staff H was asked what she meant by excited and said this meant the resident curled himself up in bed and tried to roll over to the side. Staff H commented, Sometimes we find him over to the side, so the rail helps prevent him from falling. On 02/23/2020 at 1:01 PM, Staff I, Registered Nurse (RN) and charge nurse, was asked if she had ever observed agitated behavior by Resident #74. Staff I said she had, and she was asked what this behavior had looked like. Staff I described the behavior as hyper. When asked what she meant by hyper, Staff I demonstrated by moving her arms around in a chaotic manner. Staff I said the resident's family wanted a pillow inside each side rail so the resident, can't kick the side rail. Staff I said the resident was not capable of using a side rail and did not reposition himself. Staff I was then asked why Resident #74 had side rails, and replied, Just for the safety reason because sometimes he's hyperactive . so he wouldn't jump out or fall from the bed. Staff I was asked if she thought there was any risk of injury related to Resident #74's side rails and she said there was not. When asked why this was, Staff I said it was because the resident could not jump, never hit his head, and had no falls. Staff I concluded the resident's family wanted side rails in place, and we're just following them (their instructions). When Staff I was asked if the purpose of the side rails was to keep the resident in bed, she replied it was. INTERVIEW DIRECTOR OF NURSING On 02/23/2020 at 3:37 PM, Staff B, the Director of Nursing (DON) said side rails rarely were used at the facility, and they were usually used for positioning purposes. Staff B said it was the facility's practice to try everything before using a bed device. Staff B was asked if she was aware Resident #74 had side rails on his bed. Staff B said she remembered the resident's parents wanted side rails, and added, We were going to try to get rid of them. When asked the reason for this, Staff B said it was because the facility was going to try alternatives. Staff B said the staff told Resident #74's family the facility was not supposed to use side rails, .but I remember the family really wanting them. Staff B was asked if using side rails for this resident placed him at risk. Staff B replied the resident had no ability to get out or over the rails, and clinically had no risk because the rails did not restrict the resident from doing anything. Staff B said of Resident #74's side rails, they were there for safety and, They're there basically there to keep his family happy. Staff B then commented, I'm sure we're acquiescing to what they (his family) believe to be the safest, We've done what we've done with (Resident #74) because of his family, and his family was .very insistent that this (use of side rails) was what needed to be done. Staff B said she didn't know if anyone approached the family about removal of the side rails. A Bed Rail Screen done 02/23/2020 at 6:30 PM showed the indication for side rails for Resident #74 were documented as, Medical condition and Family Request, and that alternatives to bed rails had not been attempted. RECONFIGURED SIDE RAILS On 02/25/2020 at 9:30 AM, Resident #74 was observed in bed. The two side rails were raised, and had been padded with pillows on the inner aspect of each side rails. The pillows were held in place by pillow cases. FOLLOW-UP INTERVIEWS On 03/02/2020 at 7:43 AM, Staff E, Therapy Director, was asked if therapy had evaluated the resident's side rails. Staff E referenced the physical therapy assessment done on 02/27/2020. Staff E said staff needed to keep the side rails padded due to the potential for injury to the resident, since he could hit his head or slip an arm through a rail. On 02/25/2020 at 9:30 AM, during a follow-up interview with Resident #74's representative, he said he was still concerned about the resident falling out of bed during a [MEDICAL CONDITION]. The representative was asked what the resident did during a [MEDICAL CONDITION] and the representative replied the resident's hands and legs curled up, and when he did this, his body rolled away, which made him fear the resident would fall to the floor. The representative said during a [MEDICAL CONDITION], the resident's body would move side to side and the resident could not control his body. When asked if the resident could have gotten stuck in the rails during a [MEDICAL CONDITION], the representative said he could. The representative was asked what he thought of the padded side rail modifications. He replied it was good for the resident's safety. SIDE RAIL MONITORING On 03/03/2020 at 10:29 AM, Staff D, Maintenance Director, was asked if there was a system of inspection of beds, rails and mattresses for resident safety. Staff D replied this was something staff was working on but had not been assigned to him. When asked who was responsible for inspecting bed rails before safety issues were identified during survey, Staff D replied, I don't know who it would be. I assume it would be nursing, right? Cause they're the ones that order the bed rails. Staff D said he had installed bed rails to Resident #74's bed. On 03/04/2020 at 9:18 AM, Staff A, Administrator, was asked what measure the facility used to ensure beds and side rails were inspected on a routine basis for safety. Staff A said he believed Staff D inspected side rails monthly and as needed. Staff A was asked if there was a record of regular bed/bed rail inspections and he replied Staff D logged the side rail inspections in a software program. At 10:14 AM, Staff A was asked for the side rail safety audit. Staff A said he did not have it, and that perhaps Staff D had not done it. RESIDENT #8 The 02/19/2020 quarterly MDS for Resident #8 showed the resident re-admitted on [DATE] with multiple complex medical and psychological conditions, including [MEDICAL CONDITION], hallucinations, delusions, and a progressive [MEDICAL CONDITION] condition of the nervous system. The assessment showed the resident had unclear speech, moderately impaired vision, and had short and long term memory problems. The assessment showed the resident had moderately impaired skills for daily life decisions and her behaviors included inattention, and intermittent disorganized thinking. The assessment also showed the resident was dependent on staff for bed mobility and transfers, and did not use restraints or bed rails. During the afternoon of 02/23/2020 Resident #8 was observed to have a raised side rail along the upper left side of her bed. On 03/04/2020 at 8:00 AM, the resident's bed was observed to have no side rails in use. Review of Resident #8's medical record did not reveal evidence of a safety evaluation for side rail use. Review of physician orders [REDACTED].½ side rails on bed to aid in mobility and transfers per her request. Review of Resident #8's care plan, last revised 02/23/2020, showed that on 02/23/2020 the plan was revised to include the statement, Resident uses left ½ side rails to aid on bed mobility per her request. On 03/04/2020 at 8:26 AM, Staff B said she thought side rails were initiated after Resident #8 changed rooms. Staff B said due to a change in rooms, a resident might be placed in a bed with side rails previously attached. Staff B said she saw the side rail on Resident #8's bed when a facility reassessment of side rail use was done. Staff B said, She (Resident #8) does not need a side rail and the side rail previously observed on Resident #8's bed was used by another resident. Staff B said after she observed the rail in use she asked Staff D to remove it. RESIDENT #22 Review of the medical record showed Resident #22 admitted to the facility on [DATE] with multiple care needs and [DIAGNOSES REDACTED]. A 12/13/2019 Quarterly MDS showed Resident #22 was assessed to have moderately impaired cognition. Observations on 02/23/2020 at 1:00 PM and 03/04/2020 at 8:49 AM showed a raised quarter rail on the right side of Resident #22's bed. Review of Resident #22's care plan, revised on 02/24/2020, showed The resident uses grab bar ¼ rail that is on the right side of bed to help with bed mobility, transfers, and sitting up in bed. Interventions included, Assess for appropriateness of the rail at least quarterly. Review of the medical record showed an order, dated 02/23/2020, which read, Quarter Rails that stands straight up on the right side of the bed to assist resident with mobility and with sitting self up in bed. In addition, review of the medical record showed a Bed Rail Screen completed 02/24/2020. No previous Bed Rail Screens were found. In an interview on 03/04/2020 at 8:55 AM, when asked how long the quarter side rail had been in use for Resident #22, Staff O, Certified Nursing Assistant (CNA), stated, For a long time, more than three years 'cause she used to be independent. In an interview on 03/04/2020 at approximately 8:30 AM, when asked how long the quarter side rail had been in use by Resident #22, Staff P, Licensed Practical Nurse (LPN) stated, At least nine months ago she has had it. The above findings were shared with Staff K, Charge Nurse, on 03/04/2020 at 8:58 AM. When asked how long the quarter side rails had been in use by Resident #22, Staff K stated, I'm not sure . it's not been that long probably six months or so since she had had the rail. When asked how often bed rail screens were conducted, Staff K stated, Every three months, and acknowledged, We are in error, we should have done the assessment every three months. When asked if there was an order and care plan entry for the quarter rail prior to the 02/23/2020 date, Staff K stated he would, look to see. No further information was provided. REFERENCE: WAC 388-97-1060(3)(g)

Based on interview and record review, the facility failed to develop, implement and re-evaluate interventions to prevent recurrence of falls or fall-related injuries for one (#77) of five residents reviewed for unnecessary medications. This failure resulted in harm to Resident #77, who had 12 falls between 11/11/2019 and 02/27/2020, sustained small lacerations to his head, eye or cheek, and required two hospital transfers due to lacerations incurred with falls. For one of the other five residents reviewed (#49), the facility failed to complete root cause analysis of five falls, one of which resulted in an injury. This failure resulted in staff inability to prevent recurring falls related to not completing assessments or revising care plans. Findings included . A July 2018 facility policy titled Accident Hazards/Supervision/Devices showed the facility would evaluate potential causative factors to help in the development and implementation of relevant, consistent and individualized interventions to reduce the likelihood of recurrent falls. This policy showed the facility would determine what caused or contributed to the fall, including what the resident tried to do before the fall, and the resident's care plan or facility practices would be revised as needed to reduce the likelihood of another fall. RESIDENT #77 Review of the medical record showed Resident #77 admitted to the facility on [DATE]. An 11/19/2019 Care Assessment Area (CAA) note showed, The resident has had several falls at his prior living situation, AFH (Adult Family Home). He has had two falls here, one at the bedside at 7 in the morning trying to transfer without assistance. He lost his balance and fell on his bottom. He had a second fall in the mens (sic) room, trying to transfer himself, this occurred at 915 in the morning. He is impulsive and still wants to be independent. He is at risk for falls due to dementia, [MEDICAL CONDITIONS] (lung disease). He is currently working with PT (Physical Therapy) and OT (Occupational Therapy) for improved mobility, ADL's (Activities of Daily Living), balance and safety. He is not safe walking on his own. He is able to use the w/c (wheel chair) independently but still needs help with transfers. Review of an 11/09/2019 OT Evaluation showed, Patient Goals: patient stated, I want to get stronger and not fall. Review of a Falls CP, with a date initiated and revised of 11/11/2019, identified contributing factors of Poor communication/comprehension. Interventions, also dated 11/11/2019, showed staff were to monitor changes in mental status, pain or bruises and to take vital signs one time in the first 24 hours. The resident's CP showed no additional interventions after 11/11/2019 to prevent further falls. Another Falls CP, dated 11/20/2019, showed, The resident is at risk for falls, and identified contributing factors of, Confusion, Gait/ (and) balance problems, incontinence, Poor communication/comprehension, psychoactive drug use, unaware of safety needs, vision/hearing problems. This CP showed interventions, dated 11/20/2019, which included, Anticipate and meet the resident's needs, Be sure the call light is within reach and encourage the resident to use it for assistance as needed, Bed against the wall, Ensure commonly used items are within reach of resident prior to leaving room, Ensure the resident is wearing appropriate footwear (non skid shoes, non-skid socks, etc.) prior to transfers or ambulating, PT to evaluate and treat as ordered, and to, Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter (or) remove any potential causes. The resident's CP showed no additional interventions after 11/20/2019 to prevent further falls. Review of an 11/11/2019 progress note timed at 7:15 AM showed, noted resident was sitting on the floor and facing his bed. He denies hitting his head but he did fall to the floor. Review of an 11/11/2019 Incident Report (IR) showed, He (Resident) stated he tripped on the ft. (foot) rest of w/c (wheel chair) - He was not wearing shoes, only socks on ft (feet). This investigation showed the Plan to Prevent Recurrence was to Encourage resident to ask for assist. Frequent checks. Ensure w/c breaks (sic) are on. This investigation showed the facility discussed the fall with therapy services during Stand Up (an interdisciplinary meeting). In an interview on 03/01/20 at 8:39 AM, when asked if the interventions showed how often staff would frequently check on Resident #77, that staff should ensure his wheel chair brakes were on, or how staff would anticipate the needs of a resident identified with cognitive and communication impairments, Staff B, Director of Nursing, stated, I don't know how. It's a generic or canned intervention. Review of an 11/12/2019 progress note timed at 9:48 AM showed, found (Resident) on the floor, middle stall, sitting on the foot rests of his w/c, the back of his w/c was leaning over him. Resident was holding on to the bathroom rail with his right hand . Resident was fully dressed but only wearing socks. Resident had PT/OT eval but they are currently not working with him. Will discuss with SS (Social Services) and DNS (Director of Nursing Services) for room change closer to the NS (Nursing Station) r/t (related to) his impulsive behavior . Review of the 11/12/2019 IR showed, He was up using restroom, and Bathroom is too sm (small) space, for his w/c & (and) him to use. This report showed the plan to prevent recurrence was, Move to room [ROOM NUMBER]B . for closer observation, and Let resident know he can he can use alternate bathroom (shower room). cont (continue) with PT/OT for transfer, standing balance, and ADLS. This investigation showed the facility discussed the fall with therapy services. Review of an 11/13/2019 PT note showed, Pt (Patient) educated and instructed to safety with using call light and wait for assist before getting up . Pt has had two falls in this week, in his room and in his BR (bathroom). When asked if the facility assessed Resident #77's toileting pattern to assist staff to anticipate the resident's self-transfers associated with toileting needs, Staff B stated in this continued interview, His short term memory is not great and he is totally incontinent. He doesn't self-initiate going to the bathroom. When asked if the fall interventions directed staff to an alternate toileting location that would accommodate the resident's wheel chair, Staff B stated, I'd have to look. No further information was provided by Staff B. A progress note dated 11/14/19 and timed at 11:58 AM showed, Res. (Resident) was attempting to transfer himself from bed to w/c. The w/c rolled back. When res attempted to sit back on the bed, he was further away and sat on the very edge. He was able to lower himself to the floor as writer made it to him. An 11/14/2019 IR showed, Resident trying to go to WC, as the resident's intent. The staff identified the plan to prevent recurrence was to, Encourage resident to ask for assist. Encourage resident to lock brakes. This IR's summary showed the resident, Forgot to lock brakes was the root cause of this fall. This investigation showed the facility discussed the fall with therapy services during Stand Up. Review of an 11/14/2019 PT note showed, Instruction and education on safety awareness with transfers and use of call light. An 11/15/2019 PT note showed, Pt instructed on brakes and safety awareness. Pt encouraged to use call light. An 11/18/2019 PT note showed, Pt is encouraged to use call light to remove risk for falls. In this continued interview, when asked if the facility established why Resident #77 wanted to get out of bed, Staff B stated, I don't know that we would have looked at that. I don't see it. When asked if establishing why the resident wanted to get out of bed would help to anticipate his needs, Staff B stated, I don't think the etiology of why he was trying to get up was looked at. When asked if the investigation showed when was the last time staff checked on Resident #77 prior to the fall, Staff B stated, I don't see it. Review of a 12/04/2019 progress note showed, At 00:20 (12:20 AM) patient fell on the floor while transferring himself from wheel chair to bed. he pressed the call light to get our attention, he landed on his right hip, tried to catch himself by grabbing wheel chair and bed . his pants were around his ankles, wearing socks, wheel chair was locked . stated he lost his balance . Review of a 12/04/19 IR showed the resident's intent was, Attempting to transfer to bed. This report also showed the resident was referred to therapy and the plan to prevent recurrence was, Re-educated him (Resident) on asking for assistance . Continue with POC (Plan of Care) to continue to improve transfers and calling for help. Record review showed no results from the therapy referral. In this continued interview, when asked how staff compensated for and anticipated the needs of an impulsive resident with cognitive and communication impairments, Staff B answered, They just took his wheel chair and kept it out at night. When asked if the investigation showed what Resident #77 was doing prior to the attempted transfer from wheel chair to bed, Staff B stated, I can't speak to that. When asked if the investigation showed why the resident's pants were found around his ankles, Staff B stated, I don't see it. When asked if the interventions to prevent recurrence of falls changed, Staff B stated, I don't see it. Review of a 12/05/2019 progress note showed, Still cont (continues) to self transfer, occ (occasionally) forgetting to lock his w/c brakes. Review of a 12/11/2019 progress note showed, At 3 am writer heard noise from room & (and) checked, Resi (Resident) was on floor in lying left position close to the bed. Resident did not press his call light for help. Not hit his head . found small skin scrape on his left cheek. Resident did not verbalize how he was on the floor. He was more sleepy and confused. An IR dated 12/11/2019 showed the assigned care giver was not identified. This IR also showed the staff identified the medications [MEDICATION NAME] (antipsychotic) and [MEDICATION NAME] (anticonvulsants) had been increased on 12/07/2019 and 12/10/2019 respectively. In addition, this IR showed the plan to prevent recurrence included, Educate resident to press call light for help, and to, Instruct na-c (Nursing Assistant Certified) to make round frequent to check for toileting/transfer. This IR's summary showed, . appear to be secondary to attempting to transfer himself in a confused state. In this continued interview, when asked if the IR showed why the resident transferred on his own, what he was doing before the fall, or if the assigned care giver was interviewed, Staff B stated, No. When asked if the facility followed up on the identified sleepiness and its potential impact on falls, Staff B stated, No. When asked if the interventions to prevent or decrease falls changed to reflect frequent checks on the resident in order to anticipate toileting and transfer needs, Staff B stated, Don't see it. When asked if the facility put measures in place to compensate for the resident's impaired cognition, Staff B stated, No. When asked if educating a cognitively impaired and impulsive resident was a realistic intervention when the resident continued to show he did not alert the staff to assist him with toileting needs or transfers, Staff B stated, Probably not. Review of a 12/11/2019 progress note showed, Around 3:30am resi (resident) fell again on the floor and hit his head. Unknown how or what he hit when he fell . Writer noted to have blood on his right side of his head into his hairline. Resident was not responding to question, he turned to look at this writer and noted he has a deep laceration . Called 911 . sent to the VA hospital for further assessment. A 12/11/2019 IR showed the assigned care giver was not identified. This IR showed a referral was made to PT. This IR's summary showed, He is incontinent and does not appear to be responding to needs to toilet. Record review showed no results from the therapy referral. In this continued interview, when asked if the interventions changed to prevent falls associated with self-transfers or injury from falls, Staff B stated, No. When asked if the CP changed to address toileting needs as the facility identified he does not appear to be responding to needs of toilet, Staff B stated, I'd have to find out. When asked what the result of the therapy referral was, Staff B stated, I'd have to check with Staff E (Therapy Director). No further information was provided. Review of a social services note dated 12/11/2019 showed, It is unclear what his baseline is but his AFH (Adult Family Home) caregiver did tell this writer that he always got up in the middle of the night to smoke and had many falls at the time. He even broke his nose falling in his home at one point. When asked if the facility modified interventions to show Resident #77 had a pattern of falling at night, Staff B stated, I don't know. Have to ask the case manager that charted it. No further information was provided. A 12/13/2019 progress note timed at 1146 PM showed, Res found on floor lying on his abdomen side in his room small lacerations in his left eye brow hairline. basic first aid provided. And assisted back him to W/C. A 12/13/19 IR showed, Resident didn't verbalized (sic) how he fell from bed, and that wc was standing outside the room. This IR also showed the plan to prevent recurrence was to, Educate the resident to press the call light when he needs help. Ensure with CNA to make frequent rounds in this shift. This IR showed the resident's blood pressure dropped from lying to sitting position from 141/67 to 121/69, which reflected postural [MEDICAL CONDITION], a risk factor for falls. This IR showed the facility discussed the fall with therapy services during Stand Up. In this continued interview, when asked if the record showed the facility addressed the assessment of postural [MEDICAL CONDITION], Staff B stated, I will look if nurse reassessed. When asked if staff determined why the wheel chair was found outside of the room, what the resident was doing before the fall, and when was the last time Resident #77 was checked on, Staff B stated, No. When asked if staff determined why the resident got out of bed or his intent, Staff B stated, No. When asked how the interventions changed to prevent falls associated with self-transfers or injury from falls, Staff B stated, I'm not sure. I don't know. When asked if the repeated intervention of educating the resident to use the call light was appropriate after seven falls, Staff B stated, I have no answer for that. Review of a 01/07/2020 progress note, timed at 12:12 PM showed, Res found lying on the floor next to his bed .noting small puddle of blood on the floor under his head. Resident was fully dressed, but wearing no nonskid socks . Small superficial laceration on the back of his head . CNA reported that she helped him into his wc and it appeared that he was trying to get back into bed and fell towards the left side of his wc. Record review showed no documentation staff conducted a review of this fall. On 03/01/2020 at 09:15 AM, Staff B acknowledged the facility did not conduct an analysis of this fall or addressed interventions to prevent falls or falls with injury. Review of a 01/12/2020 progress note timed at 6:50 AM showed, Writer called by med (medication) nurse to assess resident in room [ROOM NUMBER]A. He was lying on the floor next to his bed. He has laceration to his head, little bit of blood noted. No need of dressing, and that Resident #77 told the nurse, I was trying to transfer to the w/c and fell down. Review of the IR report dated 01/12/2020 showed, He (Resident) was trying to transfer himself from bed to w/c as per his usual bx (behavior). This IR showed the plan to prevent recurrence was, Encourage him to use call light. Keep the w/c out of his room. Call light within reach. The report's summary showed, Too impulsive to have WC @ (at) bedside. Reminded to call us for assist to get up. In this continued interview, when asked if it was a realistic intervention to expect an impulsive and cognitively impaired resident to consistently use the call light or call staff for assist, or if those interventions were effective in decreasing falls, Staff B stated, No, and acknowledged the facility did not develop and implement interventions to decrease a pattern of falls or falls with injury since 11/20/2019. Review of a progress note dated 01/18/2020 showed, At 2130 (9:30 PM) CNA (Certified Nursing Assistant) notified writer that res is on the floor. Upon arrival, res was sitting next to the bed. Res states he sat down Review of the IR dated 01/18/20 showed, Res was trying to put himself in bed but when he couldn't get in, he sat down next to bed looks like res was trying to put himself in the bed. The report showed the plan to prevent recurrence was, educated on the need for call light use when needing help with transfers, keeping bed in lowest position, and watching out for surrounding furniture/environment/loose cords to prevent future falls. This investigation showed the facility discussed the fall with therapy services during Stand Up. This report's summary showed, (Fall) Appears related to self transfer from w/c to bed. Continue reminders to request assist. When asked how staff determined the fall was related to environmental factors, like surrounding furniture or loose cords, Staff B stated, I just assumed. I don't think it has anything to do with the fall. Review of a progress note dated 01/19/2020 at 1:04 PM showed, . Res is on the floor in fetal position facing toward the door; asked res what happened and stated 'I don't know i fell ' noted smear of blood near edge of the right side of the dresser . small laceration noted 1 cm right side of his head . This writer asked him again what happen (sic) and stated that he wants to transfer to his w/c. Record review showed no documentation staff conducted a review of this fall. On 03/01/2020 at 09:15 AM, Staff B acknowledged the facility did not conduct an analysis of this fall or addressed interventions to prevent falls or falls with injury. Review of a 02/27/2020 progress note showed, Called to room [ROOM NUMBER] to find res lying on his back in the door way Had no shoes on . When res lifted his head, noted active bleeding. Res stated he was attempting to get into his wc, lost his balance, fell backward and hit the floor, Res has a 1 (inch) deep laceration on the back of his head. drsg applied to stop the bleeding . call to (ambulance service) for ER (emergency room ) visit for poss (possible) sutures. In an interview on 02/28/2020 at 12:12 PM, when asked about therapy's involvement with Resident #77's falls, Staff E stated, With Resident #77 it was his cognition that was an issue. He is unable to remember when to use the call light and lock his brakes and wait for assistance. When asked what was implemented to compensate for Resident #77's cognitive and impulse deficits, Staff E stated, I don't know how we would work with someone unable to follow directions or has memory deficits for those types of things. It would be nursing, it's not a PT situation. Review of the above falls showed Resident #77 fell a total of 12 times between 11/11/2019 and 02/27/2020, and continued to fall nine times after 11/20/19, the date of the last CP revision for fall interventions. On 12/11/2019, 12/13/2019, 01/07/2020 and 01/19/2020, the staff assessed the resident sustained [REDACTED]. In addition, on 12/11/2019 and 02/27/2020, the resident required a hospital transfer to address a deep laceration to the head associated with a fall. When asked if the facility evaluated factors, and developed and implemented relevant and individualized interventions, to reduce future occurrences of falls or injuries from falls between 11/21/2019 and 02/27/2020, Staff B stated, No. Obviously not well enough. RESIDENT #49 Resident #49's Annual MDS (Minimum Data Set-an assessment tool), dated 01/03/2020, showed the resident admitted on [DATE] with multiple complex medical and cognitive conditions. Review of progress notes for Resident #49 showed the following falls: 11/04/2019: Found on floor, 11/09/2019: .found screaming on floor ., 11/14/2019: found resident .sprawled on the floor ., 11/23/2019: found .on the ground outside. A note of 01/08/2020 showed the resident was found on the floor and had bleeding from the forehead. Record review, including the IR log, showed no indication the facility completed reviews or root cause analyses of the falls noted in the progress notes above. Resident #49's care plan, last revised 02/24/2020, showed the resident was at risk for falls. The plan instructed to review past falls, .attempt to determine cause of falls and Record possible root causes. The care plan listed the dates of nine falls which occurred 04/17/2019 to 01/08/2020. The corresponding interventions section had not been updated since 04/17/2019, the date of the resident's first fall. There was no indication the facility made ongoing care plan revisions to prevent recurring falls. On 03/02/2020 at 8:40 AM, the above findings were shared with Staff B, who said she would research the findings. No further information was received. REFERENCE: WAC 388-97-1060(3)(g).