Every finding on record at Bothell Health Care

Based on interview and record review, the facility failed to provide effective communication prior to a resident being transferred or discharged to another facility for 1 of 3 residents (Resident 1), reviewed for transfer/discharge. This failure placed the resident at risk for delay in care, unmet care needs, and a diminished quality of life.Findings included.Review of the Electronic Health Record (progress notes) dated 06/17/2026 to 06/23/2026 did not show the admission date to the other facility was confirmed for 06/23/2026.In an interview on 07/31/2026 at 10:30 AM, Collateral Contact 1 (CC1), stated that Resident 1 had a planned discharge to another facility that was located three hours away. CC1 stated Resident 1 arrived at the other facility on 06/23/2026 and staff were not aware that Resident 1 would be admitted that day. CC1 stated Resident 1 arrived at the other facility late in the day, and since the discharging facility was located three hours away, the other facility agreed to check for room availability. CC1 further stated that Resident 1 waited for a few hours while staff checked for room availability and made it possible for Resident 1 to be admitted that day.In an interview on 08/03/2026 at 8:30 AM, CC2 from the other facility stated that they were not aware Resident 1 would be admitted to their facility on 06/23/2026. CC2 further stated the discharge had been planned with the discharging facility a few weeks ago and that they sent paperwork, but they never heard back from the discharging facility or confirmed an admission date.In an interview on 08/03/2026 at 2:08 PM, Staff C, Licensed Practical Nurse/Resident Care Manager, stated that they tried to call the other facility to give a report about Resident 1. Staff C stated they called and left voice messages with their name and phone number and were not sure whose phone they left the messages on because the message did not identify ownership of the phone. Staff C stated they never received a return call and thought the discharge date had been confirmed for 06/23/2026, Resident 1 left the facility when transport arrived to transport them to the other facility. Staff C further stated that when Resident 1 arrived at the other facility, staff called and stated Resident 1 was not on their admissions list. In an interview on 08/03/2026 at 3:30 PM, Staff B, Director of Nursing Services, stated they could not find in Resident 1's electronic health record that the discharge date of 06/23/2026 had been confirmed for admission to the other facility. Staff B further stated Resident 1 should not have been transported to the other facility unless the staff had confirmation that the resident had been accepted for admission on [DATE]. In an interview on 08/03/2026 at 3:46 PM, Staff A, Administrator, stated Resident 1 should not have been transported on 06/23/2026 to the other facility until the admission date had been confirmed. Staff A further stated the facility staff should have verbally communicated with the other facility prior to Resident 1 leaving the facility. Reference: (WAC) 388-97-0080(1)(ii)(6).

Based on observation, interview and record review, the facility failed to ensure surrounding areas were clean, free of trash/debris and residues for 1 of 1 garbage dumpster, and 2 of 2 recycling bins (1 and 2 Recycle Bins), reviewed for environment. These failures placed the facility at risk of attracting pests, and other disease-causing organisms that could reproduce, grow, and place the residents at risk for acquiring these diseases.Findings included .Review of the facility's policy titled, Disposal of Garbage and Refuse, dated November 2017, showed, The facility shall properly dispose of kitchen garbage and refuse. The policy further showed, Containers and dumpsters shall be kept covered when not being loaded. Surrounding area shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized .Storage areas, enclosures, and receptacles for refuse shall be maintained in good repair and cleaned at a frequency necessary to prevent them from developing a buildup of soil or becoming attractants for insects and rodents.A joint observation and interview on 07/10/2026 at 12:02 PM with Staff X, Maintenance Director, showed numerous pine tree needles surrounding garbage dumpster and recycling bins. Further joint observation showed sticky, blackish-colored residues on the ground surrounding the garbage dumpster. Staff X stated that the ground by the garbage dumpster had sticky, blackish- colored residues that would require power washing.In an interview on 07/13/2026 at 11:05 AM, Staff A, Administrator, stated that they observed that numerous pine tree needls were piled on the ground with dried residue on the ground surrounding the garbage dumpster and recycling bins. Staff A further stated that the overall condition appeared unclean and that it should have been cleaner.Reference: (WAC) 388-97-1320(4)

Based on observation, interview and record review, the facility failed to develop a system that ensured grievance forms and a drop box were easily accessible to file anonymously for 8 of 8 residents (Residents 14, 15, 26, 34, 43, 59, 66 & 88) and failed to initiate/resolve grievances promptly for 3 of 4 residents (Residents 98, 59 & 34), reviewed for grievances. These failures placed the residents at risk for unresolved concerns, feelings of frustration, unmet care needs, and a diminished quality of life.Findings included. Review of the facility's policy titled, Resident and Family Grievances, revised in December 2025 showed, It is the policy of this facility to support each resident's and family member's right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. The policy showed, Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. b. Written complaint to a staff member or Grievance Official. c. Written complaint to an outside party. d. Verbal complaint during resident or family council meetings.A grievance may be filed anonymously.The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. The policy further showed, The facility will make prompt efforts to resolve grievances. GRIEVANCE FORMS/DROP BOX ACCESSIBILITYDuring a meeting on 07/08/2026 at 1:28 PM with the Resident Council (a group of residents meeting regularly to discuss about their care and daily living in the facility), Residents 14, 15, 26, 34, 43, 59, 66 & 88 stated that they did not know where the grievance forms and drop box were located. Observations on 07/08/2026 at 2:46 PM showed a drop box on the wall by the Business Office labeled, Business office after hours drop box and in smaller letters with the label and concern and comment forms. Observations on 07/08/2026 at 2:52 PM and on 07/09/2026 at 7:55 AM, showed no CONCERN AND COMMENT FORM [grievance form] available in the 500 unit nursing station and on Station A nursing station. In an interview and joint observation on 07/09/2026 at 1:01 PM, Staff C, Social Services Director, stated that residents were informed on how to file a grievance and that it was part of their admission process/admission packet. Staff C stated that they encourage people if they have concerns to let them know and that they could fill out the comment concern form or that they could help them fill it out. Staff C stated that residents were able to file anonymously if they chose to. When asked how residents would do that, Staff C stated that if they did not put their name on it or if the comment concern form was lying around. When asked if there was a drop box, Staff C stated, No. Staff C stated that the comment and concern forms were supposed to be located at the nursing stations. A joint observation at 2:44 PM, showed no CONCERN AND COMMENT FORM on the 500 Unit. Staff C pointed out that the drop box for the grievance forms by the Business Office and stated that they forgot about it. Staff C stated that the drop box was for Business Office after hours and for grievance forms. When asked if residents in their wheelchair can reach the drop box, Staff C stated, Probably not. In an interview on 07/10/2026 at 12:09 PM, Staff A, Administrator, was asked if there was a way for residents to file anonymously, Staff A stated, yes they could fill out a concern and comment form and place it in the drop box. Staff A stated that they expected the concern and comment forms to be easily available and residents to have access to the forms and the drop box. On 07/10/2026 at 1:09 PM, Resident 14 stated that they used a wheelchair to get around the facility. Observation showed Resident 14 reached out to get a CONCERN AND COMMENT FORM that was located on a wall by Station A nursing station and was not able to reach it. Resident 14 stated, I can't [cannot] really get it. Resident 14 wheeled themselves over to the drop box that was located by the Business Office, placed their hand out to reach the opening of the drop box and were not able to reach it. Resident 14 stated that they could not reach it. GRIEVANCE INITIATION/RESOLUTIONSRESIDENT 98On 07/07/2026 at 1:32 PM, Resident 98 stated that they told laundry staff that they were missing four tops and a couple of knitted pants. Resident 98 stated that staff were not able to find them and they had not been reimbursed or their missing items replaced. Review of the facility's June 2026 and July 2026 grievance log showed no documentation that Resident 98's missing items were logged. In an interview on 07/08/2026 at 11:15 AM, Staff H, Laundry/Housekeeping Manager, stated that they would complete a CONCERN AND COMMENT FORM if residents reported missing clothing. Staff H stated that it was for them and Social Services to keep track of. Staff H stated that if they were unable to find the missing items, Social Services will take over. When Staff H was informed of Resident 98's concerns of missing clothing and that they had reported speaking to them, Staff H stated that they found most of Resident 98's missing clothing and that they would double check with them. At 2:30 PM, Staff H provided Resident 98's CONCERN AND COMMENT FORM dated 06/30/2026. A review of Resident 98's CONCERN AND COMMENT FORM dated 06/30/2026 showed under Steps taken to investigate the concern/grievance: Found pants + [plus] shirt, blue blouse still missing, 7/8/26 [07/08/2026]. Staff H stated that they completed another CONCERN AND COMMENT FORM for the new missing items that Resident 98 had reported to them. Staff H further stated that they did not give Social Services a copy of Resident 98's CONCERN AND COMMENT FORM dated 06/30/2026. RESIDENT 59On 07/08/2026 at 1:28 PM, Resident 59 stated that they were missing pants that they had bought with their son. Resident 59 stated that they were expensive and were sentimental to them. Resident 59 further stated that it had been missing for two months and that they had not been reimbursed for their missing pants. Review of the facility's May 2026 grievance log dated 05/18/2026 showed that Resident 59 was logged for Missing Pant [s] and that the resolution was Still Searching/to be replaced. The grievance log further showed that the Date Resolved was blank. Review of Resident 59's CONCERN AND COMMENT FORM dated 05/18/2026 showed, Missing 2 [two] sets of headphones and a pair of black [NAME] [brand] knit pants. It further showed that the Date resolved was blank. In an interview on 07/09/2026 at 1:01 PM, Staff C stated that any grievance that was reported, they would fill out a comment concern card and that the form was given to them and a copy was provided to Staff B, Director of Nursing (DON), and Staff A. Staff C stated that depending on the concern, it was shared among the Interdisciplinary Team what the grievance was related to. Staff C stated that for missing items, staff would fill out a comment and concern form, turn it in to them and search the resident's room with the resident's consent. Staff C stated that if missing items were not found, they offered to replace them. When asked how long it took for grievances to be resolved, Staff C stated that for missing items, they have a grace way, that often times they do turn up, and that some were outstanding because they have a hard time getting in touch with family. Staff C stated that Staff H did not turn in the CONCERN AND COMMENT FORM for Resident 98 in a timely fashion and that it was not logged in the grievance log. Staff C stated that they expected Staff H to have provided them with a copy and that they could have logged it in the grievance log. Staff C further stated that they were aware of Resident 59's missing pants and that they were still missing. In an interview on 07/10/2026 at 12:09 PM, Staff A stated that they had a process for grievances and if they get a comment and concern form, they would log it in the grievance log and would try to resolve it. Staff A stated that when a grievance comes in, they and Social Services would get a copy and that they would talk about it during their meeting. Staff A stated that Staff C followed their process, maintained a log and their resolutions. Staff A further stated that grievances should be logged and resolved within five days. RESIDENT 34Review of the quarterly Minimum Data Set (an assessment tool) dated 05/13/2026 showed that Resident 34 was admitted to the facility on [DATE] and was cognitively intact. On 07/06/2026 at 2:12 PM, Resident 34 stated that they lost their glasses and could not see or read without them. Resident 34 further stated that they had notified the staff, and they searched and could not find them. On 07/08/2026 at 8:20 AM, Resident 34 stated that their glasses were still missing. Resident 34 was observed wearing their old glasses and stated that they could not see through them properly because the lens were weak. Resident 34 further stated that staff had looked all over and still could not find them. Review of the facility's July 2026 grievance log on 07/09/2026 at 11:20 AM did not show that the loss of Resident 34's glasses was reported, logged, or that an investigation was completed. In an interview on 07/09/2026 at 12:35 PM, Staff CC, Certified Nursing Assistant, stated that they were aware that Resident 34 had lost their glasses, they looked, however, they were not able to find it. Staff CC stated that the grievance process requires staff to report the loss of the resident's property to the nurse, Resident Care Manager (RCM), or management. When asked if they had reported Resident 34's missing glasses, Staff CC stated, No, I did not, but I should have reported. In an interview on 07/09/2026 at 1:43 PM, Staff BB, RCM, stated that if a resident loses their glasses, the staff would file a grievance form, and they would try to look for them. If they did not find them the resident would be referred to an optometrist (eye doctor), and the glasses would be replaced. Staff BB stated that the grievance form should be filled out, sent to the Social Services, Administrator, DON, and RCM, and acted upon immediately. Staff BB further stated that they had not received any grievance concerning this matter. In an interview on 07/13/2026 at 10:24 AM, Staff B stated that when a resident loses property, the resident should file a grievance form. Staff B stated that if staff become aware of the loss, they should report it to management as soon as possible, and management would help locate the property. Staff B further stated that if they could not find the missing item, they would replace it. In an interview on 07/13/2026 at 1:52 PM, Staff A stated that it was the facility's policy for staff to fill out a concern/grievance form for the residents if they had a concern regarding lost item. Staff A stated a copy of the form would be given to the Administrator, DON, and Social Worker to discuss and address the grievance. Staff A further stated Resident 34's grievance should have been filed Immediately. Reference: (WAC) 388-97-0460 (1)(2) .

Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the kitchen remained free of flies for 1 of 1 kitchen, reviewed for pest control. This failure placed residents at risk of infection, maggot infestation (small, worm like bugs that hatch from fly eggs) and a diminished quality of life.Findings included .Review of the facility's policy titled, Pest Control Program, revised in December 2025, showed, It is the policy of this facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.Review of the facility's policy, titled, Sanitation Inspection, revised in December 2025, showed, It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and compliance with applicable state and federal regulations. The policy further showed, All food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies and other insects.A joint observation and interview on 07/10/2026 at 11:35 AM with Staff Q, Dietary Manager, showed five flies in the kitchen. Staff Q stated that the flies had not been an issue until two days ago. Staff Q stated that two days ago they removed eight flies. Staff Q further stated that the source of the flies had not yet been identified.In an interview on 07/13/2026 at 11:05 AM, Staff A, Administrator, stated that There should be no flies present in the kitchen. Pest control services are conducting inspections monthly, and no fly activity should be reported or observed.Reference: (WAC) 388-97-3360 (1).

Based on observation, interview, and record review, the facility failed to follow Contact Precautions (measures put in place to prevent spread of infection by direct or indirect contact with the resident or environment by staff wearing gown and gloves before entering a resident's room or environment) for 1 of 1 resident (Resident 4), failed to follow Enhanced Barrier Precaution (EBP-infection control intervention designed to reduce transmissions of multi-drug resistant organisms) for 1 of 8 residents (Resident 61), and failed to perform hand hygiene during dining services for 2 of 14 staff (Staff T & U), reviewed for infection control. In addition, the facility failed to clean the shower heads as part of the facility's water management program (a structured approach that identifies and controls potential hazards in building water systems, particularly those that can lead to the growth of harmful bacteria) for 3 of 6 months (April 2026, May 2026 & June 2026), reviewed for water management. These failures placed the residents, visitors, and staff at an increased risk for infection and related complications. Findings included. Review of the facility's policy titled, Transmission-Based (Isolation) Precautions [are a set of infection control measures used in healthcare settings to prevent the spread of infectious diseases that are transmitted through contact with an infected resident, their bodily fluids, or contaminated surfaces or objects], revised in December 2025, showed, c. Healthcare personnel caring for residents on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. d. donning [put on] personal protective equipment (PPE) upon room entry and discarding before exiting the room is done to contain pathogens, especially those that have been implicated in transmission through environment contamination . Review of the facility's policy titled, Enhanced Barrier Precautions, revised in December 2025, showed that PPE for enhanced barrier precautions is only necessary when performing high-contact care activities and may not need to be donned prior to entering the resident's room. The policy further showed, High-contact resident care activities include.g. Device care or use:.feeding tubes [flexible plastic tube inserted into the stomach to deliver liquid nutrition] . Review of the facility's policy titled, Hand Hygiene, revised in December 2025, showed, All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. CONTACT PRECAUTIONSRESIDENT 4Review of Resident 4's physician orders dated 07/01/2026, showed an order for STRICT SINGLE ROOM Contact ISOLATION related to (shingles [contagious viral disease characterized by a painful skin rash with blisters that are small pocket of fluid within the layers of the skin in a localized area]). Staff to wear appropriate PPE with all cares. ALL CARE AND SERVICES PROVIDED IN THE ROOM every shift. In an observation on 07/08/2026 at 10:51 AM, showed a contact precaution signage outside Resident 4's door. Staff P, Physician, entered Resident 4's room without wearing gown and gloves. In an interview and joint record review on 07/08/2026 at 10:55 AM, Staff P stated that for contact precautions they would wear gown and gloves if they were touching the resident and that they would remove them and perform hand hygiene prior to leaving the room. When asked if they would apply gown and gloves prior to entering the room, Staff P stated, Usually, you gown up here [by the door]. A joint record review of the signage by Resident 4's door showed contact precaution. Staff P stated that they missed the sign and that they normally would have applied gown and gloves prior to entering the room. In an interview on 07/13/2026 at 7:13 AM, Staff D, Infection Preventionist, stated that staff would apply gown and gloves when entering resident rooms on contact precautions. Staff D stated that Resident 4 was on contact precaution due to shingles. Staff D stated that they expected staff, which included the physicians, to follow signage posted outside resident rooms. Staff D further stated that they expected Staff P to have followed contact precautions. EBPRESIDENT 61Review of Resident 61's physician orders showed an order for EBP r/t [related to] Tube Feeding with an order date of 05/11/2026. Observation on 07/13/2026 at 5:17 AM, showed Staff K, Registered Nurse, entered Resident 61's room, performed hand hygiene and applied gloves. Staff K filled a cup with water, took a syringe, some napkins and turned off Resident 61's feeding tube machine. Staff K placed a napkin around Resident 61's stoma (surgically created opening in the abdominal wall through which a feeding tube is placed), filled the syringe with water, connected the syringe to the feeding port and flushed it. When Staff K was done, they removed their gloves and performed hand hygiene. Staff K did not apply a gown when they provided tube feeding care to Resident 61. In an interview on 07/13/2026 at 5:26 AM, Staff K stated that Resident 61 was on EBP for their stoma and that they would wear gown and gloves when they provided care and were touching Resident 61's stoma. When asked if they would wear a gown when flushing Resident 61's feeding tube, Staff K stated, No. Staff K stated that they would wear a gown if they were going to touch the resident's stoma, bedding, gown and was going to care for them. A joint record review of the EBP signage posted by Resident 61's door showed to wear gown and gloves when providing high contact care which included, Device care or use:.feeding tube. When asked if flushing the feeding tube would be considered device care, Staff K stated, yes. Staff K further stated that if resident's were on EBP precautions, they would follow the precaution. In an interview on 07/13/2026 at 7:16 AM, Staff D stated that they expected staff to follow EBP precautions and that they would expect staff to apply gown and gloves if they provided high contact care activities listed on the signage. Staff D stated that they would expect staff to wear gown and gloves when providing tube feeding care. Staff D further stated that they would have expected Staff K to have worn a gown when they provided tube feeing care to Resident 61. In an interview on 07/13/2026 at 7:21 AM, Staff B, Director of Nursing, stated that they expected staff to follow EBP and contact precautions. HAND HYGIENESTAFF TObservation on 07/06/2026 at 12:21 PM showed that Staff T, Certified Nursing Assistant (CNA), delivered a lunch meal tray to room [ROOM NUMBER] 1 (EBP designated room). Staff T called Staff U, CNA, for help, and both staff repositioned the Resident in room [ROOM NUMBER] 1. Staff T and Staff U did not perform hand hygiene before and after entering the room. Observation on 07/06/2026 at 12:34 PM showed that Staff T was assisting two residents (Residents 12 & 64) in the Occupational Therapy kitchen/dining room at the same time. Resident 12 and Resident 64 were seated at different tables, approximately within a five foot distance. Staff T then continued to provide dining assistance, alternating back and forth between Resident 12 and Resident 64 until they finished their meals. Staff T did not perform hand hygiene in between assisting Resident 12 and Resident 64 with their meals. In an interview on 07/06/2026 at 1:21 PM, Staff T stated that when they delivered the meal tray in room [ROOM NUMBER] 1, repositioned the resident, and assisted Resident 12 and Resident 64 with their meals at the same time, I thought I did sanitize my hand, but I will be more vigilant. STAFF UObservation on 07/06/2026 at 12:29 PM showed that Staff U, CNA, delivered a lunch meal tray to room [ROOM NUMBER] (EBP designated room). Staff U did not perform hand hygiene before or after entering the room. In an interview on 07/06/2026 at 1:08 PM, Staff U stated, I think I forgot to sanitize my hand when I delivered lunch in room [ROOM NUMBER]. Staff U further stated, I was trained on proper infection control practices, but at the time I did not think about performing hand hygiene. In an interview on 07/13/2026 at 8:14 AM, Staff D stated that when staff delivered meal trays to the resident's room, they would expect them to perform hand hygiene. Staff D stated that if staff were repositioning the residents who were in EBP, staff were expected to follow the PPE protocol. Staff D further stated that Staff T should have performed hand hygiene while assisting two residents with their meals at the same time. In an interview on 07/13/2026 at 10:36 AM, Staff B stated that staff were expected to perform hand hygiene before and during tray delivery. Staff B further stated that staff must perform hand hygiene between assisting different residents to prevent cross contamination. WATER MANAGEMENTReview of the facility's water management program revised in December 2025, showed, Outbreaks of Legionella infections [a severe, potentially life-threatening type of lung disease] have been linked to poorly maintained water system in building with large or complex water systems including hospitals and long-term care facilities. Transmission can occur via aerosols from devices such as showerheads. Review of the facility's water management record log titled, Three-monthly cleaning of the shower heads, showed that the facility was required to dismantle, clean, and descale showerheads and hoses, or replace them, on a quarterly basis. Review of the maintenance records from January 2026 through June 2026 showed no documentation that the showerheads were dismantled and cleaned from April 2026 through June 2026. During a joint record review and interview on 07/13/2026 at 11:18 AM with Staff X, Maintenance Director, showed that the facility did not have records that the showerheads were being dismantled and cleaned from April 2026 through June 2026. Staff X stated they did not have the records and that they should have. In an interview on 07/13/2026 at 1:29 PM, Staff D stated that housekeeping staff were responsible for cleaning the showerheads daily, and the facility did not maintain tracking logs for this task. When asked if the showerheads were dismantled during cleaning, Staff D stated, No. When further asked if the showerheads should have been dismantled, cleaned, and recorded per the water management plan, Staff D responded, Yes. In an interview on 07/13/2026 at 2:17 PM, Staff B stated that it was their expectation that they follow the water management plan. Staff B further stated that staff should have dismantled and cleaned the showerheads and maintained records and they did not. Reference: (WAC) 388-97-1320(1)(a)(c)

Based on observation, interview, and record review, the facility failed to ensure the overhead sprinkler line was maintained in a clean and sanitary condition for 1 of 1 kitchen, reviewed for environment. This failure placed the food preparation areas at risk for contamination and increased the potential for pest attraction.Findings included .Review of the facility's policy, titled, Sanitation Inspection, revised in December 2025, showed, It is the policy of this facility, as part of the department's sanitation program, to conduct inspections to ensure food service areas are clean, sanitary and compliance with applicable state and federal regulations.A joint observation and interview on 07/10/2026 at 11:35 AM with Staff Q, Dietary Manager, showed that the sprinkler head in the kitchen was visibly dusty. The overhead sprinkler line extended from the staff hand wash area to the location where clean utensils were stored and passed over the dishwashing area. Staff Q stated that the sprinklers were cleaned every four months.A joint observation and interview on 07/13/2026 at 10:20 AM with Staff X, Maintenance Director, showed that the sprinkler head in the kitchen was visibly dusty. Staff X stated, I can see the sprinkler heads are not clean. Staff X stated that the kitchen sprinklers would be inspected either monthly or quarterly. Staff X further stated that the sprinkler heads should be maintained in a clean conditionIn an interview on 07/13/2026 at 11:05 AM, Staff A, Administrator, stated that the sprinkler heads in the kitchen should be cleaned. Staff A further stated, At present, the sprinkler head appears dusty and not clean, and maintenance is responsible for addressing it.Reference: (WAC) 388-97-3220(1).

Based on observation, interview, and record review, the facility failed to ensure food items were handled appropriately in accordance with professional standards of food safety for 1 of 1 Dry Storage Room (Kitchen Dry Storage Room), 1 of 1 Freezer (Walk-In Freezer), 1 of 1 Spice Shelf (Kitchen Spice Shelf), and 2 of 4 Refrigerators (Kitchen Walk-In Refrigerator and Resident Room Refrigerator), reviewed for food services. In addition, the facility failed to cover food items during meal tray delivery for 1 of 5 hallways (500 Unit). The failure to date, label, discard expired food items and/or items before the use by date and cover food items during delivery placed the residents at risk for foodborne illness (caused by the ingestion of contaminated food or beverages), cross contamination, and a diminished quality of life.Findings included . Review of the facility's policy titled, Food Safety Requirements, revised in December 2025, showed, Food will also be stored, prepared, distributed and served in accordance with professional standards for food service safety. The policy showed, Facility staff shall inspect all food, food products, and beverages for safe transport and quality upon delivery/receipt and ensure timely and proper storage. The policy showed, Labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and keeping foods covered or in tight containers. The policy further showed, Foods and beverages shall be distributed and served to residents in a manner to prevent contamination and maintain food at the proper temperature.Strategies include but are not limited to: a. Covering all foods when traveling a distance (i.e. [that is], down a hallway, to a different unit or floor). DRY STORAGE ROOMA joint observation and interview on 07/06/2026 at 8:13 AM with Staff Q, Dietary Manager, showed one opened package of tortillas with no open and use by date. Staff Q stated that the tortillas should have been dated when it was opened and that there should have been a use by date. WALK-IN FREEZERA joint observation and interview on 07/06/2026 at 8:29 AM with Staff Q, showed one opened 12-ounce (unit of measurement) container of ice-cream with no open and use by date. Staff Q stated that the ice cream should have been dated when it was opened and it should be discarded. KITCHEN SPICE SHELFA joint observation and interview on 07/06/2026 at 8:33 AM with Staff Q showed the following spices/food items with unclear open dates:-one opened bottle of dried whole oregano leaves dated of 1/27,-one opened bottle of dried chopped chives with no open or use by date,-one opened half-filled container of dried whole thyme with no open or use by date,-one opened half-filled container of powdered steak seasoning with an open date of 11/10,-one opened container of dried season all with open date of 11/10,-one opened half-filled container of dried rosemary leaves with open date of 5/19,-one opened bottle of ground nutmeg with open date of 4/28/25 [04/28/2025]. Staff Q stated that the dried whole oregano leaves should have been dated 01/2026 and there should have been use by date. Staff Q stated the dates marked on powdered steak seasoning, dried season all and dried rosemary leaves were wrong and that they did not understand what those dates meant. In addition, Staff Q stated that they would keep the ground nutmeg for a year and it should have been removed. Staff Q further stated that the food items that were expired should have been discarded and that opened food items without an open and use by date should have been labeled properly. WALK-IN REFRIGATORA joint observation and interview on 07/06/2026 at 8:22 AM with Staff Q, showed that an opened quarter gallon (unit of measurement) of lemon juice, an opened pound (unit of measurement) of chicken base, and an opened quarter pack of American cheese with no open and use by date. Further observation showed that two pounds of opened cottage cheese had an open date of 05/12/2026 and had no use by date. Staff Q stated that the lemon juice, chicken base, and American cheese should have had an open and use by date. Staff Q further stated that the cottage cheese should have had a use by date. In an interview on 07/13/2026 at 11:05 AM, Staff A, Administrator, stated that they expected kitchen staff to check the food items regularly, to date when first opened, and discard when expired/passed the use by date. Staff A further stated that food items that were undated/past the use by date should have been dated and/or discarded. RESIDENT ROOM REFRIGERATORObservation of the refrigerator in Resident 71's room on 07/06/2026 at 9:23 AM and on 07/08/2026 at 10:03 AM, showed one opened container of mayonnaise with a past use by date of 06/18/2026. In an interview and joint observation on 07/09/2026 at 3:48 PM, Staff J, Certified Nursing Assistant (CNA), stated that they did not know who managed the resident's refrigerators. When asked if the resident's refrigerator should have expired food, Staff J stated that the resident's refrigerators should not have any expired food items and that if they did, they would let the resident know it was expired, let the nurse know and ask the resident if they could throw it away. A joint observation of Resident 71's refrigerator showed one opened container of mayonnaise with a past use by date of 06/18/2026. Staff J stated that they would let Resident 71 know that there was expired food in their refrigerator and ask if they could throw it away. In an interview on 07/13/2026 at 11:14 AM, Staff EE, Licensed Practical Nurse, stated that housekeeping staff managed the refrigerators in the resident's room. Staff EE stated that the housekeeping staff checked the temperature of the refrigerators daily and ensured food stored in the refrigerator was not expired. In an interview on 07/13/2026 at 11:17 AM, Staff O, Housekeeper, stated that they checked the food stored in the refrigerator and that they took the temperatures. Staff O further stated that if food stored in the refrigerator were expired, they would throw it away. In an interview on 07/13/2026 at 12:12 PM, Staff H, Laundry/Housekeeping Manager, stated that the housekeeping staff managed the refrigerators in the 500 unit and 400 unit. Staff H stated that they tracked the temperatures of the refrigerators to ensure they were within the safe range. Staff H stated that they checked the expiration dates and discarded food items that were out of date. Staff H stated that they expected staff to throw food items that were past the use by date. Staff H further stated that they expected the mayonnaise in Resident 71's refrigerator to have been thrown away. In an interview on 07/13/2026 at 1:28 PM, Staff A was asked what they would expect staff to do when they observed food items that were expired/past the use by date in the resident's refrigerators, Staff A stated, They should be throwing them away. UNCOVERED FOOD ITEMS DURING MEAL TRAY DELIVERY-500 UNITObservation and interview on 07/07/2026 at 12:38 PM, showed the meal cart was parked in the middle of the hallway between room [ROOM NUMBER] and room [ROOM NUMBER]. Staff L, CNA, took a tray from the meal cart, walked down the hallway and delivered it to room [ROOM NUMBER] with the apple crisp (dessert) uncovered. Staff L took another tray from the meal cart, walked down the hallway, and delivered the meal tray to room [ROOM NUMBER] with the apple crisp uncovered. Staff M, CNA, took a tray from the meal cart, walked down the hallway and delivered it to room [ROOM NUMBER] with the apple crisp uncovered. When Staff M was done, they took another tray from the meal cart, walked down the hallway and delivered it to room [ROOM NUMBER]. In a joint observation of the meal tray delivered to room [ROOM NUMBER] showed the apple crisp uncovered. Staff M stated that it was not covered. Further observation showed that room [ROOM NUMBER] and room [ROOM NUMBER] were located at the opposite end of the hallway. In an interview on 07/10/2026 at 8:56 AM, Staff M stated that if the food were not covered in the meal tray, they would go back to the kitchen and let them know it was not covered. Staff M stated that the apple crisp never come covered, and that the main entree always had the lid, the salad came in plastic wrap, and that the little square desserts were not covered. Staff M stated that they would park the meal cart on the left side of the hallway between room [ROOM NUMBER] and 515 and that they would walk down the hallway to deliver the meal trays to the resident's room. When asked if food items on the meal tray should be covered, Staff M stated, Yes, if walking all the way down. Staff M further stated that the desserts were always uncovered and that it always came that way. In an interview on 07/10/2026 at 2:56 PM, Staff Q stated that when delivering meal trays in an uncovered cart, everything on the meal tray would be completely covered. Staff Q stated that if they were delivering food in a covered meal cart, they do not cover everything on the meal tray because the cart is the cover. When Staff Q was informed that the meal tray was parked in the middle of the hallway between room [ROOM NUMBER] and 515 and that staff would walk down the hallway and deliver the meal trays to the residents with the food items uncovered, Staff Q stated that they did not consider walking down the hallway a distance. When asked what they considered a long distance, Staff Q stated that on an uncovered cart, walking any distance it travels, everything has to be covered and for a covered cart, the cart is the cover. A joint observation and interview on 07/13/2026 at 11:22 AM with Staff R, Restorative Aide, showed that they measured the distance from room [ROOM NUMBER] to room [ROOM NUMBER]. Staff R stated that it was 80 feet. In an interview on 07/13/2026 at 1:28 PM, Staff A was asked if they would expect food items in the meal tray to be covered when staff delivered the meal trays down the hallway to resident rooms, Staff A stated, It depends on the distance. Staff A stated that if it was a closed meal cart, it depends and that if it was an open meal cart, everything on the meal tray had to be covered. When asked if they would expect food items to be covered if staff had to walk 80 feet to deliver meal trays, Staff A stated that they did not see any problem walking halfway down the hall. Reference: (WAC) 388-97-1100 (3) .

Based on observation, interview, and record review, the facility failed to properly store the nebulizer (device used to administer medication in the form of a mist that is inhaled into the lungs) mask, Continuous Positive Airway Pressure (CPAP- a therapy that pumps air into the lungs through the nose or nose and mouth that keeps the airway open) mask, and oxygen (O2) nasal cannula (flexible plastic tubing that delivers O2 through the nose) when not in use for 2 of 3 residents (Residents 50 & 34), and failed to obtain physician order for oxygen use for 1 of 3 residents (Resident 34), reviewed for respiratory care. These failures placed the residents at risk for unmet care needs, respiratory infections, and related complications. Findings included. Review of the facility's policy titled, Oxygen Administration, revised in December 2025, showed that oxygen would be administered consistent with professional standards of practice and that Staff shall perform.infection control measures that would include keeping (oxygen) delivery devices covered in plastic bag when not in use. The policy further showed, Oxygen is administered under orders of a physician, except in the case of an emergency. In such cases, oxygen is administered and orders for oxygen are obtained as soon as practicable when the situation is under control. NEBULIZER AND CPAP MASK RESIDENT 50 Review of the admission record printed on 07/08/2026 showed Resident 50 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD-a lung disease that causes blockage of airflow and makes it difficult to breathe). Review of the physician orders printed on 07/08/2026 showed that Resident 50 had a albuterol (medication to treat COPD) nebulizer treatment every four hours as needed and used CPAP at bedtime. An observation on 07/07/2026 at 10:02 AM, showed Resident 50's nebulizer and CPAP masks were on top of the bedside drawer and not stored in a plastic bag. Another observation on 07/08/2026 at 8:00 AM and at 1:12 PM, showed Resident 50's nebulizer mask was on top of the bedside drawer and their CPAP mask were not bagged or stored in a plastic bag. Additional observation on 07/09/2026 at 8:01 AM, showed Resident 50's nebulizer mask was lying on the floor and was not stored in a bag. Further observation showed the CPAP mask was on top of Resident 50's bed and was not stored in a bag. In an interview on 07/09/2026 at 8:01 AM, Resident 50 stated that staff did not store their nebulizer and CPAP masks in a plastic bag when not in use. A joint observation and interview on 07/09/2026 at 8:30 AM with Staff F, Licensed Practical Nurse, showed Resident 50's nebulizer mask was lying on the floor, and the CPAP mask was on top of Resident 50's bed. Both masks were not stored in a plastic bag. Staff F stated that Resident 50's nebulizer and CPAP masks should be stored in a plastic bag when not in use. In an interview on 07/09/2026 at 10:58 AM, Staff E, Resident Care Manager (RCM), stated that they expected staff to properly store Resident 50's nebulizer and CPAP masks in a plastic bag at bedside. In an interview on 07/09/2026 at 2:12 PM, Staff B, Director of Nursing, stated that they expected Resident 50's nebulizer and CPAP masks to be properly stored in a clear plastic bag when not in use. NASAL CANNULA/PHYSICIAN ORDERRESIDENT 34Review of the quarterly Minimum Data Set (an assessment tool) dated 05/13/2026 showed Resident 34 had intact cognition. The assessment further showed Resident 34 had a diagnosis of respiratory failure (a serious condition that makes it difficult to breathe on your own) and received O2 therapy as needed. Record review of Resident 34's electronic health record (physician order, progress notes, medication administration record and hospital notes) showed no physician order for O2 use was obtained prior to 07/06/2026. Observations on 07/06/2026 at 11:28 AM and at 2:14 PM, and on 07/07/2026 at 11:47 AM, showed that Resident 34's O2 nasal cannula tubing was lying on top of their bed and was not properly stored in a plastic bag. In an interview on 07/06/2026 at 2:14 PM, Resident 34 stated that they had been using O2 at night for the last six months. Resident 34 further stated that they were not sure how many liters (L-unit of measurement) of O2 they were receiving. A joint observation and interview on 07/08/2026 at 8:24 AM with Staff BB, RCM, showed the nasal cannula was not properly stored, it was lying on Resident 34's bed. When asked how many liters of O2 Resident 34 used and how the nasal cannula was supposed to be stored, Staff BB stated Resident 34 was on 2L of O2 and the nasal cannula should have been stored inside a clear plastic bag beside the O2 concentrator. A joint record review and interview on 07/09/2026 at 1:11 PM with Staff BB, showed that Resident 34 did not have a physician's order for O2 prior to 07/06/2026. Staff BB stated that Resident 34 had been on O2 for a while and was unsure of the exact duration. Staff BB further stated that an order from the physician was required prior to administering O2 and that they did not have the order prior to 07/06/2026. In an interview on 07/13/2026 at 10:37 AM, Staff B stated that it was their expectation that staff obtain a physician's order before administering O2. Staff B further stated that the O2 nasal cannula should be stored in a clear bag when not in use to prevent infection. Reference: (WAC) 388-97-1060 (3)(j)(vi)

Based on interview and record review, the facility failed to ensure residents' funds were transferred to the residents or residents' representative/estate within 30 days of discharge for 2 of 3 residents (Resident 99 &100), reviewed for personal funds. This failure placed the residents and/or their representatives/estate at risk for loss of funds and the interest accumulated.Findings included. Review of the facility policy titled, Resident Personal Funds, revised in December 2025, showed, Upon the discharge.of a resident with a personal fund deposited with the facility, the facility will convey within 30 days the resident's funds and a final account of those funds to the resident. RESIDENT 99Review of the admission record printed on 07/13/2026 showed Resident 99 was discharged from the facility on 10/25/2025. Review of the Resident Trust Fund Statement showed Resident 99 had a trust fund balance of $32.33 on 09/30/2025. Review of a copy of a check showed Resident 99's trust fund balance was sent to the Department of Social and Health Services (DSHS)- Office of Financial Recovery (OFR) on 01/30/2026, 97 days after Resident 99's discharge. RESIDENT 100Review of the admission record printed on 07/13/2026 showed Resident 100 was discharged from the facility on 11/29/2025. Review of the Resident Trust Fund Statement showed Resident 100 had a trust fund balance of $42.19 on 11/30/2025. Review of a copy of a check showed Resident 100's trust fund balance was sent to DSHS-OFR on 01/30/2026, 62 days after their discharge. In a joint record review and interview on 07/13/2026 at 3:23 PM with Staff A, Administrator, showed two separate copies of checks dated 1-30-26 (01/30/2026) for Resident 99 and 100 that were sent to DSHS-OFR. Staff A stated, We did not give the checks on time. We gave it on this date (01/30/2026). Staff A further stated that the checks were not sent to OFR within 30 days after Resident 99's and 100's discharged from the facility. Reference: (WAC) 388-97-0340(5).

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR - an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], Intellectual Disabilities; or Related Conditions are not inappropriately placed in nursing homes for long-term care) was documented accurately for 1 of 5 residents (Resident 34), reviewed for residents records. This failure placed the resident at risk for unmet care needs, inaccurate monitoring, and a diminished quality of life. Findings included . Review of the facility's policy titled, Documentation in medical record, revised in December 2025, showed, Documentation shall be accurate, relevant, complete, and containing sufficient details about the resident's care and/or responses to care. Review of the admission record printed on 07/13/2026 showed that Resident 34 was readmitted to the facility on [DATE] with diagnoses that included adjustment disorder (behavioral reaction to a major, stressful life change) and anxiety (having excessive/persistent worry and fear). Review of Resident 34's PASSR Level I dated 10/08/2025 showed Section 1.A (Serious Mental illness Indicators) was marked Yes for positive SMI for mood and anxiety. Review of PASSR Level I Section IV (Service Needs and Assessor Data) showed that No Level 2 evaluation indicated was checked. Further review showed that Level II evaluations referral was not checked. Review of Resident 34's social services note dated 10/08/2025 showed that PASRR Level II referral was sent to the PASRR evaluator, and No Level II was indicated. A joint record review and interview on 07/09/2026 at 10:54 AM with Staff C, Social Services Director, showed that Resident 34's PASRR Level I was marked yes for positive SMI and Section IV was checked for No Level II evaluation indicated. A joint record review of the social services note dated 10/08/2025 showed that the PASRR Level I was sent to the evaluator, and that no Level II evaluation indicated. Staff C stated that the documentation was inaccurate and that they should have checked Section IV as Level 2 evaluation referral required for SMI. In an interview on 07/13/2026 at 10:24 AM with Staff B, Director of Nursing Service, stated that it was the facility policy for staff to document information accurately. Staff B further stated that given that Resident 34 was positive for SMI, they should have checked Section IV as Level 2 evaluation referral required for SMI. Reference: (WAC) 388-97-1720 (1)(a)(i)(ii).

Based on interview and record review, the facility failed to ensure mail was delivered unopened for 1 of 8 residents (Resident 43), reviewed for resident rights. This failure placed the resident at risk for lack of privacy and a diminished quality of life.Findings included .Review of the facility's policy titled, Resident Safety to Privacy in Communication, revised in December 2025, showed, The activity staff, or another designated staff member, will ensure each resident receives any mail addressed to that particular resident promptly. Mail will be given to the resident unopened.On 07/08/2026 at 2:09 PM, Resident 43 stated that they had received an opened mail from Social Security Administration (SSA-government agency) and the bank.In an interview on 07/09/2026 at 12:00 PM, Staff DD, Receptionist, stated that mail was delivered at the front desk. Staff D stated that they would separate resident's mail and staff bills and place it in the activity box. Staff DD further stated that Activities [staff] delivered the resident's mail.On 07/10/2026 at 10:43 AM, Resident 43 stated that they received a call from SSA and were asked why they missed their appointment on 06/24/2026. Resident 43 stated that the SSA representative informed them that they had sent them a letter on 06/11/2026 and that it took four to five days to be delivered. Resident 43 stated that after speaking with the SSA representative, they went to the front desk and informed them that the they had missed their SSA appointment. Resident 43 stated that Staff DD gave them an envelope that contained a letter from SSA informing them of their appointment. Resident 43 further stated that they had received an open mail from the bank and that Staff DD stated that they had accidentally opened it.In a follow up interview on 07/10/2026 at 11:20 AM, Staff DD stated that Resident 43 gave them a letter and informed them that they had received the wrong mail. Staff DD stated that when they went through the mail, Resident 43 had a piece of paper inside the envelope that was theirs. Staff DD stated that they tucked it away and when Resident 43 informed them of a missing appointment, they gave Resident 43 the piece of paper that was inside the envelope.In an interview on 07/13/2026 at 11:00 AM, Staff I, Activities Assistant, stated that Resident's 43's mail was mistakenly opened by the front desk staff and that they had delivered Resident 43's mail with a post it note on the letter that read opened by mistake. Staff I further stated that they did not know which staff at the front desk opened it and that it was delivered in their box. Staff I further stated that resident's mail should not have been opened.In an interview on 07/13/2026 at 1:28 PM, Staff A, Administrator, stated that they expected staff to deliver resident's mail on the same day it was delivered unopened.Reference: (WAC) 388-97-0500 (1).

Based on interview and record review, the facility failed to identify, and timely report an allegation of abuse for 1 of 3 residents (Resident 4), reviewed for abuse investigations. The failure to report an allegation of abuse to the State Agency placed the resident at risk for repeated incidents and unidentified abuse and/or neglect.Findings included .Review of the facility's policy titled, Abuse, Neglect and Exploitation, revised in December 2025, showed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy further showed, Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g. [for example], law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 [two] hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.Review of the Nursing Home Guidelines, The Purple Book, dated October 2015 (sixth edition) showed, The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse .are reported to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency).On 07/06/2026 at 2:51 PM, Resident 4's representative stated that Resident 4 had complained that staff had been rough with them and that it had been reported to staff during a care conference meeting a month ago.Review of the facility's June 2026 and July 2026 incident log showed no documentation that Resident 4's concerns for rough care was logged and/or reported to the State Agency.In an interview on 07/09/2026 at 9:50 AM, Staff N, Certified Nursing Assistant (CNA), stated that everyone was a mandatory reporter and that if they observed staff rough with a resident, they would protect the resident, report it to the State Agency and their supervisor. When asked if Resident 4 voiced concerns about staff being rough with care, Staff N stated that Resident 4 had said the words that's [that is] rough or that's too rough when they provided care to the resident and that Resident 4 would say those words even when they were not touching them. Staff N stated that nurses were in the room when Resident 4 stated that it was rough. When asked for the nurse's names, Staff N stated that they did not remember their names, that there were a lot of nurses and that it was a big facility. Staff N further stated that they were not sure if the nurses had reported it to the State Agency and that they were not sure that the nurse would have told them. In an interview on 07/09/2026 at 3:11 PM, Staff G, Resident Care Manager, stated that they attended a care conference sometime in June [2026] with Resident 4, Resident 4's representative and a family member joined remotely via phone. Staff G stated that Resident 4 and their representative did not have any nursing concerns and did not voice any concerns of rough care during the meeting. Staff G stated that staff did not inform them that Resident 4 had reported rough care. Staff G stated that if a resident reported rough care, Staff G would expect staff to stop, notify the nurse, notify them and the State Agency. Staff G further stated that they would do an investigation and that the CNA would be removed.In an interview on 07/09/2026 at 3:23 PM, Staff B, Director of Nursing, stated that staff who suspected abuse, witnessed or something was reported to them, they would expect staff to report it to their supervisor and that they would need to follow their guidelines for reporting abuse/neglect. When asked if they would expect staff to report concerns of rough care, Staff B stated that they would definitely expect staff to report it, follow their process for allegations of abuse/neglect and to protect the resident. When Staff B was informed that Staff N had reported that Resident 4 would voice out it's too rough when providing care, Staff B stated that they were not aware and that they would have expected staff to report it to the nurse, report it to the State Agency as a mandated reporter and follow their guidelines.In an interview on 07/09/2026 at 3:31 PM, Staff A, Administrator, stated that they expected staff to follow The Purple Book for reporting abuse allegations. Staff A stated that they would have expected Staff N to have reported Resident 4's concerns of rough care to the State Agency.Reference: WAC 388-97-0640 (5)(a).

Based on interview and record review, the facility failed to provide a copy of the transfer/discharge notice to the State Long Term Care Ombudsman (an advocate for residents of nursing homes who protect and promote resident rights under federal and state law and regulations) office within the required timeframe for 1 of 2 residents (Resident 1), reviewed for hospitalization. This failure placed the resident at risk of not having opportunities to make informed decisions about their transfer in a timely manner.Findings included.Review of the facility's policy titled, Transfer and Discharge (including AMA [Against Medical Advice]), reviewed in June 2026, showed, The facility will maintain evidence that the notice was sent to the Ombudsman.Review of the admission record printed on 07/10/2026 showed that Resident 1 was admitted to the facility on [DATE]. Review of the discharge minimum data set (an assessment tool) dated 12/11/2026 showed that Resident 1 was discharged to the hospital on [DATE].Review of the nursing progress note dated 12/11/2026 showed that Resident 1 was transferred to the hospital for further evaluation.Review of the Transfer Discharge Ombudsman Notification Fax (Facsimile) document provided on 07/09/2026 showed that Resident 1's transfer/discharge notice was sent to the Ombudsman office on 01/20/2026. In an interview on 07/08/2026 at 3:23 PM, Staff C, Social Services Director, stated that Social Services had been responsible for sending the transfer/discharge to the Ombudsman. Staff C stated that Resident 1 was transferred to the hospital for further evaluation on 12/11/2026 and that the transfer/discharge was sent to the Ombudsman on 01/20/2026. Staff C further stated they did not know the transfer/discharge notice was required to be sent daily.In an interview on 07/13/2026 at 10:36 AM, Staff B, Director of Nursing, stated that when a resident transfers to the hospital, they would expect the transfer/discharge notice to be sent as soon as practicable. Staff B further stated that the nursing team recently assumed this responsibility, and notices were now being sent immediately after the hospital transfer occurs. In an interview on 07/13/2026 at 11:05 AM, Staff A, Administrator, stated that their expectation was that when a resident transfers to the hospital, the transfer/discharge notice should be sent to the Ombudsman office immediately.Reference: (WAC) 388-97-0120(5)(b)(i).

Based on interview and record review, the facility failed to complete a new Level I Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness [SMI], intellectual disabilities, or related conditions) and referral for Level II evaluation (a comprehensive evaluation for positive Level I screening) when a new diagnosis of mental illness was identified for 1 of 5 residents (Resident 9), reviewed for PASARR. This failure placed a resident at risk for unmet care needs and a diminished quality of life.Findings included .Review of the facility's policy titled, Resident Assessment - Coordination with PASARR Program, reviewed in December 2025, showed, This facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid [Government program that provides health coverage for low-income individuals] to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy further showed, Any resident who exhibits a newly evident or possible serious mental disorder, intellectual disability, or a related condition will be referred promptly to the state mental health or intellectual disability authority for a level II resident review.Review of the admission record printed on 07/10/2026 showed that Resident 9 was admitted to the facility on [DATE]. Further review showed that Resident 9 was diagnosed with anxiety disorder (a mental health condition in which persistent, excessive worry or fear interferes with daily functioning) on 01/23/2026.Review of Resident 9's electronic health record (progress note and miscellaneous) showed no documentation that a Level I PASARR was completed and that a Level II PASARR referral was initiated.A joint record review and interview on 07/08/2026 at 3:09 PM with Staff C, Social Services Director, showed that a Level I PASARR was not completed and a Level II PASARR referral was not initiated for Resident 9. Staff C stated, For this resident, I did not find documentation of a completed Level I PASARR or Level II referral, which I would expect to see. Staff C further stated that a Level I PASARR was required and a Level II PASARR referral needed to be initiated.In an interview on 07/13/2026 at 10:36 AM, Staff B, Director of Nursing, stated that they would expect both a new Level I PASARR and a referral for Level II to be completed whenever residents are diagnosed with SMI after admission. Staff B further stated that for Resident 9, a new Level I PASARR and Level II referral were required and should have been completed.In an interview on 07/13/2026 at 11:05 AM, Staff A, Administrator, stated that a new Level I PASARR and referral for Level II PASARR should have been completed. Reference: (WAC) 388-97-1975 (7)(9).

Based on interview and record review, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR- an assessment used to identify people referred to nursing facilities with Serious Mental Illness, Intellectual Disabilities; or related conditions are not inappropriately placed in nursing homes for long term care) invalidation report was followed up with Level II PASARR evaluator for 1 of 5 residents (Resident 34), reviewed for PASARR Screening. This failure placed resident at risk of not receiving the care and services appropriate for their needs.Findings included.Resident 34 was admitted to the facility on [DATE] with diagnoses that included anxiety disorder (persistent, excessive fear or worry that interferes with daily life) and Major Depressive disorder (MDD- persistent, intense sadness or a loss of interest in activities).Review of Resident 34's PASARR faxed records to PASARR evaluator dated 10/8/2025 at 4:35 PM, showed Staff Y, Social Service Assistant, had faxed the Level I PASARR form to the evaluator.Review of Resident 34's social service note dated 11/25/2025, showed Staff Y had spoken with the PASARR evaluator and the evaluator indicated that they would send an invalidation report for Level II PASARR.In a joint record review and interview on 07/09/2026 at 10:54 AM with Staff C, Social Services Director, showed that Resident 34 had diagnoses that included anxiety, and adjustment disorder (behavioral reaction to a highly stressful life change). Staff C stated that they faxed Resident 34's Level I PASARR referral to the evaluator on 10/05/2025 and had not received the invalidation report. Staff C further stated that they had not followed up since 10/05/2025 and that they should have followed up with them at least once a month.In an interview on 07/13/2026 at 1:52 PM, Staff A, Administrator, stated that they expected social services to routinely follow up at least monthly with the PASARR evaluator to ensure Level II PASARR determination or invalidation was complete. Staff A further stated that they would expect there to be documentation to show that they were following up with a resident's PASARR evaluator.Reference: (WAC) 388-97-1915 (4).

Based on observation, interview, and record review, the facility failed to implement a care plan for 1 of 2 residents (Resident 19), reviewed for positioning/mobility. The failure to implement a mobility/positioning care plan placed a resident at risk for unmet care needs and a diminished quality of life.Findings included.Review of the admission record printed on 07/07/2026 showed Resident 19 was admitted to the facility on [DATE] with diagnoses that included lack of coordination and low back pian.Review of Resident 19's comprehensive care plan revised on 10/27/2025 showed that staff were directed to offer, encourage, and assist with frequent repositioning while Resident 19 was in bed or seated in a wheelchair, and to document whether the resident accepted or declined repositioning.Review of Resident 19's electronic health record (progress note, task and Treatment Administration Record [TAR]) showed no documentation of the Resident 19's acceptance or refusal of repositioning.Observation on 07/07/2026 at 8:28 AM, showed Resident 19 was in the hallway sitting in their wheelchair with their head bent toward their chest. Follow-up observation at 11:31 AM showed Resident 19 remained seated in the same place at the same position.Multiple observations on 07/08/2026 at 9:01 AM, at 10:15 AM, at 11:18 AM, at 11:40 AM, at 12:01 PM and on 07/10/2026 at 8:45 AM, at 11:22 AM, at 11:48 AM and at 1:54 PM showed Resident 19 was in the hallway sitting in their wheelchair with their head bent forward toward their chest. Further observation showed that no staff had approached Resident 19 and/or attempted to reposition him during the dates/hours observed.A joint record review (progress note and TAR) and interview on 07/10/2026 at 2:09 PM with Staff S, Resident Care Manager, did not show documentation of Resident 19's acceptance or refusal of repositioning. Staff S stated that Resident 19 should have been offered repositioning when seated in a wheelchair, and the acceptance or refusal of repositioning should have been documented in the TAR.In an interview on 07/13/2026 at 10:36 AM, Staff B, Director of Nursing, stated that they expected Resident 19 to have been offered repositioning as care planned, and that Resident 19's acceptance or refusal must be documented.Reference: (WAC) 388-97-1020 (3).

Based on observation, interview, and record review, the facility failed to offer required assistive devices, and equipment for 1 of 1 resident (Resident 82), reviewed for limited Range of Motion (ROM). This failure placed the resident at increased risk of physical decline and a diminished quality of care.Findings included.Review of the facility's policy titled, Restorative Nursing Programs, revised in December 2025, showed, the programs actively focus on interventions that helps the residents achieve and maintain optimal physical, mental, and psychosocial functioning. The interdisciplinary team, with the support and guidance from the physician, will assure the ongoing review, evaluation, and decision making regarding the services needed to maintain or improve resident's abilities in accordance with the resident's comprehensive assessment, goals, and preferences. The Nursing personnel are trained on basic, or maintenance nursing care that Maintaining proper positioning and body alignment and assisting residents in adjustment to their disabilities and use of any assistive devices.Review of the admission record printed on 07/13/2026 showed that Resident 82 was readmitted to the facility on [DATE] with diagnoses that included Huntington's disease (a rare inherited brain disorder that causes nerve cells in the brain to break down over time) and functional quadriplegia (a condition where a person is completely unable to move their arms and legs due to severe disability).Review of a physician progress note dated 06/23/2026 showed Resident 82 had contractures (a permanent tightening or shortening of muscles, or skin that causes joints to become stiff) of the hands and feet.Observations on 07/07/2026 at 11:39 AM, on 07/08/2026 at 8:12 AM, on 07/09/2026 at 7:44 AM, and on 07/13/2026 at 5:10 AM, showed Resident 82 had contractures on both hands and feet. Resident 82's right and left hands were contracted and tightly clenched, with no splints or palm protectors on either hand. Further observations showed that Resident 82's right and left foot did not have a brace or splint in place.A joint record review and interview on 07/09/2026 at 2:24 PM, Staff Z, Restorative Nurse Manager, stated that Resident 82 had been diagnosed with contractures of both hands and feet. Staff Z stated that Resident 82 should have been referred to Physical Therapy (PT) and Occupational Therapy (OT) for evaluation and treatment. Staff Z further stated that Resident 82 would benefit from restorative nursing programs, including the implementation of splints, braces, positioning devices, and palm protectors to prevent a further decline in ROM. When asked if the resident had splints or palm protectors in place, Staff Z stated, No, they [Resident 82] should have.A joint observation and interview on 07/09/2026 at 2:56 PM, Staff AA, Licensed Practical Nurse, showed that Resident 82 had contractures on both hands and feet. Staff AA stated that the resident had contractures on both hands and stated that the right hand was more contracted than the left hand.In an interview on 07/13/2026 at 10:34 AM, Staff B, Director of Nursing Services, stated that if a resident was assessed and found to have contractures, the facility would notify the doctor and initiate a referral to PT/OT for evaluation and recommendations for ROM, application of splints, and palm protectors. Staff B further stated that Resident 82 had not been evaluated by PT/OT and they did not have any assistive devices in place.Reference: (WAC) 388-97-1060 (1)(3)(d).

Based on interview and record review, the facility failed to prevent physical abuse for 1 of 3 residents (Resident 1), reviewed for abuse investigations. Resident 2 entered Resident 1's room and hit them on the right side of their face with a closed fist. This failure placed residents at increased risk of injury, emotional distress, and a diminished quality of life. Findings included . Review of the facility's policy titled, Elopements and Wandering Residents revised on 12/2025, showed, this facility ensures that residents who exhibit wandering behavior and/or are at risk for elopement receive adequate supervision to prevent accidents and receive care in accordance with their person centered plan of care addressing the unique factors contributing to wandering or elopement risk. The policy further showed the following definitions: Wandering is random or repetitive locomotion that may be goal-directed (e.g., the person appears to be searching for something such as an exit) or non-goal directed or aimless. Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for discharge or leave of absence) and/or any necessary supervision to do so. RESIDENT 1Review of the quarterly Minimum Data Set (MDS - a required assessment tool) dated 04/24/2026, showed Resident 1 was admitted to the facility on [DATE] with diagnosis that included muscle weakness. The MDS also showed the resident had mild to moderate impaired thinking/memory. RESIDENT 2Review of the admission MDS dated [DATE], showed Resident 2 was admitted to the facility on [DATE] with diagnosis that included unspecified dementia with agitation (significant cognitive [thinking] decline and behavioral agitation [severe restlessness, irritability, with purposeless physical movements]). The MDS also showed the resident had severely impaired thinking/memory. Review of the admission wander risk assessment form dated 05/22/2026 showed Resident 2 was at a high risk to wander. Review of the Resident Visual Check Flow forms dated 05/23/2026 through 05/28/2026 showed staff were scheduled to visually check Resident 2's location every fifteen minutes, and initial when done. Review of the facility event summary report dated 05/28/2026, showed the facility staff received a phone call from law enforcement agency and was informed that Resident 1 had called them and reported that a person had come into their room and hit them in the face. The event summary report further showed the facility staff interviewed Resident 1 who confirmed that they did call the law enforcement agency after a person rummaged through their room, and when asked what they were doing and told them to leave, the person hit them on their chin and left the room. Resident 1 stated after the person [Resident 2] left their room, they turned on their call light and called the law enforcement agency. Resident 1 provided a description of the person seen in the room, was assessed for pain/injuries and none were identified. The facility event summary report showed Resident 1 had a follow-up interview with the provider on 05/29/2026 and Resident 1 reported to the provider that the person that came into their room and hit them in the face was [Resident 2] and that they found a book that belonged to Resident 2 in their bathroom. Further review of the facility event summary report showed staff were interviewed about the event, confirmed Resident 2 wandered in the facility at times and confirmed the book that was found in Resident 1's bathroom belonged to Resident 2. In an interview on 06/03/2026 at 2:16 PM, Resident 1 stated, I was asleep in bed, and I woke up because I heard someone trolling around in my room and my bathroom, I asked them what they wanted, what were they looking for and they would not answer me, so I asked them to leave. Then they came over to me while I was still in bed and hit me two times in the face, on my chin with their fist. And then they left my room, I turned on my call light and then I used my phone to call 911 [law enforcement agency]. I later found out that it was another resident here, they left their book in my bathroom and took a roll of my paper towels with them when they left my room. In an interview on 06/04/2026 at 1:16 PM, Staff C, Nursing Assistant Certified, stated Resident 2 was a wanderer and did wander into other residents' rooms. Staff C stated staff were assigned to check on Resident 2 every fifteen minutes to see where they were and what they were doing. Staff C stated the staff that were assigned to check on Resident 2 every fifteen minutes were also assigned to provide care for other residents, which made checking on Resident 2 every fifteen minutes difficult at times. Staff C further stated that if a resident went into another resident's room and hit them in the face, that would be physical abuse.In an interview on 06/08/2026 at 12:55 PM, Staff D, Licensed Practical Nurse, stated Resident 2 wandered in the facility and was at high risk for elopement. Staff D stated staff were assigned to visually check on Resident 2 every fifteen minutes and confirm Resident 2's whereabouts in the facility and what they were doing. Staff D further stated the staff that were assigned to visually check Resident 2 every fifteen minutes were also assigned to provide care for other residents. Staff D further stated that if a resident went into another resident's room and hit them in the face, that would be physical abuse.In an interview on 06/08/2026 at 2:13 PM, Staff B, Director of Nursing Services, stated Resident 2 was at risk of wandering in the facility. Staff B stated the fifteen-minute visual checks on Resident 2 should have been completed by the staff that was assigned to care for Resident 2, and the staff that was assigned to care for Resident 2 was also assigned to care for other residents. Staff B stated the book that was found in Resident 1's bathroom belonged to Resident 2 and during staff interviews, staff stated they had seen Resident 2 walking with a roll of paper towels. Staff B further stated that it was physical abuse when Resident 2 entered Resident 1's room and hit them in the face. Reference: (WAC) 388-97-0640(1) .

Based on observation, interview, and record review, the facility failed to provide supervision of two staff assistance and use of a mechanical lift (Hoyer) device to prevent an avoidable accident during a transfer for 1 of 3 residents (Resident 1), reviewed for accident hazards. Resident 1 experienced harm when they had an assisted fall while being transferred by one staff person without the use of the care planned Hoyer lift device, sustained a broken distal fibula (calf bone), and required transfer to the emergency room. This failure placed residents that require mechanical lift transfer or two staff extensive assistance at risk for injury, adverse outcomes, functional decline, and diminished quality of life. Findings included.Review of the facility's policy titled, Accidents and Supervision, revised in December 2025, showed Each resident will receive adequate supervision and assistive devices to prevent accidents.Review of the facility's policy titled, Comprehensive Care Plans, revised in December 2025, showed, It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Review of the facility's undated investigation report showed that Resident 1 had a witnessed assisted fall in the shower room on 04/16/2026. Further review showed that the physician was notified of the radiology results and that they gave an order to transfer [Resident 1] to the emergency room for further evaluation and treatment.Review of the facility's radiology report dated 04/16/2026, showed that Resident 1 had an acute fracture involving right distal fibula [calf bone].Review of hospital records, showed a radiology report dated 04/16/2026, which revealed that Resident 1 had a displaced fracture of the distal fibular shaft [calf bone]. Further review of a hospital progress note dated 04/17/2026, showed that Resident 1 was placed in a three-way splint [a method for immobilizing ankle injuries while allowing for swelling].Review of Resident 1's admission Minimum Data Set (an assessment tool), dated 04/01/2026, showed that Resident 1 had a fall in the last month prior to admission.Review of Resident 1's Activities of Daily Living (ADL) care plan, printed on 04/30/2026, showed that it was revised on 04/17/2026 and that Resident 1 required a Hoyer (a mechanical lift for mobility support) transfer with two-person assistance due to a right ankle fracture. Review of the ADL care plan history, initiated on 03/26/2026, showed Resident 1's ADL care plan, revealed that Resident 1 required a Hoyer lift for transfers.Review of the therapy care guide, dated 03/27/2026, showed that Resident 1 required a mechanical lift and two-person extensive assistance for transfers.Observation and interview on 04/30/2026 at 10:49 AM, showed Resident 1 in bed. Resident 1 stated that they could not get out of bed because they had a broken ankle after a fall in the shower room. Resident 1 stated, I was almost ready to go home, now I have to stay here longer. Resident 1 stated that they had been in the shower room with an aide and at the end of the shower she [Staff C, Certified Nursing Assistant (CNA)] was going to start drying me off while standing up. I told her I was going down, I screamed for help. Resident 1 further stated that there was only one person helping transfer them from the wheelchair to standing in the shower room.In an interview and joint record review on 04/30/2025 at 1:01 PM, Staff F, Physical Therapist Assistant (PTA), stated that they were aware of Resident 1's fall. When asked what Resident 1's transfer status was prior to the fall, Staff F stated that it fluctuated during therapy, between one to two person assistance and nothing was changed and that it was still a Hoyer [lift] transfer. Staff F further stated that the plan of care for Resident 1 would not change until it's consistent.In a phone interview on 04/30/2026 at 2:27 PM, Staff C stated they would look at the care plan, talk to their [a resident's] aide to find out what a resident's transfer status was when bringing a resident to the shower room. Staff C stated that on the day of the fall [04/16/2026], they had asked Resident 1's aide how to transfer them and the aide told me extensive and didn't [did not] say if they were one or two-person [transfer]. Staff C stated that I asked [Resident 1] about her transfer and she said she could do with one person assistance. Staff C stated that they brought Resident 1 to the shower room and when they finished the shower, Resident 1 had to stand up to put on the brief, she said she could stand, I thought she was okay and when she stood up again to put on clothes Resident 1 stated that it feels like I'm sliding, I'm not stable. Staff C stated that there was a bench behind her but she said she couldn't [could not] do it or get back to the wheelchair. Staff C stated that Resident 1 had a gait belt on and they helped Resident 1 get to the floor. Staff C stated that Resident 1 said that their feet were hurting and they took off Resident 1's shoes. When asked what Resident 1's care plan said for transfers, Staff C stated that they were two-person extensive assistance and later I saw she was Hoyer transfer. Staff C stated that I didn't [did not] do two-person extensive [transfer], I thought she [Resident 1] was okay, as [Resident 1] stated, 'I can do it.' Staff C stated, I was wrong and stated that they did not follow the care plan. Staff C further stated that later I found out she [Resident 1] needed a Hoyer, I went to the computer, went to her care plan, I missed it the first time.In a phone interview on 04/30/2026 at 2:19 PM, Staff D, Registered Nurse, stated on the day of [Resident 1's] fall, I was in the hall, she [Staff C] called for help. Staff D stated that when they went inside the shower room [Resident 1] was on the floor, her right leg was bent and touching the wall. Staff D stated that at the time of the fall, Resident 1 was a two-person transfer with Hoyer. Staff D further stated that when they got to the shower room, she [Staff C] was by herself with Resident 1.In an interview and joint record review on 05/01/2026 at 9:31 AM, Staff B, Resident Care Manager (RCM), stated that they expected staff to follow resident care plans. Staff B stated that if therapy changes things they [RCMs] will update care plans. Staff B stated that CNAs should check care plans every day and should look at care plans to know how a resident transfers. Staff B stated that if a resident tells staff that they could do a transfer with less assistance than what the care plan says, they can't [cannot] go against what the care plan says. Staff B stated that only therapy can make changes, doesn't [does not] matter what the resident says. Staff B stated that Resident 1 required a Hoyer for transfers at the time of their fall on 04/16/2026. A joint record review of Resident 1's ADL care plan, showed that it was revised on 04/17/2026 after the fall. Further review of the care plan history showed Resident 1's ADL care plan that was initiated on 03/26/2026 revealed Resident 1 required a Hoyer lift for transfers. Staff B stated that on 04/16/2026 Resident 1 was a Hoyer transfer. A joint record review of the therapy care guide, dated 03/27/2026, showed that Resident 1 required a mechanical lift and two-person extensive assistance for transfers. Staff B stated that I was there when she [Staff C] said 'I need help', [Resident 1] was on the floor and that Staff C was by themselves with Resident 1 and I did not see a Hoyer.In an interview and joint record review on 05/01/2026 at 10:54 AM, Staff G, PTA, stated that they made changes to a resident's transfer status when they could do it consistently with therapy, and then they train the charge nurse, then the aide in charge [of the resident] and then change the plan of care. Staff G stated that nurse staff should not change a resident's transfer status until the plan of care is changed in writing. Staff G stated that they had worked with Resident 1 prior to their fall on 04/16/2026 and stated that the plan of care hadn't [had not] been changed yet and was still a mechanical lift transfer because sometimes she was an easy transfer, sometimes hard. Staff G stated that they had started to train some aides to use a two-person with a walker transfer with Resident 1 but it [plan of care] hadn't [had not] been changed.In an interview on 05/01/2026 at 11:05 AM, Staff E, Director of Rehabilitation, stated that the process to change a resident's transfer status was to train the charge nurses, aides, and then change the plan of care. Staff E stated that we insist they [aides] follow the pocket guides [care plan] until the RCM changes it [care plan].In an interview and joint interview on 05/01/2026 at 10:10 AM, Staff A, Director of Nursing, stated they expected staff to follow resident care plans. Staff A stated that staff would know a resident's transfer status by looking in their care plan or Kardex (a care guide for CNAs). Staff A stated that if there was a change in transfer status there would be a sheet [care guide] from therapy with changes and then the nurse manager will update the care plan. Staff A stated they expected staff to follow residents' transfer status. A joint record review of Resident 1's ADL care plan printed on 04/30/2026, showed it was revised on 04/17/2026 and that Resident 1 required a Hoyer transfer with two-person assist due to a right ankle fracture. Further review of the care plan history showed Resident 1's ADL care plan, was initiated on 03/26/2026, and that Resident 1 required a Hoyer lift for transfers. A joint record review of the therapy care guide, dated 03/27/2026, showed that Resident 1 required a mechanical lift and two-person extensive assistance for transfers. Staff A provided an additional therapy care guide, dated 04/16/2026, that showed Resident 1 was a two-person extensive assist with transfer (not a Hoyer transfer). Staff A stated that the aides had been trained for a two-person extensive assist with transfer with Resident 1. In a follow-up interview at 11:28 AM, Staff A stated that they expected staff to follow residents' care plans and that Resident 1's ADL care plan showed they were a Hoyer transfer at the time of the fall [04/16/2026]. Staff A stated that Staff C should not have taken the resident's word for it. Staff A further stated that Staff C did not follow Resident 1's transfer status, should have had a second person, and that Resident 1 sustained a fracture from the fall.Reference: (WAC) 388-97-1060 (3)(g).

Based on interview and record review, the facility failed to provide necessary services to maintain personal hygiene for 1 of 4 residents (Resident 1), reviewed for Activities of Daily Living (ADL). The failure to provide bath/shower for a resident who was dependent on staff for assistance placed the resident at risk for poor hygiene, unmet care needs and a diminished quality of life. Findings included. Review of the facility's policy titled, Activities of Daily Living , revised in September 2025, showed, Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in ADLs do not diminish unless circumstances of the individual's clinical condition demonstrates that such diminution was unavoidable. Review of the admission record printed on 03/03/2026 showed that Resident 1 was admitted to the facility on [DATE] with diagnosis that included generalized muscle weakness. Review of the ADL care plan initiated on 11/28/2025 showed that Resident 1 had a self-care performance deficit related weakness, pain, and impaired mobility. Further review of the care plan showed that Resident 1 was scheduled to receive two baths/showers per week. Review of the quarterly Minimum Data Set (an assessment tool) dated 12/04/2025 showed Resident 1 had moderately impaired cognition and was dependent on staff for shower/bathing. Further review of the assessment showed that Resident 1's shower/bathing was very important for them. Review of facility provided document titled, Task Schedule, showed that Resident 1's bathing was scheduled for Tuesdays and Saturdays. In an interview on 03/03/2026 at 11:55 AM, Resident 1 stated that they were not receiving bath/shower consistently. Resident 1 stated that they went with no bath/shower for the last three weeks. Resident 1 stated that it had been three weeks since the last time they took a shower. Review of Resident 1's Kardex (care guide) showed that between 12/02/2025 and 03/09/2026, the resident did not receive shower on 12/06/2025, 12/12/2025, 12/16/2025, 12/23/2025, 12/27/2025, 12/30/2025, 01/03/2026, 01/10/2026, 01/13/2026, 01/17/2026, 01/24/2026, 01/27/2026, 01/31/2026, 02/14/2026, 02/17/2026, 02/21/2026, 02/24/2026, and 03/03/2026. Review of the Kardex further showed that Resident 1 refused showers on 02/26/2026 and 03/03/2026. In an interview on 03/09/2026 at 12:32 PM, Staff B, Residents Care Manager, stated that Resident 1 was supposed to receive bath/shower twice a week. Staff B stated that if a resident refused shower/bath it was the facility's process to offer at another time, document refusal and report it. Staff B further stated that they would expect Resident 1's shower/bath schedule and care plan to be followed as planned. In an interview and joint record review on 03/09/2026 at 1:30 PM with Staff A, Director of Nursing Services, stated that staff were expected to provide shower/bath for residents as scheduled. A joint record review of Resident 1's facility provided Electronic Health Record (Follow Up Question Report) showed that the Resident did not receive shower on 12/06/2025, 12/12/2025, 12/16/2025, 12/23/2025, 12/27/2025, 12/30/2025, 01/03/2026, 01/10/2026, 01/13/2026, 01/17/2026, 01/24/2026, 01/27/2026, 01/31/2026, 02/14/2026, 02/17/2026, 02/21/2026, 02/24/2026, and 03/03/2026. A joint record review further showed that Resident 1 had refused shower on 02/26/2026 and 03/03/2026. Staff A stated Resident 1 refused bath/shower multiple times, but it was not documented. Staff A stated that when residents refuse care, they would expect staff to document and report it. Staff A further stated that Resident 1 should have received bath/shower as outlined in their bath/shower schedule and care plan. Reference: (WAC) 388-97-1060 (2)(c).

Based on observation, interview, and record review, the facility failed to ensure residents were free of physical abuse when the facility failed to implement their abuse policy and procedures to conduct an immediate investigation that included resident interviews for potential abuse for 2 of 3 residents (Residents 2 & 1). In addition, the facility failed to protect Resident 2 and other residents from potential abuse when an identified nursing assistant (NA) remained in the facility after Resident 1 reported to staff that the same NA hit them on the right upper arm causing bruise, and mental anguish. These failures caused Resident 1 harm and had the potential to cause further abuse, pain, and fear for Resident 2 and other residents. Findings included . Review of the abuse policy revised on 05/2023, showed it is the policy of the facility to provide protection for the health, welfare, and rights of each resident by developing and implementing policies and procedures that prohibit and prevent abuse. Definition: physical abuse, includes but is not limited to hitting, slapping, punching, biting and kicking. The abuse policy also showed an immediate investigation is warranted when suspicion of abuse or reports of abuse occur, and written procedures for investigations include identifying and interviewing all involved persons including witnesses and others who might have knowledge of the allegations. RESIDENT 2 Review of the admission Minimum Data Set (MDS - an assessment tool) dated 09/19/2023 showed Resident 2 was admitted to the facility on [DATE]. The MDS also showed Resident 2 had moderate cognitive impairment, was able to make needs known, and required assistance for care needs. Review of an investigation summary dated 09/21/2023, showed on 09/19/2023 Resident 2 reported to staff being manhandled a couple of days ago by an NA. Resident 2 reported that the NA grabbed their right arm tightly and caused them pain. The investigation summary further showed Resident 2 was not able to provide the name of the NA but did provide a description of the NA that matched the description of the NA that hit another resident (Resident 1) on 09/17/2023, that same evening. Further review of the investigation summary dated 09/21/2023, showed the description of the NA provided by Resident 2 was reasonable to believe that it was the same NA that hit another resident that same evening (09/17/2023). The investigation summary dated 09/21/2023, showed Resident 2's allegation of rough handling was unsubstantiated because Resident 2 could not provide the name of the NA and had no physical injury that could be seen. An interview on 09/28/2023 at 12:39 PM, Resident 2 stated, I was manhandled here, it happened a couple of weeks ago. I did not tell anyone right away because I was afraid. I don't know the name, but I know what they look like, I told them what they looked like. It was a nursing assistant. I don't know why or what I ever did to be treated this way. Observation on 09/28/2023 at 12:42 PM, showed Resident 2 used their left hand and grabbed their right forearm/upper arm with a firm grip, and showed how they were mishandled, Resident 2 stated they did it hard and on purpose. Resident 2 further stated, That was what the NA did to me, it hurt then, but not now. I did not know why they did this to me. RESIDENT 1 Review of the quarterly MDS assessment dated [DATE] showed the resident admitted to the facility on [DATE]. The MDS assessment also showed Resident 1 was cognitively intact and required assistance to complete care. Review of an investigation summary dated 09/21/2023, showed on 09/17/2023 Resident 1 reported to Staff E, Registered Nurse, that Staff F, NA, hit them on the arm at approximately 5:00 PM that day. Further review of the investigation summary showed the allegation of physical abuse to Resident 1 by Staff F was substantiated. An interview on 10/06/2023 at 1:26 PM, showed Resident 1 stated that they hit Staff F on the arm first because they would not listen to what they wanted. Resident 1 also stated that Staff F was hard to understand. Resident 1 then stated Staff F hit them back very hard on the right arm. Resident 1 stated it happened around dinner time and that they told the nurse around that time. Observation on 10/06/2023 at 1:32 PM, Resident 1 had an approximately two to three centimeter red bruise on their right upper arm. At that same time Resident 1 stated, I hate that this happened to me! This should not have happened to me; they should not have hit me. I am upset and mad about this, that this happened to me. Resident 1 further stated that they did not want to see Staff F again. An interview on 10/06/2023 at 2:16 PM, Staff E stated that Resident 1 reported to them that Staff F hit them on the arm. Staff E stated that Resident 1 reported it after dinner on 09/17/2023, and they removed Staff F from the care of Resident 1 and had another nursing assistant provide care for Resident 1. Staff E stated Staff F took care of other residents but not Resident 1, and Staff F remained in the facility until 10:00 PM when the shift was over. Law enforcement arrived at the facility around 11:00 PM that night and told them to take a picture of the bruise on Resident 1's right upper arm because Resident 1 had been hit. Staff E stated they did not interview or ask any other residents about abuse, if they had been hit or if they had any concerns that night, just Resident 1. Staff E further stated that they should have told Staff F to leave the facility because they could have hurt or done something to other residents and that would have protected all the other residents. Interview on 10/06/2023 at 4:58 PM with Staff B, Director of Nursing, stated, I think it was reasonable to believe the same nursing assistant that hit Resident 1 also grabbed Resident 2. I was not able to substantiate Resident 2's allegation because they could not provide a name and we did not find any injuries on Resident 2. Resident 1 had a bruise and provided the name of the nursing assistant. Resident 1 will press charges against Staff F. Staff F should have been sent home immediately and not been allowed to work with other residents. Reference: (WAC) 388-97-0640(1)

Based on interview and record review, the facility failed to implement the planned preventative measure of two-person assist to prevent falls for 2 of 3 residents (Residents 1, and 2) reviewed for falls. Resident 1 experienced harm when they were not provided two-person assist with toileting, fell , and fractured their right hip. Resident 2 experienced harm when they were not provided two-person assist with transferring and experienced an injury to their left upper arm. The inability to consistently follow care planned preventative measures for falls placed all residents at risk for falls, injury, and a diminished quality of life. Findings included . <RESIDENT 1> Resident 1 admitted to the facility on [DATE] with diagnosis that included muscle weakness. Review of the admission Minimum Data Set (MDS - a required assessment tool) dated 04/23/2023, showed Resident 1 did not have impaired thinking and required a two-person assist with transfers on and off the toilet. Review of the (CP), dated 04/26/2023, showed Resident 1 required two-person assist with transfers on and off the toilet. Review of the fall investigation, dated 06/02/2023, showed Staff C, Nursing Assistant Registered (NAR), attempted to transfer Resident 1 to the toilet when Resident 1 took a step, paused, and fell to the floor. Staff C went to the doorway and asked for help. Staff B, Director of Nursing Services (DNS), responded to the call for help. Resident 1 complained of pain to the right leg. Staff called for emergency transport to the hospital. Review of the hospital records showed Resident 1 was admitted to the hospital on 06/02/2023 and was diagnosed with a right hip fracture. Resident 1 had a surgical repair of the right hip fracture on 06/04/2023. Review of a nursing note, dated 06/09/2023, showed Resident 1 was readmitted to the facility with the primary diagnosis of a fall with right hip fracture and had surgical repair of the right hip. In an interview on 06/20/2023 at 2:27 PM, Resident 1 stated, I wanted to use the bathroom, they usually have two people help me on and off the toilet. This time it was only the one person. I fell and had a lot of pain in my hip, it turned out my hip was broken, and I had to have surgery to fix it. I can't do much now until it heals. On 06/22/2023 at 1:43 PM, Staff C stated, (Resident 1) needed to use the toilet, I transferred by myself. I thought the pocket guide was for either a one person or two-person assist for transfers on and off the toilet, I was not sure. <RESIDENT 2> Resident 2 readmitted to the facility on [DATE]. Review of the quarterly MDS assessment, dated 03/14/2023, showed Resident 2 had impaired thinking and was a two-person assist for transfers. Review of a fall investigation, dated 04/12/2023, showed Staff D, NAR, transferred Resident 2 without the assist of another person. Resident 2 could not stand and Staff D lowered Resident 2 to the floor. Staff D called for assistance and supported Resident 2 to a safe position. Resident 2 sustained a 3.5 centimeter (cm) by 1.8 cm skin tear to the left upper arm. A nurse performed first aide to the skin tear. On 06/20/2023 at 3:40 PM Staff D stated Resident 2 was transferred without the assistance of another person. Staff D also said the pocket guide stated Resident 2 was a two-person transfer but did not wait for the assistance of another staff member before Resident 2 was transferred. On 06/22/2023 at 3:18 PM Staff E, NAR, stated the pocket guide lets the staff know how to care for the residents and how much assistance the residents need for transfers. On 06/22/2023 at 3:22 PM, Staff F, Registered Nurse (RN), stated the pocket guide was like a CP for the nursing assistants (NA). The pocket guide told the NA how to transfer residents and how much assistance was needed for transfers. Staff F also stated the NA were expected to follow the pocket guide. On 06/22/2023 at 3:40 PM Staff G, RN/Resident Care Manager (RCM), stated the pocket guide had the same transfer information as the CP. That it was like a CP the NA were expected to know and follow for the residents for which they provided care. Staff G also said the pocked guide was reviewed and updated daily and as needed for every resident in the facility by the resident management staff. 0n 06/22/2023 at 3:58 PM, Staff B stated the pocket guides had the same information as the CP and informed the staff of the transfer status of each resident in the facility. Staff B said the pocket guides were not followed when Staff C transferred Resident 1 without assist of another person and Resident 1 sustained a right hip fracture and when Staff D transferred Resident 2 without assistance of another staff member and Resident 2 fell and sustained a skin tear on her left upper arm. On 06/22/2023 at 4:03 PM Staff A, Assistant Administrator stated, the NA's were expected to follow the pocket guides, this would eliminate the possibility of injuries for the residents. Reference WAC: 388-97-1060(3)(g)

Based on interview and record review, the facility failed to ensure 2 of 3 residents (Residents 1 & 2), reviewed for change of condition, received timely transport to the hospital when Resident 1 had a new onset of weakness to the right upper and lower extremities, and failed to supervise safe transportation to the hospital for Resident 2 who experienced seizure like activity. Delayed transport to the hospital caused harm to Resident 1 who arrived at the hospital outside the window of a medical intervention. Transport of Resident 2 to the hospital for seizure like activity, unsupervised in a non-medical vehicle, placed the resident at risk for untreated medical complications, injury, and a diminished quality of life. Findings included . RESIDENT 1 Resident 1 admitted to the facility on [DATE] with diagnosis that included heart disease. Review of the admission Minimum Data Set (MDS - a required assessment tool) dated 01/08/2023, showed Resident 1 did not have impaired thinking, required assist with mobility and had no limitations to upper or lower extremities. Review of a progress note dated 02/03/2023 at 3:12 PM, showed Resident 1 started to feel weakness on the right side of the body after breakfast around 8:30 AM. At 3:36 PM that day, Resident 1 was transported to the hospital emergency room . Review of the hospital record dated 02/03/2023, showed Resident 1 had difficulty using the right hand and right leg that started around 8:30 AM. Further review of the hospital record showed Resident 1 arrived at the emergency room and was evaluated for a stroke (a blocked artery in the brain), and did not arrive at the hospital in time to receive thrombolytic medication (used to break-up the clot that caused blockage or disruption to the flow of blood to the brain, helps to restore blood flow to the area of the brain when administered within three hours of stroke symptoms). Additional review of the hospital record dated 02/03/2023 showed Resident 1 had new onset of a stroke that caused the right side of the body to be paralyzed (no voluntary movement). On 05/02/2023 at 2:51 PM, Staff C, Licensed Practical Nurse, stated if a resident complained of signs of a stroke, like weakness of the arms or legs on one side, they would check the vital signs and sent them to the hospital right away. On 05/02/2023 at 3:04 PM, Staff D, Registered Nurse (RN), stated if a resident had right sided weakness that was a change, they would take the vital signs, assess the resident, and send them to the hospital right away, then let the physician know. On 05/02/2023 at 4:24 PM Staff B, Director of Nursing Services, stated they should have acted faster and sent Resident 1 to the hospital when the resident complained of right-side weakness. On 05/02/2023 at 4:31 PM, Staff E, Administrator Assistant, stated Resident 1 should have been transported to the hospital earlier for complaints of right-sided weakness. RESIDENT 2 Review of the admission MDS assessment dated [DATE], showed Resident 2 admitted to the facility on [DATE] with a diagnosis that included weakness on the left side of the body that was the result of a stroke. Resident 2 required extensive assist for all care and mobility. Review of a nursing progress note dated 03/24/2023, showed Resident 2 appears fatigued and confused compared to baseline. Per reports patient had a seizure-like episode last night and this morning. Patient sent to Emergency Department. On 05/02/2023 at 2:02 PM, Resident 2 stated, I was by myself when I went to the hospital, I went in my wheelchair. I do not see or hear very well. I am not sure why I was sent there. The driver dropped me off by the door. On 05/01/2023 at 3:15 PM, Staff F, RN/Resident Care Manager, stated Resident 2 went to the hospital unsupervised in a non-medical vehicle. Staff F also stated the facility physicians decided how the residents were to be transported to the hospital. On 05/01/2023 at 3:21 PM, Staff B stated when the facility physicians were notified of the residents change of condition, they would decide how the resident would be transferred to the hospital and that a physician's order would be written that documented the way the resident would be transported to the hospital. Staff B was unable to locate a physician's order that documented the way the physician ordered Resident 2 to be transported to the hospital for seizure like activity. Reference: (WAC) 388-97-1060 (1)

Based on interview and record review the facility failed to recognize a change in condition and intervene timely in accordance with professional standards of practice to minimize the risk of severe complications for one of one resident (1) reviewed. These failures resulted in harm to Resident 1 who was hospitalized for an arterial occlusion of the right lower extremity, which required surgical intervention. Findings included . Resident 1 admitted to the facility on [DATE] with diagnoses to include dementia (memory loss) without behaviors, chronic congestive heart failure (affects the pumping power of the heart, often edema [swelling] occurs), atrial fibrillation (abnormal heart rhythm) with history of pulmonary embolism (PE - blood clots in lungs) and history of deep vein thrombosis (DVT - blood clot in deep vein) in the lower extremity. The admission Minimum Data Set assessment dated [DATE] documented the resident had severe cognitive impairment and required extensive assistance of 2 persons for bed mobility and toileting and extensive assistance of 1 person for dressing and personal hygiene. Review of Resident 1's clinical record showed there was no care plan in place regarding history of PE's or DVT's, monitoring, complications, or interventions related to either. In addition, Resident 1 had an order for TED hose (stockings to help prevent blood clots & swelling) [initiated on 09/26/2022], that was also not documented on the care plan. Review of the Medication Administration Record (MAR) for October 2022, showed on 10/10/2022 at 4:45 AM, Staff A, Director of Nursing Services (DNS), administered Tylenol for pain 8 out of 10. This was a change in the resident's condition and the only complaint of severe pain since admission on 09/21/2022. The documentation does not indicate location of pain, contributing factors or physician notification, just that as needed medication was administered. Review of the progress notes showed that Staff A, DNS failed to document any information or physician notification related to Resident 1 having a sudden onset episode of severe pain that occurred during their shift on 10/10/2022. On 10/12/2022, Staff A, DNS, initiated a facility investigation after receiving a call from Resident 1's Family Member (FM), voicing concerns with the delay in response to an acute change in Resident 1 on 10/10/2022. The investigation summary documented that on 10/10/2022 at approx. 5:00 PM, Staff D, Advanced Registered Nurse Practitioner (ARNP), gave orders for Staff C, Registered Nurse (RN) to obtain a venous and arterial doppler ultrasound (imaging to rule out blood clots), STAT (immediate). Further review of the investigation showed that Staff C was notified by the lab company that the STAT order could not be completed until the following day. Review of the progress notes on 10/10/2022 at 11:27 PM, showed Staff C, RN documented the doppler test was pending. There was no documentation that Staff D, ARNP had been notified the lab could not be completed as ordered (STAT) and would not be completed until the following day. Review of progress note on 10/10/2022 at 11:46 PM, showed Staff C, RN notified the on-call provider of Resident 1's current condition and orders were received to send the resident to the emergency room (ER). Staff C then called for non-emergent transfer to the hospital. It took almost 2 hours for transportation to arrive and transport the resident, the resident then left the facility at 1:13 AM on 10/11/2022. Review of progress note dated 10/10/2022 at 11:46 PM, showed an on-call provider was notified that Resident 1 had right lower extremity swelling and pain. The note further documented that Resident 1's FM was very concerned and insisted on the resident being sent to the hospital for evaluation and the order was given by the on-call provider to send them to the ER. On 11/16/2022 at 5:06 PM, a telephone interview was conducted with Resident 1's FM. They stated on 10/10/2022 around lunch time, while visiting at the facility, Resident 1 stated, I do not want another bad night like last night, my leg started hurting really bad around 3:00 AM and no one was helping me, so I started yelling and even my roommate was yelling for help. Resident 1's FM then proceeded to look at the resident's legs, removed the TED hose from both legs and noticed the right leg was dark purple, cold to the touch and the left was warm and pink in color. Resident 1's FM stated she immediately notified nursing and they had Staff D come see Resident 1. Resident 1's FM stated that when Staff D observed the resident's legs, they told the nursing assistant, Get them in bed and elevate the legs right now, feeling that Staff D reacted like it was an emergency. At 9:50 PM, Resident 1's FM called the facility to check on the resident and stated they insisted on Resident 1 being seen by a doctor and wanted them sent Resident 1 to the hospital immediately, but it wasn't until 2:00 AM that the facility called to notify them that Resident 1 was on the way to the hospital. Later that morning Resident 1's FM received a call from the Vascular Surgeon (a specialist who treats problems with blood vessels) at the hospital, informing them that Resident 1 had a blood clot in the major artery of their right leg, the leg was dying and could not be saved. They stated that the surgeon explained that the first 6 hours of onset of a blood clot were critical for full recovery, and Resident 1's FM was concerned that it took almost 24 hours to get Resident 1 to the hospital after their initial complaints of severe pain in the right leg, early morning on 10/10/2022. During a joint interview and record review on 12/05/2022 at 1:45 PM, Staff B, RN, stated they provided care to Resident 1 on 10/10/2022, day shift. Staff B recalled Resident 1 having multiple complaints of pain in their right leg during the shift but stated they had not documented this information into the clinical record and had not notified the doctor regarding it but should have. On 12/05/2022 at 3:00 PM, Staff D, confirmed on 10/10/2022 they ordered a STAT doppler to be done of the right leg but stated they were not notified by nursing staff that the order would not be done until the following day. Staff D also stated that they were not notified by Staff A that Resident 1 had complained of severe pain during their shift on 10/10/2022 at 4:30 AM. On 12/05/2022 at 3:50 PM, Staff C, RN, stated that as Staff D was leaving the facility for the night on 10/10/2022, a verbal order was received to obtain the doppler ultrasound STAT. Staff C confirmed they did not notify Staff D the STAT lab could not be done until the following day, because they know the lab doesn't come right away. Staff C, then stated the on-call provider was notified at the request of Resident 1's FM and orders were given to send the resident to the ER. Staff C called for non-emergent transportation at that time and received an estimated time of arrival of up to 2 hours, confirming that the provider was not notified of this delay. Reference: (WAC) 388-97-1060 (1)

Based on observation, interview and record review, the facility failed to prevent physical abuse from Resident #2 toward three other residents (Resident #3, 4, 5) when Resident #2 had a history of [REDACTED].#3 who was slapped on the face by Resident #2. Findings included . Review of the facility incident reporting log showed Resident #2 had incidents of resident to resident physical abuse altercations on 08/02/19; 07/01/19; 05/12/19; 12/30/18; 12/14/18. In an interview on 09/17/19 at 10:00 a.m., the facility Director of Nursing (DNS) stated that most of the resident to resident abuse incidents with Resident #2 had occurred in the main dining room. The DNS stated that the staff have been in-serviced to pay attention to Resident #2 in the dining room and not let her sit next to residents that she has (previously) hit. In an interview on 09/19/19 at 10:10 a.m., Staff B, a facility social worker, stated that Resident #2 did hit other residents in the facility due to her dementia. Staff B stated that Resident #2 liked to handle things in the dining room and have things a specific way and had difficulty understanding others. Staff B stated that Resident #2 really needed supervision in the dining room or in the area right outside the dining room when residents congregate so as to prevent altercations. Staff B stated that Resident #2 could be triggered by commotion and the staff needed to manage the environment for her, but they could not guarantee the staff always supervised and observed Resident #2, especially in the evening. Staff B stated that she was not aware Resident #2 had hit and pinched Resident #4 in (MONTH) 2019. Review of the facility medical records showed Resident #2 resided in the facility for long term care since (YEAR) and had Alzheimer's dementia with behavioral disturbance. According to the facility Minimum Data Set (MDS)assessment, dated 07/24/19, Resident #2 had cognitive impairment, was short tempered, and easily annoyed. Resident #2 needed set up and supervision for locomotion, limited assistance with walking and used a walker. Review of a progress note, dated 07/25/19, showed Resident #2 ambulated independently with her walker. Review of the care plan, dated 05/02/19, showed Resident #2 had physically abusive behaviors, such as hitting other residents and purposely provoking or taunting other residents. The interventions were as follows: allow distance in seating other residents around resident, intervene if necessary, avoid over stimulation, separate the residents if Resident #2 is being aggressive toward another resident, seat resident where constant or near constant observation is possible, provide at least every 15 minute checks. An observation on 08/26/19 at 3:45 p.m. showed Resident #2 ambulating independently in her room without her walker. Upon interview at that time, Resident #2 stated that she did not recall hitting anyone. August 2019 Resident #2 hit Resident #3 Review of facility medical records showed Resident #3 resided at the facility since (YEAR) for long term care. According to the facility MDS assessment, dated 07/17/19, Resident #3 had cognitive impairment with no behaviors, and was dependent on staff for activities of daily living. Resident #3 used a wheelchair for locomotion. An observation on 08/26/19 at 4:04 p.m. showed Resident #3 self propelling her wheelchair in the halls of the facility. Upon interview at that time, Resident #3 stated she did not recall getting hit by another resident. Review of the facility investigation, dated 08/02/19, showed a resident to resident altercation occurred in the main dining room. Resident #2 is occasionally observed to be disruptive in the dining room; arguing with other residents, grabbing silverware and is particular about the set up at her table. On 08/02/19 at 8:05 a.m., Resident #2 got out of her chair and slapped Resident #3 (seated in her wheelchair at the same table) on the left side of her face at least twice before staff could reach her. In an interview on 09/19/19 at 2:20 p.m., Staff D, a caregiver, stated that he was in the main dining room near the beverages as he was getting a drink for another resident, he turned and saw Resident #2 get up from her chair at her table in the dining room, and go toward Resident #3. Resident #3 tried to move her head away from Resident #2, but Resident #2 slapped Resident #3 two to three times rapidly on her face at the side toward the ear and neck. Staff D stated that Resident #3's head moved a little during the slapping. Staff D stated he went over to that side of the room and got between the residents and noticed Resident #3's cheek, jaw, and ear were red from the slapping, and her eye was teary from getting hit. Resident #2 told Staff D that she was trying to help Resident #3 eat and she was not letting her help. In an interview on 09/19/19 at 11:00 a.m., Resident #8, an alert and oriented resident, stated that he saw Resident #2 hit Resident #3 more than two times in the dining room in August. (Resident #8's MDS assessment dated [DATE] showed he was cognitively intact). July 2019 Resident #2 hit Resident #5 Review of the facility medical records showed Resident #5 resided at the facility for long term care since (YEAR). According to the facility MDS assessment, dated 07/01/19, Resident #5 had some cognitive impairment with some verbal behaviors toward others and needed assistance from staff for all activities of daily living. Resident #5 used a wheelchair and sometimes used a walker. An observation on 08/26/19 at 4:30 p.m. showed Resident #5 self propelling her wheelchair toward the dining room. Upon interview at that time, Resident #5 stated that she did not recall getting hit by anyone. In an interview with the legal representative for Resident #5 on 09/18/19 at 12:50 p.m., the legal representative stated that Resident #5 was scared after getting hit by the other resident, but she got over it. Review of the care plan for Resident #5 dated 07/02/19 showed Resident #5 could be particular and very vocal about how the dining room was set up, and the staff were to ensure her safety by removing or separating residents in the event of a possible alteration. Review of a facility investigation dated 07/01/19 showed a resident to resident altercation allegation was made by Resident #5 that Resident #2 was yelling hit her on her left arm/shoulder in the dining room at dinner. Resident #5 also said she hates me. In addition, the facility investigation noted Staff G, a medical records employee on duty in the dining room for dinner, was present in the dining room on the date of the altercation. Staff G stated Resident #5 had been swearing loudly in the dining room and was told to quiet down. Staff G also stated in the facility investigation that she observed Resident #2 stand up during dinner and make a motion behind Resident #5's back out of frustration and Resident #2 had her fist in a ball and made a swinging gesture toward Resident #5, but Staff G did not witness any actual hitting. The facility investigation showed there was an alert resident witness in the dining room (Resident #7) who stated she saw Resident #2 hit Resident #5 on the shoulder during dinner, and she stated those two ladies don't get along. In an interview on 09/19/19 at 11:15 a.m., Resident #7, an alert and oriented resident, stated that she saw Resident #2 hit Resident #5 who was sitting in her wheelchair, on the shoulder and Resident #5 said Don't hit me. (Resident #7's MDS assessment, dated 07/23/19, showed she was cognitively intact). Review of the main dining room seating chart showed Resident #5 sits at the table next to the table of Resident #2. The facility investigation showed there were no facility staff witnesses to the actual physical altercation. May 2019 Resident #2 hit Resident #4 Review of facility medical records showed Resident #4 resided in the facility since (YEAR) for long term care. According to the facility MDS, dated [DATE], Resident #4 had some cognitive impairment with no behaviors, and needed staff assistance for all activities of daily living. Resident 34 used a wheelchair and sometimes used a walker. Review of a facility investigation, dated 05/12/19, showed a resident to resident altercation occurred in the main dining room around 8:30 a.m. when Resident #2 hit and pinched Resident #4 who was upset about the incident. In an interview on 09/19/19 at 2:30 p.m., Staff C, a facility housekeeper, stated that she witnessed Resident #2 hit and pinch Resident #4 on the arm in the main dining room. Resident #4 then asked to go to her room. The incident was not witnessed by any nursing department staff. Review of a facility progress note, dated 05/12/19, showed Staff J, a licensed practical nurse, documented Resident #4 was upset due to an incident in the dining room with another resident. In an interview on 09/19/19 at 11:45 a.m., Staff J, a licensed practical nurse, stated that she saw Resident #4 come back to her hall from the dining room and she appeared ready to cry, she was frowning, and not smiling as she usually did, and she was upset about Resident #2. An observation on 09/19/19 at 11:50 a.m. showed Resident #4 in her room relaxed and alert. Upon interview at that time, Resident #4 stated that she did not recall getting hit by another resident. December (YEAR) two previous incidents with Resident #2 and Resident #5 Review of the facility incident log and investigations showed two other incidents involving Resident #2 and Resident #5 in (MONTH) (YEAR): 12/14/18: Resident #2 punched Resident #5 in the arm while sitting by the nurse station when Resident #5 was in her wheelchair waiting for her medication. Resident #5 said what is wrong with this lady. 12/30/18: Resident #2 ran into the wheelchair of Resident #5 with her walker on the way into the dining room at 7:00 a.m. and Resident #5 yelled she hit me. There were no facility staff who witnessed any hitting at that time. The facility failed to supervise and prevent resident physical abuse from Resident #2 toward three other residents (Resident #3, 4, 5) and multiple incidents of resident abuse from Resident #2 toward Resident #5. Although upon interview the residents did not recall being hit, a reasonable person does not want to be slapped during dining or anytime in the facility during their day to day activities. This physical abuse placed the residents at risk for harmful fear and pain at the time of the incidents. Reference (WAC) 388-97-0640(1)

Based on interview and record review, the facility failed to consistently monitor and evaluate condition changes for 1 of 3 Residents (2). Failure to identify condition changes and implement care plan interventions in collaboration with Resident 2's providers resulted in a rapid medical deterioration for Resident 2 and required [MEDICAL TREATMENT] due to [MEDICAL CONDITION] from antibiotic therapy. Findings include: A facility policy dated (MONTH) (YEAR), for notification of the physician included immediate attention via telephone pages to the ARNP or attending physician for critical vital signs or lab values that need immediate attention and any Stat (immediate) labs. RESIDENT 2 Resident 2 was readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The antibiotic being [MEDICATION NAME]. [MEDICATION NAME] doses administered intravenously should be individually adapted according to weight, age and renal function. [MEDICATION NAME] has been known to cause kidney damage and or swelling in the kidney. Possible side effects of [MEDICATION NAME] may include indigestion, hives, or allergic reaction. The Minimum Data Set (MDS) assessment dated [DATE] showed Resident 2's weight as 171 pounds and required set up for meals. The MDS assessment dated [DATE] showed a weight loss of 14 pounds. (157 pounds). Resident 2 had several providers involved in her care. The facility Primary Care Physician (PCP), an Advanced Nurse Practitioner (ARNP), an Infectious Disease Physician (IDP), and her Oncologist (cancer physician). Prior to her admit to the facility, Resident 2's PCP was a Naturopathic Physician. The clinical record showed that the IV [MEDICATION NAME] dosing was directed by the IDP until 11/16/17. At this time, the IDP directed the facility's pharmacist to prescribe the [MEDICATION NAME] dosing for Resident 2. On 11/8/17, the ARNP ordered weekly blood labs for Resident 2 in addition to [MEDICATION NAME] levels. The weekly blood tests were to include a blood test that gives medical providers information about the body's fluid balance and how well the kidneys and liver are working and to detect early kidney damage. On 11/14/17, the Registered Dietician (RD), recommended for staff to continue with tray monitoring (TM). The laboratory (lab) slips for the [MEDICATION NAME] blood test showed that the Licensed Nurse (LN) was notified by pharmacy of the critical high lab result on 11/15/17 at 3:37 P.M. On 11/16/17, a nursing progress note showed the facility PCP was faxed a result of a critical high lab for [MEDICATION NAME]. There was no evidence that showed that the PCP or ARNP was notified by telephone or paged regarding the critical lab in accordance to the facility policy. On 11/16/17, a telephone order by the the pharmacist showed that the current dose of [MEDICATION NAME] was discontinued and the next dose was to be given on 11/17/17. On 11/20/17 at 11:06 A.M, a [MEDICATION NAME] blood test was collected. The test results were returned to the facility at 6:50 P.M. The test results showed that it was high (above normal). The nursing progress note documented the LN would monitor and follow up on the lab draw. There was no documented evidence that the PCP was notified regarding the high [MEDICATION NAME] test level. On 11/20/17, the pharmacist wrote to hold the [MEDICATION NAME] on 11/21/17 and restart at a lower dose on 11/22/17. The resident then received [MEDICATION NAME] on 11/22/17 and 11/23/17. A note by the ARNP dated 11/21/17 documented, Resident 2 had hives on her entire back and both upper arms. The note documented that the IDP was notified regarding the hives, and felt that the hives were not related to antibiotics. The note indicated the pharmacy would be consulted in regards to the hives. There was no documented evidence the pharmacy was consulted about the hives. Resident 2's kidney function was to be monitored weekly by obtaining a complete metabolic panel (CMP) as [MEDICATION NAME] may cause kidney damage. There was no evidence the CMP blood test was done on 11/22/17. On 11/23/17 at 8:40 A.M, the [MEDICATION NAME] blood level was drawn and was higher than the previous blood test from 11/20/17. The PCP ordered the [MEDICATION NAME] be held for a day, then be resumed on 11/25/17. On 11/28/17, the [MEDICATION NAME] blood test was done, and was at a critical level. The laboratory slip for the critical level had a pharmacy recommendation to obtain a kidney function test. The lab slip showed that the ARNP was aware (11/28/17) but there was no documentation of a conversation regarding the pharmacist's recommendation to evaluate Resident 2's kidney function. A telephone order by the facility PCP dated 11/28/17 directed LNs to hold the [MEDICATION NAME] for two days (11/29/17 and 11/30/17), draw a routine blood test on 11/29/17, and then resume the [MEDICATION NAME] on 12/01/17. There was no documented evidence that the facility PCP was notified regarding the pharmacy recommendation. In addition, the weekly routine kidney function blood test for 11/22/17 had not been drawn. The test was not drawn until 11/29/17 when an order for [REDACTED]. There was no documented evidence that this Stat lab results was called to the ARNP. The lab slip and nursing notes showed that the lab result slips were faxed to the IDP, but not to the ARNP who ordered the test. Review of the nursing progress notes from 11/21/17 to 11/30/17 showed Resident 2 had episodes of abdominal pain, nausea, emesis of undigested food, a decrease in appetite and intake, and a rash with itching on her back and both arms. Resident 2's ARNP ordered medications for her rash, vomiting, and abdominal pain. Even though LNs documented Resident 2 was having a decreased intake and loss of appetite there was no further interventions or monitoring regarding hydration. Review of Resident 2's Tray Monitor from 11/15/17 to 11/30/17 showed that Resident 2's fluid intake during meals was approximately 574 cc per day. The meal intake monitoring documentation was not consistently recorded and showed Resident 2 refused most meals, intake average was 25%, and there was only one entry on 11/29/17 regarding a meal replacement/supplement. On 11/30/17, Resident 2 was transferred to the hospital for evaluation for persistent nausea and kidney failure (acute). The hospital emergency room note dated 11/30/17 confirmed the resident was transferred to the emergency department (ER) for evaluation. The ER note showed that over the last 10-14 days Resident 2 had worse symptoms (gastro/stomach) with frequent emesis, very limited oral intake, an inability to tolerate medications, and her appetite has been very poor. The ER notes also confirmed that Resident 2 was diagnosed with [REDACTED]. The resident's blood test were abnormal and high. The ER's assessment/plan documented acute kidney failure, likely multifactorial, however the biggest contributor was most likely [MEDICATION NAME] toxicity. In addition, the hospital's discharge notes dated 12/11/17 documented that Resident 2's kidney function continued to decline which required short term [MEDICAL TREATMENT]. During a interview and record review of the lab slips and physician's orders [REDACTED]. The next laboratory blood draw was done on 11/29/17 per stat (immediate) order. The DNS stated LNs had not notified the PCP or ARNP of the stat results on 11/29/17, and that documentation did not show when any providers were notified and orders were received (date/times). On 7/5/18 at 2:00 P.M., the Director of Nursing stated residents get 480 cc of fluid on each meal tray (1440 per 3 meals) and routine intake and outputs (I&0) recording/monitoring is not routinely done. During an interview on 7/5/18 at 1:35 P.M. with the ARNP, she stated Resident 2's [MEDICATION NAME] dosing was being managed by the facility's pharmacy. She verified that one weekly CMP (11/22/17) was missed. The ARNP stated Resident 2 was doing well, had anxiety and stomach aches. When asked about Resident 2's clinical status and abnormal labs and request to go 911 to the hospital, The ARNP stated Resident 2 was clinically able to do things, and that she wanted to wait to see what the other providers wanted to do. The clinical record showed that the ARNP faxed the resident's Oncologist on 11/30/17 of Resident 2's recent labs, and informed the oncologist of Resident 2's nausea, stomach issue, poor oral intake and intravenous fluids given. The Oncologist responded per fax the next day (12/1/17) and indicated kidney insufficiency and malnutrition in regard to labs. During an interview on 7/5/18 at 2:10 P.M., with Staff I, SS, regarding Resident 2's decision to be transferred to the hospital, she stated that Resident 2 was anxious and wanted her naturopathic physician to make decisions treatment choices/plan. Staff I stated the Naturopath was interfering with Resident 2's care and that Naturopath requested an emergent transfer (911) to the hospital. Documentation showed no documented evidence that pharmacy had been notified regarding Resident 2's rash, her weight loss and decreased intake. A telephone interview on 6/27/18 at 2:00 P.M. with Resident 2's outside provider, the Naturopathic PCP, was done. The Naturopathic physician stated Resident 2 had been under her care since 2007. She stated Resident 2, had called her regarding her condition, and requested her recommendations. The Naturopathic physician stated she received a copy of Resident 2's laboratory results which showed her condition was getting worse, and that she was concerned about Resident 2's stability. The Naturopathic physician stated when she went to visit Resident 2 on 11/30/17, the facility had not recognized the severity of her condition, the rash that was due to her antibiotics, and the facility staff just wanted to watch and wait. The facility had not consulted with nephrologist (kidney physician). The Naturopathic physician stated the facility was reluctant to transfer to the hospital (911) for evaluation, even though the labs revealed acute [MEDICAL CONDITION]. The Naturopathic physician also stated in addition to the rash, Resident 2 had been exhibiting gastric symptoms (nausea, vomits and decreased intake and abdominal pain). The Naturopathic physician stated the facility did not feel 911 was warranted, so Resident 2 was sent to the hospital by ambulance. During an telephone interview with Resident 2 on 6/29/18 at 8:35 A.M., she stated her rash started on her torso, then covered her entire body, even her face. She stated she refused her medications the day prior to hospitalization (11/30/17). She stated she did not know what to do, so she called her own PCP, a naturopathic physician. She stated she experienced stomach pain with vomiting, and had a decrease in appetite. Resident 2 stated the facility did not respond to my severity of my condition. Resident 2 stated that her naturopathic PCP recognized the need for a hospital transfer. She stated when she was admitted to the hospital on [DATE], the hospital's physician informed her that the rash was drug related and she was admitted with [DIAGNOSES REDACTED]. Resident 2 stated she felt if she had not had interventions from her naturopathic PCP, things would have been questionable.

Based on observation, interview and record review, the facility failed to provide adequate supervision to prevent falls for 1 of 3 residents reviewed for falls, (Resident #1). This failure led to a fall that resulted in pain, substantial bruising and decreased activity. Findings include: Review of facility medical records revealed, Resident #1 resided at the facility since 2016 and had a BIMS score of 15 on the facility MDS (Minimum Data Set assessment) dated 08/18/17. Resident #1 needed supervision for transfers for safety, extensive assistance for other activities of daily living and had a history of [REDACTED]. The facility record revealed Resident #1 had been on hospice but graduated and came off hospice care on 08/09/17. Resident #1 self-propelled around the facility in her wheelchair. The Care Plan for Resident #1 revealed, Resident #1 may sit outside with staff member present, redirect if exit seeking, check frequently to prevent falls, as she will not always ask for assistance and had poor judgement, poor recall, confusion and poor safety awareness. Review of the facility Event Investigation report dated 08/31/17 revealed the following information: Resident #1 was found on the ground outside of the facility at 12:45 p.m. by visitors who then alerted facility staff. Resident #1 sustained a purple bruise 11 centimeters (cm) by 7 cm to the left hip and pain level 8/10 (zero being no pain and 10 being the most severe pain) which was treated with 2 pain medications (Tramadol and Oxycodone a narcotic). In addition, the left hip had swelling and was painful to touch. Resident #1 stated she was unsure how she fell . The fall was unwitnessed and visitors saw her lying on the ground in the driveway, they assisted her back into her chair then alerted staff. The x-ray was negative at the facility and a CT scan was refused. The last fall for Resident #1 was in July. In an interview on 10/02/7 at 2:30 p.m., Staff A, a facility receptionist, stated Resident #1 usually sat right outside the front door at the waterfall and Staff A kept an eye on her. Staff A stated on the day the resident fell , Staff A did not see Resident #1 go outside, because Staff A was not at the reception desk at that time. When Staff A returned to the front desk, Resident #1 was lying outside on the driveway by the heart shaped bush. Observation on 10/02/17 at 2:30 p.m., revealed, the front entrance to the facility opened onto a driveway and large parking lot that led out to the main road. The front entrance door had a waterfall feature right outside the door to the right. There was an entrance walkway with shrubbery to the left. The facility receptionist pointed out the spot where she saw Resident #1 lying when she returned to the front desk: the area by the heart shaped bush was about 35 to 40 feet from the front door and on the black top driveway where cars drive. In an interview on 10/03/17 at 3:25 p.m., the facility Administrator stated, she saw Resident #1 sitting right outside the front door on the day of the fall, sitting by the waterfall (right in front of the front door at the entrance to the facility). The Administrator stated Resident #1 sits there sometimes and is watched by the facility receptionist who keeps an eye on her and helps her come back inside, however, that day the receptionist left the front desk, then a visitor reported Resident #1 was on the ground outside. In an interview on 10/02//17 at 10:40 a.m., the Director of Nursing stated the facility staff did not know how Resident #1 got out the front door. The front door does require a code to exit, but no one knew how Resident #1 got out. Review of facility Progress Notes for Resident #1 revealed: On 08/22/17, Resident #1 graduated from hospice 08/09/17 and was on a Restorative program and enjoyed walking with assistance and a walker 120 feet, as well as performing at a level 3 on exercise machines. The note also said Resident #1 needed 1 person assist with transfers and activities of daily living for safety due to history of falls. On 08/31/17, Resident #1 was wandering throughout the day shift, received Ativan (anti-anxiety medication) at noon for agitation, and fell outside the facility (at 12:45 p.m.) At 7 pm Resident #1 complained of pain to the left hip level 8/10 and had an 11 cm by 7 cm purple bruise on her left hip. On 09/01/17, facial grimacing when left hip touched, warm to touch; hip bruised, swollen and Resident #1 complained of hip aching, remained in bed most of shift; received scheduled pain medications. On 09/05/17, Resident #1 had pain in left hip; was anxious, the hip hematoma increased in size. On 09/06/17, Resident #1 was admitted back on hospice and given morphine. On 09/06/17, Resident #1 was guarding left hip due to pain from fall. On 09/07/17, Resident #1 remained in bed and was still guarding left hip from fall On 09/08/17, left hip still purple On 09/14/17 a problem of pain related to fall was added to the Care Plan for Resident #1. Resident #1 had an unwitnessed fall outside of the facility 45 minutes after receiving Ativan for agitation, and the fall resulted in pain and limited movement as well as refusal to get out of bed for a number of days. Reference (WAC) 388-97-1060(3)(g)

Based on interview and record review, the facility failed to provide services according to the care plan (POC) for 1 of 2 residents (1) reviewed for falls. Failure to adequately supervise Resident 1 according to the POC resulted in a fall for Resident 1 who experienced pain and fracture. Findings include: Resident 1 was admitted to the facility on [DATE] for skilled therapy following a left hip fracture. The Minimum Data Set assessment dated [DATE] revealed she had impaired decision making and required supervision and was unsteady getting on and off the toilet. The Care Plan revealed Resident 1 required cueing due to impaired decision making from dementia and that staff were not to leave her unattended on the toilet for fall precautions. A facility investigative report dated 5/27/17 documented Resident 1 had an unwitnessed fall. The report revealed she was on the toilet prior to the fall and was screaming for help on the bathroom floor. A Nursing Assistant Certified (NAC) documented in a written statement dated 6/15/17, regarding the unwitnessed fall on 5/ 27/17, she had initially left the bathroom door slightly open to see Resident 1. The NAC documented she left Resident 1's room to investigate a noise and when she rushed back to get her from the bathroom the resident was already on the floor with the Licensed Nurse (LN) inside the bathroom. Record review revealed Resident 1 had an orthopedic appointment on 4/19/17. The orthopedic note revealed there were three x-ray views of the pelvis that showed an almost completely fracture on the left hip and no change in fracture alignment or hardware position. The nursing progress note dated 5/27/17 documented Resident 1 was found in the bathroom, on the floor, screaming for help. The LN documented the resident was unable to move her left leg. An x-ray of the left hip revealed no new fracture. Another nursing progress note dated 5/31/17 revealed Resident 1 was guarding her right hip and crying. Due to her pain of the right hip, an x-ray was obtained. The right hip x-ray revealed no acute fracture. The progress notes revealed Resident 1 continued to experience pain in both hips even though the x-ray of the right and left hip were negative for fracture from 5/27/17 to 6/1/17. On 6/1/17, she was transferred to the hospital. Review of the hospital radiology report dated 6/1/17 documented acute right hemipelvic (half of pelvis) fractures. Review of the facility's investigative report with the Director of Nursing and Assistant Director of Nursing (ADNS) on 6/13/17, revealed that the plan of care had not been followed. The ADNS stated the NAC had left Resident 1 unattended in the bathroom. Reference: WAC 388-97-1060 (3) (g)

Based on observation, interview and record review, the facility failed to provide adequate supervision for 1 of 3 sampled residents (Resident 1) with cognitive impairment. Failure to identify potential safety risks and needed supervision resulted in harm to Resident 1, who rolled out of bed and sustained a fracture. Findings include: Resident 1 had [DIAGNOSES REDACTED]. The Minimum Data Assessment (MDS) assessment, dated 7/18/16, revealed the resident required 2 person extensive assistance with bed mobility. She had severe cognitive impairment, inattention and disorganized thinking. The CCAs (Comprehensive Care Assessments) documented she required staff to anticipate her needs due to confusion and that she was at risk for falls due to dementia with impaired cognition and poor safety awareness. During an observation and attempted interview on 9/7/16 at 10:05 a.m., Resident 1 was asleep in bed. She was positioned in the center of her bed on top of a perimeter air mattress with scooped sides. Fall mats were on the floor on both sides of her bed with the bed in a low position. During lunch time Resident 1 was observed seated in her wheelchair and had a cast on her right wrist area. she was unable to communicate. The current Care Plan for falls, dated 7/17/16, directed staff to provide frequent visual and safety checks and encourage her to be in a high traffic/visual area, when up, due to poor safety awareness. Review of the Resident Care Guide used by nursing assistants (NACs) did not specify how many staff were required for positioning even though the MDS assessment indicated 2 NACs. A nursing progress note, dated 8/20/16 documented she heard a loud noise as if someone had fallen down. The Licensed Nurse(LN) discovered Resident 1 on the floor. She was alert and confused and sounded in distress, so 911 (emergency system) was activated. The facility's investigative report, dated 8/20/16, revealed Resident 1 was discovered face down on top of the floor mat. The report documented that the NAC while assisting the resident with incontinence care needed additional supplies, so s/he stepped out of the room to get more supplies leaving the resident alone and unsupervised. Review of an x-ray report, dated 8/20/16, revealed Resident 1 had sustained a fracture to her wrist. The LN's written statement, included in the report, revealed that the NAC stepped out of the room and left resident lying on her left side facing the window with the bed in a high position. During an interview on 9/7/16 at 2:00 p.m., the Director of Nursing (DNS) stated the NAC who provided the care for Resident 1 on 8/20/16 stepped away from Resident 1, leaving her unattended. The DNS also stated the Licensed Nurse (LN) saw Resident 1, during a medication pass with her bed in an elevated position. The LN did not lower the bed according to the LNs written statement. In an interview on 9/7/16 at 1:05 p.m., the Resident Care Manager (RCM) stated Resident 1 was unable to verbalize her needs, was able to turn in bed and get feet out of bed, but was not consistent at following directions. In an interview on 9/7/16 at 2:20 p.m., NAC A stated, Resident 1 does not appear to comprehend instructions during care due to her language barrier and confusion. The facility staff did not recognize the Resident's bed being in a high position and leaving her unsupervised was a safety hazard which caused harm to the resident.

Based on observation, interview and record review, the facility failed to have a system in place to ensure facility and pharmacy staff identified allergies that could place the residents at risk of significant harm. Resident # 7 and # 8 were given medications that they were known to have allergies to, this caused resident #8 to have an adverse druug reaction and placed him/her at risk for significant side effects, decreased medication benefit, worsening of their condition, and overall decreased quality of life. Additionally, the facility failed to ensure that residents were free of significant medication errors for 5 (Residents #11, 12, 13, 15) of 13 residents sampled for medication administration. Findings include: Upon review ofthe facilty medications incident reports, the following were identifed that indicate significant system breakdown. Resident #8 Resident #8 was admitted to the facility with [MEDICAL CONDITION] and high blood pressure. The hospital transfer records revealed the Resident had multiple drug allergies including [MEDICATION NAME], an antibiotic. On 04/22/2012 the physician [MEDICATION NAME] twice a day for treatment of [REDACTED]. The Resident was given one dose [MEDICATION NAME] 04/22/2012 and developed a rash to her face along with itching. She then required treatment with [MEDICATION NAME] (an [MEDICATION NAME] medication used for allergic reactions). Her allergies were not listed on her medication administration record. This facility staff failed to check the Resident 's allergies and gave the Resident a medication that she was allergic to, placing the Resident at risk for a severe allergic reaction. Resident #7 Resident # 7 was admitted to the facility with [MEDICAL CONDITIONS] and recent hip surgery. Records revealed the Resident was allergic to " statins " which are medications used to decrease cholesterol levels in the blood. The this allergy, along with others, was noted on the transfer records from the hospital and on the MAR. On 12/31/2012 the physician wrote an order for [REDACTED]. daily. Documentation on the MAR revealed the Resident received this medication for 5 days before the error was discovered. The facility failed to check the Resident ' s allergies and gave the Resident a medication that she was allergic to, placing the Resident at risk for an allergic reaction. Resident #10 Resident # 10 was admitted to the facility with [MEDICAL CONDITION], diabetes and high blood pressure. The Resident also suffered from an enlarged prostate which made it difficult for him to urinate and empty his bladder. The Resident was prescribed [MEDICATION NAME] (a medication used to treat difficult urination) to be taken daily. The order was written on 12/18/2012 and records show the medication was delivered to the facility on that date. The medication was on the MAR to be given at 08:00 AM. A review of the MAR revealed the medication was not given from 12/18-23/2012 resulting in 4 missed doses. This facility staff did give the medication that was ordered, resulting in the potential to cause the Resident to suffer discomfort and difficulty urinating. Resident #11 Resident #11 was admitted to the facility with [MEDICAL CONDITION], stroke, and Parkinson ' s disease. He was assessed to be at risk for [MEDICAL CONDITION], dehydration, skin breakdown, and received all nutritional support and medications via a [MEDICAL CONDITION] tube (a tube inserted into the stomach). On 11/15/2012 a stool sample revealed the resident had C.diff ([MEDICAL CONDITION], a bacterial infection causing severe diarrhea and potentially life threatening complications). Records revealed the Resident was having loose stools and had an excoriation on his buttocks . On 11/24/2012 an LN (licensed nurse) took a phone order from the physician which was written as " Keflex (an antibiotic) 500 mg. TID (three times a day) for 14 days per tube feeding for C.diff. " (Keflex is not used to treat C.diff and can make the infection worse). Records revealed the Resident received 17 doses of Keflex. The Resident continued to suffer from loose stools. On 12/03/2012 the physician wrote on a lab slip " not correct. Keflex TID was never ordered. " The order was then changed to [MEDICATION NAME] (one of the two antibiotics used to treat C.diff) for 14 days. The facility staff did not administer the correct antibiotic, causing a delay in treating the Resident's infection. According to the Mayo Clinic's most recent data related to C.diff treatment, untreated C.diff infections place residents at risk of dehydration, [MEDICAL CONDITION], and toxic megacolon (distension of the bowel when it is unable to pass gas or stool, which can result in bowel perforation). Resident #12 Resident # 12 was admitted with [MEDICAL CONDITION], high blood pressure, elevated cholesterol level, and a [MEDICAL CONDITION]. The Resident was ordered to have atorvastatin (a medication that lowers cholesterol and helps prevent stroke with anti-[MEDICAL CONDITION] action) 40 mg. each night. The medication was ordered on [DATE]. Records revealed that during the recapitulation of orders from December 2012 to January 2013 the " time code was omitted on the MAR by the Health Information Manager, Staff L. Staff I checked the orders and also failed to find the error. " Two evening nurses, Staff J and K also missed the order and failed to administer the medication. As a result of this significant error, the Resident missed 7 doses of the medication. The facility staff did not give the medication that was ordered, which placed the Resident at risk for harmful effects related to his cardiovascular disease. Resident #13 Resident # 13 was admitted to the facility with [MEDICAL CONDITIONS] (a heart rhythm disorder that can result in the formation of blood clots), and dementia. The Resident required [MEDICATION NAME] (a blood thinning agent) 3.5 mg. (milligrams) per day. On 12/17/2012 the Resident had an INR (a measure of the blood clotting ability) of 3.7 (therapeutic level is 2.0-3.0). The physician wrote an order to hold the 12/17/2012 dose of [MEDICATION NAME] and to recheck an INR on 12/18/2012. Records revealed the INR was not checked on 12/18/2012 and the Resident continued to receive [MEDICATION NAME] on 12/17-12/20/12 for four additional doses. On 12/20/2012 the INR was 4.33. This facility staff did not hold the [MEDICATION NAME] as ordered, placing the Resident at risk for bleeding. Resident #15 Resident #15 was admitted with diabetes, [MEDICAL CONDITION] and high blood pressure. She was assessed to be high risk for blood clot formation in her legs and was prescribed [MEDICATION NAME] 18,000 units daily by injection to prevent clot formation. Records revealed the Resident failed to receive [MEDICATION NAME] as ordered on 01/25-01/27/2013. The facility staff did not administer the [MEDICATION NAME] as ordered, placing the Resident at risk for blood clot formation. On 02/06/2013 at 11:30 AM, Staff C, Assistant Director of Nursing, stated that the RCM ' s (Resident Care Managers) check all orders the next day and two nurses check the MAR to ensure that it is correct. On 02/06/2013 in an interview with Staff F, LN (licensed nurse), RCM at 11:00 AM, she stated that the new orders get on the MAR either by the RCM or the LN who is assigned to that resident. When asked how she verifies that the orders are transcribed correctly onto the MAR she stated " you have to trust the nurses. " She verified there is no 24 hour chart check process to verify orders. She stated that sometimes she puts the order on the MAR and sometimes she just gives the yellow carbon copy to the nurse to do it. She stated that the Health Information staff put the orders into the computer. She verified that the person who does this is not a nurse or a pharmacist. On 02/06/2013 when asked how orders are transcribed, both Staff J and K, LN ' s stated that sometimes the RCM transcribes the order and sometimes they transcribe the orders themselves. They stated that the process is different on the evening and night shift because the RCM is not there. Both verified that there was no consistent process to check orders for accuracy. On 02/06/2013 at 4:30 PM, in an interview with Staff A,B, C and I, they stated that according to their investigations, these medication errors were not significant because none of the residents had suffered actual harm. They verified that none of these errors had been reported. In an interview with Staff B on 02/08/2013, when asked about the facility policies and procedures for medication administration, she stated the facility uses the text Nursing Interventions and Clinical Skills, 4th Edition, by Elkin, Perry and Potter. A review of the text revealed that professional nursing practice requires that nursing staff " verify that an order was transcribed correctly " , verify the accuracy of the MAR, and " make sure that your client ' s MAR corresponds exactly with the prescriber ' s order " , along with other medication administration requirements. The text goes on to say that " when repeated medication errors occur within a work area, identify and analyze the factors that may have caused the errors and take corrective action. " In each case, the facility failed to implement a medication pass system that could prevent these errors that could cause the resident discomfort or jeopardize their health and safety. The facility also failed to establish why the errors had occurred and failed to formulate a plan of corrective action to prevent further errors.

Based on observation interview and record review the facility failed to develop a plan of care for 1 of 9 residents (92) reviewed for care planning. This failure resulted in the resident having unresolved pain and no plan in place to met the pain needs of the resident and also placed the resident at risk of having other unmet needs. Finding include: Resident 92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was on narcotic medications prior to admission to the facility. The resident's History and Physical (H&P) indicated the resident was taking a pain medication, [MEDICATION NAME] 30 mg every 4 hours as needed when she was at home. On 1/20/11, the admission nurse documented the resident was anxious about her pain medication regimen. Documentation included the care plan was reviewed with the resident even though there was no care plan developed for the resident's pain. In an interview on 1/21/11 at 9:45 am, the Resident stated "I have not got my pain meds since yesterday. I have not had my pain pills and my back is hurting so bad." The resident was observed sitting on the edge of the bed crying and rocking. Record review on 1/21/11 and 1/24/11, revealed no care plan had been developed for the resident including pain control. In an interview on 1/24/11 at 9:10 am, LN 4 stated the care plan for pain was that the physician changed the pain medications. LN 4 was unable to state what the goals for pain control were. In an interview on 1/24/11 at 9:50 am, LN 1, LN 2 and LN 5 were unable to find a care plan. LN 1 stated care planning should have been done 3 days earlier, on admit. LN 1 & LN 2 stated the adminssion nurse does as much of the admit paperwork as possible then the Resident Care Managers (RCMs) follow up and complete the paperwork.

Based on observation, interview, and record review the facility failed to ensure 1 of 4 residents (92) received appropriate care and services for pain. The facility failed to thoroughly assess, care plan, and ensure medications were available. This failure resulted in unresolved pain and anxiety for Resident 92 and placed Resident 92 at risk for increased pain, and a delay in medical treatment. Findings include: The facility's "Pain Management Policy" indicated residents are assessed at admission, quarterly and as needed when their condition related to pain changes. Pain was evaluated using a numbering system: 0 = No pain 1 to 3 = Discomfort 4 to 6 = Painful 7 to 9 = Very Painful 10 = Worst possible pain Facility staff determined the level of pain by asking the resident to rate their pain on a scale of 1 to 10. Resident 92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was on narcotic medications prior to admission to the facility. The resident's History and Physical (H&P) indicated the resident was taking a pain medication, [MEDICATION NAME] 30 mg every 4 hours as needed when she was at home. The resident's admission orders chronic narcotics", which was signed by the physician. On 1/20/11, the admission nurse documented the resident was anxious about her pain medication regimen and her next dose was due at 4:00 pm. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The licensed nurse gave the resident 10 mg of [MEDICATION NAME]. The LN documented the resident's response to the medication was a pain level of 5. There was no documentation of a pain assessment to determine if that was an acceptable level for the resident. At 7:00 pm, the resident's pain level was 6. The LN gave the resident 650 mg of Tylenol. At 9:00 pm, the LN documented the resident's response was "not met" and her pain level continued to be 6. There was no documentation that any further action was taken even though the result was "not met". At 10:30 pm, the resident's pain level was 8 (very painful). The LN gave the resident 10 mg of [MEDICATION NAME]. There was no time documented but the LN documented the result was still 8. There was no documentation on the back of MAR indicated [REDACTED]. There was also no documentation in the progress notes if the LN took any action even though the resident's pain level was increasing. On 1/21/11 at 6:00 am, an LN documented in the progress notes; the resident was given pain medication at 10:30 pm by the evening LN, then by 11:00 pm, the resident was "clamoring for another dose". The LN informed the resident she could only have 10 mg every 6 hours. The resident "claimed" she was taking 30 mg when she was at home. The LN told the resident she could only go by what the doctor had written. There was no documentation the LN completed a pain assessment, gave her another pain medication at the ordered time, attempted non-pharmacologic relief, or attempted to consult with the physician regarding the resident's continued level of pain. When interviewed on 1/21/11 at 9:30 am, LN 7 stated the resident kept ringing her call light wanting pain medication. "I have to keep explaining to her that the doctor did not document the quantity of pills, so the pharmacy will not send it." LN 7 stated she offered the resident Tylenol but she refused. At 9:45 am, the resident was overheard speaking in a loud voice to a therapist stating she wanted to go home. The therapist left the room and the resident was observed sitting on the edge of the bed rocking and crying out loudly. She stated she had not received any pain medication since the prior evening and "my back is hurting so bad. The nurses won't listen to me. I took 30 mg of [MEDICATION NAME] when I was at home. Now they are only giving me 10 mg. I want to go home." At 10:10 am LN 7 was interviewed and stated the facility, for the past 9 hours did not have the resident's pain medications. The resident's prescription did not include a quantity so the pharmacy would not send the medications. In addition the pharmacy would not authorize the medications to be taken out of the emergency system. At 10:20 am, 9 ? hours after the last dose of [MEDICATION NAME], the LN gave the resident Tylenol. The LN documented in the progress notes the results were "no effect". At 10:40 am, the LN 7 documented she gave the resident 10 mg. of [MEDICATION NAME] and by 11:30 it helped. There was no documentation of how much it helped or if the resident was comfortable. At 2:00 pm, the resident's family member stated the facility would not give the resident her medications the way she took them at home. "I wish they would listen to us; look at her she is a mess." At that time the resident was observed to be crying. At 4:00 pm, the Resident Care Manager (RCM) documented in the progress notes the resident was crying because she wanted [MEDICATION NAME] for pain. On 1/22/11 at 11:00 am and 3:00pm there was documentation the resident was tearful and anxious related to the pain and asking for pain medications frequently. On 1/23/11 at 3:00 pm a LN documented the resident was tearful asked for pain medication frequently even though [MEDICATION NAME] was administered every 4 hours. At 10:45 pm, an LN documented the resident was noted to be increasingly tearful. She stated the [MEDICATION NAME] were not effective. The resident stated she had been on [MEDICATION NAME] 30 mg every 4 hours and 10 mg was not effective. Three days after the resident admission to the facility the LN notified the physician that the resident felt pain consistently at a level 8. The LN received new orders from the physician to increase her medications to 30 mg every 4 hours. On 1/24/11 at 0910 am LN 4 was interviewed and was unable to state what the pain goals for the resident were. LN 4 stated the resident's pain was hard to assess because the resident was always asking for pain medication. She also stated if the resident said she was in pain, but appeared calm, then her pain was under control. There was no documentation in the progress notes for 1/24/11 to determine if the resident's pain was under control. Pain assessments and care planning were not developed until 1/24/11. On 1/25/11, the resident stated since the physician increased her medications, she was feeling a lot better. She was observed walking in the hallway and participating with therapies.

Based on observations and interviews, the facility failed to maintain consistent, appropriate labeling of all resident medications and failed to maintain access to sufficient supplies of ordered resident medications. Affected were 5 of 10 sampled residents who received medications in the facility. Failure to maintain sufficient accessible supplies of currently prescribed medications resulted in harm for Resident 92 and placed Resident 193 at risk for harm from missed scheduled medications and inadequate dosing. Failure to label multi dose vials of resident medications for Residents 46, 175 and 186 placed these residents at risk of administration of expired medications. Findings include: FACILITY POLICY: The Emergency Medication Supplies policy, provided directions for staff to obtain needed doses of medications from the facility's emergency medication supply. The facility staff were directed to complete a form and fax it to the pharmacy to request authorization. The pharmacy would provide an authorization code and then staff could access the emergency supply. 1. Resident 92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was on narcotic medications prior to admission to the facility. The resident's History and Physical (H&P) indicated the resident was taking a pain medication, oxycodone 30 mg every 4 hours as needed when she was at home. The resident's admission orders chronic narcotics", which was signed by the physician. In an interview on 01/21/11 p.m., LNs 2 and 3 stated the entire process should be completed "very quickly " If authorization was not received, the Licensed Nurse (LN) was expected to call the pharmacy and check on the request. On 01/21/11 at 10:10 a.m. LN 7 stated the facility had not received her pain medication because when she was admitted , her prescription did not have a quantity written on it so the pharmacy would not accept the prescription. The pharmacy would not give the facility permission to go into their emergency system and take the drugs out. LN 7 stated she faxed the pharmacy at 7:25 that morning, but had not heard back from them. The fax sheet was observed. In an interview on 01/21/11 10:30 a.m., LN 3 stated the pharmacy was faxed all of the information, but they still did not get the medications. The facility was having a problem with the pharmacy. Documentation in the progress notes, dated 01/21/11 at 4:00 p.m., noted 24 hours after the resident was admitted the medications were not available. The LN documented the pharmacy was called 5 times that day. When the facility made contact with the pharmacy, the pharmacy informed the facility the prescription was not valid and the physician needed to be called. The RCM documented she called the physician's assistant who did not return her call, so physician was not contacted until 4:30 p.m. An authorization number was not received until 5:00 p.m. 2. Observation of the "B" Nursing Station Medication Storage Room on 01/25/11 at 08:55 a.m. found opened multiple dose vials of vancomycin for Residents 46 and 186 and an open multiple dose bottle of fish oil for Resident 175. Neither the vancomycin nor the fish oil had a date/time and nurse initials written on the container to indicate when they were opened. At 09:00 a.m., Licensed Nurse (LN) 3 reported it was the facility policy for nurses to date/time and initial any multiple dose vial of medication when they opened it for the first dose. 3. Resident 193 had a physician order [REDACTED]. On 01/25/10 at 08:40 a.m., LN 8 reported she had no dose for that morning. She was unable to access and check for a possible supply from pharmacy maintained in the medication storage machine. LN 3 reported she would assist LN 8. LN 3 could not locate any dalteparin in the medication storage machine. At 3:45 p.m., LN 8 reported none of the other LNs were able to access any dalteparin in the medication storage machine. LN 8 reported she had FAX'd pharmacy on 01/24/11 requesting a resupply of the dalteparin. It had not yet arrived from pharmacy.

Based on observation, interview and record review the facility failed to complete a comprehensive pain assessment on admit or when the resident was having pain. This affected 1 of 9 residents (92) reviewed for assessments. Failure to assess the resident's pain resulted in the resident having unrelieved pain and prevented staff from developing a plan to treat the resident's pain. Findings include: The facility's "Pain Management Policy" indicated residents are assessed at admission, quarterly and as needed when their condition related to pain changes. Pain was evaluated using a numbering system: 0 = No pain 1 to 3 = Discomfort 4 to 6 = Painful 7 to 9 = Very Painful 10 = Worst possible pain Facility staff determined the level of pain by asking the resident to rate their pain on a scale of 1 to 10. Resident 92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's History and Physical (H&P) indicated the resident was taking a pain medication, [MEDICATION NAME] 30 mg every 4 hours as needed when she was at home. On 1/21/11 at 9:45 am the resident was observed sitting on the edge of the bed crying and rocking. She stated she had not had her pain medication since the prior evening and she was having a lot of pain. Record review on 1/21/11 at 10:15 am showed there was an initial admission assessment completed on 1/20/11. The assessment was a check box type of assessment that duplicated the minimum data set assessment. In the pain section there was a question asking if the resident had received non-medication interventions for pain. If the question was checked yes, it directed staff to complete a pain assessment form. The box was checked yes, but the pain assessment form in the medical record was blank. There were also 7 other intitial assessment forms in the record that were blank. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On each occasion the resident's pain level did not drop below a level 5. There were 16 other occassions pain medication were given between 1/20 and 24/11. Licensed staff either did not document a complete assessment or documented phases like "helpful". There were no assessments completed to determine if the pain level was acceptable or tolerable for the resident. In an interview on 1/24/11 at 9:10 am, licensed nurse (LN) 4 stated pain was hard to assess for Resident 92 because the resident was always asking for pain medication. LN 4 stated if the resident said she was in pain, but was calm, then her pain was under control. In an interview on 1/24/11 at 9:50 am, LN 1, LN 2 and LN 5 were unable to find documented pain assessments. LN 1 stated the assessments should have been done 3 days earlier, on admit. LN 1 & LN 2 stated the adminssion nurse does as much of the admit paperwork as possible then the Resident Care Managers (RCMs) follow up and complete the paperwork. In an interview on 1/24/11 at 10:25 am, LN 6 stated she needed to complete the assessments. She stated she had spoken with the resident on the day of admit, but had not completed the assessments. When asked if the assessments were documented LN 6 stated no they were all in her head. In an interview on 1/25/11 at 8:20 am the Director of Nursing (DNS) stated she did not consider documenting "helpful" was not an assessment of someone's pain.

Based on interview, and record review, the facility failed to ensure that 1 of 4 residents (Resident 1) received a sufficient amount of fluids to prevent dehydration. Failure to adequately monitor the resident ' s fluid status and to seek alternative treatments to maintain the resident ' s hydration, resulted in harm for Resident 1 who required hospitalization for aggressive hydration due to dehydration . Findings include: Resident 1 was admitted to the facility from the hospital on [DATE], with an open abdominal wound, a urinary catheter and an [MEDICAL CONDITION] (surgical formation of the opening of the small bowel to the surface of the abdomen through which waste products of nutrition evacuate and are contained in a bag). It is essential to manage the fluid intake of an individual with an [MEDICAL CONDITION] and to ensure the resident does not become dehydrated, due to the uncontrolled outflow of liquid waste from the small bowel. Resident 1's Plan of Care at the nursing facility, dated 1/7/11, revealed that the resident's nutritional status was altered due to and "acute infection, history of TPN and not consuming greater than 50% of her meal " . The approaches listed were to encourage high protein eating and fluid intake, vitamins/minerals as ordered, observe for s/s dehydration, refer to RD, supplements, and meal monitor. The facility ' s admission Nutrition Assessment by the Registered Dietitian (RD), dated 1/7/11, documented that the resident's usual intake for breakfast was 25% or refusal of the meal offered, and dinner intake was usually 25-50%. The RD indicated that Resident 1's fluid intake should be 1900 cc every day. A goal was no significant weight loss. The facility's "weight record" documented the resident ' s admission weight on 1/4/11 was 138 pounds. On 1/7/11, her weight was documented at 125 pounds. By 1/12/11, her recorded weight was 122 pounds. No evidence was found that the facility considered the apparent weight loss may be associated with loss of body fluid. Interview with the MDS nurse on 1/19/11, revealed the facility did not have a separate form to document a resident's fluid intake and output. She stated that I &0 was completed on the meal monitoring record. If the resident refused their meal or their intake was less than 50%, the nursing assistants (NACs) were to notify the licensed nurses (LNs). Review of the meal monitor flow sheet found it documented that after the RD saw Resident 1 on 1/7/11, the resident either refused her meals or only consumed 15 to 25 % of the meals offered. The resident consumed a liquid meal replacement supplement 5 times for 15 meals refused in January 2011. Her oral was intake was less than 1000 cc/24 hours for 6 of 8 days recorded. This was approximately half the fluid intake recommended by the RD in the admission assessment (1900 cc). Nursing notes documented that the drainage from the [MEDICAL CONDITION] on 1/4/11 was liquid, on 1/8/11, 500cc of green liquid and 1/9/11 200cc output. Review of the bowel sheet documented on 1/11/11, resident ' s bowel output was " loose ," in large amounts and had exceeded more than 1000cc in 24 hours. There was no documented evidence the physician was notified regarding the excessive output in relationship to the resident's limited intake. In addition, the amount of output from the resident ' s urinary catheter was not recorded. Nursing documented the resident was alert and orientated on 1/4 through 1/6/11. On 1/8/11, she was noted to have altered mentation with periods of confusion. By 1/10/11, the Care Plan conference noted the resident had increased confusion. The Minimum data Set assessment (MDS), dated [DATE], documented that the resident was having periods of [MEDICAL CONDITION]. On 1/11/11, the resident was found to have abnormal laboratory values, which were reported to the physician. On 1/13/11, the physician came to see the resident and ordered that she be sent to the hospital emergency room due to electrolyte imbalance, decreased kidney function and dehydration due to poor oral intake. The emergency room notes dated 1/13/11, documented the resident was found to be dehydrated with an electrolyte imbalance, an altered mental status and required "aggressive IV (intravenous) hydration " . Resident 1 required cardiac monitoring to prevent and treat potential complications due to dehydration and electrolyte imbalance. A hospital interim summary, dated 1/17/11, stated the resident had experienced acute [MEDICAL CONDITION] secondary to dehydration, abnormal laboratory values secondary to dehydration, and [MEDICAL CONDITION] with poor oral intake.

Based on observation, interview and record review the facility failed to provide the necessary care and treatment for 1 of 4 residents (Resident 1) with ostomies. Failure to adequately contain Resident 1's waste products/drainage from the [MEDICAL CONDITION] and provide protective skin care to avoid further skin irritation and excoriation from the waste products resulted in harm to the resident' s skin which required hospitalization for aggressive skin care and interventions to manage the [MEDICAL CONDITION]'s drainage. Findings include: Resident 1 was admitted from the hospital to the facility on [DATE] with an [MEDICAL CONDITION] to her abdomen. An [MEDICAL CONDITION] is an opening in the small bowel that is secured to the abdomen through which waste products pass - completely bypassing the large bowel (colon) and the rectum and anus. The waste drainage exiting the [MEDICAL CONDITION] may cause irritation to the surrounding skin if the waste drainage is not adequately contained by a pouching/collection device. Due to the uncontrolled waste drainage, skin care is essential to prevent skin breakdown with excoriation from the waste drainage. Review of the hospital notes, dated 12/22/10 through 1/3/11 revealed that the resident's pouch (device to hold drainage) and seal of the [MEDICAL CONDITION] pouch to the site frequently leaked which caused irritation to the surrounding skin on the resident's abdomen. In addition, due to the resident's numerous surgical procedures and limited intake, the resident had required nutritional support by artificial intravenous feeding (TPN) and [MEDICAL CONDITION] feeding (TF) during her hospitalization . The hospital's discharge note from the wound care specialist (WCN), dated 1/4/11, documented that the resident's [MEDICAL CONDITION] pouch was intact. The note provided instructions for the nursing staff regarding care of the ostomy and how to care for the surrounding skin to prevent excoriation. The WCN's instructions included when to change the ostomy pouch, stoma adaptor ring size and the need to use an ostomy belt to support the placement of ostomy bag and prevent possible leakage. The WCN also indicated to apply a powder an antifungal powder if skin becomes excoriated between [MEDICAL CONDITION] and surgical wound on the abdomen that was below the ostomy site. The facility's 1/4/11 admission assessment documented that the resident had an indwelling urinary catheter and that the skin surrounding the ostomy area and the surgical wound was "red, bumpy rash." The resident's physician's admit note, dated 1/5/11, documented that the resident's skin around the ostomy was macerated (maceration- overhydration of the skin characterized by a white, waterlogged appearance) under the dressing. The facility's " non-ulcer assessment " form, dated 1/5/11, documented that the resident had an [MEDICAL CONDITION] and a surgical wound distal to the [MEDICAL CONDITION] site. The area around the opening of the [MEDICAL CONDITION] was "red" with irritated skin from [MEDICAL CONDITION] drainage. The skin around the [MEDICAL CONDITION] had redness which measured 14 centimeters (5.5 inches) around the opening (stoma site). The facility's care plan dated 1/4/11 for impaired skin integrity indicated the residents skin would be monitored for redness, signs of skin breakdown daily during care, provide protective skin care as needed due to the resident's excoriation from the [MEDICAL CONDITION] leakage and abdominal wound below the [MEDICAL CONDITION] site. The care plan also indicated the residents skin integrity was at risk due to the resident poor intake of food and/or fluids, her decreased mobility and anticoagulant use. The goal was to prevent any further skin breakdown. The Plan of Care for elimination, dated 1/4/11, had goals including that the ostomy site would remain without skin breakdown daily and ostomy bags would remain secure and dignity maintained. The facility's skin team's "Weekly Skin Report," dated 1/11/11, documented that the skin area around the [MEDICAL CONDITION] site had deteriorated due to the skin's excoriation which measured 24cm by 14 cm in size. There was no documented evidence that the facility had notified the physician or wound care specialist regarding the deterioration of the skin surrounding the [MEDICAL CONDITION] and increased area of excoriation. A late entry dated 1/26/11 for the 1/11/11's skin assessment around the stoma on the facility's "non-ulcer assessment" form, documented that the red irritated skin area around the opening of the stoma site had extended in size and now measured 30 centimeters (cm) by 14 cm in size. There was no documented evidence, that the licensed nurses notified the physician regarding treatment options for the excoriated skin. admission orders [REDACTED]. There was no documented evidence that the licensed nurses had provided the ointment or powder to the abdominal area, even after the skin surrounding the ostomy had deteriorated with further excoriation of the resident skin as noted 1/11/11. Interview on 1/18/11 with the Resident Care Manager (RCM A) stated that the resident's [MEDICAL CONDITION] would leak into the surgical wound that was below the [MEDICAL CONDITION]. She stated that the entire stomach was excoriated from the [MEDICAL CONDITION] leakage. Interview with RCM on 1/19/11 stated that when the resident was admitted to the facility on [DATE], the skin across the abdomen and around the stoma and groin folds was excoriated, the skin had a "red bumpy " appearance. She stated that the plan was to apply a barrier cream to the excoriated skin. The RCM B stated that when the resident moved the seal around the stoma bag would lift and waste drainage would leak onto the abdomen and onto the surgical wound. She stated that a [DEVICE] was ordered for the surgical wound to protect the surgical site from the [MEDICAL CONDITION]'s drainage. She stated the facility had tried three different types of ostomy bags and finding the correct product and getting proper wound healing was a concern. She stated the facility had not contacted the CWN who had provided wound care for the resident at the hospital to consult with regarding to the deterioration of the skin from the waste drainage. Review of the treatment sheet did not specify what pouch type was to be used and nursing documentation did not indicate that licensed nurses had attempted application of various ostomy bags and appliances. On 1/18/11 at 3:40 p.m., the Licensed Nurse (LN 1) stated that the facility's policy was if a wounds were not improving, the LN should notify the physician. An interview at 10:50 a.m. on 1/19/11 with LN 2 stated that the [MEDICAL CONDITION] drainage was difficult to contain as the seal kept leaking of fecal matter. She stated that the nursing assistants "emptied the [MEDICAL CONDITION] frequently, once every hour". According to the facility transfer form, dated 1/13/11, Resident 1 was transferred to the the emergency room for further evaluation and treatment related to "fecal drainage, skin problem and abnormal labs". Review of the emergency notes, dated 1/13/11, documented that the resident's abdomen had "significant [MEDICAL CONDITION] on her lower abdominal wall with diffuse bright red inflammation and the abdomen was uncomfortable." In addition, the notes indicated the resident was dehydrated with electrolyte imbalances (abnormal) laboratory values, had altered mental status and required " aggressive IV (intravenous) hydration. The hospital's admit history and physical note, dated 1/13/11, documented the resident had a ostomy with " significant chemical irritation around the skin. The note indicated the resident ' s ostomy bag was " poorly adhered " and she has " extensive surrounding [DIAGNOSES REDACTED] (redness) in a band-like distribution horizontally and extending down into her groin. " Another admit hosptial order for 1/13/11 documented that in order to " remove debris/stool, bile salts which are causing skin breakdown" the nursing staff were directed to gently rinse the skin with saline every two hours while awake and every 4 hours while asleep. In addition, an antifungal powder was ordered for the excoriated skin on the abdomen. The hospital note, dated 1/17/11, documented that Resident 1 required admission to the hospital due to " multiple electrolyte abnormalities and [MEDICAL CONDITION], peri-ostomy inflammation and redness ". The note documented " her skin was extremely [DIAGNOSES REDACTED]tous on admission, which is likely secondary to the fact that her ostomy bag would not stay on at the skilled nursing facility and she had point of bile salts and stool all around her skin. She also has a yeast infection " . On 1/20/11, the resident was observed in the hosptial. The resident's [MEDICAL CONDITION] pouch was attached to a drainage bag and the entire skin on the abdomen and groin was red in color.

Based on interview and record review, the facility failed to provide assistance and supervision for two of two sampled residents (9 and 10) who were reviewed for accidents. Failure to remain in the bathroom with Resident 9 resulted in harm of an unwitnessed fall with injury and failure to protect Resident 10 when his electric wheelchair had a control switch malfunction resulted in harm of a laceration to his leg. Findings include: 1. Resident 9 was admitted in September 2010 with [DIAGNOSES REDACTED]. Her cognitive skills for daily decision-making were moderately impaired. She had an unsteady gait. Review of her clinical record revealed documentation of multiple falls since admission. On the "High potential fall assessment" form, dated 09/20/10, 09/28/10 and 10/04/10 nursing documented Resident 9 should not be left alone in the bathroom or on the commode. Review of the "resident care plan" form, a guide used by Nursing Assistants (NA)s when delivering care to residents, revealed no mention of not leaving Resident 9 alone in the bathroom. The resident's care plan, dated 09/20/10, had no details of not leaving Resident 9 alone in the bathroom. On 11/10/10 at 08:34 a.m., Licensed Nurse (LN) 3 reported she performed the fall risk assessment, dated 09/28/10 for Resident 9. LN 3 stated she communicated to the NAs not to leave Resident 9 alone in the bathroom verbally at shift assignment. She stated it was on the "resident care plan" form, dated 11/10/10, used by the NAs when delivering care to residents. The NAs also talked with each other to share communication of resident care. LNs likewise talked with each other regarding resident care. On 10/09/10 at 2 p.m., a LN assisted Resident 9 to the bathroom. The LN left her there alone and went to find the NA assigned to Resident 9. While Resident 9 was alone in the bathroom, she fell and suffered a deep laceration, 3 centimeters (cm) x 1 cm, above her left eye. The resident's physician ordered her sent to the hospital emergency department where sutures were placed. On 11/03/10 at 3:15 p.m., observation of Resident 9 found a dark, pale purple and yellow-brown bruise on her left cheekbone area. A scar was visible above the left eye. Resident 9 reported staff left her alone in the bathroom. She stood up and fell , cutting her head. On 11/12/10 the Director of Nursing (DNS) reported staff should not have left Resident 9 alone in the bathroom. 2. Resident 10 was admitted in September 2006 with [DIAGNOSES REDACTED]. He had diabetes and numbness in his legs and feet. His most recent MDS assessment, dated 07/16/10, identified he used an electric wheelchair as his primary means of locomotion. His cognitive skills for daily decision-making were modified independent. In an interview on 11/08/10 at 08:30 a.m., Physical Therapy Assistant (PTA) 1 reported on 10/07/10 he was present when a service representative for the wheelchair repair and service company noted the tilt switch for Resident 10's wheelchair was missing its cover. PTA 1 stated the normal function was to press and hold for the wheelchair to tilt. The PTA recalled the service representative pushed on the tilt switch and it did not work. She pressed it three or more times before it responded correctly. She did not indicate any safety concern to PTA 1. She scheduled a service repair technician to come and evaluate the malfunctioning tilt mechanism of the wheelchair in the following week. He did not recall when during that day he told his supervisor of the issue. On 10/07/10 about 4 p.m., PTA 1 and LN 2 were in Resident 10's room. Resident 10 was seated in the wheelchair in front of the sink. PTA 1 saw Resident 10 press the tilt button on the wheelchair. PTA 1 pushed the tilt button in an attempt to stop it from tilting back. The tilt function did not respond. The wheelchair tilted all the way back before it stopped. Resident 10's legs were caught in the pipes under the sink. He suffered a laceration, 12 cm in length, to his left lower leg. On 11/10/11 at 09:10 a.m., LN 2 reported she witnessed Resident 10 ' s wheelchair fully recline despite attempts by PTA 1 to halt the tilt function. The armrests of the wheelchair were under the sink counter and lifted the sink counter edge up to a 35-40 degree angle. Resident 10 ' s legs were under the sink and his left lower leg was cut. She ordered the electric wheelchair replaced with a manual style until the electric wheelchair could be evaluated and repaired. No one had informed her of the previous malfunction of the tilt mechanism earlier in the day.