Every finding on record at Brookfield Health and Rehab of Cascadia

Based on interview and record review, the facility failed to ensure residents who had personal fund accounts established received accrued interest in those accounts for 2 of 3 sampled residents (Residents 34 and 36) reviewed for Trust Funds interest accrued. This failure placed residents at risk not to receive, or have access to, monies owed to them.Findings included . Record review of Resident 34's Resident Fund Management Service (RFMS) .Resident Statement Landscape showed the following:01/02/2026 Interest Paid 0.00; Balance $415.0002/02/2026 Interest Paid 0.00; Balance $415.0003/02/2026 Interest Paid 0.00; Balance $395.0004/01/2026 Interest Paid 0.00; Balance $395.0005/01/2026 Interest Paid 0.00; Balance $395.0006/01/2026 Interest Paid 0.00; Balance $329.00 Record review of Resident 36's Resident Fund Management Service .Resident Statement Landscape showed the following:04/01/2026 Interest Paid 0.00; Balance $108.7405/01/2026 Interest Paid 0.00; Balance $326.2206/01/2026 Interest Paid 0.00; Balance $326.22 In an interview on 06/04/2026 at 1:53 PM, Staff J, Business Office Manager, said Resident 34 and Resident 36 had money in interest bearing accounts. When asked about Resident 34's interest accrued in the account, Staff J looked at Resident 34's Resident Statement Landscape and said the account had zero interest since January 2026. Staff J stated, I don't know why he doesn't, I've never noticed it before.interest is zero since January. When asked about Resident 36's interest accrued in the account, Staff J stated, He's not gaining any interest either, I don't know why, I'm glad you brought this up. Staff J said she needed to find out from RFMS why the accounts were not getting interest stating, I don't know if it's on our end or their end. Staff J said Resident 34 and Resident 36 should have been accruing interest in their accounts. In an interview on 06/04/2026 at 2:25 PM, Staff A, Chief Executive Officer, said she expected residents accrued interest to be in their accounts. Reference WAC 388-97-0340 (3)(a)

Based on interview and record review, the facility failed to complete an AIMS (Abnormal Involuntary Movement Scale) test (a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for 1 of 5 sampled residents (Resident 51) reviewed for unnecessary medications. This failure placed residents at risk for adverse medication side-effects, medical complications, and a diminished quality of life.Findings included.Record review of facility policy, titled, Psychotropic Medications, revised 04/22/2025, documented, . 5. In addition to these triggers, the facility will conduct a formal quarterly review (in accordance with CMS [Centers for Medicare & Medicaid Services] guidance under F-758 [federal regulation] and F-756) of each resident's psychotropic regimen during the interdisciplinary team (IDT) care plan meeting. a. This review includes evaluation of: . ii. Therapeutic benefit and adverse effects.Resident 51 was admitted to the facility on [DATE] with multiple diagnosis to include Dementia (disease characterized by decline in cognitive abilities such as memory, reasoning, and communication) with other behavioral disturbances. The Quarterly Minimum Data Set, an assessment tool, dated 03/12/2026, documented Resident 51 was severely cognitively impaired.Record review of Resident 51's electronic health record (EHR) showed a physician's order, dated 12/07/2025, for Quetiapine Fumarate (an antipsychotic medication) oral tablet 25 mg (milligrams) to give 12.5 mg by mouth at bedtime. Further review of Resident 51's EHR showed that Resident 51 had been on Quetiapine Fumarate since 06/12/2025. The June 2025 to June 2026 electronic medication administration record showed Resident 51 was receiving Quetiapine Fumarate as ordered.Record review of Resident 51's EHR showed an AIMS test was first completed on 06/13/2025 and the next one on 04/01/2026, 10 months later. In an interview on 06/04/2026 at 10:06 AM, Staff B, Chief Nurse Officer/Registered Nurse, reviewed Resident 51's EHR and said last AIMS test was completed on 04/01/2026 and the one before that was completed on Resident 51's admission on [DATE] (10 months prior). Staff B said AIMS test were supposed to be completed on admission and every six months for residents on antipsychotics. Refer to 756 Reference WAC 388-97-1060 (3)(k)(i)

Based on interview and record review, the facility failed to provide a written Bed-Hold notice to residents and/or residents' representative at the time of transfer to the hospital for 2 of 2 sampled residents (Residents 39 and 3) reviewed for hospitalization. This failure placed residents at risk for lack of knowledge regarding their right to hold their bed while in the hospital. Findings included . Record review of the facility policy, titled, Bed-Hold, date revised 09/09/2025, documented, Facilities are required by Federal regulation to have polices addressing holding a resident's bed during periods of absence such as hospitalization or therapeutic leave. Additionally, facilities provide this written information about these policies to residents prior to and upon transfer for such absences. The notices will be provided in writing in a manner that resident/representative [representative] understands. The second notice is provided to the resident, and if applicable the resident's advocate, at the time of transfer, or in cases of emergency transfer, within 24 hours. It is expected that facilities will document multiple attempts to reach the resident's representative in cases where the facility was unable to notify the representative. Resident 39 was admitted to the facility on [DATE]. The Modification of Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/26/2026, documented Resident 39 was cognitively intact. In an interview on 06/01/2026 at 12:02 PM, Resident 39 said he recently went to the hospital and had surgery on his left arm. Resident 39 pointed to sutures in the antecubital (the front of the arm at the bend of the elbow) area of his left arm. Resident 39 said the facility did not talk to him about holding his bed when he went to the hospital. Review of Resident 39's Electronic Health Record (EHR) showed Resident 39 was transferred to the hospital on [DATE]. Further review of Resident 39's EHR did not show documentation of a written bed-hold notice, nor was contact made to the resident and/or representative regarding bed-hold information. In an interview on 06/03/2026 at 12:44 PM, Staff H, Resident Care Manager/Licensed Practical Nurse, said when residents transferred to the hospital, they would send bed hold paperwork with the resident. Staff H said the admissions department would follow up with the resident and call them to see if they wanted a bed hold. In an interview on 06/03/2026 at 12:58 PM, Staff D, Admissions Coordinator, said they would talk about bed holds daily in their morning meeting for residents in the hospital. Staff D stated, As a team we choose one way or the other, generally we just hold it until otherwise, we try to keep as many people as we can. In an interview on 06/03/2026 at 2:30 PM, Staff B, Chief Nursing Officer/Registered Nurse, said nursing would offer a bed hold for residents. Resident 3 was admitted to the facility on [DATE]. The admission MDS, dated [DATE], indicated Resident 3 was alert and oriented. Record review of Resident 3's eInteract transfer form, dated 04/28/2026, documented Resident 3 was transferred to an acute hospital. Record review of Resident 3's progress notes, dated 04/29/2026 at 3:41 AM, documented, Resident had emesis [vomiting] x2 [twice] this shift. Resident requested to be sent out to the hospital d/t [due to] vomiting with no relief after PRN [as needed] ondansetron [medication used to prevent nausea and vomiting]. Record review of Resident 3's EHR did not have documentation the bed-hold policy was reviewed with Resident 3 prior to or after Resident 3's transfer to an acute hospital. During an interview on 06/03/2026 at 1:54 AM, Staff B said the bed-hold agreement should be reviewed with the resident at the time of transfer or just after depending on the urgency of the transfer. While reviewing Resident 3's EHR, Staff B said she could not find a bed-hold for Resident 3. Reference WAC 388-97-0120 (4)

Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was completed accurately to reflect a resident's health status and/or care needs for 1 of 5 sampled residents (Resident 46) reviewed for activities of daily living; failed to identify Hospice services for 1 of 2 sampled residents (Resident 14) reviewed for Hospice; and 1 of 5 sampled residents (Resident 52) reviewed for unnecessary medications. This failure placed residents at risk for unidentified and/or unmet care needs and a diminished quality of life.Findings included . Resident 46 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 46 was severely cognitively impaired. Record review of Resident 46's behavior progress note, dated 03/01/2026, documented, . resident refused brief and clothing change this shift. Record review of Resident 46's behavior progress note, dated 02/28/2026, documented, On alert for monitoring behaviors, resident was verbally abusive to CNA [certified nurse assistant] when he was being asked to change his shirt, he has been wearing shirt for a week, refused showers and change of clothes and peri-care [groin area]. Re-approaching ineffective. Record review of Resident 46's behavior progress note, dated 02/26/2026, documented, On alert for monitoring behaviors, refused shower and peri-area assessment, re-approached but ineffective. Record review of Resident 46's MDS assessment, dated 03/04/2026, documented Resident 46 did not refuse care. In an interview on 06/04/2026 at 11:37 AM, Staff G, Social Services, said they coded behavior MDS assessments after they reviewed behavior monitoring documentation by the provider, nurses progress notes and CNAs documentation, looking for key words like refusal of care. Staff G said Resident 46 was coded incorrectly for rejection of care. Resident 14 was admitted to the facility on [DATE]. The quarterly MDS, dated [DATE], indicated Resident 14 was moderately cognitively impaired. Record review Resident 14's significant change MDS, dated [DATE], showed the status payer was hospice Medicaid of [NAME]. Record review of Resident 14's physician's order, dated 11/30/2025, noted Resident 14 was Admit for hospice . During an interview on 06/03/2026 at 9:41 AM, Staff E, MDS Nurse/Registered Nurse (RN) said the significant change MDS was completed on Resident 14 when she was admitted to Hospice. While reviewing the significant change and the quarterly MDSs' Staff E said she should have identified hospice services on the MDSs. During an interview on 06/03/2026 at 9:49 AM, Staff B, Chief Nursing Officer/RN, said Resident 14 was currently receiving hospice services. When asked about hospice services being identified on the MDS, Staff B any changes or services should be reflected on the MDS. Resident 52 was admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 52 was severely cognitively impaired and was taking an opioid (a prescription drug that is used to relieve pain) medication. Record review of Resident 52's physician orders, dated 02/05/2026, and discontinued 04/03/2026, showed Resident 52 was prescribed Tramadol (an opioid medication used to manage moderate to severe pain) 50 milligrams every six hours as needed for breakthrough pain. Record review of Resident 52's March 2026 Electronic Medication Administration Record showed Resident 52 did not take Tramadol during the month of March 2026. In an interview on 06/04/2026 at 10:14 AM, when asked about Resident 52's opioid medication use coded on the Quarterly MDS, dated [DATE], Staff E, looked at resident 52's Electronic Health Record and said Resident 52 was prescribed tramadol but did not take it in March 2026. Staff E said the MDS would need to be corrected. In an interview on 06/04/2026 at 10:41 AM, Staff B, said she expected the MDS was coded correctly to reflect the medications a resident was taking. Reference WAC 388-97-1000 (1)(b)

Based on interview and record review, the facility failed to notify the state mental health authority coordinator of a significant change in physical condition, for 1 of 5 residents (Resident 7) reviewed for PASARR process (Preadmission Screening and Resident Review, a screening tool used to identify mental health needs). This failure placed the residents at risk for unmet care needs and a diminished quality of life. Findings included.Record review of the facility policy, titled, Preadmission Screening & [and] Resident Review Process, revision date 08/29/2025, documented, .4. As part of the PASARR process, the facility is required to notify the appropriate state mental health authority or state intellectual disability [ID] authority when a Resident that triggers a Level II PASARR [ an in-depth, person-centered evaluation triggered when an initial screen suspects a Serious Mental Illness [SMI] has a significant change in their physical or mental condition to ensure they continue to receive the care and services they need in the most appropriate setting. a. Referral to the SMH/ID authority should be made upon the criteria indicative of a significant change are evident.Resident 7 was admitted to the facility on [DATE] with multiple diagnosis to include depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in daily activities) and schizoaffective disorder (chronic mental health condition characterized by a combination of symptoms like delusions or hallucinations - and mood disorder symptoms, like depression). The Significant Change Minimum Data Set (MDS), an assessment tool, dated 04/13/2026, documented Resident 7 was cognitively intact.Record review of Resident 7's electronic health record documented a Significant Change MDS on 11/17/2025, 02/17/2026, 03/5/2026 and 05/29/2026. Review of Resident 7's EHR did not show a new Level I PASARR was completed with each significant change MDS. In an interview on 06/04/2026 at 11:52 AM, Staff G, Social Services, said Level I PASARR screenings were completed prior to admission. When asked if a new PASARR screening was completed when a Resident 7 had a significant change in condition, Staff G said that it was not completed. Reference WAC 388-97-1975(7)

Based on observation, interview, and record review, the facility failed to ensure resident care plans were revised to accurately reflect care needs for 1 of 2 sampled residents (Resident 7) reviewed for hospice and 1 of 1 sampled resident (Resident 39) reviewed for skin conditions. This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included. Resident 7 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS), an assessment tool, dated 04/13/2026, documented Resident 7 was cognitively intact. Record review of Resident 7's medical record titled, Consent for Medicare Hospice Election Statement, dated 11/10/2025, documented Resident 7 was to begin hospice on 11/11/2025. Resident 7's care plan was updated on 11/12/2025. Record review of Resident 7's medical record titled, REVOCATION OF HOSPICE BENEFIT OR DESIGNATION OF A NEW HOSPICE, dated 02/11/2026, documented Resident 7's Medicare hospice benefit was revoked. Review of Resident 7's care plan did not show a revision indicating hospice services were discontinued on 02/11/2026. Record review of Resident 7's medical record titled, Consent for Medicare Hospice Election Statement, dated 02/26/2026, documented Resident 7 was to begin hospice on 02/26/2025. Resident 7's care plan did not document a revision indicating hospice services were restarted on 02/26/2026. Record review of Resident 7's documentation from Peace Health (PH) Hospice documented Resident 7 was discharged from hospice on 04/25/2026. Resident 7's care plan was not updated to indicate hospice was discontinued. In an interview on 06/04/2026 at 10:25 AM, Staff B, Chief Nurse Officer/Registered Nurse, said Resident 7's care plan was not updated to reflect changes to their hospice status. Resident 39 was admitted to the facility on [DATE], transferred to the hospital on [DATE] and re-admitted to the facility on [DATE]. The Modification of Quarterly MDS, dated [DATE], documented Resident 39 was cognitively intact. In an interview on 06/01/2026 at 12:02 PM, Resident 39 said he recently went to the hospital and had surgery on his left arm. Resident 39 pointed to sutures in the antecubital (the front of the arm at the bend of the elbow) area of his left arm. In an interview and observation on 06/03/2026 at 9:19 AM, Resident 39 was observed lying in his bed. Three sutures were observed in the antecubital area of his left arm. When asked about the sutures, Resident 39 said he thought he should be getting them out soon. Review of Resident 39's Electronic Health Record (EHR) admission Note, dated 05/26/2026, documented, .readmitted s/p [status post] vascular [blood vessel] intervention for dialysis access (fistula/catheter revision). Review of Resident 39's EHR Health Status note, dated 06/01/2026, documented, .suture to left antecubital fossa [inner bend or crease of your left elbow] . Record review of Resident 39's care plan, Potential/actual for alteration in skin/tissue., date revised 04/28/2026, did not show a Focus, Goal, and/or Interventions/Task area related to sutures and/or a skin condition to the left antecubital area. On 06/03/2026 at 12:44 PM, Staff H, Resident Care Manager/Licensed Practical Nurse, said if a resident had a skin issue such as an incision or sutures, there would be a care plan in place regarding the skin area. When asked about Resident 39's skin care plan for sutures in his left arm, Staff H said he did not see a care plan for the sutures and there should have been. In an interview on 06/03/2026 at 2:30 PM, Staff B said she expected Resident 39's skin care plan was updated to address new skin issues such as sutures. Reference WAC 388-97-1020 (2)(a)

Based on interview and record review, the facility failed to ensure services provided met professional standards by not following physician's orders for 1 of 5 residents (Resident 51) reviewed for unnecessary medications. This failure placed residents at risk for unmet care needs, medical complications, and a diminished quality of life.Findings included.Resident 51 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 03/12/2026, documented Resident 51 was severely cognitively impaired and had a diagnosis of hypertension (elevated blood pressure). Record review of Resident 51's electronic health record (EHR) showed a physician's order, dated 11/20/2025, for amlodipine besylate (medication to help lower blood pressure) oral tablet 5 MG (milligrams) for hypertension, with parameters to not give the medication if systolic blood pressure (SBP, the top number in a blood pressure reading) was below 100 or their heart rate (HR) was below 60 beats per minute (bpm). Record review of Resident 51's EHR showed resident 51's HR was 57 bpm on 05/29/2026, 54 bpm on 05/28/2026, 59 bpm on 05/22/2026, 55 bpm on 04/17/2026, 55 bpm on 04/16/2026, 56 bpm on 04/04/2026, 58 bpm on 03/19/2026, 58 bpm on 02/27/2026, 55 bpm on 02/22/2026.Record review of Resident 51's February, March, April and May 2026 electronic medication administration record (EMAR), documented Resident 51 was administered amlodipine besylate 5mg tablet on, 5/29/2026, 05/28/2026, 05/22/2026, 04/17/2026, 04/16/2026, 04/04/2026, 03/19/2026, 02/27/2026, and on 02/22/2026, when his heart rate was less than 60 bpm.In an interview on 06/03/2026 at 1:07 PM, Staff I, Licensed Practical Nurse (LPN), said it was the expectation that if a residents SBP or HR was below physician ordered parameters, amlodipine besylate would not be administered. In an interview and record review on 06/03/2026 at 1:29 PM, Staff H, Resident Care Manager/LPN, reviewed Resident 51's HR and EMAR and said it was the expectation that the licensed nurses should have held the amlodipine besylate when Resident 51's HR was below 60 bpm. Reference WAC 388-97-1060(3)(k)

Based on observation, interview, and record review, the facility failed to obtain physician and/or treatment orders for skin and/or wound care for 1 of 1 sampled resident (Resident 39) reviewed for skin conditions. This failure placed residents at risk of injury, unmet care needs, and a diminished quality of life.Findings included. Resident 39 was admitted to the facility on [DATE], transferred to the hospital on [DATE] and re-admitted to the facility on [DATE]. The Modification of Quarterly Minimum Data Set, dated [DATE], documented Resident 39 was cognitively intact. In an interview on 06/01/2026 at 12:02 PM, Resident 39 said he recently went to the hospital and had surgery on his left arm. Resident 39 pointed to sutures in the antecubital (the front of the arm at the bend of the elbow) area of his left arm. In an interview and observation on 06/03/2026 at 9:19 AM, Resident 39 was observed lying in his bed. Three sutures were observed in the antecubital area of his left arm. When asked about the sutures, Resident 39 said he thought he should be getting them out soon. Review of Resident 39's Electronic Health Record (EHR) admission Note, dated 05/26/2026, documented, .readmitted s/p [status post] vascular [blood vessel] intervention for dialysis access (fistula/catheter revision). Review of Resident 39's EHR Health Status note, dated 06/01/2026, documented, .suture to left antecubital fossa [inner bend or crease of your left elbow]. Review of Resident 39's EHR does not show physician and/or treatment orders for monitoring sutures and/or skin condition to the left antecubital area. In an interview on 06/03/2026 at 12:44 PM, Staff H, Resident Care Manager/Licensed Practical Nurse, said if a resident had a skin issue such as an incision or sutures, there would be physician orders for wound care and/or monitoring the skin area. When asked about Resident 39's sutures in his left arm, Staff H said he did not see orders for monitoring the sutures and there should have been. In an interview on 06/03/2026 at 2:30 PM, Staff B, Chief Nursing Officer/Registered Nurse, said she expected there were physician orders and treatment orders in place to monitor Resident 39's sutures. Reference WAC 388-97-1060 (1)(3)(b)

Based on observation, interview, and record review, the facility failed to obtain physician orders for oxygen and/or BiPAP (Bi-level Positive Airway Pressure, a non-invasive ventilator that delivers air and oxygen into the lungs using a mask to help people breathe more easily) use for 1 of 2 sampled residents (Resident 39) and failed to change oxygen tubing as ordered for 1 of 2 sampled residents (Residents 60) reviewed for respiratory care. This failure placed residents at risk for worsening health complications, unmet care needs, and a diminished quality of life. Findings included. Record review of the facility's policy, titled, Oxygen Administration, Safety, Storage & Maintenance, revised 10/10/2025, documented, The facility will administer, store, and maintain supplemental oxygen safely in accordance with current standards of practice and licensed practitioner orders. 6. Verify provider order prior to initiating/changes oxygen therapy. 8. Monitor oxygen parameters as needed and/or as ordered. 1. Change oxygen supplies weekly and when visibly soiled. Equipment should be dated when set up or changed out. 2. Humidifier/Aerosol bottles should be dated and replaced every 7 days regardless of H2O [water] level. Resident 39 was admitted to the facility on [DATE], transferred to the hospital on [DATE] and re-admitted to the facility on [DATE]. The Modification of Quarterly Minimum Data Set (MDS, an assessment tool), dated 03/26/2026, documented Resident 39 was cognitively intact, was on oxygen therapy, and used a non-invasive mechanical ventilator. In an observation and interview on 06/01/2026 at 12:08 PM, a BiPAP machine was observed on Resident 39's nightstand and an oxygen concentrator was observed in Resident 39's room. Resident 39 said he used the BiPAP machine at night and sometimes used oxygen. In an observation and interview on 06/03/2026 at 9:19 AM, Resident 39 was observed lying in bed with oxygen running at 1.5 lpm (liters per minute) per nasal cannula. Resident 39 said he used the BiPAP machine last night. Record Review of Resident 39's Oxygen use care plan, revised 11/26/2025, documented Interventions/Tasks, Administer medications and treatments as ordered. BIPAP as ordered. Review of Resident 39's Electronic Health Record (EHR) showed no physician's order related to the use of oxygen and/or a BiPAP machine. In an interview on 06/03/2026 at 9:25 PM, Staff I, Licensed Practical Nurse (LPN), said for residents that used oxygen, they determined the rate of oxygen flow by the physician orders. Staff I said they had to have orders for BiPAP machine use. In an interview on 06/03/2026 at 9:36 AM, Staff H, Resident Care Manager/LPN, said they had to have orders for oxygen and BiPAP use. When asked about Resident 39's oxygen and BiPAP physician orders, Staff H looked at Resident 39's EHR and said when Resident 39 came back from the hospital the orders did not get put back in for oxygen and the BiPAP machine and they should have. In an Interview on 06/03/2026 at 2:30 PM, Staff B, Chief Nursing Officer/Registered Nurse said she expected residents using oxygen and a BiPAP machine had physician orders for use. Resident 60 was admitted to the facility on [DATE], transferred to the hospital on [DATE] and re-admitted to the facility on [DATE]. The Quarterly MDS, dated [DATE], documented Resident 60 was moderately cognitively impaired, and was on oxygen therapy. In an observation and interview on 06/02/2026 at 9:38 AM, Resident 60 was observed in bed with oxygen turned on. Resident 60 reported using oxygen regularly but was unable to recall when her oxygen tubing was replaced, or oxygen concentrator was serviced. Record review of Resident 60's EHR showed physician's order, dated 01/15/2025, documented, Change Oxygen/ Nebulizer tubing and clean concentrator filter every week. Date and provide tubing bag as indicated. Record Review of Resident 60's Oxygen use care plan, revised 05/28/2026, documented, Change disposable oxygen tubing, nebulizer supplies, connecting tubing, corrugated tubing, etc [sic] weekly prn [as needed] Cleanse concentrator external filter as indicated prn. Record review of Resident 60's EHR, dated April 2026 to June 2026, showed no documentation of oxygen tubing being exchanged or concentrator filter being cleaned as ordered and care planned. In an interview on 06/03/2026 at 2:10 PM, Staff F, Infection Preventionist/ Registered Nurse said oxygen concentrator cleaning and tubing exchange were done weekly and were documented on the Medication Administration Report (MAR). Staff F was unable to find documentation of Resident 60's Oxygen concentrator being cleaned and tubing exchanged. Staff F stated, It should be on the MAR. It was left out because of the PNR order. In an interview on 06/04/2026 at 1:42 PM, Staff B said Resident 60's order was a PRN order, which was changed since. Staff B was unable to provide documentation of Resident 60's oxygen concentrator maintenance and tubing exchange. Reference WAC 388-97-1060 (1)(3)(vi)

Based on interview and record review, the facility failed to ensure monthly pharmacy review recommendations were addressed as indicated for 1 of 5 residents (Resident 51) reviewed for unnecessary medications. This failure placed residents at risk of inadequately monitored medications, adverse effects, and a diminished quality of life.Findings included.Resident 51 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, an assessment tool, dated 03/12/2026, documented Resident 51 was severely cognitively impaired.Record review of the pharmacy recommendations, review date from 12/22/2025 to 12/24/2025, documented the facility had not conducted an AIMS test (Abnormal Involuntary Movement Scale test, which is a rating scale used to assess the severity of involuntary movements that sometimes develop as a side effect of treatment with antipsychotic medications [drugs used primarily to treat symptoms such as hallucinations and delusions]) for Resident 51 since 06/13/2025 and requested the AIMS test be updated. Review of Resident 51's electronic health record (EHR) did not show an updated AIMS test in December 2025. Record review of the pharmacy recommendations, review date from 02/07/2026 to 02/09/2026, documented a pharmacy request for an updated AIMS test for Resident 51 as last test was completed on 06/13/2025. Review of Resident 51's EHR did not show an updated AIMS test in February 2026.Record review of the pharmacy recommendations, review date from 03/09/2026 to 03/10/2026, documented, THIS IS A REPEAT RECOMMENDATION SINCE DECEMBER [December 2025]. Pharmacist documented they were unable to locate a current AIMS test in Resident 51's EHR. Pharmacy requested facility to update Resident 51's AIMS test. Review of Resident 51's EHR did not show an updated AIMS test in March 2026.Record review of the pharmacy recommendations, review date from 02/07/2026 to 02/09/2026, documented a pharmacy request for Vitamin D blood level to be drawn for Resident 51. Review of Resident 51's EHR did not show Vitamin D blood level results in February 2026.Record review of the pharmacy recommendations, review date from 03/09/2026 to 03/10/2026, documented, PROVIDER STATED TO DRAW LAB - SIGNED 2/10/2026. NO NOTED LABS DRAWN. PLEASE CLARIFY. Pharmacy requested facility to draw Vitamin D level on the next lab day. Review of Resident 51's EHR did not show Vitamin D blood level results in March 2026.Record review of pharmacy recommendations, review date from 04/13/2026 to 04/14/2026, documented pharmacy request to have Resident 51's Vitamin D blood levels drawn as was requested in February 2026. Resident 51's EHR showed Vitamin D levels were drawn on 04/21/2026, 2 months after the initial pharmacy request. In a joint interview and record review on 06/04/2026 at 10:06 AM, Staff B, Chief Nurse Officer/Registered Nurse, said AIMS test were supposed to be completed on admission and every six months for residents on antipsychotics. Staff B reviewed Resident 51's EHR and said last AIMS test was completed on 04/01/2026 and the one before that was completed on Resident 51's admission on [DATE] (10 months prior). Staff B reviewed Resident 51's pharmacy recommendations. Staff H, Resident Care Manager/Licensed Practical Nurse, said they were unable to find documentation of Resident 51 refusing his blood to be drawn.Staff B said it was the expectation that pharmacy recommendations were implemented. Staff B said it was the expectation that Resident 51's Vitamin D levels were drawn as ordered. Reference WAC 388-97-1300(4)(c)Refer to F605

Based on interview, and record review, the facility failed to ensure resident's medical records were accurate and up to date for 1 of 2 sampled residents (Resident 7) reviewed for hospice and 1 of 5 sampled residents (Resident 7) reviewed for pre-admission screening and resident review (PASARR, An assessment used to identify individuals [residents] with serious mental issues, intellectual disabilities, or related conditions are not inappropriately placed in nursing facilities for long term care). This failure placed residents at risk for unmet care needs and a diminished quality of life. Findings included.Resident 7 was admitted to the facility on [DATE] with multiple diagnosis to include depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in daily activities) and schizoaffective disorder (chronic mental health condition characterized by a combination of symptoms like delusions or hallucinations -and mood disorder symptoms, like depression). The Significant Change Minimum Data Set, an assessment tool, dated 04/13/2026, documented Resident 7 was cognitively intact.HospiceRecord review of Resident 7's medical record titled, REVOCATION OF HOSPICE BENEFIT OR DESIGNATION OF A NEW HOSPICE, dated 02/11/2026, documented Resident 7'S Medicare hospice benefit was revoked. Resident 7's EHR did not have an updated physician's order discontinuing hospice services. Record review of Resident 7's medical record titled, Consent for Medicare Hospice Election Statement, dated 02/26/2026, documented Resident 7 was to begin hospice on 02/26/2025. Resident 7's EHR did not have an updated physician's order documenting hospice service were restarted on 02/26/2025.Record review of Resident 7's care plan focus documented, End of Life Care / Palliative Care [comfort care] r/t [related/to]: Parkinson's [nerve disorder that primarily affects movement] care plan, initiated on 11/12/2025, documented Resident 7's hospice care plan was resolved on 04/17/2026. Review of Resident 7's EHR did not show documentation or physician's order discontinuing hospice service. Record review of Resident 7's documentation from Peace Health (PH) Hospice documented Resident 7 was discharged from hospice on 04/25/2026. Resident 7's EHR did not have a physician's order to discontinue hospice. Further review of Resident 7's EHR showed nurses progress notes from 04/25/2026 through 05/23/2026, documenting that Resident 7 was on hospice when he was not. Record review of Resident 7's health status note, dated 05/23/2026, documented, negative lab results, called PH hospice to confirm resident's hospice status, resident off from hospice since 4/25/26.In an interview on 06/04/2026 at 10:25 AM, Staff B, Chief Nurse Officer/Registered Nurse, said the staff member who was responsible for obtaining physician orders did not update Resident 7's medical records as was the expectation. PASARR Record review of Resident 7's electronic health record showed a Level I PASARR (a preliminary screening required for anyone entering a Medicaid-certified nursing facility), dated 10/08/2025, documented Resident 7 had a SMI (serious mental illness) and triggered a Level II PASARR evaluation. Review of Resident 7's EHR did not show a completed Level II PASARR evaluation.On 06/04/2026, Staff A, Chief Executive Officer, provided a copy of the Level II PASARR evaluation/determination, date reviewed 03/05/2026. In an interview on 06/04/2026 at 2:22 PM, Staff A said, Resident 7's Level II evaluation summary was not placed in Resident 7's EHR and it should have. Refer to F676Reference WAC 388-97-1720(1)(a)(i)-(ii)

Based on interview and record review, the facility failed to offer the Covid-19 (Coronavirus disease 2019, an infectious respiratory illness caused by a virus) vaccine and/or provide education regarding risks, benefits, and potential side effects associated with the vaccine, for 1 of 5 sampled residents (Resident 52) reviewed for unnecessary medications. This failure placed residents at risk for contracting Covid-19 infections, related complications, and a diminished quality of life.Findings included. Record review of the facility's policy titled, COVID Vaccination for Residents, revised 09/25/2025, documented, In accordance with CMS [Centers for Medicare Services] regulations, the facility will continue to provide education about COVID-19 vaccines and offer vaccination to all residents within the facility.Each resident should be offered COVID immunization unless the immunization is medically contraindicated. Resident 52 was admitted to the facility on [DATE]. The Quarterly Minimum Data Set, as assessment tool, dated 03/18/2026, documented Resident 52 was severely cognitively impaired and was not up to date on the COVID-19 vaccination. Review of Resident 52's EHR did not show documentation of education provided and/or a Covid-19 vaccination offered, declined, or medically contraindicated. In an interview on 06/04/2026 at 10:00 AM, Staff F, Infection Preventionist/Registered Nurse (RN), said upon admission they would address vaccinations for residents to include influenza, pneumococcal, and Covid-19. When asked about Resident 52's Covid-19 vaccination, Staff F looked at Resident 52's EHR and said the Covid-19 vaccination was missed. Staff F said it should have been offered upon admission and it was not. In an interview on 06/04/2026 at 10:41, Staff B, Chief Nursing Officer/RN, said she expected the Covid-19 vaccination was offered upon admission. No Reference WAC

Based on observation, interview and record review, the facility failed to provide eating assistance in a manner that promoted resident respect and dignity for 1 of 9 residents (Resident 14) reviewed for dining. This failure place residents at risk for diminished self-worth, embarrassment, and a deceased quality of life. Findings included. Review of the facility's policy, titled Dignity, dated 09/12/2025, documented, Each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the residents' individuality as well as honor and value their input. 2. Promoting resident independence and dignity while dining, such as avoiding. Staff standing over residents while assisting them to eat . Resident 14 was admitted to the facility on [DATE]. The quarterly Minimum Data Set, an assessment tool, dated 03/11/2026, indicated Resident 14 was dependent with eating and was moderately cognitively impaired.Record review of Resident 14's care plan, dated 04/06/2026, documented EATING: Dependent 1 staff with eating. 1:1 assistant with meals. During an observation on 06/02/2026 at 12:57 PM, Staff K, Nursing Assistant (NA), was standing next to Resident 14 on Resident 14's left side assisting Resident 14 with eating.During an observation on 06/02/2026 at 1:01 PM, Staff K walked over to pick up a slice of pizza for an unidentified male resident. Staff K stood in front of the resident and handed him the pizza using a napkin. During an observation on 06/02/2026 at 1:02 PM, Staff K went back to Resident 14 and assisted her again. Staff K was standing to the left of Resident 14.During an observation on 06/02/2026 at 1:03 PM, Staff K walked over to the unidentified male resident to pick up his pizza from his plate again.During an observation on 06/02/2026 at 1:04 PM, Staff K walked over to the sink, washed her hands and went back over to Resident 14 and started assisting her again. Staff K was standing to the left for Resident 14.During an observation on 06/02/2026 at 1:05 PM, Staff K walked over to the cart and grabbed an empty tray came back to the table, where Resident 14 was sitting, and put the plate of the resident sitting across from Resident 14 onto the tray. Staff K returned to the table and started assisting Resident 14 with her food. Staff K stood up next to Resident 14 while assisting.During an observation on 06/02/2026 at 1:07 PM, Staff K walked over to the cart and grabbed a tray. Staff K walked over to an unidentified female resident and put her plate, cup, and utensils on the tray. Staff K put the tray onto the cart. Staff K brought Resident 14 some pudding. During an observation on 06/02/2026 at 1:11 PM Staff K walked over to Resident 14 and stood on Resident 14's left side and assisted her with her food. During an interview on 06/02/2026 at 1:16 PM, Staff K said there were no stools to sit on and said she wasn't told by anyone they should sit when feeding residents. During an interview on 06/03/2026 at 8:46 AM, Staff H, Resident Care Manager/Licensed Practical Nurse, said we would want the NA to sit next to the residents when assisting the resident with their meals. The NA should try to create a homelike environment and respect residents' dignity.During an interview on 06/03/2026 at 9:41 AM, Staff B, Chief Nursing Officer/Registered Nurse, said staff assisting residents with their meals should be seated next to the resident to respect the resident's dignity.Reference WAC 388-97-0860 (1)(a)(2)

Based on observation, interview and record review, the facility failed to maintain a current Clinical Laboratory Improvement Amendments (CLIA Waiver- also known as a Medical Test Site Certificate of Waiver License, a license that allows the facility to legally perform certain simple, low risk medical tests like blood glucose checks and COVID-19 [Corona Virus Disease 2019, a respiratory illness] tests). This failure placed residents at risk for substandard care, delayed diagnosis and incorrect medical treatment. Findings included.Record review of the provided facility CLIA Waiver showed an expiration date of [DATE], a lapsed status of 11 months.In an observation and interview on [DATE] at 2:25 PM, Staff A, Chief Executive Officer, referred to the CLIA Waiver hanging on the wall and said it was expired, and that she would look for the current license and get it to the survey team.In an email interview on [DATE] at 12:07 PM, Staff A said she confirmed with the Business Office Manager that the renewal for the CLIA Waiver had not been completed.Reference: WAC 388-97-1620 (2)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 3 sampled residents (Resident 1) reviewed for medication errors when another resident's medication(s) were left unattended and then taken by/ingested by the wrong resident. Resident 1 experienced harm when they became unresponsive and required intensive care level hospitalization and mechanical ventilation. This failure placed all residents at risk for medical complications. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including liver cirrhosis (scarred liver with impaired functioning) and stage 3 kidney disease (impaired functioning of the kidney(s). Resident 1's Minimum Data Set (MDS/an assessment tool), dated [DATE], documented Resident 1 was unable to participate in the assessment. A nursing progress note, dated [DATE] at 3:08 AM, documented, Resident 1 ingested a Zyprexa 10 milligram (mg) pill (an antipsychotic medication) that was not his ordered medication while standing at the medication cart and taking their bedtime medications. The writing nurse documented they notified the Medical Doctor (MD) at approximately 2:00 AM when Resident 1 began to mumble incoherent speech. The MD ordered Resident 1 be transferred to the emergency room. The Facility Medication Error Report, dated [DATE], documented Resident 1 took medication off the medication cart when the licensed nurse (LN) had stepped away and that the medication was gone when she returned. Resident 1 was sent to and admitted to the hospital. The root cause identified as: cup with roommate's medication in it left on medication cart. The Facility Transfer Report, dated [DATE], documented the reason for transfer was due to Resident 1 being unresponsive. During an interview on [DATE] at 2:30 PM, Staff A, Interim Director of Nursing Services (DNS), stated that Resident 1 took a 10mg Zyprexa, became unresponsive, was sent to the hospital, and spent 3 days on a ventilator in the intensive care unit. The DNS stated that the LN gave two separate stories to her at different times being that Resident 1 took the medication off of the cart while she was right there and later stated that Resident 1 took the medication while she had stepped away from the cart. During an interview on [DATE] at 2:22 PM, Resident 1's daughter stated that the first night after admission, she received a message from a nurse at the facility informing her that Resident 1 was unresponsive and en route to the hospital. The nurse told her, [Resident 1] woke up, hobbled over to her medication cart, grabbed a pill, threw it in their mouth and swallowed it without water. Resident 1's daughter stated she immediately went to the hospital, where Resident 1 was found to be completely unresponsive. Approximately four hours later, Resident 1 was placed on life support, which the resident remained on for several days. Resident 1's daughter stated that Resident 1 was not prescribed Zyprexa, had never been on that type of medication, and she did not believe the resident would have took it on their own. Resident 1's daughter stated, This didn't happen to [Resident 1] because of [their] age, or an injury. This was done to [them]. [Resident 1] survived but could easily have died. During an interview on [DATE] at 1:04 PM, Staff D, Licensed Practical Nurse (LPN), stated that to ensure correct medication administration, she checked the medication against the Medication Administration Record (MAR), to verify identity she asks the resident their name. If the resident is nonverbal, she will look at the photo in the residents chart for reference or ask other staff. She stated medications remain secured in the medication cart until ready to administer and were never left unattended on top of the cart. During interview on [DATE] at 1:07 PM, Staff E, LPN, stated that she verified the resident's identity by asking the resident to confirm their name, resident chart photos, ID bracelets sometime if they just came from the hospital, or by consulting with familiar staff. She confirmed medications were kept locked in the cart and not left on top of it unattended. During interview on [DATE] at 1:12 PM, Staff F, a Registered Nurse (RN), stated that residents were identified by their chart picture or staff verification if non-verbal. She confirmed medications were supposed to be locked in the cart until ready to administer and ensure they were never left unattended. During an interview on [DATE] at 1:20 PM, Staff C, Chief Executive Officer, stated he was unable to comment on the incident and had not been notified it had occurred. Reference WAC 388-97-1060 (3)(k)(iii) .

Based on interview and record review, the facility failed to report a significant medication error to the State Survey Agency, as required for 1 of 3 residents (Resident 1) reviewed for medication administration and resulted in hospitalization and ventilator support. The failure to report a serious incident delayed appropriate oversight and investigation, placing residents at risk for harm. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including liver cirrhosis (scarred liver with impaired functioning) and stage 3 kidney disease (impaired functioning of the kidney(s). The Minimum Data Set (MDS) dated [DATE] documented that the resident was unable to participate in the assessment. A nursing progress note dated 05/04/25 at 3:08 AM documented: [Resident 1] ingested a Zyprexa (antispychotic medication) 10 mg [milligrams] [tablet] that was not ordered for [Resident 1] while standing at my medication cart taking their meds. This nurse notified MD [medical doctor] at approx. 2:00 AM when [Resident 1] began to mumble incoherent speech. MD ordered [Resident 1] to be transferred to ER [emergency room]. The facility incident log, dated 05/08/2025, noted the incident occurred on 05/03/2025 at 9:30 PM and confirmed that the state hotline was not notified of the event. During an interview on 05/21/2025 at 2:30 PM, Staff A, Interim Director of Nursing Services (DNS), stated that Resident 1 ingested 10 mg of Zyprexa, became unresponsive, and was transferred to the hospital, where the resident was placed on a ventilator in the intensive care unit for three days. Staff A reported that regional staff advised the incident did not require reporting, so it was not reported to the state hotline. On 06/09/2025 at 1:00 PM, Staff B, newly appointed Interim DNS, stated that the medication error should have been reported to the State Survey Agency. On 06/09/2025 at 1:20 PM, Staff C, Chief Executive Officer, was unable to comment on events and stated that he had not been notified of this incident. WAC 388-97-0640 (5)(6)(c) .

Based on observation, interview, and record review, the facility failed to ensure bed placement and bed side rails were assessed, physician ordered and had an informed consent for 3 of 8 sampled residents (29, 47 & 250) reviewed for physical restraints. This failure placed residents at risk for injury, unmet care needs, and a diminished quality of life. Findings included . Review of the facility's policy entitled, Restraints, revised 03/01/2024, documented, .Procedure 3. Appropriate assessment, care planning by the interdisciplinary team, and documentation of the medical symptoms are documented in the resident medical record . 5. Obtain a time limited physician's order for the use of a restraints. 6. Facility explains to the resident and/or resident advocate the medical symptoms the restraint addresses, potential risks and benefits of any option under consideration, and potential negative outcomes of restraint use to assist the resident in attaining or maintaining his/her highest practicable level of physical or psychological well-being . Bedrails/Side Rails . 3. If the bedrail/side rail is used, the facility ensures correct installation, use, and maintenance of the rail(s), including to but not limited to: a. Obtaining a physician's order with medical rationale. b. Explain potential risks and benefits, noting consent as indicated. c. Assessing the resident for risk of entrapment from bedrail/side rail prior to installation . 1) Resident 29 was admitted to the facility on [DATE]. The Significant Change Minimum Data Set (MDS) assessment, dated 04/07/2025, documented, in the staff assessment for mental status, Resident 29 was moderately cognitively impaired. On 05/04/2025 at 11:37 AM, Resident 29's bed was observed with a quarter rail on the middle right side of the bed. On 05/05/2025 at 8:22 AM, Resident 29's bed was observed with a quarter rail on the middle right side of the bed. At 12:13 PM, Resident 29's bed was observed with a quarter rail on the middle right side of the bed. On 05/06/2025 at 9:26 AM, Resident 29 was observed lying on his back in bed with a quarter rail on the middle right side of the bed. Record review of Resident 29's Electronic Health Record (EHR) showed no evaluation assessment, consent, or physician's order related to bed rails. 2) Resident 47 was admitted to the facility on [DATE] with diagnoses including hemiplegia and hemiparesis (paralysis and muscle weakness on one side of the body) following cerebral infarction (a stroke) affecting right dominant side. The Admission MDS assessment, dated 04/08/2025, documented, in the staff assessment for mental status, Resident 47 was moderately cognitively impaired. On 05/04/2025 at 4:12 PM, Resident 47 was observed lying in bed with the left side of the bed against the wall. On 05/05/2025 at 8:33 AM, Resident 47 was observed lying in bed with the left side of the bed against the wall. At 12:19 PM, Resident 47's bed was observed with the left side of the bed against the wall. Resident 47 was not in the room. On 05/06/2025 at 8:26 AM, Resident 47 was observed lying in bed with the left side of the bed against the wall. Record review of Resident 47's EHR showed no evaluation assessment, consent, or physician's order related to the bed against the wall. 3) Resident 250 was admitted to the facility on [DATE]. The Annual MDS assessment, dated 02/13/2025, showed Resident 250 was moderately cognitively impaired. On 05/04/2025 at 11:12 am, Resident 250 was observed lying in bed with the left side of the bed against the wall. At 11:27 AM, when asked about why the resident's bed was against the wall, Resident 250 said he did not know. Resident 250 stated, They keep it up against the wall, but it's not supposed to be . Record review of Resident 250's EHR showed no evaluation assessment, consent, or physician's order related to the bed against the wall. On 05/07/2025 at 8:32 AM, Staff I, Resident Care Manager and Licensed Practical Nurse, said if a resident had bed rails, mobility bars, or a bed against the wall, there should be an evaluation, consent, physician's order, and it should be care planned. Staff I was unable to locate an evaluation, consent, physician's order, and care plan for Resident 29's bed rail, and said there should have been. Staff I was unable to locate an evaluation, consent, physician's order, and care plan for Resident 47's and Resident 250's bed against the wall, and said there should have been. At 10:15 AM, Staff B, Chief Nursing Officer and Registered Nurse, said it was her expectation residents had evaluation assessments, consents, physician orders, and care plans in place for bed rails and/or a bed against the wall. Reference WAC 388-97-0620 (4)(a)(b)

Based on observations and interviews, the facility failed to ensure medication carts were locked when without supervision for 3 of 4 medication carts (on 200 Hall and 300 Hall) reviewed for medication storage. This failure placed residents at risk of having access to medications, and/or misappropriation of narcotic medications. Findings included . On 05/04/2025 at 10:04 AM, two medication carts in the 200 Hall were observed to be unlocked and no staff were in the hallway. On both carts, drawers were able to be pulled open. On 300 Hall, one medication cart was unlocked and drawers were able to be pulled open. At 10:07 AM, Staff M, Registered Nurse, came around the corner from the activity/dining room and locked the two carts on the 200 Hall. Staff M said he was supposed to lock the medication cart when he walked away. This surveyor told Staff M about the cart on the 300 Hall being unlocked as well. At 10:11 AM, This surveyor told Staff M the 300 Hall cart was still unlocked. Staff M was observed going over to the cart on 300 Hall and locking it. At 10:23 AM, Staff N, Licensed Practical Nurse (LPN), said she was supposed to lock the medication cart when she walked away. At 10:56 AM, Staff I, Resident Care Manager and LPN, said when staff walk away from the medication carts, they were supposed to lock them. Reference WAC 388-97-1300 (2)

Based on observation, interview and record review, the facility failed to ensure a resident's personal privacy was protected and maintained when a privacy curtain was not installed for 1 of 2 sampled residents (200) reviewed for resident rights. This failure placed residents at risk for diminished self-worth, self-esteem and overall well-being. Findings included . Resident 200 was admitted to the facility on [DATE]. The Admission Minimum Data Set assessment, dated 04/25/2025, documented the resident was alert and oriented. On 05/04/2025 at 12:14 PM, Resident 200's room was observed without having a privacy curtain installed. At 12:27 PM, Resident 200 said there had not been a privacy curtain in her room since she was admitted to the facility. The resident said the only way to maintain privacy during care was to keep the room door shut. Resident 200 stated, I can use my bed pan on my own, but I can't close the door on my own. Resident 200 said she had requested to have the privacy curtains installed, but it had not been done yet. Resident 200 said she had been concerned about her privacy for over two weeks; and stated, I am exposed, and I don't like it. On 05/05/2025 at 9:04 AM, Resident 200's room was observed without having a privacy curtain installed. At 10:13 AM, Staff L, Maintenance Manager, said a privacy curtain should be in installed for every resident prior to admitting. Staff L said he was not aware Resident 200 was missing her privacy curtain, and said he would see that it is installed. On 05/06/2025 at 8:57 AM, Staff B, Chief Nursing Officer and Registered Nurse, said she was not aware of the privacy curtain missing for Resident 200. Staff B said she would expect a privacy curtain installed in every room, including Resident 200's. See F-583 Reference WAC 388-97-0180 (1-4)

Based on observation, interview and record review, the facility failed to ensure personal privacy was maintained by not having a privacy curtain installed for 1 of 2 sampled residents (200) reviewed for personal privacy. This failure placed residents at risk for loss of privacy during personal care, embarrassment and decreased quality of life. Findings included . Resident 200 was admitted to the facility on [DATE]. The Admission Minimum Data Set assessment, dated 04/25/2025, documented Resident 200 was alert and oriented. On 05/04/2025 at 12:14 PM, Resident 200's room was observed without a privacy curtain being installed. At 12:27 PM, Resident 200 said there had not been a privacy curtain in her room since she was admitted to the facility. The resident said the only way to maintain privacy during care was to keep the room door shut. Resident 200 stated, I can use my bed pan on my own, but I can't close the door on my own. Resident 200 said she had requested to have the privacy curtains installed, but it had not been done yet. On 05/05/2025 at 9:04 AM, a privacy curtain in Resident 200's room was not observed. At 10:13 AM, Staff L, Maintenance Manager, said a privacy curtain should be in installed for every resident prior to admitting. Staff L said he was not aware Resident 200 was missing her privacy curtain, and he would see that it was installed. On 05/06/2025 at 8:57 AM, Staff B, Chief Nursing Officer and Registered Nurse, said she was not aware of Resident 200's privacy curtain missing, and she would expect a privacy curtain installed in every room. Reference WAC 388-97-0360 (1)

Based on interview and record review, the facility failed to ensure residents were free from avoidable accidents during resident bed mobility assistance for 1 of 3 sampled residents (Resident 1) reviewed for accident hazards. Resident 1 experienced harm when the resident was found to have a fractured femur (thighbone) after a fall that required medical intervention when facility staff did not use two-person assistance with bed mobility as indicated as necessary by the comprehensive care plan. This failure placed residents at risk for injury and a diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] with diagnoses including asthma, diabetes mellitus type 2, hypertension, and chronic heart failure. Resident 1's Minimum Data Set assessment, dated 07/17/2024, indicated the resident required maximum assistance to roll right and left and was dependent on staff to move from sitting on the side of the bed to lying flat on the bed. Resident 1's care plan, initiated 04/01/2024, showed Resident 1 had an [Activities of Daily Living] Self Care Performance Deficit r/t [related to] impaired functional mobility . An intervention, initiated 04/01/2024, showed, BED MOBILITY: Dependent for repositioning with assist of 2 staff . A Facility Investigation showed on 06/29/2024 at approximately 2:00 AM, Resident 1 was being provided personal care, including bed mobility assistance, by one staff member when the resident fell from the bed onto the floor. Review of a hospital orthopedic surgery consult note, dated 06/29/2024, showed Resident 1 sustained a femur [thighbone] fracture as a result of the fall from bed onto the floor and noted, At best, surgery would restore her baseline functional status of being able to transfer with a Hoyer lift [assistive sling/device used to transfer residents between a bed and a chair], but with significant risk . and in the short would not provide pain relief. [Resident 1, a family member], and I [Orthopedic Surgeon] discussed what the non-operative treatment would look like, mainly focused on comfort care in terms of pain control. We discussed this is a major injury that carries a significant risk of 30-day and one year mortality, and that transition to palliative care/hospice may be appropriate. On 07/02/2024 at 4:30 PM, Staff B, Registered Nurse and Director of Nursing Services, said Resident 1 .requires two [person] assist for bed mobility. The staff member who was assisting [Resident 1] is no longer employed here due to not following the care plan, resulting in a resident injury. Reference WAC 388-87-1060 (3)(g)

Based on interview and record review, the facility failed to assess and provide preventative equipment interventions to prevent further pressure injury development and deterioration for 1 of 6 sampled residents (Resident 1) reviewed for pressure injuries. This caused harm to Resident 1 when the resident admitted with one Stage 3 (full thickness tissue loss, subcutaneous fat may be visible) and two Stage 2 (a partial thickness loss of skin presenting as a shallow open ulcer with a red/pink wound bed) pressure injuries to the buttocks and the resident was not assessed for an air mattress (the professional standard of practice for redistribution of pressure for pressure ulcer/injury treatment and prevention) or bed mobility bars, developed three new unstageable (base of wound is covered by a layer of dead tissue and cannot be seen) pressure injuries, and one of the Stage 2 pressure injuries present on admission deteriorated to a Stage 3 pressure injury. This failure placed residents at risk for worsening of skin impairment, a change in health status, and a diminished quality of life. Findings included . Review of a facility policy entitled, Prevention and Treatment of Pressure Ulcers and Other Skin Alterations, dated 07/13/2018, documented a risk assessment is completed upon admission and at designated intervals throughout the residents stay to evaluate the resident's intrinsic risk and states residents at risk for developing pressure ulcers are identified by using the Braden Scale (an assessment for pressure injury risk). Pressure ulcer interventions are created and implemented in order to identify, prevent, or reduce the risk of acquiring pressure wounds. Based on the Braden assessment and the resident's clinical condition, interventions may include providing appropriate, pressure-redistributing, support surfaces. Resident 1 was admitted to the facility on [DATE] with diagnoses including sepsis, type 2 diabetes, chronic kidney disease stage 4, and pressure injuries. The admission Minimum Data Set (MDS), an assessment tool, dated 12/18/2023, documented the resident was cognitively intact, required maximal assistance for toileting and transfers, was at risk of developing pressure injuries, had two Stage 2 and one Stage 3 pressure injuries, and was incontinent of bowel and bladder. A Braden Scale, dated 12/12/2023, documented Resident 1 was at high risk for developing pressure injuries. Review of Resident 1's care plan, dated 12/29/2023, documented a focus of potential/actual impairment to skin integrity and being at risk for pressure ulcers, and did not include the intervention and use of a pressure relieving air mattress. A Wound Care Provider Note, dated 01/10/2024, documented, Follow up assessment of a chronic skin condition that is deteriorating. Noted increased erythema [redness] and inflammation. A Nursing Progress Note, dated 01/11/2024 at 12:25 PM, documented, Resident with x3 new unstageable pressure injuries, and x1 worsening stage 2 pressure injury. Stage 2 pressure injury now deteriorated to stage 3 pressure injury. A Nursing Progress Note, dated 01/14/2024 at 3:02 AM, documented, .resident also has several small opened areas on her buttock, has a redden area from lower back to both sides of buttock. tender and warm to the touch . A Nursing Progress Note, dated 01/14/2024 at 7:06 AM, documented, Resident has a warm to touch area on the lower back and top of buttock redden area, notified physician and received an order for Clindamycin 300 mg [an antibiotic] . A Nursing Progress Note, dated 01/14/2024 at 4:55 PM, documented, .resident has cellulitis on her lower back. The area is red and hot to the touch. Resident started ABX [antibiotics] this morning for cellulitis. Also gave PRN [as needed] Tylenol for her fever. A Nursing Progress Note, dated 01/16/2024 at 3:11 AM, documented, On call physician called with critical lab values for the patient. Creatine of 5.04, WBC of 31. Physician recommended for patient to be sent to the ED for further evaluation. Review of hospital records, dated 01/16/2024, documented emergent surgical interventions were performed to Resident 1's sacral and bilateral buttock pressure injuries. On 03/07/2024 at 2:10 PM, Staff A, Administrator, said Staff C, previous Director of Nursing Services involved in the care of Resident 1, was no longer employed at the facility. When asked about the use of pressure redistribution interventions (air mattress) for Resident 1, Staff A stated, .we [referencing to Staff C and himself] discussed using an air mattress for [Resident 1], and we have one so it would have been very easy to use it. But [Resident 1] has such a difficult time with repositioning in bed that the team felt the air mattress would not be good for her. At 2:15 PM, when asked about Resident 1 not using an air mattress, Staff B, Interim Director of Nursing Services, stated, Typically when there is someone with wounds, especially a stage three, we would put them on an air mattress to provide the best surface for their wounds and if they have difficulty with moving in their bed, we can assess them for use of bars to assist them in turning side to side. Staff A indicated wound care interventions were not his area of expertise and thus the recommendations of Staff C were followed. Reference WAC 388-97-1060 (3)(b)

Based on interviews and record review, the facility failed to ensure timely laboratory services were provided for 1 of 6 sampled residents (1) reviewed for laboratory services. This caused harm to Resident 1 when STAT (immediate) lab tests were not completed timely (three days after the STAT order) and the resident required a hospital evaluation for high lab values. This failure placed residents at risk for delay in treatment, decline in medical conditions and a diminished quality of life. Findings included . Review of facility policy, Laboratory, Radiology, Transfusion, and Other Diagnostic Services, dated 03/01/2019, defines a STAT test, to be critical to the residents subsequent treatment decisions and that laboratory services, are considered timely if laboratory tests are completed and results provided to the facility or resident physician within time frames normal for appropriate intervention. Resident 1 was admitted to the facility on [DATE] with diagnoses including urinary tract infection, sepsis (the body's extreme response to an infection, a life-threatening medical emergency), type 2 diabetes, chronic kidney disease stage 4, and pressure injuries. The admission Minimum Data Set, an assessment tool, dated 12/18/2023, documented the resident was cognitively intact, required maximal assistance for toileting, showering, dressing, and transfers and was incontinent of bowel and bladder. A physicians note, dated 01/12/2024, documented, Patient was recently sent to the hospital .during the course of her evaluation, she was found to have UTI [urinary tract infection] due to .patient's medical care was complicated by acute kidney injury . patient is having creatinine monitored .[patient] reported feeling weak and burning urination . patient agreed to plan for lab, UA [urinalysis], CS [urine culture sensitivity test], CBC [complete blood count], BMP [basic metabolic panel]. A physician's order, dated 01/12/2024, documented the facility was to obtain labs for BNP [blood test that measures protein] STAT with CBC and BMP. A Progress Note, dated 01/12/2024 at 3:11 PM, documented, .[Family Member] in today and expressed concerns with patient being out of it . Provider aware. STAT labs ordered. A Nursing Progress Note, dated 01/12/2024 at 5:59 PM, documented, Lab did not come in and draw request for blood draws, but did pick up urine sample, stated they 'did not see paperwork' for blood. Inquired for stat, they do not have anyone available for stat. Requested to have draw tomorrow, [as soon as possible], dispatch working on scheduling at the time of this writing. NP [nurse practitioner] in house, aware. A Nursing Progress Note, dated 01/13/2024 at 3:24 AM, documented, Resident has S/S [signs and symptoms] of possible UTI [urinary tract infection] and UA [urinalysis] obtained and sent to lab. Daughter called and concerned due to resident going septic in the past. Awaiting results of UA. Resident also has a redden buttock, warm to the touch. A Nursing Progress Note, dated 01/15/2024 at 1:18 PM, documented, This LN called [lab services] and requested phlebotomist to come for STAT CBC, BMP, BNP, and UA pick up. This LN obtained UA with LPN [Licensed Practical Nurse]. Specimen obtained and placed in [lab] pick up box at front of facility. Lab requestions in binder at front office. A Nursing Progress Note, dated 01/16/2024 at 3:11 AM, documented, On call physician called with critical lab values for the patient. Creatine of 5.04, WBC of 31. Physician recommended for patient to be sent to the ED for further evaluation. A Lab Results Report, dated 01/17/2024, documented the lab collection date as 01/15/2024 at 7:40 PM for the BNP STAT labs ordered on 01/12/2024 (a delay of three days). On 02/14/2024 at 3:55 PM, Staff A, Administrator, said there were issues with the lab services during the week of 01/10/2024 due to an ice storm. Staff A stated, In inclement weather, if the lab cannot make it to us, if the ordered lab is emergent, we would need to send them [the resident] out. This is all dependent on communication from the lab that they are unable to come to the facility due to weather. In the recent ice storm, there was some miscommunication from [the lab] on if they could still come to pick up samples if our nurse did the draw. We probably should have sent [Resident 1] out rather than waiting for them to come, but they said they would be here, so we waited. Reference WAC 388-97-1620 (2)(b)(i)(ii) (6)(b)(i)(ii)

Based on interview and record review, the facility failed to ensure a resident was free from sexual abuse by a staff member for 1 of 5 sampled residents (Resident 1) reviewed for abuse. Resident 1 experienced harm when the facility failed to take timely action once allegations of potential staff to resident abuse were first identified and suspected by staff in order to protect the resident from the potential of further abuse. This failure placed residents at risk for abuse and a diminished quality of life. Findings included . The [NAME] State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, defines sexual abuse to include any sexual contact between a staff person of a facility and a vulnerable adult living in that facility whether or not it is consensual. The Guidelines pertaining to Abuse showed, In general, you must presume that abuse has occurred whenever there has been some type of impermissible, unjustifiable, harmful, offensive or unwanted contact with a NH [Nursing Home] resident. The Purple Book shows sexual contact may include interactions that do not involve touching including, but not limited to, sending sexually explicit messages . The facility Abuse policy, revised 08/01/2023, documented, The facility respects the resident right to be free from abuse . Procedure 17 noted, Allegations of verbal, sexual, physical, and mental abuse . of the resident . are reported to the CEO [Chief Executive Officer] immediately and the state agency . within 2 hours . Resident 1 was admitted to the facility on [DATE] with diagnoses including congestive heart failure. The admission Minimum Data Set, an assessment tool, dated 10/07/2023, documented the resident was cognitively intact. Review of a State Agency report, dated 11/28/2023 at 6:46 PM, showed an incident occurred on 11/15/2023 where Resident 1 was an alleged victim of potential sexual abuse by a staff member. Review of a State Agency report, dated 11/29/2023 at 11:31 AM, showed accusations of inappropriate texts and phone calls of a sexual nature between a staff member and Resident 1. Review of the facility Investigation Report, dated 12/04/2023, showed an investigation was completed by Staff Q, Corporate Operations Resource, on 11/29/2023 through 12/04/2023, and showed the following: --On 11/21/2023, Staff J, Certified Nursing Assistant (CNA), told Staff B, Registered Nurse (RN) and Director of Nursing Services (DNS), that she witnessed Staff I, CNA, requesting Viagra (a medication used in the management and treatment of erectile dysfunction) from the nurse (Staff R, RN), for Resident 1, on 11/20/2023. --On 11/21/2023; Staff E, Social Services Director; Staff F, RN and Staff Development Coordinator; and Staff G, RN and Resident Care Manager (RCM); stated there was a discussion during morning standup meeting, on 11/21/2023, that Staff B brought up Staff I was being seen behind closed doors with Resident 1 and that Staff I had requested Viagra for Resident 1. --On 11/23/2023, Staff I, after clocking out from work, was in Resident 1's room for two to three hours, with the door closed for at least part of that time. --On 11/29/23 at 7:40 AM, Staff O, Corporate Chief Operating Officer, received a text message from Staff P, RN and former DNS, who reported via text that there has been accusations sexual in nature between a CNA and a resident. --On 11/30/2023, Staff I admitted to texting Resident 1 messages that were sexual in nature but refused to share text messages with Staff Q, Corporate Operations Resource. On 12/06/2023 at 2:35 PM, Staff A, Administrator, said Staff I was suspended pending the investigation on 11/29/2023 and her employment was terminated on 12/04/2023, and stated, [the termination was] due to having given her [Staff I's] personal [cell] number to the resident [Resident 1]. Boundaries. On 12/07/2023 at 11:00 AM, Staff K, CNA, stated, There was an incident last week. There had been rumors of inappropriate things happening between a CNA [Staff I] and a resident [Resident 1], and the CNA [Staff I] spending a lot of extra time with [Resident 1]. Then last Wednesday [11/29/2023], at 3:00 PM, I was passing snacks to residents. One resident [Resident 1] was going to therapy and as he was leaving his room, I asked him [Resident 1] if I could leave his snack on his bedside table; and [Resident 1] said yes. [Resident 1's] cell phone was on his table, face up. When I was setting down his snack, [Resident 1's] phone lit up with a text from [Staff I]. I can't recall exactly what it said but it said something about [Resident 1] touching [Staff I's] tits and a sex toy. I went straight to the charge nurse [Staff H, RN and RCM] and told her what I had seen. I worked the next day and when I came in at noon, [Staff H] came and spoke to me and told me she had reported what I had seen and said I should talk with the corporate representative who was in the building. That day I spoke with corporate with [Staff H] and [Staff B] present. Sometime after that, I spoke to a corporate investigator [Staff Q], also. On 12/08/2023 at 2:13 PM, Staff E stated, On the Tuesday prior to Thanksgiving [11/21/2023], in the morning meeting, we had a normal meeting. Then [Staff B] said she had heard from a caregiver that a CNA [Staff I] had an inappropriate relationship with [Resident 1] and had been spending a lot of off the clock time with him. [Staff B] said the caregiver, who reported it to her, had heard that the other caregiver [Staff I] who was spending time with [Resident 1] had also gone to the nurse and asked if [Resident 1] had a Viagra prescription . I knew it was Tuesday because I had Wednesday, Thursday, and Friday off. Staff G has Monday off and she was in the meeting. The Monday after the holiday [11/27/2023], everyone was back, and we were in morning meeting, and it came up again . I assumed at that point the DNS [Staff B] and Administrator [Staff A] were taking care of the situation and were doing all appropriate measures. The Wednesday after Thanksgiving [11/29/2023], corporate flies in. The DNS comes to me and asks me to do interviews about the alleged abuse. I told her I could right after a care conference. She did not want me to go to the care conference and said that the interviews had to be done asap- right now. Staff E said the staff present in the meeting on 11/21/2023 included Staff B, Staff G, Staff F, and herself (Staff E). On 12/13/2023 at 2:10 PM, Staff G said she heard about Resident 1 and Staff I for the first time on 11/21/2023 when Staff B notified the clinical team during morning meeting. Staff G stated, [Staff B] said a CNA [Staff I] was staying late after hours and off the clock, in the resident's [Resident 1] room, with the door closed, and there were rumors about that CNA asking if that patient had an order for Viagra. [Staff B] said she was looking into it. Then the Friday after Thanksgiving, on 11/24/2023, I was in the front office with [Staff B] and [Staff F]. [Staff F] does the scheduling, and [Staff F] asked the DNS [Staff B] about taking that CNA [Staff I] off the schedule. The DNS said she was going to bring the CNA [Staff I] in to talk to her about the situation, but I don't know if she did. [Staff F] asked if [Staff I] should be off the schedule and the DNS [Staff B] said, 'No, I want to talk to her first.' The following Monday, 11/27/2023, it was all brought up again at our morning meeting. Staff A was present. I think that's when he was first told about it. Pretty much the same things were said as in our meeting on the Tuesday before Thanksgiving. Staff G said the attendees of the 11/21/2023 morning meeting included Staff B, Staff F, Staff E, and herself (Staff G). At 3:00 PM, Staff A said he had not been told of anything pertaining to Resident 1 and Staff I while on vacation between 11/17/2023 and 11/26/2023. When he returned from vacation on 11/27/2023 and attended morning meeting, the discussion was that [Staff I] had been spending extra time off the clock with [Resident 1] in his room and the door had been closed. Then the Viagra was brought up. Staff said it was brought up the week prior that [Staff I] had asked if [Resident 1] had Viagra. Staff A said that if he had been on-site and had been made aware by staff that a CNA was spending extra time with a resident, time off the clock with a resident behind closed doors, and that same CNA had requested Viagra for that resident, That employee would be immediately pulled into my office to talk about the incident, questions would be asked of the staff member, why they are staying after the clock with the resident, why they are asking about Viagra, asking the right questions and suspending during that time so I had the ability to ask the right questions and investigate. I think in this case, new [Staff B] came in and didn't know the staff so she didn't know if she should trust or not trust this person. Is this normal behavior or no? On 12/15/2023 at 2:30 PM, Staff H stated, [Staff I] was staying and spending time with Resident 1 . sitting out in the main area visiting with him. Around that time, other aides would speculate because [Staff I] always wanted to work with [Resident 1]. Then once I was here late and I heard another resident calling for me and that resident was mad because [Staff I] was in [Resident 1's] room and ignored her; she didn't realize [Staff I] was there after her shift. It was probably 12:30 AM, after her shift on Thanksgiving. So, I went and opened the door to [Resident 1's] room and told [Staff I] it was time to rest . It was just strange [Staff I] was in there at 12:30 AM, when she was off, and the door was closed. I told [Staff I] she really needed to leave. At 3:15 PM, Staff M, CNA, stated, Thanksgiving night, [Staff I] was here after hours . I was told [Resident 1] needed a shower. I said its night so that's not usually done. The day CNA, [Staff I] said ok, I will do it. I said no that is fine, it's my job so I will. Then I go in there and [Staff I] is in the room with [Resident 1] . A different resident was frustrated because she saw a CNA and called for them and the CNA didn't help. It turns out it was [Staff I] and [Staff I] was here after hours with [Resident 1] so she wasn't working and so she didn't help the other resident . All this stuff with them [Staff I and Resident 1] started like a month or two ago. One day [Staff I] came in like 15-30 min early and she was sitting with him and eating, not too weird because it was the first time. But then it was nearly every night she would bring him food and come in like an hour early. When [Staff I] was working, if anyone else was working [with Resident 1], she would move them so she could provide [Resident 1's] care. At 3:30 PM, Staff B stated, I started Tuesday, 11/14/2023. The following Tuesday [Staff J] came in and said someone had asked [Staff C] for Viagra . I asked [Staff C] if anyone had asked for it and she said no . Afterwards I realized it was [Staff R], not [Staff C]. I didn't know who was who because I was too new here. [Staff J] had told me that on 11/21/2023 . On Friday, 11/24/2023, [Staff M] called me and was upset, saying [Staff I] had clocked out and was in [Resident 1's] room with him . Then the weekend goes by, [Staff A] comes in on Monday, 11/27/2023 . In the meeting, we talked about is it ok for a CNA to sit with residents after they punch out. At that point is when Staff E started arguing with Staff A about if it's appropriate or professional for a CNA to do this. On 01/08/2024 at 12:00 PM, Staff J stated, I heard and saw [Staff I] come out of [Resident 1's] room. [Staff I] said [Resident 1] was asking about Viagra, and the nurse [Staff R, RN] acknowledged it but said she didn't know and would have to ask about it. I can't give a time because I don't know what time. I just know I thought about it a lot afterwards and would have told the DNS [Staff B] about it the next day. The facility time clock data showed Staff I worked 23 of 26 days between 11/01/2023 and 11/26/2023. Staff I worked 11/22/2023 through 11/26/2023, without any investigation after four staff members (Staff B, Staff E, Staff F and Staff G) were made aware of Staff I spending extra time with Resident 1, while off the clock, alone with the resident behind closed doors; and that Staff I requested Viagra for Resident 1 from Staff R on 11/20/2023 and Staff J told Staff B about the request for Viagra on 11/21/2023. The facility Investigative Report conclusion, completed by Staff Q and signed on 12/04/2023, showed the following: --Staff I did admit to participating in texting messages of a sexual nature with Resident 1. --Staff I was suspended pending investigation and gave an employment termination notice which was accepted. --Staff K, CNA, observed a text on Resident 1's phone (from Staff I) with words tits, (sex) toys and being with you. --Regardless of both identifying a consensual relationship, this is not relevant as the employee is in a 'role as a caregiver and will be considered an abuse of power.' --Staff I stated she had a history of texting sexual language with Resident 1. --The investigation concluded an allegation of potential abuse was not made until 11/29/2023 when reported by Staff P, and staff had not reported abuse between Staff I and Resident 1. (Staff had reported Staff I's behavior of spending hours past her shift with Resident 1 in his room, Staff I requested Viagra for Resident 1, Staff I and Resident 1 were reported to be behind closed doors, Staff I rearranged her schedule so she was the one providing care for Resident 1, and Staff B received a call on 11/24/2023 from Staff M, CNA, who was upset about Staff I's interactions with Resident 1; all of which occurred prior to 11/29/2023 according to staff interviews.) Reference WAC 388-97-0640 (1)

Based on interview and record review, the facility failed to timely initiate and complete an investigation of potential staff-to-resident abuse and put interventions in place to prevent further potential resident abuse at the time the alleged abuse was suspected for 1 of 5 sampled residents (Resident 1) reviewed for investigation to prevent alleged abuse. This caused harm to Resident 1 when the facility's delay in investigation of potential sexual abuse allowed the alleged staff member, in a position of power (caregiver), to continue to have access to Resident 1 and did not protect the resident from further potential abuse after they were first aware of a pattern of questionable behavior. This failure placed residents at risk for abuse, having allegations of abuse not being responded to and thoroughly investigated, and a diminished quality of life. Findings included . Per the [NAME] State Reporting Guidelines for Nursing Homes (Purple Book), dated October 2015, showed facilities and mandated reporters were required to report to the State Agency immediately when there was reasonable suspicion that abuse had occurred. The Purple Book showed a reasonable suspicion meant it was possible that something happened. Sexual abuse was defined to include any sexual contact between a staff person of a facility and a vulnerable adult living in that facility whether or not it is consensual, and noted sexual contact may include interactions that do not involve touching including, but not limited to, sending sexually explicit messages . The Purple Book showed all alleged incidents of abuse . must be thoroughly investigated and, the facility must immediately begin the investigation . the first phase must be completed within 24 hours of knowledge of the incident . Resident 1 was admitted to the facility on [DATE] with diagnoses including Congestive Heart Failure. The admission Minimum Data Set, an assessment tool, dated 10/07/2023, documented the resident was cognitively intact. Review of a State Agency report, dated 11/28/2023 at 6:46 PM, showed an incident occurred on 11/15/2023 where Resident 1 was an alleged victim of potential sexual abuse by a staff member [Staff I, Certified Nursing Assistant (CNA)]. Review of a State Agency report, dated 11/29/2023 at 11:31 AM, showed accusations of inappropriate texts and phone calls of a sexual nature between a staff member [Staff I] and Resident 1. Review of the facility Investigation Report, dated 12/04/2023, showed an investigation was started by Staff Q, Corporate Operations Resource, on 11/29/2023 and was signed as completed on 12/04/2023; although there were allegations shared by staff as early as 11/20/2023 and the investigation was not started until 11/29/2023. The report included the following: --On 11/21/2023, Staff J, CNA, told Staff B, Director of Nursing Services (DNS) and Registered Nurse (RN), she witnessed Staff I requesting Viagra (a medication used in the management and treatment of erectile dysfunction) from the nurse (Staff R, RN) for Resident 1 on 11/20/2023. --On 11/21/2023, Staff E, Social Services Director, Staff F, Registered Nurse (RN) and Staff Development Coordinator and Staff G, RN and Resident Care Manager (RCM); stated there was a discussion during morning standup meeting on 11/21/2023 that Staff B brought up Staff I being seen behind closed doors with Resident 1 and Staff I had requested Viagra for Resident 1. --On 11/23/2023, after clocking out from work, Staff I was in Resident 1's room for two to three hours, with the door closed for at least part of that time. --On 11/29/23 at 7:40 AM, Staff O, Corporate Chief Operating Officer, received a text message from Staff P, previous facility DNS and RN, who reported via text that there has been accusations sexual in nature between a CNA and a resident. --On 11/30/2023, Staff I admitted to texting Resident 1 messages that were sexual in nature but refused to share text messages with Staff Q. On 12/06/2023 at 2:35 PM, Staff A, Administrator, said Staff I was suspended pending the investigation on 11/29/2023 and her employment was terminated on 12/04/2023, and stated, [the termination was] due to having given her [Staff I's] personal [cell] number to the resident [Resident 1]. Boundaries. On 12/07/2023 at 11:00 AM, Staff K, CNA, stated, There was an incident last week. There had been rumors of inappropriate things happening between a CNA [Staff I] and a resident [Resident 1] and the CNA [Staff I] spending a lot of extra time with the resident [Resident 1]. Then last Wednesday [12/29/2023], at 3:00 PM, I was passing snacks to residents. One resident [Resident 1] was going to therapy and as he was leaving his room, I asked him if I could leave his snack for him on his bedside table and he said yes. His cell phone was on his table, face up. When I was setting down his snack his phone lit up with a text from Staff I. I can't recall exactly what it said but it said something about him touching her tits and a sex toy . I went straight to the charge nurse [Staff H, RN/RCM] and told her what I had seen. I worked the next day and when I came in at noon, [Staff H] came and spoke to me and told me she had reported what I had seen and said I should talk with the corporate representative who was in the building. That day I spoke with corporate with [Staff H] and the DNS [Staff B] present. Sometime after that, I spoke to a corporate investigator [Staff Q] also. On 12/08/2023 at 2:13 PM, Staff E stated, On the Tuesday prior to Thanksgiving [12/21/2023], in the morning meeting, we had a normal meeting. Then the DNS [Staff B] said she had heard from a caregiver that a CNA [Staff I] had an inappropriate relationship with Resident 1 and had been spending a lot of off the clock time with him. [Staff B] said the caregiver, who reported it to her, had heard that the other caregiver [Staff I], who was spending time with [Resident 1], had also gone to the nurse and asked if he had a Viagra prescription . I knew it was Tuesday because I had Wednesday, Thursday, and Friday off. Staff G has Monday off and she was in the meeting. The Monday after the holiday [12/27/2023], everyone was back, and we were in morning meeting, and it came up again . I assumed at that point the DNS [Staff B] and Administrator [Staff A] were taking care of the situation and were doing all appropriate measures. The Wednesday after Thanksgiving [12/29/2023], corporate flies in. The DNS comes to me and asks me to do interviews about the alleged abuse. I told her I could right after a care conference. She did not want me to go to the care conference and said that the interviews had to be done asap- right now. Staff E said the staff present in the morning meeting on 11/21/2023 included Staff B, Staff G, Staff F, and herself (Staff E). On 12/13/2023 at 2:10 PM, Staff G said she heard about Resident 1 and Staff I for the first time on 11/21/2023 when the Staff B notified the clinical team during morning meeting. Staff G stated, [Staff B] said a CNA [Staff I] was staying late after hours and off the clock, in [Resident 1's] room, with the door closed, and there were rumors about that CNA [Staff I]asking if [Resident 1] had an order for Viagra. [Staff B] said she was looking into it. Then the Friday after Thanksgiving, on 11/24/2023, I was in the front office with [Staff B] and [Staff F]. [Staff F] does the scheduling, and [Staff F] asked [Staff B] about taking [Staff I] off the schedule. The DNS [Staff B] said she was going to bring the CNA [Staff I] in to talk to her about the situation, but I don't know if she did. [Staff F] asked if [Staff I] should be off schedule and the DNS [Staff B] said 'No, I want to talk to her first.' The following Monday, 11/27/2023, it was all brought up again at our morning meeting. [Staff A, Administrator] was present. I think that's when [Staff A] was first told about it. Pretty much the same things were said as in our meeting on the Tuesday before Thanksgiving. Staff G said attendees of the morning meeting on 11/21/2023 included Staff B, Staff F, Staff E, and herself (Staff G). At 3:00 PM, Staff A said he had not been told of anything pertaining to Resident 1 and Staff I while on vacation between 11/17/2023 and 11/26/2023. After returning from vacation on 11/27/2023 and attending morning meeting, the discussion was that [Staff I] had been spending extra time off the clock with [Resident 1] in his room and the door had been closed. Then the Viagra was brought up. Staff said it was brought up the week prior that [Staff I] had asked if [Resident 1] had Viagra. When asked what should be done when there was an allegation of resident abuse, Staff A stated, Staff should inform me immediately so I can report within 2 hours. I need them to know where to go, then if they do not trust that I will do it, they are also mandated reporters. We also have the better together hotline. It is an internal tool to report abuse if they don't feel it is being managed properly. If I receive a report, I investigate, suspend the employee in question, and interview residents, staff, etc. I try to determine what happened so I can substantiate or unsubstantiate their actions before returning them to work. First of course, making sure the resident is safe and removed from harm. Staff A said if he had been on-site and had been made aware by staff that a CNA was spending extra time with a resident, time off the clock with a resident behind closed doors, and that the same CNA had requested Viagra for that resident, That employee would be immediately pulled into my office to talk about the incident, questions would be asked of the staff member why they are staying after the clock with the resident, why they are asking about Viagra, asking the right questions and suspending during that time so I had the ability to ask the right questions and investigate. I think in this case, new [Staff B] came in and didn't know the staff so she didn't know if she should trust or not trust this person. Is this normal behavior or no? On 12/15/2023 at 2:30 PM, Staff H stated, [Staff I] was staying and spending time with [Resident 1] . sitting out in the main area visiting with him. Around that time, other aids would speculate because [Staff I] always wanted to work with [Resident 1]. Then once I was here late and I heard another resident calling for me. That resident was mad because [Staff I] was in [Resident 1's] room and ignored her. That resident didn't realize [Staff I] was there after her shift. It was probably 12:30 AM after her shift on Thanksgiving. So, I went and opened the door to his room and told her it was time to rest . It was just strange she was in there at 12:30 AM, when she was off, and the door was closed. I told her she really needed to leave. At 3:15 PM, Staff M, CNA, stated, Thanksgiving night, [Staff I] was here after hours . I was told [Resident 1] needed a shower. I said its night so that's not usually done. The day CNA, [Staff I] said ok, I will do it. I said no that is fine, it's my job so I will. Then I go in there and [Staff I] is in the room with [Resident 1] . A different resident was frustrated because she saw a CNA and called for them and the CNA didn't help. It turns out it was [Staff I] and [Staff I] was here after hours with [Resident 1] so she wasn't working and so she didn't help the other resident . All this stuff with them [Staff I and Resident 1] started like a month or two ago. One day [Staff I] came in like 15-30 minutes early and was sitting with [Resident 1] eating. Not too weird because it was the first time. But then it was nearly every night she would bring him food and come in like an hour early. When [Staff I] was working, if anyone else was working, she would move them so she [Staff I] could provide his [Resident 1's] care. At 3:30 PM, Staff B stated, I started Tuesday, 11/14/2023. The following Tuesday [Staff J] came in and said someone had asked [Staff C, RN] for Viagra. I asked [Staff C] if anyone had asked for it and she said no . Afterwards I realized it was [Staff R, RN] not [Staff C]. I didn't know who was who because I was too new here. [Staff J] had told me that on 11/21/23 . On Friday, 11/24/2023, [Staff M, CNA] called me and was upset, saying [Staff I] had clocked out and was in [Resident 1's] room with him. Staff B said the weekend went by, Staff A returned from vacation, and in the Monday (11/27/2023) morning meeting the interactions between Staff I and Resident 1 were discussed and, at that point is when [Staff E] started arguing with [Staff A] about if it's appropriate or professional for a CNA [Staff I] to do this. On 01/08/2024 at 12:00 PM, Staff J said, I heard and saw [Staff I] come out of [Resident 1's] room and [Staff I] said [Resident 1] was asking about Viagra and the nurse [Staff R] acknowledged it but said she didn't know and would have to ask about it. I can't give a time because I don't know what time. I just know I thought about it a lot afterwards and would have told the DNS [Staff B] about it the next day. The facility time clock data showed Staff I worked 23 of 26 days between 11/01/2023 and 11/26/2023. Staff I worked 11/22/2023 through 11/26/2023, without any investigation after four staff members (Staff B, Staff E, Staff F and Staff G) were made aware of Staff I spending extra time with Resident 1 while off the clock, alone with the resident behind closed doors; that Staff I requested Viagra for Resident 1 from Staff R on 11/20/2023; and Staff J made Staff B aware of the request for Viagra on 11/21/2023. The facility's Investigative Report conclusion, completed by Staff Q and signed on 12/04/2023, noted, Upon conclusion, the following is determined . [Staff I] states that she had exchanged cell phone numbers with [Resident 1] and that they visited. The two were observed in [Resident 1's] room and the front lobby together visiting. [Resident 1] states he asked for [Staff I's] cell phone number and they exchanged phone numbers related to his care requests. However, [Staff I] did admit to participating in texting messages of a sexual nature with [Resident 1]. [Staff I] refused to share any visualization of the texts during the interview process, and [Resident 1] denied the existence of any text messages between him and [Staff I]. [Staff I] was suspended pending investigation. [Staff I] gave an employment termination notice and it was accepted. The conclusion, dated 12/04/2023, continued, It is determined that there may have been written sexual contact as the Purple Book states contact may include 'sending sexually explicit messages.' It is unclear whether these messages were explicit, as [Resident 1] and [Staff I] were unwilling to share any text messages and both deny that any photos were exchanged. [Resident 1] denied any text messages existed. [Staff K, CNA] did observe [Resident 1's] phone screen and recalled seeing some words 'tits,' 'toys,' and 'being with you' but without context. The conclusion, dated 12/04/2023, continued, Regardless of both identifying a consensual relationship, this is not relevant as the employee is in a 'role as a caregiver and will be considered an abuse of power.' [Staff I] states she has a history of texting sexual language with [Resident 1] even though no proof the content was explicit. [Staff I] is no longer employed. The investigation conclusion, dated 12/04/2023, showed an allegation of potential abuse was not made until 11/29/2023 when reported by Staff P. The conclusion showed staff had not reported abuse between Staff I and Resident 1 (after Staff I was Resident 1's caregiver, staff had reported Staff I's behavior of spending hours past her shift with Resident 1 in his room, Staff I requesting Viagra for Resident 1, Staff I and Resident 1 being behind closed doors, Staff I rearranging her schedule so she was the one providing care for Resident 1, and Staff B receiving a call on 11/24/2023 from a staff [Staff M, CNA] being upset about Staff I's interactions with Resident 1 - all of which occurred prior to 11/29/2023). Reference WAC 388-97-0640 (6)(a)(b)

Based on observation, interview and record review, the facility failed to ensure the residents environment was safe and free from hazards when a resident received a significant burn from a hot beverage for 1 of 5 sampled residents (#1) reviewed for accidents hazards. This failure placed residents at risk for injury and a diminished quality of life. This failure caused harm to Resident #1. Findings include . The facility's Guidelines for Hot Beverages, dated 10/31/08, documented, Coffee and other hot beverages should be consumed at 155 to 175 degrees Fahrenheit .However, this temperature can result in a burn if the beverage comes in contact with the skin. Resident #1 was admitted to facility with multiple diagnoses. The Minimum Data Set, an assessment tool, dated 12/13/18, documented the resident was cognitively intact and required supervision with eating. The facility investigation, dated 01/09/19, documented Resident #1 spilled coffee and had a burn to the anterior of the left arm measuring 4 inches by 2 inches, the area was red with what looked like a blister forming on the upper portion of the burn measuring 1.5 inches by 1.5 inches. (Resident #1) did complain of pain. The coffee dispenser that the coffee was taken from was immediately tempted and it was 158. The kitchen had also tempted the coffee in the kitchen and it was 160-170, which was appropriate temp per guidelines. On 01/14/19 at 10:55 AM, Resident #2 said he drinks coffee 3-4 times a day and [MEDICAL CONDITION] lips at least twice a week. Resident #2 said he waits for coffee to cool before drinking. At 11:06 AM, Staff C, Dietary Manager, said the staff check the temperatures of hot beverages prior to leaving the kitchen, and stated, 160 is safe to leave the kitchen. Staff C said they log the temperatures before hot liquids leave the kitchen. At 11:21 AM, Staff C was observed taking temperatures of three (3) beverage dispensers by the nurses station and the following temperatures were obtained: 1st dispenser containing coffee was 160 degrees Fahrenheit (F), 2nd dispenser containing hot water was 130.1 degrees F and the 3rd dispenser containing decaffeinated coffee was 158 degrees F. At 11:35 AM through 11:43 AM, four (4) carts with hot beverages in carafes were observed in the kitchen and the following temperatures were taken by Staff C: Water cart 1 - 173 F, Staff C said, too hot. Water cart 2 - 170 F, Staff C said, too hot. Water cart 3 - 157.5 F, Staff C said, good to go. Water cart 4 - 158.4 F, Staff C said, good to go. Coffee cart 1 - 168 F, Staff C said, too hot. Coffee care 2 - 169 F, Staff C said, too hot. Coffee cart 3 - 166.1 F, Staff C said, too hot. Coffee cart 4 - 163.5 F, Staff C said, too hot. Staff C told dietary aid to put ice in those that were too hot and leave lids open to cool. At 12:20 PM, Staff C provided an unnamed log, dated 01/14/19, and said the hot beverage temperatures were re-taken prior to leaving the kitchen. The log documented the following temperatures: 156.5 F - Coffee 158.1 F - Water 158.4 F - Coffee 155 F - Water 155 F - Coffee 154.2 F - Water 154.7 F - Coffee At 12:35 PM, when asked about the temperatures logged on the 'Hot beverage log for (MONTH) (YEAR) and (MONTH) 2019, Staff C stated, Temps logged are safe temps to send out. Staff C said they are in the process of revising the hot beverage form, as there is no way to determine if it was out of the actual hot water machine or the carafe. At 12:55 PM, Staff C said the temperatures logged for (MONTH) 2019 had high readings as staff were tempting the liquids right after the liquid came out of the hot water machine. When asked about temperature readings for (MONTH) (YEAR) log, Staff C said the temperatures logged were taken from carafes. Staff logged them correctly, and were safe to leave the kitchen. Staff C said she has instructed staff to temp liquids in the carafes. Staff C stated, We had a brand new hot water machine in (MONTH) (2018). They have come out to turn the temperature up to 185 degrees F. At 1:10 PM, Resident #1 said occasionally she adds milk to her hot cocoa to cool it. At 2:02 PM, Resident #1 said she picked up a cup of coffee, turned a bit and I spilled it on my left arm. I cried out right away and it was painful. At 2:03 PM, Resident #1 was observed to have a reddened area, circular in shape on the left antecubital area (front of the elbow) and on top part of the reddened are was an open area. Resident #1 said there was the blister that opened. At 2:50 PM, when asked if 160 degrees F was safe for the residents in the facility, Staff B, Director of Nursing Services, stated, I asked the kitchen and they told me its supposed to be 160 and below when leaving the kitchen. Yes, it's appropriate. At 3:00 PM, Staff A, Administrator and Staff C, (Staff B present in the room), both said (MONTH) 2019 hot beverage log was incorrectly recorded. Staff A and Staff C said dietary staff logged temperature readings were from the hot water machine and not from the carafe for the month of January. When asked about monitoring the hot liquids prior to leaving the kitchen, Staff C stated, I know staff is tempting and that it is 160 and below prior to leaving the kitchen. When asked where that was logged, Staff C said staff were not logging temperature from the carafes. Staff C said dietary staff should have logged the temperature obtained from the carafe prior to leaving the kitchen. Staff C said she has provided education. Staff C stated, I have a service person coming to adjust the temperature. Staff A stated, I thought we had the right temperatures on the facility policy as the sister facilities use the same policy. Staff A indicated it was expected for staff to check temperatures in the carafe prior to leaving the kitchen. Reference WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to ensure the resident environment was safe and free from hazards when a resident received a significant burn when left next to a heater for 1 of 3 sampled residents (#1) reviewed for accident hazards. This failure placed residents at risk for injury and a diminished quality of life. This caused harm to Resident #1. Findings include . Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set, an assessment tool, dated 03/29/18, indicated Resident #1 was alert and oriented and required extensive assistance for personal care related to impairment on one side. The facility investigation, dated 04/11/18, documented Resident #1 was given a shower and requested to be placed closer to the heater/vent in the shower room. Resident #1 was in a wheelchair and was placed next to a heater for an undetermined amount of time while Nursing Assistant (NA) D was assisting/gathering his clothes and getting the resident dressed. Resident #1 complained of discomfort to left groin area. NA D continued to assist the resident to dress and noticed a red area to his left thigh. NA D immediately turned off the heater and reported the incident to a licensed nurse (LN). The resident was assessed and reported pain (6 out of 10 on a pain scale with 10 being the highest level of pain) to his groin area. The burn area was approximately 10 cm (centimeter) x 10 cm, bright pink and developing multiple blisters. The resident was sent to the emergency room (ER) for an evaluation. The Hospital Emergency Department record, dated 04/11/18, documented a burn of unspecified degree to the left thigh, measuring 13 cm x 13 cm with redness and blistering with tenderness. On 04/12/18 at 11:20 AM, the Director of Nursing Services (DNS) stated, While the resident was being showered in the shower room, he was cold. There is a vented heater in there. The caregiver placed the resident next to the heater. He has paralysis. She proceeded with the shower and when she started to dress his lower body noticed he had a large red area. It kept getting redder and redder, and blisters came up. He needed to be sent to the ER to be evaluated. It should never have happened. At 11:25 AM, Resident #1 stated, I guess I got too close to the heater. My leg was irritating and it was painful. At 11:29 AM, the wall heater was observed in the middle of the wall in the shower room. This heater was the only one of its kind in the building and had been taken out of service. The room did not feel cold without use of this heater. At 11:39 AM, Resident #1's left leg was observed to have a red area on left thigh. LN B measured it to be 10 cm x 9 cm with a yellow fluid blister that measured 5 1/2 cm x 7 cm with a height of approximately 1 - 1/2 inches. The reddened area was observed with white clusters of blisters. At 11:44 AM, NA D stated, I was showering (Resident #1). He wanted to get out and said he was cold, so I wheeled him over in front of the heater. It didn't dawn on me until I noticed his leg was all red. I shut off the heater and called the nurse to come look at it. It didn't dawn on me he was too close. I don't often work on that hall. I didn't realize it would get that hot. Reference WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to provide behavioral health care and services that created an environment promoting emotional and psychosocial well-being for 1 of 4 current sampled residents (#42) reviewed for dementia and/or behaviors. This failure caused harm to Resident #42 who engaged in self-abuse repeatedly without intervention or monitoring of known injuries, by the facility. Findings include . Resident #42 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. The resident's Minimum Data Set, an assessment tool, dated 10/20/17, documented the resident was severely cognitively impaired and required extensive assistance with activities of daily living. Resident #42's care-plan identified a problem onset date of 12/10/2008 where documentation showed a problem/need of supports for, Altered thought process related to [MEDICAL CONDITION], [DIAGNOSES REDACTED], intellectually disabled, self-abuse (hits face), bangs head, history of self-induced vomiting. Approaches documented were, Notify MD if increased self-abuse, if seen hitting self in face, assess for needs - offer foods, fluids and notify Licensed Nurse. Redirect resident by giving him something to hold i.e. stuffed animal, prior to trying mitt. Resident #42's care-plan identified a problem onset date of 06/23/2008 where documentation showed a problem/need of supports for, Risk for skin breakdown. Approaches documented were, To wear mitt on right hand when hitting self. Licensed Nurse to apply as needed. Redirect self-hitting behavior as able. Observe for any red or open areas or bruising and report to Licensed Nurse. Resident #42's care-plan, without problem onset date, where documentation showed a problem/need of supports for, Restraint: use of hand mitt as needed due to striking self in face and self-induced emesis. Goals documented were, will have no episodes of self-hitting, vomiting, or fecal play through next review date of 11/01/17. Approaches documented were, monitor behaviors. Use nursing interventions to change or disrupt behavior. Redirect from striking self by offering foods/fluids as needed. Resident #42's Nurse's Aide Information Sheet, a care delivery guide, documented that resident, Has mitt to right hand when hitting self, always notify nurse of behaviors. Behavior monitoring flowsheet was reviewed covering the dates of February 16th- February 25th showed no behaviors documented. On 02/21/18 at 5:07 PM, Resident #42 was observed hitting himself in the face under right eye. Dark bruising and swelling observed where resident's hand was making contact with face. On 2/21/18 at 5:44 PM, Resident #42 was observed hitting himself in face under right eye. Nursing Assistant (NA) A stated, He keeps doing this, maybe he doesn't like the mashed potatoes. Licensed Nurse (LN) A stated, He always does that. On 02/22/18 at 10:22 AM, Resident #42 was observed hitting himself in the face under right eye. On 02/22/18 at 10:33 AM, NA A entered room to check on resident. Resident #42 was observed alternating between hitting self under right eye and touching pinky to mouth. NA A stated, I'm sorry, (Resident #42), I don't have anything for your mouth. On 02/22/18 at 4:20 PM, Resident #42 was observed lying in bed, alternating between hitting himself in the face under his right eye and sticking the fingers on his right hand down his throat. Emesis was present on his shirt. LN's A and B were present during observed behavior. LN B stated, Sometimes he sticks his fingers down his throat and makes himself vomit. When asked if the resident had bruising under his right eye, LN A stated, Yea. he's always been here and he's always done that. We can't figure out why he does it but he always has. No documentation found regarding monitoring of bruising. Nurse's notes reviewed on 02/28/18. No documentation noted regarding episode of self-induced vomiting or self-abuse. On 03/01/18 at 09:51 AM, when asked what behaviors Resident #42 exhibits, NA B stated, He punches his chin or he would make himself vomit. When asked if she would report hitting behavior to nurse, NA B stated, When we see him do it we would tell the nurse. When asked if she has ever seen resident with a mitt to his right hand, NA B stated, No. I've never seen it. When asked if resident causes bruising to his face, NA B stated, I don't know if it's a bruise but it's always been there as long as I've ben here, about 2 years. On 03/01/18 at 10:01 AM, when asked how he would expect direct care staff to interact when resident is hitting himself and causing bruising or self-inducing vomiting the Director of Nursing (DNS) stated, I would advise them to intercede and redirect if possible. I'd want them to distract with verbal cues and if behavior escalated to notify me. When asked about the care-planned behaviors not being documented, the DNS stated, It's concerning to me. That's something that (the clinical psychologist) needs to know about. When asked if he was aware of a mitt being used for resident #42, the DNS stated, I have not seen a mitt. We can do that right now and have some staff education to make sure they are documenting behaviors.

Based on observation, interview and record review, the facility failed to develop and implement policies and procedures to protect 1 of 3 current residents (#1) from repeated abuse. Failure to identify actual and/or potential abuse, to immediately protect residents from abusive behaviors, implement effective interventions to prevent repeated abuse, immediately report abuse to appropriate authorities, and investigate the allegations, resulted in psychosocial harm to Resident #1 and placed all residents at risk of abusive treatment. Findings include: Resident #1 was admitted to the facility on [DATE] with multiple health conditions including kidney disease and [MEDICAL CONDITION]/muscle weakness of lower extremities. He used a wheelchair for mobility. The quarterly Minimum Data Set, a comprehensive assessment tool, dated 5/8/17, documented the resident was alert and oriented, made his own care decisions, and clearly made his needs known. A handwritten note to the resident from the previous administrator, dated 4/21/17, regarding the threat of police action to remove him from his room to spray for insects, showed, . I apologize for my part in our interaction this morning. I will honor your request to have no further interactions with you. On 4/24/17 at 11:15 a.m., Resident #1 said, on the evening of 4/21/17, he had taken his power wheelchair to a local store to make some purchases. The previous administrator confirmed she had asked the clerk if the resident had purchased alcohol, even though she had written an apology to him that morning to have no further interactions with him. On 6/6/17 at 5:00 p.m., Resident #1 said he had been repeatedly harassed by the previous administrator and used the above examples of being followed and viewed it as plain harassment. He said he was verbally abused and threatened repeatedly with discharge (validated in the record) by the previous administrator. He said on one occasion the previous administrator had threatened to kill him, and on another, wanted to call police to remove him from his room so it could be treated for [REDACTED]. The resident said, She (previous administrator) has an order to stay out of my room and stay away from me but she never does .she liked harassing me and what could I do .I wanted to get a restraining order and wanted to call the police. A written statement from the previous administrator, dated 4/26/17, regarding the incident/claim of her threat to kill the resident, noted, I again reiterated that I did not want to hit him with my car, and it was slick outside (January, 2017, resident outside smoking in the parking lot per his usual). He told me he would be fine. I said words to the effect that I didn't want to hit him with my car, then he would sue me, and then I would have to kill him. When asked about the previous Administrator's actions and comments about killing him, he said, Yes, she (previous administrator) said she was going to kill me. I think it was a tasteless, reckless thing to say, especially in light of our history. She was constantly trying to discharge me, harassing me, following me, watching me. I was not afraid of her physically, but it caused me a lot of emotional stress to be threatened to be kicked out of here all the time with no home .constantly being threatened about my smoking outside. When asked to share his thoughts/feelings about the threat to kill him by the previous administrator, the resident said, . I think she was saying it jokingly, but it was in bad taste to say that to any resident. She was after me and we did not get along. She went out of her way to harass me any chance she could. Telling nurses to stop medications after 4:00 p.m., following me, watching me when I went to the store, threatening me, that is not okay with me. Yes, it is abuse in my mind .it went on for months while she was here .everyone knew and did nothing. The residents' care plan for physical and psychosocial needs, initiated on 9/11/16 and revised through 5/14/17, showed interventions for the resident's negative behaviors included, 1) allow resident to express concerns, follow up to resolve issues, 2) approach resident in a calm, supportive manner, 3) Do not argue with the resident . An inservice held for one staff member, dated 4/3/17, showed, Reporting allegations made by residents immediately to the Director of Nursing Services (DNS)/Administrator, not waiting until the next day. The All Staff Meeting notes, dated 3/27/17, documented, Surveyor Questions: Who is the abuse coordinator? Answer: (Previous) Administrator. If you see a resident being abused by anyone, what is the first thing you do? Answer: Ensure the safety of the resident and separate them from the abuser. The second thing is to report the abuse to the DNS and the Administrator. The (previous) administrator's records showed abuse and neglect training on 8/19/16, that included, You are required to report abuse, neglect, exploitation, or misappropriation. If you feel a resident is in danger .immediately report to the DNS and Administrator . The Abuse Investigation policy, dated March 2013, showed, Employees of the facility who have been accused of resident abuse will be suspended from duty until the results of the investigation have been reviewed by the Administrator. The Administrator will provide a written report of the results of all alleged abuse investigation and appropriate actions taken to the state survey and certification agency, the local police department, and others as may be required by state or local laws within 5 working days of the reported incident. The Abuse Prevention Program Coordinator is the Administrator. The facility's abuse prevention policy and program failed to include the State's Purple Book (PB, Nursing Home Guidelines, 6th Edition, Partners in Protection, October 2015) that included the following: Page 1 of the PB: This document contains guidelines for the protection of nursing home residents along with guidelines for preventing, investigating, determining and reporting incidents of abuse .including reporting reasonable suspicion of a crime .these guidelines are intended to assist facilities in developing and implementing principles and procedures to help prevent resident abuse of all types . Page 6-7 of the PB: Immediate telephone reporting is required when there is reasonable cause to believe abuse .has occurred. Page 47 of the PB: PROTECT, INVESTIGATE, REPORT, CORRECT, PREVENT. In general, there is a presumption that abuse occurred whenever there has been some type of impermissible, unjustifiable, harmful, offensive, or unwanted contact with a resident . On 6/6/17, at 4:00 p.m., the new Administrator said she was not aware of facility issues as the previous administrator failed to inform the corporation of things that occurred in the facility, including the allegations made by Resident #1 about the previous administrator's ongoing abusive and threatening behaviors. The new administrator was unable to find any investigations between August 2016 to June 6, 2017, regarding Resident #1's allegations of abusive treatment by the previous administrator to include the most recent interaction on 4/21/17 and the statements by the previous administrator on 4/26/17 that referred back to an interaction with the resident in January 2017. The facility's administrator is the abuse prevention coordinator and the policy does not identify with whom residents, staff and the public could contact if the abuser is the administrator. Failure of the facility to develop and implement polices and procedures to clearly direct staff to prevent and protect residents from abuse, threats and fear of retaliation, and investigate the allegations immediately, resulted in harm to Resident #1 and placed all residents at risk of the same/similar abusive treatment. Reference (WAC) 388 97 -0640 (2)(a)(b)

Based on interview, observation and record review, the facility failed to treat residents with respect and dignity in a manner to attain and maintain the highest practicable physical, mental and psychosocial well being for 1 of 6 sampled residents (#52) reviewed for dignity. This failure placed residents at risk for decreased diminished self worth and decreased quality of life. This caused harm to Resident #52 when he experienced increased anxiety, frustration, fear of not getting medical needs addressed and fear of retaliation. Findings include: Resident #52 was admitted on [DATE] with multiple diagnoses. The Minimum Data Set (MDS), a comprehensive assessment tool, dated 11/10/16, documented resident as cognitively intact. On 4/19/17 at 3:50 p.m., Resident #52 stated, Management is retaliatory, the administrator and social services. They are harassing, intimidating, make it hard for me so I will leave. It was around a month ago that I'd been requesting daily to see the doctor .I'm really frustrated. I feel like I may have to go to the ER just to see someone. At 3:00 p.m., the Administrator (ADM) stated she had the Medical Director (MD) on the phone to discuss the resident's physician visits with the surveyor. When asked what the process for seeing residents in the facility, the MD stated the facility provided him a list. The MD stated, I can't see Resident #52 every time I come in the facility. The MD indicated he had addressed the medical needs of the resident. On 4/21/17 at 8:14 a.m. the ADM indicated there had been an issue overnight concerning an insect (ants) infestation in Resident #52's room. The ADM had told the resident the exterminator had been called and they would need to deep clean the room per their facility policy. The ADM indicated the resident was resistive to the process, and she told the resident if he did not comply she would call the police and have him removed. At 8:35 a.m., Resident #52 stated he was very upset about having bugs in his room and that the ADM was harassing him. The resident said the ADM had been trying to get him out of the facility for more than 6 months, and had an order to stay out of his room but never did. The resident stated, I had 4 or 5 ants on my bed with wings, went and got an aide. When we looked up there were hundreds of them in the room. I asked for another room set up, but there wasn't a transfer pole in the other room. The ADM came in with Director of Nursing Services (DNS) and the ADM said they had to deep clean the room. My room had just been done. I told her I didn't need to be disrupted. My room needs to be exterminated. The ADM threatened to call the police. I asked her to leave my room. About a half hour later I got a note from the administrator saying she was sorry for the interaction. The resident provided a note, dated 4/21/17, that noted, I apologize for my part in our interaction this morning. I will honor your request to have no further interactions with you. This note was signed by the ADM. At approximately 9:00 a.m., the ADM said she knew she was not suppose to talk to the resident. On 4/24/17 at 11:15 a.m., Resident #52 said on the evening of 4/21/17 he had taken his power wheelchair to a local store to make some purchases. He returned to the same store the evening of 4/22/17, and saw the same clerk who had waited on him previously. The clerk informed him a woman came to them after he had left the store to inquire about what he had purchased. The resident asked the clerk to describe the woman. The description matched that of the ADM, and another clerk who knew the ADM confirmed that. At 3:10 p.m. The ADM stated, (Resident #52) did not want to deal with social service or myself without a witness that wasn't part of management present .The most recent interaction I had didn't go well .It was because he had reported seeing ants in his room. Our policy is to do a deep clean and then call the exterminator. He refused to move out of the room. I took the DNS and an aide with me and went down to let him know we needed to clean his room. It didn't go well, he got very angry. I gave him an apology note for that interaction after that. When asked about contact with Resident #52, the ADM stated, I have put myself out there to be the target. I wanted to know things were followed up on. When asked about Resident #52 being asked about in a community store, the ADM stated, It was me. I was headed to (a local store) and I saw the resident leaving the store, so I went in and told them I work up the street and asked if he purchased alcohol. The ADM said she was told by the Medical Director to find out if Resident #52 was drinking alcohol, so I went in and asked what the resident purchased. Failure of the facility to treat the resident with respect and dignity resulted in harm to Resident #52 when he had feelings of intimidation and fear of retaliation. WAC 388-97-0860 (1)(a)

Based on interview, observation and record review, the facility failed to be administered in a manner to effectively and efficiently manage it's resources to attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident in the area of treating residents with respect and dignity. Failure to treat residents with respect and dignity resulted in harm to 1 of 6 sampled residents (#52), and placed the individualized and specific needs of resident at risk for failure to reach their highest level of function and a decrease in quality of care and quality of life. Findings include: The facility administrator failed to ensure the rights of residents were honored to exercise their rights and be treated with respect and dignity. Refer to 42 CFR 483.15(a) F-241, Dignity for facility failure to treat 1 of 6 sampled residents (#52) in a manner that enabled him to attain and maintain the highest practicable physical, mental and psychosocial well-being. This failure resulted in psychological harm to Resident #52. WAC 388-97-1620 (1)

Based on interview, observation, and record review, the governing body failed to ensure the facility was monitored and was operated in a manner to establish and implement policies and procedures to treat residents with respect and dignity. This failure resulted in harm to 1 of 6 sampled residents (#52) and placed the care and needs of residents at risk for decreased quality of life and not achieving their highest practicable physical, mental and psychosocial well-being. Findings include: Refer to 42 CFR 483.10 (a) (1) F-241, Dignity for the facility failure to treat 1 of 6 sampled residents (#52) with respect and dignity to enable the resident to attain and maintain the highest practicable physical, mental and psychosocial well-being. This failure resulted in harm to Resident #52. Refer to 42 CFR 483.75 F-490, Effective Administration, Resident Well-Being for the facility was not administered effectively and efficiently to utilize resources to attain and/or maintain the highest practicable physical, mental and psychosocial well-being of each resident. This failure resulted in harm to 1 of 6 sampled residents (#52) and placed the needs of residents at risk to not reach their highest level of well-being and a diminished quality of life. WAC 388-97-1620 (2)(c)

Based on observation, interviews, and record review, the facility failed to provide sufficient preparation and orientation to a resident to ensure a safe and orderly transfer and/or discharge from the facility for 1 of 24 current Residents (#1) reviewed for safe, orderly transfer and/or discharge. Resident #1 was issued a 30-day notice of discharge to a hotel or location of choice due to the facility's determination the Resident no longer needed skilled nursing services. This failure placed residents no longer meeting skilled criteria at risk for unsafe discharge. This caused anxiety and psychological harm to Resident #1. Findings include: Resident #1 was admitted to facility on 11/26/14 with multiple health conditions including decreased mental awareness, weakness, liver disease, muscular and neurological disease, depression, anxiety, contracture and paralysis from the waist down. The Resident is not able to walk and uses a wheelchair for mobility. On 3/13/17 at 12:05 p.m., Resident #1 stated, They gave me a 30 day notice because I no longer need their services. I don't know why they have been treating like this, intimidating, harassing me. I think they are retaliatory towards me because I complain about things. I have a voucher and my caseworker and this guy from the community is helping me find a place. They gave me a 30 day notice before and we went to a hearing and I won, and now they are trying to do it again. I have increased anxiety, and I am so stressed out and shaky now I don't know if I am going to be able to do it myself. I think they are trying to make me as uncomfortable as possible so I will leave. I am not 100% sure I can do it on my own, after all this I am so stressed. I don't want to stay here. When asked what the staff do to help Resident #1, he said: I turn myself in bed, they help with showers and put my TED Hose (compression stockings used to prevent blood clots to his legs) on and take them off, I transfer myself with the transfer pole it's getting harder and harder. I am able to urinate in the toilet or urinal, nurses give me a suppository every 2-3 days then I go the bathroom. At 12:30 a.m., when asked about care provided to Resident #1, Nursing Assistant (NA) #1 stated, We empty the commode, pick stuff up if he drops it, if he needs something and asks for stuff we will get it, I am not here when the TED Hose is put on, so I haven't done that yet .just help him when he asks. At 12:49 a.m., when asked about the discharge plan for Resident #1, the Social Service Director (SSD) stated, I was asked by him not to talk to him so I don't know much about it. He told me not to come to his room or talk to him. He doesn't like me. When asked what SSD's role was related to discharge for Resident #1, the SSD stated, I informed the admin (administrator) and DNS (Director of Nursing Services) and I will make notes in the chart per staff report. I make sure someone else interviews him. If needed I make sure he is being monitored. He has declined psych (psychology) services. He is very disruptive at night and abusive to staff. The DNS is the one who talks to him and I do the documentation. At 1:35 p.m., when asked about education for a safe discharge for the resident, the DNS stated, It has not been done. When asked what the process was for education provided to residents prior to discharge, the DNS stated, Typically all education would be given to a resident prior to discharge. I don't have an excuse. When asked about the discharge notice given to Resident #1, the DNS stated, The administrator wanted to pursue another 30 day notice as he does not need out level of care. At 1:52 p.m., when asked about the 30 day discharge notice given to Resident #1, the Administrator (ADM) stated, His health has improved. He no longer needs our services. When asked what services nursing provides to Resident #1, the ADM stated, I don't know what nursing provides. It is a different realm. He refuses what they have to offer him. I'm not saying he doesn't need help. He just doesn't need our care. He is more independent based on what he is doing for us. He is non-participatory in the care that we provide. I guess the state would need to do another assessment. The ADM stated, How do we train him if we can't get the supplies here? (question to the DNS) We can, well nursing would do the education, but we can't start education if we don't have the stuff and the insurance won't pay for it 'till we have a date, and it is on hold now because he appealed it. The last time we gave the notice we marked he was a danger to others and we were not able to prove his behaviors .the reason we wanted to discharge him, it was not ruled in our (facility) favor. This is different than the other, he continues to refuse treatment, start and stop and he is utilizing the services of the nursing facility he can live on his own. The DNS is our point person to talk to him but SSD is still in charge and the caseworkers are trying to find him a place. The ADM stated, He wouldn't have teaching until the last week before discharge. We don't have the supplies, how can we teach him? His community guide is actively searching and he is not working with his community guide at all. He has come up with several options and he has rejected several places. He has refused half-a-dozen that I know of. There isn't difficulty. There are places but he refuses and he puts up road blocks. When asked what prompted the 30 day discharge notice, the ADM stated, He no longer requires 24 hour nursing care, he doesn't meet skilled criteria. When asked if there were other residents in the facility that no longer require 24 hour nursing care and that don't meet skilled criteria, ADM stated, We do have other residents that are on the list about 20. Not all of them have received 30 day notices. When asked who had received a 30 day notices, ADM stated, None currently, just Resident #1. When asked who does not meet skilled criteria, the ADM stated, Everyone that is P (specific payment) category. We will get less money because we don't get paid very much for those people. At 2:37 p.m., the Community Choice Guide (CCG) stated, I have worked with Resident #1 for about a year. I haven't had any issues with him and once you understand his personality, he does ok. When asked if he is assisting Resident #1 with placement out in the community, CCG stated, Yes, I am looking for him a place within his voucher limit up in Longview. It has to be low income, and he is top priority. When asked if he has refused any places he has found, the CCG stated, Has not refused any apartments at all. When asked about the facility assisting with the discharge process, the CCG stated, They are willing to assist in any discharge at this point. They are impatient with the process. They gave him a discharge notice once before and I was cc'd (copied) on an email. A hotel is not a good place for him. It is not a safe discharge without a caregiver. An Assessment from Home and Community Services (HCS), dated 3/7/17, documented the following needs for Resident #1: Medication Management: Assistance required, ability fluctuates, has poor coordination. Caregiver instructions: hand medication in a cup or bowl, open containers, and remind to take medications, read labels. Treatment/Programs/Therapies Self-directed individuals who have functional impairment may direct their provider to perform health related task that they would normally be able to perform themselves if they did not have a functional impairment that prevents them from doing so. ADL Limited Range of Motion, Partial weight bearing, contractures Evacuating caregiver will assist, leave assistive devices within reach, make sure foot rest in place, keep walkways clear, recharge batteries daily. Bed Mobility One person physical assist, able to use trapeze. Has TED hose and needs assistance daily with on and off Eating Independent with Setup, bring food to client and cut food into small pieces Toilet use Independent with Set up, needs clothing adjustment, maintain inventory of supplies, will need a suppository scheduled and as needed (paralyzed from the waist down). Dressing One person physical assistance, dress lower body, put on and take off footwear Personal Hygiene Extensive assistance one person physical assist, provide set up and trim fingernails, assist with bathing, wash back, legs, and feet, shampoo hair, assist with drying. Meal preparation Assistance needed, cannot reach stove, cannot open containers, cannot reach lower shelves, cannot stand long enough to cook, cannot cut/peel/chop, cannot reach upper shelves. Ordinary Housework Assistance needed, cannot make bed, cannot use vacuum cleaner, Shopping Can pay for own purchases, cannot carry heavy items Transportation Can ride Para transit without assistance, has no car, uses motorized wheelchair The facility determined Resident #1 no longer met skilled services and issued a 30-day notice of discharge. No other resident was issued a 30-day notice of discharge, and by the facility's own admission, there are 20 other residents in the facility who no longer met skilled criteria for services. Resident #1 reported feeling harassed, intimidated and retaliated against because he voiced his concerns. The facility issued a 30-day notice of discharge without adequately assessing, educating and determined what care the resident could perform independently, and while Home and Community Services was still in the process of determining a safe discharge for the Resident. These failures caused Resident #1 to experience psychological harm, increased anxiety, stress, and fear related to the inability to care for himself.

Based on observation, interview and record review, it was determined the facility failed to operationalize its policies and procedures for protection of residents and for the prevention, identification and investigation of abuse, neglect, and/or mistreatment. The failure of the facility to recognize and prevent occurrences and/or repeated occurrences of resident-to-resident assaultive behaviors for 2 of 2 sampled residents (#1 & #2) reviewed for abuse and neglect prevention, resulted in harm to Resident #1. Findings include: Review of the facility's Abuse Prevention Program policy dated March 2013, indicated: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The Program is committed to protecting our residents from abuse by anyone . The facility would perform: An ongoing analysis of abuse incidents and implement changes to prevent future occurrences of abuse. The State's Nursing Home Guideline AKA 'The Purple Book' (Nursing Home Guidelines, 6th Edition, Partners in Protection, October 2015), Pages 6-7, direct facilities that Immediate telephone reporting is required when there is reasonable cause to believe abuse .has occurred, .Any act, when there is reasonable cause to believe the act caused a fear of imminent harm and .An incident of physical assault between residents always has to be reported via the log and/or the hotline to the Department. Review of the facility investigation regarding a resident-to-resident altercation, on 2/26/27 at approximately 10:00 p.m., showed the facility staff observed Resident #2 shake and pull on the head-rest of Resident #1's (with [MEDICAL CONDITION]) wheelchair while Resident #1 was in it. Law Enforcement was notified by Resident #1. Resident #2 was sent for an evaluation and treatment at a local hospital. Physician notes from the Emergency Department (ED) showed the facility staff had reported Resident #2 had recently had increased agitation and frustration since having a procedure to remove [MEDICAL CONDITION] from his face. It was noted Resident #2 acquired a skin tear during his outburst at the nursing facility, and was medically cleared to return to the facility after lab and x-ray studies were completed and reviewed. On 2/27/17 at 11:55 a.m., the ED noted the social worker at the hospital received a call from the Administrator (AD) of the nursing facility who reported they were unable to receive Resident #2 back due to not having a safety plan in place. At 12:32 a.m., ED staff noted staff from the facility would not accept Resident #2 back to the facility at that time, if ever. The ED notes showed Resident #2 had no episodes of violence while in the ED. A facility investigation note, dated 2/27/17, showed Resident #1 was interviewed regarding the incident that had occurred on 2/26/17, and had expressed feeling safe as long as Resident #2 was not in the facility. It showed Resident #1 would be placed on alert for psychosocial harm. Record review of the Incident Report Summary, undated, documented, There are no obvious indications of intent to harm; furthermore there was not any abuse or neglect on behalf of the facility. The facility did not notify the State Agency of the incident or implement its own policies and procedures for abuse prevention. Progress notes dated 3/1/17 indicated Resident #2 returned to the facility with one-to-one supervision. Review of Resident #1's progress note, dated 3/2/17, showed Resident #1 had stated to staff once he had seen Resident #2 was back in the building, I can't believe they took him back .they can't do that. I'm afraid to leave my room now. There was no documentation to indicate Resident #1 was placed on alert charting for observation of psychosocial concerns or that interventions were put in place to support Resident #1. The one-to-one supervision of Resident #2 was removed on 3/8/17 after being assessed to no longer require that level of supervision. On 3/13/17 at 1:35 p.m., the Director of Nursing Services (DNS) stated, I could make the assumption that he (Resident #1) was scared (during the incident). The DNS added: No monitoring was done on (Resident #1); we focused on (Resident #2) .An assessment for (Resident #1) for psychological harm was not done, but I would have expected one to be done. The facility's failure to implement its policies and procedures for abuse prevention placed all residents at risk for abuse/neglect and kept Resident #1 in fear of Resident #2.

Based on observation, interview and record review, it was determined the facility failed to ensure 5 of 7 sampled residents (#1, #2, #4, #5 and #7) and 1 discharged resident (#3), identified at risk for skin breakdown and who developed skin conditions and/or pressure sores in the facility, were assessed, monitored, evaluated and treated according to accepted standards of practice and were evaluated for the impact of the implemented interventions and/or revised treatment needs as appropriate for the residents in a timely manner. Failure to recognize, assess, monitor, report, evaluate, prevent and/or promote prompt healing of existing pressure ulcers/skin conditions resulted in harm to Resident #1, #2 and #3 and placed all residents at risk of harm from similar deficient practice. Findings include: On 3/15/16 at 2:10 p.m., Licensed Nurse (LN) A said skin assessments/body audits were performed weekly by Licensed Nurses. On 3/16/16 at 2:00 p.m., LN B said the Nursing Assistants (NA) would notify nurses on shower days if there were skin issues. On 3/16/16 at 2:30 p.m., during interviews with the Infection Control Nurse/Staff Development Nurse (ICN/SDN) and the Director of Nursing Services (DNS), all facility residents received body audits weekly. They confirmed the body audits were head-to-toe assessments and only performed by LNs and these could be done on shower days but it was the facility's expectation that full head-to-toe assessments would be completed weekly on each resident by the LNs. The DNS stated all specific skin care requirements would be found on residents' Comprehensive Care Plans (CCP). 1) discharged Resident #3 was admitted to the facility in May 2015 with multiple health conditions including pressure sores to her buttocks, [MEDICAL CONDITION] (MS) and [MEDICAL CONDITION]. She had a pressure ulcer to her left foot. She was at high risk for skin breakdown. She was alert and oriented and could make her needs known. Review of the Activities of Daily Living (ADL) records dated 1/10/16, the resident received ADL services the entire day, evening and night shifts including a shower and she had not refused care. The NN dated 1/10/16 (no time) indicated the Resident personally called 911. According to the hospital records, the resident arrived in the emergency room (ER) on 1/10/16 at 9:27 p.m. and was diagnosed with [REDACTED].ulcerations. The hospital notes continued: .necrotic (dead) flat lesion encompassing the vulva from the clitoris, obliterating (completely covering) both labia Minora and extending onto the labia Majora bilaterally (both sides) and eroding (eating away/destroying) the tissue between the clitoris and the urethral meatus (urinary opening). The erosive lesion extended approximately 6 cm (3 inches) into the vagina .unable to insert catheter as urethral opening is not visible. The resident underwent [REDACTED]. There was no documentation found in the facility's records to indicate staff members who cared for the resident daily, provided showers, performed personal care after each incontinence episode or during the attempt to catheterize the resident (prior to and the day of admission to the hospital) recognized or reported any problems prior to the hospital ER physician's assessment on 1/10/16 which demonstrated harm to Resident #3. 2) Resident #1 was admitted to the facility on [DATE] with multiple health conditions. He was assessed at high risk for skin breakdown and required extensive assistance of two people for care and services. He was alert, oriented and able to make his needs known. On 3/15/16 at 9:00 a.m., 11:00 a.m. and 1:25 p.m., Resident #1 was observed consistently leaning forward and to the right over the arm of the wheelchair. A foul odor permeated the room. The resident's CCP indicated: ensure turning, toileting/per-care is offered and done on a 2-hour rotation at a minimum .observe skin condition daily and weekly basis with bath/shower. According to the resident and per observations, no positioning or personal care had been provided to the resident yet and at 1:25 p.m., LN A was asked to assess the resident's skin. When the Resident's socks were removed, a different foul odor was noted. The resident's feet were purple with cracked, scaly skin. His feet to his knees were swollen and purple/black with a dressing that covered the mid-calf on his left leg ulcer. Some redness was noted above this dressing. When asked about the odor from his feet, the LN said it was most likely from a fungus. When asked, the LN attempted to find pulses on the resident's feet. She thought she might have felt a pulse on the right foot but unable to get a pulse on the left. There was no bed in the room so the resident stood up and held onto a transfer pole during the skin assessment from approximately 1:40 p.m. to 2:25 p.m. The LN agreed the standing position made it very difficult to perform good care and thorough skin assessments and treatments. When the resident's shirt was removed, a 4 inch by 2 inch red line along the right side of his rib cage was observed where the resident leaned against the arm of the wheelchair. Inspection of the area under his left breast revealed a bright red skin rash-appearing area approximately 6 inches long by 4 inches wide and only visible when the LN was asked to lift the breasts for inspection. The LN said: It looks really raw. The LN agreed the resident might benefit from an assessment for a better fitting wheelchair and better positioning. Review of the resident's weekly body audits dated 3/7/16 indicated: continues with ulcer to left leg .no other skin issues. On 3/14/16 the weekly body audit indicated: No new skin issues . After LN A performed the skin assessment on 3/15/16 with the above findings, the body audit documentation only indicated: Redness noted under left breast. On 3/25/16 at 4:00 p.m., the resident was observed in his wheelchair leaning to his right side over the arm of the chair. The last weekly body audit was dated 3/15/16. There were no further evaluations found in the record to indicate the resident's skin conditions. The area under his right arm where he leaned over the arm of the wheelchair was observed light purple. Review of the treatment records dated 3/20/16 showed LN C's initials as completing a head-to-toe skin assessment. During interview with LN C, she disclosed she had not performed the assessment because the resident did not have a shower that day. She stated: I just had training on this yesterday and I will do it right from now on. 3) Resident #2 was admitted to the facility on [DATE] with multiple health conditions. She was at high risk for skin breakdown and was totally dependent on staff for all care. She could communicate in short sentences. According to the CCP, the resident was to be kept clean, dry and without skin breakdown due to incontinence. She required the assistance of two staff for mobility/transfers. On 3/15/16 at 11:15 a.m., NA C assisted the resident to bed. The resident's heels were on the bed, not floated and there was no pillow/support between her knees. There was a large red (palm-sized) area on her left knee where her right knee was resting. The resident's left heel was resting on the bed and found to have a thin black strip on the outer heel. The resident's arms and legs were contracted and pulled upward in fixed position and when turned, her body moved as one unit. When observing the resident's buttocks, a small nickel-sized open area was noted on her coccyx. When asked if she had seen any of these areas, the NA said, No. The NA was asked how care was provided to the resident. She said: I couldn't find any pillows, we have been told not to use blankets .are blankets okay? When asked about the open area on the resident's coccyx covered with a yellowish cream substance, the NA said she had not used the cream and had not noticed the open area nor had she noticed the area on the left heel. At 11:45 a.m., LN A agreed to assess the resident. The resident was found to have a blanket between her knees and a rolled blanket to her back. The LN was informed about the resident's open areas to the buttocks and heel. The LN said, No, the NA had not informed her of the resident's buttocks or left heel skin issues. The open area and the crease from the resident's coccyx was covered with a yellowish cream-like substance. The LN used a washcloth to wipe the area clean. The resident said: It's sore. The LN asked the resident if her bottom hurt? The resident said: Yes, sore, very sore. The LN continued to clean the resident's buttocks until the open area was more visible with redness around the area and up the crease of her buttocks/back. She wiped the left heel but the black strip could not be removed. Review of the weekly body audit documentation after the LN's assessment indicated the finding of the open area as a Stage II pressure ulcer (partial loss of the skin, can be open or closed area) and none of the other skin areas were documented. The physician ordered special dressings to be applied to the Stage II area. On 3/16/16 at 4:00 p.m., during interview with the DNS, he stated he saw the coccyx wound today and it was healed. He said the LN who assessed the wound was new and needed more education on pressure ulcer identification. When asked about the left outer heel area, the DNS said he checked it and felt it was more of a callus (thick, hardened layers of skin that develop when your skin tries to protect itself against friction and pressure). 4) Resident #5 was admitted to the facility on [DATE] with multiple health conditions including [MEDICAL CONDITION] (inability to move arms/legs). She had pressure ulcers and a suprapubic catheter (SC). According to the record, the resident had a Stage II pressure ulcer. The care plan indicated the resident was to wear heel protector boots at all times. On 3/16/16 at 3:00 p.m., during observations of care, the resident's heels were noted on the bed without being floated and without heel protectors. No weekly skin audits were documented since admission. 5) Resident #7 was admitted to the facility on [DATE] with multiple health conditions. He was at high risk for skin breakdown. He was independent and able to make his needs known. He required extensive assistance with personal care. Review of the March treatment records indicated the resident had not received the ordered antifungal cream to his abdominal folds, breast folds and groin area twice each day nor did he receive right buttock wound care with Zinc cream applied to his buttocks and coccyx areas twice each day for skin protection. Review of the records indicated the resident had refused care for weeks and the weekly body audit indicated he refused his weekly showers without indication the head-to-toe assessments were completed. On 3/16/16 during interviews with the SD/ICN and DNS, the records for this and other residents' weekly body audits were shared. Both said the expectation was for the LNs to perform the weekly head-to-toe assessments regardless of shower days. Refer to F 315.

Based on observation, interview and record review, it was determined the facility failed to ensure appropriate care and services were provided to 4 of 7 current sampled residents (#1, #2, #4, #5) and 1 discharged resident (#3) reviewed for urinary care/management. This failure resulted in pain, skin breakdown and infections for these residents with harm to Resident #1, #2 and discharged Resident #3 and placed all residents at risk of harm from similar deficient care practice. Findings include: On 3/15/16 at noon, the Infection Control Nurse (ICN) and Assistant Director of Nurses (ADN) provided copies of Lippincott's catheter care and stated Lippincott was the facility's policy/procedure manual for all nursing care and services. Also provided was the corporation's policy for skin care guidelines that included color coded products for cleansing, moisturizing and protecting skin. Review of the infection control records revealed 7 residents with urinary catheters and 5 of them had current urinary tract infections [MEDICAL CONDITION]. Three additional residents without catheters had UTIs. The recommendations for monitoring infections for January and February 2016 were the same which was to educate staff to observe skin for redness, heat, swelling, pain, open areas, drainage, rash, discoloration and report all observed abnormalities to the nurse in a timely manner. On 3/16/16 at 11:15 a.m., during interview with the ICN, she correctly described how she taught staff to perform urinary/peri-care and catheter care. She said staff should report to the nurses when finding any problems with residents. She acknowledged she had not observed return demonstrations of staff performing urinary management care and services to residents. The following interviews and observations were shared with the ICN and the Director of Nursing Services (DNS). Both stated the practices observed/described were not in accordance with practice standards or what the facility expected of staff for urinary management and skin care. The DNS stated the residents' Comprehensive Care Plans (CCP) provided necessary directions to staff for all care and services in the absence of specific policies and procedures for positioning, bathing, skin care and toileting. 1) discharged Resident #3 was admitted to the facility in May 2015 with multiple health conditions including history of UTIs. She was incontinent of urine and bowel and required extensive assistance with mobility and toileting. According to her Care Plan, she was on a toileting program every two hours, received care after each incontinence episode and required the assistance of two people for care. On 1/7/16 (no time) the Nursing Note (NN) indicated the resident complained of burning when urinating and an odor to her urine. The NN for evening (no time) resident did not deny any care .unable to collect urine sample at this time, resident incontinent .urine is dark, concentrated and funky smell. A physician's orders [REDACTED]. The LN made an attempt to insert a catheter which would have required full visualization and preparation of the vulvar area (external female genitalia including the mons pubis, labia Majora and Minora, clitoris, urinary meatus/opening and vaginal opening). The NN dated 1/10/16 (no time) indicated the resident had been pushing the call light often and had an axillary temperature of 102.5. The NN continued: .urine was blood-tinged due to UTI. The NN continued (no time) Resident personally called 911 without telling staff. According to the hospital records, the resident arrived in the emergency room (ER) on 1/10/16 at 9:27 p.m. and was diagnosed with [REDACTED].ulcerations. The hospital notes continued: .necrotic (dead) flat lesion encompassing the vulva from the clitoris, obliterating (completely covering) both labia Minora and extending onto the labia Majora bilaterally (both sides) and eroding (eating away/destroying) the tissue between the clitoris and the urethral meatus (urinary opening). The erosive lesion extended approximately 6 cm (3 inches) into the vagina .unable to insert catheter as urethral opening is not visible. On 3/16/16 at 4:00 p.m., during interview with the DNS, he stated he did not observe the attempted catheter insertion on 1/7/16. There was no documentation found to indicate staff members who cared for the resident, provided showers, performed personal care after incontinence episodes or during the attempt to catheterize the resident (prior to and the day of admission to the hospital) recognized any problems prior to the hospital ER physician's assessment on 1/10/16 which demonstrated harm to Resident #3 had occurred. 2) Resident #1 was admitted to the facility on [DATE] with multiple health conditions including insulin-dependent Diabetes, difficulty walking/standing and generalized weakness. The resident required extensive assistance of two people for care and services. He had a urinary catheter and history of UTI. He was alert, oriented and able to make his needs known. The resident's CCP indicated: Secure (catheter) tubing to prevent pulling; catheter care every shift; extensive assist of 2 people for toileting; ensure turning, toileting/per-care is offered and done on a 2-hour rotation at a minimum .observe skin condition daily and weekly basis with bath/shower. On 3/15/16 at 1:40 p.m. until 2:25 p.m., Resident #1 was observed for personal care. There was a transfer pole between his wheelchair and recliner. There was no bed in the room. He answered questions and agreed to have his skin assessed. There was a foul odor that permeated the room. Licensed Nurse (LN) A assessed the resident. The LN asked the resident to stand and he hunched over to hold onto the transfer pole while care was being provided. When he stood up, his catheter tubing was under his buttocks and caused indentation to his swollen scrotum and the back of his right upper leg. The catheter tubing was not secured and pulled downward during care and when taking off clothing. The LN agreed that this standing position made it difficult to perform good care and thorough assessments. The foul odor was more noticeable when the resident's clothing/briefs were pulled down. The resident's briefs were completely stained yellowish up to the waistband. The resident was asked if his catheter was leaking. He stated: I think so, but nobody else does. The LN was asked if the catheter was leaking and she was not sure. When asked about the odor, the LN said the resident was just completing treatment for [REDACTED]. While holding onto the transfer pole for peri-care and skin assessment, the resident became short of breath. His oxygen saturation was 84% (92-100% reference range) on room air. He stated: I have never stood up this long before. He had to sit down frequently through the procedure. The LN used a wet wash cloth and small wipes to clean the resident's buttocks and peri-area, wiping his buttocks first and then moving to the front peri-area. When wiping the resident's scrotum, small white crusty debris fell on to the resident's wheelchair No catheter care was performed. The LN obtained a small cup of powder (antifungal) from the medication cart and patted some of it on the resident's scrotum and then his front peri-area and inner thighs. Review of the treatment record indicated: (antifungal) powder; apply topically to affected area TID (three times/day). No sites for the powder were identified. According to Lippincott's catheter care guidelines provided by the facility, avoid using powders on the peri-area--powder can encrust and cause soreness and infection .avoid pulling the catheter during cleaning as infectious organisms can enter the bladder along the outside of the catheter; secure the catheter tube to the upper thigh; keep the tubing over the patient's leg . The LN was asked if she usually applied the fungal powder to residents. She said: No, we put some in a cup and give it to the Nursing Assistants (NA's) who apply it. Since the treatment record failed to indicate where the powder was to be (or had been) applied, the LN said she did not know specifically where but it should be applied to fungus areas. After leaving the room, the LN was asked if she was done with peri-care and catheter care. She said: Yes. Failure to ensure personal care and catheter care were completed as noted in the CCP, Lippincott, facility's skin care policies and professional practice standards placed the resident at risk of repeated UTIs. 3) Resident #2 was admitted to the facility on [DATE] with multiple health conditions including bladder infection and repeated UTI's. The resident had a urinary catheter in place. She was totally dependent on staff for all care. According to the CCP, the resident was to be kept clean, dry and without skin breakdown due to incontinence. Catheter care every shift and check and change every two hours while awake and every three hours at night. Assist with toileting needs. Two person assist for bed mobility/transfers. On 3/15/16 at 11:15 a.m., NA C assisted the resident to bed. When asked if peri-care was completed, the NA said: I checked her. When asked how the resident's skin and peri-area looked, the NA said there were no skin issues. The NA assisted with observation of the resident's catheter, peri-area. The resident's legs were contracted and could only be opened about 6 inches for peri-examination. The catheter tubing caused skin indentations to her red, swollen peri-area and her left inner thigh. There was a foul odor. The urine was dark yellow (concentrated) and cloudy. The tubing continued under the resident's right leg and neither the catheter nor tubing were secured to prevent movement and pulling on the catheter. After the observation, the NA still did not provide peri-care or catheter care. At 11:45 a.m. LN A agreed to assessment of the resident. The LN said peri-care/catheter care should be provided whenever the residents were put to bed or evidence of needing care and No, the NA had not informed the her of the resident's peri-area/skin conditions. The LN observed the catheter/peri-area and wiped the area with a washcloth and wipes. When the LN wiped the resident's buttocks, the resident said: It's sore. The LN asked the resident if her bottom was sore, hurt? The resident said: Yes, very sore. Per family member's request and then physician's orders [REDACTED]. There was no final culture laboratory report in the record. The facility called the hospital and provided the lab report showing the urine culture was positive for UTI. 4) Resident #4 was admitted to the facility on [DATE] with multiple health conditions including stroke with loss of function on left side; [MEDICAL CONDITION] and a urinary catheter. He could make his needs known. According to the CCP, the resident required extensive assistance for care, needed to observed for signs and symptoms of UTI. The facility documented the resident had UTIs on 2/10/16 and 3/4/16. According to hospital records, the resident was admitted on [DATE] from the facility with a fever of 102.4 degrees F. and septic shock (life-threatening condition from an infection). The hospital note indicated: He choked on his food (at the facility) prior to admit blood pressure remained low despite 4 liters of fluid resuscitation .sent to Intensive Care Unit (ICU) and treated for [REDACTED]. 5) Resident #5 was admitted to the facility on [DATE] with multiple health conditions including [MEDICAL CONDITION] (inability to move arms/legs). She had a suprapubic catheter (SC--tube inserted into the bladder through a small hole in the abdomen). She was dependent on staff for all care. According to the care plan, the insertion site of the SC was to be cleaned with normal saline or gentle soap and water. Pat dry thoroughly. Place fenestrated (dressing with hole in center) foam or gauze around insertion site. Secure with cloth tape. On 3/16/16 at 9:40 a.m., NA B was observed to perform care to the resident. The NA put on gloves, collected care items and then provided care without changing gloves. The catheter was under the resident's left leg and not secured. The NA used an alcohol swab to clean around the SC insertion site and no dressing was applied.

Based on observation, interview and record review, it was determined the facility failed to have sufficient, qualified staff to provide and supervise care for 5 of 7 sampled residents (#'s 1, 2, 3, 4 and 5) and 1 discharged resident (#3). Observations of care, interviews with staff, combined with record reviews, revealed inadequate supervision of residents to ensure the care needs of these residents were met by licensed staff or certified nursing assistants in accordance with established clinical standards and their care plans. Staff did not adequately assess, plan, report or document information needed to formulate effective and timely interventions and evaluate the interventions for effectiveness. This failure resulted in harm when Resident #1, #2 and discharged Resident #3 were not provided care according to accepted standards of practice for residents with pressure ulcers, urinary tract infections and/or urinary catheters and placed all residents at risk of similar deficient practices. Findings include: The above information has been detailed in the following citations: 1) Refer to 42 CFR 483.25 (c) F-314, Quality of Care treatment/Service to Prevent/Heal Pressure Sores for facility failed to ensure 5 of 7 sampled residents (#1, #2, #4, #5 and #7) and 1 discharged resident (#3), identified at risk for skin breakdown and who developed skin conditions and/or pressure sores in the facility, were assessed, monitored, evaluated and treated according to accepted standards of practice and were evaluated for the impact of the implemented interventions and/or revised treatment needs as appropriate for the residents in a timely manner. Failure to recognize, assess, monitor, report, evaluate, prevent and/or promote prompt healing of existing pressure ulcers/skin conditions resulted in harm to Resident #1, #2 and #3 and placed all residents at risk of harm from similar deficient practice. 2) Refer to CFR 483.25(d)(1)(2) F 315 Urinary Incontinence and Catheters for facility failure to ensure appropriate care and services were provided to 4 of 7 current sampled residents (#1, #2, #4, #5) and 1 discharged resident (#3) reviewed for urinary care/management. This failure resulted in pain, skin breakdown and infections for these residents with harm to Resident #1, #2 and discharged Resident #3 and placed all residents at risk of harm from similar deficient care practice.

Based on observation, interview and record review, it was determined the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements which affected or potentially affected all residents in the facility. Failure to ensure compliance resulted in harm to Resident #1, #2 and discharged resident (#3) referenced in F 314 and F 315 and impacted their care, safety, dignity and quality of life. Findings include: The information below is more detailed in the individual citations: 1) Refer to 42CFR 483.30(a) F 353 Nursing Services. Sufficient Staff per Care Plans for facility failure to ensure sufficient staff members were available to provide care and services to residents in the facility to help them attain or maintain their highest practicable level of function related to pressure ulcers and urinary care and services and resulted in harm to Residents #1, #2 and discharged Resident #3. Refer to 42 CFR 483.25 (c) F-314, Quality of Care treatment/Service to Prevent/Heal Pressure Sores Refer to CFR 483.25(d)(1)(2) F 315 Urinary Incontinence and Catheters.

Based on observation, interview and record review, it was determined the facility failed to operationalize its policies and procedures for protection of residents and for the prevention, identification and investigation of abuse, neglect, and/or mistreatment. The failure of the facility to assure all was being done within its control to recognize and prevent occurrences/repeated occurrences of resident-to-resident assaultive behaviors resulted in harm to 5 of 12 current sampled residents (#1, #2, #3, #4 and #5) reviewed for abuse and neglect prevention. This was determined to be an immediate jeopardy and the facility was informed on 1/15/16. By the end of the partial extended survey on 1/21/16 the facility had taken action to abate the jeopardy. The facility was informed on 1/22/16 that the immediate jeopardy had been abated. Findings include: Review of the facility's Abuse Prevention Program policy dated March 2013, indicated: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The Program is committed to protecting our residents from abuse by anyone . The facility would perform: An ongoing analysis of abuse incidents and implement changes to prevent future occurrences of abuse. Resident #1 was admitted to the secured (locked dementia) unit on 8/29/14 with multiple medical conditions including a history of [MEDICAL CONDITION] (TBI, [AGE] years ago) from a motor vehicle accident, [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED] (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function). Between November 2015 and December 2015 the resident was involved in multiple altercations with injury to 4 residents and at least 2 unidentified staff members without facility taking active steps to prevent injuries and protect residents and staff. The most recent Minimum Data Set (MDS), an assessment tool, dated 11/6/15 indicated the resident needed extensive assistance of two people for bed mobility, transfers and toileting. He resided in the secured unit as he was identified on three incident investigations between 11/11/15 through 12/30/15 to be a danger to himself and others. On 1/15/16 at noon, the Director of Nursing Services (DNS) said s/he performed the investigations and the Administrator said s/he reviewed them. A psychologist's consultation (PC) note in Resident #1's record dated 11/11/2015 noted: Staff report patient is exceedingly violent. He has physically struck x2 staff and given them 'black eyes'. There is grave concern about his risk to residents and his behavioral violence was described as coming out of nowhere .Far more work needed to treat patient's severe behavioral disturbance/resolve . A PC note in Resident #1's record dated 12/8/2015 noted: This is an exceedingly aggressive and unsafe patient. He is initiating violence and threats . More work to stabilize patient . A PC note in Resident #1's record dated 12/30/2015 noted: Aggressive behavior towards staff and other residents has increased, probably secondary to [MEDICAL CONDITION] from motor vehicle accident in remote past . After these assessments of Resident #1's aggressive and violent behaviors, the facility continued to keep the resident on the secured unit where he was either secluded in his room behind a closed door or he was up in the hallway in reach of other confused and wandering residents. Staff members' past actions of trying to monitor the resident to keep other residents away had not been successful. Resident #1 continued with unpredictable behaviors endangering himself and others. On 1/11/16 at 6:00 p.m., Resident #1's door was closed. After knocking and entering the room Resident #1 was alone in his room in his Merrywalker (special four-sided enclosed at the waist wheeled walker). His shirt was off and food was all over the floor. The surveyor looked down the hall to ask for assistance. Nursing Assistant (NA) #13 then entered the room. On 1/13/15 at 10:30 a.m., the door to Resident #1's room was closed and he was observed in bed sleeping. On 1/15/16 at 10:30 a.m., when asked about her interactions with Resident #1, NA #10 said: He punched me three times--last time was about three weeks ago. He hit me here (placed hand on left side of my face/chin). When asked what administration had done or told her, she said: Other than filling out an incident report, they (facility) said if I wasn't going to the emergency room , nothing more to be done. On 1/15/16 at 11:00 a.m., Resident #1 was observed on the secured unit following personal care provided by NA #12 and Licensed Nurse (LN) #3. He continued yelling loudly and was taken to the front of the nurse's station via his Merrywalker. He needed a clean shirt, shave and bath. When asked how staff provided personal grooming/hygiene to the resident and how often, the staff members were unsure because of his aggressive behaviors and care was provided only when the resident could cooperate. Between 11:00 a.m. and 11:30 a.m., the resident was observed near the nurse's station in his Merrywalker. He could not be by himself unsupervised as the LN tried to attend to him frequently to keep other residents away. She said: We can't do 1:1 because we are so busy. when we get busy we have to put him in his room. I have heard he is worse on evenings. Review of the Nursing Notes (NN) between 11/10/15 and 1/15/16 revealed daily documentation of yelling, aggressive behaviors to other residents and staff and the resident frequently in his room. When asked about the resident's burn to his legs from hot cereal the NA left for him to eat in his room alone, LN #3 said she heard about the incident but was not sure why that happened because he was supposed to eat in the dining room where he could be supervised yet there was a problem being in the dining room as he demonstrated unpredictable behaviors when others came near him. The LN mentioned his radio was taken out of his room after he threw it in the sink with running water. Review of the Nursing Note (NN) dated 12/23/15 on evenings validated the resident was: Yelling out much of this shift. Attempted to punch staff multiple times. Tore NA's shirt by grabbing onto him. Placed radio in sink with water running. Radio removed from room. Assistant Director of Nurses notified. The facility failed to implement its Abuse Prevention Program by not aggressively acting upon staff members' and/or psychologist's continued verbal and documented concerns to take action to protect residents from abuse, neglect and mistreatment leaving Resident #1 vulnerable to self harm and placed others on the secure unit in harm's way. Refer to F 323 for more detailed information regarding resident to resident altercations that involved Resident # 1, 2, 3, 4 and resident # 5

Based on observation, interview and record review, it was determined the facility failed to ensure adequate supervision for 1 of 5 current sampled residents (#1) in the secured dementia unit to prevent repeated altercations/injuries to himself, 5 unit residents (# 2,3,4, and 5) and staff members. This failure was determined to be an immediate jeopardy as actual harm and the likelihood of continuing harm existed. The facility was informed on 1/15/16 of the immediate jeopardy. Evidence collected during a partial extended survey on 1/21/16 confirmed that the facility had taken sufficient steps to abate the jeopardy. The facility was informed on 1/22/16 that the jeopardy was abated. Findings include: Resident #1 was admitted to the secured unit on 8/29/14 with multiple medical conditions including a history of traumatic brain injury (TBI, around [AGE] years ago) from a motor vehicle accident, seizures, Parkinson's and [DIAGNOSES REDACTED] (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function). The most recent Minimum Data Set (MDS) an assessment tool dated 11/6/15, indicated the resident needed extensive assistance of two people for bed mobility, transfers and toileting. He remained in the secured unit as the facility identified he was a danger to himself and others on three different events between 11/11/15 and 12/30/15. According to the Nursing Notes (NN), Resident #1 was to be observed every 15 minutes for continued 72 hour periods over the last two months. During observations on 1/11/16 at 3:00 p.m. to 5:00 p.m., Resident #1's room door was closed and staff members did not make visual observations. When Licensed Nurse (LN) #1 was asked about the resident's whereabouts and if he was in his room, s/he could not say. Review of facility occurrence reports involving Resident #1 included but were not limited to: 1) On 11/7/15 Resident #1 incurred a self-inflicted burn to his left thigh from spilled hot cereal after being left alone in his room to eat. 2) On 11/14/15 Resident #1 hit Resident #2 on the chin resulting in bleeding to his chin requiring first aid. 3) On 11/17/15 Resident #1 grabbed Resident #3's neck resulting in an injury that required first aid. 4) On 11/21/15 Resident #1 grabbed Resident #4's breast resulting in bruising. The report indicated the resident was a danger to self and others. 5) On 11/30/16 Resident #1 became angry with behavioral outburst and hit a nursing assistant (NA) causing an injury. 6) On 12/1/15 Resident #1 became aggressive towards staff, scratched NA. The report indicated Revised care plan .protect resident from self-harm and other residents. Observation, medication changes. Resident is a danger to self and others. 7) On 12/16/15 Resident #1 yelled at Resident #5 and grabbed her hand causing Resident #5 to hit Resident #1. The report indicated Updated care plan .danger to self and others. 8) Review of the Nursing Note dated 12/23/15 on evenings indicated the resident was Yelling out much of this shift. Attempted to punch staff multiple times. Tore NA's shirt by grabbing onto him. Placed radio in sink with water running. Radio removed from room. Assistant Director of Nurses notified. On 1/15/16 at 11:00 a.m., Resident #1 was observed to have trouble standing up in his Merrywalker. The inside 4-legs of the chair appeared to keep the chair from moving and the resident was forced to shuffle his feet in an attempt to move the walker. According to staff and validated in the records, the Merrywalker was to help reduce repeated falls and weights were added to the walker to make it more difficult for the resident to move about and slowed his ability to come in contact with other residents and staff. Review of Resident #1's care plan failed to clearly identify measurable goals/objectives related to the resident's behaviors and the updated care plan interventions that were implemented and/or effective to reflect the type of supervision and what changes were made to the care plan that would ensure Resident #1's safety as well as other residents on the unit. The facility staff members verbalized and documented awareness of repeated occurrences that the resident was a danger to himself and others yet failed to ensure adequate supervision occurred for his and other residents' safety which continued to expose them to repeated abuse/injuries.

Based on observation, interview and record review, it was determined the facility was not administered in a manner to effectively use its resources to attain or maintain the highest practicable well-being of each resident. The administration failed to ensure the facility was in compliance with the following regulatory requirements which affected or potentially affected all residents in the facility. Failure to ensure compliance resulted in harm to at least 6 residents (#1, #2, #3, #4, #5 and #6) referenced in F226, 241, F250, F279, F323, F 353, F501 and impacted their care, safety, dignity and quality of life. Findings include: The information below is more detailed in the individual citations: 1) Refer to: 42 CFR 483.13(c)(2), F226-Abuse Policies and Procedures - for facility failure to operationalize its written policies and procedures to prohibit mistreatment, abuse and neglect related to 5 of 5 current sampled residents, who resided in the secured unit (Memory Care) and resulted in harm to Residents #1, #2, #3, #4 and #5 reviewed for abuse, neglect and mistreatment. This failure posed a repeated risk to these and other residents and resulted in immediate jeopardy. 2) Refer to 42CFR 483.15(a), F241, Quality of Life, Dignity for facility failure to ensure dignity was provided to Residents #1 and #6 and resulted in harm. 3) Refer to 42CFR 483.15(g)(1) F 250 Quality of Life. Provision of Medically Related Social Services for facility failure to advocate for Resident #1's psychosocial, physical and safety needs and resulted in harm. 4) Refer to: 42 CFR 483.25(H) (1) AND (2) F 323 Accidents and Supervision for facility failure to ensure the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision to prevent accidents and/or injuries to Resident's #1, 2, 3, 4, 5 and 6 and resulted in immediate jeopardy. 5) Refer to 42CFR 483.30(a) F 353 Nursing Services. Sufficient Staff per Care Plans for facility failure to ensure sufficient staff members were available to provide care and services to residents in the facility to help them attain or maintain their highest practicable level of function and for Residents #1, 2, 3, 4, 5 and 6 and resulted in harm. 6) Refer to 42CFR 483.75(i) Responsibilities of the Medical Director F 501 and to WAC 388-97-1040 Dementia Care for faility failure to ensure the Medical Director provided coordination of care for residents in the facility and helped identify, evaluate and resolve/address medical and clinical concerns affecting resident care, medical care and quality of life for residents who lived in the secured unit. This failure created an unsafe environment for all residents and caused harm to Resident #1, #2, #3, #4 and #5 who experienced harm while in the secured unit.

Based on observation, interview and record review, it was determined the facility failed to ensure the Medical Director provided coordination of care for residents in the facility and helped identify, evaluate and resolve/address medical and clinical concerns affecting resident care, medical care and quality of life for residents who lived in the secured unit. This failure created an unsafe environment for all residents and caused harm to 5 of 5 current sampled residents (#1, #2, #3, #4 and #5) who experienced harm. Findings include: Resident #1 was admitted to the secured unit on 8/29/14 with multiple medical conditions including a history of [MEDICAL CONDITION] (TBI, [AGE] years ago) from a motor vehicle accident, [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED]. The most recent assessment dated [DATE] indicated the resident needed extensive assistance of two people for bed mobility, transfers and toileting. He remained in the secured unit as he was identified on three occasions between 11/1/15 through 12/30/15 to be a danger to himself and others and caused harm to himself and Residents #2, 3, 4 and 5. 1) On 11/7/15 Resident #1 incurred harm when he was left unsupervised during a meal and suffered a burn to his left thigh. On 12/23/15 during the evening, the resident was yelling, punching/grabbing staff, and threw his radio in the sink under running water. 2) On 11/14/15 Resident #1 hit Resident #2 on the chin resulting in bleeding to his chin requiring first aid. 3) On 11/17/15 Resident #1 grabbed Resident #3's neck resulting in an injury that required first aid. 4) On 11/21/15 Resident #1 grabbed Resident #4's breast resulting in bruising. The report indicated the resident was a danger to self and others. 5) On 11/30/16 Resident #1 became angry with behavioral outburst and hit a nursing assistant (NA) causing an injury. 6) On 12/1/15 Resident #1 became aggressive towards staff, scratched NA . Resident is a danger to self and others. 7) On 12/16/15 Resident #1 yelled at Resident #5 and grabbed her hand causing Resident #5 to hit Resident #1 .danger to self and others. On 1/13/16 at noon, Resident #1's physician, who was also the facility Medical Director, was interviewed and asked about Resident #1's behavior and if he felt the resident was a danger to himself and others. The physician stated he did not believe the Resident's behavior was any worse than other residents' behaviors in the facility. On 1/15/16 at 4:00 p.m., the Administrator and Director of Nursing Services (DNS) were asked if the Medical Director (MD) was involved in the care of residents in the dementia unit specifically due to the frequent altercations and Resident #1 being identified as a danger to himself and others by staff and the psychologist. In addition, was there a policy in place to reflect the facility's overall approach to the care of residents with a clearly outlined process for their care. Could the facility provide any documentation to show the MD helped identify, evaluate and resolve the concerns surrounding the dementia unit issues to improve residents' safety and quality of life? The Administrator said, I'll have to get back to you on that. On 1/21/16, the facility was unable to provide information regarding these questions related to the dementia care unit program/plan and the Medical Director's responsibilities in a nursing home including the dementia care unit. Refer to F226, F250, F 490 and WAC 388-97-1040 Dementia Care.

Based on observation, interview and record review, it was determined the facility failed to provide care in a respectful manner to promote, maintain and/or enhance dignity for 1 of 6 sampled residents (#6) reviewed for dignity. Failure to treat residents with dignity and respect created an environment in which a reasonable person would have felt embarrassment, diminished self-esteem and quality of life and resulted in harm to Resident #6 when staff ignored her repeated pleas for help. Findings include: Resident #6 was admitted to the facility on [DATE] with heart failure, high blood pressure and non-Alzheimer's dementia. She received a daily diuretic. The most recent assessment dated [DATE] indicated she could make her needs known and was a one person assist to toilet with staff providing weight-bearing support. On 1/13/15 at 11:00 a.m., Resident #6 was observed in her wheelchair going into a room that was not where she lived. When asked what she needed she said: I need to go to the bathroom and proceeded to wheel herself to the bathroom. She said: I can't wait, get help, can't you help me? It was explained to the resident the surveyors would get someone who worked at the facility to help her. She said: Oh, okay. When asked if she could reach the bathroom call light she said, No. The call light was out of her reach on the other side of the toilet. The surveyor turned on the room call light. The resident kept saying: I can't wait! When are they coming? Is someone coming? After 5 minutes, the resident was begging for help and another surveyor checked the light above the door. The light was on. The surveyor went to the nurse's station to get help. The light was audible at the station where a nurse was sitting. The nurse at the desk said she would send someone to help. At 11:15 a.m., Nursing Assistant (NA) #8 arrived and wheeled the resident back to her own room which had no bathroom. The NA left the resident sitting alone near her roommate's bed in front of a commode. The resident yelled out: I have to go to the bathroom .oh, oh, can't you help me? Why can't someone help me? At 11:20 a.m., another surveyor sought help again but before help arrived, the resident wheeled herself down the hall near the nurse's station, crying and said: It hurts, I really have to go! At 11:22 a.m., the resident was taken back to her room and NAs #5 and #6 said they would help the resident but they had to wait for a Hoyer (mechanical) lift in order to put the resident to bed so she could use the bedpan. The resident asked to use the commode located behind her and NA #6 told her she needed to be placed in bed to use the bedpan. When asked why the resident needed to use the Hoyer and bedpan, NA #6 said, That's what I've always known to do. I don't know why she can't use the toilet .she usually just goes in her briefs. Regarding the long wait, NA #6 said the facility only had three Hoyer lifts and needed to wait for one. The resident continued to say she needed to go now and said: It hurts. This isn't funny! When asked how often the resident was toileted like this (Hoyer and bedpan), the NA said: Every two hours .at 8:00 a.m. and 10:00 a.m. When asked if she personally changed the resident this morning, she said: No, that would be NA #7. Interview with NA #7 indicated the resident was last changed around 9:00 a.m. and stated: She (Resident) was really wet. At 11:35 a.m., the resident was observed covered from her low back to mid-thighs and perineum with a large amount of soft and liquid brown stool and urine. Her skin was red, indented at the waist and upper thighs from the brief. The resident said: I had to go .I was really full of ____! At 11:45 when the NAs completed care, the resident was apologetic to NA #6 for being so upset. The NA tried to comfort the resident and said: Honey, it's okay. The NAs placed the resident on the bedpan, and the resident asked: How long, an hour? On 1/15/16 at noon, the Director of Nursing Services (DNS) was asked why the resident needed to use the Hoyer and bedpan. The DNS said s/he started looking into the matter at the time of the observations/staff reports but was not able to determine exactly when the resident became unable to transfer to the toilet and s/he was following up on why it took staff so long to help the resident. Failure to respond to the resident's repeated pleas to toilet and being taken to her room and left alone without staff obtaining help in a timely manner, contributed to the resident's emotional distress and physical discomfort.

Based on observation, interview and record review, it was determined the facility failed to ensure medically-related social services were aggressively pursued for 1 of 6 sampled residents (#1) reviewed for psychosocial needs. The failure to advocate for Resident #1 resulted in harm when alternatives to drug therapy were not considered; when the outcome to seclusion in his room was implemented to manage assaultive behaviors was not assessed/vigilantly monitored and when transfer options were not immediately explored to ensure the resident received the highest level of care when it was determined he was a danger to himself and others. Findings include: Resident #1 was admitted to the secured unit on 8/29/14 with multiple medical conditions including a history of traumatic brain injury (TBI, [AGE] years ago) from a motor vehicle accident, seizures, Parkinson's, [DIAGNOSES REDACTED] (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function), anxiety and depression. The most recent Minimum Data Set (MDS), an assessment tool dated 11/6/15, indicated the resident needed extensive assistance of two people for bed mobility, transfers and toileting. He remained in the secured unit as he was identified on three incident investigations between 11/11/15 through 12/30/15 to be a danger to himself and others. A psychologist's consultation (PC) notes in Resident #1's record dated 11/11/2015 indicated the resident was exceedingly violent .grave concern about his risk to residents and his behavioral violence was described as coming out of nowhere .Far more work needed to treat patient's severe behavioral disturbance/resolve . Another PC note dated 12/8/2015 indicated the resident was exceedingly aggressive and unsafe patient. He is initiating violence and threats . More work to stabilize patient . Another PC note dated 12/30/2015 indicated Aggressive behavior towards staff and other residents has increased . Review of the Nursing Notes (NN) between 11/10/15 and 1/15/16 revealed daily documentation of yelling, aggressive behaviors to other residents and staff and being secluded in his room to manage behaviors. He was placed in a onesie (one-piece) ungergarment due to fecal play and was identified as a restraint. Review of the NN dated 11/3/15 indicated the resident was alone in his room and burned his legs from hot cereal. On 12/23/15, the resident was Yelling out much of this shift. Attempted to punch staff multiple times. Tore NA's shirt by grabbing onto him. Placed radio in sink with water running. Radio removed from room . Facility documentation revealed Resident #1 consistently harmed other residents and staff with aggressive and assaultive behaviors. The Social Services Director (SSD) notes failed to indicate a detailed evaluation of all of Resident #1's medications/behaviors was done, how the Onsie undergarment effected the resident and how the safety of of the resident and the potential resident victims would be protected while an assessment of the circumstances of Resident #1's behaviors was completed. Review of the Resident's Comprehensive Care Plan (CCP) failed to provide a specific treatment plan for social services (SS) and interventions to assist the resident in meeting treatment goals. The CCP revealed SS would participate to: Monitor for restraint use due to Onesies (one-piece) undergarment to prevent fecal play; reassure the resident when he becomes agitated; review his code status; praise the resident's decisions; supervise decision-making; monitor glasses/vision; talk with the resident related to behaviors; assist with activities; discuss potential medication side effects with family; discuss all options for discharge with responsible party. Review of the most recent Care Conference (CC) note dated 11/18/15 with the SS Director, Director of Nursing Services (DNS) and sister, indicated increased behaviors, resident-to-resident altercations, continued use of Merrywalker due to falls, long-term care rights reviewed. The documentation did not indicate a discussion related to the psychologist's concerns occurred. Documentation related to progress in improving his physical, mental and psychosocial functioning was not found and the CCP was not updated to reflect goal attainment or evaluation /effectiveness of interventions. The CCP did not link goals to psychosocial functioning/well-being or safety. On 1/15/16 at 12:15 p.m., the SSD was asked about the resident's SS care plan and working with the resident. She stated: I have been working with him when there has been altercations after the events. I am in touch with his daughter (corrected by the DNS to sister not daughter) and review his care .we have had discussions with his sister about .if this is the best place for him. What her feelings are .work in progress but the doctor said we should evaluate his medications .tapering Depakote .We have not made calls outside .we have had talks about Auburn (Gero-psych facility to help stabilize the resident) with the administrator, medical records, assessment staff, all managers . The Administrator and DNS said they had not heard of any plans for Auburn and only verbal mention of Western state hospital. There was no plan to specifically address the resident's social service needs related to his dangerous behaviors and how SS had actively advocated for the Resident's well-being. Refer to F 226; F 279; F 323

Based on interview and record review, it was determined the facility failed to use the results of assessments to develop, review and revise the Comprehensive Care Plan (CCP) for 2 of 6 sampled Residents (#1 and #6) reviewed for care plans. This failure resulted in harm to Resident #1 and #6 and prevented the interdisciplinary team from being aware of residents' strengths, prevented the development of measurable goals for care provided, failed to describe the services to be furnished to the resident and failed to evaluate interventions for effectiveness that improved/maintained their health status and/or prevented decline. Findings include: 1) Resident #1 was admitted to the secured unit on 8/29/14 with multiple medical conditions including a history of [MEDICAL CONDITION] (TBI, [AGE] years ago) from a motor vehicle accident, [MEDICAL CONDITIONS] and [DIAGNOSES REDACTED] (a type of progressive dementia that leads to a decline in thinking, reasoning and independent function). The most recent Minimum Data Set (MDS) an assessment tool dated 11/6/15 indicated the resident needed extensive assistance of two people for all daily living tasks. He remained in the secured unit as he was identified on three occasions between 11/10/15 through 12/30/15 to be a danger to himself and others. On 11/7/15 Resident #1 incurred a self-inflicted burn to his left thigh from spilled hot cereal after being left alone in his room .care plan was updated. On 12/23/15 during the evening, the resident was yelling, punching/grabbing staff, and threw his radio in the sink under running water. Nothing was found on the CCP. On 11/14/15 Resident #1 hit another resident causing injury . care plan was updated. On 11/17/15 Resident #1 grabbed Resident #3's neck resulting in an injury that required first aid .care plan was revised. On 11/21/15 Resident #1 grabbed Resident #4's breast resulting in bruising . danger to self and others .care plan was revised. On 11/30/16 Resident #1 became angry with behavioral outburst and hit a nursing assistant (NA) causing an injury, observation, care plan reviewed. On 12/1/15 Resident #1 became aggressive towards staff, scratched NA. The report indicated Revised care plan .protect resident from self-harm and other residents. Observation, medication changes. Resident is a danger to self and others. On 12/16/15 Resident #1 yelled at Resident #5 and grabbed her hand causing Resident #5 to hit Resident #1 .Updated care plan .danger to self and others. On 1/15/16 at 11:00 a.m., Resident #1's CCP, in the clinical record, was reviewed with Registered Nurse (RN) #3. S/he was not familiar with the CCP and was not able to interpret several pages, specifically the fall/safety plan because of the disorganized writing all over the page. She said: He uses the Merrywalker to help prevent repeated falls .I think the DNS does them (care plans). I don't work with them .when we have something different I am supposed to be doing it. I don't know what the care plan is for him .I do know he can't be by himself or around other residents. We can't do 1:1 because we are so busy. When we get busy we have to put him in his room. I have heard he is worse on evenings. Resident #1's CCP revealed: monitor for restraint use due to 'Onesies (one-piece body suit) undergarment to prevent fecal play. The CCP failed to show evaluation of the Onesie and the effectiveness/outcome to this male resident. Resident #1's CCP failed to clearly identify the measurable goals/objectives related to the resident's dangerous behaviors/falls/safety/restraint use of Onesies and updated interventions that were implemented and evaluated for effectiveness to reflect what changes were made to the care plan that would guide and direct staff to ensure Resident #1's safety from altercations, restraints, seclusion and injury that would prevent further harm. Refer to F 226 and F 323 2) Resident #6 was admitted to the facility on [DATE] with heart failure, high blood pressure, dementia and incontinence of bowel and bladder. The resident received a daily diuretic. A bowel and bladder assessment dated [DATE] indicated total dependence on staff for toileting. The environmental factors/assistive devices section regarding the resident's toileting ability such as grab bars, bedside commode, low toilet seat was blank. The resident was dependent for transfers. The assessment indicated the resident did not know when she needed to toilet and was unable to follow commands. The most recent MDS assessment dated [DATE] indicated the resident could make her needs known and was a One person assist to toilet with staff providing weight-bearing support. On 1/13/15 at 11:00 a.m., Resident #6 repeatedly asked for help to go to the bathroom. At 11:30 a.m., rather than taking the resident to the bathroom, NA #6 said she needed to use the Hoyer (mechanic lift) and bedpan because: That's what I've always known to do. I don't know why she can't use the toilet .she usually just goes in her briefs. The NA information guide indicated the resident speaks well and 2 person assist with a Hoyer (mechanical lift). The guide did not identify use of the bathroom, bedpan or bedside commode nor why allow the resident to be incontinent when she repeatedly requested to use the toilet. On 1/15/16 at noon, the DNS was asked about the Resident's plan for toileting with assistance versus mechanical lift to bed to use the bedpan. S/he said this was unclear and would follow up to see what happened. The CCP failed to provide current measurable goals, interventions and evaluations of intervention effectiveness that resulted in staff not knowing what measures were most appropriate to implement for the resident's well-being, dignity and independence that resulted in harm to the resident when she was not helped to toilet in a timely manner. Refer to F 241

Based on observation, interview and record review, it was determined the facility failed to have sufficient, qualified staff to provide and supervise care for 5 of 5 sampled residents (#'s 1, 2, 3, 4 and 5) residing in the secured memory care unit. Observations of care, interviews with staff, combined with record reviews, revealed inadequate supervision of residents to ensure the care needs of these residents were met by licensed staff or certified nursing assistants in accordance with established clinical standards and their care plans. Staff did not adequately assess, plan, report or document information needed to formulate effective and timely interventions and evaluate the interventions for effectiveness. This failure resulted in harm when residents were not protected from repeated physical abuse. Findings include: The above information has been detailed in the following citations: 1) Refer to: 42 CFR 483.13(c)(2), F226-Abuse Policies and Procedures - for facility failure to operationalize its written policies and procedures to prohibit mistreatment, abuse and neglect related to 5 of 5 current sampled residents, who resided in the secured unit (Memory Care) and resulted in harm to Residents #1, #2, #3, #4 and #5 reviewed for abuse, neglect and mistreatment. This failure posed a repeated risk to these and other residents and resulted in immediate jeopardy. 2) Refer to 42CFR 483.15(a), F241, Quality of Life, for examples of failure by facility staff to supervise care for Resident #6, resulting in harm when staff in failed to respond to the resident's repeated pleas for help with toileting. 3) Refer to 42CFR 483.15(g)25, F-250; Social Services, regarding the failure by staff to develop a consistent plan to address the behavioral symptoms exhibited by Resident #1 when he demonstrated aggressive, assultive behaviors and placed himself and other residents, as well as staff, at risk for injury due to the residents impulsive, aggressive behaviors and resulted in harm. 4) Refer to 42CFR 483.20(k) Comprehensive Care Plans (CCP) F 279 regarding the failure to use the results of the assessment to develop, review and revise the resident' comprehensive plans of care that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and resulted in harm to Residents #1 and #6. 5) Refer to 42CFR 483.25(h), F323, Accident Hazards, regarding facility failure to supervise staff in order to ensure Resident #'s 1, 2, 3, 4 and 5 were protected from harm related to accidents and injuries. On 1/15/16 at approximately 11:30 a.m., Licensed Nurse (LN) #3 was asked about adequate staffing for the secured unit. When asked specifically about Resident #1, she said when it gets busy and staff cannot monitor him closely, he is placed in his room. LN #3 did not participate in the care planning process and was not familiar with the resident's care plan. Staff members stated they could use more staff on the secured dementia unit and since the facility no longer used agency nurses there was one LN and two Nursing Assistants (NA) on day shift; one LN and two NAs for evenings and one LN that worked another unit as well as the secured dementia unit with 1 NA for night shift. Lack of staffing for the secured unit was validated upon review of the staffing schedules for the last two months. The staffing schedule for December 2015 and January 2016 revealed the night shift schedule for the entire facility had two LNs (one scheduled for the 100 hall and 1 scheduled for both the 200 hall and secured unit with 4 NAs scheduled for the entire facility each night with one being assigned the secured unit. On 1/15/16 at noon, the Administrator and Director of Nursing Services (DNS) stated they were hiring more staff members and started to employ them before the previously determined hiring date to start in July 2016. Refer to F 226; F 241, F 250, F 279 and F 323.

Based on interview and record review, the facility failed to consult with the physician for 1 of 8 residents (#2) when the resident exhibited signs and symptoms that required physician intervention. This failure resulted in harm to the resident who required hospitalized for [REDACTED]. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was prescribed medications to increase appetite, control blood pressure and control pain. According to the Minimum Data Set (MDS), an assessment instrument, dated 8/13/14, the resident required extensive assistance with activities of daily living (ADLs). The resident was usually alert and cooperative with staff, but had some memory problems. On 6/4/14, the dietitian had assessed the resident's estimated daily fluid needs at 1540 cc (cubic centimeters), or about 6-7 glasses of liquid. On 7/10/14, the resident was seen by a physician who ordered lab work to be completed on 8/7/14. No evidence was found that the lab work was done. The resident lost 10 pounds between 8/1 and 8/19. There was no indication the physician was consulted. The resident had low systolic blood pressure (top) 21 times during August. There was no indication the physician was consulted. The resident experienced a decline in condition, despite receiving physical and occupational therapy during June, July and August. The physician was not consulted. On 8/16, the resident's fluid intake was 1429 cc. On 8/17, the resident's fluid intake was 1080 cc. On 8/18, the resident's fluid intake was 1420 cc. On 8/19/14, the resident's fluid intake was 780 cc. On 8/20/14, the resident was unable to take fluid. The resident had oral intake less than the recommended amount for several days. The physician was not notified. The resident experienced a decline in mentation on 8/19/14. The physician was not notified. On 8/20/14, the resident was unresponsive with extremely low blood pressure. She was sent emergently to the hospital where she was found to be in acute kidney failure from lack of fluid. The physician was not consulted until the resident was unresponsive and needing transport to the hospital. On 9/24/14 at 12:05, Licensed Nurse (LN) A stated "I am sure the physician was aware of the resident's condition." LN A looked through the resident's record and was unable to find evidence the physician had been consulted about the resident's declining condition until an emergency situation evolved. Refer to F 309 .

Based on interview and record review, the facility failed to provide necessary care and services to 1 of 8 residents (#2) when they failed to comprehensively assess, failed to recognize and failed to competently address possible causes of the resident's decline in physical and mental condition. This failure caused harm to the resident who required a 9 day hospitalization for severe dehydration. Findings include: Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had medications prescribed to increase appetite, control blood pressure and control pain. According to the Minimum Data Set (MDS), an assessment instrument, dated 8/13/14, the resident required extensive assistance with activities of daily living (ADLs). The resident was usually alert and cooperative with staff, but had some memory problems. The resident received physical and occupational therapy for strengthing and to help with ADL and cognitive skills. On 6/4/14, the dietitian had assessed the resident's estimated daily fluid needs at 1540 cc (cubic centimeters), or about 6-7 glasses of liquid. On 8/15/14, according to chart notes, the resident had met therapy goals and plans were underway for her to discharge to an adult family home when arrangements were finalized. Through out the stay, the resident had problems getting enough food and fluid. She required feeding assistance and was on medications to increase appetite and also took high protein, high calorie supplements. The resident's weight on admission was 113 pounds. She lost 7 pounds during the first month following admission, but with interventions her weight on 8/1/13 had returned up to 112 pounds. On 8/19/14, the resident's weight was 102 pounds, or a 10 pound loss in 2 weeks. Medication Administration Records (MARS) reflect the resident was to receive [MEDICATION NAME] 320 mg (milligrams) daily for high blood pressure. The medication was not to be given if the systolic (top) number was less than 100. August MARs show the medication was not given on 8/15 or on 8/20 because of a low heart rate. MARS also reflect the resident was to receive [MEDICATION NAME] 50 mg 3 times a day for high blood pressure. The medication was not to be given if the systolic number was less than 100. The medication was not given 19 times (out of a possible 58 times) during the month of August because of the systolic blood pressure being too low. On 8/19/14, a social services note indicated "Plan to d/c (discharge) tomorrow at 11:30. All parties aware." On 8/19/14, a nursing note written in the day time reflected "Very sleepy. Didn't eat when staff attempted to feed breakfast." The total fluid intake for the 24 hour period was 780 cc (about 3 glassfuls). A nursing note written later, on the evening shift reflected "Resident appeared very sleepy. Ate only bites this shift." On 8/20/14 at 07:15 a.m., the resident was "Very lethargic, not responding." "Doctor notified of grave condition and that resident will be sent to hospital. 911 notified." On 8/20/14, emergency department records reflect the resident was "clinically dry" (dehydrated) and non responsive. The resident was hospitalized for [REDACTED]. The final [DIAGNOSES REDACTED]." On 9/24/14 at 11:35 a.m., Licensed Nurse (LN) B stated "The resident (#2) declined during her stay here. I know she was eating less, but I can't remember what else was going on with her." At 12:05, LN A stated "The resident had been stable enough to discharge a few days before she became ill. She had a change in mentation and was not responding even with sternal rub (a procedure which can sometimes revive patients). We sent her to the hospital and I knew she was in intensive care, but I don't know what the findings were. There was a decline while she was here." LN A stated that signs and symptoms of dehydration could be confusion, a change in mental status, low blood pressure or increased respirations. When asked, LN A was unable to find indication in the record that the resident had been evaluated for possible organic causes for the decline or interventions to counteract the decline. Despite the resident's 10 pound weight loss over 2 weeks, the mental status change, steady condition decline, low blood pressure readings and poor fluid intake, the facility did not perform an assessment of the resident. It appeared the facility was proceeding with discharge planning as the resident became more and more acutely compromised. .

Based on observation, interview and record review, it was determined the facility failed to ensure the necessary care and services were provided for 2 of 19 current sampled residents (#44 & 54) reviewed for non-pressure related skin issues, positioning and bowel protocol. This failure placed residents at risk of delayed treatment to reach the highest level of physical, mental and psychosocial well-being. This failure caused harm to Resident #44 when a non-pressure related skin issue was allowed to continue for several weeks without intervention. Findings include: 1) Resident #44 was admitted to the facility on [DATE] with a re-admit on 7/18/13 with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool, dated 02/28/14, the resident had memory problems and communication difficulty. The resident was dependent on staff for all activities of daily living (ADL) care. The resident was able to move his right hand and arm, but could not move other extremities. <Non-Pressure Skin Condition> On 03/19/14 at 05:10 p.m., during care, the resident was observed to have redness with swelling and irritation under the arms, under the abdominal folds and in the groin areas. The inner thighs, perineal area and buttocks area were also noted to be red and excoriated. The areas appeared to be painful for the resident who was noted to grimace and groan during personal care cleaning. When asked, Licensed Nurse (LN) E stated "That is a yeast infection, the resident has had that for a couple of weeks." At 06:15 p.m., a review of the physician orders [REDACTED]. On 03/21/14 at 10:36 a.m., during a review of the resident's treatment supplies, Licensed Nurse (LN) D stated, "This anti-fungal cream is for {Resident #44}. I guess we should get rid of it. I didn't know he was using this cream any more. He had used in in the past." LN D then reviewed the treatment record and verified the resident was receiving no treatment for [REDACTED]. LN D was asked by the surveyor to assess resident #44's skin to see what treatments might be needed. At 12:05, LN D stated, "I have had a chance to look at (resident #44's) skin. I think he has a yeast infection. I will contact the physician and get an anti-fungal cream treatment started." <Positioning> The Positioning, Bed Policy provided by the facility stated the purpose as: To contribute to the resident's comfort. To relieve pressure on various parts of the body. To help prevent the formation of contractures or deformities. To improve circulation. A care plan for falls, dated 1/25/14, noted the resident is non-ambulatory and currently bed bound, needing total assistance with bed mobility. A pressure ulcer care plan for Resident #44, dated 2/11/14, noted, "Unable to reposition self. Full staff assist of 2-4 persons & hoyer lift for bed mobility." The care plan had an added, hand written approach of every one (1) hour monitoring and repositioning. The Nursing Assistant Care Card used for nursing aid task assignments, noted to turn and reposition every one (1) hour. On 3/17/14 at 2:30 p.m., resident #44 was observed to be in bed with a sheet across the midsection leaving legs and upper torso exposed. No clothing was visible. The resident was positioned on the left side of his body facing out and away from the wall. At 4:04 p.m., the resident was observed with his eyes shut in the same position facing away from the wall. On 3/18/14 at 10:11 a.m., Resident #44 was positioned on his left side facing away from the wall. He was observed to remain in the same position at 11:13 a.m., 11:29 a.m., and 12:15 p.m. On 3/19/14 at 8:41 a.m., the resident was observed on his right side facing the wall. He was observed in the same position at 10:15 a.m. and 10:23 a.m. At 11:46 a.m. the resident was positioned on his left side watching television facing away from the wall. At 1:46 the resident was observed to be in the same position. At 1:51 p.m. the resident nodded, "yes," when asked if he was uncomfortable. He then shook his head, "no" when asked if staff had not been in to help him reposition recently. The resident verbally responded, "No" when asked again if staff had been in to help reposition him in the last hour. He also responded verbally when asked if he wanted staff informed he would like to be repositioned and stated, "Yes." At 1:59 p.m., nursing staff entered the resident's room to assist him reposition. At 2:25 p.m., Nursing Assistant (NA) A stated positioning times are documented on a piece of paper carried in her pocket and then put in the book at the nurse's station at the end of the shift. NA A stated, "We reposition Resident #44 every hour on the hour. Usually I know he's been moved because he's faced out then towards the wall, alternating one side to the other. That's how I do it." When asked about documentation of specific repositioning times, NA A stated the times aren't documented except for Resident #44. He was the only one that gets turned every hour. He has a sheet in his room for every time he was turned. On 3/21/14 at 8:55 a.m., Resident #44 was positioned on his right side facing the wall. The resident was observed to be in the same position at 9:51 a.m. and 10:05 a.m. The resident was determined through assessment to require every hour position changes, Position changes were not observed to be completed every hour as required by the resident's plan of care. <Bowel Management> Resident #44's bowel assessment, dated 01/31/14, noted the resident was always incontinent of bowel due to a stroke, had been incontinent for years, was never constipated, used laxatives, and eliminated daily. The bowel movement (BM) record showed the resident had not had a bowel movements during the following times: 10 shifts - from 03/02/14 day shift to 03/05/14 day shift 10 shifts - from 03/07/14 night shift to 03/10/14 night shift The resident's Medication Administration Record [REDACTED]. On 03/21/14 at 11:12 a.m., the Assistant Director of Nursing Services (ADNS) stated the bowel protocol was Milk of Magnesium was given if a resident does not have a BM after 72 hours (9 shifts). If the resident still does not have a BM the following shift, then a suppository is given. If the resident still does not have a BM the following shift, then an enema is given. After reviewing the BM record and the corresponding MAR for Resident #44, the ADNS stated it did not appear anything was done for the resident during these time frames. At 11:33 a.m., the ADNS stated, "There should have been something given during those times." 2) Resident #54 was admitted to the the facility on 09/17/12 and had [DIAGNOSES REDACTED]. The resident's MDS, dated [DATE], indicated the resident was able to make needs known, had moderate cognitive impairment, was totally dependent on staff for ADLs, had a high risk for skin issues, and participated in the MDS assessment process. <Non-Pressure Skin Condition> The resident's care plan addressed skin integrity with problems of bed mobility and transferring, goals, and interventions including "ensure that turning and toileting/peri care (personal hygiene) is offered and done as frequently as resident allows. Offer q2h (every 2 hours) & (and) PRN (as needed)." On 03/17/14 during observations throughout the afternoon, the resident was observed sitting up in bed fidgeting. On 03/18/14 at 9:25 a.m., the resident was observed sitting up in bed fidgeting/shaking under the covers. At 9:29 a.m., the resident stated she was itchy and was not receiving any treatment for [REDACTED]. The Physician Orders, dated 10/05/12, documented, "Apply antifungal cream/barrier cream to bilateral axilla, abdominal folds, gluteal folds and under breasts PRN (as needed) for yeastly rash." Record review of the March 2014 Treatment Administration Record, documented the order for the antifungal cream/barrier cream. Documentation showed the cream had only been given once, on 03/19/14 with no time indicated, for the month of March 2014. On 03/20/14 at 10:18 a.m., the resident stated she felt much better today. The staff had applied the cream yesterday afternoon. On 03/21/14 at 11:48 a.m., LN B stated, "The resident will not tell staff about it (being itchy)." When asked how it is identified if the resident does not report it, LN B stated it would be identified when the resident received peri care and during skin checks. "It is the nursing assistants (NAs) who provide peri care and they may not know what they are seeing." LN B stated she would work on educating the NAs to identify when the resident is having issues with being itchy. LN B indicated the Nurse Practitioner had been in on 03/17/14 and the resident did not report it. The itchiness was not identified at that time. At 12:15 p.m., the Director of Nursing Services (DNS) stated an assessment of her skin would be added to her care. The facility failed to identify and treat the resident's itchy skin condition. Staff were aware the resident did not report to staff when she was itchy and failed to ensure treatment would be received when resident was reluctant to report itchy skin. .

Based on interview, observation and record review, the facility failed to ensure residents received the appropriate care and services for 1 of 3 current sampled residents (#9) reviewed for dealth and non-pressure skin conditions. These failures placed residents at risk for not receiving requested basic life support intervention measures, and not receiving physician ordered medications. This failure caused harm to Resident #9. Findings include: 1) Resident #9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), an assessment tool of a resident's physical and mental abilities, dated [DATE], documented the resident was able to make his needs known and understood what was spoken to him. It documented he was an extensive assist of one person for bed mobility, transfers and toileting. He was independent with locomotion once in his wheel chair. A POLST form (a document a resident and physician sign to direct medical care and interventions in case of a medical emergency or significant health change), dated [DATE], documented the resident wanted Cardio-Pulmonary Resuscitation (CPR) to be performed if his heart stopped. On [DATE], a [MEDICATION NAME] [MEDICATION]) level was to be drawn by the laboratory. There was no evidence a [MEDICATION NAME] level drawn from [DATE] to [DATE]. On [DATE], at 9:15 p.m., the Nurses Notes documented the Nursing Assistant (NA) called Licensed Nurse (LN) H to the resident's room after he had convulsions. The resident's temperature was 98.9 degrees Fahrenheit (F). On [DATE], LN F documented at 2:50 a.m., in the Nurses Notes,the resident had a temperature of 103.8 F. LN F gave the resident a tylenol suppository, and at 3:45 a.m., his temperature was 101.9 F., respirations were 40 (normal respiratory rate is ,[DATE]). It was documented the resident refused to have his blood pressure or pulse taken. The resident was placed on his left side. At 5:15 a.m., LN F documented in the Nurses Notes she was notified by the NA the resident was breathing fast, like "hyperventilating." LN F documented "I was in a room with another res (resident) at the time of alert (5:15 a.m.). Left res (resident) room to check on res (resident) respirations and recheck temp (temperature) at 5:25 a.m.,(10 minutes after notification by NA), Res (resident) appeared calm by visual check, but when assessing res (resident) noted color of hand pale white. Nail beds blue in appearance with no capillary refill present. Unable to locate pulse in all extremities. No appearance of breath sounds. Pupils non-reactive to light. Pupils fixed and glossy in appearance. At 5:30 a.m., came out of res (resident's) room to view chart and saw Day nurse and immediately told concern of Res (resident) appearance." LN E documented after LN F's above Nurses Note. "5:25 a.m.,Resident pronounced by LN K. Call placed to physician's answering service." At 5:40 a.m.,LN E documented in the Nurses Notes, the DNS was called and left a message. At 5:45 a.m., LN E documented she talked with the Administrator and updated her, the resident "had passed." At 5:50 a.m., LN E documented a message was left for a family member of Resident #9. At 6:00 a.m., LN E documented "other message left with the physician's answering service." At 7:00 a.m., LN E documented Resident #9's daughter in law was spoken with, and she stated the son of the resident would call the facility. At 7:05 a.m., LN E documented the physician had returned the call, and gave orders to release the body to the funeral home. At 7:10 a.m., LN E documented the son had called and would call later with the name of the funeral home. At 7:20 a.m., LN E documented the DNS returned her call and was updated. At 8:00 a.m., LN E documented Resident #9's family member called the funeral home and the approximate time the funeral home would pick up the deceased resident. At 10:15 a.m., LN E documented Resident #9's remains were released to the funeral home. At 1:00 p.m., RCM Q documented a late entry in the Nurses Notes, that she was notified by the MD to contact the coroners office. After the [DATE], RCM Q Nurses Notes entry at 1:00 p.m., there was no further Nurses Notes documentation in the medical record of the deceased resident. The medical record for Resident #9 was copied by the surveyor on [DATE] at 9:52 a.m.. On [DATE] at 10:24 a.m., the DNS was questioned about the resident's death. She stated "she (LN F) was notified at 5:15 a.m., by the aide and then she went to assess the resident at 5:25 a.m., and well, she is a brand new nurse and freaked out because he was cold, she got LN E, who knew he was dead and got the RN to pronounce it (the resident's death)." When questioned if CPR had been performed in accordance with the POLST and resident's life wishes she said "No, no CPR was started because he (the resident) was cold, she (LN F) just freaked out, it was her first death." On [DATE] at 4:46 p.m., the facility provided Nurses Notes that were inconsistent with the original medical record provided at the time of the onsite survey. The facility provided a policy dated [DATE] that documented "If a resident is found with no pulse and is not breathing and is a full code, regardless of how long they have been that way, CPR must be started immediately and 911 called. We must follow the resident's POLST form as it is a legal document." . . .

Based on observation, interview and record review, the facility failed to thoroughly investigate, analyze, and implement current interventions and take additional corrective actions to prevent further occurrences of falls for 1 of 3 current sampled residents (#68) reviewed for accidents and incidents. Resident #68 sustained an elbow laceration on 4/1/11, a head injury on 4/25/11 (requiring an emergency room visit), a bruised right hip on 4/28/11 and a finger laceration on 5/01/11. This failure caused harm to Resident #68. Findings include: Resident #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He received medications known to cause dizziness and weakness. According to the Minimum Data Set (MDS), an assessment tool, dated 03/14/11, the resident was cognitively impaired with memory problems. He had a history of [REDACTED]. On 5/2/11 at 5:00 p.m. and again at 6:30 p.m., the resident was observed resting in a low bed with non skid strips on the floor near his bed. On 5/3/11 at 9:00 a.m., Resident #68 was observed sleeping in his low bed with a large, yellow, puddle on the floor by his bed. There was no commode in the room or a urinal. On 5/3/11 at 2:00 p.m., an interview with resident's family member/representative stated she was concerned with the frequency of the resident's falls. "I almost like him to stay in bed all the time now, he falls twice a week, he fell last night and cut his finger, last week he hurt his right eye, he hurt his leg ...he falls all the time...." Review of the resident record revealed a care plan for falls, dated 10/21/09. Interventions included keep bed in the lowest position, ensure the resident has nonskid slippers or shoes on before getting out of bed, well lit and uncluttered environment, place personal objects within easy reach, sensor alarm next to bed to alert staff of rising to decrease slipping from inappropriate toileting, hipsters (briefs with pads positioned in the hip area) to decrease risk of fracture with falls. A bladder incontinence care plan, dated 10/21/09 documented interventions to include; " establish toileting routine for resident, resident will toilet himself frequently throughout the day requiring extensive assist for toilet hygiene and peri-care once per shift to prevent infection, monitor for resident to pat or grab at his peri-area as a sign that he needed to use the bathroom, commode at bedside due to inappropriate toileting in bedside table, and toilet resident every hour while awake." On 05/04/11 at 4:30 p.m., a bed alarm was sounding outside of the resident's room in the hallway. There was no staff in the immediate area. The door was closed to resident's room. The surveyor entered the room to discover the resident on his hands and knees by the bed patting the floor as if he was looking for something. The resident was barefoot. There was no commode in the resident's room. In an attempt to stand up, the resident held his genitals and cried, "I'm wet, I'm wet." The surveyor had to obtain staff to assist the resident. Record review revealed the resident had fallen eight times between 4/1/11 and 5/5/11. The first fall was a witnessed fall in the resident's room at 2:50 p.m. on 4/1/11. On the facility incident report a staff member who witnessed the fall documented "Resident #68 slipped in urine, hitting his right arm and elbow on the floor. An additional statement from a staff member who witnessed the fall documented there was urine on the floor. Another staff's statement documented the floor was wet. However, a question on the investigation report inquired "was the environment barrier and hazard free?" was marked "yes." The 4/1/11 facility investigation report documented "no new medications or changes in the past month." A medication review revealed the resident was prescribed a psychoactive medication (medications used to treat psychotic disorders) on 2/14/11 with an initial dose was 25 milligrams (mg) twice daily. The dose was increased on 3/3/11 to 50 mg twice daily and increased again on 3/14/11 to 75 mg twice daily. A new intervention to mitigate the risk of additional falls was to refer the resident to therapy. There was no documentation addressing the resident's incontinence or recent medication changes which may have contributed to the fall. The second fall was a non-injury, witnessed fall into a wheelchair that was in the hallway on 4/3/11 at 8:30 a.m. The facility incident report revealed one witness documented Resident #68 "seems weak. Another statement from a witness documented the resident was "confused and in pain." The facility's investigation report documented "no recent concerns or complaints of pain and no concerns or complaints of weakness " . A new intervention to mitigate the risk of additional falls was to assess for injury and complete a urine screen. The third fall was an unwitnessed, non-injury fall on 4/18/11 at 2:30 a.m. in the resident 's bathroom "having slid in urine." Documented on the incident report was resident did not have appropriate footwear, his alarm was not used and/or not verified that it worked, and his last toileting time was "self." A new intervention to mitigate the risk of additional falls was to place non skid strips on the floor in the bathroom. There was no documentation addressing the resident not having appropriate footwear, or the bed alarm not working. The fourth fall was unwitnessed, occurring on 4/19/11 at 8:00 a.m., the incident report documented Resident #68 "was on the floor in a puddle of urine in a sitting position." Additionally, the incident report revealed the resident was barefoot and his bed was moved over the grip strips that were placed by it to prevent him from slipping and no bed alarm was being used. A new intervention to mitigate the risk of additional falls was to "put a sensor alarm next to resident's bed and alert staff of attempts to toilet independently to decrease resident slipping in urine from inappropriate toileting." There was no documentation in the investigation report addressing the resident not wearing appropriate footwear, the reason for the bed being over the non-skid floor strips and the reason for the bed alarm not being used. The resident's fifth fall was unwitnessed and occurred on 4/25/11 at 9:45 a.m. The facility investigation report documented "resident fell out of bed trying to stand and hit his head on bedside table." "...Motion alarm at bedside did not sound, unknown if resident's legs were in the targeted area." The report indicated the resident had a bed alarm, but, staff did not verify the alarm was in working condition. The resident sustained [REDACTED]." There were no new interventions identified to mitigate the risk of additional falls. There was no documentation addressing the non-verification and/or non-functional alarm or an examination of the resident's legs not being in "the targeted area." The sixth fall was a witnessed fall in the hallway outside of the resident's room at 1:25 a.m., on 4/28/11. The facility's incident report documented, "Resident #68 came out of his room and urinated in the hall outside the room door, he took a step toward his room slipped on urine and fell on the floor ...resident landed on his right hip." Documentation in the facility's report indicated, "resident in pain from the fall, appears to be in pain when right hip is touched...purple bruise appearing on right hip." The investigation also documented "no recent concerns or complaints of pain and no concerns or complaints of weakness." There were no new interventions identified to mitigate the risk of additional falls from the resident's incontinent episodes. There was no documentation addressing the reason the resident was in the hallway at 1:25 a.m., or additional analysis of the fall. The seventh fall was a witnessed fall in the resident's room as he was walking out the door into the hallway at 10:15 p.m., on 5/2/11. The facility's incident report documented, "resident was coming out of his room and seemed unstable so I helped him back to his bed. As he entered the room ...he stumbled, crossed his legs over each other and he fell on to his back hitting the chair and landing in between roommate and table." Resident #68 sustained a right finger laceration/injury." Contributing factors identified by the witness who observed the fall included, "medications recently taken Trazodone (used to treat depression and anxiety) and Seroquel (used to treat psychotic symptoms)...Resident was walking around and seemed tired, unsteady and appeared groggy." A new intervention identified to mitigate the risk of additional resident falls was to "continue every one hour toileting program." There was no documentation in the investigation report addressing the affect the medications on the resident as identified by the witness. Side effect of these medications include increased thirst, urination, dizziness, drowsiness, tired feeling. The eighth fall was a witnessed fall in the resident's room as he was walking out the door into the hallway at 1:55 a.m., on 5/5/11. The facility's report indicated Resident #68 was "in the hallway outside his room ...appeared to lose his balance falling onto his right side." New interventions identified to mitigate the risk of additional resident falls were; repeat urinalysis (UA), lab work ordered, hipsters discontinued related to non compliance, and resident started on an antibiotic. There was no indication of the reason the resident was in the hallway at 1:55 a.m. On 5/5/11 at 11:00 a.m., Nursing Assistant (NA) A stated she did not know what "hipsters were and the resident was not wearing them." She stated the resident's toileting schedule was one time an hour if he was awake, if he was sleeping he was not awakened or offered use of the toilet. At 11:15 a.m., Licensed Nurse (LN) B stated this was the first she heard of "hipsters" and the resident did not use them. Between 2:45 p.m. and 4:00 p.m., the resident was observed sleeping in a straight back, wooden, dining room chair positioned at the sink in his room. The resident was barefoot, and did not have an alarm attached. No staff were observed to offer the resident toileting assistance. On 5/09/11 at 10:00 a.m., LN A said she did not know he wore "hipsters" or what they were. LN A stated resident's condition declined dramatically in the past two months and he was sleeping a lot during the day. From 10:30 a.m. to 12:30 p.m., the resident was observed lying in bed. No staff were observed to offer the resident toileting assistance. At 2:30 p.m., the Director of Nursing Service (DNS) stated several interventions were initiated to prevent the resident's falls. She stated she knew he had a couple of falls in March and than in April he had a big increase in falls. She said other interventions included resident wearing non skid shoes and/or slippers, non skid strips were placed in the bathroom and by his bed, a commode was placed in his room, he was to wear hipsters, and his bed alarm was changed to a motion sensor. "We have tried everything to prevent this resident from falling."