Every finding on record at Cashmere Post Acute

Based on interview and record review the facility failed to maintain a current Clinical Laboratory Improvement Amendment (CLIA) certificate required to perform laboratory tests within the facility. This failure placed residents at risk for substandard care, delayed diagnosis and incorrect medical treatment. Findings included. During an observation and concurrent interview on [DATE] at 1:55 PM, Staff A, Administrator, stated they had noticed the facility's CLIA certification had expired on [DATE] (an elapsed period of 9 months and 10 days). Staff A stated that they recalled paying the renewal fee for the previous year. During an interview on [DATE] at 10:03 AM, Staff A stated they were aware that the CLIA certificate was expired and stated they were ultimately responsible for the compliance of the facility's certifications. Staff A stated their quality assurance team was responsible for tracking financial stuff to ensure such fees were paid. Reference: WAC 388-97-1620 (2)(b)(i)

Based on interview and record review the facility failed to ensure 3 of 5 residents (Residents 81, 2, and 77) were reviewed for gradual dose reduction (GDRs- the slow, step-by-step process of decreasing a residents medication overtime), or provide a clinical rationale for its contraindication as required for the use of psychotropic medication (drugs that alter brain function used to treat mental health conditions) reviewed for unnecessary medications. This failure placed residents who used psychotropic medications at risk for adverse side effects (ASEs) which could negatively impact their overall health and quality of life. Findings included .Record review of a facility policy titled Use of Psychotropic Medications revised 01/2025 showed, residents who use psychotropic drugs shall receive gradual dose reductions unless clinically contra-indicated, to discontinue the use of these drugs. Resident 81 Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening or traumatic event), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety ( a feeling of fear, dread, and uneasiness that's acts as a natural temporary reaction to stress). The 12/02/2024 comprehensive assessment showed Resident 81 cognition was moderately impaired and received an anti-depressant (a medication used to treat symptoms of depression and anxiety) and an antipsychotic (used to manage symptoms such as delusions, hallucinations, paranoia, and disordered thoughts) medications. Record review of Resident 81's physicians orders dated March 2026 showed the resident's medications included daily use of three psychotropic medications: Aripiprazole 10 Milligrams [(mg) a unit of measure] (an antipsychotic- a class of medication used to treat symptoms of psychosis and PTSD), one time daily, with a start date of 09/20/2025, bupropion extended release 150 mg daily, with a start date of 07/25/2025 and trazodone 100 mg once daily ( an anti-depressant) with a start date of 07/25/2025. Review of the Psychotropic Drug Review Meeting minutes dated 07/25/2025 (admission review), 09/24/2025, 11/26/2025, and 02/24/2026 showed no documentation to show that Resident 81 had been reviewed for GDR's related to their psychotropic medications, or that a clinical contraindication had been completed and placed in the resident's medical record. During an interview on 04/02/2026 at 3:45 PM, Staff B, Director of Nursing, DON, stated staff I, Social Service Director, SSD, was responsible for keeping track of the GDR attempts and obtaining documentation if a psychoactive medication was clinically contraindicated. Staff B stated they would expect newly admitted residents to have two different GDR attempts within the first year; if not, they would expect the contraindication to be documented in the resident's medical record. During an interview on 04/03/2026 at 9:52 AM, Staff B stated Resident 81 had not had any GDR attempts since admission and did not have any clinical contraindications documented in their medical record. Staff B further stated the correct process was not followed for Resident 81. Resident 2 Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses which included dementia (a decline in cognitive function to include memory and reasoning), depression (a mood disorder which causes feelings of sadness), post-traumatic stress disorder (PTSD, (a mental health disorder caused by an extremely stressful event) and anxiety. The comprehensive assessment dated [DATE] showed the resident had moderate cognitive impairment and required limited assistance for transfers and mobility. Record review of Resident 2's physicians orders dated April 2026 showed the resident's medications included daily use of two psychotropic drugs, Seroquel 50 mg, three times daily (an antipsychotic a class of medication used to treat symptoms of psychotropic as hallucinations) and Venlafaxine 150 mg daily (an antidepressant (a medication used to treat symptoms of depression anxiety and PTSD). Review of the Psychotropic Drug Review Meetings minutes from January to March 2026 provided no documentation to show that Resident 2 had been reviewed for GDR's related to the use of their psychotropic medications. During an interview on 04/02/2026 at 3:27 PM, Staff I, SSD, when asked to provide documentation for a GDR review related to Resident 2's psychotropic medication Staff I stated, I don't have one we have not reviewed them for a GDR in our monthly psychotropic drug meetings. Resident 77 Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses which included dementia, depression and diabetes (a chronic disease which causes elevated blood sugar). Review of the 03/06/2026 comprehensive assessment showed the resident had moderately impaired cognition and required substantial assistance from staff for daily activities to include dressing, transfers, mobility and personal hygiene. Review of the Psychotropic Drug Review Meeting minutes dated January through March 2026 showed Resident 77 had their last GDR review documented as completed on 02/11/2025 (greater than a year ago). During an interview on 04/02/2026 at 3:39 PM, Staff I stated the last GDR completed for Resident 77's antidepressant medication was on 02/11/2026 and did not meet the requirement for annual review for an antidepressant GDR. Staff I stated, I realize I am behind and need to catch up on the GDRs for the residents. During an interview on 04/03/2026 at 10:10 AM, Staff B, DON, stated the GDRs were not current and the facility had fallen behind. Staff B stated the facility would be auditing the residents receiving psychotropic medications and provide GDR reviews as their expectation was that the facility be following regulations for the residents' use of psychotropic drugs. Reference WAC 388-97-1060(3)(k)(i)-0620(1)(a)

Based on observation, interview and record review, the facility failed to provide adequate supervision and implementation of care plan interventions to prevent resident-to-resident altercations for 3 of 3 residents (Residents 48, 38, and 3) reviewed for accidents. This failure placed the residents at risk for potential verbal and physical abuse, serious pain, injury, and emotional distress. Additionally, the facility failed to ensure 1 of 3 residents (Resident 77), who utilized a transfer pole, had a process in place to ensure appropriate placement of equipment for safety and to mitigate the risk of entrapment. This failure placed Resident 77 at risk for injuries if improperly placed. Findings included .Review of a policy titled, Accidents and Supervision, dated 2025, showed the resident environment would be as free from accident hazards as is possible. Each resident would receive adequate supervision (interventions and means of mitigating risk of an accident) to prevent accidents that included identifying hazards and risks, evaluating and analyzing the hazards and risks, implementing interventions to reduce them, and monitoring for effectiveness and modifying the interventions when necessary. Resident 48 Review of the medical record showed Resident 48 was admitted to the facility with diagnoses including dementia with agitation (cognitive decline with verbal aggression, physical aggression, and pacing/restlessness), Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety. The 01/05/2026 comprehensive assessment showed Resident 48 required substantial/maximal assistance of one staff member for ADLs. The assessment also showed Resident 48 had a severely impaired cognition. Resident 38 Review of the medical record showed Resident 38 was admitted to the facility with diagnoses including dementia with behavioral disturbance (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), diabetes (a group of diseases that result in too much sugar in the blood), and weakness. The 03/16/2026 comprehensive assessment showed Resident 38 required moderate to substantial assistance of one staff member for ADLs. The assessment also showed Resident 38 had a moderately impaired cognition. Resident 3 Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including dementia with behavioral disturbances, diabetes, and metabolic encephalopathy (a series of brain dysfunction caused by illness). The 12/30/2025 comprehensive assessment showed Resident 3 was independent with activities of daily living (ADLs) related to personal care. The assessment also showed Resident 3 had moderately impaired cognition. Record review of Resident 3's care plan reviewed on 01/08/2026, showed they had a crisis prevention plan related to behaviors including delusions (fixed, irrational belief that can cause significant distress or behavioral changes), hallucinations (seeing, hearing, smelling, tasting, or feeling things that seem real but are not), paranoia (an intense, irrational distrust or suspicion of others), physical/verbal aggression and sexually inappropriate behaviors. Interventions included redirecting Resident 3 to their room, providing snacks/drinks, exercise, assessing pain, calling family to talk with Resident 3, providing one-on-one supervision as needed and communicating with Resident 3 in their native language. Additionally, staff should intervene before Resident 3 agitation escalates, guide them away from the source of distress, and engage calmly in conversation. There were no interventions for supervision of Resident 3, despite their history of behaviors. Record review of a facility investigation dated 04/05/2026, showed a resident-to-resident altercation occurred on 03/02/2025 at 6:30 AM between Resident 3 and Resident 48 in the hallway outside of Resident 3's room. The investigation showed Resident 48 was self-propelling in their wheelchair down the hallway towards the nurse's station when they passed Resident 3's room. Resident 3 noticed Resident 48 passing their room, exited their room, made verbal threats and kicked Resident 48's wheelchair from behind. The residents were separated and assessed for injury, none noted. The investigation showed Staff A, Administrator, and Staff B, Director of Nursing, were notified of the incident on 04/01/2026. Record review of a facility investigation dated 03/31/2026 showed a resident-to-resident altercation occurred at 6:50 AM, between Resident 3 and Resident 38 in the hallway outside the kitchen area. The investigation showed Resident 38 was self-propelling in their wheelchair down the hallway by the kitchen door. Resident 3 had a verbal altercation with Resident 38, closed their right hand and struck Resident 38 on the left side of their face. At the same time, Resident 38 closed their right hand and struck Resident 3's right arm. A housekeeper witnessed the incident from the end of the hall, intervened, and separated the residents. During an observation on 03/30/2026 at 2:56 PM, Resident 3 was wandering, unsupervised, through the halls of the facility, glancing into various resident rooms. Resident 3 stopped at the central nursing station, continued to the television sitting area, and continued to wander the same path through the halls of the facility. There were no staff observed monitoring Resident 3's wandering. During an observation and interview on 04/01/2026 at 8:18 AM, Resident 3 was at the end of a hall, unattended, wandering past resident rooms, looking into each room as they passed the room. Staff N, Medication Assistant, stated Resident 3 constantly wandered the halls claiming they were guarding and protecting the hall. Staff N stated Resident 3 had paranoia and reported people are after them. Staff N stated Resident 3 paced around the facility and had conversations with themselves; everyone knows about (Resident 3's) tendencies and behaviors. They stated the staff tried to keep eyes on Resident 3's location. During an interview on 04/01/2026 at 11:18 AM, Staff E, Medication Assistant, stated they did not witness the resident-to-resident incident on 03/31/2026 between Resident 3 and Resident 38. They stated they were passing medications to residents on a different hallway Staff E stated there was a housekeeper at the end of the hall that noticed the residents fighting and alerted them. Staff E stated they had to put the medications away on the cart, lock the cart, and went to assist the housekeeper with separating the residents. During a follow-up interview on 04/01/2026 at 2:20 PM, Staff E stated they were working on 03/02/2026, passing medications, when the resident-to-resident incident occurred between Resident 3 and Resident 48. They stated Resident 3 came out of their room and yelled at Resident 48, then kicked the back of their wheelchair. Staff E stated they separated the residents and called for assistance as the residents continued to have a verbal altercation. Staff E stated they had seen Resident 3 physically and verbally attack residents, both recently and in the past. Staff E stated they tried to be aware of where Resident 3 was due to their history of altercations. During an interview on 04/02/2026 at 2:30 PM, Staff B stated Resident 3 did not have a resident-to-resident altercation for over a year. They stated they tried to ensure staff were in the halls to avoid resident-to-resident incidents with Resident 3. Staff B stated Resident 3 targeted specific male residents, the staff watched Resident 3 closely and tried to keep them separated from Resident 38 and other residents. Staff B stated they did not know what caused the incidents between Resident 3 and Resident 48 or Resident 3 and Resident 38. Staff B stated Resident 3 was care-planned for one-on-one supervision as needed in the past and had since been placed back on one-on-one supervision indefinitely following these incidents. During an interview on 04/02/2026 at 3:47 PM, Staff A stated they talked with staff about making sure Resident 3 was redirected off the hall where Resident 38 resided due to Resident 3 targeting Resident 38. They stated Resident 38 was typically escorted to the restorative gym (located on the same hall where Resident 3 resided) by the restorative aid or a nursing assistant and were unsure why they did not have an escort on the day of the incident. Resident 77 Review of the resident's medical record showed they were admitted with diagnoses which included dementia (cognitive decline that affects memory and reasoning), depression (a mood disorder which causes sadness and diabetes (too much sugar in the blood). Review of the comprehensive assessment dated [DATE] showed the resident had mild cognitive impairment and required substantial assistance from staff for activities of daily living (ADLs) including dressing, transfers, bed mobility and toileting. A concurrent observation and interview on 03/30/2026 at 1:10 PM showed Resident 77 sitting in their wheelchair beside their bed with a transfer pole positioned between their legs. The resident was leaning forward while rummaging through their nightstand drawer. When asked if the transfer pole was in the way, the resident stated, yes, it was in the way, but they used the transfer pole to help them get in and out of bed, so they wanted to keep it. The resident further stated their bed had been moved, which caused the transfer pole to improperly positioned. During the same continued observation showed the bed was positioned close to the window, six inches (a unit of measurement) from the heating/cooling system, leaving insufficient room to walk between the bed and window. There were no markings on the floor to indicate proper bed placement to ensure the transfer pole remained in the optimal position for safety and to prevent gaps. Record review of the resident's care plan dated 03/20/2026 showed the resident used a transfer pole; however, there were no interventions to ensure appropriate placement of the bed in reference to the placement of the transfer pole. A concurrent observation and interview on 04/01/2026 at 12:01 PM, Staff H, Registered Nurse, Resident Care Manager, was shown the resident's bed and placement of their transfer pole. Staff H stated there should be tape on the floor to indicate the correct bed position to ensure appropriate placement of the transfer pole. Staff H confirmed that there was no tape on the floor to show the staff where the bed should be placed. During an observation on 04/02/2026 at 9:30 AM, showed Resident 77's bed was no longer straight, but slightly angled at the top half of the bed. There was still no tape to mark where the bed should be placed in reference to the transfer pole. During an interview on 04/02/2026 at 9:50 AM, Staff R Housekeeping Aide, stated they were required to move resident beds weekly and clean under them. Staff R stated they just moved beds back after cleaning and had not seen tape marking the required spot where the beds with transfer poles should be placed. During an interview on 04/02/2026 at 10:34 AM, Staff B, Director of Nursing, stated they would expect the bed placement to be marked with tape for all residents using transfer poles. Staff B stated resident 77 had moved rooms a couple of months ago and the bed and transfer pole placement should have been assessed and marked with tape following the room move to ensure appropriate placement of the equipment. Cross reference to F600 for further information. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable and sanitary environment was maintained for 1 of 1 kitchen areas (dishwasher room) and 3 of 4 utility rooms (West clean and soiled utility rooms, and the South clean utility room) reviewed for environment. This failure placed the residents at risk for potential accidents and not feeling safe/secure with their environment. Findings included . Review of the facility policy titled Safe and Homelike Environment, dated 2025, showed .In accordance with residents rights the facility will provide a safe, clean, comfortable and homelike environment. Maintenance services will be provided as necessary to maintain a sanitary, orderly and comfortable environment and will report any unresolved environmental concerns to the Administrator . During an observation of the Kitchen (dishwasher room) on 03/30/2026 at 9:45 AM showed: The floor beneath and surrounding the dishwasher exhibited significant peeling, chipping, and erosion of the protective sealant, exposing an un-cleanable concrete surface measuring approximately six feet by four feet (ft, a unit of measure). A thick buildup of greasy brown debris, and splash-back residue was observed across the wall surface surrounding the dishwasher, particularly along the bottom edge where the wall meets the sink. This buildup extends across the entire span of the visible wall section. A thick buildup of dark, greasy grime, debris, and splash-back residue was observed at the floor-to-wall junctions and behind equipment legs, extending three ft along the wall. The junction between the wall and the floor underneath the dishwasher area appeared eroded with visible gaps measuring up to 1/4 inch (in- unit of measure), creating an uncleanable surface. Cleaning supplies, including a yellow scrub brush and a chemical spray bottle with no label, observed stored directly on the floor surface underneath the dishwasher area. The floor and wall base exhibited widespread localized buildup of yellowish-brown staining. During an observation of the South Clean Utility Room on 03/30/2026 at 12:14 PM showed:The wall surfaces exhibited extensive physical damage, including a deep horizontal gouge measuring four ft in length and missing plaster at the corners, exposing metal. Multiple areas showed evidence of failed or inadequate repairs, including sections of tape measuring two in. by six in., applied directly over structural wall damage. The wall area above the backsplash and surrounding the soap dispenser exhibited extensive grey and black speckled staining and splash-back residue covering a 12 in. by 18 in. area. During an observation of the [NAME] Soiled Utility Room on 03/30/2026 at 12:22 PM showed:The vinyl floor tiles exhibit significant chipping and missing sections along the seams, exposing the dark subfloor and adhesive beneath. This included two missing tile sections, each measuring 12 in by 12 in, creating a non-sanitary and un-cleanable surface. Multiple tile edges surrounding the chipped areas appear jagged and uneven. A section of yellow and black hazard tape, approximately 18 in, in length, had been applied across a tile seam; however, observation of the tape peeling and lifting at the edges. Visible gaps and separation exist between several floor tiles, measuring 1/8 in. to 1/4 in. The dark brown rubber baseboard was coated in a significant layer of white, speckled splatter, with a visible buildup of thick, dark debris where the baseboard meets the floor, extending along the room perimeter. During an observation of the [NAME] Clean Utility Room on 03/30/2026 at 12:30 PM showed:A large rectangular section of floor tiles, measuring approximately three ft by five ft, were entirely missing, exposing a significant area of dark, uneven concrete subfloor and adhesive beneath. Several dark, damp patches were visible on the exposed concrete, with the largest patch measuring 10 in. The dark brown rubber baseboard were missing entirely along a six ft portion of the wall, and the remaining wall base exhibited eroded plaster and exposed unsealed gaps of metal approximately 1 in. A heavy buildup of dark, greasy residue along the edges of the remaining baseboards 6 ft of the wall section. The caulking at the countertop-to-wall junction was significantly deteriorated with gaps measuring 1/8 inch, creating a non-cleanable surface. During an interview on 03/31/2026 at 1:10 PM, Staff C, Director of Maintenance, stated the facility utilized a maintenance checkbook to track facility repairs. Staff C acknowledged the poor condition of the kitchen. Staff C stated the floors and walls need to be done and it looks bad, but they believed it remained structurally sound. Regarding the west soiled utility room, Staff C stated they were aware of the missing tiles and damaged backsplash for about a year. Staff C stated they had not replaced them because the specific tiles were difficult to find. Staff C further stated that the repairs for the utility rooms were low on my priority list. During an interview on 04/02/2026 at 4:04 PM, Staff A, Administrator, stated they were aware of the various environmental issues in the kitchen and utility rooms. Staff A further stated that addressing these maintenance concerns was not a priority because it was not a resident area. Reference: WAC 388-97-3220 (1)

Based on interview and record review the facility failed to ensure a resident received dignified care and services by ensuring delivered care from their preference of female caregivers for 1 of 3 residents (Resident 79) reviewed for resident rights. This failure placed the resident at risk for compromised dignity, diminished self-worth, decreased self-esteem, and feelings of embarrassment. Findings included Resident 79 Review of the medical record showed Resident 79 was admitted to the facility with diagnoses to include dementia ( a decline in mental abilities, such as memory, thinking, and reasoning, that interferes with daily life), and diabetes ( a chronic condition where blood sugar levels are too high because the body does not make enough insulin or cannot use it properly). The comprehensive assessment dated [DATE] showed Resident 79 required the assistance of one staff member for toileting, showering/bathing, and touching assistance for upper and lower dressing. The assessment showed Resident 79's cognition was intact. During an interview on 03/30/2026 at 1:25 PM, Resident 79 stated they would like female caregivers only for personal care. Resident 79 stated they have told the Nursing Assistants (NAs), but the NAs would at times tell them they only have male caregivers available to do care during the evening shift and the night shift, which occurred about two times monthly. Resident 79 further stated, I don't think that it's right. I should not have a male caregiver if I do not want one. It is embarrassing for me as a woman. Even though they are good and careful, it is still embarrassing to have my pants down and my shirt off in front of a man. Review of Resident 79's care plan dated 01/09/2026 showed no care plan had been developed addressing the resident's preference for female caregivers only. During an interview on 03/31/2026 at 2:30 PM, Staff P, NA, stated Resident 79 preferred female caregivers if it involved undressing. Staff P stated they normally would find that information on the Kardex (a clinical bedside tool used by nursing staff to provide a quick overview of a resident's daily care needs and preferences). Staff P stated Resident 79's preference for a female caregiver was not on the Kardex, and they only heard that through word of mouth. Staff P stated they had provided personal cares for Resident 79 a few times when there were no female care givers available. During an interview on 03/31/2026 at 2:36 PM, Staff O, NA, stated Resident 79 preferred only female care givers and would only allow limited care assistance with a male NA. Staff O stated Resident 79 would provide their own perineal care (cleaning of the genital and anal areas). Staff O stated if there were no female staff on the floor, Resident 79 would allow certain male staff to do their cares, and they (Staff O) were one of them and they have provided personal care to Resident 79. During an interview on 04/01/2026 at 4:09 PM, Staff G, Registered Nurse/Resident Case Manager (RCM), stated they were not aware that Resident 79 preferred female caregivers. Staff G stated they would expect this information to be included in the residents' care plan, so staff were aware of how to provide care. Staff G confirmed a breakdown in the care planning process. During an interview on 04/02/2026 at 12:51 PM, Staff B, Director of Nursing (DON), stated they would expect the RCMs to know the resident's preferences to ensure they were placed on the care plan for staff to follow. Staff B stated they were not aware of Resident 79's preference for female caregivers and acknowledged Resident 79's preference was not being honored, was not on the care plan, and the correct process had not been followed. Reference WAC 388-97-0180 (1-3)

Based on interview and record review the facility failed to ensure 1 of 4 residents (Resident 100) reviewed for urinary (the body's processes, organs, or functions related to the productions, storage, and discharge or urine) catheter, were fully informed of their care. This failure placed the resident at risk of poor understanding in their health care decisions and a diminished quality of life. Findings included . Review of the undated facility policy titled, Resident Rights, showed the facility will inform the resident both orally and in writing, of their rights and responsibilities in a language that the resident understands. Review of the medical records showed Resident 100 admitted to the facility on [DATE] with diagnoses to include diabetes (a chronic condition where the body cannot properly manage blood sugar levels), lymphoma (a type of blood cancer that affects the immune system), kidney stone and acute kidney failure (a serious condition where the kidneys lose their ability to filter waste products, excess water, and toxins from the blood). The comprehensive care plan dated 03/27/2026 showed their cognition was moderately impaired and required assistance of one person for daily cares and transfers. In an observation and interview on 03/30/2026 at 1:56 PM Resident 100 was sitting in their room in a wheelchair. The resident was clean, well-groomed and had a retention catheter hanging on the bottom of their wheelchair. The resident stated they were unaware of where their catheter had been placed or if they would be going home with the catheter. The resident stated they would like to go home but had not been told when they would be discharged . During an interview on 03/31/2026 at 3:43 PM, Resident representative (RR) stated Resident 100's catheter was placed in the hospital for a kidney stone that had caused an infection and was unsure if Resident 100 would be going home with the catheter. The RR stated they were not sure what was happening with Resident 100's discharge and that would like an update on Resident 100's care. The Resident and their representative stated they had not been informed of when the catheter would be removed, or when they could expect a discharge. The RR stated they would like to speak to someone about Resident 100's care and what they would need upon discharge, that they had not yet talked with anyone from the facility. During an interview on 04/01/2026 at 3:37 PM, Staff G, Registered Nurse, stated they could not find documentation that Resident 100's care had been reviewed with the resident. Staff G stated the staff member that was responsible for ensuring the care was reviewed with the resident was on vacation. Staff G stated, no excuse Resident 100 should have had their care reviewed with them to ensure they were informed. During an interview on 04/02/2026 at 5:02 PM, Staff B, Director of Nursing, stated the care review with Resident 100 was missed. Reference: WAC 388-97-0300 (3)(a)

Based on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 3 residents (Residents 48 and 38) reviewed for resident-to-resident altercations with Resident 3. This failure placed the residents at risk for continued abuse, injury, and emotional distress. Findings included. Review of a policy titled, Abuse, Neglect, and Exploitation, dated 2023, showed the facility would develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents. Resident 48Review of the medical record showed Resident 48 was admitted to the facility with diagnoses including dementia with agitation, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety. The 01/05/2026 comprehensive assessment showed Resident 48 required substantial/maximal assistance of one staff member for activities of daily living [(ADLs) activities related to personal care]. The assessment also showed Resident 48 had a severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 38Review of the medical record showed Resident 38 was admitted to the facility with diagnoses including dementia with behavioral disturbance, diabetes, and weakness. The 03/16/2026 comprehensive assessment showed Resident 38 required moderate to substantial assistance of one staff member for ADLs. The assessment also showed Resident 38 had a moderately impaired cognition. Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including dementia with behavioral disturbances (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), diabetes (a group of diseases that result in too much sugar in the blood), and metabolic encephalopathy (a series of brain dysfunction caused by illness). The 12/30/2025 comprehensive assessment showed Resident 3 was independent with ADLs. The assessment also showed Resident 3 had a severely impaired cognition. Record review of a nursing progress note (PN) dated 03/02/2026 showed Staff E, Medication Assistant, documented that Resident 3 was observed in their room. They exited their room and yelled at Resident 48, who was in the hall in their wheelchair, stating get the f**k out of here you stupid pig! I'm going to kill you and feed you to the pigs! Resident 3 kicked the back side of Resident 48's wheelchair, sending them forward about 2 feet (a unit of measurement) before Resident 48 put their feet down to stop the wheelchair. The two residents continued to have a verbal altercation. Staff F, Registered Nurse (RN), was called to assist Staff E with separating the residents. Resident 3 continued to make threats of killing Resident 48 as Staff F redirected Resident 3 back to their room. During an interview on 04/01/2026 at 2:20 PM, Staff E stated when Resident 3 had the altercation with Resident 48, they were in the hall outside of Resident 3's room. Staff E stated after the incident, Resident 3 stayed in their room for the remainder of the day and Staff E kept their medication cart parked in the hall outside of Resident 3's room so they could watch them. Review of a nursing PN dated 3/31/2026, Staff B, Director of Nursing, showed Resident 3 was wandering in the hall when they met Resident 38 outside of the kitchen area. Resident 3 yelled at Resident 38, stating you are a dog and in my workspace! Resident 3 pulled their right hand into a fist and made contact with their fist against Resident 38's face. At the same time, Resident 38 pulled their right hand into a fist and made contact with Resident 3's right arm. A housekeeper witnessed the incident and separated the two residents. Resident 3 was placed on one-to-one observation (a resident safety intervention where a staff member is assigned to continuously monitor a single high-risk resident to prevent accidents) to prevent further altercations. During an interview on 04/01/2026 at 9:37 AM, Staff B stated they were not aware of the resident-to-resident altercation that occurred on 03/02/2026. They stated both of these incidents were abuse and Resident 3 should have been placed on increased supervision at that time of the first altercation to prevent the second altercation. Reference: WAC 388-97-0640(1)

Based on interview and record review, the facility failed to implement their abuse prevention policy in the areas of identification, investigation, protection, and reporting for 2 of 3 residents (Residents 48 and 38) reviewed for altercations with Resident 3. This failure placed the residents at risk for continued unidentified abuse, fear, and dissatisfaction with their living situation.Findings included. Review of a policy titled, Abuse, Neglect, and Exploitation, dated 2023, showed the facility would develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. New employees and existing staff would receive education inducing identifying abuse, neglect, exploitation and misappropriation, such as physical or psychosocial indicators; the reporting process for abuse, neglect, exploitation, and misappropriation, and understanding behavioral symptoms that may increase the risk of abuse and neglect such as aggressive reactions of residents, wandering, and outbursts or yelling out. This included staff to resident abuse and resident-to-resident altercations. An immediate investigation would be initiated when suspicion/reports of abuse occur. The facility would ensure all residents were protected from physical and psychosocial harm, and additional abuse, during and after the investigation. The facility would report all alleged violations to the Administrator, State Agency, Adult Protective Services, and law enforcement immediately, but not later than 2 hours after the allegation if the allegation was abuse, not later than 24 hours if the allegation did not involve abuse or serious bodily injury. Resident 48 Review of the medical record showed Resident 48 was admitted to the facility with diagnoses including dementia with agitation, Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), and anxiety. The 01/05/2026 comprehensive assessment showed Resident 48 required substantial/maximal assistance of one staff member for activities of daily living [(ADLs) activities related to personal care]. The assessment also showed Resident 48 had a severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 38Review of the medical record showed Resident 38 was admitted to the facility with diagnoses including dementia with behavioral disturbance, diabetes, and weakness. The 03/16/2026 comprehensive assessment showed Resident 38 required moderate to substantial assistance of one staff member for ADLs. The assessment also showed Resident 38 had a moderately impaired cognition. Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including dementia with behavioral disturbances (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), diabetes (a group of diseases that result in too much sugar in the blood), and metabolic encephalopathy (a series of brain dysfunction caused by illness). The 12/30/2025 comprehensive assessment showed Resident 3 was independent with ADLs. The assessment also showed Resident 3 had a moderately impaired cognition. Review of a nursing progress note (PN) dated 03/02/2026, showed Resident 3 threatened to kill Resident 48 and kicked the back of their wheelchair. Resident 3 was redirected back to their room as they continued to make threats of killing Resident 48. During an interview on 04/01/2026 at 2:20 PM, Staff E, Medication Assistant, stated they witnessed the incident between Resident 3 and Resident 48. They stated they separated the residents and reported the incident to Staff F, Registered Nurse. Staff E stated they did not report the incident to the State Agency because they thought Staff F would. During an interview on 04/03/2026 at 9:37 AM, Staff F stated Staff E called for assistance with a resident-to-resident altercation about a month ago. They stated the residents had gotten into a verbal altercation and Resident 3 had kicked the back of the wheelchair of Resident 48. Staff F stated their process for reporting incidents included obtaining an incident folder that contained the necessary forms for initiating an investigation. They would gather witness statements, write a progress note, and alert administrative staff of the incident. They stated they would also report to the State Agency. Staff F stated they did not follow this process because they did not feel like there was abuse in this situation. During an interview on 04/01/2026 at 9:37 AM, Staff B, Director of Nursing, stated they were not informed of the resident-to-resident altercation on 03/02/2026. They stated Staff F did not report the incident because there was no physical contact between the residents. Staff B stated the incident was abuse and it should have been reported. Review of a facility incident investigation dated 03/31/2026, showed Resident 3 had a resident-to-resident altercation with Resident 38 in the hall located outside of the kitchen area. Resident 3 stated Resident 38 was a dog and was in their workspace. Resident 3 close their right hand and made contact with Resident 38's face. Resident 38 closed their hand and made contact with Resident 3's arm. A housekeeper witnessed the event and separated the residents. During an interview on 04/02/2026 at 2:14 PM, Staff B stated staff missed steps with the first incident. They did not identify the abuse due to Staff F stating there was no physical contact so there was nothing to report. Staff B stated the process should have been to notify the administrative staff to ensure the residents were protected from further abuse. The incident needed to be investigated and reported to the State Agency. During an interview on 04/03/2026 at 8:19 AM, Staff A, Administrator, stated all staff were trained to the abuse/neglect policy. They stated staff were educated on the types and identification of abuse/neglect and competencies were completed after the training. Staff A stated any suspected or observed incidents of abuse should be immediately reported within two hours of the incident to the State Agency, local law enforcement, the provider, and the resident representative. The incident should be reported by the staff member that witnessed the event. Any alleged abuse incidents needed to have a thorough investigation initiated and completed within five working days. Staff A stated the incident on 03/02/2026 should have been reported to the State Agency and to the administrative staff to ensure the resident was protected and a proper investigation was completed. Cross reference F600 for further information.Reference: WAC 388-97-0640(1)(2)(a)(b)(5)(a)(a)(b)(c)

Based on interview and record review, the facility failed to ensure an incident of abuse was reported to the State Agency as required for 1 of 3 residents (Resident 48) reviewed for an altercation with Resident 3. This failure placed the residents at risk for additional/continued abuse.Findings included. Review of a policy titled, Abuse, Neglect, and Exploitation, dated 2023, showed the facility would have written procedures that included reporting of alleged violations to the administrator, State Agency, adult protective services, and all other required agencies within specified timeframes: immediately, but not greater than two hours after the allegation was made if the allegation involved abuse or serious bodily injury, or not later than 24 hours if the allegation did not involve abuse and there was no serious bodily injury. The administrator would follow up with government agencies to confirm the initial report was received and to report the results of the investigation when final, within five working days of the incident. Resident 48Review of the medical record showed Resident 48 was admitted to the facility with diagnoses including vascular dementia (a decline in thinking skills caused by condition that block or reduce blood flow to the brain, damaging brain tissue), Alzheimer's disease (a progressive, incurable disease primarily affecting memory, thinking, and behavior), and delirium (a sudden state of severe confusion and reduced awareness caused by underlying medical issues, infections, or medication side effects). The 01/05/2026 comprehensive assessment showed Resident 48 required substantial/maximal assistance of one staff member for activities of daily living [(ADLs) activities related to personal care]. The assessment also showed Resident 48 had a severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including dementia with behavioral disturbance (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), diabetes (a group of diseases that result in too much sugar in the blood), and kidney disease. The 12/30/2025 comprehensive assessment showed Resident 3 was independent with ADLs. The assessment also showed Resident 3 had a severely impaired cognition. Record review of a nursing progress note dated 03/02/2026, showed Resident 3 had a verbal and physical altercation with Resident 48 in the hall outside of Resident 3's room. Resident 3 had threatened to kill Resident 48, then kicked the back of Resident 48's wheelchair. During an interview on 04/01/2026 at 2:20 PM, Staff E, Medication Assistant, stated they witnessed the incident between Resident 3 and Resident 48. They stated they separated the residents and reported the incident to Staff F, Registered Nurse. Staff E stated they did not report the incident to administration or the State Agency because they thought Staff F would. During an interview on 04/03/2026 at 9:37 AM, Staff F stated Staff E called for assistance with a resident-to-resident altercation about a month ago. Staff F stated their process for reporting incidents included obtaining an incident folder that contained the necessary forms for initiating an investigation and reporting the incident to the State Agency. Staff F stated they did not follow this process because they did not feel like there was abuse in this situation. During an interview on 04/02/2026 at 2:14 PM, Staff B, Director of Nursing, stated Staff F should have reported to the resident-to-resident abuse incident to both the administrative staff and the State Agency. Staff B stated the incident should have been reported to the administrative staff and the State Agency as required. During an interview on 04/02/2026 at 3:39 PM, Staff A, Administrator, stated the process should have been to report the incident to the State Agency hotline and the administrative staff to ensure resident safety and to complete a proper investigation. Cross reference to F600 and F607 for further information.Reference: WAC 388-97-0640(1)(5)(a)

Based on interview and record review, the facility failed to thoroughly investigate an incident of abuse for 1 of 3 residents (Resident 48) reviewed for an altercation with Resident 3. This failure placed the residents at risk for further unidentified and/or further abuse.Findings included. Review of a policy titled, Abuse, Neglect, and Exploitation, dated 2023, showed an immediate investigation was warranted when suspicion of abuse, neglect, or exploitation, or report of abuse, neglect or exploitation occurred. The investigation process included identifying staff responsible for the investigation, identifying and interviewing involved persons, including the alleged victim, alleged perpetrator, witnesses, and others that might have knowledge of the allegation, and providing complete and thorough documentation of the investigation. Resident 48Review of the medical record showed Resident 48 was admitted to the facility with diagnoses including vascular dementia (a decline in thinking skills caused by condition that block or reduce blood flow to the brain, damaging brain tissue), Alzheimer's disease (a progressive, incurable disease primarily affecting memory, thinking, and behavior), and delirium (a sudden state of severe confusion and reduced awareness caused by underlying medical issues, infections, or medication side effects). The 01/05/2026 comprehensive assessment showed Resident 48 required substantial/maximal assistance of one staff member for activities of daily living [(ADLs) activities related to personal care]. The assessment also showed Resident 48 had a severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Resident 3Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including dementia with behavioral disturbance (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), diabetes (a group of diseases that result in too much sugar in the blood), and kidney disease. The 12/30/2025 comprehensive assessment showed Resident 3 was independent with ADLs. The assessment also showed Resident 3 had a severely impaired cognition. During an interview on 04/02/2026 at 2:14 PM, Staff B, Director of Nursing, stated a resident-to-resident incident between Resident 48 and Resident 3 on 03/02/2026 was not investigated due to Staff F, Registered Nurse, not identifying the incident as abuse. They stated the process should have been for Staff F to notify the administrative staff so a thorough investigation could have been completed. During an interview on 04/03/2026 at 8:19 AM, Staff A, Administrator, stated any suspected abuse or actual abuse needed to be thoroughly investigated, which included witness, staff, and resident statements. They stated the investigation should be initiated immediately after the incident and needed to be completed within five working days of the initial report. Cross reference F600 and F607 for further information. Reference: WAC 388-97-0640(6)(a)(c)

Based on interview and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident's bed while the resident is absent from the facility) at the time of transfer to the hospital for 1 of 3 residents (Resident 10) reviewed for hospitalization. This failure placed the residents at risk of not having the necessary information to make an informed decision regarding their ability to return to the facility.Findings included. Review of a policy titled, Bed Hold Notice, dated 2025, showed the facility would provide written information to the resident and/or their representative regarding bed hold practices both well in advance, and at the time of a transfer for hospitalization or therapeutic leave (a planned temporary absence from the facility for non-medical reasons). Review of the medical record showed Resident 10 was admitted to the facility with diagnoses including end stage renal disease (permanent kidney failure where kidney function is less than 10% and they can no longer function on their own), diabetes (a condition of having too much sugar in the blood), and muscle weakness. The 02/04/2026 comprehensive assessment showed Resident 10 required substantial/maximum assistance of one staff member for activities of daily living (activities related to personal care). The assessment also showed Resident 10 had a severely impaired cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses). Review of a nursing progress note dated 12/08/2025, showed Resident 10 experienced an unwitnessed fall from their chair in their room. The documentation showed Resident 10 was transferred to the local hospital for further evaluation of right hip pain and bruising to the right side of their forehead. Resident 10's Representative was present at the time Resident 10 transferred to the hospital. Record review of the medical record showed no documentation that a notice of bed hold was provided to Resident 10 or their Representative. During an interview on 04/02/2026 at 11:01 AM, Staff A, Administrator, stated they were unable to locate the required notice of bed hold for Resident 10. During an interview on 04/02/2026 at 2:39 PM, Staff B, Director of Nursing, stated the licensed nurse that completed Resident 10's transfer to the hospital should have had a conversation with the resident and/or their representative regarding bed hold, obtained a form, and had it signed by the resident/representative. They stated they had identified an issue with the facility not completing the bed hold notification upon transfer and were aware the facility was missing them. Reference: WAC 388-97-0120(3)(c)(4)

Based on interview and record review the facility failed to ensure residents Preadmission Screening and Resident Reviews ([PASARR], an assessment to ensure individuals with serious mental illness [SMI] or intellectual/developmental disabilities [ID/DD] were not inappropriately placed in nursing homes for long term care) were accurately completed prior to admission for 1 of 5 residents (Resident 81 ) and updated when new SMIs were identified. and had the required Level II (a comprehensive evaluation by the appropriate state-designated authority) referral if residents had a positive Level I (a pre-screening evaluation for identifying SMI/ID/DD) PASARR for 1 of 5 residents (Resident 3) reviewed for PASARR. This failure placed the residents at risk of not receiving the mental health care and services appropriate for their needs. Findings Included . Review of the facility policy titled Coordination with PASRR Program, dated 2025, showed all applicants to the facility would have a Level I PASAAR for SMI, ID/DD, and/or related conditions prior to admission to the Nursing Home (NH) and if an SMI/ID/DD should be diagnosed after admission. If the Level I showed the resident had an SMI/ID/DD, then a Level II evaluation would be completed prior to admission. The policy additionally showed any resident who was diagnosed with a SMI/ID/DD after admission would have been promptly referred for a Level II evaluation. The policy showed the Social Service Director (SSD) would be responsible for tracking resident's PASARR screening status and referrals to the appropriate authority. Resident 81 Review of the resident's medical record showed they were admitted to the facility on [DATE] with diagnoses to include post-traumatic stress disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening or traumatic event), dementia (loss of cognitive functioning, thinking, remembering, and reasoning to such an extent that it interferes with a person's daily life and activities), major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), anxiety ( a feeling of fear, dread, and uneasiness that's acts as a natural temporary reaction to stress), and obsessive compulsive disorder (OCD- a mental health condiitob characterized by uncontrollable, unwanted thoughts (obsessions) and repetitive behaviors (compulsions) a person feels driven to perform to reduce anxiety). The 12/02/2024 comprehensive assessment showed Resident 81 cognition was moderately impaired and received anti-depressant and antipsychotic (used to manage symptoms such as delusions, hallucinations, paranoia, and disordered thoughts) medications. Review of the 07/18/2025 PASARR for resident 81 showed the resident had no SMI marked for PTSD or OCD on admission to the facility. During an interview on 04/02/2026 at 1:54 PM, Staff I, Social Service Director, SSD, stated they reviewed PASARRs on admission and if they were not correct, they would then complete a new one. Staff I stated, I must of just missed that one. During an interview on 04/03/2026 at 2:53 PM, Staff B, director of nursing , DON, stated the SSD was to review PASARRs prior to admission and ensure they were corrected before admitting. Staff B stated if a current resident had a new SMI diagnosis during their stay, then the SSD should have followed up on the new diagnosis and obtain an evaluation if indicated. Resident 3 Review of the medical record showed Resident 3 was admitted to the facility with diagnoses including dementia with behavioral disturbances (a progressive disease that destroys memory and other important mental functions, with agitation, physical aggression, wandering, and hoarding), diabetes (a group of diseases that result in too much sugar in the blood), and metabolic encephalopathy (a series of brain dysfunction caused by illness). The 12/30/2025 comprehensive assessment showed Resident 3 was independent with ADLs. The assessment also showed Resident 3 had a severely impaired cognition. Record review of a PASARR Level I form dated 01/28/2020, showed Resident 3 had no serious mental health indicators that would require a PASARR Level II evaluation. Review of the medical record showed a diagnosis of delusional disorder (a serious mental illness characterized by persistent, fixed false beliefs) had been added to Resident 3's diagnoses on 10/02/2025. There was no PASARR Level I update or PASARR Level II sent for evaluation related to the new diagnoses. During an interview on 04/01/2026 at 2:00 PM, Staff I, Social Services, stated when a resident was diagnosed with a new disorder that qualified for a PASARR Level II evaluation, they would complete that evaluation and submit it to the evaluator. They stated Resident 3's new diagnosis of delusional disorder was a mental health diagnosis that would have qualified for a new PASARR. Staff I stated they did not get notified of new diagnoses and would not have known that a new PASARR was needed. During an interview on 04/02/2026 at 3:49 PM, Staff A, Administrator, stated Resident 3 should have been reassessed for a PASARR Level II when they had the new mental health diagnosis. Reference: WAC 388-97-1915 (1)(2)(a-c)

Based on observation, interview, and record review the facility failed to ensure fluids were readily available and provided to 1 of 3 residents (Resident 88) and to identify and monitor skin bruising for 1 of 4 residents (Resident 79) reviewed for quality of care. This failure placed the residents at risk for excessive thirst, dehydration, further skin injury and serious adverse health conditions. Findings included . Review of a policy titled, Provision of Quality Care, dated 2025, showed the facility would ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices. Resident 88 Review of the medical record showed Resident 88 was admitted to the facility with diagnoses including hemiplegia and hemiparesis (complete paralysis and weakness on one side of the body) following a stroke (a medical emergency that occurs when blood flow to the brain is blocked or a vessel bursts, causing rapid brain cell death), adult failure to thrive (weight loss, malnutrition, dehydration, cognitive decline, and functional impairment), and dysphagia (difficulty swallowing). The 02/06/2026 comprehensive assessment showed Resident 88 was dependent on staff for activities of daily living (ADLs-activities related to personal care). The assessment also showed Resident 88 had a severely impaired cognition. Record review of an assessment form titled, Dehydration Risk Screener, dated 02/04/2026, showed a score of 10 or higher indicated the resident was at risk for dehydration and further assessments should be conducted to review the resident's fluid status. Resident 88 scored 16 on the Dehydration Risk Screener. Record review of an assessment form titled, At Risk for Malnutrition Clinical Evaluation, dated 02/04/2026, showed Resident 88 recently lost greater than 34 pounds and was at risk for malnutrition. Record review of Resident 88's care plan dated 02/13/2026, showed the resident did not use their call list for assistance. Staff were to monitor the residents' needs and offer fluids. An addition to the care plan, dated 02/19/2026, showed staff were to encourage fluids during the day. During an observation on 03/30/2026 at 10:47 AM, Resident 88 was lying in bed sleeping. Their mouth was open, which showed their dry tongue with thick, stringy saliva. Their lips were scaly and dry. Resident 88's eyes were sunken in. The bedside table was located across the room from Resident 88. There were no beverages/fluids or toothettes (single use, disposable foam swabs designed to clean, refresh, and moisturize the mouth) in Resident 88's room. During an observation on 03/31/2026 at 12:45 PM, Resident 88 was lying in bed on their right side, their left hand on their head, stating I want to go home. They had thick saliva on their tongue and had dry, flakey lips. There were no fluids or toothettes in the resident's room. At 12:52 PM, as Staff J, Nursing Assistant (NA) walked by the resident's room, Resident 88 called out may I have a snack? Staff J did not respond to Resident 88. At 12:54 PM, Staff K walked past Resident 88's room as they called out where is my snack? Staff K did not acknowledge the resident calling out. During an observation on 04/01/2026 at 8:28 AM, Resident 88 was in the assisted dining room with 11 other residents. Their food and fluids were on the table in front of them. There was a NA sitting next to Resident 88 with their back to the resident. They were assisting another resident with their meal. Resident 88 called out please, I would like a snack. Resident 88 had a very dry mouth with stringy saliva between their lips. At 8:31 AM, Staff L, NA, assisted Resident 88 with their breakfast meal. Resident 88 attempted to drink thickened liquids from a cup and had difficulty swallowing. Record review of Resident 88's meal intake record dated 04/01/2026, showed they refused their meal, despite asking for a snack. During an observation on 04/01/2026 at 10:29 AM, Resident 88 was lying in bed on their back, the lights were out, and a fall mat was next to the bed. The bedside table was across the room. There were no fluids/toothettes in the resident's room. During an interview on 04/01/2026 at 10:31 AM, Staff M, NA, stated the residents received fluids at mealtimes. They stated if they did not have enough fluids with their meal, they would use a sponge swab (toothette) and try to have Resident 88 suck on that to get fluids. Staff M stated they checked on the resident frequently and tried to give them fluids, but they spit them out. Staff M stated they recorded the residents' intake with meals but there was no place to record fluid intake for any resident. During an interview on 04/01/2026 at 2:24 PM, Staff H, Resident Care Manager, stated Resident 88 needed assistance with feeding and ate in the assisted dining room. They stated the resident required thickened liquids and received them with their meal three times a day and with their medications. They stated the resident also had thickened liquids, which were available at the bedside and the NAs would help the resident with the liquids. Staff H stated they did not monitor the resident's fluid intake, despite Resident 88's high risk for dehydration assessment. During an interview on 04/02/2026 at 2:42 PM, Staff B, Director of Nursing, stated the Dehydration Risk Screener assessment form was used to identify residents at high risk for dehydration. They stated the facility did not do anything with the information collected on the assessment form. Staff B stated there was not a process for monitoring fluid intake; there was no way to track it. Staff B stated the staff should be offering the residents fluids each time they provide care to the resident. During an interview on 04/02/2026 at 3:51 PM, Staff A, Administrator, stated the facility had a hydration cart that was staffed by a NA and were expected to help with ensuring residents received fluids throughout the day. Staff A stated all staff were expected to address resident needs when they called out for help. Resident 79 Review of the medical record showed Resident 79 was admitted to the facility with diagnoses to include dementia ( a decline in mental abilities, such as memory, thinking, and reasoning, that interferes with daily life), and diabetes ( a chronic condition where blood sugar levels are too high because the body does not make enough insulin or cannot use it properly). The comprehensive assessment dated [DATE] showed Resident 79 required the assistance of one staff member ADls. The assessment showed Resident 79's cognition was intact and had no documented skin issues An observation and concurrent interview on 03/30/2026 at 1:32 PM, showed Resident 79 lying in bed. The resident stated they had bruises to their abdomen from insulin injections and were currently prescribed anticoagulant (blood thinner) medication. Resident 79 self-initiated a skin observation by lifting their shirt, revealing a large, multicolored (yellow and greenish) bruise measuring 4 centimeters (cm,-a unit of measure) x 3 cm to the right side of their abdomen. An observation and concurrent interview on 04/01/2026 at 3:47 PM, showed Resident 79 lying in bed. The resident again lifted their shirt and stated, Sometimes the bruises hurt if they give me another shot in the same spot. There was a total of 17 bruised areas across their abdomen: 13 on the right side of their abdomen and 4 on the left side of their abdomen. The bruises were observed in various sizes and stages of healing (various colors), ranging from dark purple to yellow green. Record review of the weekly skin evaluation form dated on 02/25/2026, 03/04/2026, 03/10/2026, 03/18/2026, and 03/25/2026 showed Resident 79 consistently marked as having none for current or active skin issues. Record review of the March and April 2026 treatment administration record showed no monitoring, no assessment, or documentation of the 17 bruised areas on Resident 79's abdomen. Review of Resident 79's Care Plan, revised on 02/18/2025, failed to identify the resident's current skin impairments. The Care Plan had no interventions for the assessment, monitoring, or treatment of the 17 bruised areas on Resident 79's abdomen and failed to address the resident's reports of pain related to injection sites. During an interview on 04/01/2026 at 3:56 PM, Staff H, Registered Nurse, stated they only document bruises if they were present upon admission or were large, massive, and dark. Staff H stated they had not documented the bruised areas on Resident 79's abdomen in the weekly skin assessments, because we know where they come from. When asked how the facility monitored complications or pain at these sites, Staff H stated they did not. During an interview on 04/02/2026 at 12:51 PM, Staff D, Resource Nurse, stated any bruising should be captured in the weekly skin assessment and formally documented in the clinical record. Staff D stated for a resident with a known risk for bruising, such as Resident 79, they would expect the bruising to be assessed, and care planned to ensure proper monitoring. Reference: WAC 388-97-1060(1)(2)(3)(h)(i)

Based on interview, and record review, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice by not identifying triggers (a stimulus that causes a reaction, often an emotional or physical response) regarding a resident history of Post-Traumatic Stress Disorder (PTSD, a mental health condition triggered by experiencing or witnessing a terrifying, life-threatening or traumatic event) for 1 of 5 residents (Resident 81) reviewed for trauma-informed care .This failure placed the resident at risk for unidentified triggers and re-traumatization. Findings included . Record review of the facility policy titled Trauma-Informed Care, dated 2026, showed: .The facility will recognize how trauma affects individuals through evaluation and identification of triggers during the admissions process. The facility will develop an appropriate plan of care and interventions based upon the residents' triggers and will modify the plan of care for any changes in behavior . Review of the resident's medical record showed they were admitted to the facility with diagnoses including PTSD. The 12/02/2024 comprehensive assessment showed Resident 81 required the assistance of one staff member for activities of daily living and had moderately impaired cognition. During an interview on 03/30/2026 at 1:42 PM, the Resident Representative (RR) stated that Resident 81 had a diagnosis of PTSD stemming from a history of sexual assault. The RR stated Resident 81 becomes nervous around men, specifically became very quiet, anxious and had reported a feeling as though men were following them. The RR further stated that the resident should only have female caregivers. Record review of Resident 81's care plan, dated 07/25/2025, showed no trauma-informed care plan that included Resident 81's triggers, behaviors, or person-centered interventions. Record review of Resident 81's trauma-informed care assessment, dated 08/08/2025, showed Resident 81 experienced a traumatic event of sexual assault and severe human suffering. Further review showed there were no resident-specific behaviors or triggers identified that would cause the resident to feel fear, panic, agitation, or depression. During an interview on 04/01/2026 at 2:51 PM, Staff I, Social Service Director (SSD), stated the process for trauma-informed care was to complete the assessment by answering the required questions and asking about triggers. Staff I stated they attempt to reach out to the RR if the resident cannot provide answers. Staff I stated they had not spoken to Resident 81's RR, stating, I normally consult the RR, but I did not do so in this case. Staff I further stated the resident's triggers should have been added to the care plan, stating, I did not follow the correct process for Resident 81. During an interview on 04/02/2026 at 12:51 PM, Staff D, Resource Nurse, stated the trauma-informed care assessment should have been completed with the RR upon admission. Staff D stated trauma-based triggers and interventions should have been included in Resident 81's care plan. WAC Reference: 388-97-1060 (3)(e)

Based on observation, interview, and record review, the facility failed to ensure expired medications were destroyed in 1 of 1 medication room and failed to ensure refrigerated medications were stored at proper temperatures in 1 of 1 medication refrigerator. These failures placed residents at risk of receiving medications that could cause unintended outcomes due to improper storage and compromised efficacy. Findings Included. Review of the facility's undated policy titled, Medication Storage, showed to ensure all medications would be stored according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security. During an observation on 04/01/2026 at 9:37 AM, the facility medication room showed the following expired supplies and medications were identified: Three port access kits (sterile, all-in-one kit that contains all necessary components to safely access an implanted venous access device [port] for medications or fluids) with a manufacturer expiration date of 8/31/2025. A box of 4 milligram (mg) nicotine lozenge that had two different dosages of a 2 mg lozenge and 4 mg lozenge with a manufacturer expiration date of 02/2026. One bottle [NAME]-Vite tab (dietary supplement) with a manufacturer expiration date of 01/2026. 25 orange top, blood collection tubes with a manufacturer expiration date of 01/31/2026. 12 light blue top, blood collection tubes with a manufacturer expiration date of 0/28/2026. Review of the medication refrigerator temperature log dated March 2026 showed staff were instructed to document temperatures twice daily, at the beginning and end of each workday. The temperature log had 14 days without the required twice-a-day documentation of the medication refrigerator temperatures. During a concurrent observation on 04/01/2026 at 9:46 AM, staff G. Registered Nurse (RN), stated the temperatures for the medication refrigerator must be checked and documented twice daily. During an interview on 04/01/2026 at 9:51 AM, staff G stated that the expectation was for the nurses to monitor expiration dates and ensure expired items were not used and were properly destroyed Staff G further stated the nurses were responsible for monitoring and documenting refrigerator temperatures twice per day. During an interview on 04/02/2026 at 5:02 PM, Staff B, Director of Nursing, stated they had discussed the expired medications and medical supplies with Staff G. Staff B stated they understood and would be working on a better system to monitor the temperatures in the medication refrigerator. Reference: WAC 388-97-1300 (2)

Based on interview and record review, the facility failed to ensure there was a designated Infection Preventionist (IP) who worked at least part-time at the facility and was responsible for the facility's Infection Control and Prevention Program (IPCP), including implementation of infection prevention measures to prevent the spread of communicable diseases. These failures placed the residents at risk for transmission of infectious disease and unmet care needs. Findings included . Review of the undated policy titled, Infection Preventionist, showed the infection preventionist was employed on site and at least part time. They were scheduled with enough time to properly assess, develop, implement, monitor, and manage the IPCP, address training requirements, and participate in required committees such as Quality Improvement and Performance Improvement (QAPI). Review of the Facility Assessment (FA), dated 09/20/2024, showed the need for an IP to develop and regularly update infection control protocols, personal protective equipment availability, and vaccination availability. The FA did not show the number of IP hours per week required for the needs of the resident and staff had been assessed. During an interview on 01/10/2025 at 9:19 AM, Staff J, IP, stated they had been in the IP role for under a year. They stated they spent approximately 15% of their working hours devoted to infection control and the rest of their time as a Resident Care Manager (a licensed nurse that is responsible for supervising, implementing, coordinating, and managing resident care). Staff J stated Staff B, Director of Nursing, shared some of the IP duties. Staff J stated they were able to keep up on antibiotic use but spent the majority of their time managing resident care. During an interview on 01/13/2025 at 10:14 AM, Staff B stated they did not perform any IP duties. They stated Staff J was the IP and that 15% of their time devoted to IP duties was not enough to cover the needs of the facility. Staff B stated Staff J probably needs more time to complete the IP duties. Refer to F880, Infection Control Reference: WAC 388-97-1320(1)(a)

Based on interview and record review, the facility failed to develop a baseline care plan, within 48 hours of admission, that documented resident-specific goals and treatment plans for 3 of 4 residents (Residents 48, 196, and 9) reviewed for baseline care plan. Failure to develop a baseline care plan placed the residents at risk of not receiving continuity of care and resident centered care needs. Findings included . Review of an undated policy titled Baseline Care Plan, showed the facility would develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care. The baseline care plan would be developed within 48 hours of a resident's admission and it was to include the minimum healthcare information necessary to properly care for the resident, including initial goals based on admission orders, physician orders, dietary orders, therapy services, social services, and Preadmission Screening and Resident Review [(PASARR) a process to determine if a potential nursing home resident had mental health/intellectual disability needs which required further assessment/treatment] recommendations, if applicable. <Resident 48> Review of the medical record showed Resident 48 was admitted to the facility with diagnoses including vertebral fractures (a break in the bones of the spine), kidney and respiratory failure, and muscle weakness. The 12/22/2024 comprehensive assessment showed Resident 48 required maximum/dependent assistance from one to two staff members for activities of daily living (ADLs). The assessment also showed Resident 48 was cognitively intact. Review of Resident 48's baseline care plan dated 12/30/2024, showed no documentation of the PASARR recommendations, behavioral health goals, or interventions until 12/23/2024, five days after Resident 48's admission to the facility. <Resident 196> Review of the medical record showed Resident 196 was admitted to the facility on [DATE] with diagnoses including heart failure and adult failure to thrive (a syndrome in older adults characterized by unexplained weight loss, decreased appetite, poor nutrition, inactivity, often accompanied by depression, cognitive impairment, and functional decline). The 01/07/2025 comprehensive assessment showed Resident 196 was cognitively intact. Review of Resident 196's baseline care plan revised 01/08/2025, showed no documentation that the baseline care plan contained PASARR recommendations or Social Services goals or interventions until 01/07/2025, four days after Resident 196's admission to the facility. During a concurrent interview on 01/13/2025 at 12:52 PM, with Staff J, Registered Nurse (RN), and Staff I, RN, Staff J stated Staff K, Minimum Data Set [(MDS) a standardized assessment tool that measures health status in nursing home residents] Nurse, was responsible for creating the baseline care plan. Staff J stated once the baseline care plan was created, they would print it, along with the physician orders, and deliver them to the resident. Staff I, RN, stated the baseline care plans were completed on admission and given to the resident within 48 hours of their admission to the facility. <Resident 9> Review of the medical record showed Resident 9 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus (a group of diseases that result in too much sugar in the blood) and vascular dementia with behavioral disturbances (a condition where damage to the brain blood vessels causes significant changes in a person's behavior such as agitation, aggression, apathy, depression, and cognitive impairments like memory loss and difficulty thinking clearly). The 11/06/2024 comprehensive assessment showed Resident 9 was dependent on one to two staff members for ADLs. The assessment also showed Resident 9 had a moderately impaired cognition. Record review of Resident 9's care plan dated 11/12/2024, showed focus areas, goals, and interventions from their previous admissions to the facility, dated back to 01/22/2024. There were no focus areas, goals, or interventions dated after 10/31/2024 (their current admission) until 11/05/2024, five days after their admission to the facility. During an interview on 01/13/2025 at 11:52 AM, Staff K stated Resident 9 was a readmit to the facility, which caused the previous care plan to pull forward in the electronic medical record. They stated they reviewed the resident's information upon admission and verified that the information was accurate. They stated the resident was considered a new admission according to the MDS, but the electronic medical record automatically pulled the previous information into their new admission record. Staff K stated each department reviewed the care plan for accuracy, including falls, skin, pain, ADLs, nutrition, and activities. During an interview on 01/13/2025 at 12:42 PM, Staff I stated the previous care plan had not been closed out in the EMR when Resident 9 previously discharged . Staff I stated, that should have been done and a new baseline care plan should have been created. Reference: WAC 388-97-1020(3)

Based on observation, interview and record review, the facility failed to 1) store Potentially Hazardous Food (PHF, food that requires time/temperature controlled to limit the growth of bacteria) and dry goods that did not have the proper labels and dates for food safety tracking for 1 of 1 kitchen reviewed, 2) adequately disinfected food preparation areas to prevent cross contamination (harmful spread of diseases) for 1 of 1 kitchen reviewed. These failures placed residents at an increased risk for food borne illnesses. Findings included . Review of the Washington State Retail Food Code [PHONE NUMBER]6(1)(2)(a,b)(3)(4), dated March 1, 2022 showed ready-to-eat or refrigerated, time/temperature control for food safety must be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than twenty-four hours, to indicate the date or day by which the food must be consumed on the premises. Prepared foods must have the date or day of preparation, with a procedure to discard the food on or before the last date or day the food can be consumed on the premises. Additionally, the concentration of the sanitizing solution must be accurately determined by using a test kit or other device, and the results of the testing must be logged. Review of facility's policy titled, Food Safety Requirements, dated 2023, showed to store food in a manner that helped prevent deterioration or contamination of the food, including growth of microorganisms. Staff were to label and date all foods when opened and the date when the food items must be used by. An observation on 01/06/2025 at 9:40 AM, showed the following items in the kitchen: <Refrigerator> One, eight-quart (unit of measure) container of green beans, no use by date. One, eight-quart container of peas, no use by date. One, eight-quart container with chicken noodle soup, no use by date. One, gallon (unit of measure) zip lock baggie with shredded American cheese, no use by date. One, 32-ounce (unit of measure) bag of carrots, no use by date. One, gallon of thickened cranberry juice, unlabeled, no use by date. One, gallon of health shake (meal replacement), unlabeled, no use by date. Three, sixteen ounce whipped topping bags, unlabeled, no use by date. <Freezer #1> Two, ten-pound (lb-a unit of measure) ground beef roll with no date received or used by date. One, five-lb diced ham roll with no date received or used by date. <Freezer #2> 12 pieces of battered fish in two-gallon zip lock bags with white ice crystals on the fish appearing as freezer burn (caused by food not being securely wrapped in air-tight packaging) unlabeled, no open date or used by date. (60) Biscuits (dough) in a clear bag, unlabeled, no open or used by date. Four, four-packs of garlic bread in clear bags, unlabeled, no open or use by date. Six packs of garden vegetable soup, no date received or use by date. Two packs of cream of potato soup, no date received or use by date. Two packs of chicken noodle soup, no date received or use by date. <Freezer #3> One, five-lb bag of chicken breast, unlabeled, no open date or use by date. One, five-lb bag of pork sausage patties, unlabeled, no open date or use by date. One, five-lb bag of beef hot dogs, no received date or use by date. Three, four-lb bags of chili, no received date or use by date. Four beef steaks with white ice crystals on the steaks appearing as freezer burn, unlabeled, open date of 11/03, no use by date. One, ten-lb ham, pork roll no received date and no use by date. Ten cinnamon rolls (dough) in gallon zip lock bag, unlabeled, no open date and no use by date. During an interview on 01/06/2025 at 10:00 AM, Staff E, Dietary Department Director, stated the process for all foods was to be labeled, have an open/received date and a use by date that was dated for three days after the food item was opened. Staff E stated the items observed in the refrigerator and freezers should have been labeled, dated when opened/received with a used by date and the process was not being followed. <Disinfectant Buckets> Review of the manufacturer's instructions for Disinfectant Multi Quat 146 (a chemical used to kill germs on surfaces) showed the parts per million (PPM- the concentration of the disinfectant solution in water) should be between 150 and 400 and the buckets should be tested every two to four hours or when the solution becomes dirty. During an observation and concurrent interview on 01/06/2025 at 10:17 AM, Staff E tested a bucket of Disinfect Multi-Quat 146 solution. Staff E stated the bucket of solutions were used to clean the counter tops. The test strip showed the solution had 100 PPM on the test strip and was outside of the normal concentration range of 150 to 400 PPM to prevent cross contamination. Staff E stated they did not have a process for testing the solution in the disinfectant buckets, and they change them about every four hours. Reference: WAC 388-97-1100(3)

Based on observation, interview, and record review, the facility failed to ensure each resident's right to choose important aspects of their life, including frequency of showers and meal preferences for 2 of 3 residents (Residents 87 and 22) reviewed for choices. This failure disallowed Resident 87 the opportunity to increase their weekly showers and Resident 22 the right to dietary preferences. Findings included . Review of an undated policy titled, Resident Rights, showed the resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. <Resident 87> Review of the medical record showed the resident admitted to the facility on [DATE] with diagnoses to include bi-polar disorder (a mental illness that causes extreme mood swings, along with changes in energy, sleep, thinking and behavior), and personality disorder (long-term patterns or behaviors and inner experiences that differ significantly from what is expected). The 11/20/2024 comprehensive assessment showed Resident 87 required supervision or touching assistance for activities of daily living [(ADLs) the basic tasks you do every day to take care of yourself including showers/bathing] and had a moderately impaired cognition. During an interview on 01/06/2025 at 1:46 PM, when asked about his choices regarding his shower schedule, Resident 87 stated they could only get one shower per week scheduled. Resident 87 stated it was a big change for them to only bathe once a week and they would like two showers a week at least. Resident 87 stated they had voiced this to staff, but they (the staff) have yet to accommodate them. Resident 87 stated they were able to wash themselves in the sink, but it was not the same as a shower. Review of the resident's shower records for November 2024, December 2024 and January 2025 showed Resident 87 received one shower per week on Thursday's. During an interview 01/13/2025 at 11:12 AM Staff B, Director of Nursing, stated the process for showering/bathing was for all residents to be placed on a once weekly schedule unless they requested them more frequently. Staff B stated staff were to inform the shower aides if any residents were to request more frequent bathing/showers and the correct process was not followed for Resident 87. <Resident 22> Review of the medical record showed Resident 22 was admitted to the facility with diagnoses including diabetes mellitus (a group of diseases that result in too much sugar in the blood), heart failure, and liver disease. The 10/09/2024 comprehensive assessment showed Resident 22 required supervision/moderate assistance of one staff member for activities of daily living (ADLs)and was independent with eating. The assessment also showed Resident 22 had an intact cognition. During an interview on 01/06/2025 at 2:42 PM Resident 22 stated there were limits on the amount of food they could have at a meal that was printed on the back of the menu. They stated for breakfast they could only have one piece of toast, one hashbrown, and one small bowl of cereal. Resident 22 stated if they were still hungry after a meal, they were out of luck. Record review of the Menu for [facility name], dated 01/12/2025 through 01/18/2025, showed no more than 3 drinks per meal, Toast, Hashbrown Patty (limit 2 patties), Pepperoni Pizza (Limit 1), Bowl of Chili (Limit 2), Hotdog w/Bun, [NAME] (ketchup), May (mayonnaise), Mus (mustard), Relish (Limit 2), Cheeseburger w/Fixin's (Limit 1). The menu also showed Only 1 entree per meal order and only 2 sides, no more then 3 items per meal. Review of Resident 22's meal intake record dated 12/16/2024 through 01/14/2025, showed there were 90 meal opportunities. Resident 22 consumed 75%-100% of their meal for 84 of the 90 opportunities. During an interview on 01/13/2025 at 9:33 AM, Staff B stated it was not the process to limit a resident's food. They stated if a resident requested an additional meals, they should have them. Reference: WAC 388-97-0900(1)(3) 48368

Based on observation, interview, and record review, the facility failed to maintain confidentiality of medical conditions through posting of signs in a Resident's room for 1 of 7 residents (Resident 84) reviewed for resident's rights. Posting a sign that identified a medical condition, prevented protection of residents' right to privacy of a medical condition. Findings included . Review of the resident's medical records showed they admitted on [DATE] with diagnoses to include schizophrenia (a serious mental illness that affects a person's thoughts, feelings, and behaviors). The 11/29/2024 comprehensive assessment showed Resident 84 ' s cognition was severely impaired. An observation on 01/06/25 at 2:31 PM, showed a laminated sign with bold black lettering on the wall above Resident 84's bed that stated, I have schizophrenia, I come in and out of reality (not from drugs), I'm also blind feed me half meals, I love my room cool and love tons of water. During an interview on 01/09/2025 at 1:23 PM, Staff I, Registered Nurse, stated resident rooms should not have signs displayed that contained private personal health history information. Reference WAC: 388-97-0380 (1)

Based on observation, interview, and record review, the facility failed to prevent an avoidable accident by ensuring the plan of care regarding transfers was followed for 1 of 3 residents (Resident 1) reviewed for accidents. The failure to safely transfer Resident 1 using two-person assist resulted in an assisted fall and Resident 1 experienced harm when they sustained a facial laceration (a skin wound usually caused by a sharp object or blunt trauma) requiring evaluation and intervention by the local emergency room (ER). Findings included . Review of the facility policy titled Fall Prevention Program, revised on 09/04/2023, defined a fall as an event in which an individual unintentionally comes to rest on the ground, floor, or other level. Review of the facility policy titled Fall Risk Assessment, revised on 09/04/2023, showed the facility would provide an environment that is free from accident hazards, and provide supervision and assistive devices to each resident to prevent avoidable accidents. <Resident 1> Review of the medical record showed Resident 1 admitted to the facility on [DATE] with diagnoses of Alzheimer's Disease (a brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks), malnutrition (poor nutrition), and chronic pain. Review of the comprehensive assessment, dated 10/03/2023, showed Resident 1 had severe cognitive impairment, was fully dependent on the assistance of one person for eating, hygiene, incontinent care, and two people for transfers and bed mobility. Review of the facility incident reporting log showed Resident 1 experienced an injury during handling on 11/26/2023 at 2:50 PM, sustaining a laceration type of injury to the resident's left forehead and temple, and was sent to the local (ER) for evaluation. Review of the facility's investigation showed on 11/26/2023 at 2:00 PM, Resident 1 was found bleeding from a facial laceration while lying in bed. Witness statements collected as a part of the facility's investigation showed Staff C, Nursing Assistant (NA), had assisted Resident 1 to bed 15 minutes prior to the discovery. The investigation showed Staff C denied knowing the cause of Resident 1's injury. Further review of the facility's investigation showed Staff C later admitted (the next day, during an interview on 11/27/2023) to losing their balance while transferring Resident 1 causing them both to fall. Staff C stated they proceeded to pick up Resident 1 from the floor, assisted them into bed and did not report the incident due to fear of disciplinary action. The facility's investigation summary attributed Resident 1's facial laceration injury to the improper handling during care from Staff C. Review of the nursing Progress Note (PN), dated 11/26/2023 at 2:50 PM, showed Resident 1 was transported to the local ER for evaluation and treatment of the laceration to their left forehead and temple. Review of Resident 1's medical record showed an ER visit note for 11/26/2023 with discharge diagnoses of left facial laceration and left face contusion (a bruise or collection of blood under the skin). The document showed Resident 1 had a five centimeter (cm) long and three millimeter (mm) deep laceration from the left temple down to the left cheek and the surrounding skin was bruised. The ER provider documented Resident 1 was not a candidate for sutures (medical stitches) due to frailty of the skin and potential discomfort. The facial wound was treated and secured with steri-strips (a type of tape used to hold wounds closed), skin glue, and covered with a gauze dressing. An observation, on 12/01/2023 at 11:50 AM, showed Resident 1 sitting up in their wheelchair at the dining room table with a gauze dressing secured to the left side of their face from the temple to the lower part of the cheek. Dark purple discoloration of the skin was noted to extend past the edges of the dressing. During an interview, on 12/01/2023 at 1:00 PM, Resident 1's Representative (RR) stated the facility had notified them of Resident 1 experiencing two falls in the last six months which surprised them because (they) cannot move on (their) own. RR stated Resident 1 had required the assistance of two people for their cares for over a year and was fully dependent on the staff for everything. RR stated, I am not sure (they) can reach up to scratch (their) eyebrow anymore, and, in their opinion, there was no way Resident 1 could have fallen or injured themselves on their own. Review of the medical record showed Resident 1 had care plan interventions, dated 08/12/2022, that required the extensive assistance of two people for transfers and bed mobility. Review of the November 2023 activities of daily living (ADL) assistance records showed staff documented transfer assistance 62 times for Resident 1. Further review of these records showed 17 out of 62 assistance opportunities were documented as using one person to transfer Resident 1. During an interview, on 12/01/2023 at 1:45 PM, Staff E and Staff F, Resident Care Managers (RCMs) stated they did not routinely review the NA documentation for ADL assistance of residents as it did not pertain to their direct duties. During an interview, on 12/01/2023 at 2:00 PM, Staff D, Minimum Data Set [(MDS) a standardized assessment tool that measures health status in nursing home residents] Coordinator, stated they were responsible for completing the comprehensive assessments and updating all resident care plans. Staff D verified the transfer and bed mobility interventions for Resident 1 were accurate and appropriate based on their last assessment. When asked if they were aware of the inconsistencies in Resident 1's transfer assistance documentation, Staff D stated no because review of the NA documentation was no longer relevant to the MDS process. When asked why some staff would choose to not follow the care plan, Staff D stated, I don't know. If the care plan says two people, then they should use two people. No exceptions. During an interview, on 12/01/2023 at 2:15 PM, Staff C stated the amount of ADL assistance they provide to residents was based on information shared from other nursing staff during report or on information obtained from asking other NAs and Licensed Nurses (LNs). When asked if they ever checked the care plan, Staff C stated, yes, sometimes. The RCS Complaint Investigator provided a scenario of a resident whose care plan showed they were a two person assist with transfers, but other NAs working stated they transferred the resident using one person. When asked how they would handle that, Staff C stated they would try to transfer the resident by themselves but would ask for help if they felt they could not do it. Continued from the above interview, Staff C confirmed on 11/26/2023 at 1:40 PM, they attempted to transfer Resident 1 from the wheelchair to the bed without a second person. Staff C stated they lost their balance during the transfer causing both Resident 1 and themself to fall to the floor. Staff C stated they assisted Resident 1 from the floor by holding on to the elastic waist band of Resident 1's pants and pulling them up onto the bed. When asked if Staff C considered these events they described as a fall, Staff C stated, yes because I assisted (them) to the floor. Staff C denied observing signs of injury prior to leaving Resident 1's room. Staff C stated they did not ask for help in assisting Resident 1 from the floor or report the fall to an LN because they did not want to get in trouble. When asked if they were aware Resident 1 was a two person assist with transfers before this incident, Staff C stated, yes. During an interview, on 12/01/2023 at 4:05 PM, Staff B, Director of Nursing, stated this incident was an avoidable accident and the expectation was for staff to refer to the care plan to know the amount of assistance the residents required for safe and comfortable care. When asked how they would know if staff were following the care plan appropriately, Staff B stated through observations of care and review of the NAs documentation. Staff B stated they were unaware the NAs documentation indicated the care plans were not consistently followed, and they expected the MDS Coordinator and the RCMs to review these records. Reference: WAC 388-97-1060(3)(g)

Based on observation, interview and record review, the facility failed to conduct testing for COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases, difficulty breathing that could result in severe impairment or death) in a manner that is consistent with current standards of practice for conducting COVID-19 testing for four of four residents (87, 77, 84, 389) and eight of ten staff (P, SS, O, C, TT, UU, YY, L) reviewed for COVID-19 testing. In addition, the facility failed to provide a designated physical space for staff testing and failed to ensure infection prevention strategies were maintained. These failures placed the residents and staff at risk for transmission of COVID-19, a diminished quality of life, and resulted in a hospitalization of one resident (36). On 09/30/2022 at 1:50 PM, the facility was notified of an Immediate Jeopardy at Code of Federal Regulations (CFR) 483.80(h)(1)(iii)(iv)(2) for COVID-19 Testing, related to the facility's failure to conduct COVID-19 testing for residents and staff, in a manner consistent with current standards of practice. This failure led to the decline and subsequent hospitalization for a symptomatic, COVID-19 positive infection for one resident (36). The facility removed the immediacy on 10/03/2022 by implementing a removal plan that included retesting all staff in the facility on 09/30/2022, following current standards of practice for resident and staff testing, preventing symptomatic staff from entering the facility, and requiring all staff to wait in the admission office for 15 minutes post test for results. Education and training were provided to all staff for the process of self-testing, and a competency was completed. Findings included . Review of the 04/04/2022 Centers for Medicare and Medicaid Services (CMS) Guidance for [CONDITION(S)]-CoV-2 Rapid Testing Performed in Point-of-Care Settings showed that surfaces within six feet of the specimen collection and the handling area should be disinfected before testing begins each day; between each specimen collection . and that a new pair of gloves should be used each time a specimen is collected from a different person and before putting a new specimen into a testing device. Further review showed that when processing multiple specimens successively in batches .to avoid cross-contamination, change gloves before putting a new specimen into a testing device. Additionally, results should be read and recorded only within the amount of time specified in the manufacturer's instructions. Review of the 04/22/2022 Washington State Department of Health's Interim Recommendations for [CONDITION(S)]-CoV-2 Infection Prevention and Control in Healthcare Settings showed that hand hygiene (alcohol-based hand rub or wash with soap and water) should be performed immediately after glove removal, and after contact with blood, body fluids, or contaminated surfaces. Further review of the document showed that a NIOSH-approved (National Institute for Occupational Safety and Health) respirator (N95 mask) was indicated for personal protective equipment (PPE) when performing procedures that create uncontrolled respiratory secretions, such as collecting or handling specimens from known or suspected COVID-19 patients. Additionally, N95 masks should be used for one patient encounter, then discarded when care had been provided for COVID-19 positive residents, quarantined residents, and those with aerosol generating procedures ([AGP] a procedure that is likely to generate a higher concentration of infectious respiratory aerosols). Review of the 09/08/2022 Centers for Disease Control and Prevention (CDC's) Types of Masks and Respirators showed that N95 masks should not be worn with other masks or respirators. Review of the CDC's 03/29/2021 Performing Broad-Based Testing for [CONDITION(S)]-CoV-2 in Congregate Settings showed that the facility should have a designated space for each specimen collection station with doors that closed fully, or protected spaces separated by physical barriers such as privacy curtains and/or plexiglass. Testing supplies should not be kept in the immediate specimen collection area to avoid the possibility of contamination of test materials. Review of the 12/31/2021 CDC guidance Interim Laboratory Biosafety Guidelines for Handling and Processing Specimens Associated with Coronavirus Disease 2019 (COVID-19) showed that waste generated during processing and testing should be discarded as biohazardous waste. Review of the CMS QSO-20-38-NH guidance, revised on 09/23/2022, showed that staff with symptoms of signs of COVID-19, regardless of vaccination status, must be tested as soon as possible and are expected to be restricted from the facility pending the results of COVID-19 testing. Review of the BinaxNow COVID-19 Ag Card instructions for use, revised on 02/2022, showed the required materials for testing included a clock, timer or stopwatch. Instructions for specimen collection showed that the nasal swab should be inserted into the nostril and firmly rotated against the nasal wall five times or more for a total of 15 seconds, then, using the same swab, repeat in the other nostril. Open the test card and lay it flat when performing the test. Hovering one half inch above the top hole on the card, slowly add six drops of solution to the hole. Insert the sample swab into the bottom hole and push upwards until the swab tip was visible in the top hole. Rotate the swab shaft three times clockwise (to the right). Close and securely seal the test card. In order to ensure proper test performance, it is important to read the result promptly at 15 minutes, and not before. Results should not be read after 30 minutes. False negatives could occur if the sample swab was not rotated prior to closing the card and/or if test results were read before 15 minutes. Additionally, all components of the test kit, including the test card, should be discarded as Biohazard waste according to Federal, State, and local regulatory requirements. Staff Testing During an interview on 09/30/2022 at 7:09 AM, Staff P, Laundry Aide, stated that they usually tested after they passed out the clean laundry, either in the Director of Nursing's (DON's) office or they ask the nurse, and they will test them right at their medication cart. During an interview on 09/30/2022 at 7:11 AM, Staff SS, Housekeeper, stated that the nurses usually performed the test, but the policy was changing, and they will start testing in the administration office. During an interview on 09/30/2022 at 7:12 AM, Staff O, Agency Nursing Assistant (NA), stated I think I go to the office, but I haven't been tested yet since I started - I have been working here on and off since the beginning of September - I think I test once a week. During a concurrent observation and interview on 09/30/2022 at 7:17 AM, Staff C, Infection Preventionist Registered Nurse (IPRN), approached a COVID-19 test cart located at the central nurse's station, where all resident halls meet. Staff C obtained a test card, opened it, and applied the test solution to the card. They then obtained an individually packaged test swab and carried the opened card and swab to the DON's office. Staff C placed all testing supplies on an upholstered bench in the office and stated, I'm congested, that is why I am testing right now. Staff C swabbed their nares and placed the swab in the test card, placed the card into a plastic and sealed the bag. They left the office, performed hand hygiene in the hallway outside of the office and stated, I am going to put this (specimen) in my office for 15 minutes and proceeded to walk back to the center of the building and continued to their office. Staff C did not perform hand hygiene prior to obtaining the test materials or leaving the DON's office. Additionally, Staff C failed to disinfect the vinyl upholstered bench that was used as a testing surface. During an observation on 09/30/2022 at 10:23 AM, Staff TT, Scheduling Coordinator, performed a self-test for COVID-19. Staff TT rotated the nasal swab twice across the nasal wall of each nostril, placed five drops of solution in both the top and bottom holes of the test card. Staff TT placed the swab into the card and closed the card. They picked up a pen to write their name and time of test on the card, placed the card into the specimen bag, and wrote their information on the test log. Staff TT failed to perform hand hygiene after performing the test, prior to using the pen, and prior to leaving the testing area. During an observation on 09/30/2022 at 10:42 AM, Staff UU, Dietary Aide, failed to perform hand hygiene prior to the start of their self-test. Staff UU picked up the pen that was used (and not sanitized) by Staff YY, completed their test, and using the same pen, documented their information on the test log. The test cart was not sanitized between Staff TT and Staff UU's tests. An observation on 09/30/2022 at 11:33 AM showed Staff L, Registered Nurse (RN), performed a self-test for COVID-19. Staff L performed hand hygiene, donned gloves after writing on their test card, and placed six drops of solution into the bottom hole of the test card. Staff L rotated the test swab five times in each nostril, put the swab into the card, and placed the card on top of a clip board located on top of the cart. They cleaned the areas around the clip board and solution bottles, removed their gloves, picked up their test card, and placed it into a specimen bag. Staff L placed the specimen bag into the designated basin and returned to their assigned work area. During an interview on the same day at 11:44 AM, Staff L stated that they read their test results after 15 minutes, but really, the first minute or so after testing shows the result, but you're supposed to wait 15 minutes. At 11:46 AM, Staff L verified negative test results at 13 minutes posttest. There was no time documented for the start of the test or when the test should have been read. During an interview on 09/30/2022 at 10:16 AM, Staff B, DON, stated that as of last week, there was a new process for testing. Prior to the new process, staff would need to go to a nurse for testing. Additionally, Staff B stated that when staff were doing their routine and/or outbreak screening tests, there was no reason for them to be off the floor waiting for results, however if they were symptomatic, they would need to wait for their results. If they were symptomatic and had negative results, they would screen the staff member further with additional questions. Staff B stated, any licensed nurse could do a secondary screening, but they confer with me before going to the floor. During an interview on 09/30/2022 at 12:11 PM, Staff C stated that they did not have additional screening questions after their test that morning despite their symptoms and did not know what an additional or secondary screening was. Staff C stated that they would find Staff B and complete that screening now. Resident Testing An observation on 09/30/2022 at 7:24 AM, showed Staff B and Staff D, Resident Care Manager (RCM), located in the East Wing of the facility with a COVID-19 testing cart that contained hand sanitizer, gloves, testing swabs, sealed test cards, 2 bottles of test solution, a marker, specimen biohazard bags, clipboard with documentation forms, clear trash bags, gowns, and a bin with N95's. A clear trash bag was taped to the right side of the cart. Staff B, wearing their N95, donned additional PPE including a gown, gloves, a single use face shield, and placed a face mask over their N95 respirator. Staff B entered the room of Resident 87 while Staff D waited outside the room at the test cart, wearing an N95, gloves, and prescription glasses with side wings. Staff B performed the nasal swab behind closed doors and handed the swab to Staff D, who placed it in the test card that had been prepared with resident information, test solution, and time of testing. Staff D placed the test card with the specimen into a specimen biohazard bag and placed the bag into a basin lined with a red biohazard bag. The remaining trash was placed in the clear trash bag. Staff D removed their gloves and put on a new pair of gloves without performing hand hygiene. Staff B doffed their PPE, cleaned the single use face shield, and carried the face shield to the next resident room. Staff B and Staff D continued to perform the resident testing for residents 77, 84, and 389 in the same manner. Staff B failed to perform hand hygiene after cleaning the face shield when exiting the resident rooms, and Staff D failed to perform hand hygiene between each glove change. Additionally, Staff D failed to clean the surface of the test cart between each test. These failures to disinfect and perform hand hygiene between testing increased the risk for cross-contamination and transmission of COVID-19. During an interview on 09/30/2022 at 7:43 AM, Staff D stated that the test cart was stored in the DON's office or the front office after testing, and the results were scanned in the records. When asked who read the results of the tests, Staff D stated that they were read when they are scanned in (despite the manufacturer's instructions stating that results must be read promptly at 15 minutes and no later than 30 minutes). Resident 36. Review of the medical record showed the resident was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The 08/12/2022 comprehensive assessment showed the resident required extensive assistance of one to two staff for activities of daily living. The assessment also showed the resident had an intact cognition. Record review of the resident's medical record showed that on 09/22/2022, the resident tested positive for COVID-19 and was placed on isolation precautions. Progress notes, dated 09/23/2022, showed the resident had increased shortness of breath overnight, especially with even minimal exertion. The resident became febrile with a temperature of 100.3 degrees Fahrenheit (normal body temperature is 98.6), with chills. The resident's oxygen saturation (the amount of oxygen circulating in the blood) was 94-95% on 4 liters of oxygen per minute (oxygen saturation values of 95% to 100% are generally considered normal), and their respiratory rate was 26 to 28 breaths per minute (normal respiratory rate is 12 to 20 breaths per minute). Progress notes, dated 09/28/2022 at 8:48 AM, showed the resident was found with respiratory distress and a small amount of emesis (vomit). Their respirations were 40 breaths per minute, oxygen saturation of 88% on 3 liters of oxygen, and a heart rate of 135 beats per minute (normal heart rate is 60 to 100 beats per minute). The resident was pale and cool and was too weak to stand. They had green-creamy sputum and lung sounds had wheezes on the left and diminished bilaterally. After notification to the provider and family, the resident was transferred to the hospital emergency department. Review of hospital records, dated 09/28/2022, showed that the resident was COVID-19 positive on 09/22/2022 and suspect that they are symptomatic from COVID which may be causing some [CONDITION(S)] exacerbation. Reference WAC 388-97-1320(1)(2)(c)(d)

Based on interview and record review, the facility failed to identify change in condition in a time consistent with the resident's needs and failed to provide the needed care, services, and monitoring for a change in mentation, decreased chewing/swallowing, and communication abilities (which started on 11/04/2021 and continued until 11/08/2021 when the resident was sent to the local emergency department for an evaluation), in one of three residents (Resident 1), reviewed for hospitalization and skin issues. This failure resulted in a delay in medical treatment/interventions, and a diminished quality of life, constituting harm. Findings included . Review of the facility's undated policy titled, Alert Charting and Change in Condition, showed the Licensed Nurse (LN) will .contact 911 for hospital transport, if the resident appears acutely ill, unless on hospice .evaluate the change in condition .advise staff of observable data needed, suggest an immediate action, and/or recommend a plan of care .document in the charting section and the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .each shift .for 72 hours or until determined the condition has resolved .any reportable criteria must be reported to the primary physician and family promptly .all attempts of communication must be documented. Resident 1. Review of the resident's medical record showed they admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's comprehensive assessment, dated 09/29/2021, showed the resident was cognitively intact, and able to make needs known. Further review showed Resident 1 had clear speech/comprehension, no behaviors, was independent for eating after set-up, no swallowing issues, and a regular (textured) consistency diet. Record review of Resident 1's nursing progress notes, dated 11/04/2021 at 2:28 PM, showed Staff F, Medical Assistant (MA), documented the resident was having difficulty eating, required more assistance, and had trouble opening their mouth wide enough for a small bite of food. The resident also complained of their hands feeling numb. The MA notified therapy for an evaluation. No further interventions were documented. Review of the resident's medical record showed no assessment and/or intervention addressing the resident's change of condition for 11/05/2021 and 11/06/2021. Record review of Resident 1's nursing progress notes showed a late entry, dated 11/08/2021, for the effective date of 11/07/2021 at 2:15 AM, Staff C, MA, documented resident had a continuance of decline. They documented the resident required assistance with eating, they were no longer able to lift their arms to feed themself, coughing when swallowing, pocketing (holds on to food in their mouth without swallowing it) food, and no response mentally or verbally with sternal rub (painful stimulus with the knuckles of closed fist to the center chest of a patient who is not alert and does not respond to verbal stimuli), or the nurse calling their name out loud. Furthermore, the resident's diet had to be downgraded to a minced and moist diet, their pills had to be crushed and put in applesauce to facilitate swallowing, the resident became stiff during care, and had non-sensical mumbled speech. Record review of the resident's nursing progress notes, dated 11/08/2021 at 11:36 AM, Staff F, MA, documented resident would not arouse to eat or drink. Unable to give medication. Record review of the resident's nursing progress notes, dated 11/08/2021 at 12:51 PM, Staff A, Director of Nursing (DON), documented attempts to reach the resident's representative about the resident's change in condition and decreased level of consciousness. Record review of the resident's nursing progress notes, dated 11/08/2021 at 2:47 PM, Staff B, Licensed Practical Nurse (LPN), documented the resident had not been swallowing on their own, diet had been downgraded over the weekend, and during breakfast was unable to chew or respond. Staff B further documented that the Nursing Assistant (NA), at breakfast, had manually removed the food from the resident's mouth, and the resident's diet had been downgraded again to a full liquid diet. They also stated that at noon the resident became non-verbal, made no eye contact, and had no response to verbal or touch stimulation. Additionally, the resident had been open-mouth breathing, gurgling at the base of their throat, used accessory muscles to breathe, and had no response while obtaining the COVID-19 (an infectious disease causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death) test, which was not baseline behavior for the resident. At this time, it was deemed necessary to ship the resident to the ER (emergency room ). During an interview, on 11/17/2021 at 3:00 PM, Staff C, MA, stated they observed the resident's decline during their shift on 11/06/2021. They observed the resident had a decline in cognition and verbal expressiveness, and was unable to feed themself, previously the resident was able to feed themself. The resident required medications to be crushed and fed to them, one-by-one with applesauce due to the decline in swallowing and chewing. The resident had previously been able to take medication whole and all at once. In addition, Staff C stated that on 11/07/2021 (three days after Staff F first noticed Resident 1's change in condition) they reported to Staff D, Registered Nurse (RN), the resident's change in condition and the inability to arouse the resident at breakfast time, the resident became groggy, and during meals was pocketing their food. Staff C stated that the NA's had reported that Resident 1 had decreased verbalization, and appeared stiff, like a log when providing them care. Staff D changed the resident's diet to minced and moist. Resident 1 continued to struggle with eating/chewing/swallowing the downgraded diet, and during breakfast, the food had to be manually removed from the resident's mouth. Furthermore, Staff C stated that alert charting should have been initiated but they did not recall if that had been done. During an interview, on 11/17/2021 at 3:17 PM, Staff D, RN, stated they were notified by Staff C of the resident's change in condition on 11/07/2021, they did not recall the time. Staff D further stated they knew the resident was going to be evaluated by Speech Therapy on Monday, 11/08/2021, and notified the kitchen to downgrade the resident's diet to minced and moist. They did not assess the resident themself. Staff D, then called the DON and informed them of the resident's decline and were told they were aware of the resident's swallowing issues and would be evaluated on Monday by Speech Therapy. Staff D further stated they did not initiate alert charting and had not processed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] During an interview, on 11/17/2021 at 3:30 PM, Staff A, DON, stated they had spoken with the physician previously about Resident 1's decline with their chronic pain issues, and the several trips to the ER. We also discussed involving the Resident's Representative in relation to the resident's decline and possibly changing their 'full code' status to a 'do not resuscitate/intubate status' but attempts to contact the family were not successful. Staff A also stated that the resident had behaviors and would cry wolf' and then would wake up and change the tone or the behavior they had been having, so this could be a reason why the nursing staff did not notify the physician. Staff A further stated they were not aware there had not been alert charting documented through the weekend regarding the resident's changes of condition. During an interview on 11/23/2021 at 10:33 AM, Staff E, Attending Physician, stated there had been no notification to them relative to the change in the condition of Resident 1, on 11/04/2021 for the need in more assistance being required to eat, or the numbness of the hands, or through the weekend of 11/6/2021 to 11/8/2021, until after the resident was sent to the hospital. Review of Resident 1's MAR, dated 11/01/2021 through 11/08/2021, showed no alert charting order to notify the LN's the resident had a change in their condition and needed to be monitored. Review of the resident's nursing progress notes, dated 11/04/2021 through 11/08/2021, showed the notes began with the change in condition of the resident on 11/04/2021, and showed no nursing progress notes regarding the resident's change in condition were documented until 11/08/2021, the day the resident was admitted to the hospital. Furthermore, the progress notes showed no interventions/changes of care had been put into place during the weekend of 11/06/2021 to 11/07/2021. During an attempted phone interview on 11/18/2021 at 1:00 PM, the day the resident readmitted to the facility, Resident 1's response to questions were non-sensical. Review of the hospital's progress note, dated 11/08/2021, showed the resident was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Reference: WAC 388-97-1060 (1)

Based on observation, interview, and record review, the facility failed to implement policies and procedures to identify, protect, investigate, and report abuse allegations for two of two residents (#12, 49) reviewed for abuse. Additionally, facility staff did not review and recognize grievances filed as potential abuse or neglect allegations. This failed practice resulted in actual harm to Residents #12 and #49 and placed other residents at risk for abuse and neglect. An immediate jeopardy (IJ) was identified on 11/29/18. The IJ was removed on 11/30/18 after the facility completed training for all employees on identifying, investigating, protection of residents, and reporting allegations of abuse and neglect. Findings included: According to Nursing Home Guidelines 6th addition (Purple Book) dated (MONTH) (YEAR), a facility must develop and implement written principles and procedures for abuse and neglect, and must protect residents from harm. A review of an undated facility policy titled Abuse Prevention Program documented the facility will identify and assess all possible incidents of abuse, investigate and report any allegations of abuse within time frames as required by federal requirements and protect residents during abuse investigations. The policy further stated that the facility would require staff training/orientation programs that included: abuse prevention, identification and reporting. A review of an undated facility policy titled Grievance policy documented grievances not related to allegations of abuse or neglect will be documented on the grievance forms. Review of the facility grievance book showed Resident #49 had reported to social services on 05/9/18 (over six months ago) an allegation of rough treatment in the shower by two NA staff. She reported that staff had picked her up by the back of the pants and caused her a wedgie. She alleged NA staff are mean and rude, and further stated NA staff had taken pictures of her during cares. Staff H and Staff V were specifically named as two of the NAs involved. Resident #49 had filed an additional grievance on 05/12/18. The resident alleged Staff V was rude and would not let her wash her hands after toileting. I feel like she has something against me. The resident stated, I get scared when they open my door. Further review of the facility grievance book revealed additional allegations of abuse and neglect concerns filed by residents. * On 03/14/18 Resident #54 filed a grievance alleging staff were rough with her during showers. * On 03/28/18 Resident #44 filed a grievance stating she had turned her call light on at 5:00 PM as she urgently had to go to the bathroom. NA Staff informed her they could not get her up because it was dinner time. The call light was not answered until 3:30 AM. * On 05/07/18 Resident #34 alleged she turned on her call light to be assisted up for Bingo. The NA came into the room and turned off the call light and refused to get her up and she missed Bingo. * On 07/02/18 Resident #62 alleged staff were being mean and he was thrown onto the bed during a transfer. * On 08/07/18 Resident #6 alleged that NAs during her shower were rude, insulting, vicious and nasty. * On 10/22/18 Resident #26 alleged the call light was turned on at 10:00 AM and not answered for two hours. * On 11/19/18 Resident #58 had an allegation filed stating he was incontinent and his pants were soaked through. NA staff were asked to assist him. He was observed later with the same soaked pants on. His brief had been changed and the wet pants were put back on. Resident #49. Review of the medical record showed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive assessment dated [DATE] showed the resident was cognitively intact and required an extensive assist for transfers, dressing, and showering. On 11/29/18 at 11:45 AM in an interview, the resident stated, I have a problem with an aide. The resident identified Staff H. She is rough with me and throws me onto the bed and shoves me around. The resident reported an additional staff person, Staff V, NA, stating, She yells at me and has no patience. She has left me on the toilet for an hour and a half which made my body hurt all over. The resident further stated that on another occasion during a shower, the aides picked me up by my pants so hard it gave me a wedgie, it hurt me. The resident stated she had reported her concerns to social services and had filed grievances several times; nothing ever gets done about it. Sometimes I am afraid to say anything because I am afraid it will get worse. On 11/29/18 1:14 PM, Resident #49's allegations were reported to Staff A and Staff B. Staff A stated she was unaware of the resident's allegations or that grievances had previously been filed. Staff B stated she was not aware of the resident's allegations and had not had any grievances reported to her. Resident #12. Per record review, the resident admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent comprehensive assessment dated [DATE] showed the resident was cognitively intact and required extensive assistance for dressing and transferring. During an interview on 11/28/18 at 09:30 AM, the resident stated, I have been abused, there is an aide here who is vicious, she is so rough. The resident pulled up the sleeve on her right arm and revealed two bruises on each side of the underside of her forearm. The bruises were light purple with fading yellow color. The bruises were round resembling a thumb and finger print. The thumb print bruise measured approximately one inch by 1/2 inch and was located on her inner forearm. The fingertip bruise was located on the outer side and measured approximately 3/4 inch by 1/2 inch. The resident pointed to the bruises and stated see what she did to me. I told her ouch, ouch, ouch, to let her know that she was hurting me but she just ignored me. I don't understand what I've done to her to make her so mean to me. Upon further questioning the resident would not identify the staff person she was referring to. On 11/28/18 at 09:50 AM, Staff A, Administrator, and Staff B, Director of Nurses, were informed of Resident #12's allegation of abuse. Staff A stated, I didn't know about it. Staff B stated, This is the first I've heard of it. On 11/29/18 at approximately 11:00 AM, Staff B reported that she and Staff J, Social Services Director, had interviewed Resident #12 and identified the staff person involved in the allegation of abuse as Staff H, Nursing Assistant (NA). Staff B stated Staff H had been placed on suspension pending the results of the facility investigation. On 11/29/18 at 3:30 PM, Resident #12 was re-interviewed. She stated, I was afraid to really tell anyone what was happening to me because I was afraid the treatment from Staff H would get rougher. It's an awful feeling lying in bed, incapacitated like I am, and being so afraid of someone. It's a relief it's all out in the open. On 11/30/18 at 12:00 PM, Staff P, Registered Nurse (RN), stated she was aware Staff H can be rough. She stated that the residents didn't report their concerns because they were afraid of the consequences from Staff H. A review of the facility Incident Reporting log did not show that the residents' grievances/allegations had been identified as potential abuse or neglect. There were no investigations initiated or resident protective measures put into place. Once the Immediate Jeopardy had been identified, facility administration continued to interview residents. Staff B, DNS, presented results of interviews conducted on 11/28/18 specific to Staff H. Nine interviews were completed, seven of the residents interviewed voiced concerns about Staff H. * Resident #49 stated Staff H is rough all the time and she did not feel safe. * Resident #44 stated Staff H likes to be fast and needs to be more gentle. She added she has felt unsafe a couple of times. * Resident #30 stated, Staff H shoves me around a bit. * Resident #26 stated, I asked Staff H last week to stop being so rough with me. * Resident #34 stated, I hate it when Staff H showers me, she is so rough. * Resident #13's spouse stated Staff H was very rough. * Resident #59 stated Staff H was rough and rude. An interview on 11/28/18 with Staff J, Social Services, showed that she was not aware how to recognize allegations of abuse and neglect filed on the grievance forms. She stated she had only been employed for a few months but had received training on abuse and neglect as a part of orientation. She further stated grievances were reviewed daily in a Stand Up meeting with the administrator and DNS. Staff J stated the process for grievances was for staff to write concerns on grievance forms and if she was unavailable, the form would be placed in her box and she would review them when she returned to work. The facility grievance form had notification boxes towards the bottom of the form. The boxes indicating administrator, DNS and social services were checked off for notification of concerns related to the grievances that had been filed. On 11/30/18 at 3:40 PM, Staff A stated she was not aware that the previous Social Services Director had not identified the grievances dating back to (MONTH) 14, (YEAR) as allegations of abuse and neglect. Additionally, she stated she had trusted the previous Social Services Director to recognize and respond appropriately to allegations of abuse and neglect with the expectation that she should have been informed. WAC 388-97-0640 (2)

Based on observation, interview, and record review, the facility failed to ensure two of two residents (#49, #12), reviewed for abuse, were free from abuse. The facility failed practice resulted in actual harm as they had experienced abuse by staff. The facility had knowledge based on previous grievances filed that the staff had allegedly abused/neglected other residents. The failure to prevent abuse placed all residents residing in the facility at risk. Findings included: According to Nursing Home Guidelines 6th addition (Purple Book) dated (MONTH) (YEAR) stated residents must not be subjected to abuse by anyone, including but not limited to facility staff. The facility undated policy titled Abuse Prevention and Reporting stated the administration will, protect our residents from abuse by anyone including but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals. Resident #49. On 11/29/18 at 11:45 AM in an interview, the resident stated, I have a problem with an aide. The resident identified Staff H. She is rough with me and throws me onto the bed and shoves me around. The resident reported an additional staff person, Staff V, NA, stating, She yells at me and has no patience. She has left me on the toilet for an hour and a half which made my body hurt all over. The resident further stated that on another occasion during a shower, the aides picked me up by my pants so hard it gave me a wedgie, it hurt me. The resident stated she had reported her concerns to social services and had filed grievances several times; nothing ever gets done about it. Sometimes I am afraid to say anything because I am afraid it will get worse. Review of the grievance book showed a grievance involving Staff H had been reported by Resident #49 on 05/09/18 (over six months ago). Nursing schedules were reviewed and it was noted Staff H continued to work unsupervised as an NA in the facility, providing care up until 11/28/18 when she was suspended. A review of the facility investigation for Resident #49, dated 11/30/18, concluded Resident #49 had been abused by Staff H. Resident #12. During an interview on 11/28/18 at 09:30 AM, the resident stated, I have been abused, there is an aide here who is vicious, she is so rough. The resident pulled up the sleeve on her right arm and revealed two bruises on each side of the underside of her forearm. The bruises were light purple with fading yellow color. The bruises were round resembling a thumb and finger print. The thumb print bruise measured approximately one inch by 1/2 inch and was located on her inner forearm. The fingertip bruise was located on the outer side and measured approximately 3/4 inch by 1/2 inch. The resident pointed to the bruises and stated see what she did to me. I told her ouch, ouch, ouch, to let her know that she was hurting me but she just ignored me. I don't understand what I've done to her to make her so mean to me. Upon further questioning the resident would not identify the staff person she was referring to. On 11/29/18, Staff B, Director of Nurses (DNS), stated she had identified the staff person who had allegedly abused Resident #12 as Staff H, Nursing Assistant (NA). Staff B further stated Staff H had been placed on suspension, pending investigation into the abuse allegation. A review of the facility investigation for Resident #12, dated 11/29/18, concluded Resident #12 had been abused by Staff H as well. Refer to F607 for further details of the facility failure to protect residents from abuse despite previous allegations reported to key staff regarding the treatment recieved by Staff H. WAC 388-97-0640 (1)

Based on observation, interview, and record review, the facility failed to ensure appropriate activities were provided for four of four residents (#2, 32, 38, and 48) reviewed in one wing (hall) of the facility. Failure to implement resident-specific and meaningful activities caused psychosocial harm to Residents #38 and #48, and decreased the quality of life of each resident reviewed. Findings included: An observation and interview with Staff A, Administrator, on 11/27/18 at 11:20 AM showed the facility designated the hallway with the rooms numbered 400 through 417 as the dementia care area. It was referred to by facility staff as the dementia 400 hall, although not all residents who resided in the 400 hallway had a [DIAGNOSES REDACTED]. In addition, at the far end of the 400 hallway was a small dining/activity area called the Vista room, where many of the 28 residents residing in the 400 hall rooms ate their meals and spent their days. Resident #38. Review of the medical record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #38's most recent comprehensive assessment dated [DATE] showed his cognition was moderately impaired and he needed extensive assistance of one to two people for his daily care needs. Observation of Resident #38 on 11/27/18 at 12:15 PM showed him sitting in his wheelchair at a table in the Vista room. His head was down, his hand was on his forehead, and his meal and glasses of thickened fluids in front of him appeared untouched. A caregiver asked if he was going to eat and he stated, I can't eat it, the food is too hard to swallow and my coffee is cold and too thick to drink. I might as well just starve to death. At 12:23 PM, the caregiver removed his lunch tray without offering any other choice of food or fluids. Observation of Resident #38 on 11/28/18 at 2:30 PM showed him sitting in the same spot as the day before in the Vista room with 15 other residents and one activity aide also in the room. He was observed slumped down in his wheelchair, head in hand, crying, and stating his bottom and hip were hurting, and repeatedly asked if he could please lay down. In an interview with Staff D, Activity Assistant, on 11/28/18 at 2:35 PM, she stated Resident #38 cried a lot of the time and complained about staying in the Vista room. She stated she could use her walkie-talkie to get a nursing assistant to come and get him, but it was her experience, it would be awhile before anyone showed up. In addition, Staff D stated the nursing assistant would only take the resident to the toilet now and not lay him down because he fell a lot and couldn't be left in his room alone. In an observation and interview with Resident #38 on 11/29/18 at 2:50 PM, he was sitting at the same table as usual with 16 other residents and an activity aide in the Vista room. He began crying and stated he wanted to go outside or anywhere out of this room. He stated, It's the same thing and the same people doing nothing in this room all day, every day. In an observation and interview with Resident #38 on 12/03/18 at 10:35 AM, he was sitting in the Vista room with 14 other residents and an activity aide in the same spots as noted on previous observations. He stated, I was just looking out the window and dreaming about being able to leave this room and go outside and get some fresh air. He began to cry and stated, I'm just a useless old man that has to sit in this room and do nothing all day. An observation on 12/04/18 at 2:25 PM showed a nursing assistant bringing Resident #38 into the Vista room in his wheelchair. He was heard telling the nursing assistant to please not take him back into that room stating, I hate it in there; it's like a jail in there; please just let me lay down on my bed. On 12/05/18 at 10:16 AM, Resident #38 was found sitting in the Vista room in the same spot as previous observations with 16 other residents and an activity aide. He was slumped forward in his wheelchair, had his head in his hand, and was crying and stating, My bottom hurts so bad from sitting in this chair for hours; I can't stand it. He repeatedly asked to go to the bathroom and lay down. On 12/05/18 at 10:44 AM, Staff C, Nursing Assistant (NA), took Resident #38 from the Vista room to the bathroom in his room and assisted him to the toilet. She stated he was continent of both his bowel and bladder if he was taken to the toilet when he asked to go. In an interview with Resident #38 at 11:20 AM, he stated he did not understand why he was kept in that room all the time and couldn't go other places or lie on his bed when he was tired. He stated, I hate that room; it's so loud with the TV always blaring and people yelling, and the same people just sitting there rotting day after day. Resident #38 stated he didn't feel like a man anymore because his arm and leg didn't work right and he cried all the time like a baby and didn't know why. He stated, If this is the way the rest of my life will be, I would rather be dead. In an interview with Staff D on 12/05/18 at 10:30 AM, she stated that she had been employed as an activity assistant for about two months. She stated she worked three to four days a week from 7:00 AM to 3:00 PM, and then another activity aide came on duty from 3:00 PM to 7:00 PM. Staff D stated there was to be an activity person in the Vista room seven days a week at all times between 7:00 AM to 7:00 PM to supervise the residents and do activities with them. She stated it was difficult finding things to keep the residents entertained for any length of time and a lot of the time they watched movies. Staff D stated that Resident #38 ate very little of his meals, cried frequently, and complained of pain and about having to stay in the room daily. She stated he was not interested in any activities she offered him and he did not interact with the other residents. Staff D stated it was her understanding that Resident #38 had to stay in the Vista room every day for supervision because he fell a lot and there wasn't enough staff to watch him all the time. On 12/06/18 at 10:26 AM, Staff M, Activity Assistant, stated she had worked at the facility for approximately four months and in the Vista room three days a week from 7:00 AM to 3:00 PM. She stated Resident #38 did cry and complain a lot of the time that he was being kept in the Vista room, and sometimes called it a jail or prison. She stated he wasn't the only one, as several residents had made that kind of comment. Staff M stated Resident #38 rarely participated in any activities anymore, didn't eat more than a few bites of his meals, and always seemed sad to her. Staff M stated it was her understanding the residents that were considered a high risk for falling or getting into others' things were to be supervised every day in the Vista room. She stated there was an activity calendar that she was supposed to follow to keep the residents entertained, but mostly they couldn't participate due to their advanced dementia and/or lack of interest. Review of an interdisciplinary care conference note dated 10/15/18 read in part, Resident #38 stays in the Vista room all day as his impulsivity puts him at a higher risk of falls. Review of Resident #38's plan of care for activities and an activity note dated 10/16/18 read in part, Resident #38 needs his days structured for him, attends scheduled group activities on the dementia unit on a daily basis as well as off the hall as appropriate. Resident #38 must be supervised at all times as he makes impulsive decisions such as trying to stand or walk. Further, there was no plan of care to address or monitor the emotional distress Resident #38 experienced daily related to having to stay in the Vista room. Resident #48. Review of the medical record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #48's most recent comprehensive assessment dated [DATE] showed her cognition to be moderately impaired and she required extensive assist of one to two caregivers for her daily care needs. Review of Resident #48's plan of care did not indicate she had any behavior problems and was a low risk for wandering into or intruding into others' space. Review of Resident #48's plan of care for activities showed in part, Resident #48 needs her days structured for her, attends scheduled group activities on the dementia unit on a daily basis as well as off the hall as appropriate. An observation on 11/27/18 at 12:55 PM showed Resident #48 in the Vista room sitting upright in her wheelchair and attempting to open the door to the dementia 400 hallway. A caregiver told her she had to wait for help before she could leave the room, and moved her wheelchair to a table away from the door. In an observation on 11/28/18 at 9:30 AM, Resident #48 was pulling open the door in the Vista room and stated, Help me with this door, I want to get out of here. Staff D told her, You need to stay in here now to which Resident #48 responded, The hell I do. Staff D then moved the resident away from the door and attempted to engage her in conversation. In an interview with Staff D on 11/28/18 at 9:35 AM, she stated Resident #48 needed to stay in the Vista room until someone came and got her because she got into the other residents' stuff if she wasn't watched. In an observation on 11/29/18 at 3:30 PM, a NA was attempting to push Resident #48's wheelchair from the hall into the Vista room. Resident #48 held on to both sides of the door jam and yelled out, No, I don't want to go in there; there's nothing to do in there. The NA then let go of the resident's wheelchair and allowed the resident to go back into the hallway. In an observation of Resident #48 on 11/29/18 at 3:33 PM in the dementia 400 hall, she stated angrily, That bunch just wants me to sit in that room all day and do nothing. She then quickly wheeled herself down the hall away from the Vista room. In an observation and interview with Resident #48 on 12/05/18 at 10:10 AM, she was found sitting in the Vista room with 16 other residents and an activity aide. The room was quiet and a movie was on the TV though no one was observed to be watching it. Resident #48 stated angrily, That's what we do in here, just sit here and look dumb at each other all day. In an observation on 12/07/18 at 12:48 PM, Resident #48 was pulling open the door from the Vista room and was angrily stating, Will someone help me out of this prison. Staff M then opened the door for the resident and three other ambulatory residents followed her out the open door into the hallway. Staff M then stated, Great; now I'll have to get help to get them all back in here. Resident #2. Review of the medical record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #2's most recent comprehensive assessment dated [DATE] showed his cognition was severely impaired and he required extensive assistant of one to two caregivers for his daily cares. Review of Resident #2's plan of care for activities read in part, Resident #2 needs his days structured for him, attends scheduled group activities on the dementia unit on a daily basis as well as off the hall as appropriate. Observations of Resident #2 in the Vista room on: 11/28/18 at 3:10 PM 11/29/18 at 10:05 AM 11/30/18 at 12:25 PM 12/03/18 at 10:30 AM 12/04/18 at 9:32 AM 12/04/18 at 11:10 AM 12/05/18 at 9:41 AM 12/05/18 at 2:50 PM 12/06/18 at 10:26 AM Showed him sitting in the same dining chair, slumped down in the chair, head on his chest with his eyes closed. Resident #2 did not speak when spoken to and was not noted to interact with staff or other residents. In an interview with Staff D on 12/05/18 at 10:30 AM, she stated she thought Resident #2 was brought to the Vista room for meals or when he was awake in his room because he was at a high risk for falling. She stated he rarely interacted in activities or with other residents. Resident #32. Review of the medical record showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #32's most recent comprehensive assessment dated [DATE] showed he was cognitively intact and required extensive assist of one to two caregivers for his daily care needs. Review of Resident #32's plan of care for activities read in part, Resident #32 needs his days structured for him, attends scheduled group activities on the dementia unit on a daily basis as well as off the hall as appropriate. Observations of Resident #32, while observing others in the Vista room throughout the survey, found him to be one of the residents that was most interacted with by the staff and other residents. He was most often seen sitting in his wheelchair after 10:00 AM at the same table with groups of anywhere between 14 and 18 other residents and an activity assistant. In an interview with Resident #32 on 12/05/18 at 9:05 AM, he was in his room sitting up in bed. He stated he usually ate breakfast in bed because it took two people to get him up in his wheelchair. He stated from there, he would be up for the rest of the day, usually sitting in the Vista room until someone came after dinner and got him to put him back to bed. Resident #32 stated he would eat and watch a movie or just watch and listen to what was going on around him. He stated things got pretty fired up in there sometimes because people didn't want to stay in there or they would yell and try to fight with each other. Resident #32 stated he didn't like staying in the Vista room for long periods of time because there was nothing to do. He stated he liked to watch movies and visit with people, but it was usually too loud in there to do that for very long. He stated the same people were in the room every day from morning until bedtime. He stated he had not been specifically told that he could not leave the Vista room, but was frequently told he had to wait until someone came to get him after dinner to lay back down. He stated this was the worst time of the day because he either got laid down in bed right after dinner, or had to wait to go to bed. He stated either way, it made for a long, boring night. Review of the facility dementia unit calendar during the survey dates and the actual activities that were observed being done in the Vista room were consistently different than those listed, or no activities were being done at all. Reference WAC 388-97-1040 (1)(a-c)

Based on observation, interview, and record review, the facility failed to ensure the necessary assessments and care were provided in the area of pain management for one of four residents (#58) reviewed for pain. This failure resulted in harm to Resident #58 who experienced repeated pain over several months while being transferred via a mechanical lift that had an ill-fitting sling and was applied incorrectly by staff. Findings included: Resident #58. Review of the resident's medical record showed the resident was admitted on [DATE] with impairment on his left side due to a stroke. The 11/12/18 comprehensive assessment showed the resident was cognitively intact and required two person extensive assistance for all transfers. On 11/27/18 at approximately 2:45 PM, Resident #58 was heard in the hallway yelling out, It hurts, it hurts as he was being transferred via the mechanical lift to the bedside commode. At approximately 3:00 PM he was observed on the commode, moaning and calling out for assistance. When staff entered his room, he stated he was hurting and wanted off the commode. On 11/28/18 at 9:38 AM, the resident stated, I came back from the hospital and was really weak, so they used the Hoyer (a mechanical lift used for transfers). It hurts like hell; I'm in constant pain when they use it. They don't listen to me when I tell them I don't want to use it. On 12/03/18 at 11:14 AM, the resident was seated in his room in his wheelchair. His buttocks were positioned close to the front edge of the wheelchair seat and he was leaning back, positioned off the right side of the hip approximately four inches from right side of the wheelchair. The resident had a white sling with rainbow colored trim underneath. The sling was crossed and bunched under the groin area. Resident #58 stated, I'm so uncomfortable. I feel like I got a big iron bar in my back and that something in my pants is hurting. It feels like there is a big lump in there. The resident stated, Staff W, Licensed Practical Nurse (LPN), and Staff T, LPN/Resident Care Manager (LPN/RCM), put me in my chair like this. They just left me. I won't even be able to move, I hurt so bad. On 12/03/18 at 11:38 AM, the resident propelled himself closer to nurse's station and turned his head toward Staff W who was seated at the desk. The resident said, I can't hardly move my chair, it hurts as he continued to make moaning sounds. Staff W did not speak to the resident or acknowledge his moaning. Staff Y, Housekeeping Supervisor, approached and the resident who was grimacing and moaning, told her he was hurting. Staff Y responded, You're leaned back a tad, more so than normal. Staff W was now standing at the resident's side and began to wheel the resident to the dining room and said, I'll go get his aide. A 09/18/18 progress note showed the Hoyer lift caused discomfort to the resident and he was provided pain medication, which was helpful. A 09/28/18 physician progress notes [REDACTED]. The resident stated the Hoyer lift would squeeze his chest and shoulders. Diagnostic workup indicated the pain was related to musculoskeletal pain rather than cardiac function. The resident was readmitted to the nursing home on 09/28/18 with an order to increase his pain medication, [MEDICATION NAME] 5 mg twice a day, to [MEDICATION NAME] 10 mg twice a day for pain management and to continue [MEDICATION NAME] 5 mg every four hours for breakthrough pain. Nursing to assess for pain every four hours and document pain level. A 11/02/18 progress note showed, He hollers out a lot as does not like the Hoyer lift as it causes him discomfort and that pain medications are assisting with pain control. A 11/16/18 progress note indicated he frequently yells as he does not like the Hoyer lift transfers as he states they are uncomfortable. On 12/03/18 at 3:14 PM, Staff S, NA, stated, We usually get the biggest sling for (Resident #58). We usually know the color from other NAs or we just get the biggest, those that are straight across, we cross in front, and those that are U-shaped, we leave them open. On 12/03/18 at 4:00 PM, Staff T, stated that sometimes therapy does the assessment for Hoyer transfer, when a resident admits from hospital. For residents that have been here, the floor nurse determines the size of the sling. She also said that sometimes Staff Z, Rehabilitation Aide (RA) would determine the size of the sling. While reviewing the resident's current plan of care, Staff T stated it did not indicate the size of the sling to be used. She said that the facility did not have a standardized process or training to identify the most appropriate sling to use. On 12/05/18 at 2:04 PM, Staff V, NA, stated, I think his (Resident #58) sling was just too small and uncomfortable. I just look at them to make sure they are big enough and the white one seemed to be big enough. On 12/06/18 at 1:22 PM, Staff AA, MDS Coordinator, stated Resident #58's plan of care did not have directives regarding which sling to use and when asked why it was not on the care plan, she replied, That is a very valid point. Review of an 11/05/18 Pain Assessment showed Resident #58 had frequent, moderate pain in the previous five days that made it hard to sleep at night and limited his day to day activities. The document did not include a staff assessment of the pain which would detail 1) Non-verbal sounds (e.g. crying, whining, gasping, moaning, or groaning) 2) Vocal complaints of pain (e.g., that hurts, ouch, stop) 3) Facial expressions . The document did not show that staff assessed the frequency with which the resident complained or showed evidence of pain. The Pain Assessment also did not show or identify the sling size as a possible cause of the pain, even though the resident exhibited routine pain with transfers via the lift. On 12/11/18, Staff Z stated, Last night I used the full sling on (Resident #58). It worked so well, he did not complain of any pain in the arms, legs or scrotum. I think the problem with (Resident #58) is that we were crossing the sling, which was causing the pain. Staff Z said that there has not been a facility training on Hoyer use and sling sizes. Reference WAC 388-97-1060 (1)

Based on interview and record review, the facility failed to ensure Quality Assessment and Assurance (QAA)/Quality Assurance and Performance Improvement (QAPI) program committee staff members followed the facility's QAA/QAPI policies and procedures related to the delivery of quality resident care and services. This failure disallowed QAA/QAPI members and staff the ability to identify and prioritize resident care issues, potentially posing a high risk to the well-being of all residents in the facility. This failed practice resulted in abuse to two of two residents (#12, 49) reviewed for abuse/neglect, harm to one of two residents (#58) reviewed for quality of care, psychosocial harm to two of five residents (#38, 48) reviewed for dementia care, and placed three of 18 residents (#42, 32, and 2) living on the hallway designated for residents with advanced dementia, at risk for a decreased quality of life and seclusion without care. Findings included: On 11/27/18 at 12:01 PM, Staff A, Administrator, reported the facility had a QAA/QAPI committee which met quarterly. The Administrator listed the committee members which included the Administrator and Staff B, Director of Nursing (DNS). On 11/30/18 at approximately 10:00 AM, the Administrator provided a copy of the QAA/QAPI committee policies and procedures. The document included: * Help identify actual and potential negative outcomes relative to resident care . * Coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff . * Scrutinize all department reports . * .Areas that may be appropriate to monitor and evaluate include .Complaints from residents and families . 1. On 11/28/18 at 9:50 AM, the Administrator and DNS were informed of the allegations of abuse/neglect for Resident #12, that occurred as recently as one week earlier, by a Nursing Assistant (NA - later identified as Staff H). Staff A and Staff B reported Staff H still worked in the facility because they had no knowledge of the allegations. On 11/28/18 at approximately 12:30 PM, Staff J, Social Services, reported she interviewed nine random residents about care and services earlier that day. She reported seven of nine residents (#49, 44, 30, 26, 34, 13, and 59) complained of abuse, neglect, and/or rough treatment from Staff H during care, most recently within the past week, and over the past six months. Documentation of allegations of abuse/neglect on Grievance forms showed dates of occurrences on seven occasions between 03/14/18 and 11/19/18, with some of the allegations against Staff H. On 11/29/18 at 11:45 AM, the Administrator and DNS were informed of Resident #49's allegations of abuse/neglect by Staff H. Each staff stated they were not aware of the allegations. This failure resulted in an Immediate Jeopardy being identified on 11/29/18, and removal of the Immediate Jeopardy on 11/30/18. Freedom from Abuse, Neglect, and Exploitation - See F600 and F607 for additional information. 2. On 11/29/18 at approximately 1:00 PM during the resident council meeting, Resident #44 reported she had voiced complaints about care staff being rough with her legs and ankles, resulting in pain while being helped into bed. Resident #58, the facility's resident council president, reported the concerns brought up at their meetings, received no follow up from management, even though the facility's Activity Supervisor, Staff Q, was present at the meetings. On 12/03/18 at 2:30 PM, Staff Q, Activity Supervisor, stated when residents made complaints during the resident council meetings, she filled out a couple of concern forms, but had not given the information to the Administrator for follow up. On 12/03/18 at approximately 2:40 PM, the Administrator stated she was now aware there were serious resident grievances, but they were not communicated properly to the Administrator or the DNS. Resident Family/Group and Response - See F565 for additional information. 3. Observation on 11/27/18 at 12:15 PM showed a dining/activity room (Vista Room) at the end of the 400 hallway. Staff reported this as the facility's designated living area for those residents with advanced dementia. Multiple observations from 11/27/18 at 12:15 PM through 12/07/18 at approximately 3:30 PM showed between 15 and 18 residents in the room at any one time with one activity aide in attendance. Observations showed little to no interaction between the activity aide present and the residents, many of whom sat slumped forward in their chairs with their heads down. On 12/05/18 at 9:20 AM, NAs who wished to remain anonymous, reported although two NAs were assigned to care for the residents on the 400 hall, they did not have enough time to provide all of the personal care the residents needed, such as toileting/changing incontinent briefs or laying residents in bed to rest. On 12/05/18 at 10:20 PM, Staff D, Activity Aide, reported activity aides worked from 7:00 AM to 7:00 PM. One activity aide was assigned to remain in the Vista room at all times to supervise the kids. Staff D said residents were to remain in the Vista room for meals and between meals. Observations from 11/27/18 through 12/07/18 showed the door to the Vista room was closed during the annual survey. Treatment/Service for Dementia - See F744 for additional information. 4. On 11/28/18 at 9:38 AM, Resident #58 said staff used a mechanical lift to transfer him in/out of his wheelchair since he returned from the hospital. The cloth sling staff used with the lift was too tight. The resident said, I'm in constant pain when they use it. Documentation in the resident's record showed staff started using mechanical lift on 09/11/18, over two months earlier. On 12/10/18 at approximately 10:00 AM, Staff Z, Restorative Aide, reported a larger cloth sling to use for Resident #58 arrived on 12/09/18, three months after staff began using the mechanical lift and the smaller cloth slings for the resident. Staff Z said she used the new, larger sling the prior evening and the resident had no complaints of pain as before. Quality of Care - See F684 for additional information. On 12/11/18 at 1:46 PM, the Administrator was questioned about the QAA committee's awareness, prior to the start of the State survey on 11/27/18, of the above issues and concerns. The Administrator reported the QAA committee identified resident falls and worked on that issue. However, the issues identified in the survey were not identified by the QAA committee until surveyors pointed them out. The Administrator reported the former Social Services Director (SSD) kept a log book for grievances. She stated, in the QAA/QAPI committee meetings, the former SSD gave the Administrator a summary of resident and family grievances. She said she thought the former SSD was doing the follow up and monitoring of the issues and that there were no serious concerns. The Administrator stated she regretted not having a signature line on the grievance forms so they would all come across her desk for review. She added there needed to be transparency on grievances and issues so everyone knows what's going on. The Administrator said, although other reports such as the incident/accident log, were routinely reviewed, neither she nor the DNS reviewed the grievance forms. Reference WAC 388-97-1710 (1)(2)

Based on interview and record review, the facility failed to ensure staff provided adequate, timely pain management for one of three sampled residents (#1) receiving pain medication. The deficient practice resulted in actual harm as the resident experienced ongoing, intense pain. Findings included: Resident #1. Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. The resident's information sheet also identified she had a designated power of attorney (POA) for healthcare and financial matters. According to the resident's ADL (activities of daily living)/Mobility care plan, last revised on 03/01/18, the resident typically required caregiver assistance for mobility including bed mobility and transfers. On occasion the resident attempted to walk independently. The resident's impaired cognition care plan, revised on 02/28/18, also noted the resident had a dementia diagnosis. She utilized the call light and had a mild language deficit and memory issue. The resident's pain care plan, revised on 04/26/18, noted the resident had pain related to severe back/pelvic fractures, arthritis with bilateral knee pain, gout, and other issues. Interventions included monitoring the resident for non-verbal signs and symptoms of pain: Changes in breathing (noisy, deep/shallow, labored, fast/slow); Vocalizations (grunting, moans, yelling out, silence); Mood/behavior (changes, more irritable, restless, aggressive, squirmy, constant motion); Eyes (wide open/narrow slits/shut, glazed, tearing, no focus); Face (sad, crying, worried, scared, clenched teeth, grimacing)(;) Body (tense, rigid, rocking, curled up, thrashing). Nursing assistants were to report the signs of non-verbal pain to the licensed nurse. The resident had medications prescribed for pain management. According to 04/23/18 Progress Notes from the ARNP (Nurse Practitioner), the resident was seen at the request of nursing staff for new right hip pain that was limiting her ability to ambulate and transfer. At the time of the ARNP's visit the resident was sitting in her recliner with a grimacing expression and reporting complaints of severe pain to her right hip of 8/10 (a pain scale with ten being the highest possible pain). She is having difficulty bearing weight, transferring and walking due to the pain. The resident had no recent falls or trauma. New orders included [MEDICATION NAME] (another pain medication) 50 milligrams (mg) orally every six hours (instead of) as needed as previously ordered, Tylenol 1000 mg orally every eight hours, and a right hip x-ray. Nursing entries on 04/24/18 showed the resident was crying out related to right hip/back pain. The ARNP was called and she ordered [MEDICATION NAME] (a narcotic pain medication) 2 mg at that time for acute pain and [MEDICATION NAME] 1 mg orally every four hours as needed. The resident was also sent to the hospital for the pain later on 04/24/18 and then returned to the facility after receiving pain medication. On 04/26/18 the resident's Physician visited the resident and documented the resident did not have a fracture. The pain appeared related to sciatica (nerve associated pain). A 04/26/18 nursing entry noted the Physician's visit and documented there were no changes. A 04/30/18 nursing entry noted a new [MEDICATION NAME] order directing staff to increase the dose to 2 mg if the 1 mg was ineffective and to continue the as needed pain medication every four hours. Warm compresses were ordered for pain relief for the right hip. Review of a 05/09/18 nursing entry showed the resident was complaining of pain and had moderate relief' from the pain medication. The resident reported the pain relief is mild and short lived with the as needed doses. The resident presented her lower back to the nurse to view as she stated she had worn her back out and raw by shifting, fidgeting and scratching at her back in a effort to find comfort and the origin of the her pain. The resident's lower back had multiple raised red areas, scratches, and a shearing type abrasion over her sacrum (above the tailbone) with a 0.4 centimeter (cm) opening (approximately 1/8 inch). The nurse called the ARNP and received a order for an increase in a current medication, [MEDICATION NAME] (often utilized to assist with pain management). The Physician saw the resident on 05/10/18 because of intractable (difficult to manage) pain. The Physician noted that since the visit to the emergency room a couple weeks earlier the resident had difficulty with adequate pain control on [MEDICATION NAME] and [MEDICATION NAME]. At the time of the visit the resident was laying in bed bed writhing in pain and clearly very uncomfortable. Nursing staff had reported that the resident had expressed a wish to let nature take its course. Her quality of life is certainly quite poor. On 05/10/18 the Physician ordered the [MEDICATION NAME] to be discontinued and the [MEDICATION NAME] be increased to 2 mg three times as day and 1-2 mg orally every four hours as needed. Additionally, staff were to call hospice or transfer the resident to the hospital for pain control depending on what the POA directed. On 05/14/18 the ARNP ordered a referral to hospice for palliative care (symptom management) services. The [MEDICATION NAME] dose was increased to 4 mg orally every eight hours routinely and staff were to continue the previous as needed order. [MEDICATION NAME] (an antidepressant also used for pain management) was also increased. According to a 05/14/18 social service entry the resident was supportive of the hospice consult as her pain was insufferable. A 05/20/18 nursing entry documented the Hospice Nurse had visited and planned to start the resident on hospice care. Hospice Nurse documentation on 05/20/18 noted the presence of increasing pain and a deteriorating wound. The resident appeared to be transitioning to active dying. The POA wishes for pain to be controlled and comfort through remainder of life. The resident was noted to have significant pain with movement and the dressing change. There was an order to increase the [MEDICATION NAME] dosing to 4 mg every four hours routinely with an additional 4 mg every hour as needed. Review of the 05/22/18 Hospice Nurse documentation showed the resident reported pain to her lower back side and to the left hip with movement. The resident displayed a facial grimace and clenched fists/face with any movement. An as needed [MEDICATION NAME] dose was administered with wound care. There was a plan to ensure pre-medication the following day prior to wound care. A 05/22/18 Hospice Social Worker note documented the resident was on her right side upon arrival and the resident was shaking and calling out in pain. She is praying out loud for her pain to stop. Facility staff were notified and they reported the resident had just been given her pain medication. According to a 05/23/18 Hospice Social Worker note, the facility had not yet placed the air overlay mattress for the resident's bed (for pressure relief and comfort). The mattress was sitting on the resident's beside table. On 05/23/18 the Hospice Nurse documentation noted the resident was alert and complaining of pain on her bottom. The resident clenched her fists and guarded against any movement. She displayed shallow quick breaths. Wound care remained painful. A named Nursing Assistant reported the resident had displayed these symptoms throughout the morning and with each interaction. There was a discussion with a facility nurse about the uncontrolled pain symptoms. The discussion included the plan to increase the routine [MEDICATION NAME] to every three hours and the use of the as needed doses every hour if needed. The air overlay mattress was applied to the bed. Review of the (MONTH) (YEAR) Medication Administration Record (MAR) revealed the resident did not receive any as needed [MEDICATION NAME] doses on 05/23/28 or on 05/24/18 until 4:19 PM. According the 05/24/18 Hospice Nurse entry in the medical record, the resident was restless, lying on her right side clutching the siderail. She cried out, God, help me and requested to be turned to her other side. [MEDICATION NAME] (an anti-psychotic) was accessed from the comfort kit for administration every six hours. Per the 05/24/18 nursing entry at 8:59 PM Staff E, Licensed Practical Nurse, called the Hospice Nurse to discuss the resident's condition when the as needed [MEDICATION NAME] was only minimally effective. Additional medication was ordered to seek increased comfort for the resident. Interviews were conducted with two Hospice Nurses on 05/25/18 at approximately 11:30 AM during their on-site visit. The Hospice Nurses stated the resident was more comfortable that morning. A facility nurse had called the night before and obtained new orders to aid in the resident's comfort. The day before the resident had been writhing in pain when they arrived. The facility had not consistently utilized the prn (as needed) medication to increase the resident's comfort. On 05/25/18 at approximately 12:10 PM, an interview was held with the resident's POA during her visit at the facility. The POA stated the facility seemed to only give medications that were scheduled (routinely scheduled versus as needed). Resident #1 often seemed uncomfortable and did not receive good pain control by the facility. A couple days earlier they didn't seem to know what to do for the resident. On 05/24/18 during the day shift it was heart breaking. Resident #1 was thrashing in her bed and calling out, help me. She would move close to the edge of the bed and the POA had to move her back several times to prevent her from falling out. I couldn't leave her. There was no one there. An interview was conducted with Staff D, Nursing Assistant, on 05/25/18 at approximately 12:40 PM. Staff D stated staff repositioned the resident every two hours. The entire week the resident had been moaning with pain, calling out, and screaming throughout the day shift. Since 05/23/18 the resident had not asked for anything specific. Staff E was interviewed on 05/25/18 at approximately 4:25 PM and stated the resident had experienced a recent decline. The resident's pain had progressively worsened. Her pain medications were increased and the pain was manageable but then her pain level would have a spike. The resident's sore (ulcer on her bottom) had also worsened. Hospice had been involved the past week. Last night, on 05/24/18, the resident was inconsolable. Staff E called Hospice and they directed the use of other comfort medication. With the medications the resident was in a comfortable state last night. On 05/29/18 at approximately 9:00 AM, a telephone interview was conducted with Staff C, Licensed Practical Nurse/Resident Care Manager. Staff C reviewed the (MONTH) (YEAR) MAR and stated no as needed [MEDICATION NAME] doses were administered on 05/23/18. On 05/24/18 no as needed [MEDICATION NAME] doses were administered until 4:19 PM. Reference (WAC) 388-97-1060(1)

Based on observation, interview, and record review the facility failed to ensure staff provided adequate supervision to prevent avoidable falls for 1 of 7 residents (#1) reviewed for accidents. This failure caused Resident #1 an injury requiring sutures and placed the resident at risk for repeated falls. Findings included: Resident #1. Per the medical record the resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. Resident #1's most recent comprehensive assessment dated [DATE] showed the resident had severely impaired cognitive skills for daily decision making and required extensive assistance of 2 persons for bed mobility, transfers, dressing and toileting needs. Observation on 11/06/17 at 2:10 PM showed Resident #1 awake in his room lying on his bed in the lowest position with fall mats placed on both sides of the bed. In an attempted interview about the fall, the resident only made laughing noises and showed no indication of understanding. A fresh scar was noted above the right eyebrow measuring approximately 3 centimeters in length. Review of the facility's incident investigation of Resident #1's injury revealed that on 10/22/17 at 9:40 PM, Staff A, CNA (Certified Nursing Assistant) had assisted the resident to stand and hold onto his walker while she cleaned his perineal area. Staff A left the room and Resident #1 standing at the bedside holding his walker unattended while she went to get more linens. The report further stated that when Staff A returned to the room Resident #1 was sitting on the edge of his bed with his hand over his right eye and had blood running down his face. Staff B, RN (Registered Nurse) was called to the room and found Resident #1 with a gaping laceration to the outer right eyebrow and immediately sent him to the emergency room for evaluation. An Employee counseling form revealed Staff A had been counseled for leaving Resident #1 unattended during cares by Staff C, the DNS ( Director of Nursing) on 10/23/17. In an interview with Staff A on 11/06/17 at 2:45 PM she stated she was working on the evening shift (2:30 to 10:30 PM) on 10/22/17 and the facility was short of staff. She stated after 8:00 PM she was working alone on the dementia unit as only 2 other nursing assistants were on duty that evening and were assigned their own halls. Staff A stated since she was alone getting Resident #1 to bed, standing him was the easiest way to clean his perineal area. She stated he was soiled worse than she thought and left him standing alone while she went to get more supplies. She stated when she returned he was sitting on his bed and had a large amount of blood on his head, face and hands. Staff A stated she did not want to leave him alone again to go get the nurse and had to wait until another staff member came by to get help. Staff A stated she had no excuse for leaving Resident #1 alone, she knew he required 2 persons to assist him for safety but there was no one else available. She stated the correct thing to do would have been to lie him back down on his bed and get assistance to provide care. She stated she had been working multiple double shifts to assist with low staffing levels and was tired and burned out and not thinking clearly. In an interview with Staff C on 11/06/17 at 4:00PM, she stated she did not think Resident #1 had fallen as he would not have been able to get himself off the floor but rather leaned forward and hit his head on the walker or dresser in his room and sat back onto his bed. Staff C stated she had counseled Staff A for leaving Resident #1 unattended in an unsafe position and that Resident #1 had been assessed as a 2 person assist for safety. Staff C stated the facility had been short of NAC staff and the regular NAC staff had been working many additional hours to cover shifts. She stated they had been utilizing agency NAC's as much as possible and were reviewing new ways to recruit staff.

Based on observation, interview and record review, the facility failed to implement policies and procedures to protect 3 of 18 female residents (#s 2, 3 and 4) residing in the dementia unit from sexual abuse. Resident #1 had a change in behavior resulting in him pursuing physical sexual contact with Resident #3. The failure of the facility to identify his behavior as potential abuse and to implement effective interventions to prevent him from further inappropriate sexual contact allowed Resident #1 to sexually abuse two other residents (#'s 2 and 4), which constituted an Immediate Jeopardy. In addition, the facility failed to report incidents involving Resident #s 2 and 3 to the state reporting hotline per facility policy. Findings include: The facility "Abuse Prohibition Program," on page 5, identified, "It is the policy of the facility to maintain an environment free of abuse and neglect. The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. Residents will not be subjected to abuse by anyone, including, but not limited to.....other residents..." On page 7, sexual abuse was defined as: "This includes, but is not limited to sexual harassment, sexual coercion or sexual assault. 42 CFR 483.13 (b) and (c)" and "Sexual contact, including fondling, with a resident caused by an employee, agent, or other resident of a long term care facility by force, threat, duress, coercion, or sexual contact where the resident has no ability to consent." In the section named "Response and Reporting" on page 41, "It is the policy of this facility that all alleged violations and all substantiated incidents will be reported to the state agency and to all other agencies as required." On page 42, employees are directed, "When a mandated reporter has reasonable cause to believe an incident is abuse, neglect, involuntary seclusion, or financial exploitation, he/she must report to the DSHS (Department of Social and Health Services) Hotline within 24 hours of the incident." Resident #1. admitted on [DATE] with [DIAGNOSES REDACTED]. His latest comprehensive assessment dated [DATE] revealed he had significant cognitive impairment, and was able to transfer and to walk about the hallway. Resident #2. admitted on [DATE] with [DIAGNOSES REDACTED]. Per a progress note dated 12/09/14, due to advancing dementia and memory loss, the resident was unable to participate in the assessment process. Resident #3. admitted on [DATE] with [DIAGNOSES REDACTED]. Review of her latest comprehensive assessment dated [DATE] revealed she did not walk and was totally dependent on staff for transferring. The comprehensive assessment also noted significant cognitive impairment, with disorganized thinking and inattention. She was identified as having highly impaired hearing and unclear speech. Resident #'s 1, 2 & 3 all resided on the dementia unit. During an interview on 02/10/15 at approximately 11:00 a.m., Staff Member C, a housekeeper, stated on 01/16/15 in the evening after dinner she noticed Resident #1's walker was outside Resident #3's door. The housekeeper stated she left the hallway and returned a short time later. Resident #1's walker was still outside the door, so she stepped into the room to investigate. She stated Resident #1 was standing next to Resident #3's bed with his blue jeans down around his legs. She saw his genitals were exposed and Resident #1 had his hand around Resident #3's hand. Her hand was being guided by his in touching his (genitalia). The housekeeper stated she "hollered at him to stop" and he did. She then reported the incident to Staff Member D, a licensed nurse (LN). She stated she did not hear Resident #3 say anything during the incident, but it was very hard to hear her because she had a sore throat. The housekeeper further noted the Director of Nursing (DNS or DON) was notified, but she did not call the state hotline number as per facility policy. During an interview on 02/10/14 at 11:45 a.m., Staff Member D, a LN, stated on 01/17/15, a nursing assistant reported to her that Resident #2 was in Resident #1's room. The LN stated she and another LN went to the room to investigate and found Resident #1 lying on his back with his private area exposed. His hands were behind his head. Resident #2 had her hand on "his private parts" and was fondling them. The LN asked Resident #2 if she wanted to be there. She said the resident replied she was tired of looking at the snow. The LN stated she directed Resident #2 out of the room, as the resident could not answer the consent question coherently. A progress note from Resident #1's medical record dated 01/19/15 at 4:55 a.m. by Staff Member E, a LN, noted Resident #1 was again in Resident #3's room. The LN documented Resident #1 was preparing to begin inappropriate sexual behavior. The LN removed Resident #1 from the room. Resident #3 stated to her "he was sexually abusing me." A progress note from Resident #3's medical record made by Staff Member E at 7:31 a.m. about the same incident noted Resident #3 thanked her for "taking him out of here." The note also further clarified the sexual abuse statement referred back to a previous interaction. Further review of progress notes revealed at 2:12 p.m. on 01/19/15, documentation by Staff Member F, a LN, noted Resident #1 tried to get Resident #2 to go to his room again. Review of progress notes from Resident #3 documented concerns Resident #3 had about Resident #1, asking on 01/19/15 if Resident #1 was still living here, and, on 01/20/15, "did that man move out?" (the writer of the note assured her he was not allowed in her room any longer). Review of Resident #1's care plan revealed it was updated on 01/19/15 to identify a behavior problem with sexual advances. The behaviors were to be managed with removing him from the situation and re-directing him from other resident's rooms immediately. Further review of progress notes revealed on 01/21/15 at 9:32 a.m., Staff Member F, a LN, noted Resident #1 was trying to go into Resident #3's room again, and a nursing aide (NA) had to re-direct him from entering the room. A later progress note by Staff Member F at 2:06 p.m. noted an interaction witnessed by an NA, between Resident #1 and Resident #2, where he pulled her hands to his groin area. Resident #2 pulled her hands away from him, and stated "you are being a little rough with me." The NA made eye contact with Resident #1 and he walked away. During an interview on 02/10/15 at 8:20 a.m., Staff Member B, the Activities Director, stated she was in the Pioneer dining room on the morning of 01/22/15 helping with breakfast. She stated she heard Resident #1 say, "I am a dirty old man and you all like it." She stated it made other residents in the dining room uncomfortable. Resident #5, a cognitively alert resident who does not reside on the dementia unit, expressed discomfort with the conversation and told her, "I don't want to be here." The Activity Director took her back to her room. She stated Resident #6, a cognitively alert resident who is mobile, got up and left on her own. Staff Member B stated she told the DNS, and the DNS talked with Resident #1, but the conversation with Resident #1 "didn't do any good." She said the DNS told her there isn't anything we can do until he "crosses the line." During an interview on 02/10/15 at 4:10 p.m., Staff Member A, the DNS, stated she had a conversation with Resident #1 on 01/22/15, after the incident in the dining room. She stated she asked him to stop the inappropriate sexual comments and behaviors, and he told her he could not promise to do that. Review of progress notes revealed continued inappropriate behaviors by Resident #1, including being in Resident #3's room again on 01/27/15, inviting Resident #2 back to his room so he could "give her some of his exercises" on 01/29/15, and inviting Resident #7, a cognitively impaired resident of the dementia unit to "come and share my bed" on 01/29/15. In a 02/10/15 interview conducted with printed questions because of her impaired hearing, Resident #3 stated she did not feel safe here. "They let him play with me. I didn't like it." She further stated she thought he (Resident #1) was still here and it bothered her he could come into her room again. The facility failed to recognize the incidents that occurred between 01/16/15 through 01/29/15 as sexual abuse or sexual harassment. There was no evidence of an effective plan to protect residents from Resident #1's abusive behaviors, thus residents continued to be at risk. Review of an incident investigation revealed on 02/02/15 at 5:00 p.m., Staff Member H, a NA, observed Resident #1 remove the Pioneer dining room key from a tray box next to the door. He unlocked the door. When she next passed by the dining room, she noted the dining room door was closed and lights were off. She entered the dining room, observed Resident #4's blouse and t-shirt "entangled lying on the floor next to some water" and "Resident #1's hands on Resident #4's breasts." The NA immediately put the t-shirt on Resident #4 and removed her from the area. The investigation concluded Resident #4 was a victim of sexual abuse by Resident #1. On 02/09/15 at 3:40 p.m., Staff member I, a LN, stated Resident #1's behavior changed "3 or 4 weeks ago," when he went from being "flirty" to more sexually aggressive. She stated they (the staff) watched him closely and tried to intervene to keep him out of other resident rooms. On 02/11/15 at 2:45, she further noted she was at the opposite end of the hall from the dining room on 02/02/15 when Resident #1 was in the dining room with Resident #4, so she did not hear or see the incident. She stated the NA's were all busy with meal time cares, so no one was in the vicinity to see Resident #1 go into the dining room. Resident #4. admitted on [DATE] with [DIAGNOSES REDACTED]. She required staff assistance to walk, but could move about in her wheel chair independently. On 02/09/15 at 12:35, Resident #4 was observed in her wheelchair coming out of the Vista dining room. She was propelling her wheelchair independently and was humming to herself. She was unable to be interviewed. On 02/10/15 at 4:10 p.m., the DNS stated she did not notify the state hotline about the incident with Resident #3 on 01/16/15 and with Resident #2 on 01/17/15 because she thought the behaviors were consensual, as the two female residents did not object to Resident #1's behavior. She further stated Resident #1 has rights that couldn't be denied, too, including sexual gratification and intimacy needs. She stated when the incident with Resident #4 happened, it was definitely "over the line," and she asked to have the resident transported to a local hospital and she reported the incident. Review of medical records for Resident #s 2, 3 and 4 revealed all had Power of Attorney representatives for care decisions and financial decisions. Care plans for all three women identified impaired cognitive function with moderate receptive and expressive language deficits, which limited decision making abilities, but there was not an assessment in the records of capacity to consent.

Based on interview and record review, the facility failed to administer operations in an effective and efficient manner to ensure resident safety, health, and well-being related to implementing policies to prevent sexual abuse. This failure resulted in harm to Resident #s 2, 3 and 4. An Immediate Jeopardy situation was identified on 02/11/15, as this issue was not recognized by the facility administration as causing serious harm to residents. Findings include but are not limited to: 1) On 01/16/15 in the evening, Resident #1 (a male residing on the dementia unit), was observed by Staff Member C, a housekeeper, in Resident #3's (a female also residing in the dementia unit) room. Resident #1 had his pants down and was guiding Resident #3's hands in touching his private area. The housekeeper stated, in an interview on 02/10/15, she immediately intervened to stop the behavior and reported the incident to the licensed nurse (LN) and the Director of Nursing (DNS). During an interview on 02/10/15, Staff Member F, a LN, stated Resident #3 was fearful after the incident. She explained the resident told her she did not want "that man" (Resident #1) in her room any more. In an interview on 02/10/15 with the DNS, she stated she felt the incident was consensual and Resident #3 was not in distress so she "let it go" (did not investigate or report the incident to the state hotline). 2) On 01/17/15, Staff Member D, a LN, was summoned to Resident #1's room by a nursing assistant (NA). The LN observed Resident #1 lying on his bed and noted Resident #2, a female resident of the dementia unit, was also in the room and was touching Resident #1's exposed "private parts." In an interview with Staff Member D on 02/10/15, she stated she asked Resident #2 if she wanted to be in the room. She stated the resident was unable to voice her preference so she re-directed the resident from the room and notified the DNS of the incident. In an interview on 02/10/15, Staff Member J, a NA, stated Resident #1 tried several more times to get Resident #2 and other female residents to come to his room after the 01/17/15 incident. The NA stated she was uncomfortable with the situation because Resident #2 was "not with it at all." In an interview with the DNS on 02/10/15, she stated she did not report or investigate the incident because it was consensual, and Resident #1 had the right to pursue intimacy and sexual gratification. 3) Review of an incident investigation report revealed Resident #1 was found in the dining room with Resident #4, a female resident of the dementia unit, on 02/02/15 at approximately 5:00 p.m. The investigation concluded Resident #1 turned off the lights, closed the door and removed a t-shirt and a blouse from Resident #4. The NA who discovered the incident observed Resident #1 touching Resident #4's breasts. The facility administration did not recognize the 01/16/15 and 01/17/15 incidents as sexual abuse, and thus did not implement an effective plan to protect all female residents on the dementia unit from further abuse. On 02/10/15, when initial findings were presented to the DNS, she continued to define the first two incidents as consensual, demonstrating a lack of recognition of the immediacy of the situation and the risk of harm to other residents. Refer to F226 and F250 for additional information.

Based on interview and record review, the facility failed to provide medically related social services for 2 of 3 (#'s 2 and 3) residents sampled for sexual harassment or sexual touching when Resident #1 became sexually aggressive toward the residents. Failure to advocate for Resident #s 2 and 3 by assessing their decision making capacity and ability to consent to sexual overtures and protecting them while the assessment was ongoing caused harm to those residents, who were subjected to sexual abuse. Additionally, failure to assess the circumstances around Resident #1's change in behavior placed all female residents in the dementia unit at risk for sexual harassment or assault. Findings include: Resident #1. admitted on [DATE] with [DIAGNOSES REDACTED]. His latest comprehensive assessment dated [DATE] revealed he had severe cognitive impairment. The assessment also revealed he was able to walk about the facility with no assistance from staff. In an interview on 02/09/15 at 12:35 p.m., Staff Member F, a licensed nurse (LN), stated Resident #1 had some anger issues since admission, but until recently, he had no sexually inappropriate behaviors. The LN described 3 to 4 weeks ago, Resident #1 began demonstrating sexually inappropriate behaviors, including inappropriate verbal statements to residents and staff, multiple attempts to go into rooms occupied by female residents on the dementia unit and inappropriate touching of female residents. Resident #3. admitted on [DATE] with [DIAGNOSES REDACTED]. Review of her latest comprehensive assessment revealed she had severe cognitive impairment, scoring 5 out of 15 on a Brief Interview for Mental Status (BIMS) exam. The assessment also revealed she had highly impaired hearing, did not walk and was dependent on staff for transferring. On 01/16/15, Staff Member C, a housekeeper, observed Resident #1 in Resident #3's room. The housekeeper noted Resident #1's pants were down. He was holding Resident #3's hand and guiding her hand in touching his private parts. The housekeeper immediately intervened, separated the two residents and called the nurse. Review of progress notes in Resident #3's medical record following the incident revealed expressions of discomfort from the resident about the incident. On 01/18/15, Staff Member E, a LN, documented Resident #1 was in Resident #3's room again. The LN documented she removed Resident #1 and Resident #3 told her "thank you for taking him out." On 01/20/15, Staff Member E documented Resident #3 was still concerned about Resident #1, asking "did that man move out?" In an interview on 02/10/15 with Staff Member A, the Director of Nursing Services (DNS), she stated she felt the incident was consensual and Resident #1 had a right to pursue intimacy. Review of Resident #3's medical record revealed she had a Power of Attorney (POA) for health care and for financial decisions. Her care plan described her as having impaired cognitive function, compounded by severe hearing loss. It directed staff to use short clear questions in writing to communicate with the resident. In an interview on 02/10/15 with Resident #3's POA, she stated she had not been notified of the 01/16/15 incident, but had been called by facility staff recently because the resident had lost weight and had "quit eating." The POA thought perhaps the appetite decline was related to being upset about the incident. She further noted Resident #3 was not competent to consent to a proposed intimate encounter. Resident #2. admitted on [DATE] with [DIAGNOSES REDACTED]. The assessment also noted she was able to walk about the unit. On 01/17/15, Resident #2 was observed by a nursing assistant (NA) being in Resident #1's room. The NA summoned Staff Member D, a LN, who observed Resident #1 lying on his back with his private parts exposed. Resident #2 was touching his private parts. The LN asked Resident #2 if she wanted to be there (in the room with Resident #1). Resident #2 responded she was tired of looking at the snow. The LN stated she directed the resident out of the room, because she could not answer the question about consent. Review of progress notes revealed further interaction between Resident #1 and #2. On 01/21/15, a note documented Resident #1 took Resident #2's hand and placed it on his groin area. Resident #2 pulled her hand away and complained he was being rough. Review of Resident #2's medical record revealed she had a POA for healthcare and finance. Her care plan included issues with cognitive impairment and indicated she had trouble making herself understood and confusion was evident. It noted she needed to be cued to her own room, the dining room and to the bathroom. The care plan was not updated following the incident. Further review of the medical record for Resident #'s 2 and 3 revealed the residents were placed on alert charting by nursing for possible distress related to the incidents, but there was no evidence of a Social Service evaluation to determine their ability to make an informed decision about a sexual encounter or evidence of support for these two residents following a difficult resident to resident interaction. In an interview on 02/18/15, Staff Member K, the Social Service Director (SSD), stated her role is to advocate for residents and families. She stated they focused on Resident #1's need to have intimacy and, in hindsight, the facility did not do all they could have for Resident #2 and #3 to be safe. She further noted nursing took the lead with these incidents and she should have been more involved. By viewing Resident #1's behavior as a pursuit of intimacy instead of potential sexual abuse, the facility failed to advocate for Resident #2 and #3's safety and well-being. This caused harm for Resident #2 and #3 by subjecting them to further abuse. Further, this placed all female residents residing on the dementia unit at risk for sexual abuse or harassment.

Based on observation, record review, and interview, the facility failed to ensure 1 of 4 residents reviewed (#1) received necessary supervision and assistive devices to prevent accidents. Resident #1, a resident with a known fall history, was left in the dining room without supervision and without her safety alarm attached. The resident got up, began walking, and fell sustaining a fractured hip. Findings include: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. A 1/14/13 fall risk assessment noted the resident remained at high risk for falls. Resident #1's plan of care identified she was to have pull away alarms on her bed and wheelchair to signal staff if she attempted to transfer independently rather than waiting for staff assistance. She required one staff member for assistance with transfers and ambulating. The resident's wheelchair was her primary mode of transportation. According to a 9/15/12 nursing entry, the associated facility investigation, and the September 2012 treatment record, the resident had a fall in the Annex dining room sustaining a bruise on the top of her head and a bruise on her right hip. The resident was left unattended in the dining room and got up on her own and fell . Nursing entries identified that on 3/24/13 the resident was sent to the hospital ER for evaluation of stools that tested positive for the presence of blood. The frail, cognitively impaired resident was sent back to the facility to receive hospice care. A 3/24/13 nursing entry documented that Resident #1 was found on the floor in the Annex dining room. Her right leg was rotated externally and she was crying out in pain. The resident was sent to the hospital for an evaluation. Review of the facility investigation documented that on 3/24/13 Staff Member A, a nursing assistant, assisted Resident #1 into a straight chair in the Annex dining room before lunch and then left the dining room to assist other residents. Resident #1 got out of the chair and walked along the edge of the table. She then lost her balance and fell sustaining a right hip fracture. The resident's alarm was not on and no staff were present. When interviewed on 3/28/13 at approximately 12:30 p.m., the Director of Nursing stated that staff were to be present in the dining room with residents. However, on 3/24/13 as noted, Staff Member A took Resident #1 to the dining room and placed her in a stationary chair without her alarm. The resident(s) were left in the dining room without staff supervision. Hospital records documented the resident had a right hip fracture. Resident #1 was sent back to the facility for comfort care later on 3/24/13. Observation of the Annex dining room on 3/28/13 at approximately 12:40 p.m. revealed the door to the Annex dining room was closed to the hallway. Six residents were present and three residents were eating. No staff members were present in the dining room. Shortly thereafter, Staff Member B, a nursing assistant, opened the door and entered the room stating she had just taken a resident to her room around the corner. Two staff members had reportedly been in the dining room to supervise earlier during the meal service. Staff Member A was interviewed on 3/30/13 at approximately 11:20 a.m. and stated s/he was aware of the resident's fall alarm and previous fall in the dining room. On 3/24/13 Staff Member A had taken Resident #1 to the dining room and left her unattended while s/he went to assist another resident out on the unit. Staff Member A reported that s/he usually brought Resident #1 down last. Reportedly, staff only needed to be present if the food or drinks were there in the dining room. Staff Member C, a licensed nurse on-duty on 3/24/13, was interviewd on 3/30/13 at approximately 11:40 a.m. and discussed the supervision plan in the dining room. One staff member was to remain in the dining room if residents were present. The other caregiver could assist with transporting residents but residents were not to be left in the dining room unattended. After all the residents were down to the dining room two staff members would be present during the meal services.

Based on observation, record review, and interview, the facility failed to implement the plan of care to prevent falls with injuries for 1 of 4 residents (#1) reviewed. Resident #1's protective interventions were not implemented at the time of the fall which resulted in the resident sustaining a laceration on her head that required staples. Findings include but were not limited to: Resident #1: Review of the medical record revealed the resident had multiple medical [DIAGNOSES REDACTED]. The resident's plan of care identified she required two caregivers to assist her with transferring between her bed and wheelchair and with repositioning in bed. Safety interventions included: 1) Anticipate needs, 2) Non-skid foot wear, 3) Rest period after lunch, 4) Low bed, and 5) Bilateral fall mats when in bed. According to the 11/06/12 nursing entries, at 7:50 p.m. the resident was found lying on the floor (next to her bed). She had a 2 centimeter laceration (nearly an inch) on the left side of her head. The physician was contacted and the resident was sent to the hospital for treatment. The resident returned to the facility late that evening. The 11/07/12 nursing entries noted the resident had 3 staples that had been placed in the hospital. Neuro checks (checks to assess on the resident's neurological status related to the head injury) were ongoing and findings were within normal limits for the resident. Observation of the resident on 12/10/12 at approximately 2:35 p.m. with Staff Member A, a Licensed Nurse (LN), the LN on-duty at the time of the fall, revealed the resident had a slightly raised, scaly area on the left upper posterior aspect of her head. The area appeared to have healed. The resident required staff assistance for positioning to allow observation of the area and she did not speak. The resident wore splints on both hands due to contractures (abnormal positioning of her hands and wrists). No facial bruising was present on 12/10/12. Staff Member A stated that on 11/06/12 the resident was found on the floor between the beds, on the window side. The floor mat was missing and the bed was in a high position. The resident had a previous history of falling from bed especially if the head of her bed was too high. The resident reportedly had demonstrated some upper body movement in the past. Review of the facility investigation pertaining to Resident #1's fall on 11/06/12 revealed the floor mat was missing and the resident's bed was not left in a low position. The resident had rolled out of bed. The assigned caregiver, Staff Member B, a Nursing Assistant, had not followed the resident's plan of care.

Based on record review and interview, the facility failed to ensure 2 of 2 sampled residents (#1 & #4) in the sample were free from chemical restraints. For both residents, a facility generated protocol was implemented causing the cognitively impaired residents to experience psychosocial harm as a result of being restrained and given injected medication against their wills and under physical protest. Findings include but were not limited to: Resident #1: Review of the medical record revealed the resident was admitted to the facility on [DATE] with multiple mental health [DIAGNOSES REDACTED]. Additionally, the resident had a [DIAGNOSES REDACTED]. According to the resident's plan of care she had communication impairment, walked independently, and demonstrated problematic behaviors such as striking out at others, verbal abuse, elopement, and resistance to care. According to the June 2012 Medication/Treatment Record, a wanderguard was placed on 6/06/12 to alert staff if the resident attempted to exit the building. The admission physician's orders did not include any psychoactive medications to treat her mental health conditions. A 6/17/12 nursing entry, by Staff Member A, documented that at 2:40 a.m. the Licensed Nurse (LN) was summoned by the Nursing Assistants because the resident was attempting to exit the facility doorway. The resident stated 'God told me to leave now .' The resident then began to wander throughout the facility, in and out of other residents' rooms, looking for an open window. The LN contacted the resident's family member and allowed him to talk with her but she only repeated to him that 'God said it was time to leave this place.' Thereafter, the LN talked with the family member and discussed possible options to handle her behavior including giving IM (an injection into the muscle) of [MEDICATION NAME] (an anti-psychotic medication) per their Aggressive Behavior Protocol to "help calm resident." It was documented that the family member was in agreement to use [MEDICATION NAME] if necessary. The resident continued to wander in and out of others' rooms shouting, 'You're wrong. Someone higher told me to leave.' The resident attempted to strike out at staff members if they attempted to get close to her. At 3:00 a.m. on 6/17/12 (20 minutes after the LN responded to the resident's elopement attempt) [MEDICATION NAME] 1 milligram (mg) was injected into the resident's right buttock per the the "facility Aggressive/Assaultive Behaviors Emergency Protocol" as 3 NAs attempted to hold her. "She was swinging and hitting all staff members." The LN notified the family member at 3:20 a.m. A follow-up nursing entry on 6/17/12 5:49 a.m. documented the resident continued to state that staff were wrong and that a higher power was telling her to leave. The resident was sitting on the floor next to the door. "[MEDICATION NAME] effective to some extent." The nursing entry also documented that a fax was sent to the physician about the use of the emergency protocol (rather than notifying the physician about the resident's escalated behaviors to seek a resident specific physician directive. Review of the facility's "Aggressive/Assaultive Behaviors Emergency Protocol For All Physicians" revealed that it was the policy of the facility to provide an environment where "the residents are free from abuse." The procedure outlined steps to be taken when the resident became physically aggressive and/or threatening, "our primary concern must be the safety of other residents and staff. If the behaviors and/or threats were determined to actually jeopardize the safety of others (residents or staff)," the protocol would be implemented. Staff were to remove the aggressor or remove other residents in the area. Additional staff were to be called as needed. There was a directive to physically restrain the aggressor only if necessary. If further intervention was needed "to control behavior....[MEDICATION NAME] 0.5 mg to 1 mg IM" could be given one time. No oral route was available in the protocol. "The resident will be observed and monitored for possible side effects and for response to the effectiveness of this chemical restraint." Interventions such as calling: the Physician, Mental Health Crisis Line, or the Police, the on-call Administrative LN, and/or the Social Service Director were listed after the directive to give the [MEDICATION NAME] IM (with a dose range requiring discretion by the LN). Review of [MEDICATION NAME] side effects, outlined on the internet medication reference site rxlist.com, noted serious potential side effects including but not limited to: restless muscle movements, tremors, [MEDICAL CONDITION], and stiffness. Additionally, elderly patients with dementia-related [MEDICAL CONDITION] treated with anti-psychotic drugs are at an increased risk of death. According to Resident #1's 7/05/12 nursing entry, by Staff Member B, at approximately 3:30 a.m. the resident was rattling an exit door and then going door to door. When staff attempted to approach her she swung her purse at them. The resident then attempted to exit through an open window but two staff members assisted her. The resident chanted that God had told her to leave. The resident was very angry and was physically assaultive toward staff. While staff restrained the resident, she was given [MEDICATION NAME] 1 mg IM. "She was even more angry at this point." The resident's family member was called and he "gave permission to do whatever it took to help her through this." A Physician was called and there was an order for [REDACTED]. 911 called for additional "manpower". The Police Officer arrived and with the help of staff, "the officer was able to restrain her and lower her safely on her stomach onto the mattress" placed next to her wheelchair. The additional [MEDICATION NAME] 1 mg IM was then administered. "Assaultive behavior event diffused safely using the Aggressive/Assaultive Emergency Protocol. Plan: Keep safe during effects of [MEDICATION NAME]." Staff Member B was interviewed on 8/15/12 at approximately 1:21 p.m. and reviewed the details of the 7/05/12 occurrence with Resident #1 as outlined above. Staff Member B recalled the [MEDICATION NAME] injection was administered in the hallway, "She was scared. We just had to help her." The resident was resisting/fighting the injection. During the second injection, the resident continued to fight the injection but the Officer was able to divert the resident's attention. Resident #4: Review of the medical record revealed the resident had multiple [DIAGNOSES REDACTED]. According to the resident's plan of care, she wandered throughout the facility in her wheelchair and would exit seek. She required staff assistance for safe transfers and ambulation. The resident had difficulty with communication due to her cognitive impairment. The resident's problematic behaviors included combativeness and resistance to care and verbally abusive behaviors. Review of the nursing entries noted the resident received [MEDICATION NAME] 1 mg on 6/06/12 after the Nurse Practitioner (ARNP) was contacted and she ordered the use of the protocol related to the resident's aggressive behaviors toward staff. In addition, the ARNP ordered [MEDICATION NAME] (an anti-anxiety medications) 0.5 mg orally as needed every 6 hours for anxiety/agitation. A 6/07/12 nursing entry documented the resident had one-on-one supervision between 2:00 p.m. and 5:30 p.m. The resident was repeatedly attempting to walk without assistance. When staff tried to assist her she became aggressive toward staff. The resident resisted non-medical interventions. Per directive of the Director of Nursing (DNS) the house protocol was implemented with the administration of [MEDICATION NAME] 1 mg IM at 5:30 p.m. The physician and family member were notified after administration. On 8/14/12 at approximately 5:15 p.m., the DNS recalled the resident was physically resisting during the injection by Staff Member C. The 8/10/12 nursing entry by Staff Member C documented the LN was called by the NAs at 6:45 p.m. as the resident was attempting to hit and bite staff as they attempted to assist the resident to ensure her safety. The resident was attempting to exit her wheelchair and her gait was unsteady. She was refusing oral medication. "Per protocol 1 mg of [MEDICATION NAME] given at 7:15 p.m. IM. (1/2 hour following the LN contact). Resident will be monitored closely." The entry also recorded the plan to notify the resident's power of attorney following administration. At 7:30 p.m. on 8/10/12 the resident was observed to have what appeared to be "a [MEDICAL CONDITION]" [MEDICATION NAME] 45 seconds. When interviewed on 7/14/12 at approximately 5:30 p.m., Staff Member C stated the cognitively impaired resident was fighting and combative during the injection. The Staff Member notified the physician after administration of the medication. After the injection the resident experienced [MEDICAL CONDITION] activity. Further review of the nursing entries between 6/06/12 through 8/10/12 did not evidence any other documented [MEDICAL CONDITION] activity. On 8/24/12 at approximately 1:35 p.m. Staff Member D, a LN, stated she recalled Resident #4 had experienced [MEDICAL CONDITION] activity 2-3 times since placement (on 4/30/12).