Every finding on record at Christian Health Care Center

Based on observation, interview and record review, the facility failed to manage and reconcile controlled medications in 1 of 3 medication storage rooms (Baker Hall/Medicare unit) reviewed. This failure allowed for the potential risk of diversion of resident's medications. Findings included . Review of facility policy titled Medication Storage in the Facility, dated 05/09/2018, documented under Controlled Substance Storage: B. Schedule II - V medications and other medications subject to abuse or diversion arestored in a permanently affixed, double locked compartment separate from all other medications per state regulation. C. Controlled substances that require refrigeration are stored within a locked box within the refrigerator. This box must be attached to the inside of the refrigerator. E. At each shift change, a physical inventory of all controlled substances, including refrigerated items, is conducted by two licensed nurses and is documented. During an observation and interview on 06/10/2026 at 1:10 PM, Staff E, Nurse Manager/Registered Nurse (RN) opened the door for the surveyor to inspect the medication room on [NAME] Hall/Medicare Unit. Upon entering the room, a medication refrigerator was observed underneath the counter and was locked. Staff E had a key on their ring and was able to unlock the refrigerator. After the fridge was unlocked the door was opened and a small plastic locked container was observed on the shelf inside. The plastic box was easily removed from the fridge and placed on the countertop. Staff E unlocked the plastic container so the contents could be inspected. This surveyor removed a small plastic bag containing 4 vials of Lorazepam (anti-anxiety schedule IV-controlled medication). Staff E stated that the pharmacy was the only one that monitors, counts and refills this emergency box. Staff E stated that nursing staff at the facility do not count or monitor these medications when locked in the fridge and each nurse working has a key to access the med rooms and locked box in the fridge. During an observation/interview on 06/10/2026 at 1:20 PM Staff F, RN, opened the door of the medication room at the Cascade nurses' station (300 hall), for an inspection. Staff F unlocked the medication fridge and inside was a plastic locked box that was locked. Staff F unlocked the small plastic box that contained four resident specific insulin pens. Staff F was asked if there were any controlled medications that were locked in this fridge and what was the process for monitoring and accounting for those drugs, they stated two nurses would come in there at change of shift when counting narcotics and count whatever was in there that was controlled and that would be documented in the narcotic ledger. In an interview on 06/11/2026 at 10:41 AM, Staff B, Director of Nursing stated that the pharmacy was the only one that would complete audits of the locked emergency plastic boxes containing controlled medications in the fridges at the nurses. Staff B stated that in 30 years of nursing, nurses have never counted or audited controlled medications in the emergency kits, unless they are resident specific. Reference WAC 388-97-1300(2)

Based on interview and record review, the facility failed to ensure the Level 1 PASRR (Pre-admission Screening and Resident Review; an assessment used to identify residents with a Serious Mental Illness [SMI] or intellectual disabilities were not inappropriately placed in a nursing facility for long term care) was accurate for 1 of 5 residents (Resident 62). The facility failed to identify a SMI or that there was a suspicion of SMI upon admission for a resident with depression. This failure placed residents at risk for psychological decline and unmet psychosocial needs.Findings included.Review of a facility policy titled, PASRR, revised date 05/2026, documented social service staff review the PASRR screen as part of their intake process. Should they identify or credibly suspect SMI, they will complete a new Level I.Resident 62 was admitted to the facility on [DATE].Review of Resident 62's hospital PASRR Level I assessment, dated 02/05/2025, documented no history of SMI.Review of the hospital Discharge summary, dated [DATE], showed Resident 62 was on mirtazapine (an antidepressant medication).Review of Resident 62's medication history showed an order for mirtazapine to be given daily for depression, ordered on 02/06/2025.Review of Resident 62's informed consent for psychotropic (medications that affect mood and behavior) medications form, dated 02/06/2025, documented the resident took mirtazapine for depression.During an interview on 06/10/2026 at 10:15 AM, Staff D, Social Services, reported the admission coordinator reviewed the PASRR for accuracy before admission. Staff D reviewed Resident 62's PASRR level 1 form and reported that the resident did not have a diagnosis for depression at the hospital, and they could not answer if the admission coordinator had reviewed medications to ensure the PASRR was accurate. Staff D reported the admission coordinator was unavailable this week.During an interview on 06/11/2026 at 9:06 AM, Staff B, Director of Nursing Services, stated if Resident 62 had received mirtazapine for depression, then a new PASRR Level 1 should have been completed.Refer to WAC 388-97-1975 (1)

Based on interview and record review the facility failed to consistently provide oral care as care planned, notify the power of attorney (POA) and medical provider timely of a change in dental condition for 1 of 2 residents (Resident 47) reviewed for dental care. Resident 47 experienced harm when they developed abscesses in their mouth that required antibiotic treatment. Findings Included .Resident 47 was a long-term resident of the facility with diagnoses which included dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) with severe agitation, mood disturbances and anxiety, high blood pressure, and dysphasia (difficulty swallowing).Review of Resident 47's Annual Minimum Data Set (MDS-an assessment tool) assessment dated [DATE] and most recent Quarterly MDS assessment dated [DATE] showed the resident did not have dentures, any mouth ulcers, masses, or oral lesions, cavities or broken natural teeth. Review of Resident 47's care plan, revised on 11/27/2024 and 04/21/2025, showed the resident had refused to be seen by the dental hygienist on 09/28/2022 and had been seen in November 2024. The care plan for oral care documented that Resident 47 had their own teeth. The care plan interventions included oral care, required oral inspection and for staff to report changes to the nurse. Resident 47 was to be set up at the sink or to use a kidney basin to brush their teeth with assistance provided to finish, and brush teeth three times a day after meals. The care plan directed staff to document if the resident refused oral care.Review of Resident 47's dental hygienist note dated 03/26/2024 documented the resident had heavy food and plaque in their mouth with severe bleeding during the cleaning process and active periodontal infection. The dental hygienist note documented to monitor Resident 47's upper right mouth for pain or swelling and refer to a dentist if observed and two teeth were found to be broken. This note documented it was reviewed on 03/26/2024 by facility staff. Review of Resident 47's dental hygienist note dated 11/25/2024 showed they had multiple broken teeth. The dental hygienist recommended that staff assist with brushing and noted the resident had heavy food and plaque present and experienced severe bleeding during the cleaning process.Review of Resident 47's clinical record Sound dental care patient notes, dated 11/27/2024, documented that the resident's family member contacted them, upset that they visited with the resident today and found dark spots on their teeth everywhere and they (the family) were unaware the resident had broken teeth. Review of Resident 47's dental hygienist note dated 05/08/2025 showed they had multiple broken teeth, possible abscesses with a recommendation to assess for antibiotic treatment and moderate food and plaque with moderate bleeding during the cleaning.Review of Resident 47's clinical record Sound dental care patient notes, dated 05/09/2025 documented an exam was completed by the dentist. The notes stated the resident had generalized moderate plaque, redness and swelling of gum tissue. The exam showed signs consistent with past or active periodontal disease (an infection of the tissues that support the teeth), requiring therapeutic intervention. There were multiple carious lesions (areas of tooth decay cased by the breakdown of enamel due to bacterial activity). Review of a nursing progress note dated 05/12/2025 at 5:00 PM, Staff D, Licensed Practical Nurse (LPN) documented Resident 47 was seen by Sound Dental Care and s noted to have a possible abscess on the upper right and upper left mouth. Staff D documented as the resident is hospice, the hospice nurse would be in the following day to assess the resident. Review of Resident 47's progress note dated 05/13/2025 at 3:37 PM, showed a hospice visit today and they will start Augmentin (antibiotic medication) for seven days related to mouth abscesses. The resident had some orbital edema (swelling near the eye socket), possibly related to the abscesses.Review of Resident 47's Medication Administration Record (MAR) dated May 2025, documented the following orders: - Amoxicillin-Pot Clavulanate 500-125 milligram tablet, give 1 tablet by mouth twice a day for mouth abscesses for seven days, started on 05/13/2025. In an interview on 05/19/2025 at 11:08 AM, Collateral Contact 1 (CC 1-Resident 47's family member) stated they believed Resident 47's teeth were not being brushed by the facility staff, were not being cared for properly and their oral health/hygiene had been neglected. CC 1 stated they had spoken to Staff D, Licensed Practical Nurse (LPN) and told them the facility was neglecting Resident 47's teeth and oral care, to which they agreed.In an attempted interview and an observation on 05/21/2025 at 2:45 PM Resident 47 was in their wheelchair in their room, they did not respond when spoken to. Their teeth were observed to be black at the gumline, with thick debris noted on their teeth. The resident was missing their front teeth. There were two laminated signs on bright paper posted (one on the wall exiting the room and one on the wall above the television), that directed staff before exiting room brush teeth.In an interview and observation on 05/20/2025 at 2:49 PM Staff D, LPN went to Resident 47's room and searched for the resident's toothbrush in the bathroom and in the dresser drawer and found them located on the top shelf of the closet inn a basin. Staff D removed the toothbrush from the basin, where it was stored, and when asked if it had been used Staff D stated the toothbrush was bone dry. Staff D stated the aide that cared for the resident must have used a toothette (a sponge attached to a stick- known as a mouth moisturizer).In an interview and observation on 05/21/2025 at 9:37 AM Staff FF, NAC stated they had started their shift at 6:00 AM and were assigned to work with Resident 47. When asked what care they had provided to Resident 47 since the start of their shift, Staff FF stated assisted them with getting out of bed, dressed, and they had a shower with the hospice aide. Staff FF stated they did not think Resident 47 had any oral care performed. Staff FF stated they were just talking about Resident 47 and knew they had to have their teeth brushed. Staff FF stated they had not completed oral care with Resident 47 yet, but knew it needed to be done. Staff FF stated they rely on the care plan to know how to care for residents and they are located at the nurse's station. Staff FF stated the night aide had provided the report to them this morning that they had provided oral care to Resident 47. When asked where Resident 47's toothbrush was kept, Staff FF entered Resident 47's room, searched in their dresser, then the bathroom, and then located the toothbrush in a kidney basin on the top shelf of the wardrobe. When asked if the toothbrush looked like it had been used, Staff FF stated they did not know. Staff FF stated there was nothing in the kidney basin led them to believe that it had been used in the morning before their shift. Staff FF stated they assumed the staff were likely using toothettes for Resident 47's oral care.In a follow up interview on 05/27/2025 at 8:51 AM CC 1 stated they had not received dental reports/notes from the facility contracted dental hygienist. CC 1 stated they had contacted Resident 47's DDS in November or December 2024 about a crown that had fallen off. CC 1 stated they were shocked in November 2024 when they found out the resident had missing upper and lower teeth. CC 1 stated they received a call from Staff D requesting the name of the resident's dentist a few days ago. CC 1 stated Resident 47's teeth had been terrible, filthy several times, before the bottom teeth broke, they had repeatedly asked the nursing staff to make sure the resident's teeth were being brushed. In an interview on 05/27/2025 at 1:36 PM Collateral Contact 2 (CC 2), dental hygienist, stated Resident 47 does not have oral mouth pain because of the medication applied after cleanings. CC 2 stated if they are documenting Resident 47 had heavy plaque and food in the mouth then their teeth were not being cleaned/brushed routinely.Reference WAC 388-97-1060(1)

Based on observation, interview and record review, the facility failed to prepare food under safe and sanitary conditions in the facility kitchen. The failure to ensure hand hygiene when changing gloves and using food-contact sanitizer to clean gloves, placed residents at risk for cross-contamination and foodborne illnesses. Findings included . In an observation on 05/21/2025 at 11:27 AM, Staff Q, Dietary Staff removed gloves and then put on new gloves without washing their hands. A few minutes later, observed the same staff, Staff Q with gloved hands reach in their left side pocket for a marker, then took their left-hand glove off and placed a new glove on without washing their hands. Then observed Staff Q use the washcloth that came from the red bucket under the sink to wipe their gloves from food debris then continued placing food on the plates without their changing gloves. In an interview on 05/22/2025 at 1:15 PM, Staff P, Chef stated that they change gloves as needed, if they see the gloves were visibly soiled or if they touched their face. Staff P added that they wash their hands after taking gloves off and before putting a new pair of gloves on. Staff P stated that they have two buckets under the sink, the green bucket which was just soap and water, and the red bucket which was a food-contact sanitizer that they used to wipe surfaces such as the kitchen counter or any spillage from the soup bowl or plates. In an interview on 05/22/2025 at 1:23 PM, Staff Q, Dietary Aide, stated that they changed gloves when their gloves were soiled. Staff Q added that they wash their hands prior to putting on new gloves. Staff Q confirmed that they did not wash their hands after they changed their left-hand glove however unable to explain why they did not wash their hands prior to putting on new gloves. Staff Q also stated that they wiped their gloved hands with the food-contact sanitizer because they were told that the chemical will clean the gloves in three seconds. In an interview on 05/23/2025 at 9:28 AM, Staff O, Dietary Manager stated that it was an expectation for kitchen staff to wash their hands prior to putting on gloves, to change gloves when visibly soiled, if they touched their face, or when staff were changing tasks such as handling meat then switching to handling vegetables. Informed Staff O was informed of observations of kitchen staff taking left hand glove off and replacing it without washing their hands, Staff O stated, if their hands were not visibly soiled, and did not touch anything prior to putting new gloves that it was acceptable not to wash their hands prior to putting on new gloves. Staff O added that if staff wash their hands all the time prior to putting on new gloves then they would not be able to finish the tray line on time and it would delay them serving lunch to residents. When asked about the staff that wiped their gloves with the food-contact sanitizer, Staff O stated that the food-contact sanitizer was for hard surface areas and not used to wipe their gloves clean. Staff O stated that if gloves were soiled, staff were expected to change gloves. Reference WAC 388-97-1100 (3)

Based on interview and record review the facility failed to ensure a system in which resident's records were complete, accurate, accessible and systematically organized for 4 of 7 residents (Residents 29, 47, 83 and 84) reviewed. This failure included inaccessible hospice visit documentation, hospice plan of care, and incomplete documentation of meal intakes which placed residents at risk for unmet needs, unrecognized changes in condition and adverse outcomes. Findings included . Review of the facility policy titled, Documentation in Medical Record reviewed in (no month and day) 2025 documented each resident's medical record shall contain an accurate representation of the actual experiences of the resident and enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Documentation shall be accurate, relevant, and complete containing sufficient details about the resident's care and or responses to care. Review of the facility policy titled, Nutrition Management reviewed in (no month and day) 2025 documented a systematic approach is to be used to optimize each resident's nutritional status including identifying and assessing each resident's nutritional status and risk factors, evaluating and analyzing the assessment information. Staff were instructed to document the intake of meals. <MEAL MONITORING> <RESIDENT 29> Resident 29 admitted on [DATE] with diagnoses to include major depressive disorder, Multiple Sclerosis (MS, disease that disrupts communication between the brain and body) and lymphedema (tissue swelling from a block). Review of Resident 29's care plan initiated on 09/23/2024 documented a nutritional problem related to MS, acute kidney injury, high blood pressure, chronic diarrhea, and chronic lymphedema. The care plan showed the resident was at risk for malnutrition. The care plan directed staff to provide and serve the diet as ordered and monitor intake and record intake each meal. Review of the meal monitors revealed the resident's meal intakes were not consistently documented. The following meal monitors were omitted: March 2025: At 7:30 AM on 03/03/2025 through 03/07/2025, 03/10/2025, 03/12/2025, 03/13/2025, 03/17/2025 through 03/21/2025, 03/26/2025 through 03/21/2025. At 1:00 PM on 03/02/2025, 03/10/2025, 04/16/2025, 03/21/2025, 03/27/2025, 03/29/2025 and 03/31/2025. At 6:00 PM on 03/18/2025 and 03/31/2025. April 2025: At 7:30 A on 04/02/2025 through 04/04/2025, 04/08/2025, 04/09/2025, 04/16/2025, 04/17/2025, 04/22/2025, and 04/23/2025. At 1:00 PM on 04/01/2025 through 04/04/2025, 04/07/2025 through 04/18/2025, 04/21/2025-04/24/2025 and 04/28/2025 through 04/30/2025. At 6:00 PM on 04/05/2025. May 2025: At 7:30 AM on 05/01/2025, 05/02/2025, 05/06/2025, 05/12/2025 through 05/16/2025, 05/20/2025 through 05/22/2025, 05/26/2025, and 05/27/2025. At 1:00 PM on 05/03/2025, 05/05/2025, 05/06/2025, 05/08/2025, 05/12/2025, 05/13/2025, 05/20/2025, 05/21/2025 and 05/27/2025. At 6:00 PM on 05/18/2025, 05/24/2025, and 05/27/2025. <RESIDENT 83> Resident 83 admitted [DATE] with Alzheimer's disease. Review of the care plan initiated 10/15/2024 showed Resident 83 was at risk for malnutrition related to advanced age, advanced Alzheimer's Disease with cognitive impairment, need for assist with eating at times, limited mobility, actual fracture and polypharmacy. The care plan directed staff to provide and serve the diet as ordered and monitor intake and record intake each meal. Review of the meal monitors revealed the resident's meal intakes were not consistently documented. The following meal monitors were omitted: March 2025: At 7:30 AM on 03/09/2025 and 03/28/2025. At 1:00 PM on 03/09/2025. April 2025: At 7:30 AM on 04/12/2025. At 1:00 PM on 04/04/2025 and 04/25/2025. May 2025: At 7:30 AM on 05/17/2025. At 1:00 PM on 05/11/2025, 05/21/2025 and 05/24/2025. In an interview on 05/23/2025 at 1:28 PM, Staff D, Licensed Practical Nurse (LPN) stated the Nursing Assistant Certified (NAC's) and dining room assistants documented residents' meal intake under tasks in Point of Care (POC, electronic health record). Staff D stated whoever picked up the tray is who is responsible to document the amount eaten and fluids consumed. Staff F stated they never audits the missed documentation but maybe Staff B, Director of Nursing completed audits. In an interview on 05/23/2025 at 2:07 PM, Staff B, Director of Nursing Services (DNS) stated meal monitors were documented in POC by the dietary aides who are responsible to document them. Staff B stated they look at the meal intake documentation for weight review on a weekly basis. Staff B stated the process was the dietary aides pick up the trays and input the information into the POC for meals consumed on hall trays and in the dining room. Staff B stated they were unaware of a documentation issue with meal monitors, and they would talk with Staff O, Dietary Manager about this. In an interview on 05/27/2025 at 9:36 AM, Staff F, Training Development Coordinator stated the dietary staff that pick up the trays are to document the meal intake and Staff O, Dietary Manager was responsible for oversight of the meal monitoring. In an interview on 05/27/2025 at 9:42 AM, Staff H, Dining Room Assistant (DRA) stated they or another DRA would pick up the trays and document on the slip, the meal and fluid intake percentages. Staff H stated when the slips are completed, the dining room hostess would input the meal intakes into the computer. <RESIDENT 47> Resident 47 admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other mental functions), high blood pressure, and dysphasia (difficulty swallowing). Review of Resident 47 Electronic Health Record (EHR) showed they started hospice services on 03/27/2025. There were no documents in the EHR, other than the election for hospice benefit, found from hospice related to their plan of care, services, or coordination of care with the facility. Review of Resident 47's paper chart showed care plans from hospice pertaining to Resident 47's care and needs. The paper chart contained plan of care updates for hospice services dates of 4/30-5/13/2025, 4/16-4/29/2025, 04/02-4/15/2025 and 3/27-4/2/2025. In an interview on 05/22/2025 at 1:57 PM Staff D stated there was a paper chart for Resident 47. When asked for the most recent hospice care plan, they printed out a care plan from Resident 47's EHR. Staff D stated the hospice documents from hospice for Resident 47, found in the paper chart was just the hospice notes and not a care plan, and stated they don't do that anymore. Staff D stated they did not know when Resident 47 was last seen by hospice, did not know how often they got notes from hospice and provided no additional information. In an interview on 05/27/2025 10:18 AM Staff EE, Medical Records, stated the day-to-day documents are completed in the EMR and if there were more forms, those were scanned and uploaded into PCC, especially the ones that required signature. Staff EE stated all the documents located in the paper chart are scanned into the EHR. When asked if there were any documents kept in the paper chart that were not scanned into the EHR, Staff EE stated, the thing about electronic records, there is no need to keep a copy in the hard chart. <RESIDENT 84> Resident 84 readmitted to the facility on [DATE] and elected hospice services on 05/10/2025. In an interview on 05/21/2025 at 9:01 AM, Staff D stated Resident 84 was experiencing end of life delirium and was seen by hospice nurse. In an interview on 05/21/2025 at 11:24 AM, Staff Z, NAC, stated Resident 84 had a new development of behaviors the last couple of days and had been seen by the hospice nurse. Review of Resident 84's EHR through 05/23/2025, showed there were no visit notes from hospice agency staff. In an interview and record review on 05/27/2025 at 9:35 AM, Staff Y, Unit Secretary, stated all medical records were kept in EHR and/or hard copy binders. Review of Resident 84's hard copy binder showed there were no visit notes from hospice agency staff. Staff Y stated there was no hospice agency staff visit notes either in EHR or hard copy binder for Resident 84. Staff Y stated hospice agency staff visit notes needed to be faxed by the hospice agency and the facility also could request for them. In an interview on 05/27/2025 at 10:35 AM, Staff C, Registered Nurse/Supervisor, stated they expected all residents' medical records were kept either in EHR or hard copy binder and unit secretary helped to upload the documentation. Staff C stated the hospice agency faxed the paperwork including the visit notes to the facility and the facility also could easily requested for the paperwork. Reference WAC 388-97-1720(1)(a)(i)(iii)(iv)(2)(d)

<DENTAL> <RESIDENT 47> Resident 47 admitted to the facility on [DATE] with diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other mental functions), high blood pressure, and dysphasia (difficulty swallowing). Review of Resident 47's Annual MDS assessment dated [DATE] showed they had no obvious or likely cavity, no broken natural teeth, no facial pain or discomfort, and no inflamed or bleeding gums or difficulty chewing. In an observation on 05/20/2025 at 2:45 PM, Resident 47 gums and teeth appeared to be black in color, with debris in their teeth, and they were missing teeth. Review of Resident 47's dental status assessment dated [DATE] showed the resident had obvious or likely cavities. Review of dental hygienist notes dated 03/26/2024 showed Resident 47 had broken teeth. Review of Resident 47's Significant Change MDS dated [DATE] showed the resident had no obvious or likely cavity, no broken natural teeth, no facial pain or discomfort, and no inflamed or bleeding gums or difficulty chewing. In an interview on 05/23/2025 at 1:19 PM Staff AA, MDS Coordinator-LPN stated they were in the middle of completing a modification to the significant change MDS for Resident 47 in the dental section. Staff AA stated there was an entry error and it was just a key stroke error. No other information was provided. Based on interview and record review, the facility failed to accurately assess 4 of 4 residents (Residents 32, 37, 47 and 72) reviewed for Minimum Data Set (MDS- an assessment tool) assessments. These failures placed the residents at risk for unidentified and/or unmet care needs and a diminished quality of life. Findings Included . <MEDICATIONS> <RESIDENT 72> Resident was admitted on [DATE] with diagnosis to include Diabetes Mellitus Type 2 (a chronic condition in which your body doesn't use insulin properly, causing high blood sugar levels). Review of Resident 72's physician orders printed on 05/20/2025, documented the resident had an order for NovoLog injection solution (a fast-acting insulin), inject 10 units subcutaneous (fatty tissue layer beneath the skin) three times a day related to diabetes mellitus. Order date 02/18/2025. Review of Resident 72's quarterly MDS assessment dated [DATE], documented that the resident received insulin for seven days. Review of Resident 72's Medication Administration Record (MAR) for March 2025, documented the resident did not receive insulin on 03/26/2025, 03/27/2025 or 03/28/2025 due to the resident being in the hospital. In an interview on 05/22/2025 at 2:05 PM, Staff S, Registered Nurse (RN)/MDS Coordinator stated that to code for medications specifically injections, they review the resident's MAR and count how many times the resident had an injection per day within the look back period (counting back 7 days starting on the reference date) and that's the number they document in the MDS. Staff S reviewed Resident 72's latest MDS and reviewed Section N, they stated that it was a coding error. The resident did not receive 7 days of insulin due to resident being in the hospital for three days. It should have been coded four and not seven. <BEHAVIOR> <RESIDENT 37> Resident 37 was admitted to the facility on [DATE] with diagnosis to include Vascular Dementia (refers to changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain). Review of Resident 37's quarterly MDS assessment dated [DATE] documented that the resident did not exhibit wandering behaviors during the seven day look back period. Review of the Treatment Administration Record (TAR) for March 2025 showed documentation that the resident had episodes of wandering on 03/19/2025, 03/20/2025 and 03/21/2025 which was within the dates of the 7-day look back period. In an interview on 05/22/2025 at 2:05 PM, Staff S stated that the Social Services Department were the ones that document and completes Section E on the MDS. In an interview on 05/27/2025 at 9:10 AM, Staff R, Social Services, stated that they complete sections A, C, D, E, Q and N in the MDS. Staff R stated, to code for behaviors they review the MARs/TARs to see the behavior documentation done by nurses or Certified Nursing Assistants (NAC). Staff R reviewed the latest MDS for Resident 37 and compared it to the March 2025 TAR for wandering behavior, and stated that it was coded inaccurately. Staff R stated they had not completed that section, and they were unable to state who did. Further review of the MDS Section E, showed that Staff R was the one that signed this section on 03/28/2025 at 2:58 PM. <RESIDENT 32> Resident 32 readmitted to the facility on [DATE]. In an observation and interview on 05/20/2025 at 11:11 AM, Resident 32 had some missing and broken upper teeth, tartar and brownish debris along the gum line, and whitish debris in between upper and lower teeth. Resident 32 stated they had missing and broken teeth for years and they had cavities as well. Review of a progress note, dated 05/07/2024 at 6:42 PM, documented Resident 32 had black fragmented molars with missing teeth throughout. Review of Resident 32's oral status dated 06/03/2024, documented they had many teeth were broken and gone. Review of Resident 32's admission assessment dated [DATE], documented they had natural teeth missing, loose, broken, carious and edentulous. Review of dental consult visit note dated 11/25/2024, showed Resident 32 had active periodontal infection, moderate to severe gum bleeding, and severe gingival inflammation. Review of Resident 32's comprehensive MDS assessment, dated 06/09/2024, documented Resident 32 had no obvious or likely cavity or broken natural teeth, no inflamed or bleeding gums or loose natural teeth, and no dental problem. The care area assessment (CAA) related to dental care was not triggered as no oral/dental problem indicated in the MDS. In an interview on 05/22/2025 at 2:05 PM, Staff S stated the MDS oral/dental status section was data entry error and needed to be modified. In an interview on 05/23/2025 at 10:25 AM, Staff C, RN/Supervisor, stated they expected MDS assessment to be completed timely with accuracy. Reference WAC 388-97-1000 (1)(b)

Based on observation, interview and record review, the facility failed to properly label and/or discard undated, opened ophthalmic medications (drugs specifically formulated for application to the eye). This failure placed the residents at risk of receiving compromised or ineffective medications. Findings included . Review of a facility policy titled, Medication Storage in the Facility, dated 05/09/2018, documented the facility would ensure all medications were stored safely, securely, and properly, following manufacturer's recommendations. Ophthalmic medications, once opened, required an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. Review of the updated package insert document for Refresh Tear eye drops, showed to discard the medication 90 days after opening. Review of the updated package insert document for Latanoprost Ophthalmic Solution, showed to discard an opened bottle after six weeks. Review of the updated package insert document for Timolol eye drops, showed to discard an opened bottle with any remaining solution after 28 days. In an observation and interview on 05/22/2025 at 9:57 AM with Staff V, Registered Nurse (RN), observed in the medication cart in cascade unit, one opened Refresh Tears eye drop with no documented open date. Staff V stated the nurse needed to label the medication with an open date. In an observation and interview on 05/22/2025 at 10:43 AM with Staff W, Licensed Practical Nurse (LPN)/Supervisor, observed in the medication cart in rehab unit, one opened Latanoprost eye drop, and one opened Timolol Maleate eye drop that had no open dates, one opened Artificial Tears that had no open date and no resident name. Staff W stated the eye drops needed to be labeled with open dates and residents' names. In an observation and interview on 05/22/25 at 11:15 AM with Staff D, LPN/Supervisor, observed in the medication cart in baker unit, one opened Artificial Tears eye drop that had no open date, one opened Latanoprost eye drop that had no open date, one opened Refresh Tears eye drop that had a date labeled but it was not readable. Staff D stated all eye drops should be labeled with an open date once opened and certain eye drops last for 30 days after opening. In an interview on 05/27/2025 at 10:15 AM, Staff C, RN/Supervisor, stated eye drops needed to be labeled with the open dates once opened and stored in a visualized resident labeled package. In a following interview and record review on 05/27/2025 at 10:35 AM, Staff C showed an email dated 05/22/2025 at 11:50 AM from a consulting pharmacist, documented eye drops should have a date opened label applied to the product with the date written as to when it was opened. Reference WAC 388-97-1300 (2)

Based on observation, interview and record review the facility failed to ensure proper hand hygiene and infection control measures were used for equipment sanitation, during staff assistance during meals, personal care and indwelling urinary catheter care for 1 of 1 resident (Resident 32) observed for cares and dining observations. The facility failed to ensure the staff were compliant with appropriate hand hygiene practices while serving meals, and during catheter care. These failed practices placed the residents and staff at increased risk of contracting and/or spreading potential infections. Findings included . Review the facility's procedure titled, Handwashing/Hand Hygiene, revised on 06/08/2020 showed the purpose of the procedure was to provide guidelines to employees for proper and appropriate hand washing and hygiene techniques that would aid in the prevention and control of the transmission of infections and diseases. The guidelines included hand hygiene after contact with secretions and mucous membranes, before moving from a contaminated body site to a clean body side during resident care, after contact with resident's intact skin and after removing gloves. <HALL TRAY OBSERVATION> <HAND HYGIENE> In a continuous observation on 05/19/2025 at 12:42 PM, Staff I, Dining Room Assistant (DRA) was observed to remove a lunch tray from the meal cart and deliver the tray to room [ROOM NUMBER]-1. Staff I was observed to place the tray on to the residents over the bed table, remove the lid and exit the room, Staff I did not perform hand hygiene. At 12:45 PM, Staff I then grabbed another lunch tray without performing hand hygiene and entered room [ROOM NUMBER]-1 where they moved some of the residents' used cups to make room for the lunch tray. Staff I was observed to exit the room, without performing hand hygiene. Staff I proceeded to remove another lunch tray from the meal cart and enter another resident room without performing hand hygiene. Staff I placed the lunch tray on the overbed table, placed a clothing protector on the resident and rearranged items on the residents overbed table. They were observed to place the meal tray on the over the bed table, move some of the residents' personal items, and exit the room without performing hand hygiene. At 12:51 PM, Staff G, DRA delivered a lunch tray to 120-2 with no hand hygiene performed prior, in the room or after. At 12:52 PM, Staff N, hospitality aide delivered the meal tray to room [ROOM NUMBER] without performing hand hygiene prior, in the room or after. At 12:54 PM, Staff G delivered a lunch tray to room [ROOM NUMBER] with no hand hygiene performed prior, in the room or after. At 12:55 PM, Staff I returned from the kitchen with a replacement for room [ROOM NUMBER]-1 with no hand hygiene performed prior, in the room or after. At 12:57 PM, Staff I was in the hall and had food on their hands and shook the food off, no hand hygiene was performed after having visibly soiled hands. At 12:57 PM, Staff I delivered to room [ROOM NUMBER], without performing hand hygiene prior, in the room or after. In an interview on 05/21/2025 at 2:48 PM, Staff E, Staff Development Coordinator was informed that on 05/19/2025 at lunch this surveyor had observed no hand hygiene before tray delivery or in between any room during direct observation on the [NAME] Landing unit. Staff E stated the expectation was for hand hygiene in between every room for meal tray delivery. In an interview on 05/22/2025 at 8:33 AM, Staff O, Dietary Manager came into the conference room and said they had heard there were hand hygiene issues on Monday, and they wanted me to verify if it was a staff member who was currently in the dining room assisting a resident with their breakfast. This surveyor stated that staff member did not look like the Staff I observed but that their name tag stated (Staff I) and their title was DRA. Staff O stated that Staff I was a germaphobe so that could not have been the staff I observed. Staff O stated maybe who I observed was not facility staff and a local college student. In a follow up interview on 05/23/2025 at 8:40 AM, Staff O confirmed that the staff member was passing trays without hand hygiene Monday was Staff I. In an interview on 05/23/2025 at 8:48 AM, Staff I stated their process when serving hall trays was that they sanitized their hands, provide a shirt saver and tray for residents who do not need assistance first. Then they deliver the food and make sure the residents have what they need. Staff I stated they carried hand sanitizer in their pocket. Staff I stated that sometimes the residents would ask them to fix something in their room so then they would hand sanitize. Staff I showed their hands and stated, My hands are destroyed by hand sanitizer. Staff I stated they sanitized a lot. Staff I was informed this surveyor did not observe them use hand sanitizer or wash her hands during continuous observation of hall trays on Monday. Staff I stated they did use the hand sanitizer Monday, and they did hand sanitize constantly throughout the day, and sometimes they double sanitized their hands. In an interview on 05/27/2025 at 11:01 AM, Staff A, Administrator stated they were unaware of hand hygiene or mechanical lift sanitation concerns. <EQUIPMENT SANITATION> In an observation on 05/19/2025 at 12:56 PM, a tag located on the Hoyer lift (a mechanical lift) that documented to use Purell Surface cleaner for the soiled utility room, The tag had a picture of the cleaner to be used. In an interview on 05/19/2025 at 12:56 PM Staff DD, Nursing Assistant Certified (NAC) stated the Hoyer's were cleaned with a rag and cleaner located in the soiled utility room after each use. In an observation on 05/22/2025 at 11:18 AM, Staff BB, NAC, left room [ROOM NUMBER] with the Hoyer lift, pushed it down the hall and parked it across from room [ROOM NUMBER] without cleaning it. Staff BB entered room [ROOM NUMBER] without performing hand hygiene. At 11:20 AM observed Staff CC, NAC moving the Hoyer from the hallway across from room [ROOM NUMBER] and entered room [ROOM NUMBER] with it. <PERSONAL CARE> <RESIDENT 32> Resident 32 readmitted to the facility on [DATE]. In an observation on 05/21/2025 at 10:59 AM, Staff X, NAC provided peri-care (the practice of washing the genital and anal area) to Resident 32 with assistance of Staff U, Licensed Practical Nurse (LPN)/Supervisor. After putting on gloves, Staff X opened Resident 32's dirty brief and wiped the perineal area and buttocks. Without performing hand hygiene or changing gloves, Staff X applied a clean brief and a clean purple draw sheet for Resident 32. With the same contaminated gloves, Staff X adjusted Resident 32's upper body clothes, tidied the bed linens and smoothed the sheets. Staff X touched and opened the privacy curtains with the same gloves. In an interview on 05/21/2025 at 11:17 AM, Staff X stated they were supposed to change gloves and perform hand hygiene after cleaning perineal area and bottom, but they had forgot to do that. In an interview on 05/23/2025 at 1:43 PM, Staff E, stated staff needed to change gloves and perform hand hygiene after cleaning resident's perineal area and before applying a clean new brief. In an interview on 05/27/2025 at 10:35 AM, Staff C, Registered Nurse/Supervisor, stated they expected staff to perform hand hygiene and change gloves after cleaning the perineal area and bottom before applying a clean new brief. Staff C stated staff needed to change gloves and perform hand hygiene when providing care from dirty to clean. Reference WAC 388-97-1320 (1)(c)(2)(b)

Based on interview and record review, the facility failed to provide the careplanned supervision that was necessary to avoid accidents for 1 of 5 residents (Resident 83) reviewed for accidents.Resident 83, who was left unattended on the toilet, sustained a fall where they struck their head and sustained a bump to the back of their head. This failed practice placed other residents with similar care needs at an increased risk of falls and serious injury. Findings included . Review of the facility's policy titled, Fall Management Plan-Safety Awareness Fall Elimination (SAFE) revised 11/06/2024, documented that each resident will be assessed on admission, quarterly and when safety issues occur to identify residents at risk for falls and implement strategies to prevent falls and injury from falls. All staff were to report immediately residents who are restless. Review of the Nursing Home Guidelines, The Purple Book, October 2015 edition documented a substantial injury would be in an area not vulnerable to trauma such as face, neck, back, chest. All injuries (regardless of the extent) occurring in non-vulnerable areas of the body will be considered substantial injuries. Resident 83 admitted to the facility on [DATE] with diagnoses to include dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems) with psychotic disturbance, anxiety (a mental health condition that involves excessive worry and feelings of fear, dread, and uneasiness), and recent left hip fracture from a fall. Resident 83 required 1 person observation for increased supervision related to impulsivity during their hospital stay 09/30/2024 to 10/07/2024. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] documented Resident 83 had significant cognitive impairment, lower extremity impairment on one side and required substantial/maximal assistance with toilet transfers. Review of Resident 83's clinical record documented the Morse Fall Scale assessment was 103 days overdue, since 02/08/2025. The resident had a Morse fall assessment on admission [DATE] and missed the quarterly assessment on 02/08/2025 and readmission assessment on 05/05/2025. Review of ADL approaches (guide for nurse's aides on how to provide care) dated 11/09/2024 documented Resident 83 was a high fall risk, very fearful and directed staff to turn and move the resident carefully and required two persons stand pivot assistance for toileting transfers. Review of the resident's High Risk for Falls care plan initiated on 10/10/2024 showed Resident 83 was at high risk for falls related to impaired cognition, limited mobility, limited range of motion to their left lower extremity, actual falls with fractures, incontinence of bowel and bladder and the need for assistance with all Activity of Daily Living (ADL) and was on high risk medications (cardiac, narcotic, antidepressant and Depakote [seizure medication]). On 03/10/2025 signage was placed by the toilet to remind resident to ask for assistance prior to toilet use. Review of a Physical Therapy note dated 02/03/2025 showed Resident 83 was a fall risk with dementia and poor safety awareness, The documentation revealed the resident was currently on high fall risk notification and staffing knew to make frequent checks. The resident required one person assistance for all mobility due to their cognitive deficits. Review of a progress note dated 04/15/2025 at 9:19 AM, documented Resident 83 had an unwitnessed fall that day in their restroom. The resident was being assisted by a Nursing Assistant Certified (NAC) who stepped out of the restroom to grab a needed item. During that short period of time, the resident immediately attempted to self-transfer, fell and hit their head. When the NAC came into the room, the resident was on floor holding onto their head. During the assessment, Resident 83 was noted to have a lump on the left side of the back of their head. Nursing continued 15-minute checks and added neuro checks. Review of the facility incident report dated 04/15/2025 at 8:30 AM, documented Resident 83 was taken into the restroom by the NAC. The resident was scheduled to have a shower that morning. The NAC assisted the resident onto the toilet, then stepped out of the room into the hallway to tell the shower aide that the resident was up and out of bed for their shower. The NAC heard a loud noise and returned to the resident's room to find them on the bathroom floor. The NAC alerted the nurse that the resident had fallen. The incident report documented that the resident was found seated on the floor with their back facing the wall between the toilet and the sink. Their legs were out in front of them towards the door and they were holding their head. The resident stated they hit their head when they fell. The resident stated they just thought they could do it themself. The resident was assessed to have an injury to the back of their head. The level of pain was documented as sad, frightened, frown facial expression, tensed distressed pacing body language and they were distracted. Predisposing physiological factors at time of fall were marked the resident was confused, with gait imbalance and impaired memory with wandering, active exit seeking and they had been ambulating without assistance. Other information included the resident was unable to sit still, was very anxious, even on the toilet and the resident was panicking and anxious 30 minutes prior to the fall. The injury description showed a lump to the left back side of their head. The description did not include color, size or other characteristics of the injury. Review of a witness statement dated 04/15/2025 included in the incident report, Staff K, the assigned NAC documented Resident 83 was restless prior to the fall, they assisted the resident to the toilet for a bowel movement and left the resident for less than two minutes to ask the bath NAC about their shower. Staff K documented when they came back, they grabbed onto the door handle and heard a crash, entered the bathroom to find a fallen wheelchair and the resident on the floor. Staff K documented the resident had been told not to get up without help. The NAC called for the nurse. Review of a comprehensive fall assessment completed on 04/15/2025 showed Resident 83 had difficulty walking, needed supervision or help when transferring, did not understand their limitations, was unwilling or unable to ask for assistance or follow instructions. The assessment documented the resident was easily frustrated, would pace and had a change in their behavior and they desired to walk. The resident was taking medications that may have side effects of dizziness and loss of balance. In an interview on 05/23/2025 at 1:30 PM, Staff D, Licensed Practical Nurse (LPN) stated Resident 83 had very poor short-term memory. Staff D stated the resident would read the signs to staff that were to remind the resident to wait for help, but they did not always comprehend them. Staff D stated Resident 83 may tell staff not to stay with them in the bathroom, but staff have to be close to them for supervision since the resident was quick, had no safety awareness and poor judgment. Staff D stated Staff K, NAC had left the resident on the toilet and the resident cannot be left alone. Staff D stated the resident was restless prior to the fall and the fall resulted in a bump to the back of their head. In an interview on 05/23/2025 at 1:47 PM, Staff T, LPN stated Resident 83 had lots of falls and was a high fall risk. Staff T stated the resident would try to get up independently, so staff needed to stay with them when they are in the bathroom. In an interview on 05/23/2025 at 2:02 PM, Staff B, Director of Nursing Services was asked about Resident 83's fall on 04/15/2025 at 8:30 AM. Staff B stated the NAC stepped outside the bathroom door to find the shower aide, very briefly then the resident fell. Staff B stated they were not sure how the fall could have been prevented when Resident 83 was moving quick. Staff B stated they had updated the care plan after the fall for staff to stay in the bathroom or just outside the bathroom door for supervision. Staff B stated the plan of care had been followed at the time of fall because there was not a Do not leave the resident unattended on the toilet care plan intervention at the time of the fall. In an interview on 05/27/2025 at 9:48 AM, Staff K stated Resident 83 was a high fall risk since admission and they required more supervision than one person assistance now. Staff K stated the resident would try to get up unattended. Staff K confirmed they were the NAC caring for the resident at the time of the fall on 04/15/2025. Staff K stated the resident was known for self-transferring to the bathroom and was antsy and jittery and they tried to assist them to the toilet as often as possible. Staff K stated the day of the fall they had left the resident on the toilet to go get washcloths for peri care and to talk with the bath aide as the resident was next to get their shower. Staff K stated when they came back the resident had fallen. Staff K stated the resident had been having panic attacks, was restless and very fidgety prior to the fall. Staff K stated when they found the resident, their wheelchair had been tipped over on its side as if the resident had pushed on the left side of the wheelchair and it tipped over and they fell. Staff K stated when they found the resident they said, Oh no and Resident 83 said they thought they hit their head. Staff K said they did not know what the resident injuries were, but the resident complained their left hip was sore after the fall. In a phone interview on 05/27/2025 at 10:04 AM, Staff J, LPN confirmed they were the nurse caring for Resident 83 at the time of the fall on 04/15/2025 at 8:30 AM. Staff J stated the resident had anxiety, was very much a fall risk since admission and they would attempt to get up unattended. Staff J stated the resident was taken into the restroom and left on the toilet while the NAC popped out into the hall to talk with the shower aide. The NAC then heard the resident fall. Staff J could not recall the resident's pain or injuries post fall, but stated they understood the concern with Resident 83 being left unattended on the toilet and could not recall if education was provided to Staff K. In a phone interview on 05/27/2025 at 10:08 AM, Staff L, NAC stated Resident 83 required substantial extensive assistance for ADL's. Staff L stated the resident had always been a fall risk, was quite confused, anxious, had no memory and they would quite often try to get up by themselves. Staff L stated they never leave Resident 83 on the toilet related to their short memory as they forget instantly that they can't transfer themselves. Staff L stated the resident was not modest and did not request privacy in the bathroom. In a phone interview on 05/27/2025 at 12:07 PM, Staff M, Registered Nurse (RN) stated they cared for Resident 83, and they were a fall risk. Staff M stated the resident should not be left alone on the toilet or anywhere. Staff M stated the resident had no short-term memory, was impulsive and restless and made self-transfer attempts. Reference WAC 388-97-1060 (3)(g)

Based on interview and record review, the facility failed to ensure adequate monitoring was conducted for use of an anticoagulant (medication that prevent blood clot) for 1 of 5 residents (Resident 53), reviewed for unnecessary medications. This failure placed the residents at risk for receiving unnecessary medications, adverse side effects, and related complications. Findings included . Review of the facility's policy titled, Anticoagulation Therapy Guideline, revised in 2025, documented all residents receiving anticoagulation therapy will be monitored by LN for signs and symptoms of bleeding and possible food and drug interactions. The policy further documented residents on anticoagulation therapy will have addressed on care plan potential risks related to therapy. Resident 53 readmitted to the facility on [DATE] with diagnoses to include atrial fibrillation (A-Fib - an irregular and often very rapid heart rhythm). According to the quarterly Minimum Data Set (MDS-an assessment tool) assessment, dated 03/13/2025, Resident 53 was cognitively intact and taking anticoagulant. Review of the Medication Administration Record (MAR) dated May 2025 showed Resident 53 had an order for Apixaban (an anticoagulant medication) oral tablet 5 milligrams (mg-a unit of measurement) to be given twice a day to treat hypertension since 11/07/2024. The MAR showed there was no documentation for monitoring signs and symptoms of bleeding in the MAR. Review of Resident 53's care plan, copy date 05/21/2025 at 1:47 PM, there was no care plan that addressed anticoagulant use or monitoring of sign and symptoms of bleeding and potential risks related to the anticoagulant medication. In an interview and record review on 05/23/2025 at 12:48 PM, Staff U, Licensed Practical Nurse/Supervisor, stated Resident 53 was taking anticoagulant for A-fib rather than hypertension, and staff needed to monitor adverse side effects, sign and symptoms of bleeding, bruises, changing of conscious level, and sign and symptoms of stroke. Staff U reviewed Resident 53's MAR and care plan and stated there was no documentation of monitoring for anticoagulant use and they would add it. In an interview on 05/27/2025 at 10:18 AM, Staff C, Registered Nurse/Supervisor, stated they expected nurses to monitor sign and symptoms of bleeding when residents are receiving anticoagulant medications and document in the MAR and care plan. Reference WAC 388-97-1060 (3)(k)(i)(4)

Based on interview and record review, the facility failed to ensure policies and procedures for timely reporting of fall for 1 of 4 residents (Resident 51) reviewed for abuse. The facility failed to report to the state agency when a resident fell after, during a transfer, in which their care plan was not being followed. This failure by the facility to identify, report, and investigate for an allegation of potential abuse or neglect placed residents at risk of being victims of unidentified and uninvestigated abuse and/or neglect and limited the thoroughness of investigations. Findings included . Review of the facility policy titled, Reporting Abuse to Facility Management dated 10/24/2022 showed: When an alleged or suspected case of serious injuries of unknown source, or abuse is reported, the facility Administrator or designee, will immediately (within two hours of alleged incident) notify the following persons or agencies of such incident as indicated by regulation; if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property and does not result in serious bodily injury, results will be reported within 24 hours, and results of all investigations of alleged violations will be reported via log within five working days: a. The State licensing/certification agency responsible for surveying/licensing the facility; b. The Resident's Representative (Sponsor) of Record; c. Adult Protective Services as appropriate; d. Law Enforcement Officials (when there is suspicion or confirmation of a crime); e. The Resident's Attending Physician (immediately); and f. The Facility Medical Director. Review of the facility policy titled, Abuse Investigations Policy dated 10/24/2022 showed the facility will report allegations of abuse and neglect to state agencies as required per regulation. All reports of resident abuse, neglect and injuries of unknown source shall be thoroughly investigated. Witness reports will be obtained, and the witnesses will be required to sign and date written reports and the resident, and their representative kept informed of the progress of the investigation. Resident 51 admitted to the facility on [DATE] with diagnoses that included symptomatic epilepsy (seizures that are cause by an underlying brain disease), retinal vein occlusion (blockage in a vein that drains blood from the retina), and Alzheimer's Disease (progressive disease that destroys memory and other important functions). Review of Resident 51's Quarterly Minimum Data Set (MDS-an assessment tool) dated 06/04/2024 showed the resident had severe cognitive impairment. Review of Resident 51's care plan dated 06/03/2024 showed they required moderate assistance of two staff members with transfer from their wheelchair to toilet with use of grab bar and to allow them extra time for feet placement and balance before the commode swap transfer was completed. Resident 51's care plan was updated 8/19/2024 for them to use a bed pan/urinal. In an interview on 08/16/2024 at 8:31 AM Collateral Contact 1 (CC1), Resident 51's representative, stated they were notified, recently, by the facility that Resident 51 had a fall in the bathroom . Review of the state incident reporting log for August 2024 showed no entries related to Resident 51's fall in the bathroom on 08/11/2024. Review of the facilities fall investigation dated 08/11/2024, showed Resident 51 experienced a fall in their bathroom after the staff caring for them lost their footing on a Hoyer (a mobile floor lift system that transfers a person from one surface to another) sling, slipped and fell , which resulted in Resident 51 falling on top of the staff onto their bottom. The incident report showed Resident 51's care plan was reviewed, and no new interventions were implemented. The incident report showed Resident 51, prior to the fall, had been changed from a two person assist with a front wheel walker to a Hoyer lift for transfers in/out of bed as they were unable to transfer safely. In an interview on 08/19/24 at 2:26 PM Staff D, Licensed Practical Nurse (LPN), stated Resident 51 sustained a fall in the bathroom after an aide tripped and fell on the Hoyer sling that was located on the resident's wheelchair during a transfer. Staff D stated the staff had not followed the care plan and was by himself during the transfer/care of Resident 51. Staff D stated abuse and neglect were ruled out as Resident 51 had not been harmed during the fall. Staff D stated they were in the process of educating the staff involved in the fall. In a follow up interview on 08/21/2024 at 9:01 AM Staff D, LPN stated they were alerted to Resident 51's fall on 08/11/2024 and they initiated their investigation on 08/12/2024. Staff D stated the facility's policy was to report any allegations of abuse/neglect to the state if they felt that it was abuse/neglect. Staff D stated they spoke to the staff involved in Resident 51's fall, could not recall the date, and they were aware they did not follow the care plan. Staff D stated the definition of neglect included not caring for a resident or providing for their needs. Staff D stated they felt the fall was an accident as the staff involved was providing care to Resident 51 and had no pattern of not providing care to residents. Staff D stated CC1 had not been notified that the staff involved in the fall was not following the care plan at the time of Resident 51's fall. Staff D stated that not following a resident's care plan could be considered neglect. In a joint interview with Staff A (Administrator) and Staff B (Director of Nurses), Staff A stated Resident 51's fall was determined to be an accident and abuse/neglect was ruled out and did not require any report to the state agency. Staff B stated the staff involved in the fall had a pattern of not following resident's care plan where they were reinstructed in June and had struggled early in the year and required extra support and training. Staff B stated the staff involved had no serious disregard for consequences thus neglect was ruled out, they did not willfully show intent to not follow the care plan and they went based on what they thought. Refer to WAC 388-97-0640(5)(a)

Based on observation, interview, and record review the facility failed to ensure possible allegations of abuse/neglect were thoroughly investigated for 1 of 4 residents (Residents 51), reviewed for abuse/neglect investigations. This failure placed the resident at risk for unidentified abuse or neglect and a diminished quality of life. Findings included . Review of the facility policy titled, Abuse Investigations Policy dated 10/24/2022 stated an incident or suspected incident of resident abuse, mistreatment, neglect or injury of unknown source be reported, the Administrator, or their designee, will appoint a member of management to investigate the alleged incident. Witness reports will be obtained and be required to sign and date written reports. The individual conducting the investigation would, as appropriate Interview the person(s) reporting the incident and staff members (on all shifts) who have had contact with the resident during the period of the alleged incident. Resident 51 admitted to the facility on [DATE] with diagnoses that included epilepsy (seizures that are cause by an underlying brain disease), retinal vein occlusion (blockage in a vein that drains blood from the retina), and Alzheimer's Disease (progressive disease that destroys memory and other important functions). Review of Resident 51's Quarterly Minimum Data Set (MDS-an assessment tool) assessment dated [DATE] showed the resident had severe cognitive impairment. Review of Resident 51's care plan dated 06/03/2024 showed the resident required moderate assistance of two staff members with transfer from their wheelchair to toilet with use of grab bar and to allow them extra time for feet placement and balance before the commode swap transfer was completed. Resident 51's care plan was updated on 8/19/2024 for staff to use a bed pan/urinal for toileting needs. Review of the facilities incident report, dated 08/11/2024, showed Resident 51 experienced a fall in their bathroom after the staff caring for them lost their footing on a Hoyer (a mobile floor lift system that transfers a person from one surface to another) sling, slipped and fell , which resulted in Resident 51 falling on top of the staff onto their bottom. The incident report showed Resident 51's care plan was reviewed, and no new interventions were implemented. The incident report showed Resident 51, prior to the fall, had been changed from a two person assist with a front wheel walker to a Hoyer lift for transfers in/out of bed as they were unable to transfer safely. There was no notation of Resident 51's transfers on/off the toilet. The incident report contained a statement from the nurse and the Nursing Assistant Certified (NAC) involved in the body of the incident report. There were no other statements or follow up interviews. In an interview on 08/19/2024 at 2:16 PM Staff E, NAC, stated they were the staff involved in the fall with Resident 51. Staff E stated Resident 51 was a standard two person assist and then they became a Hoyer transfer and staff were to always have two people in the room when transferring them. When asked about the Resident 51's fall, Staff E stated, they were unaware of the sling in the resident's wheelchair and their foot slipped on the sling buckle while holding Resident 51 and they fell , and the resident fell with them. Staff E stated they were the only staff in the bathroom at the time of the fall, the call light to the bathroom was on, and the nurse came in after the fall. Staff E stated they provided care for the resident once a week to once every two weeks. Staff E stated Resident 51 had been able to stand up by themselves and they used the gait belt. Staff E stated they were not aware Resident 51 care had changed to them requiring a Hoyer lift for transfers. Staff E stated they knew how to care for Resident 51 that day by skimming through the care plan, knew that they needed 2-person assistance and a gait belt and faulted themselves by not reading the care plan thoroughly enough. Review of Resident 51's care plan dated 06/03/2024 showed Resident 51 required moderate assistance of two staff members with transfer from their wheelchair to toilet with use of grab bar and to allow them extra time to for feet placement and balance before the commode swap transfer was completed. In an interview on 08/19/2024 at 2:26 PM Staff D, Licensed Practical Nurse (LPN) stated Resident 51 sustained a fall in the bathroom after an aide tripped and fell on the Hoyer sling located on the resident's wheelchair during a transfer. Staff D stated the staff had not followed the care plan and was by themselves during the transfer/care to Resident 51 while in the bathroom. Staff D stated abuse and neglect were ruled out as Resident 51 had not been harmed during the fall. Staff D stated they were in the process of educating the staff involved in the fall. In an interview on 08/21/2024 at 11:14 AM Staff F, Registered Nurse (RN), stated Resident 51 fell during the prior evening. Staff F entered the room and stated that Resident 51's bathroom call light was on. When they entered the bathroom they saw Staff E on the floor and the resident sitting on top of Staff E. When Staff F asked what had happened the NAC told them they finished toileting Resident 51 and they were dressing them for the night, the NAC lost their footing when their foot became tangled in the Hoyer sling. Staff F stated they reviewed Resident 51's care plan after the fall which showed they were a one person assist with use of a grab bar. Staff F stated they reviewed the paper copy of Resident 51's care plan located at the nurse's station in the binder and did not review the care plan located in the electronic health record for Resident 51. Staff F stated they notified Staff D of the incident through email and text message and started an incident report electronically. Staff F stated they were not interviewed by any facility staff regarding the incident. In an interview on 08/19/2024 at 2:36 PM Staff B stated falls require an investigation to include statements and interviews with staff and residents about what occurred. The investigation would also include completing assessments for injuries and necessary notifications. All the information would be taken and reviewed to conduct a root cause analysis. When asked how abuse and neglect were ruled out for Resident 51 and the fall sustained, Staff B stated there was not a pattern of misconduct and there was no intent by the staff to harm the resident. In a follow up interview on 08/21/2024 at 9:01 AM Staff D stated they were alerted to Resident 51's fall on 08/11/2024 and they initiated their investigation on 08/12/2024. Staff D stated the facility's policy was to report any allegations of abuse/neglect to the state if they felt that it was abuse or neglect. Staff D stated they spoke to the staff involved in Resident 51's fall, could not recall the date, and they were aware that staff had not followed the care plan during this incident. Staff D stated the definition of neglect included not caring for a resident or providing for their needs. Staff D stated they felt the fall was an accident as the staff involved was providing care to Resident 51 and had no pattern of not providing care to residents. Staff D stated CC1 had not been notified that the staff involved in the fall was not following the care plan at the time of Resident 51's fall. Staff D stated that not following a resident's care plan could be neglect. Review of employee file on 08/21/2024 at 9:30 AM, showed Staff E had been reeducated: -On 08/19/2024 to follow residents individualized are plans. -On 06/14/2024 to follow residents individualized care plans. -On 01/09/2024 to follow care plans, in addition to other identified areas. In a joint interview on 08/21/2024 at 2:08 PM with Staff A (Administrator) and Staff B (Director of Nurses), Staff A stated Resident 51's fall was determined to be an accident and abuse/neglect was ruled out not requiring any report to the state agency. Staff B stated the staff involved in the fall had a pattern of not following resident's care plan where they were reeducated in June and had struggled early in the year and required extra support and training. Staff B stated the staff involved had no serious disregard for consequences thus neglect was ruled out, they did not willfully show intent to not follow the care plan and they went based on what they thought. Refer to WAC 388-97-0640 (6)(a)(b)

Based on observations, interviews, review of the glucometer manual, and policy review, the facility failed to ensure staff cleansed 2 of 2 (Residents 186 and 187) residents' fingers before performing a fingerstick to obtain a blood glucose reading and failed to cleanse the resident's skin before administering an insulin injection. This had the potential for an increased risk of infection for both residents. Findings included . Review of the facility policy provided by the facility titled, Specific Medication Administration Procedures, revised January 2018 showed the following instructions for administering injections, including subcutaneous injections: .Gather supplies - safety syringe of appropriate volume and with proper needle for the type of injection, gloves, alcohol wipes, bandage, gauze pads, and barrier .Expose the area to be inject and clean with an alcohol wipe . 2. Clean in a circular motion, spiraling out from the center. Review of policy titled, Addendum to injectable Medication Administration Policy, implemented day 04/04/2018, provided by the facility showed, Based on WHO (World Health Organization) Best Practices for Injections and Related Procedures Toolkit, March 2010, Table 2.3 Skin preparation and skin disinfection, for administration of Intradermal [a shallow or superficial injection] and Subcutaneous [under the skin] injections it is not necessary to use alcohol swab prior to injection; may use soap and water. Review of page seven of the glucometer manual provided by the facility revealed: PERFORMING A BLOOD GLUCOSE TEST .Step 1 Wash hands and the sample site with soap and warm water. Rinse and dry thoroughly. In an observation on 04/12/2023 at 11:47 AM, Staff D, Licensed Practical Nurse (LPN), showed they performed a finger stick on Resident 186 and failed to cleanse the resident's finger before piercing their finger with a lancet (a disposable sharp point used to pierce the skin to obtain a drop of blood sample). After testing the blood sample, Staff D administered an insulin injection into Resident 186's left upper arm without first cleansing the injection site. During an interview on 04/12/2023 at 11:54 AM, Staff D was asked why they did not swab Resident 186's finger and the injection site before piercing the resident's skin and stated, it was either or. Staff D clarified that it was their choice whether they swabbed the injection site or the resident's finger and that it was their preference not to clean the injection and fingerstick sites. In an observation on 04/12/2023 at 11:57 AM, showed Staff D performed a finger stick and administered an insulin injection to Resident 187. Staff D failed to clean the resident's finger and injection site prior to performing both tasks. During an interview on 04/12/2023 at 12:17 PM, Staff D stated that they and not cleansed Resident 187's finger nor the insulin injection site, stating that they would only clean the resident's finger before a finger stick if the finger was visibly soiled, and there was no need to cleanse an injection site for a subcutaneous insulin injection. During an interview on 04/13/2023 at 10:40 AM, Staff C, LPN/Infection Preventionist (IP), stated the facility policy covered both cleaning and refraining from cleaning the injection and fingerstick sites. Staff C stated the facility adhered by the Centers for Disease Control (CDC) standards for infection prevention. When asked if CDC guidelines supported not cleansing an injection site before piercing the skin, Staff C stated Staff D should have washed the resident's hand with soap and water before performing a finger stick. Staff C stated the facility's policy revealed to clean injection sites prior to entry (administering the insulin injection). Staff C stated the WHO manual from 2010 mandated cleansing injection sites with soap and water and that the CDC guidelines did not support failure to clean injection and fingerstick sites prior to treatment. Reference: WAC 388-97-1320 (1)(a)

Based on interview and record review, the facility failed to honor bathing preferences for one of three residents (1) reviewed for bathing frequency. The failure to honor the resident's bathing choice related to the lack of frequency of bathing placed the resident at risk for poor hygiene, feelings of powerlessness, decreased self-worth, and diminished quality of life. Findings included . Resident 1 was admitted to the facility on [DATE] and has diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set assessment dated [DATE] showed the resident was cognitively intact, required set up and physical help with bathing and had no rejection of care. Review of the Care Plan focus problem noted that Resident 1 had ADL (Activity of Daily Living) self-care performance deficits related a disorder that causes pain in the lower back and hip which radiates down the back of the thigh into the legs, weakness, and pain with a revised date of 05/20/2020. The Bathing/Showering intervention noted that the resident was able to make their needs known, liked to have a whirlpool bath and would try for two times weekly. Additionally noted was that the resident said that the bath really helped with their pain. The resident preferred their baths after lunch and required a one person standby/limited/extensive assistance with getting in and out of tub. Review of the resident's last two months of bathing records showed the following: September 2022, the resident went six days without a bath from 09/08/2022 until was bathed on 09/16/2022 and another six days without a bath until 09/23/2022 and October 2022, the resident went five days without a bath from 09/28/2022 until was bathed on 10/04/2022, seven days without a bath from 10/08/2022 until 10/16/2022 and five days without a bath from 10/21/2022 until 10/27/2022. In a phone interview on 11/01/2022 at 11:21 PM, Collateral Contact (CC) 1, family member stated that Resident 1 had been complaining about not being able to be bathed on their regular schedule. CC 1 stated that Resident 1 would often bathe twice daily prior to moving into the Skilled Nursing Facility. CC 1 stated that the lack of frequent bathing was bothersome for Resident 1. CC 1 stated that the resident had told them that they had not been bathed more than weekly. In an interview on 11/03/2022 at 11:43 AM, Resident 1 stated that they had originally signed up for a bath every third day, on Sunday and on Thursday, but lately have received a bath up to seven days from the last bath. Resident 1 stated that the facility does not have a set time for them to bathe and the facility claimed that they do not have enough staff. Resident 1 stated that they tell the staff, You take a bath every day. Resident 1 stated that when it got up to seven days after the last time they received a bath it really bothered them. In an interview on 11/03/2022 at 2:26 PM, Staff A, Nursing Assistant Certified, stated that they would give an average of 12 baths/showers each day. Staff A stated that some resident's baths would take longer than other residents and, on some days, they would not be able to get everyone on their schedule bathed that day. Staff A stated that if they do not get to a resident on a scheduled bath day they are then placed on the schedule for the following day and their bath would be made a priority. Staff A stated that they documented the resident's showers in the electronic medical record. Staff A stated that they had to bump residents' baths down to once a week in order to provide the residents with a bath at least weekly as they were usually the only one providing showers most of the time. Staff A stated that they had not discussed adjusting resident bathing frequency with the nursing administrative staff. Staff A stated that the residents had complained but they do their best in their position. Staff A stated that there used to be three shower aides but now there was just one. Staff A stated that Resident 1 had complained about their bathing frequency. Staff A stated that Resident 1 would want a bath but they would have to tell them that they did not have time. Staff A stated that when the resident complains about the lack of bathing that they report that to the Unit Coordinators, (UC) and they tell them to do their best. In an interview on 11/03/2022 at 3:03 PM, Staff B, Licensed Practical Nurse/ UC, stated that when the NAC reported that a resident had a complaint of not receiving enough baths that they would investigate why they were not getting enough baths or showers. Staff B stated that if the resident was a resident that they could assist with a bath that they try to step up and help. Staff B stated that they also could reinterview the resident on their likes and choices as they may have missed something. Staff B stated that Resident 1 sometimes forgets that they have had a bath and sometimes they would asked for an extra bath if they were hurting. Staff B stated that they would give residents one bath weekly but Resident 1 perseverates that they were supposed to have two showers a week. Staff B stated that they really did not have the staff available and would really tried to provide residents with at least one bath a week. Reference: (WAC) 388-97-0900(1)(3)

Based on interview and record review the facility failed to ensure one of one resident (1) retained and exercised their right to revoke their Durable Power of Attorney (DPOA), failed to honor the resident's repeated requests to be discharged home in accordance with their wishes and preferences, and failed to include the resident in the care planning process which included discharge planning. These failed practices violated the resident's rights causing undue psychosocial distress and harm for Resident 1. The facility extended the resident's representative to make decisions for the resident and the resident's wishes were not considered when they were involuntarily secluded in a Secured Dementia Unit for 10 months and in the facility up to a year related to the facility's failure to honor the resident's rights. Findings included . Review of the Revised Code of Washington (RCW) 71.32.110 titled, Determination of Capacity, showed: (2)(a) no adult may be declared an incapacitated person except by (i) a court, if the request was made by the principal or the principal's agent; (ii) One mental health professional or substance use disorder professional and one healthcare provider; or (iii) Two health care providers. (b) One of the persons making the determination under (a)(ii) or (iii) of this subsection must be a psychiatrist, physician assistant working with a supervising psychiatrist, psychologist, or a psychiatric advanced registered nurse practitioner. (3) When a professional person or health care provider requests a capacity determination, he or she shall promptly inform the principal that: (a) A request for capacity determination had been made; and (b) The principal may request that the determination be made by a court. (4) At least one mental health professional, substance use disorder professional, or health care provider must personally examine the principal prior to making a capacity determination. Review of the facility's policy titled, Resident Rights, revised on 05/03/2019, showed the residents had the right to exercise their rights as a resident of the facility and as a citizen of the United States without interference, coercion, discrimination, or reprisal from the facility. The facility would make efforts to assure resident rights were exercised through practices that fostered engagement, confidentiality, and self-determination through encouragement of choice, in various aspects of life in the facility and in the community. Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact per the Brief Interview of Mental Status (BIMS, which was a type of cognitive assessment) with a 14 out of 15 (that showed the resident was cognitively intact) score and had no rejection of care. In an interview on 10/11/2021, the resident stated that their DPOA did not talk with them. The resident stated that the facility had not discussed discharge planning with them. The resident stated that they wanted to be able to see their own lawyer and felt that there had been an outright theft by the DPOA making changes to the resident's home and removing their personal belongings. The resident stated that they wanted to remove their current DPOA. The resident stated that the DPOA had moved people into their home and the resident had to live at the facility for another year. In a follow up interview on 10/19/2021 at 3:05 PM, Resident 1 stated that they had sent paperwork to their attorney to revoke their DPOA, and was told they were unable to unless they came in person and Staff C put a stop to that. Resident 1 stated that the DPOA had to be changed that they had threatened them with leaving the resident's furniture out in the rain. The resident stated again that the DPOA had to be changed as they were running their (the DPOA) own show. The resident stated, I cannot live like that after giving him my DPOA and he does things that I did not request. He takes it upon himself without saying anything. I ask for things he does not return; it is not worth a damn not worth a nickel I am desperately dissatisfied with the DPOA. Review of an Order Note dated 01/05/2021, showed a request for an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a letter titled, Letter of Incapacity, dated 01/11/2021, showed Staff A, Medical Doctor (MD)/Medical Director noted that the resident was mentally incapacitated related to mild cognitive impairment due to the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Part A Discharge (End of the resident's Medicare Stay) MDS assessment dated [DATE], showed the resident was discharged from Medicare and became private pay. Review of a Care Conference note dated, 01/11/2021, showed that social services and nursing staff were in daily communication with the resident's DPOA, and the resident did not have the mental capacity to benefit from a care conference; therefore, the scheduled care conference had been cancelled. All elements of typical care conferences had been covered in daily communications with the resident's DPOA. Review of a Progress Note dated 01/18/2021, showed the resident was transferred to the facility's Secured Dementia Unit from their Rehabilitation Unit. Review of the Advanced Registered Nurse Practitioner (ARNP) Nursing Home Visit note dated 03/17/2021, showed the resident was high functioning and retained the ability to toilet, groom and feed themselves. Resident 1 continued to request discharge to their home. Review of the ARNP Nursing Home Visit note dated 03/23/2021, showed the resident was seen due to the resident requested to discuss their discharge from the facility. The resident's main goals were to return to their home. The resident stated that they would rather die than stay at the facility the rest of their life. Resident 1 was willing to work with the facility to devise a plan to return to their home. The facility's team members were to discuss with the resident's DPOA whether it would be feasible to hire a 24-hour caregiver as well as a care manager to coordinate the resident's care. Review of a Care Conference Note dated 03/23/2021, showed the resident requested to return to their home. The resident's goal was to go home but the facility Interdisciplinary Team (IDT) felt that there would need to be outside services in place to help facilitate a safe discharge. Review of a Care Conference Note dated 03/24/2021, showed Staff C, Social Services (SS), called the resident's DPOA and relayed the resident's desire to return home. The DPOA stated that Resident 1 would possibly be very upset that things were not as the resident had left them if or when a home visit would be made. The IDT along with the DPOA would continue to evaluate if a discharge home with appropriate services would be a possibility for the resident. Resident 1 continued to express that their desire was to discharge home. Review of the Quarterly MDS assessment dated [DATE], showed the resident's cognitive BIMS assessment was 12 out of 15, indicating moderate cognitive impairment. The resident was assessed to have no behaviors or episodes of rejection of care and had no falls since admission. In a Social Service note dated 04/04/2021, Social Services notified IDT of the resident's feelings and desire to go home. The facility continued to assess the resident for a potential safe discharge plan that likely would require 24/7 supervision related to their cognitive impairment. Review of a SS note dated 05/19/2021, showed the resident approached both Staff C and Staff E, Registered Nurse/Unit Coordinator, to discuss their desire to go home. Review of a SS note dated 05/21/2021, showed the DPOA, SS, and the Unit Coordinator determined the resident was to successfully transition, and to adjust to another care setting. They also discussed the resident's home should be sold prior to transitioning which would play a key role in any further planning. Review of a SS note dated 06/03/2021, showed the resident's DPOA reported that Resident 1 had called their attorney and indicated they wanted to go home. Review of the Quarterly MDS assessment dated [DATE], and SS note dated 07/05/2021 showed the resident was assessed to be cognitively intact with a BIMS was 14 out of 15. The BIMS score indicated cognitive improvement of 2 points over the prior assessment, and the resident had no rejection of care. The IDT had been notified of the resident's feelings and desires relating to going home. The facility continued to assess the resident for a potential safe discharge and likely required 24/7 supervision related to the resident's cognitive impairment. Review of a Quarterly Nursing Note dated 07/13/2021, showed the resident continued to self advocate to be discharged but multiple staff and community members did not feel that the resident was safe at home without 24-hour supervision. (The nursing note did not provide further explanation to why the resident could not be discharged home). Review of a Nursing Home Visit note dated 07/14/2021, showed Staff A noted the resident's chief complaint was that, I want to go home. The resident asked to see the doctor in their room. Resident 1 reported that they wanted to go home and felt that they would do okay with hiring some help. Review of a Mood/Behavior Note dated 08/16/2021, written by Staff C, showed the resident was focused on leaving the facility to visit their lawyer's office. Staff C explained to the resident that outings would need to be arranged through their DPOA. Review of a Nursing Home Visit note dated 09/01/2021, showed the resident's chief complaint was that they wanted to go home. The resident told Staff A that they were unhappy in the facility and wanted to return home. The resident stated they were not happy with the person who was changing their house and taking all of their belongings without their permission. Resident 1 stated, I want to change that person. Review of the resident's facility medical records showed no indication the facility had copies of the resident's Psychotherapy Progress Notes. The Psychotherapy Notes were obtained from the psychotherapy clinic. In interview on 10/19/2021 at 3:26 PM, Staff C stated that they had not seen the resident's Psychotherapy Notes nor had they requested them. Review of a Psychotherapy Progress note dated 09/27/2021, showed the resident stated that they recognized they had some limitations and unsteadiness when walking on uneven surfaces but would like to be considered for a less restrictive environment such as the local Assisted Living Facility (ALF). Review of a Psychotherapy Progress note dated 09/29/2021, showed the resident had asked to be seen given the [NAME] associated with their POA and reported changes that had taken place without their awareness. The resident stated that they had a plan they wished to present to their treatment team for consideration for an alternate placement at the local ALF. Review of the Quarterly MDS assessment dated [DATE], and a SS note dated 10/05/2021, showed the resident was cognitively intact with a BIMS of 14 out of 15 and had no rejection of care. The resident's BIMS score indicated the resident was cognitively intact. The IDT had been notified of the resident's current feelings and desires relating to going home. The facility was going to continue to assess for potential safe discharge planning likely requiring 24/7 supervision related to cognitive impairment. Currently the DPOA and IDT agreed that the resident's current placement at the facility was appropriate. Review of a Psychotherapy Progress note dated 10/06/2021, showed the resident indicated that they had spoken with the staff regarding their desire for placement in a less restrictive environment. The resident indicated they planned to construct a course of action that would incorporate those elements/services that would aid them in their goal to be in a less restrictive environment. In an interview on 10/27/2021 at 12:14 PM, Collateral Contact (CC) 1, Psychologist, stated that the resident understood nature, quality and their DPOA and how they represent them. CC 1 stated that the resident had competence and presented themselves as someone who had capacity. A Social Service note dated 10/12/2021, showed the resident had asked for the papers that allowed the DPOA to tear down the porch and make modifications on their home without the resident's approval. The resident was given a copy of the DPOA paperwork. In a phone interview on 10/15/2021 at 12:05 PM, the DPOA stated that they tried to include the resident in decisions early in the year until about June 2021, but it was frustrating all the way around. The DPOA stated the resident was an acquaintance and was not a close friend. The DPOA stated that the resident had not asked them to be their DPOA and only found out that they had been named as the resident's DPOA after the resident's accident in December 2020. The DPOA stated that the resident had sufficient funds to be in their home with 24-hour care around the clock, but if the resident was to live for five years their funding would not support the resident's prior life goal to set up a scholarship fund. The DPOA stated that an individual had informed the resident that the deck on their home had been replaced and the resident had become upset. The DPOA stated that their instructions were to make decisions in the resident's best interest. The DPOA stated that they thought the resident was upset that the resident had not had input in modification in their home. In an interview on 10/19/2021 at 3:26 PM, Staff C stated that the resident had indicated they wanted to go home. The DPOA felt due to the resident's fluctuation in care that being in here (a Secured Dementia Unit) was best for the resident right now. Staff C was asked why they had not assisted with the resident's request to change their DPOA. Staff C stated that it was their understanding that it was up to the DPOA to resign from being the DPOA. Staff C stated the DPOA had told them that the resident could not change their DPOA as the facility medical director wrote a letter of incapacity. Staff C stated that legally the resident was not able to change a DPOA with one letter of incapacity and the DPOA had informed them that the DPOA could not be changed by the resident. Staff C was asked how they were assisting the resident with their repeated request to discharge to the community. Staff C stated that had been discussed and the DPOA had concerns with the resident's discharge to the community. Staff C was asked how they had ensured and supported the resident to exercise their rights without interference, coercion, discrimination, or reprisal from the facility. Staff C stated that the DPOA was saying no as the DPOA cannot assign the DPOA to someone else. Staff C stated that they had not involved the resident in discussions in changing the resident's DPOA. In an interview on 10/19/2021 at 4:49 PM, the Director of Nursing Services (DNS), stated that the resident made decisions because they allowed them to make decisions about what the resident wanted to eat or drink. The DNS stated that they were unaware that the resident had requested to change their DPOA. The DNS was informed of the concerns that the facility was not honoring the resident's rights and was removing the resident's decision-making capacity with a letter of incapacity from the Medical Doctor. In a phone interview on 10/26/2021 at 11:30 AM, Staff A, stated that they recalled they had been asked to fill out a letter of incapacity from Resident 1's DPOA. Staff A stated that the letter of incapacity covered all health care decisions, medications, appointments, where the resident lived, who the resident's DPOA was and if the resident could leave the facility. Staff A was asked why when the request to have a second opinion for the resident's capacity they had deemed it unnecessary. Staff A stated that they had heard the request was made by someone other than the DPOA, by someone not medically involved with the resident and they did not have to follow outside request. Although the resident consistently demonstrated the ability to function independently related to decision making and discharge planning, the facility did not work with the resident and instead, the facility removed and denied the resident's right to make their own decisions with one letter by the facility's Medical Director which was not in accordance with the Washington State RCW. The resident had a consistent pattern of documented repeated requests to change their DPOA and to be discharged to their home. The facility failed to honor the resident's rights by the facility's unlawful removal of the resident's decision-making capacity, failed to honor the resident's right to revoke their DPOA and failed to implement the resident's repeated stated preferences for discharge planning to discharge to a lower level of care or to their own home. Additionally, when the facility extended the resident's DPOA decision making the resident's home had been rented out to the DPOA's sister with a three-year lease. In essence removing the resident's ability to return to their home and causing further undue hardship for the resident to discharge to their home. Refer to CFR 483.12(a)(1) - Free from Involuntary Seclusion Reference: (WAC) 388-97-0240(4)(a)(5)(b)(6)(a)(b)(7)

Based on observation, interview and record review the facility failed to ensure a resident's right to be free from involuntary seclusion for one of one resident (1). This failed practice caused psychosocial harm to Resident 1 who was moved into the Secured Dementia Unit shortly after admission to the facility with a temporary change in mental status due to a change in condition. The resident displayed no behaviors and remained in the Secured Dementia Unit for 10 months which caused the resident undue psychosocial distress, diminished quality of life and loss of autonomy. Findings included . Review of the facility's policy titled, Cedar Cove - Secured Environment, dated 01/21/2019, showed the Secured Dementia Unit had admission and discharge criteria which included a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Consideration for admission into and discharge out of Secured Dementia Unit would be based on the interdisciplinary team (IDT) assessment. The resident would be routinely evaluated to determine if they still met the Secured Dementia Unit placement criteria. Review of the facility's Secured Dementia Unit consent titled, Cedar Cove Agreement and Consent, dated 01/21/2019, showed an admission and discharge from Secured Dementia Unit was determined through the IDT review of the resident's dementia related behaviors that placed the resident at significant risk of getting to a potentially dangerous place (e.g., outside of the facility), or significantly intruding on the privacy or activities of others. The Resident Assessment Instrument (RAI) Manual Version 1.17.1 dated October 2019, defined wandering as the act of moving (walking or locomotion in a wheelchair) from place to place with or without a specified course or known direction. Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed that during the assessment period the resident was cognitively intact, had episodes of wandering four to six days which did not intrude on the privacy of others. Review of a complaint to the department on 09/13/2021, showed Resident 1 expressed their concern that they had been locked up after eight months of not knowing why they were locked up and isolated. The resident stated that they had all their belongings taken away, their phone, house, passport, keys wallet, the whole ball of wax and I really don't know why. It looks as though I have committed a crime and yet my record is clean as I could show you if you were to investigate me. Thank you. In a follow up statement to the department on 09/14/2021, Resident 1 stated that Staff C refused to let Resident 1 leave the building and the resident stated they were being kept against their wishes. In an observation and interview on 10/11/2021 at 2:49 PM, Resident 1 was in the Secure Dementia Unit and stated that they walked about two miles a day in the hallway. The resident stated that they moved to the facility in mid-December 2020. The resident stated there was a snowstorm with about six inches of wet snow and got tangled up with several vehicles. The resident stated that there was a lack of intelligent conversation in the facility. Resident 1 stated that Collateral Contact (CC) 2, a local friend, suggested that they come to the facility after their hospitalization and the resident themselves wanted to come to the facility at the time but that was the worst bloody choice. Resident 1 stated that it was like a jail being at the facility. Resident 1 stated that one resident in particular upset them with their behaviors. Resident 1 stated that they walk about two miles daily in the hallway. The resident stated that no one at the facility talked to them about their discharge. Review of a letter titled, Letter of Incapacity, dated 01/11/2021, completed by Staff A, Medical Doctor (MD)/Medical Director, showed the resident's mental incapacity as having mild cognitive impairment due to metabolic [CONDITION(S)]. Staff A documented the resident was physically incapacitated due to the displaced vertebra and fracture. Review of the Progress Note dated 01/18/2021, showed that the resident was transferred to Secure Dementia Unit from the Rehabilitation Unit. Review of the Care Conference Note dated 3/23/2021, Staff E, Registered Nurse/ Unit Coordinator noted that a care conference was held per the resident's request while Staff A was in the facility. The resident met with the Advanced Registered Nurse Practitioner (ARNP) this morning and new orders for Occupational Therapy (OT) to evaluate and treat for independent living skills, to evaluate for discharge, and orders for Speech Therapy (ST) for cognitive testing. Resident 1 requested To leave this hospital, I don't belong here, I have 5-6 years left to live and I do not want to live them here, I want to go home and there's no reason why you are keeping me here. Staff A expressed cognitive concerns and safety concerns and that Resident 1 would have to discharge home with caregivers and support. Resident 1 continued to state that there was no reason why they couldn't go home. Finally Resident 1 was agreeable to a goal of allowing the staff to pursue in home services to help create and set up a safe discharge home per their wishes. Discussed that it was a process and would not happen immediately until services were set up. The resident understood that they would be seen by OT and ST to help create a safe discharge. Resident 1 understood there may be a home visit in the future, and they were agreeable to this plan. The resident's goal was to go home but was understanding that there would need to be outside services in place to help facilitate a safe discharge. Social Service (SS) had been in contact with the resident's Durable Power of Attorney (DPOA) and was notified of the current goal and the plan in place. (The facility at no time made a home visit or made arrangements for supportive community services). Review of the Quarterly MDS assessment dated [DATE], showed the resident had moderate cognitive impairment, had no behaviors or wandering noted, and with a noted improvement of prior assessed behaviors. The resident was still in the Secured Dementia Unit Review of the Quarterly MDS assessment dated [DATE], showed the resident was cognitively intact, and had no behaviors or wandering noted during the assessment period. The resident was still in the Secured Dementia Unit. Review of a Nursing Home Visit note by Staff A dated 07/14/2021, showed the resident reported they wanted to go home and felt that they would do okay with hiring someone to help the resident at home. The resident's metabolic [CONDITION(S)] had resolved but their dementia was still at least moderate, and they were at risk of wandering. The resident remained in the locked dementia unit. Review of a Late Entry SS Progress note with an effective date of 7/16/2021 at 5:00 PM, showed that Staff C, SS, met with the Ombudsman (a volunteer who advocates for residents) on today's date after the Ombudsman had met with the resident. The Ombudsman reported that the resident had contacted them from the posted State Long-Term Care Ombudsman 1-800 number and expressed their feelings of being at the facility. The resident had shown the Ombudsman reports with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Ombudsman determined that they would look into the resident's concerns and would return to the facility. Staff C offered to have another Care Conference which could be arranged to discuss the resident's concerns, so that the resident felt their concerns had been addressed. Review of a Social Service Note dated 08/02/2021, showed the resident acknowledged they were having issues with one resident who they felt was blocking their way on purpose when Resident 1 took their walks. Review of a Nursing Care Note dated 08/02/2021, the resident had a verbal altercation and expressed their frustration with a particular resident. Review of a Mood/Behavior Note dated 08/07/2021, Resident 1 was frustrated with a particular resident and stated that it was not nice for that resident to come in their way on purpose. Review of a Progress Note dated 08/07/2021 at 2:48 AM, showed the resident had come to the nurse and said, I am going to ask you a question about justice, how would you feel if someone took your house, car keys, wallet, freedom away just because of one minor accident that happened because of the snow? I do not belong here. My friends tell me that someone else lives in my house, they have made changes to my house. The nurse tried to explain why it was better to live at the facility than being alone, but the resident stated, long term care is for people who are nearing death, I am able to take care of myself. The nurse assured that the resident's concerns would be addressed upon which the resident replied, no one is going to do anything about this, why would they want to let me go? They are getting their salaries by keeping me here. I pay $300.00 per day to get peanut butter sandwiches. Because of all this B******t I am not able to sleep at night. The nurse tried to assure the resident that whatever would be the best for them would be done. The resident remained in the locked dementia unit. Review of a Mood/Behavior Note dated 08/09/2021, noted Resident 1 expressed their frustration toward a particular resident. Review of a Mood/Behavior Note dated 08/16/2021, showed Staff C, SS noted that the resident was focused on leaving the facility to visit their attorney's office. Staff C noted that they had explained that the outing would need to be arranged through the resident's DPOA. The resident had stated that was stupid and they were done with their DPOA. The resident then became upset when informed that their doctor had determined that it is unsafe for them to leave on their own. The expressed that this is all bullsh*t, and that you are just keeping me here because it helps you employ all these people, and that this is a completely un-Christian thing to do. The resident stated that they were going to call their friend to bust [them] out of this joint. The resident later apologized for getting so upset and asked that a letter be mailed for them. Review of a SS Progress Note dated 08/16/2021, showed Staff C had spoken with the resident's Durable Power of Attorney (DPOA) and SS requested a psychology referral related to the resident's ongoing adjustment difficulty, anger, and negative statements. Resident 1 continued to cycle through frustration related to their placement, insistent that they could take care of themselves, that they were being 'locked up' in this place, that they did not need to be here, and just wanting to go to their home. Resident 1 continued to place frequent calls to this effect to their lawyer, DPOA, and friends. Review of the Referral Form: Psychological Assessment & Treatment dated 08/19/2021, showed the resident's emotional signs and symptoms included negative statements, anger, [CONDITION(S)], and unpleasant mood swings. Social signs and symptoms were conflict/anger with family/friend, adjustment difficulty and unhappy with other residents. Review of a Psychotherapy Progress Note dated 09/22/2021, showed the resident's Long-Term Memory was intact. The resident's recent memory impairment was evident on the Saint Louis University Mental Status (SLUMS) assessment, i.e., inattention/concentration difficulty, word recall difficulty related to animal recall, i.e., 8 items. The SLUMS assessment results were indicative of mild neurocognitive disorder. Despite the observed cognitive difficulty, the resident was able to recall recent visits. Resident 1 had the ability to participate and benefit in psychotherapy. The facility staff reported the resident had fluctuating mood and irritation with other residents. Resident 1 described feelings of frustration/anger/anxiety on nearly a daily basis related to understanding why they were here with these others who sing to the ceiling, or they can't even speak clearly? I just don't belong here. I do need help with some things, but I think somewhere like (Assisted Living Facility) would be a better place. Review of a Psychotherapy Progress Note dated 09/27/2021, showed the resident indicated that they were placed at the facility after a head on collision the past winter. The resident stated poor road conditions were the contributing cause of the accident. The resident was able to describe the motor vehicle accident. The resident noted they recognized they had some limitations/unsteadiness when walking on uneven surfaces but would like to be considered for a less restrictive environment such as the local assisted living facility. The resident remained in the locked dementia unit. Review of a Psychotherapy Progress Note dated 10/06/2021 showed the resident indicated they spoke with staff regarding their desire for placement in a less restrictive environment. The Resident noted they clearly needed some level of care and services. Review of a Psychotherapy Progress Note dated 10/11/2021, showed the resident stated they had completed 18 puzzles to date and was looking forward to receiving new and more challenging puzzles. The resident stated they found it difficult, at times, in that many of their fell ow residents had significant cognitive challenges. The resident indicated they relied on interpersonal communication with the facility staff to provide them with intellectual stimulation, i.e., puzzles, conversation, travel channel that was often aired in the dining room that lead to further discussion. In an interview on 10/11/2021 at 3:54 PM, Staff E, Registered Nurse/Unit Coordinator, stated that the resident was in a motor vehicle accident and had a head on collision. Staff E stated that the resident was admitted from the hospital to the Rehabilitation Unit but then had erratic behaviors, was exit seeking (trying to leave the facility) and admitted to the Secure Dementia Unit. In an interview on 10/19/2021 at 3:26 PM, Staff C stated that the criteria for admission to the Secured Dementia Unit was first a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff C stated that the facility had procedures for transferring residents into the Dementia Unit which included an assessment, monitoring, tracking of behaviors, review with the resident's responsible party, a doctor's order and a risk and benefit consent. Staff C stated that the resident's discharge needs were evaluated with the MDS assessments, quarterly and as needed. Staff C stated that the resident's discharge plan was to remain at the facility unless there was a setting that had appropriate supervision per the IDT and the DPOA. Staff C stated that the resident had indicated they wanted to go home but they had episodes of care needs. Staff C stated that the resident had even brought up the possibility of discharge to an Assisted Living Facility. In a phone interview on 10/12/2021 at 12:58 PM, CC 2 stated that they had known Resident 1 for the past 15 to [AGE] years. CC 2 stated that as long as they had known the resident, the resident would go to bed early, get up around midnight, have a snack then go back to bed and get up early in the morning. CC 2 stated that the resident liked to walk in the morning and the facility thought the resident's walking was wandering. Review of the Behavior Symptom Monitors from 01/18/2021 through 10/13/2021 showed Nursing Assistant Certified (NAC) documentation noted the resident had less than 12 episodes of wandering while in the Secured Dementia Unit with no nursing documentation to correlate the resident's behavior. In an interview on 10/19/2021 at 3:26 PM, Staff C was asked about the lack of documentation which supported the need for the resident to be in the Secured Dementia Unit. Staff C stated that the Secured Dementia Unit in and of itself was a supportive environment that reduced resident behaviors. In an interview on 11/03/2021 at 11:35 AM, the DNS stated that the NAC's documented resident behaviors in the electronic portion of the medical record and if they documented a behavior, they should report the behavior to the nursing staff. The DNS stated that the nurse should then make a note in the progress notes about the reported behaviors. In an interview on 10/19/2021 at 4:49 PM, the Director of Nursing Services (DNS) stated that the facility had the responsibility to make sure the resident had a safe discharge plan and the resident's perception to go home was not safe. The DNS stated that the resident was not being held against their will. The DNS stated that it was difficult with Resident 1 as they presented initially as being cognitively intact. The DNS was informed of the resident's stated and documented repeated request for discharge and the concern of involuntary seclusion. In a phone interview on 10/22/2021 at 1:41 PM, Staff F, NAC, stated that Resident 1 would become annoyed with a couple of residents that bothered them or were in their way. Staff F stated that they offered reinforcement that it could be frustrating but redirected other residents. Staff F stated that Resident 1 had their meals in their room, it might bother them to see the staff feed the other residents. Staff F stated that they had never seen Resident 1 try to exit out of the unit. Staff F stated that Resident 1 walked a lot in the unit, and they figured out how far they walked by tallying the feet they walked and calculating them into miles. Staff F stated that Resident 1 had a planned outing to go to their home with friends and had asked the facility for some cookies to take for their neighbors as they had always been the cookie man in their neighborhood. In a phone interview on 10/22/2021 at 3:31 PM, Staff G, NAC, stated that Resident 1 did not exit seek, wander, rummage, or hoard. Staff G stated that the only behavior Resident 1 had was being sad. In a phone interview on 10/27/2021 at 12:14 PM, CC 1, Psychologist, stated that they were working with Resident 1 in a therapeutic context, and the resident was delightful. CC 1 stated that the resident's initial referral included the typical dementia with short- and long-term memory loss along with delusions, memory loss, negative statements, anger, and [CONDITION(S)]. CC 1 stated that the resident's long-term memory was intact. CC 1 stated that Resident 1 was tracking with them during their sessions and recalled information from previous session. CC 1 stated that Resident 1 was not pleased with their placement in the facility. CC 1 stated, That tells you something right there, when reviewed the resident's initial access of advocacy through the Ombudsman and Residential Care Services. CC 1 stated that the resident had reported that they had called the Assisted Living Facility (ALF) next to the Long-Term Facility as the resident recognized they needed a level of care and was told the ALF was for long term care versus short term care. CC 1 stated that the resident understood nature, quality, their DPOA and how the represented them. CC 1 stated that the resident was competent and presented as someone who had capacity. CC 1 stated that Resident 1 walked up and down the hallway and it was helpful related to the resident's frustration as the Dementia Unit residents were challenging for the resident to be around. CC 1 stated that it was surprising how well the resident had coped. The resident was transferred out of the Secured Dementia Unit on 11/01/2021 to the Long-Term Care Unit. Review of Progress note dated 11/01/2021 at 10:19 PM, showed the resident had no wandering without purpose and no exit seeking. The resident asked appropriate questions of the staff and spent time in the hall exercising and was able to relocate to their new room without cues. Review of the Progress Notes on 11/02/2021 at 3:30 PM, showed the resident and their roommate were visiting at 10:22 PM the resident had no negative comments. In an interview on 11/03/2021 at 12:29 PM, Staff H, ST, stated that they used the Addenbrooke's Cognitive Exam to assess the resident's cognitive-communication abilities. Staff H stated that Resident 1 was very intelligent and was starting to learn the test answers, so they had to adjust the test when administering the test to Resident 1. In conclusion the resident was moved into the facility's Secured Dementia Unit on 01/18/2021 after they had wandering behaviors following a MVA, hospitalization with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident showed no validated behaviors from the time they were admitted into the Secured Dementia Unit. The resident repeatedly requested to be discharged to a lower level of care or home. The resident was held in the Secured Dementia Unit for 10 months (01/18/2021 to 11/01/2021) which caused the resident unjustified psychosocial harm noted with episodes of frustration, anger, negative statements, and [CONDITION(S)] related to being locked up and held in the Secured Dementia Unit with individuals who the resident could not communicate or relate to which provoked and exasperated the resident. Reference: (WAC) 388-97-0640 (1), (3)(c)

Based on interview and record review the facility failed to provide medically related Social Services for one of one (1) resident to maintain their highest practicable physical, mental, and psychosocial well-being. This failed practice placed Resident 1 and all other residents at risk of a diminished quality of life. Findings included . Review of the Social Services Director job description, undated, showed the position plans, implemented, leads, and evaluated social services (SS) to ensure the highest quality resident care by assisting residents with the psychosocial needs of each resident. Respected and abided by Resident Rights. Provided daily leadership to the SS. Worked alongside employees to promote a team effort and maintained the highest quality resident care. Assisted in problem solving with challenging resident issues. Had knowledge of State and Federal regulations pertaining to SS in long-term care. Review of the SS job description, undated, showed the position respected and abided by Resident Rights. Identified specific resident issues and advocated for residents to contribute to resident's overall care and [MEDICATION(S)] well-being. Acted as the liaison with the facility's mental health professional. Resident 1 was admitted to the facility on [DATE] on the Rehab Unit with diagnoses to include a fractured C2 vertebrae (the second bone in the neck) following a motor vehicle accident, [CONDITION(S)] (altered mental state), with intermittent confusion and [CONDITION(S)] felt to be related to opiates. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact with a Brief Interview for Mental Status (BIMS- a type of mental status assessment) which was 14 out of 15 and was able to make self-understood and understood others and had episodes of wandering. Review of the Progress Note dated 01/18/2021, showed the resident was moved into the facility's Secured Dementia Unit. Review of the Quarterly MDS assessment dated [DATE], showed the resident's BIMS assessment declined to 12 of 15 and continued to be able to make self-understood and understood others and had no episodes of wandering indicative of the need to remain in the Secured Dementia Unit. The quarterly MDS assessments dated 07/05/2021 and 10/05/2021, showed the resident's BIMS assessment score improved back to 14 out of 15 and continued to be able to make self-understood and understood others and had no episodes of wandering indicative of the need to remain in the Secured Dementia Unit. Review of the Medical Record showed the resident's repeated request to be discharged home, to a lower level or least restrictive level of care after being admitted into the Secured Dementia Unit: - In an Advanced Registered Nurse Practitioner (ARNP) Nursing Home Visit note dated 03/17/2021; - In a ARNP Nursing Home Visit note dated 03/23/2021; - During a Care Conference Note dated 03/23/2021; - During a Care Conference Note dated 03/24/2021; - In a SS note dated 04/04/2021; - In a SS note dated 05/19/2021; - In a SS note dated 06/03/2021; - In a SS note dated 07/05/2021; - In a Quarterly Nursing Note dated 07/13/2021; - In a Nursing Home Physician Visit note dated 07/14/2021; - In a Nursing Home Physician Visit note dated 09/01/2021; - In a Psychotherapy Progress Note dated 09/22/2021; - In a Psychotherapy Progress Note dated 09/27/2021; - In a Psychotherapy Progress Note dated 09/29/2021; - In a SS Note dated 10/05/2021; and - In a Psychotherapy Progress Note dated 10/06/2021. Review of the Medical Record showed the resident's repeated discontent, request to revoke/change their Power of Attorney (POA) showed the following: - In a SS note dated 08/17/2021; - In a Nursing Home Physician Visit note dated 09/01/2021; and - In a Psychotherapy Progress Note dated 09/29/2021. In an interview on 10/19/2021 at 3:26 PM, Staff C, SS, stated that they had based the resident's incapacity on Staff A, Medical Director, one letter of incapacity. Staff C stated that they were unaware if the facility had a formal time frame to reassess a resident's decisional capacity. Staff C stated that Resident 1 had indicated they wanted to go home and even brought up off handedly of the possibility of discharge to an Assisted Living Facility (ALF). Staff C stated that the resident's POA felt due to the resident's fluctuation of their care needs it was best for the resident to remain in the Secured Dementia Unit at the facility. Staff C stated that their role was to communicate with the interdisciplinary team (IDT), support the resident and the POA in a supportive role that benefited the resident and worked as the [NAME] to give the resident autonomy even under limited circumstances. Staff C stated that they had not reviewed the resident's Psychotherapy Progress notes and in fact had not gotten them yet. Staff C was asked if they had requested the Psychotherapy Progress Notes and Staff C stated that they had not. Staff C was asked how they were advocating for the resident and assisting them in the assertion of their rights within the facility in accordance with Resident Rights and free of involuntary seclusion. Staff C stated, well an example would be their visitation, but with COVID-19 to facilitate visitations was tricky. Staff C stated that they assisted with the coordination with an outing with friends. Staff C stated that an example of how they advocated for the resident was they had challenges with the POA trusting the resident to go out of the facility with friends and they were able to make that happen. Staff C stated they ensure that the resident's placement in the Secured Unit was appropriate, it was so difficult but communicate with the POA, IDT, Ombudsman, and the State. Staff C stated they were trying to find the best quality of life the resident desired and their challenges and impairments, their access to support and resentment of support, the resident felt they did not need any of this level of care. Staff C stated they were trying to accommodate the resident's preferences as much as they could. Staff C was asked why the resident was not assisted when they had asked about changing their POA. Staff C stated the resident's POA had met with the resident's lawyer and met with another interested party, and it was their understanding with how the resident ended up in the system it was up to the POA to resign due to the resident's incapacitated letter (written by Staff A). Staff C stated they obtain their legal understanding regarding the resident's inability to change their POA from the residents current POA, who stated it could not be changed. Staff C stated that they had not had the resident involved in a discussion regarding a change in their POA, they had care conferences with him and the doctor to discuss and explain why the resident needed to continue to stay at the facility. Staff C stated that they had assessed that having the resident and their POA together in the facility in a care conference had not been done. Staff C stated that Resident 1 would talk with nursing and then the POA would be updated was a good dynamic they had found as it did not raise conflict or confusion. Staff C stated that they had not observed that Resident 1 understood the role of their POA. In an interview on 11/03/2021 at 12:39 PM, Staff I, Social Service Director, was asked the process if a resident were to want to change or revoke their POA. Staff I stated they would assist the resident to do so if they wanted to revoke or change their POA. Staff I stated that they would give the resident information on how to change and/or revoke their POA and would direct them to internet web sites available that would help them. In conclusion Social Services failed to recognize, advocate, and assist Resident 1 with their repeated pattern of requests to move to a lower level of care, home with support staff to or an ALF. Additionally, Social Services failed to honor and assist with the resident's right to change and/or revoke their POA. Refer to CFR 483.12(a)(1) - Free from Involuntary Seclusion Refer to CFR 483.10(b)(3)(ii) - Rights Exercised by Representative Reference: (WAC) 388-97-0960 (1)

Based on interview and record review the facility failed to ensure the resident's family representatives were notified of change in condition for two of three residents (1, 2) reviewed for notification. This failure placed the resident's representative at risk of emotional distress and lack of being informed timely of the resident change of condition. Findings included . RESIDENT 1 Resident 1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Record showed the resident had a Collateral Contact (CC1), Responsible Party Emergency Contact 1, with two phone contact numbers and an email address. Review of the medical record showed the following noted skin problems: · 07/22/2020, Open area to buttock, bilateral gluteal cleft, Calazinc (a type of ointment) applied; · 09/01/2020, Denuded (the loss of the outer most layer of skin, caused by exposure to urine, feces, body fluids, wound exudate or friction) area to coccyx related to moisture; · 10/07/2020, Area of impairment to coccyx assessed and dressed by the wound team; · 12/09/2020, Noted to have circular purple/reddened area to right buttock that was painful to touch, as well as sloughing wet open skin to tip of the coccyx crack; · 12/10/2020, Denuded area noted in coccyx crease area measuring 0.5 cm (centimeter) by 0.8 cm, left buttock noted with dark purple area 0.5 cm by 0.4cm non blanchable, irregular shape slightly raised, firm to touch recommend to cleanse with normal saline, apply triad [MEDICATION NAME] wound dressing paste over wound, with sacral bordered foam dressing; · 12/16/2020, Skin Note, Medical Doctor (MD) signed order for wound treatment, no new orders, noted and filed order in chart; (Wound treatment (coccyx, buttocks); cleanse area with normal saline, pat dry, apply Calazine twice a day and as needed); and · 01/06/2021, Skin breakdown to peri-area continued to be monitored by wound team, had yeasty area under left breast, requested order for [MEDICATION NAME] powder. Further review of the medical record showed no documentation the CC1 had been notified of the resident's noted skin problems and new treatment orders. Review of a complaint report dated 02/10/2021, showed the CC1 had not been contacted regarding any skin breakdown or issues for over six months. In a phone interview on 02/24/2021 at 3:56 PM, the CC1 stated no one had mentioned anything other than in the later part of the year about the resident's skin. In a phone interview on 03/08/2021 at 12:30 PM, Staff E, Registered Nurse (RN), stated that when a resident had a change in skin condition the Unit Coordinator (UC) and the physician would be notified as needed. Staff E, stated that the UC or the cart nurse would notify the family and would document the notification in the progress notes. In a phone interview on 03/09/2021 at 6:50 PM, Staff D, Licensed Practical Nurse, stated that if a resident had a change in skin condition the UC would be informed and if a big enough issue the skin team would be emailed and they would contact the doctor. Staff D stated that Resident 1 had been transferred from a different hallway to the Rehab Unit. Staff D, stated that the resident had an area on her bottom that looked like a pressure area underneath a purple red area which was mushy and wanted to document to definitely ensure the resident received offloading to her bottom. Staff D, stated that the family would be notified right away if there was something major to the point a risk management would have to be completed but if in the middle of the night would report to the UC. RESIDENT 2 Resident 2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Record review showed a progress note dated 02/17/2021, showed a new wound care order for santyl to heel daily and to increase [MEDICATION NAME] (narcotic) to five milligrams with no notation the resident or POA were notified. In a phone interview on 03/10/2021 at 11:40 AM, the CC2, Power of Attorney (POA), stated that the one request they had on admission was to be notified if the resident had a change in pain management. The CC2, stated that the COVID-19 pandemic had made it where we were not able to go into the facility and do not know about changes that occurred with the resident. The CC2, stated that they had specifically asked to be notified and then a couple of weeks ago (Resident 2) reported that they had increased the pain medication, [MEDICATION NAME]. The CC2, stated that the facility had not notify them and that did not make them very happy. The CC2, stated they called the facility and was told the resident could speak for themselves and it was not a requirement to notify the POA of changes in the resident's medication. The CC2, stated that Resident 2 had a POA for medical care, the resident was [AGE] years old and they did not understand why the facility could not give them an update on the resident's medication changes. The CC2, stated that the facility told them they could call medical records weekly and request any medication changes. The POA stated that they had not been notified of recent wound care changes, or increase in pain medication by the facility. The CC2, stated that the resident's care was wonderful but the communication was lacking. In a phone interview on 03/12/2021 at 11:32 AM, Resident 2, stated that she was not comfortable with an interview without the participation of her POA. The POA was added to the call, Resident 2, stated that she wanted the facility to notify the POA of any medication, treatment or condition changes. Resident 2, stated that they did not realize they needed to direct the facility to call the POA with changes in they're condition. The POA, stated that they had asked the facility to notify them of changes on admissions and at another time because of hearing about concerns in nursing homes in general. The POA, stated that one day the resident was great and the next day the resident would be disoriented. In a follow up phone interview on 03/12/2021 at 1:34 PM, Staff E stated that the POA would always be notified of any kind of change in orders or skin conditions. Staff E stated that the Licensed Nurses would notify the responsible party or resident representative who was indicated to call first. In a phone interview on 03/12/2021 at 1:41 AM, Staff F, RN, stated that if a resident had a new order the UC, resident family and/or POA would be notified which would also be documented in the progress notes. Reference: (WAC) 388-97-0320 (1)(c)

Based on observation, interview and record review the facility failed to provide diabetic nail care and treatment for one of three (1) residents reviewed for diabetic foot care. This failed practice placed Resident 1 at risk of discomfort and potential podiatric complications. Findings included . Review of the facility's policy titled, Diabetic Foot Care, with a revised date of 02/2021, showed the toenails should only be trimmed by personnel qualified to do so (this can be trained staff, and does not have to be a podiatrist); Podiatry referral as needed. Routine assessment and documentation of abnormal finding of the feet by Licensed Nurse (LN) should include the condition of the toes and toenails. Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessments from Admission MDS on 01/02/2020, Quarterly MDS assessments on 04/03/2020, 07/04/2020, 10/04/2020 and the Annual MDS assessment on 01/02/2021 all showed the resident required extensive assistance with personal hygiene, was cognitively impaired, and would respond to simple direct communication only. Review of the Care Plan showed the following focus problems: · Skin at risk related to disease process diabetes mellitus type 2, [MEDICAL CONDITION] with initiated date of 01/06/2020; · Cognition - impaired cognitive function/dementia and impaired thought process related to [MEDICAL CONDITION] with initiated date of 12/27/2019; and · Activity Daily Living self-care performance deficit related to activity intolerance, [MEDICAL CONDITION] with an initiated date of 01/06/2020. Review of the physician order [REDACTED]. The LN was directed to document 0 which indicated the toenails were checked and a + which indicated the toenails were cleaned and trimmed. Review of the Treatment Administration Record for January 2020 through January 2021 and the current month of February 2021, showed the resident's toenails were only checked. There were no noted documentation of when the resident's toenails were cleaned or trimmed for the past year. Review of the Progress Notes showed the following entries related to the trimming of the resident's toenails: - On 05/27/2020 at 10:49 PM, toenails were documented as being thick and yellow, received antifungal cream to between toes on right foot, and the resident's toenails were trimmed; - On 09/09/2020 at 9:54 PM, toenails were very thick, long, and unable to trim; and - On 09/30/2020 at 11:04 PM, toenails were thick, yellow, and offered to trim toenails but the resident declined. Resident 1 discharged from the facility on 02/04/2021. In an observation on 02/24/2021 at 1:42 PM, the resident's toenails were observed to be extremely thick. The first, second and third toenails were curled over the top and to the back of the resident's toes on the right foot. The resident's left foot first and second toenails were observed to be overly thick and overgrown, curled over the top of the toes onto the bottom of the resident's toes. The resident's great toes were observed to be extremely thick and the left great toenail appeared to be lifting from the nail bed. In an interview on 02/24/2021 at 2:00 PM, the Collateral Contact (CC1), community health care provider, stated that the resident's toenails were curled around her toes and she was unable to wear socks due to the discomfort. In a phone interview on 02/24/2021 at 3:56 PM, the CC2, family member, sated that the facility had not reached out and notified them regarding the resident's thick and overgrown toenails or the need for a podiatry consult. In a phone interview on 03/02/2021 at 11:30 AM, Staff A, Licensed Practical Nurse (LPN)/Unit Coordinator (UC), stated that the resident's toe nails were thick and did not recall nursing staff reporting any concerns with the resident's toenails. In a phone interview on 03/02/2021 at 11:50 AM, Staff B, Registered Nurse (RN)/ UC, stated that after reviewing the resident's chart that she had worked back on 09/30/2020 and during the evening had worked the medication cart. Staff B stated that she recalled the resident's toe nails were thick and yellow but the resident declined having her toenails cleaned, filed or trimmed. Staff B stated that after review she recalled back on 05/27/2020, she made a note the resident's toenails were thick and yellow but not trimmed. Staff B confirmed there had been no documentation the resident's toenails had been filed or trimmed. In a phone interview on 03/02/2021 at 1:33 PM, Staff C, RN, stated that she recalled Resident 1, but did not recall trimming her toe nails. Staff C stated that she remembered the resident's toes had ingrown nails and were pretty advanced. Staff C stated that she could not cut the resident's nails within her scope of practice. In a phone interview on 03/03/2021 at 12:36 PM, the CC3, Podiatrist, stated that the resident's toenails were thick and some were long yellow and brittle. CC3 stated that the resident presented with chronic overgrowth of her toenails and it appeared like no one had done routine toenail care for some time. CC3 stated that the length of the toenails were one thing but the thickness was another. CC3 stated the thicker toenails were more at risk of a nail bed injury from being compressed by even bed sheets which could cause a subungal hematoma (bleeding and bruising under the nail) under the nail bed which could lead to infection. Reference: (WAC) 388-97-1060 (3)(viii)

Based on interview and record review the facility failed to honor residents' right to make choices for frequency of bathing for seven of ten residents (# 2, 14, 21,72,79, 89 and 100) reviewed for choices. Failure to honor resident choices placed residents at risk for impaired hygiene and a diminished quality of life. Findings included . Review of the facility's ADL (activities of daily living) Standards dated (YEAR), showed, showers are to be provided weekly or PRN (as needed) based on resident preference and need. RESIDENT # 14 Resident # 14 admitted to the facility on [DATE] with muscle weakness. According to the annual Minimum Data Set (MDS) assessment dated [DATE], she required two person extensive assist for showers. Review of Resident #14's care plan and bathing task indicated the resident preferred to have two showers a week in the morning and PRN. In an interview during the resident council meeting on 05/30/19 at 3:06 PM, Resident # 14 stated, We are put on a (shower) list. It is not always when you want. They miss us too because they get pulled to the floor. Lately, it is more often. Staff are calling in because of the sun, so showers get pulled to the floor. Review of the Bathing Documentation Survey Report, from 02/01/19 through 06/07/19 showed the resident received four showers in (MONTH) (on the 1st, 8th, 12th, and 15th), four showers in (MONTH) (on the 8th, 15th, 22nd, and 29th), four showers in (MONTH) (on the 5th, 9th, 12th and 19th), three showers in (MONTH) (10th, 17th, and 24th) and one shower in (MONTH) (7th) Review of the resident's shower records showed she did not receive showers per her preference. RESIDENT # 21 Resident # 21 admitted to the facility on [DATE] with muscle weakness. According to the Quarterly MDS assessment dated [DATE], she required one-person assistance for showers. Review of Resident # 21's care plan and bathing task indicated the resident preferred to have two showers a week in the morning and PRN. In an interview during the resident council meeting on 05/30/19 at 3:06 PM, Resident # 21 stated, We are put on a (shower) list. I feel bad. I look in the mirror and my hair looks terrible. If you don't get a shower, your hair doesn't get washed. I hate to say this but I have gone eight to ten days without a shower. Review of the Bathing Documentation Survey Report, from 02/01/19 through 06/07/19 showed the resident received two showers in (MONTH) (on the 3rd and 27th), four showers in (MONTH) (on the 3rd, 6th, 20th and 31st), no showers in April, five showers in (MONTH) (5th, 15th, 22nd, 26th, and 29th) and no shower in (MONTH) as of 06/07/19 at 10:38 AM. Review of the resident's shower records showed she did not receive showers per her preference. RESIDENT # 89 Resident #89 admitted to the facility on [DATE] with [MEDICAL CONDITION] and muscle weakness. According to the Quarterly MDS assessment dated [DATE], he required one-person assist for showers. Review of Resident # 89's care plan and bathing task indicated the resident preferred to have two showers a week in the morning before or after breakfast and as necessary. In an interview during the resident council meeting on 05/30/19 at 3:07 PM, Resident # 89 stated, They miss us or don't tell us a specific time. People call in and they grab the shower people. Review of the Bathing Documentation Survey Report, from 02/01/19 through 06/07/19 showed the resident received seven showers in (MONTH) (on the 1st, 5th, 8th, 11th, 15th, 23rd, and 28th). The (MONTH) showers on 1st, 5th and 23rd occurred after his dinner. He received eight showers in (MONTH) (on the 3rd, 8th, 12th, 15th, 19th, 22nd, 26th and 30th). Three (8th, 19th and 26th) of his (MONTH) showers were given after dinner. In April, he received seven showers (1st, 5th, 10th, 11th, 15th, 19th, and 26th). He received three of the showers after dinner (1st, 5th, and 15th). He had eight showers in (MONTH) (1st, 6th, 11th, 14th, 17th, 23rd, 28th and 31st). Two of his (MONTH) showers were given after dinner (6th and 14th). He received one shower in (MONTH) (3rd) as of 06/07/19 at 10:38 AM. Review of the resident's shower records showed he did not receive showers per his preference. RESIDENT #72 Resident #72 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 05/29/19 at 11:09 AM, the resident stated I would like more showers, I only get one a week, sometimes not that. The Quarterly MDS, dated [DATE], documented the resident was cognitively intact and required extensive assistance for activities of daily living (ADLs), including bathing. The care plan, with the revision date of 05/10/19, identified the resident required extensive multi-person assist for ADLs. The interventions included bathing/showering weekly or as necessary with one person extensive assist. The resident preferred early morning showers. Review of the Bathing Documentation Survey Report for (MONTH) and (MONTH) 2019 revealed the following: Interventions: Bathing-prefers shower early morning, once a week. April: the resident received one shower, refused one shower. May: the resident received two showers, none refused. Review of the Care Conference Summary, dated 06/18/18, showed documentation that a nursing assistant was involved in the plan of care. There were no specific care concerns identified as being discussed with the resident. The resident did not receive showers per her preference. RESIDENT #100 Resident #100 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. In an interview on 05/31/19 at 10:45 AM, the resident stated she was to get two showers a week but had missed a few. I would like more. She further stated she did not remember anyone asking her how many showers she would like to get. Review of the MDS, dated [DATE], showed the resident was cognitively intact, required extensive assistance with ADLs, and required physical help with bathing. Review of the care plan showed a focus problem, revised on 02/21/19, of an ADL self-care performance deficit. Interventions included showers two times a week in the morning and as needed. Review of the Bathing Documentation Survey Report for (MONTH) and (MONTH) 2019 showed the following: Interventions: the resident was to receive a shower daily in the morning and as necessary. April: the resident received four morning showers and two evening showers. She refused two evening showers. May: the resident received five morning showers and one evening shower. There were no refusals. Review of the care conference dated, 02/19/19, showed the nursing assistant, dietary and therapeutic recreation was involved in the plan of care, but no preferences in care were identified. The resident did not receive showers per her preference. RESIDENT #2 Resident #2 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment, dated 05/24/19, showed the resident was alert and oriented. The MDS showed the resident was incontinent of bowels, and required physical help in part of bathing. The MDS showed it was very important for the resident to choose between a tub bath, shower, bed bath, or sponge bath. Review of the comprehensive care plan showed the resident required one person physical assistance with showers and preferred showers two times a week on Tuesdays and Friday mornings before breakfast. Review of the Bathing Documentation Survey Report ,for (MONTH) 2019-April 2019 showed the following: -02/01/19-02/28/19, showed the resident did not receive a shower on Friday 02/01/19 and Friday 02/22/19. The resident went six days without bathing and had two missed showers. -03/01/19-03/31/19, showed the resident did not receive a shower on Tuesday, 03/26/19, resulting in six days with no shower. -04/01/19-04/30/19, showed the resident did not receive a shower on Friday 04/26/19, and went five days with no shower. In an interview on 05/30/19 at 11:09 AM, the resident stated that sometimes she did not get her showers. The resident stated that the shower aides get pulled to work the floor, and resulted in missed showers. The resident stated she had to go to multiple department heads prior to receiving a requested shower. The resident stated that she prefers her showers in the morning. The resident was noted to have a foul odor during the interview. In an interview on 06/05/19 at 2:42 PM, the resident stated that she prefers her showers in the morning before breakfast. The resident stated that the staff do not always follow her preferences for showering due to the shower aides being pulled to the floor. The resident reported she was not offered make up showers for her missed showers. Review of the resident's shower records showed she did not receive showers per her preference. RESIDENT #79 Resident #79 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment, dated 04/25/19, showed the resident reported it was very important to choose between a tub bath, shower, bed bath, or sponge bath. The MDS showed the resident was totally dependent for bathing, and required set up help. Review of the comprehensive care plan, print date 05/31/19, showed the resident required assistance by staff with showering in the morning twice weekly and as needed. Review of the Bathing Documentation Survey Report for 05/01/19-05/31/19, showed no shower for 05/01/19-05/05/19, 05/07/19-05/11/19, and 05/17/19-05/21/19. The resident had morning showers on 05/06/19, 05/12/19, 05/13/19, 05/22/19, 05/25/19, and 05/29/19. There were two evening showers noted on 05/16/19 and 05/26/19. Review of the progress notes, dated 04/19/19-06/06/19, showed no documentation of refusals for showers or missed showers. In an interview on 05/29/19 at 2:44 PM, the resident stated that she wanted to shower daily and was not getting showers per her preferences. The resident voiced she wanted more showers than were being provided and was not getting them. Review of the resident's shower records showed she did not receive showers per her preference. In an interview on 06/04/19 at 1:13 PM, Staff F, Licensed Practical Nurse (LPN)/Unit Coordinator (UC), stated if residents wanted more showers they usually would tell us and we pass it on to the shower team. The schedule is always changing. It's the nature of the beast, the shower team aides get pulled to the floor and the schedule has to be juggled. The team always tries to make up the shower on another shift or the next day if able, depending on staffing. In an interview on 06/05/19 at 9:04 AM, Staff E, Nursing Assistant Certified, stated we have a list of residents that like more than one shower per week. They can have more if they want, they just have to ask and we can let the shower team know. In an interview on 06/05/19 at 10:11 AM, Staff A, Assistant Director of Nursing Services (ADNS), stated the residents were asked about their shower frequency preferences on admit. We also talk about general care in care conferences, but the residents are not asked on an ongoing basis. If they want more showers they ask and we try to accommodate them with what they want. In an interview on 06/07/19 at 8:36 AM, Staff F, UC/LPN, stated that resident shower preferences were obtained upon admission and then reviewed quarterly. Staff F stated shower aides get pulled to work the floor, resulting in missed showers. Staff F stated the resident would like to be showered daily, even twice a day, but upon admission agreed to have a shower twice a week. In an interview on 06/07/19 at 10:13 AM, with Staff C, UC/Registered Nurse, stated that shower preferences are obtained upon admission. The expectations was that each resident receive at least one shower per weeks, or as their preferences are listed. Staff stated shower aides do get pulled to the floor depending on staffing needs. Staff stated they are always able to make up missed showers. In an interview on 06/07/19 at 2:43 PM, Staff A, ADNS confirmed there were missed showers. She said her expectation was there should be documentation for refusals and attempts to have showers offered the following day. Reference: WAC 388-97-0090(1)(2)

Based on observation, record review and interview the facility failed to ensure potentially hazardous chemicals and medications were secured when not in used in resident rooms on 5 of 7 units (Baker Landing #1, Baker Landing #2, Cascade Harbor #1 and Cascade Harbor #2), in the secured Dementia Unit (Cedar Cove) and the beauty salon. These failures placed cognitive impaired resident's access to medications and chemicals. The failure to safely secure medications and potentially hazardous chemicals caused an unsafe environment and placed residents at risk for potential harm from ingestion of inappropriate substances. An Immediate Jeopardy was called on 03/01/18 at 2:05 PM. Findings included: According to the facility policy, Storage Areas, updated (YEAR), directed staff to ensure cleaning supplies, etc., were stored in areas separate from food storage and were stored as instructed on the labels of such products. This was the only policy available. CASCADE HARBOR #1 room [ROOM NUMBER] In an initial observation on 02/26/18 at 9:41 AM, Bath and Body Work's lotion and Johnson's baby powder were observed in view on the residents over bed table. Review of resident 98's quarterly minimum data set assessment ((MDS) dated [DATE], revealed the resident was never or rarely understood and had limited vision. Review of Resident 105's quarterly MDS dated [DATE], revealed severe cognitive impairment. Resident 105 was observed to wander utilizing her walker on all days of survey. room [ROOM NUMBER] In an initial observation on 02/26/18 at 12:23 PM, Spa Haus lotion was located on Resident 91's over bed table. Resident 91 shared a room with Resident 60. According to resident 60's significant change MDS dated [DATE], she had moderately impaired cognition and vision. room [ROOM NUMBER] In an observation on 02/26/18 at 11:01 AM, Tresseme dry shampoo spray and deodorant spray were observed in view on Resident 33's nightstand. There was Bath and Body Works Vanilla Bean fragrance spray and baby powder observed in view next to Resident 94's nightstand. Resident 33's quarterly MDS dated [DATE], revealed moderately impaired decision making. Resident 94's quarterly MDS dated [DATE], revealed she was never or rarely understood with highly impaired vision. room [ROOM NUMBER] In an observation on 02/26/18 at 9:51 AM, baby powder was observed in view to the left of the sink. Refresh eye drops and Johnson's baby lotion were located on the over bed table. Lysol aerosol spray, Preparation H ointment and [MEDICATION NAME] cream were located on the nightstand. Resident 69 stated Don't write that down. They're mine. I will get in trouble. The resident's roommate, Resident 40, was cognitively impaired with impaired vision and at risk to wander. According to the 12/18/17, quarterly MDS she had short and long term memory loss and wandered daily. room [ROOM NUMBER] In an observation on 02/26/18 at 9:58 AM, [MEDICATION NAME] lotion was located at the bedside of Resident 23. On 03/01/18 at 9:40 AM, the [MEDICATION NAME] lotion was again visible from the hallway. According to Resident 23's significant change MDS dated [DATE], she had impaired vision and wandered 4-6 days. room [ROOM NUMBER] In an observation on 02/26/18 at 12:27 PM, a bottle of [MEDICATION NAME] lotion was observed in view on Resident 58's nightstand. Review of resident 20's quarterly MDS dated [DATE], he was never or rarely understood. Review of Resident 58's care plan dated 01/04/18, his cognition varied. room [ROOM NUMBER] In an observation on 02/26/18 at 9:53 AM, two bottles of [MEDICATION NAME] lotion were located on Resident 56's over bed table. At 11:13 AM, Pantene curl gel, Paul Mitchell mousse and a bottle of Paul Mitchell super sculpt spray were located at the left of the sink visible to the hallway. According to resident 49's quarterly MDS dated [DATE], she had moderately impaired cognition and vision. Additionally, she wandered 1-3 days with a significant risk of getting to a dangerous place. Review of resident 56's quarterly MDS dated [DATE], she had moderately impaired vision. In a joint interview on 03/01/18 at 12:24 PM, the Administrator and Staff E, Assistant Director of Nursing (ADNS), were notified of numerous hazardous chemicals located in resident rooms. Staff E, stated the general policy was to keep personal care items in bins in the bathroom. The items were kept out of sight. If a resident was on a self-medication program, the medications would be locked up. BAKER LANDING #2 room [ROOM NUMBER] In an observation on 03/01/18 at 10:40 AM, a bottle of nail polish remover and a bottle of mouthwash were in view on the Resident 36's nightstand. Review of resident 36's quarterly MDS dated [DATE], she had moderate cognitive impairment. BAKER LANDING #1 room [ROOM NUMBER] In an observation on 02/26/18 at 10:25 AM and 3:34 PM, 02/27/18 at 2:16 PM, and on 03/01/18 at 10:49 AM, a quart bottle of Listerine, Old Spice and Gillette fusion hydrogel were on top of Resident 7's nightstand. Review of Resident 7's annual MDS dated [DATE], revealed the resident had severely impaired decision making, impaired vision and wandered 1-3 days. Resident 7's roommate, Resident 22 had moderate cognitive impairment and impaired vision according to the admission MDS dated [DATE]. CASCADE HARBOR #2 room [ROOM NUMBER] In an observation on 02/26/18 at 2:23 PM, two bottles of Gold Bond Diabetic lotion was located at Resident 109's bedside. The Resident's roommate (Resident 101) had moderate cognitive impairment according to the significant change MDS dated [DATE]. In an observation on 03/01/18 on or about 11:12 AM, the Gold Bond lotion was again visible on Resident 109's nightstand. room [ROOM NUMBER] In an observation on 03/01/18 on or about 11:12 AM, a bottle of baby powder was sitting on the resident's nightstand. room [ROOM NUMBER] In an observation on 03/01/18 on or about 11:12 AM, a bottle of after-shave, shaving cream and Gold Bond lotion was sitting out on the resident's nightstand. room [ROOM NUMBER] In an observation and interview of Resident 29's room on or about 11:20 AM, a bottle of hand sanitizer was out on the nightstand and a bottle of Dermasil in the bathroom. Resident 29 stated, At times confused residents do come into my room. The nurse or the aides are busy, but it is not as bad as it used to be. room [ROOM NUMBER] In an observation on 03/01/18 on or about 11:12 AM, a jar of [MEDICATION NAME] was in view on the nightstand. room [ROOM NUMBER] In an observation on 03/01/18 on or about 11:12 AM, a bottle of ACT mouthwash and a jar of Ponds were visible on the dresser. room [ROOM NUMBER] In an observation on 03/01/18 on or about 11:12 AM, aftershave and Gold Bond lotion on the nightstand. Review of each item was labeled with the warning, Keep out of the reach of children. CEDAR COVE Resident 11, 16, 28 and 54 all ambulated independently and resided in Cedar Cove, a secured dementia unit. In an interview on 03/01/18 at 2:52 PM, Resident 69 stated, They (residents) do come in here. I have had a lady in my bed. In an observation on 03/01/18 at 11:50 AM, a cabinet in the common area in the Dementia Unit was open with a tub of Sani-Cloth Plus (germicidal wipes), a spray bottle of TB-Cide Quat (a cleaner deodorizer/ disinfectant), and a bottle of glass cleaner all labeled keep out of reach of children. In an interview with Staff N, Licensed Practical Nurse (LPN), stated the cabinet was usually locked. Staff N stated they were getting the clothing protectors out for lunch. In an observation and interview at 1:01 PM, the cabinet was observed to be locked, the keys were observed draped over the nurses medication cart. Staff O, LPN, stated I am going to place these chemicals elsewhere. In an observation on 03/05/18 at 8:10 AM, the facility beauty salon was unlocked and unoccupied. Inside the beauty salon on the counter various hazardous chemicals were observed unsecured; an unidentified yellow liquid in a spray bottle, a blue spray bottle and several bottles of hair color, and Wella hair rinse. Residents in the vicinity at the time were Resident 58 and 20, both identified as cognitively impaired high risk residents. At 9:12 AM, the beauty shop door was again open with multiple items labeled keep out of reach of children. No staff were in the immediate vicinity. The beautician then walked back into the beauty shop and stated, Can I ask you a question? Do I need to close or lock the beauty shop door when I leave the shop? I am unsure, I am just helping out. I do turn off the curling iron and try to put things away, but they (the residents) are like little kids. The beautician patted her pocket and stated, Oh, well I do have a key here. On 03/05/18 at 9:18 AM, the Administrator was alerted the beauty shop was left open and unattended twice this morning. She acknowledged the beauty salon door was to always be locked when not in use In an observation and interview on 03/06/18 at 2:47 PM, the shower room door was popped open with a chair. No staff were in the immediate vicinity. A large bottle of bathing soap was sitting on the shower room floor. Staff P, Registered Nurse was sitting in the nurses station with the door closed. Staff P was informed of the open shower room, Staff P stated, The shower room is not supposed to be propped open. Reference: (WAC) 387-97-1060(3)(g)

Citation Text for Tag 0223, Regulation FF10 Scollard,(NAME)R Based on interview and record review, the facility failed to ensure 1 of 2 residents (2) was free from physical abuse. The facility failed to identify and protect Resident 2 from physical abuse when her roommate became verbally aggressive towards the resident. This failure caused harm to Resident 2 who experienced physical abuse and psychological harm from Resident 3. Findings include: Review of the Abuse Prevention Program policy stated the facility was committed to protecting their residents from abuse by anyone including other residents. The facility management and staff would institute measure to address the needs of residents and minimize the possibly of abuse and neglect. RESIDENT 2 Resident 2 was a long term care resident with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS) assessment dated [DATE], revealed Resident 2 had short and long term memory deficit and severe cognitive impairment for decision making skills. Resident 2 required extensive assist of two for bed mobility and was dependent for transfers. Review of Resident 2's care plan included the following Activity of Daily Living (ADL) interventions: the resident required a mechanical lift of two people for transfers and one person assist for bed mobility. The behavior care plan included the following interventions: attempt to re-focus the resident's behaviors when yelling. The resident will yell without warning when she thinks she needs something, usually she needed to use the bathroom. Review of a progress note dated 02/15/17, revealed the resident had scratches and bruises to her right arm and a bruise to the right eye. The bruises were substantiated from a resident to resident incident which occurred on the early morning of 02/15/17. RESIDENT 3 Resident 3 was admitted [DATE] with a [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED]. The LN monitored the following behaviors every shift: Anxiety or agitation How many times the resident bit The number of times the resident hit The number of times the resident kicked Review of the February Treatment Administration Record (TAR) revealed on 02/15/16, the first shift (the facility did 12 hour nursing shifts), the resident exhibited signs of anxiety and agitation, had bit 20, had hit 30 times and kicked 30 times. It is unclear when the resident had bitten, hit and kicked if this was directed towards staff, visitors or another resident. Review of the nursing progress notes regarding the above exhibited behaviors did not offer any additional information when the resident exhibited these behaviors, what was the precipitating factors or what the facility did to alleviate. Review of Resident 3's care plan included the following ADL intervention: the resident was able to reposition self in bed and had been noted to get out of bed independently at times. Other behavior/activity interventions included: the resident's behaviors had only been directed at staff thus far; staff were to guide the resident away from the source of distress when she became agitated; staff to intervene before agitation escalated. Resident 3 had been identified to be physically aggressive with staff during care. Additional interventions included when Resident 3 started to become distressed and yelled to be aware, step back and give space and ensure the resident was safe. RESIDENT TO RESIDENT ALTERCATION Documentation on an incident report dated 02/15/17 at 1:00 AM, Resident 3 was observed sitting half on her wheelchair and Resident 2's bed. Resident 3 was hovering over Resident 2 as she was lying in bed. Resident 3 was observed to be physically striking and grabbing Resident 2's right arm in a tight grip. Staff A, Licensed Nurse (LN), immediately intervene and separated the residents. Review of Staff A, LN's witness statement dated 02/15/17, stated the following: On the morning of 02/15/17 heard a resident yelling, went to investigate and two Nursing Assistant's (NAs), Staff B, NA and C, stated Resident 3 was yelling. Resident 3 was sitting on the edge of the bed yelling . get this woman out of here multiple times . Resident 3 was not re-directable. Staff A, LN stepped out of the room and the resident calmed for . about 1-2 min . Resident 3 yelled again, Staff A, LN went back into Resident 3's room a second time. Resident 3 was yelling get this woman out of here and she's in my room repeatedly. Staff A, LN left the room. Staff A, LN heard escalated screaming. Ran into Resident 3's room and found her hovering over Resident 2's bed. Resident 3 was half sitting/half standing and the curtain was partially closed. Resident 3 was screaming and lashing out. Staff A, LN documented Resident 3 started . yelling out 12:35 AM or so the yelling episodes started x about 2-3 episodes . Staff A, LN documented Resident 3 was not re-directable at any time. Resident 3 .seemed to have raging anger and would not listen to staff. A quiet calm approach was attempted multiple times. Resident immediately struck out at any person that came within 2 feet of her Review of Staff B's, Nursing Assistant (NA), witness statement dated 02/15/17, stated at 12:30 AM, Resident 3 was screaming. Entered the room with Staff C, NA. Resident 3 was sitting at the edge of the bed yelling .get that lady out of her house . Staff B, NA closed the privacy curtain between the two residents and left the room. Staff B, NA stated at 1:00 AM, she heard Resident 3 screaming and yelling again and went to the room. Staff B, NA saw two LN's and one NA in the room with Resident 2 and 3. Review of Staff C, Nursing Assistant's (NA) witness statement dated 02/15/17, stated at 12:30 AM, Resident 3 was screaming to .get that lady out of here . Staff B, NA closed the privacy curtain, and they left the room. Around 1:00 AM, the staff heard yelling and screaming. Staff C, NA and Staff A, LN entered the room and observed Resident 3 grabbing Resident 2's right arm. Both staff members separated the resident's. Review of Staff D LN's witness statement dated 02/15/17 stated at around 1:05 AM, Staff A, LN yelled down the hallway she needed help. Staff D, LN heard screaming. Staff D, LN seen Resident 3 swinging out towards staff and yelling .this is my house! Get out . Staff D, LN documented Resident 3 was yelling, hitting, spitting, kicking and scratching staff. Resident 3 was not re-directable. Resident 3 was transferred to the Emergency Department. Review of Staff E, LN's witness statement dated 02/15/17, revealed Staff A, LN called Staff E, LN at 1:10 AM. Staff E, LN directed Staff A, LN to call 911. Staff E, LN arrived at the facility at 2:05 AM. Staff E, LN assessed Resident 2. Resident 2 recognized Staff E, LN and .ask to not be alone was scared Staff moved Resident 2's bed to the library across from the nurses station . to watch her as she was afraid to be alone . Staff E, LN reported the incident to the state at 4:45 AM, almost 2 hours after the physical abuse occurred. On 02/17/17, the facility concluded Resident 2 was physically abused by Resident 3 and had suffered psychological harm. Resident 2 had bruising and scratches to the right arm and a bruise to the right eye. Resident 2 was not interviewable. The facility identified on Resident 3's care plan to remove Resident 3's source of aggression or agitation. In an interview on 03/20/17 at 1:00 PM, the Director of Nursing Services (DNS) stated Resident 2 was physically abused by Resident 3. The DNS stated Resident 3 did not have a history of striking out at other residents but did have a history of being physically and verbally abusive towards staff and her family members. The DNS was not able to provide any further information why Staff A, LN did not protect Resident 2 when Resident 3 was verbalizing aggression towards Resident 2. The facility failed to protect Resident 2 from Resident 3. Resident 3 had a known history of being physically and verbally abusive towards staff. Staff A, LN failed to remove Resident 2 or 3 from the room when Resident 3 was yelling at staff to get that lady out of her house. Staff A, LN documented Resident 3 had yelled/screamed out to get that lady out of her house 2 or 3 times. Review of the witness statements and facility investigation revealed at no time did the staff protect Resident 2 from abuse when Resident 3 was verbalizing aggression towards Resident 2. The facility failed to protect Resident 2 from physical abuse and psychological harm.

Based on observation, interview and record review, the facility failed to actively and consistently provide medically-related social services to attain the highest level of mental and psychosocial well-being for 2 of 2 residents (71 & 168) reviewed for roommate incompatibility issues and social services support. Failure to consistently advocate, intervene, educate staff about roommate incompatibility issues and ongoing behavioral issues caused harm to Residents 71 & 168 when Resident 71 was physically abused by Resident 168. Based on the Reasonable Person concept, Resident 168 was also harmed when the facility failed to address her pattern of escalating assaultive and disruptive behaviors. Even though there was a 7-month pattern of psychosocial and physical behaviors between these 2 residents. Findings include: RESIDENT 71 Resident 71 was admitted to the facility in 2011. Her [DIAGNOSES REDACTED]. Her Minimum Data Set (MDS) assessment dated [DATE] indicated that she had no cognitive impairment. Review of the resident's care plan dated 03/22/12, revealed an intervention that stated Resident 71 will frequently interfere w/ (with) her roommate or other residents care . There was also an intervention dated 06/20/16, that stated If Resident 71 want to talk about her roommate: remind her to bring any concerns about her roommate to LN (Licensed Nurse) or SS (Social Services). Review of a progress notes dated from 05/06/16 to 12/8/16, revealed multiple documented entries about Resident 71's own comments of unhappiness, complaints, opinions, attitude and behaviors which showed consistent turmoil between her and Resident 168. Review of an incident investigation dated 06/17/16 revealed there was a resident to resident altercation where Resident 168 got irritated and hit Resident 71 on her left arm. The investigation conclusion stated: Resident 71 has chronic struggles with being controlling and respecting boundaries of others, and struggles with being around what she calls so many people who don't have their mind. Resident 168's striking out was a direct result of Resident 71 entering her personal space, taking over the activity she was doing, and then disregarding her request to continue doing the puzzle. Even though there was physical contact made there were no aggressive consistent interventions put in place to ensure both resident were living in a safe and satisfying environment. Review of a note from taken from Resident 71's journal/diary dated 11/17/16, revealed Talked to Social Worker about Resident 168's behavior last night and today. She told me (another potential roommate name) had window bed empty. They wanted me to move tonight. I said I wanted to talk to my daughter 1st. I called Staff AA, Receptionist, asked for Administrator or the CEO, in meeting. I asked Staff AA to pass on to them. I needed to file a complaint about the danger and belligerent behavior and I should not be expected to move she's the one that is both verbally and physically abusing me. Why should I be the one to move! Why. Staff BB said I needed to file a complaint. Review of a Nursing progress note dated 11/22/16 at 4:00 PM, Reviewed w/ Resident 71 her desire to change rooms, and her dissatisfaction with current roommate. Resident 71 reports there is nothing about her current roommate that she likes. I hate everything about her, she is a grumpy mean old lady. Resident 71 reported to the LN that Resident 168 comes into the room and blocks the doorway, and multiple other complaints. The LN went on to write that she came up with a list for Resident 71 to help resolve current issues, like pulling the privacy curtain when she did not want Resident 168 talking to her, calling the staff to assist, rather than trying to deal with the roommate alone, or to have her family purchase wireless headphones to watch TV or listen to music late at night, etc . The LN concluded that she would continue to offer a room change as rooms become available, but Resident 71 says she would only want window bed. Even though the physical contact was reported there was documented follow up with social services. In an interview on 11/30/16 at 2:30 PM, Resident 71 stated her roommate had kicked her several times, the last time was about a month ago, she denied her roommate had made contact with her skin, but had made contact with her boot. Her roommate runs into her with her wheelchair, would not let her leave their room, and that her roommate would put her feet up against the door so she could not leave. Resident 71 also said that her roommate mocked and mimicked her when she was talking to other people and when she was on the phone. She said staff told her You could have someone worse. Resident 71 had talked to both the Administrator and the Director of Nursing Services (DNS) and was told by the Administrator that she could move rooms if she wanted, but she said she did not want to move because she had been in that room for about 5 years. She said her daughter had talked with the Administrator because her daughter was worried about her safety. She said she was scared to stay in the room with her roommate and she was scared to have to move to another room. Staff told her they were keeping her roommate out of the room during the day because she had been complaining so much. In an interview on 11/30/16 at 4:21 PM, the Administrator stated I have personally intervened many times with Resident 71 and her issues with her roommates. The Administrator stated an investigation was not done because when they talked to Resident 71 she said nothing happened and her roommate is not capable of kicking her. The Administrator said they did not ask Resident 168 because We didn't want to go down that path and have to talk about it for 3 months. The Administrator said they did not call it in as an allegation because We know Resident 168 is not capable of kicking out, she can move her wheelchair, but she is not capable of blocking the door. The Administrator said they were monitoring Resident 168 for striking out at other residents Because she is able to strike out at others. The Administrator stated Resident 168 was not kept out of the room, but she's not kept in the room either. Resident 168 doesn't like Resident 71 any more than Resident 71 likes Resident 168. It's not a good match . When asked why they didn't move Resident 168 into another room after the kicking allegation, the Administrator stated The thought process is if someone is unhappy they can move. Why would we move Resident 168, she's not unhappy? The Administrator stated when she talked to Resident 71's daughter, she stated her mother does not get along with anyone. Resident 71's daughter stated, I think the problem is my mom has cried wolf so much that now they won't take it serious. She also stated, the big difference with this current roommate is that she can move herself. I haven't witnessed anything physical, but I have witnessed anger and arguing. If her mom heads to the bathroom then Resident 168 acts like she needs to go to the bathroom will block my mom's path to the bathroom. I have had to block Resident 168's path so my mom can get into the bathroom by distracting her. She went on to say the main reason why the facility isn't doing anything is because her mom has complained about every single roommate she has had. The daughter told the Administrator I know my mom complains a lot, but I have never complained and that means a lot. I told her this time I see it as a possible safety issue for my mom and the Administrator seemed to agree with me. The Administrator asked the daughter if she had told the nursing staff and I did . The Administrator told the daughter that she did not see any documentation of this. The Administrator told the daughter she was not aware her mother had been kicked. She told me it wasn't witnessed so there wasn't anything they could do about it. The daughter said when she talked to the Administrator she was very defensive about it. I told her I wanted to know the protocol and what happened if it got physical again? The Administrator told me that usually it's the person that is unhappy in the room that has to move. I told the Administrator the positives of my mother being in that room. The Administrator told me she would get more information and then get back to me. The Administrator never did get back to me. Review of the progress notes revealed no documentation the Administrator had not documented the circumstances of the conversation with Resident 71's daughter or that a plan was put into place to resolve the issues. In an interview on 11/30/16 at 5:33 PM, Staff G, Social Services, stated No, when asked if the daughter's concerns were made into a grievance. In an interview on 11/30/16 at 5:33 PM, the Administrator was asked why there was no investigation after Resident 71's daughter had called to talk to her about her mother being kicked. The Administrator said it was a vague allegation in that the daughter said mom said something about being kicked, I don't even know if it occurred. The Administrator asked what more could she have done? The Administrator said No, when asked if the facility had interviewed any potential witnesses or assessed the resident's skin. The facility failed to intervene and provide ongoing social services to resolve the imcompatibility of two room mates that turned physical on two occations.

Based on interview and record review, the facility failed to promptly and actively seek a satisfactory resolution of grievances for 3 of 4 residents (42, 179, 71) reviewed for grievances. Failure to document, communicate, update, and resolve resident and family member grievances in a timely manner caused psychological harm for Resident 42 who exhibited depression, became upset and spoke of dying and committing suicide; Resident 71 who was subjected to alledged physical abuse in the form of being kicked by her room mate and placed residents at risk for diminished quality of life. Findings include: Review of the facility's Grievance Procedure revealed the facility encourages any patient, family member, advocate or legal representative to offer any complaint, verbally or in writing, signed or unsigned, at any time. It additionally states All grievances will be thoroughly investigated and reviewed with the person submitting the grievance. Social Service workers will act as patient advocate designees for the facility in event of grievances. RESIDENT 42 Resident 42 was admitted to the facility in January 2015 with [DIAGNOSES REDACTED]. In an interview on 12/01/16 at 11:00 AM, Resident 42 stated his roommate was very noisy and angry and often disrupted his sleep. He stated the nurses even asked him how he handled it. Staff told him they could not move him to another room, and the only thing they could do was to give him ear plugs which were not effective. In an interview on 12/01/16 at 2:47 PM, Resident 42's wife stated her husband was very depressed. She stated his roommate, who had been at the facility approximately 4 or 5 months was very disruptive. She stated they complained to staff about it and the only response was there is no other room for him. Review of Resident 42's August 2016 progress notes revealed documentation beginning 8/16/16 regarding complaints about his roommate. On 8/27/16, documentation revealed Resident 42 and his wife expressed frustration with the roommates noise during the night. Resident 42 was given earplugs. Review of Resident 42's October 2016 progress notes revealed Resident 42 expressed he often thought about dying/killing himself. Notes stated the current roommate situation is stressful .He isn't sleeping well and it is putting him on edge .feeling more upset because of it. Tells me he will get a roommate change when one is available. A note on 10/10/16 states Resident 42 was heard telling his roommate to be quiet. In an interview on 12/06/16, Staff H, Social Services (SS) stated she was aware Resident 42 had complaints about his roommate. She stated she offered noise canceling headphones. She stated when there are roommate concerns, she brings it up at their stand--up meeting, however she could not recall if she had brought this situation up. She acknowledged that Resident 42 was very depressed and has had suicidal thoughts and said If he needs a new roommate I will start looking right away, in fact we have a couple of open male rooms now. I will bring it up at stand-up right away. On 12/07/16 at 10:09 AM, Staff H, SS stated she did not know why a grievance card had not been completed for Resident 42. When asked how the facility defined a grievance, she stated a grievance is anything a resident is quite unhappy about. On 12/07/16 at 11:55 AM, Staff G, SSD stated a grievance card and subsequent investigation should have been completed in regards to Resident 42's roommate complaints. On 12/07/16 at 2:01 PM, the Director of Nursing Services (DNS) was informed of Resident 42's concerns. The facility did not have an investigation for the grievance. The DNS had no further information to provide. RESIDENT 71 In an interview on 11/30/16 at 4:45 PM, Resident 71's daughter stated she had called the facility Administrator about safety concerns she had regarding her mother and her mother's roommate (Resident 168). I don't want my mom to get injured, my mom told me that Resident 168 kicked her and she did not get hurt because she had a boot on. I talked to the Administrator about a week ago and she said she didn't want my mom to get injured or hurt either. She went on to say the main reason why the facility isn't doing anything is because her mom has complained about every single roommate she has had. The daughter told the Administrator I know my mom complains a lot, but I have never complained and that means a lot. I told her this time I see it as a possible safety issue for my mom and the Administrator seemed to agree with me. The Administrator asked the daughter if she had told the nursing staff and I did. The daughter stated I am concerned about my mom's safety. Resident 168 hit her a few months ago, my mom was not hurt, but it still does not seem like a good situation. The daughter said when she talked to the Administrator and felt like the Administrator was very defensive about it. I told her I wanted to know the protocol and what happened if it got physical again? The Administrator told me that usually it's the person that is unhappy in the room that has to move. I told the Administrator the positives of my mother being in that room. The Administrator told me she would get more information and then get back to me. The Administrator never did get back to me. Review of the Resident Concern Log revealed no documentation the Administrator or other staff had logged the daughter's concerns. In an interview on 11/30/16 at 5:33 PM with the Administrator and other staff present, Staff G, Social Services, stated No, when asked if the daughter's concerns were made into a grievance for further follow up. See also F 250 for further details. RESIDENT 179 Resident 179 was admitted to the facility in 2015. His Minimum Data Set (MDS) assessment dated [DATE], revealed he had no cognitive impairment. On 12/06/16 at 9:31 AM, the resident called out to the surveyor in the hall. He had a complaint that his television remote control and his roommate's television remote control kept working on the other's television so his channel kept getting changed when he was watching a program. He stated he was very frustrated and had absolutely had it! He stated he had talked to staff about it for 6 months and there had been no resolution. When asked if he had filed a grievance he stated he knew nothing about that and he just wanted it fixed. Resident 71 was very upset and loud which caused Staff H, Social Services, to come into the room. Staff H then went out to the hall with the surveyor and spoke with Staff Y, Licensed Nurse/Unit Coordinator, who said maintenance staff already knew about the issue. In an interview at 9:44 AM, Staff H, was unable to produce any documentation the facility was already working on this issue or that the complaint had been logged as a grievance. Staff H reiterated It sounds like maintenance already knew about it. Review of the Resident Concern Log from 06/02/16 - 11/29/16 revealed the issue had not been logged as a grievance. In an interview at 9:55 AM, Staff Z, Maintenance, stated he was aware of the issue. Staff Z stated It's been awhile, when asked how long they have been working on this issue. Staff Z was asked if it's been 6 months, he stated We've been working on it for a while. In an interview at 10:46 AM, Staff E, Maintenance Supervisor, notified the surveyor the television remote issue had been fixed. In an interview on 12/07/16 at 2:24 PM, Resident 179's roommate did not offer any additional information except to say it was working now.

Based on observation, interview and record review, the facility failed to follow the plan of care for 1 of 3 sample residents (1) with cognitive impairment and a fall history. Failure to provide adequate supervision for Resident 1 resulted in a fall with harm of a head injury and rib fracture. Findings include: Resident 1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 1/2/15, revealed Resident 1 had an unsteady gait but walked independently in his room. The MDS indicated he was cognitively impaired and required supervision due to his poor safety awareness. Resident 1 had an unwitnessed fall on 1/23/15. The facility's investigative report documented that he was discovered on the floor in his room. He was transferred to the hospital due to his complain of hip pain and discovered a hip fracture which was surgically repaired. After Resident 1's surgery, he returned to the facility on [DATE]. He then required 2 person assistance with bed mobility, transfers and was dependent on staff for wheelchair mobility. The nursing notes indicated he was confused "continuously talking to himself, making no sense", and required narcotic pain medication due to hip pain. The nursing notes from 1/28 to 2/3/15 documented Resident 1 had periods of agitation, was "very confused", was experiencing pain and would attempt to get out of his wheelchair. The care plan directed, dated 1/27/15, directed staff to place a sensor pad in bed and his wheelchair to alert the staff if he would attempt to transfer without assistance due to his confusion and poor safety awareness. On 2/5/15, Resident 1 was observed seated in a wheelchair, asleep next to the nurse's station. Bruising was noted around his left eye and forehead. A second fall occurred on 2/3/15 in his room. Resident 1 sustained a head injury, and a fractured rib with traumatic pnemothorax. The facility's investigative report for the fall documented he was discovered "face down on the floor in front of his w/c (wheelchair) which was tipped forward, alarm box was on a chair in room, not hooked up to the alarm pad under the resident". The report documented the resident was left unattended in his room. The reported documented that the NAC (nursing assistant) failed to follow the plan of care and properly connect the alarm device. The NAC's written statement revealed she had not even placed the alarm device in his chair when she got him up for dinner. The report documented the resident was left unattended in his room. The resident sustained [REDACTED]. The resident was transferred to the hospital. On 2/5/15, the Director of Nursing (DNS) verified the nursing assistant had not followed Resident 1's plan of care. The DNS stated the "alarm was not connected" and he was left unattended in his room.

Based on observation, interview and record review the facility neglected to respond immediately in the evaluation, treatment and the implementation of interventions regarding an unstageable (the inability to accurately stage a pressure ulcer due to not visualizing the wound bed) pressure ulcer for 1 of 3 (Resident 138) residents reviewed for pressure ulcers. This failure resulted in the development of an unstageable pressure ulcer and a wound infection causing harm to Resident 138. Findings include: The Nursing Home Guidelines, a.k.a. "The Purple Book," fifth edition, defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Resident 138 was admitted in September 2012 with multiple [DIAGNOSES REDACTED]. According to the most recent Minimum Data Set, an assessment tool, dated 6/27/14, the Resident required extensive assistance of two people for transfers and bed mobility. The Resident was identified as being at risk for the development of pressure ulcers and was moderately impaired with decision making skills. Resident 138's medical record was reviewed. The Resident was to have weekly skin assessment done. If there were any concerns, the Licensed Nurse (LN) was to document this in the electronic medical record. The resident had a skin assessment completed on 7/9/14 at 11:17 p.m., and the resident's buttocks was "... clear of redness or open areas..". Per the facility's skin assessment tool, on 7/16/14 the Resident was documented to have an 8.1 centimeter (cm) x 12.0 cm unstageable pressure ulcer to the right buttock. On 7/16/14 the facility completed an investigation regarding the unstageable pressure ulcer. The pressure ulcer was documented as being found on 7/12/14 at 6:00 a.m., four days prior to any treatment or interventions being documented. The facility identified the development of the pressure ulcer as neglect. Upon review of a witness statement, dated 7/16/14, Staff R, LN, stated on 7/12/14 at 6:55 a.m. while providing care, Staff R noted breakdown to the resident's right buttock. Staff R passed the information to the oncoming LN and was told the oncoming LN would "...take care of it (the wound)." There was no evidence the oncoming LN provided any treatment to Resident 138's pressure ulcer. In another witness statement from Staff S, Nursing Assistant, dated 7/16/14, stated during her shift on 7/13/14 while Resident 138 was being toileted, "...we found some bloody smear on the resident's brief. Then, we found a big sore on her butt and let the nurse know about it. The nurse came into the bathroom and checked the sore." On 7/17/14, the Resident was started on Keflex (an antibiotic) due to the surrounding tissue of the pressure ulcer was "... deep red, unblanchable, and hard to touch." The Resident's care plan, dated July 2014, was reviewed. Resident 138 was at risk for skin breakdown. Interventions included staff to encourage the resident to reposition every 2-3 hours, overlay mattress on bed, cushion on the wheelchair, and to monitor skin during cares and notify the LN of any changes. In an interview on 8/22/14 at 12:40 p.m., Staff B was asked if the resident had the above care plan interventions implemented. Staff B stated Resident 138 did not have a wheelchair cushion, but she implemented one immediately after the unstageable pressure ulcer was found. Staff B stated the resident was more mobile and up in her wheelchair more, prior to the pressure ulcer being identified. Staff B further confirmed there was no immediate treatment or interventions for the Resident's unstageable pressure ulcer from the date first observed, 7/12/14 until 7/16/14. The Resident's wound was observed with Staff B, Unit Manager, on 8/22/14 at 12:30 p.m. The wound bed had new tissue growth present and was free from any odor. The surrounding tissue was intact. Wound measurements were not able to be done related to the Resident was becoming agitated and was pushing Staff B away from her. Resident 138 was treated with a course of antibiotics related to the wound being infected. The facility failed to implement interventions to prevent, failed to maintain and report, and failed to provide the necessary services to avoid physical harm to Resident 138. .

Based on observation, interview and record review the facility failed to ensure services provided met professional standards of quality for 1 of 3 residents (Resident 138) reviewed for pressure ulcers. The facility failed to evaluate, treat and implemented interventions to an unstageable pressure ulcer resulting in harm to Resident 138. Findings include: The Standards of nursing conduct or practice in the Washington Administration Code 246-840-700 (3)(a)(b) stated the Registered Nurse (RN) and Licensed Practical Nurse (LPN) shall communicate significant changes in client's status to appropriate members of the health care team. This communication shall take place in a time period consistent with the client's need for care. Furthermore the RN and LPN shall document, on essential client records, the nursing care given and the client's response to that care. Resident 138 was admitted to the facility in September 2012 with [DIAGNOSES REDACTED]. In a review of the facility's incident log, on 7/12/14 an unstageable (the inability to accurately stage a pressure ulcer due to not visualizing the wound bed) pressure ulcer was discovered on the Resident 138's right buttock. In a record review on 8/20/14, the resident did not receive any documented treatment or intervention until 7/16/14, 4 days after the pressure ulcer was discovered on 7/12/14. The unstageable pressure ulcer measured 8.1 centimeter (cm) x 12.0 cm. Per the facility's investigation process, there were Licensed Nurses (LN) aware of the pressure ulcer but did not provide the necessary care and services to Resident 138. In a statement written by Staff R, LN, on 7/12/14 at 6:55 a.m. was aware of the ". . . breakdown to the residents right buttock. Nurse told oncoming nurse about it + (and) she said she'd take care of it." In a statement written by Staff U, LN, on 7/16/14, stated the Nursing Assistant alerted her to a foam type dressing to Resident 138's right buttock came off during care (the statement does not specify the date this happened). Staff U checked the physician orders [REDACTED]. Staff U was not able to find any order for the wound. Staff U assessed Resident 138's right buttock and noted a "...pretty extensive wound ..." Staff U then proceeded to send an email to the Unit Manager, and did not notify the Resident's physician or implement any interventions. On 8/22/14 at 1:20 p.m., the Director of Nursing Services (DNS) was interviewed regarding if the facility was able to identify the LN who placed a foam dressing on Resident 138's unstageable pressure ulcer. The DNS was not able to identify the which LN did this. The DNS was asked about the pixis machine (a machine that has emergent medications and supplies and requires the identification of the LN and resident for which the emergent items will be used), and if any dressing were removed and placed on Resident 138's pressure ulcer. The DNS had not reviewed the pixis machines inventory. A physician order [REDACTED]. The resident was also started on an antibiotic related to the surrounding "...tissue was deep red, unblanchable, and hard to touch." The LN's failure to accurately assess and document the pressure ulcer, timely notify the physician, timely initiate interventions or revise the care plan, resulted in the development of a unstageable pressure ulcer on Resident 138's right buttock. Refer to CFR 483.13 (c), F 224 - Prohibit Mistreatment/Neglect/Misappropriation .

Based on observation, interview and record review, the facility failed to provide increased levels of supervision when residents behavior and/or health conditions demonstrated a need for a higher level of monitoring for 2 of 11 Residents (175, and 21) reviewed for accidents. The failure to thoroughly evaluate and revise the interventions in place to prevent falls for Resident 175, contributed to her fall with injuries. In addition, the facility's failure to assess the need for increased supervision for mobility for Resident 21, resulted in a fall when she had a change of condition. Findings include: The facility policy "Assessing Falls and Their Causes", dated 7/27/09, instructed staff: "If a resident has just fallen, or is found on the floor without a witness to the event, nursing staff will record vital signs and evaluate for possible injuries to the head, neck spin or extremities... Once an assessment rules out significant injury, nursing staff will help the resident to a comfortable sitting, lying or standing position, and then document relevant details...Define the details of the fall...Identify the causes of the fall or fall risk...Perform a post- fall evaluation...Identify the complications of the fall. Documentation: 1. Condition in which the resident was found. 2. Assessment data including vital signs and any obvious injuries. 3. Interventions, first aid, or treatment. 4. Notification of physician. 5. Completion of a falls risk assessment. 6. Appropriate interventions taken to prevent future falls." RESIDENT 175: Resident 175 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The hospital history and physical, dated 4/12/11, revealed that the resident had " persistent and troublesome weakness in conjunction with the patient's longstanding balance difficulties and increasing frequency of falls. It has become apparent that the patient can no longer live alone". Another hospital note revealed the resident had injured her right arm when she fell and required the use of a sling. The facility's admit progress note, dated 4/15/11, documented that the resident's gait and balance were unsteady and that the resident required one person assist with a walker. The plan of care was to attach a mobility alarm (clip) to the resident due to her confusion and poor safety awareness. The consent form for the use of the mobility alarm, dated 4/15/11, indicated the alarm was used due to the resident's "poor safety awareness and unsteady gait". An occurrence report, dated 5/15/11, documented the resident had a fall with no witness and the resident was confused. The report indicated the resident's injuries included a bruise to right cheek, right side of lip, right brow, right thigh, right wrist, left wrist wrist, right shoulder, and abrasions to the right knee and left elbow. Review of the nursing notes from 4/15/11 through 5/15/11 revealed that Resident 175 repeatedly removed her clip alarm and got out of bed without staff assistance: "4/17/11, mobility alarm in place but is often removed by resident, restless and attempting to get up without assist...4/22/11, pt has removed clip alarm to prevent it from sounding then gotten up without assistance to go to BR. Instructed concerning using call light and waiting for assistance. Pt forgetful and oriented to self...4/23/11, Self transferred multiple times and removed clip alarm... 4/27/11, Self transferred mutiple times today and removed clip alarm multiple times, uses call light occassionally...4/28/11, Self transferred multiple times and removed clip alarm. Poor safety awareness...4/30/11, resident removed clip alarm x 10 day. Adamently refused to wear clip alarm, Stating "I don't need that miserable thing" Up independently with walker to sunroom and dining room against staff advice...5/1/11, Continues to remove alarms and to walk unassisted in hallway and room...5/2/11, constantly removing her clip alarm and self transferring...5/3/11, impulsive-removes clip alarm frequently and walks by herself. doesn't use call light...5/4/11, has clip alarm but constantly removing it and gets up on her own. Rarely uses call light...5/6/11, continues to remove clip alarm...5/6/11, able to unclip mobility alarm...5/7/11, Undid clip alarm x2 redirected back to bed... 5/7/11, resident frequently removing clip alarm and self transfered, rarely uses call light...5/9/11, removed clip alarm x10...5/10/11, medicare meeting--removes clip alarm and walks around on her own...5/14/11, resident has clip alarm but disables it and ambulates to and from BR in room...5/15/11 at 2:05 a.m., heard an unusual noise, resident on floor, states she does not know how she fell ..she had removed her alarm and had taken herself to the toilet". Interview with the licensed nurse (LN 6)on 5/20/11 at 1:45 p.m., revealed that if a resident was at risk for falls, usually a clip alarm was used. However, if a resident continually removed the clip alarm, licensed nurses should evaluate the continued use of the clip alarm and consider other interventions for fall preventions. Interview on 5/23/11 at 9:57 a.m., the resident stated she was upset about her fall and now she was "ugly" due to bruised face. Her discharge plan to go home was delayed because of the fall. She stated she had to "just resign to things", (referring to the alarms). Even though staff observed and documented the resident's repeated behaviors of removing her clip alarm and identifed Resident 175 to be at risk for injury due to her unsafe, independent self transfer attempts, documentation revealed there were no timely or alternative interventions considered for the resident until the resident had a fall with injuries which included bruises to her face, hips, shoulder. RESIDENT 21 Resident 21 was admitted [DATE] with [DIAGNOSES REDACTED]. According to the Resident's Minimum Data Set Assessment (MDS), dated [DATE], the resident was alert but not oriented to date, time, or place and her short term memory was severely impaired. The Resident required supervision when walking with minimal assistance by staff at times to help steady her. She did not use mobility aides such as a walker or wheelchair. According to the Resident's medical record, the Resident had a fever, a cough and was lethargic for days prior to a fall on 5/6/11 at 8:45 p.m.. It was thought the resident might have an upper respiratory infection. A blood test and a chest x-ray done on 5/5/11, were inconclusive. On 5/6/11 at 8:45 p.m., the Resident fell as she was coming out of the bathroom. The facility's Occurrence Report regarding the fall documented that the resident said, "I was coming out of the bathroom and I just couldn't stand anymore". She had a fever of 99.6 degrees and an elevated breathing rate and pulse. The original nurse filling out the Occurrence Report noted that the resident "had been extremely weak and slightly lethargic this evening" and that "staff had been encouraging her to use her walker with standby assistance, which she had not taken with her when she got up to the bathroom" prior to the fall. The Resident was not injuried in the fall. On 5/19/11 at 9:30 a.m., in an interview with LN 8 regarding what safety measures had been put in place to protect the Resident before and after the fall. LN 8 stated "no other safety measures had been implemented other than the ones that were already in place" prior to the resident getting sick. He stated the Resident sat in the supervised dining room most of the time and that one side of her bed was against the wall for one safe exit and staff had encouraged her to use a walker." The facility failed to change the resident's level of supervison of mobility needs when she experience a change in condition with increased weakness, fluctuating oxygen levels and fever. During random daytime observations on 5/20/11 - 5/23/11, the Resident was in the dining/activity room, which was always supervised by staff. The Resident was observed to be asleep 98% of the time in the recliner. She ate poorly during meals, even when assisted by staff. . Each day she was observed sleeping more throughout the day. On 5/23/11 at 11:00 a.m., LN 8 stated that the Resident was not getting better and had in fact had a further decline over the past weekend.

Based on interview and record review the facility failed to ensure professional standards of care were followed for 1 of 2 (Resident 1) sample residents reviewed. Failure of the licensed nurse to assess Resident 1 immediately after a spill of hot liquid into his lap placed the resident at increased risk of harm. Findings include: Resident 1 admitted to the facility 5/30/04 with multiple [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment, dated 3/2/11, indicated Resident 1 was severely cognitively impaired with no behavioral issues. Residents 1 ' s plan of care indicated he was to eat his meals in the rehabilitation dining room. He had decreased range of motion to both shoulders and was experiencing a loss of functional mobility. On 3/4/11 at 4:30 p.m., per review of Facility Incident Report, Resident 1 was in the facility rehabilitation dining room. He spilled hot coffee into his lap. The resident assistant immediately informed the licensed nurse caring for Resident 1 about the spilled hot coffee. The facility investigation regarding the burn revealed an approximate 40 minute time lapse from when the resident assistant informed the nurse regarding the spill to when the licensed nurse assessed the burn. Resident 1 remained in the dining room with only a cold pack on for treatment. The nursing assessment revealed [MEDICAL CONDITION] Resident 1 ' s skin on the lower abdomen that were red and had formed blisters. The size of the burn on his lower abdomen measured 13cm by 6cm. He also had a triangular shaped burn on the pubic area measuring 7cm by 6cm by 7cm. The Director of Nurses (DNS) stated her expectation was a licensed nurse was to respond immediately when told a Resident had just spilled hot coffee in his lap. She stated the nurse was suspended until further notice. The nurse failed to recognize Resident 1 at high risk for skin issues related to his [DIAGNOSES REDACTED]. Along with this he had decreased agility with fragile skin. Consequently, Resident 1 sustained two 2nd degree burns. Refer to CFR 483.25(h) F323 Free of Accident Hazards/Supervision

Based on observation, interview and record review the facility failed to provide adequate supervision for 1 of 2 sample residents (Resident 1) who were reviewed for burns received from hot liquids. Failure to supervise the resident and to monitor temperatures of hot liquids resulted in this resident receiving two 2nd degree burns. Also, the facility ' s failure to monitor the temperatures of hot liquids disseminated in the facility by staff placed all residents at risk of harm from burns. Findings include: Second- degree burns involve first 2 layers of skin. These may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluids, and possible loss of some skin. Resident 1 admitted to the facility 5/30/04 with multiple [DIAGNOSES REDACTED]. He also had a supra-pubic catheter. The Minimum Data Set (MDS) assessment dated [DATE] stated Resident 1 was receiving restorative nursing assistance for eating. Residents 1 ' s plan of care for eating meals indicated he was to eat his meals in the rehabilitation dining room. He was independent with eating but needed cueing by staff. He also required set up assistance with built-up utensils, a lipped plate and a 2 handled cup to drink from. On 3/4/11 at 4:30 p.m., per review of Facility Incident Report, Resident 1 was in the facility rehabilitation dining room. While using the 2 handled cup, he spilled hot coffee into his lap. The nursing assistant stated she had turned her back on him. When she turned back around, she found he had tipped over the cup of hot coffee which landed in his lap. The resident assistant attending to Resident 1 " pulled clothing away from the body and then placed a cold pack on the area for awhile " . The resident assistant immediately informed the licensed nurse caring for Resident 1 about the spilled hot coffee. The facility investigation regarding the burn revealed an approximate 40 minute time lapse from when the resident assistant informed the licensed nurse regarding the spill to when the nurse assessed the burn. Resident 1 remained in the dining room with only a cold pack on for treatment. Factors such as the resident ' s diagnoses, length of time exposed to the heat coming from the coffee and the unknown temperature of the hot water increased Resident 1's chances he would sustain a serious burn. The nursing assessment revealed Resident 1 ' s skin on his lower abdomen was red and had formed blisters. This affected area measured 13cm by 6cm. He also had a triangular shaped burn on the pubic area measuring 7cm by 6cm by 7cm. Both of these wounds were either near or surrounded the area of Resident 1 ' s suprapubic catheter site. On 3/6/11, the physician was notified of the abdominal burn was 18cm by 5.5 cm - very red with a blister in the area. The burn was defined as a 2nd degree burn. On 3/7/11 nursing began to apply Silvadene creme dressing on the burns per physicians order. On 3/9/11 at 10:15 a.m., the dietary manager stated at the time Resident 1 was burned, there was no dietary policy or procedure for checking the temperatures of any of the hot liquids dispensed from any hot coffee/water pot and or dispenser throughout the facility. She stated the coffee was poured for him by staff and set in front of him; all without checking to see if the liquid was too hot. On 3/9/11 at 9:30 a.m., a nursing assistant (NA 1) stated, prior to Resident 1 receiving the coffee burn, she had never checked the temperature of any of the coffee she poured for residents. She would pour the coffee from the urns sent from the kitchen. She would not serve the coffee or tea water if she noted a lot of steam coming from the cup. She would set the cup aside and deliver it later. She stated she had reheated coffee for residents by using a microwave oven. There was no temping of the coffee to make sure it was not too hot. On 3/9/11 at 1:00 p.m., both the director of nurses and dietary manager stated the facility had since put in measures throughout the facility to prevent recurrence such as the burns Resident 1 sustained from the hot coffee. Refer to CFR 483.20(k)(3)(i) F281 Services provided meet professional standards of practice